Do beneficiaries’ views matter in healthcare purchasing decisions? Experiences from the Nigerian tax-funded health system and the formal sector social health insurance program of the National Health Insurance Scheme

Abstract

BackgroundPurchasing is a health financing function that involves the transfer of pooled resources to providers on behalf of a covered population. Little attention has been paid to the extent to which the views of that population are reflected in purchasing decisions. This article explores how purchasers in two financing mechanisms: the Formal Sector Social Health Insurance Programme (FSSHIP) operating under the Nigerian National Health Insurance Scheme (NHIS), and the tax-funded health system perform their roles in light of their responsibilities to the populations.MethodsA case study approach was adopted in which each financing mechanism is a case. Sixteen (16) in-depth interviews with purchasers and eight (8) focus group discussions with beneficiaries were held. Agency and organizational behavioural theories were used to characterise the purchaser-citizen relationships. A deductive framework approach was used to assess whether actions identified in a model of ‘ideal’ strategic purchasing actions were undertaken in each case.ResultsFor both cases, mechanisms exist to reflect people’s health needs in purchasing decisions, including quantitative and qualitative needs assessment, mechanisms to raise awareness of benefit entitlements and allow choice. However, purchasers do not use the mechanisms to effectively engage with and hold themselves accountable to the people. In the tax-funded system, weak information systems and unclear communication channels between the purchaser and citizens constrain assessment of needs; while timeliness of health information and poor engagement practices of Health Maintenance Organisations (HMOs) are the main constraints in FSSHIP. Inadequate information sharing in both mechanisms limits beneficiaries’ awareness of entitlements. Although beneficiaries of FSSHIP can choose providers, lack of information on the quality of services offered by providers constrains rational decision-making and the inability to change HMOs reduces HMO responsiveness to beneficiary needs.ConclusionsResponsiveness and accountability to beneficiaries are undervalued by purchasers in both financing mechanisms. In the tax-funded system, civil society organisations can facilitate engagement and accountability of purchasers and the people. In FSSHIP, NHIS needs to provide stronger stewardship of HMOs to promote effective engagement with members. Furthermore, the NHIS should introduce mechanisms that allow FSSHIP members to choose their own HMO, which could encourage HMOs to be more responsive to members.

Characteristics and Effects of Multiple and Mixed Funding Flows to Public Healthcare Facilities on Financing Outcomes: A Case Study From Nigeria

“…Purchasing is a core function of health care financing that involves the transfer of pooled resources to healthcare providers in exchange for healthcare services (6) and it is high on the health financing agenda as it is critical in achieving universal health coverage (7). Purchasing entails that purchasers act as agents for the people in the purchase of healthcare services (7).…”

“…Purchasing is a core function of health care financing that involves the transfer of pooled resources to healthcare providers in exchange for healthcare services (6) and it is high on the health financing agenda as it is critical in achieving universal health coverage (7). Purchasing entails that purchasers act as agents for the people in the purchase of healthcare services (7). To fulfill this role effectively, it is important for purchasers needs to ensure that there are effective mechanisms in place to determine people's needs, preferences, and values in purchasing decisions and to hold themselves accountable to the population for which they are responsible (7).…”

“…Purchasing entails that purchasers act as agents for the people in the purchase of healthcare services (7). To fulfill this role effectively, it is important for purchasers needs to ensure that there are effective mechanisms in place to determine people's needs, preferences, and values in purchasing decisions and to hold themselves accountable to the population for which they are responsible (7).…”

“…The federal, state and local government areas provide budgets from general tax revenue to the Federal Ministry of Health (FMOH), State Ministries of Health (SMOH), and Local Government Areas' (LGA) health authorities (LGAHA), respectively, who then act as purchasing organizations using budget flows, respectively, at the three tiers of government to allocate budgets for providers at health facilities (7). The FMOH, SMoH, and LGAHA also define a minimum package of health care services which covers promotion, preventive, and curative care at primary and secondary care levels, and includes services for communicable and non-communicable diseases, child survival, safe motherhood, nutrition, health education, laboratory services and community mobilization (10).…”

Designing Interactional Pattern of Health Financing Between Ministry of Health and Social Health Insurances in Iran

“…Martin et al proposed the requirement of stewardship to achieve universal coverage and justice (9). In Nigeria, Ibe et al expressed the need for effective collaboration of stewardship on the relationship between buyers and providers in the form of a health maintenance organization (10). In the study by Velasquez et al, the role of health system stewardship in increasing the coverage of the population was considered.…”