Developing a Risk-Adjusted Capitation Regime for Nigeria NHIS

The National Health Insurance Scheme (NHIS) is set up to operate as Public Private Partnership and directed at providing accessible, affordable and qualitative healthcare for all Nigerians. The Nigerian health insurance industry is faced with the challenge of developing a sustainable fees structure owing to serious data deficits pervading the Nigerian healthcare system and unreliable critical health statistics. Using the capitation payment mechanism the health care provider assumes that for a given insured population, the provider will cover all health care services for a fixed payment per member per month. However, in this arrangement, payments assumed equal risk level for all subscribers and this may encourage risk selection. This objective of this research project is to explore the development of risk-adjusted models for the Nigeria National Health Insurance Scheme. The study relied on healthcare cost of various diagnoses based on international classification of diseases and information on enrollment to facilities with regards to enrollees characteristics.