1.0 chapter one

Introduction

1.1              Background to the study

In Nigeria, efforts to reform the health system and health care financing policies were redoubled at the start of the twenty-first century. The most noteworthy of these changes is the National Health Insurance Plan, which was implemented in 2005. Many Nigerians have yet to see the effects of these efforts, and Nigeria faces the issue of extending the National Health Insurance plan to include the sizable and primarily underprivileged informal sector (Adeyemo, 2015).

Worldwide, a healthy population and labour force are essential for quick socioeconomic and sustainable growth. Despite this undeniable reality, the availability of high-quality, cheap healthcare in Nigeria and most African nations continues to be a significant issue (WHO, 2017).

This is because there is a severe staffing shortage in the health industry, insufficient and obsolete medical technology, insufficient funds, inconsistent policy, and corruption (Oba, 2018).

Evidence indicates that in 2014, the industry accounted for just 4.6% of the GDP, both public and private (WHO, 2017). The incapacity of the customer to pay for healthcare services is one of the other reasons that hinders the provision of quality healthcare in Nigeria (Sanusi & Awe, 2019). There was gender bias due to religious or cultural beliefs and inequality in the distribution of healthcare facilities between urban and rural areas (Omoruan, Bamidele & Philips, 2019). Due to the abovementioned, the nation consistently receives low rankings from inter National organisations for the quality of its healthcare system.

In addition, just 28% of Nigerians in every 100,000 people had access to doctors during 2010 and 2017 (World Bank, 2017). Nigeria continues to lose doctors to other nations even as the situation in the health sector endures. More than 1,500 healthcare professionals were said to have emigrated from Nigeria to other nations in the last two years (World Bank, 2017)

According to a UNDP assessment from 2016, there was a severe lack of medical professionals in the Nigerian health sector, while 21,000 of them were working in the United States and the United Kingdom (Akingbade, 2016).

 According to data on the Nation's health, only 44% of Nigerians in 2014 and 39% in 2017 had access to better sanitation. 13 percent and 9 percent of Nigerians were malnourished in 2014 and 2017, correspondingly (UNDP, 2018).

In 2015, 3.9 percent of people in Nigeria between the ages of 15 and 49 have HIV (UNAIS, 2016). Numerous medical policies by succeeding administrations were made, including the institution of primary health care centers, general and tertiary hospitals, in an effort to address the precarious and depressing situation in the health sector and to provide universal access to high-quality health care services in Nigeria.

 General Abdulsalami Abubakar took the decision to enact the National Health Insurance Scheme Decree Number 35 (National Health Insurance Scheme Decree No. 35 of 1999) on May 10, 1999, based on the enduring health issue, with the intention of ensuring that all Nigerians had access to high-quality healthcare on a universal basis. National health insurance programme went into effect after being formally introduced by the Federal Government in 2005 (Kannegiesser, 2019). Nigeria's National health insurance programme has been in place for more than four years, however due to depressing reports about the country's health state, Nigerians' opinions on the program's effectiveness in tackling the country's health crisis are divided.

According to WHO (2017) defines good health as Not merely the presence of illness or disability, but also whole physical, mental, and social wellbeing. If we rigorously adhere to these criteria, no Nigerian can be considered a healthy client for the insurance market. This definition appears to be an aberration in Nigeria. Every nation aspires to offer its people access to high-quality, affordable healthcare. For instance, there is no publicly funded health insurance programme in South Africa. But the nation can boast of having healthier health indicators than Nigeria.

The country's private health insurance programmes are reasonably priced, well-developed, and running smoothly and successfully (Otuyemi 2018). The healthcare system in Nigeria, like the rest of the country's public systems, is beset by insufficient budgetary allocations, inefficiencies, and unequal resource distribution. The issue is further exacerbated by fast population growth, the advent of new diseases, particularly the HIV/AIDS plague, and the persistence of existing ailments (Otuyemi 2018).

According to data from the National health insurance programme in 2011, 5% of the populace is enrolled in the programme (National Health Insurance Scheme 2012). The majority of individuals insured work for the federal and state governments and reside in cities (Otuyemi 2018).

Nevertheless, and over 60% of Nigerians work in the unorganised sector and earn less than $1 a day while living in rural areas (UPI, 2012)When confronted with health issues, they do not have access to enough money to pay for high-quality medical care. At around 95.3% of private health spending in 2010, out-of-pocket (OOP) funding of healthcare is still high.

A nation's National Health Insurance programme is often created to considerably care for the well-being of its people, especially the less fortunate (Kutzin, 2018). In essence, this would provide access to care while minimising investment risk. The programme has been in place since 2015, and 2015 is the intended year for attaining universal health care. Nations that relied on Out Of Pocket payments for health will not be able to achieve universal health coverage, according to the World Health Report (WHR) of 2010 (WHO, 2015).

At this point, the question is whether the National health insurance programme has actually achieved its goal of ensuring that Nigerians receive quality healthcare. It also asks what influence the programme has had on the delivery of healthcare in the society. It is to this the study centers on the effect of National Health Insurance Scheme in enhancing health care delivery

1.2 Statement of the problem

According to WHO (2016) With an infant incidence and mortality that ranges from 500 per 100,000 in the South West geo - political zone to 800 per 100,000 newborns in the North East zone, preterm mortality rate of 48 per 1000, and child fatality rate of 205 per 1000, Nigeria's healthcare system is ranked 187th out of 191 World Health Organization (WHO) member nations. This implies that more than 20% of children in Nigeria would not grow pass childhood stag (UNICEF, 2016).

According to Partnership for Maternal, Newborn and Child Health (2018) show that the geopolitical zone of the North central will eventually reach a death rate of 1700 per 100,000 births. The majority of developing nations, including Nigeria, clearly lack equitable and comprehensive health care coverage. In Nigeria, the availability of healthcare is extremely constrained.

Otuyemi (2018) states that incapability of the masses to pay for the services as well as the healthcare provision that is far from being equitable have been identified among other problems facing the masses in Nigeria also Sanusi, et al (2019) In Nigeria, user fees from clients and public subsidies have been used to pay for public health care. These subsidies are mostly funded by revenue from petroleum exports. After a sharp drop in earnings from oil exports, a growing foreign debt burden, a structural adjustment programme, and a rapid rate of population growth, financing for healthcare began to decline after the mid-1980s.,

 Gana (2010), classified Nigeria as the nation with the second highest level of out-of-pocket spending on health finance in the globe due to low levels of public (government) spending and a large burden of medical costs on individuals and families (70% of total expenditures)..

More troubling is the Nigerian system's allowance of private hospitals as significant partners in spite of the creation of the National health insurance programme. The National health insurance program's covering is so extensive that it hasn't yet been possible to account for street sellers, farmers, self employed people of businesses, artists, and unemployed people. Not all public and corporate personnel are covered by the programme, even in the formal sector.

Also Therefore, the bulk of our public and private hospitals continue to operate on a fee for service basis. In addition, long lines are still a common sight, and in hospitals recognized by the National health insurance programme, the problem of unavailable resources is rearing its ugly head. Additionally, weak and ineffective referral mechanisms continue to exist, which puts an undue pressure on secondary and tertiary healthcare facilities. It is to this the study centers on the effect of National Health Insurance Scheme in enhancing health care delivery in Nigeria

1.3 Objective Of The Study

The general objective of this study will be to examine the effect of National Health Insurance Scheme in enhancing health care delivery in Nigeria using Ministry of Health in Jos as the case study. Other specific objectives are:

1. To examine the impact of National Health Insurance Scheme on health service delivery among civil servants in Ministry of Health in Jos north local government area of plateau state

2. To investigate the factors limiting successful implementation of National Health Insurance Scheme among civil servants in Ministry of Health in Jos north local government area of plateau state

3. To outline the impact of government policies towards National Health Insurance Scheme on enhancing health service delivery among civil servants in Ministry of Health in Jos North Local Government Area of Plateau state

1.4 Research Questions

The following research questions shall guide this study and in the course of this research, we shall attempt to find answers to the following questions:

1 To what extent does National Health Insurance Scheme impact on health service delivery among civil servants in Ministry of Health in Jos North Local Government Area of Plateau state?

2 What are the factors limiting successful implementation of National Health Insurance Scheme among civil servants in Ministry of Health in Jos North Local Government Area of Plateau state?

3 What is the impact of government policies towards National Health Insurance Scheme on enhancing health service delivery among civil servants in Ministry of Health in Jos North Local government Area of Plateau state?

1.5     Hypotheses

In line with the statement of research problems and the objectives of this thesis, the following hypotheses will be tested:

Hypothesis 1

HO1: there is no significant impact of National Health Insurance Scheme on health service delivery among civil servants in Ministry of Health in Jos North Local Government Area of Plateau state

Hypothesis 2

HO2: there is no significant factor limiting successful implementation of National Health Insurance Scheme among civil servants in Ministry of Health in Jos North Local Government Area of Plateau state

Hypothesis 3:

HO3: There is no significant impact of government policies towards National Health Insurance Scheme on enhancing health service delivery among civil servants in Ministry of Health in Jos North local Government Area of Plateau state

1.6 SIGNIFICANCE OF STUDY

This study would enable the researcher to pass their experience on the subject matter:

To Government ministries: This study will also help government in facilitating health insurances to civil servants. Furthermore the study will serve as a pointer to the problems which are faced by government in effectively implementation of the Scheme and there by providing solutions to these problems

To Schools and students: The will serve as a medium for further research, It is hoped that this study will serve as an available reference source and will help other researchers in this field; thus contributing to the existing literature.

1.7   Scope Of The Study   

The study would cover the effect of National Health Insurance Scheme in enhancing health care delivery within Jos North local government Area. The study was carried in Plateau state Ministry of health in Jos North Local Government Area. The geographical area is Plateau state.

1.8 Operational Definition of Key Terms

Insurance: Insurance is a means of protection from financial loss in which, in exchange for a fee, a party agrees to guarantee another party compensation in the event of a certain loss, damage, or injury. It is a form of risk management, primarily used to hedge against the risk of a contingent or uncertain loss.

Health Insurance: Health insurance or medical insurance is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among many individuals

National Health Insurance Scheme: The National Health Insurance Scheme (NHIS) is a body corporate established under Act 35 of 1999 Constitution by the Federal Government of Nigeria to improve the health of all Nigerians at an affordable cost