Effectiveness of a Social Health Security Program in improving financial risk protection against the health expenditures of the insured populations in four districts of Nepal: A mixed method study

Abstract

Background: Most low and low-middle income (LMICs) countries adopting National Health Insurance (NHI) programs to achieve Universal Health Coverage are struggling to implement the program and thus have failed to achieve the expected outputs. The Nepal NHI program initiated in 2016 has experienced numerous implementation challenges, due to inadequate inputs and throughput, resulting in negative output such adverse selection, poor health service delivery, low enrollment of the poor household and low annual non-renewals of the NHI membership. However, there is a lack of research that focuses on these problems. So, this study has two objectives. Firstly, delved into the NHI program’s inputs and throughputs/implementation bottlenecks called as process evaluation. Secondly, evaluate the NHI outcomes on intention of existing NHI members to renew their annual membership and reduced monthly out-of-pocket (OOP) and catastrophic health expense.

Method: This was a mixed method study with qualitative and quantitative data. The data were collected in two phases. The first phase concurrently collected qualitative data and quantitative with outcome on intention to renew. The second phase collected the quantitative data with outcome to reduce monthly out-of-pocket and catastrophic health expense.

The qualitative data was collected in four districts (Kathmandu, Bhaktapur, Chitwan and Kaski) of Nepal through 28 in-depth interviews, six focus group discussions. The analysis employed the Grounded Theory. The quantitative data was collected in three districts (Bhaktapur, Chitwan and Kaski), same districts from the qualitative study. A random sample of 182 current NHI members and 61 non-renewed NHI members were interviewed. The study employed univariate and multivariate regression to assess the associations between dependent and independent variables. A quantitative data for outcome evaluation to measure OOP and catastrophic health expense was based on one district (Kaski). A random sample of 100 pre-post household (HH) intervention group and125 HH control group (only recruited corresponding in time to the post intervention survey) was interviewed. The Wilcoxon signed rank and sum test, Mcnemar and chi-sqaure test was employed to measure the OOP and catastrophic expense between pre-post intervention group and with the control group.

Result: The main NHI program input challenges identified, through qualitative study, were insufficiently defined NHI implementations guidelines, conflicting Act clauses, a lack of HIB organizational guidelines, and inadequate human resources. The major throughput bottlenecks were difficulty enrolling the insurees, the inability to select the health providers competitively and to act as a prudent purchaser of the services. The quantitative study, on intention to renew the NHI annual membership, showed that the HH with high monthly income had lower odds of renewing their membership (adjusted OR: 0.14, 95% CI: 0.03-0.58). Similarly, HH with overall health service satisfaction (adjusted OR:3.59, 95%CI: 1.23-10.43) and increased frequency of visits after NHI membership (adjusted OR: 10.09, 95% CI: 1.39-73.28) had high odds of renewing their membership. The quantitative study, on monthly OOP and catastrophic health expense, showed that the total outpatient OOP and chronic illness cost has increased from NRs 1700 to NRs 3900 (p: 0.027) and NRs 1500 to NRs 2000 (p:0.058) respectively from pre to the post-intervention group. The hospitalization cost was reduced by more than half from NRs 13000 in the post intervention as compared to NRs 30000 in the pre-intervention group but the difference was not statistically significant (p:0. 465). The CHE incidence had increased by maximum 8% at 40% threshold for outpatient and chronic illness expense but has decreased by maximum 5% at 10% threshold for the hospitalization expense from pre to the post-intervention

Conclusion: The NHI program’s implementation bottlenecks caused by inadequate inputs and throughputs led to negative outputs such as insured persons refusal to renew insurance policies, low coverage of poor households and low financial risk protection. The program's sustainability might be at stake if the discussed problems, low renewals, low-quality health services persist, and are further exacerbated by the COVID-19 situation in the country. In spite of the said limitations, the study analyzes programmatic opportunities and offers practical recommendations for policymakers and programmers to strengthen the NHI program. Upon effective implementation, the NHI, the first-ever national health risk-pooling program, will pave the path to universal health coverage in Nepal.