Table 1 Category-specific stakeholders and their expected roles and implementation status, issues and challenges of NHIP

Interest groups

Medical professionals

Healthcare service providers

Public and private hospitals

Other insurance providers General public 

Service contract with eligible hospitals for expansion of NHIP [37]

NHIP service costing [38]

The interest of private hospitals:

After accreditation with NHIP, they have increased revenue

Demanded revision of the reimbursement rate set in 2017

Interest of public:

Tendency to enrol if they have a chronic illness

Tendency to seek healthcare just because they have an insurance policy

Insurance company:

No role of private insurance companies in NHIP yet

Have lobbied policy-makers to privatize the NHIP [39]

The thrust of social health security and risk-sharing among the poor is not possible with such privatization

Politicians:

Inadequate commitment to health sector structural reform

Had planned (later withdrew after public pressure) to hand over the institutional management of NHIP to the private sector [40]

Limited understanding of fundamentals of social health security and its prerequisites

Healthcare providers:

Reluctant to strengthen public healthcare system as it might affect the revenue generated through private practice

Bureaucracy

Federal, provincial and local governments

Ministries (MoHP, MoF, Ministry of Federal Affairs and General Administration)

HIB

Legislative bodies

Recruitment of enrolment assistants (EAs) by local governments [22]

Strengthening delivery of quality healthcare [41]

Services by provincial and local governments [42]

Enrolments and service expansion, ensure service quality [42]

Identification of poor households [25]

Overall execution and management of NHIP [22]

Formulation and amendment of standard operating procedure (SOP), guidelines, acts and regulations [6, 17, 22]

Autonomous role of HIB instead of being controlled by MoHP [43]

Legal frameworks:

Endorsement of HIA in 2017 and HIR in 2019 [6, 22]

Legal frameworks and procedural documents envisioned by HIA and HIR are not formulated yet [25, 44]

Private practitioners within the premises of public hospitals:

No restriction to establishing pharmacy, lab or hospitals within/adjoining public hospitals

Degrading the quality of public health facilities (sometimes with intention) to secure the market of private practice

Institutional development:

HIB lacks a separate organizational and human resource structure as envisioned in HIA [6]

Staff under HIB are deputized from MoHP [19]

Programme implementation and expansion:

Expanded to all 77 districts and 745 (out of 753) local governments (except urban municipalities of Kathmandu and Lalitpur district) [25]

Poor household identification:

Accomplished in 26 districts [45]; however, it was heavily criticized

HIB planned to identify poor households in 12 additional districts in 2019/2020 but have not accomplished [47]

Claim and reimbursement system:

Delay in reimbursement of claims to the hospitals [42]

Manual and random process of claim review

Limited human resources (about 20) [46]

Need to review more than 25,000 claims each day [47]

Excessive workload due to high volume of claims, limited workforce and manual process

High possibility of fraudulent claims from hospitals [48]

Budgets

Governmental leadership

MoF

MoHP

HIB

General public

Resource allocation for NHIP [6]

Integrating fragmented health financing schemes [9]

The flexibility of ministerial leadership [49]

MoHP for delivering quality, equitable and accessible healthcare [50]

Organizational capacity of HIB for budgetary allocation and absorption [25]

Assurance of financial sustainability [25, 51]

Timely payment of annual premium [22]

Service costing:

Service costing was revised (partially) in 2022 [52, 53]

Service contract with HIB:

440 service providers in 77 districts [54], and the majority (82.5%) are public health facilities

Some tertiary hospitals denied accreditation in NHIP

Stagnation of OOP expenditure:

High OOP expenditure (57.7%) [12] which has remained stagnant between 55% and 58% since 2009 [55, 56]

Fragmented health financing schemes:

Fragmentation of social health protection schemes like free healthcare, health insurance, conditional cash transfer and cost subsidization schemes under MoHP [9, 57]

Gaps in budget allocation versus expenditure:

More than one third of the allocated budget remains unspent [58,59,60]

Unspent resources are pooled back by the central treasury [61]

The practice of budget virement in other headings [49]

Collection and mobilization of funds:

The premium collected is deposited in the Health Insurance Fund (HIF) [6]

Procedural documents are still lacking to operationalize HIF [62]

The nonoperational amount in HIF doubled from NPR 1.4 billion to 2.8 billion between fiscal years 2019/2020 and 2020/2021 [63]

HIB has to depend on the federal budget while its fund (HIF) has remained  nonoperational [62]

No clear guidelines for provincial and local governments to contribute in HIF [62]

Doubtful financial sustainability:

Widening gap between premium collection and reimbursement over time [63]

Reimbursement exceeding the premium indicates possible threats to financial sustainability [51, 62, 64]

Leadership

Ruling party

Opposition parties

Leverage political commitments [49]

Facilitate a supportive political environment with strategies, institutions and structures [49]

Strong political commitment:

Both ruling and opposition parties have a commitment to enrol citizens in NHIP [65, 66]

Poor actions towards fulfilling the commitments of health system strengthening:

Communist Party of Nepal (CPN) committed to establish a 25-bed hospital at a minimum in each 753 local government level [65]; however, only nine additional hospitals and five PHCCs were established during their tenure of 3.5 years [67],

was not increased in sanctioned positions for medical officers in the last 4 years [47]

Beneficiaries

General public and targeted population (female community health workers, leprosy, multidrug-resistant tuberculosis, people living with HIV, null disability, senior citizens or ultra-poor families)

Regular enrolment and renewal [22]

Rational use of NHI services [22]

Poor enrolment and higher drop-out:

Economically better-off households are more likely to enrol in NHIP [68]

5.66 million (21.35% population) have enrolled in NHIP [36]

Drop-out rate is about 25% [24]

An early study in 46 districts showed that the drop-out rate was more than 38% [69]

A study in Pokhara showed that more than a quarter (28.2%) of households dropped out from NHIP [70]

More than one third (33.6%) of active insured (39.5 million) belong to the targeted population, whose premium was paid by the government [25]

Major reasons behind drop-out were health service underutilization, poor healthcare services and inadequate benefit packages [25, 71]

A high proportion of drop-out and subsidy enrolment is a key challenge for the sustainability of NHIP [25, 51]

Low value for money:

Beneficiaries receiving suboptimal service quality [19, 42]

Service payment on the activity-based model rather than quality [4]

Insured are willing to renew their membership if service quality is improved [72,73,74,75,76,77] or they are made aware of the renewal process [70]

External actors

External development partners: (GIZ, KOICA-Nepal Health Insurance Support Project, Save the Children, ILO, etc.)

Leverage technical expertise and financial resources

Leveraging donors and learning replication:

KOICA-Nepal: Capacity-building of officials through international exposure visit [78]; technical assistance in development of e-learning package; preparation of mid-term and long-term strategy of HIB [24]

Save the Children: Expansion of NHIP [24]

GIZ: Development of SOP, guidelines, insurance management information system (IMIS), customize IMIS, training and orientation related to health insurance and open IMIS, international exposure visit to HIB/MoHP delegate, human resource support in information technology and claim system [24]

ILO: Actuarial analysis

Funding sustainability:

Funding through KOICA-Nepal and Save the Children have ended from 2021

No other new partners have supported NHIP

Technical assistance priority of EDPs:

Foreign, Commonwealth & Development Office/UK Aid fund in strengthening basic healthcare services (tax-funded)

GIZ and KOICA in social health insurance programme (German model or Korean model)