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A queue forms outside the local hospital in Tikapur, Nepal. The country’s health insurance program is growing, but patients say the insurance card often leads to worse service. Kalpana Khanal, GPJ Nepal
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Why are Patients Rejecting Nepal’s Free Healthcare?

Nepal

Millions of people have signed up for Nepal’s national health insurance, which offers free service at approved healthcare facilities for an annual premium. But more than 20% are opting not to renew.

TIKAPUR, NEPAL — Parbati Devi Upadhyaya, 42, was collecting food for her cattle when she fell from a tree. She badly injured her back – but Upadhyaya considers herself lucky.

She and her family signed up for Nepal’s government health insurance program when it debuted three years ago.

“If I did not have insurance under this program, I would not have been able to get treatment in time,” she says, adding that her husband works in India and wouldn’t have been able to send funds quickly.

She visited the Tikapur Hospital twice for her back injury, and both visits were free. She has another checkup soon, which will also be free, she says.

More than 2 million people have signed up for Nepal’s health insurance program since it launched in 2016. But not everyone is as pleased with the services as Upadhyaya.

Patients say the government-assigned health facilities that accept the insurance often lack quality service. Others claim that patients who pay cash get faster treatment than those with an insurance card. New data from the Health Insurance Board shows that 24% of the people who were enrolled have now quit the insurance program.

Despite the complaints, Krishna Prasad Acharaya, information officer at the Health Insurance Board, says the health insurance program is increasingly popular and now available in 49 of Nepal’s 77 districts, with eight more districts being added. Acharaya says the government has allocated 6 billion Nepalese rupees ($52 million) to bring all districts under the scope of the health insurance in the 2019-20 fiscal year.

So far, the insured have access to 288 facilities across the country and more than 1,100 prescription drugs, all free of charge, Acharaya says.

To enroll, a family of five, which is considered one unit, pays 2,500 rupees ($22) annually. Larger families pay 425 rupees ($3.75) per additional person. Once enrolled, members receive a health insurance card which guarantees free treatment up to 100,000 rupees (about $883) from designated hospitals and health care centers.

At Tikapur Hospital, in Nepal’s Kailali district, some 450 kilometers (280 miles) from Kathmandu, the waiting room is already crowded by 8 a.m.

Patients queue at the counter for a number. Some, like Bhakta Bahadur Dagaura Tharu, 75, sit on the floor. He’s been waiting for an hour, he says.

“It’s very difficult for senior citizens like me to stand in the line for hours,” he says.

But that’s not the worst part. He says he’s had to wait four or five hours only to find out there wasn’t a doctor in the hospital that day. Once, he waited two days, and the doctor never came.

“When the government made health insurance free for senior citizens, It was a matter of joy for poor senior citizens like me,” he says. But since he enrolled in the program, his list of complaints has grown.

“Staff at the hospital discriminate between those paying in cash and patients with health insurance cards,” he says. “Even if those paying cash and those [with insurance] are in line together, people paying cash would get the ticket to see the doctor first, while we may not get our turns.”

Tharu has received treatment at this hospital six times. It’s been the same each time, he says.

“If we had money, we could have immediately completed the treatment and returned home,” he says.

Prem Bahadur Batala, 47, disagrees.

He was diagnosed with liver disease in April 2016.

“It has been a huge relief,” he says.

He had liver surgery at Bir Hospital in Kathmandu, which required a 16-day hospital stay. He also received a free CT scan, ultrasound and blood tests, along with medication.

He says there’s no doubt he’ll renew his coverage.

Janak Saud, coordinator of the Health Insurance Board for Sudurpashchim province, where Tikapur is located, says Batala’s experience is more common than Tharu’s. People who use the service are much more likely to renew, he says, since many who choose not to renew didn’t use the service during the year.

But in Sudurpashchim province, the dropout rate was higher than the national average: some 40% of policyholders quit the insurance program this year.

Still, the program remains popular, says Basudev Bajgai, public health officer at Tikapur Hospital, Kailali. On an average day, 150 of 300 patients are insurance participants, he says. He acknowledges that the increase in patients has strained the hospital’s manpower, which often leads to long wait times.

Dambar Saud, 65, bought the health insurance last year.

But after a frustrating visit to Tikapur Hopital for abdominal pain, he says he won’t renew.

“It takes a whole day in the hospital if you go there with the insurance card,” he says. “Hospital staff get irritated with patients with health insurance coverage.”

He had a similar experience at Teaching Hospital Koholpur, another participating facility, when his son had typhoid.

“There’s just too much hassle in getting services from a hospital after showing your health insurance identity card,” he says. “I was very upset to wait longer than another patient who paid money for the treatment and got service immediately.”

Bajgai says patients with insurance shouldn’t receive lower quality service, but he admits that those patients require additional paperwork.

Rumors of long lines and poor service for insured patients have spread.

Nabina Saud, 27, not related to Dambar Saud, says she doesn’t want to buy government insurance – even though she has young children.

“Children get ill frequently. But you cannot stay in line with the child in the hospital for a whole day. I hear you get your turn quickly and the treatment becomes easier if you pay cash,” she says.

Acharaya, of the Health Insurance Board, says they are committed to ensuring that people with insurance receive convenient, quality service.

And people like Batala are proof that it’s possible.

“Who knows what’s going to happen tomorrow?” Batala says. “It’s better to have health insurance today.”

No sources in this story are related.

Sagar Ghimire, GPJ, translated this story from Nepali.

Editor’s note: This story was originally published on Dec. 18, 2019.