Analyzing governance of a sub-national health insurance scheme for providing universal health care and better social health protection performance through the lenses of the principal-agent theory in Anambra state

Health system governance plays a crucial role in the performance of health reforms. In Nigeria, recent reforms like the decentralization of social health insurance to sub-national levels, aimed at improving access to services and financial risk protection, established Anambra State Health Insurance Scheme (ASHIS). This study analysed governance factors and practices influencing the effective implementation of ASHIS, focusing on principal-agent relationships among actors towards better social health protection performance and attainment of universal health care in Anambra state, Nigeria. The study adopted a descriptive qualitative design to explore governance factors and practices influencing the implementation of ASHIS. Data were collected from three categories of actors - policymakers (n = 10) and health care providers (HCPs) (n = 10) through in-depth interviews, then focus-group discussions (n = 10) with 67 health insurance enrollees. Data were analyzed using a thematic analysis approach, and the principal-agent theory was adapted for data synthesis. Within the policymakers-clients sphere, there were positive assertions on responsiveness of the health insurance manager (as agent) on enrollee’s (as principal) needs, preferences and demands. There are established mechanisms for feedback from enrollees on service delivery, including round-the-clock customer care lines, weekly radio phone-in programs, random health facility visits, and annual town hall meetings. In the policymakers-health care provider (HCPs) sphere, the respondents stated that the insurance managers provide policies, and regulatory documents including operational guidelines, service level agreement, and resources for efficient and effective performance of the scheme. Respondents noted that HCPs as the agents deliver contracted services and instructions to their principal. However, some HCPs default through provider-induced moral hazard, and information asymmetry on matters like adequacy of provider payment mechanisms due to conflicting interests. Within the HCPs-clients sphere, while some respondents claimed that the agent uses enrollee’s (principal) inputs and oversight for improving service delivery, others rebutted the claim. The study revealed series of governance practices supportive of progress, including the availability of regulatory policies/guidelines, feedback mechanisms and responsiveness to enrollee’s demands. Conversely, some disconnects in the principal-agent relationship were found. Addressing identified gaps will improve ASHIS’ performance and accelerate progress towards attaining UHC in Anambra state, Nigeria.