National health insurance schemes (NHIS) are implemented as part of health reform and as strategies aimed towards providing effective and efficient health care for citizens in many low and middle income countries (LMICs). Some LMICs are still in the early stages of implementation, while others are in the middle and late stages. Despite challenges in implementation, most LMICs such as Nigeria, India, and Kenya have increased government spending as a percentage of total health expenditure (THE) between 1 and 3 percentage points . Ghana, Rwanda, and Indonesia have increased THE between 5 and 10 percentage points after launching reforms . The incremental approach to risk pooling, used by most LMICs, commences with multiple pools for different target populations .
In Nigeria, health insurance was introduced to the citizens in mid-2005. Presently, revenue for implementation of the NHIS relies on formal-sector payroll contributions and general government revenues, despite the challenges of tax collection . The formal-sector programme is paid for with funds created by pooling the contributions of employees and employers . Contributions to the program are 15% of the employee’s basic salary, with the employee contributing 5% and employers contributing the remaining 10% [2–4]. Nigeria has adopted the incremental approach of risk pooling, using multiple stages which would later incorporate other population groups in different NHIS programs . Purchasing services, in the NHIS, is accomplished through a mix of public and private providers who are reimbursed by purchasing-agency resources controlled by health management organizations (Hmos).
There have been virtually no in-depth studies in low, middle and high income countries that deal with the performance evaluation of health insurance using optimal-resource-use (ORU) domains. The performance of health insurance schemes, which begins to dominate health care financing in LMICs, demands greater attention in the contemporary context. Fundamental and structural problems associated with ORU domains need to be understood, and effective solutions proffered. LMICs would benefit from common, comparable standards for measuring performance of schemes related to ORU, either across countries or across regions within a country, which could guide midcourse policy corrections and improve implementation .
NHIS performance measures and their indicators are instrumental in assisting policy and decision makers in identifying target groups, clarifying objectives, defining measures of performance, and developing performance information systems . These performance measures include revenue collection, pooling and purchasing in terms of ORU [1, 6–11]. Presently, there is a lack of evidence in LMICs to evaluate the performance of health insurance using optimal-resource-use as an outcome measure. Furthermore, little is known on how to evaluate this optimal-resource-use.
ORU is a health financing target used to evaluate how well social health insurance performs [6, 7]. The WHO has proposed the model of optimal-resource-use domains to monitor and evaluate the performance of health insurance schemes during the transition period of implementation [6–11], but evidence from in-depth investigations in LMICs is still lacking. These ORU domains encompass administrative efficiency, active monitoring mechanism, provider payment mechanisms, and benefit package inclusions [6–11]. ORU domains of health insurance schemes accentuate the importance of monitoring and evaluation, but the appraisals are usually not known, and the suitability and practicality have not yet been explored and examined. Moreover, the supply-side of a health insurance system and its influencing factors and characteristics are mostly neglected. Implementers, policy and decision makers should understand the key characteristics and potential factors influencing the insurance supply-side to improve the schemes’ implementation.
This paper examines the performance of Nigeria’s NHIS related to ORU domains based on providers’ experiences. Moreover, the paper addresses the key characteristics and potential issues challenging the Nigeria’s NHIS implementation according to the providers’ perspectives. As this study is exploratory in nature, we hypothesized that the ORU domains ratings would be influenced by certain provider personnel experiences and associated characteristics at individual level. These hypotheses and related assumptions are supported by the theoretical framework of performance indicators for the implementation of social health insurance and related literatures [3, 4, 6, 7, 12, 13]. This study was carried out to evaluate the progress of implementation of the health insurance scheme related to ORU domains.