Ensuring infrastructure strengthening plan for equitable and accessible quality health care services to rural population is important in the context of difficult terrain of the country. Rural population shouldn’t be deprived of the quality services

Nepal has endured significant political changes for the last three decades with a decade long conflict and movement towards advancing towards a federal republic. Despite these political odds leading to long term instability, difficult topography and slow economic development, the country has made some significant improvement on health targets better than some of the stable and fast growing economies of South Asia. However, some of these achievements are continuously challenged by unforeseen natural disasters like the 2015 earthquakes and frequent flooding and landslides etc.

Nepal has one of the highest proportions of out of pocket expenditures on health and around 25% of the people are still living below the poverty line. We have seen a slight increase of proportion of health budget over the period, but the country still relies on support from funding support of development partners. Since, the momentum has started for universal health coverage globally; Ministry of Health and Population and other partners are working continuously for a long time on various modalities of universal health coverage for the people of Nepal. This endeavour finally materialized on 11th October when the Parliament endorsed the first National Health Insurance Bill. This is a first milestone towards achieving goals of universal health coverage for its citizen. This legislation has enabled government to establish a national health insurance scheme to ensure health coverage to every citizen.

The bill has also ensured that the government will fund those who cannot afford prepayment of the premium required for the insurance while the rest of the citizens have to pay a minimum premium themselves to the national health insurance scheme. Endorsing this bill by Parliament is a first step to establish the national health insurance mechanism in the country. We are confident that the ministry will establish the scheme with adequate policies, strategies and mechanisms for its successful implementation; however, there are a number of possible challenges during establishment, initiation and implementation and possible solutions as well.

Ensuring the mechanism for implementation, operationalization and management of insurance scheme in the context of federal states can be aligned with the government’s ongoing effort of devolving national structures for the federal states. Another biggest challenge is to formulate or develop a mechanism to identify vulnerable groups who cannot pay the premium to be insured by government.

There are many unregistered labourers and the country lacks real time database of household income. There is an immediate need to develop this database in collaboration with the central bureau of statistics. This can also help strengthen the vital registration system in the country.

Ensuring adequate capacities and mechanism in place for timely management of the reimbursement or payment of the services is needed for its sustainability. Backlog of this would hamper the operation of the scheme.  Government has to establish a well delineated service delivery mechanism for both public and private sectors. Developing standards of service delivery and price tagging are essential to ensure equity on service delivery. Clear procedures of referral mechanism should be in place from the beginning and the government has to prioritise and ensure adequate funding to primary health centres in order to ensure preventive and promotive services.

Medicine policies and practices under the scheme should be clarified to address the concerns of the equity in access to drugs and their quality. The scheme should have universal standard price tags for all essential drugs at every points of service delivery. Partnering should be done not only with private sectors but also with various local institutions like civil societies to expand access to health services.

The health budget is still dependent on donor contribution and implementation of national health insurance scheme will further burden the health budget. Thus, additional funding sources should be identified upfront. Regular advocacy of increasing health budget and widening of the tax and social security nets could be possible options.

Ensuring infrastructure strengthening plan for equitable and accessible quality health care services to rural population is important in the context of difficult terrain of the country. Rural population shouldn’t be deprived of the quality services that of urban populations have.

There should be a mechanism to address the health seeking behaviour of the population, which is often delayed due to traditional beliefs especially in rural and sub-urban settings. Any devastating epidemics like Ebola, pandemic influenza, Zika etc. could be potential impediments to achieving goals of universal health coverage.

There are many countries globally implementing national health insurance mechanisms and some of them are implementing those similar to our recently endorsed bill. Sustainability of health coverage is the major challenge to maintain the health achievements, moving towards achieving goals of sustainable development goals and overall economic development.

Kandel is MBBS, MA (Anthropology), MPH, EMBA