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February Issue

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Proffessional

Proffessional Perspective Health insurance scheme of Nepal Challenge or opportunity? Chiranjeebi Shah M.Sc. M.P.H. Associate Professor, Public Health, CiST College, Kathmandu. Nepal. Health policy development in Nepal has been profoundly influenced by the 1978 Alma Ata declaration, First and Second Long Term Health Plans, Health Sector Strategies and programme, MDGs, SDP and other treaty and agreements; emphasizing the provision of community-oriented preventive, promotive, and curative health services. Although Nepal has a wide network of health facilities, the health care service has not reached to cover all population in terms of full access and utilization. Moreover, great discrepancy existed in achieving desired health among various communities mainly due to illiteracy, poverty, and topography of the land. In the past, the government launched various popular plans and programs such as Free Health services, Safer Motherhood, and Universal Health Coverage yet out of pocket expenditure remained principal means of health care. With some special provision for specific groups; people have to pay out of their pockets and often rely on private health facilities. Out-of-pocket expenditure has remained the principal means of financing health care in Nepal. Those who could not afford remained unattended; although the constitution of Nepal 2015 has declared health is the fundamental right of the people. Addressing barriers to health services needs to majority of population at community level; the Government of Nepal formed a Social Health Security Development Committee in February 2015; as a legal framework to start implementing a social health security scheme (SHS). The Health Insurance Scheme came in line with National Health Policy 2013 and in accordance Article 296(1) of the constitution of Nepal. Fund flows in the health financing system: The Government of Nepal pools funds from various financing sources (tax and non-tax revenue, pool funds from external development partners) and pays providers (hospitals, health posts, sub health posts, primary health care facilities, etc.) through the health sector budget managed by the Ministry of Health. Other bodies also act as financing agents, such as community based health insurance schemes, which manage resources on behalf of members and pay providers for services used by their members. Financing sources in Nepal can be classified by contribution mechanism as government, private (households and institutions) and ‘rest of the world’. Rest of the world refers to financial support from foreign sources (to both the public and private sector). Out-of-pocket expenditure is the largest source of funding in Nepal, followed by government expenditure. What is Health Insurance Scheme? Health Insurance is a relative term that relates to a contract wherein the individual contributes a regular premium with the expectation that if something happens to the individual in question (insure), the insurer will provide for the individual. The insurance scheme aims to ensure universal health coverage by increasing access and utilization of quality health services across the country. Health Insurance in Nepal: As per the insurance programme, a family of five members has to pay Rs 2,500 every year for the health insurance facility. A family of more than five has to pay Rs 2,500 and Rs 425 for each extra member. While a five-member family will be able to claim up to Rs 50,000 per year if needed, any family with more than five members will be liable to Rs 50,000 plus Rs 10,000 for each extra member under the insurance programme. The insurance has to be renewed every year and only covers lab test services, drugs, including the 530 types of drugs provided for free by the government. Implementation of SHS in Nepal: A national health insurance programme is aimed to ensure universal health coverage by capturing the unregulated out-of-pocket spending and facilitating the effective, efficient and accountable management of available resources. The long-term goal of this policy is to improve the overall health situation of the people of Nepal. The main objective of this policy is to ensure universal health coverage by increasing access to, and utilization of, necessary quality 44 Versatile | MARCH-CHAITRA 2018

Proffessional Perspective health services. The specific objectives of this policy are to: 1. increase the financial protection of the public by promoting prepayment and risk pooling in the health sector; 2. mobilize financial resources in an equitable manner; and 3. improve the effectiveness, efficiency, accountability and quality of care in the delivery of healthcare services. 4. The Ministry has formed a social Health Security Committee, which will train ward level health workers, volunteers, and those who have passed high school. The government conducted pilot health insurance programmes in Kailali, Baglung, Ilam, Myagdi, Kaski, Achham, Baitadi, and Palpa. The first phase of the SHS scheme has been planned to start in three districts (Kailali, Baglung, and Ilam) in 2015, but the details of the SHS design and regulations for implementation are yet to be made public. The Social Health Security Development Committee has added the districts such as Bajhang, Bajura, Humla, Mugu, Dolpa, Kalikot, Rukum, Arghakhanchi, Ramechhap, Siraha, Khotang and Bhojpur to the health insurance policy programme. In this FY, Baitadi, Achham, Myagdi, Palpa, Kaski, Jhapa, Tanahun, Gorkha, Chitwan, Jumala, Bhaktpur, Jajarkot, Mahottari, Dolpa, Makanpur, Solukhumbhu, Bardiya, Parsa, Surkhet, Sindhuli, Sunsari and, Rauthat. As of now, 233,000 families in the country have enrolled in the health insurance policy which is very encouraging. It shows that people are being aware about the advantages of signing up for the health insurance policy. That the government is planning to include all the 77 districts in the programme within the next two years should be taken positively Challenges of SHS: • Government of Nepal has limited capacity to generate more resources on a substantial scale. • The health financing system has limited ability to address inequities and identify and protect the poor. There are inefficiencies in the system due to fragmented resource allocation. • Government of Nepal has limited power to negotiate the price and quality of services due to the practice of passive purchasing. • Preparation and capacity of Federal Government to internalize and implement SHS to cater entire population. • Inadequate policy to enhance and channelize the Public Private Parternership (PPP) for SHS. • Functional mechanism of monitoring and evaluation system for SHS. Way Forward: To combat the above challenges; the government of Nepal should have the following intervention to manage 1. Improve access of the poor to specified services Access of the poor to specified health services, which are in theory being provided by the government for free, should be facilitated by allocating sufficient financial resources and simplifying procedures for utilization. 2. Merge funding arrangements for social health protection. The merging of scattered funds under the proposed Social Health Protection Centre would help to allocate resources more efficiently and simplify administrative and reporting procedures, thereby reducing the administrative costs of managing funds. The merging of vertical program funding would end the current earmarking of funds at the district level, allowing district authorities to be more responsiveness to local needs. 3. Introduce strategic purchasing Government resources should be allocated where they have the most impact using budgets and reimbursements that mitigate the differences between rich and poor areas and that reward facilities that are performing well to cover entire population of Nation. Since Nepal is moving towards federalist structure, an increased complexity under federated system is foreseeable, particularly in the face of changed political scenario and its players. It should have clear goals, financing policy and strict implementation plans for budget execution, task performance and achieving results as per planning. Additionally, collection of revenue, risk pooling and purchasing of services Versatile | MARCH-CHAITRA 2018 45

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