Dissertations and Theses

Date of Degree


Document Type


Degree Name

Doctor of Philosophy (Ph.D.)


Health Policy and Management


Diana Romero

Committee Members

Alexis Pozen

James Sherry

Subject Categories

Public Health


Health service utilization, Health insurance, Universal Health coverage, Enrollment to health insurance program, Nepal


Introduction: Nepal initiated the Health Insurance program in 2016 to achieve Universal Health Coverage by 2030. However, the enrollment rate is low, and people are already starting to drop out. Therefore, this study aimed to explore the demand and supply side (service providers) experiences with Nepal's National Health Insurance Program and its effect on insurance enrollment and health service utilization.

Methods: We employed a mixed-method design. Ethnographic methods were used to explore the rich holistic insights into people's views and actions. We conducted 14 focus group discussions and 20 key informant interviews, mainly in Kailali and Baglung districts. We used field note-taking and non-participatory observations to recalibrate the data collection tools. We employed the difference-in-difference approach to assess the health insurance program's impact on health service utilization using data from Nepal's national health information system, DHIS-2.

Results and discussions: We found a very intricate connection between demand and supply-side factors affecting the enrollment to the insurance program, its renewal, and health-seeking behavior. Quality of the health services played a central role. Other factors included lack of awareness, geographical accessibility to health facilities, household income, community solidarity, perceived risk of getting an illness, and perceived usefulness of health insurance programs. Regardless, our quantitative analysis showed an increase in patient visits after initiating the program (an average of 9 patients per day in PHCCs and 32 patients per day in hospitals). Service providers reported the increased patient flow and administrative burden without proportionate growth in resources as a significant challenge for providing service under the insurance program. Other challenges included motivation of health service providers and EAs, difficulty making claims, delay in reimbursement, tedious medicine procurement process, and insufficient information about the insurance program.

Conclusion: The effectiveness of the health insurance program inherently relies on the quality of health services. Hence, there should be coordinated efforts to improve the quality of health service delivery along with the insurance program.

Available for download on Saturday, May 20, 2023

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