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.

Willingness and ability to pay for healthcare insurance: A cross-sectional study of Seven Communities in East and West Africa (SevenCEWA)

Willingness and ability to pay for insurance that would cover primary healthcare services has not been evaluated consistently in different African communities. We conducted a cross-sectional community health survey and examined willingness and ability to pay in 3676 adults in seven communities in four countries: Nigeria, Tanzania, Uganda and Kenya. We used an open-ended contingency valuation method to estimate willingness to pay and examined ability to pay indirectly by calculating the ratio of healthcare expenditure to total household income. Slightly more than three quarters (78.8%) of participants were willing to pay for a health insurance scheme, and just a little above half (54.7%) were willing to pay for all household members. Across sites, median amount willing to pay was $2 per person per month. A little above half (57.6%) of households in Nigeria were able to pay the premium. The main predictors of likelihood of being unwilling to pay for the health insurance scheme were increasing age [aOR 0.99 (95% CI 0.98, 1.00)], being female [0.68 (0.51, 0.92], single [0.32 (0.21, 0.49)], unemployment [0.54 (0.34, 0.85)], being enrolled in another health insurance scheme [0.45 (0.28, 0.74)] and spending more on healthcare [1.00 (0.99, 1.00)]. But being widow [2.31 (1.30, 4.10)] and those with primary and secondary education [2.23 (1.54, 3.22)] had increased likelihood of being willing to pay for health insurance scheme. Retired respondents [adjusted mean difference $-3.79 (-7.56, -0.02)], those with primary or secondary education [$-3.05 (-5.42, -0.68)] and those with high healthcare expenditure [$0.02 (0.00, 0.04)] predicted amount willing to pay for health insurance scheme. The willingness to pay for health insurance scheme is high among the seven communities studied in East and West Africa with socio-demography, economic and healthcare cost as main predictive factors.

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.

Actuarial Technique of Modelling the Out of Pocket with Deductible and Stop Loss in Health Care Insurance

The paper is intended to numerically estimate health insurance out of pocket spending from the perspective of the enrollees in order to inform whether health insurance scheme pricing policy delivers value to the enrollees. We study the implications of financing health care insurance using a classification model for health care insurance under the framework of deductibles and stop loss. The paper is designed for health underwriting professionals, particularly those who consult for health insurance schemes. This is essential given the form and emergence of treating enrollees fairly, based on regulations that impact on actuarial consultants advising on health insurance scheme product lines. The objectives of this paper are to demonstrate actuarial methods for estimating (i) total health expenses (ii) out of pocket costs (iii) reimbursements by third party insurance. (iv) examine the actuarial implications of the chosen model. In computing the out of pocket and reimbursement, the Pitacco’s model was adopted because of its relatively computational superiority and the fact that both deductible and stop loss form its core parameters. Our results show that there is a positive relationship between total health expense and the share funded by out of pocket spending. As the health expenditure increases, the share funded by out of pocket progressively increases.

Determinants of Enrolment for Community Based Health Insurance Scheme among Agro-pastoralist communities of Aw-barre District in Somali region of Ethiopia: Unmatched case control study.

BackgroundEthiopia launched community-based health insurance scheme in 2011 as part of the revised health care financing strategy to ensure universal health coverage and implementation has started in most part of the country since the launching of the scheme. However, the roll out of the scheme started in Somali Region in 2020—much later the rest of the country. The aim of this study was to assess determinants of enrollment of community-based health insurance among households in Awbarre Woreda, Somali Region, EthiopiaMethodsCommunity based unmatched case control study using a mixed approach of quantitative and qualitative methods was conducted between March and April 2021 and the study participants were selected using multi-stage sampling technique. The quantitative method used interviewer administered structured questionnaire among 216 participants (54 enrolled and 162 non-enrolled), while the qualitative method used key informant interview and focus group discussions in two rural and two urban kebeles of the woreda. The quantitative data was analyzed using SPSS version 20 and thematic analysis was used for the qualitative data. Multivariable logistic regression was used to determine the determinants of enrollment for the community-based health insurance and statistical significance was set at p value of <5%. Result Awareness about CBHI scheme AOR = 9.41(1.16,76.19), households income AOR = 2.73(0.77, 9.57); and being a member of community-based solidarity groups AOR = 2.88(1.17, 7.12) were the determinants for CBHI enrollment and reaffirmed by the qualitative findings. ConclusionsThe enrollment for community-based insurance was determined by being well informed about the scheme, household income, and being a member of solidarity groups at community level. Given the early stage of implementation, enhancing sensitization of the community about the scheme using various community platforms, promotion of the existing community based solidarity groups/associations, diligent targeting of the poor households/indigents and ensuring linkage with any existing social protection program would help to increase enrolment for the scheme.

Factors Associated With Willingness To Join a Health Insurance Scheme Among Females in Uganda

Background Access to quality and affordable health services is a fundamental human right. Therefore, there is a need for more reliable, affordable, and sustainable approaches to financing health services. This study sought to identify factors associated with willingness to join a health insurance scheme among females in Uganda. Methods The assessment was done using a logistic regression model and secondary data from the 2016 Uganda Demographic and Health Survey. Results The majority of females were willing to join health insurance schemes (85.28%). The willingness to join health insurance schemes increased among females with primary or secondary education as well as among females who used the internet less than once a week or almost every day. Conclusion There is a need for government to increase literacy among women since it will have an implication on their understanding of health insurance information and subsequently influence their willingness to join and pay. There is a need for the government of Uganda to revise the tax on the internet and internet-enabled devices to increase affordability and access to the internet which provides a cheaper and faster way to disseminate health-related information.

Determinants and perception of health insurance participation among healthcare providers in Nigeria: A mixed-methods study

Background To accelerate universal health coverage, Nigeria’s National Health Insurance Scheme (NHIS) decentralized the implementation of government health insurance to the individual states in 2014. Lagos is one of the states that passed a State Health Insurance Scheme into law, in order to expand the benefits of health insurance beyond the few residents enrolled in community-based health insurance programs, commercial private health insurance plans or the NHIS. Public and private healthcare providers are a critical component of the Lagos State Health Scheme (LSHS) rollout. This study explored the determinants and perception of provider participation in health insurance programs including the LSHS. Methods This study used a mixed-methods cross sectional design. Quantitative data were collected from 60 healthcare facilities representatively sampled from 6 Local Government Areas in Lagos state. For the qualitative data, providers were interviewed using structured questionnaires on selected characteristics of each health facility in addition to the managers’ opinions about the challenges and benefits of insurance participation, capacity pressure, resource availability and financial management consequences. Results A higher proportion of provider facilities participating in insurance relative to non-participating facilities were larger with mid to (very) high patient volume, workforce, and longer years of operation. In addition, a greater proportion of private facilities compared to public facilities participated in insurance. Furthermore, a higher proportion of secondary and tertiary facilities relative to primary facilities participated in insurance. Lastly, increase in patient volume and revenue were motivating factors for provider facilities to participate in insurance, while low tariffs, delay and denial of payments, and patients’ unrealistic expectations were mentioned as inhibiting factors. Conclusion For the Lagos state and other government insurance schemes in developing countries to be successful, effective contracting and quality assurance of healthcare providers are essential. The health facilities indicated that these would require adequate and regular provider payment, investments in infrastructure upgrades and educating the public about insurance benefit plans and service expectations.

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.