Title : The cost burden of comorbidity in oncology care: Evidence from Lesotho

Background: Evidence from low- and middle-income countries (LMICs), especially in Sub-Saharan Africa, is still lacking, even though cancer places a significant financial burden on individuals, families, and health systems. Only in July 2024 did Lesotho, a landlocked LMIC completely encircled by South Africa, provide its first in-country chemotherapy injection. Before reaching this milestone, the government had to pay an estimated USD 7 million a year to refer patients to South Africa or India. Comorbid illnesses, namely diabetes, hypertension, and HIV, exacerbate financial vulnerability and clinical complexity. By analyzing the cost, accessibility, and quality aspects of oncology care for cancer patients with comorbidities at Lesotho's Maseru Oncology Center, this study filled a significant evidence vacuum.

Methods: A mixed-methods concurrent design was used.  Total of 148 cancer patients who were proven to have at least one comorbidity were recruited through successive sampling at the Maseru Oncology Center for the quantitative strand, which employed a retrospective cross-sectional technique. A standardized, interviewer-administered questionnaire was used to gather data on direct medical out-of-pocket expenses, indirect expenditures (lost wages and caregiver burden), patient views of access and quality using Likert-scale items, and sociodemographic and clinical factors. Descriptive statistics, a Generalized Linear Model (GLM) with a Gamma distribution and log link function for multivariable cost regression, and Mann-Whitney U and Kruskal-Wallis tests for comparison analysis were among the statistical studies. In order to gather theme insights on treatment pathways, obstacles, and financial mechanisms, the qualitative strand employed a semi-structured Key Informant Interview (KII) guide given to healthcare professionals. Ethical approval was obtained from the Lesotho Ministry of Health Ethics Committee.

Results: With a mean age of 57.4 years, the 148 participants were primarily female (69.6%). The most common diagnosis was cervical cancer (38.5%), which was followed by breast cancer (12.8%) and prostate cancer (22.3%). The majority of patients (Stage II: 58.1%; Stage III: 36.5%) arrived at intermediate phases. The most prevalent comorbidities were HIV alone (25.0%), HIV/hypertension co-occurrence (26.4%), and hypertension (33.1%). Thirty percent or more of the participants said they had no monthly income. The cohort's typical monthly income of LSL 1,500 was surpassed by the median direct out-of-pocket medical expense of LSL 2,030. Those impacted had mean indirect expenses of LSL 5,660, which is almost four times the median direct cost. The only variable in the comparison analysis that reached statistical significance was the 35% greater overall expenditures spent by uninsured patients compared to insured patients (p = 0.003). 
Female sex (cost ratio = 1.74; p = 0.001) and insurance status (cost ratio = 0.65; p = 0.003) were found to be independent predictors of total cost using multivariable GLM modeling. Patient perceptions showed low structural quality (only 28.4% rated wait times as satisfactory, 45.9% could afford their medications, and only 32.4% reported good or very good coping ability), but high interpersonal quality (68.2% rated staff respectfulness favorably; 69.2% felt adequately informed). Five structural weaknesses were highlighted via qualitative themes: unmet psychosocial and nutritional needs, fragmented treatment routes, prescription stock-outs, geographic inaccessibility, and insufficient financial support mechanisms.

Conclusions: In Lesotho, comorbidity in oncology care results in a structurally rooted and financially devastating burden that disproportionately affects women, rural populations, and uninsured patients. International benchmarks for catastrophic health expenditure are sometimes met by financial exposure that beyond household capacity to pay. Although health insurance offers significant protection, coverage is still inadequate. These results necessitate immediate legislative action, including the adoption of systematic financial vulnerability screening, decentralization of oncology services, reinforcement of pharmaceutical supply chains, and expansion of health insurance coverage. In addition to providing a reproducible methodology for future cancer health economics research in LMIC settings, this study closes a significant evidence vacuum for Sub-Saharan Africa.

Mathato Aumane (also known professionally as Palesa Chetane) is a PhD candidate in Public Health at Texila American University completed thesis and passed ( awaiting graduations), at Guyana, and a seasoned health policy professional with over 15 years of progressive experience in Lesotho and the Southern African region. She holds a Post Graduate Diploma in Public Health from the University of Pretoria (with Distinctions), an Honours Degree in Advanced Nursing from the University of the Free State, and a Diploma in Nursing from Maluti Adventist School of Nursing. She currently serves as Healthcare Quality Improvement Lead at Partners in Health Lesotho and Deputy President of the Lesotho Nurses Association. Currently serving as the co-chair at the Global Fund Advocates Network International steering committee and Global committee member at the Association of Nurses in AIDS care. Facultu member at the university of Witwatersrand and University of Global health Equity ( On the Clinical Leaders Program. A published researcher and international presenter, she has contributed to maternal health, HIV/TB, and quality improvement programs in collaboration with WHO, UNICEF, and the Global Fund.