स्वास्थ्य बिमा कार्यक्रम संकटमा, सुधार बिना दिगोपना कठिन : सरोकारवालाNepal’s Health Insurance Program Faces Growing Crisis, Stakeholders Warn

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.