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The Impact of Delta State Contributory Health Scheme on Workers Health Attitude, Behaviour and Practice in Delta State Civil Service, Asaba

CHAPTER TWO

LITERATURE REVIEW

2.1 Contributory Health Scheme

The Delta State Contributory Health Commission is a Healthcare Financing organization established by the Delta State Government to ensure access to quality healthcare services for all residents of Delta State irrespective of their socio-economic status and geographical location, in an effort to achieve the United Nations’ Sustainable Development Goal 3 in the year 2030.

The United Nations’ Sustainable Development Goal 3 [Ensure Healthy Lives and Promote Well-being for all at all Ages] has the attainment of Universal Health Coverage (UHC) as one of its key deliverables.

According to the World Health Organization, Universal Health Coverage (UHC) means that every person and community can have access to the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

During the United Nations Sustainable Development Summit in 2015, world leaders agreed to achieve UHC by 2030. UHC is also firmly envisaged in the WHO constitution of 1948 declaring health a fundamental human right and on the “Health for All” agenda set by the Alma Ata declaration in 1978.

Universal Health Coverage has three fundamental component objectives, namely:

– Equity in Access to Health Services where everyone who needs healthcare should get them, not only those who can pay for them.

– The quality of health services should be good enough to improve the health of those receiving services.

– People should be protected against financial-risk, ensuring that the cost of using the healthcare services does not put people at risk of financial harm.

In Nigeria, the National Health Insurance Scheme (NHIS) was established as the vehicle to achieve Universal Health Coverage in the country. The Scheme was signed into law in 1999 and officially launched on 6th June, 2005. It commenced service delivery to enrollees in September, 2005, and currently has about 5% of Nigerians covered under the Scheme in 15 years.

In Delta State, the journey towards achieving Universal Health Coverage (UHC) commenced with the transmission of an Executive Bill to the Delta State House of Assembly on the 22nd of June, 2015, to establish the Delta State Contributory Health Commission. The Bill went through a first reading on the 24th of June, 2015, second reading on the 12th August, 2015, and a public hearing on the 26th August, 2015. The Bill had its third reading and was passed by the Delta State House of Assembly on the 9th December, 2015. The Bill establishing the Delta State Contributory Health Commission was signed into Law by His Excellency Senator Dr Ifeanyi Okowa, Governor of Delta State, on the 4th of February, 2016.

The Law established The Delta State Contributory Health Commission (DSCHC), The Delta State Contributory Health Scheme (DSCHS) and other Matters Connected Thereto, as well as, a Governing Board for the DSCHC which will regulate, supervise, implement and ensure an effective administration of a “Mandatory” Delta State Contributory Health Scheme for all residents of Delta State.

 

The DSCHS has 4 Enrollee Health Plans: –

– Formal Health Plan for those whose premium are paid via Payroll % deductions covering a Husband, Wife and 4 Children below 18 years with a counterpart employer contribution for each Principal Enrollee.

– Informal Health Plan for those whose premium of N7,000/year/Enrollee are paid per individual enrollee covering only the individual enrollee.

– Equity Health Plan for those who have been classified as belonging to the Vulnerable Group (Pregnant Women, Children Under 5 Years, Elderly above 65 Years, Physically and Mentally Challenged and all residents of Delta State classified as Poor). Their Premium of N7,000/year/Enrollee is paid for by the Delta State Government.

– Private Health Plan for individuals that subscribe to pay extra premium for extra Healthcare service needs under the DSCHS.

Before commencement of service delivery, the DSCHC conducted a Baseline Assessment Survey that: –

– Determined key household demography and health seeking behavior of Deltans to guide planning for an expanded health insurance coverage.

– Determined the current household spending on health, health insurance coverage needs and willingness to pay for health insurance in Delta State.

– Estimated the proportion of Delta State residents in the lowest socio-economic quintiles, to guide decisions on subsidy and/or exemptions from payment.

– Assessed the availability and capacity of health delivery facilities in Delta State to deliver proposed health insurance services.

– Assessed the readiness of health facilities to deliver proposed services across all 25 LGAs.

The Baseline Assessment Survey Report is available at the Download Section of the DSCHC Website www.dschc.org.ng. A Post 4 years Progress Assessment Survey is currently ongoing and its report will also be on the website.

The DSCHC commenced service under the scheme on the 1st of January, 2017, and currently has provided service to over 1,044,306 Enrollees (approx. 15% of the estimated Delta State population) in 4 years.

The DSCHC currently has 478 Accredited Public and Private HCFs for Primary healthcare and Secondary healthcare services spread across the State. The quality-of-service monitoring and accreditation of HCF is a continuous DSCHC service activity to ensure regular quality care for all enrollees of the Scheme.

To ensure availability of quality services and affordable quality drugs especially for Non-Communicable Diseases which usually have a huge ‘drugs and other services’ management cost, the DSCHC representing the Delta State Government signed an MOU with Servier Pharmaceutical of France for its “Hospital Cash Cover Program” that will provide subsidized Antihypertensive and Diabetics Drugs; Train 200 health service delivery personnel in Delta State on the latest treatment protocol in management of Hypertension and Diabetes; Support the Delta State Government through support payment of Premium for an agreed number of Vulnerable people under the Scheme, and eventually produce Generic Drugs for use under the Scheme from Servier/SWIPHA manufacturing facility in Nigeria.

In an effort to further improve on the management of Non-Communicable Diseases, the Delta State Contributory Health Commission representing the Delta State Government is also partnering with SANOFI, a French Drug manufacturing company, to:

  1. Build capacity for 400 HCPs (Doctors, Nurses, Pharmacists and CHEWS) to increase the number and quality of Health Care Providers (HCPs) in rural PHCs,
  2. Upgrade of Rural PHCs, to strengthen the management of diabetes and hypertension by implementing Diabetes and Hypertension Clinics through provision of medical utility equipment, educational materials and upskilling the HCPs to increase the utilization of the PHCs by patients in underserved communities. (The “A2F” Polobubo, Oporoza, Ovwor-Olomu and Obior HCFs were selected as the initial Rural HCFs for the Diabetic Hypertensive Clinics),

iii. Enroll 2000 Patients into the DSCHS through Support Payment of their Premium by SANOFI and screening of 10,000 residents to identify undiagnosed people living with diabetes and hypertension in rural communities,

  1. Provide 50% discount price off Insulin market price by Sanofi to the Delta State Drug Revolving Fund,
  2. Provide affordable care support (with up to 40% discount price for other SANOFI’s primary and secondary care medicines) through the Delta State Drug Revolving Fund, and
  3. Engage a Patient Support Program for 2000 PLWD on Sanofi Insulin, through the provision of diagnostic tools (e.g glucometers), dedicated patient educators, 12hrs call center for patients, HBA1c check, educational materials, and 12 months follow up for each of the 2000 PLWD to improve patient adherence to treatment.

The DSCHC has commenced the implementation of the BHCPF program in Delta State. The program implementation involves NIMC National Identity Number (NIN) standard Enrollee Registration, Service delivery to Enrollees at NHIS/DSCHC accredited HCFs, Payment for service delivery to accredited Healthcare Providers from a dedicated CBN TSA account, Monitoring and Evaluation of the various service delivery components by a NHIS/DSCHC Team, and Analytics and Reporting for the service delivery outcomes. The DSCHC has commenced the NIMC (NIN) standard Enrollee registration activity, and following the signed agreement between the DSCHC and NIMC, the DSCHC is the only State Health Insurance Agency in Nigeria approved to register and directly obtain NIMC (NIN) through an “API” and the only Health Insurance Agency in Nigeria listed by the National Information Technology Development Agency (NITDA) as compliant with the National Data Protection Regulation (NDPR) requirement for National Data storage and management. Service delivery to Enrollees has commenced at the NHIS/DSCHC accredited HCFs through the incorporation of the BHCPF program into the DSCHC Equity Health Plan.

The Delta State Contributory Health Scheme has so far won 2 National Awards and several accolades since inception in 2016. In 2017, the Scheme won the Outstanding Healthcare Program of the Year, presented at the Nigerian Healthcare Excellence Award ceremony in recognition of the States outstanding service delivery in the field of healthcare and the State Supported Health Insurance Scheme program in Nigeria. In 2018, the Scheme won an award as the State with the most people covered under the State Social Health Insurance Scheme with focus on the Poor and Vulnerable population in Nigeria under the World Bank/FG – Save One Million Lives Program. The Award was presented by His Excellency, the Vice President of Nigeria, Professor Yemi Osibanjo. The DSCHC targets to achieve a 25% of Delta State population Enrollee coverage by the Year 2023.

Public view on continuity of the programme

The scheme is facing challenges or constraints, even though some of the challenges or constraints are being addressed by the scheme, it is obvious that some of them still persist, (NHIS, 2010). The absence of robust and functional health information system and Information Technology (IT), infrastructure in the country has hindered the sharing of information and creation of data base between the various stakeholders in the scheme. The nonavailability of funds to operate the various subsidy-requiring programmes in informal sector also poses a big challenge in the existing coverage to the sector. The age-long rivalry between various professional groups in the health care industry has found its way. In CHS provider network, while some providers withhold care to enrollees on flimsiest excuse, others charge additional fees on the pretence of non-inclusion of the service in the benefit package. Acceptance of global capitation at primary level and payment for secondary and tertiary care through fee-for-service has contributed to be a challenge. This has been compounded by the dispensing of drugs by primary providers without accredited pharmacies at the expense of accredited pharmacies, thereby contravening the NHIS operational guidelines (Annual Report, 2012). The scheme has over the years faced the problem of lukewarm attitude and behavior to the beneficiary in operating the programme. There have been complaints of delay in or refusal to make payments to providers by some Health Maintenance Organizations (HMOs). Some HMOs on their part have equated the operations of private health insurance to that of social health insurance which is a different variety. However, regular dialogue and consultations are gradually removing some of these distortions in the operations of the scheme. The mechanism for collecting the surcharge for extra dependants of principal enrollees has not been properly worked out. The implementation of co-payment by beneficiaries for pharmaceutical services is not being adequately enforced (Ononokpor, 2010). In spite of all the above challenges or constraints, what is, however, interesting is that the improved stakeholder’s relations series of intensive mobilization or sensitization campaigns and the unrelenting commitment of the federal government to play its role are helping to improve matters for the scheme. It is expected, according to Dogo-Muhammad, (2007), that if every stakeholder plays his/her expected role, the challenges and constraints would be positively addressed.

Perception of Quality of Care

Quality of care refers to enrollees subjective view on the care received whether excellent, very good, good, fair, and poor. According to Count (2010), it can be seen as the extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional 28 knowledge. It looks at the quality of care given to clients/patients and which can be evaluated at the individual or population level of analysis. Health care professionals are more attuned to factors such as signs of measurable clinical improvement and perhaps attention to what has often been the art of medicine, while the enrollees are more attuned to whether the behavior of health care professionals is congruent with their expectations (major component of patient satisfaction), whether their symptoms and everyday role capacity have improved, and whether they can use (access) available services. (Count, 2010). Count (2010) asserts that the major types of quality care indicators are: structure, process and outcomes. Structure: refers to characteristics of the setting(s) in which health care occurs. Structural attributes include material resources (number of personel and their qualifications) and organizational structure (medical staff organization level of reimbursement). Process refers to what is actually done during the care process. Process attributes include patient activities in seeking out care and complying with the treatment regimen as well as practitioner diagnostic and treatment activities. Outcome is the final component. Outcome addresses the effects of care on the health status of individual patients and populations. Outcome attributes include changes in a patient’s health status (physiological measures, patient’s perceptions and preferences example Reduction in child or maternal mortality. Though care assessment is subjective but it has been seen as one of the best tools to assess the quality of care, more especially in resource constrained environments

Theoretical Review

The theory underpinning this is based on the empirical theory of knowledge and reality; developed by John Dewy (Ryan, 2003) and was used as a framework for the study. This approach suggests ways in which individuals know about things or events around them. This study utilizes this theory in explaining the knowledge and perception of civil servants towards National Health Insurance Scheme as a health care financing mechanism

Dewey’s Empirical Theory of Knowledge

This theory posits that people know about things or events around them through their senses, and that knowledge can mean any of the following; to have understanding, or grasp of the object of knowledge. In this study, National Health Insurance Scheme; to be familiar with something, to be able to recognize or identify something; ability to distinguish between things; to have adequate experience and training; and to be intimate with something. For Shook (2009), experience is the source of all knowledge. People according to him, can abstract after experience have provided the basic building blocks. The thesis of this theory as it applies to the subject matter is that federal civil servants in AMAC will become knowledgeable of National Health Insurance Scheme (NHIS) when they have the understanding of the operations of the scheme – (stakeholders, benefits, roles, and responsibilities) through their senses – emanating from radio, television, discussions. The operational function of the above theory cannot be over-emphasized in this study. The theory seeks to explain why people (Federal Civil Servants) understand, identify, and recognize things, the way they do. The theories have guided researcher’s thought along certain lines when considering the phenomena at hand and thus enable her to remain focused and avoid veering off from the issues at stake. The theory, therefore, are very relevant to this study and any other related researches; hence the researcher affirms its importance and utility value.

Empirical Review

This section is concerned with a review of studies conducted in the area of knowledge and perception of National Health Insurance Scheme. Available literature indicates that most studies in this area are limited to the type of health insurance adopted by various countries which reflect their choices, contexts and peculiarities and how the operations of these health care financing models have been making impacts in their respective countries. To this end, very few studies examined the Knowledge and Perception of National Health Insurance Scheme by Federal Civil Servants. A study on perception of National Health Insurance Scheme (NHIS) by Health care consumers in Oyo State, Nigeria, by Sanusi and Awe (2009) was done using a survey design. Instrument for data collection was a structured questionnaire. The data of the 30 study were analyzed using descriptive statistics and inferential statistics (logic regression model). The findings revealed that 87.4% of the respondents were aware of the programme, and 83.2% were registered for the programme, while 58.9% of the respondents have started enjoying the programme. About 65% of the respondents wanted the programme discontinued. Furthermore gender, marital status and income level were some of the factors that did not significantly influence respondents opinion on NHIS continuity. Registration of dependants (p < 0.10) and perception by respondent of drug sufficiency under NHIS (p < 0.05) were the significant factors influencing some of the respondents having the opinion that the scheme be continued. The study shows that notwithstanding the scheme have marginal effects on the people and as such suggested that government and other stakeholders need to intensify awareness campaign, ensure universal coverage, and make registration compulsory. A study of the Awareness of National Health Insurance Scheme (NHIS) activities among employees of a Nigerian University was conducted by Adibe, Udeogaranya and Ubaka (2011). The objective was to assess the level of awareness of NHIS activities among employers of a Nigerian University using a survey design. The instrument for data collection was a 30 item questionnaire while t-test and one-way ANOVA was employed to analyze the data. The sample size was 500 employees with a respond rate of 87.2% (436 out of 500 questionnaires). The result revealed that awareness was significantly associated with all the demographical characteristics of the respondents. The total awareness mean scores for objective of the scheme, responsibility of the scheme and powers of the scheme council were 32.73 2.16, 34.22 2.48 and 33.27 3.38 respectively while the grand total awareness mean was 100.22 8.02. The conclusion of the study was that employees of University of Nigeria were marginally aware of NHIS activities. Demographic characteristics played considerable role on the level of awareness of NHIS activities. A study was conducted by Agada-Amade (2009), on the awareness of Health Insurance Model as a health care financing option by health workers and other civil servants in Abuja (FCT). The objective was to examine the level of awareness of health workers and civil servants of health insurance as a system, and benefits accruable to them from this system of health care financing. A descriptive survey 31 design was adopted for the study. The instrument for data collection was questionnaire and key informant interview. A study sample of 350 out of a population of 24,657 was used. On the whole 163(52.3%) respondents were aware of the concept of NHIS. 47.2% of the senior cadre and 51% of the junior cadre were not aware of the benefits. In the distribution of occupation of respondents and level of awareness, 54(16.9%) respondents were health workers, while 266(83%) respondents were other civil servants. 35(64.8%) of the 54 health workers were aware of Health Insurance while 35.2% were not. For other civil servants 163(61.3%) of the 266 respondents knew about the scheme, while 103(38.7%) were not aware. The result further showed that 198(61.9%) respondents were aware of the benefits accruable from NHIS, while 122(38.1%) have not heard of the benefits. The percentage of the respondents that were aware was higher (64.8%) among the health workers as against 35.2 of other civil servants. In the distribution of sex of the respondents on level of awareness of NHIS, 190(59.4%) were males, whereas 130(40.6%) were female. 125(65.8%) male respondents were aware of NHIS while 65(34.2%) have not heard about the scheme. 82(62%) female respondents have heard about NHIS while 48(37.9%) were not aware of the scheme. On the whole 207(64.7%) of the respondents (health workers and other civil servants were aware of NHIS while 113(35.3%) were not aware. In a study done by Okaro, Ohagwu and Njoku (2010), on Awareness and Perception of National Health Insurance Scheme (NHIS) among Radiographers in South East Nigeria. The objective of the study was to assess the knowledge and attitude of Radiographers in South East Nigeria towards the scheme. It is a cross sectional prospective survey. The sample size is 40. The instrument used was questionnaire. The return rate of the questionnaire was 92.5%. Data were analysed using SPSS version 14.0. Results showed that all the radiographers 100% were aware of NHIS, with majority having their source of information from seminars in the hospital. 45.9% have registered with the scheme, while 54.1% have not registered. With regard to the knowledge of the various aspects of the scheme only 59.59% knew that there is an enabling law for the operation of the scheme in Nigeria, while only one respondent being able to state the year of enactment of the law. More than 70% of the respondents could not correctly state at least two objectives of the scheme. 37.8% do 32 not know the provider payment mechanism as well as the radiological examination not covered under the scheme. In summary there is generally high level of awareness to the existence of NHIS in Nigeria among the study population, but there is poor Knowledge of the principles of the operation of the National Health Insurance Scheme; Participation is low among radiographers but they have positive attitude towards the scheme. Seminars in hospitals are very important in sensitizing the healthcare professionals. A similar study was conducted by Owu, Ifatimehin, and Shaka (2014), on Assessment of the level of Awareness of the effectiveness of National Health Insurance Scheme among workers in selected federal establishments in Kaduna metropolis, Nigeria. The study is a survey design and the instrument for data collection was questionnaire. The sample size is 200. The return rate of the questionnaire is 75.5%. Analysis were done using SPSS version 19.0 Analysis of Variance (ANOVA) (f) was used to test hypothesis. A significant value less than 0.05 was adjusted and the null hypothesis accepted. 149 (98%) of the respondents were aware of NHIS, while 2 (1.3%) were not aware of NHIS.138 (91.4%) were registered while 13 (8.6%) were not registered with NHIS. 129 (85.6%) have access to healthcare services through NHIS, while 22 (14.6%) indicated they don’t have access to healthcare services. 77 (51%) of the respondents rated their access to healthcare services as satisfactory, closely followed by 28 (18.55) who were undecided, 15 (9.9%) were highly satisfied, 23 (15.2%) were unsatisfied and 8 (5.3%) were highly unsatisfied. Looking at the level of acceptance of NHIS 131 (86.8%) respondents indicated yes, while 20 (13.2%) of the respondents indicated no. In conclusion there is high level of awareness of National Health Insurance Scheme among workers in Kaduna metropolis, health care providers in Kaduna metropolis performed well in the delivery of healthcare services to workers, and workers have positive attitudinal disposition towards the utilization of the scheme and have accepted the scheme. A study done by Olugbenga-Bello and Adebimpe, (2010) on Knowledge and attitude of civil servants in Osun state, South Western Nigeria, towards the National Health Insurance. It was a descriptive, cross sectional study with sample size of 380. The instrument for data collection was questionnaire. The result showed that about 60% were aware of out of pocket as the most prevalent form of health care financing, while 33 40% were aware of NHIS. Television and bill boards were their main sources of awareness. However none had good knowledge of the components of NHIS, 26.7% knew about its objectives, and 30% knew about who ideally should benefit from the scheme. Personal spending still accounts for as high as 74.7% of health care spending among respondents but respondents believed that this does not cover all their health needs. Only 0.3% have so far benefited from NHIS, while 199 (52.5%) of respondents agreed to participate in the scheme. A significant association exists between willingness to participate in NHIS and awareness of methods of options of health care financing and awareness of NHIS

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