Sushmita Ghimire, Sailaja Ghimire, Devendra Raj Singh, Reshu Agrawal Sagtani, Sudarshan Paudel
Health insurance has been recognised as a crucial policy measure to enhance citizens' well-being by reducing the financial burden globally. Nepal has also adopted this scheme to support achieving universal health coverage. Various factors influence the overall performance of the program in Nepal. However, there is a lack of evidence on how different factors have influenced the insurance program in the Nepalese context. Therefore, this study aims to explore facilitators and barriers to the utilisation of national health insurance services among service users and other stakeholders. A qualitative study was conducted by interviewing both demand-side participants and supply-side participants in the Bhaktapur District of Nepal. Thematic network analysis was used to analyse data using RQDA software. The socio-ecological model guides the presentation of the identified factors. The study followed the COREQ guidelines to ensure standard reporting of the results. Factors that encourage the use of health insurance services involve individual, community, and policy-related factors. These factors encompass changes in seeking treatment, assistance during enrollment and renewal by enrollment assistant, proximity to the initial point of contact for care, and policy features like individual cards, contribution amount and cashless treatment system. Likewise, lack of physical infrastructure, poor staff management, long waiting times, poor medicine availability, and delays in budget reimbursement were perceived as organisational barriers. At the interpersonal level, obstacles encompass challenges related to staff behaviour, interpersonal relationships, and the information provided by service providers. Identified health services delivery barriers at different levels emphasised the critical need for improving the quality of healthcare and services delivery mechanisms. Overcoming these obstacles is essential for realising health insurance scheme objectives and progressing toward Universal Health Coverage (UHC).
