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Table 1 Description of the formal sector programme of the NHIS[8, 9]

From: Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria

Key actors • The National Health Insurance Scheme (regulators).
• Federal, state and local governments (employers) and their employees.
• Health Maintenance Organizations (HMOs) (paid by the NHIS to manage new enrollees, and pay capitations and reimbursements).
• Healthcare providers (as individual doctors, pharmacists, etc., leaders of provider and practice associations, and facility owners).
Revenue collection and pooling • The law establishing the NHIS mandates HMOs to collect contributions from employers, but in practice, NHIS does the collection. NHIS can receive additional funds including grants, donations, and also dividends and interests from investments using pooled funds.
• The specified role of states and local governments in the FSSHIP is that they, as employers of labour, were expected to make contributions on behalf of their employees to the scheme.
• Federal government pays the equivalent of 10% of employees’ basic salary to the NHIS, and states and local governments are expected to do the same if they adopt the FSSHIP.
• Employee pays 5% of basic salary which is deducted at source. NHIS requires the states intending to adopt the programme to hand over the fund to them in advance and on quarterly basis.
• NHIS pools funds at the federal level, and allocates them to HMOs to make capitation payments and fee for service reimbursements to providers on behalf of beneficiaries allocated to HMOs.
Provider • Private and public facilities of all levels (primary, secondary, and tertiary) can provide primary care. Over 95% of providers are private.
• Referral care is provided by secondary and tertiary facilities.
Purchasing • HMOs disburse global capitation for primary care to providers. Referral care requires pre-approval by HMO, and provider is reimbursed on fee for service basis in relation to a fee schedule developed by the NHIS. NHIS pays administrative fees to HMOs for paying capitation and fee-for-service reimbursements.
Benefit package • Out-patient care (including consumables), prescriptions, and diagnostic tests as contained in the National Essential Drugs List and Diagnostic Test Lists, maternity care, preventive medical and dental care, specialist consultation, in-patient care (not exceeding 15 days per year), eye examination and care, and access to locally produced prostheses.