The government’s health insurance programme is facing rising financial pressure due to underfunding and mounting unpaid claims. With the liability from previous years carried over, the total amount owed to hospitals operating under the insurance scheme continues to grow.
According to the Health Insurance Board, its outstanding dues stand at Rs 16.45 billion as of mid-March. The board's Executive Director, Dr. Raghuraj Kafle, issued a white paper on Sunday, warning that the liability could reach Rs 24 billion by mid-July if the current situation continues. He said the board has just Rs 1 billion in hand while monthly payments to service providers amount to around Rs 2 billion—15 times more than the board’s income.
Dr. Kafle also highlighted a severe shortage of manpower to process insurance claims. Out of the 26 approved positions, only 22 staff are currently working. “Even if they work day and night for a year, they won’t be able to clear the backlog,” he said. The board has requested the Ministry of Finance to allow the hiring of 192 additional staff to settle claims within 100 days.
Since the programme’s launch on April 6, 2016, a total of 8,952,135 people have enrolled. However, only 5,753,817 had renewed their insurance by mid-March, indicating a high dropout rate. The Health Insurance Board attributes this decline in renewals to the inconvenience of having to visit service centers outside their own local levels—particularly in 397 local units. As of now, the first point of service has been reached in only 356 local levels.
The Board’s Director Kafle noted that service providers are mostly concentrated in accessible, densely populated areas, while remote regions lack adequate facilities. Board Chairman Chandra Bahadur Thapa Chhetri acknowledged that 54 percent of those who enrolled in the programme have not renewed their insurance policies. “The board has failed to create a conducive environment for renewals. We need to identify the reasons behind this high dropout rate and take corrective measures,” he said.
Moreover, only 48 percent of enrolled individuals have actually used the health services under the insurance scheme. Nationwide, 404 government hospitals, 48 private hospitals, and 33 community health institutions are listed as service providers. The board stressed the need for better coordination among federal, provincial, and local governments, as well as with the private sector, to ensure wider service availability.
The white paper also highlighted several challenges: low coverage across households, imbalanced regional participation, limited reach of the first service point, high dropout rates, and inaccurate records due to duplication of data.
Health Insurance Coverage by Province (as % of population):
- Koshi: 33%
- Madhesh: 7%
- Bagmati: 26%
- Gandaki: 34%
- Lumbini: 14%
- Karnali: 14%
- Sudurpaschim: 11%
Source: Health Insurance Board
