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 1 REVIEW ARTICLE Effective communication approaches as tool for achieving Universal Health Coverage through social health insurance in Nigeria. Salisu Hassan1, Jamila Aliyu Mohammed2 1Centre of Excellence for Development Communication Department of Theatre and Performing Arts Ahmadu Bello University Zaria Kaduna State Nigeria 2 Centre of Excellence for Development Communication Department of Theatre and Performing Arts Ahmadu Bello University Zaria Kaduna State Nigeria Corresponding author: Salisu Hassan; Address: Media and Public Relations Division, National Health Insurance Scheme Damaturu, Yobe State Nigeria; Email: Salisu2015.sh@gmail.com mailto:Salisu2015.sh@gmail.com 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 2 Abstract National Health Insurance Scheme (NHIS) designed various Social Health Insurance pro- grammes 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 involve- ment of communities in the programme were found to imbibe some practical communication principles that can help improve communications to a target audience. Keywords: NHIS, Social Health Insurance, Effective Communication Approaches, Universal Health Coverage 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 3 Introduction Increasing access to healthcare remains piv- otal to the improvement of healthcare and the attainment of Sustainable Development Goals (SDGs) in Nigeria. More importantly, the need to provide health services to vulner- able 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 So- cial Health Insurance. Health care coverage is adjudged to be an essential block of sus- tainable development, and it is a vital index for measuring the growth of a Nation. One of the important duties of government is to pro- vide the masses access to basic healthcare and protection from catastrophic health ex- penditures (1). However, financial con- straints often limit the ability of the govern- ment to provide healthcare for all using gov- ernment funding. Many responsible govern- ments 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 cov- erage to boost accessibility (2). Universal Health Coverage refers to a healthcare sys- tem in which all people who need health ser- vices can receive them without undue finan- cial hardship (3). Many authors have de- scribed social Health Insurance as ideal for quality, affordable and accessible healthcare for the masses (4,5). Because of these quali- ties, Social Health Insurance (SHI) is becom- ing a more popular option in providing healthcare, particularly in developing coun- tries where it is challenging to sustain the tax- based or out-of-pocket pay-based health fi- nancing options. Nigeria is one of the devel- oping countries that have embraced the Social Health Insurance Scheme. Nigeria christened her SHI designed to ensure Uni- versal Health Coverage. This study problem- atizes 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. Be- fore delving into the communication ap- proaches deployed by the NHIS, it is impera- tive to provide some core conceptual princi- ples of NHIS in Nigeria to its citizenry, par- ticularly the less privileged. Social Health In- surance 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 bor- rowing above her means to finance humong- ous healthcare needs. National Health Insurance Scheme in Per- spective 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 man- date to promote, regulate and administer the effective implementation of Social Health In- surance programme to ensure easy access to quality and affordable health services to all Nigerians. The NHIS has a presidential man- date for achieving Universal Health Cover- age. This is to be achieved through various programmes designed to target different so- cial-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 So- cial Health Insurance to the informal sector (Comprising over 75% of the total Nigerian Population). To give mobility to its term of 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 4 reference, the NHIS, over the years, has de- veloped 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 communica- tion strategy employed by the scheme. NHIS focuses more on conventional media in its communication (8). The level of active com- munity involvement in the various pro- grammes 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 bene- fits of the schemes (9). Specifically, authors have identified that ineffective communica- tion is one of the impediments to the success of health insurance more significantly, the In- formal Sector. (9,10). Reasons for non-pat- ronage of Social Health Insurance Pro- grammes have also been tied to ignorance of their processes, operations, and benefits at- tached to participation (11). Hence, there is the need to adopt effective communication approaches that would help increase enroll- ment rate into the NHIS programmes and en- gender active community involvement to en- able the Scheme to attain its mandate for achieving Universal Health Coverage. Methods The study has employed an integrative litera- ture review method to appraise the various is- sues in the study. Both online and offline lit- erature were reviewed, critiqued, and synthe- sized. 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 re- view by using descriptive statis- tics. Results Principles of Effective Health Communica- tion Towards ensuring that health communica- tions are effective, the WHO(2017)devel- oped six principles to guide health communi- cators. The principles demand that health communications are accessible, actionable, credible (trusted), relevant, timely, and un- derstandable (12). In Nigeria, these principles have mostly found relevance in the formal sector. At the rural and, in some cases, peri- urban 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 in- formation on the scheme's modus operandi, thereby stifling possible interest in the 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 5 scheme. Therefore, there is a gap in commu- nication about the scheme. Authors have blamed the communication gap on the acces- sibility of media through which information about the health insurance schemes is dis- seminated. Social Health Insurance is often communicated through the mainstream me- dia 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 use- ful information about the programme. Tele- vision as the only medium of information dis- semination 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 conven- tional media is that its feedback mechanism is neither non-existent nor not pulsating enough to propel the critical population to ac- tion. The goal of the NHIS messages on radio or television is basically to inform, not to share. This is problematic because the aware- ness does not translate to action. The WHO (2017) recommended that communicators identify all available channels and map their capacities to reach priority audiences. The or- ganization advises that communicators use the right mix of media to help empower audi- ences with the information they need to make informed decisions. Using the right mix of media tends to improve accessibility to infor- mation about Social Health Insurance (12). WHO's recommendation is instructive in that communication should involve both conven- tional and unconventional communication tools to facilitate participatory change. Em- powerment comes through active participa- tion. From active participation, the target au- dience learns and makes an informed deci- sion to impact or change their lives. So far, the NHIS has not used or exhausted indige- nous media in communicating its key mes- sages. 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 com- munication principles list. Actionable com- munication is communication designed to in- crease audience engagement and motivation to take action (13). To be successful, commu- nicators must understand the target audi- ence'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 cogni- zance of their culture (14). This aspect of the core principle is crucial. Where there are cul- tural 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 people- centric and direct engagement with commu- nities 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 com- munities and for the target population to bring about sustainable health practice. An- other principle of effective communication is credibility. For instance, Contributory Health Insurance Programme, as the name indicates, requires participatory funding from the audi- ence. For them to be committed to contrib- uting 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 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 6 transparent in their dealings with the audi- ence. 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 guid- ance as applicable to them, their families, or others they care about. Relevant communica- tions are essential towards the personaliza- tion 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 recom- mends knowing the background of the audi- ence and their concerns, attitudes, and behav- ior. Apart from the need for communication to be accessible, actionable, credible, and rel- evant, 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 com- munication becomes useless, leading to re- source wastage. Communications have to be delivered timely so that the audience can have enough time to evaluate and or assimi- late inherent information and decide to act on it. Finally, health communication also needs to be understandable. Making communica- tions understandable is particularly important given that target audiences are people who may not individually afford to finance their healthcare needs. Most of these people be- long to the vulnerable group who are educa- tionally disadvantaged. Hassan and Adie(2018) stated that the imperativeness of health insurance, primarily for vulnerable groups, may not be appreciated without con- sidering the state of human capital develop- ment in the country. Table 1: NHIS application of the principle of effective Health Communication Principle of Health Communi- cation Literature consulted Frequency percentage Accessible 10 Yes No 6 5 54.54 45.45 Actionable 11 Yes No 6 5 54.54 45.45 Credible 11 Yes No 7 4 63.63 36.36 Relevant 11 Yes No 8 3 72.72 27.27 Timely 11 Yes No 6 5 54.54 45.45 Understandable 11 Yes No 7 4 63.63 36.36 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 7 Given that human capital development (edu- cation) is low, particularly in Northern Nige- ria, technical jargon that impedes understand- ing needs to be avoided, or better, translated into memorable indigenous jargon that the people can relate to. Technical terms in com- munication need to be simplified and pre- sented clearly. Anything that can serve as noise should be preconceived, identified, and avoided (11). When the audience fails to un- derstand communication, counterproductive misinformation can occur (15). Having ap- praised 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 rec- ommend a better option. Communication approaches of the National Health Insurance Scheme Many studies have established that the com- munication approaches of NHIS and by ex- tension, 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 pro- gramme's overall success. Hassan (2010) re- ported that the NHIS communication ap- proaches had been mainly either proactive or reactive since inception. NHIS communica- tions have been less interactive (17). Accord- ing to Joseph & Chukwuemeka (2016), pro- active communication allows an organisation to seize control of the public relations mes- sages presented to the public (14). It enables communicators to preempt response through careful evaluation (18). Reactive public rela- tions or communication is usually impromptu and can be less thoughtful and compelling. According to Hassan (2010), reactive com- munication stems from anger, fear, resent- ment, and uncertainty(17). This type of com- munication can be counterproductive, caus- ing new problems while trying to solve exist- ing ones(19). Of the three communication ap- proaches, the interactive is considered more appropriate in disseminating information about health insurance schemes (19,20). In- teractive communication involves engaging the stakeholders through various interactive methods such as Participatory Learning and Action (PLA) tools, workshops, and story- telling. The predominant use of either proac- tive 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 dis- seminate information about the programme. Table 2: Shows the nature of the use of the three communication approaches by NHIS. Communica- tion Ap- proaches Consulted literature Frequency Percentage Proactive 13 Yes No 8 5 61.53 38.46 Reactive 13 Yes No 7 6 53.84 Interactive 13 Yes No 6 7 46.15 53.84 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 Considerations of Alternative Communica- tion Model for NHIS To make NHIS messages interactive, there is a need to consider applied interactional meth- odologies. Baezconde-Garbanati et al.(2014) recommended using various media combina- tions 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 Has- san 2019) commented that: Fusion between local indigenous media and the mainstream media would be in no small measure contrib- uted 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 agglu- tination or convergence of ideas, principles, and approaches to produce a common goal. Hence, interactive tools such as live or play- back theatre can be viable instruments across disciplines. Medical or scientific interven- tions can be re-enacted or performed for easy comprehension. For example, as seen in Ah- madu Bello University, the department of community medicine can partner with the theatre and performing arts department to or- ganize medical community outreaches where all the intended health messages are commu- nicated using the performing arts. Those mentioned above can provide avenues to sen- sitize 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 Communi- cation (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 materi- als carry messages easily understood, re- membered, and retained for future use. This aligns with the 'understandable' and 'actiona- ble' principles of effective communication highlighted by the WHO (2017). 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. Tradi- tional 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 mo- bilization is the theatre. Many empirical case studies and workshops, such as the Samaru Project and the Community Theatre engage- ments of the Department of Theatre and Per- fuming Arts of Ahmadu Bello University Za- ria, have achieved many results (Hassan, 2019). One way theatre has succeeded as a tool for social mobilization and communica- tion 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 drama- tized and acted before the local audience. The 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 9 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 de- partment, 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 Chan- nels was below average compared to the other channels of communication, such as ra- dio, television, newspapers, etc. Though so- cial media falls within the scope of the new media and targets elites, it can improve 'ac- cessibility' to information about the SHI, par- ticularly among the educated youths who are internet-inclined. Hence there is a need for more utilization of social media such as YouTube, Facebook, Instagram, etc., to reach more people, particularly those that are infor- mation 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 mu- sic can be potent. More, urban legends or ce- lebrities 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 Commu- nication 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, lo- cally-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 com- municating the various NHIS Programmes Using appropriate language plays a vital role in reaching the enrollees. Inegbedion (2015) indicates that English was the dominant lan- guage 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, espe- cially those in rural areas. Jegede (2010) ad- vocated for using local languages to enable the development partners to implement their programmes (23) fully. According to Ade- wole and Osungbade (2016), using a multi- lingual approach can rapidly facilitate the NHIS program's implementation. Emphasis on Behavior Change Communi- cation BCC is a research-based consultative process of addressing knowledge, attitude, and prac- tice by identifying, analyzing, and segment- ing audience and participants in programmes (24). NHIS should emphasize communica- tion that would change the negative percep- tion and misunderstanding of people about health insurance. 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 10 Table 3: Further confirmation of the level of effectiveness of the highlighted communica- tion approaches above that can be used towards achieving Universal Health Coverage through Social Health Insurance. Communication approaches Literature consulted Frequency Percentage media Integration 15 Yes No 14 1 93.33 6.66 Continues social mobilization 13 Yes No 11 2 84.61 18.16 Utilization of social media 11 Yes No 9 3 81.81 27.27 Demonstration of ICTs 10 Yes No 8 2 80 20 Multi-lingual Approach 8 Yes No 7 1 87.50 12.50 Emphasis on behavior change com- munication 14 Yes No 12 2 85.71 14.28 Active Community Involvement 13 Yes No 12 1 92.30 7.69 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 fol- lows the findings of Ihidero and Hassan (2019), which observes that true empower- ment comes when community people ac- tively participate in their own development affairs. NHIS as a development-oriented scheme should, therefore, be able to ade- quately involve the communities in its vari- ous activities to enable it communicated its various programmes to target enrollees (25, 16, 2). Discussion In its effort to communicate its various pro- grammes to achieve Universal Health Cover- age, we found that National Health Insurance Scheme has applied the six principles of ef- fective health communication given by WHO (2017) to some degree. Table 1 further con- firmed how the health communication princi- ples 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 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 11 54.54% of the literatures 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 "Rele- vance". However, 54.54% of the NHIS com- munication to the audience has confirmed" Timely" and 63.63% confirmed the principle of "Understandable". Evidence from this study established that the National Health In- surance 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 con- sulted approved that NHIS has been applying a proactive approach in communicating its various programmes and activities. Also, 53.84% of the consulted literature and rec- ords show that the NHIS communication ap- proach 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 be- tween mass media, inter-personal and folk media would be a viable option for sharing health 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. How- ever, it was also observed that continuous so- cial mobilization as a communication ap- proach would create awareness and enhance the knowledge of the Health Insurance enrol- lees. About 84.61% of the literature con- sulted showed that continuous social mobili- zation would facilitate the awareness and knowledge creation of health insurance cus- tomers in such a way that they would be able to take positive action toward the pro- gramme. This study also found that effective utiliza- tion of social media would provide access to information to the social health insurance en- rollees in Nigeria. About 81.61% of the sources confirm that if social media is effec- tively utilized for communicating health in- surance, there is a more favorable result. Moreover, it was observed that the domesti- cation 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 communi- cation materials and programmes of the Na- tional Health Insurance Scheme are in the English language, neglecting the other indig- enous 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. Re- ports in this study have shown that people have different cultural and religious percep- tions of social health insurance. Because of these different perceptions and attitudes, there is the need of more emphasis on behav- iour change communication by the NHIS. About 85.71% of the literature consulted has provide the need for a National Health Insur- ance scheme to focus more on behavioral change communication to change the nega- tive perception of people towards the scheme's programmes and activities. Lastly, it was observed that active involvement of the 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 12 indigenous communities during the planning and the implementation of the NHIS pro- grammes and activities would encourage ownership and sustainability. About 92.3% of the literature consulted have shown the need for active community involvement to ensure adequate coverage of social Health In- surance in rural areas. Without active com- munity involvement achieving Universal Health Coverage through health insurance would be very difficult. Conclusion NHIS has designed various Social Health In- surance 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 un- derstand the operational guidelines due to the excessive conventionalization of its commu- nication tools and channels. To find an effec- tive communication approach that can help improve awareness and participation, this study reviewed relevant literature and sug- gested alternative communication tools that can help the NHIS achieve its mandate. A re- view of principles underlying effective com- munication was done, and communication approaches with qualities that can help im- prove Social Health Insurance were identi- fied. Media integration, advocacy campaign, the use of social media, domestication of ICTs, communication in multiple languages, emphasis on behaviour change communica- tion and active community involvement were found to imbibe some of the effective com- munication principles and are therefore rec- ommended towards effective communication that would facilitate the Universal Health Coverage in Nigeria. Importantly, there is a need for more empiri- cal studies on NHIS that draws from or uses multi-disciplinary analytic approaches. Cur- rent 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 stud- ies 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. Acknowledgments First and foremost, my gratitude goes to the WHO Regional Office for Africa the organ- izer of Hideyo Noguchi African Prize for sponsoring this work. I am also using this me- dium to appreciate Dr. Dorcas Kamuya of KEMRI Welcome Trust, Kenya for her won- derful mentorship throughout this work . I am very grateful to Dr. Jamila Aliyu Mohammed of Centre of Excellence for Development Communication, ABU Zaria Nigeria, for as- sisting me with some of the literatures as well as helping me in editing this work to ensure it's better shape. Last but not the least I am very grateful to Mr. Victor Osae IHIEDERO of the Department of Theatre and Performing Arts, ABU Zaria for his advice to ensure the success of this work. Hassan S, Mohanned JA. 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