Effective communication approaches as tool for achieving Universal Health Coverage through social health insurance in Nigeria.

National Health Insurance Scheme (NHIS) designed various Social Health Insurance programmes to achieve universal coverage in healthcare delivery in the country. The Scheme is ad-judged to have failed to achieve its primary objective, especially in the informal sector, due to communication lapses. This study has employed an integrative literature review method to ap-praise the principles underlying effective health communication, the communication approaches of the NHIS, and recommended plausible alternatives. Media integration, advocacy campaign, social media, domestications of ICTs, communication in multiple languages, and active involvement of communities in the programme were found to imbibe some practical communication principles that can help improve communications to a target audience.


Introduction
Increasing access to healthcare remains pivotal to the improvement of healthcare and the attainment of Sustainable Development Goals (SDGs) in Nigeria.More importantly, the need to provide health services to vulnerable groups such as pregnant women and children under five and those in hard-to-reach communities remains a herculean task for health stakeholders to address.Universal Health Coverage (UHC) can be achieved through the effective implementation of Social Health Insurance.Health care coverage is adjudged to be an essential block of sustainable development, and it is a vital index for measuring the growth of a Nation.One of the important duties of government is to provide the masses access to basic healthcare and protection from catastrophic health expenditures (1).However, financial constraints often limit the ability of the government to provide healthcare for all using government funding.Many responsible governments consequently embrace Social Health Insurance as a governance responsibility to provide quality and affordable healthcare.Apart from quality and affordability, healthcare also needs to have universal coverage to boost accessibility (2).Universal Health Coverage refers to a healthcare system in which all people who need health services can receive them without undue financial hardship (3).Many authors have described social Health Insurance as ideal for quality, affordable and accessible healthcare for the masses (4,5).Because of these qualities, Social Health Insurance (SHI) is becoming a more popular option in providing healthcare, particularly in developing countries where it is challenging to sustain the taxbased or out-of-pocket pay-based health financing options.Nigeria is one of the developing countries that have embraced the Social Health Insurance Scheme.Nigeria christened her SHI designed to ensure Universal Health Coverage.This study problematizes the extant communication approaches the National Health Insurance System (NHIS) of Nigeria deploys in communicating health.It appraises the methods used by the NHIS vis-à-vis its reach to vulnerable groups in hard-to-reach communities in Nigeria.Before delving into the communication approaches deployed by the NHIS, it is imperative to provide some core conceptual principles of NHIS in Nigeria to its citizenry, particularly the less privileged.Social Health Insurance provides the opportunity for those who cannot afford out-of-pocket payment to access quality healthcare through various health insurance programmes.This also saves the government from having to go borrowing above her means to finance humongous healthcare needs.

National Health Insurance Scheme in Perspective
To achieve Universal Health Coverage, the National Health Insurance Scheme (NHIS)was established in Nigeria by Act 35 of the Nigerian1999 Constitution (now cited as NHIS Act Cap 42 LNF,2004) with a mandate to promote, regulate and administer the effective implementation of Social Health Insurance programme to ensure easy access to quality and affordable health services to all Nigerians.The NHIS has a presidential mandate for achieving Universal Health Coverage.This is to be achieved through various programmes designed to target different social-economic groupings in the country.It is believed that for the presidential mandate of Universal Health Coverage to be achieved, the NHIS must extend the deliverables of Social Health Insurance to the informal sector (Comprising over 75% of the total Nigerian Population).To give mobility to its term of reference, the NHIS, over the years, has developed various programmes to cater to the diverse health demands of Vulnerable Groups, Community-Based Organizations, Permanently Disabled, Tertiary Institutions, and the formal Sector (6).The spirit of these programmes was to reach people in rural and urban centres and get them to enroll in the scheme.Nevertheless, these programmatic efforts met low enrolments in many parts of the country, especially in the informal sector (7).As many studies have shown, the root of this challenge is traceable to the communication strategy employed by the scheme.NHIS focuses more on conventional media in its communication (8).The level of active community involvement in the various programmes of the scheme was also low (7).Other factors that limited high enrolment in Social Health Insurance Programmes have been found to include misconceptions and the lack of consumers' understanding about the concept, underlying principles, and the benefits of the schemes (9).Specifically, authors have identified that ineffective communication is one of the impediments to the success of health insurance more significantly, the Informal Sector.(9,10).Reasons for non-patronage of Social Health Insurance Programmes have also been tied to ignorance of their processes, operations, and benefits attached to participation (11).Hence, there is the need to adopt effective communication approaches that would help increase enrollment rate into the NHIS programmes and engender active community involvement to enable the Scheme to attain its mandate for achieving Universal Health Coverage.

Methods
The study has employed an integrative literature review method to appraise the various issues in the study.Both online and offline lit-erature were reviewed, critiqued, and synthesized.Both qualitative and quantitative data were used to establish a position in this study.For this study, about 108 publications were consulted.The information obtained was also used to support the evidence found in the review by using descriptive statistics.

Principles of Effective Health Communication
Towards ensuring that health communications are effective, the WHO(2017)developed six principles to guide health communicators.The principles demand that health communications are accessible, actionable, credible (trusted), relevant, timely, and understandable (12).In Nigeria, these principles have mostly found relevance in the formal sector.At the rural and, in some cases, periurban centres, none of these principles can be said to apply.This may be because NHIS messages are arguably communicated in English language even though most rural or peri-urban centres are speech communities of diverse indigenous languages.Furthermore, the messages shared, where they managed to be communicated in indigenous languages, does not engage people and set them to take action.The messages are passive with no channel ensuring instantaneous feedback.Accessibility, being the first point of call, constitutes its own problem.Studies have shown that, despite the numerous campaigns to create awareness about health insurance scheme in the country, many people are still not aware that such scheme exists.Other studies revealed that many people who are aware do not have an appreciable level of information on the scheme's modus operandi, thereby stifling possible interest in the scheme.Therefore, there is a gap in communication about the scheme.Authors have blamed the communication gap on the accessibility of media through which information about the health insurance schemes is disseminated.Social Health Insurance is often communicated through the mainstream media like radio and television.Radio is very well accessible to many people, particularly in Northern Nigeria.Still, the energy crisis facing the country limits the potential of radio as an effective medium of disseminating useful information about the programme.Television as the only medium of information dissemination about health insurance cannot provide a much-desired result.To pass the accessibility test, communications about health insurance need to go beyond the mass media.One of the delimitations with conventional media is that its feedback mechanism is neither non-existent nor not pulsating enough to propel the critical population to action.The goal of the NHIS messages on radio or television is basically to inform, not to share.This is problematic because the awareness does not translate to action.The WHO (2017) recommended that communicators identify all available channels and map their capacities to reach priority audiences.The organization advises that communicators use the right mix of media to help empower audiences with the information they need to make informed decisions.Using the right mix of media tends to improve accessibility to information about Social Health Insurance (12).WHO's recommendation is instructive in that communication should involve both conventional and unconventional communication tools to facilitate participatory change.Empowerment comes through active participation.From active participation, the target audience learns and makes an informed decision to impact or change their lives.So far, the NHIS has not used or exhausted indigenous media in communicating its key messages.The use of indigenous media tools is arguably, almost non-existent on the fringes of Nigerian communities.Next to accessible is 'actionable' on the WHO's effective communication principles list.Actionable communication is communication designed to increase audience engagement and motivation to take action (13).To be successful, communicators must understand the target audience's knowledge, attitudes, and behaviours to create messages that address barriers and encourage the audience to take action (12).In Nigeria, the vulnerable groups who are the prime target of the programme are often very attached to their culture and religion.In other words, the audience's knowledge, attitudes, and behaviours are assumed to have been shaped by their culture.Communications that will elicit the emotion and action of these people may, therefore, need to take cognizance of their culture (14).This aspect of the core principle is crucial.Where there are cultural or religious myths against some aspects of NHIS practices, as it is evident in some parts of Nigeria, only actionable messages can transform attitudes.This is where peoplecentric and direct engagement with communities is beneficial.Drama, as well as other theatrical performances, has proven to be helpful in this regard.However, the NHIS has not explored this option enough in rural communities and for the target population to bring about sustainable health practice.Another principle of effective communication is credibility.For instance, Contributory Health Insurance Programme, as the name indicates, requires participatory funding from the audience.For them to be committed to contributing their meager financial resource to the scheme, the scheme has to be perceived or known to be credible.Transparency is key to credibility; thus, communicators must be transparent in their dealings with the audience.Therefore, communications aimed at encouraging participation in Social Health Insurance need to emphasize the scheme's credibility by citing authoritative sources, showing verifiable case studies and perhaps, having a timeline for the measure of progress.'Relevance' is another principle of effective communication.According to WHO (2017), to be relevant, contacts must help audiences see the health information, advice, or guidance as applicable to them, their families, or others they care about.Relevant communications are essential towards the personalization of benefits derivable from participating in SHI.When the audience can identify with the problem that SHI is trying to solve and see the benefits as applicable to them, they would more likely embrace the scheme.To make relevant communication, WHO recommends knowing the background of the audience and their concerns, attitudes, and behavior.Apart from the need for communication to be accessible, actionable, credible, and relevant, it also needs to be timely.It is essential to make information, advice, and guidance available conveniently, so audiences have the information they need when they need it to make appropriate health decisions (12).Wrong timing can cause communication to become irrelevant to the audience's needs.
Once the relevance quality is lost, the communication becomes useless, leading to resource wastage.Communications have to be delivered timely so that the audience can have enough time to evaluate and or assimilate inherent information and decide to act on it.Finally, health communication also needs to be understandable.Making communications understandable is particularly important given that target audiences are people who may not individually afford to finance their healthcare needs.Most of these people belong to the vulnerable group who are educationally disadvantaged.
Hassan and Adie(2018) stated that the imperativeness of health insurance, primarily for vulnerable groups, may not be appreciated without considering the state of human capital development in the country.Given that human capital development (education) is low, particularly in Northern Nigeria, technical jargon that impedes understanding needs to be avoided, or better, translated into memorable indigenous jargon that the people can relate to.Technical terms in communication need to be simplified and presented clearly.Anything that can serve as noise should be preconceived, identified, and avoided (11).When the audience fails to understand communication, counterproductive misinformation can occur (15).Having appraised the principles/qualities that can make health insurance communication effective, it is plausible to evaluate the approaches used in the SHI communication in Nigeria to recommend a better option.

Communication approaches of the National Health Insurance Scheme
Many studies have established that the communication approaches of NHIS and by extension, the informal sector have not been very effective (11,10,16).Hassan and Adie (2018) warned that the communication lapses could have dire consequences on the programme's overall success.Hassan (2010) reported that the NHIS communication approaches had been mainly either proactive or reactive since inception.NHIS communications have been less interactive (17).According to Joseph & Chukwuemeka (2016), proactive communication allows an organisation to seize control of the public relations messages presented to the public (14).enables communicators to preempt response through careful evaluation (18).Reactive public relations or communication is usually impromptu and can be less thoughtful and compelling.
According to Hassan (2010), reactive communication stems from anger, fear, resentment, and uncertainty (17).This type of communication can be counterproductive, causing new problems while trying to solve existing ones (19).Of the three communication approaches, the interactive is considered more appropriate in disseminating information about health insurance schemes (19,20).Interactive communication involves engaging the stakeholders through various interactive methods such as Participatory Learning and Action (PLA) tools, workshops, and storytelling.The predominant use of either proactive or reactive communication approaches by NHIS has not yielded noticeable positive results in the informal sector (17), hence the need to try interactive communication to disseminate information about the programme.

Considerations of Alternative Communication Model for NHIS
To make NHIS messages interactive, there is a need to consider applied interactional methodologies.Baezconde-Garbanati et al.

Continuous Social Mobilization
Extensive Social Mobilizations contribute to awareness and knowledge creation but also helps in motivating and encouraging the community members to act positively.Traditional religious leaders, NGOs, and Health workers could be turned to mobilizers of the community on the programme (7).One tool that has proven to be effective in social mobilization is the theatre.Many empirical case studies and workshops, such as the Samaru Project and the Community Theatre engagements of the Department of Theatre and Perfuming Arts of Ahmadu Bello University Zaria, have achieved many results (Hassan, 2019).One way theatre has succeeded as a tool for social mobilization and communication is a mass appeal and the use of local or indigenous idiolects to communicate health messages.Rather than run a commentary or health talk, the health messages are dramatized and acted before the local audience.The community people are asked to dialogue on the outcome of the drama or what they have watched.This tool is engaging.It draws the target people into the performance as events in their lives, health behaviour, and practices are acted before them.This way, they can see themselves being played out for what or who they are.As deployed by the University department, the tool is even more stimulating as members of the community often take roles in the performance or story told by them and acted by them.

Effective Utilization of Social Media
A report from Hassan (2019) indicates that the NHIS utilization of Social Media Channels was below average compared to the other channels of communication, such as radio, television, newspapers, etc.Though social media falls within the scope of the new media and targets elites, it can improve 'accessibility' to information about the SHI, particularly among the educated youths who are internet-inclined.Hence there is a need for more utilization of social media as YouTube, Facebook, etc., to reach more people, particularly those that are information technology compliant.Again, using social media goes beyond uploading videos or writing health messages.It also involves identifying catch-nets to draw or attract young people.In this regard, high or pop music can be potent.More, urban legends or celebrities with mass online followership can also be branded as NHIS ambassadors and made for sharing useful health messages to their online followers.

Domestication of Information and Communication Technologies (ICTs)
ICTs can be utilised to reach people in the community efficiently.ICTs can also help enrollers to become more involved in their own decisions.Small handsets can be tailored to provide various services to rural areas by using the available ICTs.For this to work, locally-made applications should be developed to make enrolment less difficult so much so that anyone can register at every where or point in time.

Using a multi-lingual approach in communicating the various NHIS Programmes
Using appropriate language plays a vital role in reaching the enrollees.Inegbedion (2015) indicates that English was the dominant language being used by NHIS in communication with the general public (10).Hence, there is the need to use various significant languages spoken in the country to reach people, especially those in rural areas.Jegede (2010) advocated for using local languages to enable the development partners to implement their programmes (23) fully.According to Adewole and Osungbade (2016), using a multilingual approach can rapidly facilitate the NHIS program's implementation.

Emphasis on Behavior Change Communication
BCC is a research-based consultative process of addressing knowledge, attitude, and practice by identifying, analyzing, and segmenting audience and participants in programmes (24).NHIS should emphasize communication that would change the negative perception and misunderstanding of people about health insurance.

Active Community Involvement
Studies (Odeyemi, 2014;Carrin et al., 2005) suggest that when communities are actively involved during the implementation of any development programme, the sustainability of that programme would be high.This follows the findings of Ihidero and Hassan (2019), which observes that true empowerment comes when community people actively participate in their own development affairs.NHIS as a development-oriented scheme should, therefore, be able to adequately involve the communities in its various activities to enable it communicated its various programmes to target enrollees (25, 16, 2).

Discussion
In its effort to communicate its various programmes to achieve Universal Health Coverage, we found that National Health Insurance Scheme has applied the six principles of effective health communication given by WHO (2017) to some degree.Table 1 further confirmed how the health communication principles were applied to communicate social health insurance.In Table 1, 54.54% of the literature consulted ensures that NHIS has followed the principle of "accessibility" in communicating its programme.Also, another 54.54% of the consulted confirms that the NHIS has followed the principle of "Actionably" while 63.63% of the literature affirm the application of "Credibility" and also 72.72% affirms the principle of "Relevance".However, 54.54% of the NHIS communication to the audience has confirmed" Timely" and 63.63% confirmed the principle of "Understandable".Evidence from this study established that the National Health Insurance Scheme's existing communication approaches are proactive and reactive than interactive.The literature further indicated that an interactive communication approach would be needed for NHIS to ensure the achievements of Universal Health Coverage in the country.Table 2 in this study confirms 61.53% of the literature and documents consulted approved that NHIS has been applying a proactive approach in communicating its various programmes and activities.Also, 53.84% of the consulted literature and records show that the NHIS communication approach is reactive.And lastly, 46.15% of the consulted evidence provided that the NHIS communication approach is interactive.The study recommends that various media for communicating Health Insurance effectively was found in the study.Hence, a fusion between mass media, inter-personal and folk media would be a viable option for sharing insurance to achieve universal health coverage.Table 3 also shows that 93.33% of the literature and documents have confirmed that media integration would enhance health insurance communication in Nigeria.However, it was also observed that continuous social mobilization as a communication approach would create awareness and enhance the knowledge of the Health Insurance enrollees.About 84.61% of the literature consulted showed that continuous social mobilization would facilitate the awareness and knowledge creation of health insurance customers in such a way that they would be able to take positive action toward the programme.
This study also found that effective utilization of social media would provide access to information to the social health insurance enrollees in Nigeria.About 81.61% of the sources confirm that if social media is effectively utilized for communicating health insurance, there is a more favorable result.Moreover, it was observed that the domestication of information and communication technologies can enhance the promotion of health insurance in such a way that it would facilitate the attainment of universal health coverage in the country.In about 80% of the literature verified, it was found that if ICTs are carefully domesticated, this will facilitate the promotion of various health insurance programmes.In this study, however, it was found that most of the contents of communication materials and programmes of the National Health Insurance Scheme are in the English language, neglecting the other indigenous languages.Hence, about 87.59% of the consulted literature recomme nded that using indigenous language in communicating Health Insurance would motivate people to act positively towards the programme.Reports in this study have shown that people have different cultural and religious perceptions of social health insurance.Because of these different perceptions and attitudes, there is the need of more emphasis on behaviour change communication by the NHIS.About 85.71% of the literature consulted has provide the need for a National Health Insurance scheme to focus more on behavioral change communication to change the negative perception of people towards the scheme's programmes and activities.Lastly, it was observed that active involvement of the indigenous communities during the planning and the implementation of the NHIS programmes and activities would encourage ownership and sustainability.92.3% of the literature consulted have shown the need for active community involvement to ensure adequate coverage of social Health Insurance in rural areas.Without active community involvement achieving Universal Health Coverage through health insurance would be very difficult.

Conclusion
NHIS has designed various Social Health Insurance Programmes to ensure the Universal Coverage of Healthcare in Nigeria.Despite the multiple approaches put in place by NHIS to reach the Nigerians and create awareness about the Scheme, many Nigerians are not aware of the programme or do not fully understand the operational guidelines due to the excessive conventionalization of its communication tools and channels.To find an effective communication approach that can help improve awareness and participation, this study reviewed relevant literature and suggested alternative communication tools that can help the NHIS achieve its mandate.A review of principles underlying effective communication was done, and communication approaches qualities that can help improve Social Health Insurance were identified.Media integration, advocacy campaign, the use of social media, domestication of ICTs, communication in multiple languages, emphasis on behaviour change communication and active community involvement were found to imbibe some of the effective communication principles and are therefore recommended towards effective communication that would facilitate the Universal Health Coverage in Nigeria.
Importantly, there is a need for more empirical studies on NHIS that draws from or uses multi-disciplinary analytic approaches.Current accessible literature on NHIS is mainly within the disciplines of medical sciences and social sciences.Worse, the methodological approaches to such literature are mostly stand-alone and mostly depend on numbers instead of a well-triangulated outcome that shows actionable results achieved through collective community action.Empirical studies should quantify data and emphasize the process of engaging the community because therein lies development and the global call for convergence in terms of methodology.
(2014) recommended using various media combinations and testing what works and what does not(21).Besides,Hamel (2010) has shown that combining interpersonal, folk, and mass media would enhance the communication of NHIS in Nigeria(22).Dauda Mani (in Hassan 2019) commented that: Fusion between local indigenous media and the mainstream media would be in no small measure contributed toward adequate awareness creation and provision of health insurance knowledge to the local communities.Integration of media and what Steve Abah calls "methodological conversation" approaches tend to create more awareness about the NHIS and instigate the critical population to action.Conversational tools like PLA, FGDs, Drama-in-Education (DiE), Theatre for Development (TFD), and other applied methodologies can stimulate serious advocacy campaigns targeting critical stakeholders.Methodological conversation advocates for a synergy between the sciences, social sciences and humanities, to address community-centered interventions.The term is used to describe a synergizing process and interface between (TFD and PLA) to engage local communities in a constructive process of social change.It is premised on the agglutination or convergence of ideas, and approaches to produce a common goal.Hence, interactive tools such as live or playback theatre can be viable instruments across disciplines.Medical or scientific interventions can be re-enacted or performed for easy comprehension.For example, as seen in Ahmadu Bello University, the department of community medicine can partner with the theatre and performing arts department to organize medical community outreaches where all the intended health messages are communicated using the performing arts.Those mentioned above can provide avenues to sensitize people and subsequent follow-up of policymakers and other stakeholders to arouse their interest to get them committed.When NHIS engages in constant advocacy, the scheme would have an opportunity to carry Information, Education, and Communication (IEC) materials which can be essential for creating awareness, motivating people, and promoting desired changes in behavior while educating and informing people.Abosede (2003) stated that advocacy materials carry messages easily understood, remembered, and retained for future use.This aligns with the 'understandable' and 'actionable' principles of effective communication highlighted by the WHO (2017).

Table 1 : NHIS application of the principle of effective Health Communication
Hassan S, Mohanned JA.Effective communication approaches as tool for achieving Universal Health Coverage through social health insurance in Nigeria.(Review articles).SEEJPH 2021, posted: 18 May 2021.DOI: 10.11576/seejph-4449

Table 2 : Shows the nature of the use of the three communication approaches by NHIS.
Hassan S, Mohanned JA.Effective communication approaches as tool for achieving Universal Health Coverage through social health insurance in Nigeria.(Review articles).SEEJPH 2021, posted: 18 May 2021.DOI: 10.11576/seejph-4449 8