Predictors of health insurance enrolment and wealth-related inequality in Nepal: evidence from Multiple Indicator Cluster Survey (MICS) 2019
Umesh Prasad Bhusal, Vishnu Prasad Sapkota
BMJ Open · 2021 · DOI: 10.1136/bmjopen-2021-050922
Countries: Nepal
What Was Studied
This cross-sectional study used nationally representative data from Nepal's Multiple Indicator Cluster Survey (MICS) 2019, covering 10,958 households interviewed between May and November 2019. The researchers used adjusted and unadjusted logistic regression models — accounting for complex survey design, cluster effects, and sample weights — to identify socioeconomic, demographic, and geographic predictors of enrolment in any health insurance scheme. They also measured wealth-related inequality in enrolment using a concentration index and decomposed it to quantify the contribution of each factor.
What They Found
Overall enrolment in any health insurance scheme was only 6.95% of households (762 of 10,958). Households with higher secondary education or above were 87% more likely to enrol than those with no formal education (adjusted OR 1.87; 95% CI 1.32–2.64). Media exposure (radio, TV, or magazine) was a particularly strong predictor — households with access were nearly three times more likely to enrol (adjusted OR 2.96; 95% CI 2.03–4.31). Dalit households were significantly less likely to enrol compared to Brahmin/Chhetri/Madhesi households (adjusted OR 0.66; 95% CI 0.47–0.94). Households in Province 2 (Madhesh) and Sudurpashchim were 84% and 78% less likely to enrol than those in Province 1, respectively (adjusted OR 0.16 and 0.22). Richest quintile households were 2.58 times more likely to have insurance than the poorest quintile (adjusted OR 2.58; 95% CI 1.46–4.58). The concentration index of 0.25 (95% CI 0.21–0.30; p<0.001) confirmed significant pro-wealthy inequality. The three largest contributors to this inequality were: education of household head (26.70%), media exposure (17.74%), and geographic province (6.23%).
What This Means for Nepal
Nepal's Health Insurance Board (HIB) has enrolled only ~14% of the population in NHIP despite rolling out to all 753 local governments — this study explains why: enrolment barriers are concentrated among the poorest wealth quintiles, Dalit communities, and geographically disadvantaged provinces (Madhesh and Sudurpashchim, which had 2019 enrolment rates of just 2.0% and 2.3%). Nepal's OOP expenditure (~51% of total health expenditure) means financial protection is most urgently needed by exactly the groups least likely to enrol. Three targeted policy actions follow directly from these findings: (1) HIB should scale mass media campaigns specifically in Madhesh and Sudurpashchim provinces, where media exposure triples enrolment odds and existing rates are critically low; (2) the government's existing premium subsidy for ultra-poor households needs active promotion through FCHVs and ward-level outreach, as the data shows Dalit and lowest-wealth households are systematically excluded despite targeted subsidy provisions; (3) HIB's monitoring framework should track enrolment and renewal rates disaggregated by wealth quintile, caste/ethnicity, and province — the concentration index (0.25) shows current coverage is disproportionately pro-wealthy, directly contradicting NHIP's equity and universality mandate.
Contextualisation
Nepal's NHIP has achieved geographic reach — enrolling in all 753 local governments — but this study reveals only 6.95% of households were enrolled as of 2019, with coverage disproportionately concentrated among wealthier, more educated, and higher-caste households. The Health Insurance Board (HIB) subsidises premiums for ultra-poor households, yet Dalit and poorest-quintile households remain systematically under-enrolled. With OOP spending at ~51% of total health expenditure and 1.7% of the population pushed below the poverty line annually by health costs, these findings point to urgent equity gaps in financial protection that HIB's current targeting strategy is failing to close.