CHAPTER ONE

INTRODUCTION

1.0 Background to the Study

Malaria is a significant public health challenge in Nigeria, with the country accounting for a

large proportion of global malaria cases and deaths. According to the World Health

Organization (WHO), Nigeria accounted for approximately 27% of the global malaria burden

in 2020, with an estimated 61 million cases and 386,000 deaths. Malaria not only poses a

major threat to public health but also has significant socio-economic implications, including

its potential impact on the Nigerian health insurance industry. Malaria can lead to severe

health complications, hospitalizations, and even death if left untreated. As a result, health

insurance providers may experience increased claim costs due to the expenses related to

diagnosis, treatment, and hospitalization. To offset the increased claim costs associated with

malaria, health insurance companies may be forced to raise their premium rates. This could

make health insurance less affordable or accessible, particularly for individuals living in

malaria-endemic regions where the disease is prevalent.

The Nigerian health insurance industry is an essential component of the country’s healthcare

system, aimed at providing financial protection and access to quality healthcare services for

individuals and families. The industry comprises various stakeholders, including health

insurance providers, healthcare facilities, and policymakers. The effective functioning of the

health insurance sector relies on several factors, including the prevalence and management of

diseases like malaria. The need for the National Health Insurance Scheme (NHIS) in Nigeria

came up as a result of poor health indices, high mortality rate, and poor state of healthcare

services, excessive dependence on government health facilities, pressure on public health

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facilities and poor integration of private health facilities into the nation’s healthcare delivery

system (NHIS, 2012).

National Health Insurance Scheme (NHIS) was first introduced to parliament in the year

1962 when the need for health insurance in the provision of health care to Nigerians was first

recognized. It was fully approved by the federal government in 1997 and signed into law in

1999. The scheme was officially launched on the 6th of June, 2005. National Health

Insurance Scheme (NHIS) is a cooperate body under act 35 of 1999 by the Federal

Government of Nigeria to improve the health of all Nigerians at affordable cost. The NHIS is

a social security system in which the health care of employees in the formal sector is paid

from funds created by pooling of contribution of employers and employees. Beneficiaries to

the scheme include students of tertiary institutions.

The objectives of the NHIS scheme are to among others; ensure that every Nigerian has

access to good health care services while protecting families from the financial hardship of

medical bills. Under the scheme, health care providers, referred to as Health Maintenance

Organizations (HMOs) are responsible for providing and making payments for all persons

who have registered and have paid the required premium. To provide this service, the HMOS

liaise with the accredited medical establishment of a person‟s choice (ABU, 2013). The

rising cost of health care services and the need to provide quality, accessible and affordable

health care services with the people‟s demand, necessitated the establishment of the national

health insurance scheme (Omoruan, Bamidele and Philips, 2009). NHIS was officially

introduced in Edo State in September 2009 along with 24 states of the Nigeria although the

programme was said to have made progress, it goal of 90 percent converge was excessively

ambitious, especially in view of the economic strains in the Nigeria economy (NHIS, 2009).

Edo state is faced with high population growth, ignorance, poor health facilities, poor

nutrition, high rate of environmental pollution, superstitious belief and norms (Yohersor,

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2004). Prior to the establishment of NHIS several systems, ranging from free health care,

out–of–pocket purchase, retainer ship, inbuilt health facilities within corporate organization

to private health indemnity insurance have been in use. Many have lost their lives due to their

inability to meet their health needs. Statistics have shown that about 70 percent of Nigerians

pay out of pocket for their health-care needs (Agba, 2010). A situation, many countries have

eliminated through health care financing. This and many more are justification for health

watchers the NHIS to function effectively. It is not surprising that agitation for an efficient

and sustainable health insurance scheme in Nigeria has engaged government at all levels.

Since the promulgation of National Health Insurance Scheme acts. No doubt, establishment

of a health insurance scheme became imminent and the need to enlighten the general public

on the importance of the scheme to ensure utilization and consequently achieving the

Millennium Development goal as it pertains to health (Chikwe, 2013). Overall, the impact of

malaria on the health insurance industry depends on various factors such as the prevalence of

the disease, regional distribution, and insurance provider policies. Insurers need to evaluate

these factors and adapt their strategies to effectively manage the risks and costs associated

with malaria. To this end, this research will evaluate the potential impact of malaria on the

health insurance industry in Nigeria.

1.2 Statement of Problem

Health care financing has become important in the developing world. It has been

implemented as part of health reform programmes and strategies aimed at providing effective

and efficient health care for citizens. In Nigeria, evidence shows that the knowledge and

utilization of NHIS is still very low (NHIS, 2012). Funding remains a major problem to the

scheme, the percentage of government allocation to UN or WHO have always been about 2

percent to 3.5 percent of the national budget (James Robert and Jerome, 2008). Health

facilities at some lower levels hospitals were reported inadequate in spite of the capitation

3
funds paid to them for improvements. The dearth of facilities at a lower-level hospital was

mentioned as a cause of high timed referrals. While malaria affects the overall health of the

Nigerian population, its specific impact on the health insurance industry remains relatively

unexplored. Malaria imposes a substantial burden on the healthcare system, with costs

associated with diagnosis, treatment, and prevention measures. These costs may affect the

financial sustainability of health insurance providers, leading to challenges in providing

comprehensive coverage and adequate services to policyholders. Malaria-related claims and

treatment can strain healthcare facilities, leading to increased waiting times, overcrowding,

and compromised quality of care. These factors may influence the trust and satisfaction of

policyholders, affecting their perception of the health insurance system as a whole.

1.3. Research Questions

i. What implications does Nigeria’s NHIS’s level of malaria awareness have?

ii. What are the types of existing health care facilities in the study area?

iii. What are the factors that determine access and utilization of NHIS in the study area?

1.4 Research Objectives

The aim of this study is to assess the potential impact of malaria health insurance industry in

Nigeria. In order to achieve this aim, the following specific objectives will be pursued, to:

i. determine the demographic Characteristics of the respondents

ii. determine the awareness level of malaria in NHIS in the study area

iii. Identify and characterized the type of existing health care facilities in the study area.

iv. examine the factors that determine access and utilization of NHIS in the study area

1.5. Research Hypothesis

Based on the question and objectives of the study the following hypothesis is put forward:-

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H0: There is no significant difference in the access and utilization of NHIS by socio-

economic sub-groups.

H1: There is significant difference in awareness and utilization of NHIS by socio-economic

sub-group.

1.6 Significance of the Study

The major reasons for undertaking this study is that it will provide insight into health care

system and provide basic information about National Health Insurance Scheme for policy

planning to all Nigerians, the finding of this research work are expected to constitute valuable

source of data for future references and planning and provision of health care facilities where

they are lacking. The potential impact of malaria on health insurance industry, Insurance

companies may need to collaborate closely with healthcare providers, public health agencies,

and research institutions to develop comprehensive strategies for malaria prevention, early

detection, and treatment. These collaborations can help insurers better understand the disease

and implement effective coverage policies. NHIS is a fundamental pillar for sustainable

development in many developing countries including Nigeria, there is high mortality rate as a

result of inadequate awareness and utilization of NHIS. Malaria leads to severe health

complications, hospitalizations, and even death if left untreated. Studies of this type have the

potential to reveal the problems confronting health care, benefit and pave ways for policy

makers, the local government, the state government, the federal government as well as

research institutions and nongovernmental organization NGOs. It will serve as a framework

for assessing the development and potential impact of malaria on national health insurance

scheme in these areas by the government. It will help to known area that are affected by cost

imposing by the insured on NHIS, high premium rate will help to draw attention for what is

needed during budgets and other developmental projects.

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1.7 Scope of the Study

Health insurance industry covers various health issues, but for this purpose of this study,

malaria was systematically use for detailed study being one of the most significant public

health challenge in Nigeria. Hence, this study is limited to the potential impact of malaria in

Nigeria health insurance industry.

1.8 Definitions of Terms

1. NHIS – is a mechanism, which enables the burden of the direct cost of health care to

an individual to be spread among a group of people who share the risk and over a

period of time rather than being met at the point of delivery by a single individual.

Utilization is a integral part of managed care, health plans designed to control and

limit medical expenses.

2. Awareness – is a state or ability to perceive, to feel or to be conscious of events,

objects, or sensory patterns. In this level of consciousness, an observer can confirm

sense data without necessary implying understand more broadly.

3. Health Insurance – Is a system of advance financing of medical expenses through

contribution, or premium paid into a common fund, to pay for all or part of health

services specified in an insurance policy or plan.

4. Health Care – Refers to the work done in providing primary care, secondary care,

and tertiary care as well as in public health

5. Nick sharing in health care – is about humans taking care of other humans

recognizing need for enhanced information around clinical and operational best

processes, created and implemented

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 CHAPTER TWO

LITERATURE REVIEWS

2.1 Conceptual Reviews

2.1.1 Malaria

Malaria is a fatal disease caused by Plasmodium species and is responsible for ~ 438 000

deaths in 2018 globally across many tropical and subtropical countries (WHO, 2018). Human

malaria is caused by five different species of Plasmodium (P. falciparum, P. vivax, P. ovale,

P. malariae, and the most recently identified P. knowlesi). An obligate intracellular parasite,

Plasmodium requires two hosts to complete its life cycle, that is, an arthropod vector for

sexual life cycle and human host for asexual life cycle. Over the last few years the incidence

of malaria has reduced considerably, raising the possibility that eradication might be possible

in the future. Malaria is a curable disease, but there are very few effective drugs available for

its treatment such as chloroquine, pyremethamine, sulphadoxine, and their derivatives.

Additionally, due to the constant use of these conventional drugs, the parasites have evolved

resistance mechanisms to evade drug effects. As conventional drug therapies failed to provide

protection against the disease, new art emisinin based combination therapies (ACT) have

been used for the treatment of uncomplicated malaria. But, recent reports revealed the

emergence of artemisinin resistance, which is a serious concern for the reduction of the

malaria burden globally (Ataide et al, 2019). Thus, treatment and vector control alone are

insufficient to completely eradicate malaria infections. The development of an effective

vaccine, in combination with prevention, transmission control, and treatment, is likely the

winning strategy to reducing malaria infections worldwide. This requires a molecular-level

understanding of the complex physiology of the malaria parasite and the host immune

responses, as well as continuous drug development to keep up with the emergence of

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drugresistant parasites. This Special Issue on Malaria brings together cutting- edge research

and timely review articles to present a current overview of this expansive field. In this issue,

five experts review key topics in malaria research, including the progress toward vaccine

development Matuschewski, (2019) the problem of drug resistance (Thu,et al,2021) the

artemisinin-based combination therapy Kavishe, el ta, 2019) the importance of helicases in

malaria parasite biology [6], and the use of malarial proteases as viable drug targets (Renu,

2021). Four original studies from highly active malaria research groups present

groundbreaking work on the P. falciparum-specific iron-sulfur [Fe-S] assembly pathway

(Renu, 2021). characterization of an immunogenic P. falciparum surface protein for vaccine

development (Renu, 2021). identification of amino acid substitutions that underlie metabolic

adaptation in a P. falciparum mono-acid transporter [10], and identification of origins of

replication in the P. falciparum genome (Renu, 2021). Finally, two commentaries in this issue

highlight recent significant studies covering the physiology of the malaria parasite, the host

immune responses, antimalarial drug development, and transmission control (Renu, 2021). as

well as the use of metabolic modeling to identify potential drug targets in the malaria parasite

(Renu, 2021).

2.1.2 Life cycle and pathogenesis

The most important species in the phylum Apicomplexa are members of the class Sporozoea.

Members within this class, including Plasmodium and coccidians, cause a variety of diseases

in domestic animals and humans. The eukaryotic Plasmodium parasite has a very complex

life cycle (Perpetua, 2020), which is partly spent in the vertebrate (human) host and partly in

the female Anopheles mosquito. In this section, the different life stages of the Plasmodium

parasite are discussed in detail. The life cycle of the Plasmodium parasite starts when the

human host is infected by plasmodial sporozoites, when a female Anopheles mosquito takes a

blood meal. The mosquito injects saliva, containing the sporozoites, into the humans‟

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bloodstream. Some of the sporozoites are blocked by the human immune system, i.e.

antibodies, but most of them invade the liver. This process is also known as the pre-

erythrocytic or exoerythrocytic stage (Olusola, 2020). The sporozoites are transferred into the

liver via the bloodstream, where they replicate and become enlarged, to form a schizont. The

schizont fragments into a number of small cells, called merozoites, which are liberated from

the liver into the bloodstream. Each schizont produces about 32 merozoites and generally

take between 1 - 2 weeks to develop, depending on the species (Ashley et al., 2019). P. vivax

and P. ovale have a dormant stage, called hypnozoites, which can remain in the liver for

years before developing into schizonts. This is commonly associated with relapses in malaria,

years after infection (Olusola, 2020). After lysis of the hepatocytes, infection of human

erythrocytes proceeds exponentially, signalling the start of the erythrocytic schizogony stage.

Once inside the erythrocyte, the merozoites develop into a ring from where they catabolise

haemoglobin. The ring stage develops into trophozoites and finally into schizonts again,

which ruptures the erythrocytic cell to release thousands of merozoites that can further infect

erythrocytes, typically leading to clinical symptoms (Ashley et al., 2019). The mechanism by

which egress proceeds from their host cells is not well understood. Strong genetic evidence

exists that malarial cysteine proteases are necessary for this exodus of these invasive stages

from their intracellular compartments from liver stage and blood stage schizonts (Aly and

Matuschewski, 2019). The selective inhibition of this protein might be a key component for

eradicating malaria. Not all merozoites that are liberated from the erythrocytes are capable of

invading other erythrocytes. These merozoites develop into gametocytes, which signal the

start of the sexual stage, following a number of asexual life cycles. The catalyst for the

production of macrogametocytes (female) and microgametocytes (male) are unknown.

Mature gametocytes inside erythrocytes are taken up by a female Anopheles mosquito after a

blood meal and are then transferred into the midgut, where they escape the cells.

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Microgametocytes exflagellation produces eight haploid motile microgametes, which move

rapidly to fertilise macrogametocytes, resulting in zygotes formation. After about one day,

these zygotes transform into ookinetes. The ookinetes then travel to the extracellular space

between the midgut epithelium and overlaying basal lamina, where they develop into oocysts.

Nine to twelve days later the oocysts rupture, releasing thousands of sporozoites, which

invade the salivary gland epithelium of the mosquito. When the mosquito takes a blood meal

from an inclined human host, the life cycle begins anew (Olusola, 2020).

2.1.3 Haemoglobin degradation

The nutritional needs of the parasite are met by ingestion of the host’s haemoglobin and

through degradation in the digestive vacuole by a number of enzymes, including cysteine

protease (Egan, 2018). This pathway offers an unique target for chemotherapy, which is

exploited by a number of compounds, such as CQ and artemisinin ( Nnenna, 2020). It is thus

important that an overview is discussed to assist in the understanding of the mode of actions

of these compounds. During the intra-erythrocytic stage, the malaria parasite ingests between

60 - 80% of the available haemoglobin (Egan, 2018) through the endolysosomal system,

called a cytostome. The haemoglobin is transported to the digestive vacuole ( Nnenna, 2020).

where it is then digested for the biosynthesis of the parasite's own proteins (Olufemi, 2020).

This is brought about in a semi-concerted fashion, i.e. firstly the native haemoglobin is

cleaved by a family of proteases, called plasmepsins, to degrade haemoglobin into haem and

globin fragments. The haem is toxic and is subjected to haem-detoxification by the formation

of hemozoin through biocrystallization. The remaining globin fragments are then further

degraded into peptide fragments of around ten to fifteen amino acid subunits by cysteine

proteases, specifically falcipain-2 and -3 ( Nnenna, 2020). These fragments are then catabolised

10
by the metalloprotease, called falcilysin, into oligomers (6 - 8 amino acid subunits) and

transported to the cytosol. These oligomers are then further degraded into free amino acids by

aminopeptidase, such as serine protease (Renu, 2021).

2.1.4 Signs and symptoms

The initial signs and symptoms of Plasmodium infection are non-specific and commonly

associated with flu-like symptoms, such as fever, chills, headaches, loss of appetite, nausea

and vomiting (Ashley et al., 2019). If these symptoms are left untreated, especially with P.

falciparum infection, it would rapidly result in severe complications, such as renal and multi-

organ failure, hypoglycaemia, metabolic acidosis, acute anaemia, seizures, mental confusion,

coma, cerebral malaria and eventually death. Most of these symptomatic expressions are,

however, still not well understood. Despite the fact that severe malaria is uncommon (less

than 1%), it leads to a substantial number of mortalities each year (Idro et al., 2010). Acute

renal failure (ARF) complicates P. falciparum malaria in less than 5% of patients who are

inhabitants of endemic areas, but is it much more frequent among visitors from non-endemic

countries to these endemic areas (up to 30%), with a mortality rate of up to 45% (Barsoum,

2018). ARF typically presents with electrolyte abnormalities, increased urinary protein

excretion, pain, nausea and vomiting. This is most likely caused by dehydration,

cytoadherence of parasitized erythrocytes, intravascular haemolysis, intravascular

coagulation and sepsis, although the precise mechanism of malarial ARF is unknown (Das,

2008). The prevalence of hypoglycaemia, on the other hand, varies depending on area and

age groups, ranging from 8% in South-East Asian adults to 30% in African children

(Osonuga et al., 2011). Reduction of glucose levels due to starvation, parasite consumption of

glucose and cytokine induced impairment of gluconeogenesis have all been frequently

implicated in the complication of hypoglycaemia (Ogetii et al., 2010).

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Metabolic acidosis has emerged as a fundamental feature of severe malaria, and is widely

implicated as a fatal outcome in both adults and children. The most common manifestations

of acidosis are the increased production and impaired metabolism of lactate and ketoacids,

although the aetiology of malarial acidosis is not well understood (Maitland and Newton,

2019). Acidosis is generally associated with cerebral malaria and of all the complications of

severe malaria, the causative agent for most of the deaths (Festus, 2020). Cerebral malaria

(CM) is characterised by impaired consciousness, coma and asexual forms of the parasite on

peripheral blood smears, with African children bearing the majority of this burden (David,

2020) Despite the fact that CM is the best studied complication of severe malaria, it is still

incompletely understood. CM has a high mortality rate, even with active treatment and causes

sustained brain injury, which manifests as long-term neuro-cognitive impairments in some

surviving patients (Idro et al., 2010). The histopathological characteristic of cerebral malaria

is the enlargement of cerebral capillaries and venules with parasitized red blood cells

(pRBCs) and non-parasitized RBCs (npRBCs), causing intracranial pressure and swelling of

the brain (Newton et al., 2018). An increased cerebral blood volume (CBV) has been

suggested to be the likely cause of intracranial pressure. Increases in the CBV could result

from the sequestration of pRBCs in the cerebral venules, impaired venous return, or increased

cerebral blood flow caused by seizure activity and anaemia (Maitland and Newton, 2019).

Sequestration is caused by the adherence of pRBCs to capillary endothelial cells by means of

a specific interaction between a parasite derived molecule present at the surface of the pRBCs

and specific host cell receptors (Franke-Fayard et al., 2010).

2.1.5 Diagnosis

Owing to the non-specific symptomatic manifestations of Plasmodium infection, accurate and

rapid diagnosis is of paramount importance to reduce associated morbidity and mortality

(Hopkins, 2020). A positive clinical diagnosis of malaria through a physical examination

12
should always be confirmed by means of pathological tests (Mubi et al., 2021) in order to

inform malaria control strategies and to prevent the indiscriminate treatment of non-infected

patients, which could contribute to resistance (WHO, 2010).

Several methods, such as microscopy and antigen based rapid diagnostic tests (RDTs) are

routinely used to diagnose malaria. Microscopy of both thick and thin blood smears remains

the golden standard for diagnosing malaria, since it is accurate and reliable under operational

conditions (Mohammed, 2020) Thick blood smears are used for diagnoses, while thin blood

smears are used to determine the parasitaemia. Limitations of microscopy include specialised

equipment and trained personnel to operate it. RDTs detect parasite specific antigens or

enzymes, with some even incorporating the ability to differentiate between species (Renu,

2021; WHO, 2010). RDTs are overall more sensitive than traditional microscopy, and are

faster and do not require specialised equipment, nor trained personnel to operate it (Festus,

2020).

2.1.6 Control and Prevention

Control and prevention of the both the vector (Anopheles) and Plasmodia are vital strategies

against malaria infection. In this section, the most important control and prevention strategies

are discussed, which include insecticide treated nets (ITN), indoor residual spraying (IRS),

vaccination, adaptive immunity and education. Two of the most important vector control

methods include ITNs and IRS. According to the WHO, 11% of people at risk for contracting

malaria were protected by ITNs in 2011, while approximately 53% of people in endemic

areas had access to an ITN. Unfortunately, there was a shortage of roughly 90 million nets in

2012. With the life span of an ITN of no more than five years (WHO, 2012), the distribution

of these nets are regrettably unsustainable. IRS is the treatment of the inner surfaces of

dwellings where many vector species tend to rest after taking a blood meal, specifically at

13
dawn and dust when they are most active. Resistance of mosquitoes to insecticides had been

found in sixty-four countries around the world, which hamper effective vector control (WHO,

2012).

Alternatively, vaccination has largely reduced the burden of infectious diseases. Vaccination

promotes economic growth and leads to decreased morbidity and mortality. Vaccination is

therefore a proficient tool to level wealth and inequities in health. Despite research efforts

over the last four decades, no licensed malaria vaccines are currently available (Targett et al.,

2013). A number of potential candidate vaccines are currently undergoing clinical trials, with

one candidate (RTS,S/AS01) having reached Phase 3 trials, while approximately twenty

others are in Phases 1 or 2 (WHO, 2012). However, should any of these potential vaccines be

approved, it will still take a number of years before they are viable to administer. Vaccination

may in the future protect the majority of high risk individuals, like children under the age of

five, but the vital role that adaptive immunity plays in the prevention of malaria should also

be considered (Doolan et al., 2019). The evolutionary pressure that this parasite has had on

the human genome can be observed from the pre-disposition of certain individuals, residing

in endemic areas, prone to having certain genetic traits that are indicative of adaptive

immunity (Festus, 2020).These include Sickle cell anaemia, Duffy antigens and Interleukin-4.

The most significant genetic disorder for consideration is Sickle cell anaemia, with around

300 000 children born each year with this condition (Oniyangi and Omari, 2019). Sickle cell

anaemia is caused by a change of a single nucleotide in the HBB gene, on chromosome 11

coding for β-haemoglobin subunits, known as Sickle cell trait (SCT). Sickle cell disease

(SCD), on the other hand, is homozygous haemoglobin SS (HbSS), characterized by red

blood cells that assume an abnormal, rigid, sickle shape, which results in abnormal blood

flow and deprived oxygen levels (Renu, 2021). People with SCD normally have a shortened

life span, but it is believed that this condition protects these individuals from contracting

14
malaria (Wambua et al., 2006). The prevalence of both SCD and SCT are more common

among people inhabiting malaria endemic areas (Renu, 2021)). The Duffy antigen is located

on the surface of red blood cells and is the receptor of both P. vivax and P. knowlesi (Ernest,

2020) Individuals, who lack this antigen are therefore resistant towards P. vivax and P.

knowlesi infections (Nnenna, 2020). Interleukin-4 (IL-4) is a cytokine that induces

differentiation of naive helper T cells to Th2 cells, with multiple immune-modulating

functions on a variety of cell types. IL-4 has been shown to be involved in the regulation of

antimalarial antibody responses against P. falciparum, including antimalarial IgE, which

awards additional immunity (Renu, 2021).). It is thus evident that malaria immensely impacts

on the evolution of human genes. Health education strategies are central in enabling

communities to support malaria control measures (MRC, 2018). Suitable awareness

campaigns to teach inhabitants of endemic areas about what malaria is, how it is transmitted

and how it can be prevented may prove successful in addition to the control and prevention

strategies set out by the Roll Back Malaria (RBM) initiative. Additionally, education on the

proper use of ITNs may further help to decrease the global burden of that malaria causes.

2.17 Vaccination

Vaccines for malaria are under development, with no completely effective vaccine yet

available. Presently, there is a huge variety of vaccine candidates on the table. Pre-

erythrocytic vaccines (vaccines that target the parasite before it reaches the blood), in

particular vaccines based on circumsporozoite protein (CSP), make up the largest group of

research for the malaria vaccine. Other vaccine candidates include: those that seek to induce

immunity to the blood stages of the infection; those that seek to avoid more severe

pathologies of malaria by preventing adherence of the parasite to blood venules and placenta;

15
and transmission-blocking vaccines that would stop the development of the parasite in the

mosquito right after the mosquito has taken a bloodmeal from an infected person. It is hoped

that the sequencing of the P. falciparum genome will provide targets for new drugs or

vaccines. (WHO,2018).

2.2 The Concept of Health Insurance Industry

In the sphere of health, social security is critical for people’s and society’s well-being. It is

seen as a fundamental human right, and its implementation helps to achieve the Millennium

Development Goals. According to the International Labor Organization (ILO), the World

Health Organization (WHO), social protection in health is a tool for reducing poverty,

promoting social and economic development, and smoothing the negative effects of illness on

productivity, absenteeism, and the use of private income or savings for health costs (ILO,

WHO and GTZ 2012). It has been shown that many people in Africa have been unable to pay

for medical care in recent decades, with out-of-pocket costs accounting for more than half of

overall health spending. In light of this, maintaining and improving a social health insurance

system in African countries such as Nigeria is critical in order to provide inexpensive health

care to the entire population. This would significantly cut out-of-pocket spending while also

enhancing risk sharing among people of various income levels, ages, health statuses, and

geographical locations (Rock et al, 2023).

The cultural roots of Social Health Insurance (SHI) can be found in the societies that gave

birth to it (Gina et tal, 2012). Germany is frequently credited with inventing this method to

health insurance because, in 1883, it was the first western European country to codify

existing volunteer organizations into required state-supervised legislation (Owumi et tal

2012). SHI (Social Health Insurance) is a risk-pooling-based method of financing and

managing health (Rock et al, 2023). On the one hand, SHI takes into account people’s health

16
risks, while on the other, it takes into account the contributions of individuals, households,

businesses, and the government. As a result, it protects people against financial and health

risks while also being a generally equitable manner of paying health care (Ezat 2013).

Despite attempts, few least-developed and low-middle-income countries have been able to

adequately extend SHI coverage. The majority of countries rely on tax-funded financing,

which is also generally equitable (Rock et al, 2023).. Working people and their employers, as

well as the self-employed, typically pay contributions that cover a package of services

provided to insures and their dependents in more mature European SHI systems. Most of the

time, they are legally obligated to make these donations (Doetinchem 2013). Many

governments also provide financial support to these systems in order to ensure or improve

their long-term viability.

There have been a lot of differences in how SHI systems have grown among countries in this

environment. Contributions are sometimes pooled into a single fund, or multiple funds

compete for membership. These funds may be managed by the government, non-

governmental groups, or parastatal organizations (WHO, 2013). Contributions have generally

assured that the wealthy contribute more than the poor, although contributions do not

normally vary with health status (Doetinchem 2013). SHI systems have progressed as time

has passed. Governments, for example, have expanded coverage to persons who are unable to

pay, such as the impoverished and jobless, by covering or subsidizing their contributions

using government tax or non-tax resources (Owumi et tal 2012). These days, no SHI system

is totally funded by payroll deductions. The differences between systems that people refer to

as SHI are so wide these days that even systems that rely on voluntary enrolment are

sometimes referred to as SHI (Doetinchem 2013). The underlying goal of using the concept

appears to be that everyone is offered, or will be offered, the right to enroll in at least one

form of mechanism that allows financial risks to be shared over time. This could include a

17
mix of different sorts of insurance payment for some types of health services, as well as

government money for others. As a result, the feasibility and long-term viability of any SHI

system, generally defined, will be determined by the combination of traits it possesses (Rock

et al, 2023).

2.2.2 Social Health Insurance; The Nigerian Perspective

Every year, 178 million people in developing nations are exposed to catastrophic health costs,

with more than 100 million thrown into poverty as a result of these costs (Ama. 2021). Given

the high proportion of out-of-pocket health-care spending in developing countries, it is

reasonable to conclude that health-care costs play a significant influence in population

impoverishment and deepening poverty (Gina, 2021) The poor are frequently burdened

financially by illness and the resulting loss of income and savings. Illness frequently leads to

a medical poverty trap. In order to cope with the financial burden of ill health, it has been

observed that households often use welfare threatening strategies, for example selling assets

such as land (Ezat 2013). From an economic point of view, lack of access to health services

affects the competitive capacity of economies in international markets, and from a social

point of view, improved access to services and related improved equity are leading to social

development and help to promote social peace and stability (Ezat 2013).

In Nigeria and many other Low- and Middle-Income Countries (LMICs), Social Health

Insurance Schemes (SHIS) are seen as one of the most important methods for ensuring

financial security and Universal Health Care (UHC) for their inhabitants (Nwakolo, 2020).

High Out-of-Pocket Expenditure (OOPE) is a major impediment to achieving UHC in

Nigeria, where OOPE accounts for more than 70% of total health expenditure, the highest in

Africa. A variety of health reforms and health finance measures have been implemented in

Nigeria in order to minimize the country’s high OOPE. One of these reforms is the National

18
Health Act, which was signed into law in 2014 and includes a key provision of a basic

healthcare provision fund comprised of not less than 1% of the federal consolidated revenue

fund, which is disbursed to all eligible States in part (about 45 percent of the fund) in addition

to the annual budget allocation to health. States have been given rules and standards to follow

in order to gain access to these funds, which includes the implementation of state SHIS. This

is based on the premise that Social Health Insurance (SHI) will give financial security,

reducing catastrophic OOPE while also providing access to basic health services of high

quality (Nwakolo, 2020). SHIS have the potential to effectively help a country move toward

UHC by mobilizing additional domestic resources for health through premiums/contributions,

implementing critical organizational change for improved health system quality and

efficiency, and providing better coverage through increased financial risk protection,

particularly for the poor (Nwakolo, 2020). Contributory health insurance programs, on the

other hand, are not wholly new in Nigeria. Due to a variety of issues, including low

administrative capacity, small/ fragmented risk pools, and financial sustainability, a National

Health Insurance Scheme (NHIS) and several community-based health insurance schemes

have been implemented with mediocre results, such as extremely low coverage and

failed/collapsed schemes (Osamuyimen, 2017)

2.2.3 The Nigerian National Health Insurance Scheme (NHIS)

The Nigerian National Health Insurance Scheme (NHIS) was developed in 1999 and

officially started in 2005 with the goal of protecting users from financial risk and reducing

the enormous burden of Out-of-Pocket Expenditures (OOPs) on individuals and households.

(Alawode &, Adewole, 2021). The NHIS offers a variety of programs to ensure that no one is

left out, including social health insurance for formal sector employees, community-based

health insurance, private health insurance, and voluntary health insurance (Onwujekwe,

2012). The NHIS’ goal of providing all Nigerians with access to high-quality health care has

19
also been considered as a positive step toward achieving universal health coverage (UHC)

(Rock et al, 2023).However, research suggests that the NHIS has failed to accomplish the

intended population coverage while also protecting against financial risk (Onwujekwe, et tai,

2014) Out-of-pocket expenses account for approximately 90% of total private health

spending, putting a substantial financial strain on households, and about 60% of all health

spending is paid for directly by households without insurance (Ibe et tal 2017).

Going forward, Health Maintenance Organizations (HMOs) purchase care on behalf of the

National Health Insurance of USA, and Nigeria adapted the HMO system in 1999 [34].

Private organizations were encouraged to form HMOs when the National Health Insurance

Scheme (NHIS) was established. The NHIS Act authorized HMOs to act as agents for the

NHIS, and it should encompass both the public and private sectors (Obikeze & Onwujekwe,

2020) HMOs were recruited to provide the Nigerian National Health Insurance Scheme’s

(NHIS) Formal Sector Health Insurance Program (FSSHIP) a private sector makeover. The

scheme’s founders claimed that the country’s social system was riddled with flaws and

lacked checks and balances (Chima, el tal 2015). As a result, health policymakers proposed a

health-insurance system in which HMOs act as agents for the NHIS, purchasing health

services from both public and private providers (Alawode &, Adewole, 2021). HMOs are

private-sector-driven organizations that are expected to plug leaks caused by poor public-

sector management (Njau et tal, 2013). According to Alawode and Adewole , the National

Health Insurance Scheme has the following goals:

a) Ensure that every Nigerian has access to good health care services.

b) Protect families from the financial hardship of huge medical bills.

c) Limit the rise in the cost of health care services.

20
d) Ensure equitable distribution of health care costs among different income groups.

e) Maintain high standards of health care delivery services within the Scheme.

f) Ensure efficiency in health care services.

g) Improve and harness private sector participation in the provision of health care services;

h) Ensure equitable distribution of health facilities within the Federation.

2.2.4 Social Health Insurance Scheme and its Utilization/Willingness in Nigeria

Across Africa, Asia, and Latin America, a torrent of SHI initiatives has swept the continent.

The World Health Assembly issued a policy resolution for the World Health Organization

(WHO) in May 2005, stating that SHI would be used by WHO to mobilize more resources

for health, pool risk, provide more equitable access to health care for the poor, and deliver

better quality health care. The WHO is pushing its member states to pursue SHI and will

provide technical assistance to those who do so SHI is being touted by several international

aid agencies, including the World Bank, the WHO, and the German Agency for Technical

Cooperation, as a policy instrument that could help facilitate or stimulate four desirable

elements of health sector reform as outlined in the ILO report, namely:

a) When low-income countries lack sufficient tax revenues to fund health care of a reasonable

quality for all, SHI directs public funds to subsidize premiums for the poor rather than

financing and providing universal health care for all.

b) Freeing up public funds so they can be directed to public health goods and services.

c) Shifting public subsidies from the supply side to the demand side to improve the efficiency

and quality of health care. This distinguishes the responsibilities for collecting and managing

21
SHI funds from those for providing health care to patients, with services hired from distinct

corporations. Patients want providers to be accountable for the services they provide; and

d) Using nongovernmental organizations (NGOs) and commercial providers’ capacity to

improve insured people’s access to health care through contracting.

SHI may be a solution for a significant aspect of a country’s systemic health-care problem,

but it is not always a solution for the entire issue. Many developing nations suffer poor

health. In many African countries, the average infant mortality rate still surpasses 100 per

1,000 live births, compared to 4 per 1,000 live births in developed economies (Ezat 2013). In

addition to health-care underfunding, research has identified at least four other factors that

contribute to poor results in developing countries, including:

a) Poorly targeted public resources disproportionately benefit the wealthy.

b) Many countries struggle to properly and efficiently handle their public health systems. To

put it another way, they are unable to convert money into effective and high-quality high-

quality healthcare.

c) In terms of location and organization, public sector primary care services do not meet the

needs of rural residents.

d) Health risks are not effectively pooled, resulting in the exclusion of the poor, low-income,

aged, and the less healthy from insurance.

The National Health Act, which was passed into law in 2014, demonstrated Nigeria’s

commitment to lowering OOP and expanding access to excellent fundamental health services

(Cambell et al., 2016). The Act defines a legislative foundation for the provision of health

services in Nigeria, as well as an organizational and managerial structure (Nwakolo, 2020).

To achieve this important goal of providing quality healthcare to all Nigerians, “the Act

22
specifies that all Nigerians shall be entitled to a Basic Minimum Package of Health Services

(BMPHS) to be funded by a basic health care provision fund (BHCPF) derived from

contributions of not less than one percent (1%) of the Federal Government’s Consolidated

Revenue Fund (CRF) (FMH, 2013) According to the BHCPF disbursement standards, 50% of

the BHCPF is expected to go toward expanding and funding BMPHS, which States could

take advantage of by establishing a state contributory health insurance program (Nwakolo,

2020). The BHCPF’s potential and prospects have prompted many Nigerian states (including

Kaduna, Lagos, and Delta) to begin planning and implementing a State Social Health

Insurance Scheme (SHIS). As a result of the execution of health reforms in Nigeria, nearly 19

states have signed or are considering signing social health plans into law and implementing

them (Xu, 2003). According to studies conducted in other low- and middle-income nations,

many people are unaware of the existence of health insurance (Bamidele & Adebimpe ,2012)

Similarly, studies in states in Nigeria have reported low levels of awareness, only (28.9%) in

Ilorin, (19.3%) in Lagos and in Abakaliki (25.3%) of the respondents had heard of health

insurance before (Azuogo & Eze 2018). Only (30.1%) had heard of health insurance, and

only (2.5%) belong to health insurance scheme in Akwa Ibom State (Akwaowo et al. 2021).

In respect to willingness to pay for a contributory health insurance scheme, the study of

(Akwaowo et al. 2021) in Akwa Ibom State, Nigeria, revealed that majority of respondents

(82%) were willing to pay (WTP) for a contributory health insurance scheme. Other studies

carried out in states in Nigeria have also reported high levels of WTP with (87%) in Osun,

(82%) in Kaduna, (89.7%) in Port Harcourt (Ogundeji el tal; 2019) Similar findings has also

been reported in other LMICs like Sierra Leone and Ethiopia. Indicating that rural dwellers

are willing to pay for a contributory health insurance scheme (Rock et al, 2023). Therefore,

further sensitization is required for a proper utilization of social health insurance benefits.

(Rock et al, 2023).

23
 CHAPTER FOUR

RESULTS AND DISCUSSION

4.1 Demographic Characteristics of the Respondents

Table 4.1: Demographic Characteristics of Respondents (n=200)

Variables Frequency Percentage (%) Mean
Age (year)
18-25 30 1.75
26`-40 50 3.51 46.5
41-64 100 15.8
65 above 20 40.4

Sex
Male 100 45.6
Female 100 54.4
Marital Status
Single 10 7.0
Married 150 89.4
Divorced 38 -
Widow/widower 2 3.5
Educational Level ever
attained
Primary 4 7.0
Secondary 15 35.0
Tertiary 177 8.8
None 4 7.0

Religion
Christian 121 89.5
Islamic 69 10.5
Traditional 10
Have you been using
NHIS

24
Yes 89 25.7
No 111 65.7 7.5

Having Family Physician

Yes 70 36.8
No 130 63.2

Occupation :
Civil servant 40 29.8
Trader / Business person
65 29.8
Artisan
30 14.0
Teaching
45 3.5
Farming
20 3.5
Others
- 1.7
1.7
Aware of NHIS:
Yes 180 14.0
No 20 49.1 15.5
Salary level: 26.3
Grade 1-6 45 10.5
Grade 7- 12 124
Grade 12-16 31
Monthly income (Naira):
< 50000- 100000 130
100000- 150000 40
150000 – 20000 30
> 200000. -

Source: Field survey,2023

25
Section B: The Awareness Level of Malaria on NHIS in the Study Area

Variables Level of Awareness

High Moderate Low Rank

Freq (%) Freq (%) Freq (%)
Aware of the NHIS Programme 75 65 60

NHIS improve health care delivering 130 40 30

in Nigeria

NHIS ensure access to good health 180 10 10

care in Nigeria

NHIS protect families from financial 190 6 4

hardship of huge medical bills

NHIS limit the rise in the cost of 185 10 5

health care services

Availability of funds to the health 165 20 15

sector for improved service

Appropriate patronage of all levels of 190 5 5

health care

Equitable distribution of health 127 43 30

facilities within the federation

Source: Field survey,2023

Section C. Identification and characterization of the type of existing health care

facilities

26
 Variables Available Not Actual instrumenta Rank
Freq (%) Availabl Expenditure l
e Freq (%) Expenditure
Freq (%) Freq (%)
Birth center 200 - 190 10
Ambulatory surgical 190 10 175 25
centers
Blood banks 180 20 160 40
Clinic and medical 155 25 130 70
offices
Diabetes Education 40 160 180 20
center
Dialysis Centers
Hospice home
Imaging and Radiology
centers
Mental health and
addiction treatment
center
Nursing home
Orthopaedic and other
rehabilitation centers.

Section D: Access and utilization of NHIS in the study area

1. Have you been using the NHIS : Yes ( %), No ( % )

2. How many times have you visited the hospital in the past 1 year : Once (% ),

Twice (% ) Thrice ( %) More than thrice (% ) Not visited in the past 1 year ( %)

3. Altitude of health workers during visits: Friendly ( %) Harsh ( %) Sympathetic (%

) Patient and understanding ( %) No response ( %)

4. Payment for hospital consultation bills ( %) Covered by NHIS ( %) Others ( %)

Used personal savings ( %) No response ( %)

27
 5. Services used under the scheme (multiple responses) Maternal health service

( % ) Laboratory service ( %) Radiology service (% ) Dental service

( %)Ophthalmology service( %)Surgical service ( % )Others ( %)

6. Preferred health facility for NHIS

Government hospital ( %)
Private hospital ( % )
None ( %)

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 ABBREVIATION

HMO – Health Maintenance Organization

WHO – World Health Organization

UN – United Nations

NHS – National Health Service

NISER – Nigeria Institute of Social and Economic Research

33