Causes of dropout from health insurance program: An experience from Lumbini Province, Nepal

The Health Insurance Program (HIP) in Nepal is experiencing low enrolment and high dropout rates, but the causes of these issues have remained unknown. This study aimed to explore the causes of dropouts of the HIP implemented by the Health Insurance Board, Nepal. We employed an exploratory qualitative research design. We purposefully selected the informants for the data collection who had previously enrolled and currently not renewed their insurance scheme. We gathered qualitative information from 16 in-depth interviews, four key informant interviews, and four focus group discussion in Palpa and Bardia Districts of Lumbini Province, Nepal. The qualitative data were analyzed using thematic analysis. We identified two major themes and nine drop-out-related sub-themes. These were: unnecessary health insurance; negligence to renew; unable to pay the contribution amount; poor cooperation between institutions as well as insurees and insurers; limited coverage and ceiling amount; rigid processes to receive health services; health professionals' behaviors; poor quality healthcare services; inadequate information. Dropout-related factors were associated with personal or individual factors and institutional or policy-related (process-related) factors. The major causes/reasons for dropout include lengthy procedures, poor quality and unsatisfactory services, a lack of knowledge on health insurance norms and procedures, and health professionals' behavior towards insurees during treatment. Information, education, and communication programs related to health insurance are still necessary to make the insurees familiar with the insurance systems and its processes. These factors could be taken into account by policymakers while planning interventions to minimize the low enrollment and high dropout.