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Year : 2010  |  Volume : 13  |  Issue : 4  |  Page : 421-426

Knowledge and attitude of civil servants in Osun state, Southwestern Nigeria towards the national health insurance

1 Department of Community Medicine, College of Health Sciences, Ladoke Akintola University of Technology, Osogbo, Osun State, Nigeria
2 Global HIV/AIDS initiative Nigeria (GHAIN), Nigeria

Date of Acceptance27-Jan-2010
Date of Web Publication5-Jan-2011

Correspondence Address:
A I Olugbenga-Bello
Department of Community Medicine, College of Health Sciences, Ladoke Akintola University of Technology, Osogbo, Osun State
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Source of Support: None, Conflict of Interest: None

PMID: 21220858

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Introduction: In Nigeria, inequity and poor accessibility to quality health care has been a persistent problem. This study aimed to determine knowledge and attitude of civil servants in Osun state towards the National Health Insurance Scheme (NHIS).
Methodology: This is a descriptive, cross sectional study of 380 civil servants in the employment of Osun state government, using multi stage sampling method. The research instruments was pre-coded, semi structured, self administered questionnaires.
Results: About 60% were aware of out of pocket as the most prevalent form of health care financing, while 40% were aware of NHIS, television and billboards were their main sources of awareness, However, none had good knowledge of the components of NHIS, 26.7% knew about its objectives, and 30% knew about who ideally should benefit from the scheme. Personal spending still accounts for a high as 74.7% of health care spending among respondents but respondents believed that this does not cover all their health needs. Only 0.3% have so far benefited from NHIS while 199 (52.5%) of respondents agreed to participate in the scheme. A significant association exists between willingness to participate in the NHIS scheme and awareness of methods of options of health care financing and awareness of NHIS (P<0.05)
Conclusion: Poor knowledge of the objectives and mechanism of operation of the NHIS scheme characterised the civil servants under study. The poor knowledge of the components and fair attitude towards joining the scheme observed in this study could be improved upon, if stakeholders in the scheme could carry out adequate awareness seminars targeted at the civil servants.

Keywords: National health insurance scheme NHIS, out of pocket expenses, awareness

How to cite this article:
Olugbenga-Bello A I, Adebimpe W O. Knowledge and attitude of civil servants in Osun state, Southwestern Nigeria towards the national health insurance. Niger J Clin Pract 2010;13:421-6

How to cite this URL:
Olugbenga-Bello A I, Adebimpe W O. Knowledge and attitude of civil servants in Osun state, Southwestern Nigeria towards the national health insurance. Niger J Clin Pract [serial online] 2010 [cited 2023 Feb 2];13:421-6. Available from:

   Introduction Top

The sustainability and viability of a country's economic and social growth depend largely on vibrant healthcare sector of that nation. While health care needs is increasing, government expenditure on health in developing countries is declining, [1] and government expenditure on health in sub-Saharan Africa has severally been described as being inadequate, insufficient, inequitable and unsustainable. [2] The burden of paying for health care has been a performance indicator for assessment of national health systems according to the World Health Report [3]

Most Americans, approximately 86%, have health insurance provided by their employer (64.1 %), and the government (24.2%), while some have self-insurance through the private market. [2] The challenge involves covering the 39 million Americans who find it difficult to obtain affordable health insurance. [4] In Nigeria, health care delivery system is characterized by weak response toward access to health care services for vulnerable members of the society, especially women and children, and the total expenditure on health care as percentage of GDP is 4.6, while the percentage of federal government expenditure on health care is only about 1.5%. [5]

Majority of Nigerians cannot afford and access health care services because it is beyond their reach, statistics puts 70.2% of Nigerians as living below the poverty line of USD 1.00 [5] per day which encourages the vicious cycle of poverty, ignorance and disease. There is high dependence and pressure on government for funding of health services, a situation which the government has objectively not lived up to in recent years. Government expenditure on health is USD 3.40 per capita as opposed to the World Developmental Report recommendation of USD 34 per capita [6] . The continued stagnating healthcare system in Nigeria is of great social and economic consequence, as the deregulation of healthcare financing and supply in Nigeria has further shifted the healthcare system towards competitive market ideals. [7]

It was found that despite the increase in most components of health care spending in Nigeria, the health status of the average Nigerian and the condition of health infrastructure has not improved appreciably. [8] Thus an urgent need for a sustainable and equitable strategy to eliminate physical and financial barriers to health care is highly desired. The idea of a National Health Insurance Scheme was first considered by the authorities in 1962 but successive governments lacked the political will to actualize this dream, not until 43 years after that the scheme took off. To sustain the various health policies and strategies of government towards a reformed health system of a country, an adequate financing mechanism becomes imperative.

NHIS in Nigeria has been characterized by a lot of misconceptions, fears about workability of the scheme, concerns as regards workers financial contribution to the scheme overtime and the sincerity of government in financing workers in the formal sector among others. This study therefore aims to assess the knowledge and attitude of civil servants in Osun state towards the NHIS in Nigeria. This will serve as baseline for further recommendations to stakeholders in the scheme, and ultimately help in organizing and managing the scheme for better acceptability to the workforce.

   Materials and Methods Top

This was a descriptive cross sectional study among civil servants in Osun state, carried out with the use of a pre-coded, pre-tested, semi-structured, self administered questionnaire. In Osun State, there are a total number of 18,653 Government workers, out of these, about 9,129 work in Osogbo. The State government secretariat accommodates about 3,240 civil servants with one health centre made available for the workers. Workers not in government payroll and those whose appointment has not been confirmed were excluded from this study. All workers in the employment of Osun state government constitute the reference population, those in Osogbo constituting the target population while sampled workers constitute the study population.

With a calculated sample size of 344 using Leslie Fischer's formula, [9] a total of 400 government workers were sampled using a multi stage sampling method. In stage I, four out of twelve ministries were chosen at random using simple balloting and questionnaires were allocated to each ministry equally. In stage two, four out of eight blocks in a ministry were chosen using simple balloting. In stage three, all workers met on duty in the offices as at the time of study were conveniently administered the research questionnaires until it was exhausted. Verbal informed consent was obtained from individual participants with assurance of confidentiality. Questionnaires were pre-tested among 20 government workers in neighboring Oyo state.

Study variables include socio-demographic data, knowledge and attitude towards NHIS and graded perceptions towards starting the scheme. Data was analyzed using the SPSS software version 15, and association were tested using chi-square test at a level of significance of p<0.05.

   Results Top

Three hundred and eighty completely filled questionnaires were analyzed out of the 400 taken to the field. [Table 1] shows that 71(18.7%) of the respondents were within the age group of 18 to 29 years, about 156(41.2%) within 30 to 39 years, about 110(29.0%) within 40 to 49 years and 42(11.1%) were within the age group of 50 to 59 years. The mean age of respondents was 45.2(±1.6) years. One hundred and forty respondents (36.9%) were males while 239(63.1%) of respondents were females. The mean number of dependants was 6.1 (±3.0) per family while the mean number of children was 3.4 (±1.5) per family.
Table 1: Socio-demographic Characteristics of Respondents by Gender.

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[Table 2] shows that one hundred and seventy one (45.1%) of respondents believe that health care system needs to be properly funded, and 47(12.4%) believes that individuals should pay for expenses incurred. About 60% are aware of out of pocket as the most prevalent form of health care financing. About 34.15% believes that NHIS should be made compulsory for all workers while another 34.15% believes that government should take total control of the scheme. About 40% are aware of NHIS with television and billboards being their main sources of awareness. However good knowledge of components of NHIS, its objectives, and about who ideally should benefit from the scheme is very low. Personal spending still accounts for as high as 74.7% of health care spending among respondents but respondents believed that this does not cover all their health needs. Only 1(0.3%) have so far benefitted from the current NHIS [Table 2].
Table 2: Perception on Healthcare Financing.

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[Table 3] shows the attitude of the respondents to the scheme in terms of promoting improved health care, health facilities, efficiency in health care and promotion of equity among the workforce irrespective of take home pay. About 199(52.5%) of respondents agree to participate in the scheme. A significant association exists between willingness to participate in the NHIS scheme and awareness of methods of options of health care financing (P<0.05) and awareness of NHIS (P<0.05)
Table 3: Distribution of respondents by attitude towards NHIS.

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   Discussion Top

The purchasing power of a client is an important determinant of accessibility to health care services which to a large extent depends on income. As the WHO suggest that not more than 5% of individuals' income is supposed to be spent on health, [10] any attempt to spend more than 5% of ones income on health signifies a sort of deprivation to health care services. [10] About three quarters of respondents in this study fund their health care through personal or out of pocket expenses, and about one third were not satisfied with present mode of payment. This agrees with another study in which out of pocket expenses were the main source of health care financing, and when not affordable, many clients turn to patent medicine stores and traditional care." This is also comparable to Vietnam, where out-of-pocket payments were estimated to constitute as much as 80% of total health care expenditure in the years 2000, [12] and the share of households facing catastrophic health care expenditure may be as high as 10%. [13] Out of pocket expenses no doubt will stress the financial capabilities of families and her ability to attend to other issues of need and priorities, in some cases it may constitute social burden to the family.

About two thirds of respondents in this study believe that the present funding does not adequately cover all required health expenses, and not even all dependants. This is in support of a South African study, where the majority wants health care system to provide everyone with all the needed health care and medical services. [14] In the present NHIS in Nigeria, basic curative care were covered, thus neglecting preventive health matters. In addition, it caters less for rehabilitative health care, for family members outside the first wife, for the first four children and for hospital admissions outside the first twenty one days. This indirectly still constitutes financial burden to affected families most especially in the poverty ridden sub Saharan African region of the world, where polygamy and preference for children persists.

About two-fifth of respondents in this study were aware of NHIS with the TV and billboard being their major sources of awareness. This conforms with other studies that showed good (32.5%) and fair (34.5%) awareness of the scheme [15] This figure is however low when compared to another Nigerian study on medical health workers that found out that a majority or good number of studied respondents were aware of the scheme. [14],[16] The electronic media-Radio/TV (82.1%) and Newspapers (29.1%) were their main sources of information on the scheme in these studies. [17] Although some of these studies were carried out on health workers in employment of government which may explain the relative high awareness pattern, situation is a bit different now with the NHIS scheme in Nigeria compared to when it started few years ago.

In the early days of introduction of the scheme, a lot of awareness campaign was carried out by government and Health maintenance organizations (HMOs) to sensitize people's interest in joining the scheme. This trend seems to have died down now, and much advertisement exists between HMOs and Employers. This is coupled with a lot of hitches that characterize the scheme in the beginning, which dampened the interest of many people in the scheme. However the fact that an average Nigerian household has access to a television may explain the reason why this electronic media is the most common source of information in most of the studies.

Less than one third of respondents in this study knowing the objectives of the scheme agreed with another study in which only (38.8%) had good information on its objectives. [18] One third of respondents were aware of beneficiaries of the scheme. This is better compared to a study in which only 12.2% of the respondents knew who the scheme will cover. [14] About half of respondents in this study believed that the scheme will improve efficiency of the health system and well being of participants. This is however lower compared to a study in which 88.1% believed that the scheme will improve health care in Nigeria. [14] The series of knowledge exhibited by respondents in this study agreed with the low awareness of NHIS among studied respondents. Thus, in the formal sector participation may be improved if employers comply with the directive making the scheme compulsory for all employees, in which case they will be keenly interested in facts and fallacies surrounding the operations of the scheme. [18]

About 0.3% of respondents in this study have benefited from the NHIS scheme, while a little over half are willing to participate in the scheme. This is very low compared to other studies in which 87.1% [17] were willing to participate in the scheme, and another in which 91.4% [15] were willing to participate in the scheme. This may be as a result of many factors including poor detailed knowledge of the objective and components of the scheme among the civil servants as observed in this study. A significant association exists between willingness to participate in the NHIS scheme and awareness of methods of options of health care financing (P<0.05) and awareness of NHIS (PO.05).

   Conclusion and Recommendations Top

The NHIS scheme has finally taken off in Nigeria, but with a low awareness of the operations, components, objectives and mode of operation of the scheme among the formal sector or civil service. Many workers are however willing to participate in the scheme, thus, government and other stakeholders in the scheme need to continue to organize awareness programmes that will sustain this interest among workers in the formal sectors. Information should include telling them all about the scheme; dispel their fears about the scheme as well as ensuring that no loop holes exist in organizing and managing the NHIS scheme in Nigeria.

Intensified campaign should emphasize on the objective, component and workings of the scheme, employing the mass media as a way of reaching a vast majority of the workforce.

   Acknowledgement Top

The authors wish to acknowledge the cooperation of the members of staff of the office of the head of service, Osun state secretariat, for providing necessary information, also the medical students who helped in the data collection.

   References Top

1.Hoare G Policies for financing the health sector. Health Policy and Planning. 1987; 2 (1): 1-16.   Back to cited text no. 1
2.Werner D. The build up to the crisis. Contact. 1995;141:1-4.   Back to cited text no. 2
3. WHO. The World Health Report 2000, Health systems: improving performance, Geneva, WHO, 2000.  Back to cited text no. 3
4. John T. Affordable Health Insurance for All Is Possible by Means of a Pragmatic Approach. Am J Public Health. 2003; 93(1): 106109.   Back to cited text no. 4
5.Ronald JV. Financing Health Care in Sub-Saharan Africa. Westport CT: Greenwood Press, 1993:232.   Back to cited text no. 5
6. WHO. Country cooperation strategy: Federal republic of Nigeria, 2002-2007. Geneva Switzerland: WHO; 2007  Back to cited text no. 6
7.World development report (2005).World development indicators: country: Nigeria. Accessed on 24 April, 2008. Available at ext/nigeria extn.   Back to cited text no. 7
8. Lloyd AA. Government health care spending and the poor: evidence from Nigeria. International. Year: 2009;36(3):220 236   Back to cited text no. 8
9.Olawuyi JF. (ed) Biostatistics: A foundation course in Health sciences; formular for calculating sample size. 1 st edition, Toyin Alabi printing Co. 1996:114-115.   Back to cited text no. 9
10.Ajilowo J, Olujinmi B. Accessibility of rural dwellers to health care facilities In Nigeria. The Owo region experience. Pakistan Journal of social sciences.2007;4(l):44-55   Back to cited text no. 10
11.Onwujekwe BU. Socio-economic and geographic differentials in costs and payment strategies for primary healthcare services in Southeast Nigeria. Health Policy. 19X; 71 ( 3):383-397   Back to cited text no. 11
12. World Health Organization. Health systems: improving performance. World Health Report 2000. Geneva. 2000.  Back to cited text no. 12
13. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJL. Household catastrophic health expenditure: a multi country analysis. The Lancet. 2003; 362:111-117   Back to cited text no. 13
14.Akpala C, Onuekwusi N. Awareness and Perception of National Health Insurance Scheme among Nigerian Health Care Professionals, 1988;   Back to cited text no. 14
15. Banjoko SO, Banjoko, NJ, Omoleke IA. Knowledge and perception of telemedicine and E-health. Available at Accessed 15 th February 2009.   Back to cited text no. 15
16. Louis, DA, Peter SA. Orthodontic attitudes toward national health insurance. American Journal of orthodontics. 1979;75 (5):562-568.   Back to cited text no. 16
17.Sabitu K, James E. Knowledge, attitudes and opinions of health care providers in Minna town towards the national health insurance scheme (NHIS). Annals of Nigerian Medicine. 2005;1(2):9-13.   Back to cited text no. 17
18.Ibiwoye A, Adeleke IA. Does National Health Insurance Promote Access to Quality Health Care? Evidence from Nigeria. The Geneva Papers. 2008;33(2):219-233.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3]

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