स्वास्थ्य बिमा कार्यक्रम संकटमा, सुधार बिना दिगोपना कठिन : सरोकारवालाNepal’s Health Insurance Program Faces Growing Crisis, Stakeholders Warn
नागरिकलाई आर्थिक भारबिनै स्वास्थ्य उपचार सेवा उपलब्ध गराउने उद्देश्यसहित सुरु गरिएको स्वास्थ्य बिमा कार्यक्रम एक दशक पुग्न लाग्दा पनि प्रभावकारी र दिगो बन्न नसकेको सरोकारवालाहरूले बताएका छन्। कार्यक्रम विस्तार भए पनि व्यवस्थापन कमजोरी, अपर्याप्त बजेट र अस्पताललाई समयमै भुक्तानी नहुँदा स्वास्थ्य बिमा प्रणाली नै संकटतर्फ उन्मुख भएको उनीहरूको निष्कर्ष छ।
Rastriya Swatantra Party को स्वास्थ्य विभागले बुधबार विभिन्न अस्पतालका प्रमुख तथा स्वास्थ्य क्षेत्रका विज्ञहरूसँग आयोजना गरेको अन्तरक्रिया कार्यक्रममा अधिकांश वक्ताले स्वास्थ्य बिमा कार्यक्रमको वर्तमान संरचनामाथि गम्भीर प्रश्न उठाएका हुन्। कार्यक्रममा सहभागीहरूले अहिलेको मोडेललाई सुधार नगरे स्वास्थ्य बिमाप्रति जनविश्वास झन् कमजोर बन्न सक्ने चेतावनी दिएका छन्।
रास्वपा स्वास्थ्य विभाग प्रमुख तथा पूर्व स्वास्थ्य राज्यमन्त्री Dr. Tosima Karki ले स्वास्थ्य बिमा नागरिकको आधारभूत स्वास्थ्य सुरक्षासँग प्रत्यक्ष जोडिएको विषय भएकाले यसलाई कमजोर हुन दिन नहुने बताउनुभयो। उहाँले बजेट अभाव, अस्पताललाई समयमा सोधभर्ना नहुनु, नीतिगत अस्थिरता तथा व्यवस्थापन कमजोरीका कारण कार्यक्रमले अपेक्षित परिणाम दिन नसकेको धारणा राख्नुभयो।
उहाँका अनुसार बिमा प्रणाली प्रभावकारी नहुँदा सबैभन्दा बढी असर सर्वसाधारणमा परेको छ। विशेषगरी आर्थिक पहुँच बाहिर रहेका नागरिक उपचार सेवाबाट वञ्चित हुने जोखिम बढेको भन्दै उहाँले बिमा कार्यक्रमलाई थप पारदर्शी, व्यवस्थित र उत्तरदायी बनाउनुपर्ने आवश्यकता औँल्याउनुभयो।
Nepal Medical Council का उपाध्यक्ष Dr. Kunjan Sherpa ले स्वास्थ्य बिमा प्रणाली अहिले बहुआयामिक समस्याबाट गुज्रिरहेको बताउनुभयो। उहाँले बजेट अभाव, भुक्तानी ढिलाइ, पारदर्शिताको कमी र अनावश्यक परीक्षणजस्ता विकृति नियन्त्रण नगरे प्रणालीमाथिको विश्वास झन् कमजोर बन्ने चेतावनी दिनुभयो।
डा. शेर्पाका अनुसार नेपालमा स्वास्थ्य क्षेत्रमा सरकारी बजेट अझै पनि कुल बजेटको करिब ६ देखि ८ प्रतिशतमा सीमित छ। विश्व स्वास्थ्य संगठन तथा दिगो विकास लक्ष्यले स्वास्थ्य क्षेत्रमा पर्याप्त लगानी आवश्यक रहेको उल्लेख गरिरहे पनि नेपालले स्वास्थ्यलाई प्राथमिकतामा राख्न नसकेको उहाँको भनाइ थियो। उहाँले स्वास्थ्य बजेटलाई क्रमशः कम्तीमा १० प्रतिशत नजिक पुर्याउनुपर्ने आवश्यकता औँल्याउनुभयो।
कार्यक्रममा सहभागी अस्पताल प्रमुखहरूले पनि स्वास्थ्य बिमाको सबैभन्दा ठूलो समस्या समयमै भुक्तानी नहुनु रहेको बताएका छन्। अस्पतालहरूले लामो समयसम्म बिमा रकम नपाउँदा औषधि खरिद, सेवा विस्तार, उपकरण व्यवस्थापन र जनशक्ति सञ्चालनमा दबाब बढ्दै गएको उनीहरूको भनाइ छ।
Tribhuvan University Teaching Hospital का कार्यकारी निर्देशक Dr. Subash Acharya ले स्वास्थ्य बिमालाई अल्पकालीन कार्यक्रमका रूपमा नभई दीर्घकालीन राष्ट्रिय दायित्वका रूपमा अघि बढाउनुपर्ने बताउनुभयो। समयमै भुक्तानी नहुँदा अस्पताल व्यवस्थापन जटिल बन्दै गएको भन्दै उहाँले सरकारले स्पष्ट र स्थिर नीति लिनुपर्ने धारणा राख्नुभयो।
National Trauma Center का प्रमुख Dr. Rudra Marasini ले सरकारी अस्पतालमा बिमामार्फत सेवा लिन आउने बिरामीको संख्या निरन्तर बढिरहेको जानकारी दिनुभयो। तर जनशक्ति, उपकरण र पूर्वाधार पर्याप्त नहुँदा सेवा प्रवाह व्यवस्थापन चुनौतीपूर्ण बनेको उहाँको भनाइ थियो।
यस्तै Bir Hospital का युरोलोजी विभाग प्रमुख Dr. Rabin Bahadur Basnet ले स्वास्थ्य बिमाको मूल उद्देश्य नागरिकलाई आर्थिक भार कम गर्दै उपचार उपलब्ध गराउनु भए पनि कमजोर कार्यान्वयनका कारण अपेक्षित उपलब्धि हासिल हुन नसकेको बताउनुभयो।
वीर अस्पतालका पूर्व निर्देशक Dr. Dilip Sharma ले स्वास्थ्य बिमा कार्यक्रमलाई सफल बनाउन वित्तीय अनुशासन अत्यन्त महत्त्वपूर्ण हुने बताउनुभयो। उहाँका अनुसार नियमित भुक्तानी, पारदर्शी दाबी प्रक्रिया र प्रभावकारी अनुगमनबिना कार्यक्रम दीर्घकालीन रूपमा टिक्न सक्दैन।
स्वास्थ्य मन्त्रालयका सल्लाहकार Dr. Manohar Lal Pradhan ले सरकार स्वयं पनि स्वास्थ्य बिमा कार्यक्रम पुनर्संरचना आवश्यक रहेको निष्कर्षमा पुगेको जानकारी दिनुभयो। उहाँका अनुसार आगामी नीति तथा कार्यक्रममा पनि स्वास्थ्य बिमा सुधारलाई प्राथमिकतामा राखिएको छ।
Kanti Children’s Hospital का निर्देशक Dr. Pankaj Rai ले अस्पतालहरूको भुक्तानी रोकिँदा दैनिक सेवा सञ्चालनमै समस्या बढ्दै गएको बताउनुभयो। यस्तै Paropakar Maternity and Women’s Hospital का निर्देशक Dr. Shree Prasad Adhikari ले स्वास्थ्य बिमालाई दिगो बनाउन नियमित सोधभर्ना, प्रभावकारी व्यवस्थापन र पर्याप्त स्रोत सुनिश्चित गर्नुपर्नेमा जोड दिनुभयो।
सरोकारवालाहरूका अनुसार स्वास्थ्य बिमा कार्यक्रमको मूल समस्या केवल बजेट अभावमा सीमित छैन। नीति अस्थिरता, कमजोर व्यवस्थापन, अपारदर्शी दाबी प्रक्रिया तथा सेवा प्रदायक संस्थामाथिको बढ्दो वित्तीय दबाबले कार्यक्रमको प्रभावकारिता कमजोर बनाइरहेको छ। उनीहरूको निष्कर्षमा, तत्काल संरचनात्मक सुधार नगरे स्वास्थ्य बिमा कार्यक्रमले अपेक्षित सामाजिक सुरक्षा दिन नसक्ने जोखिम बढ्दै गएको छ।
Nepal’s national health insurance program, launched nearly a decade ago with the goal of providing affordable healthcare access to citizens, is increasingly facing questions over its effectiveness and long-term sustainability. Health experts, hospital administrators, and policymakers have warned that unless major structural reforms are introduced, the program could face a deeper operational and financial crisis in the coming years.
The concerns were raised during an interaction program organized on Wednesday by the health department of Rastriya Swatantra Party, where representatives from major hospitals and health institutions discussed the current condition of the country’s health insurance system. Most speakers described the program as financially strained, operationally weak, and increasingly difficult for hospitals to sustain.
Speaking at the event, Dr. Tosima Karki, chief of the party’s health department, said the insurance scheme has failed to become fully effective due to insufficient budget allocation, delayed reimbursements to hospitals, policy instability, weak management, and irregularities in service delivery. She stressed that the health insurance system is directly connected to citizens’ basic healthcare security and should not be allowed to weaken further.
According to Dr. Karki, ordinary citizens are suffering the most from the inefficiencies within the system. She said the original objective of bringing financially vulnerable populations into the healthcare network remains incomplete because of poor implementation and administrative shortcomings. She emphasized the need to make the system more transparent, accountable, and institutionally reliable.
Nepal Medical Council Vice President Dr. Kunjan Sherpa highlighted several structural weaknesses within the insurance framework, including budget shortages, delayed claim settlements, lack of transparency, and unnecessary medical testing. According to him, improving the system requires a broader multi-dimensional reform strategy rather than temporary fixes.
Dr. Sherpa noted that Nepal’s health sector currently receives only around 6 to 8 percent of the national budget, which he argued remains inadequate considering the country’s healthcare demands. Referring to recommendations from the World Health Organization and global sustainable development goals, he said Nepal should gradually increase healthcare spending closer to 10 percent of the total national budget.
One of the most serious concerns repeatedly raised during the discussion was the delay in reimbursement payments to hospitals. Health institutions say they are often forced to wait months before receiving payments for services provided under the insurance program. Hospital administrators warned that these delays are affecting medicine procurement, operational management, equipment maintenance, and overall service quality.
Tribhuvan University Teaching Hospital Executive Director Dr. Subash Acharya said the health insurance scheme should be treated as a long-term national social protection program rather than a short-term political initiative. He warned that delayed payments are creating increasing management complications for hospitals already operating under limited resources.
Similarly, National Trauma Center chief Dr. Rudra Marasini said the number of patients seeking treatment through the insurance system at government hospitals continues to rise every year. However, shortages of medical staff, infrastructure, and equipment are making service delivery increasingly difficult. He urged the government to strengthen institutional capacity alongside expanding insurance coverage.
Bir Hospital urology department chief Dr. Rabin Bahadur Basnet stated that although the core objective of health insurance is to reduce the financial burden on citizens, weak implementation has prevented the program from delivering expected outcomes.
Former Bir Hospital director Dr. Dilip Sharma emphasized that financial discipline is essential for the survival of the program. According to him, regular reimbursements, transparent claim verification systems, and stronger auditing mechanisms are necessary to restore trust in the insurance scheme.
Health Ministry advisor Dr. Manohar Lal Pradhan acknowledged that the government itself has concluded that the insurance system requires restructuring. He said reforming the health insurance program has already been prioritized within upcoming government policy discussions.
Meanwhile, Kanti Children’s Hospital Director Dr. Pankaj Rai warned that delayed reimbursements are creating operational stress for hospitals. Likewise, Paropakar Maternity and Women’s Hospital Director Dr. Shree Prasad Adhikari stressed the importance of regular payments, efficient management, and adequate financial resources to ensure the long-term sustainability of the insurance system.
Stakeholders at the discussion concluded that the crisis facing Nepal’s health insurance program is not limited to funding shortages alone. They argued that policy inconsistency, weak governance, delayed claim settlements, and increasing financial pressure on service providers are collectively undermining the system’s credibility. Without immediate structural reforms, they warned, the program may struggle to fulfill its original promise of universal healthcare protection for ordinary citizens.
