Pro and cons of social health security program

Published On: July 13, 2019 08:30 PM NPT By: Ruku Pandey

Government health insurance is a universal health insurance policy. It is regarded as a social security (social protection) scheme. This scheme is new in Nepal but its history is almost 135 years old. Germany introduced such a social security program to the world for the first time since 1889. Then, many countries have followed this policy. Universally, the social health insurance policy has some common features. It is contributed by the government, there is no means-tested, adverse selection is not applied, it is for all disregarding the economic status, case, gender, education, profession. The amount of benefits is equal. These all features are complied with by the Nepali health insurance schemes.

Being an M.Phil. student of sociology, I did social inquiry of pro and cons of the Social Health Security Program (health insurance) launched by the government of Nepal and found that there has been no previous objective benchmark of consumer satisfaction relative to the Social Health Security Program.  Prior inquiries into marketing approaches have been primarily left to the industry and the industry has generally found strongly positive comments from consumers.

Positive Aspect of Social Health Security Program (Health insurance)

A recent report says that senior citizens (aged above 70) will get free health insurance services provided by the government of Nepal. Senior citizens will get Rs one hundred thousand worth free health insurance service. The decision was made by a cabinet based on the Health Insurance Act- 2075. The premium of health insurance will be paid by the government itself. According to the government source, there are one million senior citizens at present in Nepal.

Furthermore, previously five members of a family had to pay Rs 2500 per year and Rs 425 R for an additional member of the family members exceed five and accordingly service provider provided health treatment up to Rs 50,000 per year. Now, the system is upgraded. According to the new system, five-member of a family has to pay Rs 3500 per year and for additional member Rs 700 if the family members exceed five. The upgraded service will provide treatment up to Rs 100,000 to a maximum of Rs 200,000.

Those insurance holders do not need to pay directly to the hospital after treatment. Insurance holder just needs to show their card to have the treatment facilities as a contract made by the health insurance Board with the concerned hospital. The concerned hospital gets their payment through concern ministry. Till the month of September/ October 2018 about 12, 36, 458 people were participated in an insurance policy, among them 6, 53, 486 were male and 5, 82, 972 were female.  At the time of preparing this dissertation, I came to know that the government of Nepal had lunch their insurance policies in 36 districts which were started from Kailali district on April 7, 2016

 Drawback of Social Health Security Program (Health insurance)

There is no charm among the citizen on insurance policy lunched by the government of Nepal. According to the data of the health insurance Board, “25 percent of insurance holder did not renew their insurance policy in last year". It is also becoming a big headache for the staff of hospitals or insurance providers to deal with the expectation of the patient. A source from Bir Hospital reported that “It is difficult to cover the cost of operation and admission fee for ISU from the available insurance scheme. The government had offered Rs 50,000 health insurance facilities but insurance seekers are seeking more facilities than the government provided scheme". TikaPaneru of Bir Hospital said, “One operation cost about Rs 18,000. In the case of ICU, it cost more and insurance seeker get annoyed with the hospital authority.

Ramchandra Sharma of Musikot (West of Rukum district) paid Rs 2500 premiums for the government health insurance program with the hope of getting better health service but he did not. He was compelled to buy medicine from a private pharmacy.  He further said, “What is the use of such insurance policy if it does not provide the service?” Similarly, another victim of the same place Chandrakala BC said, “I did big mistake by having insurance policy. I took loan Rs 2500 from my relative to buy insurance policy but I did not get medicine as per the commitment of insurance board so, I was also compelled to buy medicine from a private pharmacy.

While inquiring about the drawback of such system, senior Dr Shusil Pokhrel of Musikot district hospital said, “We have only one staff at the hospital so we are not able to provide 24 hours' facilities to the insurance holder and another patient. We had had a meeting with the members of Musikot Municipality on this topic, very soon we will short out this issue”.

While doing the inquiry, the sales man of the very pharmacy responded that he has no idea about the pricing system. Later on, the authority of that pharmacy said that they made an agreement with the Bharatpur hospital accordingly the pricing was fixed. Bharatpur hospital’s authorized representative further responded that they were not in fault because they are selling medicine as per the rate approved by the Beema Board.

The government health insurance program is the potential to reduce household indebtedness by addressing catastrophic health conditions. The present model of government Health insurance plan works in-contract with networks of hospitals, doctors, pharmacies, and health care providers. Whether households in rural Nepal are able to procure health insurance is still an empirical question. The scheme is ambitious but required for all people. There is a lack of qualified human resource in Health insurance Board. The structure delivery system is not sufficient. Government-owned hospitals are far from villages so that people are not interested to go there. Private hospitals are not included in the schemes. A medical professional working in the private sector also should be included in this sector. There are various areas for improvement. The list of medicine should be increased, a number of health service providers should be increased, and the amount of the benefit also needs to increase. The subsidy to the poor should be based on the poverty card and it should be identified early without any delay. The government needs to hire qualified and experienced human resource working in health insurance Board and train the fresh employees. Awareness of the Social Health Security Program needs to be increased among health insurance. Health insurance should be made compulsory. Its benefit needs to be increased and the premium should be fixed based on the affordability. The service quality of the health / medical / hospital needs to be increased. Priority should be given to the patient having a health insurance policy and all medicine and a surgical treatment needs to be provided. To make the social health insurance Program effective and sustainable all the formal job holders have to contribute a certain percentage of their total salary.

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