|Year : 2022 | Volume
| Issue : 3 | Page : 315-324
Awareness and perception of public/civil servants toward the National Health Insurance Scheme in Minna, Niger State, Nigeria
Ezekiel James1, Olaiya P Abiodun2, Olaniyi F Sanni3
1 Office of HIV and TB, United States Agency for International Development, Plot 1075, Diplomatic Drive, Central Business District, Abuja, FCT, Nigeria
2 COVID-19 Vaccination, Department of CST, World Health Organization, Accra, Ghana, Nigeria
3 Fescosof Data Solutions, Sango Ota, Ogun State, Nigeria
|Date of Submission||09-May-2022|
|Date of Acceptance||22-Jul-2022|
|Date of Web Publication||29-Sep-2022|
Dr. Olaniyi F Sanni
Fescosof Data Solutions, Sango Ota, Ogun State
Source of Support: None, Conflict of Interest: None
Background: Nigeria’s healthcare system has been characterized by a decline in healthcare service providers due to the inability of governments to adequately fund healthcare services over the years. Thus, this study aims to assess the knowledge and perception among public/civil servants toward the National Health Insurance Scheme (NHIS) in Minna, Niger State, Nigeria. Materials and Methods: The study was conducted using mixed qualitative and quantitative research methods. The study employed a descriptive research design that is also comparative. Data were collected using questionnaires and presented and analyzed using IBM-SPSS version 25.0 for Windows with the help of tables and graphs. Results: Most respondents were aware of the National Health Insurance Scheme (NHIS), but there was an overall unimpressive perception of NHIS funding, cost, and coverage. Age, gender, marital status, education, and grade level were not considerably associated with knowledge of NHIS (P > 0.05), but those spending more than 5000.00 Nigerian Naira (NGN) monthly on medical bills were more aware of NHIS than those paying ≤2000 (P < 0.05). The perception of NHIS was not significantly associated with gender, marital status, grade level, education attainment, and monthly expenses on healthcare services (P > 0.05) but was significantly associated with age. Conclusion: The study concluded that there is a high awareness of NHIS among the study respondents, although not all had in-depth knowledge of the operations of the health insurance scheme. More efforts are required to increase awareness of NHIS and its benefits among public/civil servants in Minna, Niger State, Nigeria, to improve participation in the scheme.
Keywords: Healthcare, knowledge, National Health Insurance, perception
|How to cite this article:|
James E, Abiodun OP, Sanni OF. Awareness and perception of public/civil servants toward the National Health Insurance Scheme in Minna, Niger State, Nigeria. MGM J Med Sci 2022;9:315-24
|How to cite this URL:|
James E, Abiodun OP, Sanni OF. Awareness and perception of public/civil servants toward the National Health Insurance Scheme in Minna, Niger State, Nigeria. MGM J Med Sci [serial online] 2022 [cited 2023 Feb 6];9:315-24. Available from: http://www.mgmjms.com/text.asp?2022/9/3/315/357476
| Introduction|| |
Nigeria is confronted with managing the increasing cost of healthcare services provision. These challenges revolve around finance, efficiency, equity, infrastructure, and human resource constraints., Although most developed countries have made conscious efforts to review their healthcare financing policies and to create more realistic, efficient, and sustainable options for these challenges, Nigeria, like many developing countries, has not been able to do so. The country is still faced with the challenge of mobilizing enough financial, human, and other resources to meet the healthcare needs of the citizens. Meeting the basic health needs of most people remains a challenge, and the prospect of achieving this goal in the future seems elusive. This is also the situation in Niger State.
Nigeria’s healthcare system is characterized by a decline in healthcare service providers due to the inability of successive governments to fund healthcare services over the years adequately., This challenge has resulted in the gradual deterioration of healthcare services in terms of infrastructure, human resources, spread, access, quality of care, and the state of physical facilities. The National Health Insurance Scheme (NHIS) was launched in 2005 by the Federal Government of Nigeria to make healthcare services accessible and affordable to all Nigerians., A large increase in financial resources for health is needed to scale up health interventions and develop health delivery systems to guarantee that these interventions are accessible, particularly for the poor. This scheme was presented with the potential of establishing a guaranteed pool of funds for health, boosting the efficiency of administration of health resources, and protecting individuals from catastrophic spending on health. However, the Niger State government did not domesticate the scheme until 2019. The 14 years’ gap when the project was launched in federal and Niger states meant that successive governments in the state did not give the scheme the priority attention it deserves despite its enormous benefits. Although the Niger State government had made serious efforts to launch the scheme in the state, there has been disagreement between the government and the labor unions over the obligatory 2.5% counterpart funding from civil servants. This disagreement, coupled with the lukewarm attitude of the state government, has affected the people’s trust in them and enrollment into the scheme for derived benefits.
The apathy demonstrated by the labor unions and the workers is linked to insufficient information or outright ignorance of the workings of a health insurance scheme, or mistrust, or broadly stated as political cynicism. The lack of trust or negative perception of workers about NHIS is premised on the mismanagement of past schemes, like the Nigerian Social Insurance Trust Fund and the pension scheme. Correcting the negative perception of workers about NHIS is important to the successful implementation of the scheme. The assessment of the level of awareness and perception of public servants in Minna about NHIS is what this study aimed to achieve.
A review of Nigeria’s health budget over the past 10 years (2010–2019) shows that provisions for the health sector range from 3.9% to 5.8%, which is far below the minimum 15% benchmark agreed to in 2001 when the Heads of the State of African Union Member countries met and pledged to set a target of allocating at least 15% of their annual budget to improve the health sector (The Abuja Declaration). For example, the 2020 budgetary allocation of NGN 427.3bn to the health sector out of the total NGN 9.45tn budgeted for 2020 by the Federal Government, representing 4.5%, has shown no significant improvement in the allocation over that of the previous year, 2019, which was NGN 372.7bn, representing 4.2%. Similarly, a review of the Niger State budget over the same period (2010–2019) shows a 5.1–12.5% range. The gross underfunding of the health sector has resulted in inadequate health infrastructure, a dearth of qualified health personnel leading to a shortage of healthcare workers, out-of-stock of essential drugs and basic equipment, epileptic supply of electricity to run the facilities, inadequate supply of water for day-to-day operations, emigration of health professionals to the Diaspora, otherwise known as brain drain, and frequent industrial action by health professionals.
The NHIS was launched in 2005 by the Federal Government of Nigeria as an alternative source of financing for the health sector to mobilize resources to complement the inadequate budgetary allocations to the health sector and contain the rising costs of care, which denies the poor access to improved healthcare services. At the federal level, the NHIS primarily covers the formally employed, a group representing less than 5% (10 million individuals) of the entire population of Nigeria, estimated at 206,139,589 people in 2020, according to the recent UN data. Only a few states, including Niger State, have adopted the scheme by establishing the State Contributory Health Insurance Scheme. The Niger State House of Assembly signed its bill to develop the scheme into law on December 19, 2018 and accented to by the State governor on January 9, 2019, in preparation for its take-off.
| Materials and methods|| |
The study was carried out in Minna, Niger State, located in the North Central region of Nigeria. Niger State covers 76,363 km2 and is divided into 25 local government areas. In Niger State, public officials account for just 0.7% of the state population of 3,954,772 from the 2006 National Census.
The study is a descriptive survey that is also comparative, using mixed qualitative and quantitative research methods. Semi-structured questionnaires were used to obtain data from participants selected from 10 ministries in Minna, Niger State. Participants were determined using the multi-stage sampling technique. The multi-stage sampling was carried out in three stages. Stage 1 involved a random selection of 4 out of 12 ministries; stage 2 involved the appointment of four out of eight blocks in a ministry using simple balloting; and stage 3 was the administration of research questionnaires to all workers met on duty in the offices as at the time of the study.
Study population and sample size estimation
The state has 26,000 public/civil servants and 1,740 were selected from 10 ministries. The sample population comprised staff of the Ministry of Health and Health Services-307, Tertiary Education-124, Finance-161, Justice-162, Land and Housing-173, Agriculture and Rural Development-221, Local Government, Community Development, and Contingency Affairs-104, Information and Strategy-102, Rural Water and Sanitation Agency (RUWATSAN)-106, and Gender Affairs and Social Development-280, making a total of 1,740.
The sample size was calculated using the Taro Yamane formula, as demonstrated below:
where n is the sample size, N is the population size, and e is the level of precision = 5% = 0.05 at a 95% confidence level:
A multi-stage sampling method was used to select the study respondents.
Ministries and parastatals were clustered from a list of all ministries and parastatals in the state using their functions. Ten ministries and parastatals were selected purposively from the clusters.
The civil servants were selected by stratified sampling according to their ministry/parastatal. Sampling was done using selection proportionate to size, such that:
- Health Services = 307/1740 = 0.176 * 325 = 57
- Tertiary Education = 124/1740 = 0.071 * 325 = 23
- Finance = 161/1740 = 0.092 * 325 = 30
- Justice = 162/1740 = 0.093 * 325 =31
- Land and Housing = 173/1740 = 0.099 * 325 = 32
- Agriculture = 221/1740 = 0.127 * 325 = 41
- Local Government = 104/1740 = 0.060 *325 = 20
- Information = 103/1740 = 0.059 * 325 = 19
- RUWATSAN = 106/1740 = 0.060 *325 = 20
- Gender Affairs = 280/1740 = 0.160 * 325 = 52
From each stratum, a random sample of each population was drawn.
The different ministries/pareastatals were further grouped into grade-level categories from grade levels 1 to 17/SG using the Niger state workforce distribution list by grade level accordingly: 1–5; 6–10; 12–16; and 17/SG.
The required number for each grade level category was derived from each grade level category using proportion according to grade-level size.
The standard questionnaire containing open- and closed-ended questions was pilot-tested within a sample population and modified before administering to respondents after obtaining consent. Research assistants were engaged in distributing the questionnaire to the respondents. The questionnaire was made up of five sections with questions relating to:
- i. The socio-economic and demographic characteristics of the respondents;
- ii. Assessment of awareness and general knowledge about NHIS;
- iii. Assessment of perception of respondents on the NHIS;
- iv. Assessment of attitudes of respondents toward enrollment into the NHIS; and
- v. Evaluation of factors affecting the implementation of the NHIS in Niger State.
Data were analyzed using IBM-SPSS version 25.0 for Windows. The χ2 analysis was performed to establish the association between variables and a 95% confidence interval, and a P-value of 0.05 was considered statistically significant. The outcomes of data analysis were presented in tables.
Respondents’ knowledge of the benefits and goals of NHIS was assessed with 11 questions with “True = 1” and “False =0” responses, making a total score of 11 points; higher points indicate better knowledge of NHIS. Percentage knowledge score (total correct score/total possible score × 100) was categorized into poor (0–49.9%), average (50.0–69.9%), and good (70.0–100.0%), according to Michael et al. A score of ≥50% was considered “adequate knowledge of NHIS knowledge,” whereas a score <50% was considered inadequate/poor knowledge. The overall respondents’ knowledge was very high (9.36 ± 1.66), representing 85.1% of the total 11 points assessment. Similarly, the perception was measured over seven questions, with each having a Likert scale of 1–5, meaning that the maximum score is 7 × 5 = 35 points. Higher points indicate positive perceptions. NHIS perception ≥70% (24.5 over 35) was considered good perception and score <70% average perception.
Ethical approval was sought and received from the Health Research Ethics Committee of Niger State Ministry of Health (STA/495/Vol/171). Only those individuals who were willing to participate were recruited and informed about the purpose of the study. All participants gave consent. Consideration was given to the issue of plagiarism. This research work followed all the guidelines and protocols provided by the Academic Committee of the University to prevent plagiarism, including indicating and acknowledging sources to give credit to them.
| Results|| |
The study comprised 169 (52.2%) males and 155 (47.8%) females. As shown in [Table 1], 277, representing 85.5% of the respondents, were within the age 30–59 years, with the peak age at 40–49 years [99 (30.6%)] and a minimum at 20–29 years [26 (8.0%)] and 60 years and above [21 (6.5%)]. The majority, 260 (80.2%) of the study respondents, were married, 33 (10.2%) were single, and 31 (9.6%) were widowed/divorced. Almost half of the respondents, 145 (44.8%), had a family size of three to four members, and 74 (23.1%) had seven or more members. Respondents within grade levels 6–10 years accounted for 138 (42.6%) of all respondents, 96 (29.65%) were within levels 12–16, and only 6 (1.9%) in level 17 or secretaries-general [Table 1].
[Table 2] shows that 317 (97.8%) were aware of NHIS, mainly through radio/TV [261 (82.3%)]. Almost all the respondents, 291 (91.8%) said that the information received was encouraging. Similarly, a high proportion of 273 (84.3%) respondents said that the information received had a positive influence on their attitudes toward the NHIS, 243 (75.0%) said their organizations were planning to introduce NHIS, 285 (88.0%) were willing to register on the scheme, and 277 (79.6%) preferred using government hospitals.
|Table 2: Awareness/knowledge of NHIS among public/civil servants in Niger State|
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As shown in [Figure 1], there was a high level of awareness demonstrated by the respondents on the benefits of NHIS. The majority, 306 (94.4%), knew the benefits of NHIS to them as contributors and family members with four children up to 18 years old, 303 (93.5%) knew that NHIS ensures efficiency in healthcare services, 303 (93.5%) were aware that the scheme protects families from financial hardship, and 285 (88.0%) knew that NHIS ensures availability of fund for improved healthcare services. Only 73 (22.5%) were aware that beneficiaries have the right to change their care providers after a minimum of 6 months if they are not satisfied with the services received from the providers.
Respondents’ knowledge of the benefits and goals of NHIS was assessed with 11 questions and had a total score of 11 points; higher points indicate better knowledge of NHIS. The overall respondents’ knowledge was very high (9.36 ± 1.66), representing 85.1% of the total points assessed. Knowledge of NHIS benefits and goals was not significantly different between males and females, age category, marital status, grade level, years in service, and education attainment (P > 0.05). However, the knowledge decreased with the amount spent on medical services: 90.5% among those paying ≤2,000 and 81.4% among those paying more than NGN5,000.00 each month (P < 0.05), as shown in [Table 3].
|Table 3: Association between respondents’ demographic characteristics and knowledge of NHIS|
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As shown in [Figure 2], higher knowledge of NHIS was found among ministries of Agriculture and Rural Development (10/11), Finance (10/11), Health and Health Services (9.5/11), Information and Strategy (9.7/11), Local Government, Community Developments, and Contingency Affairs (10.0/11), and Tertiary Education (9.8/11), whereas the level of NHIS awareness was lower among ministries of Gender Affairs and Social Development (8.9/11), Justice (9/11), Land and Housing (8.1/11), and RUWATSAN (8.0/11).
|Figure 2: Distribution of respondents’ knowledge of NHIS across ministries|
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The perception of respondents on NHIS was tested using seven Likert-scale questions. The majority, 199 (61.4%) and 101 (31.2%), of the respondents expressed a poor perception of the present system of health services funding by the state government, 124 (38.3%) and 162 (50.0%) about the high cost of medical services, and 106 (32.7%) and 158 (48.8%) about the limited coverage of the NHIS. There was an overall poor respondents’ perception of NHIS funding 1.52 (30.5%), cost 1.84 (36.8%), and coverage 2.04 (40.98%). However, they perceived the scheme as a good one, 4.40 (88.0%). They also expressed satisfaction with the creation of access to healthcare services 4.20 (84.0%), the level of publicity given to the scheme 3.78 (75.6%), and agreed to participate in the scheme 4.01 (80.2%), as shown in [Table 4].
The overall perception was 21.78 ± 2.63, representing 62.2%. The perception of the NHIS was not significantly different between males and females, married and unmarried respondents, grade level, years in service, education attainment, and monthly expenses on healthcare services (P > 0.05). However, the perception increases with age, from 60.5% among respondents aged 20–29 years to 66.3% among those aged 60 years and above [Table 5].
|Table 5: Association of respondents’ perception of NHIS with demographic characteristics|
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Although all the respondents showed the average perception of the NHIS, the viewpoints of respondents from the Justice and Land and Housing ministries had the least scores of 20.6 and 20.3 of 35 points, respectively, as shown in [Figure 3].
| Discussion|| |
Awareness among public/civil servants on the health insurance scheme
The majority of the study respondents (97.8%) have heard about NHIS, although not all had in-depth knowledge of the insurance system. The high level of awareness may be attributed to the fact that the majority of the respondents (91%) are literate and have attained tertiary education. Another reason may also be an initial sensitization carried out by officials from the state ministry of health to civil servants in the different ministries, agencies, and departments in preparation for the take-off of the scheme among the formal sector workers in the state. Television and radio were the significant sources of information about NHIS, and 91.8% were satisfied with the information received. This finding is in line with Adewole et al. and Olayemi, where television and radio were the major sources of disseminating information to 42.8% and 32.4% of the respondents, respectively. This may be because television and radio have wide acceptance and are the common channels of information sharing readily found in every household in Nigeria. The respondents were also aware of the benefits of NHIS, regardless of their gender, age category, marital status, grade level, years in service, and education attainment. This is contrary to the study of Adewole et al., in which awareness was shown to be significantly better among singles compared with married and among individuals with post-secondary education compared with others. However, respondents from the ministries of Gender Affairs and Social Development, Justice, Land and Housing, and RUWATSAN showed a significantly lower awareness of the benefits of NHIS than participants from other ministries (P < 0.05). The high knowledge of NHIS found in this study is similar to the reports of previous studies in Nigeria. For example, a study conducted among librarians in Abuja and Lagos revealed that 80.6% knew the objectives of NHIS; in Ilorin, 78.9% of formal sector workers were aware of the NHIS; in Sokoto, 99.3% of the academic staff of Usmanu Danfodiyo University were aware of the NHIS. Whereas a survey conducted among civil servants in Oyo reported knowledge of NHIS at 91.1%; in Kano, 80.5% of National Youths Service Corps were aware of the scheme; 92.3% of civil servants in Cross Rivers State were aware; and all (100%) radiographers in southeast Nigeria were aware. It is also similar to 89.5% awareness among health professionals in South Africa. Conversely, insufficient knowledge of NHIS was reported among 80.7% of the patients in a tertiary hospital in Lagos and among civil servants in Osun State, where only 40% were aware of NHIS. Among surgical patients in Niger Delta, only 3.06% were aware of NHIS. The variation observed in knowledge might be due to time differences and different study populations. For instance, the studies that showed high knowledge of NHIS were conducted among educated participants, including civil servants, youth corps members, and health professionals.,,,, In contrast, studies that reported inadequate knowledge of NHIS were conducted a decade ago, or among patients, some of whom may be uneducated or reside in rural areas.,,
This study did not find any significant difference between men and women and level of education concerning willingness to enroll in NHIS. However, previous research has revealed that enrollment is more prevalent among males and those who had higher education and severe illness diseases. It has been stated that people who attained a higher level of education are often more capable of accessing many sources of information, processing it effectively, and reaping the inherent advantages than those with a lower level of education or those without formal education. In this study, the majority (91.0%) of the participants are literate and have attained tertiary education, which might be a significant reason for the high level of awareness.
The study’s findings showed a significant association between knowledge and willingness to register and contribute part of their income to NHIS; 89.3% and 83.3% of the respondents are aware of NHIS and are willing to register and contribute a percentage of their monthly salary to the scheme. In addition, respondents aware of NHIS were 21 and 30 times more likely to register and contribute parts of their monthly wages to the scheme than those unaware. Knowledge of a topic or an event often occurs before activating interest and potentially active involvement in that topic or activity. Nyagero et al. demonstrated that individuals who knew about national insurance were willing to enroll. Studies have also shown that understanding correct information about NHIS is positively associated with enrollment., Sensitizing the civil servants on NHIS and its benefits might lead to a surge in willingness to enroll in the scheme. It is worthy of note that sustaining a program such as the NHIS requires adequate sensitization and understanding of its advantages.
Perception and attitudes of respondents about NHIS
Regarding the respondents’ perception of the subject matter of research, the results show a generally negative attitude about NHIS due to inadequate funding, the high cost of medical services, and limited coverage. However, participants who agreed the scheme was an excellent move to create access to healthcare services and will be ready to participate if their concerns, such as inadequate coverage of services, attitudes of operators of the scheme, insincerity on the part of the government, and availability of drugs, were adequately addressed. Respondents’ perception was similar across gender, marital status, grade level, years in service, education attainment, and monthly expenses on healthcare services (P > 0.05) but significantly associated with age (P < 0.05). Respondents from ministries of Justice and Land and Housing that showed a lower level of knowledge of NHIS also exhibited similar negative attitudes more than their counterparts from other ministries. This finding indicates the need for sensitization and awareness interventions among the staff of these ministries.
The study reveals that respondents who exhibited a better attitude about NHIS were more likely to register and contribute a portion of their monthly salaries to the scheme than those with negative attitudes. Similar to the lower level of knowledge and negative attitude observed among respondents from the ministries of Land and Housing, Justice, and Gender Affairs and Social Development, the majority of respondents from these ministries also considered the 5% deduction of their gross salaries too high, unlike their counterparts from the ministries of Information and Strategy, Agriculture and Rural Development, Finance, and Local Government, Community Development, and Contingency Affairs that considered it acceptable (P < 0.001).
Similar unimpressive attitudes have been reported in several studies among graduates, medical professionals, and individual enrollees.,,, Michael et al. associated unwillingness to enroll in NHIS among youth corps with a negative attitude about the program, despite having sufficient knowledge about the scheme. Several other studies have also emphasized the dependence of NHIS on the perceptions and attitudes of both healthcare providers and enrollees.,,
It has also been reported by Iloh et al. that willingness to continue or enroll in an insurance program depends on the enrollee’s satisfaction and perception of the program. A study conducted in Ghana by Jehu-Appiah et al. revealed that participants who perceived NHIS as beneficial were about two times more likely to enroll than those who had negative attitudes. The result of this study contrasts significantly with the results of the study conducted by Okaro et al. and Oladimeji et al. on medical doctors. The outcome of their studies shows that even though the participants believed that NHIS implementation would improve healthcare delivery, they were apprehensive that it would reduce what they take home as monthly salary. This finding underscored the need to carry out more enlightenment on public and civil servants in Niger State to encourage them to make meaningful contributions toward financing the NHIS irrespective of its impact on their monthly wages.
| Conclusion|| |
This study was carried out among public/civil servants in Minna, Niger State, Nigeria, to assess the level of awareness and perception of the health insurance scheme. Findings have shown that there is high awareness about the NHIS among the study respondents, although not all had in-depth knowledge of the operations of the health insurance scheme. However, the overall perception of the scheme was unimpressive. More efforts are required to increase awareness of NHIS and its benefits among public/civil servants in Minna, Niger State, to improve participation in the scheme.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]