Status and determinants of enrollment and dropout of health insurance in Nepal: an explorative study

Abstract

Background Compared to other countries in the South Asia Nepal has seen a slow progress in the coverage of health insurance. Despite of a long history of the introduction of health insurance (HI) and a high priority of the government of Nepal it has not been able to push rapidly its social health insurance to its majority of the population. There are many challenges while to achieve universal health insurance in Nepal ranging from existing policy paralysis to program operation. This study aims to identify the enrollment and dropout rates of health insurance and its determinants in selected districts of Nepal. Methods The study was conducted while using a mixed method including both quantitative and qualitative approaches. Numerical data related to enrollment and dropout rates were taken from Health Insurance Board (HIB) of Nepal. For the qualitative data, three districts, Bardiya, Chitwan, and Gorkha of Nepal were selected purposively. Enrollment assistants (EA) of social health insurance program were taken as the participants of study. Focus group discussions (FGD) were arranged with the selected EAs using specific guidelines along with unstructured questions. The results from numerical data and focus group discussions are synthesized and presented accordingly. Results The findings of the study suggested variation in enrollment and dropout of health insurance in the districts. Enrollment coverage was 13,545 (1%), 249,104 (5%), 1,159,477 (9%) and 1,676,505 (11%) from 2016 to 2019 among total population and dropout rates were 9121(67%), 110,885 (44%) and 444,967 (38%) among total enrollment from 2016 to 2018 respectively. Of total coverage, more than one-third proportion was subsidy enrollment—free enrollment for vulnerable groups. The population characteristics of unwilling and dropout in social health insurance came from relatively well-off families, government employees, businessman, migrants’ people, some local political leaders as well as the poor class families. The major determinants of poor enrollment and dropout were mainly due to unavailability of enough drugs, unfriendly behavior of health workers, and indifferent behavior of the care personnel to the insured patients in health care facilities and prefer to take health service in private clinic for their own benefits. The long maturation time to activate health service, limited health package and lack of copayment in different types of health care were the factors related to inefficient program and policy implementation. Conclusion There is a high proportion of dropout and subsidy enrollment, the key challenge for sustainability of health insurance program in Nepal. Revisiting of existing HI policy on health care packages, more choices on copayment, capacity building of enrollment assistants and better coordination between health insurance board and health care facilities can increase the enrollment and minimize the dropout.

Health System Capacity and Access Barriers to Diagnosis and Treatment of CVD and Diabetes in Nepal

“…In April 2016, Nepal rolled out its National Health Insurance Programme (NHIP) that offers health services to those enrolled on voluntary basis enrollees through public-sector and select private-sector facilities. Despite NHIPs subsidized premium rates for the socio-economically disadvantaged, its adoption remains low and cited reasons include limited access to services [ 51 52 ]. Ensuring uninterrupted supplies of medical commodities and services is a public health challenge, as Nepal is not a major local producer of medicines [ 12 ].…”

Utilisation of quality antenatal, delivery and postnatal care services in Nepal: An analysis of Service Provision Assessment

“…Women’s access to MNH services in private HFs can be improved through the scaling up of the Safe Delivery Incentive Program (SDIP) in additional private HFs. In addition, the NHIP can be linked with routine private MNH services through which OOP expenses can be reimbursed [ 36 ]. Furthermore, women should receive quality health services irrespective of the types of HFs management (private or public).…”

“…The cost of care of those services is low in public facilities but expensive in private HFs. Since 2016, Nepal has implemented the National Health Insurance Program (NHIP), primarily focusing on point of care public facilities and referral to contracted private HFs; however, private HFs have very limited participation in the program, low enrollment rate and high dropout rate in the renewal of premium further challenge the implementation of the NHIP [ 36 ].…”

Social Protection in Health: Characteristics and Coverage of Health Insurance Programme in Nepal

“…After the roll-out of NHIP in Kailali district in the fiscal year 2015/16, the programme was expanded to two additional districts (Baglung and Ilam) in the same fiscal year (Ghimire et al, 2019). The government in the budget speech of the fiscal year 2016/17 announced to allocate NRs 2.5 billion to expand the services to 25 districts across the country (Khanal, 2016), however, it was expanded to only 12 districts (Ranabhat et al 2020). Similarly, the programme was expanded to 22 additional districts in the fiscal year 2017/18.…”