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 benet 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 notied immediately after.
iii. Tertiary Healthcare Services: These consist of highly specialized services based on referral from the secondary care level through the HMOs.
