Results Overview
Socio-demographic Characteristics of Respondents:
The study analyzed demographic data of NHIS enrollees (Table 1), revealing a mean age of 41.65 ± 6.2 years, an age range of 21 – 65 years, with most aged 34 - 44 and with 225 participants or 60.11 % earning between 51,000 - 100,000 naira. The majority were female (53.46 %), married (81.12 %), tertiary educated (58.78 %), civil servants (64.63 %), and had access to health (82.71 %).
Table 1: Demographic characteristics of the NHIS enrolees (N = 376)
Demographic characteristics
|
Participants (n = 376)
|
%
|
Age (years)
|
|
|
15-24
|
35
|
09.31
|
25-34
|
83
|
22.07
|
35-44
|
97*
|
25.80*
|
45-54
|
89
|
23.67
|
≥55
|
72
|
19.15
|
Total
|
376
|
100
|
Gender
|
|
|
Male
|
175
|
46.54
|
Female
|
201*
|
53.46*
|
Total
|
376
|
100
|
Marital Status
|
|
|
Single
|
50
|
13.30
|
Married
|
305*
|
81.12*
|
Widowed/Separated/Divorced
|
21
|
5.59
|
Total
|
376
|
100
|
Highest Level of Education
|
|
|
Primary
|
31
|
8.24
|
Secondary
|
124
|
32.98
|
Tertiary
|
221*
|
58.78*
|
Total
|
376
|
100
|
Employment status
|
|
|
Civil servants
|
243 *
|
64.63*
|
Self-employed
|
124
|
32.98
|
Unemployed
|
09
|
02.40
|
Total
|
376
|
100
|
Average Monthly Income (N)
|
|
|
<50,000
|
107
|
28.46
|
51,000-100,000
|
119
|
31.65*
|
101,000-150,000
|
66
|
17.55
|
151,000-200,000
|
57
|
15.16
|
201,000-250,000
|
21
|
5.59
|
>250,000
|
6
|
2.00
|
Total
|
376
|
100
|
Access to healthcare
|
|
|
Yes
|
311
|
82.71*
|
No
|
65
|
17.29
|
Total
|
376
|
100
|
Socio-demographic Characteristics of Respondents in qualitative study:
Twenty (20) NHIS enrolees were selected for the in-depth interview, with a broad range of characteristics including gender (10 males and 10 females), socio-economic status (average monthly income of N50,000 – N100,000 only), mean age of 45.25 ± 21.50 years, age range of 21 – 65 years, and duration of NHIS enrolment of 5 – 11 years. Half of them were married, mostly tertiary educated and all of them had full access to healthcare. The interview lasted between 33 - 86 minutes.
Table 2: NHIS enrolees’ level of satisfaction with the quality of healthcare services
Level of Satisfaction
|
Participants (n=376)
|
%
|
95% CI
|
Strongly satisfied
|
22
|
5.9%
|
|
Satisfied
|
210*
|
55.9%
|
|
Unsatisfied
|
134
|
35.6%
|
|
Strongly Unsatisfied
|
10
|
2.7%
|
|
Total
|
376
|
100%
|
|
Enrolees level of satisfaction:
The majority of enrolees were satisfied with the quality of care received at the hospital, with 232 (61.7 %) being either satisfied or strongly satisfied, while only 144 (38.3 %) were unsatisfied (Table 2). The satisfaction rate (232/376, 61.70 %) was significantly higher (Z = 6.42; p = <.0002 two-tailed; 95 % CI= 0.16 – 0.30) than the dissatisfaction rate. This is validated by qualitative data which provided further information regarding the factors associated with enrolees’ satisfaction as reported below:
The qualitative study showed that the majority of the NHIS enrolees were satisfied with the quality of care received for reasons that included: satisfactory recovery from their illness after treatment, assurance of receiving unadulterated drugs, easy accessibility to healthcare services, and a significant reduction in healthcare expenditure. The details are provided below:
Recovery rate:
Most enrolees were satisfied that they experienced a quick recovery after treatment. One of them stated:
“I am satisfied because….. I am making a quick recovery after receiving my treatment …much more than I expected.” (Female, 34 years old)
Drug quality and effectiveness:
Enrolees were satisfied with the assurance that government-owned institutions would not dispense fake and adulterated medicinal products, and they perceived the drugs to be effective.
“The quality of care (received under the NHIS) is better than patent chemists because I am sure it came from the government hospital who will not give us fake drugs…..I don’t think they will ever give you a fake drug here….The drugs I got here worked for me, so I am very happy about it.” (Male, 19 years old).
Accessibility to specialists:
Enrolees were satisfied with the convenience of accessing diverse healthcare experts in one location, enabling easy coordination of all components of the needed healthcare services.
“I am satisfied because experts in the treatment of different diseases are here in one location. I came to see my physician for high blood pressure but he observed some rashes on my skin and promptly referred me to the skin (dermatology) clinic which is also within the hospital. I didn’t have to pay for transport to get to another location to see the skin Doctor (dermatologist)” (Female, 47 years old).
Cost of Care:
Enrolees were satisfied with the much lower health expenditure under the NHIS compared to not having it.
“I am satisfied that the cost of healthcare is affordable for me as NHIS pays the greater part of our bills while I only pay 10 % of the cost of treatment.” (Male, 37 years old).
".,. there has been a tremendous reduction in our expenses on drugs and hospital bills since we joined NHIS. I only pay 8 - 15 % of my monthly salary on hospital bills.... of which I earn about N 93,000 a month. It gives me breathing space as I spend less of my monthly income on healthcare issues…. With more money in my pocket, I can better cope with other financial challenges of daily living." (Male, 39 years old)
Unsatisfied enrolees:
Table 1 revealed that 144 (38.3 %) of NHIS enrolees were dissatisfied with the quality of healthcare they received. The reasons for their dissatisfaction were revealed in the qualitative study and included: drug stock-out, poor drug quality, poor accessibility, arduous bureaucracy, poor Information quality and technical performance (poor attitude of nurses). The details are provided below:
i. Drug stock-out and out-of-pocket expenditure:
Most enrolees expressed concerns about the drug stock-out at the hospital pharmacy or the non-inclusion of prescribed drugs on the NHIS-approved drug list. Some of the enrolees explained further:
“I am not satisfied because most of the drugs I needed for the management of my ailment are not available under the NHIS while others that are listed on the NHIS approved drug list were not stocked at the hospital pharmacy.” (Male, 43 years old).
“The hospital pharmacy only stocks the cheap drugs but not the more expensive drugs on the NHIS approved drug list…what is the gain of enrolling into the NHIS if the hospital pharmacy hardly stocks prescribed drugs …...Under the NHIS, what you see is what you get.” (Female, 44 years old)
ii. Poor drug quality and availability:
Poor drug quality was cited by enrolees as a primary cause of dissatisfaction with the standard of care provided at NHIS service clinics.
"I am not satisfied with the drug quality. Some of the drugs look like small “Akara balls” (bean cake) and a few of them smell off. I do not know where they get these drugs from. It is different from the drugs I get from private hospitals or private pharmacy stores which work better and faster for me." (Male, 58 years old).
“Though they (NHIS service clinics) will never give you the wrong medication, most of the costly and high-quality drugs are either unavailable at the pharmacy or are not included in the NHIS-approved drug list. I am not satisfied with the quality of drugs I receive for my treatment.” (Male, 43, years old)
iii. Accessibility (difficulty in accessing hospital services) and out-of-pocket expenses:
Enrolees were dissatisfied with difficulty in accessing certain diagnostic services in the hospital.
“I have been referred severally to private facilities to do my diagnostic examinations at higher costs….including some laboratory investigations, x-ray (radiological investigations) …because it is either we are told that the hospital exhausted their test kits or the equipment for the examination were unavailable or in disrepair or there is no electricity power supply.” (Female, 48 years old).
” Often, I have done laboratory and radiological investigations in private facilities at higher costs...because they (NHIS clinic) gave flimsy excuses for not providing the needed services….It was either they ran out of consumables or there was no electricity to power the equipment…, Though, this does not happen all the time more often than not, it was either one long story or the other.” (Male, 63 years old)
Bureaucracy (ardours registration procedures):
NHIS enrolees voiced displeasure with the arduous bureaucracy when obtaining codes for clinical treatments and diagnostic tests from the HMOs. One of them stated:
“It seems as if we (NHIS enrolees) are being maltreated because the procedure required to register and generate a code for treatment on each hospital visit is so tasking and discouraging. I do not know how long I can put up with it” (Male, 28 years old)
“I am unsatisfied that we (NHIS enrolees) are the first to come to the hospital in the morning, but the last to leave in the evening because of unnecessary delays in generating the treatment codes unlike those who are not enrolled on the NHIS. I do not know why they can’t find an efficient way of generating the codes.” (Female, 61 years old)
“I am not satisfied that half a day and more is spent generating codes to access treatment under NHIS. By the time I finally get to the clinic to see the doctors, the day is far spent. It is boring and frustrating to keep doing the same thing all over again on each visit” (Male, 42 years old)
Poor Information quality (inaccurate information about drug availability/medical services):
Enrolees reported a lack of accurate information to prospective NHIS enrolees about drug availability and medical services not included in the approved NHIS list, leading to some out-of-pocket payments for routine care after enrollment. Some of them further elaborated:
“Before registration, I was not informed that some of the drugs and medical services I needed were not included in the approved NHIS list. So, I routinely got referrals to access these services at higher costs in privately owned practices. Currently, my monthly healthcare expenses are similar to what it was before enrolling into the NHIS....so the more things change, the more they remain the same”’ (Female, 31 years old)
Technical performance (Poor attitude of Nurses):
Enrolees' dissatisfaction with NHIS services is also due to the impolite attitude and lack of empathy displayed by most of the nurses.:
“The practitioners, especially the nurses, are rude and lack empathy and respect. They do not greet their elders … and some of them talk to us anyhow not minding our old age” (Female, 61 years old).
Willingness to continue with NHIS:
Table 3: Willingness of NHIS enrolees to continue with NHIS
Willingness to Continue with NHIS
|
Participants (n=376)
|
%
|
Willingness to continue with NHIS
as an insured member
|
|
|
Yes
|
312
|
(83.0 %)
|
No
|
64
|
(17.0 %)
|
Total
|
376
|
100
|
If no, indication of reason/ reasons
|
|
|
Not satisfied with the treatment received
|
50
|
(78.1 %)
|
The out-of-pocket expenses of health
care is higher than I expected
|
42
|
(65.6 %)
|
The protocols involved in receiving health
care services are time-consuming
|
52
|
(81.3 %)
|
My medications are not included in the NHIS
|
40
|
(62.5 %)
|
Poor communication between patients and
health care professionals
|
30
|
(46.9%)
|
Waiting time is much
|
56
|
(87.5 %)*
|
Prescribed drugs are always out of stock
|
54
|
(84.4 %)
|
Inadequate treatment
|
26
|
(40.6 %)
|
The majority (83.0 % or 312) of NHIS enrolees were willing to retain membership of NHIS (Table 3), which was significantly (18.233, p = <.0002 two-tailed; 95 % CI = 0.60 – 0.71) higher than those expressing unwillingness to retain NHIS membership. Enrolees unwilling to retain membership in NHIS cited long waiting times, drug stock-out, time-consuming registration protocols, dissatisfaction with treatment, higher than expected out-of-pocket expenses, and non-inclusion of prescribed drugs in the NHIS-approved drug list.
Table 4: Relationship between satisfaction and willingness to continue with NHIS
Participants’ Response
|
Satisfied
|
Satisfaction
unsatisfied
|
Total
|
X2
|
P value
|
Cr’s V
|
Lambda
[A from B]
|
Lambda
[B from A]
|
Willingness to
continue with NHIS
as an insured member
|
|
|
|
|
|
|
|
|
Yes
|
232
|
80
|
312
|
121.14*
|
<.0001
|
0.57
|
0.61
|
0.79
|
No
|
0
|
64
|
64
|
|
|
|
|
|
Total
|
232
|
144
|
376
|
|
|
|
|
|
Cr’s V = Crammer’s V, * = Yates chi-square, corrected for continuity
Out of 312 NHIS enrolees who expressed willingness to retain NHIS membership, 232 were satisfied (Table 4) which was a significant proportion (McNemar Test Result: P < 0.000001, one-tailed), while none of the 64 enrolees who expressed unwillingness to retain NHIS membership were satisfied with the quality of healthcare service received. The willingness to continue with NHIS is strongly associated (X2 = 121.14, df =1; Crammer’s V = 0.57; P < .0001) with satisfaction with the quality of care received. Predicting NHIS enrolees’ willingness to retain membership of the NHIS from a knowledge of their level of satisfaction showed a higher accord (lambda[A from B] = 0.83), than when predicting NHIS enrolees’ level of satisfaction based on knowledge of their willingness to retain membership of NHIS (lambda[B from A] = 0.79).
The comments of participants in the qualitative study confirmed the above findings, offering additional justifications for their decision to retain NHIS membership, which were as follows.:
Willingness to retain NHIS membership:
Though the majority of NHIS enrolees were unsatisfied with the quality of care, they will retain NHIS membership because the services and medications are reasonably priced resulting in health expenditure being less catastrophic. Some of them explained further: -
“I am not satisfied with the quality of care and the way NHIS is operated. I did not find all that I expected in terms of efficiency and proper organisation but at least the cost of drugs and services is far much cheaper than what we get from local pharmacy stores. I am going to stick with the NHIS and pray that they improve in their services with time…..Rome was not built in a day.” (Male, 52 years old).
Unwilling to retain membership of NHIS:
Fewer NHIS enrolees voiced unwillingness to retain NHIS membership in future for reasons that included: long waiting time, drug stock-out, arduous bureaucracy, attitude of most nursing personnel who were impolite and lacked empathy. The following quotes summarise the responses of the enrolees:
Long waiting time:
The lengthy wait times in hospitals before receiving care were cited by some enrolees as a primary reason why they were unwilling to continue their participation in the NHIS.
“How can I be willing to continue patronising the NHIS when I have to wait all day just to see the doctors and hardly get prompt attention? Sometimes I do not get all the recommended medical services before the closure of work on a hospital visit because of delays. The “wahala” (problems) with this NHIS thing are too much for me to handle. I am not sure that I will retain my membership of NHIS shortly." (Male, 59 years old).
Drug stock-out and out-of-pocket expenses:
Some NHIS enrolees expressed unwillingness to retain membership due to concerns about perennial drug stock-out.:
“What advantage do I gain from enrolling into the NHIS over those who are not enrolled? I keep buying drugs from private pharmacy stores in town at high cost because most of the prescribed drugs are usually not available at the hospital pharmacy. (Male, 60 years old).
“I am unsatisfied that the important drugs I needed are always not available at the hospital pharmacy. Then what is the use of retaining my membership of the NHIS?” (Female, 47 years old).
Bureaucratic bottle-necks:
Enrolees are unwilling to retain NHIS membership due to cumbersome bureaucratic procedures for generating treatment codes, which delay clinical appointments and sometimes deny them doctors' consultations during their hospital visits.
“To generate a single code is so gruelling and takes almost half a day if one is lucky… One wonders whether this is worth all the trouble.” (Female, 55 years old).
“We are unsatisfied that half a day and more is spent generating codes to access treatment under NHIS. How can I continue like this? They are simply inefficient.” (Female, 48 years old).
“To get the NHIS codes seems like getting the Carmel through the eyes of a needle. More than half of the day is spent getting the treatment codes and paperwork from the NHIS. I am doubtful if I won't die in emergencies before the codes are obtained." (Female, 61 years old).
“It takes a long time to get anything done for those of us under the NHIS. We spend so many hours at various points trying to generate the NHIS treatment codes for different prescribed diagnostic investigations, and treatments. A whole day is spent on each hospital visit. I am so discouraged and do not see how I can continue to retain NHIS membership….. I rather go to the chemist or a private hospital when I am sick.” (Male, 45 years old).
Technical performance (Nurses):
“Some of the practitioners, especially the nurses, are ill-tempered and ill-mannered….When we want to make some enquiries about something that is not clear to us, they do not care if we are in pain or how sick we are, they just talk anyhow and make us feel miserable and disrespected.” (Female, 58 years old).