Background: Awareness of your rights and responsibilities as an enrollee of the National Health Insurance Scheme (NHIS) is key to fully accessing all benefits of the scheme. It also helps when giving a valid assessment of the healthcare services received through the scheme. This study has assessed the level of awareness of the rights and responsibilities of NHIS enrolled staff from the Federal Colleges of Education in North Central Nigeria.
Methods: The study was a descriptive cross-sectional investigation in which 165 selected participants completed a self-administered semi-structured questionnaire. The data was collated and analyzed using descriptive statistics, specifically frequency, mean, and percentages. Six research questions were raised and answered.
Results: Most (79.15%) of the respondents were fully aware of the NHIS objectives but only a few (43.15%) and (52.40%) were aware of the benefits and their responsibilities as enrollees of the NHIS. Similarly, many (47.88%) were not aware of the procedures used to seek for redress when dissatisfied with the services they received. Additionally, 80.4% believed that their healthcare providers operate in a clean environment and 80.8% felt that the doctors and nurses were friendly and cordial, though 62% claimed to have experienced a long waiting period before doctor/nurse consultations. Finally, 73.5% of the respondents agreed that they were satisfied with the quality of the service rendered by their healthcare providers.
Conclusion: This study therefore recommends the proper enlightenment of enrollees in order for them to be aware of all of the provisions of the NHIS. The government should employ more medical personnel, especially doctors, in order to reduce the pressure on the few available as well to enhance the patient consultations by making them faster.
Human productivity is greatly linked to total wellbeing as it relates to mental, psychological, sociological, and physical health status. Good physical wellbeing results in a major boost to the productivity and economic growth of individuals and nations in most developed countries. Countries of the world that prioritize the health of their citizens, especially the work force, are always known to have a higher level of productivity and economic prosperity 1 . The understanding of this has made many countries worldwide, including Nigeria, invest in the health and wellbeing of various categories of their public servants, especially civil servants in public tertiary institutions. This category of workers in the higher institutions of learning is pivotal to the achievement of the general philosophy of Nigerian education 2 .
Education has been described as an instrument par excellence for achieving national development through the provision of skilled human resources 2 . This is because the strength and level of development of the nation is hinged on the strength and efficiency of the human resources made via the educational system, especially tertiary education. Thus one of the objectives of the tertiary education in Nigeria is the advancement of Nigeriaâ€™s economic growth and global competitiveness through the provision of accessible and relevant quality education via its tertiary institutions as a worthwhile goal.
As part of achieving the economic, political, and technological aims of establishing tertiary educational institutions in Nigeria, especially through the Colleges of Education, the government is keen to provide an enabling environment by a way of health insurance for all stakeholders, especially its staff. This will enhance their general contributions to the national and institutional goals of the colleges. One way of doing this is by making sure that the staff have access to efficient and affordable healthcare facilities by enrolling them in the National Health Insurance Scheme (NHIS). The NHIS was established in 2005 with the objective of improving the health status of Nigerians through the provision of health financial protection 3 . The NHIS operates on the financing principle of social health insurance which provides financial protection to the enrollees in the event of them falling sick. The health risks and financial contributions of the enrollees are pooled together with contributions from their employers to provide them with accessible healthcare services. Contributions are based on their ability to pay while access to the services is based on need 4 . In formal sectors like higher institutions of learning, the contributions are proportional to the basic salary of the enrollees. This represents 15% of the basic salary out of which the enrollee (employee) pays 5% and the employer pays 10% 5 . This contribution covers the healthcare benefits package for the employee, their spouse, and four biological children below the age of 18 years 6 .
NHIS, as a form of Social Health Insurance (SHI), is aimed at ensuring Universal Health Coverage (UHC). This will in turn ensure equitable access to affordable healthcare services by the enrollees. There are three major dimensions to any Universal Health Coverage (UHC) program: the proportion of cost covered, the types of services available, and the groups of individual included 7 . Achieving UHC is largely dependent on the understanding of these dimensions by the participants and potential participants 8 . After 15 years following the commencement of the NHIS among formal sector workers, it is necessary to appraise the perception and level of awareness of the National Health Insurance Scheme among the beneficiary staff in the Federal Colleges of Education in the North Central Zone of Nigeria. This has become necessary because there is a dearth of information on the NHIS among the staff of the Colleges of Education in Nigeria. This will enable an assessment of their understanding of the basic NHIS concepts, benefits, packages, and responsibilities, and their level of satisfaction with the scheme.
This study therefore examines the perception and awareness of the employees of Federal Colleges of Education in the North Central zone regarding the National Health Insurance Scheme (NHIS).
Statement of the Problem
The government effort to ensure health insurance for all workers in tertiary institutions, especially Colleges of Education, through the National Health Insurance Scheme (NHIS) is commendable. This is because Colleges of Education represent an important educational sector where teachers, commonly believed to be â€śnation builders,â€ť are being trained. These teachers mold and inculcate the values of society into the upcoming generations through teaching and learning in their classrooms. All human resources involved in producing competent teachers need to perform optimally. This can only be achieved through staff who are sound in terms of both their health and emotional disposition.
Despite this laudable health insurance stride for workers in the Colleges of Education in Nigeria, there have been complaints from some of the workers on the quality of the healthcare services that they receive from their Healthcare Providers (HCP), especially the clinics located within their campus community. This dissatisfaction could be attributed to their level of awareness of the provisions of the National Health Insurance scheme (NHIS). Whether there is an adequate level of knowledge among the staff enrollees on the objectives of the scheme, the benefits, the responsibility of the enrollees, how to seek redress, their responsibilities, and the limitations of the healthcare provider as provided by National Health Insurance scheme guidelines will be very important to understand in order to fully maximize the opportunities provided by the scheme.
This study seeks to, among other things, assess the knowledge of the staff enrollees in the Colleges of Education in North Central Nigeria on their rights and responsibilities under the National Health Insurance Scheme (NHIS).
1. Are the staff enrollees aware of the objectives, benefits, and their responsibilities under the National Health Insurance Scheme (NHIS)?
2. What is the percentage of staff who have changed their HCP due to dissatisfaction?
3. What are the opinions of the staff on the adequacy of the facilities or resources at their healthcare providersâ€™ centers?
4. What are the opinions of the staff on the quality of the routine attendance services they have received from their healthcare providers?
5. What are the perceptions of the staff on their referral experiences within their healthcare providers?
6. What is the level of satisfaction of the staff on the quality of the services they have received from their healthcare providers?
Population and sample
This study adopted a descriptive research design for the data collection. The research population targeted for the study was all NHIS staff enrollees across all of the Federal Colleges of Education in North Central Nigeria. The study sample was randomly selected from the total population. A pilot study was conducted on a small separate sample. Those involved in the pilot study were not included in the investigation proper. All NHIS staff enrollees that had passed through the processes of card collection, consultation, laboratory investigation, and pharmacy for drug collection were the source population. The level of awareness and knowledge of the respondents was assessed based on their responses to the question items on the areas of the objectives, responsibilities, effectiveness, and benefits of the NHIS. The sample was collected from three Colleges of Education; the Federal College of Education Okene, the Federal College of Education Pankshin, and the Federal College of Education Zuba. One hundred and sixty five (165) staff in total from the colleges were involved.
A self-constructed questionnaire was developed and validated using the test and retest method. The final corrected copy was used for a pilot study before being adopted for the main study. The respondents were briefed on the purpose of the study and oral consent was obtained. The Staff NHIS Awareness, Perception and Evaluation Questionnaire (SNAPEQ) was used to obtain the raw data from the respondents. The questionnaire was sectioned into three (A, B and C) to accommodate the respondentsâ€™ demographic information, their awareness of the NHIS provisions (objectives, benefits, enrollee responsibility, and redress procedures) and their perceptions of the healthcare providersâ€™ service delivery respectively.
Fifteen (15) questions on the NHIS provisions were put forward and the respondents were asked to choose Yes, No, or Not Sure. Twenty-six (26) questions consisting of a 5-point response scale were developed for the survey on the perceptions of the NHIS Healthcare providersâ€™ service delivery. The respondents were requested to rate their level of perception of the NHIS Healthcare providersâ€™ service delivery on a scale of 5 to 1 (highest to lowest) in the space provided. The instrument was prefaced: Strongly agree = 5, agree = 4, Undecided =3, Disagree = 2, and Strongly disagree = 1.
Data Collection and Analysis
The researchers were involved in the distribution of the questionnaire. They provided guidance to the respondents where necessary on how to respond to the question items raised and provided assurance that their confidentiality and anonymity would be maintained. They also ensured the satisfactory retrieval of the data instrument. The completed questionnaires were sorted and entered into the Microsoft 2007 Excel package for analysis. The descriptive statistics of the respondentsâ€™ characteristics and the answers to the questions from the questionnaire were computed, including the frequency distribution, means score, percentages, and Average Weighted Response. This was then used to answer the research questions.
Figure 1 . Staff awareness of NHIS provisions.
Figure 2 . Percentge of staff who changed NHIS Health Care provviders (HCP) .
A total of one hundred and sixty five (165) participants were included in this study. Table 1 summarizes the socio-demographics of the respondents. A total of 118 (71.52%) were male and 47 (28.48%) were female. A total of 79 (47.88%) were academic staff and 86 (52.12%) were non-academic staff. A greater percentage, totaling 66 (40.0%), of the respondents were between the age of 41 â€“ 50 years old. A total of 136 (82.43%) respondents had higher education qualifications ranging from a HND to PhD, 9 (1.79%) had obtained a secondary school education, while 4 (0.80%) only had a primary education. Moreover, at least 151 (91.50%) respondents had been with their present healthcare providers for at least 3 years.
Research Question 1: Are the staff enrollees aware of the objectives, benefits, and their responsibilities under the National Health Insurance Scheme (NHIS)?
Figure 1 shows the knowledge and awareness of the respondents on the objectives, benefits, and staff responsibility under the NHIS. Specifically, 79.15% were aware of the objectives of the scheme and 9.79% were unaware while 11.15% were unsure of the NHIS objectives. Less than half of the respondents (43.15%) were fully aware of the benefits they stand to gain from the scheme while 40% were not sure of the benefits of the NHIS. Only 52.42% of the respondents were aware of their responsibilities as enrollees of the scheme while 44.85% were not aware of their responsibilities. On the knowledge of the procedures used for redress, about 52.12% were aware of the procedures used for redress whenever there was dissatisfaction while 42.42% were not aware of any of the redress procedures for when the need arises.
Research Question 2: What is the percentage of staff that have changed their HCP?
Figure 2 represents the levels at which the enrollees have changed their healthcare provider (HCP); only about 16% were aware of the enrollees changing their HCP, while 82% had no knowledge of individuals changing their healthcare provider.
Research Question 3: What are the opinions of the staff on the adequacy of the facilities or resources at their healthcare providersâ€™ centers?
Table 2 shows the staff perception of the adequacy of the facilities and resources at their NHIS centers. Specifically, 80.4% of the respondents believed that their HCP operates in a clean environment but 36.6% felt that their HCP did not have up-to-date medical equipment. Additionally, 25.8% believed that their HCP lacked an adequate number of medical personnel.
Research Question 4: What are opinions of the staff on the quality of the routine attendance services that they received from their healthcare providers?
Table 3 shows the staff opinions of the routine services that they received at their NHIS provider centers. In addition, 62% of the respondents have experienced a long waiting period before they were attended to, 31.6% felt they had not been given prompt attention while on their sick bed when they made the call, 23.6% did not enjoy the courtesy of the reception when they visit their HCP, and a handful (30.4%) claimed that they had not been too involved in decisions made about their care and treatment. Some (23.4%) are beginning to lose confidence and trust in the doctors/nurses at their HCP. However, 80.8% confessed that the doctors/nurses usually give them adequate time to discuss their medical problems, 78% attested that their questions were handled in an understandable manners, and 79.2% believed they have received adequate instructions on how to use their prescribed drugs.
Research question 5: What are the perceptions of the staff of their referral experiences with their healthcare providers?
Table 4 shows the quality of the referral services received from the NHIS centers. Only about 45% of the respondents have experienced a referral in the last 12 months and they were offered their choice of hospital for their referral.
Research question 6: What is the level of satisfaction of the staff regarding the quality of the services that they received from their healthcare providers?
Table 5 shows the level of staff satisfaction with the services received from their HCP providers. Specifically, 80% of the respondents opined that the NHIS has lessened the challenge of having to find out of pocket (OOP) financing for medical care and that they preferred the scheme to the usual cash and carry system of healthcare. Additionally, 78.6% felt that the NHIS afforded them easy access to healthcare in their institutions. However, about 23.3% indicated that they still pay a token sum of money to their healthcare providers after their medical treatment while about 26.5% claimed not to be satisfied with the quality of the services that they received from their healthcare providers.
Although all of the respondents were enrollees under the National Health Insurance Scheme (NHIS), more than 20% are not aware of the objectives of the scheme. It is likely that this group of individuals only enrolled because others were doing so or because their employers mandated them to do so. This attitude was also observed by Adewale et al. (2016) 9 when they opined that many enrollees had their salary deducted compulsorily irrespective of whether they registered with a healthcare provider or not. The enrollees were not too concerned about the scheme because they probably believe that the NHIS is one of many failed government schemes such as the National Social Insurance Trust Fund (NSITF) and the National Housing Fund (NHF) where the government generated a lot of funding for the schemes but the contributors found it difficult to access the funds set aside for their supposed needs 10 . Moreover, about 43% and 52% were aware of their benefits and responsibilities respectively due to and in relation to the NHIS scheme. It is saddening to realize that about 42% do not know how to go about getting redress when they are dissatisfied.
The lack of awareness of the provisions and operations of the NHIS will always be a hindrance to the enrolleesâ€™ proper evaluation of the scheme performance 6 . The low level of awareness of the respondents of the NHIS provisions and operations looks abnormal for people with such a high educational background. A similar lack of awareness on the operations, benefits, and responsibilities of the NHIS was also reported among librarians in Nigeria by Olayemi (2017) 11 . However, this observation is a deviation from the findings of Owumi et al. (2013) 6 and Adibe et al . (2011) 12 when they conducted a similar investigation looking into NHIS enrollees within the University of Nigeria Nsukka and the University of Ibadan respectively. Apart from the fact that this low level of awareness could hinder the enrolleesâ€™ proper evaluation of the scheme, it also limited them in terms of appropriating all of the benefits of the NHIS. Inadequate knowledge and awareness of the staff could be the main reason why there have been several reported misgivings or dissatisfactions on the side of the enrollees about the scheme. This is because as they are not fully aware of their rights and responsibilities as enrollees, their overall expectations and disposition towards the NHIS could be dysfunctional.
The enrolleesâ€™ perceptions of their healthcare providersâ€™ delivery were considered under four domains, namely facilities and resources, routine attendance to the patients, referral services, and enrollee satisfaction. The present study found the overall environmental cleanliness, diagnostic laboratory, and medical personnelâ€™s attitude to be very good. The response item for cleanliness had the highest mean score. This is similar to the findings of Adekanye et al. (2013) 13 and Olamuyiwa and Adeniji (2014) 14 . Moreover their assessment on the up-to-date equipment in the physical facilities was also encouraging.
Regarding their experiences of their routine attendance at the clinic, they adjudged the reception accorded them, as well as the consultations with doctors and nurses, prescriptions, and the respect and dignity they received at the visits to the clinic to be excellent. The consultation with the doctors and nurses was rated higher. This implies that the patients were able to freely express their health challenges with the doctors and nurses. This is because of the high level of confidence that they have developed in the medical personnel. This is similar to the finding of Adebiyi and Adeniji (2021) 15 where they assessed the enrolleesâ€™ satisfaction with the service delivery of accredited health facilities in Northern Nigeria. Michael et al . (2017) 16 also observed the same when they examined the factors affecting the utilization of the NHIS by Federal Civil Servants in River State, Nigeria. One probable reason for the high level of accorded treatment of the patients could be the recognition of the academic status of the patients. However, many of the respondents claimed that they often waited for too long before they were attended to by either the doctors or nurses. This may not be intentional based on the level of support that these patients claimed to have received from their healthcare providers. The long waiting time is instead due to an inadequate number of medical personnel, especially doctors, in the health centers of the institutions we surveyed. Similarly, an inadequate number of medical personnel was observed by Olamuyiwa and Adeniji (2021) 14 in their study.
The referral services were low according to this study. This cannot be unconnected to the availability of both facilities and resources in the clinics as noted earlier. However, those who experienced a referral attested to the high quality of the referral services that they received. Regarding their satisfaction, the majority were satisfied with the level of access to healthcare with less of a financial burden. A high level of NHIS enrollee satisfaction was also reported for the patients using the University of Port Harcourt Teaching Hospital in River State, Nigeria 14 . The overall high of level satisfaction of the NHIS enrollees in the Federal Colleges of Education in North Central Nigeria can be attributed to the excellent patient-medical personnel relationship enjoyed as well as the availability of basic medical equipment. Excellent patient-healthcare provider relationships were also reported among the patients using a tertiary hospital in South East Nigeria 17 .
The enrolleesâ€™ level of awareness of their rights and responsibilities under the NHIS is key to their taking advantage of all provisions within the scheme. Although the majority are aware of the objectives of the scheme, many are not abreast of the benefits available and their responsibilities under the scheme. This observation has been attributed to the mandatory registration of the employees onto the scheme without providing a proper orientation focused on the scheme guidelines. Thus, employers should provide an adequate orientation to their employees about the NHIS provisions. Many of the enrollees who visit NHIS clinics on their campuses seem to be happy with the services received with the exception of the long waiting time before their consultation. This can be improved by the clinics being more professional or through the application of proper time management on part of the staff in the clinics. This is as well as the employment of more medical doctors to ease the pressure felt by the few on the ground. Lastly, it can be deduced that the few complaints from the enrollees about the quality of the services received could be as a result of their inadequate knowledge about their rights and responsibilities under the NHIS.
HCP : Healthcare Provider NHIS : National Health Insurance Scheme OOP : Out of Pocket SHC : Social Health Insurance UHC : Universal Health Coverage
We would like to express our sincere gratitude to the staff of Federal College of Education Okene, Zuba ams Pankshin for their cooperation in this study.
Olatayo Bamidele Oriolowo: Conceptualization and design of the study, data collection, interpreted the results, reviewed the literature and manuscript, statistical analysis and interpretation, preparation and editing of manuscript and prepared first draft of manuscript. Antakil Asarya: data collection, proofreading of manuscripts and editing of manuscript. Ganiyu Oladimeji Olarongbe: data collection, proofreading of manuscripts and editing of manuscript. All authors read and approved the final manuscript.
The study was supported by 2016-2017 (merged) Tertiary Education Trust Fund (TETFUND) Research Project (RP) Intervention.
Availability of data and materials
Data and materials used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Ethics approval and consent to participate
This research was conducted according to the principles expressed in the Declaration of Helsinki and was approved by the Research, Ethics and publication Committee of Federal College of Education Kontagora Niger State, Nigeria
Consent for publication
The authors declare that they have no competing interests.
- Shagaya Y.J.. Assessment of student's satisfaction and quality of patient care under the Nigerian Tertiary Institutions Social Health Insurance Programme (TISHIP). Assessment. 2015;7(6):20-31. Google Scholar
- Federal Government of Nigeria. National Policy on Education. 4th Edition, NERDC, Yaba Lagos 2004. . 2004;:. Google Scholar
- National Health Insurance Scheme (NHIS). 2006 Annual Report. Abuja, Nigeria: Federal Government of Nigeria. . 2006;:. Google Scholar
- Nasiru I.. Management of National Health Insurance Schemes: the Nigeria Example. A paper presented at the ID4Africa Conference, Abuja April, 2018. . ;:. Google Scholar
- National Health Insurance Scheme. Operational guidelines. Revised October; 2012. Abuja Nigeria.(Revised)Available:http://www.ghmlnigeria.com/downloads/NHIS_OPERATIONAL_GUIDELINES (Accessed 5th October, 2019). . ;:. Google Scholar
- Owumi B.E., Omorogbe C.E., Raphael S.C.. An evaluation of the impacts of the national health Insurance scheme on the employees' health status at the University of Ibadan. African Journal of Social Sciences.. 2013;3(3):40-52. Google Scholar
- Adewole D.A., Osungbade K.O.. Nigeria National Health Insurance Scheme: A highly subsidized health care program for a privilege few. International Journal of Tropical Disease & Health. 2016;19(3):1-11. View Article Google Scholar
- Chuma J., Mulupi S., McIntyre D.. Providing financial protection and funding health service benefits for the informal sector; evidence from sub-Saharan Africa. . 2013;:. Google Scholar
- Adewale B., Adeneye A.K., Ezeugwu S.M., Afocha E.E., Musa A.Z., Enwuru C.A.. A Preliminary Study on Enrollees Perception and Experiences of National Health Insurance Scheme in Lagos State, Nigeria. International Journal of Tropical Disease & Health. 2016;18(3):1-14. View Article Google Scholar
- Ayanleye O.A.. A legal appraisal of the national health insurance scheme in Nigeria. Journal of Public and Private Law, Faculty of Law, Nnamdi Azikwe University. Awka. 2013;5:106-17. Google Scholar
- Olayemi O.M.. Awareness and Perception of National Health Insurance Scheme (NHIS) among Librarians' in Nigeria. International Journal of Perception in Public Health. 2017;2(1):56-63. View Article Google Scholar
- Adibe M.O., Udeogaranya P.O., Ubaka C.M.. Awareness of National Health Insurance Scheme (NHIS) activities among employees of a Nigerian University. International Journal of Drug Development and Research.. 2011;3(4):78-85. Google Scholar
- Adekanye A.O., Adefemi S.A., Okuku A.G., Onawola K.A., Adeleke I.T., James J.A.. Patients' satisfaction with the healthcare services at a north central Nigerian tertiary hospital. Nigerian Journal of Medicine. 2013;22(3):218-24. PubMed Google Scholar
- Olamuyiwa T.E., Adeniji F.O.. Patient's satisfaction with quality of care at a National Health Insurance clinic at a tertiary center, south-south Nigeria. Journal of Patient Experience. 2021;8:2374373520981471. View Article PubMed Google Scholar
- Adebiyi O., Adeniji F.O.. Factors Affecting Utilization of the National Health Insurance Scheme by Federal Civil Servants in Rivers State, Nigeria. Inquiry. 2021;58:469580211017626. View Article PubMed Google Scholar
- Michael G.C., Suleiman H.H., Grema B.A., Aliyu I.. Assessment of level of satisfaction of National Health Insurance Scheme enrollees with services of an accredited health facility in northern Nigerian. Annals of Tropical Medicine and Public Health. 2017;10(5):1271. View Article Google Scholar
- Iloh G.U., Ofoedu J.N., Njoku P.U., Odu F.U., Ifedigbo C.V., Iwuamanam K.D.. Evaluation of patients' satisfaction with quality of care provided at the National Health Insurance Scheme clinic of a tertiary hospital in South- Eastern Nigeria. Nigerian Journal of Clinical Practice. 2012;15(4):469-74. View Article PubMed Google Scholar