Over the last decades many low and middle-income countries have engaged in health care reform efforts. The objectives of the reforms include, but are not limited to, improving the health status of the population, increasing public satisfaction, and promoting equitable access to health care through innovative health financing mechanisms.1 In this light, the national health insurance scheme (NHIS) of Nigeria was first proposed in 1962. The insurance scheme was finally launched in 2005, initially with mandatory enrollment of formal sector employees.2
Defining a family
A recent qualitative study aims at evaluating the impact of the NHIS in northern Nigeria and specifically enrollee's perception of the quality of health care before and after enrolment.3 In early results, respondents (heads of households) have generally viewed the NHIS favorably. The majority agreed that participation in the NHIS reduced not only their health care costs, but also their fear of going to hospital to access medical care. However, respondents routinely expressed dissatisfaction over the terms of coverage. According to current policy, NHIS enrolment entitles the primary insured person, their spouse and up to four biological children (child defined as <18 years of age) access to a specified benefit package.2 The question most respondents asked was What about my other wives and children?
We are polygamous, [my] second wife should be included.3
More children need to be added…[I have] eight children and two wives.3
These observations led us to ask, what happens to those family members that are not covered by the NHIS? Could the unintended consequences of not considering other family members (wives, children and grandparents) be greater than the intended consequence of covering at least part of the family unit? Though, the amended medium term strategic plan for the scheme has lately recognized the significance of marital status, but the enrollees have to bear high cost associated with having other extra dependent family members.4 This poses another problem of equity and equality in payment of contribution for the extra dependents by the insured household head. Studies within Nigeria have shown that marital status has a significant influence on people's attitude towards insurance.4,5
Points to consider
A report by the Institute of Medicine concludes that in the United States, family members not covered by health insurance are more selective in their use of health services and wait to access care only when a crisis occurs, as compared to family members with insurance. Associated delays in seeking care, or forgoing treatment, were found to negatively impact the health of the uninsured family members. Moreover, in cases where the uninsured family members suffered a serious health problem, resulting medical bills were found to affect the financial stability of the entire family.6
The NHIS's proxy definition of a family (husband, wife and four biological children) may also lead to a perception of non-inclusiveness - that the program inherently disregards or disapproves of an accepted cultural or traditional feature of certain population subgroups. As a result, potential enrollees could view joining the NHIS as a threat to their way of life. This perception could precipitate resistance to enrolment, creating or increasing inequities in coverage. In the past, misconceptions about the insurance benefit package have caused potential enrollees to lose interest or become opposed to insurance schemes.1 Credible implementation strategies could only be ensured when problems of inequity and inequality have been minimized at onset of planning phase.
To minimize barriers to program acceptance and diffusion, perhaps more culturally appropriate approaches to defining families should be considered. In Benin, Ghana and Rwanda for example, an incentive is provided that encourages full enrolment of the family. Specifically, the greater the number of family members enrolled, the lower the premium for each individual member of a family. In this manner, the potential for savings increases with increased coverage of family members.1 A similar approach would most likely better fit the context of many regions of Nigeria, as compared to the current policy of restricting coverage to those that meet the current definition of a family which could lead to unintended side effects.
In a society where having an extended family is common and accepted practice, the definition of a family goes beyond a husband, wife and four biological children. The NHIS, as a health care reform aimed at improving quality and access to health care, needs to take into consideration regional cultural norms. Specifically, the actuarial studies used to determine the NHIS coverage parameters (e.g., the definition of the family unit),2 may not be appropriate for most parts of the country.
According to Donabedian, patients' subjective satisfaction with the processes, outcomes and structures of health care are an important element of quality, on par with more objective measures of care delivery.7 Further, Jain et al. asserted that the quality of a health care program is determined by a program's level of client-orientation and how the program helps individuals achieve their goals.8 We believe the question What about my other family members? is a justified question for the NHIS and one that requires careful consideration. However, such considerations have to be treated with good sense of equity and equality that recognize the socio-cultural context of the country.1