KNOWLEDGE AND ATTITUDE TOWARDS NATIONAL HEALTH INSURANCE SCHEME AMONG CIVIL SERVANTS
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ABSTRACT
This study examined knowledge and attitude towards national health insurance scheme among civil servants in Biase Local Government Area of Cross River State. Three research questions were posed to guide the study. The study adopted a qualitative research design in exploring the identified variables (awareness, attitude and level of uptake) of NHIS. The sample size for this study was 30 respondents, selected using a purposive sampling technique and data were generated through primary sources with the use of interview. The data generated were analyzed using thematic analysis. The result of the findings revealed that civil servants in Biase Local Government Area were aware of National Health Insurance Scheme; Civil servants in Biase Local Government Area demonstrated a positive attitude towards National Health Insurance Scheme; and the level of uptake of National Health Insurance scheme among civil servants in Biase Local Government Area was very low. It was therefore recommended among others that although, awareness is high, however there should be intensive sensitization and mobilization on utilization by the health department. Also there is need for government to increase funding of the scheme, as this would help to increase the health delivery services for which the scheme was created.
TABLE OF CONTENTS
CONTENT PAGES
TITLE PAGE – – – – – – – – I
DECLARATION – – – – – – – – II
CERTIFICATION – – – – – – – III
DEDICATION – – – – – – – – IV
ACKNOWLEDGEMENT – – – – – – – – V
TABLE OF CONTENTS – – – – – – – – VI
LIST OF TABLES – – – – – – – – IX
ABSTRACT – – – – – – – – x
CHAPTER ONE – INTRODUCTION
- Background to the Study – – – – – 1
- Theoretical Framework – – – – – – 5
- Statement of the Problem – – – – – 6
- Purpose of the Study – – – – – – – 7
- Research Questions – – – – – – – 7
- Statement of Hypotheses – – – – – – 8
- Significance of the Study – – – – – 8
- Scope of the Study – – – – – – 9
- Definitions of Terms – – – – – – – 9
CHAPTER TWO – LITERATURE REVIEW
2.0 Introduction – – – – – – – – 11
2.1 The Concept of Health – – – – – – 11
2.1.1 The Concept of Health Insurance – – – – 13
2.1.2 Concept of National Health Insurance Scheme – – – 14
- Operational Framework of National Health Insurance Scheme – 17
2.1.4 Structure of the National Health Insurance Scheme – – 20
2.1.5 Exclusions of National Health Insurance Scheme – – 21
2.1.6 Awareness and National Health Insurance Scheme – – 22
2.1.7 Attitude and National Health Insurance Scheme – – 24
2.1.8 Level of Uptake of National Health Insurance Scheme – – 26
CHAPTER THREE – RESEARCH METHODOLOGY
3.1 Introduction – – – – – – – 32
3.2 Design of the Study – – – – – – 32
3.3 Area of the Study – – – – – – 32
3.4 Population of the Study – – – – – – 33
3.5 Sample Size and Sampling Technique – – – – 33
3.6 Source and Method of Data Collection – – – – 33
3.7 Method of Data Analysis\ – – – – – 33
CHAPTER FOUR – INTERPRETATION AND DISCUSSION OF RESULTS
4.1 Introduction – – – – – – – – 35
- Analysis of Qualitative Design – – – – – 38
- Awareness of National Health Insurance Scheme – – – 38
- Attitude towards National Health Insurance Scheme – – 39
- Level of uptake of National Health Insurance Scheme –
4.3 Discussion of Findings – – – – – – 42
CHAPTER FIVE – SUMMARY, CONCLUSION AND RECOMMENDATIONS
- Summary – – – – – – – 44
- Conclusion – – – – – – – 45
5.3 Recommendations – – – – – – 45
5.4 Suggestion for Further Study – – – – – 46
References – – – – – – – 47
Appendices – – – – – – – 48
CHAPTER ONE
INTRODUCTION
- Background to the Study
The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, and political belief, economic or social condition; and the health of all peoples is fundamental to the attainment of peace and security, which is dependent upon the fullest co-operation of individuals and Government. Thus, health is considered the most valuable and precious for every individual. If the person is unhealthy, there’s nothing much that he/she could do to be productive in life. Thus, health remained an issue of central concern to all countries and societies.
According to Ibiwoye and Adeleke (2008), health is the foundation cornerstone for socio-economic development and progress of any nation. As such all countries face challenges in expanding their health care coverage. Many countries have committed themselves to achieving equity in health care coverage by including health care goals in human rights declarations, constitutions, and health policy documents (Nyembe, 2009).According to Sanusi and Awe (2009), the struggle to provide good health care to all in the society is epitomized by the Alma Ata declaration of 1978 which states that health “is a fundamental human right” and its attainment is a “most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector”. According to Sanusi and Awe (2009), Nigeria became a party to this code which prescribes that “primary health care is the key” and that “governments have the responsibility”. Regrettably, the aim of this universal primary health care, which stated in the Alma Ata declaration, has not been achieved in the country.
According to the World Health Organization (2006:1), health is state of complete physical, mental and social well-being and not merely the absence of disease and infirmity. Thus, the right to health encompasses health care and those conditions essential for good health, such as safe water, adequate food, sanitation and shelter. Ekanem (2014) thus maintained that the provision of comprehensive and adequate health care services to its citizens should be one of the central objectives of any responsible government. Agba, Ushie and Osuchukwu (2010) submitted that the sustainability and viability of a country’s economic and social growth depend largely on vibrant healthcare sector of that nation, and that no country can maintain a steady economic growth in the absence an adequate healthcare system.
In order to provide equitable distribution of health, the National Health Insurance Scheme (NHIS) was introduced in Nigeria. The need for the establishment of the scheme was informed by the general poor state of the nation’s healthcare services, excessive dependence and pressure on the government’s provision of health facilities, dwindling funding of health care in the face of rising cost, high mortality rate, poor integration of private health facilities in the nation’s healthcare delivery system and overwhelming dependence on out-of-pocket expenses to purchase health (NHIS, 2010). Mohammed (2008) added that the need for the National Health Insurance Scheme (NHIS) in Nigeria came up as a result of the rising cost of health care services and the need to provide quality, accessible and affordable health care services with the people’s demand
National Health Insurance Scheme (NHIS) was first introduced to parliament in the year 1962 when the need for health insurance in the provision of health care to Nigerians was first recognized. It was fully approved by the federal government in 1997 and signed into law in 1999 (Adeniyi and Onajole, 2010). The scheme was officially launched on the 6th of June, 2005 (Shio, 2011). National Health Insurance Scheme (NHIS) is a cooperate body under act 35 of 1999 by the Federal Government of Nigeria to improve the health of all Nigerians at affordable cost. The NHIS is a social security system in which the health care of employees in the formal sector is paid from funds created by pooling of contribution of employers and employees. Beneficiaries to the scheme include students of tertiary institutions.
According to NHIS (2010), the objectives of the scheme are to among others; ensure that every Nigerian has access to good health care services while protecting families from the financial hardship of medical bills. Under the scheme, health care providers, referred to as Health Maintenance Organizations (HMOs) are responsible for providing and making payments for all persons who have registered and have paid the required premium. To provide this service, the HMOs liaise with the accredited medical establishment of a person’s choice (NHIS, 2010). According to its guiding principles, the scheme is to provide access to health care to all citizens irrespective of socio-economic class, age, status and other considerations. The scheme is expected to be funded through monthly contributions from employers and employees from both private and public sectors (Shio, 2011).
Lawanson and Olamyaw (2014) submitted that knowledge and attitude of people towards government policies and programs can be aroused by individual interest and behaviour. Whenever people lack knowledge and there are negative perception and attitude towards these policies and programs, such policies and programs are bound to fail and vice versa. An attitude is a learned disposition to behave in a consistently favourable or unfavourable way with respect to a given object. Stated differently, it positions people into a frame of mind of liking or disliking things, of moving toward or away from them (Lawanson and Olamyaw (2014). It is acknowledged that people have attitudes toward almost everything – religion, politics, clothes, music, and food. Awareness of these government programs and activities makes the governed to have positive attitude and perception towards these programs, thus, improving their participation and responsiveness to these programs.
With respect to attitude, Agba, Ushie and Osuchukwu (2010) observed that the majority of the health managers welcomed the national health insurance scheme as a good idea that government should advocate and pursue, because they felt that it will improve health service delivery by increasing finances to the sector and that citizens will no longer have to look for money to take to health units in times of emergencies. However, they were disappointed that the scheme will not cover the poor who actually need it. They also felt that lack of infrastructure, shortage of manpower and mismanagement, particularly corruption, will be a great hindrance to the success of the scheme. Most of the health managers in the public and private sectors felt that the employees are already over-taxed and they should not pay more. Some of them said that, moreover, as health workers they already have access to the planned package without contributing. Only a minority were willing to contribute less their salaries to the scheme (Agba, Ushie and Osuchukwu, 2010).
Similarly, Augustine and Francis (2018) National Health Insurance Scheme in Nigeria: Impact on Healthcare Delivery System in Nigeria. From the findings of the study, the NHIS was seen to contribute positively to health delivery system in Nigeria, but the level of awareness was low among the general populace. Ayanleye(2013) on a legal appraisal of the national health insurance Scheme in Nigeria observed the level of poverty of the majority of the populace as one of the major factors militating against the success of the scheme. Another factor observed was the inadequacy of healthcare facilities and providers. The programme as being currently run is elitist and has not achieved the desired goal. It is against this background that this present study is conducted to examine the knowledge and attitude of civil servants in Uyo Local Government Area, AkwaIbom State towards National Health Insurance Scheme.
1.2 Theoretical Framework
This study is backed up by Theory of Reasoned Action (TRA), which was developed by Martin Fishbein and IcekAjzen in 1975.The Theory finds its origins in the field of social psychology, and it defines the links between beliefs, attitudes, norms, intentions, and behaviours of individuals. According to this theory, a person’s behaviour is determined by its behavioural intention to perform it. This intention is itself determined by the person’s attitudes and his subjective norms towards the behaviour (Fishbein and Ajzen, 1975). The theorists define the subjective norms as “the person’s perception that most people who are important to him think he should or should not perform the behaviour in question”. According to Theory of Reasoned Action, the attitude of a person towards a behaviour is determined by his beliefs on the consequences of this behaviour, multiplied by his evaluation of these consequences. Beliefs are defined by the person’s subjective probability that performing a particular behaviour will produce specific results. This model therefore suggests that external stimuli influence attitudes by modifying the structure of the person’s beliefs.
Moreover, behavioural intention is also determined by the subjective norms that are themselves determined by the normative beliefs of an individual and by his motivation to comply to the norms. The theory also claims that all other factors which influence the behaviour only do so in an indirect way by influencing the attitude or subjective norms. Ajzen (1992) refer to these factors as being external variables. These variables can be for example, the characteristics of the tasks, of the interface or of the user, the type of development implementation, the political influences, the organizational structure, etc. (Ajzen (1992). A meta-analysis on the application of the theory of reasoned action showed that the model can produce good predictions of choices made by an individual when facing several alternatives (Ajzen, 1992).
According to the theory, attitudes are one of the key determinants of behavioural intention and refer to the way people feel towards a particular behaviour. These attitudes are influenced by two factors: the strength of behavioural beliefs regarding the outcomes of the performed behaviour (i.e. whether or not the outcome is probable) and the evaluation of the potential outcomes (i.e. whether or not the outcome is positive). Attitudes regarding a certain behaviour can either be positive, negative or neutral. The theory stipulates that there exists a direct correlation between attitudes and outcomes, such that if one believes that a certain behaviour will lead to a desirable or favorable outcome, then one is more likely to have a positive attitude towards the behaviour. Alternatively, if one believes that a certain behaviour will lead to an undesirable or unfavorable outcome, then one is more likely to have a negative attitude towards the behavior (Fishbein and Ajzen, 1975).
This theory is relevant to this study because it suggests that an individual’s health behaviour is determined by his or her intention to engage in health insurance scheme. A person’s intention to enroll in health insurance scheme is predicted by a person’s attitude toward the health insurance scheme, and subjective norms (that is, the perceived social pressure) regarding the health insurance scheme. Subjective norms are the result of social and environmental surroundings and a person’s knowledge over the health insurance scheme. Generally, positive attitude and positive subjective norms result in greater knowledge and increase the likelihood of intentions towards the scheme.
1.3 Statement of the Problem
The continued stagnating healthcare system in Nigeria is of great social and economic consequence, as the deregulation of healthcare financing and supply in Nigeria has further shifted the healthcare system towards competitive market ideals. It was found that despite the increase in most components of health care spending in Nigeria, the health status of the average Nigerian and the condition of health infrastructure has not improved appreciably. According to WHO (2017), the provision of quality, accessible and affordable healthcare remains a serious problem and this has been attributed to inadequate funding and lack of government commitment to the provision of healthcare policies and covers all citizens, without taking cognizant of the beneficiaries knowledge, awareness and attitude. Also, the larger percentage of the population of Nigeria is without access to credible healthcare coverage, to show that national health insurance scheme are still in their early stage of implementation with the goal of universal coverage.
Studies such as Sabitu and James (2005); Adenike and Wasiu(2010), and Ayanleye (2013) showed persistently low response of people on the operational principles of the scheme, and a negative attitudinal predisposition among health care providers. According to these researchers, the generality of the populace are yet to benefit from the scheme due to factors such as level of poverty, inadequate healthcare facilities, inadequate healthcare providers, and poor funding without taking cognizance of knowledge and attitude of the beneficiaries. This study therefore seeks to examine if knowledge and attitude of the beneficiaries is also a factor impeding the successful implementation of the National Health Insurance Scheme in Cross River State.
1.4 Purpose of Study
The general objective of the study was to examine knowledge and attitude of civil servants towards National Health Insurance Scheme (NHIS) in Biase Local Government Area, Cross River State. Specifically, the study seeks to:
- Examine if civil servants in Biase Local Government Area are aware of National Health Insurance Scheme.
- Examine the attitude of civil servants in Biase Local Government Area towards National Health Insurance Scheme.
- Investigate the level of uptake of NHIS among civil servants in Biase Local Government Area.
- Research Questions
With respect to the above research objectives, the following research questions are posed to guide the study.
- Are civil servants in Biase Local Government Area aware of National Health Insurance Scheme?
- What are the attitudes of civil servants in Biase Local Government towards National Health Insurance Scheme?
- What is the level of uptake of NHIS among civil servants in Biase Local Government Area?
1.6 Statement of Hypotheses
The following hypotheses will be tested in the course of the study;
H0: Civil servants in Biase Local Government Area are not aware of National Health Insurance Scheme.
H1: Civil servants in Biase Local Government Area are aware of National Health Insurance Scheme.
H0: The level of uptake of NHIS among civil servants in Biase Local Government Area is high.
H2: The level of uptake of NHIS among civil servants in Biase Local Government Area is low.
1.7 Significance of the Study
The major reason for undertaking this study was to provide insight into health care system and provide basic information about National Health Insurance Scheme for policy planning and implementation.
The findings of this research work are expected to constitute valuable source of data for future references and planning and provision of health care where it is lacking.
This study will also be useful to the government for its policy review in respect of the scheme. Studies of this type have the potential to reveal the problems confronting healthcare, benefit and pave ways for policy makers, the local government, the state government, the federal government as well as research institutions and nongovernmental organizations (NGOs).
It will serve as a framework for assessing the development and level of knowledge and attitude towards national health insurance scheme in these areas by the government. It will help to understand the level of uptake of NHIS among civil servants. This information will be useful for budgets and other developmental projects.
The findings of this study will also open up vents for future research in this topical area under investigation and serve as a useful guide and information for future studies.
1.8 Assumption of Study
Certain assumptions where made during the course of the study, it is assumed that;
- Civil servants who are more involved in national health insurance scheme at work place stand a chance of health care services and benefits than those not involved.
- Some civil servants reluctant attitude towards national health insurance scheme at work place could be detrimental their health in the long run.
- The questionnaire will be accurately administered and the response given by the respondents of this study are true, objectively and reliable.
1.9 Scope of the Study
This work is intended to examine knowledge and attitude of civil servants towards National Health Insurance Scheme (NHIS). The study focused on civil servants in Biase Local Government Area of Cross River State.
1.10 Limitations of the Study
This research was constrained by the following factors:
Financial Constraints
Bearing in mind the present economic state of the nation, it was found difficult in making both ends meet, because of the exorbitant nature of things nowadays in travelling for the collection of data needed for the project.
Time Constraints
Looking at the interval between the resumption and vacation of the final semester for the project to be completed, the time given seemed to be short for the collection of required information for better work to be done.
Non-Availability of Material
During this project, it was noticed that the required materials needed for the project are not documented. Those that were documented lacked access to the storage facilities where they can be reached.
Respondent Reluctance: In most cases the selected respondents often feels reluctance over providing required information required by the researcher. This result in finding information where the structured questionnaires could not point out.
1.11 Definitions of Terms
Civil Servant – is a person employed in the public sector on behalf of a government department or agency. A civil servant or public servant’s first priority is to represent the interests of citizens.
National Health Insurance Scheme – is a mechanism, which enables the burden of the direct cost of health care to an individual to be spread among a group of people who share the risk and over a period of time rather than being met at the point of delivery by a single individual.
Health Insurance – is a system of advance financing of medical expenses through contribution, or premium paid into a common fund, to pay for all or part of health services specified in an insurance policy or plan.
Health Care – refers to the work done in providing primary care, secondary care, and tertiary care as well as in public health.
Knowledge – is the fact or condition of being aware of something. It is a familiarity, awareness, or understanding of someone or something, such as facts, information, description, or skills which is acquired through experience or education, by perceiving, discovering or learning.
Attitude: – is an individual’s predisposed state of mind regarding a value or thing and it is precipitated through a responsive expression towards a person, place, thing, or event, which in turn influences the individual’s thought and action.
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