Efforts being made to integrate all state-funded health programmes
Kathmandu, Apr. 26
Even after a decade
since the micro-health insurance facility was launched in Nepal with the aim to
establish universal access for citizens to quality health services, the
programme is facing multi-pronged challenges including the management of funds,
shortage of human resources, and inability to review the increasing claims
submitted by the service providers.
The programme was
launched on a trial a decade ago and was formally implemented after two years
following the enactment of the Health Insurance Act, 2017.
Due to the acute
shortage of funds, payment liability has piled up at the Health Insurance Board
(HIB). It has not been able to reimburse the amount claimed by the service
providers (hospitals and health centres) since the beginning of the current
Fiscal Year 2024/25.
The HIB is clearing
the dues from the last FY 2023/24 this year. It has about Rs. 17.5 billion
outstanding. "Estimating the additional claims in
the remaining period of the current fiscal year, the total amount remaining for
payment by the end of this fiscal year is expected to be Rs. 24 billion. There
is a challenge in developing the capacity to make timely payments," the
HIB said in a white paper about its status published a month ago.
Meanwhile, the amount of claims submitted
to the board goes as up as 40,000 a day while the team to review those claims
is struggling with limited human resources and technology.
"The HIB has a team of about 25
medical experts including doctors, nurses and lab technicians to review the
claims filed by 485 health institutions across the country. Without additional
human resources, this cannot be resolved," said Bikesh Malla, Information
Officer of the Board.
With the current setup, the HIB can review
maximum 7,000 cases a day. As a result, the claim verification of the last FY
2023/24 is still pending. The White Paper mentions that the number of claims
received by the board and not reviewed is about 9 million by the end of
February. The paper also maintains that due to insufficient skilled manpower in
claim review and the inherently weak method and process adopted, timely
verification of claims has not been possible.
It has left the Board, service providers,
and the insured all disadvantaged.
Deficit budget,
workforce
The HIB is struggling
with the limited sources of income. The fund earns about Rs. 3 billion to Rs.
3.5 billion from the premium charges and receives approximately Rs. 7.5 billion
from the budget in a year. For the last three fiscal years, the government has
disbursed the same amount of money to the Board.
According to Malla,
the HIB has approved a budget of Rs. 26.59 billion for this year but it is
likely to receive one third of that amount. Through the Ministry of Health and
Population (MoHP), it has asked for the funds of Rs. 17.5 billion from the
Ministry of Finance (MoF).
But since the country
is also struggling with fund management, the MoF had pledged to provide
additional Rs. 3 billion on top of the Rs. 7.5 billion announced through the
annual budget. If the sum of the premium is also added to this fund, total size
of the fund at the HIB reaches Rs. 14 billion. Even then, there will be a
shortfall of Rs. 10 billion.
Meanwhile, the Board
has been facing growing operation cost issue including Rs. 23.4 million in
house rent and millions of rupees for employees' salaries.
"The MoHP has
directed the Board to reduce the number of consultants, use government
buildings instead of renting out space for offices and maintain full
transparency," Spokesperson of the MoHP, Dr. Prakash Budhathoki, said to
The Rising Nepal.
According to him, to
overcome the challenges posed by the shortage of workforce, the Ministry has
given a positive nod to hire 25 experts to review the pending claims.
Likewise, inability to make the operations
fully automated has its toll on the board, service providers and service
seekers.
Due to the inability to use technology that
can automatically reject treatments outside the standards set by the Board and
provide information on false claims, there is a risk of some service providers
entering false claims and even receiving payments, said the Board.
To address this malady, the HIB has
accorded priority to implementation of information technology. New bylaws are
formulated and submitted to the Cabinet with a provision to audit the
prescriptions of the doctors to discourage the false claims, informed Dr.
Budhathoki.
Hassles to patients
Hospitals discriminate the patients that
come to obtain the health facility under the insurance programme. Service
seekers have complained that they have to wait for a long time to obtain the
services and have to face hassles at the hospitals.
The White Paper of the HIB has accepted the
fact that there have been widespread complaints that the health service offered
by service providers has not been effective. "Problems such as having to
receive service only at the designated first service point, unavailability of
doctors at the first service point, not being able to get tests done on time,
and unavailability of medicines are recurring," read the document.
Patients reaching Bir Hopspital, Tribhuvan
University Teaching Hospital, Chitwan Medical College and other institutions
have to spend more time to get their health checked or receive medicine due to
additional bureaucratic hassles.
Malla of the Board said that due to limited
capacity of the hospital, small number of equipment and shortage of human
resources have been the causes behind such challenges that are causing
dissatisfaction on the part of patients.
As a result, the programme has been
witnessing a high dropout rate. In the current FY 2024/25, the dropout rate
stands at 54 per cent. Although it was lower than 64 per cent two years ago,
this is significant and needs a serious attention, experts say.
A Health Ministry official said that the
Board has failed to identify the reasons behind this high dropout rate and
address it in time.
Likewise, the Board has not been able to
train the service provider health institutions with which it has agreements and
make them proficient in providing services. The capacity to monitor and
regulate the services provided by service providers has not been developed. The
Board has faced difficulties in controlling quality due to the inability to pay
service providers on time, according to the White Paper.
The Board also doesn't have monitoring and
evaluation guidelines while checklists and standards need to be updated. It
said that while the practice of joint monitoring has not taken place so far,
multiple suggestions and conclusions received from monitoring have also not
been implemented.
The NIB, in collaboration with the MoHP,
plans to bring the first service points into operation in all local levels of
the country, enhance their capacity and streamline the referral system.
Strategy to manage funds
The MoHP and NIB have begun work on
addressing the challenges in the fund management. Health Minister Pradip Paudel
has been stressing on strengthening the Board and expanding the programme so
that it could cover every citizen of the country.
He even went further to increase the health
coverage of up to Rs. 500,000 from the current purse of Rs. 100,000 per family.
Such amount for senior citizens and chronically ill people is Rs. 200,000. A
family can obtain the facility with premium of Rs. 3,500 while senior citizens
above 70 years of age need not pay any premium.
Minister Paudel has already decided to
activate the Health Insurance Fund and deposit 1 per cent of the total income
of the federal hospital into it. The Finance Ministry has already given a
positive nod to his Minister-level decision.
The Health Ministry is of the view that
more reforms would be made as per the suggestions of the Task Force on Health
Insurance Reform. It has also been saying that all the government implemented
health and treatment support programmes should be integrated with the Fund
while government employees should contribute 1 per cent from their salary and an
equivalent amount should be contributed by the government to the fund.
While accepting the report of the Task
Force last month, Minister Paudel said that if all the health-related
programmes of all levels of the governments were consolidated, about Rs. 30
billion could be collected into the Fund. Many local governments have been
executing free or subsidised health insurance programmes.
Dr. Budhathoki of the Health Ministry said
that approximately Rs. 15 billion could be consolidated into the Fund if the free
or subsidised health programme for deprived people, senior citizens, people
with disability and pregnant or lactating mothers could be brought under the
HIB.
However, it is likely to take a couple of
years to complete this task.
Similarly, the Health Ministry also wants
to bring the health insurance provided by the Social Security Fund to the
registered employees under the HIB. But the Ministry of Labour, Employment and
Social Security is reluctant to do so.
A successful programme
Given the achievements the health insurance
programme made in the last eight years, it can be termed as 'successful' minus
the shortage of funds. The programme is expanded to 749 local levels of 77
districts of the country. Cumulative registration to the programme so far has
reached 8.95 million while active insured individuals by the end of February
this year was 5.75 million – 20 per cent of the total population.
Likewise, the number of active enrolled
households has gone up from 238,492 in 2017 to 982,062 – excluding senior
citizens - by February 2024. Including senior citizens, 2.07 million families
are active in health insurance, making it a 31 per cent of the total households,
according to the Board.
While family members up to five individuals
are considered one unit in the insurance programme, senior citizens are
considered one unit per individual.
As per the NIB statistics, there is
imbalance in participation among the provinces. Gandaki province has 34 per
cent of the total insured under the health insurance, followed by Koshi with 33
per cent, Bagmati 26 per cent, and Lumbinin and Karnali 14 per cent each. But
Sudurpaschim and Madhes have only 11 per cent and 7 per cent share in the total
insured population.
"The low participation of provinces
lagging behind in human development is a matter of concern. It seems necessary
to give more priority to including everyone in health insurance, especially the
backward classes, communities, and regions," the Board said.
Published in The Rising Nepal daily on 26 April 2025.
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