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Abstract
Nepal's national social health insurance (SHI) program, which started in 2016, aims to achieve universal health coverage (UHC), but it faces severe challenges in achieving adequate population coverage. By 2018, enrolment and dropout rates for the scheme were 9% and 38% respectively. Despite government's efforts, retaining the members in SHI scheme remains a significant challenge. The current study therefore aimed to assess the factors associated with SHI program dropout in Pokhara, Nepal. A cross-sectional household survey of 355 households enrolled for at least one year in the national SHI program was conducted. Face-to-face interviews with household heads were conducted using a structured questionnaire. Data was entered in Epi-Data and analysed using SPSS. The factors associated with SHI program dropout were identified using bivariate and multiple logistic regression analyses. The findings of the study revealed a dropout prevalence of 28.2% (95% CI: 23.6%-33.2%). Households having more than five members (adjusted odds ratio [aOR]: 2.19, 95% CI: 1.22-3.94), belonging to underprivileged ethnic groups (Dalit/Janajati) (aOR: 2.36, 95% CI: 1.08-5.17), living on rented homes (aOR: 4.53, 95% CI: 1.87-10.95), absence of chronic illness in family (aOR: 1.95, 95% CI: 1.07-3.59), perceived good health status of the family (aOR: 4.21, 95% CI: 1.21-14.65), having private health facility as first contact point (aOR: 3.75, 95% CI: 1.93-7.27), poor availability of drugs (aOR: 4.75, 95% CI: 1.19-18.95) and perceived unfriendly behaviour of service providers (aOR: 3.09, 95% CI: 1.01-9.49) were statistically significant factors associated with SHI dropout. In Pokhara, more than one-fourth of households have dropped out of the SHI scheme, which is a significant number. Dropping out of SHI is most commonly associated with a lack of drugs, followed by rental housing, family members' reported good health status and unfriendly service provider behaviour. Efforts to reduce SHI dropout must focus on addressing drugs availability issues and improving providers' behaviour towards scheme holders. Increasing insurance awareness, including provisions to change first contact points, may help to reduce dropouts among rented households, which make up a sizable proportion of the Pokhara metropolitan area.
Highlights
Social health insurance (SHI) is one of the principal methods of health financing
Having more than five members, belonging to underprivileged ethnic groups such as Dalit/Janajati, living on rented homes, absence of chronic illness in family, perceived good health status of the family, having private health facility as first contact point, not utilizing the service benefits, poor availability of drugs and perceived unfriendly behaviour of service providers are statistically significant factors associated with social health insurance (SHI) dropout
We recommend that the Health Insurance Board (HIB), and service provider health facilities and other stakeholders such as federal, provincial and local governments should provide more emphasis on addressing the problems of drugs availability and improving behaviour of service providers towards the insured members
Summary
A number of countries around the world have already achieved universal health coverage (UHC) using this method, and a few others have come close.[1,2] In recent years, several low-and middle-income countries including Nepal have embarked on a path to implement various models of health insurance schemes, aiming to cover their entire population. In 2016, the Government of Nepal initiated a SHI program with the objective to ensure UHC by increasing access to and utilization of necessary quality health services. The existing evidence show that the national SHI program in Nepal has encountered a number of challenges in achieving an adequate population coverage.[4] By 2018, the SHI program had expanded to 36 districts, with more than 1.5 million members enrolled.[5] While this enrolment represented 9% of the total population, the dropout rate was 38%. Low enrolment and higher dropout rates frequently undermine the government’s goal of providing financial protection and access to quality healthcare for its citizens
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