Dropout Analysis of a National Social Health Insurance Program at Pokhara Metropolitan City, Kaski, Nepal
Prabin Sharma, Dipendra Kumar Yadav, Niranjan Shrestha, Prabesh Ghimire
International Journal of Health Policy and Management · 2022 · DOI: 10.34172/ijhpm.2021.171
Countries: Nepal
What Was Studied
This cross-sectional household survey examined why insured families drop out of Nepal's National Health Insurance Program (NHIP), administered by the Health Insurance Board (HIB) under the Health Insurance Act 2017, in Pokhara Metropolitan City, Kaski district. Researchers randomly sampled 355 households that had been enrolled in the scheme for at least one year, drawn from 11 of Pokhara's 33 wards, and used the Andersen Behavioural Model to frame predisposing, enabling, and need factors behind dropout. Data were collected through structured face-to-face interviews with household heads in May-June 2019, and bivariate and multivariable logistic regression identified independent predictors of dropout versus continuous use.
What They Found
More than a quarter of insured households (28.2%, 95% CI 23.6%-33.2%) had dropped out of the SHI scheme. In multivariable analysis, the strongest independent predictors of dropout were poor availability of drugs at the health facility (aOR 4.75, 95% CI 1.19-18.95), living in a rented rather than owned home (aOR 4.53, 95% CI 1.87-10.95), perceiving family health status as good rather than poor (aOR 4.21, 95% CI 1.21-14.65), and using a private facility rather than a public one as the first point of contact (aOR 3.75, 95% CI 1.93-7.27). Households with more than five members were also more likely to drop out (aOR 2.19, 95% CI 1.22-3.94), as were those from underprivileged ethnic groups (Dalit/Janajati), who were more than twice as likely to drop out as privileged groups (aOR 2.36, 95% CI 1.08-5.17); unfriendly provider behaviour tripled dropout odds (aOR 3.09, 95% CI 1.01-9.49). Among dropout households, the most commonly cited reason was lack of family consensus to renew (98%), followed by long waiting times (63%) and a limited number of health facilities under the scheme (60%).
What This Means for Nepal
These findings point to levers HIB can pull today. Since poor drug availability is the single strongest predictor of dropout, HIB should work with the Department of Drug Administration and public hospitals to close gaps in Nepal's roughly 98-item Free Drug List at empanelled facilities — for example by adding pharmacy services and speeding up procurement, as the study itself recommends. Because 98% of dropout households in this study cited lack of family consensus to renew and 28% cited simple unawareness of the renewal window, HIB's ward-level enrolment assistants — the same cadre that currently focuses on signing up new members — should be redirected toward proactive renewal reminders (SMS notifications or ward visits before the annual renewal window closes), a gap that is especially urgent in low-enrolment provinces such as Madhesh (~8% enrolled) where the shortage of empanelled providers (only 343 of Nepal's 753 local governments have one) already limits where insured households can seek care. As HIB confronts its 2026 arrears crisis (over Rs 16 billion owed to providers) and a benefit package it has just had to cut back, addressing this demand-side leakage is as urgent as fixing supply-side financing: every household that drops out after paying Rs 3,500-4,900 in annual premiums is a lost contribution to a scheme already spending more on claims than it collects in revenue.
Contextualisation
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.