Social health insurance: a knowledge-do gap in eastern Nepal

Area of Science:

• Public Health
• Health Economics
• Social Sciences

Background:

• High healthcare costs, especially for inpatient services, create barriers to access and contribute to indebtedness and poverty, particularly among vulnerable populations.
• Nepal's Ministry of Health is exploring alternative financing mechanisms, including community and social health insurance, to supplement government funding for the health sector.

Purpose of the Study:

• To evaluate the Social Health Insurance (SHI) scheme introduced by BP Koirala Institute of Health Sciences (BPKIHS) in Sunsari and Morang districts as an alternative healthcare financing model.
• To assess the SHI scheme's effectiveness in reducing poverty associated with healthcare expenses and preventing vulnerable families from falling deeper into poverty.

Main Methods:

• The BPKIHS SHI scheme was implemented as a pilot project, gradually expanding to include 26 organizations and 19,799 beneficiaries (14,047 rural, 5,752 urban).
• The scheme operates on principles of social solidarity, providing subsidized healthcare services through people's organizations.

Main Results:

• The SHI scheme has enabled vulnerable populations to access essential health facilities, mitigating the impact of high healthcare needs.
• A significant gap exists between premium collection and expenditures, with expenditures exceeding revenue, potentially due to knowledge gaps in program implementation.

Conclusions:

• The BPKIHS SHI scheme demonstrates potential as an alternative healthcare financing mechanism but faces challenges related to financial sustainability and operational efficiency.
• Addressing the gap between premium collection and expenditures and ensuring the program's continuity and sustainability in catchment areas are crucial for future success.
• Active community involvement and a sense of ownership are essential for the long-term viability of the SHI scheme.