The National Health Insurance Program Design and Implementation Bottlenecks – Paving the Path towards Universal Health Coverage in Nepal: A Qualitative Study

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15 September 2024/३० भदौ २०८१ (आइतबार, दिउँसो ३ बजे)
Research Seminar Series
The National Health Insurance Program Design and Implementation Bottlenecks – Paving the Path towards Universal Health Coverage in Nepal: A Qualitative Study
Gaj Gurung, PhD, Senior Analyst in Sustainable Financing, Harm Reduction International, UK

Abstract
Most of the lower-middle income countries (LMICs) adopting National Health Insurance (NHI) programs to achieve Universal Health Coverage are struggling to implement the program due to underlying problems at design and implementation levels. The Nepal’s NHI program, initiated on 2016 and managed by Health Insurance Board (HIB), has been facing problem at implementation. However, fewer studies are focused on these problems and in particular no study delved into the details of program design, governance, organization, and implementation bottlenecks in Nepal. This qualitative study, thus, delves into the Nepal NHI program’s design and implementation bottlenecks.

The study is part of a larger, mixed-method with a concurrent quantitative component and the quantitative result is not presented here. The qualitative study based in Nepal’s four districts, conducted 28 In-depth interviews, six focus group discussions, and identified 12 themes that pointed to the NHI program's design flaws, implementation bottlenecks and the opportunities. The analysis employed the Grounded Theory.

The NHI was initiated through high political-will with sparse scientific and academic consultations to formulate the policy and the NHI design. The major input challenges were insufficiently defined NHI implementations guidelines, conflicting Act clauses leading to Ministry of Health domination over HIB decision-making, lack of HIB organizational guidelines, and inadequate human resources. The throughputs bottlenecks are difficulty enrolling the insurees, inability to select the health providers competitively, and act as a prudent purchaser of the services. Amidst the challenges, the NHI program has been rolled out in all districts, has increased the health service utilization and has played catalytic role in improving the performance of primary health care centers and hospitals. The implementation bottlenecks led to negative outputs, as captured from other studies, such as adverse selection of ill and needy populations, insurees’ high dropouts, poor health service delivery and low coverage of poor households.

In order to strengthen the NHI implementations to contribute to the universal health coverage, the study proposes recommendations at policy, program and for further study. The key policy action includes revision of the Act, Regulation to ensure HIB autonomy and  mitigate the design flaws. Similarly the program actions include having adequate implementation guideline, human resource management and public-private partnership. The areas of further studies are analysis of existing payment mechanism, human resource and NHI self-sustainability projection.

Keywords: Health Insurance and financing, Universal Health Coverage, Implementation bottlenecks,

About the Speaker
Gaj Gurung is an expert in health financing and public health programs. He has a PhD in Public Health from Chulalongkorn University, Thailand, focusing on the effectiveness of Nepal’s National Health Insurance program in reducing out-of-pocket health expenses. Currently, he works (remotely based in Nepal) as the Senior Analyst, Sustainable Financing at Harm Reduction International, the global organization in UK. He supervises and conducts global and national researches on funding for harm reduction from international donors and governments. Previously, he headed Youth LEAD, the Asia Pacific regional organization on young people and HIV based in Bangkok, Thailand as the Regional Coordinator. He also served as the delegations to the Global Fund (the largest multi-lateral donor for AIDS, TB and Malaria based in Geneva) Board representing Developing Country NGO Delegation.