TABLE OF CONTENTS
Title page i
Certification page ii
Dedication iii
Acknowledgement iv
Abstract v
Table of Contents vi
List of Tables x
List of figures xi
List of abbreviation xii
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study 1
1.2 Statement of the Problem 2
1.3 Objectives of the Study 4
1.4 Significance of the Study 4
1.5 Scope of the Study 4
1.6 Justification of the Study 4
1.7 Research questions for the study 6
1.8 Literature Review 6
1.9 The Conceptual Framework: The Nigeria Health Insurance Scheme 7
1.9.1 Some definition of service 15
1.9.2 Characteristics of healthcare services 16
1.9.3 Classification of healthcare services 17
1.9.4 Healthcare service quality and quality management 18
1.10 Operational Guidelines and Current Implementation of NHIS 20
1.11 Current Implementation 22
1.12 Health Financing History of Nigeria 23
1.12.1 Health Financing in Colonial and Pre-independence era 23
1.12.2 Health Financing from 1960 to 1988 23
1.12.3 Health Financing beyond 1988 24
1.13 Health Sector and Health Financing Policy Reforms in Nigeria 25
1.13.1 Health sector reform policy programmes. (HSRPP) 25
1.13.2 National strategic health development plan. (NSHDP) 2010-2015 26
1.13.3 National health bill (2011) and the national primary healthcare development fund ( NPHDF) 27
1.14 Public health care financing in Nigeria 29
1.15 Source of Finance for the Health Sector 29
1.15.1 Criteria for assessing financing mechanism 29
1.15.1.2 Equity 30
1.15.1.3 Demand/utilization and consumer behaviour 31
1.15.1.4 Supply/provision and provider behaviour 32
1.15.1.5 Displacement effects 32
1.15.1.6 Wider effects of the health sector 33
1.15.2 Public and quasi-public sources of finance 33
1.15.2.1 General tax revenues 33
1.15.2.2 Deficit financing 34
1.15.2.3Earmarked taxes 35
1.15.2.4Social insurance 36
1.15.2.5Lotteries and betting 37
1.15.3 Private source of finance 37
1.15.3.1 Private health insurance 37
1.15.3.2 Employer - finance schemes 38
1.15.3.3 Charity and voluntary contributions 39
1.15.3.4 Community financing and self-help 40
1.15.3.5 Direct household expenditures 40
1.15.4 Approaches to improve financing of health activities 42
1.15.5 Human right principle for financing health care 43
1.15.6 Challenges of NHIS implementation in Nigeria 47
1.15.7 Population covered by the NHIS in Nigeria 48
1.15.8 Benefits package of the NHIS 49
1.15.9 Health care providers 49
1.16 Enrollees Satisfaction 49
1.17 REVIEW OF EMPIRICAL LITERATURES 50
1.17.1 The Impact of National Health Insurance Scheme on People’s Health in Taiwan 51
1.17.2 Physician’s Perception of Health Insurance in Saudi Arabia (Alnaif, 2006) 52
1.17.3 Health Insurance of Rural/Township school children in Pinggui,
Beijing: Coverage rate, 52
1.17.4 Determinants, Disparities and sustainability (Zhu et al, 2008 ) 52
1.17.5 The Perception and Demand for Mutual Health Insurance in the
Kassena-Nanka District of Northern Ghana (Akazili et al 2005). 53
1.17.6 Patients’ Perceptions of Service quality in Group versus solo practice clinics
(Lin et al, 2004). 53
CHAPTER TWO
2.0 Research Methodology 55
2.1 Introduction 55
2.2 Research Design 55
2.3 Research Setting 55
2.3.1 Inclusion Criteria 56
2.3.2 Exclusion Criteria 56
2.4 Target Population 56
2.5 Population and Sample Size 56
2.6 Data Collection Instrument 56
2.7 Method of Data Collection 57
2.8 Data Analysis 57
2.9 Validity and Reliability of the Research Instrument 57
2.9.1 Focus Group Discussion 58
2.9.2 Ethical Consideration 58
CHAPTER THREE: DATA PRESENTATION AND ANALYSIS 59
CHAPTER FOUR: DISCUSSION OF FINDINGS
4.1 Focus Group Discussion 87
CHAPTER FIVE
5.0 Summary of Findings, Conclusion and Recommendations 90
5.1 Summary of major Findings 90
5.2 Conclusion 91
5.3 Recommendation 91
5.4 Limitation of the Study 92
REFERENCES 93
APPENDIX 1 101
APPENDIX 2 105
APPENDIX 3 106
APPENDIX 4 107
LIST OF TABLES
Table 1: The Structure of NHIS in Nigeria 14
Table 2: NHIS Operational Guidelines Segments 21
Table 3.1: Socio-demographic characteristics of the respondents 59
Table 3.2: Result of knowledge of enrolees about the (N=387) 61
Table 3.3 Difficulties of Patients under the NHIS (N=387) 62
Table 3.4 Client satisfaction with the NHIS (N=387) 63
Table 3.5: Measures of abuses in the scheme(N=387) 64
Table 3.6 Assessment of Doctors - Enrolees’ satisfaction with the quality of their services 67
Table 3.7 Assessment of Pharmacists – Enrolees’ satisfaction with the Quality of their services 69
Table 3.8 Assessment of Nurses – Enrolees’ satisfaction with the Quality of their services 71
Table 3.9 Assessment of Laboratory Scientists – Enrolees’ satisfaction with the Quality
of their services 73
Table 3.10 Assessment of the Radiographers – Enrolees’ satisfaction with the Quality
of their services 75
Table 3.11: Implementation and Challenges of NHIS in OAU Health Centre - A
Focus Group Discussion (FGD) with Enrollees 77
Table 3.12: Implementation and Challenges of NHIS in OAU Health Centre - A
Focus Group Discussion with Health Maintenance Organizations (HMOs) 80
Table 3.13: Implementation and Challenges of NHIS in OAU Health Centre - A
Focus Group Discussion with Health Care Providers 82
LIST OF FIGURE
Logo of National Health Insurance Scheme 12
Knowledge of client about the scheme 65
LISTS OF ABBREVIATION
AU - African Union
BNA - Business of New Hampshire
CUFHIS - Children Under 5 Years Health Insurance Scheme
DHS - Demographic Health Survey
FMOH - Federal Ministry of Health
GDP - Gross Domestic Product
GGE - General Government Expenditure
GGHE - General Government Health Expenditure
HSB - Health Seeking Behavior
HMO - Health Maintenance Organization
HSRPP - Health Sector Return Policy Programme
HFA - Health for All
IDIS - In-Depth Interviews
LGDH - Local Government Department of Health
LGA - Local Government Area
MDG - Millennium Development Goal
NEED - New Economic Empowerment and Development Strategy
NHC - National Health Commission
NCH - National Council on Health
NHA - National Health Accounts
NHB - National Health Bill
NHP - National Health Policy
NHIS - National Health Insurance Scheme
NSHP - National Strategic Health Development Plan
NPHDF - National Primary Healthcare Development Fund
NSITF - Nigeria Social Insurance Trust Fund
PPP - Public Private Partnership
RCSHIS - Rural Community Social Health Insurance Scheme
SMOH - State Ministry of Health
SHI - Social Health Insurance
TISHIP - Tertiary Health Insurance Scheme
UNDP - United Nation Development Programmes
UNECA - United Nation Economic for West Africa
UCH - University College Hospital
WHO - World Health Organization
ABSTRACT
Background: This study investigated implementation and challenges of National Health Insurance Scheme (NHIS).
Objectives: The study examined the enrolees’ knowledge about NHIS, identified constraints encountered in implementation and assessed the level of enrolees’ satisfaction. Lapses in the scheme were also examined.
Method: A cross sectional research design with convenience sampling technique was employed and data were collected using questionnaire. A total of 400 questionnaires were administered and 387 were collected, giving response rate of 96.7%. A focus group discussion was also carried out among enrolees, health personnel and Health Maintenance Organization (HMO) workers. Data were analysed using descriptive and inferential statistics with the SPSS software version 22.
Results : Findings from the study revealed that the respondents were knowledgeable about NHIS and they were largely satisfied with the services. They opined that NHIS has made health care more affordable and accessible to them. All the respondents 387 (100%) agreed that NHIS was effective and 326 (84.3%) said the quality of drugs was good. However, most of the enrolees (80.6%) decried the long waiting time while (81.7%) complained about challenges in getting referral codes to the Obafemi Awolowo Teaching Hospitals Complex especially on weekends. It was suggested that critical units at the Health Centre who have not been operating for 24 hours should do so. These are, Laboratory, Medical Records and Radiography units.
Conclusion: Findings from the study indicated that there was delay in processing of NHIS cards and referral codes, long waiting time for patients before being attended to by health personnel, abuse of the scheme by patients through impersonation. Inadequate staff to cater for the patients was also noted. The results are anticipated to be informative for policy makers and researchers in OAU. Ile-Ife.
Key Words : National Health Insurance Scheme (NHIS), Health Maintenance Organization (HMO), Enrolees.
CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND TO THE STUDY
A well-functioning public sector that delivers quality public services consistent with citizen preferences and that fosters private market-led growth while managing fiscal resources prudently is critical in our contemporary society. A democratic system that is built on true checks and balances into government structures forms the core of good governance, helps in empowering citizens. The incentives that motivate public servants and policy makers, the rewards and sanctions linked to results help in shaping public sector performance. Sound public sector management and government spending help in determining the course of economic development and social equity, especially for the poor and other vulnerable groups such as women and the elderly. Many developing countries Nigeria inclusive, however, continue to suffer from unsatisfactory and often dysfunctional governance systems including malfeasance, inappropriate allocation of resources, inefficient revenue systems, poor healthcare management and weak delivery of vital public services. Such poor governance leads to unwelcome outcomes for access to public services by the poor and other vulnerable members of the society such as women, children, and minorities. Traditionally, public trust in public sector performance in delivering services consistent with citizen preferences is very weak in the developing countries, because the politicians and bureaucrats do show greater interest in rent-seeking activities than in delivering services wanted by their citizens. In the past several years many governments have restructured their public sectors in an attempt to deal with the twin problems of indebtedness and growing citizen disenchantment with government. In many jurisdictions, restructuring efforts have included an emphasis on the need to introduce a result based or performance-based approach to management in the public sector. Health insurance is a social security system that guarantees the provision of needed health services to persons on the payment of token contributions at regular intervals. The National Health Insurance Scheme (NHIS) is a corporate body established under Act 35 of 1999 by the Federal Government of Nigeria to improve the health of all Nigerians at an affordable cost (NHIS Decree, 1991). The NHIS Act is the statutory authority for the Scheme’s benefits programmes as well as general rules and guidelines for the operation of the Scheme. While the lack of funding, and rivalry of health workers persist.
Nigeria continually loses her professional to other countries. It was reported in 1986 that more than 1,500 health professionals left Nigeria to other countries. In 1996, UNDP report revealed that 21,000 Nigerian medical personnel were practicing in the United States of America and UK, while there was gross shortage of these personnel in the Nigerian health sector (Akingbade, 2006).
Health insurance scheme started in Germany in 1887 as a way of financing health care, followed by Austria 1897, Norway 1902 and United Kingdom 1910. By 1930, Health insurance scheme had been well established and recognized in all European countries (Okezie, 2001).
The concept of social health insurance in Nigeria started in 1962, when Halevi committee passed the proposal through the Lagos health Bill, unfortunately, it was truncated. In 1984, compelled by the desire to source more fund for health care services, the National Council on Health advised government on the desirability of health insurance scheme in Nigeria and proffered some recommendations. In 1985, the then Minister of Health (Olikoye Ransome Kuti) constituted a committee whose terms of reference included the responsibility of advising on the desirable, viability and acceptable model of health insurance scheme for Nigeria.
At the 28th meeting of the National Council on Health, another committee was setup on National Health Insurance Scheme in 1989. Prior to the moves, the Nigerian government had initially provided 'free healthcare' for its citizens funded by its earnings from oil exports and general tax revenue.
1.2 STATEMENT OF THE PROBLEM
Reports on Nigeria’s economic indicators by development agencies such as the United Nations Development Programme (UNDP), particularly on its poverty rate, put at 70 per cent, obviously because of the poor performance of the economy and service delivery in Nigeria, has been saddening. The 2009 Fund for Peace Report indicated that “about 54 per cent of the population in Nigeria lives on less than a dollar per day”, ostensibly because of what the United Nations Economic Commission for Africa (UNECA) claimed; in its 2009 report was the unsatisfactory performance of the economy. The Nigeria Social Insurance Trust Fund (NSITF) executes its mandate of delivering social security to the poor. With this indisputable fact, in Nigeria like most African countries, the provision of quality, accessible and affordable healthcare remains a serious problem. This is because the health sector is facing gross shortage of personnel, inadequate and out-dated medical equipment, poor funding, inconsistent policies and corruption. Evidence shows that, only 4.6 percent of both public and private Gross Domestic Product (GDP) in 2004 was committed to the health sector (WHO, 2007). Other factors that impede quality health care delivery in Nigeria include inability of the consumer to pay for healthcare services, gender bias due to religious or culture beliefs and inequality in the distribution of healthcare facilities between urban and rural areas. Accessibility to healthcare and at affordable cost constitutes a high profile challenge in Nigerian. While government supported universal access to health care through social policy such as National Health Insurance Scheme (NHIS), the operation of the scheme in addressing the health situation in the country require a holistic approach that every Nigeria should benefit from. However, there is steady decline in the standard of living and ethical values among Nigerians to the ever-widening income inequality, mass unemployment, pervasive poverty and social exclusion, low quality and inefficiency in service delivery.
WHO (2000), ranked Nigeria’s health system as 187th out of 191 World Health Organisation(WHO) member states with an infant mortality rate ranging from 500 per 100,000 in the south West geo-political zone to 800 per 100,000 infants in the North East Zone. In many developing countries, for instance, Nigeria, clearly lack universal coverage of health care and little equity. There is also non-availability of quality drugs which has caused NHIS enrolees to spend more than their 10% of their drug charges since they are compelled to purchase those drugs outside NHIS coverage and pay over 100% charges on drugs.
1.3 OBJECTIVES OF THE STUDY
The general aim of this study is to evaluate the implementation and challenges of National Health Insurance Scheme in Obafemi Awolowo University Health Centre Ile-Ife as a case study. To achieve this aim, the following objectives were set:
i. To assess the knowledge of enrolees about the scheme.
ii. To identify constraints under the scheme experienced by enrolees
iii. To assess the level of enrolees satisfaction with NHIS.
iv. To examine lapses in the scheme.
1.4 SIGNIFICANCE OF THE STUDY
It is expected that the study will be able to provide an important feedback to the relevant policy makers, operators of the scheme, health care workers and the Obafemi Awolowo University community. The outcome of the study will aid the operators of the scheme to curb wastages and abuse of the scheme.
Finally, it is expected that the study will give an insight with the management of the health centre to make informed decisions that will improve the level of satisfaction of the enrolees.
1.5 SCOPE OF THE STUDY
The study is limited to the NHIS enrolees at Obafemi Awolowo University Health Centre Ile-Ife. This study included all workers registered on NHIS in Obafemi Awolowo University Health centre Ile-Ife, Osun State. However, four hundred workers were sampled for the purpose of this study.
1.6 JUSTIFICATION OF THE STUDY
The NHIS in Nigeria like in other middle income countries has the potential to be a successful health financing model. In a nation of roughly 168 million people, available data shows that the scheme only provides cover for about 7 million people (NHIS, 2012b). In Nigeria, there is a past trend of ineffective implementation of government schemes (Agba et al ,2009). This has informed a general negative perception and attitude among the people towards such schemes regarding their success, effectiveness, and sustainability. The African Union (AU) Abuja declaration of 2001 recommended a budgetary allocation of at least 15% of the General Government Expenditure(GGE) to improve the health sector. This agreement has not been met by the Nigerian government and the proposed General Government Health Expenditures (GGHE) for 2012 is 6% (Presidency Nig, 2012). Governance has been lacking in implementing health sector and other social schemes, and funding the health system.
Research carried out in other developing countries shows that four out of five cases of bankruptcy are due to mounting or catastrophic health care bills (Gottret et al, 2008). High costs of medical care, especially when hospitalization is needed, are a burden that can tip individuals and their families into financial catastrophe (Xu et al, 2005). This is a situation that many similar socially and economically constructed countries like China, Taiwan, Chile, Brazil, South-Africa and near-by Ghana are taking concrete steps to eliminate through a well-structured healthcare financing system (Gottret et al, 2008 & Okma et al, 2010).
Nigeria, like these countries recognises health and access to health care as a fundamental human right and this must be translated into efficient and effective implementation of the NHIS. Fortunately, the NHIS has been launched with an operational guideline that clearly segments the population and outlines the implementation of the scheme for the different sectors. This is in keeping with the 2015 target for overall country development of the Millennium Development Goals (MDG) agreed to by all UN member states. MDG 4, 5 and 6 are directly linked to improved health care delivery and health systems (NHIS, 2010). Additionally, the scheme has been structured as a Public-Private Partnership (PPP) (PBC, 2003). The private sector in Nigeria is generally viewed favourably with visible success stories in oil and gas, telecommunications and banking. This thesis is a critical analysis of Nigeria’s health financing policies and the NHIS implementation in order to make recommendations to the government and key stakeholders. Achieving universal health coverage with the NHIS as a tool will ultimately improve the health situation of Nigerians.
1.7 RESEARCH QUESTIONS FOR THE STUDY
From the foregoing, this research work is set to answer the following questions:
Ø To what extent are the enrolees satisfied with drug in the NHIS?
Ø Do enrolees have knowledge of NHIS in Obafemi Awolowo University, Ile-Ife?
Ø Are there lapses in the scheme?
Ø What is the level of satisfaction of enrolees with the scheme in Obafemi Awolowo University, Ile-Ife?
Ø Are there constraints experienced by the enrolees under the scheme in Obafemi Awolowo University, Ile-Ife?
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1.8 LITERATURE REVIEW
Nigerians have always expressed lack of confidence in any programme or project owing to the experience with previous programmes in Nigeria. For example, in a study, Omar (2002) conducted to assess consumer’s attitude towards life insurance patronage in Nigeria, finding shows that there is a lack of trust and confidence in the insurance company. One major reason for their attitude is lack of knowledge about a life insurance product. Similarly, Enoch (2008) conducted a perceptive study of health care workers in Delta state. The findings also revealed that more than 90% said they have heard of NHIS but less than 15% could make any comprehensible description of how it could benefit the public or impact on their work, 70% don’t have faith in it and strongly believe that the leaders and champions of the initiative want to use it like other white elephant project to enrich themselves. Another 70% supported their belief on the basis that those with responsibility to implement the NHIS agenda actually receive health care service from abroad and the most equipped health care institutions in the country such as the University College Hospital (UCH) and in particular those run by oil companies.
The peoples’ notion gathered from the study portends a great level of dissatisfaction in Government project in Nigeria. This is attributed to the ways that previous projects turned out in the recent time. Sanusi (2009) report that respondents who have been treated under the program wanted it discontinued. This indicates that people have little hope in the program. They do not think that the program is worth keeping owing to the way that previous schemes and projects turned out in recent times. However, the study did not provide reason why the people wanted the scheme discontinued. Adeniji and Onajole (2010) did a study on perception of Dentists in Lagos state, findings showed that majority of them viewed NHIS as a good idea that will succeed if properly implemented and majority of them believed that the scheme will improve access to oral health service, affordability and availability of service. Onwekusi (1998) carried out a study to assess NHIS among Nigeria health care Professional workers in Nigeria. Findings showed that Nigeria health care professionals who are main stakeholders in the program have grossly inadequate knowledge of rudimentary principle of the operation of the social health insurance scheme. This study was however carried out on healthcare professionals who are also important stakeholders in the scheme. Dienye et al. (2011) conducted a study on the sources of health care financing among surgical patients in a rural Niger Delta practice on the issue of health care insurance knowledge and findings.
In a study conducted by Cafferata (1984) on knowledge of health insurance in America, findings revealed that among the population 65 years of age and above, knowledge about health insurance coverage is substantial, but generally lower than the population younger than 65 years of age. This implies that those who are likely to fall ill are more knowledgeable than those that are not likely to fall ill. A study in Canada by Broyles et al. (1983) on the use of national health insurance scheme revealed that the Medicare program has resulted in an equitable distribution of physician services. However, the focus of this study is on employee self-evaluation of their health status at the Obafemi Awolowo University Ile-Ife Osun State Nigeria.
1.