Awareness, Enrolment and Productivity Outcomes Associated with Health Insurance Participation Among Civil Servants in Delta State, Nigeria: a Cross-Sectional Study

Abstract

Out-of-pocket spending still accounts for the bulk of health expenditure in Nigeria, prompting the Federal Government to create the National Health Insurance Scheme (NHIS) in 2005. That scheme has since been replaced by the National Health Insurance Authority (NHIA) Act of 2022, which makes participation mandatory and reorganizes the sector around state-level schemes. Whether this transition has narrowed the gap between awareness and enrolment among civil servants, and whether enrolment carries any productivity dividend, remains poorly documented at state level. A cross-sectional survey was conducted among civil servants across 14 ministries of the Delta State civil service, southern Nigeria, between January and April 2024, using stratified proportionate random sampling. Ethical approval was granted by the Delta State Health Research Ethics Committee, with informed consent obtained from all participants. Productivity was assessed with the WHO Health and Work Performance Questionnaire short form; data were analysed with chi-square tests and binary logistic regression. Of 410 questionnaires distributed, 393 were returned complete (95.9%). Awareness of health insurance was high (84.4%), but only 52.7% of respondents were actively enrolled. Enrolled respondents reported markedly higher self-rated productivity than non-enrolled respondents (mean Absolute Presenteeism Score: 68.4 vs. 54.9; p < 0.001). Supervisory status, tertiary education, and health literacy independently predicted enrolment. Awareness of health insurance considerably outpaces enrolment among Delta State civil servants. Enrolment was associated with, though cannot on this evidence be said to cause, higher self-reported productivity; the cross-sectional design, self-reported outcome measure, and single-state sample all limit how far these findings can be generalised.