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 Table of Contents  
Year : 2016  |  Volume : 15  |  Issue : 1  |  Page : 18-23

Level of awareness, and factors associated with willingness to participate in the National Health Insurance Scheme among traders in Abakaliki main market, Ebonyi State, Nigeria

1 Department of Community Medicine, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
2 Department of Medicine, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria

Date of Web Publication10-Jun-2016

Correspondence Address:
Benedict Ndubueze Azuogu
Department of Community Medicine, Ebonyi State University, Abakaliki, Ebonyi State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2384-5589.183887

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Introduction: The National Health Insurance Scheme (NHIS) was introduced in Nigeria in 2005, and nine years after its inception only 3.5% of the population have been enrolled in three Sectors of the Scheme. Traders and others in the informal sector are not involvement in the scheme. This study was conducted to assess the level of awareness, and factors that could affect the willingness of traders in Abakaliki main market to participate in the National Health Insurance Scheme. Materials and Methods: A descriptive cross sectional study of 419 traders (53% males and 47% females) was carried out using a three stage sampling technique. Data was collected using interviewer administered semi-structured questionnaire, and was analyzed using SPSS (version 20) and Mathcad 7 Professional software. Frequencies and percentages were calculated, while Chi square test and Z-score were used to test for associations, with P < 0.05 set as level of significance. Results: Only 127 (30.3%) of the 419 traders were aware of NHIS, and significant majority (73.2%) of those aware of the scheme were willing to participate. No factor was significantly associated with willingness to participate. Conclusion: Awareness of NHIS was very poor among the traders, but majority of them were willing to participate in the scheme. Enlightenment campaigns should be embarked upon in the markets to increase awareness of the scheme among the traders, as this could influence their participation.

Keywords: Abakaliki main market, awareness, National Health Insurance Scheme, Traders, willingness to participate

How to cite this article:
Azuogu BN, Madubueze UC, Alo C, Ogbonnaya LU, Ajayi NA. Level of awareness, and factors associated with willingness to participate in the National Health Insurance Scheme among traders in Abakaliki main market, Ebonyi State, Nigeria. Afr J Med Health Sci 2016;15:18-23

How to cite this URL:
Azuogu BN, Madubueze UC, Alo C, Ogbonnaya LU, Ajayi NA. Level of awareness, and factors associated with willingness to participate in the National Health Insurance Scheme among traders in Abakaliki main market, Ebonyi State, Nigeria. Afr J Med Health Sci [serial online] 2016 [cited 2021 Apr 19];15:18-23. Available from: http://www.ajmhs.org/text.asp?2016/15/1/18/183887

  Introduction Top

Health insurance is a mechanism of making periodic prepayments against episodes of illness to enable the payer to obtain healthcare services when needed without paying out-of-pocket at the point of need.[1] Nine years after the inception of the National Health Insurance Scheme (NHIS; 2005-2014) in Nigeria, only about 5 million people (approximately 3.5% of the population) have been enrolled in all the three (formal, informal, and private) sectors of the Scheme.[2],[3] Unlike the situation in Nigeria, Ghana has maintained a steady increase in the coverage of her population under health insurance since its inception in 2003. For instance, in 2007 participation was 35%, and by June 2010 more than 66% of the population had been enrolled.[4],[5] Similarly, other countries with comparable health indices to Nigeria have achieved wider coverage of their populations with health insurance. These include India (19%), Thailand (80%), and Colombia (95%).[2]

The main goal of NHIS is to ensure universal coverage with access to affordable healthcare and to reduce the reliance on an out-of-pocket system of payment, so as to improve the health conditions of the people, especially the participants in the Scheme.[6] The formal sector program was the first to be rolled out and was compulsory for employees of the Federal Government of Nigeria. The informal sector of the Scheme, which includes the Urban Self-Employed Social Health Insurance Program (USSHIP) and the Rural Community Social Health Insurance Program (RCSHIP) are classified as nonprofit voluntary schemes.[5],[6] At least 500 members are required to form a User Group to guarantee adequate pooling of financial resources in the Informal Sector Program. The USSHIP covers small-scale business owners with less than 10 employees, traders, artisans, farmers, and others.

In the year 2012, the Informal Sector Scheme was formally launched in Lagos; in 2014 the RCSHIP was rolled out in one State, with plans to launch the Program in at least three local government areas of each State in Nigeria. But enrollments in the already launched programs have been abysmally poor.[7],[8] Nevertheless, the huge informal sector in Nigeria provides hope for the means of scaling up participation in the NHIS. However, the free-will nature of informal sector NHIS would require a high degree of program management, with variable financial arrangements and benefit packages that could motivate traders and other self-employed persons to make voluntary monthly contributions and remain in the Scheme. It is therefore imperative to assess the level of awareness and the factors that would determine the willingness of traders to participate (WTP) in the NHIS so as to generate evidence-based information for possible modifications of insurance packages to suit their specific needs.

Previous surveys showed that employment in the formal sector was significantly associated with access to health insurance relative to being employed in the informal sector.[4],[9] The low participation of individuals in the informal sector was attributed to a number of factors, such as low and nonregular incomes, insecure employment, and insurance scheme design features that are not adapted to people's needs and preferences.[10],[11],[12] Existing evidence also shows that membership in both formal and informal savings and credit schemes is an important predictor of participation in health insurance programs.[13],[14]

A study in Edo State, Nigeria revealed that 59.4% of rural households indicated willingness to participate (WTP) in Community-Based Health Insurance,[15] while another from Osun State, Nigeria showed that 82.4% of artisans were willing to participate in the same scheme.[16]

According to the World Health Organization (WHO), an efficient National Health Insurance model is key to achieving universal health coverage that would ensure everyone has access to good-quality health services as they need without becoming impoverished as a result.[17] It is estimated that about 100 million people globally are pushed into poverty because of out-of-pocket payments for healthcare services, and millions of people together with substantial number of households do not seek healthcare in hospitals because they have to pay at the point of service delivery.[18],[19] Nigeria has a vast informal sector as over 70% of the nation's population belongs to this category, and the majority of the self-employed workforce are traders.[20],[21] Unfortunately, members of the informal sector in Nigeria have restricted access to health insurance coverage;[8] hence this study was conducted to determine the level of awareness and the factors associated with WTP in the NHIS among traders in the main market in Abakaliki, Ebonyi State.

  Materials and Methods Top

Study setting and subject

The study was conducted in Abakaliki, the capital city of Ebonyi State. Ebonyi State was created from the old Enugu and Abia States, in the South-Eastern geopolitical zone of Nigeria on October 1, 1996. It occupies a land mass of 5,935 km 2, with a population of 2.7 million people based on the 2006 national population census, with a growth rate of 3.2%. The people of Ebonyi State are predominantly peasant farmers, but those resident in Abakaliki are mainly civil servants, bankers, and traders.[22]

There are three major markets located in the metropolis, of which the Abakaliki main market, located at the city center, is the oldest and the largest, and has both wholesale and retail traders. As a result it was purposively selected for this study. The market was established before the Nigerian Civil War but its traders' association, the Abakaliki Main Market Traders Association (AMMATA) was formally registered in 1982. Goods sold include textile materials, electronics, clothing, stationery, books, fancy materials, beverages, and foodstuff. The market has 272 well-demarcated lines (named after some State capitals and major towns in southeastern Nigeria) and 2139 serially numbered shops. Each shop is owned by one person who might run it alone or engage others as paid salespersons or unpaid apprentices. There is also a voluntary monthly contribution group, which operates like a cooperative and thrift organization among the registered members of the Association.

The traders were adults and youths in low- and middle-income social classes. They compulsorily belonged to AMMTA, which has 2244 registered members. Only those aged 18 years and above who have been registered for 2 or more years in the market were selected for this study.

Study design

A descriptive cross-sectional study was undertaken. With Fischer's formula N = Z 2 pq/d 2 [where Z = standard normal deviate (1.96 at 95% CI), P = 82.4% estimated proportion that would be willing to participate in NHIS,[16] q = 1-p and d = 0.05 desired 95% accuracy], a minimum sample size of 223 was calculated but was increased to 419. A three-stage sampling technique was adopted. In the first stage, 52 lines were selected from a sampling frame of 272 lines using a systematic random method with a sampling interval of 5. By the same method, eight shops were selected from each of the 52 lines in the second stage with a sampling interval of 6. In the final stage, a respondent in each of the 52 selected shops was recruited into the study. If more than one eligible trader was present, a simple random technique of balloting was used to select one respondent from among the eligible traders. The starting point for each stage was determined by a simple random sampling technique of balloting. All the lines do not have equal number of shops, and some selected shops were replaced with the next consecutive one if none of the occupants fulfilled the inclusion criteria.

A semistructured interviewer-administered questionnaire was used to obtain data from the respondents with the help of three trained research assistants. Data were collected over a period of 10 days. Information was collected from the respondents on their sociodemographic characteristics, facilities visited when ill, awareness and knowledge of NHIS, and WTP in the Scheme. Questions on knowledge explored respondents' understanding of the three specific domains of NHIS, namely: Principle of operation, persons that can be enrolled, and the types of health facilities that can provide services under the Scheme.

Ethical consideration

Ethical clearance was obtained from the Research and Ethics Committee of the Federal Teaching Hospital, Abakaliki and permission for the study was given by the Traders' Association Executive Committee, while verbal informed consent was obtained from the participants. After data collection, the researchers provided group education to all the traders on NHIS principles and program operations during their regular monthly prayer meetings.

Data management

Data were entered and analyzed on the IBM statistical package for social sciences (SPSS) and Mathcad-7 Professional statistics software. Frequencies and percentages were calculated, while chi-square test of significance and z-score were used to test for associations, with P value less than 0.05 set as level of significance.

  Results Top

[Table 1] shows the sociodemographic characteristics of the respondents who included 222 (53.0%) males and 197 (47.0%) females, with the mean age of 33.9 ± 12.9 years. A majority (167; 39.8%) were in the age group 18-29 years; more than half (222; 53%) were married; and most (60.6%) had secondary education.
Table 1: Sociodemographic characteristics of respondents

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[Table 2] shows the respondents' membership in monthly contribution group and first facility always visited when ill. A majority of the traders (363; 88.6%) belonged to a monthly contribution group within their association, and more than two-third (292; 69.2%) always visited facilities other than a hospital first when ill.
Table 2: Respondents' membership in monthly contribution group and first facility always visited when ill

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[Table 3] revealed respondents' awareness, WTP, and knowledge about NHIS, and it can be seen that only 127 (30.3%) of the traders were aware of NHIS. In addition, assessment of knowledge among those with awareness showed that 8 (6.3%) understood the principle of NHIS, 79 (62.2%) knew that anybody can be enrolled in the Scheme, and 32 (25.2%) correctly knew that both public and private hospitals can provide services under the NHIS.
Table 3: Respondents' awareness, WTP, and knowledge about NHIS

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In [Table 4], the association of awareness and sociodemographic factors with WTP is displayed. The majority (93; 73.2%) of the 127 respondents aware of the scheme were willing to join the NHIS and this association was statistically significant (z = 7.404, P = 0.0015). Those willing to participate were mainly males (58; 62.4%), and more individuals in the age group 30–39 years agreed to join the NHIS (34; 35.5%) than in other age groups. WTP was indicated slightly more by the married respondents than their single counterparts, and almost half (49.5%) of those willing to join the Scheme had secondary school education. More among those who always visit facilities other than hospitals first when ill were interested to participate (59.1%) than among their counterparts who usually go to hospitals. However, these associations between sociodemographic characteristics and WTP in the NHIS were not significant.
Table 4: Association of awareness and sociodemographic variables with WTP

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  Discussion Top

In this study, awareness of the NHIS was poor as only 30.3% of the respondents agreed to have heard about a scheme that has been in existence for more than 9 years. This finding is comparable with the 28.9% awareness found among artisans in Osun State.[16] The low level of awareness found in this study was rather unexpected in an urban setting where about 79% of the respondents had at least secondary education. It reflects weakness in information dissemination mechanisms about the NHIS, and thus could have a bearing on low-population health insurance coverage.[2],[3]

The WTP in the NHIS indicated by 73.2% of those aware of the Scheme in this group was rather high, and consistent with 59.4% and 82.4% found in rural households of Edo State and among artisans in Ilorin, respectively.[15],[16] However, the rural households in Edo were educated on the concept of NHIS just before data collection, while WTP among the artisans was assessed in all the participants irrespective of their awareness status. These findings underscore the critical role of awareness in the promotion of participation in the NHIS.

The strong association between awareness and WTP in the NHIS found in this study was not surprising because most of the awareness messages aired about the scheme were extractions from testimonies given by those who have benefited from health insurance, and that might have influenced their decision. The preponderance of males with intention to participate in NHIS could be due to the fact that males usually bear the burden of medical bills, which would be relieved by health insurance. It could also be attributed to our culture that allots decision-making in the family to men. This should be explored when planning events to foster awareness about the NHIS. Surprisingly, the younger age groups, purportedly with lower risk of illness, were more interested in joining the NHIS than the older groups that are likely to fall ill frequently. This could be due to the influence of the awareness of the NHIS, which was correspondingly higher in the younger age groups. Being married could encourage obtaining health insurance coverage as the subscription of a spouse to some insurance programs provide coverage to couples. In line with the earlier observations in this study, the higher WTP observed in those with secondary education could be adduced as the influence of awareness, which was the highest in this group.

Finally, it is intriguing to note that the majority of those willing to join the scheme visited unconventional facilities first when ill rather than hospitals. This could be a result of the erroneous belief held by the majority that only government-owned hospitals provide services under the NHIS; on the other hand, those who visited the hospitals might be dissatisfied with the services there and therefore not want to participate.

  Conclusion Top

This study revealed a very poor level of awareness about the NHIS among the traders, but also remarkable WTP in the Scheme. A significant number of those aware of the NHIS expressed WTP despite their relatively poor understanding of the principle and operation of the Scheme. Other factors that could engender WTP in the NHIS include male gender, young age, being married, and having at least secondary education.

It is recommended that stakeholders in the NHIS embark on regular awareness campaigns, especially during the monthly prayer meetings of the traders, to enlighten them on the importance of participating in the Scheme.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]

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