THE INFLUENCE OF HEALTH INSURANCE SCHEME IN PROMOTING
ACCESSIBILITY TO HEALTH CARE SERVICES DELIVERY
(A STUDY CASE OF FEDERAL MINISTRY OF HEALTH KANO STATE, NIGERIA)
TITLE PAGE
BY
DIBOR, MICHAEL KENECHUKWU
SPS/20/MHC/00076
A RESEARCH PROJECT SUBMITTED TO THE DEPARTMENT OF ECONOMICS,
FACULTY OF SOCIAL SCIENCES, BAYERO UNIVERSITY, KANO. IN PARTIAL
FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTERS
DEGREE IN HEALTH ECONOMICS
AUGUST, 2023
DECLARATION
I, Dibor, Michael Kenechukwu with registration Number SPS/20/MHC/00076 declare that this
project has been undertaken and written by me and it is the outcome of my research and
findings, under the supervision of my humble and able lecturer Prof. Amina Department of
Economics, Faculty of Social Sciences. All materials used have been fully acknowledged by
means of reference.
...........................................
Dibor, Micheal Kenechukwu
SPS/20/MHC/00076
............................
Date
ii
CERTIFICATION
I hereby certify that this research project titled “The influence of health insurance scheme in
promoting accessibility to health care services delivery (a study case of ministry of health Kano
State, Nigeria)’’ was supervised by:
________________________________
Prof. Amina A. Ismail
(Supervisor)
__________________
Date
iii
APPROVAL PAGE
This research project title “The influence of health insurance scheme in promoting accessibility
to health care services delivery (a study case of federal ministry of health Kano State, Nigeria)”
by Dibor, Michael Kenechukwu was carried out for the fulfillment of the requirement for the
award of Masters Degree in Health Economics (MHC) of Bayero University, Kano and is here
by approved for its contributions to knowledge and literary presentation.
________________________________
Prof. Amina A. Ismail
(Supervisor)
__________________
Date
_________________________________
Dr. Muhammad Ibrahim Abdullahi
(Coordinator Health Economics)
__________________
Date
_________________________________
Prof. Shehu Muhammad
(Head of Department)
__________________
Date
iv
DEDICATION
.
I dedicate this work to Almighty God, to whom I give all thanks.
v
ACKNOWLEDGEMENT
All thanks to Almighty God whose mercy, favour and grace saw me through from the beginning
to the end of this project.
First of all, I would like to thank my supervisors, Prof. Amina A. Ismail for her help, support,
patience, motivation, insightful comments and assistance during the period of this programme. I
would also like to thank my course coordinator Dr. Muhammad Ibrahim Abdullahi and HOD
Prof Shahu Muhammad for their advice and guidance in the development of different parts of
this work. I feel greatly honoured for the opportunity to work with them because with their
motivation and inspiration, I am able to complete this work. I would like to express my sincere
appreciation to the Bayero University Kano, particularly the Department of Economics for
providing me with the best learnin and research facilities.
To my lovely wife and children thank you for supporting me emotionally, morally and above
all, for standing by me always.
vi
TABLE OF CONTENT
Contents
Page
TITLE PAGE ......................................................................................................................................... i
DECLARATION...................................................................................................................................ii
CERTIFICATION ................................................................................................................................iii
APPROVAL PAGE ............................................................................................................................. iv
DEDICATION ...................................................................................................................................... v
ACKNOWLEDGEMENT.................................................................................................................... vi
TABLE OF CONTENT ......................................................................................................................vii
CHAPTER ONE.................................................................................................................................... 1
1.0 INTRODUCTION ........................................................................................................................... 1
1.1 Background of the Study ................................................................................................................. 1
1.2 Statement of the Problem ................................................................................................................ 2
1.3 Aim and Objectives of the Study .................................................................................................... 3
1.4 Scope of the Study ........................................................................................................................... 4
1.5 Organization of the Study................................................................................................................ 5
1.6 Justification ..................................................................................................................................... 5
CHAPTER TWO ................................................................................................................................... 6
2.0 LITERATURE REVIEW .............................................................................................................. 6
2.1 Conceptual Literature ..................................................................................................................... 6
2.2 National Health Insurance Scheme ................................................................................................ 6
2.3 National Health Insurance Scheme and Health Care Providers in Kano State ............................... 8
2.4Theoretical Framework .................................................................................................................. 11
2.4.2 Likert Scale Rating Techniques ................................................................................................. 16
2.5 Empirical Literature ...................................................................................................................... 18
CHAPTER THREE ............................................................................................................................. 22
3.0 METHODOLOGY ........................................................................................................................ 22
3.1 Study Area ..................................................................................................................................... 22
3.2 Study Population and Participants ................................................................................................. 24
3.3 Sampling Techniques and Sample Size......................................................................................... 25
3.4 Study Design and Method of Data Collection............................................................................... 26
3.5 Techniques of Data Analysis ......................................................................................................... 26
3.6 Logit Regression Model ................................................................................................................ 27
3.7 Likert Scale Rating Techniques .................................................................................................... 28
CHAPTER FOUR ............................................................................................................................... 30
vii
DATA PRESENTATION ANALYSIS .............................................................................................. 30
4.1 Introduction ................................................................................................................................... 30
4.2 Data Presentation and Analysis ..................................................................................................... 30
4.4 Discussion ..................................................................................................................................... 47
CHAPTER FIVE ................................................................................................................................. 52
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ....................................................... 52
5.1 Summary ....................................................................................................................................... 52
5.2 Conclusions ................................................................................................................................... 52
5.3 Recommendations ................................................................................................. ………………53
REFERENCE ...................................................................................................................................... 54
viii
CHAPTER ONE
1.0
INTRODUCTION
1.1 Background of the Study
Health care system across the globe differs as a result of several components in their
establishment, infrastructure, facility, organization and services. Health system also
encompasses a complex set of structural relationships between populations and institutions
which primary aim is to improve on the health care system of the mass in the Nation. Health
care services are one of the components of health system, which centered specifically on the
delivery of health care services (Lambrini et al., 2012). The delivery of health care system
should be receptive, financially affordable and access to the health services while treating
individual respectively.
The Effective, efficient and adequate provision of health care services is fundamental to attain
the objective of a nation’s health system. Nigeria operates a multiple health care system
alongside orthodox (public and private), alternative and traditional health care delivery and the
contemporary modern medical practice. The Nigeria health system is controlled by the
economic principle of the Nation (Federal/Governmental). In reality, universal access to health
care services in the Nation mostly favors the urban settlers that have the financial capability for
the service (Ogaji & Brisibe, 2015). Access to affordable health care service has consistently
been threat to most Nigerians due to poverty level and dependent on out-of-pocket payment.
Health insurance scope across the nation has scarcely catered for the masses in terms of the
total population of the Country. Health insurance scheme is one the system of contributing
financial support for the costs of using health care services (PriceWaterHouseCoopers, 2019).
The health insurance scheme is a form of statutory social health security system which insures
the national populace against the high cost of health care and it could be for public sector or
private sector whereby the payment is been provided by both the employer and the employee.
1
There is also provision for individual to register under the scheme. The health insurance in
Nigeria is a social health insurance model managed by the National Health Insurance Scheme
(NHIS) which covers payments of health care of the nuclear family, the principal; the spouse
and not more than four offspring that are below the ages of 18years (Abubakar et. al., 2018).
Furthermore, addition of more offspring or a dependent usually attract yearly fee.
To ensure an unhampered adequate coverage and continuous access to health-care services,
prepayment health-care financing mechanism such as this NHIS should be devised to suit the
different socioeconomic and cultural characteristics of the individual beneficiaries involving
those in both urban and rural area. The system of contribution into the NHIS excludes
individuals that are not in either private or public sector of the nation. These occluded
individuals are mainly rural dwellers, hence, creating an urban–rural inequality in access to
health care services (David et al., 2015). This study concentrates on the influence of health
insurance scheme in promoting accessibility to health care service delivery.
1.2
Statement of the Problem
The preponderance of the problem of illness and diseases in developing countries could be at
lower ebb in an environment where the health care system is accessible and affordable by the
masses. Also, several individuals from developing nation that could easily access quality health
care without hindrance are deterred by financial incapability. Majority of people in Nigerian
pay for health care service via out-of-pocket (OOP) and some are through benefit package of
health care services paid for from funds created by pooling the contributions of participants
with the use of health insurance scheme (David et al., 2015). However, in-depth awareness and
sensitization is highly necessary to bridge the gap.
Furthermore, some of the health care systems in Nigeria have limitations in the following
areas, staff, funds, information, supplies, transport, transparency, communication and overall
2
guidance and direction to function. Therefore, strengthening health system is a measure of
addressing vital constraints in each of these areas. The major challenge facing health sector in
Nigeria is fund which is mainly provided by the government, private sectors and international
organizations (David et al., 2015). The charges individuals pay on health care services is high,
hence, it is necessary to utilize the health insurance scheme at disposal. It has become
necessary to investigate the inherent constraints affecting health insurance scheme in
promoting accessibility to health care service delivery. It is against this backdrop that this study
seeks to provide answers to the following research questions:
i.
What are the socio-economic characteristics of staff of Federal Ministry of Health and
other stakeholders in the study area?
ii.
What is the level of accessibility to health insurance scheme in the study area?
iii.
What are the factors influencing the accessibility to health insurance scheme in the
study area?
iv.
What is the level of awareness of health insurance scheme in the study area?
v.
What are the challenges mitigating against health insurance scheme in promoting
accessibility to health care service delivery?
1.3
Aim and Objectives of the Study
The aim of this study is to determine the influence of health insurance scheme in promoting
accessibility to health care delivery service in Kano State, Nigeria.
The Objectives are to;
i.
describe the socio-economic characteristics of the staff of Federal Ministry of Health
Kano and other stakeholders in the study area,
ii.
examine the level of accessibility to health insurance scheme in the study area,
3
iii.
determine the factors influencing accessibility to health insurance scheme in the study
area,
iv.
identify the level of awareness of health insurance scheme in the study area, and
v.
identify the challenges mitigating against health insurance scheme in promoting
accessibility to health care service delivery in the study area.
1.4
Scope of the Study
Health Insurance Scheme is conceded to play an essential role to lessen the cost expended on
health of individual in developing countries, especially for the vulnerable people (Dekker and
Wilms, 2010). Many studies were conducted on the impacts of health insurance on the use of
healthcare services and out-of-pocket spending on health care by the less privilege (Nguyen,
2015; Dao et al., 2008; Sepehri et al., 2011; Sepehri et al., 2006; Owett et al., 2004). However,
in depth studies using primary data collected for analyzing the influence of health insurance
scheme in promoting accessibility to health care delivery service on the staff of the Health
Insurance Scheme have not been intensively carried out.
Primarily, this study determines the influence of health insurance scheme in promoting
accessibility to health care delivery service in Kano State, Nigeria. This cross-sectional study
would use primary data by administering semi-structured questionnaire complemented with
interview schedule to the respondents. The expected outcomes of this study would be to
determine the level accessibility to health insurance scheme, influence of health insurance
scheme on the respondent, level of awareness of health insurance scheme and their associated
factors. Consequently, these outcomes would enhance and encourage the policy makers to
support modification of the health insurance scheme for the less privileged and improve the
quality of healthcare services to increase health insurance enrolment and accessibility.
4
1.5
Organization of the Study
This thesis includes five (5) chapters. Chapter 1 is the general introduction of the study which
outlined the background, problem statement, aim and objectives, scope, organisation and
justification of the study. Chapter 2 addresses the literature review including conceptual
framework, National health insurance scheme, theoretical framework, empirical literature and
their associated factors. Chapter 3 discusses the methodology, including the study area, kano
state of Nigeria, study population, participants, design and sample size, sampling and analytical
techniques. Chapter 4 will focus on the discussion of the results of social demography and
other characteristics of the study population, including the estimated level of awareness and
accessibility of health insurance in the study area. Finally, Chapter 5 addresses the summary of
the study, conclusion and relevant recommendations on how the influence of health insurance
scheme promote accessibility to health care service delivery.
1.6
Justification
This study is intended to bring to focus the influence of health insurance scheme in promoting
accessibility to health care service delivery. It is assumed that if the community dwellers have
access and are aware of the necessity and benefits embedded in the use of health insurance
scheme will embrace this scheme and register family, religious body (Mosques and Churches),
society group, companies, public and private sectors.
Also, if the community dwellers are aware of the advantages of using health insurance scheme
and the coverage by the Health Maintenance Organization (HMO), many individuals would be
encouraged to use health insurance scheme. Thus, this study will be used to reveal how health
insurance scheme is use to increase the number of individuals using National Health Insurance
Scheme (NHIS) and accessing the health care services.
5
CHAPTER TWO
2.0 LITERATURE REVIEW
2.1
Conceptual Literature
Health care system provides individuals, family and community with promotive, protective,
preventive, diagonistic, curative and rehabilitative measures and services. It is known news that
the degree of primary health care is at a bad, years of neglect by states and local government
who is saddle with the responsibility of providing primary health care in the nation, which have
resulted in ineffective and sub-standard primary health care services delivery nation-wide.
Most often, vulnerable individuals, women and children pay the price of this ineffectiveness
(Finelib, 2022). Although, the state of primary health care service delivery in Nigeria review
indicate that it is not all doom, some states are in dreadful state while other are slightly
different. Between 2019 and 2021, a consortium that includes ONE Campaign, National
Advocates for Health, Nigeria Health Watch, and Public and Private Development Centre,
assessed the state of primary healthcare delivery in Nigeria. The aim was to identify the weak
links, showcase the strengths and highlight opportunities for improvement in Nigeria's primary
healthcare system. The assessment report, which was launched in July 2022, revealed the good,
the bad and the extremely poor in primary healthcare delivery across the country. It also
revealed the extent of implementation of the Basic Health Care Provision Fund (BHCPF) in
Primary Health Centres (PHCs) across states in Nigeria (Finelib, 2022).
2.2
National Health Insurance Scheme
National Health Insurance Scheme (NHIS) which was officially launched in the year 2004,
with the objective to strengthen the health care delivery system to the masses through the
provision of financial contributory. The NHIS has served only about 4.0% of an estimated total
population of 170 million people. Majority of the NHIS enrollees were employee in both
6
private and public sector that lives in the urban settlement, however, several individual living
in the rural area are the farmers and artisans that are in the informal sector, among whom are
not aware of any form of prepayment scheme, with a consequential poor access to and
utilization of health-care services (David et al., 2015).
The National Health Insurance Scheme (NHIS) in Nigeria was designed to provide minimum
economic security to employee and all the masses in general concerning to loss of life as a
result of domestic accident, non-domestic accident, sickness, old age, depression and
unemployment. The Insurance scheme is based on contributions to the scheme whereby a prepayment system by both the employer and employee, hence, the employee would have access
to the scheme (Sanusi & Awe, 2009). The contributions under the NHIS for the employee of
private and public sector are earning related representing 10% of basic salary or 3.25% by the
employer and 5% by the employee making a total of 15% to NHIS. The scheme contribution
substitutes the medical allowance of employee. Currently, enrollment in the NHIS in Nigeria is
voluntary. There are several other programs under the NHIS which are as follows:

Tertiary Institution Social Health Insurance Programme (TISHIP)

Formal Sector Insurance Health Insurance Programme (FSHIP)

Community-Based Social Health Insurance Programme (CBSHIP)

Urban-Self Employed Social Health Insurance Programme (USESHIP)

Children Under-Five Social Health Insurance Programme (CUFSHIP)

Groups Individual and Family Social Health Insurance Programme (GIFSHIP)

Permanently Disabled Persons Social Health Insurance Programme (PDPSHIP)
7

Prison Inmates Social Health Insurance Programme (PISHIP)
According to David et al., 2015, the implementation of this health-care financing schemes
requires adequate knowledge of the socioeconomic characteristics, cultural, values, and
perception of the individual in different communities. The study on health insurance scheme is
deficient concerning cultural values of different communities that may influence the design of
a prepayment system for residents of rural communities, especially in Nigeria. In addition,
other studies on health insurance scheme from the southwest of Nigeria focused mainly on
individual living in the urban area; however, little or no publication was recorded on
individuals living in rural communities. Hence, an assessment of influence of the health
insurance scheme and other attributes affecting prospective beneficiaries of the health
insurance scheme is important in scheming a culturally acceptable approach of implementation
that will also include the socioeconomic state of individual in such environment.
2.3
National Health Insurance Scheme and Health Care Providers in Kano State
The main aim of National Health Insurance Scheme (NHIS) is to ensure that very Nigerian has
access to healthcare services at an affordable cost and there are several benefit packages for the
enrolee which is being provided by the healthcare facilities which are into three healthcare
levels (Onwujekwe et al., 2010):
a. Primary healthcare level: The out-patient care services of the enrolee examination and
routine laboratory investigation to reach diagnosis. Other services include
immunisation, surgical procedure, internal medicine, HIV/AIDS, sexually transmitted
infections, mental health, pediatrics, obstetrics and gynecology, ophthalmology,
emergency care, family planning services and child welfare services.
b. Secondary Healthcare Level: The services include surgical procedure (complexity of
the aliment), internal medicine, HIV/AIDS, pediatrics (surgical), obstetrics and
8
gynecology (all emergency caesarean section and high-risk pregnancy), ophthalmology,
ear nose and throat (ENT), dental health, physiotherapy and radiology/ultrasonography.
c. Tertiary Healthcare Level: These are services that cannot be handled by both primary
and secondary Healthcare Level, it includes surgical procedure, HIV/AIDS, pediatrics,
obstetrics and gynecology, ophthalmology, ear nose and throat, dental health,
physiotherapy and radiology/ultra-sonography (Kutzin, 2013).
Undoubtedly, civil servants play an important role in the economic development of the
country, for an improve and active public service workforce and an effective and efficient
delivery of services, the provision of satisfactory and quality healthcare services should be
considered a top priority to the public servants (Onwujekwe et al., 2010). Hence, NHIS is
necessary and of great importance to public servants due to its comprehensive health care
system that is based mainly on primary health care. Some of its packages which include outpatient care, medical consumables, drugs, and diagnostic tests is dependent on the Health
Maintenance Organization (HMO).
Health maintenance organization deals with the implementation of social health insurance plan
sequel to the establishment of NHIS. HMOs is the Formal Sector Health Insurance Program
(FSHIP) of Nigeria and a private driven sector expected to close the gap arises from inadequate
management and bureaucratic nature occurring in the public sector (Baruwa, 2015).
HMOs are expected to function based on health insurance principles, which include generation,
pooling, purchasing and benefit packaging. Generation is carried out through taxes, levies, outof-pocket payment whereas pooling requires organizing the generated funds into a financial
pocket that gives opportunity to hedge against unexpected healthcare spending. Pooling is also
viewed as health system function by which collected health revenues are transferred to
purchasing organizations. However, purchasing refers to holding the fund and ensuring
9
disbursement to the insurance system while benefit packaging refers to what should be
included or excluded as health services, requirements for referral and other payment packages
(Emily & Onno, 2013). These instruments are the keys that steer the health systems towards
Universal Health Coverage (UHC). Some of the accredited Health Care Providers and Health
Maintenance organization available in Kano Sate is as follows;
Table 2.1: List of Health Care Providers (HCPs) and Facility Type available
S/N Health Care Providers
HCPs Number Facility Type
i.
Akilu Memorial PHC Madobi
KN/0262/P
Primary
ii.
KN/0156/P
Primary and Secondary
iii.
Al Farma Ultra-Modern Hospital and
Diagnostic Centre
Al Noury Specialist Hospital
KN/0156/P
Primary and Secondary
iv.
A/Razaq Clinic & Maternity Centre
KN/0910/P
Primary
v.
AA Bayaro MPHC
KN/0258/P
Primary
vi.
Abasawa Basic Health Centre
KN/0442/P
Basic Health Care
Provider
vii.
Abbas Basic Health Centre
KN/0445/P
Basic Health Care
Provider
viii.
Abubakar Imam Urology Center
KN/0911/P
Primary and Secondary
ix.
Achika Health Post
KN/0696/P
Basic Health Care
Provider
x.
Ahmed Ado Bayero Model PHC
KN/0647/P
Basic Health Care
Provider
xi.
Airforce Comprehensive School
Medical Centre
Aisami Health Clinic Maternity Child
Health Care
KN/0404/P
Primary
KN/0517/P
Basic Health Care
Provider
Ajingi Carthage Hospital
KN/0260/P
Primary
xii.
xiii.
10
xiv
Health Post
KN/0544/P
Basic Health Care
Provider
HCPs and HMOs Under GIFSHIP, 2022.
2.4
Theoretical Framework
The standard of Health care delivery system in Nigeria has continued to degenerate over the
years coupled with high cost of procuring health care equipment, instrument and facilities; also
the problems of geographical, bureaucratic, affordability, awareness and economic barriers to
quality health care delivery have retrogressed. In a bid to promote and improve the quality of
health care delivery system, the government, by Decree No. 35 of 1999, established the
National Health Insurance Scheme under NHIS Act CAP N42 (LFN) 2004 with the objective
of ensuring that every Nigerian has access to good and quality health care service at an
affordable cost (Ibiwoye & Adeleke, 2008).
Many primary health care providers have been registered across the country under the NHIS
programme. The activities of the health care providers are coordinated by Health Maintenance
Organizations (HMOs). Generally, HMOs receives contributions from all eligible employers
and employees hereby capitation is been paid to the health care providers. The Healthcare
facilities under the Scheme provides the following benefit package to the enrolees as outlined
in the NHIS Operation Guidelines revised October 2012;
i.
Out-patient care, including necessary consumables as in NHIS Standard Treatment
Guidelines and Referral Protocol.
ii.
Prescribed drugs, pharmaceutical care and diagnostic tests as contained in the NHIS
Drugs List and NHIS Diagnostic Test Lists.
iii.
Maternity (ante-natal, delivery and post-natal) care for four pregnancies ending in live
births under the NHIS for every insured enrollee in the Formal Sector Programme.
11
Additional care if any still birth. All live births eligible to cover will be covered during
the post-natal period of twelve (12) weeks from the date of delivery.
iv.
All preterm/premature babies eligible to cover shall be covered for twelve (12) weeks
from the date of delivery.
v.
Preventive care, including immunization, as it applies in the National Programme on
Immunization, health and family planning education. Adult Immunizations viz. HPV,
Hepatitis etc
vi.
Consultation with specialists, such as physicians, pediatricians, obstetricians,
gynaecologists, general surgeons, orthopaedic surgeons, ENT surgeons, dental
surgeons, radiologists, psychiatrists, ophthalmologists, physiotherapists, etc.
vii.
Hospital care in a standard ward for a stay limited to cumulative 21 days per year
following referral.
viii.
Eye examination and care, the provision of low-priced spectacles but excluding contact
lenses.
ix.
A range of prostheses (limited to prosthesis produced in Nigeria)
x.
Dental care (excluding those on the Exclusion list).
xi.
Annual medical checkup unrelated to illness.
According to Nguyen et Al., (2011), to ensure efficient and effective health insurance scheme,
there should be link among the principal-agent correspondents which are NHIS, HMOs,
employees and health care service providers. The NHIS and beneficiaries are the principals
while HMOs and health care service providers are the agents in the scheme. Awareness of the
scheme should be broadened especially to the populace in the rural area, proximity of the
health care facilities, and time-consuming nature of the scheme also affect the services. The
tendency of bureaucratic nature especially in government owned health care facilities could
prevent efficient and productive health care system and accessibility to the facilities.
12
Bureaucracy is not suitable in the management of health care providers as a result of the nature
of its operation. Quality health service delivery is important and essential to human existence
with the prevailing socio-economic situation of the country. Providing quality, reliable health
care service and prompt attention in government-owned health care facilities have been a
problem combatting most patients especially NHIS enrolee. The ineptness nature and lag have
its root in bureaucratic management of the health care providers and some health-care workers
have a bad attitude to work and this has an overbearing adverse effect on the quality of service
to patients and the health systems. Bureaucratic processes of health sector and poor attitude to
work of health workers is detrimental to the national economy (Kuye & Akinwale, 2020).
The problem of bureaucratic processes and delay of patient required immediate attention is
evident in the investigation of Segel (2017) which agreed with the statement, but dispute to the
fact that bureaucratic is preventing healthcare services from improving on daily basis. The
inefficiency in healthcare delivery service is prevalent especially in government owned
healthcare facilities and some factors such as patient-related, health worker-associated and
employer-associated factors interrelate negatively affect the quality healthcare service delivery
as explained by Iloh et al., (2013). Chart 2.1 shows the Theoretical Framework of the Influence
of Health Insurance Scheme on the Accessibility to health care delivery service.
Chart 2.1 Theoretical Framework of the Influence of Health Insurance Scheme on the
Accessibility to health care delivery service
13
Health Insurance Scheme in accessibility to Health Care
Service Delivery
Services
Bureaucratic
nature of the
government
owned health care
facility
Benefit Packages of
the Health
Maintenance
Organisation (HMO)
Primary health
care level: outpatient care
services
Secondary
health care
level
Awarenes
s
affordability:
Payment
Time-Consuming
nature of the
National Health
Insurance Scheme
(NHIS)
Attitude
and
profession
alism of
Health
workers
Geographycal:
Proximity of
the health care
facility
Tertiary
health care
level
2.4.1 Logit Regression Model
Logistic regression analysis is use for describing relationships and testing hypotheses between
categorical outcome variable and one or more categorical or continuous predictor variables.
The logistic regression for one continuous predictor X and one dichotomous outcome variable
Y, the result could be in two parallel lines with each of the lines corresponding to a value of the
dichotomous outcome of the analysis. Logistic regression solves the problems by applying the
logit transformation to the dependent variable, the logistic model predicts the logit of Y from X
and the logit is the natural logarithm (ln) of odds of Y, and odds are ratios of probabilities (π)
of Y occurring to the probabilities (1 – π) of Y not occurring, although, logistic regression
analysis can accommodate categorical outcomes that is polytomous (Joanne et al., 2002).
Simple logistic regression model is as follows:
∏
Logit (Y) = Ine
=
1
ᾳ + βX1-10
- ∏
The regression coefficient (β) is the logit (0.85)
β is the regression coefficient
π is the Probability of the outcome of interest or event
14
Y is the outcome of interest
α is the Y intercept
X = x1-10, a specific value of X, independent variables
e = 2.71828 is the base of the system of natural logarithms.
Logistic regression analysis was used as determinants of health insurance ownership according
to Astari and Kismiantini (2019) that the coefficient, the standard errors (S.E.), t-value and
95% confidence interval for odd ratio were determined and all the explanatory variables were
treated as continuous variables and was discovered to be statistically significant at the
significant level of 0.05. The result shows that eight (8) independent variables (job, age,
gender, highest education, chronic condition, health condition, marital and inpatient care) were
significantly associated with the ownership of health status, hence, the probability of having
insurance increased with age.
Consequently, Karim and Abdul-Wahab (2018) stated that the logistic regression analysis was
used as response method to represent the estimated function and the estimation of the
parameters in a method and the results indicated that the most important factors affecting the
lives of premature infants’ mortality (dependent variable). Hence, logistic model was a good
model for analyzing the relationship between premature infant mortality and the variables that
explain the behaviour of the independent variables and all the independents variables indicate a
good quality of the logistic model.
The researcher (Abed, 2015), also examined the factors affecting polygamy in the Palestinian
territories by comparing the models of neurological networks and logistic regression. It was
deducted that the model neural networks outperformed the logistical regression model but with
a small difference in the accuracy of the classification, and there were four (4) variables
common to the two methods, and they were of high relative importance to the two models used
for the analysis.
15
2.4.2 Likert Scale Rating Techniques
Likert scale rating technique is a series of Likert-type items that represent similar questions
combined to form a single composite variable. Likert scale data can be analyse as interval data
that is the mean is the preferable measure of central tendency by deducting the value for means
and standard deviations to describe the scale (Warmrod, 2014). The conventional means of
report and interpreting Likert scale is to determine the values of the chosen option and create a
score for each of the respondents. This score is subsequently used to represent the set attribute
(satisfied/dissatisfied or agree/disagree). The concept of reliability of Likert scale rating
technique is outline as a means of the accurate measurement of a fact or statement (Adelson &
McCoach, 2010). The reliability of a test score that quantifies psychological and social factual
means that an individual fact score is comprised of measured score subtracted from random
errors of measurement expressed by the following equation (Subedi, 2016).
Measured score − Error = True score
(1)
This principle can be applied if a group of individuals has completed a fact that measures a
specific statement; it means that the variance of the true scores for the group makes the
variance of the group’s measured scores subtracted from the variance of the random errors of
measurement.
Variance (Measured score) – Variance (Error) = Variance (True score)
(2)
However, assuming the attitude and perception of the measured variable using Likert-type
scales, the measured score taken as a composite summated score, either by summated total
score or by summated subscale score, which means that the responses of the respondents to the
statement. The variance of the measured scores is calculated by the responses of the respondent
to the Likert scale and the variance of the errors of measurement is assumed to be random,
which is subsequently estimated from the variations of the response from the respondents of
16
the statements on the Likert scale (Subedi, 2016).
The reliability as expressed as the coefficient of the proportion of the variance of the measured
scores is not attributed to random error variance and it is the ratio of estimated variance of true
scores of the variance of the measured scores. This ratio is depicted as follows.
Variance (True scores) – Variance (Measured scores) = Reliability coefficient
(3)
The variance of true scores as to the variance of measured scores is subtracted from the
variance of the random errors of measurement, the equation estimate the reliability coefficient
in Equation 4 as follows:
Variance (Measured scores) – Variance (Errors)
= Reliability coefficient
(4)
Variance (Measured scores)
The reliability coefficient is an estimate variance of the random errors and such reliability
coefficient is the estimation of the proportion of variance of the measured scores which is not
attributable to the random errors of measurement (Subedi, 2016).
Likert type data are generally used to measure the perception and attitude by conforming a
range of responses to a given statement or fact. According to Jamieson (2004), there are
majorly 5 categories of response: from strongly disagree to strongly agree, although there are
arguments in response to the scales with 7 or with the number of response categories.
Normally, Likert scale used a series of score with 5 response alternatives: strongly approved,
undecided, disapprove, and strongly disapprove. It can also be combined responses from the
series of questions to create an attitudinal measurement scale (Boone & Boone, 2012) and
Likert type data can also be a discrete contrary to continuous values, tied numbers and
restricted ranges (De Winter & Dodou, 2010).
It is necessary to measure the reliability index in Likert data and the most frequently used
reliability index is Cronbach’s alpha which is a statistic analytical tool used to measure the
consistency or reliability of the Likert data. Cronbach’s alpha is also used to measures the
17
accuracy of variables of one-dimensional specific fact of respondents. However, there is high
influence of Cronbach’s alpha in deducting reliability index in Likert data where there has been
misconception and misinterpretation (Garrid et al., 2013). Majority of the medical research
work on Likert data’s reliability were been carried out using Cronbach’s alpha.
According to McLeod (2008) a Likert-type data assumes that the strength/intensity of
experience is linear that is, it is on a continuum from strongly agree to strongly disagree, and it
makes the assumption of the perception or attitudes to be measured. The example in the table
below describes the scoring of facts:
Table 2.2: 5-Score categories of responses of Likert Scale Data
SD
D
N
Score
A
SA
Facts
Source: Computed Survey, 2023.
Where SD: Strongly Disagree
D: Disagree
N: Neutral
A: Agree
SA: Strongly Agree
2.5
Empirical Literature
The National Health Insurance Scheme is a social health insurance initiative designed by the
Federal Government of Nigeria to supplement the cost of financing the health sector and to
improve access to health care for the vulnerable populace. Majority of urban dweller were
currently enrolment at different level on the scheme, according to Akinyemi et al., (2015)
determine the perception and participation of Civil Servants regarding the National Health
Insurance Scheme whereby a descriptive cross-sectional study was conducted among 273 civil
18
servants working at the Federal Secretariat, Ikolaba, Ibadan between the month of October and
November 2015 on the socio-demographic characteristics, awareness, NHIS enrolee,
perception of NHIS, and health-seeking behaviour. Information on perceptions was sought
using a 3-point Likert scale. The result of the descriptive analysis as show by Akinyemi et al.,
(2015) was that about 60.1% of the respondents were males and their average age was
39.7±9.1 years, with 85% of the respondents being married. Majority of the respondents
(88.9%) completed tertiary education, while just 11.1% completed basic education, the mean
household size was 2.5±0.6. In addition, majority (65.2%) of the respondents were mid-level
cadre workers, 17.62% were working as senior-level workers and the remaining 17.6% were
low cadre workers. Awareness of the National Health Insurance Scheme was very high
(95.2%) with 83.5% enrolled under the scheme and 50% of the respondents joined the scheme
because it is cheap and affordable. There was a significant association between awareness,
level of education, knowledge of NHIS, and registration into the scheme by the respondents. In
conclusion, majority of the respondents (87.3%) asserted that NHIS is a better means of
settling healthcare costs than Out-of-pocket-payment and have the conception that the National
Health Insurance Scheme is a viable programme and initiative.
According to the study conducted by Obelebra and Adeniji (2021) on the factors affecting
utilization of the National Health Insurance Scheme by Federal Civil Servants which revealed
high rate of utilization of the NHIS among the civil servant that were enrolled and the
subsequent reduction in the out-of-pocket payment for health care under the NHIS. The
attitude of the health care service providers and the level of satisfaction of health care service
received by the enrollee were significantly affected by the utilization and accessibility of the
NHIS. Obelebra and Adeniji (2021) used Regression analysis to determine the factors affecting
the utilization of Health Care Service and the result shows that the rate of income and age of
the respondents are the predictors of utilization of the NHIS and the high rate of utilization
19
reflects an acceptance of the scheme by the respondents.
The study conducted by Ibiwoye and Adeleke (2008) on the scale at which the NHIS scheme is
being operated further validated the potential to promote access to quality health care coupled
with the socio-economic factors that affect its accessibility and the level of participation in the
NHIS scheme such as marital status, level of education, income and size of family. This study
also served as a guide for the government agency to structure its awareness education about the
benefits of the NHIS scheme, to achieve the objective of making quality health care accessible
to all the population through the NHIS, the scheme must be embraced by the informal sector
that would now need to choose between capitation-based providers and feed based private
providers. Since a high percentage of the respondents’ lack awareness concerning NHIS, there
is a need to raise the level of awareness of the scheme. This will require public education since
with the informal sector there is no employer to make the scheme mandatory.
The results from Nguyen, (2015) further showed that the insurance coverage of the less
privileged was lower than the percentage of the population in the urban centre. The factors
affecting the impact of health insurance on the respondents include poor health status,
awareness of health insurance, cost of insurance premiums, lack of interest by the respondents
to the use of health insurance scheme, household type and number of adults in the household
were strongly associated with insurance status. However, lack of health insurance coverage
was strongly associated with better health status, non-awareness of health insurance, high cost
of insurance premiums, lack of interest for health insurance, distance of health care center
offering health insurance, and temporary place of residence. Nguyen, (2015) further
established the fact that some socio-economic factors such as health status, marital status,
membership duration, work status, waiting times and type of illness were associated with the
use of the health insurance card. Several literatures have also identified a range of factors
associated with the variation, utilization, awareness, accessibility of health insurance scheme
20
and the quality of the health care services.
Quality of health care services provided by health insurance cannot be accurately reflected
through enrolees' perceptions, consistency in the services provided, bureaucratic processes in
the health sectors, efficiency of the health care providers, accessibility to health care providers,
patient safety, and effectiveness of the health care providers (Lambrini et al., 2021). The
continuous monitoring of health services provided by the health insurance for quality
evaluation by the enrolee is very potent, which has received significant attention in recent
years. In the past, the quality assessment of health care provided by the health insurance was
carried out without considering the perceptions, views and feedback of the enrolee. However,
today, the importance of enrolees' views and perception in evaluating the quality of services is
emphasized and depend on the clinical effectiveness of the health care provider (Lambrini et
al., 2021).
According to the Nigeria Health Watch (2020), monitoring of service delivery provided by the
insurance healthcare centres was an initiative of Nigeria Health Watch in collaboration with
Connected Development (CODE) and was designed to monitor the progress in the
implementation of primary health care services for NHIS enrolee. Primary health centers were
established primarily to provide accessible, affordable and available primary health care to
people. This assessment was designed to analyse service delivery, coverage of care and quality
of care at Primary Healthcare Centres in Kano State. The study was conducted in Kano
because it is the second most populous state in Nigeria and has several challenges on
awareness and delivery of health care services to its populace with an outcome of having poor
health index. The primary purpose of the study case is to provide an indept understanding
concerning service delivery of the health care providers and the implementation of the
minimum standards in primary health care particularly the enrolee of NHIS in the state
(Nigeria Health Watch, 2020).
21
CHAPTER THREE
3.0 METHODOLOGY
3.1 Study Area
The study case will be carried out in the Federal Ministry of Health Kano in Kano State,
Nigeria. It is located at northwest region of Nigeria. Kano state is the second largest city in
Nigeria with an estimated population of over four (4) million populations which covered
449km2, situated in the Sahel, south of the Sahara (Google Arts & Culture, 2020). Kano state
lies between latitude 130N of the North, 110N of the South while it has a longitude 80W of the
West and 100E of the East (NigeriaGalleria, 2021). Kano state was created on the 27th of May,
1967 from the initial northern Nigeria by the Federal Military Government. It is the secondlargest city in Nigeria and is also refer to as the axon center of Northern Nigeria. It has a
population of just over 4 million people and it is the largest Hausa kingdom in Africa (Kano
State Government Official Website, 2020). Kano state has an average land scape of about
137Km2 and has forty-four (44) Local Government Areas (LGAs). In addition, the city has
two more LGAs and the current total land area is 499km2 with a population density of 550
people per square kilometer (Population Stat, 2020).
Kano state consist of forty-four Local Government Area (LGA) which are Ajingi, Albasu,
Bagwai, Bebeji, Bichi, Bunkure, Dala, Dambatta, Dawaki kudu, Dawaki Tofa, Doguwa, Fagge,
Gabasawa, Garko, Garum Mallam, Gaya, Gezawa, Gwale, Gwazo, Kabo, Karaye, Kibiya,
Kiru, Kumbotso, Kunchi, Kura, Madobi, Makoda, Minjibir, Nasarawa, Rano, Rimin Gado,
Rogo, Shanono, Sumaila, Takai, Tarauni, Tsanyawa, TudunWada, Tofa, Warawa, Wudil and
Kano Municipal (Nigeria Directory & Search Engine, 2016). The two major tribes in Kano
state are Hausa and Fulani while other tribes include Teshena, Shira among others.
Kano state is the second largest industrial city after Lagos state in term of economy and it is
also the largest in the Northern part of the Country. The major economy centre is grains,
22
textiles, tanning, footwear, cosmetics, plastics, nomadic and other industries. Subsistence and
commercial agriculture are practised in the state and the common crops are maize, millet, rice,
cowpeas, sorghum and among others. Cash crops such as cotton and groundnut are grown in
the state in high quantity for industrial and export purposes. Over the years, Kano state has
always experience a booming population (Population Stat, 2020). The table below shows the
population size and the year over the past two decades.
Table 3.1: Kano Urban Area Population History
Year
2000
Population Size
2,602,000
2001
2,658,000
2002
2,716,000
2003
2,774,000
2004
2,834,000
2005
2,895,000
2006
2,958,000
2007
3,021,000
2008
3,087,000
2009
3,153,000
2010
3,221,000
2011
3,290,000
2012
3,361,000
2013
3,434,000
2014
3,508,000
2015
3,583,000
2016
3,661,000
2017
3,739,000
2018
3,820,000
2019
3,906,000
2020
3,999,000
2021
4,103,000
2022
4,219,000
23
2023
4,348,000
Survey: Population Stat, 2020
Kano state is the largest and most prosperous province of the empire. Kano state government
has several Ministries and Agencies for the implementation of its mandate among which is
Federal Ministry of Health Kano. The names of health care facilities in different LGA in Kano
state owned by Government are as follows; Tudun Murtala Health Center in Nasarawa,
Bompai Police Clinic in Nasarawa, Kundun Health Clinic in Rano, Rano Dawaki Health Clinic
in Rano, Butu Butu Primary Health Centre in Rimin Gado, Gwangwan Health Clinic in Rogo,
Nuhu Bamali General Hospital in Kano Municipal, Unguwar Gini Primary Health Center in
Kano Municipal among several others in the state. The picture of the map of Kano state is
shown below:
Figure 3.1: Map of Kano Sate
3.2
Study Population and Participants
The respondent for this case study will be the staff of Federal Ministry of Health Kano and
other stakeholder within the kano Municipal Area Council. Majority of the respondents were
24
public servant, while others were adhoc staff (Industrial attachment (IT) student, National
Youth Service Corp (NYSC) member), artisans working within the Ministry and other
stakeholder within the kano Municipal Area Council. According to the information deducted
from the office of the Federal Ministry of Health Kano (2023), their current workforce is 698;
while the total main staff is 603, adhoc staff is 85, artisan is 10 and the population of Kano
Municipal Area Council is 610,600. The questionnaire will be administered to respondents
above the age of 18 years, who is currently engaged as at the time of this study case by the
Federal Ministry of Health Kano state and other relevant stakeholder within the Kano
Municipal Area Council.
3.3
Sampling Techniques and Sample Size
Multistage sampling technique will be engaged for the study. In stage one, Federal Ministry of
health was purposively selected due to the preponderance of professional and their knowledge
on the influence of health insurance scheme on the accessibility of health care services. The
stage two of the procedure involved a simple random selection of staff of Federal Ministry of
Health Kano as well as adhoc staff (IT Student and NYSC Member), artisans in the Ministry
and other stakeholder within the Kano Municipal Area Council. The stage three will involve
probability proportional to size by sampling 20% of respondents available at the Federal
Ministry of Health and 100 respondents from the Kano Municipal Area Council will be
randomly selected.
Table 3.1: Sampled staff of Federal Ministry of Health Kano
Respondents
Sampling Frame
Staff of Federal Ministry of
Health Kano, Adhoc Staff (IT
Student and NYSC Member),
artisans with the Ministry
698
25
Sample Size
150
Other stakeholder within the
Kano Municipal Area Council
610,600
Total
200
350
Source: Computed Survey, 2023.
3.4
Study Design and Method of Data Collection
Cross-sectional, description survey will be engage for the study between the month of June and
July, 2023. Relevant information to this study will be derived through primary data; semistructured questionnaire complemented with interview schedule will be administered to the
selected staff of Federal Ministry of Health Kano and other stakeholders living within the Kano
Municipal Area Council so as to obtain the necessary information. Some of the socio economic
data that will be collected are age of respondent, gender, marital status, and beneficiary of any
health insurance scheme. Trained enumerators will be employed to assist during the data
collection.
3.5
Techniques of Data Analysis
Sampling and analytical techniques is a process of finding answers to raw data by means of
conveying the data and giving interpretation to the result with a goal of discovering useful
interference and prediction. The main aim is to disintegrate data into understandable form so as
to proffer solution to the research problems which is been analyzed and conclusion drawn from
the result for recommendation and decision making. Table 3.2 shows the various analytical
tools and data required in deriving the objectives illustrated in the study case.
Table 3.2: Analytical Tool to be used for the Objectives
Objectives
Data Requirements
Objective i
Describe the socio Frequency
distribution table,
economic characteristics of
mean and
the staffs of Federal
percentage.
Ministry of Health Kano
26
Statistical Tool
 Descriptive
statistics
and other relevant
stakeholders
Objective ii
Examine the level
accessibility to health
insurance scheme in the
study area

Frequency
distribution table,
mean and
percentage.

Descriptive
statistics
Objective iii
identify the factors
influencing health insurance
scheme in the study area

Dependent and
independent
variables.

Logit
regression
model
Objective iv
Identify the level of
awareness of health
insurance scheme in the
study area

Count variable

Likert scale
rating
techniques
Objective v
Identify the challenges
limiting the impact of
health insurance scheme in
promoting accessibility to
health care service delivery.

Frequency
distribution table,
mean and
percentage.

Descriptive
statistics
Source: Computed Survey, 2023.
3.6
Logit Regression Model
Logistic regression analysis is one of those statistical methods used to describe the relationship
between two or more variables. Logistic regression analysis is a type of regression model used
for prediction of descriptive variables based on independent variables which some of the
variables are continuous variables and the dichotomous value of the dependent variable is
quantitatively continuous (Al_Bairmani & Ismael, 2021).
Logistic regression model will be used to describe the relationship between the response
variable
(y),
and
one
explanatory
variable
(x)
that
is
multiple
explanatory
variables(x1,x2...,...xn) and the relationship is expressed in the following form:
Logit (∏) = β0 + β1X1 + β2X2 + β3X3 + β4X4 + β5X5 + β6X6 + β7X7 + β8X8 + β9X9 + β10X10 +
β11X11 + β12X12 + e
27
Where β0, β1, β2 ….. βn is the regression parameters
∏ is the probability of response (Dependent variable)
X1, X2 ….Xn is the independent or explanatory variables
X1: Age of the respondent
X2: Gender of the respondent
X3: Religion of the respondent
X4: Ethnic group of the respondent
X5: Educational background of the respondent
X6: Marital status of the respondent
X7: Household size of the respondent
X8: Income level of the respondent
X9: Status of NHIS of the respondent
X10: Proximity to NHIS Healthcare facility
X11: Awareness of NHIS
X12: Bureaucratic system of Healthcare facility
3.7
Likert Scale Rating Techniques
Likert scale is a form analytical technique of ordinal scale points used by the respondents to
rate the degree of agreement or disagreement to a statement or fact and the responses are
usually continuum for each statement in a linear scale indicating the extent the respondents
agree or disagree with each statement (Suleiman & Artino, 2013). Consequently, Likert-type
scales are mostly and preferably used in medical educational research and it is a fact that Likert
scale was developed to measure the response, perception and attitude of respondents to series
of fact and statement to the cognitive and affective components of attitudes (McLeod, 2008).
According to the model (Andrich, 1978), the probability of respondents responding in category
28
is given as follows:
Pxni = expƩ [βn – (δi + τj)]
Where τ0 =0, so that expƩ [βn – (δi + τj)] = 1
βn is the respondents response and perception on the variable
δi is the scale value estimated for each variable
P is the probability of respondents
The following are the probable facts using 3-Score to determine the Likert scale rating level of
awareness of health insurance scheme in promoting accessibility to health care service
delivery.
29
CHAPTER FOUR
DATA PRESENTATION ANALYSIS
4.1 Introduction
This chapter deals with the presentation of the data collected, data analysis and summary of
findings.
4.2 Data Presentation and Analysis
With regards to data presentation in this study a total of 350 NHIS clients enrolled with the
facility were successfully interviewed. For the NHIS healthcare providers directly involved in
the provision of outpatient care in the hospital, one hundred and thirty two (132)
questionnaires were distributed by direct issuance and one hundred and five (105) of the
questionnaires were properly completed and returned giving a return rate of 79.6%. While for
the health managers directly involved in the administration of NHIS activities in hospital ten
(10) questionnaires were distributed but only nine (9) were properly completed and returned
giving a return rate of 90%. The results would be presented accordingly in the perspective of
the NHIS clients, the healthcare providers and the health managers.
30
Table 1: Demographic and social characteristics of the respondents
Age group(years)
Frequency
Percent (%)
< 18
19 -28
29 -38
39 -48
49 -58
Total
Gender
Male
Female
Total
Marital Status
Married
Singled
Widowed
Total
Educational Qualification
Degrees
Diplomas
Prof. Certificate
Secondary school cert.
14
28
112
100
96
350
4.0
8.0
32.0
28.6
27.4
100.0
150
200
350
44
56
100.0
308
40
2
350
88.0
11.4
0.6
100.0
71
105
64
79
20.3
30.0
18.3
22.6
Primary school cert.
Koranic education
None
Total
Family Size
<6
>6
10
15
6
350
2.9
4.3
1.7
100.0
188
162
53.7
46.3
Total
350
100.0
Dependents Registered
Spouse only
Spouse & one child
Spouse & two children
Spouse & three children
Spouse & four children
None
30
27
68
80
112
33
8.6
7.7
19.4
22.9
32.0
9.4
Total
350
100.0
Source: field survey, 2023
31
Majority of respondents were between the age ranges of 29 - 38 years (32.0%) with mean age
of 40 ± 2.1 years, 56% were female while 44% were male and 88% are married. Among the
respondents 68.6% had tertiary education, 53.7% had a family size of more than six persons
and 32% registered spouse and 4 children.
Figure 1: Distribution of NHIS Clients by Sources of information
Majority of the respondents (46.9%) had friends/colleagues as source of information on NHIS while
Source: field survey, 2022
internet with 0.3% is the least as a source of information
Source: field survey, 2022
Table 2: Distribution of NHIS client’s based on the knowledge of NHIS operations
General Knowledge on Operation of NHIS
Good
Poor
Total
Frequency
146
204
Percent (%)
41.7
58.3
350
100.0
Source: field survey, 2023
Among the respondents 41.7% had good knowledge of the activities of the scheme as
against 58.3% with poor knowledge.
32
Table 3: Distribution of NHIS Clients on reason(s) that informed the choice of the Hospital
Reason(s) for choice of the hospital
Frequency
Percent (%)
Proximity to place of residence
Hospital been used before NHIS
64
120
18.3
34.3
Staff Attitude
14
4.0
Adequate Personnel& Equipments
84
24.0
Skill& Expertise of Personnel
46
13.1
Cost of Treatment
5
1.4
Friends & colleagues influence
16
4.6
No Response
1
0.3
Total
350
100.0
Source: field survey, 2023
Majority of the respondents (34.3%) chose the hospital based on previous experience
while 1.4% chose the hospital due to affordable cost of treatment at the OPD.
33
Table 4: Proportion of NHIS clients rating the importance of various indicators
Warm reception at OPD
Frequency
Percent (%)
Very important
Important
Fairly important
Not important
Indifferent
TOTAL
Waiting time to see doctor
Very important
Important
Fairly important
Not important
Indifferent
TOTAL
Doctor’s Attitude
Very important
Important
Fairly important
Not important
Indifferent
TOTAL
Need to listen to patient well
Prescription
before
Very important
Important
Fairly important
Not important
Indifferent
TOTAL
Conduct thorough physical
examination
Very important
Important
305
41
1
2
1
350
87.1
11.7
0.3
0.6
0.3
100.0
291
44
6
5
4
350
81.1
12.6
1.7
1.4
1.1
100.0
311
30
3
1
5
350
88.9
8.6
0.9
0.2
1.4
100.0
325
20
1
1
3
350
92.8
5.7
0.3
0.3
0.9
100.0
325
20
92.8
5.7
Fairly important
Not important
Indifferent
TOTAL
Request for relevant investigation
Very important
Important
Fairly important
Not important
Indifferent
TOTAL
1
1
3
350
0.3
0.3
0.9
100.0
185
138
18
4
5
350
52.9
39.4
5.1
1.1
1.4
100.0
34
Follow up visits
Very important
Important
Fairly important
Not important
Indifferent
TOTAL
Privacy
Very important
Important
Fairly important
Not important
Indifferent
TOTAL
Confidentiality
Very important
Important
Fairly important
Not important
Indifferent
TOTAL
Cleanliness of OPD environment
Very important
Important
Fairly important
Not important
Indifferent
TOTAL
Mean score = 4.58 ± 0.152
190
135
13
4
8
350
54.3
38.6
3.7
1.1
2.3
100.0
214
123
6
1
6
350
61.1
35.1
1.7
0.3
1.7
100.0
190
140
10
3
7
350
54.8
40.0
2.9
0.9
2.0
100.0
219
123
2
3
3
350
62.6
35.0
0.6
0.9
0.9
100.0
Source: field survey, 2023
Ratings
5 = very important,
4 = important,
3 = indifferent,
2 = fairly important,
1 = not important
With regards to NHIS clients’ perception of quality of care in the OPD, majority of the
respondents rated as very important the following - warm reception (87.1%), waiting time
(83.1%), doctor’s attitude (88.9%), privacy (50%), confidentiality (61.1%) and cleanliness
of OPD (62.6%).
35
Table 5: Proportion of NHIS clients rating the maximum waiting time quality of care at the
various service points of GOPD
Card room
Frequency
Percent (%)
Less than 15 minutes
300
85.7
Between 15 to 30 minutes
39
11.2
More than 30minutes
Indifferent
2
9
0.5
2.6
Total
Consulting Room
Less than 15 minutes
Between 15 to 30 minutes
More than 30minutes
Indifferent
350
100.0
91
220
37
2
26.0
63.0
10.5
0.5
Total
Pharmacy
Less than 15 minutes
Between 15 to 30 minutes
More than 30 minutes
Indifferent
350
100.0
176
150
20
4
50.3
42.9
5.7
1.1
Total
Laboratory
Less than 15 minutes
Between 15 to 30 minutes
More than 30 minutes
Indifferent
350
100.0
120
200
25
5
34.3
57.1
7.1
1.4
Total
Treatment room
Less than 15 minutes
Between 15 to 30 minutes
More than 30 minutes
Indifferent
350
100.0
92
235
21
2
26.3
67.1
6.0
0.6
Total
350
100.0
Source: field survey, 2023
Majority of the of respondents (85.7%) rated less than 15 minutes as the best waiting time in the
card room and pharmacy (50.3%) while a waiting time of between 15 to 30 minutes was
considered to be the best waiting time in the consulting room (63.0%), treatment room (67.1%)
36
Table
6: Proportion
of NHIS clients rating the most important quality issue in the
and
laboratory
(57.7%).
various service points of the GOPD
Card room
Frequency
Percent (%)
Prompt attention
254
73.4
Staff attitude
55
15.7
Orderliness
34
9.7
No response
4
1.2
Total
350
100.0
Consulting room
Prompt attention
45
12.9
Doctors Attitude
140
40.0
Detailed history taking
105
30.0
Thorough physical examination
40
11.4
Privacy
6
1.7
Confidentiality
6
1.7
Orderliness
2
0.6
No response
6
1.7
Total
350
100.0
Pharmacy
Prompt attention
37
10.6
Staff attitude
44
12.6
Explanation on the drug usage
214
61.1
Cost of drug
10
2.9
Well stocked pharmacy
36
10.3
No response
9
2.3
Total
350
100.0
Laboratory
Prompt attention
65
18.6
Staff attitude
103
29.4
Explanation on the test to be done
105
30.0
Cost of laboratory test
41
11.7
Waiting time for result to be out
11
3.1
Adequate laboratory equipment
1
0.3
Cleanliness
16
4.6
No response
8
2.3
Total
350
100.0
Treatment
Prompt attention
38
10.8
Staff attitude
86
24.6
Staff skill & expertise
184
52.6
Confidentiality
9
2.6
Privacy
10
2.8
Cleanliness
9
2.6
No response
14
4.0
Total
350
100.0
Source: field survey, 2023
Majority of the respondents rated the most important quality issue to be prompt attention in
37
the card room (73.4%), doctor’s attitude in the consulting room (40%), pharmacist
advice/counselling (61.1%), explanation on the test to be conducted in the laboratory (30%)
and staff skill/expertise in the treatment room (52.6%).
Figure 2: Distribution of NHIS clients by level of satisfaction with quality of care at GOPD
unsatisfied
Highly satisfied
No response
Satisfied
Unsatisfied
Highly
LEVEL OF SATISFACTION
Majority of the respondents (42.9%) were satisfied with quality of care at the OPD under
the scheme as against about 29.7% of the clients who were dissatisfied.
38
Table 7: Recommendations for improved quality of outpatient care under NHIS
Variables
Frequency
Review of NHIS drugs & service lists
11
Training of existing staff
41
Review of NHIS referral system
11.7
Percent (%)
3.1
More funding of the scheme
42
12.0
Employment of more staff
48
13.7
Creation of separate NHIS unit
59
16.9
No response
Total
125
350
24
35.7
100.0
6.9
Source: field survey, 2022
Majority of the respondents (35.7%) recommended creation of a separate NHIS clinic
complex as way to improve the quality of outpatient care in facility under the scheme.
ASSESSMENT OF KNOWLEDGE OF THE OPERATION OF NHIS AND QUALITY
OF OUTPATIENT CARE FROM THE PERSPECTIVE OF THE HEALTHCARE
PROVIDERS UNDER THE SCHEME
39
Table 8: Distribution of Socio-demographic characteristics of NHIS Healthcare
Providers
Age group (years)
Frequency
Percent (%)
21 -30
31 -40
41 -50
51 -60
Total
Sex
Male
Female
Total
Professional category
Doctors
Nurses
Pharmacists
Pharmacist Technicians
Medical Laboratory Scientist
Medical Laboratory Technician
Medical Record Officers
Total
Educational qualification
MBBS
B.PHARM
B.LAB. SCIENCES
RN/RM
PROF.DIPLOMAS
SSCE
Total
Years of experience
<10
10 - 19 years
20 - 29 years
>30 years
47
36
15
7
105
44.8
34.3
14.2
6.7
100.0
50
55
105
47.6
52.4
100.0
3
19
16
14
11
11
32
105
2.9
18.1
15.2
13.3
10.5
10.5
30.5
100.0
14
16
11
16
29
19
105
13.3
15.2
10.5
15.2
27.6
18.1
100.0
93
9
3
0
88.6
8.6
2.6
0
Total
105
100.0
Source: field survey, 2023
More than 70% of the professional staffs in the GOPD were within the age range of 21 to 40
years with a mean age of 33.8±2.6 years and 52.4% were females. Among the respondents
30.5% were record officers and 88.6% had worked for about 10 years.
40
Figure 3: Distribution of healthcare providers by source of information
Friends/colleagues (27.8%) constitute the highest source of information on the scheme while
internet recorded the least with 3.8%.
Table 9: Knowledge of Healthcare providers on the operation of NHIS
Variables
Frequency
Percent (%)
Good
Poor
51
54
48.6
51.4
Total
105
100.0
Source: field survey, 2023
About half of the respondents (48.6%) had good knowledge on the operation of the scheme
against 51.4% with poor knowledge.
41
Table 10: Distribution of Healthcare providers with Good knowledge on the various aspects
of NHIS operation
Variables
Frequency
Percent (%)
Registration process
Contribution mechanism
20
25
19.0
23.8
Scope of coverage
30
28.6
HMOs
34
32.4
NHIS programmes
39
37.1
NHIS referral system
40
38.1
Hospitalization process
44
41.9
Payment mechanism
54
51.4
NHIS stakeholders
67
63.8
Benefit package
69
65.7
n = 105
Majority of the respondents (65.7%) had good knowledge of NHIS benefit package while
knowledge on NHIS registration process accounted for the least with 19%.
Figure 4: Distribution of knowledge of healthcare providers on the operation of the
scheme by category of health professional
70,00%
61,40%
60,00%
50,00%
Medical record
45,40%
Nurses
Pharmacy technicians
40,00%
32,20%
30,00%
Medical lab tech
30,00%
19,10%18,20%
20,00%
Pharmacist
Medical lab scientist
Medical Doctors
13,30%
10,00%
0,00%
42
Medical record staff had highest percent score (61.4%) while Pharmacy technicians had the
lowest percent score in term of adequacy of knowledge of all aspects of the scheme activities.
The healthcare providers rated the following indicators of quality of care at the OPD as very
important: warm reception (81.0%), doctor’s attitude (91.4%), request for relevant laboratory
(76.2), cost of drugs (44.8%), privacy (78.1%), confidentiality (81.9%), cleanliness of the OPD
(84.8%) and general staff attitude (74.2%). Eighty eight (83.8%) of the healthcare providers
considered the maximum waiting time at card room to be less than 15 minutes as against about
2% that considered more than 30minutes, 54.3% of the respondents considered maximum
waiting time at consulting room to be within 30 minutes while 1% of the respondents
considered a delay of more than 30 minutes, 63.8% of the healthcare providers considered the
maximum waiting time at the pharmacy to be about 15 minutes as against 1% that considered
more than 30 minutes, 51.4% of the respondents considered the maximum waiting time at the
laboratory to be less than 15 minutes, and 56.2% of the respondents considered the maximum
waiting time at the treatment room to be less than 15 minutes, while 3.4% are satisfied with
delayed of more than 30 minutes.
The most important quality indicator in the card room was rated by 52.4% of the healthcare
providers to be prompt attention, 54.3% of the respondents ranked doctors’ attitude as the most
important quality issue in consulting room, 67.6% of the healthcare providers ranked
pharmacist advice/ explanation on the drugs as the most important quality indicator in the
pharmacy, 31.4% of the OPD professional staff ranked waiting time for the laboratory result to
be out as the most important indicator in the laboratory and 37.1% of the healthcare providers
ranked staff skill/expertise as the most important indicator in the treatment room.
43
Table 11: Recommendation for improved outpatient care under NHIS by healthcare
providers
Response to variables
Frequency
Percent (%)
Building more infrastructure
Computerization of medical records
7
10
6.7
9.5
Employment of more staff
10
9.5
Review NHIS referral system
16
15.2
Training of existing staff
18
17.1
Creation of separate NHIS unit
20
19.0
Adequate funding by NHIS
24
22.9
Total
105
100.0
Source: field survey, 2023
Majority of the respondents (22.9%) recommended adequate funding of the scheme by upward
review of capitation payment as the best way of improving the quality of the services provided by
the scheme.
Figure 5: Levels of satisfaction among Healthcare providers with regards to the quality of
care they provide under the scheme
60,00%
56,00%
50,00%
40,00%
Highly satisfied
Satisfied
30,00%
Fairly satisfied
22,00%
Unsatisfied
20,00%
11,00%
10,00%
Highly unsatisfied
8,00%
3,00%
0,00%
44
Majority of the respondents (56%) of the healthcare providers were satisfied with quality of
outpatient care been provided under the scheme against 11% that were unsatisfied.
Assessment of Knowledge of the Operation of NHIS and Quality of Outpatient Care from the
Perspective of the Healthcare Managers under the Scheme
A total of nine (9) health managers directly involved in running the activity of NHIS in the
facility were interviewed.
The mean age of the facility health managers was 44.4±2.4 years, of which 55.6% were female
and 44.4% male, all were married.
The medical doctors, nurses and the administrative officers accounted for 22.2% each of the
facility health managers respectively.
Five of the respondents (55.6%) had various forms of degrees followed by diplomas with
33.3% and professional certificates with 11.1%.
Seven of the health managers (77.8%) had been working with the hospital over the last 10
years and 55.6% had training on job more than thrice within this period. Although none had
any formal training in hospital health management, some of them had some form of capacity
building training on hospital management by PATHS.
Five (55.6%) of the health manager’s source of information was from seminars/workshops
while print media with 11.1% recorded the least as a source of information.
All the health managers of the facility had good knowledge on the operation of NHIS with an
average score of 71.5%. Of the various aspects of the operation of the scheme, majority of the
respondents (n=9) had good knowledge on all aspects of the scheme with the exception of
NHIS registration process and contribution mechanism with 22.2% and 11.1% respectively.
45
The medical record officer had the highest percent score on overall knowledge with 80%
followed by the medical doctors with 70%. Administrative officers had the least score with
55%.
All the health managers of the hospital involved in running the activities of the scheme
considered warm reception, attitude of the staff, skill/expertise of staff, communication on
service to be rendered, cleanliness of environment, privacy and confidentiality as very
important indicators of quality of outpatient care, while 44.4% rated consideration of the cost
of the drugs before prescription as not important. Staff attitude is rated highest as the most
important quality indicator of outpatient care by majority of the respondents (80%). All the
respondents suggested that the maximum waiting to receive outpatient care at the hospital
should be about 15 minutes with the exception of the consulting room in which majority of the
respondents (77.7%) suggested about 30minutes, due to shortage of medical doctors in the
hospital.
All the respondents considered increased funding of the scheme, creation of a separate unit,
reviewing NHIS drugs/services price list & referral system, training of staff on the operation of
NHIS and employment of more staff as key to the provision of quality outpatient care in the
facility.
Six of the management staff (66.6%) expressed dissatisfaction with their jobs with regards to
NHIS activities in the hospital, as incentives were lacking and work load was too much despite
the enormous resources accruing from the scheme.
LEVEL OF UTILIZATION OF OUTPATIENT CARE
The hospital had a total of 1248 registered NHIS enrollees between July and December, 2021
and the overall enrollees attendance recorded was 1248 with a mean monthly attendance of
46
208 enrollees per month. The daily average enrollees attendance was 3 enrollees per day. The
overall utilization rate of outpatient care by NHIS enrollees within the period under study was
38% per annum with a mean monthly utilization rate of 3% per month.
PATTERN OF UTILIZATION OF OUTPATIENT CARE
Table 12: NHIS clients’ utilization of the GOPD from July to December 2021
S/No. Month
Visits
Re-visits
Referred
Total
1
July
59
70
16
145
2
August
60
140
22
222
3
September
58
200
23
281
4
October
60
170
27
257
5
November
34
97
24
155
6
December
71
86
31
188
Total
342 (27.4%)
763 (61.1%)
143 (11.5%)
1248
Source: field survey, 2022
The data above are secondary data obtained from the hospital records. Majority of the patients
(61.1%) were re-visiting cases followed by first visits with 27.4% and only 11.5% were
referred cases within the period under study.
4.4 Discussion
Three hundred and fifty registered enrollees with the hospital were recruited for the study. The
majority of the respondents (33.3%) were in the age group 29 - 38 years. This implies that
majority of respondents were in active working class of the population, which is expected in
formal sector programme of the scheme currently in operation. While for the 105 healthcare
providers interviewed 44.4% were in the age range 21 - 30 years, a probable pointer to the
emerging younger labour force now at various levels of employment in the study. The majority
of the health managers (44.4%) were in the age range 41 - 50 years.
47
Most of the respondents in this study were female (56.0%), with male: female ratio of 2:3, this
is in contrast with the study of Sanusi et al 2017. This implies that more female than male
enrollees were covered by the study which is not surprising as women and children tend to
seek for healthcare more than men. For the healthcare providers, the male to female ratio in the
study of 105 respondents was 1:1; this is in line with the report of Onuekwusi et al 2008 in
Enugu while in contrast with that of Dnladi 2013 in Jos. Eighty eight percent of NHIS clients
recruited for the study were married. Fifty four percent of the respondents had large family size
of more than six persons as against 46.4% with about six persons, of which majority (32.0%)
registered a maximum of five persons as against 9.4% that registered none. These findings are
in line with earlier study of Sanusi et al in Ibadan and Shafiu et al 2009 in Zaria. About 70% of
the NHIS enrollees were educated up to tertiary level; hence significant proportions of the
respondents appreciate the programme. Majority of the healthcare providers (30.5%) are drawn
from the medical record officer followed by the nursing profession with 18.1% where the
predominance of females over the years is again exhibited. For the healthcare managers there
was an equal number for nursing, medical doctors and administrative officers with 22.2% each.
In this study, the proportion of NHIS enrollees who are knowledgeable on the overall
operation of the scheme was 41.7% which show some improvement in contrast to the finding
of Sanusi et al. On the various aspects of operation of the scheme, the NHIS clients are only
knowledgeable on the benefit package (73.4%), drug collection process (93.7%) and copayment mechanism (59.1%). About forty nine percent of the healthcare providers were
knowledgeable on the overall operation of the scheme, which is higher than the figure reported
Sabitu et al 2015 in Minna and Okaro et al 2014 in South East of Nigeria. The medical record
staff are more knowledgeable on the operational guideline of the scheme (61.4%) followed by
the medical doctors with 32.2%.
48
The reason for this finding is not farfetched, because most of the activities of the scheme in the
hospital are based in the medical records unit. With regards to the knowledge of the health
professionals on the various aspects of the operation of the scheme, the study showed that the
respondents are only knowledgeable in aspects of benefits package (65.5%), payment
mechanism (51.4%), NHIS stakeholders (63.8%), and hospitalization process (41.9%). All the
management staff interviewed had good knowledge on the operation of the scheme and
majority of the respondents (55.6%) had good knowledge on all aspects of the activity of the
scheme. The level of awareness among respondents was high but there was no correlation
between awareness exhibited by majority of respondents and their understanding of the
working of the scheme, a trend exhibited by majority of respondents in the different cadres.
Majority of the enrollees (46.9%) had friends/colleagues as their main source of information
while seminars/workshops a veritable source of information with regards to the scheme had the
least with 7.4%, these findings were similar to that of the study in Ibadan. While for the health
professionals their main sources of information were friends/colleagues (27.8%) and electronic
media (27.6%). In a similar study conducted d in Minna by Sabitu et al reported electronic
media (82.1%) and print media (29.1%), Enugu study revealed print media (39.8%) and
electronic media (37.3%) and Zaria study showed print media (33.0%) and friends/colleagues
(22.0%) as the main sources of information. It is interesting however to note that in all the
studies seminars/workshops accounted for a lower source of information. This is quite
surprising when considered that these are supposed to be important sources of information for
health professionals. With regards to the healthcare managers, their main source of information
was seminars/workshops (55.5%). Despite efforts made by the scheme to sensitize and
increase awareness of the Nigerians on the operation of NHIS two years after commencement,
only 41.7% of the respondents in this study were adequately informed.
49
There could be many reasons why patients may choose to attend a health facility. In this study,
majority of the enrollees chose the hospital because of their previous experience. This supports
the value of the patients' experience and its contribution to satisfaction. This is in agreement
with the findings of Manje in Uganda who found that clients' awareness/knowledge on the
concepts of health insurance is very poor, a perception influenced by previous negative
experience. Among other reasons that influenced the enrollees to choose the hospital include
adequate infrastructures, technical competence of the staff and proximity to place of residence.
This supported the fact that assessment of patient’s expectation is one of the ways of learning
about patients’ needs.
Findings from the study revealed that the most important quality indicator from client
perspective in the card room with a score of 73.4% was the issue of the prompt attention of
which majority of the enrollees (88.7%) suggested a maximum waiting time of about 15
minutes. A similar study conducted by Kabir 2010 in Dutse, Jigawa State was in agreement
with findings of this study. Another study in Michigan by Christine et al 2006, in contrast
reported that the most important quality issue from the perspective of the clients with regards
to record department was provision of adequate and correct information and communication.
About 52% of the facility health professionals rated prompt attention as the most important
quality issue in the card room.
The issue of doctor’s attitude was recognised by 40% of the NHIS clients as the most
important quality indicator in the consulting room contrary to the Dutse study which found
prompt attention as the most important quality indicator. Jorge et al 2014 in Bangladesh found
that the most powerful predictor of client satisfaction with public health facility was the
doctors behaviour towards the patient, particularly respect and politeness, which was found to
be more important than the providers technical competence. This finding was in agreement
50
with that of this study. Majority of the respondents (63.0%) rated the maximum waiting time at
the consulting room to be 30 minutes at most. Doctor’s attitude in the consulting room was
also rated by 54.3% of healthcare providers of the facility as the most important quality issue
as opposed to what was reported in the Dutse study with confidentiality in the consulting room
as the most important quality issue.
51
CHAPTER FIVE
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
5.1 Summary
In summary, this study found that the level of knowledge of NHIS clients and health providers
on the various aspects of NHIS activities is still poor eight months after commencement, but
there is very much improvement when compared to earlier findings of Onuekwusi in Enugu,
Sabitu et al in Minna, Danladi in Jos, Sanusi et al in Ibadan and Shafiu et al in Zaria. This
might probably be due to the aggressive public enlightenment campaign in both print and
electronic media and regular stakeholder’s interactive forum embarked upon by the scheme.
Majority of the respondents interviewed expressed satisfaction with quality of outpatient care
provided
in
the
hospital,
as
related
to
such
factors
as
staff
behaviours,
communication/information, waiting time, and hospital environment. This was supported by
the findings of this study which revealed that majority of enrollees chose the hospital based on
their previous experience and expectation.
5.2 Conclusions
The study revealed that NHIS clients, healthcare providers and health managers have good
attitudinal predisposition towards the scheme, despite their lack of adequate knowledge of the
rudimentary principles of the operation of a social health insurance scheme. This implies that if
adequate information is made available to them, the likelihood of their participation and
consequent improved implementation will be high. This calls for a conscious publicity drive
and intense educational campaigns. Also the findings of the research would be important to the
scheme as it gave a clear picture of the feelings of the beneficiaries of the formal sector
52
programme.
5.3 Recommendations
Based on the findings the following recommendations are made:
1. In order to consolidate the gains so far made there is need for the management of NHIS
to embark on an intensive enlightenment and awareness campaign of all stakeholders’,
regular interactive for a and seminars/workshops.
2. The management of the scheme should as a matter of urgency put in place an effective
monitoring and evaluation programme in order to gauge the utilization of the scheme
and fine tune its operations.
3. There is urgent need for the management of NHIS to review their policy documents
(operational guideline, benefit package etc) and update their website regularly to keep
in touch with prevailing situation.
4. There is the need for the Management of Federal Ministry of Health Kano State to
establish a quality assurance committee in the hospital and to incorporate the findings
of this study to the minimum health package of the facility.
53
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