OPUS 4 | Satisfaction and retention among NHIS enrollees at a tertiary hospital in Ebonyi State, Nigeria: facility-based insights for community-based health insurance policy

Background: The National Health Insurance Scheme (NHIS) in Nigeria aims to improve access to healthcare and reduce out-of-pocket payments, yet persistent dissatisfaction with NHIS-provided services threatens enrollee retention and scheme sustainability. This study assessed satisfaction and willingness to retain NHIS membership among enrollees at a tertiary hospital in Ebonyi State and explored implications for community-based health insurance policy and service-delivery reform. Methods: We conducted a convergent parallel mixed-methods study comprising a survey of 376 NHIS enrollees attending outpatient clinics at Alex Ekwueme University Teaching Hospital, Abakaliki, and in-depth phenomenological interviews with with 20 enrollees (10 males, 10 females, aged 24–68 years, NHIS enrolment 5–11 years). Convenience sampling was used. Satisfaction with NHIS services was measured using a 4-point Likert scale, and associations with willingness to retain membership were examined using chi-square tests, Cramér’s V and predictive Lambda at p<0.05. Qualitative data were analysed thematically with MAXQDA to contextualise service-delivery experiences and retention decisions. Results: Respondents (n=376; age 21–65 years) were predominantly middle-aged, female, married, tertiary educated and employed as civil servants, with most reporting access to healthcare. Overall, 61.8% of enrollees were satisfied with NHIS services, and satisfaction strongly predicted willingness to retain membership (Χ2=121.14, df=1; Cramér’s V=0.57; p <0.0001); 74.4% of those willing to retain membership reported being satisfied. Predictive Lambda indicated that knowing satisfaction status substantially improved prediction of retention (λ[A from B]=0.83 vs. λ[B from A]=0.79). Qualitative findings highlighted long waiting times, drug stock-outs, bureaucratic inefficiencies and poor provider–patient interactions as major sources of dissatisfaction, particularly among rural and lower-income enrollees. Conclusions: This single-centre mixed-methods study shows that while nearly two-thirds of NHIS enrollees were satisfied with the quality and affordability of scheme-provided services, persistent service-delivery gaps and administrative bottlenecks undermine retention intentions. Policy adjustments that prioritise improving service delivery, addressing administrative inefficiencies and strengthening provider–patient relationships are likely to enhance satisfaction and retention within the NHIS. These findings also offer practical insights for the design and scaling of community-based health insurance and related service-delivery reforms in similar mixed urban–rural settings, and for advancing equity-focused progress towards universal health coverage and related Sustainable Development Goals.