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Year : 2019  |  Volume : 21  |  Issue : 1  |  Page : 1-5

Trends and correlates of patient satisfaction with services under the National Health Insurance Scheme of Nigeria: A review

1 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication31-Jul-2019

Correspondence Address:
Dr. Godpower Chinedu Michael
MBBS, FWACP (Family Medicine), MSc (Hlth Econs), Consultant Family Physician, Department of Family Medicine, Aminu Kano Teaching Hospital, P.M.B. 3452, Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jomt.jomt_35_18

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Background: In spite of over a decade of operations, the National Health Insurance Scheme (NHIS) of Nigeria has continuously been criticized for its quality of services. Healthcare consumer satisfaction surveys (an important measure of service quality worldwide) in this domain have presented differing accounts of satisfaction with the services of the NHIS from their vantage perspectives. This narrative review aimed at studying the preliminary trends in the utilization of and patient satisfaction with the NHIS services. The correlates of patient satisfaction were also studied. Materials and Methods: We searched local literature whose full texts were accessible using predominantly Google Scholar. Results: We found progressive improvement in scheme enrolment, service utilization, and above-average overall satisfaction scores (i.e., >50% of respondents were satisfied) from most studies. Overall satisfaction scores/ratings were associated patients’ level of education, knowledge of the scheme, years of enrolment, facility cleanliness, consultation time, pharmaceutical services, ease in accessing medical records and laboratory results, health worker availability, health worker friendliness, and responsiveness to patients’ requests. Conclusion: The observed trajectory in service utilization, satisfaction scores, and their correlates may be useful for strategic planning to improve NHIS services in the country toward universal health coverage.

Keywords: National Health Insurance Scheme, patient satisfaction, service utilization, trends and correlates

How to cite this article:
Michael GC, Aliyu I, Grema BA. Trends and correlates of patient satisfaction with services under the National Health Insurance Scheme of Nigeria: A review. J Med Trop 2019;21:1-5

How to cite this URL:
Michael GC, Aliyu I, Grema BA. Trends and correlates of patient satisfaction with services under the National Health Insurance Scheme of Nigeria: A review. J Med Trop [serial online] 2019 [cited 2022 Nov 26];21:1-5. Available from:

  Introduction Top

Decades of struggle for an alternative health financing option from an existing but predominantly out-of-pocket payment gave birth to the National Health Insurance Scheme (NHIS) in 2005. The scheme was established to provide accessible, high-quality healthcare services to Nigerians while protecting them from high cost of care.[1] Like most institutions in low and middle-income countries, several challenges beset the NHIS; healthcare consumer utilization of services offered by the scheme is affected by known factors that influence healthcare service utilization such as geography (proximity to services), perceived-service quality, severity of illness, and user fees charged.[2] This suggests that patient satisfaction with NHIS services and the continued patronage of services are therefore crucial to achieving the scheme’s objectives.

Patient satisfaction surveys (an important measure of healthcare service performance worldwide) are therefore useful indicators to the quality of services rendered by physicians, paramedical, and other staff of NHIS-accredited healthcare facilities.[3],[4] Patient satisfaction refers to a patient’s judgment and subsequent reactions to what he/she perceives of the healthcare environment before, during, and after a clinical encounter in the context of the patient’s appraisal of his/her expectations of the healthcare.[5],[6] Globally, satisfaction scores vary based on the structural, interpersonal, and technical components of healthcare services offered as well as patients’ characteristics.[7],[8],[9],[10] By inference, studies in parts of the country are expected to vary in patient satisfaction scores of NHIS services.

Furthermore, there is a dearth of reports on trends in the utilization of and patient satisfaction with NHIS services since the establishment of the scheme. This narrative review, therefore, aimed at describing the healthcare services of the NHIS in the context of a healthcare system with several challenges, highlighting trends in NHIS service utilization, patient satisfaction scores/ratings of the scheme since its inception, and reported factors associated with the satisfaction ratings. It is hoped that the expositions in this review would be useful in strategic planning to improve the quality of service of existing and emerging facilities under the scheme as the country strives toward universal health coverage.

  Methods Top

Google Scholar was the major search engine utilized in the search of original research and review articles from July 1998 to July 2018. We also searched Nigerian journals that are not indexed and contacted local Nigerian experts in patient satisfaction (who have published articles on patient experience) for potential articles. Only articles whose full texts were accessible were used. The search terms used included “patient satisfaction in Nigeria,” “National health insurance scheme,” “utilization of the National Health Insurance Scheme,” “patient satisfaction with the National Health Insurance Scheme,” “Nigerian healthcare system,” and “trends and correlates.”

  Discussion Top

Healthcare services provision under the NHIS

The NHIS was established in the context of a deficient healthcare system with a compelling need to build capacity in all areas of the health system functioning namely stewardship, financing, and service provision.[1],[11] The NHIS was therefore established to improve the health of Nigerians through efficient, effective, and high-quality care. Already, preliminary reports suggest improvements in quality of care in some facilities after the introduction of the scheme.[12],[13] Participation of the healthcare facilities in service provision under the NHIS is rewarded by reimbursements and payment of claims from which facility and manpower needs are addressed. It is imperative to mention that under the NHIS, the healthcare facilities (both private and public) are responsible for securing accreditation with the NHIS, providing services in line with benefit packages agreed with the Health Maintenance Organizations (HMOs), complying with NHIS operational guidelines and very importantly ensuring enrolee (patient) satisfaction.[1] The healthcare facilities provide services through a three-level arrangement, namely primary, secondary, and tertiary services. However, primary healthcare facilities serve as the first point of contact with services rendered by the scheme and provide preventive, curative, and rehabilitative care.[1]

Trends in service utilization under the NHIS

Despite the pessimism that greeted the commencement of the scheme,[14] there are mixed reports on the enrolments into the scheme having started with federal government workers. A study in 2009 (4 years after the scheme commenced) reported that 83% of respondents (predominantly government workers) in Ibadan, south-west Nigeria were enroled into the NHIS.[2] We noted a paucity of data on the pattern of scheme enrolment in the north-east region of Nigeria; however, only nine NHIS-accredited healthcare facilities and four HMOs covering 360 federal government workers existed in Yobe State in 2009.[15] A different study in Jos north-central Nigeria reported that only 24% of study respondents in Jos Metropolis were enroled and utilizing NHIS services in 2010.[16] By March 2011, Kaduna State had 159,789 enrolees who were receiving care at 116 accredited healthcare facilities.[17] By January 2012, there were still many unenrolled federal government workers in Enugu, south-east Nigeria.[18] However, later in 2012, another study found that 87% of respondents (federal government workers and their families) were enroled at a tertiary health institution’s staff clinic in Kano, northwest Nigeria.[19] In 2013, another study among healthcare consumers in Calabar, south-south Nigeria, reported that only 37% of respondents were enroled into the scheme.[20] Differences in the year of study, the study populations, and the awareness of scheme among Nigerians may be responsible for the differential enrolment rates. However, there have been remarkable increases in enrolment into and utilization of service under the NHIS.[21],[22]

Enrolee (patient) satisfaction with NHIS services and its correlates

Studies have assessed healthcare consumers’ satisfaction with services of accredited healthcare facilities under the NHIS with also mixed results. A study in Zaria, north-west Nigeria, in 2011 showed a low overall patient satisfaction rate of 42.1% (suggesting 42.1% of the study participants were satisfied with services offered by the facility).[22] This level of satisfaction was associated with low level of knowledge of the scheme and awareness of the monetary contributions of enrolees at the time. Low knowledge of scheme has similarly been reported by another study.[14] However, there are other reports of higher satisfactions rating in parts of the country. For instance, a study in Yobe State, north-east Nigeria (2009) had a satisfaction score of 62%,[15] in Umuahia, south-east Nigeria (2012) had 66.8%,[23] in Jos north-central Nigeria (2012) had 74%,[16] and in Ibadan, south-west Nigeria (2014) had 83.6%[24]; another study in 2014 among university staff and students in Kano, north-west Nigeria, had a satisfaction score of 52.6%,[13] whereas two more studies in Kano, north-west Nigeria (2015 and 2016)[25],[26] had satisfaction scores of 65.8% and 80.5%, respectively.

Although the study in Umuahia, south-east Nigeria, did not include inferential statistics,[23] Osungbade et al.[24] observed that length of years of enrolment were predictors of satisfaction with waiting time and staff attitude, suggesting improvements in satisfaction in these two domains with increasing familiarity with staff and services. Similarly, higher education and type of facility in the hospital influenced enrolee satisfaction with the healthcare facility’s services. They concluded that the undulating nature of satisfaction ratings in the different domains studied called for stakeholders to embark on targeted interventions to improve the enrolee satisfaction.[24] Furthermore, Kabuga et al.[13] reported that consultation time with the physician, pharmaceutical services, knowledge of NHIS operations, and percentage of employee’s contributions to NHIS were associated with overall satisfaction. They concluded by imploring the NHIS management and HMOs to live up to their roles in ensuring that high-quality services are offered to enrolees to improve the satisfaction scores. Furthermore, the Yobe study included enrolees, healthcare providers, and administrators in their study population but their satisfaction rating did not markedly differ from ratings from other studies as they reported a satisfaction score of 62%. However, inferential statistical data were excluded in their study.[15] Another Kano study observed that clinic cleanliness, ease in retrieving medical records and laboratory results, doctors’ availability in sufficient number, friendliness and responsiveness of the health workers (especially the clinical assistants), efficiency of cashiers, and receiving satisfactory explanation on how to use prescribed drugs and unavailable drug from the pharmacy staff were correlates of overall patient satisfaction.[27] However, they noted that the efficiency of cashiers’ (who receive copayments for prescribed drugs) and the responsiveness of the clinical assistants (female community health extension workers used to organize the clinic flow) were the predictors of overall satisfaction. They highlighted the need for an appointment system, computerization of medical records and laboratory services, and training and retraining of health workers’ especially in area of interpersonal skills.[27] In another study in Keffi, north-central Nigeria, with overall satisfaction rate of 63.1% in 2016, the correlates of satisfaction were sociodemographic variables such as younger age, male gender, marital status, and lower educational level.[28] They highlighted the need for accredited healthcare facilities to deliver high-quality healthcare services in line with the NHIS operational guidelines to address areas of dissatisfaction.

Challenges of the scheme

Several challenges beset the scheme since its inception. These include the persisting bureaucratic bottlenecks at the level of NHIS and HMOs that have resulted in many potential enrolees spending several months before enrolment.[19] Although the intensity of these bottlenecks may have reduced since the scheme’s commencement, they have not been eliminated. Delay in healthcare provider reimbursement by the HMOs is another challenge that has resulted in lost revenues that would have been used to develop and maintain the healthcare facilities. Recent efforts by NHIS management to sanction HMOs involved in delayed reimbursement are steps in the right direction. Additionally, there is also multilevel poor healthcare system resource management (e.g., fund misappropriation and other corrupt practices).[29] The intensification of the anticorruption drive of the federal government is required as the healthcare system is not insulated from the systemic corruption in the country. Lack of or obsolete equipment at the healthcare facilities have compelled enrolees to drift toward the few equipped ones resulting in overcrowding and long waiting times.[30] Improved healthcare budget at all levels along with efficient management of available resources will make resources available for equipment procurement at the facility level. There is a poor referral system in many facilities that have resulted in avoidable delays before receiving care.[15] Most healthcare facilities are currently not computerized. This has been cited as the cause of avoidable delays at registration, payment, and laboratory-result collection points.[27] There is also poor public awareness of the scheme; many enrolees lack good knowledge about their benefit package.[14],[15],[22] Scale-up of operations to include the informal sector and the vulnerable groups have been slow.[14] The informal sector and the vulnerable groups who need healthcare services the most are currently denied needed services. Finally, suboptimal monitoring and supervision of the scheme have resulted in multilevel deviations from the operational guidelines of the scheme.[15]

Policy implication of this study

The increasing utilization of NHIS services observed in this review suggest the need to increase the capacity of existing and new healthcare facilities in the country. There appears to be an above-average enrolee rating (>50% of respondents in most studies are satisfied) of NHIS services in the country. However, only a few studies have satisfaction ratings ≥80%, indicating that a lot still have to be done by stakeholders to improve the quality of NHIS services. This will involve improving the quality/numbers of facilities along with trained manpower as these are important reasons why many enrolees choose these facilities.[29] Improvements in the clinic processes also require improvements. Challenges such as difficulty in retrieving medical records or laboratory results can be mitigated by ensuring that accredited facilities (especially those with high clientele load) are computerized as a matter of policy. The poor referral system requires supervised policy guidelines to mitigate enrolee sufferings and improve satisfaction. Increasing NHIS population coverage is also imperative as this will likely improve people’s confidence in the scheme and the healthcare system, in general; some reports have shown association between higher level of satisfaction with services and NHIS enrolment.[31]

Strengths and weakness of this study

This study has clearly shown that Nigerians may have embraced the NHIS with the increasing enrolment into scheme since inception. It also observed that most enrolees are satisfied with services offered by the scheme. It has identified some important factors associated with the current level of enrolee satisfaction and the several multilevel challenges facing the scheme. The factors identified may be useful for strategic planning to improve NHIS services and enrolee satisfaction. Among the limitations of this study, being a narrative review, the literature search and studies included for discussion may not have been exhaustive. In addition, the perceived enrolee satisfaction scores in the reported studies may be subject to social desirability bias and as such must be interpreted with caution. Finally, many technical aspects of healthcare, for example, quality of treatment and expertise of health workers, may not have been properly assessed by the enrolees.

  Conclusion Top

The services offered by the NHIS have received above-average ratings (>50% of respondents are satisfied in most studies) in most parts of Nigeria but leaves improvement gaps. The identified correlates of enrolee satisfaction may form important bases for strategic planning to improve the services of the scheme. Improvements in enrolee satisfaction scores may also need to include addressing the outlined challenges besetting the scheme.

Financial support and sponsorship

The study was solely funded by the authors.

Conflicts of interest

There are no conflicts of interest.

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