Even as the government sets an ambitious plan to provide health insurance coverage to all Nepalis, problems with identification of poor households and inadequate inter-ministerial coordination are likely to impede a nationwide coverage of the insurance scheme.

The lack of legal basis for identifying “too poor”, “poor” and “the marginalised” has even affected spending of the money allocated for insurance programmes. 

According to Rule 11 of the Social Health Security Programme (Operating) Regulations, 2015, the government will waive the premium fees for persons with the identification cards issued by the Ministry of Cooperatives and Poverty Alleviation. 

The regulation states that it will waive Rs2,500 in premium for people in abject poverty while 75 percent and 50 percent of the premium will be waived for the poor and the marginalised, respectively. However, the ministry is yet to issue identity cards that recognise the poor. 

For the current fiscal year, the government has earmarked Rs2.5 billion to expand the insurance programme to 25 districts. 

“The present identification is entirely on voluntary basis. Sometimes this would miss out the vulnerable population group who need insurance the most,” said Dr Guna Raj Lohani, executive director of the Social Health Security Development Committee (SHSDC).

The government on May 14 began the health insurance programme from Kailali and expanded it to Baglung and Ilam districts later. Under the current health insurance programme, a household of five has to pay an annual premium of Rs2,500. 

For additional household members, each of them should pay Rs425. With this insurance scheme, the household can avail of health services worth up to Rs50,000.

Officials said they are working to finalise the poverty mapping done in 25 districts that categorises 356,418 households as poor. “The Health Ministry has been asking us for the data. But we still need two weeks to process it,” said Suresh Pradhan, joint-secretary at the ministry. 

The 25 districts surveyed include Baglung and Kailali but not Ilam, meaning that the programme run in Ilam might not be scientific unless the poor are identified.

Questioning the quality of the health services available, Dr Ghanashyam Gautam, a health economist, said: “Without improving the services delivered by the health institutions, people might hesitate to join the insurance programme.”

Dr Gautam, who had played a crucial role in designing the insurance programme, said since people are not used to paying for future consequences, the government has to work hard in informing the people.

The insurance covers healthcare bills of ensured family members including the cost of medicine, doctor’s consultancy fees and diagnostic services such as x-ray, ECG, ultrasound, endoscopy and physiotherapy. For patients willing to use private hospital services, the SHSDC is planning to sign an agreement with the operators.

‘Working to prepare legal ground’

Have you done preparations for universal health insurance coverage or is this just an idea you are floating?

Health insurance has been discussed for quiet some time now. We are working to finalise the Social Health Protection Bill that mandates health insurance coverage for the whole population. The bill to be tabled in Parliament within a month will provide a strong legal basis for universal coverage of the insurance programme.

How would this be funded? How would the poor pay for it?

The concept is the poor people will get the government’s support for the premium while those who can afford will pay for the services.

So the important thing here is identification of the poor, for which another government agency is working. We have been asking them to complete the work soon.

Do you have a working timeframe?

Besides the three districts in which the programme is running, we plan to add 22 new ones this year.

It is the same facilities that provide health services to the people who are insured. Given their sorry state, how can people be encouraged to sign up for the programme?

I agree that our health facilities are not up to the mark. But we need a point to begin the programme. If we wait for the health facilities to be fully equipped for implementing insurance, it might take ages. Alongside, we will be working to upgrade the health services.