Formal Sector Social Health Insurance Programme


The Formal Sector Social Health Insurance Programme is a social health security system in which the health care of employees in the Formal Sector is paid for from funds created by pooling the contributions of employees and employers. 

The Formal Sector consists of the following: 
a.  Public Sector 
b.  Organized Private Sector 
c.  Armed Forces, Police and other Uniformed Services 

Roles and responsibilities of Healthcare Facility under the Formal Sector 
Social Health Insurance Programme  
i.	Secure appropriate Accreditation with NHIS 
ii.	Provide services as agreed with HMOs in the benet package 
iii.	Comply with NHIS Operational Guidelines 
iv.	Sign contract with NHIS through HMOs 
v.	Ensure enrollees satisfaction 
vi.	Provide returns on utilization of services and other data to NHIS 
through HMOs  
vii. Report any complaints to HMOs and NHIS 
viii. Limit delivery of services to level of accreditation. 
Roles and responsibilities of NHIS under the Formal Sector Social   
Health Insurance Programme  
i.	Setting guidelines and standards for the Programme 
ii.	Accredit Healthcare Facilities and HMOs 
iii.	Carry out continuous quality assurance to ensure qualitative  
healthcare services and programme management  
iv.	Technical Support  
v.	Carrying out Actuary Review to determine contribution rates to be 

Paid by Government and payment rates to service providers. 
vi.	Sensitization and mobilization. vii.	Health education.  
viii.  Liaison with owners of health facilities on the use of their facilities 
and retention of funds by the facilities.  
ix.	Other things to ensure the viability of the programme 

Organization of Health Service 
Healthcare  services  will  be  provided  through  a  three  level  of  service 
arrangement. These are primary, secondary and tertiary level services.  
i.	Primary Healthcare Facilities: These refer to the entry point and point 
of rst contact of individuals with the Healthcare Facilities. They serve as the gatekeepers to the scheme. They provide preventive, curative and rehabilitative services.  
ii.	Secondary Healthcare Facilities: Offer specialized services to patients referred from the primary healthcare Facilities through the HMOs. Occasionally, particularly in cases of emergencies, direct referrals without recourse to the HMOs can be made. However, the HMOs must be notied immediately after.  
iii.	Tertiary  Healthcare  Services:  These  consist  of  highly  specialized services based on referral from the secondary care level through the HMOs.