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CHAPTER ONE

INTRODUCTION

 1.1 BACKGROUND OF THE STUDY

Social Health Insurance (SHI) is a health sector financing alternative to the cash-and-carry system that had been in operation in the past. The health burden in countries world over has continued to escalate. The most vulnerable are the poor while the wealthy are the healthier. This means that whereas the economic statuses of the poor could not accommodate their health needs, the wealthy seem to spend less (in percentage terms) of their income on healthcare needs. One of the basic principles of the World Health Organization (WHO) in the 1946 constitution states that “the enjoyment of the highest attainable standard of healthcare is one of the fundamental rights of every human being without distinction of race, political belief, economic or social condition” (WHO, 2006). This declaration brought to the fore one of the greatest challenges of governance in this century. It puts on governments the burden of creating and maintaining a healthcare system that will ensure complete physical, mental and social well-being of their peoples. The responsibility of establishing, financing and sustaining a high profile health system that can facilitate the accomplishment of this noble obligation by governments has never come easy anywhere in the world. These challenges coupled with the fact that national growth is a function of the wellness of the citizens, led Emperor Otto Vo Bismark of Germany to enact a mandatory law on “sickness funds” in the year 1883, (Awosika, 2005). This “sickness funds” is what has metamorphosed into what is called Social Health Insurance (SHI) in almost all the countries of the world today.

Japan enacted her own insurance law in 1922 (Ijeomah, 2005). In Britain, the National Health Service Act of 1946 which went into effect in 1948 provided a socialized health care system for all citizens because “citizens were deemed to have a right to free health care regardless of income”, (Microsoft Encarta, 2006). By 1970 s, nearly all urban Chinese population and 85% of ruralites had been covered by one form of health insurance or the other, according to World

Bank Report, (Zhu et al, 2008). The National Health Insurance Scheme was implemented in

Taiwan, in 1995, (Lee et al, 2004) and in 1996, the Government of Tanzania initiated the Community Health Insurance Scheme with the aim of improving access to health care, (Jutting et al, 2004). For our own “Giant of Africa”, Nigeria, the scheme did not take off until 2005 even though the idea was muted as far back as 1962 (Awosika, 2005). The actual promulgation of the enabling legislation, Degree 35 of 1999 became the first major government commitment that facilitated the schemes eventual take off, six years later.

The objectives of the scheme ordinarily will appear easily achievable to many until they are viewed in the light of Nigeria’s health indices. According to World Development report (2005),Nigeria’s population as at 2003 was 135.6 million. Annual growth rate was 2.1%, life expectancy at birth was 45.3, infant mortality was 100 per a thousand live births and under -5 mortality per a 1000 live births was 108 deaths. With respect to disease control, access to improved water was 60%, improved sanitation 30% success rate of treated Tuberculosis (registered cases) was 70 while directly observed therapy short-course (DOTS) detection rate per registered cases was 18%. In reproductive health, fertility rate stood at 5.6%, adolescent fertility (per 1000) was 122, and pregnancy related mortality rate (per 10,000) was 800 deaths. 13% of women (aged 15-45) made use of contraceptives. While 35% of deliveries were attended to by skilled staff, 17% were not. Risk factors and future challenges showed Tuberculosis prevalence, 293 per every 100,000, HIV prevalence between ages 15-49 was 5.4% while incidence of diabetes (within ages 20-79) was 0.4%. In a country with a population of one hundred and thirtyfive million citizens, financing the health sector could no longer be handled from dwindling Government resources alone. This need for equitable distribution of healthcare cost led to the establishment of NHIS in Nigeria in the year 2005.

1.2 STATEMENT OF THE PROBLEM

The National Health Insurance Scheme (NHIS) was established by Decree 35 of 1999, thereby creating a new frontier of healthcare financing in Nigeria. This became a major breakthrough in healthcare administration in the country. Until then, funding of the sector in Nigeria had been grossly inadequate (Ijeomah. 2005). The scheme is a social security system designed to provide access to healthcare for all Nigerians at an affordable cost through various prepayment systems (Executive Secretary NHIS, 2010). Under the scheme, 15% of the contributors’ basic salaries are deducted at source and paid to NHIS. While employer pays 2/3 of this (10%), the employee pays 1/3, that is 5% of his basic salary. The establishment of the scheme has become the fulcrum of healthcare development in Nigeria since inception in 2005. The scheme was designed to provide the following benefits (among others) to healthcare consumers in Nigeria: (1) Easy access to healthcare (2) reduction in healthcare financing burden, (3) high standards of healthcare delivery

(3) efficient care delivery, (4) spread of healthcare facilities in Nigeria.

Despite these laudable aims, evidences on ground seem to suggest that a number of problems still militate against the scheme. Enrollees’ awareness of the scheme’s objectives and operations is may not be what is supposed to be. No proper health education efforts for the enrollees were being carried out. Enrollees seem not to be aware of their rights under the scheme. This was indicated in the fact that complaints for redress were not being sought by consumers at the NHIS Arbitration panel.

To the generality of Nigerians, access to healthcare is still very limited. The scheme took off in the formal sector of the economy in 2005 (see table 1). This sector includes among others the Public services, the military and the paramilitary which includes the prisons and the police. Students of tertiary institutions as well as the organized private sector are accommodated in this first phase of the programme. A part from this problem, accessibility to healthcare is a function of location. Many enrollees who live in rural areas like the police find it difficult to have to travel distances since NHIS accredited HCPs are available only in 3 LGAs out of 9 in Kogi East that is in Idah, Dekina and Ankpa LGAs.

Healthcare financing burden still subsists in many service centres. Facts on ground show that enrollees are still being subjected to this problem. Many health care providers are not equipped with requisite manpower and up-to-date equipment to handle complaints of the consumers. Sometimes, prescribed drugs are not available. These leave the consumer with no other option but to seek alternative cash-and-carry health practitioners to treat him/her pending when he is reimbursed a month or so later. In emergencies where referrals cannot be quickly arranged, the consumers source their funds in order to get medical attention in referral hospitals without being reimbursed. This is so because the process of effecting referrals is quite cumbersome. All these increase the financial burden of the enrollees.

Efficiency of healthcare delivery refers to the ability of service providers to produce desired healthcare outcomes satisfactorily. Customers always expect quick services at the point of receiving medical attention with their HCPs but what one sees in many service points are long wait lines eitherbecause the General Physician (GP) is not on seat or there is no electricity to conduct necessary tests. Regular industrial conflicts have led to shut downs in many general hospitals registered as NHIS service providers. Customers have had cases whereby a particular service provider prescribed the same set of drugs for different ailments. N.Y.S.C Doctors are found everywhere consulting under no one’s particular tutelage. A casual visit to some of these HCPs will reveal disenchantment on the faces of the enrollees.

Health infrastructural spread is also lacking largely in the region. Though many primary HCPs regularly receive their capitation, not much has been seen by way of expanding and or upgrading of facilities. This leaves the consumer with no other option but to travel far for medical attention elsewhere at an additional cost. Because these facilities are not available where these enrollees reside and work, enrollees have to resort to trado-medical practitioners in period of medical emergencies. Others have been fallen financial victim of false faith healers because their HCPs lacked the capacity to handle their cases. The scheme depends solely on existing health institutions particularly at service points. All of them have been in operation for years running. Sights of dilapidated infrastructure, obsolete equipment and unhygienic hospital environments are common attributes of many of these HCPs.

Essentially, these problems pointed out indicate, among other things, the lack of consumer orientation of the HCPs. The fact that they seem to be operating in a sellers’ market has continued to encourage this thereby lack of consumer orientation amongst staff of HCPs leading to further loss of consumer faith in the system. Examined vis-a-viz the stages of marketing orientation, the health sector seem to still be operating in sales orientation stage bereft of any marketing consciousness.

1.3 OBJECTIVES OF THE STUDY

The aim of the study is to determine the perception of NHIS healthcare delivery by healthcare consumers in Kogi East, Kogi State. The specific objectives of the study were to:

1. Assess the significance of awareness of NHIS Policy objectives and operations amongst NHIS healthcare consumers in Kogi East;
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2. Ascertain NHIS healthcare consumers’ access to healthcare services in Kogi East;

3. Determine reduction in healthcare financing burden among NHIS healthcare consumers in Kogi East;

4. Appraise the perception of NHIS healthcare service delivery efficiency among NHIS healthcare consumers in Kogi East;

5. Determine respondents’ satisfaction with their NHIS HCPs in Kogi East; and

6. Ascertain NHIS healthcare consumers’ brand preference for NIHS healthcare services in Kogi East.

1.4 THE RESEARCH QUESTIONS:

The following specific research questions were formulated to direct the study:

1. Are healthcare consumers in Kogi East significantly aware of NHIS policy objectives and operations?

2. Has the implementation of NHIS provided access to healthcare services for NHIS healthcare consumers in Kogi East?

3. Has NHIS implementation reduced the healthcare financing burden on healthcare consumers in Kogi East?

4. Do NHIS healthcare consumers in Kogi East perceive NHIS healthcare service

delivery as being efficient?

1. Is the level of satisfaction of NHIS enrollees in Kogi East with their HCPs

significant?

1. Do NHIS healthcare consumers in Kogi East prefer NHIS services than the cash-andcarry system?

1.5 RESEARCH HYPOTHESES:

Ho 1: The level of awareness of NHIS objectives and operations amongst

NHIS Healthcare consumers in Kogi East are not significant;

Ho 2: Implementation of NHIS has not created access to healthcare delivery for enrollees in Kogi East;

Ho 3: There is no significant reduction in Healthcare financing burden amongst NHIS Health consumers in Kogi East;

Ho 4: NHIS healthcare consumers in Kogi East do not perceive NHIS healthcare services as efficient;

Ho 5: NHIS Healthcare consumers’ satisfaction with HCPs in Kogi East is not significant;

Ho 6: NHIS Healthcare consumers in Kogi East do not prefer NHIS healthcare services than the cash-and-carry system.