Knowledge and Implementation of Tertiary Institutions’ Social Health Insurance Programme (TISHIP) in Nigeria: a case study of Nnamdi Azikiwe University, Awka

Introduction Tertiary Institutions’ Social Health Insurance Programme (TISHIP) is an arm of the National Health Insurance Scheme (NHIS), which provides quality healthcare to students in Nigerian higher institutions. The success of this scheme depends on the students’ knowledge and awareness of its existence as well as the level of its implementation by healthcare providers. This study was therefore designed to assess students’ knowledge and attitude towards TISHIP and its implementation level among health workers in Nnamdi Azikiwe University Medical Centre. Methods Using a stratified random sampling technique, 420 undergraduate students of Nnamdi Azikiwe University, Awka were assessed on their level of awareness and general assessment of TISHIP through an adapted and validated questionnaire instrument. The level of implementation of the scheme was then assessed among 50 randomly selected staff of the University Medical Center. Data collected were analyzed using Statistical Package for Social Sciences (SPSS) version 20 software. Results Whereas the students in general, showed a high level of TISHIP awareness, more than half of them (56.3%) have never benefited from the scheme with 52.8% showing dissatisfaction with the quality of care offered with the scheme. However, an overwhelming number of the students (87.9%) opined that the scheme should continue. On the other hand, the University Medical Centre staff responses showed a satisfactory scheme implementation. Conclusion The study found satisfactory TISHIP awareness with poor attitude among Nnamdi Azikiwe University students. Furthermore, the University Medical Centre health workers showed a strong commitment to the objectives of the scheme.


Introduction
In order to provide effective and efficient health care for their citizens especially, the poor and vulnerable [1], most developing countries recently initiated the implementation of some health financing strategies focusing mainly on, social health insurance scheme. These reform programmes and strategies were aimed at providing easy access to healthcare at an affordable price through various prepayment systems with expected results of improving the overall health status of the citizens. Nigeria, like most other African countries, keyed into this Health Insurance Scheme programme by enacting the National Health Insurance Scheme Act, 1999 with the aim of providing easy access to qualitative, equitable and affordable healthcare for all Nigerians [2]. The first phase of this scheme was rolled out in 2005, with the formal sector social health insurance programme being on the lead [3,4]. This formal sector social health insurance scheme recognizes the principal beneficiary and the spouse with four biological children below the age of 18 years, with more dependents only recognized on additional contributions.
As a means of catering for the healthcare needs of Nigerians who may not have been captured by the formal sector scheme, more schemes including the Tertiary Institutions' Social Health Insurance Programme (TISHIP) were introduced. The TISHIP is a social security system whereby the health care of students in tertiary institutions in Nigeria is paid for from funds pooled through compulsory contributions involving the students and the government. The programme promotes the health of students with a view to creating conducive learning environment and uninterrupted academic activities due to poor health [5]. It applies to students in universities, colleges of education, polytechnics, schools of nursing and midwifery and other specialized colleges including monotechnics without any discrimination or segregation [6]. This programme was therefore established to ensure access to qualitative service for students in tertiary institutions thus promoting the health of the students with a view to creating conducive learning environment.
The knowledge of TISHIP, its acceptance, and utilization by the students as well as, its proper implementation in the health care facilities is crucial for the actualization of its goals and general benefits. Previous studies revealed that students barely visit institutions' health care facilities due to high costs of medical services, poor working conditions and inadequate referral services [6] most of which TISHIP is meant to address. It has also been shown that most Nigerian policies such as this, are often poorly understood with a resultant low level of knowledge about its standard procedures and regulations [7]. This study, therefore, was designed to assess students' awareness and attitude to TISHIP as well as to assess the level of implementation of the scheme among Nnamdi Azikiwe University Medical Centre healthcare workers.

Study design and sampling
This study was a cross-sectional prospective study carried out amongst Nnamdi Azikiwe University students and the staff of the University Medical Centre sampled from four campuses of the University located at Awka, Nnewi, Agulu and Mbaukwu between February and July, 2015. A desired sample size of 396 students calculated from a total number of 43, 396 students of the University (Department of Students' Affairs records) using Yamane sample size calculation technique was considered ideal for the study. However, to account for potential refusals and incorrect filling of some questionnaires, an additional percentage of the participating students were added bringing the total number of students to 420.
The 420 students were sampled using a stratified random sampling technique. Then, 50 health workers comprising of the medical doctors, pharmacists, medical laboratory scientists, nurses and others in the medical centre were randomly selected and used for the study.

Survey instrument
Two research questionnaires were used for the study. The first questionnaire, adapted from previous studies [1,8,9] with validation was used for the students' assessment. This instrument consisted of three sections that assessed demographic characteristics, TISHIP awareness and general assessment of TISHIP by the students. The second questionnaire used to assess the extent of implementation of the scheme by the health workers was developed using the objectives of NHIS and independently face validated by four pharmacy lecturers and an NHIS staff in Anambra state. A pilot study was then carried out on both instruments to ensure the internal consistency of the instruments, using 30 students and 10 staff who did not participate in the main study.
Page number not for citation purposes 3 Results of the pilot study were used to further modify the questionnaires to improve on clarity and flow. The questionnaires were then, distributed to respondents and retrieved after filling.

Data analysis
The data collected from the questionnaires were entered into an excel sheet and analyzed using a computer Software Package for Social Sciences version 20.0. Descriptive statistics was calculated for the demographic variables. Quantitative data were analyzed by computing frequency tables, means, proportions (percentages) and descriptive cross tabulations. Categorical variables were summarized using frequencies and percentages.

Results
A total number of 470 questionnaires were distributed (420 for students and 50 for health care workers) with 94.3% and 100% retrieval rate for the students and healthcare workers respectively.
The demographic characteristics of the students ( ; Agree (60.9 %)) and also, ensures that every student in the higher institution has access to quality healthcare (Strongly agree (22.9%); Agree (60.9%)). A summary of the students' assessment of TISHIP program (Table 3) showed that only about half of the students believed that the institution is utilizing this program with about one-third not actually sure of its utilization although, more than half of the respondents had benefited from the scheme. The healthcare professionals' attitude was reported to be unfriendly by 28.8% of the students with 52.8 % not feeling satisfied with the quality of care they received.
However, an overwhelming number of the students (87.9%) were of the opinion that TISHIP should continue. The major drawbacks to TISHIP implementation as reported by the students ( visit to the clinic since the onset of this programme. However, more than two-third of the staff (70.0%) reported poor availability of the TISHIP drugs in the clinic without reimbursement when drugs are sourced from outside the clinic. Among the points suggested by the health workers on how to improve TISHIP as presented in Figure 1, efficient supply of drugs (70%), adequate funding of the health system (66%) and enrollment of more staff (64%) ranked high.

Discussion
The result of this study showed a high level of TISHIP knowledge and awareness with poor attitude, however, among Nnamdi Azikiwe University students as well as a satisfactory scheme implementation report by the healthcare workers in the institution's Medical Centre.
Although this study has some limitations like the use of one hospital and small sample size, the result indicated the need for proper and wider assessment of TISHIP activities in Nigerian higher institutions to ensure that the objectives of this programme are maximized.
National Health Insurance Scheme was enacted in 1999 in Nigeria to ensure the provision of standard quality of healthcare which is a fundamental human right [10,11]. One of the several programmes given most of their drugs without payment [5]. However, not all medications/drugs are captured in the NHIS list implying that the drugs not captured in the list will be paid for. Therefore, the few that indicated paying under the scheme could be for drugs or other services which were not included in the NHIS accredited drugs or services list [5].
Contrary to other findings [1,12], our study found that more than half of the students showed dissatisfaction with TISHIP quality of care but, the overwhelming number that opined that TISHIP should not be discontinued is indicative of their belief in the programme.  Surveyed students showed dissatisfaction with some of the scheme's operations but desired that the scheme be continued while all the lapses which include majorly shortage/lack of drugs, payment for some drugs and nonreimbursement after the purchase of some drugs be addressed.

Competing interests
The authors declare no competing interests.

Authors' contributions
MUA and SON designed the study. CHJ was responsible for data collection. CHJ and SUU and SON conducted data analysis. SON and MUA drafted the manuscript. All the authors reviewed and approved the final manuscript. Table 1: Socio-demographic characteristics of the respondents       Some providers charge additional fees 9.8

Tables and figure
Poor attitude and behavior of service providers 30.6 Long waiting time and poor service delivery 35.9 Shortage/lack of essential drugs 78.3 Poor level of cleanliness in the clinic (Non-conducive environment) 11.9 Lack of privacy and inadequate visiting hours 13.6