Rapid assessment of the implementation of national health insurance program in Nepal: a qualitative study

BACKGROUND: Nepal's national health insurance program (NHIP) initiative, launched in 2016, endeavors to attain universal health coverage (UHC). However, it encounters significant hurdles in ensuring sufficient coverage across the population. Despite the remarkable progress it has made in improving access to health services, there are problems resulting into poor enrollment and retention and challenges regarding ensuring quality of care. OBJECTIVES: This study aimed to assess the current implementation challenges of NHIP through consumer and providers perspectives and thereby identify the facilitators and barriers for enrollment in NHIP. METHODOLOGY: We conducted an exploratory qualitative research design and employed thematic analysis approach. A total of 22 health facilities across the 14 districts of 3 provinces of Nepal were included in the study. We conducted 62 key informant interviews with the providers and 39 focus group discussions with the community members to determine the factors impacting enrollment and retention to health insurance program. All the interviews were audio-recorded, translated and analyzed thematically using the WHO six-building blocks as a theoretical framework. The analysis was done in Excel. RESULTS: The results are presented under the WHO six building blocks. The Health Insurance Board's (HIB) leadership lacks effectiveness due to the limited administrative delegation power held by provincial and local governments. The existing financing mechanism is viewed as unsustainable in the long term, highlighting the necessity for mandatory population enrollment. Poor awareness of the program and mistrust regarding care quality emerge as primary factors contributing to low enrollment and retention rates. Addressing these challenges requires urgent implementation of training and retention strategies for community-level enrollment assistants. Additionally, facility-based monitoring and supervision, currently lacking, could serve as a means to improve and rebuild trust in the quality of healthcare service. CONCLUSION: With rigorous monitoring and iterative approach, Nepal has a historic opportunity to create a model of success on universal health coverage in a low-income setting.