Patient satisfaction with the Nigerian National Health Insurance Scheme two decades since establishment: A systematic review and recommendations for improvement

Background: To improve healthcare access and mitigate healthcare costs for its population, Nigeria established a National Health Insurance Scheme (NHIS) in 1999. The NHIS remains Nigeria’s leading vehicle for achieving universal health coverage; nonetheless, questions remain regarding its quality and effectiveness. Studies on patient satisfaction have served as a useful strategy to further understand the patient experience and the efficacy of health systems.Aim: To synthesise current knowledge on patient satisfaction with the NHIS.Methods: The authors performed a systematic review of primary literature from 1999 to 2020 reporting on NHIS patient satisfaction in eight databases (including PubMed, Embase, and Africa-wide Information).Results: This search returned 764 unique records of which 21 met criteria for full data extraction. The 21 qualifying studies representing 11 of the 36 Nigerian states, were published from 2011 to 2020, and found moderate overall satisfaction with the NHIS (64%). Further, when disaggregated into specific domains, NHIS enrolees were most satisfied with provider attitudes (77%) and healthcare environments (70%), but less satisfied with laboratories (62%), billings (62%), pharmaceutical services (56%), wait times (55%), and referrals (51%). Importantly, time trends indicate satisfaction with the NHIS is increasing – although to differing degrees depending on the domain.Conclusion: The beneficiaries of the NHIS are moderately satisfied with the scheme. They consider it an improvement from being uninsured, but believe that the scheme can be considerably improved. The authors present two main recommendations: (1) shorter wait times may increase patient satisfaction and can be a central focus in improving the overall scheme, and (2) more research is needed across all 36 states to comprehensively understand patient satisfaction towards NHIS in anticipation of potential scheme expansion.

Is value-based payment for healthcare feasible under Ghana’s National Health Insurance Scheme?

Background Effective payment mechanisms for healthcare are critical to the quality of care and the efficiency and responsiveness of health systems to meet specific population health needs. Since its inception, Ghana’s National Health Insurance Scheme (NHIS) has adopted fee-for-service, diagnostic-related groups and capitation methods, which have contributed to provider reimbursement delays, rising costs and poor quality of care rendered to the scheme’s clients. The aim of this study was to explore stakeholder perceptions of the feasibility of value-based payment (VBP) for healthcare in Ghana. Value-based payment refers to a system whereby healthcare providers are paid for the value of services rendered to patients instead of the volume of services. Methods This study employed a cross-sectional qualitative design. National-level stakeholders were purposively selected for in-depth interviews. The participants included policy-makers (n = 4), implementers (n = 5), public health insurers (n = 3), public and private healthcare providers (n = 7) and civil society organization officers (n = 1). Interviews were audio-recorded and transcribed. Data analysis was performed using both deductive and inductive thematic analysis. The data were analysed using QSR NVivo 12 software. Results Generally, participants perceived VBP to be feasible if certain supporting systems were in place and potential implementation constraints were addressed. Although the concept of VBP was widely accepted, study participants reported that efficient resource management, provider motivation incentives and community empowerment were required to align VBP to the Ghanaian context. Weak electronic information systems and underdeveloped healthcare infrastructure were seen as challenges to the integration of VBP into the Ghanaian health system. Therefore, improvement of existing systems beyond healthcare, including public education, politics, data, finance, regulation, planning, infrastructure and stakeholder attitudes towards VBP, will affect the overall feasibility of VBP in Ghana. Conclusion Value-based payment could be a feasible policy option for the NHIS in Ghana if potential implementation challenges such as limited financial and human resources and underdeveloped health system infrastructure are addressed. Governmental support and provider capacity-building are therefore essential for VBP implementation in Ghana. Future feasibility and acceptability studies will need to consider community and patient perspectives.

Effect of the National Health Insurance Scheme on Healthcare Utilization and Out-of-Pocket Payment: Evidence from GLSS 7

The Ghana National Health Insurance Scheme (NHIS) was established in 2003, Act, 2003 (Act 650), but was later replaced with the National Health Insurance Act, 2012 (Act 852) to get rid of the then “cash and carry” system of paying for healthcare. The aim of the scheme was to reduce the cost of healthcare provision and increase access to healthcare. This paper investigates the effect of the National Health Insurance Scheme (NHIS) on healthcare utilization and out-of-pocket payment, from the providers’ perspective. The study uses data from the seventh round of the Ghana Living Standards Survey (GLSS 7) conducted in 2016/2017 and employs the estimation method of Propensity Score Matching (PSM). The findings are that enrollment onto Ghana’s National Health Insurance Scheme (NHIS) increases healthcare utilization by 26% and decreases out-of-pocket payment by 4%. However, about 48% of the population are still not enrolled, citing various reasons. Even those who enrolled, about 30% had dropped out for several reasons. The study identifies age, income, education, sex, and location of residence as the main determinants of enrolling onto the NHIS. I show that the National Health Insurance Scheme increases healthcare utilization and reduces out-of-pocket payment in Ghana. A number of Ghanaians have either not registered or registered but have stopped enrolling citing no money, no need for NHIS, and no confidence in the system’ as reasons. Any policy to invigorate the public confidence in NHIS and increases enrollment should be targeted at the young, poor, less educated, males, and rural dwellers.

What alternative and innovative domestic methods of healthcare financing can be explored to fix the current claims reimbursement challenges by the National Health Insurance Scheme of Ghana? Perspectives of health managers

Background Low-and-middle -income countries (LMICs), to achieve sustainable universal health coverage (UHC) governments are implementing local and sustainable methods of healthcare financing. However, in Ghana, there is limited evidence on these local methods for healthcare financing to inform policy. This study aimed at exploring health managers views on alternative domestic and sustainable methods of healthcare financing for UHC under the National Health Insurance Scheme (NHIS). Methods A qualitative study using in-depth interviews with 16 health facility managers were held. The health facilities and participants were selected using convenience and purposive sampling methods. A written consent was obtained from participants prior to participation in the interview. Data was transcribed verbatim and analyzed using thematic framework approach. Results Health managers across all the health facilities mentioned delayed and erratic claims reimbursement to health facilities as the main challenge. Participants attributed the main reason to lack of funds by the National Health Insurance Authority (NHIA). They said the delayed and irregular payments has been a challenge to efficient delivery of quality healthcare to clients. That in some instances they have been compelled to demand cash or out-of-pocket payment from insured clients or insurance card bearers to be able to render needed healthcare services to them. Participants think that to ensure regular reimbursement of claims to the health facilities by the NHIA, the managers think alternative local sources of funding need to be explored to fill the funding gap. To put in place this, they suggested the need to start levying special taxes on natural resources such as crude oil and gas, gold, bauxite, cocoa, mobile money transfers, airtime and increasing the proportion of levies on the existing Value Added Tax (VAT). Conclusion The study provides important insights into potential innovative alternative domestic sources for raising additional funds to finance healthcare services in Ghana. Despite the potential of these sources, it is important for governments and health policy makers in Ghana and other LMICs who are working towards implementing innovative local methods using special levies on mobile communication services and natural resources to finance their UHC, to implement those that best suit their economies to ensure equity for better health.

Knowledge, attitude and practice of adults to the national health insurance scheme (NHIS) in Unguwar Soya, Kabong Ward of Jos North LGA, Plateau State-Nigeria

Health, according to the World Health Organization is defined as a state of complete physical, mental, social and spiritual wellbeing, and not merely the absence of disease or infirmity. This was a cross sectional community based descriptive study using a multi stage sampling technique in Unguwar Soya Community, Kabong, Jos North LGA, Plateau State, Nigeria with the aim of assessing and establishing the knowledge, attitude and practice of the residents to NHIS. An interviewer administered structured questionnaire was utilized and a total of 252 questionnaires were administered to the eligible members of the community. Majority of the Respondents are aged 20-29 years (33.7%). Majority of the respondents were females (63.5%), largely married (54.0%), most have attended secondary level of education (47.2%) and are mostly Artisans (32.1%) with majority earning above 30,000 naira (25.8%).59.5% of the respondents had heard about NHIIS; family and friends were the most common sources of NHIS awareness (25.5%). Majority of the respondents (49.3%) had heard about NHIS more than five years ago. Majority of the respondents (70.7%) had good attitude towards NHIS. Only 13.3% of the respondents are registered with NHIS. 88.5% of the respondents fund their health expenditures through Out-of-pocket payment. Results depicted that the index population has inadequate awareness and knowledge of the National Health Insurance Scheme. Resulting in the small portion of the population participating in the scheme. The government can come to the aid of this community and other communities by providing adequate awareness, knowledge and privilege to participate in the scheme to better their health.

Health Personnel and the Implementation of National Health Insurance Scheme (NHIS) in Federal Capital Territory, Abuja, Nigeria

Acknowledged as a policy target for the government of Nigeria, healthcare provision represents an important preoccupation for the government. As with other public policies, the achievement of policy goals in Nigeria is usually encumbered by numerous factors of implementation across various sectors. In the health sector, factors such as inadequate physical infrastructure, shortage of healthcare personnel, limited medical supplies etc. have hindered the implementation of several health policies. National Health Insurance Scheme (NHIS) is one of such policies and this study examined the effects of shortage of healthcare personnel on the implementation of NHIS policy in FCT, Abuja. Specifically, the study evaluated the opinions of health workers as well as enrollees of NHIS in four purposively chosen Area Councils of the six Area Councils in FCT. This study adopted a survey research design with Rensis Likert’s five-point scale questionnaire instrument administered to both categories of respondents. The data were analyzed using the Statistical Package for Social Sciences (SPSS Version 25) and the T-tested statistical tool was used to test the hypothesis. The study found out that shortage of health personnel is a major barrier to the effective implementation of NHIS in the FCT, Abuja. Consequently, the study recommends that there should be massive recruitment of qualified healthcare personnel; training and retraining of healthcare workers; and timely and adequate remuneration for the healthcare workers in FCT, Abuja.

Narrowing the Gap of Inequity in the Indonesia’s National Social Health Insurance Scheme, 2014-2018

Background. Indonesia is nearing its 7-year implementation of its national health insurance scheme, or the Jaminan Kesehatan Nasional (JKN), as a facilitator for achieving universal health coverage (UHC). Despite its long-running system, it is contentious as to whether JKN has been narrowing the gap of inequity in its delivery. This paper aims to explore on whether the national health insurance scheme in Indonesia have been promoting equity of access towards health services.Methods. This study analyzes findings from JKN statistic data of 2014-2018 published by Government of Indonesia. Using a retrospective design, this study identified membership and utilization of health services within JKN, based on different membership enrollment groups as proxy for income.Results. JKN has been expanding its enrollment significantly within 5 years, during year 2014 to 2018. Moreover, the study concludes that there was increased access for outpatient in all membership groups. Inpatient care was increased in low-income group, but not in high-income group. Result also showed inpatient access was correlated with adequate supply side intervention, particularly hospital beds.Conclusion. JKN has been successful in narrowing the inequity gap, particularly by serving the low-income group better in terms of access. Going forward, equity needs to be incorporated into JKN achievement indicator, particularly to accelerate Indonesia’s effort to realize universal health coverage.