Patient satisfaction among national health insurance enrollees in an accredited hospital of Kathmandu Valley: A cross-sectional, mixed methods study

Background: The national health insurance program was piloted in 2016 in Nepal with a political commitment of reducing out-of-pocket expenditure and improving access to quality healthcare services. However, it has been facing challenges of declining renewal rates and high drop-outs over the years. The study sought to assess patient satisfaction and factors influencing satisfaction among national health insurance enrollees. Method: A sequential explanatory mixed methods study was conducted in a provincial government hospital of Nepal. Patient satisfaction was first assessed among 391 insured patients, followed by in-depth interviews with seven healthcare providers to explore barriers to healthcare provision underlying the observed levels of patient satisfaction in quantitative survey. Both insured patients and providers were purposively selected. Quantitative data was analyzed using descriptive and bivariate analysis, as well as ordinal logistic regression, while qualitative data were analyzed thematically. Lastly, an integrative analysis was undertaken to synthesize and draw inferences from both the quantitative and qualitative findings. Findings: The satisfaction was recorded as highest in the domain of interpersonal manner (79.54%) and lowest in the domain of accessibility and convenience (32.33%). Medicine availability stood as a strong predictor of patient satisfaction across multiple satisfaction domains which was validated by the qualitative findings. Qualitative findings revealed barriers to provision of healthcare including explanations to the observed levels of satisfaction: limited resources, medicine stock-outs, delays in reimbursement, and ex-post moral hazard among service users. Interpretation: The study gives insights into both patient-based and provider-based determinants of patient satisfaction. The findings provide recommendations for maintaining an uninterrupted medicine supply chain under the insurance benefit package and necessitate the allocation of enrollees according to the human resource capacity of health institutions which can influence the perceived quality of health services for the long-term sustainability of the insurance program.