ABSTRACT

One major component of access to healthcare is utilization of healthcare services. The National Health Insurance Scheme (NHIS) was designed to reduce the impact of poverty on the ability of the enrollee to utilize healthcare services. The question is has NHIS increased the utilization of health care services and offered financial protection to its beneficiaries? The purpose of this study is to analyze comparatively, the healthcare cost and utilization of healthcare services by the insured and uninsured federal civil servants in Abakaliki Ebonyi State. A comparative descriptive cross-sectional design was used for the study. The sample size was 216. A multistage sampling procedure was employed to draw respondents for the study. The instrument for data collection was a researcher developed questionnaire. A total of 186 copies of the administered questionnaire were analyzed. About 84.7% of the NHIS insured and 98.4% uninsured federal civil servants had poor utilization of healthcare services. The un-insured paid more out of pocket on medicine and diagnostics (1000-5000), than insured federal civil servants (600-3000). The insured had good satisfaction with healthcare services [mean 2.7(±0.5)] while the un-insured had poor satisfaction with Healthcare services [mean 1.7(0.4). There was no significant difference in Healthcare utilization between the insured and the un-insured (p > 0.05) despite a significant difference in early visit to hospital (access to Healthcare) (p < 0.05). There was a significant difference in Healthcare cost between the insured and the un-insured (p < 0.05). There was significant difference in satisfaction with Healthcare services between the insured and the un-insured (p < 0.05). The study concluded that NHIS offered financial protection to its beneficiaries. It was recommended that a well structured federal civil service employment process be instituted such that enrollment into the NHIS would be part of the statutory requirements for employment into the Federal Civil Service and public enlightenment programmes on the operations of the NHIS be intensified. 

CHAPTER ONE

INTRODUCTION

Background to the Study

A nation’s achievement of the tenets of Universal Coverage may be grim without an effective Health Insurance System. Ensuring that people who use a needed health service are not unduly exposed to financial hardship is the doctrine of an effective health insurance (Metiboba, 2011). Globally, at least 1 billion people suffer each year because they cannot obtain the health service they need (World Health Organization, 2014). About 150 million people who do use health services are subjected to financial catastrophe annually (Ujunwa, Onwujekwe, & Chinawa, 2014). About 100 million are pushed below the poverty line as a result of paying for the services they receive (Community Health Sciences Center for Health Policy, 2008). In a bid to efficiently manage resources, even the more developed countries have not been able to achieve a completely comprehensive health insurance system (Spreeuwers & Dinant, 2015). According to Rogers (2012), the USA spends as high as seventeen percent of Gross Domestic Product (GDP) on healthcare. With Private healthcare spending of forty six percent of all healthcare spending, and a ratio of about 24 Physicians to 10,000 population; 30 million adults still remained uninsured at the end of 2014 (World Bank, 2015). The United States Center for Disease Control (CDC) (2013) puts the figures at twenty percent population uninsured, sixteen percent population on Public health insurance and sixty four percent on Private health insurance (World Health Organization, 2014). This may suggest a possibility that some persons within this

30 million do not see any benefit of health insurance for the insured over the uninsured; therefore motivating them to strive to remain uninsured. It could also connote that some individuals among this 30 million do not meet the basic requirements to be enrolled into any insurance scheme.

In Nigeria, the National Health Insurance Scheme (NHIS) is the major health insurance plan for a major section of the Nigerian population (Metiboba, 2011). It is funded primarily by contributions from members based on income. In the Social Health Insurance programme for the Formal Sector, contributions are premiums that make up fifteen percent of an individual’s basic salary. In this the employer contributes ten percent while the employee pays five percent for coverage of themselves, their spouse, and up to four children. Participants in the Informal Sector Programme are expected to make a monthly contribution based on the benefit package of their choice. Nonetheless, the very poor, elderly, veterans and disabled are exempted from paying membership premiums (The National Health Insurance Scheme, 2015).

Currently, allocations from general government revenue comprise about twenty six percent of overall funding; six percent comes from private organizations and one percent from development partners. Household out of pocket expenditures remain the largest source of financing, providing about fifty five of total revenue. About 5 million Nigerians representing approximately three percent are enrolled in this scheme. Most of them are those in formal sectors of society. According to The National Health Insurance Scheme (2015), sixty seven percent of civil servants and professionals make use of NHIS (National Health Insurance Scheme) services. Use of NHIS services is lower among low-income groups and young people. This may be because the programme that targets these populations has not been introduced or fully incorporated into the NHIS system. Thus, while it appears that coverage has been extended greatly for the population, there are still about 46 million Nigerians, or thirty three percent of the population, with no access at all to organized modern health insurance.

Access to healthcare is a central aspect of healthcare quality (Ujunwa, Onwujekwe, & Chinawa, 2014). Several authorities view it as the timely use of personal health services to achieve the best health outcome possible (Agency for Health Care Research and Quality, 2007). Seven million under-five deaths were recorded in 2011(WHO, 2014). Forty one percent of these deaths occurred in sub-Saharan Africa with Nigeria having twelve percent even though the vast majority of the deaths are preventable using low-cost public health interventions  (World Bank, 2015). By convention, for a population to be termed healthy, that population is expected to have easy access to health care. This is what the NHIS is geared towards achieving.

One major component of access to healthcare is “utilization of healthcare services” (Ujunwa, Onwujekwe, & Chinawa, 2014).  Utilization of healthcare services focuses on the realized access to health. Generally, utilization of healthcare services may seem limited in Nigeria. Some authors have attributed this to many reasons. For instance, long distance to healthcare facilities has long been established as one of the barriers to health care utilization  (Community Health Sciences Center for Health Policy, 2008). This may even be worse in rural and semi-urban communities of developing countries like Nigeria, where the road networks are not in good condition and poverty is a significant challenge. The NHIS insurance policies are therefore designed to reduce the impact of poverty on the ability of the enrollee population to realize access to healthcare or utilize healthcare services.

The uninsured are individuals who by choice or other factors are not enrolled in any health insurance package. Although windows have been created by policy makers to absorb individuals operating within the formal and informal sector for enrollment into the NHIS, it may seem that some are rather staying out of the scheme for some unknown reasons. It could be that they do not perceive any expected benefit with regard to improved accessibility to healthcare services, if they were to be insured.

In our ever changing world gearing more towards critical evidence-based decision making, both at an individual and communal level; there may be need to assess the impact of the NHIS on the affordability and use of healthcare services by the insured, while enjoying the expected financial protection on healthcare cost supposed of an insurance plan.

Statement of the Problem

One of the major functions of health insurance is to provide financial protection against high cost of health care. Such evidence has been shown to be inconsistent for developing countries (Nguyen, Yogesh, & Wang, 2011). The impact of health insurance in such low and middle income countries has been documented only partially and the evidence on financial protection due to health insurance is not definite  (Metiboba, 2011).

Being insured or not has impact on access to health and this is an important question for policy makers because lack of insurance has implications both for individual health and societal cost (Xu, Carrin, Nguyen, Dorjsuren, & Mylena, 2006). Uninsured individuals may forgo some needed health services which can lead to poorer health expenditures in the long term (Nguyen, Yogesh, & Wang, 2011). Nevertheless, having insurance does not guarantee that the health services provided through the health insurance will be affordable, accessible, acceptable and satisfying (Lasser & Himmembetum, 2006). Thus there is need to investigate the effect of

National health insurance on cost and utilization of health services of individuals with a view to informing policy making.  The question being raised in the study is: Has NHIS increased the utilization of health services and offered financial protection to its beneficiaries? There is still knowledge gap on the effect of NHIS among federal civil servants. This study is therefore designed to compare the healthcare cost and utilization of healthcare services by the insured and uninsured federal civil servants in Abakaliki Ebonyi State.

Purpose of Study

The aim of this study was to analyze comparatively, the healthcare cost and utilization of healthcare services by the insured and uninsured federal civil servants in Abakaliki Ebonyi State.

Objectives of the Study

The objectives of the study were to:

1. Compare the healthcare service utilization by the insured with the uninsured federal civil servants in Abakaliki Ebonyi State under the formal health insurance scheme.
2. Compare the Out-of-Pocket healthcare cost of the insured with those of the uninsured federal civil servants in Abakaliki Ebonyi State.
3. Compare the satisfaction with healthcare services received by the insured and uninsured federal civil servants in Abakaliki Ebonyi State.

Research Hypotheses

1. There will be no significant difference in healthcare service utilization by the insured and the uninsured federal civil servants in Abakaliki Ebonyi State under the formal health insurance scheme
2. There will be no significant difference in Out-of –Pocket healthcare cost of the insured and uninsured federal civil servants in Abakaliki Ebonyi State.
3. There will be no significant difference in the satisfaction with healthcare services received by the insured and uninsured federal civil servants in Abakaliki Ebonyi State.

Significance of the Study

Any identified difference in healthcare cost and utilization between the insured and uninsured Federal Civil Servants will uncover the amount of financial and health protection individuals get as a result of being insured or uninsured. The result of this study will serve as evidence for policy making within legislative circles as it may lend evidence to policy options. This it will do by lending more empirical evidence to policy making arguments relating Health insurance. It will further inform evidence-based but targeted intervention programmes towards an improved health insurance enrollment scheme. This it will do by adding more support to already existing knowledge on the extent to which health insurance protects the health utilization of a population. Since this study is carried out on an indigenous population, the finding of this study will serve as a source of evidence based knowledge to Health Administrators and Health Practitioners by adding to existing empirical literature. It is also hoped that the findings from this study will serve as a source of knowledge to society, and result in reduced healthcare cost burden on individuals and communities at large. This it could do by stimulating informed behaviour among health consumers in line with the findings of this study. Academically, this work will serve as a reference to other researchers in related fields of study. 

Scope of Study

This study focused on comparing the healthcare cost and utilization of healthcare services of the insured and uninsured federal civil servants in Abakaliki, Ebonyi State. The study was delimited to individuals under the employment of three selected federal government agencies only who have spent a minimum period of 3years in service.

Operational Definition of Terms

Comparative analysis of healthcare cost: This refers to a process of item by item comparison of alternatives that deals with out-of-pocket payments and catastrophic healthcare cost for healthcare services obtained by respondents. For the purpose of this study, Healthcare cost would be the out-of-pocket payments for healthcare within a period of 3months.

Out-of-Pocket payments: Refers to non-reimbursed direct cash expenditure in exchange for healthcare services within a period of 3months.

Catastrophic healthcare cost: refers to out-of-pocket payments above 40% of household income within the past 3months.

Utilization of healthcare services: Refers to the number of times the respondents in this study used health services within the past 3months.

Access to healthcare: Refers to visit to hospital at the early stage of illness less than 4 days from the start of illness

Satisfaction with Healthcare service: Refers to how much a patient’s healthcare expectations are achieved by a healthcare provider based on the patient’s perception. It will be graded as poor satisfaction and good satisfaction.

Insured federal civil servants: Refer to individuals under the employment of the Federal Government of Nigeria who are enrolled into the National Health Insurance Scheme.

Uninsured federal civil servants: Refer to individuals under the employment of the Federal Government of Nigeria who are not enrolled in the National Health Insurance Scheme.