Assessment of the design and implementation challenges of the National Health Insurance Scheme in Nigeria: a qualitative study among sub-national level actors, healthcare and insurance providers.

BACKGROUND: Health insurance is an important mechanism to prevent financial hardship in the process of accessing health care. Since the launch of Nigeria's National Health Insurance Scheme (NHIS) in 2005, only 5% of Nigerians have health insurance and 70% still finance their healthcare through Out-Of-Pocket (OOP) expenditure. Understanding the contextualized perspectives of stakeholders involved in NHIS is critical to advancing and implementing necessary reforms for expanding health insurance coverage at national and sub-national levels in Nigeria. This study explored the perspectives of sub-national level actors/stakeholders on the design and implementation challenges of Nigeria's NHIS. METHODS: A descriptive case study design was used in this research. Data were collected in Ibadan, Oyo State in 2016 from health insurance regulators, healthcare providers, and policymakers. Key informant interviews (KII) were conducted among purposively selected stakeholders to examine their perspectives on the design and implementation challenges of Nigeria's National Health Insurance Scheme. Data were analysed using inductive and deductive thematic approaches with the aid of NVIVO software package version 11. RESULTS: Implementation challenges identified include abject poverty, low level of awareness, low interest (in the scheme), superstitious beliefs, inefficient mode of payment, drug stock-out, weak administrative and supervisory capacity. The scheme is believed to have provided more coverage for the formal sector, its voluntary nature and lack of legal framework at the subnational levels were seen as the overarching policy challenge. Only NHIS staff currently make required financial co-contribution into the scheme, as all other federal employees are been paid for by the (federal) government. CONCLUSIONS: Sub-national governments should create legal frameworks establishing compulsory health insurance schemes at the subnational levels. Effective and efficient platforms to get the informal sector enrolled in the scheme is desirable. CBHI schemes and the currently approved state supported health insurance programmes may provide a more acceptable platform than NHIS especially among the rural informal sector. These other two should be promoted. Awareness and education should also be raised to enlighten citizens. Stakeholders need to address these gaps as well as poverty.

Tuberculosis treatment outcomes and associated factors in two states in Nigeria.

OBJECTIVE: To determine the treatment success rate among TB patients and associated factors in Anambra and Oyo, the two states with the largest burden of tuberculosis in Nigeria. METHODS: A health facility record review for 2016 was conducted in the two states (Anambra and Oyo). A checklist was used to extract relevant information from the records kept in each of the selected DOTS facilities to determine TB treatment success rates. Treatment success rate was defined as the proportion of new smear-positive TB cases registered under DOTS in a given year that successfully completed treatment, whether with bacteriologic evidence of success ('cured') or without ('treatment completed'). Treatment success rate was classified into good (≥85%) and poor (<85%) success rates using the 85% national target for TB treatment outcome. Data were analysed using descriptive statistics and chi-square at P < 0.05. RESULTS: There were 1281 TB treatment enrollees in 2016 in Anambra and 3809 in Oyo (total = 4835). An overall treatment success rate of 75.8% was achieved (Anambra-57.5%; Oyo-82.0%). The percentage cure rates were 61.5% for Anambra and 85.2% for Oyo. Overall, only 28.6% of the facilities in both states (Anambra-0.0%; Oyo-60.0%) had a good treatment success rate. More facilities in Anambra (100.0%) than Oyo (40.0%) had a poor treatment success rate (p < 0.001), as did more private/FBO (100.0%) than public health facilities (60.0%) (p = 0.009). All tertiary facilities had a poor treatment success rate followed by 87.5% of secondary health facilities and 56.5% of primary healthcare facilities (P = 0.035). CONCLUSION: Treatment success and cure rates in Anambra state were below the 85.0% of the recommended target set by the WHO. Geographical location, and level/tier and type of facility were factors associated with this. Interventions are recommended to address these problems.

OBJECTIF: Déterminer le taux de succès du traitement chez les patients TB et les facteurs associés à Anambra et Oyo, les deux Etats avec la plus grande charge de TB au Nigéria. MÉTHODES: Un examen des dossiers des établissements de santé pour 2016 a été réalisé dans les deux Etats (Anambra et Oyo). Une liste de contrôle a été utilisée pour extraire les informations pertinentes des registres conservés dans chacun des établissements DOTS sélectionnés afin de déterminer les taux de succès du traitement antituberculeux. Le taux de succès du traitement a été défini comme la proportion de nouveaux cas de TB à frottis positif enregistrés dans le cadre du DOTS au cours d'une année donnée qui ont terminé le traitement avec succès, que ce soit avec des preuves bactériologiques de succès («guéri¼) ou sans («traitement terminé¼) . Le taux de succès du traitement a été classé en bons (≥ 85%) et mauvais (<85%) taux de réussite en utilisant l'objectif national de 85% pour l'issue du traitement de la TB. Les données ont été analysées à l'aide de statistiques descriptives et du Chi carré à p <0,05. RÉSULTATS: Il y avait 1.281 personnes inscrites au traitement antituberculeux en 2016 à Anambra et 3.809 à Oyo (total = 4835). Un taux de succès global du traitement de 75,8% a été atteint (Anambra, 57,5%; Oyo, 82,0%). Les taux de guérison en pourcentage étaient de 61,5% pour Anambra et de 85,2% pour Oyo. Dans l'ensemble, seuls 28,6% des établissements des deux Etats (Anambra, 0,0%; Oyo, 60,0%) avaient un bon taux de réussite du traitement. Plus d'établissements à Anambra (100,0%) qu'à Oyo (40,0%) avaient un faible taux de réussite du traitement (p <0,001), tout comme plus d'établissements de santé privés/FBO (100,0%) que publics (60,0%) (p = 0,009). Tous les établissements tertiaires avaient un faible taux de réussite du traitement, suivis de 87,5% des établissements de santé secondaires et 56,5% des établissements de soins de santé primaires (p = 0,035). CONCLUSION: Le succès du traitement et les taux de guérison dans l'Etat d'Anambra étaient inférieurs aux 85,0% de l'objectif recommandé fixé par l'OMS. L'emplacement géographique, le niveau et le type d'établissement étaient des facteurs associés à cela. Des interventions sont recommandées pour résoudre ces problèmes.

General and tuberculosis-specific service readiness in two states in Nigeria.

BACKGROUND: Tuberculosis is the world's deadliest infectious disease and a leading cause of death in Nigeria. The availability of a functional healthcare system is critical for effective TB service delivery and attainment of national and global targets. This study was designed to assess readiness for TB service delivery in Oyo and Anambra states of Nigeria. METHODS: This was a facility-based study with a mixed-methods convergent parallel design. A multi-stage sampling technique was used to select 42 primary, secondary, and tertiary healthcare facilities in two TB high burden states. Data were collected using key informant interviews, a semi-structured instrument adapted from the WHO Service Availability and Readiness Assessment tool and facility observation using a checklist. Quantitative data were analysed using descriptive and inferential statistics while qualitative data were transcribed and analysed thematically. Data from both sources were integrated to generate conclusions. RESULTS: The domain score for basic amenities in both states was 48.8%; 47.0% in Anambra and 50.8% in Oyo state with 95% confidence interval [- 15.29, 7.56]. In Oyo, only half of the facilities (50%) had access to constant power supply compared to 72.7% in Anambra state. The overall general service readiness index for both states was 69.2% with Oyo state having a higher value (73.3%) compared to Anambra with 65.4% (p = 0.56). The domain score for availability of staff and TB guidelines was 57.1% for both states with 95% confidence interval [- 13.8, 14.4]. Indicators of this domain with very low values were staff training for the management of HIV and TB co-infection and training on MDR -TB. Almost half (47.6%) of the facilities experienced a stock out of TB drugs in the 3 months preceding the study. The overall tuberculosis-specific service readiness index for both states was 75%; this was higher in Oyo (76.5%) than Anambra state (73.6%) (p = 0.14). Qualitative data revealed areas of deficiencies for TB service delivery such as inadequate infrastructure, poor staffing, and gaps with continuing education on TB management. CONCLUSIONS: The weak health system remains a challenge and there must be concerted actions and funding by the government and donors to improve the TB healthcare systems.

A cost effective analysis of fixed-dose combination of dutasteride and tamsulosin compared with dutasteride monotherapy for benign prostatic hyperplasia in Nigeria: a middle income perspective; using an interactive Markov model.

BACKGROUND: The number of Nigerian men presenting with benign prostatic hyperplasia is on the rise because of increase awareness about the ailment. With the renewed effort by the national health insurance scheme to cover the informal sector, it becomes imperative to determine the cost implication for managing Benign Prostatic Hyperplasia (BPH) and the cost effective drug combination to be adopted. The objective of this study is to estimate cost effective analysis (CEA) of fixed -dose combination of dutasteride and tamsulosin compared with dutasteride monotherapy from the health service provider perspective design. METHODS: An interactive Markov's model was used to generate incremental cost per QALY and incremental cost per life years gained. 2.9 million Men who were 50 years of age were fed into the model. The outcome measures included: costs of drug treatment, consultation, acute urinary retention (AUR), transurethral resection of prostate (TURP), hospitalisation post TURP, and quality adjusted life years (QALYs), incremental cost per life years gained, and incremental cost per QALY gained. RESULTS: Fixed-dose combination of dutasteride and tamsulosin (FDCT) produced an Incremental cost-effectiveness ratios of US$1481.92 per Quality adjusted for life-years saved. CONCLUSION: Universal FDCT provision for Nigeria has major economic implications. This study in the context of its limitations has demonstrated the cost effectiveness of FDCT for the long term treatment of patients with moderate to severe BPH from the perspective of a developing country. Currently, there are few studies available to give economic data evidence to policy makers in Nigeria which is applicable to developing countries with similar economies. As such, the findings in this study will be relevant to policy makers in these countries.

Access to healthcare and social determinants of health among female migrant beggars in Ibadan, Nigeria.

Introduction: Migration is a social determinant of health, and a major underlying factor of inequity of access to health and disparities in health outcomes. Migrant beggars from Northern part of Nigeria are a common feature in Southern Nigeria. Not too much is known about the challenges associated with access to healthcare and social determinants of health among this group of people in Nigeria. This study aims to fill existing gaps and contribute to the efforts of stakeholders in ameliorating the perennial challenges faced by this group of people. Materials and methods: The study was a descriptive cross-sectional study carried out among female migrants in the city of Ibadan. Using Open Data Kit (ODK), a semi-structured interviewer-administered questionnaire was used to collect data from respondents relating to access to health and basic social amenities, and challenges associated with these and as well as coping strategies. Data analysis was done with STATA version 15. More than a third-fifth of the respondents gave birth to their babies at home, used open defecation 189(49.6%), well/borehole 204(53.6%) is the source of drinking water. Three hundred and fifty-six (90.8%) of the respondents sleep in open space. Respondents with secondary school level of education, had a 129% increased odds of using health facilities compared to those who did not have any formal education (OR=2.29, p=0.014, CI: 1.18-4.44). Access to healthcare services and social amenities among women beggars was poor. There is a need for stakeholders to address this.

Geospatial distribution and bypassing health facilities among National Health Insurance Scheme enrollees: implications for universal health coverage in Nigeria.

BACKGROUND: This study was carried out to enable an assessment of geospatial distribution and access to healthcare facilities under the National Health Insurance Scheme (NHIS) of Nigeria. The findings will be useful for efficient planning and equitable distribution of healthcare resources. METHODS: Data, including the distribution of selected health facilities, were collected in Ibadan, Nigeria. The location of all facilities was recorded using Global Positioning System and was subsequently mapped using ArcGIS software to produce spider-web diagrams displaying the spatial distribution of all health facilities. RESULTS: The result of clustering analysis of health facilities shows that there is a statistically significant hotspot of health facility at 99% confidence located around the urban areas of Ibadan. The significant hotspot result is dominated by a feature with a high value and is surrounded by other features also with high values. Away from the urban built-up area of Ibadan, health facility clustering is not statistically significant. There was also a high level (94%) of bypassing of NHIS-accredited facilities among the enrollees. CONCLUSIONS: Lopsided distribution of health facilities in the study area should be corrected as this may result in inequity of access to available health services.

Factors Influencing Satisfaction with Service Delivery Among National Health Insurance Scheme Enrollees in Ibadan, Southwest Nigeria.

Perceived quality of care is a determinant of uptake of health services. This study aimed to assess the determinants of quality of care of enrollees in the National Health Insurance Scheme (NHIS) in Nigeria. The outcome was satisfaction with health care services, which was used as a proxy for quality. Findings will assist in the intervention to enhance enrollment in the scheme and for universal health coverage attainment. This was a descriptive cross-sectional study conducted among enrollees in selected NHIS facilities in Ibadan, Nigeria. Data on satisfaction with health care were collected among selected 432 enrollees with the aid of an adapted semi-structured WHO-USAID interviewer-administered questionnaire. Data were analyzed using chi-square and multiple logistic regression models (α = 0.05). Among predictors of satisfaction with health services were younger age (OR = 1.85, 95% CI = 1.05-3.25, p = .024), working in the private sector (OR = 1.84, 95% CI = 1.03-3.28, p = .022), and seeking information about quality of services prior enrollment (OR = 1.63, 95% CI = 1.04-2.53, p = .013). Targeted intervention based on the findings of this study should be implemented to improve satisfaction with the services offered.

The Role of Trust in the Pattern of Enrollment to a Social Health Insurance Scheme and Distribution of Healthcare Facilities in Ibadan, Southwest Nigeria.

The National Health Insurance Scheme (NHIS) of Nigeria established in the year 2005 aims to minimize the inequity of access to quality healthcare services in Nigeria. As of the year 2017, enrollment in NHIS-accredited facilities in the southwest region of Nigeria was significantly clustered, with more than three-quarters of NHIS enrollees registered with only 10% of the available NHIS-accredited facilities in the six states of the region. This study explored the factors associated with the skewed distribution of enrollees across facilities and the influence of stakeholders. This is a descriptive, qualitative, case study design among stakeholders of the NHIS in Ibadan, Oyo State, Southwest, Nigeria. In-depth interviews were conducted between March and June, 2019, with all selected individual stakeholders as listed earlier. Data analysis was done using an inductive thematic approach. Across the board, there was a low level of trust in government and government policies among healthcare providers and enrollees. Few healthcare providers were willing to render services under the scheme at inception. The majority of the enrollees were compelled to register with the few available healthcare providers. Among the enrollees, a few personally chose healthcare facilities and providers that were perceived to render better quality services to receive care. Priority should be given to building trust among stakeholders in the NHIS as this would facilitate cooperation and better working relationship, and reposition the scheme for better performance.

The bypassing of healthcare facilities among National Health Insurance Scheme enrollees in Ibadan, Nigeria.

BACKGROUND: Bypassing occurs when patients knowingly visit a health facility other than the one they live nearest to. In Ibadan, southwest Nigeria, the majority of enrollees in the National Health Insurance Scheme (NHIS) receive medical care in just 12% of the available NHIS-accredited facilities. Given that enrollees access healthcare services at highly subsidized rates under the scheme, this study aimed to determine the factors responsible for the observed distribution of enrollees across these health facilities. METHODS: The study was a descriptive cross-sectional survey conducted among NHIS enrollees receiving care at outpatient departments of five randomly selected accredited health facilities in Ibadan. A total of 311 NHIS enrollees were consecutively recruited and a semistructured, pretested, interviewer-administered questionnaire was used to elicit information from respondents. Descriptive and inferential statistics were used to present results at 5% level of significance. Distance traveled by patients from their residence to the facilities was measured using Google maps. RESULTS: The mean age of respondents was 37.1±16.1 y. There were 167 (53.7%) males and 224 (72.3%) were married. The bypassing rate was 174 (55.3%). More than a third of enrollees, 127 (41.0%), reported that their hospital choice was made based on physician referral, 130 (41.8%) based on personal choice, 26 (8.4%) based upon the recommendation of the Health Management Organization (HMO), while 27 (8.7%) were influenced by friends/family/colleagues. Bypassing was positively associated with educational status (X2 = 13.147, p=0.004). Respondents who bypassed expended additional time and money traveling to the farther away hospitals, 35.1 (±34.66) min and 389.51 (±545.21) naira per visit, respectively. CONCLUSION: The level of bypassing among enrollees was fairly high. Enrollees should be properly guided regarding the need to access healthcare in facilities closer to them by their HMOs and physicians in the case of referrals. This will reduce bypassing and the cost of travel leading to better outcomes among enrollees.

Enrollees' Knowledge and Satisfaction with National Health Insurance Scheme Service Delivery in a Tertiary Hospital, South West Nigeria.

BACKGROUND: Social health insurance scheme provides a platform for mobilizing revenue for health and enhances universal health-care coverage. In addition, knowledge about patients' satisfaction with health care under the scheme will help in identifying gaps and provides evidence toward strengthening the scheme. This study assessed enrollees' knowledge about the National Health Insurance Scheme (NHIS) and satisfaction with health services provided under the scheme. MATERIALS AND METHODS: The study was a descriptive cross-sectional survey conducted among the NHIS enrollees accessing health-care services in the University College Hospital, Ibadan. A total of 373 individuals were consecutively recruited for the study, and a semi-structured, pretested interviewer-administered questionnaire was used to obtain information from respondents. Descriptive statistics was used to present results, and Chi-square test was used to test for the association between categorical variables. The level of significance was set at P < 005. RESULTS: The mean age was 42.5 ± 10.0 years. Of the respondents, 209 (56.0%) were male and 359 (96.2%) were married. About two-thirds, 227 (60.9%), had good knowledge about the NHIS. Majority of the respondents 303 (81.2%) reported paying for some of the costs of service (drugs, laboratory tests, consultation fees, and X-ray) through out-of-pocket and of these, 218 (71.9%) reported that such payments were occasional. Overall, slightly more than half, 197 (52.8%), of the respondents were satisfied with service delivery under the scheme. Female respondents were significantly more satisfied with health-care services (χ2 = 3.894,P = 0.048). CONCLUSION: There was good knowledge of NHIS, but the level of satisfaction with service delivery was not outstandingly appreciable. There is an urgent need to improve on all areas of quality of service to improve satisfaction with care among enrollees in the scheme.

Understanding the concept of health insurance: An innovative social marketing tool.

Health insurance scheme is relatively new in many low to middle income countries. Awareness about and knowledge of the scheme is poor among potential beneficiaries. There are some misconceptions associated with health insurance, which contributes to its low acceptance in affected nations. The aim of this work is to present an information-education and communication concept that will serve as a social marketing tool that could enhance peoples' understanding of the modus operandi of health insurance scheme, and as well as to demystify superstitious belief associated with it. This will contribute to a better understanding of the scheme among the people and enhance its uptake.

Men's perception of maternal mortality in Nigeria.

Innovative and effective options toward reducing maternal mortality rates in African nations must include the active participation of all stakeholders. This study was carried out to assess men's level of knowledge and attitude to preventing maternal deaths. In a cross-sectional, community-based survey complemented with exploratory in-depth interviews, data were collected from men from different socio-economic areas using a two-stage cluster sampling technique. Mean age of the 316 respondents was 39.9 years (range 19-66). Nearly half (47.8%) knew someone who had died at childbirth. They blamed maternal deaths on healthcare workers not being skilled enough, financial barriers, failure to use family planning, emergency, antenatal, and delivery care services. Factors associated with knowledge and attitude to preventing maternal mortality are discussed. Healthcare reforms must be coupled with socio-economic improvements and efforts made to improve men's attitudes and knowledge in such a way as to make them active stakeholders, more supportive of preventing maternal mortality.

Self-referral patterns among federal civil servants in oyo state, South-Western Nigeria.

INTRODUCTION: Primary health care is widely accepted as the first point of care; yet, individuals requiring healthcare engage in self-referrals to higher levels of care thereby by-passing primary care. Little is known of the extent to which self-referrals are carried out when care is needed. This study thus sought to determine the prevalence of self-referral, its patterns and factors influencing self-referrals amongst federal civil servants in Southwestern Nigeria. METHODS: A cross-sectional study was carried out among 300 federal civil servants who were interviewed using validated and pre-tested interviewer-administered semi structured questionnaires. Data was analyzed using univariate and Chi-square test at level of significance set at P <0.05. RESULTS: Mean age of the respondents was 39.96 ± 9.1 years with majority being married (80.7%); 90.7% completed tertiary education (and 76.7 % were middle grade (7-12) level officers. Most (60.0%) of the respondents had ever engaged in self-referral. Malaria was the commonest health problem (39.7%) for self-referral to secondary or tertiary facilities. Desire for quality service (35.7%) and competent staff (35.2%) were the commonest reasons for self-referral to a higher level of health care. More female respondents (76.0%) compared to male respondents (64.0%) significantly engaged in self-referral (p = 0.02, X2 = 5.14). Respondents having good knowledge of referral practices engaged less in self-referral compared to those with poor knowledge. (p = 0.02, X2 = 5.43). CONCLUSION: Having good knowledge of referral practices and being male are positively associated with referral practices. Creating awareness and improving knowledge on referral practices with special emphasis on women population are desirable strategies for encouraging the use of primary health care as first of point of contact with health systems.

Expanding health insurance scheme in the informal sector in Nigeria: awareness as a potential demand-side tool.

INTRODUCTION: The implementation and expansion of a health insurance scheme in the informal sector, particularly in developing countries, is a challenge. With the aid of an innovative Information-Education and Communication model, titled 'Understanding the concept of health insurance: An innovative social marketing tool', an assessment of the awareness and perception of the scheme among market women was carried out. METHODS: This is a cross-sectional descriptive survey, carried out among market women in Ibadan, Nigeria. In a multi-stage sampling technique, a total of 351 women were interviewed using an interviewer-administered, semi-structured questionnaire. The data was analysed using SPSS version 16. Chi-square test was used to test associations between selected variables of interest. Logistic regression model was used to determine predictors of awareness of the National Health Insurance Scheme (NHIS). A model controlling for participants' enrolment status was built and Adjusted Odds Ratio (AOR) reported. Level of statistical significance was set at p < 0.05. RESULTS: A total of 344 market women aged 18 years and above participated in the study, a response rate of 98.0%. Respondents' educational status was the only predictor significantly associated with awareness of the NHIS. Respondents with post-primary education had 10 times the odds of being aware of the NHIS than respondents with no education or only primary education (Adjusted Odds Ratio = 10.3; 95% CI = 4.1-26.0). CONCLUSION: Innovative models to enable potential beneficiaries, especially among the informal sector, to better comprehend and accept the concept of prepayment methods of financing healthcare costs is important in efforts to implement and expand a social health insurance scheme.

Stigmatising Attitudes Towards Co-workers with HIV in the Workplace of a Metropolitan State, Southwestern Nigeria.

BACKGROUND: Despite demonstrating global concerns about infection in the workplace, very little research has explored how co-workers react to those living with HIV in the workplace in sub-Saharan Africa. This study aimed to assess the level of stigmatising attitude towards co-workers living with HIV in the workplace. METHODS: The study was a descriptive cross-sectional survey involving 403 respondents. They were recruited from selected companies through a multistage sampling technique. Survey was carried out using pre-tested semi-structured questionnaires. Data were analyzed using the Statistical Package for the Social Sciences to generate frequencies, cross tabulations of variables at 5% level of significance. Logistic regression model was used to determine the predictors at 95% confidence intervals. RESULTS: Mean age of respondents was 32.9 ± 9.4 years with 86.1% being females. Overall, slightly below two-third (63.0%) had good knowledge on transmission of HIV/AIDS while 218 (54.1%) respondents had a high stigmatising attitude towards co-workers with HIV in the workplace. More female respondents (69.6%) demonstrated high stigmatising attitudes towards co-workers with HIV in the workplace (p = 0.012). Female workers were twice more likely to have high stigmatising attitudes towards co-worker with HIV [OR 2.1 (95% CI: 1.13 - 3.83)]. CONCLUSION: Stigma towards people living with HIV/AIDs is still very persistent in different settings. Good knowledge amongst our participants about HIV/AIDs did not translate to low stigmatising attitudes among workers. Concerted efforts and trainings on the transmission of HIV/AIDs are essential to reduce stigma that is still very prevalent in workplace settings.

Exploring the threshold premium for viable community based health insurance schemes in Nigeria.

BACKGROUND: The national health insurance scheme of Nigeria recently proposed a national premium for community based insurance scheme. This study determined the capacity of households in the rural and urban areas in Nigeria to pay for the premium and different hypothetical health insurance schemes namely national health insurance scheme, national urban health insurance scheme, national rural health insurance scheme and regional health insurance schemes. It determined the likely impact of different premiums on membership across socio-economic status quintiles, and then determined the threshold premium affordable to rural and urban households. RESULTS: The results show that the mean capacity to pay for the households in different regions ranged from US$194 ± 100 to US$986 ± 907. The threshold premiums of the national health insurance scheme, urban national health insurance and rural health insurance schemes were US$66, US$154 and US$53 respectively. CONCLUSIONS: Overall, the threshold premium for rural national health insurance scheme and national health insurance schemes were affordable to the lowest socio economic group. Hence, it is recommended that threshold premium for rural national health insurance scheme be adopted as the maximum premium not to be exceeded in the proposed national health insurance scheme.

Payment for Health Care and Perception of the National Health Insurance Scheme in a Rural Area in Southwest Nigeria.

Health insurance coverage of the informal sector is a challenge in Nigeria. This study assessed the methods of payment for health care and awareness about the National Health Insurance Scheme (NHIS) among members of selected households in a rural area in the southwest of Nigeria. Using a multistage sampling technique, a semi-structured, pretested interviewer-administered questionnaire was used to collect data from 345 households. The majority of the people still pay for health care by out-of-pocket (OOP) method. Awareness about the NHIS in Nigeria was poor, but attitude to it was encouraging; and from the responses obtained, the people implied that they were willing to enroll in the scheme if the opportunity is offered. However, lack of trust in government social policies, religious belief, and poverty were some of the factors that might impede the implementation and expansion of the NHIS in the informal sector. Stakeholders should promote socioculturally appropriate awareness program about the NHIS and its benefits. Factors that might present challenges to the scheme should be adequately addressed by the government and other stakeholders associated with prepayment schemes in Nigeria.

Understanding the concept of health insurance: An innovative social marketing tool

Health insurance scheme is relatively new in many low to middle income countries. Awareness about and knowledge of the scheme is poor among potential beneficiaries. There are some misconceptions associated with health insurance, which contributes to its low acceptance in affected nations. The aim of this work is to present an information-education and communication concept that will serve as a social marketing tool that could enhance peoples' understanding of the modus operandi of health insurance scheme, and as well as to demystify superstitious belief associated with it. This will contribute to a better understanding of the scheme among the people and enhance its uptake