Chapter I

Introduction

1.1. Background
Social Health Insurance Program (hereafter SHIP) was introduced in Nepal
since 2015. Nepal Government has constituted a separate governing body- Health
Insurance Board (hereafter HIB). The SHIP aims to increase the accessibility of
citizens to quality health care services without placing financial burden on them. It
has directly involved the households, communities and government. It helps
preventing people from falling into poverty due to health care costs, i.e. catastrophic
expenditure due to accidents for disease by combining prepayment and risk pooling
mechanisms. This program also advocates towards quality health services by
attempting to address barriers in health service utilization and ensure equity and
access and disadvantaged groups as means to achieve Universal Health Coverage
(hereafter UHC). According to WHO, UHC means that all people have access to the
health services they need, when and where they need them, without financial
hardship. It includes the full range of essential health services, from health
promotion to prevention, treatment, rehabilitation, and palliative care.
The Heath Insurance Act, 2017, has been issued to protect the right to
citizens to receive quality health care, to reduce the financial risk of the insure
through prepayment by health insurance and to ensure easy access of health
services to population by enhancing the efficiency and accountability of health care
providers. The passing of health Insurance Regulation, 2017 by the parliament to
further streamline this function has been an important step for health insurance
program. This regulation doubles the existing benefits package and provides health
insurance up to NPR 1 lakh with an arrangement of government paying the
premium amount for all the senior citizens (70 years and above) ultra-poor and

1
high-risk groups. In addition to that, it has been mandatory for all formal sector to
be insured by contributing one percent of their total income.
The HIB has been implementing the SHIP, as well as learning from the
experiences as a result there are minor changes in guidelines. At the beginning
private hospitals were allowed to be first service point, but from the last year, the
insured can go to the private hospital with the referral of government hospitals or
PHC for the special service. Meanwhile, the amount of premium and maximum
amount of reimbursement has been increased, and the number of insured are
increasing. Four years ago the HIB had got the suggestions of (1) The service
availability should be improved that can increase service utilization and motivate
service providers, and (2) Regular monitoring from central and district level is
necessary to identify the problem and find solutions, from e the service providers'
(NHRC, 2018). Last year, HIB had got suggestions from insured; hospitals;
enrollment officers and assistant; and experts in the sector. The major suggestions
were- (1) the service should be provided a more fast, a more near and a more
quality; (2) reimbursement must be timely and as per the claim; and (3) lacking
coordination among HIB center, HIB district offices, hospitals, insured, and local
government.
The HIP started with an aim of reduce barriers in health service utilization
and ensure equity and access of all the citizens to quality health care. It has been
expanded to all 77 district of Nepal. There are various level of public health service
providers which includes PHCC, Basic hospital, province hospitals, federal hospitals
and academy of health science. Similarly, private service providers that include 15
to 500 beds hospitals providing health services to the insured populations through
the country. Even after rapid expansion of the program there are major challenges
like quality of health services, low enrolment, and high dropout rates, sustainability
of the program in long run.
Service providers' perspectives play important roles in tracing the
performance, proress and quality of health services provided under the health
insurance program, They are well versed with the day to day functionaing of the
progtram, major obstacles, complaints from the insured populations and the

2
corrective measures required. So there is a need for a robust study to identify the
factors that can improve the quality health services, increase easy access and
utilization of services and expansion of health insurance program throuhj the
perspectie of serivice providers.
In this context this study, on the one hand, aims to assess the satisfaction of
health service provides toward the HIB and the quality of the service they are
proving to the insured. Meanwhile, the level of incorporation of the suggestions
made by different studies, and its impacts. Previous studies had indicated that the
lacking of government hospitals capacity to address the high flow of patients in
government hospitals. Contradictorily, the number of insured in increasing day by
day and first service points is confined to the government hospitals (HIB, 2078BS).
This contradiction, raise a curiosty of how the governmnrt hospitals are managing
to provide quality service to the insured. Thus an evaluative research emerged in
this background.

1.2. Objectives

Major Objectives
To identify the factors that can improve the quality of health services, increase
access and utlization of health services and expansion of health insurance program
through the perspective of the service providers at the government health facilities.
Specific objectives

Objectives
1. To assess the awareness of service providers about HIP
Key Informants for the topic were the medical superintendent and the focal
person of HIB. They were talked revolving around the content of- principles of
health insurance; health insurance policy in Nepal, health Insurance act and bylaws,
process of claim, structure and nature of HIB

a. To assess the major obstacles encountered while providing services

3
b. To identify the major complaints received from insured populations

c. To identify the key factors behind low enrollment and high dropout rates
(from service providers' perspective?? Or from clients' perspective??)

d. To develop the corrective measures required for the overall improvement of

the HIP from service providers' perspective

4
 Chapter II

Review of Literature

This study aims to assess the effectiveness of SHIP, from the indicators of
service providers' satisfaction. Service providers on the one hand serve the insured,
and get reimbursement from HIB, and these two sides relationships are the sources
of satisfaction. Literature has been reviewed to contextualize the concepts of the
SHIP, and measuring satisfaction.

2.1. Social Health Insurance: Risk Pooling

SHI entails risk pooling that means healthy share the health cost of the sick,
and the young subsidize the old. When health care is costly, can risk-pooling be an
effective device to protect households from excessive health care expenditure
(WHO, 2003). A healthy and a young earn much than the unhealthy and old. There
are different models of risk pooling. SHI is one of such the financing approaches for
mobilizing funds and pooling risks. The revenue is allocated for the poor and near-
poor to improve their financial access to health care. SHI targets public funds to
subsidize premiums for the poor rather than financing and providing universal
health care for all. SHI may be a solution for a critical part of a nation’s systemic
health care problem, but is not necessarily a solution for the whole problem (Hsiao
& Shaw, 2007, p. 16). Most developing countries do not rely on the insurance
mechanism to pool health risks. When they do, the risks are pooled only for civil
servants, and perhaps for workers in the formal sector. These people are employed
and tend to be more affluent than other segments of society, and the poor and the
less healthy are unable to benefit from these insurance pools (Lagomarsino et al.
2012). Consumers purchase insurance to guard against this uncertainty and risk.
Instead of citizens pay directly for the full costs of their health care, the costs are
paid indirectly through coinsurance and through insurance premiums.

5
 In low income nations, they do not have adequate tax revenues to fund health
care of a reasonable quality for everyone, and many countries are unable to manage
their public health services efficiently and effectively to transform money into
efficient and good quality health services. Public sector primary care services do not
match rural people’s demand in terms of their location and organization. Health
risks are not appropriately pooled, thus the poor, the low income, the elderly, and
the less healthy are excluded from insurance (ibid, p. 17). WHO (2003) has
mentioned the problem in SHI is compounded by communication problems, such as
lack of adequate roads, telecommunications and banking facilities, that would
inhibit a SHI scheme to collect contributions and organize reimbursements, to
manage revenues and assets and to monitor the necessary health and financial
information, and suggested to manage it from community level.
The amount of premium, maximum cost coverage; and nature of risk are well
studied and balanced to sustain the companies. Increases in health insurance,
however, also affect the allocation of health care resources. Cost sharing decreases
the out-of-pocket price paid by the patient, which increases the amount of medical
care demanded (moral hazard). Because consumers would not purchase this
additional care if they had to pay its full cost, the extra services' value to consumers
falls short of the social cost of producing that care. The larger the response to cost
sharing, the greater the decrease in social well-being resulting from more health
insurance (Manning & Marquis, 1996). Therefore, cost-sharing is a way of health
caring by paying for the poor otherwise they could not; and by encouraging to near
poor otherwise they would not suppress the disease. In essence, it is the approach of
making citizens healthy.
Montagu and Goodman (2016) has suggested the ways of involving private
sectors in SHIP- (a) Engagement with private for-profit providers has occurred on
four levels: prohibition, regulation, encouragement and subsidy, and purchase of
services; (b) Prohibiting the private sector where demand for services is high and
capacity to regulate imperfect is very unlikely to succeed, and the ability to
constrain private providers through statutory regulation is limited, especially in low
income countries.

6
2.2. Study of Satisfaction
Longman Dictionary of Contemporary English (online) defines satisfaction to
a feeling of happiness or pleasure because you have achieved something or got what
you wanted. Oxford Advance Learner’s Dictionary (online) rendered satisfaction as
the good feeling that you have when you have achieved something or when
something that you wanted to happen does happen; something that gives you this
feeling. Satisfaction is defined by Locke (1976) as an emotional response or
affection toward an object. Satisfaction is seen as an expression of fulfilment of an
expected outcome influenced by prior expectation regarding the level of quality.
Studies of patient satisfaction with health care originated in the USA in the
1950s where survey research was the method of choice, and throughout the 1960s
several such studies were carried out in the UK, including Cartwright's study
'human relations and hospital care' (Cartwright, 1964). Between the late 1960s and
the mid-1970s around 200 patient satisfaction surveys were performed in the UK
(Bowling, 1992). But there is no study found on service providers' satisfaction
toward the clients (insured), and the agency of reimbursement (government or
insurance board).
Hunt, (1982), noted that the study on satisfaction grown rapidly in the 1970s,
with over 500 studies carried out on the concept. Satisfaction has appeared in many
fields such as in office evaluation by employee satisfaction, hospital evaluation by
patient satisfaction, and site evaluation by visitor satisfaction. Quirk (2006)
suggested that the satisfaction evaluation is a proxy to health service provider
organization's evaluation. It includes feedback on financial performance, quality of
care, and customer service; staff satisfaction. Staff satisfaction is measured through
a variety of instruments. The work group discussion method can be challenging;
how does one keep the discussion open and constructive, avoid discouraging
negativity, yet draw out engagement? With these dilemmas in mind, individual
interview with open ended question is the most suitable. A study to assess the
effectiveness of SHIP had surveyed the service providers' opinion (NHRC, 2018)
where the service provides reported that the insured people request to prescribe

7
specific medicines or investigation even when not required; and they also expect
costly and complicated treatment, referral service and cost of transportation should
be covered by SHI scheme (pp. 14 &15). It was reported that the fragmented scheme
for elderly people, for poor and ultra-poor people, accommodation cost for people
utilizing the service, etc., are unpractical and erring.

2.3. Conceptual framework

Health service providing institutions should be satisfied to the HIB which
provides them reimbursement, otherwise they would not attempt to provide the
health service of their optimum level. At the same time, though they are motivated
from the side of HIB, but due to their institutional capacity and efficiency, the service
providing institutions may not be satisfied to the services they are providing to the
insured. Timely payback of reimbursement to health institutions; practicality of
claiming process; and ease of communication and software, and mutual trusts
between two institutions not only motivates the health providers but also fosters
their institutional capacity.

8
 Health
Chapter III
Institutions
Satisfaction Satisfaction
Research Methodology
Public With the Quality they
With the cooperation they get from HIB Private are providing to the
Working culture insured patients
3.1. Study design Organizational
Individuals' response Value
Policy & laws This is an evaluation research, intended to have some real-world effect. It has
Perception/attitude to hospitals
employed survey and KII methods. The studyOrganizational
was conducted with mixed method
Others…… Performance
research approach whereby researchers collect and analyze both quantitative and
qualitative data within the same study (Creswell & Plano, 2011). Both primary and
secondary dataFigure
have 1: Conceptual
been Framework approach, by collecting and
used in quantitative
generating information with the help of questionnaire that was developed by
researcher and approved by the client organization. The guideline for key
informant interview (KII) was adjusted with the questionnaire. As per the process
of evaluation research, it consists of data analysis and reporting in a rigorous,
systematic process that involves collecting data about the health service providing
institutions, processes, projects, services, and resources. It enhances knowledge and
decision-making, and leads to practical applications.

3.2. Study area

As the study aims to assess the satisfaction of health service providing institution
towards the service providees (the insured patients) and the payer
(reimbursement) of the service/medical charge (the HIB), the study area is
geographically all the hospitals of the country, and on the basis of issue- service
quality, motivation, obstacles, etc., The study was carried out in a total of 21
hospitals. As per the different interest, and nature of hospitals the issue of privately
owned and government funded were separately studied. Among them 10 were
private and other were the government funded. The government funded hospitals
were ranged from smallest unit of Primary Health Centre to central hospital and
medical academy.

9
3.3. Sampling techniques and sample size
As the study employed both quantitative and qualitative approach, sampling
of the hospitals incorporated the nature of mixed design. The stratified sampling of
representative technique was employed. The One private, one government hospitals
and one PHC were taken from each of the provinces. While selecting the hospitals
inside a province the purposive (information rich) and convenience (accessible for
in-depth study) sampling was used for the qualitative approach. Table 3 depicts the
frame of sampling technique.
Table 1
Sampling Scheme

Province Hospitals as unit of study Respondents

from hospitals
Government Private PHC /
Community
1. Province Koshi Noble Medical Gramthan 1. Medical
1 Hospital College head of
2. Madhesh Janakpur Shuva Swostik, Janakpur Eye institution
Hospital Bardibas Hospital 2. Doctor
3. Bagmati Bharatpur Chitwan 3. Nurse
Hospital Medical College 4. Counter
College of staff
Medical 5. Lab in
Sciences charge
4. Gandaki Western Gandaki Bhedabari 6. Pharmacy
Regional Medical College PHCC in charge
Hospital 7. Insurance
5. Lumbini Lumbini Dev Daha Lumbini Eye claim
Provincial Medical College Hospital department
Hospital

10
6. Karnali Surkhet Surkhet Eye Abalching
Regional Hospital PHC
7. Sudurpschim Malakheti Naba Jeevan Chaumala
Hospital Hospital PHC

3.4. Data collection tools and technique

A set of seven structural questionnaire for seven different respondents were
developed for government hospital and similarly a separate set was developed for
private hospitals. Interview guideline was adjusted in the questionnaire.
Researchers and assistant researcher visited the hospitals, and individually talked
to the respondent. In the process of writing response to each of the question (of the
questionnaire) the health-workers were asked their experiences, views, opinions
toward the SHIP, its consequences to the insured and hospitals. Meanwhile, the KI of
the hospital was identified and dug out the further information. The researchers had
developed the questionnaire and KII checklist, and the assistant researcher
(assigned to collected information from some hospitals) were trained accordingly.

2.5. Data Management and Analysis

Data entry, sorting and data management was done using MS-excel.
Graphical presentation of data was done by MS-excel. The edited/managed was then
exported to SPSS for further statistical analysis. The qualitative information was
analyzed by the identification, examination, and interpretation of patterns and
themes in textual data and determines how these patterns and themes help answer
the research questions at hand.

3.6. Ethical Consideration

 Research participants had not been subjected to harm in any way
 Full consents of the participants were taken before the study

11
 Adequate confidentiality of the participants has been maintained
 Deception or exaggeration about the objective of research was avoided
 Personal information of the respondent only relevant to research has been
assessed but anonymously.

12
 Chapter IV

Analysis and Interpretation

Quantitative Analysis

4.1 General Overview of Health Insurance Service Providers

4.1.1 Types of Hospitals

Out of 53 private, 32 community, and 367 hospitals (primary health care centre to
specialized referral hospitals) spread out in seven provinces, we have included the
opinion of 20 HSPs of seven provinces as below:

Table 4. 1: Structure of HSPs

Types of Hospital Sub total Total

Government owned Hospital 11

Hospitals 7

PHCs 4

Private Hospital 10

Teaching Hospital 6

General Hospital 1

Community hospital 3

Total 21

Source: Field Survey, 2022

Out of total 11 government owned entity, four are PHCCs and seven are hospitals
whereas out of 10 privately owned entities, six are teaching hospitals, three are
13
community hospitals and one is general hospital taken for the study. All Community
hospitals are eye hospitals.

4.1.2 Geographical Coverages

The study area covers all provinces where the distribution of the HSPs in each
province is presented in the cross tabulation as below:

Table 4. 2: Geographical Distribution of HSPs

Types of Hospital Province Total

1 2 3 4 5 6 7

Government Hospital 1 1 1 1 1 1 1 7

Primary Health Care Centre 1 0 0 1 0 1 1 4

Community Hospital 0 0 0 1 1 1 0 3

Private General Hospital 0 0 0 0 0 0 1 1

Private Teaching Hospital 1 1 2 1 1 0 0 6

Total 3 2 3 4 3 3 3 21

Source: Field Survey, 2022

The study area covers all provinces where the distribution of the HSPs in each
province

4.1.3 Objective to tie up with SHIP of HIB

There is the mix opinion among the hospital to be a Health Service Providers under
the SHIP program. Majority (70%) of the hospitals opined that rendering the service
to the people is the prime objective to tie up with Health Insurance Board's Social
Health Insurance Program. One hospital has the objective of increasing the income,
another hospital believes on cooperation, and one hospital agree on that
combination of three objectives like earning, services and cooperation.

14
4.2 Satisfaction of Health Service Provider

The study aims to obtain the level satisfaction Government owned hospitals and
private hospitals towards the Health Insurance Board. The satisfaction is subjective
and abstract phenomena which is tried to measure in different perspectives. Viz. a)
Rate of Medicine and Health Services, b) Satisfaction towards the software, c) Claim
settlements, d) Grievances handling practices.

The opinion of the medical and non-medical staff working in HSPs are the key
sources of the information of this study. Considering the rights of privacy of the
respondents, name of the individual respondents has not been disclosed. The
collective opinion in different issues have been presented.

4.2.1 Rate of Medicine and Health Services

The rate of medicine and health services was fixed during FY 2074/75. It is
published as in Baishakh 2075 as "List of facilities and rate under the Health
Insurance Schemes". The rate is not revised yet. In this ground, all hospitals and
most of the staff of all hospitals suggested to HIB for the review of the rate and
update the existing list of medicine and medical services. Hospitals have offered the
health services and provided medicine in the existing rate as provided by HIB. More
than two third of the hospitals (70%) said that hospital is facing losses due the
existing rate, one hospital said that there is neither loss nor profit, and one hospital
said that they are getting somehow profit not due to the existing rate but due to the
frequent visit by the large number of patients in the hospital. One hospital denied to
comment of over the rate. Most of the hospital suggested that the rate need to be
reviewed. When to review is most important input suggested by the respondents.
Their responses are presented in diagram (Figure 4.1).

Figure 4. 1: Number of respondents

15
 No. of Respondents

No response 1

As per necessary 2

Every 2 years 4

Every year 3
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

Source: Field Survey, 2022

The price of medicine and medical services is changed every year due to the
inflation, increase in dollar and other various reasons but HIB has not increased the
price of the medicine, diagnosis, surgery etc. Including the rate of medicine, several
other issues are also need to improve by HIB. Hospital authority had suggested to
HIB to improve the operational style. The experience of respondents regarding the
acceptance of the suggestion by the Board in Figure 4.2. Out of 10 respondents,
seven expressed that our suggestion was not accepted, while one suggestion was
accepted and another one suggestion was partially accepted. One respondent did
not put his opinion.

16
Figure 4. 2: Number of respondents

8 Number of Respondents
7
7
6
5
4
3
2
1 1 1
1
0
Decision is done Decision is done Suggestion is not Not answered
as per sugges- partially accepted
tion

Source: Field Survey, 2022

4.2.2 Satisfaction towards the software

Health Insurance Board has installed a software to operate the SHIP smoothly and
accurately. The software is also claim call API (Application Program Interface). It is
used by hospital to register the name of patient, to upload all related documents and
share to the HIB. Without the software, insured are not allowed for medical services.
So, in case of disturbances in the software or delay in the software, the process of
obtaining health services by the insured also will be delayed. It is found that eight
hospitals experienced that sometimes the software runs delay while one hospital
experienced the delay situation every time and one experienced frequently.

Basically, software is interfaced by the staff working in the registration desk, staff
who involve in uploading the documents, and who issue the bill for the medicine,
diagnosis etc.

The opinion of the staff has been summarized and presented below:

 Software is good but there is a lack of certain features and need to add some
essential feature. For example, software has no photograph of insured so that
there is the possibility of the misuse of the health card by another person.

17
  Software has various feature but, still, we have not facilities to know the
balance of patient.
 Staff face difficulties while uploading the large number of documents.

4.2.3 Claim settlements

Claims settlement is a genuine issue in insurance industry disregarding the

commercial or social, micro or community-based insurance. Customers want to get
the claim amount on time or faster. In health insurance mechanism, health service
providers provide cashless health services to the insureds. The health care cost is
paid to HSPs by Health Insurance Board. HSPs expect the reimbursement of the
health cost that occurred to the insured on time. According to the HSPs, they have
not received the health cost on time. Their opinion regarding the different
perspectives of claims is presented below:

Table 4. 3: Opinion on Claims

Frequenc
 Statements y

Problems of not reconcile of the accounts 7

Problems of not settled the claims on time 6

Process of claim settlement is not practical 5

The accounting between HSPs and HIB is not accurate and

transparent 5

Problems of partially settle of the claims 3

There was no dispute with HIB regarding the claims 3

Source: Field study, 2022

18
Out of the 10 respondents, more than fifty percent of the hospitals have the
complaint to HIB that the claim amount is not properly reconciled between HSPs
and HIB.

Another grievance stated by the respondents is that claim is not settled on time.
Similarly, fifty percent of the hospital argued that process of claim settlement is not
practical and accounting between HSPs and HIB is not accurate and transparent.
However, less than one third of the respondents said that there is no dispute
between the HSPs and HIB regarding the claim amount. Few of the hospitals said
that there is no dispute with HIB regarding the claims. The study found the mix
opinion.

4.2.4 Grievances handling practices

Satisfaction of customers depends on how often grievances are heard and tried to
solve the grievances. There should be a mechanism of getting suggestions,
grievances and complaints. If these suggestions have been addressed by
management properly, customers would be satisfied. The opinion of the staff
regarding the grievances handling in different issues have been presented below.

Table 4. 4: Grievances Handling by Health Insurance Board

Privat Governme Percentag

Frequency e nt Total e

Seldom 5 6 11 52%

Frequently 3 2 5 24%

Every time 2 3 5 24%

Total 10 11 21 100%

Source: Field study, 2022

Majority of the hospitals said that the grievances was handled seldom. Less than
fifty percent of the respondents experienced that the HIB addressed the problems of

19
the hospitals frequently or every time. The study shows that the attempt of the
grievances handling of the Board is satisfactory. In coming days, Board needs to
establish a separate section to redressal the grievances by a dedicated staff.

4.2.5 Condition of renew of the agreement

Government owned hospitals have no options to join the HIB as health service
provider. So, a queries was put forth to the private hospitals that whether they are
going to continue health insurance services to the client. Most of them said that they
will do but there are some conditions. The common conditions are: a) Increase the
existing rate of medicine and medical services, b) up date the list of medicine
including the new medicine. The private hospitals are ready to continue to support
(renew the agreement) to HIB in certain conditions. Fifty percent hospitals demand
that the existing rate need to be increased, followed by (30%) possible to provide
the services in the existing rate, and only 10 percent said that the service in existing
rate is possible if first service point is granted.

Figure 4. 3: Condition for the continuation of the health services

Percent

Possible if First service point is granted 10

Not possible to provide service in existing rate 50

Possible to provide in a existing rate 30

0 10 20 30 40 50 60

Source: Field study, 2022

20
4.2.5 Overall Satisfaction of the Private Hospitals

As HSPs are the key players of the health insurance systems, to know the level of
satisfaction by HIB is very important. The queries was directly put forth to the staff
with three option, fully satisfy, partially satisfy and not satisfy. The opinion of the
private hospital is mix that half are partially satisfy and half are not satisfy, but there
is none of the hospitals who is fully satisfy.

Figure 4. 4: Condition for the continuation of the health services

Overall Satisfaction of HSPs

Not Satisfy Partially Satisfy

50% 50%

4.5 Awareness towards the SHIP among the HSPs

During the study, it has been found that HSPs are aware on the SHIP carried out by
Health Insurance Board. The following indicators proved that they are aware on the
SHIP.

21
Table 4. 5: Causes of affiliation

Causes of Affiliation with Frequency of respondents

HIB
Governmen Privat
Total
t e

Additional Income 0 1 1

Service to insured 4 6 10

Cooperation to government 2 0 2

Legal Compliance 5 0 5

Income, Service and

0 3
Cooperation 3

Total 11 10 21

Source: Field Survey, 2022

Private hospital affiliate with the HIB to run the SHIP with basic three motives i.e.
income, service and cooperation to government whereas government hospitals are
affiliated due to the legal compliance, services to insured and cooperation to
government. Both types of hospitals have proper idea about the insurance so that
we can say that they are aware about the social health insurance program.
However, staff other than Chief of the Hospital and Claim Officer, suggested to the
researchers, to provide regular training, orientation and organize interaction
program to orient about the SHIP, motives of the program. The objective of the
interaction is to obtain more ideas about the SHIP and health insurance.

22
4.6 Major Obstacles

In course of the service providing to the insured, HSPs have faced various problems.
Some major challenges are obtained in course of discussions. The obstacles are
different between the private and government HSPs.

Government Hospitals

Major obstacles faced by the government hospitals are: lack of human resources,
lack of equipment and medicine, lack of fund (claim reimbursement).

Specially in province and zonal hospitals, flow of the patient is significantly

increased but human resources is not increased accordingly. As a result, patient
needs to wait for longer period.

According to the Doctor, Nurses and other staff of the government hospital, they
said in conversation that serving to the insured is a noble work. Most of the insured
are coming from the middle class and higher lower classes people. They hardly
ready to pay for the diagnosis of the diseases. Large number of people have got free
of cost medical services. But, HSPs perspectives, the expenses of the treatment and
medicine is increasing, claim amount is piled up day by day. Due to the delay on the
reimburse of the claims, hospitals are facing fierce financial crises. Some of them are
not able to buy additional medicine and equipment, pay salary for the staff. They are
no more sustained to continue their business.

Primary Health Care Centre are not crowded as insured prefer to go to the big
hospitals. The income of the PHCCs is not increased as per the increment in the
number of insured.

The software related problems also occur frequently to the staff while registering
the name of patient and while uploading the claim related documents.

Some of the medicines are not available in hospital pharmacy. These need to be
purchased from the private pharmacy. Customers does not trust over the SHI since
some of the medicine need to buy outside the hospital pharmacy paying personal
pocket.

23
Private Hospitals

Similar to government hospitals, private hospitals have faced some common

problems. These problems are not getting the claims amount on time, confusion on
the amount settled and amount outstanding, there is still not reconciled the
accounts between the HIB and particular hospitals.

4.7 Major Complaints of Insured

The major complaints of the insured to the HIB and Hospitals have been explored
during the study discussing with the staff of the hospitals.

 Medicine is the major concerned of the insured. They wanted the medicine of
the specific branded which may not be available in the pharmacy sometimes.
 Long queue is another complaint of the insured in registration, lab test,
pharmacy and even to get back the Health Card.
 The health Card is thin and not properly quoted by the plastic. Most of the
people carried out the card in the body that is damaged by moisture.
Sometimes, the ID number is not properly readable. The card should be cared
seriously otherwise easily damaged. In the time of registration staff guess the
number and enter many times. That makes the operation delay and irritation
to the waiting patient.
 Some of the patient seat in the queue for a long time, but they could not get
the medicine as per the prescription of the doctor. Some of the medicine they
need to buy from the private pharmacy from out of pocket. It makes the
patient anger.
 Some of the insured comes to the doctor and request for the whole-body
investigation, providing the vitamin, and other nourishing medicine. Doctor
denies to do so until and unless required by the doctor.
 The HSPs need to be patient friendly.
 HSPs need to manage as much possible as medicine in the pharmacy.
 The minimum service quality of hospital needs to be maintained.

24
  Patient feels uncomfortable and painful standing in the queue for
registration, waiting the physicians, getting medicine from the Pharmacy,
getting reports from the Laboratory. The queue needs to be reduced adding
more staff.
 Some insured complaints to HIB, as their date of birth is inaccurate.
 The counselling by Enrollment Assistant to the insured is not sufficient as a
result, insured expects more benefits from the HSPs.

4.8 Factors of Low enrollment and high dropout rates

According to the key informants, there are several factors of the low enrollment and
high drop outs. The information was obtained from the key staff of the hospitals. We
have not discussed with the insured.

 Insured expects at least three things from the health insurance viz. hospital
need to be nearby of their residence, they get the health care services on
time, and they get the medicine as per their needs.
 Drop out is higher in the districts / villages where hospital is far from the
residence, hospital is nearby but the quality of the health services is poor,
medicine is not available properly.

4.9 Develop the corrective measures required for the overall improvement of
the SHIP from service providers' perspective

The role of HSPs is very important to make the SHIP success. Health Insurance
Board is operator of SHIP. It purchases the health services from various types of
health services providers which are broadly categorized in two categories
government owned and rest of the others. There are further divided in six
different categories like:

 Government owned hospitals (district level, zonal level, province level,

central level (specialty),
 Government funded Teaching colleges (hospitals)
 Primary Health Care Centre

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  Hospitals owned by NGOs,
 Privately owned hospital
 Privately owned teaching college (Medical College).

The opinion or suggestions of the government hospitals and private hospitals have
some contraries and some similarities. The suggestion given to HIB by the privately
owned HSPs, NGO run hospital, and government hospital are presented separately
as follows:

A. Suggestions by the Private Hospitals

 The rate of medicine and medical services has not been reviewed since long
time. The rate needs to be reviewed, and new medicine need to be added in
the list every year.
 Need to improve the capacity of the software (IMIS) so that document can be
uploaded easily
 Frequent communication with chief of HSPs, doctors, focal persons is
required,
 Timely payment of claims is essential
 In case of rejection of the claim that should be communicated to the HSPs
with the reasons on time.
 The existing list of medicine and medical services is not perfect, it need to be
updated every year.
 The patient has various problems. These to be solved by HIB immediately.

 The IMIS (software) should have various facilities viz. balance inquiry,
immediate information about the balance of insured.

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Qualitative Analysis
Health Insurance Board (HIB) is a social protection program of the Government of
Nepal that aims to enable its citizens to access quality health care services without
placing a financial burden on them. The households, communities and government
are directly involved in this program. Health Insurance program helps prevent
people from falling into poverty due to health care costs i.e. catastrophic
expenditure due to accidents or disease by combining prepayment and risk pooling
with mutual support. This program also advocates towards quality health services.
This program attempts to address barriers in health service utilization and ensure
equity and access of poor and disadvantaged groups as a means to achieve Universal
Health Coverage.

Findings
a. To assess the major obstacles encountered while providing services
The SHIP has brought different obstacles for the different types of hospitals. The
government hospitals in city and town are over-crowed. For example, the Bharatpur
Hospital which is newly declared as central hospital, for it the number of OPD
patients (daily 1200 in average) is beyond the capacity of the hospital's
infrastructure, human resources, and management. Visiting OPD for even in minor
problems; insistently request for whole-body check-up and multivitamins;
repeatedly visiting unless the money is not finished make the hospitals
overcrowded and obstacle for smooth performance.

The SHIP induced obstacles to private hospitals is timely reimbursement of the

claimed amount of money. Their complained to HIB is that HIB in the name of
investigation linger, and reduced the claim amount. Moreover, does not provide
feedback such as- "this case of claim has been reduced because of this reason".
Another obstacle is referral system- patients visit PHC, and ask for refer to private
(teaching) hospitals. The referral is specified to any one department, but in the
private hospital the patients report other allied problems related to other
departments, but the referred hospitals are not allowed to do so.

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b. To identify the major complaints received from insured populations

The major complaints received from insured populations are: (a) over crowd in
government hospitals, no seats for waiting, dirty and bad smelling; (b) 5/6 months
long queue in certain surgery and 7/8 days queue for CT scan; (c) sometimes no-
stock of insurance c listed medicine; (d) patients wants all the medicines (if
prescribed by doctors) available in insurance (if need, increase the premium
amount); all treatment from insurance (if need, increase the premium amount); (e)
listing private hospitals too, as first service point; or a validating a referral for all the
departments; (f) no referral for follow up patients;

c. To identify the key factors behind low enrollment and high dropout rates (from
service providers' perspective?? Or from clients' perspective??)
A detail study of unenrolled and dropout is necessary. But, from the the key
factors behind low enrollment and high dropout rates are- (a) the local government
has not bought the insurance policy for the ultra-poor households; (b) the persons
who do not have time to spend whole days for taking medical services free of cost
dropped out due to the long waiting (queue) in government hospitals; (c) removing
private hospitals from first service point resulted to the drop out for those who need
fast service in neat and clean environment of private hospitals.

d. To develop the corrective measures required for the overall improvement of the
HIP from service providers' perspective

The chairman of Bharatpur Hospital reported that our hospital is a

significant partner of HIB, once at the initial stage the officials of HIB had visited the
hospitals but here is gap over 5 years. HIB should visit the (big) hospitals, make
dialogues with the health-workers on how to improve the health. HIB has
distributed the card without considering the capacity of the hospitals. For example,
there are more than 450 thousand people holding card, and expect to have general
checkup at least once in 6th months. More than 70% of them come here the HIB

28
consulted us neither while distributing cards nor make any query how their clients
have been treated. HIB, must come here observe the gaps and lapse in HIB intention
and practice; and attempt to add infrastructure and human resource in this hospital.
I think, it is not their responsible behavior just distributing the cards, without
evaluating the capacity of the hospitals to provide them quality service. If HIB
cannot improve government hospitals, it must make a more suitable laws or rules to
utilize the resources of private section to provide the service to the insured.

Suggestion from the hospitals:

1. Stress to the Targeted People
This study raise an issue of- who should be the target people of the SHIP. A
household of maximum 5 members get the health facilities (OPD; diagnostic tests;
treatment; medicines and materials) that costs maximum of NRs. 100 thousands.
Therefore, those households which cannot arrange this much amount of money, in
the case of emergency, and because of this the member either loss the life or get
deteriorate, must be included in SHIP. However, those households that can bear the
cost of NRs. 100 thousands annually in health is not necessary to be included. Such
households are of two kinds-
(a) Those households who cannot bear the cost of premium (NRs. 3500); for them
concerned ward or municipality should pay after identification.
(b) Those household who can hardly arrange this much amount for premium; for
them concerned ward or municipality should force to buy SHI package by
making obligatory rule.
Health institutions are dissatisfied to the HIB's arrangement that includes all
the educated, health-conscious, and able to afford health service households in SHIP
but unable to include all the uneducated, almost no awareness to health, and unable
to afford health services households in hospitals. There is social security unit in
government funded hospitals that bear the treatment cost of the poverty-stricken
and indigenous patients. For example, the Chepang, Darai, and Bote inhabitants of
Chitwan, Makawanpur and Nawalpur are treated free of cost from social security
unit. Though, their access to quality health service is deprived due to the exclusion

29
of some of the treatments packages, and logistic costs (food, transportation, helper
costs, etc.,). Most of the households from such community do not visit hospitals with
insurance cards because either they do not know about it, or they have no money to
buying the SHIP policy.
The former types of people calculate the package amount, influence health
personnel, get referred to facilitated private hospitals and thus get service fast and
comfortably, but the latter type of people , if any, arrive in hospitals go round and
round to the different windows of crowded government hospitals, get delayed and
unconfuted health facilities, that discouraged them.
2. Copayment to reduce the crowed
Doctors like a social-psychologist describe the attitude of Nepali society with
the reference of patients, by mentioning a proverb- "Nepalese people if get free of
cost, drink even tar." they inferred that Nepalese are so crazy that their behaviors
are more competitive and jealous, than rationalistic and altruistic. Relatively
educated and powerful (in term of voice and network) people compare self to their
neighbors, how much rupees they have withdrawn or spend from the package of
hundred thousands, everyone wants to spend more than the other to be contented
by proving self as cleverer. Meanwhile, they calculate the remaining amount, and
request doctors to prescribe different diagnostic tests (whole body check-up) and
multi-vitamins to finish the amount at the end of expiry day. Since, people crowded
here requesting whole body check-up, at the last months of expiring the package-
Asar, Asoj, Push, Chaitra.
To avoid such a misuse of government fund, health personnel recommended
that the SHIP with the coordination of concerned ward must identify the
households. Then (a) compulsorily include the poverty-stricken people; and either
(a) excludes the middle class; or (b) applies a co-payment system of HIB (80%) and
patients (20%). Like a social-psychologist, they predicted that the co-payment
reduces the frequency of visiting hospital (now they are coming even in minor
problems) and amount of diagnosis and medicines they demand. Co-payment, thus,
reduces the crowd in hospitals, and make easy service to the genuine patients.

30
3. First Service Points and Referral: Practicality
The first service point of the insured is their nearest PHC or government
funded hospitals. From these institution the patients are referred to the hospitals of
their choice either government or private. The referred patients must take their all
services within seven days of the referred date from the refereed hospital; if their
treatment process takes 8th day they must bring the referring again. For example, a
patient referred form Darchula hospital get surgery treatment in Chitwan Medical
College. The discharge patient is called after 7 days for follow up. The patients must
go to Darchula to get referred paper for the follow up. Doctors are mostly
dissatisfied with this legal provision- "how can a just discharged weak and sensitive
patient can travel and bring referred paper within seven days?"

4. Improving the IMIS software, and Posting-Claiming mechanism

The reception or first desk or ticket counter employees feel the pressure of
long queue of patients. According to them, that can be reduced by reducing fill up
the description of insured; stopping software hang/slow down; and changing the
rule of posting that causes repeatedly coming of insured in queue. It is also a
request or suggestion to HIB
a. The out-patients required to complete their diagnostic tests, and taking medicines
pharmacy within the fourth day of first visit so that hospital can submit the
documents to HIB for claiming. But this is not always possible while there dread
queue of patients. Similarly, hospital provides OPD ticket of two pages (one white
and next red). For example, today a patient shows his wound to OPD, and gets
prescription of some medicines to employ immediately and some texts- e.g., USG,
X-ray and blood tests. The patients get medicine from the pharmacy by submitting
the white page today. Tomorrow he shows the reports of tests to the OPD, the
doctor adds some other medicines in the red paper, and the pharmacy does not
accept the red paper. Since, the patients go to queue to buy another white OPD
ticket. Thus, patients unnecessarily spend, and OPD counter gather crowed. Better,
the HIB accept red paper also.

31
b. Hospitals have a provision of mentioning the balance amount of the insured in
OPD ticket or admission file if the balance amount is below or equal to 10,000 to
ensure the reimbursement of spending. Therefore, the employees request the
software must shows red sign if the card has the balance amount below or equal
to 10,000 so that they can easily and quickly identify it and use the saved time in
fast ticketing.
c. While issuing OPD ticket, employees must fill all the descriptions, even the date
of the day, of the insured (patients) in software to print an OPD ticket. The
system must automatically fill other descriptions of the insured (patients) as the
claim ID number is filled by counter so that they can use the saved time in fast
ticketing
d. HIB and its enrollment officers must carefully verify if there are missing/gap
between the descriptions filled in insured cards and their IMS mentioned in the
software or displayed in system.

Issue of SHIP
a. Trading-off the misuse and unwillingness
Doctors confess that they are willy-nilly involve to make undue spending of
HIB. There is a significant numbers of insurance patients from middle class. Their
vehicles, dress up, social-status, jobs, etc., indicates that that they can easily bear the
cost of medical expenses beyond the 100 thousands. Some of such people are getting
health facilities of even taking medicines to US and Australia (for 6/8 months), or
whole-body check up by calculating the remaining amount of money and aiming to
spend all. Only those people have the 'social capital' as per Pierre Bourdieu: “the
aggregate of the actual or potential resources which are linked to possession of a
durable network of more or less institutionalized relationships of mutual
acquaintance or recognition (Bourdieu, 1986, p. 248)", to influence doctors or
hospitals for getting such benefits.
But there is an opposite trend in Nepalese society. The doctors, nurses,
pharmacists, lab technicians, for their experiences opine- the mainstream attitude of
patients is that "they want as less diagnosis tests and medicines (types and

32
days/dose) as possible if it is to pay themselves, and as much as possible if get in
free of cost." They added that the patients (insured) are mostly educated and
economically affordable people. One of such examples they reported that is- one a
lecturer brought his job-holder wife to the doctor, the doctor referred for MRI to
diagnose the cause of back-pain and dragging one leg. But, the lecturer instead of
taking MRI from the nearby teaching hospital requested to diagnose from x-ray.
Doctor insisted for MRI but the couple did not come with MRI. After two years, the
couple came with MRI report that was paid by SHIP, and asked for further
treatment.
Doctors reported that before introducing the SHIP, patients used to
observing carefully line by line while the doctor was writing the medicines (R x), and
request to avoid mostly the acid inhibitors, and vitamin complex. But, now due to
the SHI fund, they not only accept the doctors' prescriptions, but also requests for a
more tests and medicines. Thus, SHIP, has benefited to those misery persons.
Though, it is not abstracted (or theorized), this study substantiate to establish a
truth that there is a tendency in Nepalese people that they make saving and transfer
to the siblings (even if the children are not expecting) even by suppressing their
desires and needs; which they want to fulfill if get in free of cost.
If we exclude middle class, or impose co-payment, they hesitate to take
necessary tests and buying essential medicine. Prolonging suppression or ignorance
of disease may cost to loss of property or take life. Unless we develop their attitude
of willing to buy medical services and materials without hesitation.

33
 CHAPTER V

Conclusions

 Some very important medicines are not included in the list of insurance (e. g.,
Gastro).
 Dermatology related medicine need to include in the list of insurance.
 The implant materials are also not included in the list of insurance.
 Ticket is not provided by HIB. We need to print the ticket. The same is made
available to the government owned hospitals.
 First, private teaching hospital (GMC) was treated as the first service point
hospital but now, it is only the referral hospital.
 The ENT should be in a package.
 Sometimes some of the patients bring the documents to their home and do
not come to the hospital to handover the document. We cannot submit such a
expenses for the claims. Neither patient pay for nor HIB reimburse. We have
to bear ourselves.
 Some of the patients' age has not been shown the accurate figure. There is
several mistakes about the information of the patient in IMIS.
 No orientation to the staff of hospital.
 No proper orientation to the Enrollment Assistant as a result patient comes
to the hospital with high expectation and argue on unnecessary issues.
 Due to the small difference between the list of medicine of HIB and medicine
prescribed by physicians, patient gets troubles, HIB does not pay to Hospitals
(e.g., 10 mg vs. 5 mg.).
 Uploading time is not sufficient.
 Sometimes, upload of the document is not possible in the same day since
entire checkup and medication is not completed within a day. Patient needs

34
 to attend in the next day to complete the checkup. So that, the uploading time
need to extend.
 Validity of referral paper is one week. But, sometimes, more than one week is
required to complete the medication. In this situation, patient, need to go to
first service point to get the referral paper. It takes more time, cost and
energy. The one-week referral time need to extended at last one month.
 In referral slip, the name of the referred hospital has not been mentioned. It
creates the problems in the time of claims. So, first service point hospital
(PHCC) needs to mention the name of the referral hospital clearly.
 Patient who comes for follow up they are also required to bring the referral
paper. The referral paper should be waived who are coming for the follow up
only.
 Within a week, if one come seven times in follow up, his cash need to be
deducted every times.
 Private hospitals are allowed to charge only Rs. 140 per patient for the
referral slip. But, government hospitals charge Rs. 200 for the same referral
slip
 Date of Birth is typed sometimes in Bikram Sambat and sometimes in
Gregorian calendar, there should be uniformity in the information.

35
 Chapter VI

Recommendation

We had made suggestions to Service providers- (1) The service availability should
be improved that can increase service utilization and motivate service providers,
and (2) Regular monitoring from central and district level is necessary to identify
the problem and find solutions.

Schokkaert and Van De Voorde (2013) define “user charges” or “user fees” or
"consumer prices" for health care as official payments charged by the providers to
the patients at the point of delivery. One of the model of this is 'cost-sharing' by
patients in systems of (private or social) health insurance, one speaks about co-
payments (a fixed amount per service), coinsurance (when patients have to pay a
fixed percentage of the cost) and deductibles (where patients only are reimbursed
above a certain minimum cost ceiling) (p. 412).

Instead of a profitmaking or a self-running company, social health insurance in

Nepal is government funded. The GoN, on the one hand pays premium of the
poverty-stricken people to buy SHI policy through local government, and
reimburses to the hospital for providing medical services to the insured through
HIB. The reimbursement is many time more than the premium collection, therefore,
the risk transferring is not a sharing like in a company of balance, but contributing
by rich and healthy to the poor and unhealthy. Therefore, SHIP in Nepal is not
running with the principle of insurance. GoN, collects as public fund mostly from the
tax, and spends this money in the medical services of the poverty-stricken people
who cannot afford with their own earning.

36
Here is a general assumption that private hospitals' opinion or view or suggestion to
SHIP is oriented by the motive of profit-making; and the government hospitals are
motivated by the public interest that is to provide health service in minimum cost or
reimbursement of government (as funder to HIB). It is heard that SHIP has reduced
the patients' number in private hospitals, and there are significant numbers of
doctors who are permanent in government hospitals but invested in private
hospitals are not satisfied to SHIP. Therefore, analysis and suggestion by such
doctors, though there are from government hospitals, to HIB is not out of suspicious.

37
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