Nepal has endured significant political changes in the last three decades, with a decade-long conflict and a movement towards a federal republic being the major highlights. The problems presented by a difficult topography and slow economic development have been further exacerbated by the long-term instability brought about by recent political changes. Despite these challenges, Nepal has still managed to cover significant ground in reaching health targets. However, these achievements have been continuously hampered by unforeseen difficulties like the 2015 earthquake, frequent flooding and landslides, and the months long economic blockade by India.

Nepal has one of the highest proportions of out of pocket expenditure on health and around 25 percent of the people are still living below the poverty line. There has been a slight increase in the proportion allocated for the health budget but the country still relies on the funding support of development partners. The Ministry of Health and Population (MoHP) and other partners have been working continuously to develop various modalities of universal health coverage for the people of Nepal.

This endeavour finally bore concrete results on October 11, when Parliament endorsed the first Health Insurance Bill. This legislation has enabled the government to establish the national health insurance scheme to ensure health coverage for every citizen. The Bill has also ensured that the government will fund those who cannot afford prepayment of the premium required for insurance while the rest of the citizens have to pay the minimum premium to the national health insurance scheme themselves. This Bill is the first step towards establishing a national health insurance mechanism in the country. We are confident that the MoHP will establish the scheme with adequate policies, strategies and mechanisms for its successful implementation; however, there are a number of possible challenges during establishment, initiation and implementation.

Governance and Management

• There will be a significant challenge in ensuring the mechanism for implementation, operationalization and management of the insurance scheme in the context of federal states. This can be aligned with the government’s efforts to devolve national structures for the federal states.
• Another challenge is to formulate a mechanism to identify vulnerable groups who cannot pay the premium for the insurance. The country lacks a real-time database of household income. There is a need to develop this database in collaboration with the central bureau of statistics.
• Ensuring adequate capacities and mechanisms for timely management of the reimbursement or payment of the services is essential for its sustainability. Without this, the operationalization of the scheme would be hampered.
• The government has to establish a well delineated service delivery mechanism for both public and private sectors. Developing standards of service delivery and price tagging are essential to ensure equity on service delivery.

People centred service delivery 

• Clear procedures of referral mechanism should be in place from the beginning and the government has to prioritise and ensure adequate funding for primary health centres in order to ensure preventive and promotive services. 
• Medicine policies and practices under the scheme should be clarified upfront to address the concerns of equity regarding the` access to drugs and their quality. The scheme should have universal standard price tags for all essential drugs at every point of service delivery.
• Partnering not only with private sectors but also with various local institutions like civil societies to expand access to health services.

Ensuring adequate financing

• The health budget is still dependent on donor contribution and the implementation of the national health insurance scheme will further burden the health budget. Regular advocacy for increasing the health budget and widening of the tax and social security nets could be possible options.
• Ensure adequate funding in the initial phase due to a rapid surge of people seeking healthcare with the implementation of the new system. When the public knows that the health services are provided by scheme, there will be increased tendency of the population to visit health facilities. The positive aspect here is that people with chronic illnesses who have never visited health facilities will start seeking care. The other side of the coin is that some groups of people will visit with complaints to collect free medicine. 

Equity

• Ensuring an infrastructure strengthening plan for equitable and accessible quality healthcare services is paramount in the context of the difficult terrain in Nepal.
• Mechanisms to address the health seeking behaviour of the population, which is often delayed due to traditional beliefs especially in rural and sub-urban settings. Promotional activities and penalty mechanisms should be in place to incentivise people to come to healthcare centres. 

Ensuring preparedness for emergencies

• Any devastating epidemics, such as Ebola, Influenza, Zika etc. could be potential impediments to achieving goals of universal health coverage and can cost health insurance schemes more than expected. Thus it is essential to have adequate preparedness and response capacities that can be ensured during outbreaks, epidemics and pandemics.
• Many countries are implementing a national health insurance mechanism, some of which are extremely similar to our recently endorsed Bill. Therefore, it is imperative to thoroughly analyse and review the lessons learned from these countries during the development of mechanisms and procedures to ensure the effectiveness of the national health insurance scheme. Sustainability of health coverage is the major challenge to maintaining health achievements, and moving towards achieving sustainable development goals and economic development. 

[email protected], Kandel is a public health physician based in Geneva