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Background: Out-of-pocket payments for healthcare services hinders the attainment of universal health coverage.
Objectives: To assess the current level of knowledge, perception, and willingness to enrol in a health insurance scheme among uninsured persons in Nigeria.
Methods: This was a descriptive cross-sectional study conducted among residents of Uyo, a city in southern Nigeria, who had not enrolled in any health insurance scheme
Conclusion: Knowledge of the concept of health insurance as well as awareness of the existence of affordable insurance plans is poor in a significant proportion of the population studied. Many respondents had a poor perception regarding health insurance schemes with the majority unwilling to enrol in one.
Keywords: Health Insurance, Knowledge, Out-of-Pocket Expenditure, Perception, Willingness To Enroll
Out-of-pocket payments for healthcare services is common in Nigeria with millions of citizens becoming impoverished each year due to this mode of payment for healthcare delivery [1, 2]. A report by the Nigerian National Health Financing Policy suggests that in about four percent of households in the country, more than half of the total expenditure is on healthcare services, while about twelve percent of households spend approximately a quarter of their total expenditure on the same [3]. Out-of-pocket payment for these services hinders the attainment of universal health coverage and may negatively affect the health seeking behaviour of citizens. Since the mode of payment for healthcare services has been identified as a determinant for attaining universal health coverage [4], various health insurance models have been developed to reduce the costs of healthcare delivery [5, 6, 7]. Healthcare delivery services are widely considered to be basic and essential, and thus should be provided to citizens by the government [8, 9]. In Nigeria, the national health insurance scheme was introduced by the federal government in a bid to improve access and reduce the cost of healthcare delivery in the country. Enrolment into the scheme is however voluntary for persons not employed by the federal civil service who constitute a vast majority of the Nigerian population. Previous studies show low enrolment into the scheme, particularly among the informal sector labour force [10, 11]. Because out-of-pocket payment is the predominant healthcare financing mechanism in Nigeria, access to healthcare services is greatly hindered for poor households and individuals with low financial purchasing power. To ameliorate this disturbing reality, various schemes have been proposed, including prepayment and community based insurance schemes [8, 12-14]. Community based health insurance schemes offer subsidised healthcare services and bridge the gap between access to available healthcare resources and the lack of funds among people in poor and vulnerable communities. Unfortunately, a lack of appropriate sensitisation and poor awareness of the benefits among most vulnerable populations hinders enrolment into such schemes [8]. Previous studies in other regions of Nigeria have reported varying levels of willingness to subscribe to health insurance schemes [8, 15-17]. However, some of these studies were undertaken more than a decade ago and it can be assumed that the trend may have changed with time. This descriptive cross-sectional study was thus aimed at assessing the current level of knowledge, perception, and willingness to enrol in a health insurance scheme among uninsured persons in Nigeria.
This was a descriptive cross-sectional study among persons who had not enrolled in any health insurance scheme (uninsured persons). Uninsured residents of Uyo, a city in southern Nigeria, who expressed willingness to participate in study were recruited. They were then interviewed using a suitably designed survey instrument. The main aim of the survey was to assess their level of awareness, perception of, and willingness to enrol in a health insurance scheme. Survey instrument The survey instrument was designed and pre-piloted by the researchers. It consisted of three (3) sections that assessed data on the respondents’ socio-demographic details/utilization of healthcare resources, knowledge of health insurance, perception of healthcare insurance, and their willingness to enrol in and pay for a health insurance scheme. Participants’ recruitment/Eligibility criteria All adults of 18 years and older, residing in Uyo, who had not subscribed to any health insurance scheme, formed the sampling frame for the study. Only those who provided written informed consent to participate were recruited into the study.
A sample size calculation was determined with the aid of the Raosoft online sample size calculator wherein the margin of error, confidence interval and response distribution were set at 5%, 95% and 50% respectively. The estimated adult population of Uyo LGA is placed at 1,329,000 persons [18]. The calculated minimum sample size for uninsured residents of Uyo metropolis using the Raosoft online sample size calculator was 385 uninsured persons. However, for this study we interviewed 504 respondents. Data analysis Data analysis was conducted using the IBM Statistical Products and Services Solution (SPSS) version-25.0 software. The obtained data was summarised using descriptive statistics with frequencies and percentages used as appropriate. Ethical clearance Ethical approval was obtained from the Health Research Ethics Committee of the Akwa Ibom state Ministry of Health (approval reference number: AKHREC/21/06/23/157). In addition, informed consent was obtained from each participant before recruitment into the study.
Socio-demographic details The majority of our respondents were aged between 18 – 24 years (322; 65.9%). One hundred and seventy-six (34.6%) were self-employed, while 58.3% (294) had attained a tertiary level of education. The respondents’ socio-demographic details are presented in Table 1.
Knowledge/awareness of health insurance schemes Our results showed that although 335 (66.5%) of our respondents had heard of health insurance schemes, only 92 (18.3%) claimed to know how they work. Moreover, about 61.9% (n = 312) of respondents were not aware of the existence of an affordable health insurance plan for low-income earners in Nigeria. The respondents’ knowledge and awareness of health insurance is shown in Table 2. Perception of health insurance schemes About 42.3% (n = 213) of respondents perceived health insurance schemes as being expensive, while 20.2% (n =102) considered them a waste of resources. Table 3 presents the respondents’ perception of health insurance schemes. Willingness to enrol in health insurance schemes Our respondents’ willingness to enrol in health insurance schemes and the amount they were willing to pay in monthly subscriptions is presented in Table 4. Our results showed that only 25.4% (n = 128) of participants were willing to subscribe to a health insurance scheme.
Knowledge of the concept of health insurance and awareness of the existence of affordable insurance plans is poor in a significant proportion of the population studied. Many of the respondents had a poor perception regarding health insurance schemes, with a majority being unwilling to enrol in a health insurance scheme. The implementation of a comprehensive awareness campaign, designed to dispel misconceptions and enlighten the population about the workings and benefits of health insurance, would increase enrolment, improve access to healthcare services, and reduce out-of-pocket expenditure on healthcare resources.
The results of this study may not be a true reflection of the entire population of uninsured persons in Nigeria as it is limited in generalisability. We relied on self-reported data from respondents, which may be subject to social desirability bias. Furthermore, there may be a risk of selection bias in the sampling as patients who were willing to participate in the study may differ from those who chose not to participate.
The Helsinki Declaration was adhered to in this study, and ethical approval was obtained from the Health Research Ethics Committee of the Akwa Ibom State Ministry of Health. In addition, informed consent was obtained from the respondents. Consent for publication Not applicable. Availability of data and materials The datasets used and analysed during this study are available from the corresponding author on reasonable request. Competing interest The authors declare no competing interests.
The authors did not receive funding for this study.
The authors extend their appreciation to all the respondents who participated in the study.
UIE conceived and designed the study; UIE, AS, JU, BU, IN and VM all contributed to the questionnaire design, data collection, analysis and interpretation. UIE wrote the manuscript and reviewed it critically for important intellectual content. All authors read and approved the submitted manuscript.