Health Financing

Umesh Prasad Bhusal, Vishnu Prasad Sapkota · 2021 · BMJ Open

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.

Arjun Kumar Thapa, Achyut Raj Pandey · 2020 · Journal of Nepal Health Research Council

This is among the first nationally representative estimates of catastrophic health expenditure (CHE) in Nepal at both national and provincial level, and its national CHE estimate of 11.11% closely matches the ~10-11% figure commonly cited for Nepal's catastrophic health spending. Because the data (Nepal Living Standard Survey III, 2012) pre-date the Health Insurance Board's NHIP pilot (2016) and the 2015 federal restructuring, the study is best read as a pre-insurance baseline: with out-of-pocket spending still at 54.2% of current health expenditure and 1.7% of the population pushed into poverty by health costs every year (NHA 2019/20), the highest CHE recorded here -- in Sudurpaschim (13.4%) and Karnali (13.3%) provinces -- maps directly onto the same two provinces that today have Nepal's weakest health workforce (0% of sanctioned physician and consultant posts filled in Karnali) and among the lowest NHIP enrolment.

Prabin Sharma, Dipendra Kumar Yadav, Niranjan Shrestha et al. · 2022 · International Journal of Health Policy and Management

Nepal's NHIP continues to hemorrhage members after enrolment: national cumulative-ever renewal stands at only around 57%, district-level dropout has historically ranged from 15% to 96%, and the scheme now faces a 2026 solvency crisis with arrears exceeding Rs 16 billion owed to providers. This Pokhara study's finding that poor drug availability (aOR 4.75) and unfriendly provider behaviour (aOR 3.09) are among the strongest dropout drivers speaks directly to the demand side of that crisis, since dissatisfied members simply do not renew. With only 343 of Nepal's 753 local governments hosting an empanelled provider, the study's finding that choosing a private facility as first point of contact more than triples dropout odds (aOR 3.75) also reflects the empanelment bottleneck that limits where insured households can actually access care.

Timothy Powell-Jackson, Kara Hanson · 2012 · Journal of Health Economics

Nepal's Safe Delivery Incentive Programme (SDIP) — launched nationwide in July 2005 and rebranded 'Aama' in January 2009, when institutional delivery became fully free — is the direct policy ancestor of Nepal's current safe-motherhood financing model, and this paper is the first rigorous impact evaluation of its early (2005-2008) rollout. Its central finding, that the cash incentive alone raised institutional delivery by a modest 4 percentage points because barely a quarter of women knew about the programme and only 26.5% of those eligible were ever actually paid, is a direct cautionary lesson for any Nepali demand-side financing reform — including the currently strained National Health Insurance Programme (NHIP), where administrative bottlenecks (e.g. HIB's claims-review backlog) similarly threaten to blunt benefit design on paper.

Suman Chandra Gurung, Kritika Dixit, Bhola Rai et al. · 2019 · Infectious Diseases of Poverty

Nepal's National TB Programme (NTP) provides free DOTS treatment, yet TB incidence remains high (229 per 100,000 in 2023, WHO Global TB Report 2025) and roughly half of estimated cases go unnotified — a gap partly attributed to financial and access barriers patients face before ever reaching a diagnosis. This study, conducted in two BNMT TB REACH districts (Bardiya and Pyuthan), is the first in Nepal to directly compare patient-incurred costs between active case finding (ACF) and passive case finding (PCF), providing evidence for the NTP's National Strategic Plan ambition to scale up ACF toward the End TB Strategy's milestone of zero TB-affected households facing catastrophic costs. With out-of-pocket spending already 54.2% of Nepal's current health expenditure (NHA 2019/20), the finding that even 'free' TB treatment produces catastrophic costs for a majority of affected households (53% overall) underscores why social protection, not clinical care alone, is essential to closing Nepal's TB financial-protection gap.

Anup Karan, Winnie Yip, Ajay Mahal · 2017 · Social Science & Medicine

Nepal's National Health Insurance Programme (NHIP) shares RSBY's core goal — protecting low-income households from high out-of-pocket (OOP) healthcare costs, which stood at 54.2% of current health expenditure in FY2019/20, among the highest in South Asia. This rigorous quasi-experimental evaluation of RSBY — India's national insurance scheme for below-poverty-line families, which had enrolled roughly 150 million people by 2016 — found that enrolment did not reduce inpatient OOP or catastrophic spending, and actually raised the likelihood of any OOP spending by 30%. This is a direct cautionary signal for Nepal's Health Insurance Board (HIB) as NHIP — now facing a 2026 arrears crisis of more than Rs 16 billion owed to providers and a benefit-cutting Third Amendment (2083) — expands coverage while active enrolment remains only about 16% (FY2022/23): geographic rollout and enrolment growth are not proof of financial protection.

Kavita Singh, Ambalam M Chandrasekaran, Soumyadeep Bhaumik et al. · 2018 · BMJ Open

Nepal's NCD burden is severe -- cardiovascular disease and diabetes together drive an estimated 66-71% of all deaths, with adult hypertension at 24.5% and raised blood glucose at 5.8% (STEPS 2019) -- yet government health spending remains only about 4.9% of the national budget (FY2025/26) and out-of-pocket spending covers 54.2% of health costs. This systematic review compiles South Asian cost-effectiveness evidence directly relevant to Nepal's current reform priorities of expanding the WHO Package of Essential Non-communicable Disease interventions (PEN) at primary care and stocking essential NCD medicines in the Basic Health Service Package (BHSP), including a Bhutan modelling study that found the PEN-based diabetes and hypertension screening programme to be cost-saving compared with no screening at all. Critically, however, none of the review's 42 included studies were conducted in Nepal (37 were from India alone) -- an evidence gap that the Ministry of Health and Population (MoHP) and Department of Health Services (DoHS) should address as WHO PEN scale-up proceeds.