|ORIGINAL RESEARCH REPORT
|Year : 2016 | Volume
| Issue : 3 | Page : 122-131
National health insurance scheme: Are the artisans benefitting in Lagos state, Nigeria?
Princess C Campbell, Omowumi M Owoka, Tinuola O Odugbemi
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
|Date of Web Publication||4-Jul-2016|
Princess C Campbell
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos
Source of Support: None, Conflict of Interest: None
Background: Health insurance (HI) can serve as a vital risk protection for families and small businesses and also increase access to priority health services. This study determined the knowledge, attitude of artisans toward HI as well as their health-seeking pattern and willingness to join the HI scheme. Methodology: This descriptive cross-sectional survey used a multistage sampling technique to recruit 260 participants, using self-designed, pretested, interviewer-administered questionnaire. Data were analyzed using Epi-info version 7.0. Chi-square test, Fisher's exact test, and logistic regression were used for associations; the level of significance was set at 5%. Results: The respondents were predominantly male, i.e., 195 (75.0%), with a mean age of 32.36 + 6.20 years and mean income of N 29,000 + 5798.5 ($1 ~ N 161). Majority of the respondents, i.e., 226 (86.9%) were not aware of HI. The overall knowledge was poor (6.5%) and the main source of information was through radio/television (41.2%). Nearly, half of the respondents (33 out of 67) identified the concept of HI as a pool of contributors' fund for only healthcare service. A high proportion of the respondents (27 out of 34) were aware of the benefits of HI, although majority, i.e., 27 (79.4%) identified access to medication as the benefit. The majority of the respondents, i.e., 228 (87.7%) expressed negative attitude toward the scheme; however, 76.5% were willing to join the HI scheme. Conclusion: The artisans had low awareness/poor knowledge of HI which translated to a negative attitude toward the scheme. There is need for an aggressive stakeholders' enlightenment campaign for increasing coverage.
Keywords: Attitude, health insurance, national health insurance scheme knowledge, practice, uptake
|How to cite this article:|
Campbell PC, Owoka OM, Odugbemi TO. National health insurance scheme: Are the artisans benefitting in Lagos state, Nigeria?. J Clin Sci 2016;13:122-31
|How to cite this URL:|
Campbell PC, Owoka OM, Odugbemi TO. National health insurance scheme: Are the artisans benefitting in Lagos state, Nigeria?. J Clin Sci [serial online] 2016 [cited 2019 Sep 22];13:122-31. Available from: http://www.jcsjournal.org/text.asp?2016/13/3/122/185249
| Introduction|| |
Over the decades, African public health system has grossly deteriorated with deepening economic crisis while introduction of user fees at the point of healthcare delivery further impeded access to care and aggravated inequity.  Expanding access to health insurance (HI) is crucial to achieve universal health coverage (UHC). UHC implies ensured access to the use of high-quality healthcare by all citizens and protection of all individuals from catastrophic financial effect of ill health. UHC can be a major determinant of improved health outcomes for all citizens especially the poorest. 
By definition, informal sector workers (artisans) operate outside official tax collection and business registration systems. They do not receive regular salaries or income flows from which premiums could easily be deducted. Their cash income may be highly seasonal or entirely unpredictable.  The difficulty in collecting contributions and the administrative cost required in expanding the coverage of prepayment scheme to the informal sector has been a challenge in many developing countries. Thus, to overcome the constraint they transfer resources from general tax to the insurance fund, however this is not always feasible when the informal sector constitute a large percentage of the entire population as observed in most developing countries. 
Globally, it has been urged that all countries should strive and plan for universal coverage within their economic, sociocultural, and political context of each country.  Analysis of household expenditure survey in 89 countries established that 13% (44 million) households are forced into catastrophic health care cost in any given year and 6% (25 million) households are pushed below the poverty level.  Poor knowledge of HI is a major factor in decreased access to health care and thereby reducing overall utilization of healthcare services in a study carried out in Australia. 
In China, about 140 million informal sector workers in urban areas do not have HI.  Similar issues were documented in Bangladesh where 88% of employment is in informal sector, but poor knowledge of HI is responsible for poor uptake of the scheme in the country.  Furthermore, in Nicaragua, poor awareness of HI exists among informal sector workers, and statistics shows that about 93% of these people are without any form of HI. 
In many African countries, majority of the people have to bear the financial burden of catastrophic healthcare expenditures by themselves without access to insurance or government assistance.  In Tanzania, poor knowledge of HI among majority of the artisans was documented.  In Nigeria, inequity and poor accessibility to quality health care has been a persistent challenge in the healthcare sector.  Although sometimes the attitude of artisans toward HI is favorable, poor knowledge of the scheme abound. In Osun state of South Western Nigeria, out of 387 participants in a study, only 28.9% participants had knowledge of the scheme.  Knowledge of the National Health Insurance Scheme (NHIS) has been found to be low in various work groups. A study among civil servants in Osun reported that only 40% were aware and only 26.7% knew about the objectives.  In another study, 39% of health care providers, 20% of teachers and artisans in Enugu and Ebonyi, knew about the scheme, with over 80% of them expressing negative attitude towards its success in Nigeria. 
One of the biggest challenges of the social HI in the developing countries is the integration of the expanding informal sector and inclusion of the poor.  The informal sector (artisans) has not been fully integrated in the implementation of the scheme even with their significant proportion in the population and their contributions to development. ,
The study determined the knowledge of, attitude toward, uptake of, and willingness to enroll in the national insurance scheme.
| Methodology|| |
Kosofe local government is one of the 20 local government areas (LGAs) of Lagos state.
Kosofe is located at the northern part of Lagos state. It is bounded by three other local governments, namely Ikeja, Ikorodu, and Shomolu. It also shares a boundary with Ogun state. Its jurisdiction comprises seven wards and encompasses an area of about 17.85 km 2 . The local government currently falls under the East senatorial district.  There are several settlements within Kosofe local government. These are delineated into seven wards by the Independent National Electoral Commission, namely Oworonshoki 1, Oworonshoki 2, Gbagada, Anthony Village, Mende, Ojota, and Ogudu. Based on the National Population Census 2006, the residents of the area were estimated to be about 1 million. 
The study was a descriptive cross-sectional survey of 260 registered artisans in Lagos state selected using multistage sampling technique. Stage 1: One local government (Kosofe LGA) of the 20 LGAs in Lagos state was selected using simple random sampling (balloting). Stage 2: Two out of seven wards in the Kosofe LGA were selected (Ward C [Gbagada/Ifako] and ward F [Ojota]). Stage 3: Major groups of artisans (mechanics, vulcanizers, panel beaters, barbers, tailors, and hairdressers) were identified within the wards. Members of these groups attending the association meeting were selected using a systematic sampling technique. Based on the list of artisans (sample frame) attending the association meeting, artisans were systematically selected until the required number of participants were interviewed. The first artisan to arrive at each meeting was selected as the first respondent.
The pretested, self-administered questionnaire, adapted from previous studies, ,,, was structured to suit the study objectives and was divided into four sections: Social demographic background, knowledge, attitude, and practice and willingness to participate in the NHIS. Data analysis was done using Epi Info 7.1.3 (trademark of Centre for Disease Control and Prevention). Frequency tables were generated and relevant summary statistics were computed. The level of significance was set at 5%.
The responses were scored using the following criteria obtained from a previous study. 
Respondents were allocated a maximum of one full mark for correct responses on their knowledge of the definition, concept, type, possible contributors, and enrollees of the NHIS scheme and no mark for incorrect answers. A maximum of 2 marks for the objectives, benefits, and types of services was offered if more than 60% of the responses were correct and 1 mark if 40-60% were correct, and no mark if <40% were correct. Response options were either "Yes" or "No." Highest obtainable score was 11 and least was 0. Scoring was graded into two levels based on the score obtained: inadequate knowledge (0-6) and adequate knowledge (7-11).
Respondents' attitude were assessed using 15 statements which covered themes on the relevance, success of the scheme in Nigeria, adequacy of publicity, ease of access to healthcare services, preference to other healthcare financing options, ease of making financial contribution to the scheme and reducing financial hardship/elimination of payment at point of need for health service in particular for emergency services, view on the scope of service/illness covered, risk pooling, and sharing of scheme. Response options of the attitude were obtained using a four-point Likert scale and scored thus strongly disagree (1 mark), disagree (2 marks), agree (3 marks), and strongly agree (4 marks). The highest mark obtainable was 60 marks and least 15 marks. Attitude was graded as either positive (30 marks and above/≥50%) or negative (<30 marks/<50%) based on the marks obtained by each respondent.
Ethical clearance was obtained from the Health Research and Ethics Committee of the Lagos University Teaching Hospital. Permission was granted by the LGAs and the affiliated associations of artisans.
| Results|| |
A total of 260 participants were recruited for this study, of which majority were male (75%) and of yoruba ethnicity (75.8%). Almost half of the respondents, i.e., 129 (49.6%) were within the age of 31-40 years with a mean age of 32.36 + 6.201 years. More than half of the respondents, i.e., 153 (58.8%) had secondary school education and 19 (7.3%) had tertiary education. Majority, i.e., 157 (89.7%) of the 175 (67.3%) married respondents were monogamous, 64 (26.6%) had no children, while just 14 (5.4%) had more than 4 children. One-third of the respondents, i.e. 95 (36.5%) earned > N 30,000 a month, and the average monthly income was N = 29,000 + 5798.5 [Table 1].
Majority of the respondents, i.e., 226 (86.9%) had not heard of HI; the main sources of information for those aware of the scheme (27 [79.4%]) were radio/television and television. Of the 34 (13.1%) respondents who had heard of HI, 30 (88.2%) correctly defined HI as pooling of prepaid funds that allows health risk to be shared, while 3 (8.8%) assumed that it was a scheme that limits access to healthcare services. Regarding the types of HI known, all cited national HI and 9 (26.5%) community-based health insurance (CBHI). With regard to contributor of the scheme, a high proportion cited government 33 (97.1%) and employer 32 (94.1%). Relating to NHIS concept, most of the respondents, i.e. 33 (97.1%) knew it was "pooling of contribution for only health needs," the "funds of other contributors can take care of my health need (47.1%)," and "my money contributed can take care of others health needs when I am not ill" 18 (52.9%) [Table 2].
Majority of the respondents reported knowing the objectives/advantages of the scheme that the scheme ensures availability of funds to the health sector (31, 91.2%), protects family against financial hardship (27, 79.4%), and ensures that every Nigerian has access to quality care (24, 70.6%). Only 27 (79.4%) of the respondents who had heard of NHIS were aware of the health benefits of the scheme. Of these, the main benefits reported were medications (79.4%) and eye care service (52.9%). The services known by over one third of respondents were treatment of diarrhea (67.6%), immunization services (41.2%), treatment of malaria, and same proportion of domestic accidents (35.3%). More than half of the respondents (55.9%) reported that the scheme was meant for only government workers [Table 2].
Majority opined that the scheme was irrelevant (86.6%), cannot succeed in Nigeria (84.2%), disagreed with the scheme being of advantage to improve access to health care (90.0%), and believed that the publicity in Nigeria was not adequate (77.7%) [Table 3]. This translated to negative attitude as only 32 (12.3%) of the respondents demonstrated positive attitude toward the scheme. The overall level of knowledge was poor as only 6.5% of the respondents had adequate knowledge of the scheme [Table 4].
|Table 4: Overall knowledge and attitude of respondents on health insurance (n=260)|
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Only one-fifth of the respondents would always visit a healthcare facility when ill while a few (3.8%) said they would never visit. The most common healthcare facilities used by the respondents were government (76.2%); community pharmacy or chemist (67.7%); and herbal/traditional care (137, 52.7%). In the last 3 months, about half (49.1%) of the respondents and 67.9% of wives/children had gone to a health facility for treatment at least once. Out-of-pocket (OOP) was the most common mode of payment by the majority (96.9%) and about a quarter (24.2%) would borrow to pay medical bills [Table 5]. Only 1 (0.4%) had registered with NHIS and was dissatisfied with the services. About three-fourth, i.e., 199 (76.5%) of the respondents were willing to join the scheme. Most of the respondents were willing to join the scheme because "out-of-pocket was too expensive" in 168 (84.9%); the scheme "covered all family members" in 157 (79.3%) and was perceived to be of value 156 (78.8%); and "cheap to participate in" 153 (77.3%). Reasons cited by a majority of participants for not willing to join the scheme were lack of trust in fund administrators (60, 98.4%); limited scope of coverage (46, 75.4%); and lack of trust in government and unwarranted contribution before illness (43, 70.5%). Three-quarters (74.9%) were willing to inform others about the scheme and 145 (55.8%) would prefer the community to drive the scheme [Table 5].
|Table 5: Health-seeking pattern and willingness of respondents to join health insurance (n=260)|
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| Discussion|| |
Most of the artisans in this study were within middle age, i.e. 31-40 which is similar to the results from previous studies in Osun, Oyo, and Malaysia. ,, However, the mean age of respondents obtained from studies carried out in Igbobi and Edo was slightly higher. , The male predominance in this study (75%) is in consonance with artisan study in Osun state with 72.6%.  This could be attributed to the nature of the job majorly requiring heavy workforce and men are usually more predisposed to heavy jobs than their female counterparts by nature. The educational status of majority, i.e. 15 (58.8%) of the respondents was secondary and also close to Osun with 55.6%.  Most of the artisans in this study, i.e. 34.2% had an estimated monthly income between N 30,000 and N 49,999. Less than 10% (7.7%) of respondents in this study earned < N 10,000, which was the amount; about 50% of artisans were reported as earning in a similar study in Osun state and of which 20% earned in a study carried out in Edo state. , Thus, a higher proportion of artisans in this study earned more than those in Osun or Edo state. The differences observed in the income of artisans in the different states could be attributed to the higher economic standard of Lagos State as a commercial nerve center of the country; prices and cost of living would probably influence the income of those working within the state.
Knowledge of respondents toward health insurance
Inadequate knowledge about HI, enrollment options, and procedures involved in the scheme has been identified and documented to be barriers why many informal sector workers such as artisans have not been enrolling in the insurance scheme.  From this study, only 13.1% of the respondents had heard about HI, of which half had adequate knowledge of the scheme. This is in contrast to the findings from previous studies that reported higher levels of awareness among artisans in Osun (28.9%) and Lagos state (32%), , and much higher among civil servants in Osun (40%),  Minna (49.1%),  and the general population of Osun and Jos. , The low awareness found in this study regarding the HI may be because Lagos state is one of the nonparticipatory NHIS states, and awareness campaign is relatively lower than other states. In addition, mainly the federal workers are still being enrolled and the informal sector is yet to be involved.  Therefore, a plausible explanation for the higher level of HI awareness reported in other states could be a result of high level of exposure to campaigns and access to HI information and higher level of education among other populations studied. The main sources of information in this study were radio and television 14 (41.2%) and newspaper 13 (38.2%), similar to the Lagos study among artisans.  The government was identified by almost all the respondents, i.e. 34 (97.1%) as the contributor to the HI scheme followed by employer 32 (94.1%), then employee 9 (41.2%), and self-employed with the least figure of 38.2%. This response could be attributed to the fact that majority of the citizens' belief that provision of healthcare services should be the responsibility of the government.
The NHIS was set to achieve nine objectives. Of all these objectives majority (91.2%) of respondents knew that the scheme is meant to ensure availability of funds to the health sector. This implies that majority of the artisans perceive the scheme mainly as a source of funding to the health sector. About 80% of the respondents knew that the scheme protects family against financial hardship and 24 (70.6%) knew that ensuring that every Nigerian have good access to good health care is an objective of the scheme. Only 13 (38.2%) knew that the scheme helps to limit the rising cost of healthcare services, 23.5% knew that it ensures high standards of healthcare delivery, 20.6% reported it allows participation of private sector and ensures equitable distribution of health care, while only 17.6% knew that the scheme ensures efficiency in healthcare services. These figures showed an improvement in the level of knowledge of the scheme when compared with a study carried out in Osun, which reported that only 26.7% knew about the objectives of the scheme, and another study among health workers reported that 38.8% had good information about the objectives of the scheme. ,
The study revealed that out of the respondents who are aware of the scheme, about 27 (79.4%) were aware of the benefits. The majority of the respondents, i.e., 27 (79.4%) identified provision of pharmaceutical services in terms of medication, 18 (52.9%) chose eye care services, 15 (44.1%) and 13 (38.2%) knew about general practitioners services and hospital in-patient care, respectively. Only 4 (11.8%) identified physicians specialist services as one of the schemes benefit, while a mere 5.9% and 2.9% chose dental care and ancillary services, respectively, as a benefit of enrolling in HI scheme. These figures indicate that majority of the respondents are not familiar with the various benefits that are associated with enrolling in the scheme. The reason for this could be because many of the artisans do not exhibit adequate knowledge about the scheme itself, it might be difficult to be familiar with the benefits associated with the program.
When the respondents were asked about the services rendered under the HI scheme, more than half 23 (67.6%) chose treatment of diarrhea, followed by immunization services 14 (41.2%), while 12 (35.3%) chose treatment of malaria and domestic accident, one of the services rendered under the scheme. Less than One-third identified treatment of skin infections, treatment of upper respiratory tract infections, and pneumonia.
About half of the respondents (55.9%) chose only government workers as those that can enroll in the scheme while about one-fifth indicated that everybody can be accommodated or only private workers can enroll in the scheme. The plausible explanation for this response could be that majority of those presently enrolled under the NHIS are government workers, and the government is now working toward ensuring universal coverage, therefore it is expected that an average citizen would assume that since only formal sector workers dominate the scheme, it is probably meant for them alone.
Attitude of respondents toward health insurance
HI in Nigeria has been characterized with a lot of misconceptions, fears of workability of the scheme, concerns as regards to financial contribution to the scheme, and sincerity of government in financing the scheme among others.  Enrollment in HI has been shown to largely depend on the attitude and perception of people; perception related to provider, the scheme and community plays a role in enrolling, and remaining enrolled.  From the study, the overall attitude was negative with 228 (87.7%) expressing poor disposition toward the scheme. This is in consonance with what was reported in previous studies from Edo and Lagos that expressed negative attitude toward the scheme and similar studies from developed countries supported these findings. ,, Furthermore, a study carried out to access the general opinion of Nigerians toward insurance services reported similar findings of negative expressions toward any insurance service.  However, a different opinion of the scheme was observed in other studies carried out among NHIS clients and public where a positive disposition was expressed toward the scheme. ,
Only 4.2% strongly agreed that the scheme is relevant in Nigeria, while about half of the respondents said the scheme cannot succeed, this was a disparity when compared with a study carried out in Minna where 71.2% expressed optimism that the scheme can succeed. 
From this study, 41.9% disagreed that the level of publicity is adequate, and this is in consonance with a report from a previous study that documented 45.7% agreed that the publicity of the scheme was adequate.  The low level of publicity expressed by the respondents could be responsible for the negative attitude that existed among them. Almost half of the study participants (118, 45.4%) strongly disagreed that the scheme can help them access healthcare services and when this response was compared with previous studies, it was observed that the uninsured citizens are less likely to utilize healthcare services than those insured. ,
Only 12.7% (33) of respondents strongly agreed that HI is a preferred mode of payment of healthcare service, and this is however different from what was reported in another study carried out in Jos where almost all the respondents (82%) agreed that HI is preferable to other payment mechanisms. 
Practice and willingness to join the scheme and influencing factors
Over 70% of Nigerians cannot afford and access healthcare services because it is beyond their reach,  many times this inability to access quality healthcare services is largely due to financial incapability; therefore, many resort to poor practices regarding the way they seek for medical attention and this was reflected in a study carried out in rural Ecuador where 92.2% of the respondents said they will visit the hospital more often if affiliated with a HI scheme. , From this study, 76.2% (198) of the respondents visit the health facility "sometimes" when ill, only 20% indicated that they always go to health facility, and 3.8% said they never go there. This response differs from what was reported in another study carried out in Osun state among artisans where 76.4% said they always go to the hospital when ill.  Majority of the respondents, i.e. 76.2% said that they visit government health facility (public) when ill, while 67.7% visited community pharmacy, 52.7% preferred herbal treatment, 52.3% chose self-medication, and only 24.2% visited private health facility. Disparity was observed in another study where it was documented that 72% of respondents visited pharmacy outlet for treatment.  Although another study reported that 65.7% visited medical professional for medical services, 32.9% resorted to self-medication and 21.8% used unprescribed medication due to lack of funds to sought for proper medical attention.  However, in a study carried out in North Central Nigeria, 44.7% sought treatment in public health facility while 25.4% delayed treatment because of lack of fund. 
When those who go to health facility for treatment were asked how many times they had visited the hospital in the past 3 months, 135 (51.9%) said they never did, 82 (31.5%) said only once, 29 (11.2%) indicated 2-3 times, while only 14 (5.4%) said 4 times and above. This response is similar to the report of a study carried out among households in Osun state that documented that 44.8% never went to the hospital, 30.7% did only once, 15.1% said twice, while 5.7% and 1.4% did thrice and 4 times, respectively.  However, another study in Edo state reported that the respondent who never visited a hospital in the past 3 months was 28.6%, 56.9% did 1-3 times, while 13.1% said between 4 and 6 times.  Only 33.1% reported not taking their wives or children for treatment in the past 3 months, while most (45.1%) had two or more times.
Almost all the respondents, i.e. 252 (99.6%) use OOP in paying for medical expenses with only one respondent (0.4%) using HI. This figure is a little similar to what was reported in a study among artisans in Osun state where 74.7% use OOP and only two of the respondents (0.5%) were registered with CBHI and none in the Enugu study. , When the respondents were asked if they ever had to borrow or sell personal property to pay for medical bills, 63 (24.2%) said yes; 33 (52.4%) and 28 (44.4%) had to borrow twice and once, respectively, in the past to pay for medical bills, while two (3.2%) had to borrow thrice. This figure is higher when compared with 6.5%,  but much lower than 40% in Edo, and may be due to the different economic situations in the study locations. Only 1 (0.4%) of the respondents had registered for HI and the type registered for was the NHIS. This is in consonance with a study carried out among artisans in Osun that had only two artisans registered with CBHI,  while in another study, none of the artisans registered for HI. 
Concerning willingness to join HI, the majority of the respondents, i.e. 199 (76.5%) were willing to join. This is similar to what was reported in other studies where 78%, 76.11%, and 74.4% were willing to join the insurance scheme. ,, The figures reported in China, Malaysia, and Ecuador were slightly lower with willingness to participate, i.e. 50%, 63.1%, and 69.3%, respectively. ,, However, the figures from Namibia, Nairobi, Osun, and Minna were slightly higher with 87%, 80.5%, 82.4%, and 87.1%, respectively. ,,, Various reasons were given by respondents for their willingness to participate; 133 (51.2%) said it is convenient, 145 (55.8%) responded that they can afford payment, while 125 (48.1%) said the scheme is workable. About 101 (38.8%) were willing to join because they visit the hospital often, 157 (60.4%) said that coverage of all family members was their reason, 137 (52.7%) said cost is okay, 155 (59.6%) responded that their reason is because prepayment is better, while 168 (64.6%) reasoned that OOP is too expensive, 156 (60%) said program has value, and 153 (58.8%) said it was cheap to participate. This response is similar to what was reported in previous studies across Nigeria. ,,
Majority of the respondents, i.e., 60 (98.4%) said that the reason for not willing to join HI was because of lack of trust in the fund administrator, 46 (75.4%) said that the scope of coverage is limited, and 43 (70.5%) said they do not trust the government and contribution before illness is unwarranted. Only 9 (14.8%) of respondents said their reason for not willing to join is because HI is confusing, while 16 (26.2%) said multiple contributions are unfair, and 42.6 said there is lack of trust in the insurance scheme itself. This is similar to reports of a study from Edo state where lack of trust in the government and programs was a significant reason for not willing to join HI scheme.  This is possibly so because of poor attitude of citizens toward government-initiated programs due to fear of fraud and misappropriation of contributors' fund.
From the study, majority, i.e., 149 (74.9%) of the participants who are willing to join were also willing to inform others about the scheme. This could be because since they belong to similar associations, it is would not be strange for them to share ideas about a program that is perceived to be beneficial to them. According to respondents, over half, i.e., 145 (55.8%) preferred organizer of the scheme community, this is similar to findings of another study that also chose community as a preferred organizer.  However, this response is different from other studies that reported that government is the preferred organizer. , The reason why most of the respondents prefer community-organized program might be because of their earlier overwhelming response of lack of trust in government, fear of misappropriation of fund, and this could be responsible for their preference for the community as the preferred organizer of the scheme.
| Conclusion|| |
The poor level of knowledge and awareness of HI among the artisans observed in this study translated to a negative attitude toward the scheme. Although only 20% would always visit a health facility when ill, majority paid for medical bills by OOP in public hospitals, some had to borrow or sell property to settle medical bills. Only one of the respondents had joined the HI through NHIS. Encouragingly, three-fourth of the respondents were willing to participate in the scheme and also inform others about it. Aggressive public enlightenment awareness campaign is crucial to reach the unreached community groups for improving coverage of the scheme and viability.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]