People’s health is a standard for measuring a nation development in all nations of the world. It shows how developed a nation is because an unhealthy nation is bound to remain undeveloped [1]. Despite Nigeria's immense resources, a significant proportion of the citizens still live in extreme poverty, which has serious implications for health. The Nigerian health care system is underperforming especially at the grassroots level, leading to devastating health outcome. This is evident in the decayed infrastructure, poor remuneration of workers and bad conditions of service, inadequate medical professionals and total neglect of rural areas in the availability of medical personnel [2]. The household remains the focal point of health management as home remedy is usually the first line of care in the treatment of illness and disease. According to Asuzu [3], the negligence of the health care system has resulted in Nigeria being ranked 187th in position due to her health systems performance.

According to World Health Organization [4], prepaid financing system in health care can improve access to health care and in the bid to achieve this, National Health Insurance Scheme (NHIS) was introduced by the government. However, coverage in the NHIS is still limited to people employed by the government or the corporate private sector, leaving the self-employed, artisans and the unemployed to financial risk in any health crisis. A cooperative society is an independent group people who agreed address their common economic, social and cultural problems in a democratically controlled enterprise. 

According to Mufutau [5], cooperative societies are group of people who through collective means, earn income through sales of their outputs to non-members and share their surplus produce among themselves. This follows the principle of rational action as put forward by Weber in the social action theory. A rational application of the pooled resources of cooperative group member to solving problem which they could otherwise been unable to solve. According to Agabi [6], there are two kinds of cooperative societies which include the orthodox or primary cooperative societies or community-based. The second type is called departmental or secondary cooperatives, which operates in places of work [7]. 

The importance of community participation in health care delivery has been stressed increasingly in recent years as social development has gradually changed orientation from ‘top-bottom’ to ‘bottom-up’ approach. This change in approach focuses on collective action as a means of influence or control, which allows people to satisfy their needs and determine their own actions [7]. Despite recorded success of cooperative societies in attending particularly to member’s business concerns and as a source of burial funds, their resources have yet to be channelled to equally life-improving areas as health care. Researchers have also paid negligible attention to exploring the possibilities of incorporating cooperative societies into health financing mechanisms to ensure more access to health care. Limited literatures also exist that have examined or explored community- and work-based cooperative societies as a veritable source of Community Health Insurance Scheme (CHIS). It is on the basis of this that this study examined the role of cooperative societies in accessing health care services for its member in Ibadan, Nigeria. The following research question was postulated to guide the study:

• In what way is health insurance integrated into cooperative societies

Research Design

A descriptive cross-sectional survey was conducted among members and executives of cooperative societies registered and operational in Ibadan metropolis.

Study Area

Ibadan is the capital of Oyo State, Nigeria and the largest indigenous city in West Africa. Ibadan is located in the south-western part of the state in a hilly settlement with urban and rural sectors covering a total land area of 3,123km2. The Urban Ibadan and Rural Ibadan occupy 15% and 85% of the land mass, respectively. Ibadan municipality is divided into 11 LGAs which can be categorised into urban: Ibadan North, Ibadan North East, Ibadan North West, Ibadan South East, Ibadan South West and rural: (Less Cities or Suburbs): Akinyele, Egbeda, Ido, Lagelu, Ona-Ara, Oluyole. There are traders, civil servants and farmers who meet the food needs and other requirements of the urban population.

Population

The population for this study comprised of all members of cooperative societies in Ibadan metropolis.

Sample Size

A sample size of four hundred and eighty members (480) from different cooperative societies in Ibadan metropolis was included in the study.

Sampling Technique

Using a simple random sampling technique, two LGAs each from the rural and urban clusters were selected for this study, namely, Akinyele and Ido (rural), Ibadan North and Ibadan North West (urban). The selection of each cooperative member was based on availability. For the qualitative component, participants were selected using purposive sampling method on the basis of availability and consent.

Instrument

A self-administered semi-structured questionnaire was used to generate data on socio-demographic characteristics, proportion of cooperatives income spent on health care service and how activities of cooperative societies can be integrated into CHIS. 

Administration of Questionnaire

The KII was conducted with the members and executives of cooperative societies. The KIIs elicited information on the cooperative social organisation and their contributions to members’ health care as well as how activities of cooperative societies can be integrated into CHIS. The research instruments were translated into Yoruba language. Translation of the instrument was to ensure accuracy and consistency and also to ensure that participants were in no doubts whatsoever about what they were being asked during the interview. Ethical approval was obtained through University of Ibadan and University College Hospital and verbal consents were also obtained.

Data Analysis

Descriptive statistics were used at the univariate level while content analysis method using the NVivo 8 software was used to analyse the qualitative data.

The demographic information shows that only 5.8% of the population were aged 60 years and above indicating that the majority were in the active and productive age of their lives who are believed to be at the peak of their physical energy, mental awareness and psychological disposition. It was also observed that majority (60.8%) of the respondents were female and Christians (64.4%) while 34.2% were Muslims. The ‘never married single’ and the ‘ever married single’ represented (11.9%) and (0.6%), respectively, while those married made up 86.3%. Majority (95.4%) of the respondents were Yoruba with a relatively small proportion of Igbo (2.9%) and Hausa (1.7%). Only 2.9% of respondents had at most primary education; half had a post-secondary school education with 41.0% having secondary education. 

Many of the respondents were petty traders (29.6%); self-employed professionals and government workers accounted for 26.9% and 25.4% respectively. It should be noted that the unemployed in this category also benefitted from the huge impact of these cooperative societies and put them in line through the capital received from the system.

Table 1 shows that more than half (54.8%) of the respondents felt that their cooperative societies were not effective in providing support to meet the health needs of their members. This could be because the primary objective of a cooperative society is not heath care of members but business-related progress. 

Further, 30.8% of the respondents admitted that cooperative societies have budget for members’ health care, while majority (59.8%) of the respondents insisted there is no budget for health care. This implies that a considerable number of the respondents did not acknowledge that cooperative societies budget for members’ health care needs. This further corroborates the responses of the participants that majority (79.4%) of respondents are yet to benefit from cooperative grant for treatment of illness.

Generally, cooperative societies do not grant loans to members in pursuit of health care. Indeed, any member who is having serious health challenges may find it difficult to even access a business-related loan. The reason for this is the fear that poor health would make it impossible for repayment of the loan on time and the debtor who is in poor health may even die without paying the loan leaving the cooperative to bear the risk. However, in the spirit of friendship and group solidarity, the cooperative society usually provides a member in need of health care assistance in terms of a grant that is not to be repaid. Usually the amount for which the cooperative is willing to support the member is way too little compared to the actual health care costs. Individual members of a cooperative society can also decide to pool resources in support of their colleague with a health challenge for which they do not expect repayment. The cooperative societies are operated on the basis that members who obtain loans must repay them within a specified time. Anything (e.g. health issues) that may interfere with the prompt repayment of loans must be taken into consideration before a member applying for a loan can be granted.

Table 1: Frequency Distribution of Respondents According to Perceived Effectiveness of Cooperative Society in Members’ Health Care

Theme 3

Integration of Health Insurance into Cooperative Societies.

Mixed awareness and understanding of NHIS were elicited from respondents as majority (77.1%) of the respondents were aware of the scheme, which was established as one of the fundamental driving forces to tackle the problems of poor quality of health care, inequalities and limited access to health, inefficiencies in the service delivery, level of accountability as well as insufficient responsiveness to client needs. Many (21.5%) of the respondents knew nothing about NHIS and only 1.5%were not sure of the programme. This shows that not all respondents are fully aware of the importance of NHIS and even some that have heard about it, were not sure of its functions or benefits. This uncertainty can best be captured with the following excerpts from a KII with a union leader thus:

I only heard about it on the television but the scheme has never been introduced formally to us and we have not also gone to meet them. If they come, we will be willing to partner them (Male/KII/Union President/August 29, 2018).

Similarly, another interviewee supported the fact that there is superficial knowledge about the scheme in the following way:

I have heard about it as well as my cooperative members. But we have not been properly enlightened (Male/Past President/September/4/ 2018).

However, an interviewee puts it differently:

I have not heard about it at all. Even if they advertise it on the Radio, I do not pay attention to it (Female/President/KII/August 29, 2018).

It is clear from the interviewees’ comments that there is a major gap in the area of disseminating NHIS information to members in the cooperative societies. Among the study participants, NHIS has different meanings and this is attributable to the fact that there is no uniform conceptualization of CHIS to members of cooperative societies. About 30% (29.4%) believed that NHIS is a pool through which the government or organizations subsidize medical expenses of registered participants. Also, they see NHIS as a means of funding through which the medical cost of a patient is subsidized using the pre-determined percentage. For some respondents, NHIS means a hospital provided for patients who cannot afford the medical expenses (16.9%).

Factors that participants will considered before cooperative societies can be integrated into NHIS included a consideration of the benefits the health insurance scheme (54.2%) financial strength of the cooperative (27.3%) and (10.8%) knowledge members regarding the activities of health insurance scheme (10.8%). 

In addition, qualitative data revealed an element of fear and ignorance of benefit that may emanate from the scheme if integrated as captured in this excerpts:

There is nothing wrong if they want to integrate the NHIS with cooperative societies, but the question to be asked is – who will be running it – is it the government or the cooperative society? The reason is that the money we have is not even much and in the society, we buy money and sell money. We do not keep money in banks. We collect it, gather it and borrow the person in need with a little interest as a gain for the cooperative and with the agreement that they will pay back at a specific time. So, we do not have enough to run NHIS and we even expect from the government (Female/President of the Union/KII/August 29, 2018).

Motivation tops priority as the best factor been emphasized for integrating NHIS into the cooperative society. This is highlighted from comments that the financial strength and the benefits that will accrue to members emerged as the first consideration as this will contribute to business finance, social welfare and human development.

Also, most preferred agency indicated by the respondents for partnership with the cooperative societies was the government agencies (36.9%) and non-governmental agencies (6.5%). This was further corroborated with findings from the qualitative studies as excerpts indicate:

It is good if government can come in since it is a capital project which requires a lot of funds that should be handled by the government. The government can subsidize – say 60% for the government and 40% for the cooperative members. On that 40%, members should be rest assured on the benefit that they will get in return. If this is done, there will be no problem at all (Male/President of the Union/KII//August 29, 2018).

Some respondents (28.5%) maintained that the best way through which the cooperative societies can be partakers of NHIS is through encouragement while 13.3% believed that mandating all cooperatives to partake in health insurance scheme will be a better option. This latter option may be better because some members or cooperative societies may not want to be involved in the scheme. The above points were reinforced with responses from different KII:

I think it should be on the media so that people will be encouraged to do it. I personally heard about it on Radio, but it has not circulated well and that is why it should go round among members so that the benefit that they will gain will be clear to them (Male/KII/President of Societies/September 29, 2018).

A female participant also shared her view on how the scheme could be integrated thus:

I have heard about NHIS but it has not come to the cooperative society. This can be done by informing the members through lectures and seminars because if they are not properly informed, they will think of it as a plan to embezzle their money. So if they have heard about it through the media, lecture and seminars, they will be encouraged to participate fully in the scheme (Female president/KII/August 29/2018).

Numerous roles performed by cooperative societies are quite huge and functional. They are channelled towards helping their members in so many areas. Apart from meeting the needs of their members by contributing money to improving businesses, this is the primary aim of cooperative societies (for which they are labelled egbe alajeseku). In other words, according to Dogarawa [8], cooperatives societies offer a special advantage through which a competitive global economy can be achieved. Indeed, members of the cooperatives societies in this study believed that in providing assistance for members in business and other areas, their needs had been met. However, it was worrisome that despite this, the activities of the societies were not channelled towards providing health care opportunity for the members. The level of awareness about health care system by respondents was good. Although majority of the respondents had heard about the NHIS, obviously, only those who were employed in the public or corporate private sectors had partaken in the scheme; others only have information about it through the media, without proper enlightenment.

Members had a positive perception of the likelihood of integrating the health insurance scheme into cooperative societies. This shows the readiness on the part of members of cooperative societies to accept the integration, but resting the whole burden on the government. Of course, the government is expected to play a large part in financing the scheme and as the findings revealed, the enormous role of the government is required as partner in progress. This necessitated the fact that the scheme is a huge capital project, which can only be handled properly by the government to ensure smoothness, flawlessness and perfection in all ramifications. The establishment of health cooperative, which will manifest in the community health insurance scheme if managed by the government, will undeniably, regulate the uneven distribution of health services in the rural areas due to highly unequal income by the rural dwellers as put forward by Abdulraheem et al. [2]. It will also support the cooperation that will emerge as a result of the interaction between the government and the community and bring the government closer to the community with adequate health education that will be divulged to individuals.

Dogarawa [8], also corroborate this finding when he stated that cooperative societies are democratic groups ruled by policies and decisions set by members. Omobowale [9], also support this finding when he stated that the establishment of cooperative societies is predicated on trust, friendship and kinship, which explain the Yoruba social structural system and speak more of communal relationship and social survival rather than the survival of the fittest, a feature of capitalist orientation.

Despite the enormous effort of cooperative societies, the token set aside for taking care of the health of members was not encouraging and this could be attributed to the fact that adequate enlightenment on national health insurance scheme has not been received by the co-operators. There is a need for social workers working with various local government within Ibadan metropolis to organise enlightenment programms for cooperative societies’ members on the need to incorporate health components into their activities. At this time, even if the modalities for integrating health insurance into cooperative societies are still unclear, in the self-help and communal spirit in which cooperative societies are based, it is important to recognise the place of members’ health and accord it the necessary attention it deserves. The findings showed that the efforts of cooperative societies in catering for members’ health was not effective and there was no special budget set aside for members’ health care. What this means is that, all members’ contributions are aimed at economic investment such as landed properties with no contribution towards health. This can have serious implications for accessing healthcare because no matter how much savings one makes with the cooperative societies, since there is no provision for healthcare programm, whenever a member suffers a health problem, there may be inadequate or no funds to cover health costs. This testifies to the need for the introduction of community health insurance scheme, which is aimed at providing prompt and easy access to health care for members. 

Finally, findings revealed that the integration of health insurance into cooperative societies will bring about development in socio-economic, socio-cultural and socio-political arena. Integration will enhance growth in businesses, improved members’ standard of living and help to eradicate poverty among the people. Also, improvement in health care system will enhance easy access to care for the low-income earners who otherwise would be denied prompt and adequate care. It will also enhance better group relations, promotes communalism, solidarity, group cohesion and bring the government closer to the society. Theoretically, cooperative society activities, with reference to postulations of social action, are woven around the group members’ culture, rational and essentially goal-specific.

Going by the assertion that “health is wealth”, the study concludes that effectiveness of cooperative societies can be further utilized to improve health care of co-operators. Almost all the co-operators across occupations, differing levels of education, gender and age showed interest and expressed enthusiasm that integrating health insurance scheme into cooperative societies will be beneficial. However, they emphasised the need for widespread orientation of members from time to time in order to convince them of the potency and workability of the programme. It was equally stressed that unless government is prepared to subsidize greater percentage of the project, the integration might not be successful. This is justified on the basis of the known fact that primary target of cooperatives are not tailored around health.

Implications for Social Work Practice

• Community social workers as a matter of urgency should work in conjunction with cooperative societies and government on how to introduce the health scheme programme into the activities of cooperative societies

• They should also embark on educational programme to educate members who are not knowledgeable about the scheme so that they can have understanding of the benefits of the scheme

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3. Asuzu, M.C. “The necessity for a health system reform in Nigeria.” Journal of Community Medicine and Primary Health Care, vol. 16, no. 1, 2004, pp. 1–3.

4. World Health Organization. Equitable Access to Essential Medicines: A Framework for Collective Action. World Health Organization, 2004.

5. Mufutau, A. “Definition, evolution and ideological roots of cooperative societies and institutions.” 2012, www.kwasu.info/index.php.

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7. Jegede, A.S. African Culture and Health. Rev. and enl. ed., Bookwright Publishers, 2010.

8. Dogarawa, A.B. “The role of cooperative societies in economic development.” 2005, mpra.ub.uni-muenchen.de/23161/1/MPRA_paper_23161.pdf.

9. Omobowale, A.O. “Social capital and ajo system among working class traders in iBADAN, Nigeria.” WorkingUSA: The Journal of Labour and Society, vol. 6, 2011, pp. 333–346.