Social Health Insurance of Nepal also comparison with AB-PMJAY of India

1. Social Health Insurance in Nepal
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DR SONALI SHAH
MDHA 2018
BPKIHS

2. CONTENTS
 Introduction
 Global scenario
 Health insurance in Nepal
 Comparison of health insurance policy of India and Nepal
 Conclusion
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3. Introduction
● Insurance refers to a contractual arrangement in which one
party, i.e. insurance company or the insurer, agrees to
compensate the loss or damage sustained to another party, i.e.
the insured, by paying a definite amount, in exchange for an
adequate consideration called as premium.
● Insurance provides protection against financial losses by
pooling the resources of policyholders.
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4. Types of Insurance
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Insurance
Life Insurance
Group Life
Insurance
Individual life
Insurance
Health Insurance
Group Health
Insurance
Individual Health
Insurance
General
Insurance
Motor, Property,
Marine, Fire

5. Global scenario
● More than half of the world’s 7.3 billion people do not receive all of the
essential services they need. (WHO, 2017)
● About 100 million people are still being pushed into extreme poverty (defined
as living on 1.90 USD or less a day) because they have to pay for health care.
Over 90 % of these occur in LMICs.
● Available data shows that 60.4 percent of current health expenditure was paid
by OOP (World Health Organization, 2016) which is a barrier of UHC.
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6. Global scenario
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7. Scenario in Nepal
● Financial protection is measured through two indicators:
(1) impoverishment
(2) catastrophic health expenditure
● Impoverishment: 1.7% or approximately 473 000 people are being pushed
into poverty because of out-of-pocket health spending
● Catastrophic expenditure on health: 10.7% of people spent more than 10% of
their household's total expenditure on health care
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8. UHC IN SDGs
3.8 Achieve UHC, including financial risk protection, access to quality essential
health-care services and access to safe, effective, quality and affordable
essential medicines and vaccines for all by 2030.
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9. Universal Health coverage
● In response to adverse effects of direct out-of-pocket payments,
the World Health Organization (WHO) is encouraging countries
to move towards universal health coverage(UHC).
● The World Health Organization has identified universal health
coverage (UHC) as a key approach in reducing equity gaps in a
country, and the social health insurance (SHI) has been
recommended as an important strategy toward it.
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10. SHI Contd…
● “Social health insurance (SHI) is a financing mechanism that
is used in a variety of forms in high, middle and low income
countries alike. Insurance as a means of financing typically
involves a defined contribution (premium) linked to a defined
package of benefits for a specific period of time. The risks of
needing health care expenditures are pooled across individuals
who are enrolled in insurance plans or programs.”
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13. 13

14. Objective of SHI
● Achieving universal access through introducing national health
insurance coverage and protecting from health-related poverty.
● Striving for sustainability and solidarity in financing based on
good governance and efficient use of resources.
● Supporting an active role of the state in facilitation, promotion
and extension of national health insurance.
● Equality of treatment and equal access to health services and
Solidarity in financing through risk pooling.
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15. Health Insurance in
Context of Nepal
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16. Historical Perspective
● An early initiative to health insurance in Nepal began from 1976
through United Mission to Nepal (UMN) as Lalitpur Medical
Insurance Scheme in Ashrang, which was later expanded to
other facilities.
● The government funded community-based health insurance
program was initiated in 2003 in two districts and expanded to
additional four districts in 2005/06.
● National Health Insurance Policy was passed by Government of
Nepal in 2014.
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17. National Health Insurance Policy 2014
● National Health Insurance Policy 2014 was implemented after
endorsement by cabinet decision of 25th April 2014 of GoN.
● The main objective of this policy is to ensure universal health
coverage by increasing access to, and utilization of, necessary
quality health services.
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18. ● For emergencies, insurees can access services from any service point without
a referral slip.
● The program is IT-based with enrollment assistants using smart phones.
● Purchaser-Provider Split: SHSDC acts as the service purchaser while
government and listed private hospitals provide the services.
● 928 types of medicines (70 Free essential drugs +25 ayurvedic drugs+833
others) were included in the benefit package in F 2073/74.
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19. ● Premium amounts are subsidized by the Government at specified rates for the
extremely poor, poor or vulnerable.
● Such concessions are based on the identification card issued by Ministry of
Poverty Alleviation and Cooperatives.
● A family identified as impoverished, poor and marginalised get 100%, 75%
and 50% discounts respectively.
● FCHVs get NRS 250 discount in their family contribution
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20. Constitution of Nepal 2014
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In ‘Part Three: Fundamental Rights and Duties
ARTICLE 35 has provision for right to free basic health services under
which following provisions have been made
•Every citizen shall have the right to free basic health services from the State,
and no one shall be deprived of emergency health services
•Every person shall have the right to get information about his or her medical
treatment.
•Every citizen shall have equal access to health services.

21. Social Health Security (Health Insurance)
Program (SHSP)
● The Social Health Security Program (SHSP) is a social
protection program of the Government of Nepal that aims to
enable its citizens to access quality health care services without
placing a financial burden on them.
● In 9th Feb 2015, the ordinance for formation of Social Health
Security Development Committee was passed by Government
of Nepal and Social Health Security Development Committee
was established to implement Social Health Security Program
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22. SHSP Contd…
● In FY 2071/72, the Government of Nepal had announced to roll out SHSP to
three districts (Kailai, Baglung and Illam) but the enrollment process at
Kailali was started only from 25 Chaitra 2072 (07 April 2016) and at
Baglung and Ilam from 15 Asar 2073 (29 June 2016).
● The Social Health Security Program was rolled out to three districts viz.
Kailali, Baglung and Ilam in FY 2072/73.
● The SHI scheme was implemented in 2016 and has reached population
coverage of 5% in the implemented districts in just within a year of
implementation.
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23. Objectives of Social health security program
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 To ensure Universal Health Coverage by increasing access to, and utilization of
necessary quality health services.

24. Need for Social Health Security (Health
Insurance) Program in Nepal
● To improve the health situation of the people of Nepal.
● To increase accessibility to, and equity in, the provision of
health care services by removing financial barriers to the use of
health care services, focusing on the poor and marginalized
● Promote pre-payment and risk pooling mechanisms to mobilize
financial resources for health in an equitable manner;
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25. Contd…
● Encourage output-oriented expenditure in the health sector and
improve the effectiveness, efficiency, accountability and quality
of care in the delivery of health care services.
● Strengthen health systems in an integrated manner; and
● Improve the health seeking behavior of the public through clear
entitlement procedures, awareness raising and behavior change
communication.
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27. Enrollment - earlier
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28. SHSP- Recent Revisions
● From Jestha 1, 2076
● Premium: Rs 3500 / 5 member /year, additional member Rs 700/person (
Max insured sum 200, 000 per household)
● Benefit: Rs 100,000.0 / 5 member /year (Max 20,000 per person)
● Free treatment to older citizen age more than 70 year, up to 1 lakh per year.
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30. Current Status of SHSP in Nepal
By the end of FY 2074/75 (15 July 2017),
● a total of 11,30,575 people have registered in the SHSP Program. This
includes 904,739 new registrations and 225,836 renewals.
● SHSP Program has been launched in 44 districts. The government plan to
launch SHSP in 11 district in first quarter of 2075/76 and remaining 30
districts by end of FY 2075/76.
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S. No. Fiscal Year Male Female Other Total
1 2072/73 5,972 6,647 4 12,623
2 2073/74 107,804 120,277 32 228,113
3 2074/75 533,829 596,633 113 1,130,575
Note: The Total number insured includes new as well as renewals.

31. Benefit package
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NPR 1,00,000 / 5 members /year ;
NPR 20,000 /member / max 200,000 for additional members.
1133 types of
medicines has
been included in
the benefit
package in FY
2075/76. (43
surgical iteams
+25 ayurvedic
drugs+1108
others)

32. Insurance Management Information System (IMIS)
● It has been initiated in Nepal Health insurance Board with the
aim to collect and manage information related to health
insurance program.
● It is based on internet system.
● It provide information related to enrolled members, service
providers, claim for insurance and services provided to
members.
● It consist of features like registration and renewal of insurance.
● In this IMIS, smartphones are used for exchange of information.
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33. Budget allocation
● In this fiscal year (FY 2018/19), the GoN has provided NPR
56.41bn to the Federal Ministry of Health and Population
(FMoHP) out of which NPR 4.2bn (7.4%) was allocated to
provincial governments and NPR 18.15bn (32.2%) allocated to
LGs(local Government).
● Ministry of Finance of GON has allocated 6 billion rupees in
SHSP (2076/77).
● (*1.6 NPR = 1INR)
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34. Comparison of health insurance policy of
India and Nepal
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Social Health Security Programme
(Nepal)
Ayushman Bharat PMJAY (India)
INTRODUCTION The Social Health Security Program
(SHSP) is a social protection program
of the Government of Nepal that aims
to enable its citizens to access quality
health care services without placing a
financial burden on them.
Under the ambit of Ayushman Bharat,
a Pradhan Mantri Jan Arogya Yojana
(PM-JAY) to reduce the financial
burden on poor and vulnerable groups
arising out of catastrophic hospital
episodes and ensure their access to
quality health services was conceived.
PM-JAY seeks to accelerate India’s
progress towards achievement of
Universal Health Coverage (UHC) and
Sustainable Development Goal - 3
(SDG3).

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SHSP PMJAY
LAUNCHED 25th April 2014 by GoN 23rd September 2018 by
Prime Minister.
COVERAGE 5lakh thirty thousand
families
11lakh citizens
10 crore families approx
HOSPITALS 300 15,909
DISTRICTS/STAT
ES
44 out of 77 districts All states except 4 states
Telangana,Odisha,Andhra
Pradesh,Delhi

36. SHSP PMJAY
BASIC PRINCIPLE Risk pooling by family contribution Government will bear expenses of
healthcare for poor families
FAMILY SIZE Family members of 5. Additional
premium has to be given for extra
family member.
No capping of family size.
PREMIUM NRS 3500/ 5 members of a family per
year
NRS 700/extra family member
No premium required. It is entitlement
based.
BENEFITS Covers insurance of 1lakh/5members
NRS20,000 per extra member of family
Max 2lakh
Covers insurance of INR 5lakh per family
per year
PORTABILITY Insure has to choose nearest health
facility as first point of care (PHCCs).
For tertiary care they have to be
referred from first point except in
emergency cases .
All across India in all empanelled
hospitals.
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37. SHSP PMJAY
ELIGIBILITY All citizens of Nepal are eligible
under this security programme.
They are entitles according to SECC
data of 2011 .
LEVEL OF CARE Primary ,secondary and tertiary
care services provided.
Secondary and tertiary care services
are provided.
PACKAGES
GOVERNANCE Ministry of Health Ministry of Health and Family
welfare
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