Background : This study examined the challenges in the implementation and scale-up of the National Health insurance Scheme (NHIS) in Nigeria. Materials and Methods : We designed this descriptive cross-sectional study to investigate the knowledge and opinions of 150 randomly selected adults in urban Kano regarding the NHIS. Data was analyzed using Epi Info™ 3.2.05 statistical software. Respondents’ knowledge of NHIS was scored and graded using a system adapted from previous studies. Results : The mean age of respondents was 39.1 ± 11.1 years, and the majority were currently married (76.7%), males (76.0%), had formal education (82.0%), and were civil servants (52.7%). More than half (52.0%) of the respondents had poor knowledge of the NHIS. Respondents’ knowledge of NHIS did not differ significantly by age, sex, ethnicity, marital status, educational level, or occupation. Although the majority (74.7%) opined that the NHIS is a good initiative, a significant proportion was pessimistic about the scheme: 31.3% said that it is a good scheme but not practicable and 28.0% felt that it is only for the rich. Conclusion : In view of the poor level of knowledge and the pessimism about the NHIS, the government/NHIS office should expedite the implementation of the package for the under-five children and/or the disabled to demonstrate the usefulness of the scheme. The Federal Ministry of Health, the NHIS, and the development partners should intensify efforts for public enlightenment, using electronic and print media as well as other traditional methods of communication.
Keywords: Awareness, challenges, National Health insurance Scheme, Nigeria, opinion
|How to cite this article:
Lawan U M, Iliyasu Z, Daso AM. Challenges to the scale-up of the Nigerian National Health Insurance Scheme: Public knowledge and opinions in urban Kano, Nigeria. Ann Trop Med Public Health 2012;5:34-9
|How to cite this URL:
Lawan U M, Iliyasu Z, Daso AM. Challenges to the scale-up of the Nigerian National Health Insurance Scheme: Public knowledge and opinions in urban Kano, Nigeria. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Aug 9];5:34-9. Available from: https://www.atmph.org/text.asp?2012/5/1/34/92878
The increasing pressure to deliver proper healthcare to the populace with the limited financial resources available has always been a source of concern for the government and health managers in Africa. The situation has led the government to explore alternative healthcare financing initiatives, including various types of health insurance schemes. , Many African countries, including Nigeria, decided to implement the National Health Insurance Scheme (NHIS) to complement funding for the health sector, with a view to improve equity in health. ,
Health insurance is a system in which a prospective consumer of healthcare make payments to a third party on the understanding that in the event of a future illness this third party will pay for some or all of the expenses incurred.  The NHIS was first conceived in Nigeria in 1962 but was actually launched without an enabling law for its implementation in October 1997 after a series of failed attempts by successive administrations.  The scheme gained legislative recognition under Decree No. 35 of 1999 of the Federal Republic of Nigeria, though its actual implementation commenced only in 2002.  In order to ensure that every Nigerian has access to good healthcare services, the Nigerian NHIS was structured to cover all groups in society. Thus, there is the formal sector health insurance program; urban self-employed health insurance program; rural community program; the under-five children insurance program; the permanently disabled social health insurance program; the prison inmates program, and the international travel health insurance program.  NHIS implementation in Nigeria started with compulsory enrollment of employees in the public sector.  Thus, only part of the formal sector health insurance program was implemented by June 2005.  Today, no fewer than 2.5 million Nigerians have access to the scheme, most of them employees of the Federal civil service. , The next phase of the implementation will cover the State civil servants and the other groups.
Experience with other health programs demonstrates that the availability of a service does not ensure its utilization.  Adequate information about the content, processes, roles of stakeholders/consumers, and the perceived benefits of program packages are crucial for proper implementation and the buy-in of prospective consumers. The success of the implementation of the remaining phases of NHIS in Nigeria will largely depend on how much information the prospective beneficiaries/consumers have regarding the scheme. This, in addition to the opinions or attitudes of recipients/prospective consumers, is often not given due importance during the design or implementation of health programs in Nigeria. This study was therefore planned to find out how much the adult residents of urban Kano (Kano metropolis) know about NHIS and what their opinions are about the entire scheme. Findings from this study will be useful to the NHIS program managers and policy makers in Nigeria during the roll-out of the other NHIS components and will also pave the way for further research.
|Materials and Methods|
The study was carried out among the adult residents of the eight metropolitan local government areas (LGA) of Kano State, namely Kano Municipal, Dala, Gwale, Fagge, Nassarawa, Tarauni, Kumbotso, and Ungogo. Data collection was done in the months of December 2009 and January 2010.
Kano State is located in northwestern Nigeria and is one of the oldest and largest states in the country and perhaps also the most traditional. Commerce and agricultural production have been the backbone of the Kano economy. Islam is the dominant religion, though there are significant groups of Christians. Urban drift from rural areas within Kano, from other states in Nigeria, and from West Africa has provided a steady stream of migrants, adding to Kano’s growing population. Kano is therefore a cosmopolitan melting pot of people. The city is characterized by overcrowding, poor sanitation, pollution from traffic and ailing industries, and a weak health system that breeds inequity and poor health outcomes. There were 9383682 people in Kano State during the 2006 national census,  with the metropolitan LGAs contributing 2828861 (30.1%) of this figure. The majority of the residents are traders, civil servants, farmers, and students.
Study design and sampling
We used a cross-sectional descriptive study design. A sample of 150 adults from these LGAs was selected for the study. The sample size was calculated using Fisher’s formula for estimating the minimum sample size for descriptive studies (n=Z 2 pq/d 2 ),  assuming a prevalence (p) of 90.3% awareness of NHIS among healthcare providers (value obtained from a previous study).  The minimum sample size was inflated by 10% to compensate for nonresponse and incomplete responses. A multistage random sampling method was used to select the study subjects. In the first stage, three LGAs (Dala, Kumbotso, and Gwale) were randomly selected from the list of eight LGAs in Kano Metropolis. The lists of settlements from the selected LGAs served as the sampling frame for the second stage. One settlement was selected randomly from each of the LGAs by drawing lots. The houses in all the selected settlements were then numbered and proportionately 20, 17, and 113 houses were selected from the sampled settlements in Dala, Kumbotso, and Gwale LGAs, respectively. Houses were selected using systematic random sampling. Finally, one adult was selected from among the eligible adults in the selected houses using simple random sampling (by drawing lots) and this person was administered the survey instrument.
Instrument description/data collection
An interviewer administered the pretested semi-structured questionnaire. The questions were designed to elicit sociodemographic characteristics, knowledge of NHIS, and opinions about the scheme. Pretesting of the instrument was conducted in another LGA in Kano State (Kura LGA). Some of the questions were rephrased for clarity based on observations made during pretesting. The questionnaires were administered by eight Hausa-speaking Nigerian field assistants who were trained by the researchers on the tools and techniques of data collection and the study protocol. They worked in teams of two interviewers each (one male and one female). Each team had a female member so as to facilitate communication with female respondents. The interviews were conducted in the local language (Hausa).
Informed consent was obtained from all prospective respondents. The consent form was in the local language (Hausa) and literate respondents indicated acceptance by signing the consent form, while nonliterate participants affixed their thumbprint. Ethical clearance for the study was obtained from the Institutional Review Board of Aminu Kano Teaching Hospital. Permission was also obtained from Kano State Ministry of Local Government and Chieftaincy Affairs before the commencement of data collection.
Data was analyzed using Epi Info® 3.5.1 statistical software package (CDC Atlanta, Georgia, USA). Quantitative variables were summarized using appropriate measures of location and variability, whereas categorical variables were presented as frequencies and percentages. Respondents’ knowledge of NHIS was scored and graded using a system adapted from past studies. , Each correct response to questions assessing knowledge attracted one point, with no point given for a wrong or ‘don’t know’ answer. Respondents scoring ≥26 points out of a total of 40 points were considered as having ‘good’ knowledge, those who scored 13-25 points were adjudged as having ‘fair’ knowledge, and those with score of ≤12 points were considered to have ‘poor’ knowledge.
The Chi-square test was used to test for significant associations between categorical variables. P≤.05 was considered statistically significant.
All the 150 adults approached to take part in the study responded positively, giving a response rate of 100%.
Sociodemographic characteristics of respondents
Most of our respondents (93.3%) were between 25 and 65 years. The mean age was 39.1 ± 11.1 years. The majority were married (76.7%), males (76.0%), had formal education (82.0%) and were civil servants (52.7%) [Table 1].
|Table 1: Sociodemographic characteristics of respondents (n = 150)
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Knowledge of NHIS
The parameters used for assessing the respondents’ general knowledge of the NHIS are presented in [Table 2]. The majority (82.0%) had heard of the NHIS. However, less than half of the respondents knew the objectives of the NHIS, the ways of enrolling in the scheme, or the amounts to be paid as premium by the employer and employee. The responses to questions assessing subjects’ knowledge about specific areas of NHIS were also not encouraging.
|Table 2: Parameters used to assess respondents’ general knowledge of NHIS (n=150)
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Specifically, less than one-third of the respondents knew which age-group (among children) was eligible for registration under the scheme, what the special social insurance provisions were, or what services were offered under the NHIS [Table 3].
|Table 3: Parameters used to assess respondents’ knowledge on specific areas of NHIS (n=150)
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The respondents’ grading based on their composite knowledge scores is depicted in [Figure 1]. The assessment revealed that more than half (52.0%) of the respondents had poor knowledge of NHIS. Very few (4.0%) had good knowledge of the scheme. Interestingly, respondents’ knowledge of NHIS did not differ significantly by age, sex, ethnicity, marital status, educational level, or occupation [Table 4].
|Figure 1: Respondents’ grades on knowledge of NHIS
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|Table 4: Relationship between respondents’ knowledge of NHIS and their sociodemographic characteristics
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Respondents’ opinion about NHIS
Although the majority (74.7%) were of the opinion that the NHIS is a good initiative, a significant proportion had reservations about the program: 31.3% feeling that the NHIS is good but not practicable and 28% saying that the scheme is only for the rich [Figure 2].
|Figure 2: Respondents’ opinions about NHIS
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More than half of our respondents (99/150; 66.0%) opined that all Nigerians should register with the scheme, although only 50 (33.3%) believed that the scheme could actually cover all Nigerians. Of the 150 respondents, 108 (72.0%) were willing to participate in the scheme; this included the 44 respondents (29.3%) who were already registered.
Less than half of our respondents knew the objectives of NHIS or how it was to be implemented. Low level of awareness was also reported amongst health workers in Minna town, where only 38% were well informed about the objectives of the NHIS.  Similarly, other studies among healthcare providers  as well as consumers of public sector health services  in Nigeria have shown an abysmally low level of knowledge of the NHIS. The consumers’ knowledge was especially defective with regard to the amount to be paid as premium and the potential benefits one stands to gain from the scheme. The findings from this study and others clearly show that lack of awareness is a major challenge in the implementation of NHIS in the formal sector in Nigeria. This will perhaps be even more marked in the nonformal sector, where enrollment will not be compulsory.
Greater awareness among the adult population regarding the NHIS scheme, especially with regard to its mode of implementation and the benefits that will accrue to the insured, is crucial to win public enthusiasm for enrollment and active participation in the scheme. It is well known that knowledge is power and, ceteris paribus, a strong stimulus for informed decision making. Thus, services requiring the active participation of individuals in the form of financial commitment or otherwise will require that people, ab initio, have full information on the outstanding benefits of such schemes.
We also found that the majority of our subjects were of the opinion that the NHIS is a good initiative. This is corroborated by reports from past studies in Nigeria, where also the majority of respondents stated that they were willing to participate in the scheme as it is currently packaged. ,,, However, many opined that both the public and the healthcare providers have not been adequately mobilized because of the low level of publicity the scheme received. , A general readiness of the public to participate in social health insurance schemes has also been reported in similar studies from other countries. ,,
A significant proportion (31.3%) of our respondents were of the opinion that while the idea of the NHIS is good, it would not be practicable in Nigeria. Interestingly, less than one-third felt that the NHIS is only for the rich, while 20.7% opined that it is not useful at all and should be scrapped. These misconceptions do not augur well for the success of NHIS in Nigeria. It is widely acknowledged that scarce economic resources, modest economic growth, and in-adequate technical know how explain why design of adequate health financing systems in low-income developing countries remains cumbersome and mired in controversy.  There is no doubt that social health insurance is an effective strategy for granting equitable access to healthcare services. NHIS implementation in Nigeria has recorded remarkable achievements, although the scheme has so far concentrated mostly in the Federal public sector, where participation in the scheme is compulsory. Generally speaking, when the NHIS program is made compulsory, certain population groups such as the poorest and the most vulnerable get excluded, perhaps because of lack of capacity to pay the regular contributions (premium). On the other hand, compulsory membership sometimes has certain advantages, for example, it can prevent ‘adverse selection,’ when people in good health choose not to enroll because they consider the insurance contributions as unnecessary and expensive.
If universal coverage by the NHIS is to be achieved in Nigeria the scheme must extend beyond the formal sector to include those in the nonformal sector, who constitute the majority of Nigeria’s 120 million population. One way of ensuring the success of NHIS implementation, particularly in the nonformal sector, is through wide-spread dissemination of information on the health benefits people stand to gain from the scheme. The findings from our study are clear indications for the dire need to intensify public awareness campaigns regarding the NHIS in Nigeria. In view of our findings, we recommend that the government/NHIS office should expedite the implementation of the package for the under-five children and/or the disabled to demonstrate the usefulness of the scheme. The Federal Ministry of Health, the NHIS, and development partners should use the electronic and print media and other traditional methods of communication to inform the general public of the principles of health insurance and the potential benefits of the NHIS. This will help dispel the prevailing misconceptions about the scheme. As the country is preparing for the scale-up of the NHIS to cover the informal sector, it is important to understand the level of awareness in the target group so that necessary adjustments can be made when implementing the program.
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Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]