International Journal of Advanced Scientic Research |IJASR

International Journal of Scientic Research in Social Sciences & Management Studies | IJSRSSMS
ISSN Print: 2579–101X | ISSN Online: 2579–1928
Volume 3, Number 3, December, 2018

Enrollees Assessment of Health Maintenance Organizations

(HMOs) in the Implementation of National Health
Insurance Scheme (NHIS) in Abuja, Nigeria

Dahida, D. Philip, 2Obioma, Ike Christopher & 3Nweke, Obinna Innocent

1

Department of Public Administration, University of Abuja

1&3

Kessington Business School

2

Abstract

T he abysmal performance of the healthcare sector in Nigeria led to the

introduction of the National Health Insurance Scheme (NHIS) in 2005
with the hope of increasing the performance of the healthcare
delivery system in the Country. The pro-poor Scheme aimed at increasing
coverage as well as affordability of healthcare services in Nigeria. As an
Insurance Scheme, designed with Health Maintenance Organizations as
intermediary, enrollees have disparate levels of satisfaction with the role of
the HMOs. This study examines the perception of enrollees on the role of
HMOs in the implementation of NHIS scheme in three tertiary medical
institutions- University of Abuja Teaching Hospital (UATH); National
Hospital (NH), Abuja; and Federal Medical Centre (FMC) Abuja. Anchored
on Systems Theory, this survey study used self-administered structured
questionnaire to elicit information from enrollees of the Scheme in the
Tertiary Health Institutions in Abuja. The study found that the enrollees
were not satised with the role of the HMOs in the implementation of the
Scheme due to the problems of indelity in the remittance of premium by
employers; difculty in generating authentication codes; no-show
weekends; lack of skilled personnel; nonchalant attitudes of hospital staff;
and ineffective means of communication. The study hence, recommends
employers should remit to HMOs their employees premium; HMOs should
decentralize their structure to have representatives in tertiary health
institutions and that the staff of the affected hospital. The NHIS has a duty to
prevail on the HMOs to act according to the objectives of the Scheme which
is to create healthcare satisfaction among Nigerians.

Keywords: NHIS, HMOs, Enrollees, Satisfaction, Healthcare

Corresponding Author: Dahida, D. Philip

http://internationalpolicybrief.org/journals/international-directorate-for-policy-research-idpr-india/intl-jrnl-of-sci-research-in-social-sciences-mgt-studies-vol3-no2-december-2018

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Background to the Study
Prepayment method for health care nancing has been adopted as the most certain
strategy to ensure universal coverage for health (Chuma, Mulupi & Mclntyre, 2013). Most
countries in the developed world have a prepayment scheme for health (Evans, 2002;
Mossialos & Dixon, 2002a) and have been existing for a considerable period of time.
However, majority of the people in the developing countries especially in Africa pay for
health care through the out-of-pocket method. This exacerbates the high burden of
chronic illnesses, disabilities and mortality which cumulates in sub-optimal productivity,
low life expectancy and poor development compared with the developed world (Murray
& Lopez, 2013, Murray et al., 2013). In recent times, many countries in Africa have
embraced prepayment methods to nance health care services (Chuma et al., 2013).

In Nigeria, the National Health Insurance Scheme (NHIS) was established in 2005 with
the aim to; ensure that every Nigerian has access to good health care services; protect
families from the nancial hardship of huge medical bills; limit the rise in the cost of
health care services; ensure equitable distribution of health care costs among different
income groups; maintain high standards of health care delivery services within the
Scheme; ensure efciency in health care services; improve and harness private sector
participation in the provision of health care services; ensure equitable distribution of
health facilities within the Federation; ensure appropriate patronage of all levels of health
care;and ensure the availability of funds to the health sector for improved services (NHIS,
2018). However, efforts of the agency to achieve these aims have been less than
satisfactory owing to a number of factors. The resultant effect is that at present, the scheme
has only coverage of about 4% of the general population (NHIS 2018). This scenario is
attributed, among others, to the fact that enrolment into the health insurance scheme in
Nigeria is presently voluntary unlike in neighbouring Ghana where it is mandatory and
thus with better coverage in the latter (Odeyemi and Nixon, 2013). The major stakeholders
in the health insurance industry in Nigeria are the state actors such as the federal
government through the National Health Insurance Scheme, (NHIS), the States and the
local governments, as well as the non-state actors such as the Health Maintenance
Organizations (HMOs), health services providers (public and private), pharmaceutical
industries, the Nigerian Medical Association (NMA) and the masses who are the
potential beneciaries.

The medium of interface for the masses is the HMOs with whom the beneciaries
maintain their medical records and accounts. To a large extent, whether the scheme is
successful or not depends on the efcacy of the HMOs since they represent the interface
platform of the scheme. Enrollees' perception of these organizations is a signicant
scorecard of the entire scheme. This paper focuses on the perception of the attitude of
HMOs in the implementation of NHIS in Abuja specically by the enrollees in three
tertiary medical institutions- University of Abuja Teaching Hospital (UATH); National
Hospital, Abuja; and Federal Medical Centre (FMC) Abuja. The assessment is bordering
on enrollees perception of the effectiveness of HMOs towards the implementation of
NHIS in these organizations.

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Statement of Problem
The NHIS policy was designed to increase accessibility and affordability of healthcare
services to vast majority of the Nigerian population. It was discovered, prior to the
introduction of the Scheme that Out-of-Pocket (OOP) expenses of the masses were
committed to ensuring healthy living and given the precarious economic conditions of
these people, the OOP method may not be sustainable hence the scheme was a natural
response to the problems of healthcare in Nigeria.

As an insurance scheme, NHIS was designed to be contributory as both the beneciaries

and their employers contribute to the pool of funds held in trust and used to defray
accrued medical expenses of the beneciaries by the HMOs. The operational effectiveness
of these HMOs has been called to question as many of the enrollees experience disparate
service support from their various HMOs. Enrollees have had to cope with late or non-
response of the HMOs in cases of referrals and outright refusal to pay accrued nancial
backlog of medical cost of the enrollees resulting in disenchantment and in some cases
withdrawal from the scheme by these frustrated enrollees. This study, therefore,
evaluates enrollees' opinions on the effectiveness of the HMOs in the operations of NHIS
in Nigeria with a special focus on tertiary health institutions in Abuja-University of Abuja
Teaching Hospital (UATH); National Hospital, Abuja; and Federal Medical Centre (FMC)
Abuja. The study tries to provide answers to the following questions;
a. What are the enrollees' perceptions on the role of different HMOs in the operation
of NHIS?
b. What are the challenges of assessing NHIS as occasioned by the HMOs?

Objectives of the Study

The general objective of this study is to examine the perception of enrollees to NHIS in
various HMOs on the performance of the scheme in University of Abuja Teaching
Hospital (UATH); National Hospital, Abuja; and Federal Medical Centre (FMC) Abuja.
The specic objectives are;
i. To nd out enrollees' perceptions on the role of different HMOs in the operation of
NHIS;
ii. To ascertain the challenges of assessing NHIS as occasioned by the HMOs.

Conceptual Issues
National Health Insurance Scheme
Nigeria has the highest out-of-pocket health spending and poorest health indicators in the
world (Gustafsson-Wright & Schellekens, 2013) and this has been the propelling force for
the Nigerian federal State to initiate the National Health Insurance Scheme. Its policy was
drafted in 1997 and its legal framework signed into law in 1999 and launched for
implementation on 16th June, 2005. It was designed with the aim at universal health
coverage targeted at providing comprehensive health care at affordable costs to
employees of the formal sector, self-employed, ruralites and indigent population of
Nigerians (Onyedibe, Giyit & Nandi, 2012). The health situation in the country shows that
only 39 per cent of the population in 1990 and 44 per cent in 2004 have access to improved

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sanitation. Also, in 1990-92 and 2002-04, 13 per cent and 9 per cent of Nigerians were
undernourished respectively (UNDP, 2008). HIV prevalence in Nigeria in the age bracket
15 to 49 years was 3.9 per cent in 2005 (UNAIS, 2006). In an attempt to address the
precarious and dismal situation in the health sector, and provide universal access to
quality health care service in the country, various health policies by successive
administrations were made including the establishment of primary, secondary and
tertiary health care facilities across the length and breadth of the country. The perennial
health challenges in Nigeria informed the decision by Gen. Abdulsalam Abubakar on
May 10, 1999, to sign into law the National Health Insurance Scheme (NHIS) Decree
Number 35 (NHIS Decree No. 35 of 1999); with the aim of providing universal access to
quality healthcare to all Nigerians. NHIS became operational after it was ofcially
launched by the Federal Government in 2005 (Kannegiesser, 2009).

The provisions of the NHIS toward the health care needs of Nigerians is targeted at the
formal sector of the population with emphasis on federal civil servants engaged in the
Ministries, parastatals, agencies and extra-ministerial corporations. It provides for both
outpatient and inpatient care for the insured, his/her spouse and four siblings under
18years (Akande, Salaudeen & Babatunde, 2011). The general purpose of NHIS is to
ensure the provision of health insurance “which shall entitle insured persons and their
dependents the benet of prescribed quality and cost-effective health services” (NHIS
Decree No. 35 of 1999, part 1:1). The specic objectives of NHIS include:
1. The universal provision of healthcare in Nigeria.
2. To control/reduce arbitrary increase in the cost of health care services in Nigeria.
3. To protect families from high cost of medical bills.
4. To ensure equality in the distribution of healthcare service cost across income
groups.
5. To ensure high standard of healthcare delivery to beneciaries of the scheme
6. To boost private sector participation in healthcare delivery in Nigeria.
7. To ensure adequate and equitable distribution of healthcare facilities within the
country.
8. To ensure that, primary, secondary and tertiary healthcare providers are
equitably patronized in the federation.
9. To maintain and ensure adequate ow of funds for the smooth running of the
scheme and the health sector in general (NHIS Decree No. 35 of 1999, part II: 5;
NHIS, 2009).

The provision of healthcare is a concurrent responsibility of the three tiers of government

in Nigeria. The mixed economy practiced in the country gives room for private sector
participation in medical care provision (Wikipedia, 2009).

NHIS is, therefore, operational through three broad categories of stakeholders-

government, the private sector as well as other agencies appointed by the government
and international donor agencies. A breakdown of these stakeholders includes
government at all levels, employers (both public or private sectors), self-employed, Rural

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Community Health Insurance Program agency, health maintenance organizations, board
of trustees, health providers, commercial banks, NGOs, community leaders and the
media (Executive Secretary NHIS, 2009). Government under the scheme provides not
only standards and guidelines but ensures the enforcement of policies, monitoring of
implementation and evaluation of programs and services for the smooth and effective
running of the scheme. Apart from funding by government and donors or partnering
organizations, employees under the scheme contribute 5 per cent of their basic salaries
and another 10% counterpart contribution by the employer toward the success of NHIS
(Executive Secretary, NHIS, 2009). An overview of the provisions of NHIS shows that
virtually no provision is made for the healthcare needs and social security of the elderly
population in Nigeria.

Inclusions versus Exclusions in NHIS

Since the launch of NHIS in 2005 and its operations, it has been the major initiative to
expand health insurance in Nigeria. Hospitalization, as provided by NHIS, is limited to
15days. The extent of NHIS coverage this far is such that artisans, farmers, sole
proprietors of businesses, street vendors and the unemployed are not captured
(Onyedibe, Goyit & Nnadi, 2012). Again, certain health care services are not covered by
NHIS and where some are covered, it is a partial coverage. For instance, some radiologic
investigations and major surgeries e.g. magnetic resonance imaging (MRI), computerized
tomography (CT) scan, laparoscopic or uoroscopic examinations, mammography,
hormonal assays, prostatectomy and myomectomy are given partial coverage while care
for occupational or industrial injuries, cosmetic surgery, open heart surgery,
neurosurgery, family planning and epidemic outbreaks are excluded from NHIS
coverage. Also, injuries arising from natural disasters (earthquakes, landslides,
tornadoes, hurricanes, etc.), social unrest/upheavals and terrorist attacks are excluded
from its benets package. Similarly, injuries from extreme sports activities such as car
racing, boxing, wrestling, polo and other martial arts are not covered by NHIS. In
addition, therapies accruing from drug abuse, addictions, sexual pervasiveness, organ
transplant, surgical repairs of congenital abnormalities and purchases of spectacles are
excluded. These exclusions of major illnesses and therapies show that the NHIS is shallow
and segregatory in its coverage. It does not give a holistic coverage thereby negating the
philosophy of its establishment. It strongly allows for more out-of-pocket expenditure by
insurers and preventing universal health coverage by citizens of the country.

Workability of NHIS
NHIS can be a major determinant of improved health outcomes for all citizens especially
the poorest poor of the population who cannot afford the basic necessities of life. Since its
launch in 2005, the scheme claims to have issued 5million identity cards, covering about 3
per cent of the population. (Gustafsson-Wright &Schellekens, 2013). Under the National
Health Insurance Act 2008, the NHIS started a rural community-based social health
insurance program (RCSHIP) in 2010. The majority of the enrollees, however, are
individuals working in the formal sector and the community scheme still leaves large
gaps among the poor and informally employed. Several proposals are currently in the

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pipeline to expand the reach of NHIS. One such proposal is to make registration
mandatory for federal government employees. Earlier in 2013, the creation of a “health
fund” targeting an earmarked “health tax” of 2 per cent on the value of luxury goods was
proposed. This fund would be used for the health insurance of specied groups of
Nigerian citizens, including: children under ve, physically challenged or disabled
individuals, senior citizens above 65, prison inmates, pregnant women requiring
maternity care, and indigent persons. (Gustafsson-Wright & Schellekens, 2013; Akande,
Salaudeen & Babatunde, 2011; Onyedibe, Goyit & Nnadi, 2012; Agba, Ushie &
Osuchukwu, 2010). At a broader level, the National Health Bill which was rst proposed
in 2006 to improve Nigeria's poor healthcare administration, by allocating at least 2 per
cent of the federal government's revenue to the health sector is still not signed into law.
However, as of mid-2012, NHIS still covered only about 3 per cent of the population (5
million individuals). Currently, NHIS programs exist that target the formal and self-
employed sectors, with mixed success. The formal-sector program operates as a social
health insurance scheme. Although the NHIS launched a rural community-based social
health insurance program to cover more Nigerians, its uptake has been slow.

Challenges of NHIS in Nigeria

There are a number of challenges facing the actualization of NHIS in Nigeria. Funding
remains a critical issue to the scheme. The percentage of government allocation to the
health sector has always been abysmally low, about 2% to 3.5% of the national budget. For
example, in 1996, only 2.55% of the total national budget was spent on health; 2.99% in
1998; 1.95% in 1999; 2.5% in 2000 and a marginal increase to 3.5% in 2004 (WHO,
2007ab&c). Consequently, per capita public spending for health in the country is less than
US$5; which is far below the US$34 recommended by WHO for low-income nations
(WHO, 2007a & c). While the Nigerian per capita health expenditure dwindles, the South
African per capita health expenditure, for example, is US$22 in 2001 (The Vanguard
Editorial, 2005). NHIS is also impeded by obsolete and inadequate medical equipment
used by health services providers. The country suffers from perennial shortage of modern
medical equipment such as radiologic and radiographic testing equipment and
diagnostic scanners (Johnson & Stoskopt, 2009). And where these equipments are
available, their repairs/servicing are always a problem. According to Oba (2009), this
situation is not unconnected with corruption. Money meant to boost the health sector
ends up in private pockets. An example is the 300 million naira scam involving the
Minister of health and his assistants in 2008.

Again, lack of adequate personnel in the healthcare sector is another impediment to the
scheme. The country, for instance, had 19 physicians per 100,000 people between 1990 and
1999 (The Vanguard Editorial, 2005). In 2003, there were 34,923 physicians in Nigeria,
giving a doctor-patient ratio of 0.28 physician per 1000 patients and 127,580 nurses or 1.03
nurses per 1000 patients as compared to 730,801 physicians or 2.5 per 1000 population in
2000 in the United States of America; and 2,669,603 nurses or 9.37 per 1000 patients. Out-
migration of health personnel to the US, UK, Europe and other western/eastern countries
is signicantly responsible for the personnel situation in the health sector in Nigeria. For

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instance, in 2005 alone, there were 2,393 Nigerian doctors practicing in the US and 1,529 in
the UK. Attributing factors include poor remunerations, limited postgraduate medical
programs and poor conditions of service in Nigeria (WHO, 2007a).

According to the World Bank Development Indicators (2005), the personnel situation in
the healthcare sector inuenced birth attendance in Nigeria. For instance, between 1997
and 2005 only 35% of births were attended to, by skilled health personnel in the country.
Also, cultural and religious practices impact on the effectiveness of NHIS in Nigeria.
Sexual inequality still exists and is encouraged by some religious/cultural sects in the
country. Because of lack of awareness, women are being discriminated against and have
limited access to social services such as education and healthcare (NCBI, 2009). Other
challenges include inequality in the distribution of healthcare facilities between urban
and rural areas and policies inconsistency (Omoruan, & Philips, 2009). Furthermore,
poverty and the inability to pre-pay for healthcare in Nigeria are signicant challenges to
the success of NHIS. According to Schellekens (2009) “people are not willing to pre-pay;
and because people do not pre-pay there is no risk pool. And because there is no risk pool,
there is no supply side.” The NHIS‟s role in Nigeria is somewhat diluted. It manages
subsidy programs for certain population groups (not the elderly population), who pay
100 per cent of their premiums, and negotiates with HMOs for their service provisioning,
while it delivers oversight and regulation functions for the system. Therefore, NHIS
functions may require some streamlining, as recommended in the Ministerial Expert
Committee Report in Nigeria (MEC, 2003).

Some of the recommendations in this regard made by the Ministerial Expert Committee
were adopted for creating appropriate institutions for the different tasks in a large system
of social health insurance, such as the National Health Insurance Council to govern NHIS
(MEC, 2003; JLN, 2012). Another striking challenge to the success of NHIS is the epileptic
and sometimes lack of electricity in most parts of Nigeria which hampers the smooth
operation of NHIS. Take for instance, a physician is carrying out a major operation on a
patient and there is power disruption. This will threaten the success of that surgical
procedure and endanger the life of the patient.

In addition to the above challenges, State governments in Nigeria have still not played a
signicant role in expanding health insurance (Asoka, 2012). The division of roles
between the central government ministries, state governments, local government
agencies, and the actual insurers is lacking the luster for the effective and efcient service
delivery by NHIS. Finally, the commodication of health services could mar the
objectives of NHIS. This is because healthcare providers see their services as economic
commodity which they sell at a bargained and exorbitant cost to those who could afford
it. This negates one of the objectives of NHIS aimed at giving UHC to all Nigerians.

Theoretical framework
System Theory
According to Okotoni (2010), a system is a collection of part or sub-system integrated to
accomplish an overall goal. It involves inputs, process, outputs and outcomes to achieve a

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specied goal. The idea of system theory came from the discovery of a collection of cells
by a microbiologist in the person of Bertalanffy (1968) where he observed the coming
together of cells to form a specialised unit to achieve a purpose. His idea was taken by
other scholars who related it to different elds such as management, political science and
public administration. A system comprises of four main units like inputs (raw materials,
human resources, capital, government, formal and informal sector, medical experts,
medicines) processing (interaction of inputs), output (affordable health care delivery
services) and the recycling (evaluation of National Health Insurance Scheme) (Chuang &
Inder, 2009). These four units come together in form of cells to produce results which are
in turn utilised to better the system.

The Input phase is the cornerstone of achieving the policy thrust of the NHIS in any
country. Any system whose Inputs are not sufcient to meet its outcomes is bound to
have challenges. These Inputs work together in harmony through a transformation
process that involves contributions from experts to bring forth achievements of specied
purpose of the system. The concluding part of the theory is the recycling phase which
allows an evaluation of the entire health delivery system in order for it to be fortied
especially in the area of health insurance. This theory presents an understanding of the
interaction of major stakeholders in the health care delivery services.

Methodology
This survey study generated information for analysis through the use of structured
questionnaires from selected enrollees of NHIS in University of Abuja Teaching Hospital
(UATH); National Hospital (NH), Abuja; and Federal Medical Centre (FMC) Abuja. The
study conveniently chose a sample of 13 out of the 77 registered HMOs by the NHIS for
evaluation. The 13 sampled HMOs are the top list HMOs in Abuja according to the
statistics provided by the HCPs under review. These HMOs are; United Healthcare
International Limited, Premium Health Limited, Integrated Healthcare Limited,
Managed Healthcare Services Limited, Princeton Health Group, Maayoit Healthcare
Limited, Defence Health Management Limited, Healthcare Security Limited,
International Health Services Limited, Zenith Medicare Limited, Zuma Health Trust,
Prepaid Medicare Services Limited, and Police Health maintenance Limited. The study
proportionally chose 15 respondents each operating with respective HMOs, across the
three health institutions in Abuja, 5 each from a particular institution. Therefore, 195
copies of the questionnaire were personally administered by the researcher to the
respondents for data collection. Face to face interview was also used to elicit the opinion
of the managers of these HMOs in order to balance the views of the respondents. Analyses
were done using frequency of responses to infer conclusion.

Findings and Discussion

The data generated for the purpose of this study were organized to answer the research
questions in section 1.2 of this report. The responses to the rst questions were in line
with the general assessment of the respondents on the efcacy of the HMOs. The
responses were organized to show whether each HMO has been “Good” or “Poor” in the

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performance as relates to the operations of the NHIS. The responses to the rst research
question are as follows;

Table 1: Enrollees Assessment of the HMOs in the Operation of NHIS

ENROLLEES ASSESSMENT OF THE HMOs IN THE OPERATION OF NHIS
HMO/HCP UATH NH FMC DECISION
United Healthcare Good/Poor(42/23) Good/Poor (29/36) Good/Poor (47/18) ( 118/77)GOOD
International Limited
Premium Health Limited Good/Poor (50/15) Good/Poor (39/26) Good/Poor (43/22) ( 132/63)GOOD
Integrated Healthcare Limited Good/Poor (15/50) Good/Poor (17/48) Good/Poor (12/53) ( 44/151)POOR
Managed Healthcare Services Good/Poor (20/45) Good/Poor (32/33) Good/Poor (27/38) ( 79/116)POOR
Limited
Princeton Health Group Good/Poor (16/49) Good/Poor (28/37) Good/Poor (23/42) ( 67/128)POOR
Maayoit Healthcare Limited Good/Poor (12/53) Good/Poor (18/47) Good/Poor (22/43) ( 52/143)POOR
Defence Health Management Good/Poor (39/36) Good/Poor (59/6) Good/Poor (50/15) ( 138/57)GOOD
Limited
Healthcare Security Limited Good/Poor (42/23) Good/Poor (45/20) Good/Poor (40/25) ( 127/68)GOOD
International Health Services Good/Poor (27/38) Good/Poor (23/42) Good/Poor (25/40) ( 75/120)POOR
Limited
Zenith Medicare Limited Good/Poor (18/47) Good/Poor (23/42) Good/Poor (20/45) ( 61/134)POOR
Zuma Health Trust Good/Poor (52/13) Good/Poor (48/17) Good/Poor (46/19) ( 146/49)GOOD
Prepaid Medicare Services Good/Poor (28/37) Good/Poor (31/34) Good/Poor (26/39) ( 85/110)POOR
Limited
Police Health maintenance Good/Poor (44/21) Good/Poor (38/27) Good/Poor (41/24) ( 122/73)GOOD
Limited

Source: Tertiary Health Institutions, Abiya

Table 1 above shows the breakdown of responses from the enrollees to NHIS in the 13
listed HMOs in the three tertiary health institutions in Abuja. The result shows that,
generally, the enrollees are not satised with the services provided by the HMOs as seven
of them were rated as poor while only six of them are rated to be good. There is an
observable consistency in the pattern of assessment by the enrollees as they unanimously
rate as “Poor” seven of the thirteen HMOs across the three health institutions. It sufces
to conclude that the operations of these HMOs have left so much to be desired.

Gleaning from the interviews with representatives of the HMOs under review, it was
discovered that part of the reasons the enrollees might want to assess them poorly is
because majority of their employers have failed to remit their contributions to the scheme
and the HMOs duly discontinued coverage of the affected beneciaries. The handlers of
the HMOs believe that they are not to be blamed for the failure of the enrollees to access
healthcare since they are often denied the premium from various employers.

In addition to the above, the study uncovered various problems plaguing the scheme as
occasioned by the HMOs and they are as follows;
I. Difculty in generating Authentication Codes: majority of the patients in tertiary
health institutions are on referral while having their different HCPs, there is need
to obtain authentication codes which will enable them to shift the recipient of the
payment of their medical expenses from their primary HCP to the tertiary
institution. There is often delay running into hours and sometimes days before
the representatives of HMOs will respond to the request of the patient through

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 the tertiary institution. Sometimes the responses are negative due to misspelt
names or interposition of characters of names, all of which, mostly, are no faults of
the patient. As urgent as medical matters should be, this type of difculty, is
unhealthy to the success of the scheme.
ii. No-Show Weekends: medical services are required every hour of the day and
every day of the week. Majority of the HMOs operate from 8 am to 5 pm from
Mondays to Fridays and do not operate during the weekends. This unavailability
of nancial succor to access medical services during the weekends poses great
challenge to the success of the scheme.
iii. Inadequate skilled Manpower: this study found that some of the staff in the NHIS
department of these tertiary health institutions lacks the necessary skills for the
job. It was found that in some cases, there is only one person with the requisite
skill and no matter how long the person is out of ofce, the job remains undone
until (s)he is back.
iv. Nonchalant attitude of hospital staff: in addition to the problem of shortage of
qualied personnel, the staffs available show lack of enthusiasm towards lifting
the plights of the patients. Sometimes, sheer indifference to the consequences of
misspelling patients' details, causes the delay in response.
v. Ineffective means of communication: this study found that there are challenges
associated with the usual method of communication which is the usage email,
SMS and voice call services. Sometimes patients are caught between abandoning
the course of chasing affordable healthcare through NHIS and seeking
unorthodox alternative as a result of the delay of network services or total
blackout in response from the desks of the HMOs.

Conclusion and Recommendations

It is obvious that the provision of affordable and accessible healthcare services in Nigeria
through the instrumentality of National Health Insurance Scheme (NHIS) is challenged.
No doubt, the NHIS initiative is lofty by the achievement of its objectives is contingent
upon the resolution of these various challenges. As a tool of implementation of the
scheme, the HMOs have played important roles in the operation of NHIS however; they
have hardly been placed under academic scrutiny. This study evaluated the opinions of
the enrollees to the scheme as covered by the various HMOs and concludes that the role of
the HMOs has been ineffective. The opinions sampled revealed that the activities of a few
of the HMOs are good while the majority of them are poor. This was possible because of
the problems of indelity in the remittance of premium by employers; difculty in
generating authentication codes; no-show weekends; lack of skilled personnel;
nonchalant attitudes of hospital staff; and ineffective means of communication.

The study hence recommends that;

1. The employers should remit the NHIS premium of their staff to the HMOs.
2. HMOs should decentralize their structure to accommodate their representatives
in the tertiary health institutions to ensure that the generation of authentication
codes for patients on referral is made easy.

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 3. Training and retraining of hospital staff are very important in order to inculcate in
them the necessary skills and competence required for the job.

References
Agba, A. M. O., Ushie, E. M. & Osuchukwu, N. O. (2010). National health insurance
scheme and employees access to healthcare services in Cross River State, Nigeria.
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