Assessment of social health insurance scheme in selected districts of Nepal.

Research Report.

SUMMARY: In past decades, Nepal has made notable progress in improving the overall health status of the population. However, the overall progress in health outcomes masks the significant equity gap that continues to persist. Many citizens still face several barriers - financial, socio-cultural, geographical, and institutional - in accessing quality health care services. Protecting people from catastrophic health care spending, thereby preventing people from falling into poverty trap, the government has rolled out the Social Health Security scheme in February 2015, to increase the financial protection by promoting pre-payment and risk pooling in the health sector. Before social health insurance scheme, a different health insurance scheme was implemented in Nepal, but none of them succeed. On the basis of evidence from the previous insurance scheme, social health insurance is implemented with the aim of universal coverage and with the plan for subsidizing premium for poor population who are not able to pay for the insurance package. However plan with universal coverage considering the present poverty level, awareness regarding need and working modality of health insurance among the general population and availability and access to quality health care services seems challenging. Furthermore, subsidizing premium for the poor population tends to incur significant financial expenses to the government of Nepal besides the administrative cost of implementation of the package. In this context, the experiences in implementing health insurance need to be regularly reviewed considering the coverage, inclusiveness of a vulnerable population, financial viability of the scheme for the improving efficiency and effectiveness of the insurance. In this context, this study has been planned to assess the performance of social health insurance scheme in terms of patient satisfaction, impact on service utilization, coverage, and financial viability and to document the experience and challenges in implementation of social health insurance in Nepal. The study covered three districts namely, Kailali, Baglung and Ilam, where the health insurance scheme has been rolled out in the first phase. The study was a mixed method study. In the process of documenting experiences and identifying key challenges in implementation of health insurance, a qualitative study was undertaken among health personnel. Purposive sampling of health personnel was considered in qualitative component of the study. Qualitative data were analyzed through thematic analysis technique. Quantitative assessment of service quality satisfaction was done through exit client interviews in health facilities implementing health insurance. Total of 338 participants were enrolled for exit client intervieew. The key informant interview was used to collect data on experiences and identifying key challenges in implementing health insurance in selected districts. Quantitative data were entered in epi-data and analysis was done in SPSS version 20. Ethical clearance was obtained from an Ethical Review Board of Nepal Health Research Council. Quantitative study found that in both insured groups and non-insured groups found that 9 out of 10 participants heard about SHI scheme and opined that their enrollment in SHI is an appropriate option to reduce the financial burden. Similarly, more than 90 % of insured groups were willing to renew membership and recommend a friend about SHI. The study found 61% had not sought any health services from health facilities outside the SHI among insured groups. Radio/newspaper/TV was the most common source of information about the SHI. Most of the participants were positive towards the enrollment assistant and other service provided by SHI scheme. Participants were more than 90% satisfied with nature of changes in different aspect of health services after SHI scheme. Similarly, qualitative study among health personnel involved in the delivery of health services found different experiences and challenges in implementation of SHI in Nepal. The study reported that people were much interested in the insurance scheme initially, however it was declined in forthcoming years because due to unavailability of drugs, adequate laboratory services inadequate human resource, awareness and interaction among people. They opined that health insurance policy came as an effort to reduce impoverishment and catastrophic health expenditure, and it is critical to ensure easy enrollment of the poor and marginalized population into the SHS scheme. Service utilized by participants engaged in SHI scheme were due to communicable disease, however, visits with chronic diseases like diabetes and hypertension was increasing after inception of SHI in the district. Some changes were also seen in service utilization pattern. Service providers had noted that participant with health insurance scheme visit health facilities in earlier stages of disease compared to those who do not have health insurance. Thus, our study finds that health personnel bear numerous problems and challenges regarding the implementing SHI scheme, however, improving and implementing a suggestion given by health personnel for every shot of the problem and challenge seems to be a milestone for better implementation and development of the social health insurance scheme in Nepal. Despite the problems and challenges in SHI program, the utilization of services has gradually increased in all health facilities. Participants also shared that it can ultimately have a positive impact on the overall economy of the country as healthy people tend to be more productive.