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Strategic purchasing for universal health coverage: examining the purchaser–provider relationship within a social health insurance scheme in Nigeria
  1. Enyi Etiaba1,2,
  2. Obinna Onwujekwe1,2,
  3. Ayako Honda3,
  4. Ogochukwu Ibe1,2,
  5. Benjamin Uzochukwu1,2,4,
  6. Kara Hanson5
  1. 1 Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
  2. 2 Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, Nigeria
  3. 3 Department of Economics, Sophia University, Tokyo, Japan
  4. 4 Department of Community Medicine, College of Medicine, University of Nigeria, Enugu, Nigeria
  5. 5 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
  1. Correspondence to Dr Enyi Etiaba; enyi.etiaba{at}


Background In an attempt to achieve universal health coverage, Nigeria introduced a number of health insurance schemes. One of them, the Formal Sector Social Health Insurance Programme (FSSHIP), was launched in 2005 to provide health cover to federal government and formal private sector employees. It operates with two levels of purchasers, the National Health Insurance Scheme (NHIS) and health maintenance organisations (HMOs). This study critically assesses purchasing arrangements between NHIS, HMOs and healthcare providers and determines how the arrangements function from a strategic purchasing perspective within the FSSHIP.

Methods A qualitative study undertaken in Enugu state, Nigeria, data were gathered through reviews of documents, 17 in-depth interviews (IDIs) with NHIS, HMOs and healthcare providers and two focus group discussions (FGDs) with FSSHIP enrolees. A strategic purchasing lens was used to guide data analysis.

Results The purchasing function was not being used strategically to influence provider behaviour and improve efficiency and quality in healthcare service delivery. For the purchaser–provider relationship, these actions are: accreditation of healthcare providers; monitoring of HMOs and healthcare providers and use of appropriate provider payment mechanisms for healthcare services at every level. The government lacks resources and political will to perform their stewardship role while provider dissatisfaction with payments and reimbursements adversely affected service provision to enrolled members. Underlying this inability to purchase, health services strategically is the two-tiered purchasing mechanism wherein NHIS is not adequately exercising its stewardship role to monitor and guide HMOs to fulfil their roles and responsibilities as purchasing administrators.

Conclusions Purchasing under the FSSHIP is more passive than strategic. Governance framework requires strengthening and clarity for optimal implementation so as to ensure that both levels of purchasers undertake strategic purchasing actions. Additional strengthening of NHIS is needed for it to have capacity to play its stewardship role in the FSSHIP.

  • strategic purchasing
  • purchaser provider split
  • contracts
  • provider payment methods
  • National Health Insurance Scheme
  • Formal Sector Social Health Insurance Programme
  • Nigeria

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  • Handling editor Seye Abimbola

  • Contributors KH, OO, AH, BU: conceived the study. EE, OI: carried out the study. EE, OI: analysed the data. EE, AH: wrote the first draft. All authors read and agreed the final draft.

  • Funding EE, OO, AH, OI, BU and KH are members of the Consortium for Resilient and Responsive Health Systems (RESYST). This document is an output from a project funded by the UK Aid from the UK Department for International Development (DFID) for the benefit of developing countries.

  • Disclaimer The views expressed and information contained in it are not necessarily those of or endorsed by DFID, which can accept no responsibility for such views or information or for any reliance placed on them.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Ethical clearance was obtained from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital Ituku Ozalla, the Ministry of Health, Enugu and the London School of Hygiene and Tropical Medicine. Informed consent was obtained from respondents before each interview.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The datasets during and/or analysed during the current study are available from the corresponding author on reasonable request.