The document summarizes social health insurance in Nepal. It provides background on the program, including its history starting in 1976. Currently, the government aims to expand coverage to all districts by 2020. Key findings include that enrollment is universal for families of up to 5 members. Contributions are on a sliding scale but most services covered are free. Overall utilization is high, with 91% of members using outpatient services. The conclusion recommends increasing funding and awareness while ensuring proper implementation and provider training to strengthen the program.

1. SOCIAL HEALTH
INSURANCE IN NEPAL
PRESENTED BY
SACHIN POKHAREL
BPH 7TH SEMESTER

2. CONTENTS
• Introduction
• Statement of Problem
• Objectives
• Methodology
• Findings
• Conclusion
• Recommendations
• References
2

3. INTRODUCTION
• The Social Health Insurance is a social protection program
of the Government of Nepal that aims to enable its citizens
to access quality health care services without placing a
financial burden on them.
• The households, communities and government are directly
involved in this program.
• It helps prevent people from falling into poverty due to
health care costs i.e. catastrophic expenditure.
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4. HISTORICAL BACKGROUND
• An early initiative to health insurance in Nepal began from 1976 through
United Mission to Nepal (UMN) as Lalitpur Medical Insurance Scheme in
Ashrang, which was later expanded to other facilities.
• The government funded community-based health insurance program was
initiated in 2003 in two districts and expanded to additional four districts in
2005/06.
• National Health Insurance Policy was passed by Government of Nepal in
2014.
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5. • In FY 2071/72, the Government of Nepal had announced to roll out
SHSP to three districts (Kailai, Baglung and Illam) but the
enrollment process at Kailali was started only from 25 Chaitra
2072 (07 April 2016) and at Baglung and Ilam from 15 Asar
2073(29 June 2016).
• The Social Health Security Development Committee aims to
expand this program to all districts by 2020.
5

6. NO OF ENROLLMENT AS BY 22
JAN 2017
6
18178
6183
8663
823 932
4603
8006
559
0
5000
10000
15000
20000
Kailali Baglung Ilam Baitadi Aacham Palpa Kaski Myagdi
NoofEnrollment
Districts

7. GENDER WISE ENROLLMENT7
40
50
60
Baglung Ilam Kailali
46
48 47
54
52 53
PERCENTAGE
Chart Title
Male Female

8. INSURED MEMBERS UTILIZING
SERVICES BY TYPES
4% 4%
1%
91%
Referal
Emergency
IPD
OPD
8

9. OBJECTIVES
General Objective
• To review arrival literatures about social health
insurance in Nepal.
Specific Objectives
• To know about the history of social health insurance in
Nepal.
• To know about the current trends and system of social
health insurance in Nepal.
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10. METHODOLOGY
• To prepare this seminar, different literatures were searched using
PubMed and Google scholar.
• Literatures were searched from December 8-December 11 2018.
• The key words used were social health insurance and Nepal, situation
of social health insurance in Nepal and so on.
• By using PubMed search engine, I find 15 articles in which I read first 8
articles and 4 are used in it. And by using google scholar I find more
than 1000 articles in which I read first 2 pages selectively and out of
them 2 were used.
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11. FINDINGS
RISK AND CONTRIBUTION POOLING
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12. FEATURES OF SHI12

13. ENROLMENT
• Eligibility - universal coverage
• Family unit - up to 5 members
• Door-to-door visits by EAs
• Members need to select ‘First Service Point’
• Yearly Renewal
• Enrollment assistants paid per enrolled person
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14. CONTRIBUTION
• NPR 2500/ 5 members /year (NPR 425 for every addition
member)
• Subsidy By Government for the poor
 Ultra-poor-100%
 Poor-75%
 Vulnerable group-50%
 FCHV -50% discount
 Not Refundable, Not transferable,
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15. BENEFIT PACKAGE
POSITIVE LIST
• OPD
• Emergency
• IPD/Procedures / Operations
• Promotive , Preventive Curative
and Rehabilitative services
• Investigations (Lab +Radiology )
• Drugs
• All Free
NEGATIVE LIST
• Cosmetic surgery
• Equipment like artificial organ,
• Artificial insemination services,
organ transformation.
• Injuries treatment cost due to
personal warfare .
• Accident related treatment due
to alcoholic and drug use
• Abortion
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16. SWOT ANALYSIS
STRENGTH
• Increasing community
participation to health insurance
programme by providing special
focus to poor and marginalized
population
• Coordination between different
government and private health
instutions.
• Sustainable health development
WEAKNESS
• Inadequate drug supply
• Providers attitude
• Limited package scheme
• Long waiting time for the
patients to get services.
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17. OPPORTUNITIES
• Government
commitment(Budget, HR,
equipment, pharmacy)
• Health system strengthing
• Implementation of health
insurance policy
• Increasing budget in health
sector
THREATS
• Decreasing in the trust of
client towards health
insurance.
• Inadequate knowledge of
client.
• Dropout of clients.
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18. CONCLUSION
• At last we came to conclusion that Social health insurance is in initial
phase which is beneficial and effective to Nepalese people.
• It is rapidly expanding in many districts and will cover all 77 districts
of Nepal soon.
• Around 91% of users utilize OPD services.
• It is mainly beneficial to poor and rural people and is provided by
both public and private health institutions.
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19. RECOMENDATIONS
• Government should increase budget on social health insurance.
• Awareness should be provided to people about the benefit of
social health insurance.
• Proper and systematic procedure should be implemented in
health care centers.
• Training should be provided to health care providers.
• Sufficent drugs should be provided to health care centers.
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20. REFERENCES
1. Pokharel R, Silwal PR. Social health insurance in Nepal: A health
system departure toward the universal health coverage. The International
journal of health planning and management. 2018.
2. James TG, Sullivan MK, Dumeny L, Lindsey K, Cheong J, Nicolette G.
Health insurance literacy and health service utilization among college
students. Journal of American college health : J of ACH. 2018:1-7.
3. Jha N, Karki P, Das BP, Chapagain N. Social health insurance: a
knowledge-do gap in eastern Nepal. Kathmandu University medical journal.
2007;5(2):268-72.
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21. 4.MoHP. Nepal Health Sector Strategy (2015 - 2020).
Kathmandu: Ministry of Health and Population; 2015.
5.https://www.actuariesindia.org/downloads/gcadata/10t
hGCA/Emerging%20Health%20Insurance%20in%20India
-An%20overview_J%20Anitha.pdf
6. ttps://publichealthupdate.com/social-health-security-
health-insurance-program-in-nepal/
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