Table 8.

Evidence of provider behavior, related attributes, and implications for health systems goals.

Types of provider behavior	Evidence of provider behavior	Related attribute/characteristic	Implications for health system goals
RESOURCE SHIFTING(from less valuable to more valuable funding flows)	Assignment of designated doctors, nurses in outpatient department (OPD) and pharmacy for insured (NHIS) clients although the overall doctor/nurse-patient ratio in facility is low. Designated doctors are better qualified. This occurs because NHIS contributes significantly to hospital funds (size of funding). And the hospital needs to ensure continued patronage of NHIS clients, as well as to honor the MoU with NHIS-HMOs (State-owned tertiary hospital) “Like the NHIS people are being given preference…in the out patients' unit. We have the doctors that are assigned to be seeing the NHIS patients when they come…despite the crowd or whatever. They have assigned doctors that see only them, and they also do it in other clinics. Even when they come with their children, you also give them attention” (KII /R23)	Relative share of funding	NHIS clients get better quality of care than uninsured clients because waiting times are reduced
	Funds meant for drug revolving fund (DRF) for uninsured clients are used to purchase drugs for the NHIS pharmacy to prevent stock-outs that arise from delays in capitation payments in the Federal government-owned tertiary hospital. This results in depletion of DRF stock and delays in paying suppliers	Relative predictability of funding Relative flexibility	Depletion of the DRF funds for uninsured clients
	Health facility staff are shifted to philanthropy provided services (eye care, dental care, surgeries)	Gaps in service delivery	Improves access to specialized health services for the community
	Cardiothoracic unit is prioritized for resource mobilization (basic amenities, drugs and staff) during the annual free open-heart surgery programme provided by medical missions (VOOM foundation) to UNTH. This programme is valuable to the hospital because it fills a gap in service delivery “What we are seeing in this current management is that interest is in open heart surgery, we know there are mission people in Diaspora coming to assist but the management attention has completely gone to that place to the detriment of every other aspect….” (FP/KII/R05)	Gaps in service coverage associated with funding flows	Other health care services are under-resourced for the period resulting in differential quality of care
	In ESUTH, TB, and immunization clinics are under-resourced compared to other clinics because they do not generate any revenue for the hospital (services are provided free of charge) “I will give you a typical example, immunization unit and the TB clinic are not well funded by the hospital the way they fund the SOP. The reason is that they don't see the money. Now, the quality of services rendered by TB and immunization cannot be compared to anything you run in clinical services because the funding doesn't come directly to them” (FP/KII/R29)	Relative share of funding	Quality of services is poorer in these clinics (long waiting time & unconducive environment)
PATIENT SHIFTING(from less profitable to more profitable funding flows)	NHIS clients are made to pay user fees (the difference in fees) when drugs are prescribed outside of the NHIS-approved drug formulary. Purpose is to make up for inadequacy of NHIS billing as well as avoid delays in HMOs' authorization process. “There are some drugs that are not in the list of NHIS approved for their enrolees, so if you have a case like that you have to go and buy the drugs by yourself and pay…At the moment what we actually do is to subtract the amount. For instance, for a brand of Ceftriaxone that is sold at ₦ 3,600, if the price [on NHIS drug list] is ₦ 600, we subtract the ₦ 600 and work out its 10% [co-payment] which is ₦ 60…So, the person is paying ₦ 3,060” (FP/KII/R32)	Relative adequacy and predictability (time) of funding flows	Ensures that clients get the quality of services they require. Also has equity implications for insured clients who cannot afford the user fees
	Some NHIS clients are shifted from capitation to fee-for-service for expensive procedures that are not sufficiently covered by NHIS capitation payment	Relative adequacy of funding flows	Ensures that clients get the quality of services they require
	NHIS clients are made to pay OOP for services that are not covered by capitation due to communication gap between HMOs and health facility	Accountability	Implications for efficiency and equity (cost escalation)
	Free MCH—mothers are made to pay part of the fees to make up for unpredictability (time and amount) of reimbursements	Relative predictability	Implications for equity
	OOP clients are shifted from non-commercialized (public-funded) to commercialized (privately funded) laboratories in the hospital for two reasons: (i) the private laboratory offers wider range of investigations, is accessible at all times and has quicker turn-around time; (ii) the private laboratory generates more revenue for the hospital “…There is a part of the hospital that runs their laboratory services and charges like a private place and the management knows they can get money directly from there so they do not fund the public typical labs so that these ones are not running and people will go to the private places.…where they pay more so that they can get what they want. Because government is not funding that one (public labs) it has made the services to go down. At a point it stopped running some tests” (FP/KII/R10)	(i)Gaps in service coverage associated with funding flows (ii)Relative share of funding	Improves quality of care for those that can afford but creates inequities in access
	Different fees are charged to out-of-pocket paying clients for the same laboratory tests depending on whether they use the commercialized (privately-owned) laboratories or the non-commercialized (public-owned) laboratories in the hospital	Relative adequacy of funding flows	Improves quality of care for those that can afford but creates inequities in access
COST SHIFTING (different rates are charged to different funding flows for the same service)	NHIS is charged higher rates than out-of-pocket payment for the same laboratory investigations in UNTH The privately managed laboratory in UNTH charges higher fees than the public laboratories for the same laboratory tests. The private-owned laboratory operates like other for-profit private laboratories outside the hospital	Relative adequacy of funding flows	Inefficiency