Table of Contents  
Year : 2016  |  Volume : 18  |  Issue : 1  |  Page : 22-27

A comparative study of quality of care before and after introduction of National Health Insurance Scheme in health facilities in Zaria, Kaduna State, Northwestern Nigeria

Department of Community Medicine, Faculty of Medicine, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Web Publication1-Mar-2016

Correspondence Address:
Muhammad Bello Garba
Department of Community Medicine, Ahmadu Bello University Zaria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2276-7096.177831

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Background: The National Health Insurance Scheme (NHIS) in Nigeria was introduced in 2005 to remove financial barriers to access of care and to improve quality of care. However, since introduction of the scheme, there has not been any documented study to assess whether there has any improvement in quality of care in the participating facilities as a result of its introduction.
Objectives: This study was undertaken to determine and compare the quality of care before and after introduction of NHIS in health facilities in Zaria, Kaduna State, Northwestern Nigeria.
Materials and Methods: The study was cross-sectional, descriptive, and comparative in design. Using stratified sampling one public and two private NHIS accredited secondary health facilities were selected. Adherence to Federal Ministry of Health performance standards for emergency obstetric care was used as proxy for quality. A retrospective analysis of a total of 320 case notes of female patients that were managed in these facilities for five maternal complications was undertaken, 160 before and 160 after introduction of NHIS.
Results: Results showed that quality of care, represented by levels of adherence to standard treatment guidelines, was generally poor (42%). The mean adherence to standards of care levels at facility level of 37.9% before and 46.3% after introduction of NHIS was observed; this difference was statistically significant (P = 0.005), with the public facility performing significantly better, with an adherence level of 59% compared to 30% for private facilities (P = 0.001).
Conclusion: The study demonstrated improvement in quality of care following introduction of NHIS in the facilities. Integrating supportive supervision and rapid expansion of the scheme are recommended to widely spread its quality-related benefits.

Keywords: Funding, health insurance, health facilities, quality of care

How to cite this article:
Garba MB, Ejembi CL. A comparative study of quality of care before and after introduction of National Health Insurance Scheme in health facilities in Zaria, Kaduna State, Northwestern Nigeria. J Med Trop 2016;18:22-7

How to cite this URL:
Garba MB, Ejembi CL. A comparative study of quality of care before and after introduction of National Health Insurance Scheme in health facilities in Zaria, Kaduna State, Northwestern Nigeria. J Med Trop [serial online] 2016 [cited 2022 Nov 26];18:22-7. Available from:

  Introduction Top

Quality of care is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.[1] According to Donabedian model, quality can be measured by assessing the three aspects of care: Structure, process, and outcome.[2] Process indicators of quality focus on what is done in receiving and giving care during a patient–physician contact. Process indicators of quality of care are most conveniently and perhaps objectively assessed against standard treatment protocols. Thus, the last two decades have witnessed an increasing prominence of standard treatment guidelines among professional regulatory bodies, training institutions, and health care delivery systems.[3]

Adherence to standard treatment guidelines is widely used as the most potent process indicator of quality of care. This is because the guidelines are evidence-based, representing best available knowledge, and providing practitioners with specific recommendations on the common clinical situations.[3] A number of studies have demonstrated that the implementation of evidenced-based, guideline-driven care results in improved clinical and economic outcomes.[4],[5],[6] An important appealing feature of these guidelines/protocols is their potential in decreasing the cost of care while improving outcome. This is because these guidelines take economic considerations into account, thus serving the purpose of cost containment by reducing the number of unnecessary tests and treatments.[7]

Studies show that close to a half of Americans (45.1%) did not receive recommended care which is a measure of desirable quality of care.[8],[9],[10] Furthermore, Cantrell et al. reviewed the management of eight common chronic conditions and concluded a significant under-treatment of chronic diseases according to national guidelines.[11] A systemic review of studies of quality of clinical care in general practice in the UK, Australia, and New Zealand concluded that in almost all studies, the processes of care did not attain the standards set out in national guidelines or those set by the researchers themselves.[12] Similarly, up to half of deaths among severely ill in South Africa are attributed to failure in adherence to guidelines.[13] In Nigeria, there has not been a nationwide coordinated quality assurance program in the health sector; in fact, most of the recent quality assessment efforts are driven by developmental partners.[14] A facility-based assessment of adherence to standard treatment guidelines in University of Benin Teaching Hospital, one of the country's tertiary facilities found adherence level of 49% (n = 501). With this outing at the apex of the country's health care delivery system, one expects a much lower performance in the lower tiers.[15]

The National Health Insurance Scheme (NHIS) was introduced in Nigeria in 2005. The main objectives of the scheme were to remove financial barriers to access and to improve quality of care.[16] Since the introduction of the scheme, there has not been any documented study to assess whether there has been any improvement in quality of care as a result of its introduction. This study was therefore conducted to determine and compare the quality of care before and after introduction of NHIS in health facilities in Zaria, using adherence to standard treatment protocols as proxy.

  Materials and Methods Top

Study Area

The study was carried out in Zaria town, the second largest city in Kaduna State, Northwest Nigeria. The town comprises two local governments (Sabon Gari and Zaria) and has a total population of 830,638 spread across 23 political wards.[17]

The population of Zaria is made up of predominantly Hausa/Fulani Muslims. Subsistence farming and petty trading are the main occupations of the people. Educational level is moderate. Patriarchy is rife; early marriage is widely practiced, and the women live in seclusion and leave their compounds, even for health care seeking only with the expressed permission of their husbands. Economically, these women are dependent on their husbands.

There are 102 health facilities in the two local government areas (LGAs) in Zaria. Of these, 80 are public and 22 are private. At secondary level, the private sector has a total of seven health facilities while the public sector has two. The main source of financing heath care in the area is through out-of-pocket household expenditure. The NHIS was introduced in Zaria in 2006. At the time of the study, six public and 12 private health facilities were participating in the scheme.

Study Design

This study was cross-sectional, descriptive, and comparative design.

Study Population

The study population comprised secondary health facilities accredited by NHIS and case notes of patients managed for five maternal conditions (malaria in pregnancy, severe preeclampsia/eclampsia, incomplete abortion, severe anemia in pregnancy, and postpartum hemorrhage [PPH]) in the facilities a year before and 5 years after introduction of NHIS.

Sample Size and Sampling

There are 3 public and 7 privately owned secondary health facilities accredited by NHIS in Zaria.[18] Using 1:2 ratio, one public and two private hospitals were selected using simple random sampling technique by balloting. Sample size of case notes for each category was obtained using the formula for comparative study [19] and level of quality of care from previous studies conducted before and after introduction of NHIS.[20],[21] as follows:

Where n = minimum sample size for each group

Z1−a, Z1−B = are standard normal deviates

(Z1−a + Z1−B)2 = (1.96 + 1.282)2 = 10.51 at 95% confidence interval and power of 90%

P1 = The proportion of respondents who were satisfied with quality of maternal health services in Sabon Gari LGA in a study conducted before commencement of NHIS [20] =41%; Thus, p1 = 0.41

q1 = (1−p1) = (1−0.41) = 0.59

p2 = The proportion of respondents who were satisfied with the quality of emergency obstetric care services in study conducted in Kano Municipal LGA, Kano State, after introduction of NHIS [21] =76%, Thus, p2 = 0.76

q2 = (1−p2) = (1−0.76) = 0.24


The sample size of 80 was used for each of the comparative group before and after the introduction of NHIS. For the public health facilities where one facility was sampled, the sample size was allotted proportionate to the patient caseload.

All the case notes meeting the inclusion criteria were retrieved and numbered. The retrieval rates were of 97% and 54% in the public and private facilities, respectively. Systematic sampling technique was employed for the selection of the case notes. A total of 320 patient case notes were reviewed 160 before and 160 after introduction of NHIS. These were allocated equally between the public and private facilities 80 before and 80 after introduction of NHIS in each category.

Data Collection Tool and Data Collection

A checklist was developed for standard of care for each of the conditions using the Federal Ministry of Health Performance Standards for EONC in Nigerian Hospitals protocols.[22] In each of the facilities, studied case notes of patients managed for the five maternal complications in 2004 and 2011 were sorted out from inpatient admission registers in the various record departments, checked for completeness, and code numbered.

The management of each patient was assessed against these standards of care. A score of one-point for each standard observed was awarded and nonobservance of a standard.

Data Analysis

Data were analyzed using the SPSS statistical package version 20 and presented using tables and summarized using means and proportions. Total adherence score for case reviewed was computed as percentage of total standards observed in relation to the total available standards.

Aggregated adherence level was graded; thus,

  • Poor adherence = percentage score <50
  • Good adherence = percentage score 50–69
  • Very good adherence = percentage score >70.

Adherence levels to standard protocols before and after NHIS as well as between public and private facilities were compared using bivariate analysis. Statistical significance for differences observed in levels of adherence before and after as well as between public and private facilities was tested using paired t andChi-square tests. The level of significance was set at P < 0.05.

Ethical Considerations

Ethical permission was obtained from the facility authorities.

  Results Top

A total of 320 patient case notes were reviewed during the study, 160 before and 160 after introduction of NHIS in the facilities surveyed. [Table 1] shows that incomplete abortion was the most frequent maternal complication encountered representing more than one-third of the total (33.7% before and 36.3% after), followed by severe preeclampsia/eclampsia representing a quarter (23.8% and 27.5%) and PPH (23.8% and 20.6%).
Table 1: Distribution of cases of maternal complications reviewed in the facilities

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Overall, quality of care represented by level of adherence to standard treatment protocols was found to be poor with mean adherence level of 42.12% [Table 2]. This is put at 37.90% before NHIS and this has risen to 46.34% after introduction of NHIS as shown in [Table 3]. The improvement in adherence level following introduction of NHIS was found to be statistically significant (P = 0.005).
Table 2: Comparison of the of the mean adherence levels to standard treatment protocols before and after introduction of National Health Insurance Scheme in the three facilities

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Table 3: Relationship between adherence to standard treatment protocols and facility ownership

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Of the five maternal complications, only severe anemia was managed to a level of good quality (57.29%) before NHIS, with PPH and severe malaria recorded least quality with adherence level of 23.20% and 28.97%, respectively. After introduction of NHIS, a general improvement in adherence to protocols was observed, more marked in management of incomplete abortion (52.33%) and severe anemia (70.56%). Despite some improvements, severe malaria remained the most poorly managed with average adherence level of 38.29% [Table 2].

Generally, the most poorly observed standards, with nonadherence of 100%, were observed in the following cases. In management of incomplete abortion, these included giving TT, informing client of postprocedure care, telling client about signs of recovery, counseling on family planning, and informing client when to come for follow-up. In severe preeclampsia/eclampsia, signs of toxicity to MgSO4 and clotting test were the most left out in the management. Whereas applying anti-shock garment in PPH with shock, Trendelenburg positioning, administration of oxygen, monitoring of uterine contraction, and bleeding monitoring during follow-up are examples of standard practices that were performed least during patient care.

As shown in [Table 4], facility wise, the two private facilities had the worst performance before NHIS with good adherence level of 0% and 10% in Savannah Polyclinic and Ladiya Hospital, respectively. The level in the public facility, Hajiya Gambo Sawaba General Hospital, was found to be 20% before NHIS. Following introduction of NHIS, an improvement in adherence level was recorded, Savannah Polyclinic, a private facility, recorded the highest improvement as good adherence level rose to 55%, followed by the publicly owned Hajiya Gambo Sawaba General Hospital with a rise from 20% to 54% adherence. In the other private facility, Ladiya Hospital, the change was a marginal increase in adherence level from 10% before to 12% after [Table 4].
Table 4: Comparison of level of adherence to standard treatment protocols in the facilities before and after joining National Health Insurance Scheme by facility ownership status

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Analysis of the results further reveals a statistically significant difference in adherence level between the facilities based on ownership status (P = 0.0001), with the public facility performing better than the privately owned facilities reviewed [Table 3].

  Discussion Top

Using adherence to standard treatment guidelines as a proxy of quality of care, this study demonstrated a general poor quality of care, with a mean adherence level of 42.12%. This is significantly higher than the baseline of Standard Based Management and Recognition (SBM-R) project in some selected states in Northwestern and South-Southern Nigeria, (5–15%)[23] but lower than what was recorded in University of Benin Teaching Hospital, South-Southern Nigeria (49%).[15] Though in the same country, the wide difference observed between the results of this study and that of both the SBM-R intervention and Benin study could be attributed to difference in the level of care of the facilities surveyed. Whereas this work was done in secondary tier of care, the study in Benin was carried out in a tertiary tier, a teaching hospital, where more capable hands and better supervisory mechanism are available, and these may have a lot to bear on the process of care provision by the health workers. The SBM-R intervention on the other hand was carried out at the primary level of care where the setting is certainly less supportive of adherence to guidelines, due to shortage in number and skills of personnel, among other structural limitations. It is noteworthy that the finding of this study is quite higher to the findings in rural Kenya, Eastern Africa, where only 28% of patients were prescribed antimalarials as recommended by the National guidelines.[24] This could also be explained by the difference in the setting and level of care between the two studies. The study in Kenya was carried in primary care facilities in rural environment as against this study conducted in secondary care facilities in an urban setting. Expectedly, the finding of this study is far below the reports of similar studies in Germany (average to high adherence)[4] and the USA (54.8–59%).[9] These studies similarly used adherence to standard treatment guidelines as proxy to quality of care, with the clear difference of wide circulation and prominence of such guidelines amidst professional circles supported by a robust supervisory mechanism and a well-informed population.

Another striking finding of this study is the presence of significant difference in facilities adherence performance following their enrollment into NHIS, P = 0.0001. The association of resource availability with adherence to guidelines as an aspect of quality is not always that of a linear relationship. This is as Wennberg et al. assert greater spending does not purchase the infrastructure needed to ensure compliance with the standards of practice dictated by evidence-based medicine.[4] To ensure the system and the populace get value for their money, Jurges advocates changing the reimbursement system “to include quality-related or guideline-based fees” as one possibility to improve adherence to guidelines.[4] Furthermore, Karlsson provides an interesting analysis that allows optimizing reimbursement schemes in a capitation system, in terms of quality provided, instead of the traditional fixed monthly stipend per enrollee.[4] The suggestion by Greenberg and Greenberg of involving other medical professionals is even more appropriate in our environment where paramedics serve as the first point of contact to most patients/clients, especially at lower levels of care. Other measures that can serve the ultimate purpose of promoting adherence to guidelines include implementation and strengthening pay-for-performance initiatives and evolving physician-level measurement of performance.[8],[12]

Our finding of a significant association between facility ownership and quality of care measured as adherence to standard treatment guidelines is in agreement with the findings of a systemic review meta-analyses of over 40 studies which showed a statistically significant difference in quality of care in not-for-profit (public) compared to for-profit (private) health facilities (P < 0.05).[25] This is shown in the for-profit context, to be due in part to, proprietors' quest for returns on their investments, of at least 10–15%. Minimizing expenditures in turn may lead to lower quality staffing and therefore low quality of care.[26] This observation is very relevant because up to 80% of health facilities accredited by NHIS for service provision are privately owned.[26]

A limitation of this study is its reliance on practitioners documentation of what they do during patient care which most often than not is not comprehensive and thus missing aspects of the performance standards on patient–doctor interpersonal relationship that is, usually not recorded in case notes.

  Conclusion Top

This study demonstrated that quality of care is generally low, but a significant improvement following introduction of NHIS and a more proactive measures to promote adherence to standard practice and inclusivity of the private sector in government programs are recommended. The scheme should also be rapidly expanded to ensure more coverage owing to its potential for improving quality of care.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]

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