The impact of health maintenance organizations in the implementation of the Nigeria national health insurance scheme in the federal capital territory (Abuja), Nigeria

Abstract

Background: The activities of Health maintenance organizations (HMO) are central to the achievement of universal health
coverage. This study sought to examine the number of HMOs actively operating in the FCT and to determine whether the
HMOs are promoting or inhibiting universal coverage and proffer recommendations for the overall progress of the scheme.
Methodology: A descriptive prospective cross-sectional study design was used and mixed (qualitative and quantitative)
methods A pre-tested interviewer-administered questionnaire make was used to collect quantitative data while qualitative
data were collected through a review of literature and in-depth interviews to examine the roles of HMOs from stakeholders’
points of view. A total of 250 participants comprised predominantly 230 enrollees into three major programs of the NHIS that
is the formal sector social insurance program (FS-SHIP), tertiary institution social health insurance program (TI-SHIP), and
community-based social health insurance program (CB-SHIP). The remaining 20 (twenty) enrollees comprised NHIA desk
officers, HMO managers, community-based representatives, and healthcare providers.
Results: The majority of the respondents (64.8%) reported a high level of awareness of the knowledge of NHIS, while fewer
than 19% indicated a lack of awareness as compared to 17% who did not respond to the question. Similarly, most of the
respondents (62.2%) reported having satisfactory knowledge of the structure-function modalities of HMOs, while 20.4% were
not aware of the mode of operation of HMOs.
Contrasting contributions of HMOs to NHIS implementation, approximately half of the respondents (50%) reported
dissatisfaction. Likewise, about 50% of the study subjects were of the view that HMOs are not putting the desired commitment
towards achieving this goal of universal health coverage. The report from the in-depth interview reiterated that the enrollees
were not well satisfied due to the perceived poor and inadequate operational mechanisms of both the HMOs and NHIS.
Conclusions: The study revealed a high level of awareness of the knowledge of NHIS and good working knowledge of the
structure and function of the HMOs. However, this study demonstrated a low understanding of the working interactions
between the NHIS and HMO, among the respondents. Understanding HMOs and how they work is critical for choosing a
health plan during open enrollment, hence, there is a need for more client enlightenment.