Prime Minister Sushila Karki has expressed concern over a funding shortfall in the national health insurance programme, which provides coverage to over 10 million people or nearly one-third of Nepal’s population.

Summoning Minister for Health and Population, Dr Sudha Gautam and senior officials, Karki said that hundreds of thousands of people who cannot afford to pay out of pocket for health care would be deprived of treatment if the health insurance programme is stopped.

“As the prime minister showed concerns about problems with the health insurance programme by summoning the minister and senior health officials to her office, we hope that the government will provide funds to clear all outstanding dues,” said Bikesh Malla, information officer at the Health Insurance Board. “The prime minister also asked us to take steps to sustain the programme.”

Some hospitals, including the Tribhuvan University Teaching Hospital, have stopped providing services under the government’s health insurance scheme since January 15. Several others have warned that they will be forced to stop services if long-overdue payments are not reimbursed immediately.

Every day, hundreds of patients who arrive at the hospital for treatment with a health insurance card either return without receiving care or are required to pay hospital charges, just like patients without insurance coverage.

The TU Teaching Hospital administration cited overdue payments of around Rs400 million, rejected claims, and low service rates as major issues. According to officials, around 50 percent of the hospital’s claims were not approved by the board, so the hospital lost over Rs20 million every month.

Moreover, most hospitals providing services under the health insurance scheme have warned they will be forced to discontinue services if dues are not cleared immediately.

Officials at the board said all government funds allocated for health insurance and premiums collected from the public have already been paid to health facilities. Altogether, Rs14 billion had been paid by December. This included Rs11 billion from the Ministry of Health and over Rs3 billion collected in premiums from the public.

The board needs to pay an additional Rs10.5 billion in dues to over 500 health facilities, including the TU Teaching Hospital. Officials said this shortfall is due to a funding crunch, not intentional delays. On average, about 50,000 people use services each day, and over 10 million people are covered by health insurance.

Officials at the board said the government had committed to providing funds to clear the remaining dues in the budget speech, but the funds have not yet been released.

“Apart from the Rs11 billion budget, the government has also committed to paying outstanding dues of the hospital,” said Malla. “If the government provides the funds, ongoing problems will be sorted out, and patients of insured families need not be worried about the treatment cost.”

Malla added that Prime Minister Karki did not give any order to withhold the decision to set a ceiling on outpatient care, which has been reduced to Rs 25,000.

As per the Board’s new decision, outpatient services will be covered only up to Rs25,000 per patient or the same amount may be used collectively by up to four members of an insured family. Previously, patients could access services worth up to Rs100,000, covering outpatient, inpatient, and emergency care.

The decision will be implemented on February 13.

Officials say the new decision to lower the ceiling for outpatient care is in line with an expert panel's recommendation. The Health Ministry has also asked the board to limit expenses to around Rs14 billion, and the new decision to set a ceiling in outpatient care is in line with the ministry’s direction, they say.

Experts, however, say the decision to limit outpatient care contradicts the health insurance policy and could affect policy renewal.

Under the original scheme, a family of up to five members pays Rs3,500 for treatment, including medicines, check-ups, and counselling. One family member can use the insurance coverage worth Rs100,000 per year, or the amount can be divided among five members. Families with more than five members pay Rs700 per additional member for an extra Rs20,000 in health insurance coverage.

People covered by the insurance can access healthcare services at designated facilities by presenting their identity cards. Expenses incurred by health facilities are reimbursed by the Health Insurance Board.

For patients of chronic diseases, the government provides Rs200,000 in insurance coverage, and as of this fiscal year, the board has paid over Rs50 million, officials said.

The government also covers premiums for certain groups—those living below the poverty line in 26 districts, those above 70 years, family members of people living with HIV, disabled people, and those suffering from leprosy and multi-drug resistant tuberculosis.

Currently, the government pays the insurance premiums for around 55 percent of people enrolled in the scheme.