**6. Discussion**

Evidence from both quantitative and qualitative data in this study has shown that capitation payment increases the revenue of the healthcare facilities. For instance, 88.63% of the respondents believed that capitation payments increased the revenue of the providers. In comparing the amount of capitation being paid by the National Health Insurance Scheme in Yobe State with that being paid by the Yobe State Contributory Healthcare Management Agency (YOTCHMA), NHIS pays more than the amount (YOTCHMA) pays per head to the healthcare facilities for the same kind of services. The National Health Insurance Scheme uses HMO as an intermediary for the payment of capitation, while the YOTCMA pays capitation directly to the healthcare providers.

However, capitation is not the only payment mechanism to the healthcare providers in Yobe State that is contributing to the revenue generation of healthcare facilities but also the fee for service. According to the NHIS [3], fee for service is payment made by HMO to secondary/tertiary healthcare providers that render service to enrollee, and can also be paid on a service basis for emergency cases.

Apart from fee for service, there is co-payment which also contributes to the revenue of healthcare providers. This is payment made by the enrollee to the accredited pharmacy provider at the point of service. It is 10% of the total cost of drugs dispensed per prescription in accordance with the NHIS Drugs price list [3].

Other forms of payment to providers include Per diem and co-insurance. The former is payment made by primary providers and HMO to secondary/tertiary healthcare providers for bed space (per day) during hospitalization, while the latter refers to the part payment made by the enrollee for treatment/investigation covered under partial exclusion list while the HMO pays the balance.

The findings of this study have shown that capitation payment to the health care facilities in Yobe State contributed to the efficient utilization of the facilities fund. Since the fund is coming prepaid before service is given to the enrollee, this would

### *An Assessment of the Effect National Health Insurance Scheme Capitation Payment… DOI: http://dx.doi.org/10.5772/intechopen.102545*

enable providers to budget for drugs and other consumables, adequately. Sometimes when the healthcare facilities have enough funds at their disposal, they are utilized for the purchasing of equipment and the maintenance of infrastructure, and the improvement of staff welfare. This view was confirmed by the quantitative data in **Table 2**, for instance, where a majority of the respondents 88.63% have agreed that providers used the part of the capitation money paid to them for the purchase of drugs and consumables.

When comparing the utilization of funds generated by the healthcare facilities from capitation payment and other payment mechanisms such as fee for service usually, the generated fund from capitation is used for the procurement of drugs and consumables. Fund from fee for service payment usually comes after service is provided to the enrollee and it takes time to be collected from the HMO on behalf of NHIS. There are various protocols before the fee for service fund is being delivered to the healthcare facilities. Before accessing the fee for service payment from the HMO, a provider must request for referral code and after providing services the provider must send a claim to the HMO before payment would take place. According to National Health Insurance Operational guidelines of (2012) when the provider is unable to send a claim within 3 months of given service to the enrollee, that payment would not be paid.

This study confirmed that the capitation payment mechanism contributed to the increase of competition among the healthcare providers in Yobe State. In **Table 3** of this study, 79.54% of the respondents believed that capitation payment to healthcare facilities increases competition. In Yobe State, there are some healthcare facilities that are competing in terms of quality of care in order to have more enrollees so that more money can be received from capitation payment. According to an unpublished NHIS report (2021), some healthcare facilities are not collecting 10% copayment of drugs in order to attract more enrollees and retain the existing ones not to change to other facilities.

Concerning customers'satisfaction, the result of this study presented in **Table 4** points to the trend of satisfaction. Indeed, the majority of the NHIS enrollees in Yobe State were satisfied with the services provided. This may be explained by the way healthcare facilities are treating people in order to retain them in their facilities so that they would not change to other ones.

Regarding capitation payment sustainability, the majority of the respondents, about 78% in this study confirmed that the payment system should be continued and sustained, perhaps because of the positive impact of the payment method on the healthcare facilities. According to the unpublished report from NHIS (2021), since the flagging off of the Formal Sector Social Health Insurance Scheme, capitation payment mechanisms have been used for the payments of primary healthcare service in the whole federation, which may sign the potential sustainability of this payment method.

Without a doubt, capitation serves as a critical source of income to the healthcare facilities. It also promotes adherence to guidelines and policies and encourages providers to work better and give health education to patients. However, in this study, some challenges associated with the capitation payment mechanism were identified, which need to be addressed by the National Health Insurance Scheme so that qualitative services will continuously be provided by the accredited healthcare facilities in the Yobe State.
