HEALTH ECONOMICS

I will be taking part of unit 3, then unit 4 and 5

NATIONAL HEALTH INSURANCE SCHEME

National Health Insurance Scheme is a body set up by Decree 35, of 1999 (now Act 35)
operating as Public Private Partnership and directed at providing accessible, affordable and
qualitative healthcare for all Nigerians. Dr. Kelechi Ohiri, is presently the Director-General and
CEO of the National Health Insurance Agency. NHIS slogan: Easy Access to Health Care For
All.

The National Health Insurance Scheme is a social health insurance programme designed by the
Federal Government of Nigeria to complement sources of financing the health sector and to
improve access to health care for the majority of Nigerians. The National Health Insurance
Scheme underwent significant legislative reforms last year, transitioning to a Public-Private
Partnership model. This transformation is aimed at ensuring accessible, affordable, and high-
quality healthcare for all Nigerians.

THE NEW NATIONAL HEALTH INSURANCE ACT OF NIGERIA

The Nigerian government signed into law the new National Health Insurance Act (NHIA) 2022
on 19 May 2022. The NHIA replaces the National Health Insurance Scheme Act of 1999, which
failed to enrol more than 10% of the population. The NHIA seeks to promote, regulate and
integrate health insurance schemes. It aims to secure mandatory health insurance for every
Nigerian and legal resident, and establishes a fund for the vulnerable groups, which will provide
‘subsidy for health insurance coverage for vulnerable persons and payment of health insurance
premiums for indigents.
The majority (70%) of Nigerians make out-of-pocket payments for health. A 2018 Nigeria
Demographic and Health Survey indicated that about 97% of Nigerians lack any form of health
insurance; thus, NHIA brings hope to over 83 million Nigerians living in poverty. The inclusion
of vulnerable groups will increase health-seeking behavior and access to quality healthcare
among this group; though, there is a need for an explicit definition of this vulnerable group and
who qualifies to be included.

The NHIA will create health insurance schemes in states that do not have them and the
accreditation of primary and secondary healthcare facilities that are more accessible to the
population. These healthcare facilities are imperative in achieving universal health coverage
(UHC), given their proximity and easy accessibility by people living in rural and semi-urban
areas, with the majority of these facilities owned by the government. They provide
comprehensive, good quality care that meets patients’ needs and covers basic health services for
disease prevention, health promotion and health maintenance, including offering basic diagnostic
tests and supplying safe, affordable medicines and vaccines, and so aiding in the attainment of
universal health coverage (UHC).

NHIS BENEFITS

The NHIS enrolees are entitle to the following benefits:

 Out-patient care, including necessary consumables.

 Prescribed drugs, pharmaceutical care and diagnostic tests- as contained in the National
Essential Drug List and Diagnostic Test List.
 Maternity care for up to four (4) live births for every insured contributor/couple in the
Formal Sector Programme.
 Preventive care, including immunization as it applies to the National Programme on
Immunization, health education, family planning, antenatal and post-natal care.
 Consultation with specialist such as physicians, pediatricians, obstetricians,
gynecologists, general surgeons, orthopedic surgeons, ear nose and throat (ENT)
surgeons, dental surgeons, radiologists, psychiatrists, ophthalmologists, physiotherapists.
 Hospital care in a standard ward for a stay limited to a cumulative 15 days per year in non
military Hospitals and no limit in Military Hospitals. The primary provider shall pay per
diem for the bed space for a total of 15 days cumulative per year. Thereafter, the
beneficiary and/or the employer Pay.
 Eye examination and care excluding provision of spectacles and contact lenses; a range
of prostheses limited to artificial limbs produced in Nigeria.
 Preventive dental care and pain relief including consultation, dental health education,
amalgam filling, and simple extraction.
 All providers are expected to provide counselling as an integral part of quality care.
  Etc

HOW MUCH IS NHIS IN NIGERIA?

Even though the Nigerian federal government covers the bill for the Formal Sector Social Health
Insurance Program (FSSHIP), the cost of the other programs (including the private sector) varies.
The cost of National Health Insurance Scheme registration for parents and their children is
N9,000 per head.

On the other hand, private healthcare providers usually charge between N35,000 and N220,000
for individual plans, while family plans range from N125,000 to N650,000. It costs N15,000 to
register for Voluntary Contributor Social Health Insurance Program (VCSHIP) and N10,000 per
head.

It costs N12,000 to register for National Mobile Health Insurance Program (NMHIP) and N9,000
per head. All NHIS fees for service renew annually.

How to register

 Visit the NHIS website.

 On the homepage, select the 'Register' button.
 Fill out the spaces with your NHIS membership number, surname, date of birth, and
random code provided by the website. After filling out all the fields, click 'Submit.'
 You'll then create an online NHIS account by providing your email address and the
password you'll be using to log in.
 Now, you're fully registered to NHIS online.

If you're not a member of the FSSHIP but want to enrol in NHIS, you can always do so as a
voluntary contributor. Follow these steps:

 Find your preferred Health Maintenance Organization (HMO) nearby and buy a voucher.
 Then visit the NHIS website. On the homepage, select the 'Voluntary Contributors'
option.
  Scroll down the page and select 'Register.'
 Fill out all the fields provided with the correct information.
 Towards the end of the process, you'll be required to provide the name of your state and
Local Government Area (LGA).
 After doing so, you'll get a list of all NHIS accredited primary healthcare facilities near
you. Choose the most convenient one for you and your family. If you don't get this list,
proceed to provide a different LGA or state.
 At the end of the application, you'll be required to provide your preferred payment
method.

If you don't have an internet connection, you want to register for NHIS; you can do so by dialling
*616#. After filling out all the necessary information required and submitting it. If the
application is successful, you'll receive a text message with your e-ID.

If you are a stakeholder of the Formal Sector Social Health Insurance Program (FSSHIP), you
don't need to enrol on NHIS because employers usually register all their employees.

Some of the members of the FSSHIP include employees of companies with at least ten people,
students of tertiary institutions, and members of uniformed services. Every month, the company
will deduct 5% of your total salary to pay your NHIS.

How Can I Check My NHIS Status?

Technological advancement makes checking NHIS status easier and more convenient. You need
to:

 Dial *929# on a network

 Select option 1
 Select NHIS card
 Enter your NHIS membership card number

CHALLENGES OF NHIS

Inadequate knowledge,
Poor awareness, and capacity regarding an insurance-based health system.

Corruption,

Lack of transparency, and accountability in the country

The provision of quality, accessible and Affordable healthcare remains a serious problem

Inadequate and outdated medical equipment,

Poor funding,

Inconsistent health policies,

Inability of the consumer to pay for healthcare services,

Gender bias due to religious or cultural beliefs,

Inequality in the distribution of healthcare facilities between urban and rural areas

RESEARCH
Measurement in Research
Measurement is all about assigning values to observations, objects and variables as studied in
research. It is important and appropriate to assign numerical and other values to designate
quantity, and also to assure the reliability and validity of the measures so designated. The two
key qualities of good measurement are validity and reliability.

The Importance of Measurement in Research

Measurement is important in research because the variables in research may not be directly
observable, like satisfaction, motivation, self -esteem etc. It therefore becomes necessary to
assign numbers that would enable the researcher to decide on that variable. Knowledge of
measurement enables the researcher;
Levels of Measurement
There are typically four levels of measurement that are defined.
• Nominal
• Ordinal
• Interval
• Ratio
There is a hierarchy implied in the level of measurement idea. At lower levels of measurement,
assumptions tend to be less restrictive and data analysis is less sensitive. At each level up the
hierarchy, the current level includes all of the qualities of the one below it and adds something
new. It is desirable to have a higher level of measurement than a lower one.
Nominal level – It is the weakest level, and the attributes are only named. There is no ordering
of the cases implied. Example 15, 10, 3, 20.
Ordinal level – The attributes can be ordered according to rank. The distances between the
attributes however do not have any meaning. For example, one could assign 0 in educational
attainment to someone who has none, 1 to one with primary education, 2, to one with secondary,
3, to another with tertiary education, and so on and so forth. In this measure, higher numbers
mean more education, but the interval between values cannot be interpreted, and the distance
between them is not the same.
Interval level – In interval measurement, the distance between the attributes is meaningful,
and can be interpreted. For example, when we measure temperature in centigrade, the distance
between 37.4 and 38.4 is the same as from 36.4 – 37.4. It is possible to compute an average of
an interval variable, but it is not possible to do so with ordinal variable.
Ratio level – The ratio level of measurement is the strongest, and has an absolute zero that is
very meaningful. It means that it is possible to construct a meaningful fraction (or ratio) with a
ratio variable. Weight is a ratio variable. Count variables are ratio, like the number of patients
seen in a clinic in the past five months. There may have been zero patients or twice as many
patients in the past five months than was the case in the previous five months.

Validity and Reliability measurement

The challenge in measurement is to collect data or evidence, on good enough observable
manifestations. This has to do with the issue of credibility. Validity looks at whether we are
measuring what we are. It is defined as the ability to measure what is supposed to be measured.
Reliability refers to how consistent, stable or predictable what we measure is. A clear example
could be made with the bathroom scale. It could measure your weight (valid, that is what a scale
measures), but should it give you 60kg at the first time, and 80kg the second time, you will
question that value. It shows that the scale is not reliable, though valid. The types of validity
crucial to measurement include content validity, concurrent and construct validity. There are
four types of reliability – inter rater or inter – observer reliability, test – retest reliability, parallel
forms reliability and internal consistency reliability. Let us discuss each of them and the types.
Validity • Face – It is a method of deciding on the ability of the instrument to do what it should
based on the face value. It is subjective.
• Content – It refers to the comprehensiveness of the instrument, the ability of the measuring
instrument to cover all the relevant areas, and is usually determined by expert opinion. •
Concurrent – It shows how valid an instrument is by comparing it with an already valid
instrument. • Predictive – This implies the ability of the measure to predict expected outcomes.
Note: Correlation is used to compute this and the higher the correlation, the more evident the
predictive validity.
Reliability • Inter rater or inter observer reliability – This estimation is used to assess the degree
to which different raters/observers give consistent of the same event. For example in observing a
student perform a task in the clinical setting, two observers using a checklist may rate the
student. At the end the ratings of the two observers could be correlated to give an estimate of the
reliability or consistency between the two raters.
• Test retest reliability – This is used to assess the consistency of a measure from one time to
another. The same test could be administered to the same sample on two different occasions. It
is assumed that there is no substantial change in what is being measured in the two occasions.
The interval between the two tests matters and the shorter the gap, the higher the correlation.
Different estimates may therefore be obtained depending on the interval.
• Parallel form reliability – It is used to assess the consistency of results of two tests constructed
in the same way from the same areas. The researcher constructs large number of test items from
for example human biology course, Respiratory system, and randomly divides them into two
equal halves. Both tests are administered to the same group, and the scores correlated to estimate
the reliability
. • Internal consistency reliability – It is used to assess the consistency of results across items
within a test. A single measurement is used to estimate how the items yield similar results. The
most commonly used is the split half method, where the total items are divided into two sets.
The entire instrument is then administered to a group of people, and the total score for each
randomly divided half is calculated. The split half reliability will be the correlation between the
total scores. This is often called the odd-even method due to the way the split is made for the
two halves. Another measure to assess internal consistency is the Cronbach’s Alpha or
Coefficient Alpha. These two words are interchangeably used.
Coefficient alpha reliability, sometimes called Cronbach’s alpha, is a statistical index that is
used to evaluate the internal consistency or reliability of an assessment. That is, it quantifies
how consistent we can expect scores to be, by analyzing the item statistics. A high value
indicates that the test is of high reliability, and a low value indicates low reliability. This is one
of the most fundamental concepts in psychometrics, and alpha is arguably the most common
index.
Cronbach's alpha is a way of assessing reliability by comparing the amount of shared variance,
or covariance, among the items making up an instrument to the amount of overall variance.
Coefficient alpha is used to assess the degree to which the items are internally consistent. A
high coefficient indicates that the items are interrelated. More specifically, the performance on
any one item can predict the performance on each of the remaining items
In general, alpha will range from 0.0 (random number generator) to 1.0 (perfect
measurement). However, in rare cases, it can go below 0.0, such as if the test is very short
or if there is a lot of missing.

Relationship between Validity and Reliability

The validity and reliability indices of measuring instruments in research give credibility to the
research. An instrument that is valid most often is reliable, but an instrument may be reliable
without being valid. It is therefore very important that researchers pay attention to these qualities
to ensure that the data collected in research is not only adequate, but useful and amenable to data
analysis procedures.
Measurement is therefore a very important aspect of the research process, and it enables the
researcher to decide how to interpret the data from the variable, and ensures the selection of the
appropriate statistical analysis. The criteria expected of instruments are those of validity and
reliability. Knowledge of measurement levels and validity and reliability would facilitate the
work of every researcher.