Bullion Bullion

Volume 41 Number 1 Article 2

3-2017

National Health Insurance Scheme (NHIS) implementation in National Health Insurance Scheme (NHIS) implementation in

Nigeria: issues, challenges and way forward Nigeria: issues, challenges and way forward

Bandele A. G. Amoo Central Bank of Nigeria

Adedapo T. Adenekan Central Bank of Nigeria, atadenekan@cbn.gov.ng

Halima U. Nagado Central Bank of Nigeria, hunagado@cbn.gov.ng

Follow this and additional works at: https://dc.cbn.gov.ng/bullion

Part of the Health and Medical Administration Commons, and the Health Services Administration

Commons

Recommended Citation Recommended Citation Amoo, B. A. G., Adenekan, A. T., & Nagodo, H. U.(2017). National Health Insurance Scheme (NHIS) implementation in Nigeria: issues, challenges and way forward. CBN Bullion, 41(1), 15-33.

This Article is brought to you for free and open access by CBN Institutional Repository. It has been accepted for inclusion in Bullion by an authorized editor of CBN Institutional Repository. For more information, please contact dc@cbn.gov.ng.

Volume 4l No.l

Bondele A. G. Amoo Ph.D

Adedopo L Adenekon Ph.D

Holimo U. Nogodo (Mrs./

l.0lntroduction

Healthy citizenry is crucial togrowth and development ofany economy. As the age-long

NATIONAL HEALTH INSURANCE SCHEME (NHIS)iMPLEMENTATION IN NIGERIA:

lssues, Challenges :nd Way Forward

Reor secf oroDrvision, ii,;;:f:, :;: ff ̂ " ",

Jonuory - Morch, 2017

Abstract

The paper discussed the National Heolth lnsuronce Scheme (NHIS) odopted byNigeria for improved occess to heolthcare, especially to the low incomeeorners. The objective of the study is to review developments ln theimplementotion of the Nigerian NHIS and determine whether its ochieving its

objectives. Specificolly, the study focused on key issues ond chollenges

confronting the NHIS, with o bid to proffer oppropriate recommendotions

towords sustoinobility, effectiveness ond efficiency. The study odopted adescriptive qualitative onalysis methodology ond found limited coverage,

religious ond culturol limitotions, in-extensive prescriptions, conflict ofinterests (NHIS ond HMOs), low participants' coveroge, issues of mistrust,

totol government financing limitotion os well os low budget ollocation

compored to need, os mojor issues confronting the ochievement of quolity

heolthcore delivery from the Scheme. lt proffered some recommendotions

which include: more privote sector pofticipotion, governonce right to HMOs

on the Boord of NHIS, creation of Notionol Heolth lnsuronce Fund ond

co m m e nce me nt of co nt ri b uti o n from pa rti ci po nts.

JEL: 173

Key words: Notional Health lnsuronce Scheme (NHIS); Heolth core providers

(HCPs); Heolth Mointenonce Orgonizotions (HMOs)

adage goes, "health is wealth,"so it is that a country's healthand wealth are inextricablylinked. This assertion isunderscored in the variousgrowth theories thatprominently feature labour as a

key input of production. For

instance, the EndogenousGrowth Model emphasizes thatan enhancement of a nation'sh u ma n ca pita I contributesignificantly to its economicgrowth. Human capital conceptrecognizes that not only doesthe quality of labour matters,improvement of labour

through education, trainingand health investments areequally important. The NewGrowth Theory also avers thatpeople have control over theirknowledge capital and argues

that real gross domesticproduct (real GDP) per person

will perpetually increasebecause of people's pursuit ofprofit. To the New GrowthTheorists, innovations ortechnologies don't occur simplyby random chance, butdepends on a number of people

seeking out these innovationsand how hard they look for

rThe enabling Decree 39 was promulgated in May 10, 1999 at the twillght of the

Milrtary Regime under General .A,A.Abubakar.

t:f

Volume 4l No.l Jonuory - Morch, 2017

review the developmentsabout the NHIS in Nigeria inorder to gain insight into theimplementation of the schemeand determine whether it is

achieving its goal. Specifically,

the study focuses on the keyissues and challengesconfronting the scheme, with a

bid to proffer appropriaterecommendations towards itssustainability, effectivenessand efficiency. The rest of thepaper is structured as follows.Following this introduction,section two presents a

theoretical and empiricalreview on health servicesprovision and insurance.Section 3 presents somestylized facts on health sector inNigeria, while section 4discusses the overview ofNHlS.. Section 5 highlightschallenges and issuesconfronting the NHIS and alsooffers some policyrecommendations.

2.0 Literature Review

2.l Theoretical Review

The demand for health care ispremised on several theories.The conventional theory,pioneered by Mark Pauly,among others, postulates thatdemand for health insurance is

primarily driven by the desire toavoid risk, claiming that peoplepurchase insurance becausethey prefer the certainty ofpaying a small premium to therisk of getting sick and paying alarge medical bill. Oneadvantage of health insuranceobligation is that it allows the

high. The weakened PublicHealth Care (PHC) system withlow coverage of keyinterventions has resulted inthe persistence of high diseaseburden. According to a nationalHealth Policy Report, "lifeexpectancy at birth hasdropped over years from 53.8years (females) and 52.6{males} in 1991 to48.2(females) and 46.8 {males)in 2OOO and 41.3 in males and41.8 in females by 2003 forreasons which includedeterioration in both structureand organization of thehealthcare system, lack ofskilled personnel especially inthe prima ry health carec€nters, lack of financial andgeographic accessibility for thernajority of the populace to thelimited heahhcare fu cilities.

The eff o rts to im provehealthcare services and reducehealth cost in Nigeria led to theestablishment of the NationalHealth lnsurance Scheme(NHIS), which was formallylaunched in 2005, in a bid toimprove accessibility. Theestablishment of NHIS as a

group insurance plan providesan enhanced opportunity forinclusive growth, given that notNigerians all have access toquality healthcare services. Thescheme promises to play a

prominent role in allowing allcitizens to be included in theopportunity set for improvingaccess and affordability tohealthcare services, hencecontributi ng to growth.

The objective of this study is to

transfer of income from thepool of insurers who do not fallsick to finance the medical care

of those who become ill.

Schoemaker (1982)'s expectedutility theory of healthinsurance is one of theforemost decision-makingtheories that reflects onaversion and demand forincome certainty. Due touncertainty about theunknown future health,insurance choice is not madebased on utility alone but onconsumers' expectation aboutfactors such as their healthstatus. Schoemaker is howeversilent on the associationbetween household socio-economic status and insuranceenrolment. Theories ondecision-making underuncertainty are often used todescribe insurance enrolment(Cameron et al (1988)). Underthe assumption that insuranceis a normal good, with positiveincome elasticity of demand,the higher the income, thehigher the tendency to key intoa health insurance scheme.

Manning and Marquis (1989)avers that the choice of aneconomically optimal healthinsurance package involves a

trade-off between the gainsfrom reducing families'financial risks and the lossesfrom inappropriate incentivesforthe purchase of more healthcare. They argued that, otherthings being equal, individualsare generally willing to pay

more than an actuarially fairamount to reduce the risk of a

L7

Volume 4l No.l Jonuory - Morch, 2017

out consumption (or wealth)across time by sacrificing a littlewhen healthy to becompensated in the event ofinjuryorillness.

The nature of healthcaresystems and how they arefinanced determine whetherpeople can obtain neededhealthcare and whether theysuffer financial hardship at theinstance of obtaining care(Carrins, Evans and Xu (20071.

Likewise, Rao et al (2005)reiterated that the pattern ofhealth financing is closely andindivisibly linked to theprovisioning of services andhelp define the outerboundaries of the system'scapabilities to achieve theoverall goal of enhancingnation's economicdevelopment. Povertyliteratures also show that socio-economic characteristics ofeconomic agents can revealthechoice of whether or not todemand health insurance. Poorhouseholds are expected tobecome increasingly risk averseif they move closer to, orfurther below the poverty line(Wagstaff, 2000).

Nevertheless, due touncertainty about theunknown future health,insurance choice is not madebased on utility alone but onconsumers' expectation aboutfactors such as their healthstatus. Thus, theories ondecision-making underuncertainty are often used todescribe insurance enrolment.On the contrary, poor

large financial loss caused bythe possible future occurrenceof illness and the resultantmedical care expense. To

Manning and Marquis, healthinsurance however affects theallocation of health careresources; the cost sharingdecreases the out-of-pocketprice paid by the patient andincreases the amount ofmedical care demanded. This

however underscores higherrisk of moral hazard, given thatconsumers would not purchase

this additional care if they had

to pay its full cost, the extraservices' value to consumersfall short of the social cost ofproducingthat care.

John Nyman (2000) furtherposited that consumersdemand for health insurance toobtain extra income when theybecome ill; in effect, insurancecompanies act to transferincome from those who arehealthy to those who are ill.This additional incomegenerates purchases ofadditional high-value care,often allowing sick persons toobtain lifesaving care that theycould not otherwise afford. By

implication, the theorysuggests that health insuranceis substantially more valuableto consumers and consumersprefer the risk of a large loss toincurring a smaller loss withcertainty. Nyman posited thatthe central rationale for buyinginsurance is the individual'sdesire to obtain an lncometransfer from the risk poolwhen ill. One possibility is thatthe consumer seeks to smooth

households, who are morelikely to have credit constraintsin the future, may be morewilling to sacrifice currentincome and insure in order toface less risk in the future(Morduch 1995).

Conversely, Wagstaff et al(2003) postulates that lowincome consumers couldpurchase health insurance. This

is premised on the confidencethat it can help reduce asset

sales and additional debt, whileincreasing the quality andquantity of available healthcarecosts when the need arises. The

assumption here is that,typically, rise in medicalexpenses as a result of healthissues leads to a decline in thecontribution to householdincome and home productionsuch as feeding and childcare.

Budget allocations to socialservices, including health werereduced by various Africancountries during the OPEC oilcrisis of the 1970s. Economiccircumstances in the 1980s led

to even bigger problems,thereby forcing various Africancountries to seek for loans andgrants from such financialinstitutions as the lnternationalMonetary Fund (lMF) and theWorld Bank. As a major fundingconditionality, thesegovernments were required toswitch from their socialist-based development policiestoward open-market reformsunder the StructuralAdjustment Programs(Mensah, 2006). Removal ofgovernment subsidies and

Volume 41 No.1 Jonuory - Morch, 20.l7

the group with more insurance.

Similarly, Finkelstein (2004)

found that areas whereMedicare caused the largest

increase in health insurance

coverage experienced fasterincrease in health careutilization.

With respect to the relationshi p

between insurance status and

health expenditures, mixedresults are obtainable.(Oppong, 2001) found that outof pocket health financingyielded detrimental results;health indicators plummeted as

health care became lessaccessible. A negativerelationship betweeninsurance coverage and healthexpenditures is also found insome studies (Jutting (2004) inSenegal; Jowett, et al (2004) inVietnam; and Yip and Berman(2001) in Egypt). Yet otherstudies found that out-of-pocket spending remains thesame or is even higher in thecase of the insured whencompared to the uninsured.Wagstaff et al (2007) explainedthis fact as a result of theinstitutional structure of healthcare in China, being that itfavors increased utilization andsubstitution toward moreexpensive services a ndtreatments.

Phillip et al (2012) examinedthe behavior of providers underthe NHIS in Ghana by assessing

the views of providers,insurance managers, insuredand uninsured clients. Theperceived opportunisticbehavior of the insured by

imposition of user-fees forsocial services such as

education and health care

became common req uirementsby the early 1990s (Mensah,

2008a). Out-of-pocketpayment for health careservices, which used to be theexception in the early post-

independence years in Africa,became the rule (Mwabu,2008; Vandemoortele et al.,

t9971.

2.2 EmpiricalReview

For convenience, the empiricalreview commences withHanratty (2005) that compa red

the health outcomes for thosethat adopted the universalhealth insurance in t962against those that adoptedsame later in L972 acrossCanadian Provinces. Findingsindicated that there was a

significant reduction in infantmortality rate of 4 per cent anda smaller reduction of 1.3 percent in low birth weight in theformer group. This outcomewas attributed due to thegovernment health insuranceprogram.

ln a study by Lichtenberg(2OO2l, the effect of Medicarewas examined by comparingthe health and health careoutcomes of people just belowthe age of 65, many of whomlack health insurance, to thoseof people just over 65, all ofwhom are covered byMedicare. More care andbetter health outcomes wereattributed by both studies to

providers was responsible forthe difference in the behaviorof providers favoring theuninsured. Besides, the delaY in

reimbu rsement also accountedfor providers' negative attitudetowards the insured. Thescheme was seen to bebeneficial and led to anincrease in the utilization ofhealth care services for theinsured and mobilized healthresources for facilities. Surveyfindings indicated that insuredand uninsured were satisfiedwith the provided ca re.However, most insured clientsreported verbal abuse, longwaiting times, not beingphysically examined anddiscrimination in favor of theuninsured and the cashcustomers. Providers also thinkthat the insured were abusingtheir services by frequentingthe facilities, and sometimesfaking illness to collect drugs fortheir uninsured relatives. This

had affected significantly thebehavior of providers towardsthe insured.

Particularly underscored inPhilip (2012) was the challengerelating to the delay inreimbursement. Managers andproviders agreed that theNational Health lnsuranceAuthority (NHIA) had notreimbursed providers foralmost six months. As a result,providers were not able topurchase drugs and non-drugsupplies and hence wereprescribing drugs for theinsured especially, to purchase

outside the facilities. The delayalso affected providers' ability

19

Volume 4l No.1 Jonuory - Morch, 2017

because of the feelings of beingcheated, especially by thesubscribers with nodependents and those whobelieved that available drugsare insufficient. Also, somerespondents were of theopinion that there was notmuch difference in healthcareservice delivery, before andafter the adoption of thescheme. The studyrecommended the need tointensify awareness campaignand expand coverage to reducethe burden of dependency onthe few contributors.

Employing multivariateanalytical tool, Riman andAkpan l20L2l also assessed thedemand for health servicewithin the context of serviceaccessibility, affordability and

equity in financing. They alsoreviewed the patterns of healthexpenditure in Cross RiverState, including financialcontribution of the public andprivate sectors, as well as otherstakeholders. High levels ofinfant mortality and morbidityrate was associated with highincidence of out-of-pocketpayment and wide disparityand inequality in incomedistribution. The study furtherhighlights the disparity inspatial distribution of healthfacilities, concentrated at theurban areas leading to poorservice delivery.

Mohammed et al (2074)conducted an in-depthperformance evaluation ofhealth insurance in Nigeriausing four Optimal Resource

to pay their casual employeeswho were not on government'spayroll. This also influenced thebehavior of providers wheresome of them preferred clientswho would make instantpayments for ca re

The contribution of NationalHealth lnsurance Scheme tohealthcare delivery and thechallenges against itssustainability in Ghana wasassessed by Agyemang, et al(2013). Findings showed thatthe scheme has improvedaccessibility of health servicesto general public, especially thepoor. The study however notedsome of the challengesconfronting the scheme toinclude delay inreimbursement, corruption,low level of awareness, weakinstitutional capacity andi nadequate h uman resou rces.

Among the few studies onhealth insurance scheme in

Nigeria is Sanusi and Awe(2009) that assesses theperception of the scheme and

the prospect of its sustainabilitywithin the context of thesocioeconomic characteristicsof health service consumersand providers in Oyo State.

While, several issues could beraised with respect to themethodology employed, suchas the very small sample size

and the bias tendency in thesocioeconomic characteristicsurveyed, findings could still bea ppreciated in termy ofperception signal-majority ofrespondent wanted theprogramme discontinued

Use (ORU) domains-providerpayment mechanism(capitation and fee-for-servicemethods), benefit package,administrative efficiency andactive monitoring mechanism.Applying logistic regressionanalysis, their findingsconcluded that fee-for-servicepayment method and claimsreview in the provider paymentand active monitoringmechanisms, respectively,performed weakly, according tothe perception of the providers.And, on the supply-side ofhealth insurance, a shortfall onthe supply-side could lead to a

direct or indirect adverse effecton the demand side of thescheme.

The review of literatures on theNHIS in Nigeria indicates thatthe developments, trend andassessment of the role, impactand sustainability of thescheme are only just evolving.To this extent it is pertinent tocontinue to explore itsunderstanding, with a bid tounravel the inherent complexissues relating to the scheme.The next section presents a

brief overview of nationalhealth policy in Nigeria as wellas some stylized facts.

3.0 Overview of the National

Health Policies in Nigeria and

Some Stylized Facts

Over the years, several nationalhealth policies have been put inplace for the provision andmaintenance of efficienthealthcare delivery system in

20

Volume 41 No.l Jonuory - Morch, 2017

was passed, that is, The 2014

National Health Act, whichestablished a basic health care

provision fund to be financedf rom Federa I Govern mentAnnual Grant of not less thanone per cent of its consolidatedrevenue fund, as well as grants

from international donorpartners and any other source.Out of the fund, 50 per centshall be used for the provision

of primary health andsecondary health care throughthe NHIS primary andsecondary health care facilitiesthrough the National Healthlnsurance Scheme (NHIS); 20per cent shall be used toprovide essential drugs,vaccines and consumables foreligible primary health carefacilities; 15 per cent shall beused for the provision andmaintenance of facilities,equipment and transport foreligible primary healthcarefacilities; 10 per cent shall be

used for the development ofHuman Resources for PrimaryHealth Care Delivery;5 per centfor Emergency MedicalTreatment. The fund is to beadministered by a committeeappointed by the NationalCouncilon Health.

4.0Stylized Facts

Figure 1 presents the total,private and public healthexpenditure as a percent ofGross Domestic Product (GDP)

in Nigeria. As the figureillustrates, the total healthexpenditure as percentage ofthe GDP in Nigeria was 2.8percent in 1995, and rose

Nigeria. The first NationalHealth Policy was adopted in

1988, with the goal to bringabout a comprehensive health

care delivery system driven byprimary health care that is

extensive, preventive,protective, restorative,rehabilitative and affordablethrough a functional referralsystem. The policy was geared

towards achieving health for all

by the year 2000 and definedthe roles and responsibilities ofthe three tiers of government,as well as Non-GovernmentalOrganizations (NGOs)participating in health careservices. The policy documentstipulated that a

comprehensive health caresystem should include maternaland child health care, as well as

fami ly pla nning services.

ln 2004, the National HealthPolicy was reviewed to focus onNational Health System andManagement, National HealthCare Resources, NationalHealth lntervention and ServiceDelivery, National Healthlnf ormation Systems,Partnership for HealthDevelopment, Health Research

and Healthcare Laws. Therevised policy was to enhancethe implementation of thehealth component of theNational EconomicEmpowerment andDevelopment Strategy(NEEDS), New Partnership forAfrican Development (NEPAD)

and Millennium DevelopmentGoal(MDGs).

ln 2014, a national health bill

steadily to a local peak, at 3.5percent in 1998, beforeexhibiting a downward trenduntil it reached the global

trough in 2002. The followingyear in 2003, the total health

expenditure increasedsubstantially to 4.0 percent ofGDP. Afterward, and through2014, the highest value andglobal peak was 4.5 percent ofthe GDP in 2007, but with a

downward trend that hoveredaround 3.5 percent of the GDP.

Private health expenditure as apercent of GDP wasconsistently higher anddisplayed more variations thanpublic health expenditure as apercent of GDP. The lowestvalue for the privateexpenditure was 1.8 percent in2002, while

highest value was in 2003. For

the public expenditure, thelowest was 0.6 percent of theGDP in 1996, and while thehighest was 1.5 percent in 2OO7

a n d 2008, res pective ly.Furthermore, except in 2000,when the private to publicexpenditure gap was 0.9percent of the GDP widenedthe gap ranges from 1.1 lo 2.2percent of the GDP from 1995

to 2OL4. For the ZO-year period

under study, the private-publicexpenditure gap averaged 1.5

percent ofthe GDP.

2L

Volume 4l No.l

Figure 7: Health Expenditure as o Percentoge of GDP

Source: CBN Stotistical Bulletin

Jonuory - Morch, 2017

public health expenditure aspercent of the GDP, at 0.9percent, worsened to 182 outof t87. However, Nigeriarecorded an improvement withrespect to the private healthexpenditure as a percent ofGDP, at 2.8 percent, attracting a

ranking of 74 among 787countries.

During the same period, at25.7percent, Nigeria ranked 173 outof t87, on public healthexpenditure as percent of totalhealth expenditure. Similarly, itranked 137 out of 187, onpublic health expenditure as

percent of total governmentexpenditure, at 8.2 percent.

The na rratives f rom th isstatistics demonstrate that,when compared to the rest ofthe world, less priority is placed

on health sector in Nigeria.

Table 1 also presents howNigeria ranks among othereconomies in 2014, withrespect to H ea lth sectorspending patterns. As the table

Further analysis of the publicand private health expenditurein the period under study (1995to 2074) revealed that theprivate expenditure

highlights, Nigeria ranks 162

among 187 countries, on thecontribution of total healthexpenditure to the GDP at 3.7percent. The ranking on the

Prrblic Heqllh Ex;rendilure As Percent of GDP

Hecrllh Expendlture As Percerrl of GDP

r Publlc Hecrlth Expenditt re As Percenl of Tolol HeollhExpendllrrre

Publlc Heqllh Expendilrrre As Percenl of TolcrlGovernrl.rerrl Expendlture

component represents thegreater share, at annualaverage of 77.5 percent. By thesame token, public expenditureaccounted for an average of

142

74

162

173

137

28.5 over the 2O-year period.This implies that the publicsector plays fewer roles inhealth care delivery (Figure 2).It is particularly interesting to

-hanqa,rx$ED

-a- F[lQ * -t,d

to

iar

LA

:15

ta

zl

29

L'

LE

cl

oe*{r8 s*{f lF#f #f ,f ,i.f {*lP&*

^-ar^*l*_1 /*:?-:--- -_-

/-=-+

.lftgu.!ks!dry{!-f!'!S, q W- &'c,..ae@l

o.9

2.4

Tolcr! Hecrlth Expendlture As Percenl of GDP 3.7

25.1

Source:

i.:ir.)1.:i:.!.1

r-i

tt

I"- .:j

22

a-2

Volume 4l No.l Jonuory - Morch, 2017

note that out-of-pocketspending as a proportion of theprivate health expenditure was

consistently and substantiallyhigher, averaging 95.0 percentover the period under study.

Similarly, the proportion of outof pocket to the public healthexpenditure was 68.0 percent.

This development reflects thepeople's response to the lack

of, or inadequate healthinsurance and care servicesprovision by the government.The implication is that people,either have no choice, or arewillingto payforthe services ontheir own.

4.1 National Health lnsurance

Scheme (NHISI in Nigeria

The National Health lnsuranceScheme (NHIS) was establishedunder Decree Number 35 of1999 Laws of the Federation ofNigeria. The objectives of theNHIS as articulated in theDecree areto:. ensure that every Nigerian

has access to good healthcare services

Figure 2: Public Vs Privote Heolth Expenditure in Nigerio

Figure 3: Out-of-Pocket, Private Vs Public Heolth Expenditure

care servicesimprove and harness private

sector participation in theprovision of health careservicesensure equitabledistribution of healthfacilities within theFederationensure appropriatepatronage of all levels ofhealth care, andensure the availability offunds to the health sectorfor improved services

The NHIS is structured intothree sectors, comprisingthe formal, informal andvulnerable sectors. Theformal sector has twocategories, namely: theFormal Sector Social Healthlnsurance Programme(FSSHIP) and VoluntaryContributors Social Healthlnsurance Programme

protect families from thefinancial hardship of hugemedicalbillslimit the rise in the cost ofhealth care servicesensure equitabledistribution of health care

costs among differentincome groupsmaintain high standards ofhealth care deliveryservices within the schemeensure efficiency in health

EPublkHeahhbe.as?6ofToblHeallfiExp. EPdrateHeahhEp.as!6ofToblHealdrEry.

HEATTH INvsPUBUC PRIVAIE

10096

80%

6W,

40Yo

2Wo

0%

Out -of-pocket (Fercent), Priyate vs. Public Health Expenditure

.5 94.7 94-5 95.0 .8 96.2 95.3 95.8 95-6 95.8 95.7 95.8 95.7 95.7 95.5 95.8 95.792.7 91.4

-,.? - 572.1 '''- 71.3 tO.Z ,).r\ - r:; ----s r?--,-l--

64.2 o''t

64.7 *.t *., tt.t 65-8 65.6

61.7 52.7

-Out-of-pod€t,

hivate thalth Expenditure

- -Out-of-podct Puhlic HElth Expenditure

r$srf Frdr$Fl#pdPdFldF1a@lOpnu$5+SzOd2olF2d1o1p1or} 1$I2o91p*

23

Volume 4l No.I Jonuory - Morch, 2017

(VCSHIP). The informalsector includes the Tertiarylnstitution Social Healthlnsurance Programme(TlSHlP), Community Based

Social Health lnsuranceProgramme (CBSHIP) andPublic Primary Pupil SocialHealth lnsuranceProgramme (PPPSHIP). The

third sector is for thevulnerable group, which is

designed to provide healthsecurity for permanentlydisabled persons aged and

children underfive.

4.2FORMALSECTOR

Under the Formal Sector SocialHealth lnsurance Programme(FSSHIP), enrolment ismandatory and coversemployees in the federal public

service and organized privatesectors with ten (10) or moreemployees Health care benefitsincludes: out-patientconsultancy, prescribed drugsas contained in the NHIS

essential drugs list, antenatalcare, maternity care for up tofour (4) live births for everyinsured person, post natal care,routine immunization ascontained in the NationalProgramme on lmmunization(NPl), family planningconsultations, mentaldisorders, eye examination andcare excluding prescriptionglasses/spectacles and contactlenses, and dental care (limitedto pain relief and treatment.Contributions are earnings-related and currently represent15.0 per cent of basic salary.

NHIS Programmes

!:: Fti;

i Ea ilh ai te F rLr,r lff:

!-'4if

Figure 4: NHIS ProgrommesSou rce : www. n h i s. gov. n g/

The employer pays 10 per centand the employee,5.0 per cent.Enrolment entitles the insuredperson, a spouse and four (4)

children less than 18 years ofage, to full health benefits. Thecontributions of two workingspouses cover the spouses andfour (4) children for each ofthem.

Enrollment under theVoluntary Contributor SocialHealth lnsurance ProgrammeVCSHIP is at the discretion ofwilling individuals or employerson behalf of employees in

organizations with less than tenstaff This is a non-profit healthi nsu rance programme coveringgroups of individuals withcommon economic activitiesrun by their members.lndividuals who are membersof socially cohesive groups,which are occupation-based,are free to join the Programme.The participants, based on theirhealth needs, will choose thehealth care benefits. A

prospective participant mustbe a member of an alreadyexisting Association. ThisAssociation, together withother associations, cometogether to form a user group.

There must be a membership ofat least 500 participants foreach user group to ensureadequate pooling of resources.Contribution is at a flat monthlyrate, depending on the healthpackage chosen by members ofthe user group. Eachcontributor will be given an

identity card with which he/shewill obtain health care from thechosen health care provider(public or private).

4.3 INFORMAL HEALTH

INSURANCE PROGRAMMES

The three programmes underthe informal sector are Tertiarylnstitution Social Healthlnsurance Programme (TlSHl P),

Community Based SocialHealth lnsurance Programme

;:1', !rl;1,

24

Volume 4l No.l Jonuory - Morch, 2017

(cBsHrPl

This is a non-profit healthinsurance programme for a

cohesive group of householdsor individuals (i.e. a

community) which is run by itsmembers. Membershipcomprises individual and othermembers of the community,will choose the health carebenefits. Prospectiveparticipant must be membersof a community comingtogether to form a user group.There must be a membership ofat least 500 participants foreach to ensure adequatepooling of resources.

The contribution is in cash, paid

as a flat monthly rate or atinstallments by participantsand the contribution rate willdepend on the health package

chosen by members. A seven-

member Board of Trustees,elected from among themembers, i.e., Chairman,Secretary, Treasurer and fourothers, will manage the fundsand run the user group formed.Each contributor will be given

an identity card with whichhe/she will obtain health carefrom the chosen health careprovider.

4.5 VUNERABLE SECTOR

There is also the VulnerableGroup Social Health lnsuranceProgramme (VGSHIP), which isdesigned to provide health careservices to the vulnerables,such as people with disability,senior citizens, children underfive years of dB€, prisoninmates, etc.

(CBSHIP) and Public PrimaryPupil Social Health lnsuranceProgramme (PPPSHIP).

The TISHIP is designed forstudents in Tertiarylnstitutions, with the purpose

to provide health insurance toNigerian students who cannotbenefit under other healthinsurance programmes.Through this mechanism,health care services are paid forfrom funds created by poolingof contribution of participatingstudents and institutions.Membership is for students(full and part-time) of federal,state and private tertiaryinstitutions. lnstitutions andstudents will contribute a

determined rate at the point ofpayment of school fees.Participating institutions shallremit the contributions to theNHIS Fund at the beginning ofeach academic year. The NHIS

will appoint a HealthMaintenance Organization(H MO) registered andaccredited by the Scheme forthe purpose of health care

management. The HMO shallbe responsible for paying theprovider for services renderedand shall also be responsible formaintaining quality assurancein the delivery of health care

services under the programme.

Students can be registered withaccredited health centers of thelnstitutions, or any public orprivate accredited primaryhealth care facilities of theirchoice

4.4 Community Based SocialHealth lnsurance Programme

4.5.1 Voluntary ContributorsSocial Health lnsuranceProgramme (VCSHIP)

This is a non-profit healthinsurance programme coveringgroups of individuals withcommon economic activitiesrun by their members.lndividuals who are membersof socially cohesive groups,

which are occupation-based,are free to join the Programme.The participants, based on theirhealth needs, will choose thehealth care benefits. Aprospective participant mustbe a member of an alreadyexisting Association. ThisAssociation, together withother associations, cometogether to form a user group.There must be a membership ofat least 500 participants foreach user group to ensureadequate pooling of resources.

Contribution is at a flat monthlyrate. The contribution rate willdepend on the health package

chosen by members of the usergroup. Each contributor will begiven an identity card withwhich he/she will obtain healthcare from the chosen healthcare provider (public orprivate).

4.5.2 The Vulnerable GroupSocia! Health lnsuranceProgramme (VGSHIP)

This is designed to providehea lth security for perma nentlydisabled persons, aged andchildren under five. The healthcare benefits cover commonillnesses. The beneficiary

25

Volume 4l No.l

Source: NHIS, Heod ffice, Abuja

Source: NHIS, Head Office, Abujo

As illustrated in Figure 6, thepattern and trend in thebudgetary allocation to theNHIS from 2005 to 2076.Allocation has been highlyirregular and inconsistent overthe years. From N860.16million in 2005, it increased toN1856.49 million in 2006, and

Toble 2: Selected Data on Notional health lnsuronce Scheme (NHli)

Jonuory - Morch, 2017

and since then has declinedconsistently through the years

to a low N54.3 million in 2016.This irregular pattern hasserious implication for thesustainability and credibility ofthe scheme in Nigeria.

Figure 5: Totol NHIS Enrolment

then declined steadily toN1155.7 million in 2009.Subsequently, budgetaryallocation rose and reached itsglobal peak, at N3601.25million in2077 before slumpingback to N1255.32 million a yearlater. ln 2OL3, allocationincreased again to N2599.78,

1105,221 2,5il,18i 2,76114t 2B32,64!1,l4gp7t 1,ffi7^g1i 3,125"882 t,MtAti 3,647,69! 3p4tgt:l 4,192J5i615,69

I lt/t tnr I (r, nn314,15( fi?,771 $9,4S l,140,59l ,,,417 )82 1,525/63 t728/,tl 1.889,95! 2,035,591 \162;141

, n2nnt,t rtf,fni I mnn?,302,53t 561,205 miB lp64,5il 1\126,16/i 1,501,11! lr&$,03; l,?il,74t 1B0512!

, nE7 rot , r0, mr 7 07772',L13632" 2,565,54143t,[lt 814,053 1,174,69! 1^553,85! t,t79/lti 1939,151 2,7U,01t

79 528 31 27 26 29 28 70 6l 76 n9f500 43 175 196 24t 325 5,187 t616 5,99 7,420 10,710

4t652 16,243 19,179 17,735 n,4n 96t 941 898 8fl 582 569

0 0 0 0 0 0 E 20 24 8 t2 4t

0 158 4,40 1,481 23tt 2,9n0 0 0 0 0 0

0 0 0 0 0 0 0 40 0 0 0

IG & rot za.:tIE m rso u!, ailr IG' 41lt r[attfil *.r71 EL'' TJ'IBI r.f,rlr r'.,r.r r.nu,o t-elr rJas tlrlr r,qa tI8,rtE ltr !u"a

Total EnrcImcrrg2ffito 2[116lr5q'E

rpqtro

!,5q,o0

LOGqOE

,a+:

o

26

"mt

Volume 41 No.1 Jonuory - Morch, 2017

2,59:r,7fl3

\72s,44O

7,255,3261,t55,75.4

3,@r,2il

223

ffi{t,L6L

3r,2,O58

Figure 6: BudgetaryAllocation to NHIS, 2005 to 2016

Sou rce : www. bu d g etolfice. gov. ng/

TABLE 3: ACTIVE HEATTHCARE PROVIDERS (HCPs) BY STATE$ AS AT JUNE 2016

55 1-5 t47 a

103 2-7 204 2-93'. -.:::-. :.$....:'-. '':1. '.,.:*41*.:..._ **:r..-.,.:.. ,_ .....:*,*€..,._; t

24 o.6 62 o-9..:g]il:,:',,.1':.7:t;:7a:liw:F-ii41,rihw&ia@igat&fi$*rltj1r1,jtr*,@e

_'.64 a-7 111 1-6

4,4 2-2 151 2-2rir':Bry....e, .: - " (I.r ao €.8

a32 3,5 255: o-?, 61

2-O a96

3-7:' ',,s$,t-. ''ri

7S 2-8

9a 2-6!al:..,,tlj'3:,;i',;.....,&w4*.g,<1,:1,1ll:.]l'a'.:.9..

s7 0-a

o-4 55 o_8

1-9t:.;€#:,:,i,a,.:,...:,,.,,,,.!:t,...*aXF?:r,*FAE!i!i+frj... .._oE{. , : . _:.!. -.,..*.?, ..5,.... ,,,:+.

a7 L 2-4.'i't.:.r:=;1!:=,: :.@*&* -*- -r:jr!r4 0-6...dlr,+i .,r*414q6 .-r.::f# q'i. i.'ttr{: ....i..-..

437 2-O

L4 o-4

3-2illiiral€iit ffi :.*xiii'!]*:

a-5 a4 L-2

L34 3_6 156 2-2a=r ':!&€:.::=:''-=

1,352 t-4 90

7a 2-L 7-64 2-3

55 1-5 59 o-a

No of PrimaryHCP

Prirn.ary liCP A. ".-

ol No <tf Scrorrd j!rV I lC l, SF. rrrr.lar V rra l. /li'ri..tt Nnll.r.ril

St ate

22 o.6 50 o-7

27

Volume 41 No.1 Jonuory - Morch, 2017

Similarly, not allthe states havedomesticated the State Healthlnsurance Scheme, asstipulated in the NHIS Act. OnlyKwara and Lagos states have

done so, with Kwara having theCommunity Based State Healthlnsurance Programrnes(CBSHIP). Lagos has recentlyenacted its own variation ofNHIS law.

There are not enough healthcare providers (HCP), such as

the medical practitioners(doctors, nurses and otherparamedics professionals),who plausibly not willing toregister or participate in thescheme. This is a reflection ofthe apathy toward the scheme,due to the shallow knowledgeand understanding of theworkings of insurance system.

This is further compounded bypoor and inadequate medicalor other support infrastructure.The implementation of thescheme is also constrained by

some institutionalarrangements that allows forconflict of interest orresponsibilities. There appearsto be non-clarity of mandatebetween NHIS and HMO. For

example, NHIS, which is a

regulatory body, doubles as theimplementer of the scheme.Similarly, the membership ofthe HMO, with a voting power,in the NHIS board that regulatesHMO constitutes conflicts ofinterest. This creates theperception of weak regulatoryeffectiveness, abuse of rulesand standa rd, i nefficiency.The Nigerian workforce has theconcern that the benefit

5.0 Challenges and lssues

relatingto NHIS in Nigeria

As it is in Nigeria, NHIS stillgrapples with the usualteething challenges usuallyassociated with theimplementation of any newinitiative. The scheme is not yetuniversally accepted orpopular, and currentlybedeviled with poor perceptionin performance and quality ofservice by the people that thescheme is meant to support.This is attributable to lack ofunderstanding, despite theefforts by the authorities tomake it succeed.

Another major challenge is

concerned with the religiousand cultural dimension thatnegativeiy affects theperception about healthinsurance. Culturally, someperceive that preparing forunforeseen unfortunate eventsis believed to be a self-fulfillingprophesy of an invitation to ill-luck or ill-health.

Also, there is a challenge of lowenrollment and inclusion acrossthe country. Membership is

majorly limited to the Federal

Government workers. Theenabling act does not makesubscription and participationmandatory for the privatesector, unlike the Pension Act.ln addition, it is usually difficultto identify the targetpopulation and how best toguarantee that the interventionreaches the targetedpopulation in a timely andefficient manner.

package is limited in scope. lnaddition, the Nigeria labourCongress (NLC) and TradeUnion Congress (TUC)continued to be againstemployee payment, insistingthat the Federal Governmentshould bear the full cost ofcapitation. There is also theclaim management of thescheme has been afflicted withmistrust, especially in a corruptenvironment where citizenshave developed the anxiety orsuspicion and propensity ofbeing cheated.

Sustainability of the schememay be in question because ofinadequate funding, especiallywith the low budget provisionsin recent times. The schemerelies heavily on governmentappropriation, implying thatdwindling government reven uecould portend adverseimplication for theimplementation agenda of thescheme. The attendantinsolvency tendency or signalcould be a disincentive toparticipating HCP, fuel furtherunwillingness on the part ofpopulace to register for thescheme.

Entwined with the above is theconcern that allthe NHIS fund islumped and held in theTreasury Single Account (TSA)

of the Federal Government.This could pose furtherproblem given that the Fund isnot a revenue generation andcould not be an accrual to thegovernment purse. The schemehas also experienced orconfronted with "trust issue."

28

Volume 4l No.l Jonuory - Morch, 2017

functions, as well as enablingthe policy and institutionalenvironment. Policyconsideration is particularlyunderscored to facilitate theeffective performance andutilization of the scheme toattain the desired objectives ina sustainable basis.

Steps should be taken toreposition the NHIS for optimalservice delivery. Therelationship with the laborunion should be engendered tomake stewardship credible andpurposeful in a bid to addresscredibility issue.

The success of any insurancescheme is premised on the lawof large numbers, hence toensure sustainability, largememberships enrollmentshould be facilitated to createlarge pool of fund over a largepopulation set. Similarly, toprevent fund misappropriationor related risk, it may benecessary to remove the NHIS

fund from the Treasury SingleAccount (TSA), as beingcanvassed by the NationalAssembly and otherstakeholders.

The negative perception andattitudinal cultural challengerelating to the lack ofunderstanding of importanceof insurance could be

H MO had been recentlyinvolved with an incidence ofbreach of trust, regardingallegation of N90 scam or fraud.This development underpinnedthe endemic and systemiccorruption ravaging all thesectors of the economy,propelling the negativeperception and attitude againstthe effective implementation ofNHIS.

5.1 PolicyRecommendation/WayForward

Health service delivery, being a

public good, is understood tobe a core responsibility of thegovernment. To improveaccess, inclusion and qualitydelivery the political will andcommitment to universalhealthcare service delivery is ofutmost importance. Yet, thegovernment alone cannot solveall the problems; there is theneed to encourage full privatesector participation andinvestment, as well as thecoalition of other interests,such as Non-GovernmentalOrganizations, Advocates andFoundations, among others.

The Authorities are urged todeepen an enhancedimplementation process,especially with respect to theregulatory and oversight

addressed by embarking onserious campaign, sensitizationand education about NHIS. This

will help in promoting positiveperception and acceptance ofthe scheme, while reducingskepticism and poorexpectation. By the sametoken, authorities are alsourged to safeguard againstcorruption, be moretransparent and engendertrust, which is the backbone ofinsurance system.

Federal government authorityis urged to encourage all statesto domesticate the insurancescheme in their respectiveterritories, and especiallystrengthen the community-based insurance. The necessarytechnical assistance andcapacity development couldalso be provided for the statesto assist in expediting thelaunching of the scheme.

Finally, it is criticalto establish aNational Health lnsurance Fund(NHIF), independent of theNHIS to append credibility andengender transparency in theimplementation of the scheme.Similarly, authorities are also

u rged to reconsider theimplication of the HMOrepresentation with a votingright on the board of the NHIS.

29

Volume 41 No.l Jonuory - Morch, 2017

REFERENCES

A. J. W. Goldschmidt: Der'Markt'Gesundheitswesen. ln: M. Beck, A. J. W Goldschmidt, A. Greulich, M.Kalbitzer; R. Schmidt, G. Thiele (Hrsg.): Management Handbuch DRGs, Hrlthis/ Economica, Heidelberg,1. Auflage 2003 (ISBN 3-87081-300-8):5.C3720/7-24,with3 revisions/additionaldeliveries until2012

Agyemang, K., Adu-Gyamfi, A and Afrakoma, M (2013), "Prospect and Challenges of lmplementing a

Sustainable National Health lnsurance Scheme: The Case of Cape Coast metropolis, Ghana,"Developing Countries Studies, Vol. 3, No. 12 (140-148)

Annear, P. 1., D. Wilkinson, et al. (2007). Study of Financial Access to Health Services for the Poor in

Cambodia. Phnom Penh, Cambodia Ministry of Health, WHO, AugAlD, RMIT University.

Annual Report (2010) National Health lnsuranceScheme (NHIS), Ghana

Cameron AC, Trivedi P, Milne F, Piggott J. 1988. A micro econometric model of the demand for healthcare and health insurance in Australia. Review of Economic Studies LV: 85-106.

Carrin G., D. Evans., and K. Xu (2007) Designing Health Financing Policy towards Universal Cverage.

Bulletin of World Health Organisation. Vol 85(9)

Charles E. Phelps (7997), Health Economics, 2"0 Edition, Addison-Wesley Educational Publishers, lnc.,

United States (pages 344-345)..

Das, Jishnu, Jeffrey Hammer and Kenneth Leonard. 2008. "The Quality of Medical Advice in Low-I ncome Co u ntries." Jou rna I of Economi c Perspective s, 22(21: 93-7L4.

E. REINHARDI UWE. "A German lmport That Could Help U.S. Health Reform". The New York Times.

Retrieved 25 May 2013

Finkelstein, A. and J. Poterba (2004). "Adverse Selection in lnsurance Markets: Policyholder Evidencef rom the U. K. An n uity Ma rket. " J o u rna I of Pol itica I Economy tL2(7l,.

Germany Country Profile, Library of Congress Federal Research Division (December 2005). This articleincorporatestext from this source, which is in the public domain.

Government of Ghana (2003); The National Health lnsurance Act (Act 650, 2003), Ghana

lnternational Labour Organization (2005) lmproving Social Protection for the poor: Health lnsurance inGhana, lLO, Accra

John A. Nyman: Health Affairs 23, no.5 (2O041:79a-199; ls 'Moral Hazard' lnefficient? The PolicyI mplications of a New Theory

Jowett, M., A. Deolalikar, P. Mattinsson. 2004. "Health insurance and treatment seeking behaviour:evidencefrom a low-income country." Health Economics 13 (9):845-57.

30

Volume 41 No.l Jonuory - Morch, 2017

JUtting, J. P. (2004). "Do Community-based Health lnsurance Schemes lmprove Poor People's AccesstoHealth Care? Evidence From RuralSenegal." World Develooment 32(21:273-288

Laws of the Federation of Nigeria 1999, Nigeria National Health lnsurance Scheme Decree No.35 of1999, Nigeria

Lichtenberg F.R (2002), "The Effects of Medicare on Health Care Utilization and Outcomes." ln: GarberAM, editor. Frontiers in Health Policy Research. Vol.5. Cambridge, MA: MIT Press.

MV. Pauly, "Moreon MoralHazard,"Journalof Health Economics2, no.1(1983):83.

Mensah, J. (2008a)- "World Bank" in Philip O'Hare (ed.) lnternational Encyclopedia of Public Policy-Governance in a globalAge. Volume 1: Global Governance and Development (Perth:GPERU), pp.434-449

Mensah, J., Oppong-Koranteng, R., Frempah-Yeboah, K. 2006. "Understanding Economic Reforms: TheCase of Ghana" ln Joseph Mensah (ed.) Understanding Economic Reforms in Africa: A Tale of SevenNations. Basingstoke: Palgrave Macmil la n, 95-130.

Metiboba. S. (2011); "Nigeria's National Health lnsurance Scheme: The Need for BeneficiaryParticipation" Research Journa I of I nternationa I Studies, N igeria

Mohammed et al. (2014), "Performance Evaluation of a Health lnsurance in Nigeria Using OptimalResource use: health Care Providers Perspectives, BMC Health Services Research, 74;L27( http://www. biomedcentra l.com/ L427 -6963 / L4l L27 |

Morduch J. 1995. lncome smoothing and consumption smoothing. Journal of Economic Perspectives9:103-14.

Mwabu G, (2008) Schultz Pl StraussJ. "Health Economics for Low-income Countries." ln: Handbook ofDevelopment Economics. Amsterda m : Elsevier.

National Development Planning Commission, Ghana (2009); 2008 Citizens Assessment of the NationalHealth lnsurance Scheme, GPRS ll (2006-2009), Accra, Ghana

NationalHealth lnsuranceScheme (2OLzl;Summaryof activities, reportpreparedforCBN, NHlSAbujaNational Health lnsurance Scheme Decree No.35 of 1999 Laws of the Federation of Nigeria

National Health lnsurance Scheme. Corporate HQPlot 297, Shehu Yaradua Way, UtakoNyman JA. 1999. The value of health insurance: the access motive. Journal of Health Economics 18:t4t-52.

Omoruan A.l; Bamidele A.P; Phillips O.F, (2009); Social Health lnsurance and Sustainable HealthcareReform in Nigeria, Ethno- Med 3(2):105-110(2009), Nigeria

Oppong, J.R. 2001. "Structural Adiustment and the Health Care System" in Kwadwo Konadu-Agyemang (ed.), IMF and World Bank Sponsored StructuralAdjustment Programs in Africa: Ghana'sExpe rie nce, 1983-1999. Al de rshot : Ashgate, 357 -7 O.

31

Volume 4l No.l Jonuory - Morch, 2017

Osuoroji E. C (2001); Rescuing Health Care Delivery, Journal of the University of Nigeria, College of

Medicine, Nigeria

Phelps CE. 1973. Demand for health insurance: a theoretical and empirical investigation. Santa Monica,

CA: RAND Corporation.

Philip A.D and Alexander S.L. (20L20, The national health insurance scheme: perceptions and

experiences of health care providers and clients in two districts of Ghana.

Primarolo D., Mallock-Brown, M., and Lewis, I (2009), "Health is Global: A UK Government Strategyfor

2008 - L3:' The Lancet 373, lssue 9662 (February 7, 2009). Retrieved online at

www.thelancet.com/journals/lancetlafticle/PllSO140-6736(08)61820-6/fulltext.

Rao, S K., S. Selvaraju., S. Nagpal., and S. Sakthivel (2005) Financing Health in lndia.

Riman, H. B. and Akpan, E. S. (2012), "Healthcare Financing and Health Outcome in Nigeria: A State

Level Study Using Multivariate Analysis," lnternational Journal of Humanities and Social Sciences,

Volume 2, Number 15,August 2072(p296-308)

Sanusi, R.A and Awe, A. T. (2009): Perception of National Health lnsurance Scheme (NHIS) by

Healthcare consumers in Oyo State, Nigeria. Parkistan Journal of Social Sciences. 6(1): 48 -53

Schoemaker P. 7982. The expected utility model: its variants, purposes, evidence and limitations.

Journalof Economic

Van Damm€, W., L. V. Leemput, et al. (2004). "Out-of-pocket Health Expenditure and Debt in Poor

Households: Evidence from Cambodia." Tropical Medicine and lnternational Health 9l2l:273-280.

Vandemoortele,J., D. Broun, D and R. Knippenberg.7997. Epilogue. lnternational

Wagstaff A. 2000. Research on equity, poverty, and health: lessons for the developing world.

Washington, DC: World Bank, Human Development Network.

Wagstaff, A., E. van Doorslaer, and N. Watanabe. 2003. "On Decomposing the Causes of Health Sector

lnequalities, with an Application to Malnutrition lnequalities in Vietnam." Journal of Econometrics

t72l7l:219-27.

Wagstaff, Adam, Magnus Lindelow, Gao Jun, Xu Ling, and Qian Juncheng. 2007. "Extending Health

lnsurance to the Rural Population: An lmpact Evaluation of China's New Cooperative Medical Scheme."

w

Volume 4l No.1 Jonuory - Morch, 2017

Pol icy Resea rch Worki ng'Pa per 4150, World Ban lC Wa sh i ngton, DC.

WHO, UNICEF and UNFPA. Geneva: World Health Organization

Willard G. Manning M. Susan Marquis (1989) Health lnsurance: The Tr:ade-Off Between Risk Pooling

and Moral Hazard -- Prepared for the National Center for Health Services Research and Health Care

TechnologyAssessment

World Health Organization Statistical lnformation System: Core Health lndicators{2014)

Yip;W.; andP. Berman. ZOOL. "Targeted health insurance in a low irrcome country and its impact on

access and equity in access: Egypt's school healttrinsurance." Health Economics 10 (3): 2O7-2O.