Ensuring health insurance for all Nepalis

Ever since Finance Minister Janardan Sharma in his budget speech last month announced a plan to hand over management of Nepal’s national health insurance program to the private sector, experts are concerned that it will make medical treatment unaffordable for most people.

Indeed, privatising health insurance is like the government abandoning its people, experts say, and it defeats the very purpose of the program — to provide affordable care for the most underserved communities who can neither access private plans nor expensive hospitals.

"Health insurance delivers the right of citizens to proper healthcare. As soon as it is implemented through a for-profit company, the social security aspect will be forgotten and serve purely as a business,” warns public health expert Sharad Onta.

Private companies already provide health insurance schemes to those who can afford its expensive premium. The private sector therefore mainly serves the affluent, as public health experts Gaj B Gurung and Sushil Koirala argue in their op-ed for Nepali Times:

‘But can they really contribute to national public health security, understand equity, expand access to the poorest and the most marginalised population, and negotiate with the government providers for quality services? Are they fundamentally designed to serve the poor?’

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In 2017, then health minister Gagan Thapa introduced a national insurance scheme with a premium of Rs2,500 a year for a benefit package of Rs50,000 for a family of five. This was later increased to Rs3,500 premium and Rs100,000 payout. But this is still too low, and needs to be revised.

Hospitals also complain of late reimbursement, and some are considering pulling out of the program. Dhulikhel Hospital alone is owed Rs250 million in reimbursements. Patients are not happy about the service either, and are dropping out.

But it is too early to give up, says SP Kalaunee, former director of Nyaya Health Nepal which implements the national insurance scheme at its Bayalpata Hospital in Achham.

“Nepal’s health insurance policy is fairly new and such challenges are to be expected,” he says, “But they can be and should be addressed within the existing structure.”

He adds: “The goal of the program was to make healthcare accessible, affordable and equitable to all. The fact that we have an additional feature to the program to strengthen service providers means it was never just a financial mechanism.”

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A mandatory health insurance scheme where people pay the premium based on their per capita income could eventually include benefits that include treatment of chronic illnesses, say experts.

Hiring competent staff with expertise in the field at the Health Insurance Board (HIB) might be a good start to improving the existing program. HIB should also be an autonomous body capable of making its own decisions without interference from the Health or Finance Ministry.

Digitising reimbursement will also address some of the grievances, especially as the program should also look into signing up as many hospitals and care providers including the private establishments for the scheme. The private sector can be involved, but only in carrying out research on the sustainability of the program and for technical expertise.

Nepal’s healthcare is divided into three levels:

1. Primary health care (PHC) which is free in government hospitals
2. Secondary care which is paid for by national health insurance and has waived premiums of the elderly, completely disabled, leprosy and Multi-Drug Resistant TB patients, people living with HIV, and the ultra-poor.
3. Tertiary care that needs specialised treatment of chronic illnesses like cancers for which the government provides up to Rs100,000.

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All three aim to eliminate user fees at the point of care, but there are implementation challenges — the main one being the lack of government investment in the health sector and the limited understanding of what constitutes good health.

“Health is more than just treatment and hospitals. A large part of it is prevention, from preventive measures against infection to building safer roads so that there are fewer road traffic accidents,” explains Sangeeta Kaushal Mishra of the Ministry of Health and Population.

But health is not the priority of the government and there is not much investment in training medical personnel, making it incapable of meeting public demand. This gap is now being filled by the private sector.

The government’s lack of capacity can be addressed to some measure by working with non-profits much like Nyaya Health Nepal and Nick Simons Institute which work with government hospitals to upgrade service.

Read also: Is free health care possible in Nepal? S P Kalaunee

Community outreach is another crucial aspect in building a people-centric health system, and Nepal has a head start with its thousands of female community health volunteers across the country. They are primarily responsible for high childhood immunisation rates and reducing maternal mortality.  This now needs to expand to also include healthcare professionals at the grassroots, and retaining them.

In the meantime, Nepal’s national health insurance policy also needs to address emerging problems like non-communicable diseases which with injuries make up two-thirds of death and disabilities in Nepal. The program must also include provisions for geriatric care and mental health conditions, all the while making sure the interests of the most vulnerable in the society are addressed.

"Private entrepreneurs will not fulfil the responsibility of the state. The access to the health care of the poor will be further weakened as soon as health insurance is privatised,” warns Damodar Basaula of the Health Insurance Board.

Ensuring accessible and affordable health care for the people is the prerequisite of any government. Passing the buck to the private sector or any other group will further impoverish families unable to pay the medical cost of treating relatives.

Says SP Kalaunee: “If you do not invest in the lives of people now it will cost much more tomorrow. The national health insurance program is set to become our biggest investment soon, and we must prepare the groundwork for it."

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