Table of Contents

Introduction

The Health Insurance Program (HIP) is a social security program of the Government of Nepal that aims to enable its citizens to access to quality health care services minimizing a financial burden on them. Health Insurance Board (HIB) is responsible to carry out the health insurance program in Nepal. Although good progress has been made on improving access, much remains to be done. Out-of-pocket expenditure still puts vulnerable households at risk of catastrophic spending and prevents them from using services. Health insurance program is a family-based program. The family has to pay contribution amount to enroll in the program. The enrollment is voluntary now. The households, communities and government are directly involved in this program. The HIP helps to prevent people from falling into poverty due to health care costs i.e. catastrophic expenditure due to accidents or disease by combining prepayment and risk pooling with mutual support . This program also advocates towards quality health services. This program attempts to address barriers in health service utilization and ensure equity and access of poor and disadvantaged groups as a means to achieve Universal Health Coverage. The HIP is started firstly from Kailali district on 25thChaitra, 2072 and then expanded in other parts of country in phase wise manner.

General Objective

To ensure Universal Health Coverage by increasing access to, and utilization of necessary quality health services.

Specific objectives

To increase the financial protection of the public by promoting pre-payment and risk pooling in the health sector;
To mobilize financial resources in an equitable manner; and
To improve the effectiveness, efficiency, accountability and quality of care in the delivery of health care services.

Strategies

Increasing participation of communities towards health insurance program by providing special protection to the poor and marginalized and
Extending coordination and cooperation with government and non-government service provider health institutions for gradual expansion of health insurance program throughout the country.

Main features of Health Insurance

It is a voluntary program based on family contributions. Families of up to five members have to contribute NPR 3,500 per year and NPR 700 per additional member.
Government bears contribution amount for ultra-poor, MDR TB, Leprosy, HIV /AIDS and disable people’s families having a poverty identity card and red card respectively.
Insures have to renew their membership through annual contributions.
Benefits of up to NPR 100,000 per year are available for families of up to five members with an additional NPR 20,000 covered for each additional member. The maximum amount available per year is NPR 200,000.
Government bears contribution amount for up to 70 years old citizens and Benefits of up to NPR 100,000 per year.
Insures have to choose their first service point. Insures can access specialized services elsewhere that are not available at the first service point on production of a referral slip from their first contact point.
It is cash-less system for members seeking health services.
The program is IT-based with enrolment assistants using smart phones.
HIB acts as the service purchaser while government and listed private hospitals provide the services.

Opportunities

Overall, despite the hurdles and initial scepticism, the scheme itself is operating. The scheme has also introduced a number of innovations, including:

The scheme empowers of patients as they have a greater voice on account of having paid for the services; the health insurance scheme will be able to better negotiated prices than the patient would be able to secure as an individual.
Until now the MoH has financed primary health care centres and hospital regardless of their productivity (the exception is the Safe Motherhood Programme). The health insurance scheme provides for case payment against claims.
A number of private health care providers have been contracted into the scheme with their strong commitments to provide services in the given prices as mentioned at benefit packages.
Reinforces referral system as gate-keeping function.
The additional money generated for health care facilities by the scheme (in the form of payment of claims) might encourage more ‘business-like thinking’ on the part of public health care providers.
Gradual increase in access and outrage of people in health services
Improving quality of health services along-with infrastructures.
Increasing people’s awareness towards health insurance and services.
Nepal has transitioned from unitary centralized system to federalized government structure– the health insurance scheme will be one of the central funds remaining in the health sector and can secure funding for health services to all provinces and local authorities as per the spirit of constitution of Nepal.