National Health Insurance Program in Nepal: Early Experiences and Its Effect on Health Service Utilization

Introduction: Nepal initiated the Health Insurance program in 2016 to achieve Universal Health Coverage by 2030. However, the enrollment rate is low, and people are already starting to drop out. Therefore, this study aimed to explore the demand and supply side (service providers) experiences with Nepal\u27s National Health Insurance Program and its effect on insurance enrollment and health service utilization. Methods: We employed a mixed-method design. Ethnographic methods were used to explore the rich holistic insights into people\u27s views and actions. We conducted 14 focus group discussions and 20 key informant interviews, mainly in Kailali and Baglung districts. We used field note-taking and non-participatory observations to recalibrate the data collection tools. We employed the difference-in-difference approach to assess the health insurance program\u27s impact on health service utilization using data from Nepal\u27s national health information system, DHIS-2. Results and discussions: We found a very intricate connection between demand and supply-side factors affecting the enrollment to the insurance program, its renewal, and health-seeking behavior. Quality of the health services played a central role. Other factors included lack of awareness, geographical accessibility to health facilities, household income, community solidarity, perceived risk of getting an illness, and perceived usefulness of health insurance programs. Regardless, our quantitative analysis showed an increase in patient visits after initiating the program (an average of 9 patients per day in PHCCs and 32 patients per day in hospitals). Service providers reported the increased patient flow and administrative burden without proportionate growth in resources as a significant challenge for providing service under the insurance program. Other challenges included motivation of health service providers and EAs, difficulty making claims, delay in reimbursement, tedious medicine procurement process, and insufficient information about the insurance program. Conclusion: The effectiveness of the health insurance program inherently relies on the quality of health services. Hence, there should be coordinated efforts to improve the quality of health service delivery along with the insurance program