Experiences and Effect of Implementing Social Health Insurance Program in Nepal- A Mixed Method Study

Abstract Background Nepal initiated the National Health Insurance Program (NHIP) in 2016, but the enrollment rate is low, with an increasing dropout rate. This study examined the experience from the demand and supply side (service providers) with NHIP and its effect on insurance enrollment and health service utilization. Methods We employed a mixed-method design. Ethnography was used to explore rich holistic insights into people’s views and actions. We conducted 14 focus group discussions and 20 key informant interviews in Nepal's Kailali and Baglung districts. Field note-taking and non-participatory observations were used to recalibrate data collection tools. We employed the difference-in-difference (DID) estimation using Nepal's District Health Information System (DHIS-2) data. Results We identified a complex interconnection between demand- and supply-side factors that influence the enrollment and renewal of the insurance program, as well as health-seeking behavior. The quality of health services played a pivotal role. Other contributing factors included a lack of awareness, limited geographical accessibility to health facilities, household income, perceived risk of getting an illness, and the perceived usefulness of health insurance programs. Conversely, the quality of services was contingent upon several challenges, such as increased patient flow and administrative burden without proportional resource growth, motivation of health service providers and enrollment assistants, difficulty in claims processing, reimbursement delays, cumbersome medicine procurement process, and insufficient information about the insurance program. Our quantitative analysis demonstrated an approximate increase of 9 and 32 client visits per day in Primary Health Care Centers and hospitals, respectively, with an enrollment of about 5%. Conclusion The effectiveness of the health insurance program inherently relies on the quality of health services. Regardless, there was an increase in patient flow in the health facilities under the insurance program, which warrants a concomitant increase in resources for these facilities. There should be coordinated efforts to improve the quality of health service delivery along with the insurance program.