|Year : 2022 | Volume
| Issue : 1 | Page : 89-96
Enrollees’ knowledge, satisfaction, and barriers to uptake of National Health Insurance Scheme in north-central Nigeria
Kenny Ewulum1, Olaiya P Abiodun2, Abiodun O Ogunniyi3, Olumide F Ajani4, Andrew N Yashim5, Michael O Tomori1, Azeezat A Oyewande6, Chidinma A Udah7, Friday I Igbinovia1, Doreen O Enejoh8, Zachary T Gwa2, Olaide L Afelumo1, Felix O Sanni9
1 Department of Public Health, University of Central Nicaragua, Abuja, Nigeria
2 Public Health Department, Axios Foundation Inc., Abuja, Nigeria
3 Prevention, Programs, and Knowledge Management Department, Nigeria Center for Disease Control, Jabi Abuja, Nigeria
4 Department of Logistics and Supply Chain Management, University of Science and Technology, Selangor, Malaysia
5 Department of Haematology and Blood Transfusion Service, National Hospital, Abuja, Nigeria
6 Department of Family Medicine, Lagos State Health Service Commission, Owerri, Nigeria
7 Department of Paediatrics, Federal Medical Centre, Owerri, Imo State, Nigeria
8 Department of Public Health, James Lind Institute, Ogun State, Nigeria
9 Research and Development Department, Fescosof Data Solutions, Ogun State, Nigeria
|Date of Submission||20-Oct-2021|
|Date of Acceptance||02-Feb-2022|
|Date of Web Publication||23-Mar-2022|
Dr. Kenny Ewulum
Department of Public Health, University of Central Nicaragua, Managua 12104
Source of Support: None, Conflict of Interest: None
Background: Enrollees’ knowledge, behavior, and perception of health insurance substantially influence a decision about the uptake of sustainability of the program. This study assessed enrollees’ knowledge, satisfaction, and barriers to the National Health Insurance Scheme (NHIS) uptake in Benue State, Nigeria. Materials and Methods: The study was a descriptive survey conducted among hospital clients enrolled in the formal sector program of the health insurance scheme in Makurdi, Benue State, Nigeria. A structured questionnaire was used to collect respondents’ demographic information and data related to the knowledge, satisfaction, and barriers to the uptake of NHIS in Nigeria. IBM-SPSS version 25.0 was used to analyze the data. Results: The study comprised 53.2% males, and 46.8% were females. The majority (82.9%) of the enrollees were aware of the objectives of the NHIS, but only 33.4% were aware of their benefits as enrollees and only 56.0% were satisfied with NHIS services. Factors that significantly influenced enrollees’ satisfaction include sex, age, education level, income, and knowledge of enrollees’ entitlements (P < 0.05), but the family size and knowledge of the objectives of the NHIS were not significantly associated with the level of satisfaction (P > 0.05). The most common barriers to the uptake of the NHIS include cultural and religious norms (67.4%) and poor social infrastructures (60.6%). Conclusion: This study revealed that the enrollees had poor knowledge of their entitlements for enrolling in the NHIS and a low level of satisfaction. There is a need for more awareness interventions across Nigeria to sensitize citizens of the scheme’s importance, objectives, and benefits.
Keywords: Barriers, health insurance, insurance scheme, satisfaction
|How to cite this article:|
Ewulum K, Abiodun OP, Ogunniyi AO, Ajani OF, Yashim AN, Tomori MO, Oyewande AA, Udah CA, Igbinovia FI, Enejoh DO, Gwa ZT, Afelumo OL, Sanni FO. Enrollees’ knowledge, satisfaction, and barriers to uptake of National Health Insurance Scheme in north-central Nigeria. MGM J Med Sci 2022;9:89-96
|How to cite this URL:|
Ewulum K, Abiodun OP, Ogunniyi AO, Ajani OF, Yashim AN, Tomori MO, Oyewande AA, Udah CA, Igbinovia FI, Enejoh DO, Gwa ZT, Afelumo OL, Sanni FO. Enrollees’ knowledge, satisfaction, and barriers to uptake of National Health Insurance Scheme in north-central Nigeria. MGM J Med Sci [serial online] 2022 [cited 2022 Jul 6];9:89-96. Available from: http://www.mgmjms.com/text.asp?2022/9/1/89/340594
| Introduction|| |
Good health is essential for maintaining economic and social growth and reducing poverty. Access to primary health services is vital to sustaining and enhancing wellbeing. Also, communities need to be shielded from being forced into poverty due to the high cost of healthcare services. Despite the Nigerian government’s establishment of the National Health Insurance Scheme (NHIS), most Nigerians are not covered by the scheme. The purpose of the NHIS is to offer social health insurance in Nigeria by paying for contributors’ healthcare services from a pool of funds donated by the scheme’s participants. The funds are pooled, allowing Health Maintenance Organizations to cover the costs of medical care for individuals in need.
Good knowledge and acceptability of health insurance services are crucial to efficient use and access to health care to meet the desired goals of the NHIS. Enrollees’ knowledge, behavior, and perception substantially influence a decision about a product or service. Several scholars have explored the knowledge, satisfaction, and barriers to the uptake of the NHIS, both in Nigeria and in other countries. Abdulqadir and Alhaji, in a study conducted in Minna, Niger State, found that only 40.7% of NHIS clients had good knowledge of the various aspects of the NHIS with a very poor level of satisfaction. A study conducted among 487 adult patients attending a tertiary health facility in Lagos revealed that 80.7% of the patients had poor knowledge of the NHIS, with just 12.3% of them registered with the scheme, although there was a high level of satisfaction among the respondents using the services. In a cross-sectional study conducted among the 535 Usmanu Danfodiyo University Sokoto staff, Mustapha Kurfi et al. found low satisfaction with the scheme among respondents. They also identified barriers to the uptake scheme, such as knowledge of the scheme, education, marital status, and occupation.
Another study conducted among 287 academic staff of Usmanu Danfodiyo University, Sokoto, Nigeria found a very high awareness of the NHIS (99.3%) among respondents. However, less than half (48.9%) of them enrolled in the scheme, more than half (53%) had poor knowledge of how the scheme works, and 31.6% were not satisfied with the attitude of NHIS staff. The study further revealed that 58.8% were dissatisfied with waiting time, 72.8% were dissatisfied with drug administration, and 72.1% rated the overall satisfaction poor and would not recommend it for family or friends. A recent study conducted in Minna, Niger State, Nigeria found that all the respondents (100%) showed some level of knowledge of the NHIS, but less than 50% had adequate knowledge about the objectives and guiding principles of the scheme. The study further disclosed high positive perceptions (81.5%) of the respondents toward the scheme, although only a few (22.8%) were using the scheme. This study also documented some barriers to uptake of the scheme among the respondents, including out-of-stock problems for most medications, poor-quality medications, and services as well as the rate of out-of-pocket payments.
Several barriers and challenges to the uptake of NHIS services have been identified. These barriers include culture, poor accessibility, facility environment, poor quality of service, poor program implementation, poor social infrastructure, traditional and religious belief, inadequate legislation (weak system), lack of public awareness, and insufficient funding. Despite numerous studies related to the uptake, knowledge, and accessibility of HNIS in Nigeria, no study has addressed these issues among NHIS enrollees in Benue State, Nigeria. This study was designed to determine the knowledge of enrollees about the objectives of the NHIS, entitlements, satisfaction, and barriers to the scheme’s uptake, considering the enrollees’ views.
| Materials and methods|| |
This descriptive survey was conducted in Makurdi, Benue State, Nigeria. The health facilities are spread around the metropolis and its environs. The study population was hospital clients enrolled in the formal sector program of the health insurance scheme in Nigeria. The study sites were chosen because they had one of the largest enrollees in the health insurance scheme identified by the regulatory agency. The study participants were drawn from the federal and state health facilities in the local government area.
Sampling method and sampling size
Enrollees were selected at the healthcare centers using a proportionate method based on the size of the enrollees. The research covered only eligible people who had been involved in the NHIS program for more than 1 year. Enrollment review was performed in coordination with NHIS desk officers in Benue State, Nigeria. Based on the 89% prevalence of knowledge and uptake of health insurance obtained from a previous study, the sample size calculated for the study was 350.
A structured questionnaire was used to collect respondents’ demographic information and data related to the knowledge, satisfaction, and barriers to the uptake of the NHIS in Nigeria between February 3 and 21, 2020. Depending on the level of literacy of the respondents, some of the questionnaires were interviewer-administered. The questionnaire was pretested within a small population, and corrections were made before administration to respondents after obtaining their consent. Additionally, the questions used in the study were adopted from previously validated questionnaires.
Sample size estimation
To obtain the sample size n, this formula was used:
n =Z2p q/d2,
Z is the standard normal deviate of alpha set at 1.96 corresponding to 95% confidence level;
p the prevalence of knowledge and uptake of health insurance obtained from the previous study.
p = 89% = 0.89,
d =level of precision = 5% = 0.05,
q =1−P = 1−0.89=0.11,
n = (1.96)2 × 0.89 × 0.11/(0.05)2 = 150 for population less than 10,000: nf = n/(1+(n/N)),
nf = sample size when the study population is less than 10,000,
n = sample size when the study population is greater than 10,000,
N = estimate of the population size which is 350 workers,
nf = 150/ (1+(150/350)) =150/1.2 = 105,
nf = 105, this is the minimum sample size for this study.
Making allowance for 10% attrition = nf = 105 = 116.7,
100%−10% = 0.9.
The total number to be recruited (sample size) for this study will be at least 117.
The stratified sampling technique will be utilized to calculate the proportion of each group of health insurance providers and clients who will participate in this study.
Target population, percent, stratified sample are as follows:
Enrollees in healthcare centers= 247, 77%, 90
Personnel of health insurance provider = 103, 23%, 27
Total = 350, 100%, 117.
Statistical analysis and ethical approval
All returned questionnaires were analyzed using IBM Statistical Package for Social Sciences (SPSS) version 25, a 95% confidence interval was used, and P-values less than 0.05 were considered statistically significant. Approval was obtained from the Ministry of Health and Human Services, Benue State, with MPH/STA/204/Vol.1/40.
Inclusion and exclusion criteria
The study included participants between the ages of 10 and 60 years, healthcare insurance providers, and enrollees, whereas those below 10 or >60 years were excluded from the study.
| Results|| |
Socio-demographic characteristics of respondents
The sample size for this study was 350, but 293 (84%) responses were retrieved. [Table 1] shows the socio-demographic profile of the respondents. The study comprised 53.2% males, and 46.8% were females. The majority were within age 31–40 (53.7%), graduates (72.0%), civil servants (66.9%), and earn between 50,000.00 and 100,000.00 naira monthly (36.2%). The majority of the respondents had a family size of 3–6 (69.7%), 31.4% have been with their healthcare provider for 5–6 years, whereas 51.5% spend less than 10% of their monthly salary on insurance.
[Table 2] shows the knowledge of enrollees on the objectives of the NHIS and their entitlements as enrollees. The majority of the enrollees were highly aware that the goals of the NHIS include “ensuring access to quality care (84.3%)” and “protecting enrollees and their families against huge medical bills (86.7%).” However, the respondents’ general awareness of their entitlements was 33.4%, with a minimum and maximum of 28.0% and 37.5%, respectively.
Enrollees’ perception and satisfaction about NHIS healthcare service delivery
[Table 3] shows the perception and the level of satisfaction with NHIS healthcare service delivery. Although 70% of the enrollees agreed that the implementation of the NHIS had reduced the problem of getting money for medical care, only 58.0% agreed that their NHIS service providers have up-to-date medical equipment. Also, 58.7% agreed that the physical facilities of my service provider are beautiful, the NHIS has provided easy access to healthcare in Benue State, and their healthcare providers are reliable in providing service. Only 60.4% agreed that their healthcare providers know how to handle any medical problem they brought, and the overall satisfaction with NHIS services was 56.0%.
As shown in [Table 4], the level of satisfaction with NHIS service was higher among males (62.8%) than among females (P = 0.003). It significantly increased with the increase in age of the enrollees from 41.3% for enrollees aged 30 years and below to 62.2% for those above 40 years (P = 0.002). Enrollees who attained postgraduate education level showed a significantly lower level of satisfaction (46.9%) when compared with those who attained secondary education (55.0%) and graduates (57.2%) (P = 0.015). The highest level of satisfaction was found among enrollees who earn between 50,000 and 100,000 naira per month (65.1%) and those who had good knowledge of their entitlements as enrollees (66.4%; P = 0.001), but the family size and understanding of the objectives of the NHIS were not significantly associated with the level of satisfaction.
Barriers to uptake of NHIS services
When asked about the barriers to NHIS services, the enrollees identified cultural and religious norms (67.4%) and poor social infrastructures (60.6%) as the most significant barriers to the uptake of the NHIS in Nigeria. Other barriers include a weak NHIS system, poor quality of care, and vulnerability among social groups [Figure 1].
| Discussion|| |
Enrollees’ knowledge of the objectives of the NHIS and their entitlements
Health insurance is one of the health financing options to ensure the viability of the health sector. Surprisingly, uptake is still very poor despite attempts by various governments to put in place such schemes to ensure equity and accessibility to quality healthcare services. The majority of the respondents knew the objectives of the NHIS, with an overall knowledge of 83%. No consistent level of awareness has been reported from previous studies, but different levels of understanding of health insurance have been reported from other countries, states, and professions or occupations. For example, reports from various studies conducted in the Lagos state found a low level of awareness among artisans and a high awareness rate among private healthcare practitioners and residents of a suburb in Lagos. A higher proportion of respondents in our study was aware of the objectives of the NHIS than 52% observed in Kano, 6.4% seen in Orire, Oyo State, Nigeria, 30.3% among traders in Ebonyi State, and 13.1% among artisans in Lagos, but corresponded to the high awareness rates of 80.2% and 97.5% reported in different studies conducted in Lagos, Nigeria,, 82% in Jos, North-central Nigeria, and 99.3% in Sokoto State. The finding also corresponds to the high level of awareness (80.3%) found in South Africa and Kenya. This finding underscores the need to create more awareness on the importance and benefits of health insurance across Nigeria, professions, and occupations.
The study revealed poor knowledge of the enrollees about their entitlements such as maternity care up to four live births, free immunization, free family planning, antenatal and post-natal services, free hospital care in a standard ward, and eye examination and eye care; only 33.4% of the enrollees were fully aware of these. This high level of ignorance displayed by the enrollees shows that many of the respondents just enrolled in the program because it is mandatory, part of the requirements or benefits from their companies or organizations, and may be responsible for the poor perception and satisfaction found among them. This finding contrasts what was observed among artisans in the Lagos state, in which a high proportion of the artisans, 79.4% (27 out of 34), was aware of the benefits of health insurance and slightly lower than 49.5% of the respondents attending a tertiary health facility in Lagos were aware of the benefits of the health insurance scheme. Studies have proven that poor knowledge of the benefits package of insurance schemes is one of the barriers to utilization rates of health facilities among enrollees, especially in developing countries.
Enrollees’ perception and satisfaction about NHIS healthcare service delivery
Respondents in this study displayed suboptimal positive perceptions of NHIS services ranging from 50.0% to 70% and a low overall satisfaction of 56.0%. This finding emphasizes the need for intensive education by policymakers and service providers to change the negative perception of the people about the quality of NHIS services. Factors such as gender, age, education, income, and awareness of the enrollees’ entitlement were significantly associated with satisfaction with NHIS (P < 0.05). Poor perception and satisfaction recorded in this study may be partially attributed to the poor knowledge of the benefits of NHIS among the enrollees. Perception of NHIS services among enrollees in this study contrasts positive perception noticed among rural dwellers in South West, Nigeria. Also, a more significant percentage (81.5%) of respondents at federal healthcare facilities in Niger State showed positive perceptions toward the scheme, similar to what was observed among academic staff in Sokoto State.
The level of satisfaction seen in this study is higher than what several scholars have reported in previous studies in Nigeria. In 2011, 42% satisfaction was reported among NHIS enrollees in a survey conducted in Ahmadu Bello University, Zaria. Similar to this study, the study found that clients with more knowledge of the objectives and benefits of the scheme were more satisfied than those without adequate knowledge. Other similar factors associated with the client’s satisfaction in their study include income and their healthcare providers’ enrollment duration. A study conducted in Minna, Niger State, and Jos, Plateau State found that only 48.9% and 34% of the enrollees were satisfied with the scheme’s services., The level of satisfaction in this study is also higher than 27.9%, and 46.7% reported the general and academic staff of Usmanu Danfodiyo University Sokoto, Nigeria.,
This study found that factors such as up-to-date medical equipment, easy access to healthcare, attending to patients promptly, reliability, and dependable healthcare outcomes were among the significant factors that influenced the enrollees’ satisfaction. This finding is similar to what was reported in a recent review of the NHIS from 1998 to 2018 by Michael et al. They found that more than 50% of respondents from most of the studies reviewed were satisfied with the scheme. The satisfaction level was associated with factors such as education, knowledge of the scheme, length of enrollment, cleanliness of the facilities, time spent during a consultation, relationship with health workers, and responsiveness to patients’ needs. Other studies have also enumerated gender, age, education, income, and awareness of the scheme among the significant factors influencing client satisfaction.,,,,,,
Barriers to uptake of NHIS services
The enrollees identified cultural and religious norms and poor social infrastructures as the most significant barriers to the uptake of the NHIS in Nigeria. Other barriers include a weak NHIS system, poor quality of care, and vulnerability among social groups. These findings agree with the results documented in a study to review the barriers and facilitators to implementation, uptake, and sustainability of community-based health insurance schemes in low-and middle-income countries by Fadlallah et al. The study highlighted culture, poor accessibility, facility environment, and poor quality of service as significant factors influencing enrollment and sustainability of health insurance schemes. Another study conducted in Nigeria to assess the prospects and challenges of health insurance in Nigeria listed barriers to the uptake of health insurance as poor program implementation, poor social infrastructure, traditional and religious belief, inadequate legislation (weak system), lack of public awareness, and insufficient funding.,, Mohammed et al. also discovered that religious and cultural norms were the major barriers to uptake of NHIS in northern Nigeria. In Kebbi State, Nigeria, religious or cultural beliefs and inequality such as gender bias were found as the major barriers to the uptake of NHIS in the state. Similar findings were also reported by other scholars in Nigeria.,,,, A study in Ghana highlighted similar barriers, including perceived poor quality of services, negative attitude of service providers, culture, and religious belief. Overcoming these barriers requires regular awareness and quality interventions for the general public and service providers. The government also needs to provide social infrastructures such as steady and stable electricity and good roads and make funds available to implement the scheme successfully.
| Limitation|| |
The study was conducted in Makurdi Local Government Area, limiting generalization to perception in Benue State, Nigeria. However, it gives scientific facts about the limitations to achieving universal health coverage in the state. It also guides toward the required changes in strategic direction, especially for the State Ministry of Health.
| Conclusion|| |
This study revealed that most NHIS enrollees were unaware of their entitlements and benefits from the scheme; this was seen in the poor satisfaction and perception displayed by the respondents. Comparing the findings of this study with some previous studies in Nigeria shows a need for more awareness interventions across Nigeria to sensitize the citizens of the importance, objectives, and benefits of the scheme. Service providers also need to scale up the quality of services offered to their clients; this will, in turn, enhance clients’ satisfaction and thus increase the scheme’s uptake. Successful implementation and sustainability of this scheme require direct and full support from the government. Making funds available and providing social infrastructures will significantly promote the successful implementation of the scheme in Nigeria. More in-depth studies would also be suggested.
Approval was obtained from the Institutional Ethical Committee, Ministry of Health and Human Services, Government of Benue State of Nigeria for undertaking the study on “The perception of providers of health insurance and enrollees accessing healthcare facilities on the barriers to uptake of National Health Insurance Scheme,” which has been obtained vide letter no. MPH/STA/204/Vol.1/40, dated October 27, 2017.
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]