Health Policy Research Group, College of Medicine, University of Nigeria, Enugu PMB 01129, Enugu, Nigeria.
Health Res Policy Syst. 2013 Jun 13;11:20. doi: 10.1186/1478-4505-11-20.
The National Health Insurance Scheme (NHIS) in Nigeria was launched in 2005 as part of efforts by the federal government to achieve universal coverage using financial risk protection mechanisms. However, only 4% of the population, and mainly federal government employees, are currently covered by health insurance and this is primarily through the Formal Sector Social Health Insurance Programme (FSSHIP) of the NHIS. This study aimed to understand why different state (sub-national) governments decided whether or not to adopt the FSSHIP for their employees.
This study used a comparative case study approach. Data were collected through document reviews and 48 in-depth interviews with policy makers, programme managers, health providers, and civil servant leaders.
Although the programme's benefits seemed acceptable to state policy makers and the intended beneficiaries (employees), the feasibility of employer contributions, concerns about transparency in the NHIS and the role of states in the FSSHIP, the roles of policy champions such as state governors and resistance by employees to making contributions, all influenced the decision of state governments on adoption. Overall, the power of state governments over state-level health reforms, attributed to the prevailing system of government that allows states to deliberate on certain national-level policies, enhanced by the NHIS legislation that made adoption voluntary, enabled states to adopt or not to adopt the program.
The study demonstrates and supports observations that even when the content of a programme is generally acceptable, context, actor roles, and the wider implications of programme design on actor interests can explain decision on policy adoption. Policy implementers involved in scaling-up the NHIS programme need to consider the prevailing contextual factors, and effectively engage policy champions to overcome known challenges in order to encourage adoption by sub-national governments. Policy makers and implementers in countries scaling-up health insurance coverage should, early enough, develop strategies to overcome political challenges inherent in the path to scaling-up, to avoid delay or stunting of the process. They should also consider the potential pitfalls of reforms that first focus on civil servants, especially when the use of public funds potentially compromises coverage for other citizens.
尼日利亚的国家健康保险计划（NHIS）于 2005 年启动，作为联邦政府努力通过财务风险保护机制实现全民覆盖的一部分。然而，目前只有 4%的人口，主要是联邦政府雇员，参加了健康保险，这主要是通过 NHIS 的正规部门社会健康保险计划（FSSHIP）。本研究旨在了解为什么不同的州（州以下）政府决定是否为其雇员采用 FSSHIP。
本研究采用比较案例研究方法。通过文件审查和对政策制定者、计划管理人员、卫生提供者和公务员领导人的 48 次深入访谈收集数据。
尽管该计划的福利对州政策制定者和预期受益人（雇员）似乎是可以接受的，但雇主缴款的可行性、对 NHIS 透明度的关注以及州在 FSSHIP 中的作用、政策拥护者（如州长）的作用以及雇员对缴款的抵制，都影响了州政府对采用该计划的决策。总的来说，州政府对州一级卫生改革的权力归因于允许各州审议某些国家一级政策的现行政府制度，加上 NHIS 立法使采用该计划具有自愿性，使各州能够决定是否采用该计划。
该研究表明并支持这样的观察结果，即使计划的内容普遍可以接受，但背景、角色以及方案设计对角色利益的广泛影响可以解释政策采用的决策。参与 NHIS 计划扩大规模的政策执行者需要考虑到当前的背景因素，并有效地吸引政策拥护者，以克服方案设计对利益相关者的已知挑战，从而鼓励州以下政府采用该计划。在扩大医疗保险覆盖范围的国家中，政策制定者和执行者应该尽早制定战略，克服扩大规模过程中固有的政治挑战，避免拖延或阻碍这一进程。他们还应该考虑首先关注公务员的改革的潜在陷阱，特别是当使用公共资金可能会损害其他公民的覆盖范围时。
