Perception towards national health insurance scheme among enrollees of central Terai: a qualitative study

INTRODUCTION

Health care financing has been playing a major role in delivery of health care services worldwide. Most of the developed countries have well established financing system. But many low and middle income countries are adopting different financing system as their health system has always been under funded.^1,2

In Nepal, public health care system includes health posts, primary health care centers, district hospitals, central and specialized hospitals. Whereas private health care system includes privately run clinics, nursing homes, pharmacy and hospitals, where everything has to be paid from entry to exit. Since after the Alma Ata declaration in 1978, government of Nepal planned to provide health services to its people in equitable manner, but it fails to do so due to allocation of limited financial resources which further leads to lack of other resources. Due to liberalization of economy in Nepal after 1991, mushrooming of private sectors in health further increases the inequity in health care services.³ This enhances poor-rich difference in utilization and urban-rural unequal distribution of health care services. Out-of-Pocket Expenditure has always been a primary means of financing health care service in Nepal. Hence, regulating Out-of-Pocket Expenditure was essential for achieving universal health coverage. Universal health coverage was taken as solution to health care needs of countries with low resources.⁴ Realizing this, Nepal Government formulated national health insurance program. For effective implementation of this program National Health Insurance Policy-2013 was prepared by the government.⁵ After this government has formed Social Health Security Development Committee in 2015 as a legal framework for implementing a social health security scheme. It is a government run health insurance scheme, which aims to increase accessibility and affordability of the health care services to poor and marginalized people without financial hardship and reduce out-of-pocket payments. Under this scheme, a household was considered as a unit and has to pay premium of Rs 2,500 for up to five members and an additional of Rs 4,25 per member per year to get the services worth up to Rs 50,000 per year for families of up to five members with an additional Rs. 10,000 covered for each additional member. The maximum amount available per year is Rs. 100,000. For the effective implementation of this insurance scheme, financial constraint remains major barrier.

Perception of people largely affects the success and failure of the National Health Insurance Scheme (NHIS). The utilization and adherence towards the health care services provided by NHIS is determined by their perception. As this program is a nation level and largely depends upon the premium paid by the enrollees, it should address the gap that the present health care system is not addressing.

As majority of health care providers under health insurance scheme in Nepal are government health institutions, where drugs and consultation charges are either free of subsidized by government. Hence, less involvement of private sectors as health care provider and subsidized cost at government institutions might affect the enrollment of people. Although, 94.90% enrollees of Baglung, Kailali and Ilam districts are willing to renew the insurance scheme for next year.⁶ For smooth roll-out of the insurance program along with strengthening health system, the supply and demand side needs to be focused.³ Different studies has suggested that there is a positive effect on health care delivery system after the implementation of Nation Insurance Programmes.^7,8 There are 220,273 peoples enrolled in NHIS in chitwan district.

This study aims to assess the perception of enrollees among residents of central terai towards NHIS. Assessing perception of enrollees towards the insurance scheme helps to evaluate the service provided through this scheme. The findings will be helpful for policy maker, experts and the providers to provide better service focusing on unmet needs of people under this scheme.

METHODS

A community based qualitative cross-sectional study was conducted to assess the perception regarding NHIS among the enrollees of Bharatpur metropolitan city, chitwan district. The study was conducted from April 2018 to September 2018. Two focused group discussions (FGD) were conducted in order to collect the data. The qualitative data were analyzed as thematic analysis technique. FGD was conducted by the trained researcher. During preparation of FGD guideline and conduction the study was reviewed9. The prepared FGD guideline was pretested among the enrollees of NHIS of Bhaktapur district. Each discussion was facilitated by a moderator and a note taker. The group discussion was recorded by using a digital recorder and later it was transcribed by the researcher themselves. To maintain privacy and confidentiality of the information, group discussion was conducted in a closed room, where other than participants, moderator and note taker were not allowed. The FGD guideline was prepared by extensive literature review and consulting to the experts of the concerned field. All the FGDs lasted for 60-80 minutes. Participants were selected purposively by consulting the enrolment assistants. These enrolment assistants are the residents of the respective places who used to assist people during enrolment to NHIS.

Institutional review committee of Manmohan memorial institute of health sciences (MMIHS) provided ethical clearance for conducting the study. The purpose of the study was clearly explained among the participants and informed written consent was taken from each participants. They were fully ensured about the confidentiality of the recorded information.

RESULTS

Two focused group discussions were conducted among the enrollees of Bharatpur metropolitan city of Chitwan district to assess their perception towards NHIS. Socio-demographic characteristics of the participants are shown in table 1. There were 11 male participants in first FGD (Male group, M1) and 9 female participants in second FGD (Female group, F1). Enrollment Assistants were considered as primary source of information about NHIS.

The responses of FGDs were grouped into the three themes as perceived quality of care, perceived benefits and provider’s behaviour. Themes of perception towards NHIS are summarized in Table 2.

Perceived quality of care

Treatment provided under this scheme

The respondents did not find any differences in the treatment provided under this scheme. Instead the process was full of jargons.

The jargons includes, standing in long queue for registration, less number of administrative staffs, no visible boards indicating the availability of information for health insurance.

“I went to Primary Health Care Center (PHCC), which is near to my home for seeking treatment last month. There I did not find any special care as being insured…… I got free consultation and free medicine, which was free before I was involved to this scheme”. (55 year, FGD-M1).

Drugs

The expectation regarding availability of drugs was totally opposite. The participants thought that within the package (benefit up to Rs. 50,000) they could get drugs of their choice and all the drugs they were prescribed. But they could get only those drugs which were already freely available by government and is difficult to get other medicines.

“When I went to pharmacy after consultation to doctor in hospital, they gave some medicine (free drugs) ….then I was surprised after knowing that other medicines were out of stock…..it was very difficult for me to get those medicines”. (61 year, FGD- M1).

Waiting time

It was perceived that the waiting time for consulting health worker was similar, as separate health workers were not allocated for insured. But they noted long waiting time during registration.

“I went to hospital with friend (she was not enrolled in insurance scheme), I was waiting for registration until she finished her checkup……” (50 year, FGD-F1)

Adequate number of providers

It was reported that, there were not adequate number of health care providers. They thought separate health workers were allocated for insured under this scheme, before the time of enrolment.

“… as I have already explained that there was long waiting time during consultation with doctor, which clearly indicates that there are less number of doctors in hospital (feeling sad)….. (60 year, FGD-M1)”.

Perceived benefits

Cost savings

This scheme was found to be cost savings. Disease may occur to anybody at any time. So being insured to this scheme helps to reduce financial burden as they could get benefit up to Rs. 50,000 by paying premium of Rs. 2,500. It was applicable to different services like OPD visit, lab diagnosis, purchasing medicines.

“…I used to visit hospital frequently for my illness, most of the time I had to pay for lab diagnosis. After being insured, it reduces my expenses as the cost was paid by this scheme”. (52 year, FGD- M1)

Provision of specialized care

Most of the participants perceived that under this scheme they will have easy access to specialized care. Generally they are getting those specialized care that are found in government health facility.

“My neighbor (who was also insured) was referred to cancer hospital and there she was diagnosed as having cancer…. I was happy that she got specialized care in subsidized cost”. (42 year, FGD-F1).

Low premium charge

Almost all of the participants expressed the premium charge as low in comparison with private health insurance. They were happy as the scheme do not consider individual as unit but provides economic benefit to all family member.

“(feeling happy)…. regarding the premium of this insurance we are very happy. Government trying to give good health services under low charge can be appreciated…” (50 year, FGD-M1)

Provider’s behavior

Adequate time provided during consultation

Participants argued that the consultation time was so short, even sometimes they could not express all the symptoms to health workers. There were limited number of providers and patient flow was high.

“…it might be compulsion of health care workers…. there are high numbers of patients, so they have to give time to all the people. Health care workers are also less in number, due to which we could not get enough time during consultation” (48 year, FGD-F1)

“….i have noticed that in PHCC the patient flow is high from 10 am to about 12 noon but after that patient flow is low. Those who visit at this peak time could get lesser time that who will visit after 12 noon…..” (51 year, FGD-F1).

DISCUSSION

Despite of different health insurance schemes from public and private sectors, government of Nepal has run National Health Insurance in order to prevent Nepalese people from financial burden and to provide quality of health care services. Understanding the perception of insured people is essential for further improvement during expansion of this program nationwide. This study identified the perception of residents of Bharatpur metropolitan city of Chitwan district towards NHIS.

The insured people did not find any difference in the treatment provided under this scheme in comparison to usual care. The only difference was in mechanism of payment for treatment. Although in some health facility the medicines were out of stock, the availability of drugs had improved. Similar study conducted in the health insurance implemented districts of Nepal also found the consistent result6. But study from Ghana reported that availability of drugs was not satisfied under the national health insurance scheme.¹⁰ Availability might have improved as government of Nepal has enlisted more than one thousands of medicines under this scheme. When medicines were out of stock, even the service providers were confused as there was lack of information about the steps to be taken when there was not medicine in health facility.⁶ This creates mistrust among the service users.

Some of the participants stated that waiting time for consulting doctor and during the registration was very lengthy. Although most of the health facility had allocated separate staffs for registration process, it was not sufficient as number of enrollees were increasing. Study conducted by Nepal Health Research Council also reported that participants did not find improvement in waiting lines.⁶ This result was supported by study from Ghana, as the enrollees stated long waiting hour during health facility visit.¹¹ Separate health workers were not allocated for them. But before enrollment, they were informed that separate health worker will be allocated for them. Enrollment Assistants were considered as major source of information followed by radio and television. But the study revels radio and television as major sources of information about the health insurance.^6,12 Although Government of Nepal could not categorize poor and issue card in order to provide subsidize in premium, participants were satisfied with the benefit package paid for the premium. Benefit package of Rs. 50,000 for the premium of Rs. 2,500 which could be utilized by any family member was the best part of the scheme.

Under this scheme, both government and private health care facility can be provider. This study found that participants had easy access to specialized care that has been provided through both government and private sector. As the service charge and package of service has been clearly defined by government, it was easy for both service provider and receiver. Result reveled that health care providers did not provide adequate time during consultations. This might be due to less number of health workers. The study from South Africa reported that there was increase in number of providers after implementation of NHIS.¹² Participants also reported that due to lack of time management also this problem has occurred. Large number of patients at early hour and very few at second half of the day might have created pressure to health workers. Study done by Okaro’ et al., believed that NHIS would improve healthcare delivery mechanism.¹³

To best of my knowledge, this is the first study to understand perception of insured people towards NHIS. This study is limited to a single metropolitan city, so we suggest further study covering different geographical area with different socio-economic status.

CONCLUSION

This study found that long waiting time, difficulty during registration and less number of service providers and shortage of medicines remain challenge to receive quality of care under NHIS. Although participants perceived that the benefit package under affordable premium charge is in favor of them. There was less involvement of private sectors under this scheme, so government need to promote their involvement, which might decreases patient flow in public health institutions and could get specialized care of private health institutions in affordable cost. Addressing these factors in expansion of this program in other district might leads for success of this scheme.

ACKNOWLEDGEMENTS

We would like to acknowledge all the participants for their help during study and thanks to all the faculties of Department of Public Health, Manmohan Memorial Institute of Health Sciences.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Review Committee, MMIHS

REFERENCES

1. 1. Dalinjong PA, Laar AS. The national health insurance scheme: perceptions and experiences of health care providers and clients in two districts of Ghana. Health economics review. 2(1):13.
2. 2. James C, Hanson K, McPake B, Balabanova D, Gwatkin D, Hopwood I, et al. To Retain or Remove User Fees? Reflections on the current debate. Appl Health Econ Health Policy. 2006;5(3):137-53.
3. 3. Mishra SR, Khanal P, Karki DK, Kallestrup P, Enemark U. National health insurance policy in Nepal: challenges for implementation. Global Health Action. 2020;8(1):28763.
4. 4. Fusheini A, Eyles J. Achieving universal health coverage in South Africa through a district health system approach: conflicting ideologies of health care provision. BMC health services research. 2016;16(1):558.
5. 5. MInistry of Health and Population. National Health Insurance Policy-2013. Department of Health Services, NHSP, Kathmandu; 2013.
6. 6. NHRC. Assessment of Social Health Insurance scheme in selected districts of Nepal. Kathmandu, Nepal: Nepal Health Research Council, 2018.
7. 7. Adamache KW, Sloan FA. Competition between non-profit and for-profit health insurers. Journal of health economics. 1983;2(3):225-43.
8. 8. Mennemeyer ST. Effects of competition on Medicare administrative costs. J Health Econom. 1984;3(2):137-54.
9. 9. Eeuwijk P, Angehrn Z. How to … Conduct a Focus Group Discussion (FGD). Methodological Manual. 2017.
10. 10. Jamilatu A. Household perceptions and their implications for enrolment in the National Health Insurance Scheme at Sekyere South District 2016.
11. 11. Adei D, Amankwah E, Mireku SI. An Assessment of the National Health Insurance Scheme in the Sekyere South District, Ghana. Current Research J Social Sciences. 2015;7(3):67-80.
12. 12. Oladimeji O, Alabi A, Adeniyi OV. Awareness, Knowledge and Perception of The National Health Insurance Scheme (NHIS) Among Health Professionals in Mthatha General Hospital, Eastern Cape, South Africa. Open Public Health J. 2017;10(1).
13. 13. Okaro A, Ohagwu C, Njoku J. Awareness and perception of national health insurance scheme (NHIS) among radiographers in south east Nigeria. Am J Sci Res. 2010;8:18-25.