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Resource theory and the patriarchy perspective maintain that wives have less family decision-making power either due to their lack of valuable resources or the persistence of male dominance culture. We examine a somewhat different pattern in post-Mao urban China, where wives have fewer resources and do more housework but nonetheless have greater family decision-making power than their husbands. Our in-depth interviews of 43 couples in Beijing show that resource-based power use is common among individualized or incompatible families. However, the dominant family organization is collectivized, in which the couple shares family resources, denounces equity- oriented exchange, and is guided by relational harmony. Among the couples from collectivized families, household responsibilities are recognized as a vital contribution to the family’s well-being and thus are a primary source of family decision-making power. Male dominance culture is found more evident among collectivized than individualized or incompatible couples, but its presence does not seem as strong as that of household responsibilities regarding family decision-making.

Background: Nepal’s national social health insurance (SHI) program, which started in 2016, aims to achieve universal health coverage (UHC), but it faces severe challenges in achieving adequate population coverage. By 2018, enrolment and dropout rates for the scheme were 9 percent and 38 percent respectively. Despite government's efforts, retaining the members in SHI scheme remains a significant challenge. The current study therefore aimed to assess the factors associated with social health insurance program dropout in Pokhara, Nepal. Methods: A cross-sectional household survey of 355 households enrolled for at least one year in the national social health insurance program was conducted. A structured questionnaire was used to conduct face-to-face interviews with household heads were conducted using a structured questionnaire. Data was entered in Epi-Data and analysed using SPSS. The factors associated with social health insurance program dropout were identified using bivariate and multiple logistic regression analyses. Results: The findings of the study revealed a dropout prevalence of 28.2% (95% confidence interval: 23.6%-33.2%). Households having more than five members [adjusted odds ratio (aOR) 2.19, 95% CI: 1.22-3.94], belonging to underprivileged ethnic groups (Dalit/Janajati) (aOR 2.36, 95% CI: 1.08-5.17), living on rented homes (aOR: 4.53, 95%CI 1.87-10.95), absence of chronic illness in family (aOR 1.95, 95%CI: 1.07-3.59), perceived good health status of the family (aOR 4.21, 95%CI: 1.21-14.65), having private health facility as first contact point (aOR 3.75, 95%CI: 1.93-7.27), poor availability of drugs (aOR 4.75, 95%CI: 1.19-18.95) and perceived unfriendly behaviour of service providers (aOR 3.09, 95%CI: 1.01- 9.49) were statistically significant factors associated with SHI dropout. Conclusion: In Pokhara, more than one-fourth of households have dropped out of the Social Health Insurance Scheme, which is a significant number. Dropping out of SHI is most commonly associated with a lack of drugs, followed by rental housing, family members’ reported good health status and unfriendly service provider behaviour. Efforts to reduce SHI dropout must focus on addressing drugs availability issues and improving providers’ behaviour towards scheme holders. Increasing insurance awareness, including provisions to change first contact points, may help to reduce dropouts among rented households, which make up a sizable proportion of the Pokhara metropolitan area.

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