The IUs’ experiences of the responsiveness of health care services within the NHIS were assessed in this study, according to several responsiveness domains. The performance of each domain during the implementation period (since 2005) of the NHIS was determined and the relative importance of each was also investigated. Scientifically, there is a tradition of both evaluating responsiveness and assessing the importance of its related domains when studying the health care services of any health system or program [9, 10]. The importance attached to each domain by the users might augment their respective expectations, which are, in turn, contextually related to their country’s general perception [9, 10]. Furthermore, the IUs’ factors and concerns, potentially related to responsiveness domains, were examined based on their experiences with the NHIS. Principal enrolees with more than one year in the insurance scheme were considered to have relevant experiences that could provide information on the responsiveness domains. The findings of this study are discussed according to the responsiveness domains.
Prompt attention
The domain of prompt attention was poorly rated by the IUs. Valentine et al. [10] explained that this domain covers people’s experience with access to rapid care and short waiting periods for treatment. Previous studies have shown that lack of prompt attention by providers, due to delays in administrative processes and settling of insurance claims, negatively affects the IU’s encounter with health care services [9, 10, 24]. The evidence from our findings suggests that the NHIS should ensure that IUs receive the necessary healthcare within an appropriate time period, either in public or private health facilities. Active monitoring might help promote and enhance prompt attention to the IUs.
Our findings are similar to those of other studies in Nigeria, Ghana and South-Africa where the type of facility was found to influence prompt attention: the public providers performed poorly in the domain of prompt attention compared to private providers [25, 26, 29]. Several studies explain that the poor performance of public providers is attributable to giving patients an appointment for a particular day without a specific patient consultation time [25], high patient numbers exceeding the capacity of public facilities [25], poor quality of public services [30], especially poor attitude of providers versus the insured-users and bad interpersonal relationships [17, 29].
Male IUs were found in our study to rate the prompt attention domain higher than female IUs. In a male dominated society like Nigeria, a possible explanation may be that males are given priority over females during demand for services. If this interpretation is correct, attention should be focused on females receiving equal priority in these services. We found the likelihood that, IUs who had ever been referred for secondary or tertiary care rated higher in the prompt attention domain. This may not be surprising, because a cross-countries analysis by Valentine et al. [10] suggested the possibility that people who were referred for secondary or tertiary care might have been favoured by the providers.
Dignity
In Nigeria, dignity of users is explicitly considered as an important element of responsiveness within health care services [25]. Similarly, we found users of health care services rated their contentment with this domain second highest in the NHIS. Similar to the World Health Report 2000, Valentine et al. [10] revealed that the domain of dignity assures users of health care services receive care in a respectful, caring and non-discriminative manner. Generally, our findings suggest that IUs were treated with some respect by providers of health care services. It has been suggested that good program incentives given to providers could influence their behavior towards patients [10].
In our study, IUs of public facilities reported being treated with less dignity than those of private facilities. This observation agrees with earlier reports which found that private providers show more respect for patients’ dignity than public providers [22, 25, 26]. A cross-country comparative analysis at aggregate level showed countries where education is higher experience higher levels of dignity [22]; however, in a country with low levels of education, we also observed at the individual level that highly educated IUs received more respect by providers than poorly educated IUs. It appears relevant that the NHIS promotes respect for patients’ dignity. One approach to improve client-provider relationships and to encourage improved interactions might be to provide the necessary informational materials to both the IUs and health care providers.
Communication
As in other parts of the world, communication was found to be of high importance in Nigeria [9, 25]. Communication should assure clear patient-provider interactions and Valentine et al. [10] explained that clarity of communication implies that the provider listens carefully to patient’s concerns and explains about an illness’ symptoms, treatment and implications. Furthermore, studies have shown that this communication has to be done in a comprehensive manner which permits the patient to ask follow-up questions [10, 31]. However, we found the IUs in our study were not pleased with this domain. Overall, our findings revealed that IUs in the NHIS felt that providers did not listen to them with sufficient concern related to their illness and also did not always give the chance to ask follow-up questions.
We observed that IUs using public facilities reported relatively better communication than those using private facilities. This finding is consistent with earlier observations and implies that private providers are less likely to provide a good chance for communication with patients [9, 10, 25]. We also found that IUs with lower income were more pleased with the information given by and interactions with providers. A previous study in Nigeria showed that IUs’ knowledge of the NHIS is an important positive determinant of contentment with health care services [17]. In addition, a further possible explanation might be that IUs with high income levels have higher expectations from their health care services.
This study indicates that IUs with a shorter duration of enrolment were more likely to be pleased with communication than those with a longer enrolment in the NHIS. Previous studies have cautioned that poor attitudes of providers and high expectations by IUs could have future adverse consequences on health care services [29]. Our observation that IUs who had been referred to secondary or tertiary care were relatively less pleased with communication by the providers, suggests that improving the referral system might mitigate some of the challenges faced by both IUs and providers in the NHIS.
Autonomy
IUs identified “autonomy” as weakly important for responsiveness, and this is similar to another related study in Nigeria [25]. Moreover, we found that IUs were least contented with the “autonomy” domain related to NHIS services. Several studies have explained that this “autonomy domain” incorporates the concept of empowerment, where users have the right to medical information, make informed choices and may refuse medical treatment [10, 32]. This implies that the providers should involve the patients (and their families where appropriate) in the decision-making process of the treatments [10]. Based on our findings, the IUs were not involved as much as they’d like to be in making decisions regarding their health care treatments. Due to the asymmetry of information between patients and clinicians, the IUs lacked the necessary tools to empower themselves in the decision-making process.
We found that public providers involved IUs less in decision-making than private providers. However, males were relatively more pleased with the “autonomy” than females. By contrast, IUs with longer duration of enrolment in the NHIS were apparently less pleased with their involvement in the decision-making process of their treatment. This study suggests that the health insurance schemes should encourage patients’ empowerment in health care services. Our findings raise the possibility that IUs who were referred for secondary or tertiary care were less likely to experience autonomy. This is similar to previous studies which found that patients who are referred feel discontent with the “autonomy” rendered by the providers during referrals [9, 10].
Choice of provider
We found the “choice of provider” was the third most valued of the responsiveness domains. Valentine et al. [10] explains that this “choice of provider” domain assures that users have the choice of consulting the same providers if desired, while consulting different providers in the event of dissatisfaction. In essence, providers who know that patients have a choice of provider tend to offer quality health care services to their patients with empathy [10]. Although services in the Nigerian NHIS are purchased through a mix of public and private providers, and IUs theoretically have the option to choose their health care providers, this has not been effective in practice [12, 14]. Our findings confirm that, despite their displeasure, IUs encountered difficulties in choosing their providers. Further studies have shown delays experienced by providers in receiving authorization to offer services to clients, as well as to receive approval to refer patients across the levels of primary, secondary and tertiary care [24].
The type of facility was found to influence the “choice of provider”. This agrees with previous studies in that users of private providers are usually more contented with their choice of providers than those with public providers [9, 25, 26]. This evidence from our study suggests that the NHIS might encourage competition among public and private health care providers and concurrently promote IUs’ choice of providers in the event of dissatisfaction. Our findings revealed that low income IUs were better pleased with their “choice of provider” than those with high income status. By contrast, those practicing polygamy were more discontent with the “choice of provider” domain. A possible explanation might be that some expectations of polygamous IUs, such as the inclusion of all their family members in the NHIS, are not fulfilled [33].
Short duration of enrolment was found to increase the likelihood of a highly contented “choice of provider” response compared to a longer duration of enrolment. Possibly, the longer people were enrolled in the NHIS, the less leverage they had in “choice of provider”. We also found that IUs who were referred to secondary or tertiary care level tended to be displeased with the “choice of provider”, suggesting that the NHIS and health care providers might reasonably facilitate IUs’ choice of providers, but concurrently also avoid over-congestion by IUs of a particular facility or provider.
Quality of basic facilities
Our study agrees with others in finding that “quality of basic facilities” is important to patients in their experience of responsiveness from health care services [9, 10, 22, 25, 26]. Our findings indicate that users of the NHIS were most pleased with this domain. According to the World Health Report (2000) [9] and Valentine et al. [10], quality of basic facilities implies that health facilities have clean waiting rooms, toilet facilities, examination rooms and surroundings. We found that there are variations between the IUs characteristics and their contentment with the quality of basic facilities of the providers.
The IUs from public providers were more likely to be displeased with the quality of basic facilities than those from private providers. This implies that there is still the need for public providers to improve the quality of their basic facilities so that they can retain and attract clients. Previous studies in Nigeria and South-Africa have shown that patients who visit private health facilities are better pleased with the quality of basic facilities as compared to the public health facilities [25, 26]. We also found that IUs with lower education were displeased with the “quality of basic facilities” of health services.
This study on responsiveness of health care services within the NHIS was facility-based, but we further employed the household tracking approach (as a mop-up) to trace the IUs. During our data analysis, due to the limitations of ordinal logistic regression that inflates the effect of explanatory variables on the outcome variables, we used the generalized ordered logit regression that fits other models with less restriction and reliable interpretations [27, 28, 30]. Further similar studies should be conducted in other parts of Nigeria and LMICs to explore variations in responsiveness domains of the NHIS related to health care services. This future research should, therefore, concentrate on the investigation of possible regional variations in and comparisons between responsiveness of health care services of States in Nigeria and regions in LMICs.