The Universal Health Coverage (UHC) seeks to address the problem of people’s financial hardship in accessing healthcare and providing quality care to the needy. There was a long effort to introduce health insurance in Nepal. Protecting people from financial risk is crucial as more than three-fourth health expenditure comes out-of-pocket.
This reality contradicts the provision in the new constitution that says “every citizen shall have the right to seek basic healthcare services and no citizen shall be deprived from emergency healthcare” under fundamental rights in Article-35. Financial risk protection is one way to implement this constitutional provision.
For this, the government in 2015 planned to introduce social health insurance in three districts—Ilam, Kailali and Baglung. The program was started from Kailali in April 2016. The government has allocated Rs 2.5 billion this fiscal to expand the services to 25 districts. It has promised that all citizens will have health insurance within three years. But the government should have evaluated progress of its earlier program in three piloted districts before announcing this ambitious goal.
In the new health insurance policy, a family of up to five members is considered as one unit and it will have to pay Rs 2,500 as a premium to cover health expenses up to Rs 50,000. However, if there are more than five family members, the extra person will have to pay another Rs 425, for a total maximum coverage of Rs 100,000 for the family. To be eligible the family will have to have resided at a particular place for at least for six months. The policy is valid for one year and beneficiaries will be entitled to services one month after enrollment.
The program covers OPD expenses and 66 types of illnesses. It does not cover abortion and cosmetic surgery. Nor does it compensate for expenses above 500 for spectacles, injuries related to alcoholism or confrontation and diseases like dementia and Alzheimer’s.
The beneficiary of the insurance scheme should choose first point of contact health institute at the time of enrolment. However, the service can be sought from any listed health facility in the case of emergency. “The individual can receive the service by presenting their identity card and the government will reimburse service providers according to bills and invoices,” says the director of Social Health Security Development Committee, Ministry of Health.
There are, however, a number of implementation challenges. The objective of this policy is to reduce impoverishment and catastrophic health expenditure as existing health system doesn’t protect the poor. The policy provides subsides to the poor and marginalized based on their identity card. But how will one obtain this card?
Getting the card issued by local authorities might be a challenge for various political and social reasons. Besides, not all poor people may be able to afford premium and contribution money. Thus enrollment of the poor and marginalized in the insurance will be a key issue.
Besides, the first point of contacts (health institutes) will often lack medicines and human resources. There is shortage of both at a number of health institutes. The infrastructure of our health facilities is not sound enough to offer required health service as well. Unless these shortcomings are addressed, people are unlikely to enroll.
According to the insurance policy, private hospitals are also required to provide health services to members of the policy scheme. Health services are pretty costly in private health facilities. Private service providers are often blamed for unnecessary diagnostic tests and medicines. So it will be difficult to bring private health facilities under the radar of the scheme.
This will be the case so as long as private health facilities don’t offer fair and uniform prices, and right amounts of diagnostic tests and medicines. We also need clear regulatory and monitoring guidelines.
There is a provision of referral system if the required service is not available at the first point of contact. But for that our peripheral health system needs to be strengthened. The major barriers in accessing the care are transportation costs and low income of people in remote areas.
Hence it is important to strengthen existing health system and offer quality care. Implementation of insurance program and strengthening existing health facilities should go side by side. But budget is silent on this.
There have been various efforts in last three decades to improve public health. So it is good that this government has made public health a priority by announcing health insurance for all Nepalis. But it would have been more effective if along with financial protection, there were also efforts to improve the quality of care.
The budget announcement has promised to formulate Public Health Act to regulate and monitor quality of services provided by public and private health institutions. This is encouraging. But the agenda of equity in access and utilization of quality healthcare by those who need it the most remains unaddressed. This could prove to be a major hurdle in achieving Universal Health Coverage.
The author works in the field of Public Health in Nepal