Despite the creation of the National Health Insurance Scheme (NHIS) by the Nigerian government, most Nigerians are not covered by the scheme.
The aim of this study was to assess the knowledge and utilisation of NHIS among adult patients who attended a tertiary health facility in Lagos state, South-Western Nigeria.
Outpatient clinic, Lagos State University Teaching Hospital, Ikeja, Lagos.
A descriptive cross-sectional study of 487 respondents recruited using a multi- stage sampling method. Data were collected using pretested semi-structured self-administered questionnaires, and analysis was done using Microsoft Excel 2007 and EPI Info 7 statistical software. Level of significance was set at
A total of 487 of the 500 self-administered questionnaires were retrieved and analysed, giving a response rate of 97.4%. The study showed that 80.7% of the respondents had poor knowledge of NHIS, only12.3% of the respondents had registered with the NHIS, and 43.8% of respondents who had not registered with NHIS claimed they do not know where to register. There was a statistically significant association between age and utilisation (
Majority of the respondents had poor knowledge of NHIS and also majority of those who had registered were satisfied with the scheme. There should be increased awareness campaigns so that all Nigerians can benefit from the scheme.
The National Health Insurance Scheme (NHIS) is a type of formal sector social health insurance programme.
The National Health Insurance Scheme aims at ensuring that every Nigerian has access to good healthcare services, protecting families from the financial hardship of huge medical bills.
The benefits of implementing the Compulsory Health Insurance Scheme includes three aspects: the scheme provides for the pooling of resources for cross subsidisation of health costs where those in high-income bracket subsidises those in low income bracket
Members who are enrolled in this scheme get to enjoy several benefits and services such as hospital care (limited to only 15 days in a year and admission in the general ward), outpatient care, pharmaceutical care as in NHIS essential drug list, diagnostic tests as in NHIS diagnostic test list, maternal care for up to four (4) life births; preventive care (immunisation, health education, antenatal and postnatal care), eye care and preventive dental care.
However, Nigeria remains the country with the highest number of out-of-pocket payments for healthcare, yet the health system is still very poor.
The major objective of the NHIS was to ensure that it covers all indigent Nigerians across the country with the purpose of delivering a comprehensive and affordable healthcare nationally. It comprises employers, employees, self-employed, unemployed and rural communities.
The specific objectives of this study were to assess the knowledge of health insurance among adult patients to find out the degree of utilisation of health insurance among these patients and to determine some of the factors that affect the utilisation of health insurance among these patients in the Lagos State University Teaching Hospital, Ikeja.
The study was conducted in the adult outpatient department of the Lagos State University Teaching Hospital (LASUTH), formerly known as Ikeja General Hospital. The Lagos State University Teaching Hospital is a tertiary health institution situated in Ikeja, Local Government Area of Lagos State in South-western Nigeria. It is a multi-disciplinary tertiary hospital and it has a total bed space of 520. It is a major referral centre serving the whole of Lagos State, which is the economic nerve centre of Nigeria. It has many specialists’ clinics and runs 24 hours-accident and emergency services and inpatient care services.
The study was a descriptive cross-sectional study assessing the knowledge, attitude and the utilisation of NHIS among adult patients who were 18 years and above, attending the outpatient clinics of Lagos State University Teaching Hospital (LASUTH). The minimum sample size required for the study was approximately 465 using the Cochrane formula for cross-sectional study:
The number of clients selected in each clinic was determined by proportionate allocation based on the statistics obtained from the administrative department.
Patients aged 18 years and above and also attending any of the outpatient clinics in LASUTH.
Patients who were unconscious or had mental illness
Data were collected from the respondents in the clinics using a pretested, semi-structured self-administered questionnaire. The questionnaire was divided into three sections: (1) Section A: Socio-demographic characteristics of the respondents such as age, sex, tribe, level of education, employment status, (2) Section B: Knowledge about National Health Insurance Scheme and (3) Section C: Utilisation of National Health Insurance Scheme.
Data were analysed using Microsoft Excel 2010 and EPI info software version 7, a public domain software developed by Centre for Disease Control and prevention (CDC). Data were summarised using means, standard deviation and proportions. The data were presented using tables. Relationships between categorical variables were tested using the Chi-square test and Fisher’s exact test. Relationships between continuous variable were tested using the student
The knowledge questions were scored and the overall grade was ascertained. One point was awarded for each correct answer given to the questions and no point was awarded for incorrect or ‘I don’t know’ responses.
Knowledge had a total score of 11 and knowledge was graded as either poor (score of 0–6) or good (score of 7–11).
Ethical approval was obtained from the Health Research Ethics Committee of LASUTH (LREC. 06/10/912). Verbal permission for the study was obtained from the Doctors and Matrons on duty in the outpatient clinics. Informed consent was also obtained from each respondent. The confidentiality of information collected was secured by restricting access to the data collected to investigator and research assistants. Anonymity of the respondents was ensured by not including the personal details of the respondents in the instrument. Respondents were assured that their responses will not be used against them and it will not influence the care they will receive in the facility.
A total of 487 of the 500 administered questionnaires were retrieved and analysed giving a response rate of 97.4%. The mean age of the respondents was 34.1 ± 12.1 years. Among the respondents, 35.3% were in the age range of 21–30 years, 56.7% were married, 54.0% were females, 65.5% were Christians, 58.7% had tertiary education, and 32.7% were civil servants (
Socio-demographic characteristics of the respondents (
Variables | Frequency | Percentage |
---|---|---|
> 18 | 57 | 11.7 |
21–30 | 172 | 35.3 |
31–40 | 140 | 28.8 |
41–50 | 72 | 14.8 |
51 and above | 46 | 9.4 |
Mean ± s.d. | 34.1 ± 12.1 | - |
Male | 224 | 46.0 |
Female | 263 | 54.0 |
Christian | 319 | 65.5 |
Muslim | 157 | 32.2 |
Others | 11 | 2.3 |
Single | 184 | 37.8 |
Married | 276 | 56.7 |
Divorced/Separated/widow | 27 | 5.5 |
No formal education | 15 | 3.1 |
Primary education | 20 | 4.1 |
Secondary education | 166 | 34.1 |
Tertiary education | 286 | 58.7 |
Civil servant | 159 | 32.7 |
Private sector | 104 | 21.4 |
Self-employed | 134 | 27.5 |
Student | 54 | 11.1 |
Unemployed | 36 | 7.3 |
s.d., standard deviation.
Only 7.2% of the respondents knew that NHIS does not provide maternity care for more than four live births for every insured person. Eleven point one percent (11.1%) of the respondents knew the total monthly contribution by both the formal sector employee and employer, and 13.6% of the respondents knew the percentage of the employee’s wages to be contributed by the employee (
Respondents’ knowledge of National Health Insurance Scheme (
Knowledge of NHIS | Correct response |
|
---|---|---|
Frequency | Percentage | |
The NHIS is based on the concept of social health insurance | 252 | 51.8 |
The NHIS aims to ensure that every Nigerian has access to good health care services | 348 | 71.7 |
The NHIS does not provide maternity care for up to five (5) live births for every insured person | 35 | 7.2 |
The NHIS implementation is in phases, starting with employees in the formal sector (public and private) | 250 | 51.3 |
The NHIS makes provision for vulnerable groups | 73 | 15.0 |
A contribution made by the insured person entitles him or herself, spouse and four (4) children under the age 18 years | 241 | 49.5 |
The total monthly contribution by both the formal sector employee and employer is not 20% of his or her wages | 54 | 11.1 |
The employee is to pay 5% of his or her wages | 66 | 13.6 |
Health Maintenance Organisations are the financial managers of NHIS | 124 | 25.5 |
Capitation is the sum of money paid monthly by the HMOs to healthcare providers on behalf of a contributor whether or not services are rendered by the healthcare provider | 111 | 22.8 |
An insured person pays 10% of the actual cost of drugs | 72 | 14.9 |
NHIS, National Health Insurance Scheme, HMOs, health maintenance organisations.
Most (87.7%) of the respondents have not registered with the NHIS and 43.8% of those who have not registered did not know where to register. Most (83.3%) of the respondents who had registered with NHIS had utilised the scheme for treatment in the last 6 months. Only 10% of those who have registered with NHIS have utilised it for surgical treatment. Majority (96.0%) of those who had utilised the NHIS claimed that they are satisfied with the healthcare services provided by the scheme (
Respondents’ utilisation of National Health Insurance Scheme.
Variables | Frequency | Percentage |
---|---|---|
Yes | 60 | 12.3 |
No | 427 | 87.7 |
I don’t know where to register | 187 | 43.8 |
I am not interested in NHIS | 71 | 16.6 |
I do not have time to register | 66 | 15.5 |
Others | 103 | 24.1 |
Yes | 47 | 78.3 |
No | 13 | 21.7 |
Yes | 50 | 83.3 |
No | 10 | 16.7 |
Yes | 6 | 10.0 |
No | 54 | 90.0 |
Yes | 48 | 96.0 |
No | 1 | 2.0 |
I don’t know | 1 | 2.0 |
NHIS, National Health Insurance Scheme.
Factors affecting knowledge of National Health Insurance Scheme among respondents (
Variables | Knowledge of NHIS |
||
---|---|---|---|
Poor, |
Good, |
||
0.160 | |||
Mean ± s.d. | 2.5 ± 1.9 | 6.7 ± 1.0 | |
0.166 | |||
Male | |||
Frequency (n) | 185 | 39 | |
Frequency (%) | 47.1 | 41.5 | |
Female | |||
Frequency (n) | 208 | 55 | |
Frequency (%) | 52.9 | 58.5 | |
0.112 |
|||
Christian | |||
Frequency (n) | 249 | 70 | |
Frequency (%) | 63.4 | 74.5 | |
Muslim | |||
Frequency (n) | 135 | 22 | |
Frequency (%) | 34.4 | 23.4 | |
Others | |||
Frequency (n) | 9 | 2 | |
Frequency (%) | 2.2 | 2.1 | |
0.321 |
|||
Single | |||
Frequency (n) | 152 | 32 | |
Frequency (%) | 38.7 | 34.0 | |
Married | |||
Frequency (n) | 216 | 59 | |
Frequency (%) | 55.0 | 62.8 | |
Divorced/separated/widow | |||
Frequency (n) | 25 | 3 | |
Frequency (%) | 6.3 | 3.2 | |
0.050 |
|||
No formal education | |||
Frequency (n) | 13 | 2 | |
Frequency (%) | 3.3 | 2.1 | |
Primary | |||
Frequency (n) | 20 | 0 | |
Frequency (%) | 5.1 | 0.0 | |
Secondary | |||
Frequency (n) | 137 | 29 | |
Frequency (%) | 34.9 | 30.9 | |
Tertiary | |||
Frequency (n) | 223 | 63 | |
Frequency (%) | 56.7 | 67.0 | |
0.208 | |||
Civil servant | |||
Frequency (n) | 121 | 38 | |
Frequency (%) | 30.8 | 40.4) | |
Private sector | |||
Frequency (n) | 88 | 16 | |
Frequency (%) | 22.4 | 17.0 | |
Self-employed | |||
Frequency (n) | 106 | 28 | |
Frequency (%) | 27.0 | 29.8 | |
Student | |||
Frequency (n) | 48 | 6 | |
Frequency (%) | 12.2 | 6.4 | |
Unemployed | |||
Frequency (n) | 30 | 6 | |
Frequency (%) | 7.6 | 6.4 | |
0.023 |
|||
Yes | |||
Frequency (n) | 42 | 18 | |
Frequency (%) | 10.7 | 19.1 | |
No | |||
Frequency (n) | 351 | 76 | |
Frequency (%) | 89.3 | 80.9 |
NHIS, National Health Insurance Scheme; s.d., standard deviation.
, Fisher’s exact.
Factors affecting registration with National Health Insurance Scheme (
Variables | Registration with NHIS |
||
---|---|---|---|
Yes, |
No, |
||
0.001 | |||
Mean ±s.d. | 38.9 ± 14.5 | 33.5 ± 11.6 | |
0.239 | |||
Male | 25 | 199 | |
Frequency (%) | 41.7 | 46.6 | |
Female | 35 | 228 | |
Frequency (%) | 58.3 | 53.4 | |
0.711* | |||
Christian | 40 | 279 | |
Frequency (%) | 66.7 | 65.3 | |
Muslim | 18 | 139 | |
Frequency (%) | 30.0 | 32.6 | |
Others | 2 | 9 | |
Frequency (%) | 3.3 | 2.1 | |
0.169* | |||
Single | 19 | 165 | |
Frequency (%) | 31.7 | 38.6 | |
Married | 40 | 236 | |
Frequency (%) | 66.7 | 55.3 | |
Divorced/separated/widow | 1 | 26 | |
Frequency (%) | 1.6 | 6.1 | |
0.273* | |||
No formal education | 0 | 15 | |
Frequency (%) | 0.0 | 3.5 | |
Primary | 1 | 19 | |
Frequency (%) | 1.7 | 4.4 | |
Secondary | 18 | 148 | |
Frequency (%) | 30.0 | 34.7 | |
Tertiary | 41 | 245 | |
Frequency (%) | 68.3 | 57.4 | |
0.001* | |||
Civil servant | 24 | 135 | |
Frequency (%) | 40.0 | 31.6 | |
Private sector | 20 | 84 | |
Frequency (%) | 33.3 | 19.7 | |
Self-employed | 1 | 133 | |
Frequency (%) | 1.7 | 31.1 | |
Student | 13 | 41 | |
Frequency (%) | 21.7 | 9.6 | |
Unemployed | 2 | 34 | |
Frequency (%) | 3.3 | 8.0 |
Factors affecting utilisation of National Health Insurance Scheme among respondents (
Variables | Registration with NHIS |
||
---|---|---|---|
Yes, |
No, |
||
0.0007 | |||
Mean ±s.d. | 39.6 ± 12.3 | 33.5 ± 11.9 | |
0.369 | |||
Male | 20 | 204 | |
Frequency (%) | 40.0 | 46.7 | |
Female | 35 | 233 | |
Frequency (%) | 58.3 | 53.3 | |
0.435* | |||
Christian | 34 | 285 | |
Frequency (%) | 68.0 | 65.2 | |
Muslim | 14() | 143 | |
Frequency (%) | 28.0 | 32.7 | |
Others | 2 | 9 | |
Frequency (%) | 4.0 | 2.1 | |
0.016* | |||
Single | 13 | 171 | |
Frequency (%) | 26.0 | 39.1 | |
Married | 37 | 239 | |
Frequency (%) | 74.0 | 54.7 | |
Divorced/separated/widow | 0 | 27 | |
Frequency (%) | 0.0 | 6.2 | |
0.483* | |||
No formal education | 0 | 15 | |
Frequency (%) | 0.0 | 3.4 | |
Primary | 1 | 19 | |
Frequency (%) | 2.0 | 4.3 | |
Secondary | 15 | 151 | |
Frequency (%) | 30.0 | 34.6 | |
Tertiary | 34 | 252 | |
Frequency (%) | 68.0 | 57.7 | |
0.001* | |||
Civil servant | 20 | 139 | |
Frequency (%) | 40.0 | 31.8 | |
Private sector | 16 | 88 | |
Frequency (%) | 32.0 | 20.1 | |
Self-employed | 1 | 133 | |
Frequency (%) | 2.0 | 30.4 | |
Student | 11 | 43 | |
Frequency (%) | 22.0 | 9.8 | |
Unemployed | 2 | 34 | |
Frequency (%) | 4.0 | 7.9 |
More than one-third of the respondents were between 21 and 30 years’ age range with a mean age of 34.1 (12.1 standard deviation [s.d.]). This is in contrast to a similar study conducted in rural southwest of Nigeria where about 69% of the respondents belong to the age range of 24–45 with the mean age of 39 (7.12 s.d.).
Furthermore, the results of this study revealed that less than one-third of the respondents have good knowledge of NHIS, which is consistent with findings from a similar study carried out in Lagos state among primary healthcare managers in which 17.9% had good knowledge
According to this study, less than one-fifth of the respondents have registered with the NHIS, which is similar to the study carried out in secondary health facilities in Lagos state, where only 10.1% of the respondents registered with NHIS.
In this study, over three-quarters of those who registered have obtained their NHIS cards. It was found out that most of those registered rarely used the NHIS for surgical services. This may be because most of the surgical procedures are not covered by the NHIS and patient has to pay out-of-pocket for such procedures. Almost half of the respondents used NHIS to treat medical ailment, which is similar to a study carried out in Ibadan where 52.9% of the respondents utilised the NHIS to also treat medical ailments such as Malaria.
Respondents who had attained tertiary level of education had more knowledge of NHIS and therefore registered with the scheme compared with respondents who had a lower level of education. In addition, it was also found out that age and employment status are determining factors for registration with the NHIS. Majority of the respondents who were civil servants registered with the NHIS as it is made mandatory by the government for this category of workers. Furthermore, respondents who were married utilised the NHIS services more because the scheme covers a registered member, a spouse and four children. Older respondents tend to have increased morbidity; hence they require the services of NHIS than respondents who are younger and healthy.
In summary, the study demonstrates that majority of the respondents have poor knowledge of NHIS. Majority of the respondents have not registered with the NHIS and their excuse was that they did not know where to register. A large percentage of the respondents who had registered claimed they are satisfied with the services provided by the scheme. There were significant association between age, and employment status of the respondents and their registration and utilisation of NHIS.
A potential bias in this study was recall. However, recall bias was reduced by limiting enquiries on utilisation of NHIS to the last 6 months. This may tend to underestimate the level of utilisation. Another limitation was that the implementation of the NHIS outside of the original intentions and policy framework accounted for the poor utilisation measured. Also, this is a facility-based study and the results cannot be generalised to the general population.
Majority of the respondents involved in this study had poor knowledge of the NHIS, but majority of those who had registered were satisfied with the services of the NHIS. Those who had not registered with the NHIS claimed they do not know where to register. There should be increased awareness campaigns on all forms of media with emphasis on locations of registration centres and a step-by-step process of how to register with the scheme. The government should ensure that the NHIS is mandatory for both the formal and informal sector employee so that all Nigerians can benefit from the scheme.
The authors would like to acknowledge Adetunji Emmanuel Adekunle for his contribution towards the collection and analysis of data in this study, and also Onochie Martins for his intellectual contributions and review of this study.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
A.O.A. was the project leader, reviewed the result of data analysis, reviewed the manuscript and was responsible for project design and data collection. O.A.O. was responsible for data collection, data entry, data analysis and co-wrote the manuscript. T.W.L-A., G.K.O., O.I.O. and A.T.A. were responsible for data collection, project design and review of the manuscript.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data will be made available on request.
The views expressed in the submitted article are that of the authors and not an official position of the institution or funder.