Status and determinants of enrollment and dropout of health insurance in Nepal: an explorative study.

BACKGROUND: Compared to other countries in the South Asia Nepal has seen a slow progress in the coverage of health insurance. Despite of a long history of the introduction of health insurance (HI) and a high priority of the government of Nepal it has not been able to push rapidly its social health insurance to its majority of the population. There are many challenges while to achieve universal health insurance in Nepal ranging from existing policy paralysis to program operation. This study aims to identify the enrollment and dropout rates of health insurance and its determinants in selected districts of Nepal. METHODS: The study was conducted while using a mixed method including both quantitative and qualitative approaches. Numerical data related to enrollment and dropout rates were taken from Health Insurance Board (HIB) of Nepal. For the qualitative data, three districts, Bardiya, Chitwan, and Gorkha of Nepal were selected purposively. Enrollment assistants (EA) of social health insurance program were taken as the participants of study. Focus group discussions (FGD) were arranged with the selected EAs using specific guidelines along with unstructured questions. The results from numerical data and focus group discussions are synthesized and presented accordingly. RESULTS: The findings of the study suggested variation in enrollment and dropout of health insurance in the districts. Enrollment coverage was 13,545 (1%), 249,104 (5%), 1,159,477 (9%) and 1,676,505 (11%) from 2016 to 2019 among total population and dropout rates were 9121(67%), 110,885 (44%) and 444,967 (38%) among total enrollment from 2016 to 2018 respectively. Of total coverage, more than one-third proportion was subsidy enrollment-free enrollment for vulnerable groups. The population characteristics of unwilling and dropout in social health insurance came from relatively well-off families, government employees, businessman, migrants' people, some local political leaders as well as the poor class families. The major determinants of poor enrollment and dropout were mainly due to unavailability of enough drugs, unfriendly behavior of health workers, and indifferent behavior of the care personnel to the insured patients in health care facilities and prefer to take health service in private clinic for their own benefits. The long maturation time to activate health service, limited health package and lack of copayment in different types of health care were the factors related to inefficient program and policy implementation. CONCLUSION: There is a high proportion of dropout and subsidy enrollment, the key challenge for sustainability of health insurance program in Nepal. Revisiting of existing HI policy on health care packages, more choices on copayment, capacity building of enrollment assistants and better coordination between health insurance board and health care facilities can increase the enrollment and minimize the dropout.

Correlates of the Timely Initiation of Complementary Feeding among Children Aged 6⁻23 Months in Rupandehi District, Nepal.

Although the predictors of the timely initiation of complementary feeding are well-known elsewhere, there is less awareness of the topic in Nepal. The current study was undertaken to identify the correlates of timely initiation of complementary feeding among children aged 6⁻23 months. A community-based cross-sectional study was conducted in the Rupandehi district, Nepal. A total of 155 mother-child pairs were selected using a simple random sampling technique. Logistic regression with adjustment for potential confounders was employed to examine the independent association between risk factors and the timely initiation of complementary feeding. Fewer than 3 in 5 children aged 6⁻23 months received complementary feeding at the recommended time. Literate mothers and a maternal occupation in the service or business sectors were found to be associated with complementary feeding at 6 months. In addition, child characteristics such as birth order, male children, and those fed micronutrients were also more likely to have been received complementary feeding at 6 months than their counterparts. Maternal education and occupation, and child characteristics such as, birth order, male gender, and micronutrient consumption, which are correlates of the timely initiation of complementary feeding, suggest that the Nepalese Infant and Young Child Feeding (IYCF) programme should target these predictors while designing preventive strategies.