Sriram Shyamkumar, Adhikari Saroj, Saud Bhuvan
University of North Texas, Denton, TX, United States.
Ministry of Health and Population, Kathmandu, Nepal.
Front Public Health. 2025 Jun 18;13:1609219. doi: 10.3389/fpubh.2025.1609219. eCollection 2025.
Nepal's transition to federalism and the rollout of the National Health Insurance Program (NHIP) marked critical steps toward universal health coverage. Yet, structural misalignments between health financing policies and purchasing practices persist, weakening the effectiveness of these reforms. Strategic purchasing-a key lever in health financing-has the potential to improve system efficiency, equity, and responsiveness by actively allocating pooled funds based on population needs, provider performance, and service value. However, in Nepal, legacy practices such as line-item budgeting, fragmented programmatic funding, and overlapping institutional roles hinder the adoption of this approach. The Ministry of Health and Population continues to play simultaneous roles as policymaker, purchaser, and provider, weakening accountability and the purchaser's autonomy. Public providers are funded through both historical budgets and reimbursement schemes, diluting incentives for performance. Moreover, NHIP's purchasing decisions are not guided by health technology assessments or cost-effectiveness analysis, raising concerns about the allocative efficiency of the benefit package. This Perspective argues that Nepal's health financing reforms require institutional realignment, clearer role demarcation, and stronger contractual mechanisms to support strategic purchasing. Drawing on both national experience and international frameworks, it highlights the systemic disconnects and offers a way forward for embedding strategic purchasing into Nepal's health financing architecture. By correcting these foundational misalignments, Nepal can better leverage public resources to deliver high-quality, equitable care, advancing the goals of federalism and universal health coverage simultaneously.
尼泊尔向联邦制的过渡以及国家医疗保险计划（NHIP）的推出标志着朝着全民健康覆盖迈出了关键一步。然而，卫生筹资政策与采购实践之间的结构失调依然存在，削弱了这些改革的成效。战略采购——卫生筹资的一个关键杠杆——有潜力通过根据人口需求、提供者绩效和服务价值积极分配统筹资金来提高系统效率、公平性和响应能力。然而，在尼泊尔，诸如按项目预算、分散的项目资金以及机构角色重叠等传统做法阻碍了这种方法的采用。卫生与人口部继续同时扮演政策制定者、采购者和提供者的角色，削弱了问责制和采购者的自主权。公共提供者通过历史预算和报销计划获得资金，淡化了对绩效的激励。此外，NHIP的采购决策并非以卫生技术评估或成本效益分析为指导，引发了对福利包分配效率的担忧。本观点认为，尼泊尔的卫生筹资改革需要进行机构调整、更明确的角色划分以及更强有力的合同机制来支持战略采购。借鉴本国经验和国际框架，它突出了系统性脱节问题，并为将战略采购纳入尼泊尔的卫生筹资架构提供了一条前进道路。通过纠正这些基础性失调问题，尼泊尔能够更好地利用公共资源来提供高质量、公平的医疗服务，同时推进联邦制和全民健康覆盖的目标。
