| Abstract|| |
Introduction: Consumer satisfaction is one of the driving goals of goods and service production. Patient satisfaction surveys, as a means of periodic evaluation of the quality of services offered by the National Health Insurance Scheme (NHIS) accredited facilities, is necessary to ensure that the goals of the scheme are achieved and sustained. Materials and Methods: This was a cross-sectional study of 202 respondents randomly selected from NHIS enrolees attending the Staff Clinic of Aminu Kano Teaching Hospital. It assessed respondents' perceived waiting time, level of satisfaction at the clinic's service units, and overall clinic satisfaction using a modified general practice assessment questionnaire. Results: The mean age of respondents was 36.4 ± 8.1 with a near equal sex ratio. They were predominantly civil servants (79.2%) with tertiary education (75.7%). Most respondents (70.3%) felt waiting time was too long; with 79.7% of those, feeling they spend at least 30 min after arrival at the registration unit to see their doctor. A majority of respondents: 90.1%, 86.8%, 79%, 76.8%, 75.9%, 77.5%, and 80.6% were satisfied with the consultation time, doctors' consultation, medical records, pharmacy, laboratory, accounts, and nursing services, respectively. However, 65.8% were satisfied with the overall clinic services. The perceived sufficiency of the consultation time was associated with overall satisfaction (χ2 = 6.199, P = 0.013). Conclusion: Although 65.8% of respondents were satisfied with the clinic services, the perceived clinic waiting time was dissatisfactory; therefore, further studies on the determinants of overall satisfaction may be required if improvement in the proportion of satisfied service consumers is desired by the clinic managers.
Keywords: Health insurance, patient satisfaction, primary care, staff clinic
|How to cite this article:|
Michael GC, Suleiman HH, Grema BA, Aliyu I. Assessment of level of satisfaction of national health insurance scheme enrolees with services of an accredited health facility in Northern Nigerian. Ann Trop Med Public Health 2017;10:1271-7
|How to cite this URL:|
Michael GC, Suleiman HH, Grema BA, Aliyu I. Assessment of level of satisfaction of national health insurance scheme enrolees with services of an accredited health facility in Northern Nigerian. Ann Trop Med Public Health [serial online] 2017 [cited 2018 May 22];10:1271-7. Available from: http://www.atmph.org/text.asp?2017/10/5/1271/217527
| Introduction|| |
Health-care quality remains an important component of efforts toward achieving the sustainable development goal 3 which seeks to ensure healthy lives and promote well-being for all at all ages., Patient satisfaction surveys are important measures of health service performance and a key indicator to the quality of health services rendered by physicians, paramedical staff and other staff of a hospital. Patient satisfaction follows a patient's judgment and subsequent reactions to what they perceive of the healthcare environment just before, during and after their clinic visit. Patient satisfaction is associated with care provider's competence/courtesy, privacy, treatment outcome/cost, age, and educational status.,, It is also associated with how efficiently services are rendered by a health facility; which includes promptness of care received by patients, duration of waiting and consultation time, quick response to emergencies, the quick dispensation of drugs, fast, and accurate laboratory tests., Health service managers use patient satisfaction surveys in making important decisions regarding operational and treatment plans.
In Nigeria, the National Health Insurance Scheme (NHIS) established by Act 35 of 1999 was formally launched in 2005 to provide accessible, high-quality healthcare services to all Nigerians while protecting them from the high cost of care. After a decade of operations predominantly as the formal sector social health insurance program, anecdotal evidence shows that the quality of services provided by NHIS accredited facilities has come under criticism from many health-care consumers. Health-care consumers are demanding for the accommodation of their busy schedules, provision of useful information, and involvement in the planning of health-care services. This suggests that health-care facilities that recognize their patients as customers will ultimately develop and maintain a better competitive advantage. In addition, the enrolees of the NHIS have the right to switch providers if dissatisfied with services.
In 2012, a service utilization study at this study site revealed that 87% of the clinic users were NHIS enrolees and that high clinic service utilization and prolonged waiting time were two challenges besetting the facility. To the best of our knowledge, there had been no previous satisfaction survey at this clinic since obtaining NHIS accreditation. This study may, therefore, serve as a performance audit of the clinic services though from the patient's perspective. It may also help the clinic managers to react appropriately.
| Materials and Methods|| |
The study was a descriptive cross-sectional study among NHIS enrolees attending the staff clinic of Aminu Kano Teaching Hospital Kano (AKTH), Northwest Nigeria. The clinic serves over 2700 hospital employees and their families. It is run by family medicine senior registrars with oversight from consultant family physicians. The clinic consists of two consulting rooms with two different sets of doctors and a clinic assistant per shift. It operates from 8 am to 9 pm during weekdays (two shifts) and 8 am to 2 pm during weekends and public holidays (one shift). An average of 250 patients are seen at the clinic weekly for undifferentiated medical and nonmedical conditions on a “ first come first serve basis.” The clinic has pharmacy, account, and medical records units (MRUs) that serve the over 30,000 NHIS enrollees registered with the hospital (staff and their dependents inclusive). The MRU is run by three records officers in the morning shift (8 am–2 pm) and one for the afternoon shift (2 pm–9 pm) during week days and one records officer during weekends and public holidays. The different service units of the clinic are clearly marked for easy identification.
Using 83%, the proportion of satisfied respondents reported by Iliyasu et al. and the formula for estimating sample size for descriptive studies where the population is >10,000, a sample size of 216 was obtained. Again, using the formula for estimating sample size for populations <10,000 (n/[1 + n/N]) a sample size of 177 was subsequently obtained. An additional 10% was added for possible incomplete data and nonrespondents. Hence, a rounded off total of 200 respondents were recruited between 24th July and 21st of August 2015 (4 weeks). The systematic random sampling method was used to select every fifth patient who attended the clinic after the first had been selected by balloting. The sampling interval was obtained from the ratio of the sample size (200) to the sample frame (250/week × 4 weeks = 1000), i.e., 1:5. Patients who were 18 years and above, who had accessed care from the clinic for at least the preceding 1 year, and possessed an NHIS-enrolment card were included in the study. Patients <18 years, critically ill, the nonenrolled and those who did not consent were excluded from the study.
Ethical approval was obtained from the AKTH Research Ethics Committee. A self-administered pretested modified general practice assessment questionnaire was given to respondents in the waiting area for completion in English and Hausa (the local language) after written informed consent had been obtained and the study protocol explained. The questionnaire was originally in English language but was translated into Hausa language by a family physician and a Hausa linguistic professional experienced in health surveys and back translation into in English to check for consistency and semantic validity. The questionnaire assessed the respondents' sociodemographic characteristics (completed in the waiting area), perceived waiting time (completed just before entering the consulting room and immediately after exiting), their level of satisfaction with the individual service units and their overall satisfaction with clinic services (completed after exiting consulting room from current and previous clinic experiences).
The Likert scale response was used to assess the respondents' level of satisfaction. The respondents were asked to tick one of the following responses: satisfied, indifferent, or dissatisfied for the different service units and to tick 1, 2, 3, 4, 5 for overall satisfaction; where the satisfaction items were scored as follows: 1 = Very dissatisfied, 2 = Dissatisfied, 3 = Fairly satisfied, 4 = Satisfied, 5 = Very satisfied. Ratings of 1 and 2 were considered dissatisfied while ratings of 3, 4 and 5 were considered satisfied. The primary outcome measures were satisfaction and dissatisfaction. The perceived waiting time was defined as the time between arrival at the MRU for registration and entry into the consulting room. Respondents were asked how much time they had spent since arrival at the MRU; whether they thought they had stayed for too long since arrival (yes/no); if they felt they had stayed for too long (yes/no) and what they thought was responsible. The perceived consultation time was defined as the time interval between entering into and exiting from the consulting room. This was assessed by asking the respondents: “Was the time spent with your doctor sufficient to discuss your problems and needs?” (yes/no).
Data were entered using Epi Info Version 126.96.36.199 (CDC, Atlanta GA, USA, 2012). Categorical variables were described in percentages whereas quantitative variables were described using proportions and measures of central tendencies and dispersion. Chi-square tests were used to determine the association between sociodemographic characteristics, perceived waiting times, and overall satisfaction. P < 0.05 was considered as statistically significant.
| Results|| |
A total of 202 participants were recruited for the study and were analyzed. A slightly higher proportion of respondents were males 103 (50.99%) [Table 1]. Their ages ranged from 18 to 59 years with a mean of 36.38 ± 8.01 years. The modal age interval was the 31–40 years 132 (50.50%). One hundred and 21 (59.90%) respondents were married while 81 (40.10%) were single. One hundred and sixty-one (79.70%) respondents were principal enrollees while 41 (21.30%) were dependents. They were mostly Muslims 198 (98.02%) of the Hausa 164 (81.19%) tribe. They were predominantly civil servants 160 (79.21%) with tertiary education 153 (75.74%).
Respondents' satisfaction with services at the different service units
[Table 2] shows that most respondents were satisfied with the services offered by the medical records 150 (79.0%), doctors' consultation 164 (86.8%), pharmacy 146 (76.8%), laboratory 145 (75.9%), accounts 148 (77.5%), and nursing 158 (80.6%) units of the clinic. Fewer respondents were dissatisfied or indifferent at all the service units. However, doctors' consultation was the service unit that satisfied the highest proportion 164 (86.8%) of respondents. One hundred and thirty-three (65.84%) respondents were satisfied with clinic services [Figure 1].
Respondents' perceived waiting and consultation times
Only 41 (20.30%) respondents reported a waiting time of <30 min before seeing their doctor [Table 3]. A majority of respondents 142 (70.30%) felt they had stayed too long since arrival at the clinic and most of those 119 (83.80%) attributed the delay to either no or few doctors were available to attend to them on time or that the patients were too many. However, a preponderance of respondents 182 (90.10%) felt that the consultation time was adequate enough to discuss their problem and needs.
Relationship between respondents' sociodemographic characteristics and overall satisfaction
There were no significant associations between sociodemographic characteristics of the respondents and overall satisfaction [Table 4].
|Table 4: Relationship between respondents' sociodemographic characteristics and overall satisfaction|
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Relationship between perceived clinic times and overall satisfaction
There was no significant association between perceived waiting time and overall satisfaction (χ2 = 0.0005, P = 0.982) [Table 5]. However, perceived sufficiency of consultation time was associated with overall satisfaction (χ2 = 6.199, P = 0.013).
|Table 5: Relationship between perceived clinic waiting time, consultation time and overall clinic satisfaction|
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| Discussion|| |
Though anecdotal evidence suggested that many NHIS enrollees criticized the services rendered by accredited facilities, this study found that 65.8% of the respondents were satisfied with the services of the clinic. This proportion of respondents was higher than 52% reported in Sokoto Northwest Nigeria by Adamu and Oche among general out-patients  but lower than 83% reported earlier by Iliyasu et al. among both out-and in-patients in Kano also in northwest Nigeria and 87.5% found by Kausar et al. in India. However, these studies were done on populations without health insurance. Health insurance is known to confers certain documented service rights to the enrolee, and hence their expectations from the care provider are higher. Higher expectations are generally associated with lower satisfaction. The lower proportion of satisfied respondents found by Adamu and Oche  despite using similar tools with that of this study, may not be explained by insurance cover and relatively higher proportion of respondents with lower education alone but could be due to other unstudied variables. Furthermore, Mohammed, et al. in Zaria northwest Nigeria, also found a lower proportion of satisfied respondents (42%) but observed that those with good knowledge and/or awareness of the NHIS were more satisfied with services than those without. Our study did not assess respondents' knowledge of the scheme; whether this influenced our study finding may need to be investigated.
However, the proportion of respondents satisfied with different units of the clinic was quite high and contrasted with the proportion with overall clinic satisfaction. This suggests that there were many unstudied variables that influenced their assessment of the overall clinic services which may need to be explored in a future study. Our study found that the sociodemographic characteristics of respondent were not associated with overall satisfaction. This is at variance with the findings by Adamu and Oche in Sokoto northwest Nigeria, were the age of 35 years and above was a determinant of overall satisfaction. This difference may be due to our respondents' high level of education. Seventy-five percent of respondents in this study compared with 36% of respondents in their study had tertiary education. The high educational level is known to reduce satisfaction through increased knowledge of patients' rights and demand for better services; this may have neutralized the effect of age.,,
Furthermore, 70.3% of respondents felt that the clinic waiting time was too long. This was similar to 68% of university students dissatisfied with the clinic waiting time found by Shagaya in Zaria, Nigeria. However, our result differed from findings reported by Adamu and Oche  where half of the respondents were dissatisfied with the clinic waiting time and attributed it to lack of qualified staff, lack of appointment system and relatively higher proportion of respondents (25.7%) with lower education; it also differed from earlier findings by Bodur et al. in Turkey where less than a quarter of the respondents were dissatisfied with the clinic waiting time in the health centres studied. This study found that 83.8% of respondents who felt the waiting time was too long also felt it was due to the absence or an insufficient number of doctors to attend to them on time or that the patients were too many. This observation by the respondents' casts aspersion first, on the doctors' punctuality to their duty post even though there were no sign-in/sign-out registers during the study period and secondly, on the doctor-patient ratio. Imbalance in the doctor-patient ratio in many developing countries has been cited by some authors as a cause of prolonged waiting time in many health facilities. Few doctors are made to attend to an overwhelming number of patients. The hospital's Patient Charter recommends that a doctor sees 25–35 patients at the outpatient clinics per shift. However, high enrollee utilization of the clinic previously observed at the study site, makes this ratio to be exceeded, especially at the beginning of the week when more patients sought care. Expectedly, this will impact not only on the waiting time but also the quality of care and treatment outcome., The clinic managers may also need to improve supervision, device measures for improving staff punctuality and patient-doctor ratio.
The Institute of Medicine had recognized prolonged clinic waiting time as an important cause of dissatisfaction among healthcare consumers and recommended that at least 90% of patients should be seen within 30 min of their scheduled appointment time. However, only 20.3% of our study respondents spent <30 min before seeing their doctor. In Nigeria, Adamu and Oche had similarly reported clinic waiting time as an important predictor of overall satisfaction with clinic services. However, the perceived waiting time was not associated with overall satisfaction in our study. This could be due to the differing modes of clinic-waiting-time measurement. In this study waiting time was subjectively measured by the respondents while it was objectively measured (using time clock by the investigator) in the Sokoto study. However, we suspect that the prolonged patient waiting time observed 3 years earlier  was still existent and the clinic managers may need to investigate the modifiable and nonmodifiable patient and system factors associated with waiting times at the clinic.
The highest proportion of respondents in this study were satisfied with the doctors' consultation (86%) though closely followed by nursing services (80%). This is at variance with results reported by Adamu and Oche, Patavegar, et al., Lee and Kasper, and Ajayi  where the nursing services received the highest levels of satisfaction from respondents. The reason for the difference is not fully understood but could be as a result of the performance of the doctors in attending to their needs. This could also be inferred from the association observed between the perceived sufficient time given by doctors during their consultation and overall satisfaction.
Among the limitations of this study, was the use of 1-year clinic experience as inclusion criteria which precludes comparison of different durations of clinic usage with overall satisfaction. This will, therefore, require future research. The use of staff enrollees as respondents may have also affected some responses since it was their colleagues that were invariable been assessed.
The policy implication of this study is that the result of this study result may aid the clinic managers in recognizing and instituting strategies in dealing with the problems of dissatisfaction with services reported by 34.2% of respondents and the perceived increase in the clinic waiting time. This is necessary at a time when there are large numbers of accredited private and public hospitals competing for enrolee patronage.
| Conclusion|| |
Despite the higher proportion of respondents satisfied with the different units of the clinic, waiting time was perceived by most respondents to be prolonged and 34.2% of them were dissatisfied with overall all clinic services. Further improvements in overall satisfaction of the clinic would require investigation into the extent to which unstudied variables in the clinic's structural, interpersonal, and technical components of health care affected overall satisfaction.
The authors are grateful to the research assistants Saminu Shehu, Zainab Wada, Firdausi Sani, and staff of the family medicine department of Aminu Kano Teaching Hospital.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Godpower Chinedu Michael
Department of Family Medicine, Aminu Kano Teaching Hospital, Zaria Road, P. M. B. 3452, Kano
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]