Health Insurance Board Nepal

Presentation by Shambhu Prasad Jnawali, Spokesperson, Health Insurance Board Nepal (19.04.2023)

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Context

• there have been 7 game changing health programs by the government of Nepal, one out of them is the health insurance program

• strong legal foundation for HIB / this health insurance program – one of the priority program of the government of Nepal

• major roles & responsibilities of HIB

  • Policy and system development

  • Enrollment of membership: (registration and renewal)

  • Listing or delisting of health service providers

  • Claim management

  • Main operation tools is Insurance management information system

  • Capacity enhancement to HIB staffs and Service providers

  • Demand generation activities/community engagements

  • Grievances management

  • Update of the benefit package 

  • Monitoring and Evaluation

• National Social Health Insurance by HIB is a contributory scheme for the informal sector  

• Specifics of contribution and benefit

Open

• Major features of the program from provider perspective

  • Purchaser and Provider Split (HIB=purchaser, hospitals= provider)

  • IT-based (openIMIS)

  • subsidy (of government to premiums) to poor and targeted population (e.g. 70 years and older, HIV or leprosy patients)

  • contributory / family (household of 5 family members) based

  • cash-less and upper cap

  • public and private providers on medical services

• Enrolment figures:

  • nationwide 77 districts covered

  • close to 2 Mio families, 6.4 Mio beneficiaries

  • 458 providers under HIB (91% public providers, 9% private) – unequally distributed over municipalities, strong urban focus = lack of coverage in some rural areas

•  HIB expects more social health protections schemes incl. for formal sector to be integrated under HIB (for sustainability of HIB activities, formal sector brings in more contributions by insured employees)

•  Way forward for HIB

  • system digitalisation (online referral system, online renewal system, online registration etc., API for claim management)

  • improve claim management system (e.g. AI module in support of manual claim review9

  • increase enrolled and renewal rate

  • introduce co-payment system

  • regular monitoring and training (to staff of health service providers)

Discussion, Q & A

 … On funding of the National Social Health Insurance, definition of premium level and eligibility to subsidies

• National Social Health Insurance is a voluntary program, based on family contributions; families of up to five members have to contribute NPR 3,500 per year and NPR 700 per additional member; the premium is 100.000 NRP per year per household

• HIB was able to identify exemptions for the poor in 26 (out of 77) districts

• 30% of funding of health services are paid out of HIB re-imbursement funds, 70% are paid from the government budget – means currently strong dependence on government budget allocation (background: news in April 2023 on budget cut for health by around 42% )

• HIB cannot cover all medical services from premiums collection, so the government provides subsidies yearly to re-imburse services to hospitals for e.g. elderly and those who cannot pay premiums; question of from whom to collect contributions and for whom to subsidies access to medical services

• though insurance for the informal sector is mandatory, it is not mandatory in practice in Nepal - challenges in enacting it on the local level …

  • awareness of households of health insurance

  • actual coverage of some provinces with health service providers, e.g. in remote areas

• HIB expectations to raise share from re-imbursement fund and lower share from government / efforts to raise premium collection to make health insurance (funding) more sustainable

  • some local governments try to make health insurance mandatory and tie it with other government services to ensure collection of more premiums.

  • practically enact compulsory health insurance in informal sector

  • Integrate formal sector health insurance with those working being able to pay higher premiums

  • Integrate other parallel government services and avoid duplications in administration

… On role of private sector

• Question: We saw that 9% of the providers are from private sector. What are your ideas to attract more of private providers to empanel with HIB or what is currently a hindering factor for more of private providers to join? + How do you decide whom to accept as a provider? What are the selection criteria?

• committee of 9 members under HIB is in charge of selecting providers based on the Health Insurance Act.; for the selection of private providers certain standards of a guideline have to be met by a facility - the committee will select facilities, prepare a report on the suggested providers and present it to the board (HIB)

• the number of public providers is higher than the one from private sector and they differ in distribution between urban and rural places - there is at least one public health facility (provider) in each municipality; private health facility concentrate on the urban areas, not in the rural areas

• on the other hand public providers in rural areas face challenges – they might not be able to provide service regularly as they sometimes struggle with a lack of human resources, or a shortage of medicines (to pre-scribe)

• there are a lot of first health service points (assigned by HIB) all over the country – which are public providers; from there patients can be referred to either public or private hospitals; private health facilities are only referred hospitals, not first health service points.

… On political support for HIB / Nactional Social Health Insurance

• Question: For such a political program, like the health insurance program, you need political support. How do you see the collaboration between the HIB board members, the different ministries, academia, beneficiaries?

• under the health insurance act there is a provision on the composition of the HIB board - The chairman is a political assignment; two members are from the Ministry of Health and Population, one from Ministry of Finance, 4 members are appointed by the Ministry of Health and Population, one member will be appointed by the Cabinet - this ensures broad political support

• cooperation with academia can still be improved

… On HIB claims management

• HIB receiving 25.000 claims / day

• openIMIS AI claims module intended to support timely claims management

Illustration of openIMIS managed business processes under HIB Social Health Insurance scheme

Video  openIMIS Use in Nepal