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AMAHALU, EUPHEMIA CHIOMA

PG/M.Sc/06/45738

KNOWLEDGE AND PERCEPTION OF FEDERAL CIVIL SERVANTS IN ABUJA

MUNICIPAL AREA COUNCIL TOWARDS NATIONAL HEALTH INSURANCE

SCHEME

DEPARTMENT OF NURSING SCIENCES

FACULTY OF HEALTH SCIENCES AND TECHNOLOGY

Ebere Omeje Digitally Signed by: Content manager’s Name

DN : CN = Webmaster’s name

O= University of Nigeria, Nsukka

OU = Innovation Centre

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KNOWLEDGE AND PERCEPTION OF FEDERAL CIVIL SERVANTS IN ABUJA MUNICIPAL AREA

COUNCIL TOWARDS NATIONAL HEALTH INSURANCE SCHEME

M.Sc DISSERTATION

BY

AMAHALU, EUPHEMIA CHIOMA

PG/M.Sc/06/45738

DEPARTMENT OF NURSING SCIENCES

FACULTY OF HEALTH SCIENCES AND TECHNOLOGY

UNIVERSITY OF NIGERIA

ENUGU CAMPUS

NOVEMBER, 2015

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TITLE

KNOWLEDGE AND PERCEPTION OF FEDERAL CIVIL SERVANTS IN ABUJA MUNICIPAL AREA

COUNCIL TOWARDS NATIONAL HEALTH INSURANCE SCHEME

M. Sc DISSERTATION

BY

AMAHALU, EUPHEMIA C.

PG/M.Sc/06/45738

DEPARTMENT OF NURSING SCIENCES

FACULTY OF HEALTH SCIENCES AND TECHNOLOGY

UNIVERSITY OF NIGERIA

ENUGU CAMPUS

IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF SCIENCE

(M.Sc) DEGREE IN NURSING SCIENCE

(COMMUNITY HEALTH NURSING)

Supervisor: Dr (Mrs) I. L. OKORONKWO

NOVEMBER, 2015

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APPROVAL

This dissertation has been approved for the award of Master of Science Degree in Nursing in

the Department of Nursing Sciences, Faculty of Health Sciences and Technology, University

of Nigeria, Enugu Campus.

………………………………….. …………………….

Dr. (Mrs.) I. L. OKORONKWO Date

(Supervisor)

………………………………….. …………………….

Dr. A. C. Nwaneri Date

Head, Department of Nursing Sciences

………………………………….. …………………….

Date

External Examiner

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________________________________ _____________________

Prof. K.K. Agwu Date

(Dean Faculty of Health Sciences and Technology)

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CERTIFICATION

I, Amahalu, Euphemia C.; certify that this dissertation is an original work carried out by me,

and that neither the work nor any part of the work has been submitted to this University or

any other Institution for the award of any Degree.

…………………………….. …………………….

Amahalu Euphemia C. Date

(Student)

………………………………….. …………………….

Dr. (Mrs.) I. L. OKORONKWO Date

(Supervisor)

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DEDICATION

This work is dedicated to the Holy Trinity (God the Father,

God the Son, and God the Holy Spirit).

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ACKNOWLEDGEMENT

My profound gratitude goes to God Almighty, who has sustained me emotionally, physically,

financially and in all other ramifications. To Him alone be ascribed all the glory and honour.

My special appreciation also goes to my able and diligent supervisor, Dr. (Mrs.) I.L.

Okoronkwo who has encouraged and taught me, out of her wealth of knowledge, montherly

disposition and experience how to work hard and go about this research work, and has

assisted me consistently in bringing this work to required standard. Mummy may good God

bless and repay you abundantly in Jesus name. Amen.

My thanks also goes to the Head of Department of Nursing Sciences Dr. A. Nwaneri for her

motivation and all the lecturers in the department for their assistance in one way or the

other. I say thank you all.

I am highly grateful to my siblings and friends Mr. Okwy Amahalu, Mrs. Nneka Nkwu, Mrs.

Oby Igbozurike, Mrs. Nnenna Iloh, Mrs. Ngozi Ukeagu, Mrs. Onovo Beatrice, Mrs J. Noble

and Mrs. C. Ndolo for the support and assistance they accorded me in carrying out this

research work. I pray that God rewards you all richly.I specially appreciate my beloved

husband for his prayers, patience and financial support, I appreciable my beloved children

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Maryangel, Chigozirim, Chiadikamma and my beloved nephew Osigwe, who supported me

and prayerfully had contributed immensely to the success and conclusion of this work.

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TABLE OF CONTENTS

CHAPTER ONE

INTRODUCTION

Background to the Study . . . . . . 1

Statement of Problem . . . . . . . 3

Purpose of the Study . . . . . . . 4

Research Questions . . . . . . . 4

Research Hypothesis . . . . . . . 5

Significance of the Study . . . . . . 5

Scope of the Study . . . . . . . 6

Operational Definition of Terms . . . . . 6

CHAPTER TWO

LITERATURE REVIEW

Conceptual Review . . . . . . . 8

Theoretical Review . . . . . . . 15

Empirical Review . . . . . . . 16

Summary of Literature Reviewed . . . . . 22

CHAPTER THREE

RESEARCH METHODS

Research Design . . . . . . . 23

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Area of Study . . . . . . . . 23

Population of the Study . . . . . . 24

Sample . . . . . . . . 24

Inclusion Criteria . . . . . . . 24

Sampling Procedure . . . . . . . 24

Instrument for Data Collection . . . . . 25

Validity of the Instrument . . . . . . 25

Reliability of Instrument . . . . . . 25

Ethical Consideration . . . . . . . 26

Procedure for Data Collection . . . . . 26

Method of Data Analysis . . . . . . 26

CHAPTER FOUR

PRESENTATION OF RESULTS

Analysis of Results . . . . . . . 27

Summary of Findings . . . . . . . 37

CHAPTER FIVE

DISCUSSION OF FINDINGS

Discussion of Major Findings . . . . . . 38

Summary of the Study . . . . . . 39

Implication of the Study to Nursing Practice . . . . 43

Conclusion . . . . . . . . 43

Recommendation . . . . . . . 44

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Limitation of the Study . . . . . . 44

Suggestion for Further Studies . . . . . 45

References . . . . . . . . 46

Appendix . . . . . . . . 51

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ABSTRACT

National Health Insurance Scheme (NHIS) is a system of healthcare financing introduced by

Federal Government of Nigeria to help reduce the risks and minimize the costs of

healthcare. Since its inception, only the Formal Sector Social Health Insurance Programme

(FSSHIP) has comprehensively taken off. This study investigated the knowledge and

perception of Federal Civil Servants in Abuja Municipal Area Council (AMAC), Federal Capital

Territory (FCT). A sample size of 383 Civil Servants were selected. The instrument for data

collection was a researcher – designed 30 item questionnaire. Data were analysed using

descriptive statistics such as frequencies, percentages, mean and standard deviation.

Hypotheses were tested using inferential statistics such as student’s t-test and Chi-square.

Findings showed that majority of the civil servants (56.3%) had fair knowledge of NHIS

programme. The civil servants had a positive perception of the NHIS programme (Overall

Mean = 2.81). Majority of the respondents (60%) accessed care under the scheme. Findings

from the study also showed that the civil servants who utilized the scheme had a better

perception of the programme (mean = 2.84) when compared to those who didn’t (P =

0.038). Education was significantly associated with knowledge and positive perception of the

programme. There was no association between grade level and knowledge of NHIS

programme. In addition, their perception of the programme was not dependent on their

gender. The study concluded that intensified campaign on the objectives, benefits and

workings of the scheme should be ensured. This should be facilitated by the nurses and use

of mass media in order to reach a vast majority of the workforce and enhance their

perception of the programme.

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CHAPTER ONE

INTRODUCTION

Background to the Study

Health system are designed to improve the standard of health care of the population.

Improved funding and management of health systems lead to social stability.

Population’s coverage is a clear indicator of the performance of the health system.

The policy of National Health Insurance Scheme (NHIS) aims at increasing coverage

of the Nigerian population. Health insurance as a health care financing mechanism

has become a sought-after approach to the problem of financing healthcare all over

the. world. The current concern with financing, and the specific interest in health

insurance is often the result of parallel trend; the recognition of basic healthcare for all

citizens as a fundamental human right on the one hand, and the difficulties faced by

governments in developing and maintaining resources to provide health care through

general taxation revenue on the other (Mgbe & Kelvin, 2014). World Health

Organization (WHO) has been giving tremendous support and cooperation to nations

that pursue their citizen’s welfare through health insurance. They further noted that,

nations equally are channeling large chunk of their budget to the attainment of good

health for their people.

Health insurance can be categorized as social (or government) health insurance and

private health insurance. Where a system is financed by compulsory contributions

mandated by law or taxes and the system provisions as specified by legal status, it is

social (or government) health insurance plan. On the other hand, private health

insurance is usually financed on a group basis but most plans also provide for

individual policies (Adeoye, 2015).

Health Insurance, according to (Adeoye, 2015) is assuming the status of a global

phenomenon. It was first introduced in Germany in 1883 under General Von

Bismark’s old age and disability insurance scheme. Since then, health insurance has

continued to gain prominence in the other industrialized nations like France, United

Kingdom etc. Developing countries too have joined in beaming their health search

light on health insurance. Prominent among them are Costa-Rica, Brazil, Bangladesh,

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China, India, Pakistan, Thailand, etc. In Africa it has been introduced in Tanzania,

Kenya, Ghana, South Africa, Zimbabwe etc (Agada-Amade, 2007).

In Nigeria, the rising cost of medical care, coupled with poor funding of the health

care sector by government, in addition to severe down turn in the Nigerian Economy

in the 1980’s and 1990s resulted in the abysmal patronage of the orthodox medical

and other healthcare or health institutions (Afoloyan-Oloye,2008). Most of these

health institutions either down-sized or closed down completely and their health

practitioner’s brain-drained for greener pasture. Majority of the people according to

Afoloyan-Oloye (2008) resorted to patronizing alternative health care practitioners,

such as the herbalists and the spiritualists. Mortality from common diseases became

the order of the day. This resulted in government implementing various intervention

designs which included the Bamako initiative, user-fee and Drug Revolving Fund.

After several committees and commissions, the Federal Government approved the

National Health Insurance Scheme (NHIS) in 1989 as a viable means of health care

financing for the achievement of easy access to quality health care for the Nigerian

people (Adeoye, 2015). It was formally launched on October 15, 1997 and the decree

was signed into law in May 1999.

National Health Insurance Scheme (NHIS) is a body established under Act 35 of 1999

by the Federal Government of Nigeria to improve the health of all Nigerians at an

affordable cost (Adeoye, 2015). NHIS according to Mgbe & Kevin (2014), is a social

security system adopted by Nigerian Government to guarantee the provision of

needed health services to persons on the payment of token contribution to the

common pool, at regular intervals. In the context of this study, NHIS is a system of

health care financing introduced by Federal Government of Nigeria to address the

problems of health care delivery which has been affected by challenges. It can be seen

as a typical example of Public Private Partnership [PPP] in health care delivery in

Nigeria. Its main goal is to enhance the health status of the citizens through provision

of financial risk protection and customer satisfaction. The hope of the average

Nigerian to have a reliable and affordable healthcare delivery system has been

brightened with the take-off of the long awaited National Health Insurance Scheme

(Mgbe & Kevin, 2014).

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However, since its inception, it is only the Formal Sector Social Health Insurance

Programme of the NHIS that has comprehensively taken off (Agu, 2010). The Formal

Sector Social Health Insurance Programme (FSSHIP) is a social health security

system in which the health care of employees in the formal sector is paid for, from

funds created by pooling the contributions of employees and employers.

Contributions are earnings related. The employer pays 10%, while the employee pays

5%, representing 15% of the employees’ basic salary (NHIS, 2012). Given that the

Formal Sector Social Health Insurance Programme is new, the federal government of

Nigeria chose to exempt its employees from paying their share of 5%, insisting the

programme runs on its own 10% contribution for some months. This was meant to

secure employees’ confidence in the programme, assuming that once the employees

perceive the benefits, contributions will be facilitated. Presently, the Formal Sector

Social Health Insurance Programme provides health insurance coverage for

contributors, one spouse and four biological children below 18 years of age (National

Health Insurance Scheme, 2012).

Despite its take off, NHIS has been characterized by a lot of misconceptions, fears

about workability of the scheme, concerns as regards workers’ financial contribution

to the scheme overtime and the sincerity of government in financing workers’ health

care in the formal sector among others (Adeoye, 2015). There have been mixed

feelings about the impact of the programme on workers (Ononokpo, 2010). This study

is therefore being conducted to determine the Knowledge and Perception of National

Health Insurance Scheme (NHIS) among Federal Civil Servants in Abuja Municipal

Area Council (AMAC) Federal Capital Territory (FCT) Abuja. This will serve as

baseline for further recommendations to stakeholders in the scheme, and ultimately

help in organizing and managing the scheme for better acceptability to the workforce.

Statement of the Problem

The introduction of National Health Insurance Scheme (NHIS) as a health care

financing mechanism should be welcomed with enthusiasm and sense of relief by all

stakeholders in the health care industry, especially Federal Civil Servants in Abuja.

Dogo (2008), are of the opinion that National Health Insurance Scheme, which is a

health care risk spreading mechanism is probably what is required to solve the

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problem of inequality in the provision of health care services in Nigeria. Thus the

scheme was proposed to help spread the risks and minimize the costs of health care.

Regrettably the emergence of NHIS seems not to gain the much expected acceptance,

support and cooperation from the civil servants. Ononokpo (2010) observed that

majority of civil servants are still reluctant with accepting NHIS programme.

According to him, they are all suspicious of government’s motive, intention and

strategies especially when they realize that there will be monthly deduction from their

salaries as their contribution into the “solidarity pool” for running the scheme.

Anecdotal records and personal experience as a health care worker with the NHIS

have shown that many civil servants fail to access the NHIS services. Moreso, there is

dearth of literature on why many of these civil servants who are expected to be aware

of the services and the benefits do not access the service. The questions raised in this

study are: what knowledge do the Federal Civil Servants in AMAC have concerning

NHIS programme? What is the perception of Federal Civil Servants in AMAC on

NHIS program. What is the perception of the Federal Civil Servants on the quality of

care provided by the NHIS programme? This study is an attempt to address the above

questions.

Purpose of the Study

The purpose of the study is to determine the Knowledge and Perception of Federal

Civil Servants in Abuja Municipal Area Council (AMAC) towards NHIS.

Objectives of the study

Specifically, the objectives are to:

1. determine the knowledge of Federal Civil Servants in AMAC on NHIS.

2. determine the perception of Federal Civil Servants in AMAC on NHIS

programme.

3. ascertain the perception of Federal Civil Servants in AMAC on the quality of

care provided under the NHIS programme.

4. determine the differences in the opinion of users and the non-users of the

NHIS programme among Federal Civil Servants in AMAC.

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Research Questions

The following research questions were formulated to guide the study:

1. What knowledge do Federal Civil Servants in AMAC have on NHIS.

2. What is the perception of Federal Civil Servants in AMAC on NHIS

programme.

3. What is the perception of Federal Civil Servants on the quality of care

provided under the NHIS programme.

4. What are the differences in the opinion of users and the non-users of the NHIS

programme among Federal Civil Servants in AMAC.

Research Hypothesis

Ho1: There is no significant difference in the perception of users and non-users of

the NHIS programme among Federal Civil Servants in AMAC.

Ho2: There is no significant association between Federal Civil Servants’ level of

education and their knowledge of NHIS programme.

Ho3: There is no significant association between Federal Civil Servants’ grade level

and their knowledge of NHIS programme.

Ho4: There is no significant association between Federal Civil Servants’ level of

education and their perception of NHIS programme.

Ho5: There is no significant association between Federal Civil Servants’ gender and

their perception of NHIS programme.

Significance of the Study

The findings of the study will reveal the knowledge and perception of Federal Civil

Servants in AMAC on NHIS programme. If their views and perceptions are positive

the civil servants will be encouraged to uphold them by the workers in the NHIS. If

their views are negative, there will be need for enlightenment of civil servants on the

benefit of NHIS by the workers in the NHIS through special sensitization seminars.

If the result indicates that the Federal Civil Servants do not have enough knowledge,

it will serve as a reason for the NHIS workers, HMOs and the government to organize

public enlightenment programme and appropriate information on the concept,

objectives, roles, and responsibilities, operations of the scheme and benefits of NHIS.

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This will enable Federal Civil Servants to make informed choices on adoption of the

scheme. Good understanding and awareness will create positive impact on them.

If findings show good knowledge and perception, the civil servants will be

encouraged to maintain it.

The findings will equally motivate NHIS workers and health policy makers to step up

effort in the area of sensitization, seminars, and workshops with a view of raising the

level of awareness of the people regarding NHIS, their engendering positive attitude

and adoption of the scheme.

NHIS and other operators of the scheme (providers and HMOs) will benefit from the

findings of the study, as it will help them to re-appraise their functions and

responsibilities and make adjustments where necessary with a view of making NHIS

more attractive to Federal Civil Servants to adopt the scheme. The findings will also

serve as a guide for future planning, monitoring and evaluation of the programme by

the federal government.

Future Researchers will find data generated from the study very useful, as they could

build on the findings in furthering researches in this area of knowledge. This study

will contribute in the literary world. It will, particularly add to the existing literature in

the field of health insurance.

Scope of the Study

This study wase delimited to all Federal Civil Servants within Abuja Municipal Area

Council (AMAC). The study will specifically be delimited to the determination of

knowledge of NHIS by Federal Civil Servants in AMAC, the perception of Federal

Civil Servants in AMAC on NHIS programmes, the perception of civil servants on

quality of care under NHIS programme, and the differences in the opinion of users

and the non-users of the NHIS programme.

Operational Definition of Terms

Federal Civil Servants: refer to all levels of the federal government employees

(junior and senior civil servants) working within Abuja Municipal Area Council

(AMAC).

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Perception of NHIS among employee: refer to feelings, opinions and views about

NHIS, whether they want the scheme to continue or not and problems they encounter

in the scheme.

Knowledge about NHIS: refer to the respondents awareness or understanding of

employees about the NHIS programs, what the civil servants identify as role of NHIS,

advantages inherent in NHIS like curative services for common ailments and injuries,

primary eye care services etc. 40% and below is poor knowledge, 41% - 69% is fair

knowledge, 70% and above is good knowledge.

Perception on quality of care provided: Refer to the enrollees view/opinion on the

care received, in terms of the promptness, the time spent to see the Doctor,

relationship with the Doctor, relationship with the hospital workers, whether

excellent, very good, good, fair, and poor.

Users of NHIS: refer to registered civil servants in AMAC who have accessed NHIS

services such as visiting a hospital for healthcare service.

Non Users of NHIS: refer to registered civil servants in AMAC who have not

accessed NHIS services such as visiting a hospital healthcare.

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CHAPTER TWO

REVIEW OF RELATED LITERATURE

This chapter presents the review of literature related to the present study under the

following headings: conceptual review – concept of National Health Insurance

Scheme, operation of the Formal Sector Social Health Insurance Programme,

perception of Federal Civil Servants about NHIS, knowledge about NHIS, public

view on the continuity of the programme, perception of quality of care; theoretical

review – (theory of knowledge); empirical review of health Insurance.

Concept of National Health Insurance Scheme

Insurance, according to Neisten (2009), refers to an arrangement by which a company

gives customer financial protection against loss or harm. It is an act, measure or

provision that gives protection against an undesirable event or risk. Hacker, (2011)

defines insurance as an arrangement with a company in which you pay them regular

amount of money and they agree to pay the cost for illness or death. Hamza (2007),

defined health insurance as a system in which prospective consumers of care make

payment to a third party in the form of an insurance scheme which in the event of

future illness will pay the provider of care some or all of the expenses incurred.

Simply put, it is a payment plan in which participants pay a regular amount which is

pooled to provide for those needing care. In the present study health insurance refers

to a mechanism in which people contribute some amount of money which is pooled

and later utilized for members against unplanned and unaffordable expenditure for

health care services in the event of illness.

Social Health Insurance (SHI) as a category of health insurance to which NHIS falls,

is a form of financing that pays for health services through contributions to a health

fund. The most common basis for contribution is payroll, which contributors from

both employer and employees determine the percentage they contribute. The

contributions are based on ability to pay, and access to services depends on need

(Hamza, 2007). The health fund is usually independent of government, but works

within a tight framework of regulations. Social health insurance is based on mutual

support and involves a transfer of resources from the relatively richer and healthier

people to the relatively poor and sickly people. Hamza (2007), asserted that there is

no stereotyped or standard design for a national health insurance scheme. Individual

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countries design their own insurance systems that suit their socio-economic, cultural

and political backgrounds.

National Health Insurance Scheme (NHIS) is a body corporate established under the

Act number 35 of 1999 by the Federal Government of Nigeria to improve the health

care of all Nigerians at a cost the government and the citizens can afford (Adeoye,

2015). NHIS, according to Dogo (2007) is a social security system adopted by

Nigerian Government to guarantee the provision of needed health services to persons

on the payment of token contribution to the common pool at regular interval. The

fundamental rationale for social (national) health insurance is risk sharing. In the

present study, NHIS refers to a system of health care financing introduced by Federal

Government of Nigeria for addressing the problems of the nation’s health care

delivery which has been affected by challenges. It is non-profit in concept and

contribution is based on the ability to pay. As a social health insurance, the NHIS’s

main thrust is easy and equitable access to health care of adequate quality and

affordable type. The system is financed by compulsory contribution, mandated by

law, and by the taxes and the systems provisions are specified by legal statute

(Adeoye, 2009). The scheme is comprised of four main components namely: Formal

sector group, Informal sector group, vulnerable group and others.

The formal group consists; of public sector (Federal, State, Local Government, Armed

Forces, Police and other Uniformed Services, Organized Private Sector, Students of

Tertiary Institutions and Voluntary Participants). Since the operations and coverage of

the scheme is carried out in phases, formal sector is where the efforts of NHIS is

focused the most for now, Federal Civil Servants in AMAC fall under this sector. It is

mandatory for every organization with ten (10) or more employees, (Dogo, 2008).

Operation of the Formal National Health Insurance Programme

According to National Health Insurance Scheme Operational Guideline (2012), an

employer registers itself and employee with the scheme. Thereafter-, the employer

affiliates itself with an NHIS approved Health Maintenance Organization (HMO) who

now provide(s) the employee with a list of NHIS approved health care providers

(public or private).The employee registers himself and dependants with such provider

of his choice. Upon registration, a contributor will be issued an identity card with a

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personal identification number (PIN). In the event of sickness, the contributor

presents his identity card to his chosen primary health care provider for treatment. The

contributor accesses care after a waiting period of ninety days and this completes the

administrative process.

According to the 2012 National Health Insurance Scheme Operational Guideline, a

contributor has the right to change his primary provider after a minimum period of

three months, if he is not satisfied with the services being given. The HMO makes

payment for services rendered to a contributor to the health care provider. A

contributor may, however, be asked to make a small co-payment (where applicable) at

the point of service.

Contributions are earnings-related and currently represent 15% of basic salary. The

employer pays 10% while the employee contributes 5% of the basic salary to enjoy

health benefits. The contributions made by/for an insured person entitles

himself/herself, a spouse and (4) children under 18 years of age, to full health

benefits. Extra contribution will be required for additional dependants. The

contributions of two working spouse cover the spouse and four (4) children for each

of them (National Health Insurance Scheme Handbook, 2005).

According to Ononokpo (2010), the core functions of the scheme include, among

others; maintenance and operation of health insurance fund; developing, promoting

and ensuring the quality of health insurance scheme under the act, issuing guidelines

and setting standards for providers and health insurance actors, mobilizing additional

resources (domestic and external) to fund the health sector, defining benefit packages

and to introduce and market health insurance products, registration of Health

Maintenance Organizations and Health Care Providers and approval of contracts

between various actors etc.

For the smooth running of the scheme, the stakeholders, according to Dogo-

Mohammed (2006) are expected to play their roles and accept and carry out their

responsibilities as at when due. These stakeholders include: The enrollees, the

Healthcare providers, the Health maintenance organizations, banks, insurance

companies etc. and all should work according to NHIS operational guideline.

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Perception of National Health Insurance Scheme

Perception is the process by which organisms interpret and organize sensation to

produce a meaningful experience of the world. Sensation usually refers to the

immediate, relatively unprocessed result of stimulation of sensory receptors in the

eyes, nose, tongue or skin (Lambert, 2008). Perception, on the other hand, better

describes one’s ultimate experience of the world and typically involves further

processing of sensory input (Agu, 2010). According to Hornby (2013), perceiving is

the process of using the senses to acquire information about the surrounding

environment or situation. It is an impression, an attitude or understanding of what is

observed or thought.

In the context of this study, perception refers to feelings, opinion, of civil servants

about NHIS; the way in which civil servants see, understand, and interpret NHIS

programme. Their views on the operations of the scheme, especially as it concerns the

benefits accruable from participating in the NHIS programmes form the basis for their

decision and action. If enrollees behave on the basis of their perception, we can

predict their behavior in the changed circumstances by understanding their present

perception of the environment. One person may be viewing the facts in one way,

which may be different from facts as seen by another viewer (Katz, 2011). With the

help of perception, the needs of the enrollees can be determined, since peoples’

perception are influenced by their needs. Different people perceive the same situation

differently (Katz, 2011). In order to deal with the enrollees effectively, their

perceptions have to be understood properly.

Lambert, (2008), put forward that, perception of an enrollee can also be influenced in

many ways because of differences in personality, background and set of experience.

He classified them as follows:

• Physiology: perception of an individual is influenced by his physiological

conditions; example, an enchanting NHIS jingles may not be impressive to

one who is hard of hearing.

• Family: The perception of an individual is influenced considerably by the

family in which he has been brought up. In a family where a child has seen the

elders adopting good health habits, he will take it as the normal way of life.

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• Culture: the society and culture in which one lives has an indelible impact on

his attitudes, values and way of perceiving the world.

• Stress: is a situation, which is created by the pressure of the environment. It is

uncommon situation, which a person confronts. Sometimes stress helps in

perceiving things in proper perspective and more often it leads to less accurate

impressions.

• Group pressure: The perception of an individual (minority) changes with the

majority to be in conformity with the group. More often his perception

automatically changes when he finds that others do not share in his beliefs,

attitudes and perception. Conversely, if he finds that there are some who fall

in line with him, he will try to estimate the effect of majority. The effect of

the group pressure depends on the extent of clarity with which the group is

exercised.

• Interaction: Interaction among group members helps in improving perception

about a person or situation. The interaction provides opportunity for sifting

and sharpening perception.

• Role: Role and perception are related if the role is properly perceived. A

person is the son, father, husband, student, brother etc. hence he will play

differently in different roles. Hence while perceiving the behavior of a person,

his role, has to be taken into account; otherwise the perception about the

person will be wrong.

• Reference Group: Groups are expected to perform normative and comparative

functions.

• Organizational Position: The position held by an individual in organizations

influences his perception e.g. An economic consultant will view every

problem in the organization from an economic angle.

• Reward system: Reward system in organizations has an impact on individual

behavior which is preceded by the perception process.

Knowledge about NHIS

Aristotle (2009) defined knowledge as the sum of conceptions, views and propositions

which has been established and tested. Babbie (2007) sees knowledge as an

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understanding of a subject matter. Such subject matter could be National Health

Insurance Scheme (NHIS) as is the case in the present study. This means that for a

person to be knowledgeable of something he or she must be aware of the property of

the object, event or situation. Knowledge means the information, understanding and

skills that one gains through education or experience (Hornby, 2013). Knowledge as

used in this present study refers to adequate information and understanding possessed

by Federal Civil Servants in Abuja Municipal Area Council (AMAC) regarding

National Health Insruance Scheme (NHIS) and its benefits. Hyman (2010) state that,

not everyone knows everything, and not everything that is in principle is knowable.

So it is important to determine both the extent and quality of knowledge a person has

about a particular issue. This according to them is because knowledge is instrumental

in accepting or resisting any change. Turri (2011), asserts that knowledge is cultural

application of information. This prepares the way for meaningful health perception

and positive health practice. Agada-Amade (2007) highlighted that the knowledge

about benefits of NHIS can only be acquired and improved through proper education.

He believes that mass media, therefore, becomes indispensable in the attainment of

this objective. Adequate knowledge (information and understanding) of NHIS and its

benefits will reshape and influence the perception of Federal Civil Servants in Abuja

FCT towards the NHIS.

The overall benefits of the National Health Insurance Scheme as enshrined in the

Federal Republic of Nigeria Official Gazette of May 1999 include:

Easy access to vast variety of good and efficient health care services at all times;

Protection from financial hardship of huge medical bills; improved private

participation in the provision of healthcare services; affordable health care services

for all income groups; an equitable distribution of health care facilities; availability of

funds in the health sector and equitable patronage at all levels of healthcare.

Public view on continuity of the programme

The scheme is facing challenges or constraints, even though some of the challenges or

constraints are being addressed by the scheme, it is obvious that some of them still

persist, (NHIS, 2010).

The absence of robust and functional health information system and Information

Technology (IT), infrastructure in the country has hindered the sharing of information

27

and creation of data base between the various stakeholders in the scheme. The non-

availability of funds to operate the various subsidy-requiring programmes in informal

sector also poses a big challenge in the existing coverage to the sector. The age-long

rivalry between various professional groups in the health care industry has found its

way. In NHIS provider network, while some providers withhold care to enrollees on

flimsiest excuse, others charge additional fees on the pretence of non-inclusion of the

service in the benefit package. Acceptance of global capitation at primary level and

payment for secondary and tertiary care through fee-for-service has contributed to be

a challenge. This has been compounded by the dispensing of drugs by primary

providers without accredited pharmacies at the expense of accredited pharmacies,

thereby contravening the NHIS operational guidelines (Annual Report, 2012).

The scheme has over the years faced the problem of lukewarm attitude and behavior

to the beneficiary in operating the programme. There have been complaints of delay

in or refusal to make payments to providers by some Health Maintenance

Organizations (HMOs). Some HMOs on their part have equated the operations of

private health insurance to that of social health insurance which is a different variety.

However, regular dialogue and consultations are gradually removing some of these

distortions in the operations of the scheme. The mechanism for collecting the

surcharge for extra dependants of principal enrollees has not been properly worked

out. The implementation of co-payment by beneficiaries for pharmaceutical services

is not being adequately enforced (Ononokpor, 2010). In spite of all the above

challenges or constraints, what is, however, interesting is that the improved

stakeholder’s relations series of intensive mobilization or sensitization campaigns and

the unrelenting commitment of the federal government to play its role are helping to

improve matters for the scheme. It is expected, according to Dogo-Muhammad,

(2007), that if every stakeholder plays his/her expected role, the challenges and

constraints would be positively addressed.

Perception of Quality of Care

Quality of care refers to enrollees subjective view on the care received whether

excellent, very good, good, fair, and poor. According to Count (2010), it can be seen

as the extent to which health services for individuals and populations increase the

likelihood of desired health outcomes and are consistent with current professional

28

knowledge. It looks at the quality of care given to clients/patients and which can be

evaluated at the individual or population level of analysis. Health care professionals

are more attuned to factors such as signs of measurable clinical improvement and

perhaps attention to what has often been the art of medicine, while the enrollees are

more attuned to whether the behavior of health care professionals is congruent with

their expectations (major component of patient satisfaction), whether their symptoms

and everyday role capacity have improved, and whether they can use (access)

available services. (Count, 2010).

Count (2010) asserts that the major types of quality care indicators are: structure,

process and outcomes. Structure: refers to characteristics of the setting(s) in which

health care occurs. Structural attributes include material resources (number of

personel and their qualifications) and organizational structure (medical staff

organization level of reimbursement). Process refers to what is actually done during

the care process. Process attributes include patient activities in seeking out care and

complying with the treatment regimen as well as practitioner diagnostic and treatment

activities. Outcome is the final component. Outcome addresses the effects of care on

the health status of individual patients and populations. Outcome attributes include

changes in a patient’s health status (physiological measures, patient’s perceptions and

preferences example Reduction in child or maternal mortality. Though care

assessment is subjective but it has been seen as one of the best tools to assess the

quality of care, more especially in resource constrained environments.

Theoretical Review

The theory underpinning this is based on the empirical theory of knowledge and

reality; developed by John Dewy (Ryan, 2003) and was used as a framework for the

study. This approach suggests ways in which individuals know about things or events

around them. This study utilizes this theory in explaining the knowledge and

perception of civil servants towards National Health Insurance Scheme as a health

care financing mechanism.

29

Dewey’s Empirical Theory of Knowledge

This theory posits that people know about things or events around them through their

senses, and that knowledge can mean any of the following; to have understanding, or

grasp of the object of knowledge. In this study, National Health Insurance Scheme; to

be familiar with something, to be able to recognize or identify something; ability to

distinguish between things; to have adequate experience and training; and to be

intimate with something. For Shook (2009), experience is the source of all

knowledge. People according to him, can abstract after experience have provided the

basic building blocks. The thesis of this theory as it applies to the subject matter is

that federal civil servants in AMAC will become knowledgeable of National Health

Insurance Scheme (NHIS) when they have the understanding of the operations of the

scheme – (stakeholders, benefits, roles, and responsibilities) through their senses –

emanating from radio, television, discussions.

The operational function of the above theory cannot be over-emphasized in this study.

The theory seeks to explain why people (Federal Civil Servants) understand, identify,

and recognize things, the way they do. The theories have guided researcher’s thought

along certain lines when considering the phenomena at hand and thus enable her to

remain focused and avoid veering off from the issues at stake. The theory, therefore,

are very relevant to this study and any other related researches; hence the researcher

affirms its importance and utility value.

Empirical Review

This section is concerned with a review of studies conducted in the area of knowledge

and perception of National Health Insurance Scheme. Available literature indicates

that most studies in this area are limited to the type of health insurance adopted by

various countries which reflect their choices, contexts and peculiarities and how the

operations of these health care financing models have been making impacts in their

respective countries. To this end, very few studies examined the Knowledge and

Perception of National Health Insurance Scheme by Federal Civil Servants.

A study on perception of National Health Insurance Scheme (NHIS) by Health care

consumers in Oyo State, Nigeria, by Sanusi and Awe (2009) was done using a survey

design. Instrument for data collection was a structured questionnaire. The data of the

30

study were analyzed using descriptive statistics and inferential statistics (logic

regression model). The findings revealed that 87.4% of the respondents were aware

of the programme, and 83.2% were registered for the programme, while 58.9% of the

respondents have started enjoying the programme. About 65% of the respondents

wanted the programme discontinued. Furthermore gender, marital status and income

level were some of the factors that did not significantly influence respondents opinion

on NHIS continuity. Registration of dependants (p < 0.10) and perception by

respondent of drug sufficiency under NHIS (p < 0.05) were the significant factors

influencing some of the respondents having the opinion that the scheme be continued.

The study shows that notwithstanding the scheme have marginal effects on the people

and as such suggested that government and other stakeholders need to intensify

awareness campaign, ensure universal coverage, and make registration compulsory.

A study of the Awareness of National Health Insurance Scheme (NHIS) activities

among employees of a Nigerian University was conducted by Adibe, Udeogaranya

and Ubaka (2011). The objective was to assess the level of awareness of NHIS

activities among employers of a Nigerian University using a survey design. The

instrument for data collection was a 30 item questionnaire while t-test and one-way

ANOVA was employed to analyze the data. The sample size was 500 employees with

a respond rate of 87.2% (436 out of 500 questionnaires). The result revealed that

awareness was significantly associated with all the demographical characteristics of

the respondents. The total awareness mean scores for objective of the scheme,

responsibility of the scheme and powers of the scheme council were 32.732.16,

34.22 2.48 and 33.273.38 respectively while the grand total awareness mean was

100.22 8.02. The conclusion of the study was that employees of University of

Nigeria were marginally aware of NHIS activities. Demographic characteristics

played considerable role on the level of awareness of NHIS activities.

A study was conducted by Agada-Amade (2009), on the awareness of Health

Insurance Model as a health care financing option by health workers and other civil

servants in Abuja (FCT). The objective was to examine the level of awareness of

health workers and civil servants of health insurance as a system, and benefits

accruable to them from this system of health care financing. A descriptive survey

31

design was adopted for the study. The instrument for data collection was

questionnaire and key informant interview. A study sample of 350 out of a population

of 24,657 was used.

On the whole 163(52.3%) respondents were aware of the concept of NHIS. 47.2% of

the senior cadre and 51% of the junior cadre were not aware of the benefits.

In the distribution of occupation of respondents and level of awareness, 54(16.9%)

respondents were health workers, while 266(83%) respondents were other civil

servants. 35(64.8%) of the 54 health workers were aware of Health Insurance while

35.2% were not. For other civil servants 163(61.3%) of the 266 respondents knew

about the scheme, while 103(38.7%) were not aware. The result further showed that

198(61.9%) respondents were aware of the benefits accruable from NHIS, while

122(38.1%) have not heard of the benefits. The percentage of the respondents that

were aware was higher (64.8%) among the health workers as against 35.2 of other

civil servants. In the distribution of sex of the respondents on level of awareness of

NHIS, 190(59.4%) were males, whereas 130(40.6%) were female. 125(65.8%) male

respondents were aware of NHIS while 65(34.2%) have not heard about the scheme.

82(62%) female respondents have heard about NHIS while 48(37.9%) were not aware

of the scheme. On the whole 207(64.7%) of the respondents (health workers and other

civil servants were aware of NHIS while 113(35.3%) were not aware.

In a study done by Okaro, Ohagwu and Njoku (2010), on Awareness and Perception

of National Health Insurance Scheme (NHIS) among Radiographers in South East

Nigeria. The objective of the study was to assess the knowledge and attitude of

Radiographers in South East Nigeria towards the scheme. It is a cross sectional

prospective survey. The sample size is 40. The instrument used was questionnaire.

The return rate of the questionnaire was 92.5%. Data were analysed using SPSS

version 14.0. Results showed that all the radiographers 100% were aware of NHIS,

with majority having their source of information from seminars in the hospital. 45.9%

have registered with the scheme, while 54.1% have not registered. With regard to the

knowledge of the various aspects of the scheme only 59.59% knew that there is an

enabling law for the operation of the scheme in Nigeria, while only one respondent

being able to state the year of enactment of the law. More than 70% of the

respondents could not correctly state at least two objectives of the scheme. 37.8% do

32

not know the provider payment mechanism as well as the radiological examination

not covered under the scheme. In summary there is generally high level of awareness

to the existence of NHIS in Nigeria among the study population, but there is poor

Knowledge of the principles of the operation of the National Health Insurance

Scheme; Participation is low among radiographers but they have positive attitude

towards the scheme. Seminars in hospitals are very important in sensitizing the

healthcare professionals.

A similar study was conducted by Owu, Ifatimehin, and Shaka (2014), on Assessment

of the level of Awareness of the effectiveness of National Health Insurance Scheme

among workers in selected federal establishments in Kaduna metropolis, Nigeria. The

study is a survey design and the instrument for data collection was questionnaire. The

sample size is 200. The return rate of the questionnaire is 75.5%. Analysis were done

using SPSS version 19.0 Analysis of Variance (ANOVA) (f) was used to test

hypothesis. A significant value less than 0.05 was adjusted and the null hypothesis

accepted. 149 (98%) of the respondents were aware of NHIS, while 2 (1.3%) were not

aware of NHIS.138 (91.4%) were registered while 13 (8.6%) were not registered with

NHIS. 129 (85.6%) have access to healthcare services through NHIS, while 22

(14.6%) indicated they don’t have access to healthcare services. 77 (51%) of the

respondents rated their access to healthcare services as satisfactory, closely followed

by 28 (18.55) who were undecided, 15 (9.9%) were highly satisfied, 23 (15.2%) were

unsatisfied and 8 (5.3%) were highly unsatisfied. Looking at the level of acceptance

of NHIS 131 (86.8%) respondents indicated yes, while 20 (13.2%) of the respondents

indicated no. In conclusion there is high level of awareness of National Health

Insurance Scheme among workers in Kaduna metropolis, health care providers in

Kaduna metropolis performed well in the delivery of healthcare services to workers,

and workers have positive attitudinal disposition towards the utilization of the scheme

and have accepted the scheme.

A study done by Olugbenga-Bello and Adebimpe, (2010) on Knowledge and attitude

of civil servants in Osun state, South Western Nigeria, towards the National Health

Insurance. It was a descriptive, cross sectional study with sample size of 380. The

instrument for data collection was questionnaire. The result showed that about 60%

were aware of out of pocket as the most prevalent form of health care financing, while

33

40% were aware of NHIS. Television and bill boards were their main sources of

awareness. However none had good knowledge of the components of NHIS, 26.7%

knew about its objectives, and 30% knew about who ideally should benefit from the

scheme. Personal spending still accounts for as high as 74.7% of health care spending

among respondents but respondents believed that this does not cover all their health

needs. Only 0.3% have so far benefited from NHIS, while 199 (52.5%) of respondents

agreed to participate in the scheme. A significant association exists between

willingness to participate in NHIS and awareness of methods of options of health care

financing and awareness of NHIS (p<0.05). In conclusion poor knowledge of the

objectives and mechanisms of operation in NHIS characterized the civil servants

under study. The poor knowledge of the components and fair attitude towards joining

the scheme observed in this study could be improved upon, if stakeholders in the

scheme could carry out adequate awareness.

In a study done by Aggrey and Appiah (2014), on The influence of Clients’ Perceived

Quality on Healthcare Utilization. It was a cross-sectional study involving health

clients (18 to 70 years) who accessed health services in the Bantama sub – metro in

the Kumasi metropolis. The sample size was 400. Data was collected through

interviewing using semi- structured questionnaires using SPSS and analysed into

descriptive and inferential statistics with STATA II. Results showed that majority of

the enrollees accessed healthcare with their NHIS cards. Eight percent (8%) had

never accessed healthcare with their NHIS cards. Respondents’ reasons included not

falling sick and low quality of healthcare under the NHIS. Respondents 216 (54%)

indicated delay in seeing a doctor, getting laboratory done, and accessing healthcare

as a whole. Seventy - four of the entire population attributed both NHIS and cash and

carry systems as the payment methods associated with delays in health facilities.

Clients who viewed the overall quality of health provision as good or very good were

more likely to access healthcare with NHIS card as compared to those who rated the

overall health provision as poor or very poor(p<0.01). Majority of the respondents

(50.9%) were of the judgement that their level of satisfaction of healthcare was good,

with 26.2% going the extra mile to express their satisfaction as excellent. However

20.4% express their satisfaction as average, 2.0% as poor and 0.5% as very poor.

51.1% see the scheme as cost friendly. In conclusion clients’ perceptions and

experiences with quality of health provision influence their utilization of healthcare

34

under the NHIS. Increased enrollment in the scheme should be supported with

provision of quality services to enhance clients’ satisfaction.

A study was conducted by Agu (2010), on knowledge, Attitude and Practice of

National Health Insurance Scheme (NHIS) by Civil Servants in Federal Capital

Development Authority (FCDA) Abuja. A cross-sectional research design was

utilized. The sample size is 400. The instrument used was questionnaire with return

rate of 96.75%. Objective of the study was to determine the level of knowledge,

attitude and practice of NHIS by the respondents. The major findings reveal that

Federal Civil Servants had high (75%) knowledge of NHIS, had positive attitude

towards NHIS, and demonstrated moderate practice of NHIS.

Study done by Evans and Shisana (2012) on Gender differences in public perceptions

on National Health Insurance. It is a cross-sectional survey. The sample size is 1000.

Questionnaires and face to face interview was used. The response rate is 89%. SPSS

version 20. Chi square were conducted to test for differences between groups. A p

value of <0.05 was considered statistically significant. Support for National Health

Insurance(NHI) was stronger among females (78.8%) than males ( 67.7%). A higher

proportion of females (76.1%) than males (70.0%) preferred NHI to holding down

taxes and thought that their families would be better off with NHI - females (76.1%)

males (68.7%), and that NHI would improve health care quality – females (76.1%)

and males (70.8%). Support for NHI was strong among both males and females;

however, the data supported their hypothesis that females are stronger supporters of

NHI than males. This support is independent of race, marital status, education,

employment, location of residence, health status and type of healthcare used. He went

further to say that females’ gender role as care givers (children and elderly) could

encourage them to perceive NHI as a benefit not only for themselves, but also for

their families and communities. Furthermore, females’ sexual and reproductive health

needs as well as their poor health status could encourage them to seek healthcare more

frequently than men. .

In a study done by Fletcher and Frisvold (2012), on impact of education on preventive

care. Regression analysis was used, siblings fixed effects, and matching estimates to

examine the impact of education on preventive care. They used a cohort of 10,000

35

Wisconsin high school graduates that has been followed for nearly 50 years and find

evidence that attending college is associated with an increase in the likelihood of

using several types of preventive care by approximately five to fifteen percent for

college attendees. They also find out that greater education may influence preventive

care, partly through occupational channels and access to care. These findings suggest

that increase in education have the potential to spill over on long-term health choices.

Summary of Literature Review

A conceptual review on concept of NHIS, operation of formal sector NHIS,

perception of NHIS by the civil servants, knowledge about the scheme and its

benefits, care assessment by enrollees. Theories related to knowledge Dewey’s

Empirical theory of knowledge were also reviewed.

Empirical review on knowledge and perception of NHIS by Federal Civil Servants

was also carried out. Some works have been done on Health Insurance worldwide but

no research has been done on knowledge and perception of NHIS by Federal Civil

Servants in Abuja; as regards to; knowledge of NHIS by Federal Civil Servants in

AMAC, the perception of Federal Civil Servants in AMAC on NHIS programme, the

perception of Federal Civil Servants on quality of care provided under the NHIS

programme, differences in the opinion of users and non-users of NHIS programme.

This study tried to fill these gaps.

36

CHAPTER THREE

RESEARCH METHODS

This chapter presents the: methods used for the study under subheadings as research

design, area of study, population of the study, sample and sampling procedure,

instrument for data collection, validity of instrument, reliability of instrument, ethical

consideration, procedure for data collection and method of data analysis.

Research Design

A cross-sectional descriptive survey research design was used to achieve the objective

of the study. Araonye, (2004), stated that this design facilitates the description of a

situation in its current state, and elicits information directly from the respondent.

The design was, therefore, considered appropriate for use in the present study because

it enabled the collection of current information on the perception and knowledge of

National Health Insurance Scheme by Federal Civil Servants in Abuja Municipal

Area Council (AMAC).

Area of Study

The area of study was Abuja Municipal Area Council (AMAC), the new capital of

Nigeria (Federal Capital Territory). According to Abuja Geographic Information

System (AGIS) (2010), Abuja came into existence by virtue of the Federal Capital

Territory Act of 1976. The territory covers a total land area of approximately 8,000

square kilometers, while the city proper covers a total land area of 250 square

kilometers. It is located at the centre of Nigeria, north of the confluence of the Niger

and Benue rivers. It is bounded by the states of Niger to the west, Kaduna to the

Northeast, Nassarawa to the east and south, and Kogi to the Southwest. Abuja (FCT)

is comprised of six Area councils which include: Abuja Municipal Area

Council(AMAC), Gwagwalada, Kwali, Abaji, Kuje, and Bwari Area Councils.

Outskirts of Abuja include Madalla, Suleja, and Mararaba.

The choice of AMAC in the study is due to its nature as the heart of Abuja as a

cosmopolitan city where the concentration of people, especially civil servants are

mainly found than in the other area councils. Other characteristics that favour AMAC

as the choice of study is that most of the Ministries and Parastatals are located in

37

AMAC. It is one of the growing area councils in the FCT (Abuja Geographic

Information System, 2002).

Population of the Study

The population of the study consisted of all the Federal Civil Servants from 30

establishments in Abuja Municipal Area Council (AMAC).The population was

estimated at 155,250 Federal Civil Servants (Core Ministry – 77,625, Parastatals –

46,575, Extra Ministerial Department – 31,050). (National Salaries, Incomes and

Wages Commission, Abuja, 2011).

Sample

The sample size for this study was 383. The sample was statistically determined

using Krejcie and Morgan formular (2012) (see Appendix IV).

S = X2 NP (1 – P)/d2 (N – 1) + X2 P(1 – P) (KENPRO, 2012)

S = required sample size

X2 = The table value of chi-square for one degree of freedom at the desired

confidence level (3.841)

N = The population size (155,250)

P = The population proportion (assumed to be 0.5 since this would provide

the maximum sample size)

d = the degree of accuracy expressed as a proportion (0.05)

Inclusion Criteria :

• Full time employed Federal Civil Servants.

• Having worked with the federal civil service for at least 5 years.

• Willingness to participate

Sampling Procedure

The population was stratified according to 15 Core ministries, 9 Parastatals and 6

Extra Ministerial Departments of the Federal Civil Service, with population of

38

155,250. Proportionate allocation was used to select subjects from each establishment

(see Appendix III). Finally, convenient sampling technique was used to select subjects

from each establishment until their size was reached.

Instrument for Data Collection

The instrument for data collection was a researcher-designed 30 item questionnaire to

measure the Knowledge and Perception of the Federal Civil Servants in AMAC,

otherwise known as KAP questionnaire (See Appendix 1).

The KAP questionnaire consisted of two sections: A and B. Section A dealt with the

demographic profile such as age, sex, level of education and grade level while

Section B consisted of 26 questions constructed based on literature review and

objectives of the study. The structured questionnaire has a modified 4 point Likert

scale ranging from Strongly agreed (1), Agree (2), Disagree (3) and Strongly

Disagree (4).

Validity of the Instrument

The face and content validity of the instrument were established by submitting a draft

copy to a statistician, researcher’s supervisor, two lecturers from the department and

two staff of the NHIS. The purpose of the study, research objectives and research

questions were also given to them as guide to decision on appropriateness of items for

the purpose of the study. Due modification were done before approval by the

researcher’s supervisor.

Reliability of the Instrument

A pilot study was conducted by administering 30 copies of the questionnaire to 30

federal civil servants from Kuje Area Council not covered by the study. The results

were subjected to split-half reliability test. The copies were divided into two equal

halves and the two sets of scores obtained were used to compute a correlation co-

efficient using Pearson Product Moment Correlation Co-efficient statistics. A

correlation (r) of 0.75 was obtained and this was regarded as satisfactory.

39

Ethical Consideration

Ethical approval was obtained from the Research and Ethical Committee of Federal

Capital Territory, Health Services Ethical Committee, Abuja. Informed consent was

obtained from each study participant who met the inclusion criteria (See Appendix II).

Confidentiality and anonymity were assured to the respondents. This enabled them to

give necessary assistance on the collection of data.

Procedure for data collection

With the ethical approval and the introductory letter from the Department of Nursing

Sciences, administration permit was sought from the head of the selected

establishments, to administer the questionnaires to the civil servants. Four research

assistants ( Youth Corp Members) were recruited from the federal secretariat FCT,

and trained by the researcher on the purpose of the study and how to collect data from

the respondents. The researcher and her assistants administered the questionnaire to

workers in the various offices and collected the completed copies from the

respondents on the spot. Data collection lasted for a period of four weeks.

Method of Data Analysis

Data collected were analysed using descriptive statistics such as frequency,

percentages, means, standard deviation and presented in Tables and Charts. The

decision rule was determined using the Likert 4-point scale. A cut off point of 2.5

was derived. The responses were compared with this mean value of 2.5 to ascertain to

which extent the overall responses differed from the mean. The item with a mean

value equal to and greater than 2.5 has a positive impact on the respondent’s

perception of NHIS while a mean value less than 2.5 has negative perception on

NHIS. Analysis was done using the statistical package of social science (SPSS)

Version 18.0.

.

40

CHAPTER FOUR

PRESENTATION OF RESULTS

This chapter dealt with presentation of data collected. Three hundred and

eighty three (383) copies of questionnaire were distributed to federal civil servants

while three hundred and eighty two (382) were duly completed and returned, one was

mutilated giving a return rate of 99.7%. The responses are presented in frequency

tables and percentages according to research questions.

Table 1: Socio demographic characteristics of respondents

n = 382

Demography Frequency

n = 382

Percent

(%) 100

Age group

< 26 12 3.1

26 – 30 88 23.0

31 – 35 92 24.1

36 – 40 83 21.7

41 – 45 71 18.6

> 45 36 9.4

Mean (± SD) 36.7 (± 8.6)

Sex

Male 182 47.6

Female 200 52.4

Educational Level

Primary Education 4 1.0

Secondary Education 29 7.6

Tertiary Education 349 91.4

Grade level

1-6 56 14.7

7-13 298 78.0

14 and above 28 7.3

Table 1 shows that 12 (3.1%) of the respondents were less than 26 years of age, 88

(23%) were within 26 and 30 years, 92 (24.1%) were within 31 and 35 years, 83

(21.7%) were within 36 and 40 years, 71 (18.6%) were within 41 and 45 years while

41

36 (9.4%) were greater than 45 years of age. Average age of the respondents was 37.

With regards to gender 182 (47.6%) of the respondents were males, while 200

(52.4%) were females. On educational level, 4 (1.0%) of the respondents have

primary education, 29 (7.6%) secondary education while 349 (91.4%) attained tertiary

education level. Fifty-six (56) (14.7%) were in grade levels 1 to 6, 298 (78.0%) in

grade levels 7 to 13 while 28 (7.3%) in grade level 14 and above.

Research question 1:

What level of knowledge do the Federal Civil Servants in AMAC have on

NHIS?

In order to answer the above research question, two questions were analyzed.

1a: What are the Federal Civil Servants’ understanding on NHIS?

In order to answer the above research questions items 5,6,7 and 8 were used.

Table 2a: Understanding of NHIS by Respondents

S/N Items Frequency Percent

1 What is the meaning of health insurance?

System of health care delivery 199 52.1

System of health care financing 146 38.2

Alternative to primary health care 30 7.9

Pooling of government resources for free treatment 67 17.5

2 What is National Health Insurance Scheme?

Federal government establishment 364 95.3

State government property 8 2.1

Local government property 0 0.0

Private company 0 0.0

Non-governmental organization project 10 2.6

3 How many children are considered primary dependants in the NHIS?

4 children 362 94.8

6 children 18 4.7

8 children 2 0.5

10 children 0 0.0

12 children 0 0.0

4 What benefits to enrollees derive from NHIS?

Easy access to good and efficient health care services 189 49.5

Free education at all levels 4 1.0

Protection from financial hardship of huge medical bills 121 31.7

Affordable healthcare services for all income groups 148 38.7

42

Table 2a shows that 199 (52.1%) of the respondents defined health Insurance as a

system of healthcare delivery, 146 (38.2%) defined it as a system of health care

financing, 30 (7.9%) said it meant alternative to primary health care while 67 (17.5%)

defined it as pooling of government resources for free treatment. Most of the

respondents (95.3%) agree that National Health Insurance Scheme (NHIS) is a

Federal Government establishment. Just 8 (2.1%) and 10 (2.6%) of them respectively

thought that NHIS is a State Government property and a Non-governmental

organization project. Majority of the civil servants (94.8%) were of the opinion that 4

children are considered primary dependents in the NHIS. However, only 18 (4.7%)

said 6 children while 2 (0.5%) went for 8 children. The Table also reveals that 189

(49.5%) reported that Easy access to good and efficient health care services is a

benefit of NHIS to enrollee while 4 (1.0%) said it is Free education at all levels.

Whereas 121 (31.7%) were of the opinion that one of the benefits of NHIS is

Protection from financial hardship of huge medical bills, 148 (38.7%) said it is

Affordable healthcare services for all income groups.

Research question 1b: What do the Federal Civil Servants in AMAC

identify as the role of NHIS?

In order to answer the above question, respondents responses to items 9, 10,

11 were used.

43

Table 2b: Respondents’ responses on the role of NHIS

S/N Items Frequency Percent

1 The role of NHIS includes the following

Maintenance of operation of Health Insurance Funds 219 57.3

Inspection and accreditation of Healthcare Facilities 71 18.6

Inspection and accreditation of Health Maintenance

Organizations (HMOs)

179 46.9

Paying the 5% of enrollees basic salary for workers 65 17.0

Organizing workshops and seminars for stakeholders 64 16.8

2 The role of healthcare providers in NHIS is/are?

Register their facilities according to NHIS guidelines 208 54.5

Register civil servants under NHIS 209 54.7

Determine the choice of healthcare provider for enrollees 52 13.6

Determine how much money to charge enrollees 28 7.3

Not to refer enrollee to higher level of care 21 5.5

3 Responsibilities of healthcare providers in NHIS is/are?

Paying for the cares received by enrollees 90 23.6

Financing the day to day administration of the scheme 16 4.2

Providing prescribed health benefits to contributors and

their dependants

272 71.2

Table 2b shows that 219 (57.3%) respondents indicated maintenance of operation of

health Insurance Funds as the role of NHIS, 71 (18.6%) went for inspection and

accreditation of healthcare facilities, 179 (46.9%) went for inspection and

accreditation of health maintenance organizations (HMOs), 65 (17.0%) said paying

the 5% of enrollees basic salary for workers is the role while 64 (16.8%) referred to

the role as organizing workshops and seminars for stakeholders. Whereas 208

(54.5%) respondents refer to the role of healthcare providers in NHIS as to register

their facilities according to NHIS guidelines, 209 (54.7%), 52 (13.6%), 28 (7.3%) and

21 (5.5%) respectively refer to their roles as to register civil servants under NHIS,

determine the choice of healthcare provider for enrollees, determine how much money

to charge enrollees and not to refer enrollee to higher level of care. The table shows

that 90 (23.6%) respondents were of the opinion that paying for the cares received by

enrollees is the responsibility of healthcare providers in NHIS. Financing the day to

44

day administration of the scheme was referred to as their responsibility by 16 (4.2%)

respondents while 272 (71.2%) were of the opinion that providing prescribed health

benefits to contributors and their dependants is their responsibilities.

Fig 1: Knowledge of NHIS programme

Figure 1 shows that 61 (18.1%) of the respondents have poor knowledge of NHIS

programme, 215 (56.3%) have fair knowledge while 98 (25.7%) have good

knowledge.

Research question 2: What is the Federal Civil Servants’ perception on NHIS

programme?

In order to answer the above research question, responses to items 12, 13, 14, 15, 16,

17, 18, 19, 20, 21, 22 were analysed.

45

Table 3: Perception of respondents on NHIS programme

n = 382

S/N

Items

Strongly Agree (%)

Agree (%) Disagree (%)

Strongly Disagree n (%)

Mean ± SD

1 The objective of every Nigerian having access to good healthcare services is nice

267 (69.9) 109 (28.5) 4 (1.0) 2 (0.5) 3.68 ± 0.52

2 Health Insurance is not worth the money it costs

51 (13.4) 119 (31.2) 141 (36.9) 71 (18.6) 2.61 ± 0.94

3 Equitable access to healthcare as a goal of NHIS is achievable

110 (28.8) 194 (50.8) 54 (14.1) 24 (6.3) 3.02 ± 0.83

4 Easy access to efficient healthcare service at all times is achievable

99 (25.9) 178 (46.6) 83 (21.7) 22 (5.8) 2.93 ± 0.84

5 Protection from financial hardship of huge medical bills is not achievable

65 (17.0) 104 (27.2) 165 (43.2) 48 (12.6) 2.51 ± 0.92

6 The arrangement of making monthly deduction from salary is not fair

67 (17.5) 82 (21.5) 168 (44.0) 65 (17.0) 2.60 ± 0.97

7 To maintain high standard of healthcare delivery services with the scheme is a good idea

203 (53.1) 133 (34.8) 10 (2.6) 36 (9.4) 3.32 ± 0.91

8 Minimizing quackery as a benefit of NHIS is a lofty idea

111 (29.1) 119 (31.2) 76 (19.9) 76 (19.9) 2.69 ± 1.09

9 Employment opportunities for health professionals as a benefit of NHIS is encouraging

124 (32.5) 209 (54.7) 40 (10.5) 9 (2.4) 3.17 ± 0.70

10 Co-payment for the cost of prescribed drugs as a benefit of NHIS is not ideal

60 (15.7) 95 (24.9) 166 (43.5) 61 (16.0) 2.60 ± 0.94

11 The idea of NHIS programme not covering cancer/HIV/AIDS treatment is not good

194 (50.8) 102 (26.7) 49 (12.8) 37 (9.7) 1.81 ± 0.99

Overall Mean 2.81 ± 0.91

Table 3 shows that majority of the respondents were of the opinion that the objective

of every Nigerian having access to good healthcare services is good. This is indicated

by a high mean of 3.68 (0.52). More respondents disagreed that Health Insurance is

not worth the money it costs this was indicated by mean response of 2.61 (0.94). The

table also reveals that majority of the respondents were of the opinion that equitable

access to healthcare as a goal of NHIS is achievable with a mean of 3.02 (0.83).

Similarly, a good number of them agree that easy access to efficient healthcare service

at all times is achievable with a mean of 2.93 (0.84). More respondents disagree that

46

protection from financial hardship of huge medical bills is not achievable 2.51 (0.92).

Similarly, they also disagree that the arrangement of making monthly deduction from

salary is not fair (2.60). Majority of the respondents in their opinion said that to

maintain high standard of healthcare delivery services with the scheme is a good idea

(3.32). Minimizing quackery as a benefit of NHIS was seen as a lofty idea by majority

of the respondents (2.69). Most respondents agree that employment opportunities for

health professionals as a benefit of NHIS is encouraging (3.17) while a good number

of the respondents disagree that co-payment for the cost of prescribed drugs as a

benefit of NHIS is not ideal. However, majority of the respondents agree that the idea

of NHIS programme not covering cancer/HIV/AIDS treatment is not good (1.81).

With an overall mean of 2.81 (0.91) respondents perception on NHIS programme is

positive.

Research question 3: What is the perception of Civil Servants’ on quality

of care provided under the NHIS programme.

In order to answer the above research question, respondents’ responses to item 23, 24,

25, 26, 27, 28, 29, 30 were analysed.

Fig 2: Proportion that have accessed care under the NHIS programme

Figure 2 shows that 231 (60%) respondents have accessed care under the NHIS

programme while 151 (40%) respondents have not.

Key

Respondents that have not accessed care under NHIS

Respondents that have accessed care under NHIS

47

Table 4a: Users assessment on quality of care provided under the NHIS

programme.

n = 231

S/N Items Frequency Percent

1 Time spent in the records and data section

Less than 30mins 95 41.1

30mins to 1hr 75 32.5

1hr to 2hrs 25 10.8

2hrs and above 30 13.0

Do not know 6 2.6

2 Time spent waiting to see a doctor

Less than 30mins 39 16.9

30mins to 1hr 84 36.4

1hr to 2hrs 49 21.2

2hrs and above 29 12.6

Do not know 30 13.0

3 The quality of drug given to you in terms of

cost

Very cheap 63 27.3

Less expensive but not too cheap 120 51.9

Expensive drugs 16 6.9

Very expensive drugs 20 8.7

Do not know 12 5.2

Table 4a shows that 95 (41.1%) spent less than 30 minutes in the records and data

section, 75 (32.5%) spent 30 minutes to 1 hour there, 25 (10.8%) spent 1 to 2 hours,

while 30 (2.6%) spent 2 hours and above at the section. The table also shows that 30

(16.9%) respondents spent less than 30 minutes waiting to see a doctor, 84 (36.4%) of

them spent 30 minutes to 1 hour, 49 (21.2%) spent 1 to 2 hours, while 29 (12.6%)

spent 2 hours and above. As regards the quality of drug given with respect to cost, 63

(27.3%) respondents reported very cheap, 120 (51.9%) said less expensive but not too

cheap, 16 (6.9%) said they are expensive while 20 (8.7%) said very expensive.

48

Table 4b: Rating on quality of care by users

n = 231

S/N

Items

Excellent n (%)

Very good n (%)

Good n (%)

Fair n (%)

Poor n (%)

Do not know n (%)

1 How would you

describe the hospital

staff in relation to the

care given

18 (7.8) 36 (15.6) 95 (41.1) 48 (20.8) 20 (8.7) 14 (6.1)

2 The current payment

structure (co-payment)

in the NHIS programme

for enrollee

15 (6.5) 31 (13.4) 83 (35.9) 54 (23.4) 24 (10.4) 24 (10.4)

3 The referral chain of

NHIS programmes

15 (6.5) 44 (19.0) 62 (26.8) 38 (16.5) 35 (15.2) 37 (16.0)

4 Overall quality of care

you received

20 (8.7) 38 (16.5) 87 (37.7) 44 (19.0) 26 (11.3) 16 (6.9)

Table 4b shows that 18 (7.8%), respondents described their relationship with hospital

staff as excellent, 36 (15.6%) rated it as very good and 95 (41.1%) respondents

described it as good. While 48 (20.8%) described the relationship as fair, 20 (8.7%)

respondents described it as poor. On current payment structure, 15(6.5%) rated it as

excellent, 31 (13.4%) as very good and 83 (35.9%) described it as good. While 54

(23.4%) rated it as fair, 24 (10.4%) saw it as poor. The referral chain of NHIS

programmes was seen as excellent by 15 (6.5%) respondents, very good by 44

(19.0%), good by 62 (26.8%), fair by 38 (16.5%) and poor by 35 (15.2%)

respondents. The overall quality of care received was rated to as excellent by 20

(8.7%) respondents, very good by 38 (16.5%), good by 87 (37.7%), fair by 44

(19.0%) and poor by 26 (11.3%) respondents.

49

Hypotheses Testing

Ho1: There is no significant difference in the perception of users and non-users of the

NHIS programme

Table 5: Difference in the perception of users and non-users of the NHIS

programme.

Variables N Mean Std. Deviation t P value

Perception Users 231 2.84 0.39 5.902 0.038

Non- users 151 2.67 0.31

Decision rule:

Since the significant value (p = 0.038) of the t – statistic is less than 0.05 level of

significance, the null hypothesis is hereby rejected. Therefore, there is a significant

difference in the perception of users and non-users of the NHIS programme. The

respondents who utilized had better perception of the scheme (2.84)

Ho2: There is no significant association between Federal Civil Servants’ level of

education and their knowledge of NHIS programme.

Table 7: Association between Federal Civil Servants’ level of education and

their knowledge of NHIS programme.

Knowledge

Level of education Poor

n (%)

Fair

n (%)

Good

Primary 0 (0.0) 4 (1.9) 0 (0.0)

Secondary 10 (14.5) 15 (7.0) 4 (4.1)

Tertiary 59 (85.5) 196 (91.2) 94 (95.9)

Total 69 (100.0) 215 (100.0) 98 (100.0)

X2 = 9.616, p = 0.047

Decision rule:

Since the significant value (p = 0.047) of the chi square statistic is less than 0.05 level

of significance, the null hypothesis is hereby rejected and the alternative accepted.

Therefore, there is a significant association between Federal Civil Servants’ level of

50

education and their knowledge of NHIS programme. Their knowledge increased with

higher level of education. Hence 86% respondents with poor knowledge, 91% with

fair knowledge and 96% with good knowledge attained tertiary level of education.

Ho3: There is no significant association between Federal Civil Servants’ grade level

and their knowledge of NHIS programme.

Table 8: Association between Federal Civil Servants’ grade level and their

knowledge of NHIS programme.

Knowledge

Grade level Poor

n (%)

Fair

n (%)

Good

1 – 6 13 (18.8) 33 (15.3) 10 (10.2)

7 – 13 51 (73.9) 167 (77.7) 80 (81.6)

14 & above 5 (7.2) 15 (7.0) 8 (8.2)

Total 69 (100.0) 215 (100.0) 98 (100.0)

X2 = 2.666, p = 0.615

Decision rule:

Since the significant value (p = 0.615) of the chi square statistic is greater than 0.05

level of significance, the null hypothesis is hereby accepted. Therefore, there is no

significant association between Federal Civil Servants’ grade level and their

knowledge of NHIS programme.

Ho4: There is no significant association between Federal Civil Servants’ level of

education and their perception of NHIS programme.

51

Table 9: Association between Federal Civil Servants’ level of education and

their perception of NHIS programme.

Perception

Level of Education Positive

n (%)

Negative

n (%)

Primary 2 (50) 2 (50)

Secondary 28 (96.6) 1 (3.4)

Tertiary 291 (83.4) 58 (16.6)

Total 321 (84.0) 61 (16.0)

X2 = 6.950, p = 0.031

Decision rule:

Since the significant value (p = 0.031) of the chi square statistic is less than 0.05 level

of significance, the null hypothesis is hereby rejected and the alternative accepted.

Therefore, there is a significant association between Federal civil servants’ level of

education and their perception of NHIS programme. Their perception increased with

higher level of education. Hence 83.4% respondents with positive perception and

16.6% with negative perception attained tertiary level of education.

Ho5: There is no significant association between Federal Civil Servants’ gender and

their perception of NHIS programme.

Table 10: Association between Federal Civil Servants’ gender and their

perception of NHIS programme.

Perception

Sex Positive

n (%)

Negative

n (%)

Male 85 (85.2) 27 (14.8)

Female 166 (83.0) 34 (17.0)

Total 321 (84.0) 61 (16)

X2 = 0.333, p = 0.564

Decision rule:

Since the significant value (p = 0.564) of the chi square statistic is greater than 0.05

level of significance, the null hypothesis is hereby accepted. Therefore, there is no

52

significant association between Federal Civil Servants’ gender and their perception of

NHIS programme.

Summary of major findings

The findings from the study were summarized under the following:

• The ages of civil servants were evenly spread between 22 and 57 years, with

mean age of 37 (8.6) years.

• Above average (56.3%) of the civil servants had fair knowledge of NHIS

programme.

• The civil servants had a positive perception of the NHIS programme with an

overall mean of 2.81 (0.91).

• The proportion of the respondents that accessed care under the scheme was

(60%).

• Quality of care provided was rated as good (37.7%) by the users.

• Level of education was significantly associated with knowledge of NHIS

programme, (p < 0.05).

• There was no association between grade level and knowledge of NHIS

programme, (p > 0.05)

• In addition, there was a statistically significant association between level of

education and perception of the scheme, (p < 0.05).

53

CHAPTER FIVE

DISCUSSION OF FINDINGS, SUMMARY, CONCLUSION AND

RECOMMENDATIONS

This chapter presented the discussion of findings, summary, conclusions,

recommendations, limitation of study and suggestion for further research.

Discussion of findings

Major findings were discussed based on objectives.

Research Question 1: What knowledge do federal civil servants in AMAC have

on NHIS.

Findings showed that above average of respondents (56.3%) had fair knowledge of

NHIS programme. This is in line with findings from a study by Adibe, Udeogaranya

and Ubaka (2011) that employees of University of Nigeria were marginally aware of

NHIS activities. Also, findings from Agada-Amade (2009) revealed that (52%) of the

respondents were aware of the benefits accruable from NHIS. This does not agree

with the study done by Olugbenga – Bello and Adebimpe (2012), which found that

there was poor knowledge of the objectives and mechanism of operation of NHIS.

This may be due to the level of public enlightenment campaign which is not mounted

steadily concerning the scheme, especially the Federal Civil Servants who are the

major stakeholders in the formal sector programme of NHIS. However the finding

varies with the study by Agu (2010), on knowledge, attitude and practice of NHIS by

Civil Servants in FCDA Abuja, which revealed that (75%) of the Civil Servants had

good knowledge of NHIS. The variation may be due to differences in the timing of

the studies. There was a significant relationship between level of education and

knowledge of the scheme. The respondents with higher level of education were more

knowledgeable about the scheme. Hence higher level of education is associated with

knowledge of the NHIS. This is consistent with findings from a similar study done by

54

Fletcher and Frisvolt (2012), who suggests that greater education may influence

preventive care, and increases in education have the potential to spill over on long-

term health choices.. However no significant association was found between grade

level of the workers and their knowledge of the scheme. Thus knowledge of NHIS is

not dependent on grade level. In this study, the civil servants had low level of

knowledge despite their grade level.

Research Question 2: What is the perception of Civil Servants in AMAC on

NHIS.

Respondents had positive perception of the NHIS programme. Level of education also

had significant relationship with their perception. This finding is in contrast with the

study of Sanusi and Awe (2009), which reported that health care consumers in Oyo

state had negative perception of the scheme and therefore suggested that the

programme should be discontinued. This difference could be due to timing and

geographical location of the study. Furthermore, level of education was significant

with respondents perception. Respondents with higher level of education had good

perception of the programme. This in support with the study of Fletcher and Frisvold

(2012) that higher level of education influences preventive care and health choices.

When people have good knowledge of a progamme or understanding of its operations,

it will influence their perception positively. However there was no association

between gender and their perception. This agrees with the finding of Sanusi and Awe

(2009), that gender did not influence the perception of healthcare consumers in their

study. On the other hand the finding is in contrast with the study of Evans and Shisana

(2012) where females had positive perception than males. Gender differences may not

be surprising, considering the fact that the females are more sensitive, and pay more

attention to health matters (Evans and Shisana, 2012). This may be attributed to the

effect of campaigns for women education, enlightenment and participation, which are

paying off handsomely.

55

Research Question 3: What is the perception of federal civil servants’ on quality

of care under NHIS programme.

The perception of users on the quality of care was rated as good. This finding is in

agreement with Owu, Ifatimehin & Shaka (2014) who found that civil servants in

Kaduna reported that the quality of care from the scheme was good and that access to

health care facilities was satisfactory. He also found that the health care facilities were

accessible. Similarly the findings of the study was also in consistent with the study

done by Aggreh & Apiah at Kumasi metropolis on influence of clients perceived

quality of healthcare utilization. Majority (92%) of the enrollees accessed NHIS with

their cards due to high quality of healthcare. This shows that the workers have

positive perception towards utilization of the NHIS programme.

Research Question 4: What is the differences in the opinion of users and the

non-users of NHIS programme.

From the study, a significant difference was found between the perception of civil

servants who utilized the programme and those who did not. Workers who

participated had a better perception of the scheme than those who are yet to utilize

the scheme. Evans & Shisana found that female gender role as care givers encourage

them to perceive NHIS as a benefit, also their sexual and reproductive health needs as

well as their poor health status could encourage them to seek healthcare more

frequently than men. This implies that their utilization of the scheme is dependent on

their perception. Better perception translates into better utilization. Aggrey and

Appiah (2014), also reported that positive perception of the scheme is associated with

the utilization.

Summary of the study

The main purpose of the study was to determine Federal Civil Servants’ knowledge

and perception of NHIS. The specific objectives were: to determine the knowledge of

NHIS by the Federal Civil Servants in AMAC; to determine the perception of Federal

Civil Servants in AMAC on NHIS programme; to ascertain the perception of Federal

Civil Servants on assessment of care under the NHIS programme; to determine the

differences in the opinion of users and non-users of the NHIS programme. The study

answered four research questions and tested 5 hypotheses. A descriptive survey

design was adopted for the study. The area of study was Abuja Municipal Area

56

Council (AMAC). The population of the study consists of all the Federal Civil

Servants from 30 establishments in Abuja Municipal Area Council. A sample size of

383 was statistically determined from population of 155,250 using Krejcie and

Morgan formula. The stratified random sampling technique was used to select the

samples for the study. The pretested instrument (questionnaire) was administered and

collected for data analysis using SPSS version 18.

Findings from the study have shown that the civil servants have fair knowledge of

NHIS and their perception towards the scheme is positive. A greater proportion of the

civil servants have utilized the scheme and they all expressed satisfaction in terms of

time spent waiting to see a doctor and cost of quality drugs. They were also satisfied

with the payment structure for enrollee and the referral chain of the programme.

A significant difference was found between the perception of civil servants who

utilized the programme and those who did not. Similarly, civil servants with higher

level of education have better knowledge of the scheme. However, significant

association was found between grade level of the workers and their knowledge of the

scheme. Civil servants with higher level of education were significantly associated

with good perception of NHIS. Conversely, no association was found between

Federal civil servants’ gender and their perception of NHIS.

Implication of the Study to Nursing Practice

The result of the study found that the civil servants have fair knowledge and their

perception towards the scheme was positive. Therefore to improve the knowledge of

civil servants in NHIS, there should be adequate enlightenment, sensitization of

enrollees by nurses etc. because they always come in contact with the enrollees on

day to day basis. This will help to avoid `confusion and equally improve the

operation of NHIS programmes at the service points.

Conclusion

From the foregoing this study has been able to examine the knowledge and perception

of Federal Civil Servants in AMAC towards NHIS.

57

1. The study has identified the knowledge of the federal civil servants on NHIS.

The civil servants had fair knowledge of NHIS and civil servants who are

graduates had good knowledge of the scheme.

2. The workers have positive perception towards NHIS which further explains

why many of them have participated in the scheme. Their gender do not affect

their perceptions.

3. Quality service delivery was attributed to the scheme by participants. A high

level of satisfaction was expressed by many of them after utilization of the

scheme. Workers who participated had a better perception of the scheme than

those who are yet to utilize the scheme.

Recommendations

The following recommendations were made based on the study:

• Government and other stakeholders in the scheme need to continue to organize

awareness programmes that will enhance the interest among workers in the

formal sector.

• Intensified campaign should emphasize on the objective, and benefits of the

scheme, using the mass media as a way of reaching a vast majority of the

workforce.

Limitations of the study

• The study was conducted in Abuja using Federal Civil Servants alone, which

may limit generalizing the results. In addition, the study was carried out in the

Federal Capital Territory Abuja; hence there is a tendency that civil servants in

other states in the country may not have access to all the packages in the

scheme or behave differently towards the scheme.

• Another potential limitation of the investigation is the use of questionnaires to

measure knowledge and perception which may lead to information bias.

58

Suggestion for Further research

• There is the need for further research to cover civil servants from other states

to assess their knowledge and perception of NHIS.

• Awareness and level of utilization can also be studied to measure coverage

and efficacy of the program

• There is need to carry out similar studies to ascertain more comprehensive

factors (e.g. socio-economic, residence, marital and cultural).

59

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APPENDIX I

Sample of the Questionnaire for Data Collection

Department of Nursing Sciences Faculty of Health Science & Technology College of Medicine University of Nigeria Enugu Campus.

Dear Respondent, I am an M.Sc student of the above Department conducting a research study on, “Knowledge and Perception of Federal Civil Servants in Abuja (AMAC) on NHIS, for my dissertation”. Kindly answer the questions in this questionnaire. Your answer on each question will be highly appreciated and confidentiality is assured as your name is not required.

Thanks for your co-operation. Amahalu, Euphemia C.

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(QUESTIONNAIRE)

SECTION A

SOCIO - DEMOGRAPHIC DATA

In this section you are expected to place a tick (√ ) in the appropriate box applicable to you.

1. What is your age as at last birthday? …………………. Years

2. Sex

a) Male

b) Female

3. What is your highest level of education?

a. Primary Education

b. Secondary Education

c. Tertiary Education

d. Others please specify _________________________________

4. Grade Level a. 1 – 6

b. 7 – 13

c. 14 and above

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SECTION B

Below are the list of statements about your possible understanding of NHIS, (Items 5 – 8. Please indicate the ones you think is appropriate. You may tick [√] more than one option.

5. Health Insurance means

a. system of health care delivery

b. System of health care financing

c. Alternative to primary health care

d. Pooling of government resources for free treatment

6. National Health Insurance Scheme (NHIS) is:

a. Federal government establishment

b. State government property

c. Local government property

d. Private company

e. Non-governmental organization project

7. How many children are considered primary dependants in the NHIS?

a. 4 children

b. 6 children

c. 8 children

d. 10 children

e. 12 children

8. What benefits do enrollees derive from NHIS?

a. Easy access to good and efficient healthcare services

b. Free education at all levels

c. Protection from financial hardship of huge medical bills

d. Affordable healthcare services for all income groups

Which of the following options will best be appropriate for the items below (tick [√] as applicable). You may tick [√] more than one option

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9. The role of NHIS includes the following?

a. Maintenance of operation of Health Insurance Funds

b. Inspection and accreditation of healthcare facilities

c. Inspection and accreditation of Health Maintenance

Organizations (HMOs)

d. Paying the 5% of enrollees basic salary for workers

e. Organizing workshops and seminars for stakeholders

10. The role of healthcare providers in NHIS is/are

a. Register their facilities according to NHIS guidelines

b. Register civil servants under NHIS

c. Determine the choice of healthcare provider for enrollees

d. Determine how much money to charge enrollees

e. Not to refer enrollee to higher level of care

11. Responsibilities of health care providers in NHIS is/are

a. Paying for the cares received by enrollees

b. Financing the day to day administration of the scheme

c. Providing prescribe health benefits to contributors and their dependants

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In your own opinion to what extent do you agree with the following statement Tick [√] as appropriate for Strongly Agree (SA), Agreed (A), Disagree (D) or Strongly Disagree (SD)

SA A D SD

12 The objective of every Nigerian having access to good health care services is nice

13 Health Insurance is not worth the money it costs

14 Equitable access to health care as a goal of NHIS is achievable

15 Easy access to efficient health care service at all times is achievable

16 Protection from financial hardship of huge medical bills is not achievable.

17 The arrangement of making monthly deduction from salary is not fair

18 To maintain high standard of health care delivery services with the scheme is a good idea

19 Minimizing quackery as a benefit of NHIS is a lofty idea

20 Employment opportunities for health professionals as a benefit of NHIS is encouraging

21 Co-payment for the cost of prescribed drugs as a benefit of NHIS is not ideal

22 The idea of NHIS programme not covering cancer/HIV AIDs treatment is not good

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23. Have you ever visited a hospital to access care under the NHIS programme

a) Yes

b) No

Less than 30mins

30mins to 1hr

1hr to 2hrs

2hrs and above

Do not Know

24 Time spent in the

records and data

section

25 Time spent waiting to see a Doctor.

Very Cheap Less Expensive but not too cheap

Expensive Drugs

Very Expensive Drugs

Do not No

26 The quality of drug given to you in terms of its cost?

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Excellent Very Good

Good Fair Poor Do not know

27 How would you describe the hospital staff in relation to the care given

28 The current payment structure (co-payment) in the NHIS programme for enrollees.

29 The referral chain of NHIS programmes

30 Overall quality of care you received

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APPENDIX II

INFORMED CONSENT FORM

I am a post graduate student of Department of Nursing Sciences, Faculty of Health Science and Technology, College of Medicine University of Nigeria Enugu campus.

Voluntary Nature of participation: - Respondent’s participation in this study is purely voluntary. You have the right to withdraw your consent and discontinue participation in the study at any given time.

Study procedure: I am studying the knowledge and perception of Federal Civil Servants in Abuja Municipal Area Council (AMAC) FCT on National Health Insurance Scheme. In this study, you will be required to fill the questionnaire. Please feel free to ask for clarification on any question you do not understand.

Risk: The process of filling the questionnaire will not cause you any harm.

Confidentiality: Please note that any information you give will be kept confidential. Your name will never be used in connection with any information you give.

Feedback: In case of any clarification you can contact me via this phone number 08033316858.

Response: The study has been explained to me and I finally understood the details of the study process.

________________ _______________ ____________

Signature of Participant Signature of Witness Signature of Researcher

________________ _______________ ____________

Date Date Date

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APPENDIX III

Establishment Number of

Establishments Population

Size Proportion to be

Studied

Core Ministries 15 77,625 191.5

Parastatals 9 4,6575 114.9

Extra Ministerial Departments

6 31,050 76.6

Total 155,250 383

To statistically determine the number to be selected from each establishment

Establishment proportion Establishment Size Sample Size

To be studied = Total Population X 1

Core Ministries = 77,625 383

155,250 x 1 = 191.5

Parastatal = 46,575 383

155,250 x 1 = 114.9

External Ministerial = 31,050 383

155,250 x 1 = 76.6

Total = 383.0

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APPENDIX IV Sample Size A sample size of 383 was determined using Krejcie and Morgan formula as follows:

Krejcie and Morgan Estimation of Sample Size in research writing Krejcie and Morgan used the following formula to determine sample.

S = X2 NP (1 – P)/d2 (N – 1) + X2 P(1 – P) (KENPRO, 2012)

S = required sample size

X2 = The table value of chi-square for one degree of freedom at the desired

confidence level (3.841)

N = The population size (155,250)

P = The population proportion (assumed to be 0.5 since this would provide

the maximum sample size)

d = the degree of accuracy expressed as a proportion (0.05)

3.841 x 155,250 x 05 (1 – 0.5)/0.05)2 (155,250 – 1) + 3.841 x 0.5 (1 – 0.5) = 383

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APPENDIX V

Scale: All Variables Case Processing Summary

N %

Valid 30 100.0

Cases Excluded a 0 .0

Total 30 100.0

a. Listwise deletion based on all variables in the procedure.

Reliability Statistics

Part 1 Value .802

N of Items 21a

Cronbach’s Alpha

Part 2 Value .783

N of Items 21b

Total N of Items .765

Correlation Between Forms

a. The items are: B5b, B6, B7, B8a, B9a, B9b, B9c, B9e, B10a, B11c, B5c, B5d, B8b, B9d, b10b, B10c, B10d, B10e.

b. The items are: B11a, B11b, B12, B13, B14, B15, B16, B17, B18, B19, B20, B21, B22, B23, B24, B25, B26, B27, B28, B29, B30.

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Department of Nursing Sciences Faculty of Health Science & Technology College of Medicine University of Nigeria Enugu Campus.

2nd December, 2013 The Chairman Abuja Municipal Area Council Health Services Ethical Board Committee Abuja Dear Sir, APPLICATION FOR ETHICAL APPROVAL I am a Postgraduate student of the above Department with Reg. No. PG/M.Sc/06/45738. The topic of my work is Knowledge and perception of National Health Insurance Scheme by Federal Civil Servants. I hereby apply for an ethical approval to enable me go to the field to collect data for my project. The proposal for the study is hereby attached for your consideration. Thanks for your co-operation Yours faithfully, Amahalu Euphemia C.

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78

Department of Nursing Sciences Faculty of Health Science & Technology College of Medicine University of Nigeria Enugu Campus.

2nd December, 2013 The Chairman Abuja Municipal Area Council FCT, Abuja Dear Sir, APPLICATION FOR PERMISSION. I am a Postgraduate student of the above Department with Reg. No. PG/M.Sc/06/45738. My Research Topic is Knowledge and perception of National Health Insurance Scheme by Federal Civil Servants. I hereby apply for permission to enable me to collect data for my project in your Municipal Area Council. Thanks for your co-operation Amahalu Euphemia C.