Chuda Mani Bhandari

Nepal has expressed commitment to the universal health coverage (UHC) of Nepalis and formulated policy, enabling laws and regulations with short-, mid- and long-term goals to this end. The country has introduced the provision of free basic health services, social security scheme and National Social Health Insurance Programme. Unveiled in 2005, free healthcare policy marked major progressive step towards the healthcare financing in this sector. It seeks to realise health as the fundamental right of citizen as envisaged in the constitution. Several policy and legal instruments such as the 15th periodic plan, National Health Policy and Nepal Health Sector Strategy 2015-21 were adopted accordingly.
There were few piloted programmes before the Social Health Insurance (SHI) was practised in Nepal after the endorsement of the National Health Insurance Policy in 2071 B.S. as envisioned by the then 14th periodic plan targeting 60 per cent of public participation. The current SHI programme started from Kailali district in 2015 AD. Of late, social health insurance has received high political commitment and has emerged as a reform strategy.
Implementation
The health insurance scheme gained momentum with the formulation of Health Insurance Act, 2074 and Regulation, 2075. Health Insurance Board (HIB) has overseen its functional and managerial aspects. Its main objective is to ensure universal healthcare by increasing the people’s access to essential and quality health services. Similarly, it provides financial protection to the citizens by promoting prepayment and risk pooling in health sector while enhancing effectiveness, efficiency, accountability and quality delivery of health services. To fulfil these objectives, there is a provision of payment premium from the government to the identified poor. Both government and private hospitals have been involved in implementing this scheme. The basic features of the health insurance include contributory and subsidy to the poor, marginalised and other target groups and referral service. It targets to all citizens with family as a unit. Based on cashless system and information technology, service seekers can register and renew insurance scheme round the year.
Currently, it has been implemented in 59 districts with the aim of 60 per cent coverage within the 14th periodic plan. The policy and programme of the current fiscal year seeks to expand the health insurance in rest of 17 districts. Despite resource crunch, 31, 36,823 citizens are enrolled in the scheme as of the data of Ashad 2077 B.S. Of them, 16, 37,712 are female and 14, 99,111 male, accounting for about 12 per cent of the total population. The number of identified poor is 434,318, senior citizens 302,658, people living with HIV/AIDS 6284, lepers 1070, the disabled 29,415, and Female Community Health Volunteers (FCHV) 32,128. State-wise, the scheme covers 18 per cent in State 1, around 1.47 per cent in State 2, around 11 per cent in Bagmati State 17 per cent in Gandaki State, 10 per cent in Lumbini State, 14 per cent in Karnali State and 12 per cent in Sudurpaschim State. The data shows that service utilisation in fiscal year 2076/077 B.S. is 808,618. If we analyse the utilisation trend, we can find the incremental rate in the last three years - 234,635, 560,058 and 808,618 - respectively. The renewal rate is 75 per cent as of May 2020.
The premium is Rs. 3,500 and the benefit package is Rs. 100,000 per family as a unit. With the increase in the members by more than 5, the premium of Rs. 700 each is to be added for which the benefit will be increased to Rs. 20,000 for each member. Mostly, health services including 1,133 listed drugs are included in the benefit package with few negative lists that are provided through 348 listed health facilities. Health insurance being high priority programme of the government, the partners are also very enthusiastic for its success. The number of insurees and health service providing outlets at local level are interested in it. The government needs to deal with a number of policy-related issues, including service providers, purchaser split, uninterrupted quality health service, moral hazards, capacity level, fraud claim, delay reimbursement, scattered social security and insurance programme, staff mobilisation, user-friendly IT, linkage with basic health services, low coverage and governance.
A clear roadmap of health insurance, including financial sustainability with a permanent structure and strong leadership at the HIB is required. There is the need for amendment to the policy, strategy and Act. Health service providers should be ready to provide quality services. Skilled and motivated staff with functional units, uninterrupted services and effective referral as well as performance-based incentive to the institutions and staff will give an added value. Efficient and user-friendly information management system should be implemented with data privacy and ownership by the government. It should be linked with monitoring system to maintain standards through accreditation or grading of hospitals.
Management of moral hazards from service providers and consumers, fraud management with a provision of penalty to the frauds and linking benefit package for renewal poverty mapping, implementation of National ID or poverty categorisation integration, merger or harmonisation to other social security programmes and clear linkages with basic health services to the insurers with efficient management, transparency and strong monitoring mechanism is a must.
Policy debate
Policy debate is going on for clarity on provider, purchaser split and selection. But it should not affect the expansion of insurance scheme. Practical suggestions are to be considered with broader participation and knowledge management of different stakeholders as well as strong coordination mechanism with role and responsibility from federal, state and local levels.
Finally, population coverage, financial protection to prevent from catastrophe due to health care cost by reducing out of pocket expenditure and quality of health services are also the fundamental components of health insurance as well as the UHC. So the success of UHC depends upon health insurance and is linked with the basic health services. The health insurance programme will be a milestone in ensuring UHC and the socio-economic development of country, thereby materialising the government's vision of ‘Samriddha Nepal, Sukhi Nepali.’

(An MPH, MPhil scholar, Bhandari works at the Ministry of Health and Population. cmbgulmi@gmail.com)