When Paying for Care Becomes a Crisis: Affordability Barriers, Coping Strategies, and Financial Consequences of Chronic Illness in Lagos, Nigeria.

BACKGROUND: Chronic non-communicable disease (NCD) care in Nigeria remains largely financed out of pocket, exposing households to affordability barriers and harmful coping strategies. This study examined the prevalence and patterning of affordability barriers, financial coping strategies, and predictors of foregone care and distress financing among chronic NCD patients attending public health facilities in Lagos, Nigeria. METHODS: A facility-based cross-sectional survey was conducted among 480 adults receiving outpatient care for chronic NCDs, such as hypertension, type 2 diabetes, cardiovascular disease, chronic kidney disease, cancer, chronic respiratory conditions, and sickle cell disease across primary, secondary, and tertiary public facilities. Participants were recruited using a multistage sampling approach, with eligible patients selected systematically from clinic registers. Data were collected using a structured, interviewer-administered questionnaire capturing sociodemographic and household characteristics, employment status, chronic NCD diagnosis and treatment duration, out-of-pocket healthcare expenditure, affordability barriers, and financial coping strategies. Affordability outcomes included being offered unaffordable treatment, cost-driven treatment decisions, irregular clinic attendance, and inability to access care because of inability to pay. Financial coping strategies were grouped as self-directed financing, social-network support, and distress financing, defined as borrowing or the sale of assets. Prevalence estimates were reported with exact 95% CIs. Facility-tier differences and subgroup associations were assessed using chi-square, Fisher's exact, and ANOVA tests. Binary logistic regression models identified predictors of foregone care and distress financing, with average marginal effects and adjusted predicted probabilities estimated to aid interpretation. Statistical significance was set at a two-sided p<0.05. RESULTS: Affordability barriers were common: 42.9% of patients had been offered unaffordable treatment, 41.9% reported that cost shaped treatment decisions, and 45.0% had forgone care because they could not pay. Among affordability challenges, medication unaffordability was especially prominent and was comparable across facility tiers, suggesting system-wide pharmaceutical cost pressures rather than isolated access gaps. Coping followed a clear financial hierarchy: patients first relied on savings or household income (82.9%), many then mobilized social-network support (69.6%), and a substantial minority resorted to distress financing through borrowing or asset sale (28.5%). Financial-exposure intensity and treatment duration independently predicted distress financing; financial-exposure intensity also predicted foregone care. Pension income reduced the probability of distress financing by 15.2 pp, while insurance showed no detectable protection. CONCLUSION: Chronic NCD care in Lagos public facilities becomes a financial crisis through pervasive affordability barriers, prominent medication unaffordability, reliance on informal household coping, financial-exposure intensity, and treatment chronicity, which drive care rationing and distress financing. Nigeria's universal health coverage agenda should include scaling insurance enrolment for chronic NCD patients, benefit-package redesign, pharmaceutical-pricing reform, and income-protection mechanisms that absorb the recurrent costs of chronic illness care.