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[Healthcare in Low-resource Settings 2013; 1:e8] [page 31]

Cost of treatment as a barrier
to access and continuity 
of healthcare for patients with
mental ill-health in Lagos,
Nigeria 
Olufemi B. Olugbile,1 Ayodele O. Coker,2
Mathew P. Zachariah2
1Department of Psychiatry, Lagos State
University Teaching Hospital, Ikeja;
2Department of Behavioural Medicine,
Lagos State University College of
Medicine, Ikeja, Nigeria

Abstract

In Nigeria, there are several barriers to
access to effective mental healthcare, e.g. cost,
distance to the mental health facility, social
stigma, cultural beliefs, attitudes and taboos.
This study aimed at i) determining the cost of
treatment of a random sample of psychiatric
patients and to compare the sample with a
matched group of patients from the internal
medical department clinics; ii) assessing the
impact of cost on access to care and mainte-
nance treatment for the study group in the
context of their exclusion from the Lagos
State free health services and the National
Health Insurance Scheme. Medical records of
100 patients currently attending the outpa-
tients’ clinic of the Department of Psychiatry
of the Lagos State University Teaching
Hospital (Ikeja, Nigeria) were randomly
selected and audited. A similar exercise was
also conducted for patients attending the med-
ical outpatients’ clinic in the same hospital.
The monthly costs of prescribed medications
were computed and compared. The monthly
cost of treatment of patients from the
Department of Psychiatry compared to
patients with physical ailments from the med-
ical outpatients’ clinic was found to be signif-
icant vis à vis the average income of average
Nigerians. Contrary to expectations, the mean
cost of drug treatment borne by medical outpa-
tients was much higher (N=2549.07 vs
N=1904.5) (P<0.05) than that of patients
attending the psychiatric outpatients’ clinic.
However, the expensive cost for the psychi-
atric patients far exceeded the expensive
costs for the medical patients. The findings
from this study showed that the average
monthly cost of treatment of patients attend-
ing the psychiatric clinic was lower than
patients from the medical outpatients’ clinic.
However, the most expensive cost for psychi-
atric patients far exceeded the most expensive
cost for medical patients. This study also
revealed that there is no free health program

covering psychiatric treatment anywhere in
Nigeria and mental health drugs are funded
from personal and family expenses. It is there-
by suggested that policy makers should
change policy regarding the coverage of
Nigerians with mental illness. In doing so, the
major barrier to assess and the treatment gap
can be reduced. 

Introduction

Recent evidence showed that mental illness-
es are among the most disabling illnesses glob-
ally. These reports also showed that more than
half of all people with serious mental disorders
are not receiving treatment and the situation
is even worse in low and middle-income coun-
tries (LAMICs).1,2 The reviewed literature also
indicated that the prevalence of mental disor-
ders varied from 26.4% in USA, 17.6% in UK,
31% in Colombia and 12.1% in Nigeria.3,4 In the
same vein, evidence derived from past studies
indicated that in LAMIC mental health disor-
ders are highly prevalent and disabling and
sufferers of mental health disorders are not
likely to patronize the few available mental
health hospitals for assistance.4,5

Many studies have also demonstrated that
among the several major impediments to the
provision of quality mental health in LAMICs
are the lack of adequate mental health facili-
ties, insufficient human resources and poor
funding for increasing mental health servic-
es.1,6,7 In Nigeria, there is little acknowledge-
ment of mental illness at the primary health
care level, which is run by the local govern-
ment. Local studies have shown that doctors at
primary care levels show little interest or apti-
tude for diagnosing mental disorder or carry-
ing out interventions.4,8-11 Other identified fac-
tors preventing access to mental health care by
patients in LAMICs include cultural perception
about the nature and origin of mental disorder,
social stigma attached to mental illness and
the logistics of travelling long distances to the
few general hospitals with psychiatric facili-
ties or specialist psychiatric hospitals.1,4,6,8,9

However, the most reported important barri-
er to mental health care is finance.1,4,6,8,9 In a
country such as Nigeria and many other sub-
Saharan countries, evidence shows that about
45% to 60% of the population lives below the
poverty line.12 Therefore, it stands to reason
that if individuals suffering from mental disor-
ders in LAMICs cannot relatively afford quality
mental health care, it is expected that govern-
ments from these countries should provide
free mental health care services or subsidize
the cost of mental health care. Previous stud-
ies from other parts of the world show that
patients with mental health conditions receive
special consideration to relieve the cost bur-

den of their care.13,14 That may not be the case
in Nigeria, where the National Health
Insurance Scheme (NHIS) does not provide
coverage for people with mental health disor-
ders. This means that the cost of mental health
treatment by patients is from personal or fam-
ily expenses. The explanation for this may not
be far-fetched. Mental health disorders, espe-
cially the severe forms, are regarded as prob-
lems for the society.11,15

Studies focusing on the issue of cost and
access to mental health care were mostly car-
ried out in the developed countries of the
world. Manual and electronic searches of the
literature showed that very little work has been
carried out in sub-Saharan countries. A study
on this important topic in Nigeria cannot be
over-emphasised. This study, therefore, was
aimed at: i) determining the cost of treatment
of a random sample of psychiatric patients and
compare them with a matched group of gener-
al patients from the medical department; ii)
assessing the impact of cost on access to care
and maintenance treatment for the study
group in the context of their exclusion from
the Lagos State Free Health services and the
NHIS.

Materials and Methods

The study was a cross-sectional descriptive
and comparative survey carried out at the
Department of Psychiatry and Medicine of the
Lagos State University Teaching Hospital
(LASUTH) (Ikeja, Nigeria) from April to June
2010. The LASUTH is a tertiary health institu-

Healthcare in Low-resource Settings 2013; volume 1:e8

Correspondence: Ayodele O. Coker, Department
of Behavioural Medicine, Lagos State University
College of Medicine, P.M.B. 21266, Ikeja, Nigeria.
Tel./Fax: +234.8033267544.
E-mail: cokerrotimi@gmail.com 

Key words: cost of treatment, barrier to access,
continuity of healthcare, Nigeria.

Contributions: the authors contributed equally.

Conflict of interests: the authors declare no
potential conflict of interests.

Received for publication: 20 December 2012.
Revision received: 4 February 2013.
Accepted for publication: 16 February 2013.

This work is licensed under a Creative Commons
Attribution 3.0 License (by-nc 3.0).

©Copyright O.B. Olugbile et al., 2013
Licensee PAGEPress, Italy
Healthcare in Low-resource Settings 2013; 1:e8
doi:10.4081/hls.2013.e8



[page 32] [Healthcare in Low-resource Settings 2013; 1:e8]

tion situated in Ikeja, Local Government Area
of Lagos State. It was formerly known as Ikeja
General Hospital. It is a multi-disciplinary ter-
tiary hospital and it has a total bed space of 520
beds. It has many specialists’ clinics; it runs 24
hour-accident and emergency services and in-
patient care services. The hospital also pro-
vides clinical services in internal medicine,
general surgery, obstetrics and gynecology,
community health, family medicine, radiology,
clinical pathology, hematology and blood trans-
fusion, pediatrics, psychiatry, dentistry, and
orthopedics and trauma, among others.
Although the hospital is a tertiary centre, it
also serves as a primary, secondary and tertiary
centre. For this reason, its services are afford-
able because consultation and other services
are rendered free of charge and only prescrip-
tion medicine and laboratory investigations
are paid for by the patients. However, children
under the age of 12 and adults above the age of
60 are not supposed to pay for their prescribed
medications. Permission to carry out the study
was sought from the Research and Ethics
Committee of the hospital. Likewise, written
informed consent was sought from every par-
ticipant that took part in this study. One hun-
dred participants attending the LASUTH outpa-
tients’ psychiatric clinic were randomly select-
ed. The cost of prescription medication pro-
cured and used for one month was also quanti-
fied for each patient. All the recruited partici-
pants paid for their medication prescription
from their personal or family expenditures. A
matched group of 100 patients was also ran-
domly selected from the internal medicine out-
patients’ clinic. Their prescription costs over
the same period were also computed and ana-
lyzed. Participants with multiple medical or
mental conditions were excluded from the
study. The average national minimum monthly
income in Nigeria is 18,000 Naira (N), an
equivalent of $110 US Dollars per month. The
currency used in the study is the Nigerian
Naira. It has an equivalent of N160 Naira to $1.

Statistical analysis 
The data collected was analyzed with the aid

of Statistical Package for Social Sciences
(SPSS; version 14 windows). P<0.05 was con-
sidered significant. 

Results 

One hundred psychiatric patients attending
the outpatients’ clinic of the LASUTH
Psychiatric Department formed the study
group, while another 100 patients from the
internal medicine outpatients’ clinic of the
same hospital formed the comparison group.
The findings showed that the mean cost of
drug treatment borne by patients attending the

medical outpatients was much higher
[N=2549.07 ($15.9) vs N=1904.5 ($11.9)]
than that of patients attending the psychiatric
outpatients’ clinic. However, the standard devi-
ation (SD) for the psychiatric patients was
very wide (3991.3) compared to the medical
patients (1904.5) as reflected in Table 1. Table
2 shows the T test significance of difference
between the means and it shows that there is
no significant difference between the means.
One observed factor was that, despite the fact
that most of the psychiatric patients appeared
to receive treatment at somewhat cheaper cost
than the medical patients, the most expensive
cost for the psychiatric patients far exceeded
the most expensive costs for the medical
patients.

Discussion 

This study sought out to determine the cost
of monthly treatment of a sample of psychiatric
patients from LASUTH, to compare them with
a matched group of patients from the internal
medicine outpatients’ clinic, and to assess the
impact of cost on access to care and mainte-
nance treatment for the psychiatric patients.
The findings from this study did not detect a
significantly higher cost for psychiatric treat-
ment over treatment for patients with medical
conditions. However, the top costs for a small
minority of the mentally ill were observed to be
much higher. The explanation for this findings
could probably be due to the observed best
practice within the mainstream of psychiatry
which now requires that atypical antipsy-
chotics and new generation antidepressants
such as the Selective Serotonin Reuptake
Inhibitors (SSRIs) are prescribed as first line
medications for newly diagnosed cases of con-
ditions such as schizophrenia, mania or severe
depression.16-18 Again, the results of this study
also showed that all the patients surveyed who

attended the psychiatric outpatients’ clinic,
virtually paid for their psychiatric medications
from personal and family expenditures. In
Nigeria, where the poverty rate is high, access
to quality mental health care is achieved by
travelling long distances, which could also be
disincentive to treatment. Due to the nature of
mental disorders that run a long course, indi-
vidual with chronic mental disorders may find
it relatively difficult to continue to pay for the
costs of their medications. In Lagos State and
perhaps in the whole Nigeria, psychiatric
patients may possibly not be getting the best
possible treatment for their psychiatric illness-
es and this should be evaluated by future stud-
ies. Unfortunately, this situation may remain
the same until the barrier to access to good
care is removed either through a comprehen-
sive National Health Insurance Scheme or
through some direct policy specifically aimed
at reducing the cost of medications of people
who suffer from mental illness.
However, the literature has demonstrated

that changes are going on globally with regard
to the funding of mental health care.1,4,19,20 The
increasing emphasis on community mental
health care is putting an increasing cost of
burden on the healthcare provider, even in
those countries with comprehensive NHIS,
such as the UK.21 Nonetheless, health policy
planners have the twin challenges of keeping
cost to the state or managed care provider
down, and ensuring that the cost issue even
with the most expensive drugs does not
become a major barrier to access or mainte-
nance for patient.22-24 For example, after per-
sistent complaints from different sectors about
the marginalization of the mentally ill in the
managed care system in the USA, there has
recently been a lot of attention focused on how
to include patients with mental health disor-
ders without being exorbitant about cost of
drug.25 The limitation of this study includes its
small size. It was also carried out only in one
teaching hospital in Nigeria, thus its general-

Article

Table 1. Mean cost of drug treatment borne by psychiatric and medical outpatients.

Group No. Mean SD Min Max

Psychiatry 100 1796.0 3991.3 150 35210
Medicine 100 2549.07 1904.5 60 9080
SD, standard deviation; significance=P<0.05.

Table 2. Means between the cost of medications of the two departments

Group No. Mean SD df Mean Significance 2-tail
difference

Psychiatry 100 1796.0 3991.3 198 -752.47 .09 -
Medicine 100 2549.07 1904.5 - - - -
SD, standard deviation; df, degree of freedom; significance=P<0.05.



[Healthcare in Low-resource Settings 2013; 1:e8] [page 33]

ization may be difficult. However, the provision
of mental health services and the supply of psy-
chotropics to patients in all teaching hospitals
in Nigeria are quite similar and if there are
differences, they may be insignificant.
Nonetheless, in light of these findings, it is
desirable that future studies on cost of care
and other barriers to mental healthcare should
involve a larger multi-centred random sample. 

Conclusions

This study provided evidence that the cost of
care of psychiatric patients as compared to med-
ical patients might not be significant. Findings
of this study also showed that patients suffering
from mental health disorders in Lagos State and
Nigeria pay out-of-pocket for their medications
which may eventually affect long-term compli-
ance to their drug intake. Psychiatrists and
mental health policy makers in Lagos State and
Nigeria must formulate a policy that will take
into consideration prescribing affordable drug-
regime in managing patients with psychiatric
disorders which should also be determined sub-
stantially by the clinician’s assessment of
patients’ financial ability to bear the costs of
medications.  

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