CONSTRAINTS TO EFFECTIVE UTILIZATION OF NATIONAL HEALTH INSURANCE SCHEME (NHIS) BY BENEFICIARIES IN ENUGU METROPOLIS

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ABSTRACT
Introduction
The abysmal failure of public healthcare system in Nigeria has attracted comments and criticism from local, national and even international levels. In spite of the current health sector reforms by the government, the public healthcare system in Nigeria is still inefficient in all ramifications. It is therefore argued that the problems facing the health system in Nigeria could be traced to poor implementation of National health Insurance Scheme (NHIS) as well as individual and health-related constraints. The major objective of the study was to assess constraints to the utilization of NHIS by beneficiaries in Enugu Metropolis.
Method
The study population was 1997 from six federal institutions in Enugu metropolis. It comprised of 250 staff from Federal School of Dental Technology , 731 staff from Federal Neuropsychiatric Hospital Enugu, 889 National Orthopaedic Hospital Enugu, 61 staff from Bureau of Statistics Enugu (zonal), 35 staff from National Agency for Food and Drug Administration and Control (NAFDAC) and 31 staff from Federal Ministry of Education (zonal). A sample size of 333 was determined in line with Taro Yamani (1967) formula. Multistage sampling technique was adopted which comprised of simple random sampling, proportionate sampling, and purposeful sampling to select respondents from the stratified population. The data for the study was generated from both primary and secondary sources. The instrument of primary data utilised in this research included questionnaire administered to purposefully selected workers in the six federal establishments in Enugu metropolis used for the study.
Results
The study established some health related and individual factors that constrained beneficiaries of NHIS in Enugu state. The health system factors include inadequate drugs, inadequate health facilities and the poor attitudinal factors from health service provider among others. Individual factors include the inability of the NHIS scheme to cover the beneficiaries health needs, secondly, accessibility to health facilities, poor quality of healthcare delivery rendered.
Conclusion 
The study recommended proper monitoring and sensitization of all the accredited facilities in the country and the setting up of NHIS beneficiaries/stakeholders forum.  

TABLE OF CONTENTS

Title page
Table of Content
List of tables
Abstract

Chapter One
Introduction
Background to the Study
Statement of problem
Research questions
Purpose of the study
Scope of the study
Significance
Operational definitions

Chapter Two
Literature review
Conceptual Review on Health Care Financing
Methods of Health Care Financing
Health Care financing in Nigeria
National Health Insurance Scheme
National Health Insurance Scheme (NHIS)
Utilization of Health Care Services
Health System Factors that Constrain Utilization of National Health Insurance Scheme
Individual Factors that Constrain Utilization of National Health Insurance Scheme
Theoretical Review
Conceptual framework
Empirical Review of Related Studies
Summary of literature

Chapter three
Study Area
Research design
Population of the study
Sample
Sampling procedure
Instrument of data collection
Validity of Instrument
Reliability of the instrument
Ethical consideration
Procedure of data collection
Method of data Analysis

Chapter four            
Presentation of data

Chapter five
Discussion
Conclusion
Recommendation
Suggestion for further studies
References
Appendix 


CHAPTER ONE
INTRODUCTION
Background to the Study
The establishment of the National Health Insurance Scheme (NHIS) in Nigeria was targeted to ensure equal access to health care for all Nigerians and as a form of social health insurance since the launching in 2005. Kannegiesser (2009) reports show that its uptake has been very slow. For example about 4% of the total population have been enrolled (public sector workers), and no indication of what percentage of this enrollees have benefited from the scheme. However, experience from low income countries show that individuals are at risk of unexpected ill health and incurring possible large unplanned expenditure from ill health (Mclntyre, 2007; WHO 2008). In addition, the health indicators in Nigeria have been worse when compared to other countries within and beyond Africa. For instance, maternal mortality ratio and child mortality rates have remained very high. These and other factors necessitated the establishment of the NHIS in Nigeria.
National Health Insurance Scheme (NHIS) simply defined, is a social health insurance programme designed by the federal government of Nigeria to complement sources of financing the health sector, and to improve access to health care for the majority of Nigerians (Osuorji, 2006). Report in Nigeria has also indicated that National health insurance has been used by most advanced countries in it various forms to fund health care (Awosika, 2005). This same report indicated that insurance in one form or the other remains a veritable and sustainable tool for financing the hard way, delivery structure and systems of healthcare. However, it is only recently being applied by low income nations to address the glaring problem of inadequate healthcare provision, which was hitherto financed exclusively from public taxation (Awosika, 2005). 
The NHIS was set up with the mission of facilitating fair financing through pooling and judicious utilization of financial resources to provide financial risk protections and cost burden sharing for people, against high cost of healthcare, through various prepayment programmes/products (http://www.nhis.gov.ng). This is in addition to provide regulatory oversight to health maintenance organization (HMOs) in the country. The objectives of the scheme are: to ensure that every Nigeria has access to good health, to protect families from ill health and distribute health care costs equitably among different income groups, to set and monitor standards of health care delivery services and to effectively ensure efficiency in health care services. In addition, the scheme is meant to ensure private sector participation in the provision of health care services, adequate distribution of health facilities within the federation, equitable patronage of all levels of health care, and to make funds available to the health sector improved services.
In order to ensure that every Nigerian has access to good health care services, the National Health Insurance Scheme has developed various programmes to cover different segments of the society, which includes  Formal Sector Health Insurance Programme,  the Urban Self-employed Social Health Insurance Programme, Rural Community Social Health Insurance Programme, Children Under-Five Social Health Insurance Programme, Permanently Disabled Persons Social Health Insurance Programme, Prison Inmates Social Health Insurance Programme,  Tertiary Institution and Voluntary Participants Social Health Insurance Programme, Armed Forces, Police and Other Uniformed Services (NHIS operational guidelines, 2005). The scheme operations commenced with the launching of the formal sector programme on 5th June 2005. The launch represented the first step towards attaining the objective of universal coverage for all Nigerians. 
The formal sector programme is meant to draw enrollees working with the private sector and those working with the public sector at federal, state and local government levels based on the scheme’s design. It is mandatory for public servants working in all government ministries, agencies and parastatals to enroll in the scheme. Private sector organization employing more than 10 people are also required to ensure that their employees are enrolled in the programme. All other Nigerians can voluntarily enroll along with their households. All formal sector employer (including the government) pays an equivalent of 10% of the wages for each enrollee to NHIS. These funds are channeled to a single pool like the National Health Insurance Fund and managed centrally by the NHIS. Some studies have indicated that people in the formal sector are generally more financially secure than average, and also more easily organized into health insurance scheme since their income is readily identified and can often....

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