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ORIGINAL ARTICLE

Level of awareness, and factors associated

with willingness to participate in the National Health
Insurance Scheme among traders in Abakaliki main
market, Ebonyi State, Nigeria
Benedict Ndubueze Azuogu, Ugochukwu C. Madubueze, Chihurumnanya Alo, Lawrence Ulu Ogbonnaya,
Nnennaya A. Ajayi1
Departments of Community Medicine and 1Medicine, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria

Address for correspondence:

Dr. Benedict Ndubueze Azuogu,
Department of Community Medicine, Ebonyi State University,
Abakaliki, Ebonyi State, Nigeria.
E-mail: bnazuogu@gmail.com

Access this article online

Website: www.ajmhs.org
DOI: 10.4103/2384-5589.183887
Quick Response Code:
ABSTRACT
Introduction: The National Health Insurance Scheme (NHIS) was introduced in Nigeria in 2005,
and nine years after its inception only 3.5% of the population have been enrolled in three Sectors
of the Scheme. Traders and others in the informal sector are not involvement in the scheme.
This study was conducted to assess the level of awareness, and factors that could affect the
willingness of traders in Abakaliki main market to participate in the National Health Insurance
Scheme. Materials and Methods: A descriptive cross sectional study of 419 traders (53%
males and 47% females) was carried out using a three stage sampling technique. Data was
collected using interviewer administered semi-structured questionnaire, and was analyzed using
SPSS (version 20) and Mathcad 7 Professional software. Frequencies and percentages were
calculated, while Chi square test and Z-score were used to test for associations, with P < 0.05
set as level of significance. Results: Only 127 (30.3%) of the 419 traders were aware of NHIS,
and significant majority (73.2%) of those aware of the scheme were willing to participate. No
factor was significantly associated with willingness to participate. Conclusion: Awareness
of NHIS was very poor among the traders, but majority of them were willing to participate in
the scheme. Enlightenment campaigns should be embarked upon in the markets to increase
awareness of the scheme among the traders, as this could influence their participation.

Key words: Abakaliki main market, awareness, National Health Insurance Scheme, Traders,
willingness to participate

INTRODUCTION
Health insurance is a mechanism of making periodic
prepayments against episodes of illness to enable the payer
to obtain healthcare services when needed without paying
out-of-pocket at the point of need.[1] Nine years after
the inception of the National Health Insurance Scheme
(NHIS; 2005-2014) in Nigeria, only about 5 million people
(approximately 3.5% of the population) have been enrolled
in all the three (formal, informal, and private) sectors of
the Scheme.[2,3] Unlike the situation in Nigeria, Ghana
This is an open access article distributed under the terms of the
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Cite this article as: Azuogu BN, Madubueze UC, Alo C, Ogbonnaya LU,
Ajayi NA. Level of awareness, and factors associated with willingness to
participate in the National Health Insurance Scheme among traders in Abakaliki
main market, Ebonyi State, Nigeria. Afr J Med Health Sci 2016;15:18-23.

18 © 2016 African Journal of Medical and Health Sciences | Published by Wolters Kluwer - Medknow
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Azuogu, et al.: NHIS awareness and willingness to participate among traders
has maintained a steady increase in the coverage of her
population under health insurance since its inception in
2003. For instance, in 2007 participation was 35%, and
by June 2010 more than 66% of the population had been
enrolled.[4,5] Similarly, other countries with comparable
health indices to Nigeria have achieved wider coverage of
their populations with health insurance. These include India
(19%), Thailand (80%), and Colombia (95%).[2]
The main goal of NHIS is to ensure universal coverage with
access to affordable healthcare and to reduce the reliance on
an out-of-pocket system of payment, so as to improve the
health conditions of the people, especially the participants
in the Scheme.[6] The formal sector program was the first
to be rolled out and was compulsory for employees of
the Federal Government of Nigeria. The informal sector
of the Scheme, which includes the Urban Self-Employed
Social Health Insurance Program (USSHIP) and the Rural
Community Social Health Insurance Program (RCSHIP)
are classified as nonprofit voluntary schemes.[5,6] At least
500  members are required to form a User Group to
guarantee adequate pooling of financial resources in the
Informal Sector Program. The USSHIP covers small-scale
business owners with less than 10 employees, traders,
artisans, farmers, and others.
In the year 2012, the Informal Sector Scheme was formally
launched in Lagos; in 2014 the RCSHIP was rolled out in one
State, with plans to launch the Program in at least three local
government areas of each State in Nigeria. But enrollments
in the already launched programs have been abysmally
poor.[7,8] Nevertheless, the huge informal sector in Nigeria
provides hope for the means of scaling up participation in
the NHIS. However, the free-will nature of informal sector
NHIS would require a high degree of program management,
with variable financial arrangements and benefit packages
that could motivate traders and other self-employed persons
to make voluntary monthly contributions and remain in
the Scheme. It is therefore imperative to assess the level
of awareness and the factors that would determine the
willingness of traders to participate (WTP) in the NHIS
so as to generate evidence-based information for possible
modifications of insurance packages to suit their specific
needs.
Previous surveys showed that employment in the formal
sector was significantly associated with access to health
insurance relative to being employed in the informal
sector.[4,9] The low participation of individuals in the informal
sector was attributed to a number of factors, such as low and
nonregular incomes, insecure employment, and insurance
scheme design features that are not adapted to people’s
African Journal of Medical and Health Sciences / Jan-Jun 2016 / Vol 15 | Issue 1
needs and preferences.[10-12] Existing evidence also shows
that membership in both formal and informal savings and
credit schemes is an important predictor of participation in
health insurance programs.[13,14]
A study in Edo State, Nigeria revealed that 59.4% of rural
households indicated willingness to participate (WTP) in
Community-Based Health Insurance,[15] while another from
Osun State, Nigeria showed that 82.4% of artisans were
willing to participate in the same scheme.[16]
According to the World Health Organization (WHO), an
efficient National Health Insurance model is key to achieving
universal health coverage that would ensure everyone has
access to good-quality health services as they need without
becoming impoverished as a result.[17] It is estimated that
about 100 million people globally are pushed into poverty
because of out-of-pocket payments for healthcare services,
and millions of people together with substantial number
of households do not seek healthcare in hospitals because
they have to pay at the point of service delivery.[18,19] Nigeria
has a vast informal sector as over 70% of the nation’s
population belongs to this category, and the majority of the
self-employed workforce are traders.[20,21] Unfortunately,
members of the informal sector in Nigeria have restricted
access to health insurance coverage;[8] hence this study was
conducted to determine the level of awareness and the
factors associated with WTP in the NHIS among traders
in the main market in Abakaliki, Ebonyi State.
MATERIALS AND METHODS
Study setting and subject
The study was conducted in Abakaliki, the capital city of
Ebonyi State. Ebonyi State was created from the old Enugu
and Abia States, in the South-Eastern geopolitical zone
of Nigeria on October 1, 1996. It occupies a land mass of
5,935 km2, with a population of 2.7 million people based on
the 2006 national population census, with a growth rate of
3.2%. The people of Ebonyi State are predominantly peasant
farmers, but those resident in Abakaliki are mainly civil
servants, bankers, and traders.[22]
There are three major markets located in the metropolis, of
which the Abakaliki main market, located at the city center,
is the oldest and the largest, and has both wholesale and
retail traders. As a result it was purposively selected for this
study. The market was established before the Nigerian Civil
War but its traders’ association, the Abakaliki Main Market
Traders Association (AMMATA) was formally registered
in 1982. Goods sold include textile materials, electronics,
clothing, stationery, books, fancy materials, beverages, and
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Azuogu, et al.: NHIS awareness and willingness to participate among traders

foodstuff. The market has 272 well-demarcated lines (named
after some State capitals and major towns in southeastern
Nigeria) and 2139 serially numbered shops. Each shop is
owned by one person who might run it alone or engage
others as paid salespersons or unpaid apprentices. There
is also a voluntary monthly contribution group, which
operates like a cooperative and thrift organization among
the registered members of the Association.
The traders were adults and youths in low- and middle-income
social classes. They compulsorily belonged to AMMTA,
which has 2244 registered members. Only those aged
18 years and above who have been registered for 2 or more
years in the market were selected for this study.
and permission for the study was given by the Traders’
Association Executive Committee, while verbal informed
consent was obtained from the participants. After data
collection, the researchers provided group education to all
the traders on NHIS principles and program operations
during their regular monthly prayer meetings.
Data management
Data were entered and analyzed on the IBM statistical
package for social sciences (SPSS) and Mathcad-7
Professional statistics software. Frequencies and percentages
were calculated, while chi-square test of significance and
z-score were used to test for associations, with P value less
than 0.05 set as level of significance.

Study design RESULTS

A descriptive cross-sectional study was undertaken. With
Fischer’s formula N = Z2 pq/d2 [where Z = standard normal Table 1 shows the sociodemographic characteristics of
deviate (1.96 at 95% CI), P = 82.4% estimated proportion the respondents who included 222 (53.0%) males and 197
that would be willing to participate in NHIS,[16] q = 1-p and (47.0%) females, with the mean age of 33.9 ± 12.9 years. A
d = 0.05 desired 95% accuracy], a minimum sample size of majority (167; 39.8%) were in the age group 18-29 years;
223 was calculated but was increased to 419. A three-stage more than half (222; 53%) were married; and most (60.6%)
sampling technique was adopted. In the first stage, 52 lines had secondary education.
were selected from a sampling frame of 272 lines using a
systematic random method with a sampling interval of 5. Table 2 shows the respondents’ membership in monthly
By the same method, eight shops were selected from each of contribution group and first facility always visited when ill.
the 52 lines in the second stage with a sampling interval of
6. In the final stage, a respondent in each of the 52 selected Table 1: Sociodemographic characteristics of respondents
shops was recruited into the study. If more than one eligible Variables Frequency (%), N = 419
trader was present, a simple random technique of balloting Gender
was used to select one respondent from among the eligible Males 222 (53.0)
Females 197 (47.0)
traders. The starting point for each stage was determined by Mean age 33.9±12.9
a simple random sampling technique of balloting. All the Age group (in years)
lines do not have equal number of shops, and some selected 18-29 167 (39.8)
30-39 108 (25.8)
shops were replaced with the next consecutive one if none 40-49 69 (16.5)
of the occupants fulfilled the inclusion criteria. 50 and above 75 (17.9)
Marital status
Married 222 (53.0)
A semistructured interviewer-administered questionnaire Single 190 (45.3)
was used to obtain data from the respondents with the help Separated/widowed 7 (1.7)
of three trained research assistants. Data were collected Level of education
Primary education and below 88 (21.0)
over a period of 10 days. Information was collected from Secondary education 254 (60.6)
the respondents on their sociodemographic characteristics, Postsecondary education 77 (18.4)
facilities visited when ill, awareness and knowledge of NHIS,
and WTP in the Scheme. Questions on knowledge explored Table 2: Respondents’ membership in monthly
respondents’ understanding of the three specific domains of contribution group and first facility always visited when ill
NHIS, namely: Principle of operation, persons that can be Variables Frequency (%), N = 419
enrolled, and the types of health facilities that can provide Member of monthly thrift contribution group
services under the Scheme. Yes 363 (88.6)
No 56 (13.4)
First facility always visited when ill
Ethical consideration Government and private hospitals 127 (30.3)
Ethical clearance was obtained from the Research and Ethics Others (chemist/pharmacy shop, laboratory, 292 (69.2)
Committee of the Federal Teaching Hospital, Abakaliki church/prayer house, herbal medicine shop)

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Azuogu, et al.: NHIS awareness and willingness to participate among traders

A majority of the traders (363; 88.6%) belonged to a monthly Table 3: Respondents’ awareness, WTP, and knowledge
contribution group within their association, and more than about NHIS
two-third (292; 69.2%) always visited facilities other than a Variables Frequency (%)
hospital first when ill. Awareness of NHIS: N=419
Yes 127 (30.3)*
No 292 (69.7)
Table 3 revealed respondents’ awareness, WTP, and WTP among those aware of NHIS: N=127
knowledge about NHIS, and it can be seen that only 127 Yes 93 (73.2)
(30.3%) of the traders were aware of NHIS. In addition, No 34 (26.8)
Understanding of NHIS principle: N=127
assessment of knowledge among those with awareness Correct response 8 (6.3)
showed that 8 (6.3%) understood the principle of NHIS, Wrong response 119 (93.7)
79 (62.2%) knew that anybody can be enrolled in the Knowledge of those that can be enrolled in NHIS
Correct response (“Anybody”) 79 (62.2)
Scheme, and 32 (25.2%) correctly knew that both public Wrong response (“Only government employees”) 48 (37.8)
and private hospitals can provide services under the Knowledge of health facilities providing services under
NHIS. NHIS
Correct response (“Both public and private 32 (25.2)
hospitals”)
In Table 4, the association of awareness and sociodemographic Wrong response (“Only government-owned 95 (74.8)
factors with WTP is displayed. The majority (93; 73.2%) of hospitals”)
*
Only the 127 with awareness proceeded to questions on knowledge;WTP:Willingness
the 127 respondents aware of the scheme were willing to join to participate
the NHIS and this association was statistically significant
(z = 7.404, P = 0.0015). Those willing to participate were
Table 4: Association of awareness and sociodemographic
mainly males (58; 62.4%), and more individuals in the age
variables with WTP
group 30–39 years agreed to join the NHIS (34; 35.5%)
Variable WTP in NHIS: N = 127
than in other age groups. WTP was indicated slightly more
Yes No Test of
by the married respondents than their single counterparts, Frequency (%) Frequency (%) significance
and almost half (49.5%) of those willing to join the Scheme Awareness of 93 (73.2) 34 (26.8) z=7.404+ (a=1.96)
had secondary school education. More among those who NHIS P=0.0015
Gender χ2 and P value
always visit facilities other than hospitals first when ill Males 58 (62.4) 16 (47.1)
were interested to participate (59.1%) than among their Females 35 (37.6) 18 (52.9) 2.399 (df=1) 0.121
counterparts who usually go to hospitals. However, these Age group
(in years)
associations between sociodemographic characteristics and 18-29 30 (32.3) 8 (23.5)
WTP in the NHIS were not significant. 30-39 34 (35.5) 11 (29.4) 1.927 (df=3) 0.578
40-49 14 (12.9) 7 (17.7)
50 and above 15 (9.6) 8 (17.7)
DISCUSSION Marital status
Married 51 (54.8) 23 (67.7)
In this study, awareness of the NHIS was poor as only Single 42 (45.2) 11 (32.3) 1.68 (df=1) 0.195
Level of
30.3% of the respondents agreed to have heard about a
education
scheme that has been in existence for more than 9 years. Primary 15 (16.1) 5 (14.7)
This finding is comparable with the 28.9% awareness found education and
below
among artisans in Osun State.[16] The low level of awareness Secondary 46 (49.5) 14 (41.2) 1.028 (df=2) 0.598
found in this study was rather unexpected in an urban education
setting where about 79% of the respondents had at least Postsecondary 32 (34.4) 15 (44.1)
education
secondary education. It reflects weakness in information First facility
dissemination mechanisms about the NHIS, and thus visited when ill
could have a bearing on low-population health insurance Public and 38 (40.9) 9 (26.5)
private
coverage.[2,3] hospitals
Other facilities 55 (59.1) 25 (73.5) 2.211 (df=1) 0.137
The WTP in the NHIS indicated by 73.2% of those aware +
Test of proportion using Mathcad 7 Professional; WTP: Willingness to participate

of the Scheme in this group was rather high, and consistent

with 59.4% and 82.4% found in rural households of Edo State artisans was assessed in all the participants irrespective
and among artisans in Ilorin, respectively.[15,16] However, the of their awareness status. These findings underscore the
rural households in Edo were educated on the concept of critical role of awareness in the promotion of participation
NHIS just before data collection, while WTP among the in the NHIS.

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Azuogu, et al.: NHIS awareness and willingness to participate among traders
The strong association between awareness and WTP in
the NHIS found in this study was not surprising because
most of the awareness messages aired about the scheme
were extractions from testimonies given by those who
have benefited from health insurance, and that might have
influenced their decision. The preponderance of males
with intention to participate in NHIS could be due to the
fact that males usually bear the burden of medical bills,
which would be relieved by health insurance. It could also
be attributed to our culture that allots decision-making in
the family to men. This should be explored when planning
events to foster awareness about the NHIS. Surprisingly, the
younger age groups, purportedly with lower risk of illness,
were more interested in joining the NHIS than the older
groups that are likely to fall ill frequently. This could be
due to the influence of the awareness of the NHIS, which
was correspondingly higher in the younger age groups.
Being married could encourage obtaining health insurance
coverage as the subscription of a spouse to some insurance
programs provide coverage to couples. In line with the
earlier observations in this study, the higher WTP observed
in those with secondary education could be adduced as the
influence of awareness, which was the highest in this group.
Finally, it is intriguing to note that the majority of those
willing to join the scheme visited unconventional facilities
first when ill rather than hospitals. This could be a result
of the erroneous belief held by the majority that only
government-owned hospitals provide services under the
NHIS; on the other hand, those who visited the hospitals
might be dissatisfied with the services there and therefore
not want to participate.
CONCLUSION
This study revealed a very poor level of awareness about the
NHIS among the traders, but also remarkable WTP in the
Scheme. A significant number of those aware of the NHIS
expressed WTP despite their relatively poor understanding
of the principle and operation of the Scheme. Other factors
that could engender WTP in the NHIS include male gender,
young age, being married, and having at least secondary
education.
It is recommended that stakeholders in the NHIS embark on
regular awareness campaigns, especially during the monthly
prayer meetings of the traders, to enlighten them on the
importance of participating in the Scheme.
Financial support and sponsorship
Nil.
22 African Journal of Medical and Health Sciences / Jan-Jun 2016 / Vol 15 | Issue 1
Conflicts of interest
There are no conflicts of interest.
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