Table 3 represents sociodemographic characteristics of study participants in Kampala. Sixty-two (62) participants were enrolled into the study. Of these, 42 (68%) were females. The median age of participants was 30 years. All participants had attained advanced training with the Diploma level being reached by the majority 25 (40%). Health workers 21 (34%) were the most interviewed.
Table 3. Participant characteristics of FGDs and KIIs
Socio-Demographic Characteristic
|
Number
|
Sex
|
Males
|
20
|
Females
|
42
|
Age (Median=30)
|
21-30
|
29
|
31-40
|
20
|
41-50
|
8
|
Above 51
|
5
|
Education status (Tertiary/advanced)
|
Diploma level training
|
25
|
Undergraduate training
|
19
|
Post Graduate training
|
18
|
Employment role of participants
|
Health workers (4 FGDs)
|
21
|
Finance & Administration (6)
|
29
|
Procurement & Logistics
|
12
|
Participant category
|
Insurance organizations (KI’s)
|
4
|
Health Care Providers (KI’s: -3HMOs, 2 non-HMOs)
|
5
|
Insured clients (FGDs)
|
53
|
The expectations of health care services across actors as expressed by the client, insurer, and provider under the health Insurance arrangement were inter relational. Table 4. Detailed findings on bilateral expectations from each set of actor-based dyadic interactions; the client- insurer, client-provider, and provider-insurance relationships are summarized under three research sections: 1. Expectations within the client-insurer relationship. 2. Expectations within the client-insurer relationship and 3. Expectations within the insurer-provider relationship as shown below.
Table 4. Summary of key findings across the three actor relationships
Interpretation guidance of the matrix-Table 4
Views about actor expectations in columns are interpreted across their corresponding actor responses in rows. Examples are provided below:
Example 1. Client expectations of the insurer: Initially, the clients expected a comprehensive orientation about their service benefit packages from the insurer. However, instead of receiving clear explanations, they were provided with inadequate policy orientations that were characterized by unclear benefit packages. The clients also realized that insurers delayed paying providers, which affected their access to services.
Example 2. Providers’ expectations of the clients: Providers initially expected clients to have adequate knowledge about their benefit service packages. However, they later discovered that most clients did not know the range of services that they were entitled to receive. As a result, providers reported that clients were making unrealistic demands for services they were not eligible to receive. Additionally, clients' unrealistic sense of entitlement led to their poor attitude towards correction, especially when they made irrational suggestions, such as offering services outside their coverage.
Example 3: Insurers’ expectations of the clients: Insurers reported orienting some clients, specifically the principal policy holders, about their insurance policies. These clients were then expected to re-orient their other beneficiaries on the service packages. However, it was later reported that this re-orientation was not generally done by the principal policy holders. Additionally, it was reported that clients did not use feedback platforms provided by the insurers to share necessary information concerning their experiences with service consumption.
Expectations within the client-insurer relationship
Respondents were critical on issues of service eligibility, payment timeliness and feedback mechanisms. Clients received inadequate orientation on their insurance policies resulting into their seeking of health care under unclear benefit packages. Delayed payments to the provider facility by the insurer was also reported by clients.
Service eligibility - “Shallow policy orientation” and “Unclear benefit packages”
Insurers should orient clients before signing up for their specific service packages. The type, volume, and the mode of delivery inform the clients’ expectations from the provider. In this study, clients sought care under unclear service benefit packages. One of the clients whose knowledge on his insurance policy and benefit package were not clear was quoted saying,
“…they say, insurance? Ohh!! the insurance is covering this much, for you, you will pay this much. So probably, there are certain things that the insurance does not cover and that was not made very clear.” FGD 3-Finance & Administration
Timeliness of payment- “Delayed facility payments"
Payment is a function undertaken by insurers in compensating providers for the volume of services that clients (patients) consume for a specified period. Effecting timely payments in line with initial contract negotiations support uninterrupted service delivery to meeting client expectations. Clients reported delayed provider payments which influenced the provider’s motivation to provide services to insured clients. Clients reported that providers were instead prioritizing and attending to cash patients. One client complained about non-payment of hospital by the insurers saying that;
“…but also, the case of non-payment…, these insurance companies do not pay the hospitals, so those hospitals are not motivated enough to work on clients. …some get blunt and tell you that those ones (their insurer) don’t pay, so you kweyiya (find alternative ways to pay for your care) somehow.” FGD 1-Health workers
Another participant commented on the provider preference to cash patients instead of insured clients saying;
“If the insurance doesn’t pay promptly, I don’t know what to use. Then also the facility, they are happy in receiving cash. There are some people coming with cash but for you, with your promises, they will not give you the same attention. They will see you as a burden” KII-Procurement & Logistics officer.
Feedback mechanisms- “Inadequate feedback”
Providing feedback to insured clients on service delivery and its use is key to improving service quality. Since Insurers negotiate service provision on behalf of clients with the provider, their periodic feedback is very important for accountability as It builds confidence in the service delivery processes. In this study, the Insurer’s inability to provide adequate feedback to Insured clients on service consumption was strongly expressed. Some clients incurred unexpected expenses in purchasing services from the provider and expressed concerns with the untimely feedback.
“…no one warns me that you are exceeding your (service consumption) limits…you pay more money from your salary. …feedback is that it is not timely hence it’s not helpful”. FGD 3-Health workers
Another participant said that,
“…they also wait on someone to give feedback, which takes very long”. FGD 5-Finance & Administration
Expectations within the client-insurer relationship
Participants majorly pointed to issues on waiting time, prompt attention and soundness of facilities under this section. Whereas clients were very pleased with clean care environments at most provider facilities, they also expressed dissatisfaction with long waiting time. On the other hand, a few clients observed respectful care and attention (prompt care) from the provider.
Waiting time- “long waiting time”
The mode of service delivery at service points necessitate that clients are attended to at intervals. Client volumes and procedural processes influence the time between arrival and receipt of services. Insured clients may rate this either fulfilling or not. Proximate waiting time is considered as a good indicator of quality services.
In this study, the average waiting time for clients was four to five hours (4-5hrs). They reported high client volumes in facilities which caused congestion and long approval processes. Additionally, those who had emergencies opted to pay cash in avoidance of delays. Where a client was socially well known “connected”, it then earned him or her an easier way of being attended to faster than they expected. A client commented about high number of clients saying,
“… there was congestion, because all kinds of patients come in from all different kinds of insurers. So, the waiting time was longer than what I expected. I waited for almost three hours…” FGD 6-Finance & Administration
Another participant complained about lengthy approval processes which prompted cash payments in emergencies saying,
“...where it is most horrible is at the approval process, … you wait for three hours and then you are like no, they tell you, just wait, just wait!...here, you kill a day. Be ready to kill a day when you come. But even when you go there and you have an emergency, approval takes almost three to four hours. So, for someone who has an emergency, they will have to pay cash.” FGD 6-Finance & Administration
A client also commented on being socially well known “having connections” as a precursor for timely access to insurance service saying that,
“…if you don’t have connections, they take long to work on you which becomes a problem.” FGD 4-Health workers
Very few respondents expressed a satisfactory opinion about their waiting time. This was minimal to the extent that they felt that no time was wasted. One participant said,
“I remember, the reception was better. They are too quick. They don’t waste time …” FGD 2-Health workers.
Prompt attention- “prompt care received by a few”
Friendly handling and adequate involvement of clients in service delivery processes contribute to service quality. Psychologically, the client is positively inclined to receive quality health services to the best of his or her expectations. In this study, clients mentioned that some healthcare providers’ staff acted and behaved in a manner that was unfriendly. Poor attitude and impoliteness of health workers was mentioned. A few providers commented on the over exaggerated social status attitude among clients. A client commented about the poor health worker attitude saying,
“The attitude issues! …So, every time I called that same person, he began to get tired. I could feel he is tired. So, they even give you someone else to take care of you, you begin to feel very small. Attitude!” FGD 1-Health workers.
Impolite handling of clients was also emphasized by some providers. The reported poor attitude among health workers was a result of clients’ misunderstanding of service processes amidst competing activities. One of the healthcare providers commented saying,
“I realize that most of the insured clients view themselves as cooperate.…they require that kind of service that is high class, that is timely and prompt and probably like everything should be put on hold when they are here” KII-Health care provider Liaison officer.
However, a few participants reported that they were respectfully handled. Health workers were very friendly and guided clients to different service stations. Waiting clients were approached and asked if they had received the services. One satisfied client was quoted saying,
“The attention for me; it was okay, the health workers were friendly like from [deidentified] hospital. l was able to be directed very well and there was a lot of friendliness….” FGD 3-Health workers
One participant commented about customer care received saying,
“…they have like ushers, so they are always moving around so when they see that you have been siting for a long time they come and ask; have you been attended to?….” FGD 3-Health workers.
Soundness of facilities- “clean facilities”
Clients achieve better health outcomes if care is dispensed in a conducive environment. Clean amenities, adequate space and ventilation provide good aesthetics. These contribe to healing, psychological wellbeing and infection prevention and control. A conducive care environment was reported for almost all the health care provider facilities. Clients reportedhigh-level maintenance of cleanliness at facilities. One client said that,
“…this place is just sufficient and clean, and everything is in order.”FGD 4-Finance and Administration.
Another client commented about regular and timely cleanliness saying,
“…these private facilities are putting in some effort to ensure cleanliness of the facilities. For example, one time a patient vomited, and she was trying to clean up…. like every 10 minutes someone is passing through.” FGD 6-Finance and Administration
Expectations within the insurer-provider relationship
Service eligibility, periodic assessments and payment mechanisms were key themes under this section. Almost all provider respondents mentioned that clear payment timeliness were agreed upon between the insurer and provider. However, insurers did not adequately orient their clients on insurance policies. Lastly, while the insurer dedicated some focal point staff to support periodic assessments in few facilities, they lacked in other facilities thus selective periodic assessment.
Service eligibility issues- “less orientation on the policy”, “unclear benefit packages”
Orienting clients on the expected service benefit packages from the provider should be a function of the insurer at the time of policy purchase by clients. The insurer shares details of services the client is legitimately entitled to while at the provider facility. Deviations from this, become grounds for service misuse and unmet expectations. In this study, providers reported that they suffered the burden of explaining to clients their service eligibility which is a function of insurers. Where some attempts were made, the insurer only provided generic service information. This was less helpful to the client at the point of seeking care thus exaggerating client’s unrealistic demands.
“There is someone who told me that the insurance had told them that they can see any private doctor they want. They can take as much drugs as they want. And they can treat their family. So, for them, they thought they can come and take any drug of which insurance limits some drugs…. So, it also goes back to the kind of orientation they were given when they were signing them up. Some of them are told unrealistic things” KII-Health Care Provider Liaison officer.
Periodic assessments- “selective periodic assessment”
Conducting periodic monitoring of service delivery systems informs deviation from or conformity to set service delivery processes. Identified gaps inform remedial actions by the responsible insurance actor. Such may include improvement, payment of fines, suspension of services or complete withdraw of contracted services. In this case, this study reveals that performance assessments were selectively done. Deployment of focal point persons at provider facilities was only done in a few facilities. Where insurer focal persons were completely lacking, clients were denied services since they could not be assisted in responding to their inquiries. In this way, clients perceived that the insurer had sold to them unrealistic insurance plans.
“…we also went further to put in some places our representatives to see how the whole process is going, may be on standby to see how you treat customers with insurance something of the sort [periodic assessment]” KII-Insurer liaison officer
“…So, if they[clients] are entitled to that benefit and they bounce them, then it makes me(insurer) feel like I made an empty promise to them…So the client looks like you (Insurer) sold to them something that was not realistic”. KI-Insurer liaison officer
Payment mechanisms- “delayed facility payments”
Provider payments contribute to a revenue base whose resources are used to either maintain or improve quality service delivery. Continuity of client assurance in accessing improved quality service is dependent on the insurer’s ability to make payments on agreed timelines. Any deviation from this may lead to compromised quality of service delivery.
Clients earlier mentioned that insurers delayed making payments to the providers. Similarly, insurers expressed disappointment that most providers misunderstood how the health insurance model worked. This was ground for preference of cash clients to insured clients thus negating equitable service provision. The strong inclination of Uganda’s economy to cash transactions as compared to insurance models was mentioned as a key influencer of this providers’ behavior where cash patients are preferred to Insured clients.
“Medical providers out there are improving their services but obviously they seem not to understand the medical insurance because Uganda being a cash economy those things of serving a client and you wait for payments do not make a lot of sense for them businesswise …” KII-Insurer liaison officer.
The Insurer’s inability to provide feedback to providers was also an area of concern. For example, until a suspension threat of the insurers services was made by the providers, the insurer was still relaxed to attend to the critical issues which had temporarily halted clients’ services.
“…it took like two years. Then I wrote, Dr, we are going to suspend the service… that’s when they responded. That’s when they remembered to give me the contact of the new Dr. to resolve the issue” KII-Health care provider Liaison officer.