Ann Ibd. Pg. Med 2021. Vol.19, No.

1 49-55

NATIONAL HEALTH INSURANCE SCHEME: PERCEPTION AND

PARTICIPATION OF FEDERAL CIVIL SERVANTS IN IBADAN
O.O. Akinyemi1, O.F. Owopetu2, and I.O. Agbejule1

1. Department of Health Policy and Management, College of Medicine, University of Ibadan.

2. Department of Total Quality Management, University College Hospital, Ibadan.

Correspondence: ABSTRACT
Dr. O.O. Akinyemi Introduction: The National Health Insurance Scheme is a social health insurance
Dept. of Health Policy and Mgt., programme designed by the Federal Government of Nigeria to complement
College of Medicine, sources of financing the health sector and to improve access to health care for
University of Ibadan. the majority of Nigerians. Presently, the enrolment level on the Scheme is
Email: seunakinyemi@[Link] majorly among those in the formal sector and user experiences have been
different. This study seeks to determine the perception and participation of
Civil Servants regarding the National Health Insurance Scheme in Ibadan.
Methods: A descriptive cross-sectional study was conducted among 273 civil
servants working at the Federal Secretariat, Ikolaba, between October and
November 2015. An interviewer-administered questionnaire was used to collect
information on socio-demographic characteristics, awareness, and membership
of the NHIS, perception of NHIS, and health-seeking behaviour. Participation
was defined as the number of civil servants registered or enrolled under the
scheme, in other words, members of the scheme. Information on perceptions
was sought using a 3-point Likert scale. Descriptive statistics and chi-square
tests were used for data analysis at a 5% level of significance.
Results: About 60.1% of the respondents were males. The average age was
39.7+9.1 years, with 85.0% of the respondents being married. The majority
(65.2%) of the respondents were mid-level cadre workers, 17.62% were working
as senior-level workers and the remaining 17.6% were low cadre workers. The
majority (88.9%) completed tertiary education, while just 11.1% completed basic
education. The mean household size was 2.5+0.6. Awareness of the National
Health Insurance Scheme was very high (95.2%) with 83.5% enrolled under the
scheme. About (50%) of the respondents joined the scheme because it is cheap
and affordable. There was a significant association between awareness, level of
education, knowledge of NHIS, and registration into the scheme by respondents.
The majority of the respondents (87.3%) claimed that NHIS is a better means
of settling healthcare costs than Out-of-pocket-payment. The majority of the
respondents thought that health insurance is a viable programme.
Conclusion: The perception of health insurance among civil servants was varied
while participation was high. Relevant intervention should be introduced to
remove bottlenecks to accessing and operating the scheme.

Keywords: National Health Insurance Scheme, Perception of health insurance, Civil servants.

INTRODUCTION
The wealth of any country depends on the health of expenditure is relatively low, even when compared with
its citizens. Therefore, any country seeking to develop other African countries.2 The total health expenditure
its economy should strive to improve the health of its (THE) as a percentage of the gross domestic product
citizens so they can contribute to economic (GDP) from 1998 to 2000 was less than 5%, falling
development. 1 Health, as a social service, is very behind THE/GDP ratio in other developing countries
important to the teeming population of any country such as Kenya (5.3%), Zambia (6.2%), Tanzania (6.8%),
as the health sector in any country has been recognized Malawi (7.27%) and South Africa (7.5%). 3. Limited
as the primary engine of growth and development. institutional capacity, corruption, unstable economy, and
lack of political will have been identified as factors
However, health care in Nigeria is financed by a why some financing mechanisms of financing health
combination of tax revenue, out-of-pocket payments, care have not worked effectively.4
donor funding, and health insurance.2 Nigeria’s health
Annals of Ibadan Postgraduate Medicine. Vol. 19 No. 1, June 2021 49
Further, insurance is a risk transfer mechanism in which bias due to religious or cultural beliefs,13 and inequality
the insured makes small periodic payments called in the distribution of healthcare facilities between urban
premiums to another (the insurer), in return for the and rural areas. 10 Therefore, this study sought to
payment of benefit packages on the occurrence of a determine the perception and participation towards
specified event.5 Therefore, health insurance involves NHIS among civil servants working in the federal civil
the pooling of health risks and funds. The National service system at Ibadan.
Health Insurance Scheme (NHIS) in Nigeria was
designed to provide minimum economic security to METHODOLOGY
workers with regards to unfavourable losses resulting Study Design
from accidental injury, sickness, old age, unemployment, A descriptive cross-sectional study was conducted
etc. It is based on a pre-payment system where both between October and November 2015.
the employer and employee make contributions to the
scheme and the employee accesses the scheme Study Site
whenever he/she is ill.5 The scheme was officially This study was conducted among the civil servants at
launched on June 6, 2005, and services to enrolees the Federal Secretariat Complex, Ikolaba, Ibadan,
started later in 2005. According to Osae-Brown, 2013,6 Nigeria. The complex consists of 8 ministries and 13
over four million identity cards have been issued, 62 agencies having a staff population of 853 (as of
HMOs (Health Maintenance Organisations) have been September 2015).
accredited and registered and more applications are
being processed. The NHIS is unarguably an Sample Size
indispensable strategy for improving the poor health A minimum sample size of 246 was calculated at a
indices of the country and reducing out-of-pocket 5% level of significance and 20% prevalence of people
expenditure for quality health care services. Since the who utilise formal healthcare providers.17
implementation of NHIS, about five million Nigerians
can readily access care through the NHIS.6 The NHIS Sampling Technique
benefits packages are very comprehensive, covering The selection of respondents was through systematic
virtually all the medical needs of the enrollees from random sampling. Three ministries and six agencies
consultation, to drugs, consumables, and other minor were selected randomly out of the seven ministries
surgeries. and 15 agencies in the secretariat by balloting. The
selected ministries and agencies had a total strength of
Undoubtedly, civil servants play a very significant role 425. The required number of respondents were then
in the economic development of the country. In proportionally allocated into the different ministries
desiring a better public service workforce and an according to their staff strength after which required
effective and efficient delivery of public services, the respondents were selected at regular intervals of the
provision of good, quality healthcare should be sampling fraction. The sampling fraction was obtained
considered a top priority to civil servants.16 The NHIS by dividing the required number of respondents in
would be of great importance to civil servants because the ministry or agency by the total number of staff in
it has attractive packages. Some of its packages include there.
out-patient care, medical consumables, drugs, and
diagnostic tests. Free in-patient care in a standard ward Inclusion and Exclusion Criteria: This study
for fifteen cumulative days per year is also inclusive. included all federal civil servants working within the
Secretariat who have been employed for at least two
However, in Nigeria, there is inadequate knowledge, years as at the time of the study. However, the study
awareness, and capacity regarding an insurance-based excluded all temporary or contract staff under the
health system.7,43-44 The level of corruption, lack of employ of any of the agencies or ministries.
transparency, and accountability in the country are still
very high which has negatively impacted the The respondents were divided into three categories
effectiveness of NHIS. 7 The provision of quality, based on their salary grade level. The junior cadre
accessible and affordable healthcare remains a serious workers were those who belonged to salary grade level
problem. This is because the health sector is 6 and below, while those belonging to salary grade
continuously faced with a gross shortage of personnel), level between 7 and 10 were considered as mid-level
inadequate and outdated medical equipment,11 poor workers. Finally, those whose salary grade levels were
funding, policies inconsistent health policies, 8 and higher than 10 were considered senior workers.
corruption. 8-11 Other factors that impede quality
healthcare delivery in Nigeria include the inability of Ethical clearance for the study was obtained from the
the consumer to pay for healthcare services,12 gender UI/UCH Ethical Review Committee (Reference
Annals of Ibadan Postgraduate Medicine. Vol. 19 No. 1, June 2021 50
number: UI/EC/15/0415). Permission to administer Table 1: Sociodemographic characteristics of
the questionnaires was obtained from the Heads of respondents.
Departments. Informed consent was obtained from
Characteristics Frequency Percentage
participants before the administration of the
(n) (%)
questionnaires. Participation was voluntary and data Age group
collected were kept strictly confidential. ≤ 30years 46 16.8
31-40 years 110 40.3
Data Collection Tool 41-50 years 87 31.9
The instrument used to collect data for the study was >50 years 30 11.0
a semi-structured, self-administered, questionnaire. The Gender
majority of the questions were pre-coded while some Male 164 60.1
Female 109 39.9
were open-ended. The questionnaire was divided into Marital Status
four sections: Section A consisted of 8 questions aimed Single 41 15.0
at assessing the socio-demographic characteristics of Living with partner 232 85.0
the respondents; Section B comprised of 12 questions Religion
on the awareness and membership of the National Christianity 194 71.1
Health Insurance Scheme; Section C included 6 Islam 79 28.9
Highest educational level
questions on the attitudes of the respondents towards
Secondary school 30 11.0
NHIS and Section D consisted of 5 questions on the Tertiary 243 99.0
health-seeking behaviours of the respondents. The Salary grade Level
research instrument was pre-tested among civil servants Junior Cadre 47 17.2
in the state secretariat in Agodi, Ibadan, after which Mid-level Cadre 178 65.2
ambiguous questions were rephrased. Senior Cadre 48 17.6

Data Analysis respondents believed that NHIS would not succeed

Descriptive statistics were used to present the results, even if it was implemented properly. Also, 233 (89.6%)
and the chi-square test was used to test for associations respondents thought the Scheme will succeed if
between categorical variables at a 5% significance level. implemented properly, while 19 (6.9%) were neutral.
Data were analysed using the Statistical Package for The same pattern of responses was observed regarding
Social Sciences (SPSS) version 21. their perception of the NHIS about being able to
deliver improved access to healthcare, protection from
RESULTS debts and other forms of catastrophic health
About three out of every five of the respondents were
males (60.1%), and 41 (15.0%) were single. Over half Table 2: Participation of civil servants in the NHIS.
of the respondents (50.5%) had completed tertiary
Characteristics n %
education, and the majority were mid-level cadre
NHIS enrolment
workers (178, 65.2%) as shown in Table 1. Yes 217 83.5
No 43 16.5
The self-reported awareness of the respondents Reasons for joining NHIS
towards NHIS was high as 260 (95.2%) of them Free medical care 59 27.8
reported being aware of the Scheme. Only 13 A particular health issue 5 2.4
respondents reported being unaware of the scheme. Cheap and affordable care 107 50.5
When asked about their primary source of Peer pressure 5 2.4
Work in the health sector 24 11.3
information about the Scheme, the response with the Mandatory registration 12 5.7
highest response was from radio/TV programs Reasons for not joining NHIS
(29.3%). Other information sources included: through Poor education 12 35.3
a health worker (25.6%), another enrollee of the Inadequate coverage 4 11.8
Scheme (25.3%), and from a manager of the Scheme Not necessary 6 17.6
(16.5%). Cannot afford the premium 10 29.4
Experienced barriers to registration
Yes 64 24.4
Concerning their perception of NHIS, the majority
No 188 75.6
(87.3%) of the 260 enrolled respondents posited that Forms of barriers
NHIS is a better means of settling healthcare costs Card Issuance 23 35.9
than OOPE (Out of pocket expenditure). Only 14 Cumbersome registration 34 53.1
respondents (5.5%) believed OOPE to be a better Distance of registration centre 2 3.1
payment option to NHIS. However, 9 (3.5%) Poor Enlightenment 5 7.9
Annals of Ibadan Postgraduate Medicine. Vol. 19 No. 1, June 2021 51
expenditure (CHE), and improved quality and government hospitals, private hospitals, and
affordability of health services. comprehensive health centres. Fevers and other acute
illnesses such as slight pain and stomach disorders
Regarding their participation in the NHIS, the majority formed the majority of the diseases reported by the
(83.5%) of the respondents were enrolled in NHIS. respondents. Concerning the reason for their choice
The major reason most of the participants (50.5%) of health facility, the most common response was
joined the Scheme was for the cheap and affordable friendly workers and quality services (29.3%) followed
health care services and free access to medical care by proximity (15.8%) and prompt attention (8.1%).
(27.8%). The most mentioned reason for not
participating in the Scheme was stated as poor DISCUSSION
enlightenment about the Scheme (35.3%) while the The results of this study revealed that most employees
inability to afford the premium charges (29.4%) of the Federal Civil Service in Ibadan were aware of
followed closely. Only 24.4% of the respondents NHIS activities as the majority of them already
experienced barriers to NHIS registration with the most registered in the scheme. This is not surprising as it is
common barrier being cumbersome registration expected that government employees should be aware
processes (53.1%) and delays in the issuance of the of all the activities of the government. The awareness
identity card (35.9%). See Table 2. of respondents on NHIS is very high, which agrees
with studies by Ibiwoye and Adeleke,18 and Agba.19 A
Concerning their knowledge of the NHIS, 189 (86.7%) higher level of awareness about NHIS was found in
of the total respondents believed that they were well our study compared with the report by Ibiwoye and
informed about the scheme. Approximately three out Adeleke,18 but slightly lower than that of Agba.19 This
of every five respondents (59.9%) had attended a is probably due to the various awareness campaigns
lecture on the NHIS. carried out in the media by the federal government
regarding the scheme as well as the different population
Table 3: Health-seeking behavior of the civil servants. groups i.e. state and federal civil servants.
Characteristics n %
However, the current participation levels might be a
Suffered health conditions in the past
6 months result of reported corruption in the public sector, lack
Yes 167 60.8 of accountability, poor management of available
No 106 37.7 resources, management and running of schemes by
Method of diagnosis (N=167) non-professionals, and poor financing by the
Formal health system 81 48.5 government. Efforts should be made by all the
Informal health system 86 51.5 stakeholders to reduce and remove these reported
Choice of health care facility (N=167) bottlenecks in the scheme.
Formal health care system 161 97.8
Informal health care sources 6 2.2
Type of illness The majority of the respondents in this study were
Fever and acute illnesses 139 83.2 currently insured under the NHIS. The level of
Surgery/Natal services 12 4.4 enrolment contrasts with existing literature that shows
Chronic illnesses 16 5.9 low enrolment among the poor to be a problem facing
Reason for choice of health facility health insurance schemes in low-income countries21,22
Friendly health workers 80 29.3 including Ghana.23 These contrasting findings might
Availability of drugs 14 5.1 have been as a result of increased education on the
Prompt attention 22 8.1 benefits of the scheme among the populace. The
Close proximity 43 15.8
enrolment level in this study is higher than the 2006
Cheap services 11 4.0
Others 5 1.9
enrolment rate of 31.6% reported by Ibiwoye and
Adeleke,18 indicating almost a three-fold increase in
enrolment of Federal civil servants within the period.
From Table 3, about three out of ever y five However, it is to be noted that the majority of
respondents (167, 60.8%) suffered a form of health unenrolled respondents belonged to the junior level
condition within the past 6 months. Of this population, cadre. This is an indication that campaigns to sensitise
almost half (48.5%) reported using the formal health civil servants need to be increased towards those in
care system. This includes laboratory tests, these cadres, especially as these cadres usually have civil
confirmation from qualified health personnel. On the servants with lower educational qualifications. Hence,
other hand, almost all (161, 97.8%) of the respondents they may require repeated and simpler enlightenment
used the formal health system when seeking health care strategies.
services. The formal health care facilities included
Annals of Ibadan Postgraduate Medicine. Vol. 19 No. 1, June 2021 52
As shown in this study, the effectiveness and scheme is influenced by health care expenditure.39 Some
attractiveness for participation in the scheme was respondents in this study expressed their dissatisfaction
somewhat a determinant of people’s decision to enroll with the technical processes of the scheme. These
or not to participate. This was evident as some included the cumbersome process for the collection
respondents said the ineffectiveness of the scheme, of NHIS cards. These issues regarding the technical
the long registration process, lack of money, low level processes have also rendered the scheme unattractive
of awareness, and having alternative sources of care to some people as stated earlier in this discussion. The
as reasons for not enrolling in the scheme. Some other price of insurance is another factor influencing the
reasons why some respondents did not enroll in the demand for health insurance. In this study, the decision
scheme include the high cost of premiums, poor to enroll in the NHIS was significantly influenced by
enlightenment about the scheme, and lack of confidence perception about the premium package for the
in the scheme. However, as shown by other studies, insurance and the registration fee. Respondents who
trust is a sine-qua-non for enrolment. Previous studies disagreed that the premium package was not too high
reported that demand for health care is sensitive to were significantly more likely to enroll in NHIS.
the quality of ser vice provided and that poor Affordability of premiums or contributions is often
households limit their demand for health care when mentioned as one of the main determinants of
the services are poor quality, but they are less sensitive membership in other studies.40,41,45 For instance, in the
to changes in quality of service.26,27 Nkoranza scheme in Ghana, the estimated cost of
contributions varied from 5% to 10% of annual
As the entry-level qualifications for civil service require household budgets,40,41 and it was recognised that such
some level of education, the health-seeking behaviour contributions could be a financial obstacle to
of civil servants in this study was remarkably better membership. A review of the premium perhaps with
than that of the general population. 26,27 This study regards to work cadres may be an option for
showed that the majority of respondents utilised the consideration going forward to improve participation.
formal health sector when seeking treatment. This is The quality of services offered under the scheme goes
higher than reported by Onwujekwe 28 and Onah.29 a long way to boost clients’ confidence in the scheme
These studies reported that only about 30% to 40% and make the scheme more attractive to prospective
of the population sought health care from formal clients. Providing quality health care increases the trust
health centres. This is not surprising though as these of clients in the health system and insurance in general.
studies were carried out either wholly or in part within Mladovsky and Mossialos, 42 from a health system
the rural populace in South-eastern Nigeria. The figures perspective, proposed that trust decreases the
reported in this study are however consistent with likelihood of adverse selection and moral hazard and
findings by Ujunwa,30, and other studies that used increases willingness to pay for health care. This include
federal civil servants as their study population. The improving behaviour of medical staff to patients such
high proportion of formal health system use reported as increased level of politeness, improving quality of
in this study is considerably higher than what other care, through strategic purchasing, transparency, and
studies found where values ranged from between 8% accountability among those managing the scheme;
and 30%.29,36 This is a further indication of better health- recourse to justice to punish fraud, and increased
seeking behaviour among federal civil servants than community participation in the scheme’s management.
the general population. Finally, to enhance the renewal and retention of
members, the NHIS policy should allow flexibility of
In this study, the majority of the respondents agreed premium payments to make the insurance scheme
that joining the scheme will benefit them and this more affordable.
perception significantly influenced the decision to enroll
in the NHIS. Other respondents also believe that the Like any cross-sectional study, this study did not
scheme offered some form of financial protection in attempt to establish a causal relationship between
terms of their health care expenditure and this participants’ perceptions and participation in the NHIS
influenced their decision to enroll in the scheme. scheme. Also, although patients were reassured of the
Similarly, respondents from other studies reported confidentiality data collected and their use for research
similar reasons for enrolling in NHIS. 37 This was purposes only, social desirability bias and recall bias
supported by evidence from a study in Rwanda which were still possible.
reported that insurance membership has significantly
decreased out-of-pocket spending for sick members CONCLUSION
and at the same time has substantially improved National Health Insurance Scheme (NHIS) in Nigeria
members’ access to the modern health care system. 38 is unarguably an indispensable strategy for ameliorating
The decision to participate in a given health insurance the poor health indices of the country and reducing
Annals of Ibadan Postgraduate Medicine. Vol. 19 No. 1, June 2021 53
out-of-pocket expenditure for quality healthcare 15. Onwujekwe O, Onoka C, Uguru N, Nnenna T,
services. The findings from this study brought to the et al. Preferences for benefit packages for
fore the fact that perception of health insurance among community-based health insurance: An exploratory
civil servants was varied while participation was high. study in Nigeria. BMC Health Serv Res 2010;10:162.
The majority of the respondents were aware of the 16. Onwujekwe O, Uzochukwu B, Obikeze E, et al.
benefit packages under NHIS and were enrolled under Investigating determinants of out-of-pocket
NHIS. Relevant intervention should be taken to spending and strategies for coping with payments
remove bottlenecks to accessing and operating the for healthcare in southeast Nigeria. BMC Health
scheme. Serv Res. 2010; 10:67.
17. Ewelukwa O, Onoka C, Onwujekwe O. Viewing
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