Patient satisfaction with the Nigerian National Health Insurance Scheme two decades since establishment: A systematic review and recommendations for improvement.

BACKGROUND: To improve healthcare access and mitigate healthcare costs for its population, Nigeria established a National Health Insurance Scheme (NHIS) in 1999. The NHIS remains Nigeria's leading vehicle for achieving universal health coverage; nonetheless, questions remain regarding its quality and effectiveness. Studies on patient satisfaction have served as a useful strategy to further understand the patient experience and the efficacy of health systems. AIM: To synthesise current knowledge on patient satisfaction with the NHIS. METHODS: The authors performed a systematic review of primary literature from 1999 to 2020 reporting on NHIS patient satisfaction in eight databases (including PubMed, Embase, and Africa-wide Information). RESULTS: This search returned 764 unique records of which 21 met criteria for full data extraction. The 21 qualifying studies representing 11 of the 36 Nigerian states, were published from 2011 to 2020, and found moderate overall satisfaction with the NHIS (64%). Further, when disaggregated into specific domains, NHIS enrolees were most satisfied with provider attitudes (77%) and healthcare environments (70%), but less satisfied with laboratories (62%), billings (62%), pharmaceutical services (56%), wait times (55%), and referrals (51%). Importantly, time trends indicate satisfaction with the NHIS is increasing - although to differing degrees depending on the domain. CONCLUSION: The beneficiaries of the NHIS are moderately satisfied with the scheme. They consider it an improvement from being uninsured, but believe that the scheme can be considerably improved. The authors present two main recommendations: (1) shorter wait times may increase patient satisfaction and can be a central focus in improving the overall scheme, and (2) more research is needed across all 36 states to comprehensively understand patient satisfaction towards NHIS in anticipation of potential scheme expansion.

Guidelines on the use of race as patient identifiers in clinical presentations.

The value of including race as part of the patient identifier in care and medical education has been a topic of debate among clinicians, medical educators, and sociologists.1,2,6,7,8 The perceived benefit of using racial identifiers is that it may allow physicians to predict the risk of disease and inform drug therapy.9 This association is thought to be useful to medical students and trainees as they form their clinical knowledge base. However, there is a larger body of evidence that the use of race leads to bias and stereotyping by physicians. In many cases, patients are assigned to racial categorizations that are inconsistent with their self-reported identities.1,15 It is unclear which medical schools have a policy that explicitly detail their stance on this topic. In this article, we propose a frame of thinking to guide medical educators as they develop policies on race as patient identifiers.

Polypharmacy Exposure, Aging Populations, and COVID-19: Considerations for Healthcare Providers and Public Health Practitioners in Africa.

Given the continent's growing aging population and expanding prevalence of multimorbidity, polypharmacy is an increasingly dire threat to the health of persons living in Africa. The COVID-19 pandemic has only exacerbated these issues. Widespread misinformation, lack of vaccine access, and attempts to avoid being infected have resulted in increases in Africans' willingness to take multiple prescription and nonprescription medications and supplements. Issues with counterfeit pharmaceuticals and the relatively new recognition of emergency medicine as a specialty across the continent also create unique challenges for addressing this urgent public health need. Experts have called for more robust pharmaceutical regulation and healthcare/public health infrastructure investments across the continent. However, these changes take time, and more near-term strategies are needed to mitigate current health needs. In this commentary, we present a nonexhaustive set of immediately implementable recommendations that can serve as local strategies to address current polypharmacy-related health needs of Africans. Importantly, our recommendations take into consideration that not all healthcare providers are emergency medicine trained and that local trends related to polypharmacy will change over time and require ever-evolving public health initiatives. Still, by bolstering training to safeguard against provider availability biases, practicing evidence-based prescribing and shared decision making, and tracking and sharing local trends related to polypharmacy, African healthcare providers and public health practitioners can better position themselves to meet population needs. Furthermore, although these recommendations are tailored to Africans, they may also prove useful to providers and practitioners in other regions facing similar challenges.

Perspectives on the current state of Nigeria's emergency care system among participants of an emergency medicine symposium: a qualitative appraisal.

INTRODUCTION: Emergency care systems provide timely and relevant care to the acutely ill and injured. Published commentaries have characterised deficiencies in the Nigerian emergency care system and offered potential solutions but have not included the perspectives of the Nigerian public. A more inclusive approach that includes feedback from the public may help improve the Nigerian emergency care system through better understanding of the needs, values and expectations of the community. METHODS: Participants of an emergency medicine symposium participated in focus group discussions that were randomly divided into small groups led by two trained facilitators. These facilitators asked open-ended, semistructured questions to lead discussions in the English language. Participant responses were audio-recorded and transcribed verbatim into transcripts. Two independent investigators employed conventional content analysis to code the transcripts until thematic saturation was achieved. RESULTS: Three descriptive themes emerged characterising the current state of Nigeria's emergency care system as it relates to prehospital care delivery, hospital care delivery and health system governance: rudimentary, vulnerable and disconnected. At the prehospital level, concepts revolved around emergency recognition and response, ambulance and frontline providers, and cultural norms. At the hospital level, concepts centred around the health workforce, clinical competency, hospital capacity and the burden of financial hardship. At the health system level, concepts concentrated on healthcare access and healthcare financing. Opportunities for emergency care system improvement at each component level were identified and explored. CONCLUSIONS: The participants in this study identified shortcomings and opportunities to improve prehospital care, hospital care and health system governance. The results of this study may help healthcare professionals, policy makers and community leaders identify gaps in the emergency care system and offer solutions in harmony with the needs, values and expectations of the community. If successful, these community-informed interventions may serve as a model to improve emergency care systems throughout Africa.

Emergency medicine as a career: Knowledge, attitudes and predictors in Nigerian medical students.

INTRODUCTION: Despite the high burden of deaths from emergency conditions in Nigeria, there are no formal emergency medicine (EM) residency programs in the country. Due to the absence of training programs in the country, we hypothesised that there may be a lack of awareness of these benefits of specialised emergency care among medical students and also a lack of interest in it. In this study, we assessed the knowledge and attitude of Nigerian medical students towards EM specialty and their willingness to undergo EM training. METHODS: Online surveys were shared among medical students in six selected medical schools, one in each of the six geo-political zones in Nigeria. The surveys were designed to assess the knowledge of, attitude towards, and interest in EM residency programs. A total of 439 responses were received and analysed using Epi Info 7 analytical software. RESULTS: Among the 439 respondents, the average knowledge score was 27.5%. Thirty-three percent (CI 28%-37%) of all the respondents had good knowledge about the availability of and opportunities in EM. Good knowledge was determined by a score of >50% on the knowledge portion of the survey, 97%% (CI 96%-99%) of the respondents felt that EM training program should be established in Nigeria and 20.5% % (CI 17%-25%) of the respondents were interested in pursuing EM as a specialty of choice. CONCLUSION: Our research showed that there is a low level of knowledge about EM residency training programs among Nigerian medical students. This is likely secondary to the current absence of these programs in Nigeria. Almost all of the respondents felt that an EM training program should be established and a substantial number of medical students indicated an interest in pursuing the specialty.

Results from the implementation of the World Health Organization Basic Emergency Care Course in Lagos, Nigeria.

Background: The emergency care of time-sensitive injuries and illnesses is increasingly recognized as an essential component of effective health care systems. However, many low- and middle-income countries (LMICs) lack healthcare providers formally trained in the care of emergency conditions. The Disease Control Priorities 3 project estimates that effective emergency care systems could avert up to half of all premature deaths in LMICs. Nigeria, a lower-middle income country of nearly 200 million people in Sub-Saharan Africa, could save approximately 100,000 lives per year with an effective emergency care system. The World Health Organization developed the Basic Emergency Care (BEC) course to train frontline healthcare workers in the management of emergency conditions in low resource settings. In this study we describe our work implementing the BEC course Nigeria. Methods: This study was designed as a mixed methods research analysis comparing pre- and post- course examination results and surveys to evaluate participant knowledge acquisition and levels of confidence with management of various emergency conditions. Thirty-two participants were involved in the course which took place over four days at the Lagos University Teaching hospital. Quantitative data was analyzed using Stata 14.2 (College Station, TX). Paired data sets were analyzed using McNemar's chi-squared. Unpaired data sets were analyzed using a Wilcoxon signed-rank test. Results: Post-course test scores showed significant improvement (p-value <0.001) as compared to pre-course. The average pre-course test score was 73% and average post-course score was 86.5%. Pre- and post-course questionnaires demonstrated significantly increased confidence in managing emergency conditions and agreement with course objectives. Conclusions: The WHO Basic Emergency Care (BEC) course successfully increased the knowledge and confidence of frontline emergency care providers in Nigeria. The course was well received by participants. Future study should focus on BEC course scalability and long-term knowledge retention.

Patient satisfaction with the Nigerian National Health Insurance Scheme two decades since establishment: A systematic review and recommendations for improvement

Background: To improve healthcare access and mitigate healthcare costs for its population, Nigeria established a National Health Insurance Scheme (NHIS) in 1999. The NHIS remains Nigeria's leading vehicle for achieving universal health coverage; nonetheless, questions remain regarding its quality and effectiveness. Studies on patient satisfaction have served as a useful strategy to further understand the patient experience and the efficacy of health systems. Aim: To synthesise current knowledge on patient satisfaction with the NHIS. Methods: The authors performed a systematic review of primary literature from 1999 to 2020 reporting on NHIS patient satisfaction in eight databases (including PubMed, Embase, and Africa-wide Information). Results: This search returned 764 unique records of which 21 met criteria for full data extraction. The 21 qualifying studies representing 11 of the 36 Nigerian states, were published from 2011 to 2020, and found moderate overall satisfaction with the NHIS (64%). Further, when disaggregated into specific domains, NHIS enrolees were most satisfied with provider attitudes (77%) and healthcare environments (70%), but less satisfied with laboratories (62%), billings (62%), pharmaceutical services (56%), wait times (55%), and referrals (51%). Importantly, time trends indicate satisfaction with the NHIS is increasing ­ although to differing degrees depending on the domain. Conclusion: The beneficiaries of the NHIS are moderately satisfied with the scheme. They consider it an improvement from being uninsured, but believe that the scheme can be considerably improved. The authors present two main recommendations: (1) shorter wait times may increase patient satisfaction and can be a central focus in improving the overall scheme, and (2) more research is needed across all 36 states to comprehensively understand patient satisfaction towards NHIS in anticipation of potential scheme expansion