Introduction

In recognition of the challenges of the healthcare system limiting access to care due mainly to affordability and poor funding, Nigeria introduced many reforms which included the introduction of the social health insurance scheme (NHIS) in 1999, as a health financing mechanism. The insurance system has since become a preferred choice of many systems for sustainable health financing due to its many positive features that promote and support achievement of the Universal Health Coverage (UHC) goals for enhanced population health. Efforts at addressing poor health indices in Nigeria such as high child and maternal mortality rates, poor healthcare services, high out-of-pocket payments informed the establishment of the Scheme .^[1] Hence, the scheme was aimed among others to improve access to quality, affordable and sustainable health care for the citizens, to reduce the financial burden of OOP payments which has remained very high above 70% .^[1] As a contributory scheme, beneficiaries were to pay 15% of their salary to the scheme; but the government took 10% of the payment leaving 5% to the beneficiaries to pay. The NHIS cover only about 4-5% of Nigerians in the formal sector ^[2]. The contributions of NHIS to health funds remain low at about 2% of overall expenditure on health and also challenged by low acceptance, poor awareness, and limited benefit packages .^[3]

Since the launch of the NHIS in 2005, it has recorded its success and challenges .^[4]Coverage remains low at only about 4% of the Nigerian population, mostly in the formal sector .^[5,6,7] This could be attributed mainly to voluntary rather than compulsory enrolment as practiced in some countries such as Ghana ^[8]. At the launch of the Scheme in 2005, Nigeria set a target of achieving UHC by the year 2015, which obviously was not achieved but was extended to 2025. This however remains uncertain going by the current poor enrollment progress.

Availability of a service does not guarantee its utilization ^{[9, 10]}; neither does awareness of a programme translate to knowledge about a programme. Hornby ^[11] describes knowledge as “information, understanding and skills that one gains through education or experience.” In this study, knowledge denotes adequate understanding and information possessed by enrollees regarding NHIS, its objectives and guiding principles. Awareness of a policy such as NHIS strongly impacts on perception of individuals toward the policy and ultimately utilization. Studies have shown that awareness can enhance individuals’ knowledge of existing beneficial social policies and improve enrolment in any prepayment scheme for health. [^12] Studies in Nigeria suggest that current level of awareness about the NHIS in Nigeria is low. [^13,14] Beside awareness, the quality of services rendered to enrollees and their level of satisfaction is of optimal importance. The out-of-stock (OS) syndrome and limited benefit packages encourage OOP payments, limiting utilization of services which impact negatively on the decision of potential enrollees.

The NHIS is expected to reach its peak in delivering effective and quality services due to its small target population of only the employees of the federal government in the first instance, as the formal sector health insurance (FSHIS).However, this has not been the case as many enrolees are still forced to pay out-of-pocket for healthcare. Although, there are few reports on the effectiveness of NHIS and client satisfaction, such data are lacking in Niger State. Lack of information on the issues outlined above will make it difficult to evaluate NHIS services and its performance among accredited health facilities such as Federal Medical Center, Bida. It will also be difficult for relevant authorities to properly track progress of the scheme with enrolment to ensure the achievement of its goal towards UHC, especially in the northern part of the country. Consumers of the healthcare services should have adequate knowledge of the scheme and its benefits so as to enhance optimal use. Poor knowledge and awareness about the scheme will lead to underutilization of the services. Therefore, the success of the scheme would be greatly determined by its acceptability which is dependent on the level of knowledge and awareness. It becomes pertinent to investigate awareness, perception and utilization of the scheme by employees. This study aimed to investigate enrollees’ awareness, perception, and utilization of the NHIS services among employees of the FMC, Bida, Niger state, north central Nigeria, who are automatically enrolled as federal staff. The study findings will contribute information on factors that constitute barriers to efforts at enhancing access to healthcare through the NHIS, to inform policy for improved performance of the scheme.

Methods

Study area

This study was carried out in Bida town, Bida Local Government Area of Niger State. Niger state is the largest state in Nigeria by area (76,363km²) with Minna as the seat of government. Other major cities are Bida, Kotangora, and Suleja. It is located in the North-Central Region of Nigeria and bounded by Kaduna state and Federal Capital Territory, Abuja in the East and South- east respectively, Kebbi and Zamfara in the North; Kwara and Kogi States in the South and Benin Republic in the West. It has total of 25 LGAs. Bida is the second largest city in Niger state with an estimated population of 178,840 in 2007 according to 2006 census. It is located south-west of Minna. The town comprises of individuals of diverse background and ethnic groups; dominated by Nupe indigenes. Hence, headquarter of the Nupe Kingdom led by the Estu Nupe. The town is known for its Durban festival and production of traditional crafts. It has an Urban-Rural setting with high poverty rate among the indigenes. Agricultural activities form the mainstay of the people’s economy majoring in Paddy rice, yam, cassava, sorghum, millet, sugarcane, peanuts, and Shea nuts among others. The public formal sector institutions in the town are the Local government service commission, State parastatal, as well as Federal civil service and parastatal.

Study site and population

Federal Medical Center, Bida is located at No 4 Efu Etsu Yisa Street Bida, Bida LGA of Niger State. The facility has two outposts; the Comprehensive Health Centre, Zungeru and Family Medical Practice Centre, Gawu Babangida. It is a tertiary health care facility that provides services ranging from paediatrics care, diagnostics services, obstetrics and gynaecology treatments, internal medicine, orthopedic care, among others. The institution has about 2000 employees which include doctors, pharmacists, nurses, and other health professionals and administrative staff. The facility has a total of 200 in-patient beds in its 13 wards. It is accredited by NHIS as service provider.

Study design and sampling

A descriptive cross-sectional survey involving employees of Federal Medical Center was conducted to investigate their knowledge and attitudes towards the utilization of the NHIS services in the center, and factors affecting utilization of the scheme in the facility. A pre-tested semi-structured questionnaire was developed to collect relevant information from the selected respondents/staff. Facility records of the participants were also reviewed to collect and compliment information on available services and utilization levels. The sample population consisted of Federal civil servants working at the FMC Bida, Niger State.

The sample size was derived using the Taro Yamane formula: n= N/1+N (e²).

Where n is the sample size, N is total number of employees, and e is the sampling error (constant=0.05).^[15] Sample size (n) = 1332/1+1332(0.05²) = 307.6. Therefore 308 employees were used for the study, adjusted by 10% to account for attrition

The number of staff was obtained from the Administrative Department (Human Resource). Stratified random sampling technique was used to recruit respondents from all departments to ensure full representation. Criteria for inclusion include willingness to participate in the study, availability at the time of study, and an employee of the facility, FMC, Bida (excluding house officers and interns).

Validity and reliability of the instrument

The research instrument was submitted to the project supervisor, a lecturer in the department of Health Administration and Management, University of Nigeria, Enugu campus, and the Health Research and Ethics committee of Federal Medical Center Bida, for face and content validity. Their corrections, suggestions, and observations were effected before the printing of the final copy of the research instrument.

The tool was pretested among 31employee civil servants of Federal Polytechnic, Bida , representing 10% of the sample size. Data collected were computed using split half technique. A Cronbach Alpha Value of (x=0.801) was obtained which indicates reliability of the test instrument.

Data collection

Quantitative approach informed data collection process. A well-structured self-administered questionnaire which reflected the study objectives and reviewed literatures was used to collect relevant information from the respondents. The questionnaire had 41 items which was divided into 4 sections (A, B, C, and D). Section A was used to collect information on socio-demographic data; age, gender, marital status, highest educational qualification, ethnic group, number in the family, job description, and number of years in the health facility. Section B sought information on employees’ awareness of NHIS. Section C sought to elicit information on employees perception towards NHIS measured on a 5-point Likert Scale (5-strongly agreed, 4-agreed, 3-undecided, 2-disagreed, 1-strongly disagreed). Section D, the major dependent variable of the study sought information on utilization of NHIS services. Data collection was carried out with the help of two (2) trained assistants. The collection process was completed within three weeks.

Data analysis

The data was analyzed using SPSS version 23. Frequencies, tables, mean, and standard deviation were generated. Chi-square test was used to test association between categorical data and utilization of NHIS. Level of statistical significance was set at P<0.05.

Ethical Consideration

Ethical clearance for the study was sought and obtained from the Health Research and Ethics Committee of Federal Medical Center, Bida. Information sheet containing general information about the study was given to the respondents before signing the consent form. Informed consent form was used to obtain respondents’ permission for the interview.

Results

Demographic characteristics of respondents

Three hundred and seven (308) questionnaires were distributed, 288 were returned (93.5% return rate). Of the 288 questionnaires, 270 (87.7%) were valid, while 18(5.9%) were invalid and discarded. Table 1 shows that of the 270 respondents, greater percentage (37.8%) were within the ages of 31- 40, while the least number (4.8%) were within the ages of 51 – 60. Up to 45.6% were males while 54.4% were females. Majority (76.7%) were medical personnel while 23.3% were non-medical personnel. Only 23.3% of the respondents have spent 10 years and above with the hospital.

Awareness/knowledge of enrollees towards NHIS

Table 2 shows that all the respondents (100%) indicated awareness about the NHIS services. Highest number (33.0%), knew about the scheme through the media (radio, television, newspaper, internet), followed by those who knew about it through circular issued by the institution (32.6%). Table 3 shows that 91.5% of the respondents knew the full meaning of NHIS, while only15.9% knew all about the programmes. A little above half of the respondents (56.0%) are aware of a law that mandates employees to register with NHIS. Only about 18.4% have correct knowledge of the percentage of their salaries as contribution to the scheme. Majority (80.3%) are aware of the number of dependents expected to register under a member, while only 12.4% correctly identified all the services provided by the scheme.

Employees’ perception/attitude towards the NHIS

Table 4 shows that a greater percentage of respondents have positive perceptions towards the scheme, according to the decision rule: Strongly agreed-5, Agreed=4, Undecided=3, Disagreed=2, strongly disagreed=1. Mean below 3.0 indicates non affirmation of the respondents to the statement, while a mean above 3.0 shows affirmation of the respondents to that statement.

Utilization of NHIS services by employees

Table 5 shows that majority of the respondents (81.5%) are registered with NHIS while 18.5% are not. Up to 69.3% of beneficiaries’ dependants are registered. A greater percentage of respondents and their dependants (78.1% and 63.5% respectively) have access to the services. However, only 22.8% regularly utilize the services.

Table 1: Summary demographic description of respondents: N=270