Implementation and Assessment of Facilitation Support for Improving Health Insurance Coverage in Achham

BACKGROUND: Health insurance is a critical strategy for achieving universal health coverage, reducing out-of-pocket (OOP) healthcare expenditures, and improving access to healthcare services. Despite the implementation of the National Health Insurance Program (NHIP) in Nepal, enrolment and renewal rates remain low, particularly in districts like Achham. This study aimed to assess the effectiveness of facilitation support, delivered through patient navigators, enrolment assistants, and community health workers (CHWs), in increasing health insurance coverage. Methods: A mixed-methods approach was employed. The descriptive analysis examined enrolment trends and assessed the impact of CHW-led counselling on enrolment and renewal processes. The qualitative component explored program acceptability, adoption, feasibility challenges, and systemic barriers encountered during implementation. Results: Facilitation supports improved health insurance uptake, leading to a 5.1 percent increase in new enrolments within three months. While awareness of NHIP was high (62.7%), only 37.7 percent of households had at least one insured member, and 43.1 percent of policies were inactive. Among those counselled for renewal, 76.3 percent agreed to enrol or renew, with 71.3 percent successfully completing the process. Enrolment increased from 57,556 individuals in FY 2079/80 to 58,630 in FY 2080/81, representing a 1.9 percent growth in Achham district. Despite these gains, service gaps persisted; Stakeholders identified limited availability of enrolment assistants, barriers to referrals, activation time, first service point, healthcare service availability, insufficient financial support, stockouts of essential medications, and procedural complexities as key obstacles. Conclusions: The facilitation strategy improved health insurance enrolment in Achham by addressing awareness, affordability, and procedural barriers. To sustain impact, efforts should focus on reducing Enrolment Assistant dropout rates, improving the referral system, ensuring timely healthcare services for insured individuals, and providing financial support for low-income groups. Scaling up these targeted improvements can enhance NHIP's effectiveness. Keywords: Barriers; enrolment; feasibility; healthcare; health Insurance.