ABSTRACT

      The insurance scheme health services have been playing dominant role in improving health services in Nigeria.

This research work was carried out to survey the problems, abuses and effect of insurance scheme in health services.

The main aims of this organisation is to ensure that all its citizens receive good medical services.  Also to make available to all residents no matter the class or status, race, age and sex in need of medical care.

Finally, to ensure that good health services can be spread to the poor and rich by payment of premium.  Also majority members of the populace receive medical services from selected health care centre without difficulties.

CHAPTER ONE

 INTRODUCTION

·         BACKGROUND OF THE STUDY

It is been said that health is the most important thing a human life.  But before I delve into the steps that will be taken by the Nigerian government to institute a health insurance scheme, it is necessary to have an idea of what the federal government and some state governments have done in the area of health insurance scheme for the country and some states.

On August 23rd 1985, the minister for health, Chief (Dr) Emmanuel Nsan inaugurated a special advisory committee on National Health Insurance Scheme in Nigeria to examine issue related to health insurance scheme as a National Health Insurance Scheme as a way of financing personal health care services.  The terms of reference of this committee were:

1.    To examine the feasibility of the National Health Insurance Scheme in Nigeria.

2.    To advise on the modalities for the implementation of such a scheme.

3.    To examine any other matter which in the consideration of the committee is deemed relevant to the operation of a workable health insurance scheme in Nigeria.

4.    To make recommendations

·         STATEMENT OF PROBLEMS

The usual problems associated with the scheme are many and in our society they will even be more, some of these are

1.    Level of sincerity in billing by hospital. It is always common that hospitals send fantastic bills or are in collusion with the users of the scheme.   This problem will be solved if a pre agreed amount is fixed for each type of illness.

2.    Settlement of bills when cases are referred to other hospitals not in the group.

In many cases there are referred cases to hospitals not listed in the group and settlement of their bills becomes difficult since they are not bound by the standard which are applied to hospitals in the group.  These hospitals should be made to abide by the charges for those in the group otherwise the user or the organization may have to pay higher amount for the cost.

3.            Managerial decisions involving abuses Health Care Organizations and Monitoring the system.

Having set the system, it is important to set up the various parameter for monitoring the scheme.  It is the physicians who manage the health care organizations even though non – physicians may carry the title of administrator.  Even though these doctors are highly qualified in their various disciplines, they do not have the technical know-how to perform the role of administrator in health insurance scheme.  The physicians and insurance companies do also cooperate in controlling unnecessary costs by participating in the peer review committees that evaluate utilization patterns.  These committees composed of doctors have been used in a number of areas to oversee medical reimbursement, limit overpayment and deter furture over utilization abuses.  It is known that these schemes have been successful in many occasions especially when they are organized by the doctors themselves. The bad moral aspect mentioned also is that our people will tend to collude with hospital in order to defraud the insurance scheme by feigning to be ill while they are not.  They could also send relations or members of the public who are not covered by insurance schemes to hospitals and forward the bills to the insurance scheme for settlement.  Other abuses are in the areas of prolongation of stay in the hospitals as an ordinary healthy person could decide to go to the hospital to get some rest and pass the bill to the scheme to pay.  The problem of increased charges when the patient is insured is a particularly serious one.  There is no reasons for those with insurance to be charged more than those without insurance.  If those without insurance who have been prudent should try to provide for their health expenses through the advance payment of premium should in the end have to pay more for medical services than if without insurance, then the effect will be penalize them for the foresight of those who insured.

4.            Lack of statistics and records

It is unfortunate that there are no available statistics in most of our hositals regarding the number of patients who attend hospitals and the type of diseases or illnesses they are treated for.  There are also no statistics fo relapses or recurrences of such illnesses.  It is my view that this workshop should consider seriously the issue of maintaining statistics of those who attend hospitals and the illnesses for which they are treated at hospitals and to make it possible for anybody to obtain this information to enable both doctors who fix rate of premium and the insurance companies to determine the basis of their rating.

·         PURPOSE OF THE STUDY

The purpose of this study will be to evaluate the role and strength of the insurance scheme in health services in Nigeria.

1.    To make recommendations in the modes of operations and other matter as may be considered relevant to the establishment of the scheme.

2.    To examine specifically the policy implementation, planning arrangements ad any existing or potential administrative structure that may be required for a timely introduction of the scheme.

3.    To examine the phase in of the implementation of the scheme and advise on a time frame for its implementation.

4.    To examinein the light of the recommendations made in previous rpeorts on the subject, the establishment of health insurance scheme as an option for funding health care services in Nigeria.

1.            SIGNIFICANCE OF THE STUDY

The committee enlisted the well-known benefit that will be derived form such scheme.  These are:

1.    The proposed scheme should provide the basic primary health care together with some aspects of secondary and tertiary health care services at no extra cost to the eligible recipients of the services.

2.    Primary health care, preventive, curative promotive and rehabilitative services  including child immunization, nutrition oral dehydration therapy, family planning services, family planning devices at subsidized cost, health education, consultation, diagnosis and drugs of common diseases.

3.    In respect of secondary health care, there will be free hospitalization and rehabilitation.

4.    In respect of tertiary health care under the scheme, it should cover specialized services.

 1.5     LIMITATIONS OF STUDY

The difficulties encountered in this work were mainly due to the nature of the research they were also a result of the research.  They were also as a result of the technique adopted in data collection.  As the theme of the study suggested at its face value, many workers were reluctant at giving information to this effect determined to succeed the writer inspite of acute time and financial constrains, used the interior techniques to get the much needed information.  The research was not easy.  The researcher was moving from one office to another.  It needed lots of patience, for the executives to give needed information.  It took the writer trips to so many insurance companies to accomplish the tack.

·         DEFINITIONS OF TERMS

The National Health Insurance Scheme is a public motivated insurance arrangement to cover health costs funded with compulsory or voluntary contribution of all income earning residents and goernment subsidy, the beneifts of which are made available to all residents in need of medical care.  Its definition is so wide that it tends to achieve the objective of government by ensuring that all its citizens receive good medical care.  Within the ambits of such National Health Insurance Scheme are various types of health insurance scheme.