While candidates are reaching out to the door with promises and promises, the health insurance program is on the verge of being shut down. The program itself is in crisis after 14 billion rupees of treatment could not be paid. The parties have not come up with any concept to sustain and expand this program, which covers one-third of the country's population.

Health Minister Dr. Sudha Sharma also said that the insurance program is on the verge of being closed. In a discussion held on Wednesday, she told Prime Minister Sushila Karki and Finance Secretary Ghanshyam Upadhyay, ‘If there is no budget of 14 billion immediately, the health insurance program will be closed. If the Finance Ministry cannot provide the funds, permission should be given to close the program.’ 

On the other hand, the Finance Ministry has also given a clear message that the funds cannot be released. ‘We have already provided 10 billion this year, additional budget cannot be provided, we need to find ways to improve the operation of the insurance program, the insurance program has not become like insurance,’ Finance Secretary Upadhyay replied.

The constitution states that ‘every citizen shall have the right to receive basic health services free of charge from the state’ by placing the right to health under a fundamental right. The health insurance program, which was implemented in phases to implement that provision, has collapsed in a short time.

Currently, the Health Insurance Board has yet to pay about 14 billion for treatment under the insurance to 510 hospitals. The hospital has started closing the facilities under the insurance program, saying that the Health Insurance Board has not paid for a long time. 

Raghunath Kafle, the executive director of the Health Insurance Board, resigned in the first week of last Magh after a disagreement with the government and the Health Minister over the issue of payment to the hospital. He complained that the government itself was not cooperating with the insurance program and that the Health and Finance Ministries were neglecting to provide grants to the board. 

Before resigning, Kafle had put forward the options of the government providing adequate grants or increasing the premium fees charged by the insured or cutting services and making administrative reforms in the board.

The board's annual budget has reached about 26.59 billion rupees. Last fiscal year, the board had a liability of 23 billion rupees in health insurance. Only 4.5 billion was collected from insurance premiums. In addition to insurance payments, the money is spent on office operations and employee salary facilities across the country. 

The government had been providing grants of 7 to 10 billion rupees annually until 2080/081. The board has already spent an additional Rs 1 billion after the Rs 10 billion allocated for the current fiscal year. But there are Rs 14 billion left. At one time, the arrears to be paid to hospitals had reached Rs 26 billion.

According to the board's information officer, Rs 6.5 billion has yet to be paid to hospitals until Asoj and around Rs 7.5 billion for Kartik, Mangsir and Poush. The board's financial liability for providing treatment to the insured increases by Rs 2.5 billion per month. An additional budget of Rs 15 billion is required from Magh to mid-Asard.

The Health Insurance Board has stated that it has decided to tighten the amount of treatment services to make the insurance program sustainable. An additional service facility of Rs 25,000 per family (maximum 5 people) and Rs 5,000 for each additional member has been fixed for treatment in OPD.

‘The limit has now been set to control the excess tests done by patients in OPD and the unnecessary tests done by hospitals,’ says Krishna Prasad Poudel, Executive Director of the Board. ‘Even though the limit of 25 thousand has been set in OPD, patients can get health treatment facilities of up to 100,000 through admission or emergency services as before.’ He also said that they are looking for a solution to the Board’s financial problems. 

According to the Board, 71 percent of the insured patients go to the hospital to get services in OPD, and they spend 22 to 23 thousand rupees per family annually while consuming health services.

An employee said that the Board, which has been struggling due to the imbalance between income and expenditure, is now in a state of crisis. ‘If the government does not provide subsidies, the insurance program cannot run. Either the premium fee has to be increased or the health services received by the insured have to be reduced. There is no other option,’ he said.

98 lakh 74 thousand 415 people are affiliated with the insurance program. This number is 33 percent of the total population. However, only 59 lakh 27 thousand 836 people are insured. 1 million 95 thousand households affiliated with the insurance pay an annual premium of 3500. 16 lakh 17 thousand 85 households belong to the target group, they are affiliated with free insurance. The government has arranged free insurance for senior citizens, extremely poor, disabled, handicapped, women health volunteers, leprosy patients, HIV, cancer and other complex diseases. 

According to the board's data, 93 percent of those who pay the insurance fee come to the hospital for services. Officials say that the number of target groups receiving concessions in premium fees is increasing and the board is in financial crisis due to limited government subsidies. 

Of those who receive services, 71 percent are OPD patients, 10 are emergency patients and 19 percent are admitted patients.

510 hospitals across the country are affiliated with the health insurance program. 68 percent of the amount spent on health insurance goes to 441 government hospitals. The board has details that 25 percent of the amount goes to 39 private hospitals and 7 percent to 30 community hospitals. 

Hospitals are increasingly stopping the health insurance program due to delays in payment. On 1st Magh alone, the teaching hospital, Maharajgunj, stopped the service. According to the hospital, about 400 million rupees of insurance payment is pending. 

Dr. Subash Acharya, executive director of the teaching hospital, said that the monthly health insurance expenses had reached 45 million to 50 million rupees, but the board was paying only 25 million rupees, so the program had to be stopped. ‘Despite repeatedly asking the Health Insurance Board about this, the problem was not resolved,’ he said, ‘How can health insurance be operated with a monthly loss of more than 20 million rupees?’ After the service in the teaching hospital was stopped, the board has been suggesting patients who come in contact to go to Bir or Patan Hospital. 

Balaram Malla, medical director of Dhulikhel Hospital, said that it is difficult for a hospital that earns money every day and spends on the treatment of patients to operate health insurance-related services. "70 to 80 percent of patients who come to the hospital are insured. Most of the insured patients cannot afford to go to big hospitals, so the pressure has increased," he said, "But the insurance board does not pay the treatment expenses on time. This can affect the quality of health care." Malla, Medical Director of Dhulikhel Hospital, mentioned that although there is a provision that the hospital must claim the insurance amount within 24 hours of the completion of treatment, the board delays payment for up to 6 months.

There is a provision for insured members to receive services from designated government health institutions as the first service point. If they cannot receive treatment there, there is a provision for them to be referred with a referral document and receive services from government, private and community service providers that have agreements with the Insurance Board. "But patients do not receive services at the first service point. There is no state-of-the-art health equipment, skilled health workers and necessary medicines. That is why there is a pressure on patients in big hospitals. The fees charged in big and small hospitals are the same," Malla, Medical Director of Dhulikhel, said.

Former executive director of the board, Kafle, says that the board needs to be strengthened in terms of finances as well as institutional, good governance and internal administration. ‘The number of people taking health insurance has increased significantly. As the number of people receiving treatment increases, the expenses also increase, but the government sets a limit on the treatment expenses,’ he says. ‘The health insurance program will not last long by ensuring resources through government grants or by ensuring resources on its own.’

Kafle says that resources will be ensured only if the common citizen can be connected to health insurance. ‘Currently, only those who need treatment are insured,’ he says. ‘The program will be sustainable only if healthy citizens, all civil servants and people in the organized sector are connected.’ He says that Section 3 of the Health Insurance Act 2074 BS provides for the association of every citizen, including employees.

Kafle also complains that the Ministry of Health, which is supposed to regulate and control hospitals, is trying to interfere with the board. ‘There is a situation where we have to work with a small number of employees on contract. "The board itself is weak, so monitoring and action have not been taken," he says. "There have been irregularities such as hospitals claiming insurance claims."  

Former chairman of the board, Dr. Gunaraj Lohani, says that the insurance program has collapsed and is no longer operational due to not working according to the spirit of the act. He argues that the health insurance program is in crisis due to the government and vested interests. "Health insurance was started on the model of taking money from those who have income, including people in the formal sector (employees, teachers, police, army, laborers), and treating those who do not have money," he says. "So far, the provisions of the act to include people in the formal sector in compulsory insurance have not been implemented. The poor, the poor, and those who are backward in education have not been able to join the insurance. Insurance has fallen into the hands of those with access. It has only been a matter of taking treatment services worth 100,000 to pay 3500, which does not always work this way."

Dr. Lohani concludes that the board has been in even more trouble after the Social Security Fund introduced the health insurance program. ‘People in the formal sector who have regular incomes have started receiving health insurance services from the Social Security Fund,’ he says, ‘Only by involving people in the formal sector in the health insurance program and operating it without taking subsidies from the government can it be sustainable and effective. This program can only move forward if it is based on social justice and contribution, it is not always possible to get subsidies from the government.’ 

Dr. Lohani says that the cost has also increased because some hospitals aim to make a profit from the insurance program. ‘The government has been found to be weak in implementing the health insurance program. Even when an insured patient goes to the hospital with a headache, there is a tendency to charge multiple fees and prepare a bill of 1 lakh,’ he says.

There is a system based on family contributions so that all family members participate in the insurance program. According to this, a family of up to 5 people must pay a contribution of 3,500 per year. If there are more than 5 people, there is a system where the amount is increased by 700 per member and treatment services up to 1 lakh are provided. After the insured member pays the contribution once and the service becomes active, he will receive treatment services according to the limit of the facility bag throughout the year. There is a provision to give 100 percent discount on the contribution amount to the families of the target group and 50 percent discount to the families of female health volunteers. The target group that will get 100 percent discount includes senior citizens (70 years of age and above), families with identity cards of the very poor, the very disabled, the disabled, lepers, HIV infected and complex tuberculosis patients.

Malla, Medical Director of Dhulikhel Hospital, says that the health insurance program has not reached the group that needs insurance. He says that the low number of insured people in backward provinces including Madhesh, Karnali and Sudurpaschim confirms this. ‘There is a risk of the program failing if the target group is not identified. Currently, only those who have access have taken the service,’ he says. 

According to the board, the health insurance program has been expanded to 750 local levels. Of these, first service centers have been designated for treatment in 382 local levels.   According to the board, only 21 percent of the active population across the country is affiliated with health insurance. The lowest number of active citizens is 8 percent in Madhesh and the highest is 36 percent in Gandaki Province. Only 12 percent of active citizens in Sudurpaschim Province, 14 percent in Karnali, and 15 percent in Lumbini have health insurance. 27 percent in Bagmati and 35 percent in Koshi are participating in insurance.

The government had announced in the fiscal year 2080/081 that it would extend the health insurance program to 50 percent of households. But now only 33 percent of households across the country are covered by health insurance. 22 percent of households in Madhesh, 24 percent in Karnali, 26 percent in Sudurpaschim, and 27 percent in Lumbini are participating in health insurance. Despite the insurance program being launched to increase access to quality health services for the poor and disadvantaged, Madhesh, Karnali, Sudurpaschim, and Lumbini lag behind the national average. 49 percent of households in Gandaki, 48 percent in Koshi, and 34 percent in Bagmati are covered by the program. 

बोर्डका अनुसार स्वास्थ्य बिमा कार्यक्रम ७ सय ५० स्थानीय तहमा विस्तार भएको छ । तीमध्ये ३ सय ८२ स्थानीय तहमा उपचारका लागि पहिलो सेवा केन्द्र तोकिएका छन् । १२ सय ८९ किसिमका औषधि बिमामार्फत दिने भनिएको छ । तीमध्ये ४ सय प्रकारका औषधि बढी प्रयोग हुनेमा पर्छन् । 

सरकारले चैत ०७२ मा इलाम, बागलुङ र कैलालीबाट स्वास्थ्य बिमा कार्यक्रम सुरु गरेको थियो । यसलाई क्रमैसँग विस्तार गर्दै ०७९ मा ७७ वटै जिल्लामा पुर्‍याएको थियो । 

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ऋण खोजेर भए पनि नागरिकको स्वास्थ्य बिमा गर्नुपर्छ : प्रधानमन्त्री कार्की 

प्रधानमन्त्री सुशीला कार्कीले स्वास्थ्य बिमा कार्यक्रमलाई जसरी भए पनि निरन्तरता दिनुपर्ने बताएकी छन् । स्वास्थ्य बिमा बोर्डसँग बुधबार भएको छलफलमा उनले निमुखा नागरिकको स्वास्थ्य उपचार गर्ने दायित्व सरकारको भएकाले ऋण खोजेर भए पनि निरन्तरता दिनुपर्ने उल्लेख गरिन् ।

प्रधानमन्त्री कार्कीले अर्थमन्त्रीसँग समेत छलफल गरेर निकास निकाल्नुपर्ने बताइन् । काठमाडौं बाहिर रहेका अर्थमन्त्री रामेश्वर खनाल फर्केलगत्तै छलफल गर्ने उनले जानकारी दिइन् । ‘अनिकाल लागे बालबच्चाको मुन्द्रा (गहना), भाँडाकुँडा बेचेर पनि अनिकाल टार्नुपर्छ,’ उनले भनिन्, ‘स्वास्थ्य बिमा पनि त्यस्तै भएको छ । यसमा अनियमितता भएको पनि सुनेको छु । स्वास्थ्य बिमा कसैलाई व्यापार, कसैलाई अपार हुनु हँॅदैन । निमुखाले निःशुल्क सुविधा पाउने व्यवस्था पनि गर्नुपर्छ ।’

प्रधानमन्त्री कार्कीले स्वास्थ्य बिमामा देखिएका कमीकमजोरी हटाउन एकद्वार प्रणालीबाट सेवा सञ्चालनको व्यवस्था गर्न निर्देशन दिएकी छन् । ‘बिमा भनेपछि बिमा जस्तो पनि हुनुपर्छ । त्यो कसरी बनाउने हो, स्वास्थ्य मन्त्रालयले हेर्नुपर्छ,’ उनले भनिन्, ‘सरकारी अस्पतालमा निःशुल्क औषधि बाँडेर, सडेर खेर जान्छ । उता बिमा बिरामीले औषधि पाउँदैनन् । यस्तो अवस्था अन्त्य हुनुपर्छ ।’ 

स्वास्थ्य तथा जनसंख्यामन्त्री डा. सुधा शर्माले सरकारले बजेट व्यवस्था नगरे स्वास्थ्य बिमा कार्यक्रम बन्द हुन सक्ने बताइन् । ‘बजेटमा गत वर्षको बक्यौता तिर्न ११ अर्ब दिने भनियो । थप १० अर्ब दिन्छौं भनियो,’ उनले भनिन्, ‘११ अर्बले गत आर्थिक वर्षको बक्यौता भुक्तानी भयो । यो वर्षका लागि बजेट नै आएन । तत्काल १४/१५ अर्ब बजेट नभए स्वास्थ्य बिमा कार्यक्रम बन्द हुन्छ ।’ अर्थ मन्त्रालयले रकम दिन नसक्ने भए स्वास्थ्य बिमा कार्यक्रम बन्द गर्न अनुमति दिनुपर्ने उनको भनाइ थियो । 

अर्थ सचिव घनश्याम उपाध्यायले स्वास्थ्य बिमा कार्यक्रममा व्यापक सुधार आवश्यकता रहेको बताए । स्वास्थ्य मन्त्रालयले बजेट निर्माणमा स्वास्थ्य बिमालाई महत्त्व नदिँदा अहिलेको अवस्था आएको टिप्पणी पनि उनले गरे । ‘लोकप्रिय निर्णय गर्ने अर्थ मन्त्रालयलाई जानकारी नदिने, बिमा भन्ने तर बिमाको सिद्धान्तअनुसार नचल्ने हुँदै आएको छ,’ उनले भने, ‘स्वास्थ्य बिमा कार्यक्रममा स्वास्थ्य मन्त्रालयले व्यापक सुधार गर्नुपर्छ ।’ स्वास्थ्य मन्त्रालयलाई चालु आर्थिक वर्षका लागि छुट्याएको बजेटबाटै बिमाको खर्च व्यवस्थापन गर्नुपर्ने उनको भनाइ थियो । 

स्वास्थ्यमन्त्री डा. शर्मा भने स्वास्थ्य मन्त्रालयको बजेटबाट ७० करोड रुपैयाँ मात्रै व्यवस्था गर्न सकिने बताउँछिन् । ‘त्यही बजेट रकमान्तर गर्न अर्थ मन्त्रालयमा प्रस्ताव लगिए पनि रोकिएको छ,’ उनी भन्छिन्, ‘स्वास्थ्य बिमा कार्यक्रम जटिल अवस्थामा पुगेको छ । अहिले सुझावले चल्दैन । बजेट चाहिएको छ । अर्थ मन्त्रालयले झुक्यायो भन्ने गुनासो स्वास्थ्य मन्त्रालयको रहेको छ ।’ 

स्रोत सुनिश्चित नगरी खर्च गरेर बोर्डले अपरिपक्व काम गरे पनि बिमाको रकम नागरिकको स्वास्थ्य उपचारमा खर्च भएको स्वास्थ्यमन्त्री शर्माको भनाइ छ । स्वास्थ्य बिमाका सबै कार्यक्रमलाई स्वास्थ्य बिमा बोर्डको कार्यक्रमभित्र ल्याउन, सबै नागरिक र राष्ट्रसेवकलाई बिमामा आबद्ध गर्न सहयोगका लागि उनले प्रधानमन्त्री र अर्थ मन्त्रालयसँग आग्रह गरिन् ।

नीतिमा समस्या औंल्याउँछन् पूर्वस्वास्थ्यमन्त्री

  पूर्वस्वास्थ्यमन्त्री तथा कांग्रेस महामन्त्री प्रदीप पौडेल स्वास्थ्य बिमामा नीतिगत सुधारको खाँचो रहेको बताउँछन् । ‘म स्वास्थ्यमन्त्री भएको बेला नीतिगत रूपमै सुधार गर्न प्रयास भएको थियो । सुधारको दस्तावेज बनाएर कार्यान्वयनको अन्तिम चरणमा पुग्दै गर्दा सरकार र संसद् विघटन भएर रोकियो,’ उनी भन्छन् । स्वास्थ्य बिमा कार्यक्रमबाट मात्रै आमनागरिकलाई सस्तो, सर्वसुलभ र विशेषज्ञ सुविधा दिन सकिने पौडेलको भनाइ छ । ‘यो कांग्रेस र मेरो पनि एजेन्डा हो,’ उनी भन्छन्, ‘यो विषय चुनावी घोषणापत्रमा पनि आउँछ । बिमा कार्यक्रमलाई व्यवस्थित गर्छौं ।’ 

सरकारले अनुदान रोकेर वैकल्पिक उपाय खोज्नुपर्ने पूर्वस्वास्थ्यमन्त्री पौडेल बताउँछन् । ‘स्वास्थ्य बिमा ऐनमा निजामती कर्मचारीसहित संगठित क्षेत्रमा सबैलाई बिमामा आबद्ध गर्ने भनिएको छ । सबैले आम्दानीको १ प्रतिशत बिमा रकम जम्मा गर्ने, सरकारले १ प्रतिशत थप गर्ने हो भने स्रोत सुनिश्चित हुन्छ,’ उनी भन्छन्, ‘नागरिकको योगदानमा आधारित बिमा प्रणाली लागू गर्न कांग्रेस प्रतिबद्ध छ । चुनाव जितेर आएपछि यो व्यवस्था गर्छौं ।’

एमाले नेता एवं पूर्वस्वास्थ्यमन्त्री पदम गिरी स्वास्थ्य बिमा सञ्चालनको नीति नै परिवर्तन गर्नुपर्ने बताउँछन् । नीति परिवर्तन गर्न लागे पनि आफ्नो कार्यकाल छोटो भएकाले नसकेको उनको भनाइ छ । ‘अहिले कार्यक्रम नै फेल गराउन खोजिएको छ । बजेट नदिने र बिरामीले उपचार नपाउने अवस्था छ । यसको अन्त्य तत्काल गर्नुपर्छ,’ उनी भन्छन् । 

स्वास्थ्य बिमा कार्यक्रमको विकल्प नभएकाले नयाँ ढंगबाट सञ्चालन गर्नॅपर्ने गिरी बताउँछन् । ‘सार्वजनिक स्वास्थ्य र शिक्षा सुधार एमालेको प्रमुख एजेन्डा हो । स्वास्थ्य बिमाबाट मात्रै गुणस्तरीय स्वास्थ्य सेवा दिन सकिन्छ,’ उनी भन्छन्, ‘यस विषयमा पार्टीले पनि आफ्नो धारणा राख्छ, घोषणापत्रमा पनि ल्याउँछ । चुनाव जितेर आएपछि लागू गर्छौं ।’