Nepal's Health Insurance Laws

Health insurance is a type of insurance that covers the medical expenses of an individual or a group of individuals in case of illness, injury, or disability. Health insurance can help reduce the financial burden and risk of health care costs for the insured and improve their access and quality of health care services.

In Nepal, health insurance is a relatively new concept that was introduced by the government in 2017 with the enactment of the Health Insurance Act 2017. The act aims to provide universal health coverage to all Nepali citizens by making health insurance mandatory and affordable for everyone. The act also establishes the Health Insurance Board (HIB) as the main authority for implementing and regulating the health insurance system in Nepal.

The main features and provisions of the Health Insurance Act 2017 are as follows:

•  The act requires every Nepali citizen to enroll in the National Health Insurance Program (NHIP), which is a social health insurance scheme that covers basic health care services for its members. The NHIP is funded by contributions from the government, employers, employees, and individuals, as well as other sources such as donations, grants, etc.

•  The act makes it the responsibility of parents or guardians to enroll their newborns, children, senior citizens, and persons with disabilities in the NHIP within six months of their birth, adoption, or disability. The act also makes it the responsibility of employers to enroll their employees in the NHIP within three months of their employment.

•  The act sets the annual premium for the NHIP at NPR 2,500 per person, which can be paid in installments or lump sum. The act also provides subsidies and waivers for the premium for certain categories of people, such as poor, marginalized, disabled, elderly, etc., based on certain criteria and procedures.

•  The act defines the health care services that are covered by the NHIP, which include preventive, promotive, curative, rehabilitative, and palliative care services. The act also specifies the health care providers that are authorized to provide these services under the NHIP, which include public and private health facilities that are accredited by the HIB.

•  The act empowers the HIB to formulate and implement policies, rules, guidelines, standards, and procedures for the effective operation and management of the NHIP. The HIB is also responsible for monitoring and evaluating the performance and quality of the NHIP and its providers, as well as resolving any disputes or complaints related to the NHIP.

•  The act provides for various penalties and sanctions for any violations or offences related to the NHIP. These include fines, imprisonment, cancellation of license or accreditation, suspension or termination of membership or service contract, etc.

The Health Insurance Act 2017 is a landmark legislation that aims to improve the health status and well-being of Nepali citizens by providing them with universal health coverage through a social health insurance scheme. However, the implementation and enforcement of the act face various challenges and issues, such as:

•  Lack of awareness and understanding: Many people are not aware of their rights and obligations under the act. They are also not familiar with the benefits and procedures of enrolling in and claiming from the NHIP.

•  Lack of resources and capacity: The HIB lacks adequate human and financial resources to carry out its functions effectively. It also lacks technical expertise and experience to deal with complex issues such as actuarial analysis, risk pooling, provider contracting, etc.

•  Lack of coordination and cooperation: The HIB faces difficulties in coordinating and cooperating with other government agencies and stakeholders involved in the health sector, such as the Ministry of Health and Population (MoHP), Nepal Rastra Bank (NRB), Social Security Fund (SSF), local governments, private sector associations, civil society organizations, etc.

•  Lack of quality and accessibility: The quality and accessibility of health care services covered by the NHIP vary across different regions and providers. There are also gaps and disparities in the availability and affordability of essential medicines, equipment,

and supplies. Therefore, it is important for Nepal to address these challenges and issues and improve its health insurance system. This would require a holistic and multi-stakeholder approach that involves various actions, such as:

- Raising awareness and understanding: Conducting awareness campaigns and training programs for people on the benefits and importance of health insurance. Providing guidance and assistance for enrolling in and claiming from the NHIP.

- Enhancing resources and capacity: Increasing the budget and staff of the HIB. Providing training and capacity building for the HIB members and staff on technical and legal aspects of health insurance. Hiring or consulting experts or consultants for complex issues.

- Improving coordination and cooperation: Establishing formal and informal channels of communication and collaboration with other government agencies and stakeholders involved in the health sector. Participating in regional and international forums and networks on health insurance.

- Strengthening quality and accessibility: Improving the quality and accessibility of health care services covered by the NHIP by setting and enforcing standards, guidelines, and protocols. Increasing the availability and affordability of essential medicines, equipment, and supplies.

By addressing these challenges and issues and improving its health insurance system, Nepal can provide universal health coverage to its citizens and improve their health status and well-being.