Assessment of patient satisfaction with healthcare delivery: A comparative study among insured and uninsured patients

INTRODUCTION

Concerted efforts targeted at improving access to quality and affordable health care are being made globally. Social health insurance has been identified as an effective intervention to improve access to healthcare delivery as it provides a medium through which revenue can be mobilized and used to provide healthcare services to the general population at a minimal cost.^[1] It is a social security system that provides required healthcare services to people after the due payment of a token contribution at specified intervals.^[2] In Nigeria, social health insurance, termed the National Health Insurance Scheme (NHIS), was established by the Federal Government with the aim of providing affordable healthcare services to the Nigerian people.

The measure of patient satisfaction can be described as a subjective assessment of the quality of healthcare services, as it is the patient’s perception of the quality and outcome of healthcare services. It is also described as the extent to which patients perceive that their overall well-being, needs, and expectations have been met through the healthcare services provided.^[3,4] It is an important parameter that can be used to audit and improve services offered by health systems, as it reflects the quality of care provided.

Research findings have shown a correlation between satisfaction and utilization of healthcare services.^[5] Satisfaction with health services has also been reported to be a determinant of treatment outcomes.^[6] There is a link between patient satisfaction with healthcare delivery and compliance with medical recommendations, including keeping clinic appointments and adherence to prescribed medications.^[2,7] Hence, patient satisfaction can affect the sustainability of an implemented healthcare intervention program.^[2]

A number of factors associated with patients’ satisfaction with healthcare services have been identified. These factors include the neatness of the facility/environment, the patient-healthcare provider relationship, ease with which patients access care, ease of payment for services, clinic waiting time, and the attitude of healthcare providers.^[1,6,8,9] A number of studies comparatively evaluating satisfaction with healthcare services between insured and uninsured patients have been conducted to provide valuable insights into understanding the relationship between health insurance status and satisfaction with care. Findings from some of these studies conducted in non-Nigerian populations indicate that insured persons are more likely to be satisfied with healthcare delivery than uninsured persons.^[10,11] A similar study in Nigeria, with a unique healthcare system that is characterized by disparities in resource allocation, access, and quality^[12] is therefore necessary. Moreover, previous studies in Nigeria that evaluated patients’ satisfaction with healthcare services offered under the NHIS have reported contrasting findings. The NHIS still remains the country’s most viable pathway to attaining the World Health Organization’s sustainable development goal of universal health coverage by the year 2030. However, the country seems to be far from attaining this feat.^[13] This study was thus undertaken to comparatively evaluate satisfaction with the quality of healthcare delivery among uninsured patients and patients insured under the NHIS.

MATERIALS AND METHODS

RESULTS

DISCUSSION

Patient satisfaction, usually viewed as a patient’s perception and assessment of the quality of healthcare services provided, is an important parameter for consideration in the assessment of the quality of healthcare delivery.^[14] Our study, conducted among insured and uninsured patients receiving care at a public tertiary healthcare facility in southern Nigeria, found a statistically significant difference in the satisfaction with healthcare delivery between uninsured patients and patients insured under the county’s NHIS. Patients who received care under the health insurance scheme were more satisfied with healthcare delivery in the facility than the uninsured patients. Previous studies carried out in Nigeria among patients who received care under the NHIS have reported a high level of satisfaction.^[3,18-21] Similar studies on satisfaction with healthcare delivery among insured patient populations in Europe and Asia have also reported high overall patient satisfaction scores.^[22,23]

An item-by-item comparative assessment of satisfaction with healthcare delivery between the uninsured and insured patients in our study revealed that the patients insured under the NHIS were significantly more satisfied with the access to information and guidance on healthcare services and procedures provided in the hospital than the uninsured patients. The insured patients were also significantly more satisfied with the convenience of using available medical services in the hospital, the explanation and guidance received from physicians in the hospital, the services provided by the nurses; inter-professional collaboration among clinicians, and the clinic waiting time. Research findings have shown that patients who are more satisfied with healthcare services are more likely to utilize available clinical services, keep clinic appointments, and adhere to treatment recommendations, and thus, satisfaction with care is a predictor of treatment outcomes.^[2,6,7,9]

The extent of a patient’s satisfaction with healthcare intervention program influences their perception or attitude and responsiveness toward such program. The reluctance to access healthcare services among members of a population can be attributed to their level of satisfaction with the services provided. A similar study in South East Nigeria by Ele et al. reported that patients who enrolled into the NHIS were relatively satisfied with the patient–staff relationship, including patient–staff communication and information dissemination.^[15] Their report also showed that the patients were satisfied with the clinic’s waiting time. On the other hand, a previous study in a hospital in Port-Harcourt, Nigeria, showed patient dissatisfaction with clinic waiting time.^[14] Delays in attending to patients at different service points in the hospital may affect patient perception of the quality of care provided, causing patients to seek alternative means of meeting their healthcare needs. Long waiting time in hospitals is commonly attributed to a large volume of patients assessing care in the hospital and insufficient clinical personnel. Implementing measures to reduce clinic waiting time may boost satisfaction with healthcare services among patients.^[16]

We found no significant difference in the level of satisfaction with the clinic infrastructure/neatness, pharmaceutical services, availability of drugs, and quality of drugs between the insured and uninsured patients. Enrollees of the NHIS in a study in Port-Harcourt, Nigeria, by Olamuyiwa and Adeniji expressed satisfaction with the level of cleanliness of the clinic where they received healthcare services under the insurance scheme.^[14] This is similar to the findings of previous studies where majority of the patients rated the clinic environment as being comfortable, clean, and suitable for healthcare delivery.^[24,25] A report from Yola, Northern Nigeria, showed that majority of the patients were dissatisfied with the availability of drugs in the healthcare facility.^[16] This appears to be a common finding, as other studies in different parts of the country have reported similar results.^[9,18] When prescribed drugs are not available in the hospital where insured clients receive care, they are compelled to make out-of-pocket payments to obtain the medications at pharmacies outside the hospital, thus negating the essence of the insurance scheme, undermining its primary purpose, and may contribute to the feeling of dissatisfaction among the insured patients. A study at an NHIS clinic in southeastern Nigeria found that non-availability of drugs was a common complaint among the insured patients. Other complaints from the enrollees of the insurance scheme reported in the study were poor services, long waiting times, poor attitude of members of staff, and denial of services.^[21]

The non-availability of essential medicines, which appears to be a frequently occurring situation in many government-operated hospitals in the country, may be due to delays in the release of funds for drug purchase caused by the bureaucratic administrative procedures in these hospitals.

The results of our study also showed that gender, age, the level of education, marital status, and the presence of a chronic medical condition were predictors of satisfaction with healthcare delivery among patients insured under the NHIS. Evidence derived from studies suggests that the interaction between patient sociodemographic variables and factors within the healthcare system varies and thus results in varied determinants of satisfaction with healthcare services among its users.^[5,26,27] In our study, younger age was a predictor of satisfaction. Several studies have also identified age as a predictor of satisfaction with healthcare services. For example, Adewole et al. had reported that younger age was a predictor of satisfaction with healthcare services among enrollees of the NHIS in Ibadan, Nigeria.^[5] Another study in Ethiopia had also suggested that younger patients are more likely to be satisfied with healthcare services than older patients.^[27] This finding is also corroborated by other reports from Europe and Africa.^[28,29] The higher degree of satisfaction that is reported among younger persons may be due to the absence of certain chronic coexisting diseases in this population of patients. Unlike the young, elderly patients often present with multiple morbidities and thus tend to be less easily satisfied with the provision of basic healthcare services.^[5]

We did not find salary range as a predictor of satisfaction among the insured respondents. However, for the uninsured, the salary range was negatively correlated and a predictor of satisfaction with care. This is probably because, unlike the insured, the uninsured made out-of-pocket payments before being able to access healthcare. Out-of-pocket payment is the predominant healthcare financing mechanism in Nigeria. It limits access to healthcare services for poor households and individuals with low financial purchasing power. It also hinders the attainment of universal health coverage and may negatively affect the health-seeking behavior of the people.^[30,31]

Our results show that among the insured patients, those with a higher level of education were more likely to be satisfied with healthcare services received than those with a lower level of education. It is at variance with the findings from an earlier investigation among women receiving ante-natal care services, which found that women with lower levels of education were more likely to be satisfied with healthcare services than those who attained a tertiary level of education.^[32] It is also inconsistent with that of Seenivasan et al., who reported a lower level of satisfaction with healthcare services among highly educated people seeking care at a dental clinic.^[33] Persons with higher levels of education are believed to have better access to information regarding best healthcare practices and services available in various settings than less educated persons,^[5] thus the expectation of a high-quality healthcare service delivery may be found more among those with a higher level of education. These high expectations, if not met, may affect their level of satisfaction with the services actually provided, as it is believed that people with low expectations of quality of healthcare services are more easily satisfied with the service provided than those with a higher level of expectation.^[5]

The findings of this study may not be a true reflection of the entire Nigerian healthcare system, as it is limited in generalizability because only one facility was used in the study. Furthermore, the study relied on self-reported data from patients, which may be subject to recall and social desirability bias. Furthermore, there may be a risk of selection bias in the sampling, as patients who were willing to participate in the study may differ from those who choose not to participate in the study. Moreover, without controlling for baseline differences in access or resources, it may be difficult to attribute observed satisfaction solely to the presence or absence of insurance.

Nonetheless, our findings provide valuable insights and trends to inform future efforts aimed at improving the quality of healthcare delivery in the country. The questionnaire used in this study can serve as a tool to evaluate the quality and efficacy of healthcare systems in the country.

CONCLUSION

Patients receiving care under the NHIS were more satisfied with healthcare delivery than the uninsured patients. The insured patients were significantly more satisfied with the convenience of using available medical services in the hospital, the explanation and guidance received from physicians in the hospital, the services provided by the nurses, inter-professional collaboration among clinicians, and the clinic waiting time. Gender, age, the level of education, marital status, and the presence of a chronic medical condition were determinants of satisfaction with healthcare delivery among the NHIS enrollees. Targeted interventions to address disparities in healthcare delivery are thus necessary.