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

Abstract

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14742-5.

Background

Nepal, like many low- and middle-income (LMIC) countries, strives to achieve universal health coverage (UHC), with the National Health Insurance Program (NHIP) launched in 2016 as a crucial component. This social health insurance scheme aims to enhance healthcare access and quality while reducing household financial burdens [1–3]. This family and contribution-based program offers subsidies for specific groups, and services are accessible through both public and private health facilities via a cashless mechanism [4]. A total of 440 service locations, including primary health centres, government hospitals, private hospitals, and community hospitals, are registered as service providers with the Health Insurance Board (an agency for purchasing health care services) to provide these services. These health services are provided across all three tiers of the healthcare system, encompassing local levels, primary healthcare centres, and district and provincial hospitals for secondary care, and specialised services are rendered through the tertiary level of the healthcare system [5, 6]. Enrollees pay an annual premium of NPR 3,500 (approximately $26) for households with five or fewer members, providing coverage up to NPR 100,000 (approximately $745) [7]. The NHIP also offers subsidies for vulnerable populations, including seniors, ultra-poor families, female community health volunteers, and individuals with specific health conditions [7]. The benefits package covers outpatient, inpatient, and emergency services, including 1,133 types of drugs at 440 service sites across Nepal [8].

The Government of Nepal (GoN) initiated a health insurance program since 2016 in three districts as a pilot project and expanded it to all provinces and districts as well by 2023 [8, 9]. The NHIP in Nepal has completed almost one decade of implementation, where the Health Insurance Board (HIB) is the apex body to implement, regulate, and monitor the NHIP. The main aim of the NHIP is to increase individuals’ access to quality healthcare services and reduce financial trouble while receiving healthcare services. During a short period, the program has been expanded throughout the country within seven years of its introduction [10]. Despite expanding to all 77 districts and reaching over seven million enrollees, NHIP faces challenges. As of 2023, enrollment reached only 25% of the population, far below the 60% target for 2022, alongside an annual dropout rate of approximately 23% [8]. Contributing factors were reported to include drug shortages, unfriendly health worker behavior, and indifferent treatment of insured patients [11, 12]. These issues jeopardize the NHIP’s financial sustainability and its capacity to deliver comprehensive services, ultimately hindering Nepal’s goal of achieving over 90% UHC by 2030 [12].

This study investigates the implementation of the NHIP from both provider and consumer perspectives, examining the enablers and barriers to its success. Considering both the demand and supply aspects, the insights derived from this study fill the evidence gap essential for policymakers and program administrators to reconsider strategies and devise inventive methods to implement social health insurance in Nepal effectively. The findings can inform policy development to improve the NHIP in Nepal and offer lessons for other LMIC countries grappling with similar challenges in pursuing universal health coverage.

Methods

Study design

We adopted an exploratory qualitative approach, using thematic analysis based on data from Focus Group Discussions (FGDs) and Key Informant Interviews (KIIs). The study was conducted to understand the perception of both beneficiaries and providers-healthcare, leaders, and government authorities towards barriers and facilitators to enrollment and retention in insurance programs.

Settings and sampling

We adopted purposive sampling for our study where 22 health facilities from 3 provinces (Bagmati, Madhesh and Karnali) were selected. For the selection of provinces, the enrollment percentage and service utilization were assessed across all seven provinces based on the data extracted from the Annual Report 2020/21 of the HIB [10]. Specifically, the provinces were chosen in accordance with their calculated average ranks of enrollment rate and service utilization, indicating those with notably higher, intermediate, and lower levels of enrollment coverage and service utilization. We then select 22 health facilities to represent primary, secondary, and tertiary care levels, with a mix of public and private ownership and variations in enrollment rates and claim reimbursement levels (Fig. 1). The selection of the provinces and health facilities was performed in consultation with the HIB.

Fig. 1.

Study sites- Provinces and respective count of health facilities

Study population and sampling

In documenting experiences and perceptions of the providers and beneficiaries about the performance of the NHIP, we purposively included the participants considering the diversity of setting (Policy makers, health provider management), and level of health facilities (Federal specialized care hospitals, Provincial Hospitals, District Hospitals, PHC, community health facilities) and patients.

For the KIIs, a representative member from the provincial level- Provincial Health Directorate from each selected province were interviewed. At the local level, district coordinators were interviewed from the providers’ side. Similarly, KIIs with the insurance focal person of health facilities were conducted from the selected health facilities.

Likewise, FGDs included community members (insured, uninsured, and dropout patients) and health insurance enrollment assistants. These discussions aimed to understand the perspective on the program’s effectiveness and identify existing gaps. Enrollment Assistants, who are responsible for conducting home visits to enroll new members and renewing the insurance coverage of existing members in the health insurance program assisted in identifying those participants for the FGDs.

Sample size

We conducted 62 KIIs with health service providers and policymakers as well as 39 FGDs- 11 with health enrolment assistants and 28 with the insured, uninsured, and dropout groups. Two community leaders were interviewed towards the end of the study. Also, we conducted three in-depth interviews with enrollment assistants in Karnali province instead of focus group discussions due to geographical distances. The sample size determination was based on reaching saturation which signifies the point at which no new or additional information emerged from the interviews [13].

Data collection tools and techniques

We developed interview guides based on a thorough literature review and expert input (Supplemental File 1), which were validated through pre-testing in Dhulikhel municipality. Research assistants received training on qualitative methods and clear communication of technical terms before data collection. Data collection occurred between September 2023 and January 2024. For data collection, a face-to-face interview approach utilising an interview guide was employed [14]. Regarding the setting, KIIs were conducted at participants’ workplaces or other locations preferred by the participants. Likewise, FGDs were held in workplace halls or designated private spaces to ensure a comfortable environment and to minimize interruptions or interference from non-participants during the discussions. Interviews were conducted in local language by the research assistants, There were no prior relationships between interviewers and participants, and participants were informed about the research objective and consent processes. None of the participants refused to participate in the study. The KIIs ranged in duration from 15 to 45 min and FGDs ranged from 30 to 65 min. With participants’ consent, interviews were recorded on a audio-recording device. Along with the audio record, notes were also taken during the interview. An iterative process involved reviewing interviews shortly after completion to adjust and probe deeper to ensure information accuracy. Post-interviews, researchers engaged in discussions with participants to validate comprehension of conveyed ideas and get their feedback. The number of interviews was guided by data saturation theory [13] .

Subsequently, recorded Nepali-language interviews were transcribed and translated into English by researchers. To safeguard anonymity, codes were assigned to interviewees, and confidentiality was maintained by storing interviews in a password-protected folder on a laptop. An independent research team member verified English translations for accuracy check, quality and completeness by comparing transcripts to audio files.

Data analysis

The data were analyzed using thematic analysis [15]. The initial codebook was deductively developed based on the interview guide and revised to include emerging code using an inductive approach. Initially two transcripts were coded independently by two researchers involved in the study, referring to the initial codebook and checked for coding consistency. The majority of codes and sub-codes were similar, except for few, which were discussed among the study team members and a consensus was reached to assign a common code. The analysis involved an iterative process of coding, analysis, writing, diagramming, and revision.

We used the World Health Organization’s (WHO) health system building blocks framework to structure our study findings [16]. The World Health Organization’s (WHO) Health Systems Building Blocks is a classic framework used in various studies and contains six building blocks: leadership and governance, service delivery, health workforce, information, financing and, logistics. The leadership/governance block emphasizes effective management and coordination of the health system. The financing block underscores the need for sustainable funding mechanisms; workforce block focuses on ensuring a skilled and sufficient healthcare workforce. The information system block highlights the importance of reliable data for effective decision-making, and the access to essential medicines block emphasizes the equitable availability of medicines. The service delivery block emphasizes providing quality healthcare services. The Standards for Reporting Qualitative Research (SRQR) guideline (Supplemental file 2) was used to prepare this manuscript [17]. The analysis was performed in Excel. To enhance the transparency and depth of our findings, illustrative quotes have been included in the manuscript as supporting information, providing direct insights from participants and adding contextual richness to the themes identified.

Results

We conducted a total of 62 KIIs and 39 FGDs. The socio-demographic details of the participants are shown in Table 1 and the discussion guide/themes in Table 2.

Table 1.

Socio-demographic characteristics of the participants

Key-Informant Interviews Participants
KII participants ( n  = 62)			N (%)
Age (mean ± SD)			34.1 ± 7.7
Gender
Male			50 (80.7)
Female			12 (19.3)
Marital status
Never married			16 (25.8)
Married			46 (74.2)
Educational Status
Secondary level (6–12)			7 (11.3)
Bachelors and above			55 (88.7)
Years of experience in Insurance (mean ± SD)			3.5 ± 2.5

Focus Group Discussion with Enrollment Assistants
Enrollment Assistants ( n  = 84)			N (%)
Age (mean ± SD)			34.5 ± 6.4
Gender
Male			21 (25)
Female			63 (75)
Marital status
Never married			7 (8.3)
Married			77 (91.7)
Educational Status
Secondary level (6–12)			58 (69.1)
Bachelors and above			26 (30.9)
Years of experience in Insurance (mean ± SD)			4 ± 2

Focus Group Discussion with community (insured, uninsured and drop-outs)
Characteristics	Overall ( n  = 240)	Insured ( n  = 85)		Uninsured ( n  = 80)	Drop-out ( n  = 75)
Age	45.5 (13.3)	47.6 (14.5)		42.5 (12.3)	46.5 (12.6)
Gender
Male	97 (40.4)	40 (47.1)		31 (38.8)	26 (34.7)
Female	143 (59.6)	45 (52.9)		49 (61.2)	49 (65.3)
Marital status
Married	224 (93.3)	81 (95.3)		72 (90)	71 (94.7)
Unmarried	10 (4.2)	1 (1.2)		4 (5)	2 (2.7)
Widow	6 (2.5)	3 (3.5)		4 (5)	2 (2.7)
Educational Status
Illiterate	22 (9.2)	5 (5.9)		6 (7.5)	11 (14.7)
No formal education	38 (15.8)	15 (17.6)		10 (12.5)	13 (17.3)
Primary education (1–5)	10 (4.2)	6 (7.1)		2 (2.5)	2 (2.7)
Secondary level education (6–12)	138 (57.5)	42 (49.4)		54 (67.5)	42 (56)
Bachelors and above	32 (13.3)	17 (20)		8 (10)	7 (9.3)
Total Years/duration of enrollment		3 (1.6)			1.6 (1.2)

Note: data are presented as frequency (percentage)

Table 2.

Major components in the interview/discussion

Components	Beneficiaries	Service Providers	Policymakers
Knowledge regarding NHIP	Y	-	-
Benefits of NHIP	Y	Y	Y
Facilitators and Barriers of NHIP and enrollment	Y	Y	Y
Challenges in implementation	-	Y	Y
Recommendations to improve NHIP	Y	Y	Y

Y = Yes

The findings are presented under 6 major themes and 16 sub-themes as shown in Fig. 2. The findings are supported with quotes from participants.

Fig. 2.

Themes and sub-themes under WHO six building blocks

Leadership and governance

Centralized authority of the Health Insurance Board

The NHIP is currently administered by the Health Insurance Board (HIB) which has organizational structures at three tiers of government. The organizational structure follows one central office (HIB), seven provincial offices and district offices in each district. The central HIB provides membership cards, makes decisions on contribution amounts, develops mechanisms for subsidies to poor and disadvantaged groups, as well as negotiates with service providers on benefit packages, their costs and deals with provider payments. However, the centralized autonomous model of HIB in administrative matters has led to a detachment among the insurance bodies at provincial and district level.

The enrollment assistants and insured individuals come to us with complaints, but all matters are handled by HIB. We can’t even correct spelling mistakes of the insurees; it feels like we’re just here to watch things. (KII-District focal person)

Moreover, limited coordination of HIB with line ministries further isolates the NHIP as a standalone initiative, detached from broader governmental efforts.

Other vertical programs have good intergovernmental coordination, but this insurance program lacks such connections. (KII- Provincial officer)

Inadequate community engagement

At the community level, the Enrollment Assistants (EAs) act as a bridge between the community and NHIP. The EAs make door-to-door visits in the communities for awareness activities and facilitating the new enrollment as well as renew of the insurance policy in the insurance program. Besides the EAs, the program also envisions the engagement of local leaders and stakeholders for creating awareness and generating the demand for the insurance program. However, the demand generation activities have not been implemented as expected because of the lack of regular monitoring from HIB.

The local government has many responsibilities, and I haven’t been informed about my role in the insurance program. I had only heard about the premium and benefit amount from my relatives. (KII-Local leader)

The current initiatives for disseminating the information have been limited to EAs. On top of that, there is no assurance if the information disseminated is sufficient to attract the household in the NHIP. It is a matter of concern that the EAs, who have been trained about the NHIP six years back, with so many policy changes, and no refresher trainings, are disseminating the information to the communities on a 10% incentives per household enrollment. Though unintentional, at times, the limited information can be misleading.

Convincing people to renew their insurance has become difficult…. people have many questions about the program but at times, we also do not have appropriate answers. (FGD- Enrollment assistant)

Financing

Financial sustainability

The key sources of funds for NHIP are tax funds and premium collection. This pool fund is utilized for the claim reimbursement, partial and/or full subsidies for different groups and expenditure in operational cost of HIB. Though there are other avenues like, local and federal government’s contribution to the pool funds and collaboration with external organizations but it has not been effectively utilized. With the current status of enrollment rate and grant allocation trend from government, the sustainability of the funds is questionable in the long run.

The concept of free healthcare is problematic……I don’t think the government can hold this insurance program in the long run with the current funding. (KII-District focal person)

Budget constraints

As the administrative authority, HIB dictates all activities and budgetary decisions from the central level. However, participants at the provincial and local levels highlight significant financial deficits hindering additional initiatives. Essential activities such as refresher training for EAs, district-level meetings, monitoring and supervision activities and community awareness programs are all sidelined due to severe budgetary constraints.

It might seem like we are not doing anything but our hands are also tied because of the budget constraints. (KII-Provincial Officer)

in certain programs, like for the meetings with enrollment assistants, I have contributed expenses from my pocket. But it cannot continue forever. (KII-District focal person)

Delayed reimbursement to providers

Healthcare facilities have benefited from increased patient flow under NHIP, leading to expanded services and more job opportunities for health professionals. This influx of resources has allowed for the expansion of hospital services and job opportunities for healthcare professionals as well. The increased income is dedicated to maintaining and improving the quality of services provided emphasizing on the patient-centered care by the institutions.

Patient flow at Gaushala PHC surged from 60 to over 100 daily after insurance implementation. (KII- HSP)

We increased our bed capacity from 15 to 50, and eventually to 100 beds to accommodate the rising demand. (KII-Insurance Focal person)

But side-by-side there are many complaints from the health facilities as well which primarily include the delayed reimbursement of the claims. In health facilities, the payment is made through case-based payment (outpatient and emergency services) and fee-for-service (inpatient and diagnostic services) based on the defined rates of the benefit package. In both cases, the claim is made digitally through the IMIS (Insurance Management Information System) software and managed by the claims and IT section if HIB.

Despite the protocol dictating regular reimbursement cycles—monthly, bi-monthly, or quarterly—HIB fails to adhere to this, resulting in irregular reimbursements. Shockingly, some health facilities have gone over a year without receiving any reimbursement. Furthermore, claims are sometimes rejected after prolonged periods, leaving health facilities with unanswered questions and exacerbating the gap.

We submit claims monthly, expecting reimbursement 12 times a year, but unfortunately, we only receive payments 7 or 8 times annually. (KII- Insurance Focal Person)

These delays are forcing hospitals to provide services on credit, creating a financial burden and jeopardizing their ability to serve patients effectively.

There is no written guideline and we have to follow what we hear from the upper level and we do hit and trial sometimes to check whether it will fall in rejection during the claim process. (KII-HSP)

Workforce

Lack of human resources

The Health Insurance Board (HIB) Regulation 2018 only outlined the responsibilities of Enrollment Assistants (EAs) who are currently employed as HIB district officers, without specifying the qualifications for EAs. According to the regulation, the local government can recruit EAs as needed. However, most of the sanctioned positions of NHIP at the Health Insurance Board district office are vacant. The lack of personnel leads to an overburdened responsibilities on the existing workforce.

We are overloaded; only two out of six sanctioned posts are filled. (KII-District Focal person)

The limited number of available human resources is struggling to manage the workload, leading to increased pressure on existing staff. Due to the work burden, staff have to work overtime to complete work on time.

Due to the workload, we work from 7 am to 11 pm to complete our task. (KII-District Focal person)

The issue of an overburdened workforce extends to health facilities, where patient flow has surged due to the insurance program. However, the number of medical professionals, particularly in rural areas, remains insufficient to meet this demand.

The doctor-patient ratio is terrible. One doctor should examine 80 patients in a single day. (KII-HSP)

Limited training

The NHIP started in 2016 A.D with a certain number of staff who received orientation and training for the program. Besides the initial training, there have not been refreshment training programs. Most of the staff are either learning by doing or calling someone for assistance.

Due to inadequate training, we struggled to enroll people, needing multiple calls to the enrollment officer for assistance. (FGD-Enrollment assistant)

I haven’t undergone any health insurance training. Instead, I’ve relied on my experience, sought guidance from colleagues, and conducted independent research online to carry out my responsibilities. (KII-Insurance Focal person)

The limited training programs have hindered the efficiency of the performance at all levels. The EAs who are not updated with the enrollment related policy level changes, the healthcare professionals who are not aware of the health service related changes have led to widespread confusions among the providers.

Frequent policy changes create difficulty……Also, we do not know whom to contact during confusion. We often work in a trial and error manner. (KII-HSP)

Turnover of enrollment assistants

The Enrollment Assistants (EAs) receive a mere 10% of each successful enrollment without any additional benefits, which proves insufficient to cover their travel and communication expenses. This issue is particularly acute in rural and hilly communities with challenging geography and widely dispersed households. Consequently, when EAs struggle to convince households to enroll, their time and efforts are often wasted, leading to frustration and eventual dropout.

We often need multiple visits to enroll one household, earning just NRS. 350. Is it worth the two days of effort. (FGD-Enrollment Assistant)

As the link between the NHIP and the community, EAs serve as the primary contact for both appreciation and criticism, with the latter often overshadowing the former. The EAs serve as a protective barrier, absorbing criticism from the community without receiving sufficient backup support from the responsible authority. This lack of support contributes to their demotivation in fulfilling their duties and often discontinue their roles.

As we collect the premium, people presume that we took their money. (FGD-Enrollment Assistant)

The absence or drop-out of EAs is often unnotified as there are no regular meetings with the EOs, though it was supposed to be on a monthly basis.

Initially, 12 enrollment assistants were trained…… But now only 8 remain, forcing each to take a larger workload. (FGD-Enrollment Assistant)

Information and research

Lack of awareness at community level

Despite efforts to raise awareness, community knowledge of NHIP remains inadequate. It’s imperative to acknowledge that the inputs provided thus far have also fallen short of the necessary standard.

An awareness campaign should be held. People don’t openly discuss insurance, but they would enroll if they understood the services provided. (FGD-Insured)

Given its importance, the insurance program has not received the prioritization it deserves. Progress has been regular rather than exponential. (KII-Provincial Officer)

Frequent turnover and insufficient refresher training have left Enrollment Assistants (EAs) without crucial, current information, contributing to low community awareness. Consequently, only individuals with prior family experience accessing services are informed about the health insurance program, leaving many others uninformed.

People ask us about the benefit package and we tell them about what we have known, using the brochures we have. We have been doing this for more than 4 years and with time, it is getting difficult to convince them. Previously, they also showed interest but these days, it is not the same. It is like moving in the opposite direction. (FGD-Enrollment assistant)

Insufficient knowledge flow

The EAs serve as critical intermediaries within the community, yet a gap exists in information flow from central level to the community, hindering effective communication and implementation. Although enrollment assistants received basic training at the start of the program, they weren’t provided with timely orientation on the updates and information regarding the insurance program which created confusion while enrolling beneficiaries.

We’ve never had orientation about the service packages. …… It’s been three years since any interaction from the center. (FGD- Enrollment assistant)

The turnover of the trained EAs and existing EAs lacking regular refresher training for further impedifies the knowledge gap. This barrier hampers the effective communication between EAs and the insurance beneficiaries, resulting in the limited understanding of the benefit package among the community people. Consequently, community members erroneously believe insurance covers all aspects of their treatment, posing challenges for service providers to provide accurate counseling.

Patients often believe that obtaining an insurance ticket guarantees coverage for all treatments and services. However, when we explain that certain medications are not covered by insurance and must be paid for separately, convincing them of this reality becomes challenging. (KII- Insurance Focal person)

Lack of monitoring and evaluation mechanism

The HIB monitors and supervises the NHIP through site visits, lot screening of claims, and annual reflection meetings with service providers and EAs. However, these mechanisms are not consistently operational.

We have many complaints from the insured people, dropouts and some from our side too. The insurance focal person ignores our voice and even doesn’t answer our calls. (FGD- Enrollment assistant)

While attempts to address complaints through site visits have been made, they are limited due to budget constraints.

I understand there are numerous community queries. I visited some sites initially, but there’s no budget for ongoing site visits. (KII-Province officer)

Medical products, technologies

Expansion of infrastructures/ services

The implementation of insurance has substantially increased daily patient flow attracting more service users benefiting both the institution and service users thereby generating additional revenue for the health facility. This influx of resources has allowed for the expansion of hospital services, resulting in the creation of job opportunities for doctors, nurses, and radiography staff. It has also resulted in upgrading of the hospitals.

We’ve added staff as needed, upgraded from a municipal to a provincial hospital, and improved all our performance indicators. (KII-Insurance focal person)

Frequent stockout of medicine/logistics

Although the increased patient flow has provided benefits to the service providing institutions, it has created frequent stockout of medicines and related materials causing challenges in providing services to all the beneficiaries.

There is no regular supply of medicine. If the patient can receive medication this month, we must refer that patient to another hospital the following month for medication. All laboratory tests are also unavailable. (KII-Insurance focal person)

Service delivery

Satisfaction with services

The implementation of the NHIP has led to a notable improvement in health-seeking behavior among the insured patients. Previously, individuals hesitated to seek medical attention due to financial constraints, but with insurance coverage, they now visit health institutions more frequently, averaging 2 to 3 times a week. This increased accessibility has encouraged patients to address even minor health concerns promptly.

Insured patients visit health institutions 2 or 3 times a week. Before the program, they hesitated to seek care due to costs. (KII-HSP)

Health insurance has significantly eased the financial burden associated with healthcare expenses, allowing individuals to receive treatment without the need for out-of-pocket payments when they fall ill.

Health insurance simplifies things; we save money that would otherwise be spent on hospital visits, which can range from RS. 5,000 to Rs. 7,000. (FGD- Insured)

Influence from insured individuals

While health insurance has expanded access to different healthcare services, dissatisfaction arises when it fails to offer crucial support during critical times. Many individuals, rather than enduring lengthy waits in public hospitals covered by their insurance, choose to seek immediate care at nearby private hospitals.This has led to low motivation among uninsured individuals to enroll in the program, as they’ve observed the insured clients bearing half of their healthcare expenses.

I don’t see much benefit in this insurance. My neighbor’s mother couldn’t fully utilize her insurance, paying almost half of her treatment costs. What’s the point if it doesn’t provide necessary support? (FGD- Uninsured)

I’d rather go to a private hospital for instant care than wait in a public hospital queue for 2–3 days. (FGD- Dropout)

Complicated referral mechanism

The first point of contact is only the public health facility selected by the insured during the enrollment process as the first center to receive services. In the current NHIP structure, it is mandated that insuree initially visit a specified first point of contact for medical care. Insured people reported having difficulty accessing health care services while visiting certain places. The requirement for referrals from the first service point for checkups in the visiting place has led to challenges for beneficiaries.

People may not always stay in one place. If I fall ill while visiting Kathmandu, I can’t return for a referral. (FGD- Insured)

However, specialized services are not provided through primary-level health centers; hence, patients requiring these services are referred to other hospitals. Health service providers stated that the referral process has caused inconvenience for patients in accessing services.

The referral process poses a challenge for patients. For example, a patient from Dhading must first obtain a referral card from Dhading to access health services at Bir Hospital. This requirement has caused inconvenience for the patients. (KII- HSP)

Interconnections across health system building blocks

The findings indicate that challenges of NHIP are not confined to individual system components but are deeply interconnected. For instance, limitations in financing constrained workforce recruitment, which in turn affected service delivery capacity. Likewise, the awareness activities are poorly coordinated in the absence of a clear communication strategy and dedicated budget allocation for these activities. The centralized governance structure of HIB, coupled with unclear communication mechanisms, has created gaps among insurance-related bodies at the local level, further exacerbating information and communication challenges. Additionally, service-related issues such as long waiting times for appointments, limited availability of medications, and inadequate treatment options have contributed to dissatisfaction with the quality of services offered under the program, discouraging individuals from renewing their enrollment. Moreover, the low rate of enrollment and renewal poses a significant challenge to the sustainability and effectiveness of the national health insurance program. Collectively, these findings demonstrate that weaknesses across governance, financing, workforce, information systems, and service delivery are mutually reinforcing rather than isolated problems. Addressing these challenges therefore requires a systems-oriented approach that recognizes the interdependence of health system building blocks and promotes coordinated action across sectors and levels of government. Meaningful engagement of key stakeholders including policymakers, local governments, healthcare providers, insurers, and communities is essential to strengthen accountability, improve communication and service quality, enhance public trust, and ensure the long-term sustainability of NHIP in Nepal.

The summary of the findings are illustrated in a network diagram shown in Fig. 3 below:

Fig. 3.

Network diagram with the major findings

Discussion

This study explored the barriers and facilitators influencing enrollment and retention in Nepal’s National Health Insurance Program (NHIP) from the perspectives of both providers and beneficiaries. The utilization of NHIP included facilitators such as improved health-seeking behavior, reduced out-of-pocket expenses, and support from local government. However, significant barriers included a lack of human resources, inadequate training, insufficient supervision of service providers and Health Insurance Board (HIB) staff at the provincial and district levels, and a limited understanding of the benefit package.

The key features of this insurance program are household as a unit of enrollment, community participation and risk-pooling mainly by the families. Although the Health Insurance Act (HIA) of 2017 mandates health insurance for both formal and informal sectors, its current implementation is voluntary for general families and mandatory for formal sector [2]. However, HIB is not able to implement the enrollment of formal sector and now only focuses primarily on the informal sector and specific target populations. The analysis of top 10 service beneficiaries of NHIP revealed that people with chronic illness and conscious and literate are more attracted to NHIP services which indicates adverse selection [18]. The context of increased utilization after implementation of health insurance is consistent with studies in Ghana, Ethiopia and Zambia [19–21]. But, with the current enrollment of 23% with annual drop-out rate of 24%, the voluntary prepayments cannot be a long-term solution [7, 22]. This poses a significant challenge in countries like Nepal, where the informal sector contributes a substantial portion (62.2%) to the national economy [23]. To ensure sustainability, Nepal may have to enhance population-wide enrollment to address adverse selection, refine patient-end co-payment and provider payment mechanisms to counter moral hazard, and diversify funding sources to improve program financing. None of these challenges are easy, but China’s experience in rapidly achieving near-universal enrollment in its voluntary rural health insurance program suggests that strong political commitment can make them possible [24].

This study identified several categories of barriers to enrollment and retention in the NHIP, each requiring tailored policy responses. Firstly, unmet needs and expectations emerged as significant deterrents, such as long wait times, poor care quality, disrespectful provider behavior, medication unavailability, inconvenient referral mechanisms, and insufficient service coverage. These findings underscore the need for the NHIP to prioritize quality of care alongside access [25, 26]. International experiences suggest that insurance payment methods for providers can be a powerful tool to incentivize quality care. However, the NHIP’s reliance on fee-for-service payments is not ideal for promoting quality [27]. Secondly, communication and information gaps were found to hinder enrollment, as reported by the enrollment assistants as well as uninsured and drop-outs. These findings align with previous studies where many potential beneficiaries lack awareness of NHIP and face misinformation about its policies [26]. NHIP should leverage implementation science to develop strategies that effectively address these information deficits [28]. However, we should note that many civically engaged and well-informed individuals aged 15–49 remain unenrolled [29]. Therefore, communication strategies must be tailored to address specific needs of various low-enrollment segments, including government employees, business owners, affluent families, migrants, and the ultra-poor. The third group of barriers relates to frontline staff motivation and competency. High workloads and inadequate training reduce their effectiveness in promoting enrollment. Lessons from international experiences, such as Thailand’s focus on human resources and Kyrgyzstan’s capacity-building efforts, provide valuable insights for Nepal [30, 31]. Finally, systemic governance challenges, such as limited local autonomy for NHIP agencies, poor coordination among stakeholders and government entities, and delayed reimbursements, complicate program operations. These challenges are often complex to address due to political dynamics and vested interests. However, abundant international experiences can be combined with local insights to drive improvement.

From provider’s perspective, one of the challenges raised by the health facilities was increased patient flow resulting in overburdened health workforce. This challenge in not a new one for NHIP but initiatives must be taken for solving them. Similar to Thailand’s provision of creating primary care units within hospitals as the first point of contact before getting to hospital, in Nepal we have PHCCs [30]. To tackle this problem, there is a need to strengthen the primary healthcare centres in Nepal. In Nepal, the cases where the patients demand for referral just to utilize their insurance contribution (moral hazards) has to some extent reduced because of the introduction of co-payment mechanism and has been mentioned by our study participants too. A systematic review by World Health Organization (WHO) showed that after the copayment policy in China, Taiwan and South Korea, the coverage increased and dropout was reduced [32]. But continuous efforts to maintain the chain of referral is needed along with improving the efficiency of PHCCs.

To counter the low enrollment rate, country needs to adapt strategies proven effective in similar settings. The PhilHealth in Philippines has increased access to primary health care services through various packages and ensured the quality of services through its accreditation system [33]. Additionally, the introduction of Sin-Tax (excise tax on tobacco and alcohol, channeling most of its revenues to health) has been a remarkable feat to provide subsidies in Philippines [34]. Several studies have shown that trust and satisfaction with the insurance benefit package play a major interplay in the decision of enrollment and renewal in the health insurance program [35–38]. To increase the trust and satisfaction, the engagement of social networks and informal group meetings could be utilized as in Ghana, where these strategies have impacted positively with a plausible explanation that previously registered members shared their positive experience about the insurance program which convinced others to take up [39].

While various barriers hinder the NHIP’s success, a critical underlying issue is the top-down approach to policy implementation as revealed in this study. The Constitution of Nepal (2015) envisioned three tiers of government to formulate necessary legislation, policies or regulations, but strengthening the NHIP from provincial and local level governments is still insufficient [40]. The provincial and local governments are envisioned with a supportive role but ownership and coordination from these bodies has not been sufficient to accomplish their roles as expected and envisioned in the Health Insurance Act. Policy reforms in Nepal have predominantly been implemented through top-down approaches by the government, rather than in response to active demands from targeted communities or individuals. Such approaches need to be approached cautiously, as a lack of understanding of community needs could lead to the unsustainability or failure of the NHIP [41, 42]. Literature suggests that enhanced intra-community solidarity, interpersonal trust, community participation, and empowerment can increase the success and stability of insurance programs [43]. Therefore, it is imperative for local governments to actively engage in demand-generating activities such as raising awareness, strengthening trust, motivating enrollment and renewal, establishing accountability regulatory mechanisms, and tracking progress [44].

The idea of the health insurance program in Nepal is to pool the risks of a large number of people and share the financing of adverse events that strike at random, through prepayment of a contribution, so that no or limited payment is required at point of care when needs arise. The concept is rich support the poor and poor support the ultra-poor; and healthy support the ones who become sick [45]. However, there are overlaps among the packages offered by various health insurance schemes such as the Social Security Fund (SSF) endorsed in 2019 and the Employee Provident Fund (EPF) endorsed in 2020, both of which cover medical expenses for their contributors. Notably, these schemes were established after the implementation of the National Health Insurance Program (NHIP) and share similarities with it [46]. Such fragmentation of resources and duplication of schemes can reduce the effectiveness of risk redistribution [47]. Therefore, there is a pressing need for a single health insurance fund that consolidates various social protection schemes, vertical programs, and public healthcare funding to reduce healthcare disparities and ensure optimal quality healthcare for all.

Strength and limitation

This study offers a comprehensive understanding of factors influencing enrollment and retention in the NHIP by incorporating diverse perspectives from both providers and beneficiaries across different levels of the healthcare system. Exploring experiences from multiple stakeholder groups enabled identification of the multifaceted challenges and facilitators affecting NHIP implementation. The use of the WHO health system building blocks framework provided a systematic and policy-relevant structure for organizing and interpreting the findings. In addition, the qualitative design allowed an in-depth exploration of participants’ perceptions and lived experiences, generating rich contextual insights to inform policy and program improvement.

However, several limitations should be considered while interpreting the findings. The qualitative nature of the study limits the generalizability of the results beyond the study settings. Although purposive sampling was effective in capturing diverse perspectives, it may not fully represent all NHIP stakeholders and introduces the possibility of selection bias among facility representatives and FGD participants. There is also a potential for social desirability bias, as some participants may have provided responses they perceived to be favorable or socially acceptable.

Furthermore, although the WHO health system building blocks framework offered a useful analytical structure, reliance on a predefined framework may have influenced the interpretation and presentation of findings by emphasizing issues that fit within existing categories while potentially overlooking emerging or cross-cutting themes that did not align neatly with the framework. To minimize this limitation, efforts were made to incorporate inductive insights during analysis; however, some contextual nuances may still have been underrepresented. Additionally, the interconnected nature of health system challenges means that certain findings could not be fully captured within a single building block category.

Finally, the absence of quantitative measures, such as statistical analysis of enrollment, renewal, or utilization data, limits the ability to assess the magnitude of program effectiveness and associated determinants. Future studies could adopt mixed-methods approaches integrating quantitative and qualitative evidence to provide a more comprehensive evaluation of NHIP implementation and sustainability.

Conclusions

The Nepal government is committed to achieving Universal Health Coverage (UHC) by 2030, and NHIP has been considered as a critical policy instrument towards it. While our health insurance program has demonstrated commendable progress, it faces significant challenges as we navigate through the perspectives of beneficiaries and providers. While he program has contributed to improved healthcare utilization and financial protection, our findings indicate that persistent challenges related to service quality, provider responsiveness, information gaps, and system-level implementation continue to undermine its effectiveness and long-term sustainability. These challenges are closely interconnected, particularly at the point of service delivery, where weaknesses in governance, coordination, communication, and accountability directly shape beneficiaries’ experiences and trust in the program. Strengthening NHIP therefore requires more than expanding coverage; it demands comprehensive quality improvement measures, stronger service delivery mechanisms, and improved public engagement and awareness. Sustained political commitment, evidence-informed technical reforms, and coordinated action across all three tiers of government are essential to ensure effective implementation. In addition, further research is needed to better understand barriers to enrollment, renewal, utilization, and public preferences regarding health services. Addressing these systemic and operational challenges is crucial for enhancing the credibility, effectiveness, and sustainability of NHIP and for ensuring meaningful progress toward equitable and resilient universal health coverage in Nepal.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

EPF

Employee Provident Fund

SSF

Social Security Fund

NHIP

National Health Insurance Program

PHCC

Primary Health Care Centre

LMICs

Low-and middle-income Countries

EA

Enrollment Assistant

GoN

Government of Nepal

HIA

Health Insurance Act

HIB

Health Insurance Board

UHC

Universal Health Coverage

KII

Key Informant Interview

FGD

Focus Group Discussion

NHRC

Nepal Health Research Council

WHO

World Health Organization

Author contributions

BMK, RMS, PK and DRX conceptualized the study. SM and RMS prepared the study proposal and tools and coordinated with the study sites. SM, SP, DG, IBS collected the data. SM, SS analyzed the data. SM, SP, SS drafted the manuscript. SPJ, DRX, SS reviewed and revised the manuscript and SM finalized the manuscript. BMK, DRX supervised the study. All authors met the ICMJE criteria for authorship. All authors have read and approved the manuscript.

Funding

The study was conducted with the funding support from Swiss Agency for Development and Cooperation (#81067392). However, no direct funding was provided for preparation and submission of this article.

Data availability

Data will be made available upon reasonable request to the corresponding author by email.

Declarations

Ethics approval and consent to participate

Ethical approval for the study was obtained from the national ethical review board of Nepal Health Research Council (Reg. no. 371/2022). Written informed consent (thumbprint in presence of witness for those who could not provide written consent) was obtained from the participants prior to the data collection. The consent included the details of the study purpose, expected roles of the participants, clear communication about the benefits of the study and autonomy of participation in the study. The study adheres to the ethical principles outlined in the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.