Government Discusses Health Insurance Program Reforms

Kathmandu. The government has started working to make the health insurance program, which has been facing problems including payment in the past, effective. In the first phase, the Prime Minister's Office discussed with senior officials of the Ministry of Health and Food Hygiene, and health workers and officials from the provincial and local levels about making the insurance program effective, ensuring access for the needy, and making the insurance claim payment process problem-free.

In the discussion, Health and Food Hygiene Minister Nisha Mehta informed that the government is working on restructuring the insurance program and ensuring it does not become a financial burden. "We need to identify which are the most essential groups for the health insurance program, and work is underway for that," she said.

In the program, Prakriti Dhakal, private secretary to the Prime Minister's Office, presented the progress made in the health insurance sector and the summary of various studies. According to her, although the health insurance program has become problematic due to various structural and procedural issues, there is no alternative but to correct it and move forward.

Furthermore, the insurance program is at an annual loss of Rs 6.75 billion. Even after the new government was formed and the insurance amounts were made available immediately, it is still at an annual loss of Rs 6.57 billion. She also informed that Rs 16 billion is required to pay the remaining insurance amounts to the hospitals.

The reasons for such losses include insufficient collection of funds in the risk fund when only patients purchase insurance, the lack of a sufficient risk fund due to voluntary participation in the insurance program, unrealistic and false claims, unnecessary additional amounts in bills, and double claims, and a lack of honesty from both patients and service providers. She stated that the insurance premium only covers 24% of the claims, resulting in an annual loss of 6.75 billion.

According to Health Secretary Dr. Bikash Devkota, in the current fiscal year, out of a total claim of Rs 1.99 billion, only Rs 1.17 billion has been reimbursed. Thus, there is an outstanding amount of Rs 1.11 billion in the current fiscal year. Although the government has been increasing the payment volume since its formation, it is working on a long-term solution to this problem.

Short-term measures such as mandatory enrollment for civil servants, teachers, etc., income-based progressive premiums, and feasibility studies for age-based premiums will be adopted.

Similarly, the Ministry of Health is preparing structural reforms such as establishing a mechanism to prevent false and inflated claims, and strengthening district and local hospitals, informed Health Secretary Devkota.

Experts have also suggested imposing separate taxes on smoking and alcohol to facilitate insurance payments and to pay the outstanding amount of Rs 16 billion to hospitals. Representatives of provincial and local governments participating in the discussion mentioned that the low enrollment in health insurance is due to the general public's lack of awareness about insurance, distrust in services, unavailability of medicines and treatment, lack of listed hospitals nearby, financial difficulties in paying premiums, lack of knowledge about the services provided by insurance, and complexity of the enrollment process.

In Gandaki Province, the service delivery is difficult because the rate of the package is lower than the hospital's purchase rate. Similarly, in Karnali, insured individuals do not receive timely services; in Lumbini, service providers' behavior is not conducive, and the quality is lacking; and in Madhesh Province, there is a shortage of medicines, and listed hospitals are not located conveniently for service recipients, they stated.

In a different context, Minister Mehta said that public trust in government hospitals needs to be regained, and this should start with small things. "Regular cleaning schedules, queue management, and regular doctor attendance are factors that attract people to private hospitals, but public health institutions are superior in terms of quality manpower, equipment, etc. However, this is due to not paying attention to small things," she said.

Minister Mehta urged health officials from provincial and local levels to send a list of unused equipment to the ministry, noting that in some hospitals, equipment is not being used and is lying idle, while in others, there is a shortage. "We need to discourage the tendency to keep equipment that requires minor repairs in the same condition and then plan to buy new ones when needed," she said.

Prime Minister's Health Advisor Prof. Dr. Jagdish Agarwal stated that health insurance will remain a problematic issue as long as the tendency to claim insurance amounts incorrectly is not discouraged. He emphasized that health workers at the district and local levels should work with the mindset of being servants rather than bosses.