Assessing the quality of care received by diabetes patients under the Nigeria National Health Insurance Scheme: does enrollment in health insurance matter?
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BACKGROUND AND PURPOSE OF RESEARCH: Nigeria’s National Health Insurance Scheme (NHIS) was setup to secure universal access to affordable quality care. However, after 11yrs, and despite launching different programs, NHIS coverage is still less than 3% nationally, and out-of-pocket payments (OOP) remain the major health financing mechanism. The reasons for the low level of enrollment in NHIS are not well understood. Quality of care may be a factor in enrolment. This study compares technical and perceived quality of care between NHIS enrollees and the uninsured, using diabetes as a tracer condition. It also compares OOP and generic prescription patterns by health insurance enrollment status. METHODS: We conducted a cross sectional clinic-based intercept study. Subjects were adult diabetes patients recruited from 10 NHIS accredited hospitals in Abuja, Nigeria. Data collection included survey and chart review, covering technical aspects of quality – performance of eye and feet exam and HbA1c request; perception of quality, generic medication prescribing pattern and OOP. We performed logistic regression analysis to evaluate the effect of NHIS enrollment status on the technical quality of care, perceived quality of care, generic prescribing and OOP. RESULTS: Out of 455 participants, 149 (33%) were NHIS enrollees, 10 (2%) were enrolled in private health insurance and 296 (65%) had no insurance. After adjusting for correlated data and controlling for facility, BMI, chronic disease score, age, sex, and education, patients under NHIS coverage were 0.85 times less likely to have eye exam (Cl=0.4–1.8), 0.98 times less likely to have feet exam (Cl= 0.4–2.2), and 0.98 times less likely to have A1c test requested (Cl= 0.7–1.3), compared to those without insurance. These findings were not statistically significant at alpha=0.05. On the other hand, compared to the uninsured, NHIS covered patients perceived care to be worse even though they spent significantly less, 56% (Cl=45%–69%) in OOP in public hospitals. DISCUSSION/CONCLUSION: Perception of care quality under the NHIS could be a contributory factor to the reluctance of prospective enrollees. To advance towards the goal of universal health coverage, NHIS must strengthen policy to overcome identified barriers such as medication stock outs and wait times at the facility level.