Dropout Analysis of a National Social Health Insurance Program at Pokhara Metropolitan City, Kaski, Nepal

Abstract

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.

Adopting social health insurance in Nepal: A mixed study

“…Furthermore, a scaled scenario of the Pokhara metropolitan Kaski district also showed that the dropout proportion is as high as one-fifth, as revealed by Sharma et al ( 26 ), which is nearly double our study (9.1%). This may show in high dissatisfaction among families, especially among urban dwellers.…”

“…This may be obvious when we ignore the extraneous factors in communication and behavior between the beneficiaries and the HCPs. Furthermore, in the same line, a dropout analysis carried out in Pokhara metropolitan showed moderate odds (OR, 3.09; 95%CI, 1.01–9.49) of dropout due to unfriendly behavior of HCP ( 26 ). This may indicate that there is a sheer of background variables behind the poor beneficiary-provider communication, such as perceived opportunistic behavior of the insureds by providers and, thus, deviating toward the uninsured, long waiting time, poor patient management, and unmet expectations of the beneficiaries.…”

“…A dropout analysis of SHIP carried out in Pokhara metropolitan showed that families living in rented houses have four times more odds of dropout than their counterparts. This may indicate that SHIP may be less preferred than paying for rent or other things ( 26 ). However, inversely, some HHs' willingness to pay the threshold for SHIP seemed to be as low as NPR 1,000 (1 US$ = 120.51 NPR) ( 24 ) indicating the inclusion groups to be identified.…”

“…Efforts to decrease SHI dropout must focus on addressing medicine supply difficulties and enhancing providers' conduct toward scheme holders. Rented households may experience fewer dropouts if insurance awareness is raised and includes provisions to change first contact points ( 26 ).…”

Qualitative evaluation of the health insurance program in Nepal: Expectations beyond limitations

“…Almost 3 out of 10 (28.2%) of the insurees recorded dropped out of HIPs in Pokhara (a major metropolitan city in Nepal and capital of the Gandaki Province), which indicated that there has been a major challenge to the sustainability of the new HIP (Sharma et al, 2021). According to HIB, people's participation in enrolling in the new HIPs remains low (HIB, 2020), and the rate of dropout is high.…”