ASSESSMENT OF BENEFITS AND CHALLENGES OF NATIONAL HEALTH INSURANCE SCHEME ( NHIS) AS A TOOL FOR ACHIEVING UNIVERSAL HEALTH CARE IN KWARA STATE NIGERIA

ASSESSMENT OF BENEFITS AND CHALLENGES OF NATIONAL HEALTH INSURANCE SCHEME (NHIS) AS A TOOL FOR ACHIEVING UNIVERSAL HEALTH CARE IN KWARA STATE NIGERIA
ABSTRACT
National health Insurance Scheme (NHIS) is a health care scheme established by the Federal Government of Nigeria in 2005 for better healthcare delivery to its populace. The main thrust of the study is on Assessment Of Benefits And Challenges Of National Health Insurance Scheme ( Nhis) As A Tool For Achieving Universal Health Care In Kwara State Nigeria. Questionnaires were administered randomly to 200 adult respondents in Kwara metropolis. The findings show that only 24% of adults were enrolled in the scheme. Notably, 82% of enrolled respondents were aware of NHIS and prefer it to the fee for service system. There was some level of dissatisfaction in the scheme (26% of enrollees). Sources of dissatisfaction included poor registration services, poor referral system, delays in receiving required services and unavailability or non coverage of some required services. It was statistically determined by the Chi Square tool of analysis that there was a direct relationship between the percentage of enrollees and the poor health indices of the populace. We strongly recommend modification of existing policies to enable enrollment of the self employed and unemployed as well as improved coverage and quality of services within the scheme.
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Several approaches abound in financing healthcare. These range from fees for service to private insurance, general taxation, social insurance, community financing, loans and grants. In Nigeria, combinations of all these in different proportions have been practiced for decades. The most basic form of health care financing is that of fees for service, where a fee is charged to cover all or part of the cost of the service provided. In many low and middle income countries a fixed fee for service, known as a user charge, is used by government health facilities, both as a means of raising revenue and as a means of discouraging what may be viewed as ’unnecessary demand’. This form of health care financing has a number of disadvantages. The direct payment of fees for service is regressive in that it causes the greatest hardship for the poor, and may cause major difficulties in payment for waged labourers, who are unpaid during sickness (Goodman, 1993).
The rising cost of health care 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; Katibi and Akande, 2003). It was fully approved by the Federal Government in 1997, signed into law in 1999 and launched officially on the 6th June 2005. The Scheme is designed to provide comprehensive health care delivery at affordable costs, covering employees of the formal sector, self employed, as well as rural communities, the poor and the vulnerable groups a fee for service system with government funds supplementing in capital project financing. External loans and grants in form of technical assistance and free drugs especially for preventive services are common in Nigeria. The Global fund for HIV/AIDS, Malaria and Tuberculosis is one of such initiatives. Immunization campaigns are also supported by donor agencies. So far, the common man is yet to get the best of healthcare in Nigeria. The fee for service system takes so much from his pockets and leaves him unprepared for most medical expenses.
As a result of the possibility of very high and unpredictable medical costs, many users of the fee for service system arrange cover through private insurance schemes, where the risk of illness is pooled among the insured group. Private insurance schemes attempt to spread the risk of illness over all insurees and as such discriminate less against the sick than pure fee based systems (Green, 2007). Social insurance schemes on the other hand widen the base of private schemes with payments tied to wage levels. Contributions to the scheme are made by employees, employers, and in some cases the state. This system is identical for all enrolees, and the premiums are based on income rather than health status with collection systems for contributions organized within industrialized setting (Abel-Smith, 1992). In some countries social insurance systems have been the forerunners of national health systems through either national insurance or tax.
The Nigerian government instituted a social health insurance system in 2005 to bring succour to the plight of its citizens through the National Health Insurance Scheme (NHIS). Health insurance involves the application of insurance principles to cover cost of defined medical benefit packages. It involves risk sharing between those who will need the benefits and those who will not. It also involves spreading the burden of cost of healthcare services to the insured over time so that the insured can access services anytime without paying.
There is dearth of literature on the effect of various health financing options for low and middle income countries (Ekman, 2007; Mills, Rasheed, Tollman, 2006). More so enrolment in insurance has been found to result in altered behavior, such as utilizing unnecessary medical care, a concept known as ‘moral hazard’ (Sulzbach, Garshong, Owusu-Banahene, 2005). Statistics form a workshop on NHIS-MDG/MCH project by NHIS between 6^th -10^th June, 2011 reveals that the number of enrolees registered and processed by some states in Nigeria as at March, 2011 are: Bayelsa-184,685, Gombe-161,847, Niger-162,408, Imo-90,597, Oyo-158,152, Sokoto-161,738, Katsina-80,272, Jigawa-105,739, Bauchi-158,144, Yobe-102,556, Cross River-59,910. Furthermore, evidences from countries that have institutionalized national health insurance programme indicate positive impact on the health care system (Sanusi and Awe, 2009; Collins, White, Kriss 2007). In a study in Baltimore USA, health insurance was found to lead to an increase in non urgent utilization of health facilities(Speck, Peyrot, Hsaw, 2003).Similarly in Taiwan, the utilization of most prenatal and intrapartum care services increased after commencement of NHIS(Li-Mei, Shi, Chung-Yi, 2001). Also in a related study about public insurance in North Carolina, USA, it was reported that publicly insured children were more likely to have emergency department visit than un-insured children (Luo, Liu, Frush, Hey, 2003). Same trend was also noticed in Minnesota, USA (Kane, Keckhafer, Flood, Bershadsky, Siadaty, 2002). Also in Jordan, insurance was found to have a positive effect on the utilization of curative care and significantly increased the number of visits per illness episode. (Sanusi and Awe, 2009).
Generally, insurance is found to increase the intensity of utilization and reduce out of pocket spending (Ekman ,2007). However in Nigeria, since the NHIS was established; not much has been carried out to investigate utilization and access to quality health care as a result of the introduction of the Scheme (Ibiwoye and Adeleke, 2008). In Ghana, the utilization of health facilities under insurance cover revealed that Malaria, Respiratory problems and Diarrhea were the commonest illnesses (Sulzbach, Garshong and Owusu-Banahene, 2005). In a survey in Oyo State, Nigeria, among health care consumers, 15.8% of respondents were dependants while 84.2% were workers (primary beneficiaries) (Sanusi and Awe, 2009). Pattern of utilization of general practitioners under universal health insurance in Canada indicated that females made more visits than males (Segovia, 1999).
1.2 Statement of the Problem
Nigeria’s health system is ranked 187^th of 191 World Health Organisation (WHO) member states (WHO, 2000), 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; Prenatal mortality rate of 48 per 1000 and child mortality rate of 205 per 1000. This means that over 20% of Nigerian children would not survive beyond childhood (UNICEF, 2006). More recent figures (Partnership for Maternal, Newborn and Child Health, 2008) show the North East geo-political zone attaining a mortality rate of 1700 per 100,000 births.
 
In most developing countries, Nigeria in particular there is a clear lack of universal coverage of health care and little equity. Access to healthcare is severely limited in Nigeria, Otuyemi, (2001). Inabilities of the consumers to pay for the services as well as the healthcare provision that is far from being equitable have been identified among other factors to impose the limitation, Sanusi, et al (2009). Financing of public health services in Nigeria has been through government subvention funded mainly from earnings from petroleum exports and user fees for patients. Decline in funding for healthcare commenced after the mid 1980’s following a drastic reduction in revenue from oil exports, mounting external debts burden, structural adjustment programme and rapid population growth rate, Shaw et al (1995). The result as in most other developing countries was a rapid decline in the quality and effectiveness of publicly provided healthcare services, Shaw, et al (1995). Funding of healthcare in Nigeria has not only affected the quality of healthcare services but led to impoverished health standard of the populace. Gana (2010), identified these funding challenges as low level of public (government) spending, high burden of healthcare costs on individuals and households (70% of all expenditure); thus ranking Nigeria as the country with the second highest level of out-of-pocket spending on health financing in the world.
More worrisome is the fact that the Nigerian System allows private healthcare providers as major stakeholders despite the establishment of the NHIS. The extent of coverage of the NHIS is such that artisans, farmers, sole proprietors of businesses, street vendors, traders and the unemployed are not yet accounted for. Even within the formal sector, not all government and corporate organisation employees are enrolled within the scheme. Our public and private hospitals therefore are still operating on a fee for service basis for the majority of its clients. Besides that, long queues are still usual sites while the issue of unavailability of required services is rearing its ugly head in NHIS approved hospitals. In addition, there is still weak and ineffective referral systems’ resulting in over burdened secondary and tertiary health facilities. Furthermore, education of the teaming populace on the pros and cons and the need to participate in the NHIS is also a challenge yet to be surmounted. In view of the aforementioned, this study seeks to assess the extent of coverage of the scheme and the degree to which the enrolees are satisfied with the Scheme in Jos.
1.3 Research Questions

1. What proportion of people in Kwara is benefiting from the scheme?
2. What proportion of the beneficiaries is satisfied with the scheme?

iii What are the problems and prospects of the NHIS?
1.4 Objective of the Study
The main purpose of this study is on  Assessment Of Benefits And Challenges Of National Health Insurance Scheme ( Nhis) As A Tool For Achieving Universal Health Care In Kwara State Nigeria while the specific objectives include:
i.To determine the percentage of enrolees that have benefited from NHIS
ii.To determine the level of satisfaction with NHIS.
iii To exzmine the challenges facing the scheme
1.5 Research Hypotheses
Hypothesis I
Ho: The enrolees have not significantly benefited from NHIS in Kwara.
Hypothesis II
Ho: A significant percentage of the enrolees are not satisfied with NHIS in Kwara
1.6 Scope of the Study
The primary area of focus for this study will be the communities within  Kwara metropolis. This will include the working populace who are adults above the age of eighteen (18) years who have enrolled into the scheme. The period under study is 2005 to 2019. The choice of this period coincides with the start of NHIS in the country.
 
1.7 Significance of the Study
It is hoped that this study will serve as an available reference source and will help other researchers in this field; thus contributing to the existing literature. Moreover, the study will help government and managers of the scheme in policy formulation and administration for better service delivery and improvements in the scheme.