Table 7.

Summary findings of the beneficiaries (insured and uninsured) (qualitative).

SN	Theme/Pattern	Summary (intellectual translation)
1	Knowledge about the SHIP	The proportion of the population knowing SHIP ranged from a few to a 100%. A Participant from Baglung reported that all of them had the knowledge and knew few too many participants from Kailai and Ilam had heard about SHIP. The majority of the insured participants were more ere knowledgeable than the uninsured while some of the insured participants did not have comprehensive knowledge about SHIP.
2	Utilization of SHIP	Enrollment in SHIP was encouraging in all the study districts as almost 50–90% population were enrolled in the program. The new enrollments each year from the inception of the program have been increasing; however, the dropout among the insured population was also continued. Among the uninsured population, they remain uninsured because of a lack of awareness, and financial limitations and some felt that less importance of the program. Both the insured and uninsured people had received the services from SHIP-implemented health care institutions. For those who discontinued the SHIP, the major reasons for the discontinuation were the poor perceived quality of care, limited availability of care, and health workers' unfriendly behaviors.
3	Perception of SHIP	There was a mixed perception regarding the premium amount charged for SHIP enrollments. The majority of the beneficiaries opined that it is appropriate and affordable while some others stated that it is expensive. It is better if the premium cost is borne by the government in the case of marginalized people or those who face financial hardship. Participants from Baglung stated, “If we fall sick, then there is an increase in expenditure for treatment, so SHIP is good while in case of no sickness, it is a waste of money.” Household/family size as the unit beneficiary for SHIP was perceived to be a good idea. Nonetheless, it's a problem for a family with members of more than 10. The inclusion of members up to 6 with a minimum premium could cover the grand parent's insurance which may become a useful model in Nepal. Coverage of care under SHIP has been increasing since its inception with 70-80 % population in SHIP-implemented areas being covered for this scheme while dropout/discontinuity was also reported among large populations. Door-to-door visits made by insurance agents made it possible to improve enrollments in SHIP. Since the nature and the type of services covered under the SHIP do not meet the needs of health care, patients have to seek care from other health care institutions which limit the coverage. In the meantime, the uninsured claimed that the coverage of the SHIP is low and services are not satisfactory. Participants from Ilam opined that the management of services has been improving gradually whereas it was reported to be poor in Baglung and Kailali. Shortage of medicines and equipment, limited availability of service items, poor smoothing in service delivery, long waiting time, non-coverage of expensive medicines, and unfriendly renewal system of SHIP have made limiting attractions toward the program. Therefore, the benefits package under the SHIP was perceived to be low and expressed the need for expansion.
4	Private sector involvement	The private sector's involvement in SHIP was negligible except in areas where the SHIP was implemented in Private hospitals.
5	Perceived promoting factors	Community and group-based awareness programs, spreading the information to the peripheral level, the addition of service packages, placement of citizen charter, orienting the benefits of service packages under SHIP, mobilizing FCHVs to inform people, engaging local authorities, timely follow up for renewal, timely delivery of services and mobilizing insured beneficiaries to motivate the public might have promoted the acceptances of SHIP.
6	Suggestions to improve SHIP	Effective mobilization of insurance agents, an extension of services to private institutions, periodic monitoring continuously, tracking of the service delivery mechanism, further addition of services into existing benefit packages, extending services for NCDs, availing services from all service points irrespective of the first contact point and developing the user-friendly referral mechanisms are useful in strengthening SHIP. Similarly, advertising of SHIP program in wider dimensions, paying equal attention to both the insured and uninsured people, training the health workers, and social leaders, and orienting the local people could promote the SHIP. Furthermore, the provision of insurance free of cost for an underprivileged population with increasing awareness and improving the management of health institutions for effective delivery of services are also useful strategies for the promotion of SHIP.