The Effect of Citizenship status on Satisfaction with Healthcare Services: Implications for Policymaking in Qatar
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Objectives Using data collected before the roll out of the Qatar National Health Insurance Scheme, this study explores the role of citizenship as a predictor of general satisfaction with healthcare services and its potential interaction with utilization and health insurance type. These questions are particularly relevant in light of the goals and expansion of the new insurance scheme. Methods A population-based survey was commissioned by the Supreme Council of Health and conducted by the Social and Economic Survey Research Institute in 2012. A probability-based sampling approach was used to select a representative sample of citizens and non-citizens, 18 years of age or older. Of the 3,080 who completed face-to-face roster interviews, 2,751 reported their opinion about Qatar’s healthcare system, regardless of recent utilization. General satisfaction was measured on a 1-to-5 Likert scale. Dissatisfied respondents were asked to select up to three reasons for their discontent from a pre-coded list with an additional choice of an open-ended response. Information was collected on self-reported health status, utilization, private health insurance, age, gender, education, and income. In addition to bivariate analyses, multivariable logistic regression models were fit to data to estimate the main effects of citizenship on overall satisfaction with healthcare services while accounting for other predictors. Two interaction terms were introduced to test for whether associations between utilization or private health insurance and general satisfaction differed by citizenship status. All statistical analyses were weighted and carried out in STATA version 13. Results In the combined model adjusting for all variables, a statistically significant negative association was found between citizenship status and overall satisfaction (OR=0.43, p<0.001). No evidence that the association between private health insurance and overall satisfaction was different among citizens and non-citizens (p=0.1). However, a significant interaction was found between citizenship status and utilization of healthcare services on overall satisfaction (p<0.05). The design adjusted Wald test comparing models with and without citizenship by utilization interaction was significant (p>0.001). In the citizen model adjusting for all variables, users were more likely to be satisfied than non-users (OR=1.87, p<0.01). Females were more satisfied than males (OR=1.81, p<0.01) and those with any private health insurance than no private coverage (OR=1.7, p=0.07). Outpatient users were more likely to be satisfied than non-users (OR=1.82, p<0.05), but a weaker association was detected for inpatient users relative to non-users (OR=1.1, p=0.79). Conclusion Citizenship status emerged as an important predictor of general satisfaction with healthcare services above and beyond previously identified determinants. Utilization to general satisfaction association differed for citizens and non-citizens. Among the Qataris, non-users were less likely to be satisfied than users while users were less likely to be satisfied relative to non-users among the non-Qataris. This may suggest that expectations rather than recent experience drive satisfaction among citizens of Qatar with important implications for policy makers in this part of the world. Relative to non-users, outpatient rather than inpatient services were the strongest driver of satisfaction among Qatari users. Furthermore, among the Qataris, having any private health insurance appears to be an important predictor of general satisfaction, an indication that the advent of QNHIS may garner more satisfaction from citizens in the future.
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