Implementation bottlenecks of the National Health Insurance program in Nepal: Paving the path towards Universal Health Coverage: A qualitative study

Abstract

Most low and low-middle income countries adopting National Health Insurance (NHI) programs to achieve Universal Health Coverage are struggling to implement the program due to underlying problems at implementation. However, there is a lack of research that focuses on these problems. The Nepal NHI program initiated in 2016 has experienced numerous implementation challenges. This qualitative study delves into the NHI program's inputs and throughputs/implementation bottlenecks. The study based in Nepal's four districts included 28 in-depth interviews, six focus group discussions, and identified 12 themes that pointed to the NHI program's inadequate inputs causing bottlenecks. The analysis employed the Grounded Theory. The main challenges identified were insufficiently defined NHI implementations guidelines, conflicting Act clauses, a lack of HIB organizational guidelines, and inadequate human resources.The major throughput bottlenecks were difficulty enrolling the insurees, the inability to select the health providers competitively and to act as a prudent purchaser of the services.These inadequate inputs and throughput bottlenecks led to negative outputs such as insurees' high dropouts, and low coverage of poor households. The NHI program's sustainability might be at stake if the identified problems persist, further exacerbated by the plummeting economic situation in the country due to COVID-19.

Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions?

“…These EAs receive 3-day training and conduct home visits to explain the NHIP, enrol households and collect the premium [ 23 ]. The EAs are not salary-based staff but are incentivized with a commission (10% of the premium amount) [ 19 ]. Local stakeholders are engaged in enrolment, entry, premium collection and community awareness activities, while provincial and federal structures are involved in monitoring and quality assurance.…”

“…According to the HIA, HIB is an autonomous entity responsible for purchasing and managing NHIP services. But in reality, HIB is indirectly placed under the jurisdiction of the MoHP [ 19 , 50 ]. For instance, MoHP nominates the board members of HIB, examines the balance sheet and approves the organization and management (O&M) structure.…”

“…However, the policy provisions for local and provincial governments are still inadequate [ 63 ]. Some local and provincial governments have allocated resources to NHIP; however, their financial contribution seems invisible due to poor reporting systems [ 19 ].…”

“…Fund pooling (including premium collection) occurs through different mechanisms. The federal government pays the premium for targeted populations, while provincial and local governments and some nongovernmental organizations also pay the premium for poor and marginalized people [ 19 ]. The providers claim the expenses through the insurance management information system (IMIS) and are later reimbursed after necessary verification from HIB.…”

“…The NHIP is a social health protection programme implemented by the Government of Nepal to provide quality healthcare to its citizens without financial hardship. The programme is designed to help prevent people from becoming impoverished due to healthcare expenditures incurred because of accidents or illness [ 19 ]. NHIP also promotes high-quality healthcare for all, by addressing barriers to service utilization and ensuring equity and access for all.…”