Nepal’s national health insurance program (NHIP) initiative, was launched in 2016, to attain universal health coverage (UHC). There are obstacles towards achieving this coverage across the Nepali population. Although it has made remarkable progress, there are significant problems causing poor enrollment, retention, and challenges while accessing quality healthcare.
The social health insurance scheme aims to enhance the healthcare access and quality while reducing financial burdens. The family and contribution based program offers subsidies for specific groups, and services are accessible through both public and private health facilities via a cashless mechanism. There are 440 service locations which includes the primary healthcare centres, the government hospitals, the private hospitals and the community hospitals that are registered as service providers with the Health Insurance Board in order to provide these services. These healthcare services are provided across all three tiers of the healthcare system, encompassing the local levels, the primary healthcare centres, and the district and the provincial hospitals for secondary care, and specialised services are rendered through the teritiary level of healthcare.
Payments is of an annual premium of 3,500 NPR for the households with five or fewer members. The NHIP offers subsidies for the vulnerable populations including seniors, the ultra-poor families, the female community health volunteers, and the individuals with specific health conditions. The benefits package covers outpatient, inpatient, and emergency services including 1,133 drug types at 463 service sites in Nepal.
The Government of Nepal (GoN) is a health insurance program since 2016, in three districts as a pilot project and expanded it to all provinces and districts as well by 2023. The NHIP in Nepal has completed almost one decade of implementation, where the Health Insurance Board (HIB) is the apex body to implement, regulate and monitor the NHIP. The main aim of the NHIP is to increase the individuals’ access to quality healthcare services and reduce financial trouble while receiving healthcare l. During a short period, the program has been expanded throughout the country within seven years of its introduction. Despite expanding to all 77 districts and reaching over seven million enrollees, NHIP faces challenges. As of 2023, enrollment reached only 25% of the population, far below the 60% target for 2022, alongside an annual dropout rate of approximately 23%. Contributing factors were reported to include drug shortages, unfriendly healthworker behaviour, and indifferent treatment of insured patients. These issues jeopardise the NHIP’s financial sustenance and capacity to deliver its healthcare services.
Here we examine the barriers to its success.
1. Leadership and Governance
◇ Centralised authority of the Health Insurance Board
◇ Inadequate community engagement
2. Financing
◇ Financial sustainability
◇ Budget constraints
◇ Delayed reimbursement to providers
3. Workforce
◇ Lack of human resources
◇ Limited training
◇ Turnover of enrollment assistants
4. Information and research
◇ Lack of awareness at community level
◇ Insufficient knowledge flow
◇ Lack of monitoring and evaluation mechanism
5. Medical products and technologies
◇ Expansion of infrastructure/services
◇ Frequent Stockout of medicines/logistics
6. Service delivery
◇ Satisfaction with services
◇ Influence from insured individuals
◇ Complicated referral mechanism
◇ Interconnection across health systems building blocks
These options of pre payments isn’t feasible in the long run for a country like Nepal where 62.2% accounts for the informal sector of Nepal. Nepal may have to enhance population-wide enrollment to address adverse selection, refine patient-end co-payment and provider patient mechanisms to counter moral hazard, and diversify funding sources to improve program funding. None of these challenges are easy but China, its neighbour, is rapidly achieving a near universal enrollment in its voluntary rural health insurance program which suggests that a strong political commitment can make it possible. Doctors for Nepal is a UK based charity improving lives in the rural areas of Nepal by educating handpicked locals in medical care through the power of scholarships and they will serve in these rural areas after completing their medical training.
Limitations of this study are that sampling may not fully represent all NHIP stakeholders and it could introduce the possibility of selection bias and that the WHO health system building blocks may have influenced the interpretation and presenting of findings.
Ethical approval for conducting this study was obtained from the National Ethical Review Board of the Nepal Health Research Council.
Additional links;
http://www.doctorsfornepal.org
Credit and Source;
BMC Health Services Research
Karmacharya B.M., Marasini S., Shrestha R.M. et al. Rapid assessment of the implementation of national health insurance program in Nepal: a qualitative study. BMC Health Serv Res (2026). https://doi.org/10.1186/ s12913-026-14742-5
Image Credit; Doctors for Nepal
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