IMPLEMENTATION AND CHALLENGES OF NATIONAL HEALTH INSURANCE SCHEME

(A CASE STUDY OF OBAFEMI AWOLOWO UNIVERSITY HEALTH CENTRE)

By

Author

Presented To

Department of Computer Science

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

11 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

12 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 46 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

13 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

14 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

15 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

16 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

17 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?

18 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

19 CONCEPTUAL FRAMEWORK: THE NATIONAL HEALTH INSURANCE SCHEME

The importance of good health status cannot be overemphasized This is because health is essential to the preservation of the human species and organized social life (Zanden 1996) NHIS is one of the fastest growing Social organizations in the world (Dogomohamed 2010) and in Nigeria dates back to 1962 when the need for insurance was first recognized by Dr Majekodumi who was then the Health Minister Since then there have been different policies by successive administrations including the establishment of primary health care centres, general and tertiary hospitals ( Agba 2010) NHIS in Nigeria is modelled after the practice of health insurance in the United States of America and Britain (Ikechukwu and Chiejina, 2010) The general objective of NHIS in Nigeria is to ensure the provision of health insurance “which shall entitle insured persons and their dependants to the benefits of prescribed good quality and cost effective services” (NHIS Decree No 35 of 1999, part 1:1) While the specific objective of the scheme include:

i The universal provision of health care in Nigeria

ii To control/reduce the arbitrary increase in the cost of health care services in Nigeria

iii To protect families from the high cost of medical bills

iv To ensure equality in the distribution of health care service cost across income groups

v To ensure high sector participation in healthcare delivery to beneficiaries of the scheme

vi To boost private equitable sector participation in health care delivery in Nigeria

vii To ensure adequate and equitable distribution of healthcare facilities within the country

viii To ensure that, primary, secondary and tertiary health care providers are equitably patronized in the federation

ix To maintain and ensure adequate flow of funds for the smooth running of the scheme and the health sector in general (NHIS Decree No 35 of 1999, part II: 5 NHIS, 2009

It is contemplated that the health care providers under the scheme shall provide the following benefits for the contributors The contributors to the scheme are expected to enjoy the following benefits under the scheme Outpatient care, including necessary consumables; prescribed drugs, pharmaceutical care and diagnostic tests as contained in the national essential drug list and diagnostic test lists; Maternity care for up to four live births for every insured contributor/couple in the formal sector program; Preventive care, including immunization, as it applied in the national program of Immunization, Health Education, Family planning, antenatal and postnatal care; Consultation with specialists, such as physicians, pharmacists paediatricians, obstetricians, gynaecologists, general surgeons, orthopaedic surgeons, ENT Surgeons, dental surgeon radiologist, psychiatrist, ophthalmologists, physiotherapist etc Hospital care in a standard ward for a stay limited to cumulative 15days per year Thereafter the beneficiary and/or the employer pay However, the primary provider shall pay per diem for bed space for a total 15 days cumulative per year; optical examination and care, excluding the provision of spectacles and contact lenses; a range of prostheses (limited to artificial limbs produced in Nigeria) and Preventive dental care and pain relief (including consultation, dental health education, amalgam filing, and simple extraction) Nigeria which is comprised of 36 states and the Federal capital territory FCT as well as the 774 Local Government Area (LGAs) has a Federal structure that has shaped health delivery in Nigeria There are also three tiers of government that are involved in health care delivery and organization The provision of healthcare is a concurrent responsibility of the three tiers of government in Nigeria All the three tiers of government are involved in the healthcare delivery organization, management, and financing

Despite the efforts of the Nigeria’s health care system to widen health services, and offer satisfactory health care services, health status of the vast majority of the citizens remain a major problem Nigeria’s overall health system performance is reported to be ranked 187^th among the 191 member states of the UN The 2006 MDG report of the country indicates that the country is still struggling to meet the MDG health goals (NPC 2006)

Many studies have argued that inadequate resources are one of the main reason for the low health status of Nigerians and this could also explain the regional variations in health status It is therefore not surprising that the health outcomes in the country vary across the geopolitical zones of the country For instance, the total fertility rate for the country is 57 in 2008, 65 and 43 in the Northern and Southern parts of the country respectively, the same disparities exist in child nutritional indicators According to 2007 multiple indicator cluster survey (MICS), 83percent of children was underweight while 194 were stunted These are indications that the differential development in the two locations might not be unconnected Demographic Health Survey (DHS) that provide information on a wide range of indicators in the areas of population, health and nutrition, findings suggest that the introduction of the NHIS has a positive and significant effect on utilization of health care services In particular, findings show that being enrolled in the NHIS positively affect the (a) probability of formal antenatal check-up before delivery (b) the probability of delivering in the institution and (c) the probability of being assisted during delivery Whereas the American system of health care delivery is not evenly distributed geographically, the existing health care delivery system is a conglomerate of health practitioners, agencies and other institutions The health insurance coverage in US for persons aged 65 and over is by Medicare while the remainder of the American population under age 65is provided by private insurance and paid for by the individuals, the individual employer or by some combination thereof The program that currently exists includes health insurance, old age pension, sickness benefits for income loss to illness or injury and unemployment insurance in the form of an allowance for children By contrast, the health care delivery in the Federal Republic of Germany is organized around three principle components – (i) compulsory insurance, (ii) free health service, (iii) sick benefits The German government does not play a major role in the financing of health services The government primary function is one of administration The federal ministry of labour and social affairs exercise general supervision of the health care board Sweden does not have a National insurance policy but has a National Health Service that is financed through taxation In Great Britain, Business of New Hampshire (BNH) Services which was founded in 1948 caters for the health needs of the citizens by funding the hospital facilities employing health workers through the use of funds collected by taxation Health services are essentially free to those who use them

Despite the efforts of the Nigeria’s health care system to widen health services, and offer satisfactory health care services, the health status of the vast majority of citizens remains the major problem Nigeria’s overall health system performance is reported to be ranked 187^thamong the 191 UN member states (Wikipedia 2006)

Despite all the short-comings in health sector and health financing reforms, the NHIS received a push and was launched in 2005

THE LOGO OF NATIONAL HEALTH INSURANCE SCHEME IN NIGERIA

Fig 1: NHIS logo

Source: wwwnhisgovng

The first core objective of the scheme is to ensure access to healthcare for all Nigerians A closer look at the NHIS logo (fig1) reveals the following “NATIONAL HEALTH INSURANCE SCHEME, EASY ACCESS TO HEALTHCARE FOR ALL” This is the ultimate goal of the scheme in a summary form Embedded in the core objective are the benefits the Healthcare Consumer (HC) is entitled to which include the followings:

(a) Defined elements of curative care;

(b) Prescribed drugs and diagnostic test;

(c) Maternity care for up to four live births for every insured person;

(d) Preventive care, including immunization, family planning, ante-natal and post-natal care;

(e) Consultation with defined range of specialists;

(f) Hospital care in a public or private hospital in a standard ward during one’s stay for physical or mental disorders;

(g) Eye examination and care, excluding tests and the provision of spectacles and

(h) A range of prosthesis and dental care as defined

In addition to these benefits, the Health Management Organizations (HMO’s) under the scheme also have the obligations of maintaining ethical marketing strategies, and putting in place effective quality assurance systems for quality service delivery to the healthcare consumers, (Awosika, 2005)

THE STRUCTURE OF NHIS IN NIGERIA

Table 1 : Classification of NHIS Programmes

Source: NHIS Hand book 2006

The National Health Insurance Scheme (NHIS) is a social health insurance programme established to aid healthcare financing in Nigeria Table 1 above shows the various groups in the scheme The formal or organized sector covers the public sector, organized private sector, the armed forces and students of tertiary institutions The informal sector includes the rural community and urban self-employed while the vulnerable group includes the permanently disabled, children under 5 years of age and prison inmates Others would include international travelers, pregnant women and orphans as well as retirees and the unemployed The scheme took off in the formal sector in 2005 Until its commencement, the cash-and-carry system was the only available option With the many shortcomings of the pay-as-go system, the Millennium Development Goals’ (MDG) health-related goals were at the risk of failure NHIS was then established to bridge the healthcare financing gap that existed in the country

191 SOME DEFINITIONS OF SERVICE

A service is any activity offered one for which the offeror or recipient reciprocates by offering equivalent value mostly in monetary terms The recipient pays money or anything else that has value to the service giver Many definitions have been put forward by both local and international scholars Osuagwu in Akalabu et al (2002) defined service as any activity or benefit that one can offer to another which is essentially intangible and does not result in ownership of anything Kotler and Keller (2006) defined a service as “any act or performance that one party can offer to another that is essentially intangible and does not result in the ownership of anything” Lamb et al (2000), on their own part described a service as the outcome of engaging human or mechanical efforts to people or objects They further stated that services involve a deed, a performance or an effort that cannot be physically possessed From the foregoing descriptive definitions, we conclude that a service is an act performed by man or machine which removes discomfort or creates an environment or situation conducive for a particular system, human or machine to function according to desired objectives It is the creation of intangible satisfactions

192 CHARACTERISTICS OF HEALTHCARE SERVICES

Healthcare services have four major points of departure from products called characteristics These include intangibility, inseparability, variability and perishability Many authors are unanimous in these respects HC service intangibility deals with the fact that services though enjoyed and paid for are not physical that one can see, feel or smell In other words, services do not appeal to the sense organs This does not mean that service outcomes are not enjoyed; it is the performance that is intangible HC service intangibility makes it difficult to store them or take a patent on them Price, especially, for new services is not easy to set Surrogate branding is done because services cannot be displayed

HC services also have the characteristics of being inseparable from the service giver This means the contact level in service delivery is very high A medical surgery service cannot be done without the recipient coming in contact with the man or the machine that will perform the act

HC service variability also known as service heterogeneity is a third characteristic that makes the service standardization almost impossible Some quality cannot be assured especially if the act is a pure service like in the case of healthcare But in product or machine-based services like inflation of an automobile tire, there could be a measure of quality assurance A barber who gave a wonderful and beautiful hair cut last month can produce a dismal outcome this month to the point of serious misunderstanding with his customer

HC services are also perishable This makes it impossible for them to be inventoried Imagine containers of doctor’s consultation on a supermarket shelf? Where services can be stored, it is now the product that contains those acts or performance of value that becomes the point of attraction, for example a musical VCD is a product The VCD is not bought for its sake but for the music This represents the case of product-based services In the case of pure, human-based services, they are perishable thereby making it compulsory for production and consumption to be simultaneous

The four service attributes identified above also characterize NHIS services They need high contact between the patient and the medical personnel They are variable because service outcomes by the same medical personnel may differ to a lesser or a greater extent depending on the mood of the contact staff The more serious issue is the fact that these services cannot be stored The worth of medical consultations, for example are time-relevant

193 CLASSIFICATION OF HEALTHCARE SERVICES

As it is with products, HC services can be classified using a number of criteria A HC service may be equipment or people-based when we are using degree of labour intensiveness It is equipment-based when equipment is the major dispenser of service On the contrary, it is people-based when more of human effort is involved in dispensing the service An automated service, like the one rendered by medical scanning is machine or equipment-based Medical consultations rendered or dispensed by a Gynecologist or an Obstetrician is people-based It is labour-intensive

Another criterion for HC service classification is the degree of customer contact High customer contact services require the physical coming together of the customer and the service provider Medical services like physician’s consultation and treatment are a good example of high customer-contact service On the other hand, is the low customer-contact service like drug prescriptions which can be delivered to a customer mile away with the aids of advanced technology such as the internet Online medical consultations are quite common today Professional and non-professional HC services are based on the skill of service provider – thus we have skilled and unskilled services Skilled services are provided by skilled or highly trained personnel like gynecologists, obstetricians and midwives, etc Unskilled services are provided by personnel who need no specialized training to dispense the service The category includes the services of auxiliary nurses, cleaners, launders and night guards’ services

Another criterion used in classification of HC services is with respect to the goal of the service provider Here, we have profit and non-profit oriented services Services of chartered firm of accountants or marketing consultants are profit-oriented services whereas legal counsels given by Legal Aids Council are a non-profit oriented service Medical services provided by Government Hospitals are non-profit while those provided by private medical practitioners are profit-oriented service Services which are meant for the final consumer are distinguished from those meant for the industrial user End-user services include healthcare services dispensed to individual enrolees of the National Health Insurance Scheme (NHIS) Such other services are barbing, nail cutting, repair of home electronics like VCD players, TV sets and dish-washers to mention just a few These same services will be regarded as industrial services if they are provided by an organization that renders catering and lodging services One may also add online and offline services depending on whether it is dispensed through the internet or by a face-to-face contact The list continues Pride and Ferrell (1987) noted that a company’s offering would include both goods and services which could be displayed on a continuum of product tangibility and intangibility

194 HEALTHCARE SERVICE QUALITY AND QUALITY MANAGEMENT

Earlier expose in this chapter showed that services differ from products in respect of intangibility, variability, perishability and inseparability These same characteristics also account for the difficult in defining and measuring service quality Research evidences show that customer service quality can be evaluated in five ways, viz reliability of service, responsiveness of service provider, assurance of service provider; empathy displayed towards the customer and tangibles, the physical evidence of service quality, (Zeithaml and Bitner, 1996) Reliability is one HC service quality element that is of major concern to the consumer A HC service is considered reliable if the act can be performed accurately, consistently and dependably It means performing the act right at the first time and at all times Personal beauty and healthcare recipients value this element most

A high quality HC service must also be responsive Customers’ expectations are high with respect not only to price and quality but also to time Ability to meet up with time expectations makes a HC service provider responsive Emergency cases in a healthcare Centre should not observe the bureaucratic rules A customer is aching or hungry To be responsive means that the HC service provider will attend to his patients with all urgency Assurance deals with skill, the ability and the courtesy of the service provider The medical personnel of a healthcare outfit must not only be competent, but must also be seen to be so The service provider must also be in the position to imbue trust in the customer Respect for enrolees and their opinion as well as confidentiality are important to quality assurance in HC services marketing The “heart-to-heart” signs seen in health centres and hospitals as one travels by convey confidentiality in handling HIV/AIDS cases

Individualized care and attention given to service recipients is proof of empathy in service Recognition of individual patient’s needs is a measure of diligent concern and interest a service provider has in his patients A story is told of Yoidoo Gospel church headed by David Yongi Cho The church has a data base for all his members It is said that before a member comes to see the leader, the secretary would have transferred the data of that member to Yongi Cho showing the names occupation, spouse name, children’s names, sexes, age and all person-specific data

By the time the member enters the pastor’s office, he/she is greeted with his/her first name Inquiries are made about the spouse and or the children by their names! No member would want to leave an assembly where diligent where care and concern are displayed Empathy dictates that service providers should of necessity realize that no two enrolees’ needs are the same This means individualized or customized services lends additional credence to service quality The last component of service quality is tangibles The only evidence of service quality available to prospective HC consumers is the physical evidence-the things that one can see It is very hard to think of an institution where image and reputation matters more than in the service industry According, to Nebo, (2005) service institutions like financial institutions with rickety vehicles and buildings, poorly-dressed and underpaid staff, obsolete equipment, sour-faced staff have already shown the enrolees evidences of an ailing institution, and we add that these are surrogates to low brand equity anywhere they are found

110 OPERATIONAL GUIDE-LINE OF NHIS

In order to ensure that every Nigerian has access to health care services, the Nigerian government deemed it necessary to commence a NHIS The NHIS was established under decree no 35 of 1999

The NHIS is designed as a Social Health Insurance (SHI) programme; its aim is to provide easy access to healthcare for all Nigerians at an affordable cost through various pre-payment systems The strategy of the NHIS segments the entire population into formal and informal sectors, vulnerable groups and others The scheme is expected to provide financial access to good quality health care via multiple programmes The scheme is a Public Private Partnership (PPP) and the NHIS accredits privately owned Health Maintenance Organization (HMOs) to operate nationally and also regionally (in the 6 geo-political zones) The NHIS also accredits a mix of public and private health care providers to provide health care at primary, secondary and tertiary levels Enrolees are free to choose any accredited primary provider as first contact for obtaining care Secondary and tertiary levels of care are only accessed via referrals from the primary level (NHIS decree no 35 of 1999) There are presently 62 accredited national and regional HMOs and 5,949 accredited providers (public and private) (NHIS, 2012a) The HMOs deal directly with the health care providers as fund and quality assurance managers for enrolees; the government regulates all activities of the scheme The NHIS programmes aimed at different segments of the society are summarized below

Table 2

Source: NHIS Operational Guidelines May 2005

111 CURRENT IMPLEMENTATION OF THE NHIS:

In 2005, the NHIS was officially flagged off with the formal sector programme which aims to provide Social Health Insurance (SHI) coverage to all workers in the civil service (public sector, armed forces, police and other uniformed services) and the organized private sector The states (except Bauchi, Rivers and Cross-Rivers) however did not immediately embrace the scheme (Asoka, 2011) The formal sector SHI scheme being implemented is funded by pay-roll deductions, and the NHIS is currently responsible for collection of funds The payroll deductions are proportional and theoretically comprise employer = 10% of basic salary; employee = 5% of basic salary Notably, at the roll-out stage, the government waived the initial 5% which was to be contributed by the employee, and the NHIS commenced the programme with the 10% of basic salary provided by the federal government ie the employer (NHIS, 2012a) Till date, this is how the scheme is being funded due to widespread resistance from the NigerianLabour Congress (NLC) to have the 5% employee contribution deducted for the scheme, citing widespread poor salaries and non-inclusion in decision-making (Asoka, 2011)

In addition, the joint NHIS/MDG-Millennium Development Goal, maternal and child health (MCH) project was piloted in phases over 3 years (2008 – 2010) in 12 states It is being expanded nationwide to provide care for pregnant women and children less than 5 years (CU5) only up till 2015 and is presently funded by the MDG debt relief funds Beyond 2015, the state governments are required to incorporate the project into state funded SHI programmes (Briscombe & McGreevey, 2010) Other methods of revenue collection are yet to be designed to fund the scheme for the informal sector, vulnerable and other groups

In 2011, blueprints for the Tertiary Institutions Social Health Insurance Programme (TISHIP) and voluntary participants SHI schemes were launched to complete commencement of the formal sector programmes The target populations are students of higher schools, the urban self-employed sector and any interested individuals, including those in the formal sector contributing on behalf of their dependants in the informal sector Some tertiary institutions have commenced the TISHIP but the voluntary participants’ scheme has not progressed beyond the blueprint phase (NHIS, 2012a) Some states have initiated donor and state-funded community health insurance pilot schemes (Uzochukwu et al, 2009) In addition, fractions of the organized private sector subscribe for direct premium-based voluntary private health insurance schemes with the HMOs (Asoka, 2011)

112 HISTORY OF HEALTH FINANCING IN NIGERIA

The WHO has described the health system in terms of six building blocks which include: financing, service delivery, health workforce, governance, medicines and information (WHO, 2007) The Nigerian health system is decentralized by devolution into the federal, state and local government levels Health care providers use modern or traditional (including faith healing) methods of health care delivery Nigerians seek care from these providers, at times doing so concurrently (WHO, 2010b) For clarity, this section will focus on the health financing history of modern health service delivery Adequate health care has been recognized as a right and not a privilege, and ideally should be provided for Nigerians by the government based on need and not the ability to pay Historically, health financing options for Nigerians has been fragmented and several attempts at health financing policy reforms have been made over the years These reforms culminated in the formal launch of the NHIS in 2005 The scheme commenced with the formal sector SHI programme, and informal sector programmes are yet to fully commence

1121 Health financing in colonial and pre-independence era:

The 1st Nigerian colonial development plan in 1946 regionalized the health system and lasted into the 1950s (Asuzu, 2005 & Orubuloye, 1996) Most public hospitals provided cost-free care for civil servants and their dependants while parallel church-owned hospitals provided care for the most needy in this period

1122 Health financing from 1960 to 1988:

Immediately post-independence in 1960, the 2nd and 3rd national development plans (by the 1970s) focused on building and expanding modern health facilities No defined policy framework designated responsibilities including resource generation, development of human resources for health and service delivery between the three levels of government Cost-free, tax-based care continued for all Nigerians under 18 years, civil servants and their dependants with subsidized services for the rest of the population till 1984 (Asuzu, 2005 & Orubuloye, 1996) Continuing attempts at improvement include the UN sponsored Bamako initiative of 1987 (Hardon, 1990), and introduction of the drug-revolving fund in 1988 (Uzochukwu, 2005) These two schemes achieved little success and government allocation of resources to the health sector dwindled in this period, ranging between USD 42-62 cents per capita or 16–19% of the Global Expenditures (GE) Orubuloye, 1996) This led to a rise in the general cost of health care and a decline in the quality of care offered by public hospitals The private sector responded with a proliferation of hospitals and clinics and their charges were mostly exorbitant and out of reach of the poor and low income earners (Abdulraheem, 2012)

1123 Health financing beyond1988:

Health for all (HFA) by the year 2000 was declared at Alma Ata in 1978 by WHO member states, and the Nigerian government began making concerted efforts to achieve this by 1988 (Asuzu, 2005 & Orubuloye, 1996) Attaining the goal of HFA was anchored on improving primary health delivery The National Commission on Health (NCH) was established and it developed a National Health Policy (NHP) which made resource allocation a major focus The NHP led to the adoption of a National Health Accounts (NHA) framework which is an internationally accepted tool for analysing health financing at various levels of governance and capturing a nation’s expenditure on health The framework is useful for improving health system performance by supporting stewardship and the decision-making process with the financing structure of the health sector Even when health services are provided free at the point of service to the general population, there is always a cost attached to it which is borne by someone, somewhere In order for NHAs to be useful for health financing policy making, countries must utilize accurate, complete and consistent data in producing it International standards and definitions should be adhered to in order for the NHAs to be useful for comparison with other countries (Soyibo, 2005 & Soyibo, 2009) In 2001 the AU Abuja Declaration recommended that member countries allocate 15% of the GGE to health In 2012, GGHE as a percentage of GGE is 6% and Nigeria is yet to live up to the declaration In 2009, the global average of the GGHE as a percentage of THE was 408%, the highest being 999% and the lowest 82% With a below average rate of 351%, Nigeria was 141 out of the 163 countries ranked (WHO, 2012) Prepared annually, NHAs provide information on health care financing, how much is allocated to purchasing goods and services, who is providing the services, and who is paying for the services

113 HEALTH SECTOR AND HEALTH FINANCING POLICY REFORMS IN NIGERIA

The Nigerian health system has been chronically underfunded since independence The health system competes with other social service systems like power, education, transportation, security, the environment and servicing of external debts Public financing of healthcare in Nigeria has faced several challenges including lack of political will, corruption, poor institutional capacity, lack of data on health status and utilization Other challenges include unstable political and economic climates (Soyibo, 2005 & Soyibo, 2009) The beginning of the 21st century witnessed several renewed attempts of successive governments at health sector and health financing policy reforms

1131 Health Sector Reform Policy Programme (HSRPP) :

The federal government in 2004 committed to a sustained process of health system strengthening, focusing on policies, regulation, improved financing,