Health Insurance (Social Health Security Program) in Nepal

health insurance in NepalSocial Health Security Progam, Health Insurance is the Government program based on the comprehensive social contributory scheme with the subsidy to the poor and Universal Health Coverage.
  • To ensure access to quality health service (equity & equality).
  • To protect from financial hardship and reduce out-of-pocket payments.
Risk and Contribution Pooling:
  • From Low Risk to High Risk
  • From Rich to Poor
  • From Productive to nonproductive age group

Features of Health insurance in Nepal:

  1. Contributory/Family Based
  2. Subsidy to Poor 
  3. Purchaser and Provider Split
  4. Cash-less (Upper Cap )
  5. IT based (IMIS) 
  6. Public and Private Providers  

Health Care services (Benefit Package):

1) Free Drugs
2) Free care services.
3) Targeted free care service

Negative List:

1) Cosmetic surgery
2) Abortion
3) Equipment like an artificial organ, reading glass not more than 500 once in a year, hearing machining
4) Artificial insemination services, organ transformation, Sex transformation etc.
5) Injuries treatment cost due to personal warfare
6) Accident related treatment due to alcoholic and drug use
7) In the case of dental treatment, modern dental implant, root canalling, etc.

Major features of Social Health Security Program (Health insurance) of Nepal

  • Universal coverage: People of all ages are eligible.
  • Family size: five members. Additional members can be added.
  • Premium payment is annual. Annual renewal.
  • Registration: door to door visit by enrollment assistance.
  • Co-payment: yes for medicine but not for free medicine
  • Payment for service by patient: Rs 140 for OPD and emergency service and Rs 80 for Primary centers.
  • Referrals: Available in central, regional and zonal hospitals.
  • Premium: NPR 2500 for five members of the family per year, NPR 425 for each additional member of the family per year                                                    
  • Subsidy by the government for poor: 100% for ultra poor, 75% for poor, 50% for the vulnerable group and 50% discount for FCHV
Reference: Dr. Guna Raj Lohani, Executive Director, Social Health Security Development Committee