Ghimire Sushmita, Ghimire Sailaja, Singh Devendra Raj, Sagtani Reshu Agrawal, Paudel Sudarshan
Department of Public Health, Asian College for Advance Studies, Purbanchal University, Lalitpur, Nepal.
School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal.
PLOS Glob Public Health. 2024 Jul 26;4(7):e0003538. doi: 10.1371/journal.pgph.0003538. eCollection 2024.
Health insurance has been recognised as a crucial policy measure to enhance citizens' well-being by reducing the financial burden globally. Nepal has also adopted this scheme to support achieving universal health coverage. Various factors influence the overall performance of the program in Nepal. However, there is a lack of evidence on how different factors have influenced the insurance program in the Nepalese context. Therefore, this study aims to explore facilitators and barriers to the utilisation of national health insurance services among service users and other stakeholders. A qualitative study was conducted by interviewing both demand-side participants and supply-side participants in the Bhaktapur District of Nepal. Thematic network analysis was used to analyse data using RQDA software. The socio-ecological model guides the presentation of the identified factors. The study followed the COREQ guidelines to ensure standard reporting of the results. Factors that encourage the use of health insurance services involve individual, community, and policy-related factors. These factors encompass changes in seeking treatment, assistance during enrollment and renewal by enrollment assistant, proximity to the initial point of contact for care, and policy features like individual cards, contribution amount and cashless treatment system. Likewise, lack of physical infrastructure, poor staff management, long waiting times, poor medicine availability, and delays in budget reimbursement were perceived as organisational barriers. At the interpersonal level, obstacles encompass challenges related to staff behaviour, interpersonal relationships, and the information provided by service providers. Identified health services delivery barriers at different levels emphasised the critical need for improving the quality of healthcare and services delivery mechanisms. Overcoming these obstacles is essential for realising health insurance scheme objectives and progressing toward Universal Health Coverage (UHC).
在全球范围内，医疗保险已被视为一项至关重要的政策措施，通过减轻经济负担来提升公民福祉。尼泊尔也采用了这一计划以支持实现全民健康覆盖。多种因素影响着该计划在尼泊尔的整体表现。然而，在尼泊尔背景下，关于不同因素如何影响保险计划的证据却很缺乏。因此，本研究旨在探索服务使用者及其他利益相关者在使用国家医疗保险服务方面的促进因素和障碍。通过对尼泊尔巴克塔普尔地区的需求方参与者和供应方参与者进行访谈，开展了一项定性研究。使用RQDA软件，采用主题网络分析法对数据进行分析。社会生态模型指导对所确定因素的呈现。该研究遵循COREQ指南以确保结果的标准报告。鼓励使用医疗保险服务的因素涉及个人、社区和政策相关因素。这些因素包括就医行为的改变、参保助理在参保和续保过程中的协助、与初始就医接触点的距离，以及诸如个人卡、缴费金额和无现金治疗系统等政策特征。同样，缺乏实体基础设施、人员管理不善、等待时间长、药品供应不足以及预算报销延迟被视为组织障碍。在人际层面，障碍包括与工作人员行为、人际关系以及服务提供者提供的信息相关的挑战。在不同层面所确定的医疗服务提供障碍凸显了提高医疗保健质量和服务提供机制的迫切需求。克服这些障碍对于实现医疗保险计划目标以及朝着全民健康覆盖（UHC）迈进至关重要。
