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Advanced Neurology Stroke care in sub-Sahara Africa

Multiple factors are responsible for this observation: toward attaining sustainable development goals in health-
(i) There are limited hospitals and acute care facilities care improvement initiatives. 121,122 An increasing number
capable of providing good stroke care in the region of citizens in SSA countries are experiencing catastrophic
(ii) SSA is comprised mostly of low-income countries health-care expenses, defined in several studies as direct
with insufficient resources medical expenses exceeding 10% of the annual income
(iii) The health-care budget in most countries represents per capita of the household. Using this definition, a
a small fraction of the total budget and is not a high systematic review and meta-analysis of population-based
priority for policymakers studies published between 2000 and 2021 on catastrophic
(iv) Inadequate or poorly maintained infrastructure for health expenditure in 31 SSA countries, involving over
the few hospitals capable of providing quality stroke one million household participants, showed a pooled
care is rampant. annual incidence of catastrophic health expenditure
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These factors are accentuated by poor education about of 16.5% (95% CI: 12.9 – 20.5). In a tertiary hospital-
the importance of seeking medical care for stroke when it based study conducted in Ibadan, Nigeria, in 2015,
occurs. 29.1% of patients met the criteria for catastrophic health
expenditure. In that study, the average direct cost for a
In 2001, African Union (AU) countries launched the single hospitalization for OOP patients was Nigeria Naira
Abuja Target declaration, urging participating countries (₦) 195,672.20 (US$983.00), and for those whose medical
to allocate at least 15% of their annual budget to the expenses were subsidized by social health insurance, the
health-care sector by 2015, and for donor countries to OOP expenditure was ₦189,817.40 (US$954.00). The
scale up their support toward this mission. Recent data average household annual income of the study participants
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suggest that fulfilling this pledge has been a struggle for was ₦696,865.70 (US$3,501.00). This single acute
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the Southern African Development Community (SADC) hospitalization direct cost for OOP payees represents 28%
member states and the Economic Community of West of their annual household income and does not include
African States (ECOWAS). The 2018 WHO Data-Based stroke rehabilitation and secondary stroke prevention costs
on Global Health Expenditure showed that all SADC and or loss of productivity associated with debilitating stroke.
ECOWAS member states were struggling to meet the 15% Similar studies addressing the short- and long-term costs
annual target. 116-118 One of the main reasons cited for the of stroke have shown substantial direct cost burdens. 125-128
failure to meet this declaration target was the member These findings underscore the urgent need to develop a
nations’ reliance on external aid to cover their expenditure robust and effective universal insurance scheme to reduce
requirements. 117 the burden of OOP expenses for citizens.
African countries spend US$8 to US$129 per capita on
health care compared to high-income countries that spend 7. Proposed framework for the
over US$4,000. Unfortunately, even for some African improvement of stroke care in SSA: The 5 Ps
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countries with recent economic growth, an increase in The state of health care, particularly stroke care, in SSA is
economic growth does not equate to an increase in health- suboptimal, primarily due to a lack of adequate economic
care spending budget. Indeed, the reverse is usually the resources. Unfortunately, these challenges are expected to
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case. Between 2001 and 2015, government spending on worsen, with stroke cases predicted to increase by nearly
health care as a proportion of overall spending decreased in 50%, from 6.6 million in 2020 to 9.7 million in 2050, and
21 African countries. Low budgets with poor execution, stroke-related DALYs projected to rise from 144.8 million
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coupled with wastefulness, diminish the available resources to 189.3 million worldwide. However, these challenges are
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for health. Low government spending hurts citizens the not insurmountable and will require fundamental changes
most, resulting in high out-of-pocket (OOP) spending and in systems operations and actions in many SSA countries.
a health system that only guarantees access to those who Pragmatic solutions to mitigate this global stroke burden
can afford it. have been proposed by the World Stroke Organization-
Lancet Neurology Commission. These solutions include
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6.3. Cost of stroke care in SSA implementing primary and secondary stroke prevention
According to the WHO’s 2023 fact sheet, about two strategies, evidence-based acute care and rehabilitation
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billion people worldwide are facing financial hardship, services, monitoring and assessing stroke burden and its
including one billion experiencing catastrophic OOP risk factors, early detection and control of hypertension,
health spending or 344 million impoverished due to health and workforce training and capacity building. A “5 Ps”
costs. OOP payments represent the major source of health- framework is proposed to improve the state of stroke care
care financing in SSA and have hindered the region’s drive and enhance outcomes in this region. The 5 Ps involve

Volume 3 Issue 2 (2024) 12 doi: 10.36922/an.2804