Promoting well-being by ensuring healthy lives remains one of the key agendas in the Sustainable Development Goals (SDG) adopted by the UN member states in 2015. The main targets on this front is to achieve universal health coverage, including financial risk protection, access to quality essential health-care services and safe, effective and affordable essential medicines and vaccines for all. Provision of health insurance especially for the poor and vulnerable can play an integral role in that direction. At present, very few countries in the world have fully covered health insurance schemes. This is mainly limited to European countries, Japan, South Korea, Australia and Israel having already achieved universal (cent percent) health insurance. Further, countries like Algeria, Mexico, Chile, Slovakia and Turkey have achieved a coverage of more than 90% . At the same time, health insurance systems in some of the developed and particularly developing countries like Nepal also vary in a wide array of dimensions, including risk bearing, choices allowed, sources of revenue and its redistribution, cost saving strategies and presence of specialized and secondary insurance .
Evidences from developing countries show that most of them are struggling to expand the coverage of health insurance and there is no sufficient data regarding health insurance coverage at national level. Particularly, in the case of South Asia, the provision of health insurance is at its infancy stage with most countries limited to subsidizing treatment for poor people . Almost, treatment package appears limited to essential health care services and distribution of free medicine are not available throughout the year . There are some state funded pro-poor schemes in India, Pakistan, and Bangladesh focused on primary health care services and some subsidy in maternal and child health, but there is no organized practice considering wide population coverage of health insurance . This has led to increasing commercialization and privatization of health care, creates the ground of expensive treatment and reduces the credibility of public health care facilities [5, 6]. In Nepal, only 5% of population has been covered by HI . Nepal government has prioritized the expansion of HI program however, there are many challenges regarding modality, sustainability, cost effectiveness and quality of health care.
Globally, there are different philosophical and theoretical discourses regarding health insurance. Scholars are divided on describing health insurance in terms of political ideology or models of political economy and implementation framework. Fundamentally, it is the philosophy of health equity, influenced by political ideology and implemented under the umbrella of social security principles. A majority of schemes provide assurance of need based health care that is mostly based on an individual’s economic capacity and financial contribution . Hoffman  describes health insurance in three perspectives: (1) Health Promotion theory–relies on using health insurance to pay for medical care that most cost-effectively preserves and improves health; (2) Financial Security theory–demands that health insurance limits financial insecurity from these costs and (3) Brute Luck theory–highly sensitive to the possibility of adverse-incentive effects arising from moral hazard . Social health insurance is a concept that can play an instrumental role in enhancing social protection and equity. A health insurance system is a means through which healthy people share the risks with unhealthy; young people contribute for the treatment of elderly and children; employed people cover the healthcare costs of unemployed, able people for disable ones etc. . A state operated social health insurance program might ensure that health service is equitable and available to everyone in which the financial contribution is based on income and health service on need  since health insurance is social protection of health (SPH). Social protection consists of a menu of policies that addresses health, poverty and vulnerability through user fee removal, fee waivers, and social assistance in healthcare. Social health insurance and other similar schemes such as result-based financing mechanisms are aimed at increasing access to healthcare among disenfranchised communities [12,13,14,15,16]. It has been part of the World Health Assembly agenda and United Nations (UN) General Assembly resolutions  and is strongly advocated to become one of the post-2015 millennium development goals namely sustainable development goal (SDG) .
In Nepal, there is no defined philosophy and theory regarding current practice of health insurance program. A review of present schemes in operation suggests an amalgam of different hybrid theory and practice in operation, particularly focused towards government’s commitment to UN SDG and upgrading of social health protection. SPH is a simple interaction between the consumer and the provider of healthcare services, in which demand for healthcare services are met by the provision of the service. Consumers are linked to demand side factors (pattern of usage and demand of the population, and the resulting potential workload) while providers are linked to supply side factor (human, physical, and other resources required to provide services). The literature highlights basically four supply side factors that constraint SPH namely, institutions, human resources, infrastructure, and funding [19,20,21,22,23]. These factors are mostly responsible for increasing enrollment and reducing dropout of health insurance with quality health care and determine the overall success of a health insurance program.
For the universal health coverage, financial coverage is the most important part and it is possible if there is > 90% coverage of prepayment health insurance. Under the current health insurance policy, a family of 5 members must pay 3500 Nepalese rupees per year to cover all types of health service with maximum limit of 100,000 rupees . If there are more than 5 members in family, they need to pay 700 rupees per person. Service is provided by registered health care facilities, enrollment assistants at the field enroll in health insurance program, and enrollment officer verifies and approves the intake of a policy. After enrollment, it takes 3-months time to be matured. Insured gets identification card and utilizes the health service. Although, the health insurance program has been expanded in Nepal to about 50 districts, the national coverage (family or individual) is very low. On the other hand, the national drop-out rate of health insurance is increasing in number which is a challenge for the success of this program. Due to the poor intake of health insurance, it is difficult to achieve more than 90% for UHC till 2030. Every year, Nepal government has increased budget for health insurance, but the coverage is not satisfactory and has raised a big question about the sustainability of program itself. In Nepal, currently ‘out of pocket’ payment (OPP) is more than 2/3rd, catastrophic health expenditure at 40% threshold is > 1% and overall UHC index is 46 . This coverage status is mostly from government subsidy groups mainly poor and marginalized people. It has increased financial responsibility of government and a big question on program sustainability. Many private business companies like commercial banks have declared the insurance for their clients but those schemes are not under social security umbrella and under the regulation of health insurance policy.
There is a scant literature on health insurance in the case of Nepal. The literature available basically focus on the enrollment among the poor and health care package/scheme , challenges of health insurance [26, 27], etc. Benefit packages and tedious enrollment process were the discouraging factors for enrollment in Community Based Health Insurance (CBHI) . On demand side, socio demographic factors like education, economic status, access to health care facilities etc. are seen responsible for health care utilization in health insurance, but these studies are in small scale [28,29,30,31]. A study conducted by Nepal Health Research Council (NHRC) suggests that insured > 90% want to renew the health insurance scheme if it increases the coverage of the service package. About 36% faced difficulties in accessing health care facilities and not satisfied with health workers, and about 40% utilized health service out of scheme . Initially, people who were educated found interested to enroll in health insurance and also, those who belonged to high economic status, access with media and susceptible to disease had better enrollment ratio [33, 34]. Normally, health care utilization is positively associated with health insurance coverage elsewhere  and similar trend is found in Nepal as well . Nonetheless, these studies have not explored the factors that might contribute to enrollment from purchaser side. Usually, these studies are lacking a balance in both demand and supply, poor in policy and program review  and have drawn one sided conclusion. None of the studies clearly investigated the characteristics of dropout, multiple factors associated with enrollment and drop-out in wide array and how the program would be successful.
This study explores the dropout and enrollment rate of HI program in Nepal and explores the barriers in the field during program operation. Study participants are carefully selected who had a say while observing both demand and supply side and the program implementation. More importantly, this study provides the composite results (demand, supply and policy and program operation perspective) regarding the determinants of enrollment and dropout of HI. The findings mitigate one sided conclusion and argue for practical remedies to reform the existing HI policy, program and implementation bottlenecks.