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Table 2 Key policy context and design issues influencing actor roles

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

Policy context Ebonyi (Non-adopters of the programme) Enugu (Programme adopters)
Policy agenda of government –interest in financial risk protection Existing public programmes for financial risk protection. Existing public programmes for financial risk protection.
Spends about US$100,000 monthly on free maternal and child health (MCH) services in rural areas using public and non-profit private facilities. The focus on rural areas was based on the governor’s philosophy that the share of the financial consequences of ill health was more on the more populous rural dwellers. Funds free MCH services (state-wide using public facilities).
Funds a vesico-vaginal fistula programme. No medical allowance for civil servants though previously requested by them.
Medical allowance (10% of basic salary paid to civil servants monthly to help defray health care expenditure).
Role of states in the FSSHIP States as federating units are allowed to deliberate on health policies even when approved by the federal government. Concerns were raised that the scheme was a federal government programme which meant states had to transfer funds to the federal level for a scheme which was established by federal law that did not specify a role for states apart from their broad inclusion as employers of labour. Concerned about absence of role for states and initially considered setting up a state level health insurance scheme.
Civil servants and policy makers had previous negative experiences with a contributory federal led programme (national housing fund): they made contributions, were yet to enjoy the benefits, and could not retrieve their funds. The choice of the FSSHIP was made to take advantage of existing institutional structure and technical capacity for managing insurance considered lacking in state but available in the NHIS.
Accountability systems for FSSHIP Concerns expressed by policy makers that the NHIS had not presented any audited report to the state or the general public since its inception which created the feeling of distrust towards the scheme. This view was also corroborated by HMOs. Accountability issues were not raised during the adoption process.
Design issues   
Employer contribution Policy makers considered the level of employer contribution (10%) acceptable and economically feasible as long as the already paid medical allowance would be reallocated to the programme. Government was willing to make contribution.
Employee contribution Civil servants considered wages too low to allow deductions even though the rate of 5% was considered reasonable. Civil servants considered capitation rate reasonable.
  Wanted payment deferred and to allow them time (at least one year of benefiting from the programme) to be convinced about actor commitment to implementation.
  Also felt they would not be asked to contribute in the long run because NHIS had allowed federal employees not to pay since inception of the programme in 2005, which suggested that employer contribution was sufficient for running the FSSHIP.
Capitation rates and drug list Generally considered inadequate by providers. Considered inadequate by providers given that the failure of the NHIS to revise the rates within the first 6 years of implementation.
Most providers report frequent conflicts with dissatisfied federal employees that they provide services to for two main reasons: low capitation and an unrevised schedule of drugs (since 2005) that meant patients had to buy unlisted drugs out of pocket. Concerns about drug schedule which had not been revised.
Benefit package Considered sufficient enough to address most needs of civil servants and their households. Same as for Ebonyi state.