Last week, Sanu Maiya Dhakal, a resident of Sundarijal, Kathmandu, went to Jorpati-based Nepal Medical College after developing severe back pain.

She chose it because it is the referral hospital under the health insurance scheme for which she had paid premiums about eight months earlier.

The hospital, however, denied outpatient services under the health insurance scheme, following the government’s decision to discontinue outpatient care at private hospitals.

“I waited hours for a ticket and a few hours to see a doctor at Bir Hospital,” complained Dhakal, who is 38. “The doctor asked me to come with a Magnetic Resonance Imaging (MRI) report immediately, but I am told that I have to wait until September to get it done in the hospital.”

The pain was so severe that it was radiating down, causing weakness in the leg and the ankle. Dhakal was warned by the doctor that she could suffer from paralysis if the treatment was delayed. She underwent an MRI scan at a private facility, paying Rs18,000, which is two times the cost at Bir Hospital. The report showed that she had a lumbar spine problem in which a spinal disc or bone may be pressing on a nerve root.

Emergency surgery was carried out at the Bir Hospital to release the struck nerves. Dhakal was asked to arrange medicine worth Rs40,000 for surgery. Her family thought that they had insurance, so that they would not have to pay for them, but they got medicine only for Rs3,500 from the hospital pharmacy, which lacked most medicines provided under the health insurance scheme.

This has become a common refrain among thousands of people across the country affected by the government’s decision to halt the out-patient care under the health insurance scheme at private hospitals and medical colleges, going back on the commitment made at the time of selling premium months ago.

Patients who had paid premiums in the hope of getting insurance coverage or those from poor and marginalised groups, who were covered by insurance, have lately been forced to seek care at private hospitals and pay exorbitant fees even after approaching state-run hospitals.

Had the government not stopped out-patient care at private centres, Dhakal would not have to wait hours at Bir Hospital for tickets and meet doctors, would not have to pay exorbitant prices for MRI and around 36,000 out of pocket for medicines.

Thirty-three-year-old Ashmita Neupane from Narayantar, Jorpati suffered from severe headaches over a long period of time. She thought that it was a migraine and did not seek treatment. When she started having blurred vision, she went to the Tilganga Eye Hospital at Gaushala for treatment. An ophthalmologist asked her to bring an MRI report at the earliest, as they sensed that she may have had a swollen vein of the brain, which could also burst and endanger her life. Neupane first sought MRI scanning at the Tribhuvan University Teaching Hospital and then at Bir Hospital, as there is no MRI service at the Tilganga Hospital.

“Due to months-long queues in both state-run hospitals, I could not get the service and was forced to go to a private hospital,” she said. “I was forced to pay an excessive amount in private for service.”

The government first lowered the ceiling for outpatient services to Rs25,000 for patients and their family members from Rs100,000 and now has halted outpatient care at private hospitals under the health insurance scheme, citing a growing financial burden.

Prior to this, major hospitals in the country, including Tribhuvan University Teaching Hospital, Manmohan Cardiothoracic Vascular & Transplant Centre, and several medical colleges, halted services under the government health insurance scheme, as they were not reimbursed for the services they had provided to patients. Thousands of patients from across the country use to see services in those hospitals.

Even state-run hospitals—Bir Hospital and others, which have been operating with grants from the government and others—and Shahid Gangalal National Heart Centre, which also receives some government funding, have been providing only partial services to patients under the health insurance scheme.

Officials say that halting service at the private hospitals is not a choice but a forced measure to reduce the financial burden. They say that around eight percent of patients receive health insurance service from private hospitals but 40 percent of total bill claims are from private hospitals.

“The decision to stop out-patient care is taken by the board meeting,” said Bikesh Malla, information officer at the Health Insurance Board. “The decision aims to ease the growing financial crisis faced by the board.”

When asked why patients are forced to seek services at private centres even after reaching state-run hospitals, why services do not resume at state-run hospitals and why all medicines and medical devices are not made available at the pharmacies of state-run hospitals, officials say the decision is made from higher authority and the board is in serious financial crisis.

Experts say that reneging on commitments made while selling premium, forcing patients to run from one hospital to another and compelling them to pay out of their own pocket is betrayal from the government side.

“This is betrayal and unjust to the patients, who were lured to health insurance policy,” said Dr Senendra Upreti, former chief of the Health Insurance Board. “As I am not on the board currently, ask the board officials what they are doing.”

Patients who bought the government’s health insurance policy lodged complaints at the board that they are being discriminated against by hospitals in treatment, made to wait in long queues, given surgery dates months later, and forced to pay for lab services and medicines that are supposed to be covered by the scheme.

“Have the capacities of state-run health facilities been boosted significantly so the government decides to halt services at private centres?” questioned Dr Sarad Onta, a public health expert. “And how would the government incur an additional burden by accessing services of private centres when the same amount is paid to both kinds of hospitals?”

Experts say commitment to universal health coverage will not be achieved by refraining from commitments and responsibilities and betraying citizens. They reason that if there are irregularities in the bill claim and reimbursement of private hospitals’ costs, it is a problem of management at the Health Insurance Board, not of patients.

Officials say the board said that the board owes hospitals Rs18 billion for health care services provided under the government health insurance scheme until mid-May. Additional liabilities of around Rs20 million are accruing each day.

The health insurance scheme is the government’s priority programme aimed at ensuring universal health coverage. However, it has been mired in financial problems and has almost collapsed.

With the government lowering the ceiling for outpatient services, the renewal rate of the health insurance scheme has declined to around 50 percent. Officials say they do not worry about the declining renewal rate, as it reduces the burden.

Officials had hoped that problems with the health insurance scheme would be resolved once the new government was formed, but the problems remain as they are. Instead, many hospitals and medical colleges stopped providing services under the programme after the new government took charge.

A family of up to five members pays Rs3,500 for treatment, including medicines, check-ups, and counselling, under the original scheme. As per the rule, 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.