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Abstract

The difficulties encountered in out of pocket financing of healthcare have compelled the introduction of pre paid health insurance in many countries, including Nigeria. This is borne out of a universal and equitable healthcare cover as a fundamental human right. This initiative works on pooling of resources. This study assessed the utilization of National Health Insurance Scheme among healthcare providers working at University of Nigeria Teaching Hospital, Ituku-Ozalla. Descriptive survey design quantitative was used. Five objectives were set,viz: to determine the number of healthcare providers registered, determine the number that  are card holders, assess access to benefit packages, determine the number of the respondent’ dependents registered and are assessing the benefits and identify the challenges encountered by the beneficiaries. A population of 311 who met the inclusion criteria were selected using power analysis. A self structured questionnaire was used for data collection. A pilot study was carried out with a reliability index of 0.83 after face and content validation..frequencies, percentages and chi-square were used for descriptive and inferential statistics for data analysis. Findings revealed that 50.3% of the respondents have partial knowledge of the principles of the scheme, did not know the percentage they contribute and that of the employers. It was also observed that majority of the respondents (83.6%) were registered with the scheme, but the number of the registered dependents did not tally based on the marital status of the respondents (70% as against 55.9%). This showed that the respondents do not have confidence in the scheme. Furthermore, some of the respondents were not registered, where registration is supposed to be mandatory and their money is collected at source. Some of the registered beneficiaries do not have identity cards with which to access healthcare. The waiting period for the cards was quite lengthy as 34.0% indicated one year and above, while 5.5% indicated that they obtained their cards within the normal 30 to 60days. The respondents were not accessing healthcare services as and when due. There were a lot of challenges identified like delay or denial of healthcare services, provision of low quality drugs, non accessibility of Health Maintenance Organization (HMOs), especially out of pocket expenditures. In conclusion, the mandatory registration is not enforced. In recommendation, there is a need for multiplication of Health Maintenance Organizations for primary healthcare providers, in order to give the beneficiaries the room to make informed choices, also seminars and workshops should be organized to update the employees on the principles guiding the utilization of the scheme.

CHAPTER ONE

INTRODUCTION

Background to the Study

Health insurance as a health care financing mechanism has become a sought after approach to the problem of financing healthcare all over the world. The current concern with financing, and the specific interest in health insurance is often the result of the parallel trend; the recognition of basic healthcare for all citizens as a fundamental human right on the one hand, and the difficulties faced by the governments in developing and maintaining resources to provide health care through general taxation revenue on the other (Ron, 2006). World Health Organization (WHO) has been giving tremendous support and cooperation to nations that pursue their citizen’s welfare through health insurance. Nations equally are channelling large chunk of their budget to the attainment of good health for their people, (Kupferman& Ron 2007).

 

Several approaches abound in financing healthcare, ranging from fee for service, general taxation, community financing, loans and grants, Bamako initiative, User-fee and Drug Revolving funds. All these were attempts to address the precarious and dismal situation in health sectors and to provide universal access to quality healthcare services in the country. According to WHO (2010), NHIS is one of the health financing approaches with a strong potential for sharing risks across population and time. NHIS implies that everybody should be able to access quality health services without being subjected to financial hardship in the process.

Health insurance can be categorized as social health insurance and private health insurance. Where a system is financed by compulsory contributions mandated by law ortaxes and the system is specified by legal status, it is government or social health insurance plan. On the other hand, private health insurance is usually financed on a group basis but most plans also provide for individual policies, (Agade-Amade, 2006).

According to Carrin, Kirigia, Matheur, Doetinchem and Musango, (2008), NHIS was launched in Kenya in 1966, oldest in Sub- Saharan Africa. Revenue was collected through a payroll tax paid by employees. In Tanzania, it was launched in 2001, with a contribution of 6% split between the employers and employees. In Ghana, it was launched in 2005, predominantly financed from taxation. In Nigeria, the rising cost of healthcare services as well as the inability of the government health facilities to cope with the people’s demand necessitated the establishment of National Health Insurance Scheme, (NHIS). The start of the NHIS dates back to 1962 when the need for health insurance in the provision of health care to Nigerians was first recognized, (Akande and Bello, 2002,Kabiti and Akande, 2003). It was fully approved by the Federal Government in 1997, signed into law in 1999 and launched officially on the 6^th June 2005. The scheme is designed to provide comprehensive health care delivery at affordable costs, covering employees of the formal sector, self employed, rural community as well as the poor and the vulnerable. There cannot be healthcare services without the healthcare provider such as nurses, radiographers, pharmacists and so on, who influence both the quality and cost of healthcare through their influences on the nature and quality of treatment required, hence the place of healthcare providers cannot be overemphasized. (Onuekwusi, 2008).

Generally, insurance is expected to increase the intensity of utilization and reduce out of pocket spending, (Eknam, 2007). However in Nigeria, since the NHIS was established, not much has been carried out to investigate utilization and accessto quality healthcare, especially among healthcare providers, (Ibiwoye&Adeleke, 2008).After nine years of NHIS existence in Federal teaching hospitals in Nigeria, opinions are polarized amonghealthcare providers on the efficacy of the scheme in addressing the health problems in the country, because of the disheartening reports. Also health insurance has not been considered and promoted as the major financing mechanism to improve access to health services as well as to provide financial risk protection, as there more than 65% of     healthcare     financing     comes     from    household     out     of    pocket     payments, (Onwujekwe,2005). Inabilities of the consumers to pay for the services as well as the health care provision that is far from being equitable have been identified among other factors to impose limitation on utilization of NHIS. (Sanusi and Awe 2009).It is the opinion of the Nigerian government that the National Health Insurance Scheme will probably solve the problem of inequality in the provision of health care services and help improve accessibility to health care which are yet to be met. (Ibiwoye&Adeleke 2007).According to Sanusi and Awe (2009), respondents who have been treated under this scheme wanted the programme discontinued. This indicates that people have little hope in the programme.According to Wahab (2008), the ten stated objectives of implementation of the scheme which are equity, risk equalization, cross subsidization, ownership, partnership, quality of care, solidarity, efficiency, community or subscriber, reinsurance and sustainability have not been met.This study will provide a preliminary assessment of the scheme as well as inform its development, because in the long term, the investment costs in the NHIS will be justified only if it is able to increase the cost effectiveness of purchasing and the responsiveness of the system as a whole. It is obvious that Nigeria will get to 2015 without a significant change in health status of her citizenry which is part of the Millinieum Development Goals which the government is committed to thereby not achieving the aim of National Health Insurance Scheme. Consequently, this study will be carried out to assess the utilization of NHIS among healthcare providers, with a view of bringing out ways of improving on accessing healthcare services equitably and affordably. 

Statement of Problem

Garshong,Ansah, Dakpallah, Huijts and Adjei (2011) reported that informal payment were rare in the years before the scheme was introduced, with user free collection closely controlled at health facility level. But recently informal payment has increased. In Nigeria, NHIS was conceptualized with the major aim of improving access and equity in health care delivery, but the scheme has suffered a long lag between conception and implementation. This is due to the opposition by health care providers and health administrators owing to misconception and inadequate knowledge of the principles of health insurance (Onuekwusi 2008). Osuorji (2006) also stated that the high level of awareness of the existence of the scheme is not translated into participation. The trend is the same among healthcare providers who take care of NHIS registered patients in NHIS accredited health facilities, but do not utilize the benefit packages such as free childbirth up to four live children, laboratory investigations, treatment of ailments and so on. This may be because they lack interest on the scheme, which could be due to limited enlightenment or non-charllant attitudes on the part of the workers. Observation based on information revealed that the NHIS accredited health facility  have no equipped and spacious offices or consulting rooms and beneficiaries are asked to stand out a long hour before services are rendered to them.This situation havelead to discouragement on the part of the beneficiaries, increasing out of pocket expenditures on the part of healthcare providers.

Furthermore, there is inadequate management of the scheme, where only one Health Maintenance Organization takes care of all the beneficiaries registered under a primary healthcare provider like University of Nigeria Teaching Hospital, Ituku- Ozalla. The researcher was a victim of deprivation of healthcare services when her son was taken to the hospital for a tooth extraction. The Health maintenance organization incharge of the primary healthcare provider could not be accessed to approve the authorization letter for the said procedure leading to out of pocket expenses on the part of the beneficiary. This may discourage participation in the scheme and healthcare providers are no exception.

Membership of the scheme which is supposed to be legally mandatory, however in practise is optional as the number of card holders are less than the non-card holders(Mclnytre, Doherty & Gilson 2003).Observation based on information revealed that some of the healthcare providers are reluctant to register while some were denied registration.This is due to the fact that some lack interest due to lack of awareness and inefficient operation of the scheme and would like the scheme to be discontinued.Owing to all these outstanding problems facing utilization of NHIS among healthcare personnel working in UNTH, Ituku-Ozalla, this study was carried out to help bring out solutions so as to bridge the existing gap.

Purpose of the Study

The aim of this study is to assess the utilization of National Health Insurance Scheme amonghealthcare providers working at UNTHItuku-Ozalla.

Objectives of the Study

This study sought to:-

• Determine the number of healthcare providers registered with National Health Insurance scheme.
• Determine the number of healthcare providers that are card holders.
• Assess whether healthcare providers access the benefit package of NHIS
• Determine whether healthcare providers’ biological children accessNHIS benefit package.
• Identify the challenges that beneficiaries experience in the use of the scheme.

Research Questions

1. How many healthcare providers are registered with NHIS?

1. How many healthcare providers are card holders of the scheme?

2. Do healthcare providers access the benefit packages of NHIS?

3. Do the biological children of the healthcare providers access the benefit package of NHIS?

4. What challenges are experienced by the beneficiaries of the scheme?

Hypotheses

The following null hypothesis tested at 0.05 level of significance were established to guide this study.

HO1:  There will be no significant relationship in the utilization of NHIS (registration) between male and female beneficiaries.

HO2: There will be no significant relationshipbetween educational qualifications of respondents and the utilization of NHIS, (registration of dependents).

HO3: There will be no significant relationship between years of experience of the respondents and the utilization of NHIS, (owing of ID cards).

HO4: There will be no significant relationship between professional status of respondents with the utilization of NHIS, (accessing NHIS package).

 

Scope of the Study

This study is delimited to assessing the utilization of NHIS among healthcare providers working at UNTH Ituku-Ozalla. These include the nurses, physiotherapists, medical laboratory scientists, radiographers and pharmacists. It is also specifically delimited to assessing coverage, beneficiaries’ and dependents assess of the benefit packages of the scheme, challenges encountered in the use of the scheme.

Significance of the Study

This study will  serve as a guide and an eye opener to beneficiaries on utilization of benefit packages of the scheme with regards to healthcare services accessible to them. Having an insight will help in correcting misconception, thereby encouraging them.

The findings from this study will expose some of the challenges experienced by the beneficiaries, if utilized by the managers of the scheme will help them re-strategize better when rolling out another phase of the NHIS component.

The findings will expose the number of staff and dependents registered, this will guide the primary health care providers on their choice of health maintenance organizations (HMOs). This will also help in determining the number of HMOS needed to cover the services of the scheme in their establishments.

It will also go a long way in the utilization of the fund (capitations) generated from the scheme in provision of both health care services and infrastructure in their institutions. The findings from this study will be of importance to the Federal Government of Nigeria in determining the level of achieving the Millennium Development Goal 4&5.

Finally, findings from this study will add to the already body of existing knowledge on the principles guiding the scheme.

Operational Definitions of Terms

Beneficiary of the scheme- An individual, a spouse and four live children registered  with NHIS and has a card and registration number which he/she uses to access treatment or other benefit from the scheme.

Utilization of the benefit package – this implies a state when a registered member of NHIS have access to free healthcare services as stipulated in the working guide of the scheme. The beneficiary is further entitled to have an identity card with which to access free healthcare, free consultation, drugs and investigations except those under exclusion list. The user is further privileged to register a spouse and four biological dependents.

Challenges to utilization – these are some of the barriers to use of the approved benefit packages like delay or denial in accessing healthcare services. This may further involve not collecting prescribed drugs or investigations. Non equipped offices for NHIS personnel and so on.

Out of pocket expenses – this is the money paid by a registered member of NHIS in the course of accessing healthcare services, which is not expected to be paid. This is because being a registered beneficiary, fee for services has been withdrawn from the person’s salary at source.

Benefit package – this includes all the healthcare services that a registered, card holder member of NHIS is entitled to receive upon presenting himself or herself. This is so because the beneficiary has already contributed 5% of the basic salary, which is taken every month. This includes free consultation, deliveries up to four live babies, drugs except chemotherapy, laboratory investigations except some that are in exclusion list and so on.