Journal of Nepal Public Health Association (JNEPHA) Perspective

Nepal’s Health Insurance: Perspective on Health System

Strengthening
Sudarshan Paudel1, Sushmita Ghimire1, Deepak Kumar Karki2
1 2
School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal, Nepal Health Economics Association, Kathmandu,
Nepal (dekarki@gmail.com)

*Correspondence: sudarshanpaudel@pahs.edu.np

ABSTRACT

Health insurance, as one of the health financing mechanisms, has been adopted by the Government
of Nepal since 2014 to achieve Universal Health Coverage by 2030.Though it is at the formative
years of implementation, there are several challenges identified from design of the insurance
scheme to enrolment and renewal, availability of the services, payment to providers and users’
trust and citizen engagement. There are many angles that Nepal’s national health insurance has
been critiqued. This article adjures an eccentricity of Nepal’s health insurance, prospective on
health system strengthening.

Keywords: Health insurance, health financing, health system, universal health coverage, Nepal

Introduction Context of Nepal’s health insurance

Health insurance is one of the health financing
mechanisms to provide financial protection in
citizen’s health (1).In many low- and middle-
income countries (LMICs), a state cannot run
the pubic funded healthcare system; thus, a
contribution-based health insurance (of pre-
payment and risk pooling) can be one of the
pathways to provide financial protection to the
citizen(2).
A contribution-based health insurance plays a
significant role to increase the Gross Domestic
Product (GDP) by improving access to the quality
of health services and reducing the Burden of
Disease (3). In a LMIC setting like Nepal, premium
collected for health insurance could reduce
the domestic borrowing of healthcare costs. In
micro-economics, it supports an individual along
with households by reducing the direct cost of
healthcare and contributing to increasing demand
for health services. It contributes to reducing the
morbidity of the people and saving healthcare
costs. Thus, health insurance could pillar a linkage
between the citizen’s health and the country’s
economic development (4).
The Constitution of Nepal 2015 has guaranteed
health as a fundamental human right.(5) However,
inadequate allocation of public resources for
health, inefficiencies in delivery of available
package of healthcare and lack of people’s
participation in health planning often ends up poor
implementation of the health plan, excluding the
poorest and most marginalised populations (6,7).
The government is unable to allocate a sufficient
budget (less than eight percent of total national
budget) in the health sector (8), and people pay out
of their pockets over half of the total healthcare
bills(9). This poses a serious challenge in ensuring
the right of citizens to health in Nepal.
Before 2013, the Government of Nepal (GoN) and
non-government organizations had launched
several Community Based Health Insurance
(CBHI) and institutional schemes, which failed to
achieve universal coverage due to low enrolment,
inadequate coverage of the healthcare package
and poorly managed the schemes. Learning from
the CBHI, a strong national health insurance (NHI)
is a need for Nepal (10).In the 2012 resolution
of the UN General Assembly, the member states

Received :
Revised :
Accepted : Page 1
 Perspective Nepal’s Health Insurance: Perspective on Health System Strengthening
including Nepal recognized health insurance as a
principle vehicle towards achieving the Universal
Health Coverage (UHC)(11). Learning from the
past and others that the voluntary and community
health insurance schemes have limitations to
achieve the goal of UHC, GoN started national
health insurance in 2014 (1). However, the low
and slow coverage and weak implementation in
six years have slowed down the enthusiasm it
generated to the public(12).
Since the new scheme started, GoN has remained
committed to allocate budget to rollout the
NHI(13). The scheme enrols a family as a unit
with an annual premium of NPR 3,500 (27.5 USD)
per family. A family of more than five will pay
NPR700 (5.5USD) for each additional member in
a family. A unit may claim up to NPR 100,000 (784
USD) per year while an additional member will
get NPR 20,000 (157 USD) for utilizing benefits.
The Health Insurance Act, 2017 has provision to
enrol all government personnel, formal sector
employees and foreign employment seekers. It
has provisioned subsidies to senior citizens (70
and above years), families of people living with
HIV, Multi-Drug Resistant Tuberculosis (MDR-TB),
Leprosy, complete disability (red card holder),
ultra-poor and Female Community Health
Volunteers(50%). About one-third of insured
people constitute these reservation categories
groups(14).
As of April 2022, over 4.5 million people have
been enrolled in the scheme from 75 out of 77
districts of the country(12). The gap of enrolment
and dropout rates is widening. The enrolment
status among total population was1%in 2016 and
attained15%in 2021 while dropout rates were
67% and 30% respectively. The poor enrolment
and dropout were mainly due to unavailability of
drugs, unfriendly health facilities, and indifferent
behaviour of health workers towards the insured
people and willingness of insures to take health
service in specialized facilities or private clinics
(13). The government employees, local political
leaders, relatively well-off families, poor families
were often reluctant to enrol and continue. The
main reasons for ineptness about the scheme
were inadequate health benefit package to
meet the people’s healthcare needs, inefficient
administrative and financial procedures at health
1USD = NPR 127.5 on 6 July 2022 (https://www.nrb.org.np/forex/)
Page 2
facilities and delays in reimbursement (13,15,16).
Emerging issues
Through discussion with stakeholders of Nepal’s
NHI and literature review, five key themes emerged
influencing the NHI scheme and its management
(7,11,13,15–19).
First shifting expectations– Today’s service users
have set new standards of convenience, ease of
use and value. There are two types of service users
- one group of users who get subsidies from the
government to enrol in the insurance scheme,
and another group of users who pay a premium
to enrol. All users expect personalized high-touch
service, whereas they experience lack of quality
interactions with the service providers, indeed,
they often felt ignored while seeking healthcare.
Second bundling services– Health insurance
requires improvising the core products,
like financial management, health service
strengthening and programme monitoring, to
attract more service users. The service users expect
to expand their contribution to the ecosystem
which is yet to experience.
Third delimiting services– The changing forces
allow every sector to draw borders with arrange
of products and services and customer ownership
as the ultimate prize. Some schemes such as
employee’s health insurance through employee
provident fund, and social health security
programmes from social security fund impede
NHI due to unhealthy and disproportionate
choices within the public sector. The current
system is more focused on clinical care. A holistic
set of interconnected products and services such
as, nutrition, physical activities, entertainments,
social and good neighbourhood environment help
build a good health system and such lifestyle is yet
to be experienced in Nepal.
Fourth digitalisation of services– Technological
innovation has been the backbone for the success
of NHI. According to Nepal Telecommunication
Authority, more than 90% of the population
has access to communication with internet
connectivity. However, Nepal’s health system
is struggling to digitise basic health services,
Nepal’s Health Insurance: Perspective on Health System Strengthening
products, and related procedures. In the NHI,
digitalisation of enrolment, premium collection,
health services utilisation and reimbursement to
providers are keys for success. Improved access to
a rich stream of customer data from these services
can help in honing offerings as well as enhancing
the delivery efficiency.
Fifth minding equity– The health insurance has
rendered services from existing public and private
health facilities. Although there might be some
basis to enlist health facilities as providers, people
living in rural Nepal are less likely to get quality
services compared to their urban counterparts
because the rural areas are deserted with
specialized services hence compel high indirect
costs to get health services(20,21).
Health service delivery system
The key players of NHI are registered health
facilities of the national health system. Most of
the service users in the public sector in Nepal
are lower-middle-income families from rural and
semi-urban settings where many public health
facilities often lack trained healthcare providers
and essential drugs and health supplies(12).
Public health facilities have often been criticized
for providing poor quality health services (6,7,12).
In this context, the NHI benefits provided from
the public health facilities result in a growing
impression of the state imposing additional
financial burden to the citizens through health
insurance which is a major hindrance to its
success. Hence, to overcome the situation, service
users’ expectations are to be fulfilled with the
proven high-quality services.
Public trust is the major source of success for any
health programme. Many public health facilities
have been often accused of being unaccountable
to the public (22). The NHI programme is unable
to adequately address this, and prepare the
public and private health sector, their employees
and administration to be more responsive to the
healthcare needs of the people and accountable
to the users (13,20). This leads to a dilemma for
the service users whether to complain or drop out
from the scheme in which they have contributed
but are not satisfied with the services.
Perspective
Nepal’s NHI is weak in communicating policy to the
public. It is largely reliant on enrolment assistants
who are in limited numbers and are mainly
responsible to facilitate the enrolment procedures.
The inadequate communication of health benefit
package, premium, process to participate and
access health services when needed has been
inhibiting the success and sustainability of health
insurance. Lack of clear information regarding the
benefit packages and the users’ responsibility after
getting enrolled has created a mismatch between
people’s expectations and their experience. This is
a major contributing factor for increased dropout
of health insurance. Improving service users-
providers communication leads to enjoy the
benefits and success of the scheme(19).
Nepal experiences high disease morbidity and
mortality rates (7). The emerging and re-emerging
disease (e.g. COVID-19, MDR-TB, dengue), natural
disasters (e.g. earthquake, floods and landslides)
and socio-political and economic hitches and
managerial weakness are making the health
system weaker and process more complicated
(22).
The health workers are the real change makers
of the health system, and their performance
and behaviours transform the level of people’s
trust in the system. COVID-19 pandemic has
helped set this standard across the world. In a
weaker, less responsive, and poorly accountable
health system, the rewards to the healthcare
providers are often determined by the extent
of the political connections rather than from
their actual performance. A robust performance
appraisal system is yet to be realised in the public
and private health sector in Nepal. Training for
the healthcare providers is often considered
as a financial incentive rather than a learning
event for improving skills. The health system
cannot ensure the right healthcare providers
and managers are getting the right learning and
serving opportunities. This limited use of robust
performance appraisal not only affects the
motivation of the healthcare providers but also
distracts their career opportunities (23).
There are new dimensions emerging in the
healthcare markets in Nepal. The private sector
is increasingly getting lucrative not only for the
Page 3
 Perspective Nepal’s Health Insurance: Perspective on Health System Strengthening
private providers but also for users mainly in
the big cities(24). Unavailability of skilled and
specialised providers and services in public health
facilities has often compelled users to visit private
health facilities and providers. The efficiency and
productivity of the high-cost medical equipment
at the government health facilities are not
regularly assessed and monitored but undermined
the value for money they could have generated,
whereas the efficiency gain has remained a
key performance track of high-cost medical
equipment in the private health sector. This can
inform the efficiency gains across the health sector
(public and private). A fair and robust NHI scheme
can inject such potential to gain efficiency and
promote responsiveness among the public and
private providers in a fair healthcare marketplace.
In the first few years, public providers who
participated in the health insurance may behave
like private providers by incentivising the public
health facilities to upgrade and expand services
and promote healthcare providers to deliver more
and quality health services (25). This should not
be worried too much but tracking such behaviour
regularly is critical though.
Financial management
Nepal moves to a LMIC status in 2020 with the rise
of gross national income (GNI) per capita to $1,090,
exceeding the required threshold of $1,036 (26).
However, Nepal’s annual health budget remained
below eight percent and less than two percent
of the GDP. Evidence suggests that countries
should strive to spend at least five percent of GDP
for progressing towards UHC (22). Nepal’s NHI
has adopted resource-pooling as membership
premium to ensure the financial envelope to buy
services for insured.
Some people believe that insurance is the
financial management of health services and
should be competitive in the market to regulate
quality and price of the service. In countries,
such as Canada, Estonia, Taiwan, the UK, South
Korea and Cuba, which have successfully
operated social health insurance, a single system
of government-controlled health insurance is
paying off (12). Nepal should have a clear legal
provision to regulate and control the retail trade
of insurance that has come into operation in the
Page 4
market in the form of different schemes to cater
different populations. The Health Insurance Board
(HIB) should be further empowered to maintain
the financial transparency and orderliness of
managing the funds that generated mostly
from taxpayers’ contribution, public grant and
contribution amount collected from the insured.
HIB has no alternative but to be an accountable
purchaser of the health services. There are many,
parallel and often contradictory social security
schemes from the public sector (in health) in Nepal.
Government should find appropriate mechanisms
to mainstream the schemes to gain good value for
the taxpayers’ investment in health.
Nepal’s NHI has some early experience, though
it was rattled by massive political devolution of
power into federalism and COVID-19 pandemic,
how the local market has responded to the
scheme. This home grown learning and global
knowledge can inform the long-term reform to
make the NHI a strong vehicle for providing social
and financial protection of health to Nepalese
citizens. Cuba has strictly adhered to a single
service provider from the beginning and gradually
reduced the contribution from its citizens along
with improving the quality and specialization
of the services (27).Though there are some
progressive provisions of subsidies for enrolment,
Nepal has maintained a flat contribution rate to
the citizens from all strata and regions. This may
be considered regressive. Thus, there should be a
diverse contribution amount based on their ability
to pay for multiple schemes (to cater to different
health care needs) as relevant. The scheme should
have arrangements to enrol and coverall services
to the most marginalised and disadvantaged
individuals and families with low socioeconomic
status.
Existing dilemma
There are some critical policy choices for
leadership to consider. How long will the
enrolment process go as voluntary? The insurance
scheme considers the family as a unit. Is it not
too late to discuss and consider the formal sector
and institutions to mandatorily join health
insurance? Despite expanding the geographical
coverage, it is critical to include emerging and re-
emerging health problems such as COVID-19 and
Nepal’s Health Insurance: Perspective on Health System Strengthening
other health threats, which could cost medical
bills to people. To reduce the direct and indirect,
including opportunity costs, service providers
need to outreach to insured mostly in rural areas,
otherwise they have to travel far to get the health
service. This can be achieved by setting up a fair
and competitive incentive payment mechanism,
and also helps meet the effectiveness targets(14).
Insurance is often challenged as a financing
scheme in market economics to envision profit.
So, an oblivious query- Is health insurance for
profit? Another dilemma is when and how the
Government, a leading state machinery, ensures
the fundamental constitutional rights of the people
to access free basic and emergency healthcare?(5)
The other aspect is to ensure financial security
of HIB for longer-term sustainability. Delay in
responding to these issues appropriately and
adequately will hamper both HIB and Nepal’s
efforts towards achieving UHC.
Way forward to improve the health insurance in
Nepal
Financial management, especially service
premium, is the key to any successful health
insurance scheme. The following options can be
viable and relevant to Nepal:
• Pay capitation to all the providers against the
services cater-up to the level of health posts
and primary health care centers.
• Motivate healthcare providers to serve more
people and health facilities to offer a range
of health services from the same facility. It
will minimize the referral burden and reduce
the costs to health systems and ultimately to
the service-users who pay. An appropriate
payment arrangement can address this.
• Enroll health facilities, as providers, by the level
of healthcare functions and quality standards.
Provide competitive rates of payment to health
institutions for services and quality.
• Ensure transparency in provider payment
and establish (and track progress in) social
accountability arrangements in health.
Perspective
Harmonization of the various social security
schemes run by the government on health is
essential to avoid the operation of the parallel
systems. A legal provision can be a strong force
towards making the scheme compulsory to all
formal sectors first and to the public. A broader
policy discourse will benefit to set right health
financing strategic directions, and define a
medium- and longer-term plan answering three
major questions: a) who will buy what package
of health services and at what price; b) who will
deliver the health services, where, how and at
what price; and c) who will pay for the health
services and how.
The most probable answer would be making
enrolment and renewal core functions of local
governments (Palikas). They can enrol the people
in the right package, and indeed buy a package
for the people they are closely accountable to.
Obviously, HIB (and the federal government) can
incentivise enrolment and renewal. Indeed, the
vision of HIB should be lifetime renewal for the
members of this scheme.
The matter that makes a difference is who will
pay and how for the scheme? Is it the people
directly paying for health services annually or
the government paying for people for lifelong,
or people generally prefer to pay through tax for
broader social and economic security? In the case
of (relatively) large state contribution from the
taxpayers to the NHI, what is the role of the HIB
– why not to strive for health sector reform, or
missed the opportunity to save resources for other
life-balance development works?
The literature babbled in identifying the risks
and hazards and, developing and implementing
the mitigation measures set the life in any
programme. There is a high chance of ‘adverse
selection’ and ‘moral hazard’ in any health
insurance that costs the system (28). HIB needs
to continuously identify the extent of such risks
and apply the minimization measures across the
system. Robust monitoring, evaluation & learning
and research are the circulatory functions of a
good health insurance. It will be critical to update
(and upgrade) the health insurance package and
improve the overall system of the current NHI
Page 5
 Perspective Nepal’s Health Insurance: Perspective on Health System Strengthening
scheme. Research, particularly the service users’
health seeking behaviours, will help further
update the package and set up a subset of the
scheme as necessary. Nepal’s health insurance
needs entire data systems digitalised to track
the services and improve system performance.
Digitisation of enrolment, service provision,
payment and performance tracking are key steps
of good governance.
An annual mapping of people and households who
are poor and where they live is critical to inform a
scientific plan to meet their healthcare needs. The
HIB, Ministry of Land Management and Poverty
Alleviation and National Planning Commission
can discuss and decide who to lead and how
to coordinate to make the poverty mapping
comprehensive, efficient and used. This will be
instrumental to safeguard the financial health of
the poor and most marginalized individuals and
families.
The current health insurance scheme of Nepal
has overlooked health promotion and disease
prevention. All successful health insurance
schemes in the world do implement strong public
health and prevention programmes. HIB will
achieve more if there are few unhealthy people
in the population; if people are sick, and they can
access to health services at an early stage – that
will not only provide people a good quality of life
but also low cost to the HIB. HIB needs to ensure
changes in the behaviours of the providers and
match the healthcare needs of the people with
service providers and the adaptive capacity of
the board to address the new challenges if any.
It is critical because, over the years, even the
public providers will start behaving like private
providers, which is expected in a matured health
insurance system. It will further strengthen the
health system to be more efficient and financially
sustainable. HIB needs continued tracking of such
system behaviours and adjusts the system knobs to
ensure the healthcare delivery system is balanced
to cater to the health needs of the public (accessible
and affordable), and it is efficient and financially
viable to provide the highest quality of healthcare.
Page 6
Conclusions
NHI is a good initiation to meet UHC. It is relatively
younger compared to that of developed and
emerging economies. Penetration and density are
the key performance indicators of any insurance
scheme, these parameters are crippling here. The
coverage and continuity of the same population in
the coming years are getting more challenging to
sustain the scheme and meet its longer-term goals.
Further, there is a huge gap between insurance
coverage (premium collected) and reimbursement
to service provider’s payments made, which places
the health insurance at the state of risk. HIB needs
to learn quickly and apply the evidence to reduce
the gaps both by long-term policy measures and
quick fixes to set the path right.
The current health insurance scheme must
address the five key service-related issues -
shifting service users’ expectations, bundling of
basic and other services, delimiting services in the
package, digitalisation of services and minding
gaps. Having robust financial management and
accountability arrangements is key not only to
deliver the healthcare needs of the people but also
to ensure substitutable and innovative financing
for the health insurance scheme. The government
policies need to be clearer for all on the objectives
and strategic and tactical directions of the
scheme, participation, payment, accountability
and learning, and benefits to insured, providers
and the taxpayers. The health system is evolving,
and any reform and improvement will be justified
only by ensuring equitable access to quality health
services for all. Hence, it is now to take reform
actions so that Nepal’s health insurance gets in the
right shape at its adulthood.
Competing Interests
The authors have declared that no competing
interests exist.
Acknowledgements
All the views expressed in this article are entirely
the opinion of the authors, and this does not
necessarily reflect the views of agencies to which
they are affiliated to.
Nepal’s Health Insurance: Perspective on Health System Strengthening
Contribution of authors
SP conceptualized and outlined the research
paper. SP and SG reviewed literatures and drafted
manuscript. DKK- reviewed the manuscript All
authors finalized the manuscript
References
1. Pokharel R, Silwal PR. Social health insurance in Nepal:
A health system departure toward the universal health
coverage. Int J Health Plann Manage. 2018;33(3):573–
80.
2. El-Sayed AM, Palma A, Freedman LP, Kruk ME.
Does health insurance mitigate inequities in non-
communicable disease treatment? Evidence from 48
low- and middle-income countries. Health Policy (New
York) [Internet]. 2015;119(9):1164–75. Available from:
http://dx.doi.org/10.1016/j.healthpol.2015.07.006
3. Raghupathi V, Raghupathi W. Healthcare Expenditure
and Economic Performance: Insights From the United
States Data. Front Public Heal. 2020;8(May):1–15.
4. Choudhary ML, Goswami KI, Khambhati SB, Shah VR,
Makwana NR, Yadav SB. Awareness of Health Insurance
and Its Related Issues in Rural Areas of Jamnagar District.
Natl J Community Med [Internet]. 2013;4(2):267–71.
Available from: www.njcmindia.org
5. Government of Nepal. The Constitution of Nepal.
Nepal Gaz. 2015;1–226.Available from: https://www.
mohp.gov.np/downloads/Constitution%20of%20
Nepal%202072_full_english.pdf
6. Gaihre RH. Identification of poor households for targeting
in Nepal. A Decad action 2030 Agenda Stat that leaves
no one nowwhere behind [Internet]. 2020;(June):15–20.
Available from: https://www.unescap.org/sites/default/
files/APS2020/73_Identification_of_poor_households_
for_targeting_in_Nepal.pdf
7. Shrestha MV, Manandhar N, Dhimal M, Joshi SK.
Awareness on Social Health Insurance Scheme among
Locals in Bhaktapur Municipality. J Nepal Health Res
Counc. 2020;18(3):422–5.
8. Federal Ministry of Health and Population; Policy
Planning and Monitoring Division; Government of
Nepal. Budget Analysis of Ministry of Health and
Perspective
Population FY 2018/19. 2018;(September).
9. Thapa AK, Pandey AR. National and Provincial Estimates
of Catastrophic Health Expenditure and its Determinants
in Nepal. J Nepal Health Res Counc. 2021;18(4):741–6.
10. Stoermer M, Franziska F, Rijal K, Bhandari R, Cyril
N, Gautam GS, et al. Review of Community-based
Health Insurance in Nepal. 2012; Available from:
http://library.nhrc.gov.np:8080/nhrc/bitstream/
handle/123456789/518/686.pdf?sequence=1
11. Carrin G, James C. Social health insurance: Key factors
affecting the transition towards universal coverage.
Int Soc Secur Rev [Internet]. 2005;58. Available from:
https://doi.org/10.1111/j.1468-246X.2005.00209.x
12. Ranabhat CL, Subedi R, Karn S. Status and
determinants of enrollment and dropout of health
insurance in Nepal: An explorative study. Cost Eff
Resour Alloc [Internet]. 2020;18(1):1–13. Available
from: https://doi.org/10.1186/s12962-020-00227-7
13. Health Insurance Board. Health Insurance Act 2074
[Internet]. 2017. Available from: https://hib.gov.np/
public/uploads/shares/notice_hib/health-insurance-
act-2074.pdf
14. Health Insurance Board. Benefit packages 2074
[Internet]. 2018. Available from: https://hib.gov.np/
public/uploads/shares/notice_hib/benefir-package.pdf
15. PwC. Competing in a new age of insurance : How
India is adopting emerging technologies Messages
from PwC [Internet]. 2019. Available from: https://
www.pwc.in/assets/pdfs/consulting/financial-services/
competing-in-a-new-age-of-insurance.pdf
16. Shankar P. Attracting and retaining doctors
in rural Nepal. Rural Remote Health [Internet].
2010;10(4):1638. Available from:https://www.rrh.org.
au/journalarticle/1420
17. Lohani G. Social Health Security Program (Health
Insurance) [Internet]. 2017. Available from: https://
dohs.gov.np/wp-content/uploads/2017/09/Health-
Insurance.pdf
18. Mishra SR, Khanal P, Karki DK, Kallestrup P, Enemark
U. National health insurance policy in Nepal: Challenges
for implementation. Glob Health Action [Internet].
Page 7
 Perspective Nepal’s Health Insurance: Perspective on Health System Strengthening

2015;8(1). Available from: 10.3402/gha.v8.28763

19. Yadav DK. Utilization pattern of health care services

at village level. J Nepal Health Res Counc. 2010;8(1):10–4.

20. Acharya S, Ghimire S, Jeffers EM, Shrestha N. Health

care utilization and health care expenditure of Nepali
older adults. Front Public Heal. 2019;7(FEB):1–10.

21. Bhatt LD, Dhami SS, Yadav DK. Health Service

Utilization and Out-Of-Pocket Health Expenditure
Among Insured and Uninsured: A Comparative Study in
Baglung District, Nepal. 2019;1–15.

22. McIntyre D, Meheus F, Rottingen JA. What level of

domestic government health expenditure should we
aspire to for universal health coverage? Heal Econ Policy
Law. 2017;12(2):125–37.

23. Nepal Health Research Council (NHRC) Ministry of

Health and Population (MOHP), Monitoring Evaluation
and Operational Research (MEOR) Nepal. Nepal Burden
of Disease 2017: A Country Report based on the Global
Burden of Disease 2017 Study [Internet]. 2017. Available
from: http://nhrc.gov.np/wp-content/uploads/2019/04/
NBoD-2017_NHRC-MoHP.pdf

24. Mishra S, Acharya P. What is fuelling privatization in

health care in Nepal? Heal All [Internet]. 2013;1(1):8–
11. Available from: www.nepjol.info/index.php/JHFA

25. Dorjdagva J, Batbaatar E, Svensson M, Dorjsuren B,

Togtmol M, Kauhanen J. Does social health insurance
prevent financial hardship in Mongolia? Inpatient care:
A case in point. PLoS One [Internet]. 2021;16(3 March
2021):1–12. Available from: http://dx.doi.org/10.1371/
journal.pone.0248518

26. Prasain S. Nepal moves up to lower-middle-

income country, says World Bank report. Kathmandu
Post [Internet]. 2020; Available from: https://
kathmandupost.com/money/2020/07/03/nepal-is-
now-officially-a-lower-middle-income-country-the-
world-bank-says

27. Keck CW, Reed GA. The curious case of Cuba. Am J

Public Health. 2012;102(8):13–23.

28. Einav L, Finkelstein A. Moral hazard in health

insurance: What we know and how we knowit. J Eur
Econ Assoc. 2018;16(4):957–82.

Page 8