FORMAL SECTOR SOCIAL HEALTH INSURANCE PROGRAMME (FSSHIP) REGULATORY REFORMS: CRITICAL FACTORS

How to cite this paper: Igwe, A. A., Ejike, I., & Ukpere, W. I. (2022). Formal Sector Social Health Insurance Programme (FSSHIP) regulatory reforms: Critical factors [Special issue]. Journal of Governance & Regulation, 11(1), 327–336. https://doi.org/10.22495/jgrv11i1siart12 Copyright © 2022 The Authors This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0). https://creativecommons.org/licenses/by/


INTRODUCTION
The pressure to render quality healthcare to the general public using scarce resources is a major concern for healthcare managers and government officials alike in Africa. This situation has forced healthcare managers and government officials to search for alternative sources of funding the healthcare system, such as health insurance scheme among many others (WHO, as cited in Lawan, Iliyasu, & Daso, 2012). Subsequently, many countries in Africa embraced prepayment methods to finance healthcare services (Onoka, Onwujekwe, Uzochukwu, & Ezumah, 2013). Despite healthcare reforms in Nigeria, the provision of healthcare services to the public has not been an easy task (Eteng & Ijim-Agbor, 2016;Scott-Emuakpor, 2010). The goals of the Nigerian government to provide qualitative healthcare has been elusive due to the high cost of healthcare delivery in the country, in addition to the fact that a vast majority of people live below the poverty line (Ayanleye, 2013) and this has contributed to the weakness of the health system. The healthcare system has always witnessed fee-for-service with government supports augmenting capital project funding. Nigeria is accustomed to borrowing from outside sources and obtaining support in the form of technical aid and free medications, particularly for preventive services (Onyedibe, Goyit, & Nnadi, 2012). Out-of-pocket spending accounts for over 70% of all healthcare spending, making it the country's most important source of healthcare funding.
In 2005, the Nigerian government adopted National Health Insurance Scheme (NHIS) to provide supplemental funding to the sector for improving equity in health (National Health Insurance Scheme [NHIS], 2009; Meessen, Criel, & Kegels, 2002). Health insurance is a healthcare system in which a potential consumer pays a third party with the expectation that in the case of a future sickness the third party will cover some or all of the associated costs (Chaleunvong et al., 2020b;Sikosana, Dlamini, & Issakov, 1995). Many countries employed health insurance as a vital healthcare financing mechanism to provide financial risk protection (Witter & Garshong, 2009). NHIS in Nigeria was established primarily to guarantee high-quality medical services, offer financial risk protection, mitigate increasing healthcare costs, improve healthcare efficiency, and boost Nigerians' health status, all of which add to existing poverty-reduction strategies (Adibe, Udeogaranya, & Ubaka, 2011;Awosika, 2012). The programme was first implemented in 2005 (Falegan, 2008) when employees in the public sector were required to join via the Formal Sector Social Health Insurance Programme (FSSHIP).
The Social Health Insurance Programme was established to offer high-quality healthcare to every government employee, their spouses, and four biological children who are covered by social health insurance (NHIS, 2009). The services available for the federal civil service beneficiaries of the scheme include childbirth for up to four babies, immunizations, post-natal care, and family planning services for registered employees, eye examinations, and the chance to be cared for by specialists or be referred for advanced investigations, for example, surgical, diagnostic or physiological services (Falegan, 2008). However, the type of health services beneficiaries receive depends on the inclusion and exclusion criteria. Under the present arrangement, 3.25% of the fund is contributed by the employers, while employees contribute 1.75% from their salaries. However, this arrangement is not swiftly observed because Federal Government pays only N 750 per life covered quarterly (Adewole & Osungbade, 2016).
Even though the Formal Sector Social Health Insurance Programme includes both federal and state workforce, its implementation among all state employees has garnered less attention than that of federal employees since its inception in 2005 (Adebiyi & Adeniji, 2021;Amu et al., 2021). States, in particular, are underrepresented in the Formal Sector Health Insurance Programme, with just five states participating out of a total of 36 in the Federation. States' low involvement is due to a lack of clearly defined state duties in the scheme as well as a lack of specific accountability and financial reporting on the programme's operations since its inception (Onoka et al., 2013).
The Formal Sector Social Health Insurance Programme, which was formed over a decade ago, has yet to accomplish the goal for which it was created. Eteng and Ijim-Agbor (2016) have observed several factors that undermine the successful implementation of this scheme in Nigeria such as the public poor conception of the scheme, cultural and religious practices, inadequate and dilapidated health infrastructure, rural backwardness, delay in reimbursing service providers, dearth of medical personnel to address urban and rural health needs, excessive bureaucratization of the administrative process as well as corruption. Enrollees are often refused access to healthcare services unconditionally or are obliged to pay the extra cost by health providers, who claim that the services demanded are out of coverage (Sales, Reyes, Ting, & Salvador, 2020; Uzochukwu et al., 2015). Registrants have also expressed dissatisfaction with some of the programme's healthcare professionals (Gabriel & Oluseye, 2017;Osungbade, Obembe, & Oludoyi, 2014).
There is inadequate and ineffective awareness campaign while the presence of high-quality, reachable, and affordable healthcare is still a major concern (WHO, 2008; Omoruan, Bamidele, & Philip, 2009). As a result, the success of FSSHIP in Nigeria is mainly dependent on how much information potential beneficiaries know about the scheme and how high-quality the health programme is for the beneficiaries in terms of meeting the aims of the plan. . This study looked at the important elements that influence the effective implementation of FSSHIP, especially among federal civil servants in selected Federal ministries, departments, and agencies (MDAs) in South-East Nigeria since previous studies mainly focused on the employees of federal hospitals. This study, therefore, leveraged the theory of Social Health Insurance (SHI) as developed by Arrow (1963). It argues that every year a proportion of people suffer from one serious illness or the other which can be life-threatening and demands urgent medical expenses that the ill person may not be able to afford and as such, faced with life and death decisions. Hsiao and Shaw (2007), leaning on the notion of the theory, found that individuals would seek out expensive medical care even if the expenses will impoverish patients and their families. This emphasizes the need for such a scheme in serving as a welfare option in reducing the burden of expenditure on health, an endemic problem faced in developing nations. The aim of this study is to probe the awareness level of prospective FSSHIP adopters and the inherent challenges within the policy environment. The research questions are: RQ1: What are the awareness levels of FSSHIP in Nigeria?
RQ2: What are the challenges affecting its upscaling among federal workers in South-East Nigeria?
The findings of this study would provide veritable insights on the extent of acceptability, awareness, and adoption of the FSSHIP of federal workers since its inception in 2005, and help policymakers determine how the scheme would benefit more workers, especially in South-East Nigeria. The study made use of a simple random sampling technique in selecting the samples from the federal institutions in the region while PCA was employed to test the hypotheses. Findings revealed a low level of awareness of FSSHIP services and that cultural and religious practices, poor public perception of the scheme, corruption, and inadequate financing significantly affected the scaling up of FSSHIP in South-East Nigeria among federal workers in southeastern states of Nigeria.
The rest of this paper is structured as follows. Section 2 reviews the relevant literature. Section 3 analyses the methodology that has been used to research the awareness and implementation of FSSHIP in developing countries. Section 4 clearly shows the results of the analyses done. While Section 5 and Section 6 include the discussion and conclusion of the study respectively.

Formal Sector Social Health Insurance Programme: Regulatory reforms
The Social Health Insurance Programme is a social healthcare system where employees are covered by funds established by combining employees' and employers' payments. The plan is supported by both the business and the employees through monthly payments. Contributions are based on earnings. The employer pays 3.25% and the employee pays 1.75% for the public (federal) sector programme. For the private sector programme and other levels of government, the employer pays 10%. However, an employer may elect to pay the whole contribution. Extra payments from the employer may be made to supplement the benefits package (NHIS, 2012). Principals are allowed to register up to four children; however, a spouse or kid cannot be registered more than once. A ninety (90) day processing/waiting time is required before a participant may get healthcare services (NHIS, 2012).
The beneficiary is at liberty to choose his/her NHIS with an accredited primary healthcare institution; to change a primary healthcare facility after 6 months with the current primary healthcare facility; to access care once the beneficiary's name is on the current NHIS participants register after proper identification, and to receive emergency treatment at the nearest NHIS accredited healthcare facility.

Awareness of FSSHIP
It has been observed that the awareness of insurance prepayment schemes and universal health coverage is low which is associated with gross inequity in health care utilization ( However, a high level of awareness among the potential beneficiaries, better understanding of the basic concepts and the benefits package of an SHI is essential to ensure acceptance of a scheme. Bawa and Ruchita (2011) assert that there is a low degree of knowledge and desire to participate in health insurance. Yellaiah (2012) investigated the factors that influence health insurance knowledge in Andhra Pradesh focusing on variables such as age, education, gender, occupation, income, family type, and health spending. Religion, family type, education, employment, and yearly income were shown to be predictors of health insurance knowledge in the study (Totin Vodounon, 2021). Furthermore, better education and income had a favourable relationship with health insurance awareness.
Reshmi, Nair, Sabu, and Unnikrishnan (2007) assert that only 64.0% of people are aware of health insurance. The media, which played a major role in the transmission of information, was responsible for around 45% of the respondents' knowledge of health insurance. This implies that improved commitment of knowledge dissemination by policy actors should enhance the community buy-in (Acharya, Devkota, Gautam, & Bhattarai, 2020; Chaleunvong et al., 2020a). This should be the expectation within targeted policy environments around developing nations; and on that premise, the first hypothesis is: H1: The level of awareness of FSSHIP should be significant among the federal workers in South-East Nigeria.

Challenges of FSSHIP
The National Health Insurance Scheme (NHIS) in Nigeria has been challenged by several factors, the implementation of the national health insurance system, as asserted by Johnson and Stoskopt (2009), is hampered by healthcare professionals' use of outdated and insufficient medical equipment. The country has a constant lack of contemporary medical equipment such as radiologic and radiographic testing equipment as well as diagnostic scanners; even when the equipment is available, repairs and maintenance are always an issue.
Oba (2008) sees corruption as one of the challenges confronting the implementation of NHIS, whereby the money designed to ensure that the scheme reaches private individuals are siphoned, resulting in insufficient funding for the plan. Similarly, the NHIS faces a shortage of competent people in the healthcare industry. FMOH (2006) submits that the country had 19 physicians per 100,000 inhabitants between 1990 and 1999. This is due to low pay, a lack of postgraduate medical schools, and terrible working conditions in Nigeria (WHO, 2007). In addition, World Bank data reveal that only 35% of births were supervised by qualified health practitioners. Similarly, National Center for Biotechnology Information (NCBI) reports that religious and cultural beliefs impact the function of NHIS in Nigeria.
Likewise, Eteng and Ijim-Agbor (2016) assert that public ignorance of the NHIS poses a big threat to the scheme in Nigeria. He believes that a lack of understanding of the functioning of the scheme and limited education are major challenges to the success of the programme. Moreover, Eteng and Ijim-Agbor (2016) identified the large informal sector, diversity in economic status, group determination and implementation of exemption package, and the reluctance of the health maintenance organization (HMO) to work in rural areas as major constraints to the scheme implementation of SHI in Nigeria. These challenges could constrain the adoption of FSSHIP among workers in Nigeria. The second hypothesis is therefore stated as thus: H2: Cultural and religious practices, poor public perception of the scheme, corruption, and inadequate financing would significantly affect scaling up FSSHIP in South-East Nigeria.

METHODOLOGY
This paper adopted a survey method. The choice of the research design suits the purpose of this study because it aims at collecting information that reveals the characteristics or features of an existing phenomenon (Onwumere, 2009). The study utilized primary and secondary sources of data. The target population is 4,682 workers which included federal workers in the selected Ministries, Departments, and Agencies (MDAs) of the five states -Abia, Anambra, Ebonyi, Enugu, and Imo -in South-East Nigeria. The choice of the selection is based on the premise that a large percentage of health insurance enrollees in Nigeria comes from the FSSHIP and is federal government workers (FMOH, 2005; NHIS, 2012).
The technique for the selection of population is simple random sampling upon which all the federal workers in the selected MDAs of the five states in South-East Nigeria were randomly selected using balloting. An alternative method of sampling would be the use of quota or convenience sampling to determine the respondents for the study in a more cost-effective manner.
A sample size of 513 federal workers was determined using Cochran's (1963) formula for sample determination. The sample size for each ministry selected was determined using Bowley's proportional allocation statistical technique. In selecting the sample from each ministry, a simple random sampling technique by way of the lottery was employed. The questionnaire was used in collecting data.
A five-point Likert scale questionnaire was designed in line with the objectives of the study. Content validity was carried out using three management experts from the University of Nigeria, Enugu Campus, and two experts from the Federal Ministry of Education in Enugu. Their responses, comments, and suggestions were used to modify the instrument. A test-retest method was adopted in ascertaining the reliability of the research instrument. The scores from the two exercises were correlated using Spearman's rankorder correlation. The computed correlation coefficient was 0.87. The result indicated a very strong positive relation between the two test-retest exercises. A one-sample t-test and principal component analysis (PCA) were adopted in testing the research hypotheses. An alternative to the use of t-test is the use of Mann-Whitney U-test which is used to compare two distributions in independent samples while factor analysis may be employed as an alternative to PCA.

The first research hypothesis
The first research hypothesis (H1) ascertained the extent of awareness of FSSHIP among federal workers in South-East Nigeria. Table 1 was used to test the hypothesis and decision taken based on the rule. The t-test result above with a coefficient value of -1.73 and associated probability value of 0.14 > 0.05 confirmed that there is a low level of awareness of FSSHIP services among federal workers in the southeastern states of Nigeria. Particularly, the result showed that the extent of consciousness of FSSHIP services among the federal workers in the states is insignificantly negative, which calls for acceptance of the null hypothesis that the level of awareness of FSSHIP is not significantly positive among the federal workers in South-East Nigeria.

The second research hypothesis
The second research hypothesis (H2) ascertained the major challenge facing the FSSHIP in South-East Nigeria. Table 2  Level of significance ( ) = 0.05. Strata means greater than 3.0 (Likert mean) and standard deviations less than 1.581 (Likert standard deviation) respectively shows that the out listed are the challenges facing FSSHIP in southeastern states of Nigeria. From the ranking statistics, it was shown that the major challenge facing the FSSHIP is corruption followed by excessive bureaucratization of the administrative process and lastly infrastructural challenge. Since these findings are based on descriptive statistics, the researcher further subjected these factors to inferential statistical evaluation to be able to make a solid decision. The principal component analysis techniques were employed and the results are shown below.     The Varimax with Kaiser Normalization rotated matrix above indicates that in the first component, a cultural and religious practice is extracted against corruption and excessive bureaucratization of the administrative process.
In the second component, poor public perception of the scheme is extracted against cultural and religious practices and infrastructural challenges. In the third component, poor public perception of the scheme is extracted against excessive bureaucratization of the administrative process and corruption.  The component score matrix indicates that poor public perception of the scheme is extracted in the first component, corruption in the second component, while cultural and religious practices are extracted in the third component.
The researchers, therefore, conclude that the major challenges affecting the scaling up of FSSHIP in South-East Nigeria include cultural and religious practices in the area, poor public perception of the scheme, and corruption, which leads to inadequate financing of the scheme. The component plot in rotated space indicates that the second and the third components are more related than the first and the third components, and the first and the second.

DISCUSSION
The findings of this study to identify the greatest challenge of FSSHIP in South-East Nigeria showed that the major challenges associated with FSSHIP included cultural and religious practices, poor public perception of the scheme, corruption, and inadequate financing in the area. Hence, this study concludes that these factors significantly affect scaling up FSSHIP in South-East Nigeria. This agrees with the study carried out by Alhassan, Nketiah-Amponsah, and Arhinful (2016), who examined sustainability, challenges, and prospects of the NHIS in Ghana. The results revealed that increased cost, political interruption, low technical capacity, and poor monitoring mechanisms were factors that negatively affected NHIS operations in Ghana.
The results of this study to assess the extent of awareness of FSSHIP among federal workers in South-East Nigeria showed that the level of awareness of FSSHIP among the federal workers was low with most of the respondents not having excellent knowledge of the role of HMOs and some benefits packages of FSSHIP. The results also showed that the level of awareness of FSSHIP among the federal workers in the five states is insignificantly negative. This development could be attributed to low sensitization of the programme by the HMOs and the inability of HMOs to market the approved health plans to the enrolees as perceived in other studies (Acharya et al., 2020;Chaleunvong, et al., 2020a). This finding is supported by Onwujekwe et al. (2010), who evaluated the level of NHIS awareness of civil servants in South-East Nigeria. Their findings synchronized with previous studies.

CONCLUSION
The study concluded that aside very low level of awareness of the scheme, cultural and religious practices, poor public perception of the scheme, corruption, and inadequate financing significantly affected the scaling up of FSSHIP in South-East Nigeria. It is important to note that while social schemes like the FSSHIP are low-cost veritable instruments to improve the welfare of a sizeable group within developing nations, the community buy-in and ownership of such well-conceived initiatives could be threatened by a lack of awareness of the target community, combined with a lack of appreciation about context-specific idiosyncrasies; raising further sustainability questions. This means that just because a health policy is generally acceptable does not imply that it has received wide publicity. The government and other policymakers have a role to play in the promotion of FSSHIP especially among civil servants who are not directly linked to the health sector. They should be informed on how to get enrolled as well as the benefits they would enjoy for doing so. In fact, policymakers and implementers of the programme should identify those context-related issues and challenges that are peculiar to each of the five southeastern states to assist those states to overcome the challenges they face in scaling up adoption. It is important to note that the level of awareness and acceptance of FSSHIP may be affected by the success, relevance, and effectiveness of current/similar programmes which may shape the adoption processes. The potential drawbacks of adopting and implementing universal health insurance programmes that are peculiar to civil servants should be identified. One of such drawbacks is the risk that the provision of health insurance for this group of people may reduce the public funds that should have been used to provide health insurance to other groups of the populace. The importance of policy champions in the creation of awareness and scale-up should not be ignored. Policy champions such as governors and commissioners of health play a significant role in the promotion and sensitization of their workforce on the adoption of health reforms that would be beneficial to them. The incorporation of specific health institutions in the formulation and implementation of health policies and programmes such as FSSHIP may be a huge difference in terms of awareness creation and increased adoption. Hence, to enhance awareness and scale-up, both NHIS and HMOs as the stakeholders of the FSSHIP should improve their level of monitoring and evaluation of the success of the scheme in the region; especially among those health institutions that are accredited to the FSSHIP. This would increase the level of compliance with the demands of the scheme in a more extended manner. Also, those who misapply the scheme and flout the guidelines of operation should be identified and punished severely to minimize incidences of corruption that have hampered its successful scale-up in the southeastern region of Nigeria.
The focus of most policy research within developing nations is mostly driven by the need to convince policymakers to implement certain initiatives, with little effort targeted towards enhancing the knowledge of the target community. Other studies should therefore consider how the knowledge capital investment of policymakers influences community buy-in, especially within hostile policy environments. This would be an important probe as our study was limited in scope-focusing solely on the community (employees) and not on those HMOs who should have an expenditure outlay to both drive community awareness and check institutional challenges unique to their operational environment. Further studies can also replicate this research in other geopolitical zones of the country to tease out the peculiar challenges of awareness and adoption that may be critical for scaling up the programme within those regions.