INTRODUCTION

Economists are concerned with the wants of human beings. Among other things
human beings want love, recognition, comfort of life and material things. Economists
are concerned with our material wants which ultimately is to improve our well-being
or make a living. Society’s material wants are virtually unlimited and insatiable.
Human basic needs include air, water, food, shelter and clothing but we seek to have
much more than this in terms of goods and services that will make us live
comfortably or have standard living.

Human wants are several times more that the productive capacity of our limited
resources, it is therefore difficult to satisfy our material wants. The means of
producing goods and services are limited and scarce. Our desires for goods and
services cannot be completely satisfied. Over time wants of man change and multiply
and this might be a result of development of new products and extensive promotion of
the product or change in circumstances.

Definition of Economics
There are several definitions of Economics, some of the definitions which you can
familiarize yourself with include: Study of how we use scarce resources to produce
goods and services to satisfy our wants.
Social science concerned with the efficient use of limited
or scarce resources to achieve maximum satisfaction of
human material wants

The study of how best to allocate scarce resources among competing ones

These definitions are similar and clearly related to each other, each has its own
special terms and meaning. There are no significant differences in the definitions.

Basic Concepts in Economics

The basic concepts include goods, scarcity, opportunity cost, rational choice,
economic resources, utility, demand and supply.

Good is a tangible object that is capable of satisfying human wants. Materials like
cars, clothes, food, cookers can be regarded as goods and health can also be
considered an economic good.

Service is an intangible action that is capable of satisfying human want – such

services include water supply, health care, waste disposal, etc. Services satisfy our
wants as much as goods do. Goods such as sphygmomanometers, suction machine are
used to provide services.
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Scarcity Scarcity is said to occur when we cannot have every good or service that we
need or when we want something that we cannot have. No one can have everything
that he or she wants, and we therefore have to select goods and services we think can
give us greatest satisfaction.

Opportunity Cost is defined as the value of the second-best choice that is given up
when a first choice is made. Every choice one makes is a trade-off between the
benefits and costs of one’s decision. Usually one will want to make a choice that will
result in the smallest opportunity cost and the greatest possible benefit. If this is the
case then one has made a rational choice.

If a person chose to use little money available to him to buy prescribed drugs for his
child as against the other choice of buying alcoholic drink, that choice can be
considered rational. From this example one can imagine how well people choose to
make rational choice. Rational behaviour means that different people will make
different choices because their preferences, circumstances, and available information
differ. Rational decisions may change as circumstances change. Try to imagine how
our culture makes people spend their money on ceremonies rather than spending such
money to take care of them so that they can live well.

Utility is the benefit consumers get from the purchase of goods and services. It helps
to determine how much the consumer is willing to pay. Marginal utility is the
additional utility gained by consuming one more unit.

Demand and Supply

Demand is the quantity of a product that consumers will purchase at each possible
price.

The law of demand states that if everything else remains equal, more of a product will
be purchased at a lower price than at a higher price or less of a product will be
purchased at a higher price than a lower price. For example a doubling in the cost or
price of a spaghetti will result in less demand if all else are equal and conversely a
reduction in the price or cost will result in increase in demand.
Determinants of demand

[Link] and preferences

2. Personal feelings toward the value or desirability of various products.
3. Disposable income, this is the amount of income that people have left after they
pay their taxes. The quantity of products that people buy depends on the disposable
income. If you were given some money as a gift you are likely to make demand for
certain items which you probably may not demand for if you were not given this gift.
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There is a direct relationship between disposable income and demand under normal
circumstances.
4. Price of related goods – Increase in price of certain drugs may result in higher
demand for alternatives to the drugs. When the price of a good changes it often have
effect on the demand for a related product (substitute good) which can be used in
place of the other.
5. Number of consumers – Increase in the number of people who purchase a product
or utilize a service will bring about a change in demand. In epidemics, the large
number of people affected brings about an increase in demand of some drugs or
vaccines required to manage or control the epidemics.
6. Expectation of the future – Demand for a product can change based on their
expectation for the future

Supply

Supply is defined as the quantity of a good or service that firms will offer for sale at
each possible price. The Law of supply states that if not else changes, more of a
product will be offered for sale at a higher price than at a lower price or conversely
less of a product will be offered for sale at a lower price than at a higher price If the
price of a product increases the quantity supplied will increase.

Determinants of supply are:

[Link] prices – the price used in the production of the good or service. This
determines the price of the goods. If the price of production becomes higher it may
reduce the supply of such goods.
[Link] of production – With improvement in technology some goods become
cheaper to produce and thus improve the supply of such goods.
[Link] and subsidies – Increase in sales or service tax will increase cost of good or
service and where subsidies increase then the cost reduces. Government subsidy on
drugs can increase supply of drugs
[Link] of other goods – In manufacturing firms, increase in price of a particular
product may make the firm shift to production of similar product of lesser price and
through this increase supply
[Link] expectations – Expectation of the future price of a product can affect the
producers current willingness to supply that product

6. Number of sellers in the market – Other things being equal the more the number
of people or firms involved in the supply of a product or service the more the
market supply. Increase in the number of firms producing anti-retroviral drugs
(ARV) result in increase in the supply of the drug in the market.

An equilibrium price in demand and supply

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 Occurs when the price, the quantity offered and the quantity demanded are the
same. As supply goes up and demand goes down, the price is likely to go down.

As the supply goes down and the demand goes up, the price is likely to go up. You
will observe that the later is usually what is faced during scarcity of petrol in Nigeria
in which case the price of petrol goes up.

Global Economy

Economic Systems

Economic system is a set of rules or understandings that govern how scarce resources
are used to produce goods and services that satisfy human wants. All nations have
economic systems. All nations are faced with the problem of scarcity because of
limited resources. There are three central economic systems in the world.

Capitalism – An economic system in which the factors of production are owned and
controlled by the people. In capitalism people sell goods or service to earn a profit.
Role of government in market economy is limited and there is competition. Private
clinics exist to make profits and are privately owned by individuals or groups.

Socialism – An economic system in which the government owns and controls the
factors of production. Socialists believe that the system of private ownership and
control in capitalism results in many resources being allocated to the production of
goods and services for the rich, while the poor are ignored. Socialists believe people
should receive a share of the goods and services that are produced, regardless of the
value of their contribution to production. Socialism is not the same as communism.

Communism – is an economic and political system that combines government

ownership and control of the factors of production with a totalitarian form of
government.

Mixed economies – where capitalism and socialism as economic systems are in

place, this is commonly the case in many countries.

Definition of Health Economics

Health economics is defined as the application of the theories, concepts, and
techniques of economics to the health sector. It is concerned with issues like
allocation of resources within the various health care strategies, quantity and quality
of resources used in health care delivery, funding of health care services, efficiency in

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use resources allocated for health care and the effects of preventive, curative, and
rehabilitative health services on individuals and the society.

Globalization And Health

Globalization is reshaping the social geography within which humanity strives to
create health or prevent disease. The determinants of health and disease – be they
SARS virus or increasing HIV/AIDS are affected by increasing global mobility. You
often here people say the world is a global village. What happens in one country
readily have effect on other countries.

Driven by economic liberalization and changing technologies, the phenomena of

‘access’ is likely to dominate to increasing extent the unfolding experience of human
disease and well-being. The extent to which individual countries are able to engage
the process of globalization on their own terms differs widely from country to
country. Child mortality, for example, changes quickly in response to subtle changes
in purchasing power in impoverished communities. In affluent communities however,
a small change in income has little effect on utility in either direction. The long term
effect of globalization on wellbeing is different for populations who are dependent on
fragile local economics.

A significant change in the price of some goods in some of the developed countries
or even policy shift may have effect on another country which may affect the health
of its people. Globalization has brought about high movement of people from one
country to the other mainly a result of economic activities. With these movements
are some diseases that easily get across borders of countries.

DEMAND AND SUPPLY IN HEALTH CARE

Supply and demands lead to demand-based pricing. Higher prices are paid for
products or services that are in high demand. Reduced demand leads to lower prices.
Strategic planning is needed to determine which activities can be in the most demand
and make the most profits. In the early 1960s, economists first became interested in
estimating demand for health services. Supply of trained nurses in United States is not
increasing nearly as fast as the demand. The demand for medical services will depend
on the price of that service, other prices, income and tastes. In this unit you will read
through demand and supply in health care.

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Concept of Demand and Supply in Health
Care
Every individual has a need or a potential need for health care in the form of health
promotion, prevention, cure or rehabilitation. This need is not always translated into
a demand for health care particularly in developing countries for various reasons.
Health need is transformed into a health care demand for example when a patient
seeks a medical care.

All the needs and wants of society can not be met at the same time even in richer
countries, so that opportunity cost are incurred by all users of resources, and the
scarcer the resources, the higher the opportunity costs.

In the case of health and health services, these costs are incurred both by producers
of health services, through their use of staff, buildings, equipment and materials
supplies, and by consumers, who use transport to health services, buy drugs, etc.

Not all demand will become needs and not all needs will find expression as demand.
You do know that some people get sick and have the need to be treated but they do
not demand for treatment.

Reasons Why Need For Health Care Far

Exceeds The Effective Demand For It
Includes
a. Price of health care may not be affordable by the individuals (Affordability).
b. The Individuals may not have ready access to the health facility at a
time or place that is convenient (Geographical
accessibility).
c. The service required may not be available to the individual (Availability).
d. Religious and cultural believes and practices may hinder the use of the health
facilities (Acceptability).
e. Cost of time off from work and costs of waiting.

Demand And Supply Of Health Care Services

In Developing Nations

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The demand for health care in developing countries is largely influenced by the
above factors. The extents to which these factors are being reversed in developing
countries vary considerably among nations and even within nations. The global
economic recession has made affordability of health care service far from the reach
of the common man in these countries. Therefore, utilization of health facilities is
seriously affected particularly with the changing trend in which free health care is
fast disappearing.

The supply of health care is multifaceted. The supply can be in the form of promotion,
preventive, curative, and rehabilitative health care. In Nigeria, this can be provided at
the various levels of health care namely; primary, Secondary and Tertiary health Care.
The health sector in developing countries consists of a heterogeneous mixture of
public or government activities and non-government activities including services
provided by both modern and traditional practitioners. The level of demand for health
care goes far beyond the level of supply. Economic recession has made geographical
accessibility and availability of health care difficult, this affect coverage.

Elasticity Of Demand
This is the degree to which the demand for a good or service decreases in response to
a price increase and increase in response to a price decrease.

The demand for health care is generally inelastic.

Demand for health care is generally elastic because of the nature of health problems
which often require that sufferers take some action to demand for care. Demand for
health care, especially curative health care tend to be price inelastic, meaning that any
increase in user fees will result in a less than proportionate drop in demand and thus
increase in revenues. This is because when it gets to some stage people will have to
take up health care even when they can not readily afford it unlike the case with some
other goods. Most of those consumers that are unable to utilize service in public
facilities because of cost seek care from some other sources particularly if the private
providers are price-competitive.

COST OF HEALTH CARE

The cost of health care is high and has increased rapidly. Higher health care prices
combined with an increase in the quantity of services provided has resulted in rising
healthcare cost.

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The production of health care requires scarce resources such as capital in the form of
hospital facilities and diagnostic equipment and the highly skilled labor of physicians,
technicians, nurses and other paramedical staff.

Types of Health Care Cost

The economic cost of a disease consists of direct and indirect cost. Direct cost is
monetary expenditures attributable to the disease and indirect cost is what can be
associated with loss of output attributable to the disease owing to premature death or
disability.

There are four (4) different types of health care cost, and they include:

Direct medical cost – Medical cost incurred for medical products and services used
to prevent, detect, and or treat a disease. These covers costs for drugs, laboratory tests
and supplies. This cost has monetary value that is you cost it terms of Naira.

Direct non-medical cost – This type of cost cover non-medical services that results
from illness but do not involve purchasing medical services. Example of this type of
cost include cost of transportation, food, family care. This type of cost is usually
enourmous in developing countries where several relatives, friends come around to
get involved in the care of patients.
an equilibrium price an equilibrium price an equilibrium price
Indirect non-medical cost – This type of cost result from reduced productivity
because of ill-health. When a patient is unable to do his usual job, the loss of
productivity and income is at a cost.

Intangible costs – These are non-financial outcomes of disease and medical care not
expressed in monetary value. The non-financial outcome can be in form of suffering,
pain and grief. This cost can not be estimated in monetary value.

Benefits from Health Care

The types of benefits the individual receives from health care could be psychic or
monetary, they include:

a. Relief from pain, suffering, anxiety etc.

b. Benefits in the form of capital good being monetary “pay off” measured by
increased production.

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 Reasons for the Present Trend in Cost of
Health Care
The reasons for the current trend in cost of health include:

i. Demographic reason – There is population growth in developing countries, to

keep pace with this growth, health care cost has to increase.
ii. Labour intensive nature of health services – Health care is labour intensive and
there is limited scope for saving on labour cost in personal health services.
Skilled people are required to provide health care
iii. Quality of health services – Advances in technology has improved quality of
diagnosis and therapy. Unfortunately the cost is often greater than the
increased effectiveness achieved. Try and think of the various equipments we
use today as compared with what obtains some 10 – 20 years ago.
iv. Public expectation – People desire increasing standard facilities in health
services, there is high demand for curative health care while underutilizing
preventive personal health service particularly in developing countries.
v. Changing epidemiological picture during socio-economic
development – chronic and degenerative diseases and their high cost of care or
cure.
vi. Organization and structure of health system – There are situations where
multitude of agencies are financing and delivering parallel and uncoordinated
health services with consequent overlapping. This is much more in preventive
health care services.
vii. Extension of health services coverage – The attempts to extend the range,
coverage or impact of services to a larger population increase costs.

BUDGETING
Every health organization is involved in budgeting. Organizations budget for their
humans and material resources. Nurses particularly at the managerial level need to be
familiar with the pricinples and process of bugeting. Nursing managers also also need
to analyze expenses, anticipate, recognize and creatively deal with budgetary
problems. Budgets help coordinate the efforts of the organization by determining
what resources will be used by whom, when and for what purpose.

Definition of Budget
Budget is defined as a quantitative statement, usually in monetary terms, of the
expectations of a defined area of the organization over a period of time in order to
manage financial performance.
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Budget can also be seen as a plan for the allocation of resources and a control for
ensuring that the results comply with the plans. The results are expressed in
quntitative terms.

Basic Concepts Related To Budget

Budgeting – Is the process of planning and controlling future operations by
comparing actual results with planned expectations.

Controlling – It is the process of comparing actual results with the results projected
in the budget.

Incremental (line-by-line) budget – This is a budget worksheet listing expense items

on separate lines. This is usually divided into salary and non-salary expenses. The
worksheet may include several columns for the amount budgeted for the current year,
the amount actually spent year-to-date, the projected total for the year based on the
actual amount spent, increases and decreases in the expense amount for the new
budget, and the request for the next year with an explanation attached.

This line-by-line budget has the advantage of simplicity but the disadvantage that it
discourages cost-efficiency. Astute managers ensure that they spent the entire amount
budgeted for the year to avoid budget cuts in the next year.

Zero-based budget – This is a budgetary approach that assumes the base for
projecting next year’s budget is zero. Managers are required to justify all activities
and every proposed expenditure, regardless of the level of expenditure in previous
years. Every expenditure for the new year must be justified in view of organization’s
objectives and current environment.

Fixed budget – A budget in which budgeted amounts are set regardless of changes
that occur during the year such as volume of patient, unanticipated inflation

Variable budget – A budget developed with the understanding that adjustments to the
budget may be made during the year based on changes in revenues, patient volume,
utilization of supplies, and other expenses.

Fiscal budget – A specified 12-month period during which operational and financial
performance is measured.

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Types of Budget
Operating Budget

This is also known as Revenue-and –expense budget or annual budget. It is the

organization’s statements of expected revenues and expenses for the coming year. It
coincides with the fiscal year of the organization which in the public sector in Nigeria
corresponds to the calendar year – January to December. The operating budget reveals
an input-output analysis of expected and revenues and expenses.

The revenue budget for a nursing unit may represent the patient care income
expected for the budget period.
The expense budget consists of salary and non-salary items. Among the factors that
nurse managers might include in their operating budget are personnel salaries,
employee benefits, medical and surgical supplies, drug and pharmaceuticals, office
supplies among others.

Expense budget should be comprehensive and thorough; it should take into

consideration, all available information regarding the next year’s expectations. Both
controllable and non-controllable expenses are projected. Examples of non-
controllable expenses include indirect expenses like lighting, equipment depreciation.
The non-controllable expenses and the probability of rises in materials and labour costs
during the budgetary period need to be accommodated in the budget to provide for changes
that are beyond the control of the organization or unit.

Personnel Budget

Personnel budgets estimate the cost of direct labour necessary to meet the agency’s
objectives. This budget is used as a guide to recruit, hire, lay off and discharge
personnel. In developing the budget the nursing manager need to determine the level
of need of nursing care that will meet the need of estimated patient population in its
unit. The nursing manager will need to estimate number of the various cadres of
nursing personnel required during what shifts, in what months and in which areas.

Capital Expenditure Budget

Capital budget is an important component of the plan to meet the organization’s long
term goals. Capital expenditures include physical changes such as replacement or
expansion of the plant, major equipment and inventories. Organizations define capital
items based on certain criteria; must have an expected performance of a least 1 year
or at least cost a minimum of certain amount like equivalent of $500 or $ 1,000.

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Cash Budgets

Cash budget are planned to make adequate funds available as needed and to use any
extra funds profitably. Cash budget ensures that the organization during the budgetary
period has enough, but enough but not too much cash on hand. This is necessary
because incomes do not necessarily coincide with expenditures and also seasonal
variations should be anticipated which result in fluctuations in resource needs.
Flexible Budgets

Some expenses are unpredictable and can only be determined after change has
commenced. Because of this it is necessary to have flexible budget. The changes can
be compensated for by having periodic budget reviews. Sometimes variation in cost
can be predicted through historical analysis of costs in previous budgets. Attendance
of health facilities in many places in Nigeria drops significantly during festivities and
in some cases attendance of clinic is higher soon after workers receive salaries. These
forms of variations require that budgets are made flexible. There are a lot of
uncertainties in the Nigerian environment which makes flexible budget to be
advantageous.

Advantages and Disadvantages of

Budgeting

Advantages of budgeting

The advantages of budgeting include:

1. Budget plans for detailed programme activities

2. Help fix accountability by assignment of responsibility and authority
3. State goals for all units, offer a standard of performance, and stress the nature of
the planning and control process
4. Encourage managers to have careful analysis of operations and to base decisions
on careful consideration
5. Minimize hasty judgments in decision making
6. Can expose organizational weaknesses and allow corrective measures to be taken
7. Resources can be projected and waste minimized
8. Financial matters can be handled in orderly fashion and activities of
organizations ca be coordinated and balanced

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Disadvantages of budgeting
The disadvantages of budgeting include:

1. Only aspects of organization activities that are easy to measure are considered in
budgeting as budget convert all aspects of organization performance into
monetary values
2. May become an end in itself instead of a means to an end. Particularly in
situations where symptoms are treated as causes, it is important to find out the
underlying reasons for the symptoms
[Link] goals may sometime supersede the organization’s goals and gain
autocratic control of the organization
[Link] of over-budgeting making the budget cumbersome and expensive
[Link] consuming and expensive
[Link] skill and experience for successful budgetary control
7. Require forecasting but his can be uncertain because budgetary control is subject
to human judgment, interpretation and evaluation

a. .

POVERTY AND HEALTH

Poverty is related to the economic activities of the

country. There is no society that has the resources
necessary to produce enough goods and services that will
satisfy all wants and desires of its people. The production
of goods and services within an economy can be
measured by the Gross Domestic Product (GDP). Gross
Domestic Product is the measure of all final goods and
services produced within an economy during a year.
Countries with low GDP among other causes have
problem of poverty, though in some countries with high
GDP poverty can be found “poverty amidst plenty”.

Poverty creates ill-health because it forces people to live in environments that make
them sick, without decent shelter, clean water or adequate sanitation.

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Definition of Poverty
Poverty is concerned with the relationship between the minimum needs of people and
their ability to satisfy those needs. Poverty can be difficult to define because of the
relative meaning of minimum needs. The United Nations uses living on less than $1
(N130.00) per day to define poverty.

The poor are at greater risk of becoming ill. Poor health has adverse effects on
productivity which further contribute to poverty. Poverty affects access to health
services. Poverty also limits ability to meet the cost of health care. The poor have
worse health outcomes than other economic and social groups. Infant, child and
maternal mortality rates are higher in poor communities.

Health Problems and the Economy

Major causes of death and illness – Perinatal, infectious, and parasitic illnesses are
responsible for 75% of infant deaths. This illnessess can largely be attributed to
poverty. Infectious diseases and parasitic diseases are responsible for 71% of deaths
of children aged one to four and 62% of deaths in children aged five to fourteen. The
typical African child under five years has five episodes of diarrhoea per year, it also
accounts for 25% of all childhood illness and 15% of admissions in health facilities.
Vaccine preventable diseases are implicated in the deaths of 20% of all children in
Africa. Maternal mortality rates in Africa are higher than anywhere else in the world.

The heavy burden of ill-health in Africa is a reflection of the level of poverty in the
[Link] need to know that the effect of poor health goes beyond physical pain
and suffering; Learning is compromised, returns to human capital diminish, and the
environment for entrepreneurial and productive activities is constrained. Poor health
imposes immense economic costs on individuals, households, and society at large.

Household survey in Cote d’Ivoire showed 24% of the adult labour force experienced
an illness or injury in the previous month to the study, 15% became at least
temporarily inactive. The workers on average lost nine full days of work and the cost
of treating them amounted to 11% of their normal monthly earning. In Nigeria,
Guineaworm disease temporarily incapacitated 2.5 million Nigerian in 1987.
Cost/benefit study revealed the net effect of the disease was to reduce rice production
by 50 million dollars and it was estimated that the benefits of a worm control program
would exceed its costs only after 4 years. These studies show you how ill-health
further worsens sufferers’ economic state.

In view of the demonstrated importance of human capital to economic progress, a

country can not attain high level of economic development with a population

14
burdened by high infant and maternal mortality, pervasive illness of its workforce and
low life expectancy.

Economic status of an individual, community, and country is related to the health of

the individual or its people, though wealth does not necessarily bring health. A
buoyant economy can create the enabling environment for health. A poor economy
show features of poor housing, inadequate food and nutrition, poor water supply,
inadequate environmental sanitation, and low level of education, low affordability of
health care.

AIDS is a cause of deaths and Illness in developing countries which has heavy toll on
economy of countries. Prevalence of AIDS in sub-Saharan Africa countries remains
high. In hard-hit African countries the active age group is most affected. Deaths in
this age group affect skilled manpower and professionals which take a heavy toll on
countries.

Malaria is endemic in most of sub-Saharan Africa and it appears to be worsening in

much of Africa and results in high childhood morbidity and mortality. The cost of
treatment of malaria in most countries when put together is enormous. This money
would have helped families, communities and the country at large to improve on
quality of life. Absenteeism from work among adults affected by malaria is also high,
this affects productivity. From the examples described you can appreciate how poor
health imposes immense economic cost on individual and the nation.

Some Health Effects of Poverty

1. Poverty creates hunger which in turn leaves people vulnerable to diseases.

2. Poverty denies people access to reliable health services and affordable medicines
3. Denies people access to prevent health care. For example it denies poor children
access to immunization.
4. Poverty creates illiteracy which eventually make people less informed about
health risks
[Link] people to live in environments that make them susceptible to certain diseases

5. One of the barriers to health care for the poor is the time it takes to get treatment.
Time is a resource since the time taken away from work may mean lost income.

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HEALTH CARE FINANCING

INTRODUCTION
There is a growing financial need to fund health care in almost all nations, with
resources becoming limited because of the global economic recession, health
financing now take a major focus of attention. Health costs have been increasing
because of the aging population with increased health care needs, increased use of
technology, new and expensive treatment modalities and increasing administrative
costs.

Options in Health Care Financing

They may be grouped into 5 major categories: Direct government financing, User
charges (Out-of–pocket expenses), Community financing, health insurance, Donors
(foreign aid).

Direct Government Financing

Direct government financing of health activities is the most widespread approach to

health financing in the developing world. Government either provides periodic
allocations from general government revenues or assigns the proceeds of a designated
tax to the health sector or both.

Because national governments are responsible for overall health policy and strategic
planning for health, it might be assumed that governments are also the major sources
of healthcare financing and health expenditures. We know in reality that government’s
share of total health expenditure varies widely all over the world.

16
Public revenues are obtained from various sources and then generally are added
together, in which case the source of financing for a particular public program cannot
be identified. However, in some cases governments dedicate the proceeds of a
particular tax instrument to the health sector. For example in several countries in the
Americas and in Asia, lotteries have been organized to benefit social welfare
programs such as health care, primary education, etc.

Direct government funding of health activities alone has been inadequate in many
countries particularly in developing countries. The World Health Organization
(WHO) recommends that all levels of government should allocate at least 15% of
their total budgetary expenditure to health care. You know that in Nigeria,
government financing of health care is inadequate. Reasons why African governments
have committed less money to health than other countries include:

Economic condition of some of the countries, since the expenditure on health in

these countries is largely from general tax revenues, including duties on imports and
exports
Structural Adjustment programmed in some of the countries which is responsible for
cutbacks in government expenditure on social services
Some countries spend heavily on other sectors like defense to the detriment of the
health sector whereas there is little evidence that defense expenditures contribute
positively to economic growth or sustainable development.

User Charges (Out-Of-Pocket Expenses)

User charge is also known as out-of –pocket expenses. Another way of financing
health care is by charging patients. These charges take a variety of forms. Fees for
medical services are diverse. The definition of the item on which fees is to be charged
varies widely. A fee may be required for an encounter with the health care provider,
an episode of illness or a fixed number of contacts with the health care system.

A single encounter may be broken into items like laboratory test, drugs, procedures,
etc. The fees for each of this vary. There may be a uniform priced charged for all the
patients or with the exception for the poor, children or some are exempted from
paying. In some places, there are sliding scales of rates applied such that persons of
lesser means pay lower fees.

User charges have the advantage of providing a link between financial responsibility
and the provision of services. This link has generally enhanced willingness to
contribute to the cost of health programs and has encouraged both consumers and
providers to be cost conscious. In addition user charges help to control the use of
health services by imposing financial disincentives to consumers. You know that
when people pay for a service they are careful since it costs them something but if
they do not pay then they may not be bothered about careful use of such service.

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When user fees are low or not practiced, consumers have no reason to pay attention to
costs.

User fees are also a tool for reinforcing the referral system. In some countries people
who are not referred from the lower levels are made to pay more than those referred.
User fees are becoming increasingly common in Africa. This method of cost recovery
directly addresses the problem of under-funding of government health facilities.
The administration of user charges throws some challenges in developing countries
where it is observed that the largest reduction in the use of services is as a result of
charges for health services particularly among the poor. You are familiar with this
problem of the poor who are not able to afford health care because of user fees. This
then call to question the need for equity. However, some people are of the opinion that
user fees that result in availability of services is better and more people are cared for
than a free health service with services not available because money is not available.

Important arguments in favour of user charges include:

Fees make the patient more conscious of the services they ask for, it therefore
strengthens self-caring
User fees however small will make up some level contribution to the health
financing.
Keep services running and improves quality of care and confidence in the services

Arguments not in favour of user fees include:

Fees collection and its management requires management capabilities which may
not be available at some lower levels of health care delivery
Revenues collected in some instances are not substantial compared to cost of
providing services

18
Community Financing

The emphasis of community support in most developing countries has been on

providing resources, either financial or material and human for the establishment or
improvement of health and sanitation infrastructure e.g. Health facilities, latrines,
wells, etc.
Community financing of health activities requires community organization. The most
serious problems have arisen in trying to sustain contributions to pay for the recurrent
costs of programs. People have frequently been unwilling to continue to pay for
programs from which they were not benefiting at the time.
Greater reliance on community financing off health care has been advocated for
several reasons, which include:
Individuals / households spend a lot of money purchasing modern and traditional
health care from the private sector. It would not be additional burden if this
expenditure were redirected towards services that have a greater impact on health.
Community financing will attract other unexploited resources like labor, land and
contributions in kind.
People will readily use and cooperate with services that they have helped to create
and later help to maintain.
It is a suitable mechanism for mobilizing contributions from the self-employed.

HEALTH CARE FINANCING II

INTRODUCTION

Health Insurance
Health insurance is a system in which prospective consumers of care make payment
to a third party in the form of an insurance scheme, which in the event of future
illness will pay the provider of care for some or all of the expenses incurred. Health
insurance is a mixed source of finance as it often draws contributions from both
employers and employees and sometimes government. Contributions to such schemes
are often mandatory. There are three main types:

1. Government or social insurance – maybe compulsory or voluntary often

employed in the formal sector. Contributions based on individuals income not
on actual risk
2. Private insurance – coverage through third-party payer institutions.
3. Employer based insurance- employers or parastatal or private bodies serve as
the third party payer or collection agent.

19
Health insurance diversify sources of revenue of the health sector, individuals play
some role in paying for their own health care and to spread the burden of health costs
over time and across a wider population which will reduce risk.

A variety of insurance mechanisms can be used to help finance the health services
rendered to individuals and families. These entails collection of funds directly from
potential users of the health care system, either to pay the providers for their services
or to reimburse users in full or in part for payments made to providers.

Membership of health insurance scheme can be voluntary or compulsory.

Government, statutory agencies, profit making organizations, or non-profit making
organizations such as, cooperatives or benevolent societies can operate these schemes.
The insuring agency may employ the providers of health care and own facilities (the
direct method) or contract with health care providers – public or private (the indirect
method).

The advantage of insurance is that it converts unpredictable future health expenses

into payments that can be budgeted for in advance. The agreements convert large,
infrequent and unpredictable expenditures into smaller, periodic payments. These
payments are collected to a pool of resources that can be drawn upon to meet the
needs of a participant who encounters misfortune of ill-health.

4. Compulsory insurance – These schemes are generally financed by employers

and or employees contributions calculated as a percentage of pay roll.
Compulsory insurance schemes may cover the self-employed as well on a
compulsory or voluntary basis. However, it is extremely difficult even in
developed countries to collect compulsory contributions from the self-
employed.
5. Voluntary insurance – People may be allowed to be voluntary contributors to a
social security scheme, run by government or statutory agencies, which is
compulsory to others. Alternatively they may insure with profit or non-profit
agencies or they may join a group scheme.

Foreign Aid
Donors are important financiers of health care in Africa; especially where the
government has been unable to meet health needs due to revenue shortfalls. During
the 1980s bilateral donors accounted for 62% of total health assistance in Sub-
Saharan Africa, while multilateral agencies provided 32% and non-governmental
agencies 6%. External financing is generated mostly through development–oriented
institutions such as bilateral agencies, multilateral organizations and banks e.g.
UNICEF, WHO, UNDP, World Bank, EEC, and USAID etc.
20
Financial cooperation is generally channeled through a central authority in the
recipient country such as Ministry of Finance or Ministry of National Planning. In
some cases funds may be routed directly to particular ministries, agencies or NGOs.
While NGOs in financial terms may be small in most cases, their potential for
mobilizing people and strengthening their self-reliance cannot be overlooked.

Foreign Aid has played invaluable role in public expenditures in developing countries
but has some negative effects like:

1. Emphasis on vertical programmers

2. Sustainability problem
3. Priority program often determined by donors and not recipient countries
4. Some donor funding of programs are out of proportion to total health
needs
5. Poor coordination of efforts by various external agencies involved in
funding of the programmers.

Voluntary contributions
These are contributions usually from individuals or groups within the country.
Philanthropists may make cash donations and/or donations in kind (buildings,
equipment, etc). Religious groups also fall into this category. Some groups run non-
profit making health services.

HEALTH INSURANCE
Everyone no matter how healthy needs medical care at some point in time. This may
be in form of preventive care or treatment for sicknesses and injuries. With medical
care comes payment of fees in one form or the other.

Affordability of such fees at the point of use may be difficult. Health insurance
provides a form of financing which make payment for the fees relatively easier.
Health insurance is an institutional and financial mechanism that helps households,
individuals and organizations to set aside financial resources to meet costs of medical
care in the event of illness.

Definition Of Health Insurance

21
Health insurance is a system in which prospective consumers of care make payment
to a third party in the form of an insurance scheme, which in the event of future
illness will pay the provider of care for some or all of the expenses incurred. Health
insurance is a type of insurance whereby the insurer pays the medical costs of the
insured if the insured becomes sick due to covered causes, or due to accidents. The
insurer may be a private organization or a government agency. Health insurance is an
agreement between a person, who is called the policy holder, and an insurance agent.
Insurance agents or carriers are organizations that offer financial protection in case of
illness or injury and pays for the policyholder’s medical treatment.

The fundamental concept of health insurance is that it balances costs across a large,
random sample of individuals. For instance, an insurance company has a pool of 1000
randomly selected subscribers with each paying N1000.00 per month. Fifty of them
get really sick that month while the others stay healthy, which means the insurance
company, can use the money of the paid by the healthy people to treat the sick
persons.

INSURANCE

AGENT

(POOL OF FUND)

STRUCTURE OF HEALTH INSURANCE

History And Evolution

The concept of health insurance was proposed in 1694 by Hugh the Elder Chamberlen
from the Peter Chamberlen family. In the late 19th century, early insurance was
actually disability insurance that covered cost of emergency care for injuries that
could lead to disability. This continued until the 20th century where all laws in some
jurisdictions in US regulating health insurance actually referred to disability insurance
and patients were expected to pay for all other costs of medical care in a form of fee

22
for service. Today health insurance schemes cover a wider area of health care to
include the cost of routine, preventive, and emergency health care procedures.

The origin of health insurance can also be traced to medieval Europe when labour
unions, associations of employers of labor and craftsmen formed guilds which in turn
created funds to help members in times of need on account of illness. Although they
started with cash benefit they later broadened the scope to request doctors to certify
illnesses and paid them to provide health care for members. New incentives then
came from employers with the scheme becoming compulsory as employers in specific
high-risk industries such as mining, began to make employment often tied together
with willingness to pay contributions. With these came the development of earnings-
related contributions rather than risks-related contributions. This potential for such
solidarity was exploited in Germany in 1883, Austria in 1887, Norway in 1902 and
the UK in 1910. By the early 1930s compulsory health had been developed in most
industrialized countries of Europe under the name of sickness and maternity
insurance.

Types of Health Insurance

Private Health Insurance

Private health insurance is a contract between an insurance company and the customer
and in the private sector. Private insurance can be for groups like companies, labour
unions, professional association or for individuals.
Private: This is through employer owned on-sight health facilities or through contract
with outside providers, contribution payable is based strictly on the needs of the
individual i.e. the higher the health needs of the contribution the higher the payment.

Public Health Insurance

The public sector third party may be Parastatals, insurance scheme, government, and
social security and sometimes the [Link] the publicly funded health insurance
the good and the bad risks all receive coverage without regard to health status, which
eliminates the problem of adverse selection and amplifies the problem of moral
hazard.

Social Insurance

Insurance program financed by government through tax revenues that guarantee

citizens financial benefits for events which are beyond individual control, such as old

23
age, disability and poor health. Payment is irrespective of the needs and is usually
based on employment and income.

1. Based on the principle of solidarity

2. Contribution based on ability to pay
3. Resources are pooled together among a large population It
enhances security of each individual in the group.
4. Higher income earners will subsidize those with lower income and those
with lower health needs will subsidize those with higher health needs.

Community Sponsored Insurance

A community based program which normally operates in the rural areas and mostly
localized e.g. health care scheme in Thailand, Tsonga in Kwara State, Nigeria.

Other types of HIS include

Direct

Here the Health Insurance Scheme builds or rents its own health care premises
exclusively for the use of the insured persons.
Indirect

Here the scheme makes contracts with selected providers for the provision of defined
services at negotiated prices, the authority rather than the insured persons makes the
payment.

Reimbursement
The patient buys his own medical care in the private market and then sends the
receipted bills to the insured who reimburses the insured person either for part of the
full cost or on the basis of standard payment for a particular service which will
normally be well below the prices actually paid.

Problems Of Health Insurance Include:

1. Increasing cost of health care

2. Some private insurance companies charge people at different rates based on their
own personal health
Some medical problems may not be covered by the scheme
3. Health care recipient is not involved in negotiating the cost of care. Some health
care providers have popular and unpopular ways of controlling these costs.

24
4. Some providers may have different rates for the same procedure for those insured
and those not insured.
Problems With Private Health Insurance

There two main problems and these are adverse selection and moral hazard.

Adverse selection - Describes the tendency for only those who will benefit from
insurance to buy it or participate in it. Adverse selection can leave an insurance
company with primarily sick subscribes and will have the problem of balancing out
the cost of medical expenses with a large number of healthy subscribers. This is
because unhealthy people are more likely to purchase health insurance because they
anticipate heavy medical bills whereas those who consider themselves to be healthy
may decide that medical insurance is an unnecessary expense; if they see a doctor
once in a year and it costs N500.00, that much better than making monthly insurance
of N600.00. The insurance companies too can deny those with medical history
suggestive of a future a heavy financial burden may be denied or screened out.

Moral hazard – Describes the state of mind and change in behaviour that results
from the knowledge the health insurance will take care of medical bills and people
therefore overuse medical care since they do not incur out-of –pocket expenses.
Where health insurance is in practice, people who do not have insurance cover or are
under-insured may wait for too long out of fear of high medical bills until the illness
become life-threatening.

HEALTH CARE FINANCING IN NIGERIA

INTRODUCTION
Health is fundamental to the socio-economic development of any nation. Nigeria like
many other countries have its people health funded by government, but as result of
the inadequacy of government funding several other options in health care financing
are also in place.

All tiers of government are involved in health car financing even though the level of
health they fund differ. The proportional allocations of money to health sector out of
the total budgetary expenditure by these tiers of government vary considerably.
Effective use of the meager financial resources available to the health sector in
Nigeria remains a problem and challenge.

25
National Health Policy on Health Care
Financing
The 1988 National health policy declares that Federal and State Government shall
review their allocation of resources to the health sector and within available resources
give priority to primary health care, community resources are to be mobilized in the
spirit of self-help and self-reliance.

In the 1988 policy it states that efforts shall be made to redistribute financial
allocation among primitive, preventive and curative health care services to ensure that
more emphasis is placed on primitive and preventive services other highlights on
health care financing include;

1. Exploration of health insurance scheme

2. User charges for curative services but subsidized preventive services
3. Public assistance shall be provided to the socially and economically
disadvantaged segments of the population
4. Governments of the Federation shall encourage employers of labour to participate
in financing health care services to employees
5. Within the rights of individuals to participate in the economy of the nation,
private individuals shall be encouraged to establish and finance private health
care services in under-served areas.
6. Within the concept of self-reliance, communities shall be encouraged to finance
health care directly or find local community solutions to health problems through
contribution of labour and materials
7. Mechanisms shall be established to undertake continuing studies on benefit of v7.
rious health programmers in relation to costs and inclusion of analysis of needs in
terms of cost, material and personnel in all consideration of health technology and
of the establishment and maintenance of health infrastructure.

Health Financing By Tiers of Government

Local Government

The provision of primary health care is largely the responsibility of the various Local
Governments within their Local Government Areas. Each the Local governments are
expected to provide the various components of PHC. This requires facilities,
equipments and personnel.

The Local Government provides funding for this levels of care particularly the public
institutions providing this care.

26
State Government

The State governments provide secondary health care which is specialized care to
patients referred from the Primary Health Care through in-patient and out-patient
services of hospitals for general medical, surgical, pediatrics patients and community
health services.

Specialized supportive services such as Laboratory, Blood Bank, Rehabilitation and

Physiotherapy services are supposed to be available at this level. This type of care is
expected to be at the level of districts, Local governments and zonal levels of each
State.

In addition to the secondary health care service, the State Governments also provide
supportive PHC services to the Local Governments.

Federal Government

The Federal Government is involved in provision of specialized services through

Teaching Hospital and other special hospitals which provide care for specific disease
conditions or specific group of patients e.g. Orthopedic, Ophthalmic, Maternity and
Pediatric Hospitals. This level of care requires big facilities, infrastructures and
equipment as well as highly skilled personnel. This is financed by the Federal
Government although presently some State governments now get involved in
provision of this level of care. In addition to this role, the Federal Government also
provide supportive and supervisory role to Primary Health care at the State and Local
Government Levels.

Options in Health Care Financing

Government Financing of Health Care

This option has in Health care financing has been in place since the colonial period.
From independence government continued to fund health care in form of primitive,
preventive and curative health care as described above.

In the past there were some governments had free health care programmers where the
government make health care free to its people and bear the cost of such care. The
coverage of such health care was however grossly inadequate. In view of the very
cost required to provide such free health care which some of the State government
were unable to provide, the free health care programmers virtually became ‘no’ health

27
care. Some particular health needs are still provided free by some State government
e.g. free eye tests, maternal care, children care.

User charges

This option in health care has been in place over a long period though initially at a
low scale but now increasing and now the most dominant in health care financing in
Nigeria. This is with its advantages ad disadvantages. Remember you learnt the
various advantages and disadvantages of this option in health care financing in Unit 6
of this module. Affordability of cost of health care is a big problem to many Nigerians
and this is affecting utilization of services. Unfortunately patients go for alternatives
that are usually sub-standard in terms of quality of care.

Community Financing

In Nigeria there are several community based organizations. Some of these

organizations engage in self-help projects which include health related activities.
Some communities erect buildings for health centre.

Some provide labour to augment health care financing in their areas.

Communities are sometimes involved in preventive health care services I the form of
digging of public wells, construction of public latrines.

Some communities are however faced with poor contributions to sustain projects they
had earlier embarked upon. At the same time some community projects that were
completed and handed over to government are poorly maintained.

Health Insurance

The National Health Insurance scheme which had been on the drawing board for
decades in Nigeria has been launched and is in its early phase of implementation.
Most of the people currently enrolled on the scheme are public civil servants. The
scheme with time will cover increasing number of people in the country.

Private health care financing is also available in some urban settings in Nigeria. Unit
9 discuss in more details health insurance scheme in Nigeria.

Foreign Aid

28
Nigeria receives foreign aid from several International Agencies, bilateral government
agencies. Some of these funds are channeled through the National Planning
Commission. A number of International Agencies also channel funds directly to
various levels of government, Non-Governmental Organizations and Religious
groups.

NATIONAL HEALTH INSURANCE SCHEME IN

NIGERIA

INTRODUCTION
Health Insurance Scheme is now in place in Nigeria as one of options for health care
financing. The history of health insurance scheme in Nigeria is over 3 decades but not
until 1997 that the scheme was officially launched. The implementation of the scheme
in Nigeria is planned to be in phases commencing with pubic civil servants. Private
sector involvement is incorporated into the scheme with the use of Health
Maintenance Organizations (HMOs) to collect contributions from participants and
also pay providers of services.

Historical Perspective
In Nigeria the first search for health insurance system started in1962 during the first
republic. The federal government invited Dr. Halevi through the International Labour
Organization (ILO) to look into starting an health insurance system in Lagos.
Dr. Halevi supported the system but the Nigerian Medical Association opposed it. The
civil war years, caused the matter to be shelved but was resuscitated by the National
Council on Health in the early 80s, two decades after. The Minister of Health,
Admiral Patrick Koshoni, on the advice of the National Council of Health
commissioned a study led by Professor Diejomaoh of the Nigerian Institute for social
and economic research (1984). This was later followed in 1965 by a feasibility study
chaired by Mr. Yinka Lijadu of the National Insurance Corporation of Nigeria which
found the scheme feasible, workable and desirable in Nigeria. Finally, in 1988,
Professor Olikoye Ransome Kuti, commissioned the National Committee on
Establishment of the NHIS, chaired by Emma-Eronini and recommended the
capitation model, which is easy to run and almost tailor made for our health system
and traditions. The United Nations Development Programme (UNDP) and
International Labour Organization (ILO) consultants along with others conducted
their own studies in Nigeria to provide costing, draft legislation and implementation
guidelines for establishing the scheme in 1992. Then the federal executive council,
which had given its approval in 1989, directed federal ministry of health in 1993 to
29
start the scheme, which was launched in 1997, and finally signed to law in May 10,
1999 by the then Head of State General Abdulsalam Abubakar.

NHIS: The Nigerian Concept

It is a social health security arrangement to provide financial security to the citizens
against unforeseen ill health. A scheme established by law number 35 of 1999 to
improve health care delivery by providing a sustainable alternative source of funding
health care services. The scheme works on the principle that higher income earners
will subsidize those with lower income; and those with lower health needs will
subsidize those with higher needs. Resources are pooled among a large population so
that sufficient fund will be made available to take care of individuals needing health
care at any one time. It will be a solution to the problem of inappropriate use of the
levels of health care leading to unnecessary costs and underutilization.

It guarantees access to health care as of right to participants.

The establishment of the scheme was informed by the general poor state of the
nation’s health care services especially in relation to accessibility, quality of services
rendered, utilization and distribution, the excessive dependence and pressure on the
government provided health services, and dwindling funding in the face of rising cost
of heath care services.

The objectives of NHIS include:

1. To ensure that every Nigerian has access to good health care services.
2. Protecting families from the financial hardship of huge medical bills.
3. To ensure equitable distribution of health care costs among different income
groups.
4. Limiting the rise in the cost of health care services.
5. To improve and harness private sector participation in the provision of health
care services.
6. To ensure equitable patronage of all levels of health care.
7. To maintain high standard of health care delivery services within the scheme.
8. To ensure availability of funds to the health sector for improved services.
9. To ensure efficiency in health care services.
10. To ensure adequate distribution of health facilities within the federation.

30
Health Care Benefits of the Scheme
The benefits derived from participating in the scheme are defined by law, are fairly
comprehensive and include the following:

1. Defined elements of curative care such as:

Out patient attendance

Maternity care for up to four births for every insured person
Consultation with defined range of specialist
Hospital care in a public or private hospital in a standard ward, during a stated
duration of stay, for physical or mental disorders.
Eye examination and care, excluding tests for and the actual provision of spectacles
Defined dental care:

1. Consultant, Oral examination, preventive care and pain relief

2. Preventive care including immunization, family planning, antenatal, post-natal
care and health education.
3. Prescribed drugs and diagnostic tests
4. Prostheses and rehabilitation

From the above it is evident that the contribution of a small affordable amount buys a
lot in terms of health care.

How the Scheme Works

For participation in the scheme, contributors will first register with an NHIS approved
Health maintenance Organization (HMO) and thereafter register with a primary health
care provider of his choice for an approved list of providers supplied HMOs. When a
contributor is registered he will be issued an Identity card (ID) card with a personal
identification number. In the event of sickness the contributor presents his ID card to
his chosen primary health care provider (PCP) for treatment. A contributor has a right
to change his PCP after a minimum period of six months if he is not satisfied with his
services. Disputes between actors in the scheme shall be settled by arbitration boards
to be set up at state level, whose membership includes representative of NMA;
Pharmaceutical Society of Nigeria; The National Association of Nigerian Nurses and
Midwives and the public. The HMO will make payment for services rendered to him
to the health care provider. A contributor may be asked to make a small co-payment
per prescription at the point of service.

31
A contribution made by the insured person entitles himself or herself, spouse and four
children under the age of 18 years to full health benefits. However students in school
upon to the age 25years qualify as dependants. Extra contributions will be required
for additional dependants. Contribution to be made by formal sector employees for
health benefits under the scheme will be 15% of wages, the payment of which will be
by both the employee and the employer. The employee pays 5%, while the employer
makes up the remaining 10%. The employee’s part of the contribution is to be
deducted from his pay with the employer adding his own and subsequently
forwarding the total payment to the appropriate quarters.

The implementation of the scheme is planned to be in phases to cover all Nigerians

categorized as follows:

1. Employers in the formal sector (public and private) – their contribution will be
paid by their employers and those in public sector by the federal state local
governments Parastatals and agencies as appropriate.
2. Self-employed person (market women, traders, artisans, farmers and
Businessmen etc) – they will be encouraged to pay their contributions either by
themselves or through cooperatives formed by them.
3. Rural dwellers –for this group suitably priced programmers designed for them
will be implemented in consultation with various organizations such as the
community banks, cooperatives, local state and federal governments as well as donor
agencies and other NGOs.
4. Vulnerable groups which include the unemployed, the aged, the disabled, the
street children, the retarded and the retirees – their contribution will be paid on their
behalf by the federal government, state government and local governments NGOs,
local community and philanthropists.

It is however important to emphasize that coverage will be phased starting with

employees in the formal sector representing a definable group.

Classification of Health Care Providers

1. Primary Health Care Providers

First contact with the Scheme i.e. gatekeepers. These include:

Primary Health Care Centers

i) Comprehensive health care centers

ii) Nursing and maternity homes (With prove of access to Medical Practitioner).

32
iii) Out-patient departments of General Hospitals, Specialty Hospitals, Specialist
Hospitals, Federal Medical Centers, Teaching Hospitals, Armed Forces, the
Police and other uniformed services Hospitals/Clinics, University Medical
Centers, and Federal Staff Clinics/Hospitals.
iv) Non-specialist private hospitals and clinics.

2. Secondary Health Care Providers provide health services on referral from

Primary Providers

These include:

i) General/Divisional Hospitals (out-patient specialist

care and in-patient care for medical, surgical,
pediatrics, obstetrics and gynecology etc),
ii) Specialist Hospitals/Reference Hospitals iii) Federal
Medical Centers iv) Pharmacies
v) Laboratories vi) Dental clinics vii)
Physiotherapy clinics viii) Radiography
centers, etc.

3. Tertiary Health Care Providers provide health services on referral from

primary and secondary levels. These include:

i) Teaching hospitals ; ii) Specialist hospitals,

iii) Specialty/specialized hospitals (orthopedic, psychiatric, etc), iv) Federal
medical centres, and v) Military reference hospitals.

33