An Assessment of the Effect National Health Insurance Scheme Capitation Payment to the Healthcare Facilities in Yobe State

Abstract

With the transition of countries from financing healthcare through government revenue, general taxation, and out-of-pocket to Social Health Insurance in order to ensure the achievement of Universal Health coverage, the global health research community has made very important efforts to advance knowledge about the effects of various health schemes. Although there is a large amount of literature about the effects of various payment mechanisms, usually it does not focus on the effects of capitation payment to the healthcare facilities. To fill this knowledge gap, this study assessed the effects of National Insurance Scheme (NHIS) capitation payment on revenue generation, expenditures, utilization of funds, and enrollees’ satisfaction with healthcare facilities in Yobe State, Nigeria. The framework of this study is system theory. The study employed a survey method to obtain both quantitative and qualitative data. Structured questionnaires were applied and key informant interviews were conducted. The study revealed that the capitation payment mechanism to the healthcare facilities impacted positively on the NHIS, providers, and the enrollees. Specifically, the study revealed that capitation increased the revenue of healthcare facilities, increased quality of services, improved provision of drugs and consumables as well as ameliorated the maintenance of infrastructures. Generally, capitation payment mechanism was found to increase competition between healthcare facilities and reduced the out-of-pocket expenses for healthcare by the enrollees. The study recommends proper monitoring and evaluation of the way capitation payments are made by the Health Maintenance Organizations to the healthcare providers. Also, National Health Insurance Scheme should ensure regular payment of capitation by HMO to facilities to avoid unnecessary delay of payment and finally, the capitation amount should be reviewed on regular basis by the National Health Insurance Scheme so that healthcare facilities would be funded adequately to provide qualitative services to the enrollees.

1. Introduction

The paradigm shift from financing healthcare through government revenue, general taxation, and out-of-pocket to social health insurance is not new. In most of the developing nations, reform on the purchasing side is moving hand in hand with development of pooling functions. According to Moreno-Serra and Wagstaff, many countries of Europe and Central Asia include case-based payment for tertiary care and capitation payment for primary care. Likewise, Nigeria has adopted a similar system of financing healthcare through these two major options of payment [1].

Since the flagged in the Formal Sector Social Health Insurance Programme in Nigeria in June, 2005 capitation payment has remained one of the social health insurance payment mechanisms to the healthcare facilities through the Health Maintenance Organizations (HMO).

Health Maintenance Organization is a private or public incorporated company registered by the National Health Insurance Scheme (NHIS) solely to ménage the provision of healthcare services through healthcare providers accredited by the NHIS [2]. HMO provides the following main functions:

1. effect timely payments to healthcare facilities;

2. ensure the quality of healthcare services;

3. ensure timely approval of referrals and undertake necessary follow up to complete referrals; and

4. carry out continuous sensitization of enrollees [3].

In Nigeria, presently there are 94 registered HMOs that are responsible for the payment of primary, secondary, and tertiary health services to the healthcare facilities on behalf of NHIS. Primary healthcare services include: out-of patient care, immunization, surgical procedures, internal medicine, HIV/AIDS, obstetrics, gynecology, pediatrics, laboratory investigations, and emergency care [4]. These services are covered by capitation payment. All other procedures that cannot be handled at the primary level of care can be undertaken at the secondary level, which the HMO paid healthcare facilities as the fee for service.

Capitation is defined as a payment method where the provider is paid in advance, a predetermined fixed rate to provide a defined set of services for each individual enrolled with the provider for a fixed period [5]. Capitation usually occurs under Bismarck or social health insurance healthcare system [6]. Bismarck model involves people (those who need healthcare) paying a fee to a fund that in turn pays health care activities, that can be provided by state-owned institutions, other government body-owned institutions, or a private institution. It is different from the Beveridge system (or National Health Insurance Schemes) in which government or central authority takes the responsibility of collecting and pooling funds and also pays for providers [7].

Every year, the National Health Insurance Scheme (NHIS) in Nigeria has been paid a large amount of money in the form of capitation. In Yobe State alone from January to December 2021 approximately, NHIS paid about (USD$700985. 75) for the payment of capitation to the accredited healthcare facilities for primary services in the state [8].

If the amount of money in funds received as a capitation by the healthcare facilities is properly allocated by providers, then one may expect the following:

1. positive impact on the effective delivery of healthcare services to the enrollees,

2. increase on providers’ revenue and improvement in infrastructure of the healthcare facilities,

3. enhance the welfare of the healthcare workers.

This study aims to test these hypotheses concerning the effect of capitation payment on healthcare providers in Yobe State. There is a large amount of empirical literature on the capitation payment method, which focuses on the nature of this payment mechanism, but in general, it does not address the potential effect of capitation on services provision, infrastructure, and other ways of efficient utilization of the capitation fund, nor are the challenges of capitation payment system described in Sub-Saharian African Countries. This study represents an effort to fill this gap in the literature using the experience of Yobe State of Nigeria, where capitation payment has been introduced within the National Health Insurance Scheme.

2. Theoretical framework

Our world is complex and made up of subsystems. These subsystems interact with each other and each has vividly coherent dynamics and defined boundaries. Ludwig von Bertalanffy developed the Systems Theory in 1932 with an aim of simplifying the world’s complexity and making it more comprehensible to human beings. Basically, the theory aims at explaining how things function around us. The theory views the world as a set of smaller subsystems that humans utilize on a daily basis. For instance, a hospital is a system that has outputs, processes, and inputs. In itself, the National Health Insurance Scheme (NHIS) is part of a bigger health care system. This study is premised on System theory. NHIS as a system has many subsystems that contribute to its proper functioning. Therefore, NHIS must work hand in hand with the healthcare facilities, the enrollees, the Health Maintenance Organizations, the banks, the insurance companies, and the other stakeholders. Hence, the System theory is relevant to the present study and will be used to support our work. In this regard, NHIS gives inputs, which are the resources that are capitation to the healthcare facilities through the HMO, which they use banks to transact the fund to the facilities. When NHIS gives money to HMO for the payment of capitation to the healthcare facilities this is called the process. Therefore, when the healthcare facilities successfully received capitation funds from the HMO and utilize the fund for the purchasing of drugs, consumables, and the procurement of expenditures and give services to the enrollees this is called the output, which is the effect of capitation. This flow of money called capitation payment is represented in Figure 1.

Figure 1.

How capitation payment is being made. Source: The Author, 2021.

3. Review on sub-Saharian Africa experiences

This subsection presents a brief review of the operation, outcomes, experiences, and perceptions of users and partners in the social health insurance scheme in Sub-Saharan Africa. The snapshot review on different experiences across several Sub-Saharian Africa is next summarized.

Barasa et al. examined the perceptions and experiences of informal sector people living in two of Kenya’s provinces with contributory National Hospital Insurance Fund (NHIF). The study was qualitative in design, making use of data from carefully selected informants in the provinces. Findings revealed poor perception and experiences related to inadequate and inconsistent information about registration and membership process, affordability issues, and discrimination against NHIF patients over those paying out-of-pocket [9].

The governments in Africa often partner with private healthcare providers for better coverage of their health insurance schemes. Against this background, Sieverding et al. examined the perspective and experiences of private health providers with the National Health Insurance Scheme (NHIS) in Ghana and the NHIF in Kenya. The study was an interview-based survey with a qualitative research design. Interview responses were coded and content-analyzed thematically. Poor communication of requirements for registration/accreditation and complex accreditation process was reportedly the major constraint in Kenya in line with the finding of Barasata et al. [9]. The accreditation experience in Ghana differs as it was found to be mostly straightforward. Private healthcare providers participating in health insurance schemes reportedly perceived the schemes to be worthwhile but identified poor engagement due to poor communication as barriers to active participation in the scheme.

Against the backdrop of low enrolment level in health insurance schemes in Ghana, Duku et al. analyzed the differences in perceptions between the insured and uninsured of the non-technical quality of healthcare and a possible association between insurance status and perception of healthcare quality with a view to ascertain whether insurance status matters in the perception of healthcare quality or not. The study was a primary survey, using quantitative research design. Results show that those insured had a more negative perception of the scheme compared to the uninsured, indicating the quality of service received. This finding appears to corroborate the discrimination against patients insured under social health insurance over those paying out-of-pockets by Barasa et al. [10].

Fenny et al. comparatively examined access to social health insurance schemes in five sub-Saharan African countries including Ghana, Rwanda, Tanzania, Ethiopia, and Kenya with a special focus on access by the poor. Access is key to experience, and experience informs perception. In Rwanda, both the poor were observed to have comparable lower inequality access unlike Ethiopia and Ghana with large access inequality between the poor and the rich. Only about 2% of the poor in Ghana and Ethiopia reportedly had access to the social health program. Fraudulent claims, difficulty in identifying who are actually the poor, poor funding, policy inconsistency, and enrolling the poor into social health insurance schemes were identified as barriers to widespread access to the schemes [11].

Amu et al., performed a quantitative secondary study using demographic and health surveys data and; assessed variations in health insurance coverage in four African countries including: Ghana, Kenya, Nigeria, and Tanzania. The data were analyzed using bivariate and multivariate techniques. Findings revealed that coverage was highest in Ghana (Females =62.4%, Males =49.1%) and lowest in Nigeria (Females =1.1%, Males =3.1%). Age, level of education, residence, wealth status, and occupation were the socio-economic factors influencing variations in health insurance coverage in the countries [12].

Erlangga et al., examined the public health insurance impact on health care utilization, financial protection, and health status in low- and middle-income countries based on a systematic literature review. Findings revealed that the public health insurance schemes generally appear to increase healthcare utilization, offer appreciable financial protection to their users, and have a positive effect on the health of the insured [13].

Adeniran et al. investigated cesarean delivery (CD) experience among out-of-pocket (OOP) and health insurance clients in Ilorin, Nigeria with a special focus on pregnancy events and financial transactions for the CD. The study was quantitative in design, using randomized sampling and inferential statistics. Findings revealed that OOP payers are prone to catastrophic spending on health. The waiting time before reimbursement to healthcare providers was found to be significantly prolonged; private insurers reportedly offered earlier and higher reimbursement compared to public insurers. Suboptimal referral and transportation of health-insured clients were found [14].

Adewole et al., examined enrollees’ knowledge about the National Health Insurance Scheme (NHIS) and satisfaction with health services provided under the scheme in a cross-sectional questionnaire-based descriptive study. Findings revealed that 67% of the respondents had good knowledge about the NHIS. Majority of the respondents reportedly paid for drugs, laboratory tests, consultation fees, and X-ray out-of-pocket (81.2%) to supplement their health insurance cover. Slightly more than half (52.8%) of the respondents were found to be satisfied with service delivery, under the scheme with female respondents being significantly more satisfied than their male counterparts [15].

The foregoing review shows that there is a mixed outcome, experience, and perspectives on the impact of health insurance scheme in Sub-Saharian Africa. A common experience across the countries captured in the review is discrimination against and/or exploitation of enrollees in the health insurance schemes compared to those who pay out-of-pocket. Communication barriers, bureaucratic delay in paying partnering private healthcare providers, and policy inconsistencies via politics appear to be central issues militating against effective service delivery and good experience of the schemes by enrollees. Coverage appears to be low in the subregion except for Rwanda’s experience. Particularly in Nigeria, going by the reform in the National Health Insurance Scheme there is significant improvement in the coverage of the various segments of the population through the introduction of Group Individual and Family Social Health Insurance Program.

4. Methods

The survey design was used in this study. According to Kerlinger [16], a survey is the best research design for obtaining social facts, beliefs, and attitudes for both large and small populations to discover relative distribution and interrelation of sociological and psychological variables. Survey uses questionnaires, likewise, our study used questionnaires to obtain the data. Also, the survey has an interview, hence this study also uses key informant interviews to generate information to support data obtained from the questionnaire. In other words, this study employed a mixed research approach that is both quantitative and qualitative [16].

The quantitative data were obtained from the population of healthcare facilities’ staff of 27 NHIS accredited hospitals and clinics in Yobe State. Convenient sampling was employed to select two officials in each of the healthcare facilities to make the selected 54 officials. Hence, 54 closed-ended questionnaires were distributed to the healthcare officials who are mostly the Medical Directors and the NHIS Desk Officers. Out of 54 questionnaires administered, 44 were successfully returned, which represents an 81.48% response rate.

The distributed questionnaires were used to gather data on the effect of capitation on revenue generation, efficient use of resources by the healthcare providers, and the data of whether the capitation payment is sustainable or not.

Another questionnaire was used to obtain information regarding enrollee’s satisfaction. This questionnaire instrument was administered to determine whether the enrollees were satisfied with the services of healthcare facilities or not. Prior to the distribution of this questionnaire, the sample size in this study was determined to be approximately 32,000 NHIS enrollees. By using a Survey Monkey sample size calculator, the sampling size arrived at 354 enrollees. Hence, 354 questionnaires were administered to the enrollees in the various healthcare facilities and the NHIS office of Yobe State. Out of the 354 administered questionnaires, 343 represent 96.89% response rate.

Moreover, qualitative data were obtained through the key informant interviews conducted with the 7 officials of the NHIS Yobe State Office.

The information obtained in these interviews was mainly used to support the quantitative data obtained from the questionnaires already administered. Also, the information regarding the challenges of the capitation payment system to healthcare facilities was obtained through key informant interviews.

For the data interpretation and analysis, descriptive statistics have been employed, that is to say, the data were presented using tables with frequencies and percentages. In the case of qualitative data, except on the information regarding the challenges of capitation payment, narrative statements of the key informant interview respondents’ were directly presented to support or juxtapose the quantitative data that had already been presented.

5. Results

Table 1 shows the results obtained from the respondents to the question: “Does capitation increase the revenue of your healthcare facility?”

Option	N	%
Yes	39	88.63
No	4	9.09
Not sure	1	2.27
Total	44

Table 1.

Effect of capitation in healthcare facilities revenue.

Source: Field Survey, 2021. Note: N—number of respondents; %—percentage.

Table 1 presents data on whether the capitation payment to the healthcare facilities by the NHIS had increased the revenue of the facilities or not. Majority of the respondents 88.63% said the capitation paid by the NHIS through the Health Maintenance Organization (HMOs) had increased the revenue of the providers.

The view of the majority of the respondents who took part in this study was equally the view of the NHIS Coordinator Yobe State AlhajiDabo I. Abdullahi one of the key informants. He claimed that:

One of the objectives of the Scheme is to ensure the availability of funds to the healthcare sector for improved services. Without a doubt, the NHIS capitation payment to the healthcare providers has served as a fundamental way of generating the healthcare facilities’ revenue. NHIS has been paying a lot of money for both public and private health care facilities [17].

(KII with AlhajiDabo I. YobeState, NHIS Coordinator on, 4th November 2021)

Table 2 shows the results obtained from the respondents to the question: “Do you efficiently utilize capitation resources in your healthcare facility?”

Option	N	%
drug supply/consumables	Yes   39; No    4; Not sure 1	88.63; 9.09; 2. 27
Infrastructure/hospital equipment	Yes   25; No   12; Not sure 7	56.81; 27.27; 15.90
Maintenance and other services	Yes   29; No    12; Not sure 3	65.90; 27.27; 6.81
Staff welfare	Yes   31; No    9; Not sure 4	70.45; 20.45; 9.09
Maintenance and other services	Yes   29; No   12; Not sure 3	65.90; 27.27; 6.81

Table 2.

Effect on efficient utilization of capitation resources by healthcare facilities.

Source: Field Survey, 2021. Note: N—number of respondents; %—percentage.

Table 2 sheds an insight on the effects of the utilization of the resources paid to healthcare facilities as a capitation by the Scheme. Table 2 shows that the majority of the respondents 80.63% have agreed that the capitation paid to facilities have been used for the supply of drugs and other consumables.

More so, for the maintenance of the healthcare facilities, Table 2 also shows that 56.81% of the respondents confirmed that the capitation has been utilized for the provision of infrastructure and other hospital equipment. Additionally, it shows that 65.90% of the respondents proved that part of the capitation resources had been used for daily maintenance of the facilities.

In regards to the staff welfare, Table 2 also shows that about 70.45% of the respondents have agreed that part of the capitation payment had been used for the improvement of the workers’ welfare in the facilities.

The effect of capitation payment to the healthcare facilities in Yobe State is not only confirmed by the respondents in the table twos above but also the evidence below from the interview with the Yobe State Coordinator. The Coordinator Alh. Dabo I. Abdullahi commented like this:

The impacts of NHIS capitation payment to the healthcare facilities through Health Maintenance Organizations (HMOs) are tremendous. In my experience as Coordinator in the state, I came across many facilities that had judiciously utilized their capitation resources for purchasing qualitative drugs as well as facilitating infrastructural development in their facilities. However, in some facilities with a high number of enrollees, part of their capitation also had been utilized for the welfare of their staff [17].(KII with Alh. Dabo I. Abdullahi NHIS, Yobe State Coordinator, on the 4th November, 2021)

Table 3 shows the results obtained from respondents to the question: “Do you think competition to have more enrollees increase among the healthcare facilities?”.

Option	N	%
Yes	35	79.54
No	5	11.36
Not sure	4	9.09
Total	44	100

Table 3.

Effect of capitation in the increase of competition among the facilities.

Source: Field Survey, 2021. Note: N—number of respondents; %—percentage.

Table 3 sheds light on how capitation payments by the NHIS to the healthcare facilities increase competition among the facilities in the state. About 79.54% of the respondents confirmed that capitation payment had increased competition to have more enrollees among the healthcare providers in Yobe State. This table indicates that, only 11.36% of the respondents said capitation did not increase competition.

The data were obtained from the key informant interview with Alh. Mansur Akilu, Head of Human Resources and Administration NHIS Yobe State reinforced the position of 79.54% of respondents in Table 3. The position is captured below:

I observed that the capitation system increased competition to acquire more enrollees. The private healthcare facilities are competing to provide quality services to their NHIS patients in order to have more people and to retain their existing customers. Undoubtedly, facilities with more enrollees get more money from capitation payments [18].

(KII with Alh. Mansur Akilu, NHIS Head Human Resources and Admin Yobe State on 5^th November 2021)

Additionally, AdamuShuwa an Accountant in the Yobe State NHIS Office concur the above view where his opinion is expressed below:

Capitation payment had increased competition by the hospital to provide qualitative service with the view to have more customers. In Yobe State, sometimes the healthcare facilities stop collecting 10% co-payment on drugs in order to retain their enrollees and not change to other providers [19].

(KII with AdamuShuwa, Accountant, NHIS Yobe State on the 5th November 2021).

Table 4 shows the results obtained from the respondents to the question: “Do you satisfy with the services given to you by your chosen healthcare facility?”

Option	N	%
Satisfied	255	77.23
Not satisfied	80	22.66
Not sure	8	5.09
Total	343	100

Table 4.

Effect of capitation on the Enrollees’ satisfaction.

Source: Field Survey, 2021. Note: N—number of respondents; %—percentage.

Table 4 above presents the data on whether the enrollees are satisfied with the Scheme service or not. The table indicates that the majority of the respondents, about 72.23%, were satisfied with the Scheme services that have been given to them in their respective healthcare facilities. While 22.66% of the respondents that have taken part in this study said that they were not satisfied with the services given to them by the healthcare facilities.

One of the key informants Alhaji Abubakar Uthman, the Head of Quality Assurance, supports the view of the majority of respondents, about 72.23% that said they were satisfied with the services given to them. The key informant commented, thus:

NHIS is very serious about the quality of services given to its enrollees, hence, we are always engaging on the quality assurance visit to the healthcare providers. In Yobe State, knowing it by healthcare facilities, substandard service can lead to the finality on their side so they give services that would satisfy the enrollees [20]

(KII with Alh. Abubakar Uthman SQA Yobe State, on 4th November 2021)

Another view from Alh. Gambo Gwadabe of Enlightenment Division NHIS Yobe State on the enrollee satisfaction:

Enrollees usually come for a change of providers if they are not satisfied with the services given to them by the healthcare providers. NHIS gives the provision of change in order to make facilities to provide quality services to the customers.

On top Alh. Gambo also stated the following:

Enrollees do not need only quality drugs or other services but also the cutesy, good reception, since from the gate of the hospital. Time is also crucial to the enrollees; customers are very happy with the provider that would promptly attend them without wasting much of their time [21].

(KII with Alh. Gambo Gwadabe Head of Enlightenment NHIS, Yobe State on 6th November 2021)

Finally, another key informant, Dr. Auwal Ibrahim expresses that:

Regular spot checks by the NHIS can boost the quality of services provided by the healthcare facilities, hence regular visits help NHIS to identify the lapses in healthcare facilities and recommend where to improve for better services to the enrollees [22].

(KII with Dr. Auwal Ibrahim SQA NHIS Yobe State on 6th November 2021)

Table 5 presented the data on whether the capitation payment would be sustained to the question and provides the answers “Do you think the capitation payment is sustainable?”. Majority of the respondents, 77.27% confirmed that the capitation payment system is sustainable. Only 18.88% of the respondents that have taken part in this study said the system is not a sustainable kind of payment.

Option	N	%
Yes	34	77.27
No	8	18.18
Not sure	2	4.54
Total	44	100

Table 5.

Sustainability of the capitation system.

Source: Field Survey, 2021. Note: N—number of respondents; %—percentage.

The qualitative data from the key informant interview referred to just below agrees that the capitation payment system would be sustainable. This view is the opinion of Alh. Sani Zakari of the Formal Sector Social Health Insurance Programme unit who stated, thus:

Since the flagging off of the formal sector program in 2005 capitation payment has continued to flourish as one of the best payments of the NHIS to healthcare facilities through the HMOs. In my own opinion capitation payment has come to stay.

(KII with Sani Zakari Formal Sector, NHIS Yobe State on 4th November 2021)

The findings of this study may be summarized as follows:

1. Capitation payment increases the revenue of the healthcare facilities in the state. About 83.63% of the respondents confirmed that capitation contributed to the revenue of HCFs in Yobe State;

2. Capitation has contributed to the efficient utilization of resources of the healthcare facilities in the state. Both qualitative and qualitative data of this study have shown that the majority of the respondents in the study have agreed on the fact that resources acquired from the capitation were used for the efficient supply of drugs/consumables, provision of infrastructures, maintenance of equipment as well as the improvement of the staff welfare;

3. Both the qualitative and quantitative data established that capitation has enhanced competition for acquiring more lives or enrollees by the healthcare facilities. Hence, this contributes to the provision of qualitative services to the enrollees;

4. The study seems to support the idea that capitation is one of the sustainable payment mechanisms of healthcare services by the NHIS. About 77% of the respondents believe that capitation is going to be sustained. As well almost all the key informant interviews agreed that capitation is a sustainable way of financing healthcare;

5. The study concludes that majority of the enrollees were satisfied with the services provided by the healthcare facilities in Yobe State;

6. The study infers that the capitation system may reduce the out pocket payment of healthcare services by the enrollees;

7. Finally, this study also gathers information about some challenges of capitation payment to the healthcare providers as the delay in payment by the HMOs, sharp practices by the HMOs, mismanagement of the fund by the healthcare facilities, default of making payment by the HMOs, and lack of monitoring of the utilization of the fund by the healthcare facilities.

As a result of the findings from key informant interviews, the following challenges of capitation payment to the healthcare facilities in Yobe State were created:

1. There is a delay of the capitation payment by the Health Maintenance Organizations (HMOs) to the healthcare facilities. Studies show that even though the NHIS gives money for the capitation to the HMOs, sometimes they refuse to transfer the money to the healthcare facilities in due time usually after every 3 months;

2. There are sharp practices and mismanagement of the capitation fund by some of the healthcare facilities;

3. There is inadequate monitoring of the way the capitation fund is used by the healthcare facilities.

6. Discussion

Evidence from both quantitative and qualitative data in this study has shown that capitation payment increases the revenue of the healthcare facilities. For instance, 88.63% of the respondents believed that capitation payments increased the revenue of the providers. In comparing the amount of capitation being paid by the National Health Insurance Scheme in Yobe State with that being paid by the Yobe State Contributory Healthcare Management Agency (YOTCHMA), NHIS pays more than the amount (YOTCHMA) pays per head to the healthcare facilities for the same kind of services. The National Health Insurance Scheme uses HMO as an intermediary for the payment of capitation, while the YOTCMA pays capitation directly to the healthcare providers.

However, capitation is not the only payment mechanism to the healthcare providers in Yobe State that is contributing to the revenue generation of healthcare facilities but also the fee for service. According to the NHIS [3], fee for service is payment made by HMO to secondary/tertiary healthcare providers that render service to enrollee, and can also be paid on a service basis for emergency cases.

Apart from fee for service, there is co-payment which also contributes to the revenue of healthcare providers. This is payment made by the enrollee to the accredited pharmacy provider at the point of service. It is 10% of the total cost of drugs dispensed per prescription in accordance with the NHIS Drugs price list [3].

Other forms of payment to providers include Per diem and co-insurance. The former is payment made by primary providers and HMO to secondary/tertiary healthcare providers for bed space (per day) during hospitalization, while the latter refers to the part payment made by the enrollee for treatment/investigation covered under partial exclusion list while the HMO pays the balance.

The findings of this study have shown that capitation payment to the health care facilities in Yobe State contributed to the efficient utilization of the facilities fund. Since the fund is coming prepaid before service is given to the enrollee, this would enable providers to budget for drugs and other consumables, adequately. Sometimes when the healthcare facilities have enough funds at their disposal, they are utilized for the purchasing of equipment and the maintenance of infrastructure, and the improvement of staff welfare. This view was confirmed by the quantitative data in Table 2, for instance, where a majority of the respondents 88.63% have agreed that providers used the part of the capitation money paid to them for the purchase of drugs and consumables.

When comparing the utilization of funds generated by the healthcare facilities from capitation payment and other payment mechanisms such as fee for service usually, the generated fund from capitation is used for the procurement of drugs and consumables. Fund from fee for service payment usually comes after service is provided to the enrollee and it takes time to be collected from the HMO on behalf of NHIS. There are various protocols before the fee for service fund is being delivered to the healthcare facilities. Before accessing the fee for service payment from the HMO, a provider must request for referral code and after providing services the provider must send a claim to the HMO before payment would take place. According to National Health Insurance Operational guidelines of (2012) when the provider is unable to send a claim within 3 months of given service to the enrollee, that payment would not be paid.

This study confirmed that the capitation payment mechanism contributed to the increase of competition among the healthcare providers in Yobe State. In Table 3 of this study, 79.54% of the respondents believed that capitation payment to healthcare facilities increases competition. In Yobe State, there are some healthcare facilities that are competing in terms of quality of care in order to have more enrollees so that more money can be received from capitation payment. According to an unpublished NHIS report (2021), some healthcare facilities are not collecting 10% copayment of drugs in order to attract more enrollees and retain the existing ones not to change to other facilities.

Concerning customers’ satisfaction, the result of this study presented in Table 4 points to the trend of satisfaction. Indeed, the majority of the NHIS enrollees in Yobe State were satisfied with the services provided. This may be explained by the way healthcare facilities are treating people in order to retain them in their facilities so that they would not change to other ones.

Regarding capitation payment sustainability, the majority of the respondents, about 78% in this study confirmed that the payment system should be continued and sustained, perhaps because of the positive impact of the payment method on the healthcare facilities. According to the unpublished report from NHIS (2021), since the flagging off of the Formal Sector Social Health Insurance Scheme, capitation payment mechanisms have been used for the payments of primary healthcare service in the whole federation, which may sign the potential sustainability of this payment method.

Without a doubt, capitation serves as a critical source of income to the healthcare facilities. It also promotes adherence to guidelines and policies and encourages providers to work better and give health education to patients. However, in this study, some challenges associated with the capitation payment mechanism were identified, which need to be addressed by the National Health Insurance Scheme so that qualitative services will continuously be provided by the accredited healthcare facilities in the Yobe State.

7. Conclusion

This study proved the capitation payment system in social health insurance financing positively impacted the Scheme, in the healthcare facilities availability, and the health of enrollees themselves. This study also showed that capitation had increased the revenue of the healthcare facilities in Yobe state. The findings obtained here suggest that the fund generated by capitation is mainly used to pay for the provision of drugs, consumables, and the infrastructural development. Capitation payment appears to have improved competition among the healthcare facilities for enrollees and to retain the existing ones. Moreover, capitation seems to reduce out-of-pocket healthcare expenses of the enrollees in Yobe state. Finally, despite limitations, the present study provides an overall framework that can be utilized to guide future research and data collection efforts for evaluating the result of capitation payment not only in Yobe State but in the country at large.

Based on the findings of this study, the following recommendations are provided to the National Health Insurance Scheme:

1. The Scheme should engage in proper monitoring and evaluation to the healthcare facilities to know the level of the compliance on how the capitation funds are being utilized;

2. The Scheme should put more effective measures to ensure that the HMOs are transferring the capitation payment promptly without delay. That is to ensure effective reconciliation of the fund given to the HMOs and the healthcare facilities;

3. The capitation amount should be reviewed from time to time by the NHIS so that healthcare facilities would be funded adequately to provide qualitative services to the enrollees.

4. According to the theoretical framework used in this study, the National Health Insurance Scheme is a system, therefore, in order to be more successful, there is the need to integrate all its subsystems together that are the stakeholders. A good provider payment method has to address and be implemented within strong support systems. Wider systems issues of importance in developing and implementing a successful provider payment method include governance and accountability, financial management and stakeholder relationships, management information systems, monitoring, and evaluation.

Acknowledgments

First and foremost, my gratitude goes to Ana Cink Author Service Manager IntechOpen Limited, and Professor Aida Isabel Tavares for their encouraging me to write a chapter in this book. I also appreciate all the staff of the National Health Insurance Scheme, Yobe State Office, Nigeria for their support toward the success of this writeup. I also use this medium to thank Alh. AbdulsalamBala of Ama consulting for encouragement to me. Last but not the least, I am grateful to Dr. Emmanuel Jegede of the Department of Theater and Performing Arts Ahmadu Bello University Zaria, Nigeria for his advice to ensure the success of this work.

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The researcher is conducting a study on the topic “An Assessment of the Effect of National Health Insurance Scheme capitation payment to the Healthcare Facilities in Yobe State”. The study is for the purpose of producing a chapter in a book titled “Health Insurance” which is to be edited by Professor Aida Isabel Tavares and to be published by IntechOpen.

Name of the Respondent ------------------.

Department------------------

The following are the expected questions for the interview, please for your preparation.

1. What do you think are the ways in which Healthcare Facilities in Yobe state utilize their capitation fund under the Formal Sector Health Insurance Programme?

2. What is your opinion about the quality of services given to the enrollees by the Yobe State Healthcare Facilities?

3. Do you think enrollees are satisfied with the services given to them by Healthcare Facilities in this State?

4. Do you think the capitation payment is sustainable?

5. What do you think are the challenges of capitation payment system?

6. Please what are the possible solutions to the challenges of the capitation payment system to the Healthcare Facilities in Yobe State?

Thank you for your responses.

Hassan Salisu Ph.D.

The researcher is conducting a study on the topic “An Assessment of the Effect of Capitation Payment to the Healthcare Facilities in Yobe State”. The study is for the purpose of producing a chapter in a book titled “Health Insurance” which is to be edited by Professor Aida Isabel Tavares and to be published by IntechOpen. Please we need your maximum cooperation and your response will be treated with confidentiality and for the purpose of this study only.

Type of Healthcare Facility ----------------------

Rank/Position of the Healthcare Facility’s representative-------------

Questions

S/N	Questions	Responses
		Yes	No	Not sure
1.	Does capitation increase the revenue of your healthcare facilities?
2.	Do you use fund generated from capitation to buy drugs/consumables for the NHIS enrollees?
3.	Do you use the fund generated from capitation to build infrastructures or purchase hospital equipment?
4.	Do you use fund generated from capitation for the provision of staff welfare?
5.	Do you use the fund generated from capitation for maintenance and other services in your facility?
6.	Do you think as a result of capitation payment healthcare facilities compete to have more enrollees?
7.	Do you think capitation payment mechanism to the healthcare facilities would be sustained?

Thank you for your response.

Hassan Salisu, Ph.D.

The researcher is conducting a study on the topic “An Assessment of the Effect of National Health Insurance Scheme capitation payment to the Healthcare Facilities in Yobe State”. The study is for the purpose of producing a chapter in a book titled “Health Insurance” which is to be edited by Professor Aida Isabel Taveres and to be published by IntechOpen. Please we need your maximum cooperation and your response will be treated with confidentiality and only for the purpose of this study.

Organization ----------------------

Your Healthcare Facility ----------------------

Please tick the appropriate box.

Question: do you satisfy with the services given to you by your chosen Healthcare Facility?

Yes   □

No    □

Not sure □

Thank you for your response.

Hassan Salisu, Ph.D.