This document provides an overview of health insurance in Nepal, including: 1) Health insurance in Nepal began in 2016 under the Health Insurance Board to provide universal health coverage. It aims to improve access to quality healthcare without financial hardship. 2) All Nepali citizens can enroll to receive benefits like coverage of medical expenses. Households and the government contribute premiums which are pooled to cover members' healthcare costs. 3) The program reimburses costs of services like outpatient and inpatient care, surgeries, and deliveries. It excludes some services like cosmetic procedures and injuries from personal conflicts.

1. Health Insurance In Nepal
(Social Health Security Program)
Presented by Group “E”

2. Members of Group “E”
• Manoj Mehta (Leader)
• Surendra Kumar Yadav( Co-Leader)
• Jitendra Kumar Sutihar
• Tej Narayan Yadav
• Om Yadav
• Bhoganand Mandal
• Yogendra Rajbansi

3. Outline of Presentation
• Background
• Concept of health insurance
• History of health insurance in Nepal
• Services utilization and benefit package
• Enrollment procedure
• Diagram of IMIS
• Coverage
• SWOT analysis of Health Insurance

4. History of Health Insurance
• There are many stories of people having
difficulty in getting health care services due to
financial problem.
• The Social Health Insurance was started from
1883 A.D. From Germany ( Bismarck Model).
• In 1948 A.D. – National Health Services
(Beveridge Model) started from Belayat.

5. Health Insurance
• Health insurance is a government program
based on comprehensive social contributory
scheme with subsidy to the poor and universal
health coverage.
• It is not focus on benefit and loss.

6. Health Insurance in Nepal
• Health insurance program of government is
non- profit nature. Previously GON started this
program under Social Health Security
Development Committee (SHSDC). It was
established in 2014.Now it is turned into
Health Insurance board (HIB).It is
implementing health insurance program since
2016.

7. Health Insurance Board (HIB)
• HIB 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.
• Health insurance programs helps prevent people
from falling into poverty due to health care cost
i.e. catastrophic expenditure due to accidents or
disease by combining prepayment and risk
pooling with mutual support.

8. Cont….
• This program also advocates towards quality
health services.
• This program attempts to address barriers in
health services utilization and ensure equity
and a access of poor and disadvantaged
groups as a means to achieve universal
services out-of-pocket expenditure has always
been the largest source of founding in Nepal,
followed by government expenditure.

10. Development of Health Insurance in
Nepal

11. Vision and Mission
General Objectives:
To ensure universal health coverage by
increasing access to, and utilization of
necessary quality health services (equity and
equality)

12. Specific Objectives:
To increase financial protection of the public
by promoting pre-payment and risk pooling in
the health sector;
To mobilize financial resources in an equitable
manner.
To improve the effectiveness, effective,
accountability and quality of care in the
delivery of health care services. hardship and
reduce out-of- pocket payments.

13. Risk and Contribution pooling

14. Features of Health Insurance in Nepal

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9/11/2022 Your Health is Our Concern 15

16. Difference Between Life Insurance and Health
Insurance
Life Insurance Health Insurance
Life insurance depending upon the
insurance you choose offers both
survival and death benefits at the
end of the insurance.
To reduce economic condition if it
will be
Caused by health problem.
Not included health risk group All neplease are join members .
Services received by her family
members.
All member of joining people can
receive services
Life insurance is a long-term plan. Health insurance is a short- term
plan.
To give extra money at the end
time of insurance.
The medicine and check up when
becoming sick is benificial.

17. Organogram
Health Insurance
Board
CENTRAL
Province Health Insurance
Office
Enrollment Officer
Enrollment Assistant
PROVINANCE
LOCAL LEVEL

18. Services Utilization and Benefit
Package

19. Benefit Package
Previous Now
• 555555555
1 Member
Rs. 700
UP TO 1
LAKH
20,000 up
to
2 Lakh
Rs. 3500

20. Special Package

21. Package of Services

23. Services of Negative list
1. Cosmetic Surgery
2. Abortion
3. Equipment like artificial organ, reading glass not
more than 500 once in year, hearing machine.
4. Injuries treatment cost due to personal warfare
5. Accident related treatment due to alcoholic and
drug use
6. Modern dental implant, root canalling, etc

24. Enrollment Process
Rs. 3500/member/year
Rs. 700/add member/year

26. Services Activation Time
Enrollment
Time
Activation
Time
Baisakh,
Jestha, Ashar
From Bhadra 1
Shrawan,
Bhadra, Ashoj
From Mangsir
1
Kartik,
Mangsir, Poush
From Falgun 1
Magh, Falgun,
Chaitra
From Jestha 1

27. Services Utilization Process

30. Financial Management
Income
• Government Budget
• Premium from Membership
• Technical Assistance from
EDPs
(KOICA, GIZ, Save The Children,
WB, WHO, H4L, SABAL/ USAID)
Expendature
• Encentives to Enrollment
Assistants
• Reimbursement to services
providers
• Program implementation/
Promotion Services
• Administrative cost
100% Beruju Clearance

31. Challanges
Enrollment
 Voluntary
Poverty Card Implementation
Coverage = 5%
Target
2017– 20%
2020– 50%
2030– 100%

32. Challanges
Health Services
• Availability
• Continuity
• Increase Access
• Quality- Clinically quality
- Quality care

33. SWOT
• Strength: Resources, capacity and capability for
attainment of goal.
• Weakness: Limitation, fault and defect in the
organization which obstructs effective use of
resources.
• Opportunity : Favorable environment for the
organization which it can take advantages of but
is not in the control of the organization.
• Threats: Situation potentially damaging to the
organization and is not under the control of the
organization.

34. SWOT ANALYSIS
• SWOT analysis is a strategic planning
technique used to help a person or organizing
identify strengths, weakness, opportunities,
and threats related to business competition or
project planning.

35. Strengths
• A primary focus on quality improvement (save
from quality projects).
• Internal teams dedicated to research and
analytics( Spent on research).
• High-quality medical personnel (of staff with
external recognition)
• Modern medical equipment and a well- equipped
facility (average age of medical equipment)

36. Weakness
• Outdated healthcare facilities and technology
• Insufficient management training
• Lack of funding and resources to support
programs.
• Poor location that’s not easily accessible for
staff and patients
• High staff turnover

37. Opportunities
• Collaborate with different health care
organizations to knowledge share
• Increase funding for analytics and researching,
including both staff and technology
• Create mentor programs

38. Threats
• Economic or political insecurity
• Policy and legislation changes that result in
budget deficits
• Increase competition from newly built
hospitals.

39. Thank you