KATHMANDU, APRIL 10 Nepal's national health insurance programme has grown 178-fold in eight years, enrolling nearly 9.8 million people across all 77 districts since its launch in 2072 BS - but only 60% of those are currently active members, and the Health Insurance Board is now confronting a projected funding shortfall of Rs 25.26 billion in the upcoming fiscal year. According to a comprehensive report released by the Board, the programme launched on Chaitra 25, 2072 BS from Kailali district and has since expanded to cover all 750 local levels. It works with a provider network of 505 facilities - 441 government, 37 private, and 27 community-run - with 451 designated as first-point-of-service institutions. Enrollment has surged from 32,000 members in 2016 to a cumulative total of 9,874,415, but a significant renewal gap has emerged: only around 5.97 million of enrolled members are currently active, meaning roughly four in ten have not renewed their coverage. Among active members, utilisation remains high at approximately 92 percent in fiscal year 2081/82 BS. Despite its expansion, the programme faces a projected funding shortfall of Rs 25.26 billion for the upcoming fiscal year. Average daily claims have reached Rs 8 crore, with monthly claims totalling Rs 2.5 billion. Adding to the financial pressure, the current annual premium of Rs 3,500 per family covers only 25 percent of total programme costs. The staffing situation has emerged as a parallel crisis. Daily claim volume has grown from 9,963 in fiscal year 2077/78 to 50,100 in 2081/82, while staff numbers have remained unchanged, causing mounting payment delays to service providers. The government currently provides free insurance to 1,631,279 vulnerable individuals, including 1,236,581 senior citizens aged 70 and above - roughly 75 percent of the free-coverage category - and 192,865 persons with severe disabilities. Coverage also remains uneven. While the programme has reached 57 percent of households in targeted vulnerable groups, penetration among general households stands at only 43 percent - a gap the Board acknowledged requires significant additional effort. To address sustainability concerns, the Board has introduced a series of policy reforms, including a Rs 25,000 ceiling on outpatient services, additional coverage of up to Rs 1 lakh for eight severe or chronic illnesses, a one-month waiting period before coverage activates after enrollment, and co-payment mechanisms to curb unnecessary utilisation.