|Year : 2015 | Volume
| Issue : 1 | Page : 9-14
The role of National Health Insurance Scheme on structural development of health facilities in Zaria, Kaduna State, North Western Nigeria
Muhammad Bello Garba, Clara Ladi Ejembi
Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
|Date of Web Publication||21-Aug-2015|
Muhammad Bello Garba
Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The National Health Insurance Scheme (NHIS) in Nigeria was introduced in 2005 to ensure universal access to good health care services, by protecting families from financial barriers to health care, and ensuring availability of funds to the health sector for improved services. Since introduction of the scheme, however, there has been no documented study carried out to assess whether there has been any improvement in human resource available for provision of health services and for other basic infrastructure in the participating facilities.
Aim: This study was undertaken to assess and compare the funding patterns, and infrastructural and manpower development in health facilities in Zaria, Kaduna State, following the introduction of the NHIS.
Materials and Methods: This study was comparative cross-sectional in design. Using stratified sampling technique one public and two private health facilities were selected from 16 secondary health facilities (5 public, 11 private) accredited by the NHIS. Retrospective analysis of data collected from their records on the pattern of funding, the levels of hospital infrastructure, and manpower in the facilities was carried out before and after the introduction of the NHIS.
Results: The study demonstrated an almost three-fold increase in financial resources availability to the health facilities following enrolment into the NHIS, with the private facilities having a higher increase (300%) than the publicly owned facility (261%). Funds from the scheme, now constituting up to 36% of the total revenue, accounted for almost half (47%) of the increase. The facilities also witnessed improvement in physical infrastructure, staff strength, and diagnostic capability with variable statistical significance.
Conclusion: The study demonstrates that the relationship between financial resource availability and facilities' staffing, laboratory diagnostic capability, and physical infrastructure is not always linear.
Keywords: Funding pattern, health facilities, hospital infrastructure, manpower development, national health insurance scheme
|How to cite this article:|
Garba MB, Ejembi CL. The role of National Health Insurance Scheme on structural development of health facilities in Zaria, Kaduna State, North Western Nigeria. Ann Nigerian Med 2015;9:9-14
|How to cite this URL:|
Garba MB, Ejembi CL. The role of National Health Insurance Scheme on structural development of health facilities in Zaria, Kaduna State, North Western Nigeria. Ann Nigerian Med [serial online] 2015 [cited 2020 Apr 5];9:9-14. Available from: http://www.anmjournal.com/text.asp?2015/9/1/9/163327
| Introduction|| |
The performance of the Nigerian health system is seriously undermined by weak health infrastructure, inadequacy in the number and competency of health personnel, as well as organizational failures.  Care is often sought in a setting of decaying physical facilities and given by an overstretched workforce, working with obsolete equipment. A survey of primary health care (PHC) facilities, for instance, shows that only a quarter of health facilities had >50% of the minimum equipment package, and up to 40% of the facilities had less than a quarter.  These facts were corroborated by findings of a study in rural Osun in South Western Nigeria conducted by Oyekale and Eluwa in 2009, where the general ratings of the conditions of health facilities were found to be very poor.  This is represented by the country's very low health indicators when compared with other less endowed African countries, resulting from the systems' perennial inability to sufficiently meet the increasing demand for care. 
This dismal performance of Nigeria's health system is strongly associated with poor funding of the sector. The average budgetary allocation to health recorded as percentage of total has been around 5%, with per capita health expenditure of US$10 (compared to US$34 per person per year recommended by the Commission for Macroeconomics and Health, needed to deliver an essential package of intervention to achieve the Millennium Development Goals).  This leads to prominence of out of pocket health expenditure, reaching a staggering 70%, with its attending negative impacts on access, and perpetuation of poverty and ill-health. 
Structural aspects of health care that are described in terms of physical, technological and social infrastructure, as well as a human resource for health; are an indirect measure of performance and quality of care.  They are useful in that they are expected to influence the direct provision of care. In stimulating infrastructural growth and development in personnel skills, and increasing the number of health personnel, the funds from National Health Insurance Scheme (NHIS) are expected to impact positively on access and quality of care; by expanding fiscal base of health facilities. Poor condition of the physical environment of health care facilities is associated with the compromised safety of patients and staff, decrease in productivity of health personnel, rise in nosocomial infections, and generally undesirable outcome of care. , This is in addition to the effects of sub-optimal health infrastructure on access to care and on utilization of services,  which may directly take the form of placing functional limitation to access; and indirectly, by dampening patients/clients confidence in the system. This results in the patronage of alternative care or medical tourism, as the case may be, thus decreasing demand. 
The government response to this deplorable condition of the health system was to commit to the Abuja declaration, which seeks to correct the anomaly of poor funding of the health sector, by raising the total annual budgetary allocation to 15% between 1999 and 2008; and by the introduction of a NHIS beginning in 2005. Through its fund re-imbursement mechanisms and capitation fees, the scheme provides a financial incentive to registered health care providers for capital investment in infrastructure and human resources for health. Through this, the scheme seeks to achieve most of its principal goals; strengthening the health system, attaining universal access by 2015, and raising and maintaining standards in health care practices.  These are to be achieved through, among other things, removing financial barriers to good health care and ensuring the availability of funds to the health sector for the provision of improved services. Since introduction of the scheme however, there has been no documented study carried out to assess whether there has been any improvement in human resource available for provision of health services and other basic infrastructure in the participating facilities.
This study was conducted to determine and compare funding patterns in the facilities before and after introduction of the NHIS; and to determine the relationship between financial resources availability and facilities' physical infrastructure, staffing, and laboratory diagnostic capabilities.
| Materials and Methods|| |
This comparative cross-sectional study was conducted in Zaria, the second largest city in Kaduna State, in North-Western Nigeria. The cosmopolitan city serves as headquarters to two of the 23 local government areas (LGAs) of the state, Zaria and Sabon Gari, with projected populations of 480,638 and 350,000 respectively (2006 census).  The city is served by 102 health facilities (41 in Zaria LGA and 61 in Sabon Gari LGA), which include 82 PHCs, two secondary health facilities (one each for the 2 LGAs), 18 registered private clinics/hospitals and one tertiary center, Ahmadu Bello University Teaching Hospital. 
The study population comprised of NHIS accredited secondary health facilities. These include 5 public and 11 privately owned health facilities  giving a public: Private ratio of 1:2. Thus, one public hospital (Hajia Gambo Sawaba General Hospital) and two private hospitals (Ladiya Hospital and Savannah Polyclinic) were selected for the study, using simple random sampling technique by balloting.
Data were collected using a checklist developed from NHIS accreditation requirements for secondary level of care,  and pretested in the neighboring Giwa LGA. In each of the facilities surveyed, data were collected from records on funding, physical structures, laboratory diagnostic capability, and number of staffs, a year before (2005) and 5 years after (2011) joining the NHIS. Facilities were surveyed to verify some of the recorded data.
Data were analyzed using SPSS statistical package version 20 (IBM Corporation) and presented using tables and graphs. Statistical significance was tested using Wilcoxon rank test and Pearson correlation tests at P < 0.05 level of significance.
The reluctance of health facilities to allow access to their financial, personnel and other records to be used for the study resulted in only three facilities satisfying the eligibility criteria and to give consent. This presented as a major limitation to the study.
| Results|| |
In general, fees for service (90%) and monthly government subvention (10%) were the two main sources of income in the facilities before the introduction the NHIS. Following the introduction of the NHIS, fees from the scheme accounted for more than a third (36%) of the facilities' income while payment for services fell to 61%. Government subvention to the public facility was, however, withdrawn as shown in [Table 1].
|Table 1: Comparison of facilities' sources of funds before and after introduction of NHIS|
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Results of this study further demonstrated an overall 2.87-fold increase in financial resource availability in the health facilities reviewed following enrolment into NHIS, with the two private facilities having a higher increase (300%) than the publicly owned facility (261%). Funds from the scheme, now constituting up to 36% of the total revenue, accounted for almost half (47%) of the increase [Table 2]. Wilcoxon rank test indicates that the increase was not statistically significant (P = 0.109). The general pattern of increase in income shows a sharp rise with a peak in 2008, followed by a plateau [Figure 1]. The trend in Ladiya Hospital is strikingly similar to the overall pattern, contrasting with a much smaller and gradual rise in Savannah Polyclinic and some drop in total annual revenue observed in Hajia Gambo Sawaba General Hospital from the year 2008, this coinciding with withdrawal of state subvention.
|Figure 1: The trend of financial resource availability in the three facilities during the 5 years period since joining the National Health Insurance Scheme|
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A comparison of the physical infrastructure in the facilities before and after their joining the NHIS service provision shows some increase only in the publicly owned Hajia Gambo Sawaba General Hospital. It remained almost the same in one of the private facilities, Ladiya Hospital. In the second private facility, Savannah Polyclinic, some of the facility's infrastructures like number of beds have witnessed a decline during the period since the introduction of the NHIS. Analysis of the facilities' laboratory diagnostic capability reveals only a marginal increase in the number of laboratory tests carried out in one of the private facilities, Savannah Polyclinic (18%) and in the public facility, Hajiya Gambo Sawaba General Hospital (26%), 5 years after joining NHIS. The number of tests carried out by the Ladiya Hospital's laboratory, on the other hand, remains same after joining the scheme.
|Table 2: Comparison of financial availability in the facilities before and after introduction of NHIS|
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The three facilities have recorded overall increase in staff strength, the number of laboratory tests, and number of beds of 27%, 18% and 25%, respectively, 5 years after the introduction of NHIS. Wilcoxon rank test carried out on the aggregate data before and after joining NHIS show that the increases were not statistically significant, with P values of 0.535, 0.593 and 0.157, respectively [Table 3].
|Table 3: Comparison of facilities' financial resource availability, number of clinical staff, laboratory tests and number of beds before and after introduction of NHIS in the facilities surveyed|
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However, when disaggregated by the facility, the analyses show a variable level of statistical significance. In a privately owned Ladiya Hospital, there exists a strong positive correlation between increase in revenue and rise in the number of clinical staffs since the introduction of NHIS (r = 0.992), a relationship found to be statistically significant (P = 0.001). The number of beds and laboratory tests carried out in the hospital remained the same over the 5 years period surveyed [Table 4].
|Table 4: Relationship between financial resource availability, number of clinical staff, laboratory tests and number of beds before and after introduction of NHIS in Ladiya Hospital|
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In the other private facility, Savannah Polyclinic, whereas a strong positive correlation was established between increase in average annual revenue following introduction of NHIS and the number of laboratory tests carried out in the hospital (r = 0.950, P = 0.013), the relationship with both number of clinical staff and the number of beds in the hospital was that of a strong negative correlation [Table 5]. As revenue increased over the 5 years period since the facility joined the NHIS, the staff strength (r = −0.936, P = 0.013) and number of beds (r = −0.955, P = 0.012), went down significantly.
|Table 5: Relationship between financial resource availability, number of clinical staff, laboratory tests and number of beds before and after introduction of NHIS in Savannah Polyclinic|
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In the publicly owned Hajia Gambo Sawaba General Hospital, however, though the correlation between change in average annual revenue and the number of clinical staff (r = 0.603), laboratory tests (r = 0.863) and the number of beds (r = 0.724) were positive, these were found not to be statistically significant, with P values of 0.282, 0.06, and 0.166, respectively as shown in [Table 6].
|Table 6: Relationship between financial resource availability, number of clinical staff, laboratory tests and number of beds before and after introduction of NHIS in HGSGH|
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| Discussion|| |
In the general economic model, investment in infrastructural development leads to growth, enhances productivity, and gives increasing value for the fixed capital, through network effects.  It therefore follows that providing additional financial resources for the facilities which might be used for capital investment will return the health system to a growth path, which in addition to skills, innovation, entrepreneurship and competitiveness are enumerated among the five principal drivers of productivity. ,
Though an increase in income was recorded following introduction of NHIS, the rise in the quantum of money accrued to the facilities was shown to be statistically not significant, which could be attributed to very low coverage of the scheme (<5%, halfway into the period targeted for universal coverage), low capitation fee (recently increased from N550 per head to N750), and a relatively high administrative cost, which is up to 22%, comparing poorly with 5-15% administrative cost observed in other countries with much better administrative practices. 
Despite the appealing nature of the theoretical model explaining the impact of financial resources on hospital physical infrastructure, this study demonstrates that the increase in hospitals revenue accruing from NHIS has not yet produced universally good results. Whereas the relationship between increased financial resources and improvement in staff strength is found to be statistically significant in one of the private facilities Ladiya Hospital, This was not the case with the number of laboratory tests carried out and number of beds in that same hospital; as well as with the three indices in the publicly owned Hajia Gambo Sawaba General Hospital. Conversely, the relationship between increase in hospital revenue and the three indices is shown to be a negative one in the other private facility, Savannah Polyclinic. This finding of no statistically significant association between availability of financial resource and increase in facilities' infrastructure and workforce development following introduction of NHIS, is in consonance with the conclusion by Kim and Moody, that the effect of health care expenditure on both the level of medical infrastructure and on health outcomes, is not significant.  Major constraints explaining this gap may include the paucity of efficiency in resources utilization, systemic bureaucracies and the fact that medical expenditure is very expensive to provide and maintain.  Another factor is the passive approach adopted by the NHIS regarding providers investment in infrastructure. This is because apart from the initial accreditation requirements for facilities, the scheme has no clear regulation and enforcement mechanism for infrastructural expansion and manpower development to cater for the envisaged increase coverage.  The fall in the staff strength, number of beds and laboratory tests recorded in Savannah Polyclinic coinciding with increase in revenues from NHIS is similar to what the Canadian Health Coalition in 2009 reported on Brampton Civic Hospital of Ontario and Royal Ottawa Mental Health Centre in Canada. Drawing from public private partnership project funds, the hospitals ended-up with fewer beds and fewer nursing staff than planned for in the project, despite spending an additional 72% of the project funds. 
Another striking finding of this study is that although collectively the two private facilities recorded higher increase in revenue due to the NHIS, an increase in infrastructure and staffing was observed more in the public facility. This is in agreement with the assertion that private funding of hospital infrastructure, done in the purview of partnership, is costlier, economically inefficient, lacks accountability and is more unlikely to succeed. , This difference may not be fully explained by the differential utilization of funds from the scheme, as most of capital projects in public facilities are undertaken centrally by the State Ministry. Nonetheless, this finding is particularly important, as NHIS service provision is mainly private driven, as up to 80% of the accredited providers are private facilities. ,
| Conclusion|| |
We observed some improvement in financial resource availability in the health facilities reviewed with enrolment into the NHIS, with revenue from the scheme accounting for almost half (47%) of the increase. There was also a consequent improvement in physical infrastructure, staff strength, and diagnostic capability, with varying statistical significance. The study thus, establishes that the relationship between financial resource availability and facilities' staffing, laboratory diagnostic capability and physical infrastructure is not always linear as many people had thought. Systemic factors like supervision mechanisms, general state of the health care system, bureaucracies, and the overall macroeconomic milieu; as well as efficiency in resource utilization in individual health facilities may have contributory roles.
We recommend that the scheme should expand the participation of the public facilities, help decrease administrative costs, and set a framework for infrastructural development in its continuous provider supervision mechanism. There is also need for larger studies involving more health facilities.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]