Bharati Rajani, Romero Diana, Pozen Alexis, Sherry James, Paudel Bhuwan, Adhikari Mukesh, Acharya Prakash
CUNY Graduate School of Public Health and Health Policy, New York, New York, United States of America.
Ministry of Health, Kathmandu, Bagmati, Nepal.
PLOS Glob Public Health. 2025 Apr 24;5(4):e0003492. doi: 10.1371/journal.pgph.0003492. eCollection 2025.
Nepal initiated the National Health Insurance Program (NHIP) in 2016, but enrollment rates remain low, with an increasing dropout rate. This study examined the experience of service providers and beneficiaries with NHIP and its effect on insurance enrollment and health service utilization.We employed an exploratory sequential mixed-method design, involving 14 focus group discussions and 20 key informant interviews, supplemented by quantitative data from Nepal's District Health Information System (DHIS-2). We identified a complex interconnection between demand- and supply-side factors affecting enrollment, renewal, and health-seeking behavior within NHIP. Both NHIP enrollees and non-enrollees cited the quality of health services as crucial for enrollment. Other significant factors included inadequate awareness, insurance scheme design (service lag time, referral requirements), limited geographical accessibility to health facilities, ability to pay premiums, perceived illness risk, and the perceived usefulness of health insurance. Service providers reported that NHIP implementation increased patient flow and administrative burden without proportional resource growth. They faced challenges such as a lack of motivation, claim and reimbursement difficulties, tedious medicine procurement, and insufficient information about the insurance program. Our quantitative analysis confirmed increased patient flow and referrals due to the policy's effect. In intervention districts, there was an increase in the average number of total client visits, new client visits, and referrals by 4,729, 2,721, and 163 respectively, compared to comparator districts. These increases occurred when the enrollment rate was at 5%.Our findings highlight the dependency of NHIP enrollment on the quality of the healthcare delivery system. To improve NHIP effectiveness, there should be increased awareness and insurance literacy, enhanced insurance scheme design features, and improved geographical accessibility to health facilities. Efforts should also focus on resource availability, expanding the qualified health workforce, and improving stewardship and accountability mechanisms.
尼泊尔于2016年启动了国家健康保险计划（NHIP），但参保率仍然很低，且辍学率不断上升。本研究考察了服务提供者和受益者参与NHIP的经历及其对保险参保和医疗服务利用的影响。我们采用了探索性序列混合方法设计，包括14次焦点小组讨论和20次关键信息人访谈，并辅以尼泊尔地区卫生信息系统（DHIS-2）的定量数据。我们发现，影响NHIP参保、续保和就医行为的需求侧和供给侧因素之间存在复杂的相互联系。NHIP参保者和未参保者都认为医疗服务质量对参保至关重要。其他重要因素包括认识不足、保险计划设计（服务滞后时间、转诊要求）、卫生设施的地理可及性有限、支付保费的能力、感知到的疾病风险以及健康保险的感知有用性。服务提供者报告称，NHIP的实施增加了患者流量和行政负担，但资源增长不成比例。他们面临着缺乏动力、索赔和报销困难、繁琐的药品采购以及保险计划信息不足等挑战。我们的定量分析证实，由于该政策的影响，患者流量和转诊有所增加。与对照地区相比，在干预地区，客户总就诊次数、新客户就诊次数和转诊次数的平均增加量分别为4729次、2721次和163次。这些增加发生在参保率为5%的时候。我们的研究结果凸显了NHIP参保对医疗服务提供系统质量的依赖性。为提高NHIP的有效性，应提高认识和保险素养，增强保险计划设计特点，改善卫生设施的地理可及性。还应努力确保资源可得性，扩大合格卫生人力队伍，并改善管理和问责机制。
