Perceptions of healthcare finance and system quality among Nigerian healthcare workers

Background: Nigeria’s healthcare system faces significant challenges in financing and quality, impacting the delivery of services to its growing population. This study investigates healthcare workers’ perceptions of these challenges and their implications for healthcare policy and practice.

Methods: A cross-sectional survey was conducted with 600 healthcare professionals from eight states across Nigeria, representing a variety of healthcare occupations. Participants completed a questionnaire that assessed their perceptions of healthcare financing, quality of care, job satisfaction, and motivation using a 5-point Likert scale, closed- and open-ended questions. Descriptive statistics, Chi-squared test, and regression analysis were used to analyze the data.

Results: The findings revealed that healthcare workers were generally not satisfied with the current state of healthcare financing and system quality in Nigeria. Poor funding, inadequate infrastructure, insufficient staffing, and limited access to essential resources were identified as major challenges. These challenges contributed to low job satisfaction, demotivation, and a desire to leave the profession. Socioeconomic factors, location State of practice, professional designation (clinical vs nonclinical), clinical designation (profession), and employment type (full-time vs part-time) were found to influence healthcare workers' perceptions (p < 0.05).

Conclusion: The findings indicated a need to improve healthcare workers' satisfaction and retention, and quality of care in Nigeria, by increasing healthcare funding, transparent fund management protocols, investing in infrastructure and human resource development, and addressing regional healthcare disparities. By implementing these reforms, Nigeria can enhance the quality and accessibility of healthcare services and improve the health and well-being of its citizens.

Methods
Research Design

This study employed a quantitative cross-sectional survey design to assess healthcare workers’ perceptions of quality, challenges, and best financing interventions within the Nigerian healthcare system over the preceding period.

Population and Scope

The research focuses on healthcare workers in Nigeria, a West African nation (Figure 1) with a population exceeding 220 million as of 2024 (Worldometer, 2024).

The nine States selected for the study have a combined population of 72,025,500.  Nigeria has an overall estimated healthcare worker density of 19.97 per 10,000 individuals (WHO, 2023). Therefore, the target population for the study was 143,835 healthcare workers in addition to some non-clinical healthcare workers who are working in Nigerian government health facilities currently or within the last year  (WHO, 2023).

Healthcare workers were sampled from two randomly selected representative States in each of five geopolitical zones (except one for the South-east, the smallest geopolitical zone), capturing Nigeria’s cultural and economic diversity. The North-east zone was excluded due to logistic difficulties.   The States are Kwara and Plateau (North-central); Kano and Kaduna (North-west); Lagos and Oyo (South-west); Delta and Rivers (South-south); and Enugu (South-east geopolitical zone) (Figure 1).

Sample Size Determination:

The sample size was calculated with the formula Z^2*p*q / m^2, {where Z = 1.96 at 95% Confidence Interval, p = 0.5 (incidence rate), q = 0.5 (non–incidence rate) and m = 0.05 (Margin of error)} using a total healthcare workers population of 143,835 across the nine States. The resultant sample of 384, predominantly comprised of clinical healthcare workers, was proportionately selected across the nine states (Table 1). For inclusiveness, a broader range of perspectives, enhanced statistical power, and representativeness in the selected States, non-clinical healthcare workers were added to the sample.

In Nigeria, the proportion of clinical and non-clinical team members is approximately 65% to 35%, respectively, based on a pilot study conducted in Edo and Imo States. This is unlike the composition of the estimated 19.97 density reported by the WHO which significantly excludes the non-clinical staff from the measurement even though they closely interact with the healthcare system and typically make up about half of the healthcare staff (Health, 2018).  An additional sample of 216 (36%) non-clinical workers was, therefore, selected during the survey to increase the initial sample size to a target of 600 participants (Table 1).

                Table 1: Sample size determination.

State (Locations)

Total Population (N)**

+Estimated Healthcare Workers [N/10,000)*19.97]

Targeted Sample

Clinical

Non-Clinical

Total

Lagos

13,481,800

26,923

72

38

110

Delta

5,636,000

11,255

30

19

49

Kwara

3,551,000

7,091

19

21

40

Plateau

4,717,300

9,420

25

12

37

Kano

15,462,200

30,878

82

34

116

Enugu

4,690,100

9,366

25

13

38

Kaduna

9,032,200

18,037

48

25

73

Rivers

7,478,800

14,935

40

31

71

Oyo

7,976,100

15,928

43

24

67

Total

72,025,500

143,835

384

216

600

+ Average National Healthcare workers density applied **projected (CityPopulation, 2024).

Data Collection Tools

Data was collected via a structured questionnaire in print and online on Google Forms, measuring sociodemographic data, perceptions of healthcare quality, challenges, and areas of improvement as developed based on Donabedian healthcare quality assessment model (Donabedian, 1988), the SERVIQUAL framework (Parasuraman et al., 1988), Mosadeghrad conceptual framework for quality of care (Mosadeghrad, 2012) as applied by other similar studies (Akinyinka et al., 2019), as well as the Patient Satisfaction Questionnaire (PSQ-18) which is used for the measurement of patient satisfaction with the medical care received (RAND, 2023). It was composed of both yes or no questions and a Likert scale that measured the perceptions of healthcare quality. A reliability test was conducted with two samples of 25 healthcare workers from Imo and Edo States respectively with a reliability coefficient (Cronbach alpha) of 0.70.

Data Collection Process

At least three government health facilities were randomly selected in each state and visited to engage the workers for data collection: one urban (capital city) and two semi-urban/rural areas. The selected settings were approached by providing the National Research Ethics Committee approval and research protocol to the hospital management teams who granted the Researchers access to their employees. Participants were randomly selected and engaged during the data collection with print paper and online questionnaires, proof of ethical clearance, and consent forms provided to each participant to review and sign before interviews or provision of responses. Some respondents were accessed online via social media groups and emailing lists.

Data Analysis

The survey was conducted between 8/6/2023 and 20/8/2023 and the data was collated with Google sheet and transferred to Microsoft Excel and SPSS version 29 to be analyzed. The Likert scale evaluation of the Nigerian healthcare system, ratings were assigned as follows: 5 for Excellent, 4 for Good, 3 for Fair, 2 for Poor, and 1 for Very Poor. The cumulative scores of participants were then categorized into ranges: 6-10 for Very Poor, 11-15 for Poor, 16- 20 for Fair, 21-25 for Good, and 26-30 for Excellent. Simple frequency distributions and percentages were applied to the sociodemographic data and various variables. Multiple linear regression analysis and Chi-square test were used to evaluate relationships between the workers’ healthcare quality and system ratings and several factors like professional designations, clinical designations, type of employment, the States, and other sociodemographic attributes. The variations within each State were not examined due to the unified approach in data collection at the State level.

Ethical Consideration

The study is the healthcare workers' aspect of a compounded proposal submitted as “Critical review of healthcare financing and end-users’ quality perception in Nigeria”, which received approval from the Nigerian Health Research Ethics Committee (NHREC) with ID: IRB-23-018. The research is designed to separately access healthcare workers and the patient’s perspectives on healthcare financing and the quality of care they receive using separate questionnaires as approved. This ethical process ensured that voluntary participation, anonymity, and secure data storage, were observed throughout this research. Also, written consents were obtained from each participant prior to their participation in the study.