Implementation bottlenecks of the National Health Insurance program in Nepal: Paving the path towards Universal Health Coverage: A qualitative study

Most low and low-middle income countries adopting National Health Insurance (NHI) programs to achieve Universal Health Coverage are struggling to implement the program due to underlying problems at implementation. However, there is a lack of research that focuses on these problems. The Nepal NHI program initiated in 2016 has experienced numerous implementation challenges. This qualitative study delves into the NHI program's inputs and throughputs/implementation bottlenecks. The study based in Nepal's four districts included 28 in-depth interviews, six focus group discussions, and identified 12 themes that pointed to the NHI program's inadequate inputs causing bottlenecks. The analysis employed the Grounded Theory. The main challenges identified were insufficiently defined NHI implementations guidelines, conflicting Act clauses, a lack of HIB organizational guidelines, and inadequate human resources. The major throughput bottlenecks were difficulty enrolling the insurees, the inability to select the health providers competitively and to act as a prudent purchaser of the services. These inadequate inputs and throughput bottlenecks led to negative outputs such as insurees' high dropouts, and low coverage of poor households. The NHI program's sustainability might be at stake if the identified problems persist, further exacerbated by the plummeting economic situation in the country due to COVID-19.