Experiences and effect of implementing social health insurance (SHI) program in Nepal-A mixed method study

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.