https://hdl.handle.net/20.500.14356/8 2026-04-14T06:51:59Z https://hdl.handle.net/20.500.14356/718 Title: Review of community-based health insurance initiatives in Nepal Authors: Stoermer, Manfred; Fuerst, Franziska; Rijal, Kailash; Bhandari, Ram; Nogier, Cyril; Gautam, Ghan Shyam; Hennig, Jennifer; Hada, Junu; Sharma, Shyam Abstract: Executive Summary: This study assesses community-based health insurance (CBHI) schemes in Nepal, both government operated (public) and private. Provider-based health insurance was introduced in Nepal in 2003 as six pilot schemes. In parallel, some privately-operated CBHI schemes have been established and are supported by non-governmental organisations (NGOs) and cooperatives. CBHI schemes in Nepal complement a number of specialised programmes of the Government of Nepal for improving people’s access to health care services. Renewed interest in a contributory insurance mechanism arose in January 2012 when a directive was sent by the Prime Minister’s Offi ce to the Ministry of Health and Population (MoHP) directing the Ministry to formulate and implement a “health insurance policy for all Nepalis”. However, the only experience the Ministry has in operating health insurance mechanisms is from the six pilot schemes it is running. Against this background, there is a great need to understand Nepal’s experience in implementing health insurance and to assess the role that government-supported CBHI schemes play in the current health financing system in Nepal, as well as their possible future role. In this study, existing CBHI schemes were analysed using a number of common standards and indicators (e.g., coverage, resource generation, pooling and purchasing, quality of delivered health services, patient satisfaction) and by looking at the contribution of CBHI schemes to health care financing in the main areas of universal coverage (financial protection, services covered, population covered). Specific attention was given to determining whether or not CBHI schemes improve their members’ access to health services and the quality of health care, and are technically and financially viable. The study revealed the following about private and public CBHI schemes: Benefit packages: In general, both private and public CBHI schemes provide members with access to health services beyond those covered by the government’s Free Health Care programme. There is no clear difference between private and public schemes in terms of the content of their benefit packages. Coverage: CBHI schemes have achieved very limited coverage of the population. As all public schemes are facility-based, their geographical coverage is generally limited to the working area of that particular facility. However, even within their catchment area an average of only 3.4 per cent of the population are covered, which demonstrates the low range of influence of these schemes. The coverage rate of the six private schemes sampled is even lower at 2.7 per cent. Membership composition and poverty orientation: The study found that disadvantaged groups (Dalits, disadvantaged janajatis, disadvantaged non-Dalit Terai caste groups) enrol more in public CHBI schemes (constituting 53 per cent of members) than in private ones (26 per cent of members). This refl ects the subsidy inflow into public schemes linked to the number of poor families enrolled. Enrolment: Enrolment in both public and private CBHI schemes is done through local motivators, female community health volunteers (FCHVs) and management committee members. Targets for enrolment are set in the public schemes, but hardly achieved. Premiums and subsidies: Premiums in public CBHI schemes are not determined on the basis of actuarial calculations (except for Saubhagya scheme), but rather set by the CBHI management on the basis of experience. The Ministry of Health and Population provides annual block grants to public CBHI schemes to subsidise premiums for people from disadvantaged groups and to cover part of their running costs. The study found that there is no consistency in the proportion of members subsidised in the six public CBHI schemes. The mechanism for providing a lump-sum subsidy in public CBHI schemes does not provide any incentive to increase the number of poor families enrolled beyond the target of 30 per cent. To the contrary, with each additionally enrolled family the subsidy per family is reduced. Private schemes do not have provisions for subsidising premiums based on socioeconomic conditions. Some discounts are granted at the time of renewal of membership for clients who wish to re-enrol, but not for socioeconomic reasons. Utilisation of health services: The survey found that the overall utilisation rate for health services among members of a CBHI scheme is higher than among non-members, regardless of whether it is a public or private scheme. Th ese findings indicate that CBHI schemes do in fact offer financial protection to their members, which enables them to use health services more often than non-members. How much this higher utilisation constitutes an ‘over-utilisation’ requires further investigation. Quality of health care: The survey found that the quality of health care provided to CBHI members, mainly in the public health facilities, is in line with the capacity and infrastructure of the health facility. There is no positive discrimination in facilities towards CBHI members. The same services are available to both insured and non-insured patients. The chances of improving the quality of health care through the negotiation power of health care purchasers is virtually nil as there is no purchaser-provider split in public CBHI schemes. In private schemes, the coverage of CBHI members among the population in the catchment area and their weight in terms of the total number of clients of the facility is low. Therefore, the influence of private CBHI schemes on health care providers is very limited. Technical efficiency: Accounts and record keeping systems are manual in all public CBHI schemes. Public schemes do not have any financial or administrative guidelines for properly implementing CBHI activities. Only two schemes (Mangalabare and Tikapur) had their accounts audited in the last fiscal year (2010/11). None of the public schemes have supervision and monitoring mechanisms in place, but CBHI management committees were found to be actively involved in CBHI activities. Public CBHI schemes have not sought any legal identity because they were initiated by the Government of Nepal. CBHI management committees have been formed in four out of the six public CBHI schemes. In Tikapur and Chandranigahapur, facility management committees look after the CBHI scheme. CBHI staff and committee management members have not undergone any specific health insurance or management training, and their capacity is variable and usually limited. In the best case, the CBHI staff had been exposed to other CBHI schemes during field visits. None of the CBHI schemes have a human development plan. Human resources available in public CBHI schemes are limited, and most CBHI activities are undertaken by health facility staff. In cooperative-initiated schemes, the executive board of the cooperative is responsible for insurance activity; there is no separate insurance management committee. In other private CBHI schemes, the health facility operation and management committee (HFOMC) is in charge of health insurance management. Both cooperative schemes present the same situation: no specific staff has been appointed to look after the CBHI scheme. The information system is managed in an ad-hoc way. There have not been any annual audits of CBHI activities for quite a long time. The analysis reveals weaknesses in the management systems of both private and public schemes. All schemes would benefit from rigorous technical support to develop into technically viable organisations. 2012-01-01T00:00:00Z https://hdl.handle.net/20.500.14356/724 Title: Needle stick injury: The incidence and contributing factors among proficiency certificate level nursing students in Kathmandu Valley Authors: Paudel, Binita Kumari; Karki, Kanchan; Dangol, Leena Abstract: An academic institution based cross- sectional survey was done to identify the incidence density of needle stick injury and its contributing factors among PCL level nursing students. Multi stage sampling method was used to select 407 samples from nursing students studying inside Kathmandu valley. Self administered questionnaire and review the records guideline were used as research tool. Incidence density was calculated and logistic regression model was fitted by using R software. Out of total students participated in the study, 46.9 % had already experienced NSIs and 44.7% of them experienced it more than once. The overall incidence density was found 5.82/person 1000 days exposure. Incidence density in night shift (6.86) and in second year (6.91) practicum period was found higher than morning +evening shift (5.41) and first year (4.21). Number of clinical posting days, year of study, universal precaution practice, vaccination and duty shifts were found associated with needle stick injury. Unexpectedly, college was also found significantly associated with needle stick injury. Out of total 298 injuries included for further analysis, 67.8 % were happened during medication, 41% while drawing medicine, 20% while recapping the needle and 45.1 % at medical ward. Only 46.6% injuries were reported and prophylaxis was used only in five injuries. However almost all the students (98.3%) stated that they follow universal precaution but only 28% practicing no-recapping. There is a practice of reusing syringe; therefore 31.3% stated that needle should recap properly by using one hand technique for the prevention of needle stick injury. Therefore, it is recommended that content in the curriculum and universal precaution training should revise in the context of Nepal and include the process of safe recapping the needle if it is necessary to reuse. It is also recommended to develop Standard Operating Procedure for proper post exposure management of needle stick injury. 2013-01-01T00:00:00Z https://hdl.handle.net/20.500.14356/721 Title: Tracking of post basi nursing graduates of Nepal Institute of Health Sciences Authors: Thakur, Laxmi Shrestha; Sapkota, Binita; Ale, Pabitra Abstract: The study traces out the placement of the post basic nursing graduates of the Nepal Institute of Health sciences, from 2002 to 2008. The aim of the tracer study was to determine, the relevance in terms of, utilization status of curriculum of the Purbanchal University, prescribed for, in the post basic nursing graduates. The sectoral objectives of this study were to determine the level and extent of employability, demand basedutilization, and the changing congruency between demand and supply. A total of 100 respondents, out of 265, were selected based on their placement within and outside Kathmandu as well as out of Nepal. Proportionate stratified random sampling was used to collect information through telephone, email and direct contact. Data was analyzed using SPSS program. An overwhelming (98%) number of respondents reported that they were able to perform their duties in a satisfactory way though some orientations were required. Majority of the respondents reported that the theory and clinical portion of the curriculum was relevant to meet the market demand. The major recommendations include: 1.periodic review of the market demand and subsequent modification in the curriculum. 2. institutional policy for more inclusive nursing population. 3. increasing focus on midwifery and community health nursing. 4. timely carrier development incentives and 5. expansion of master degree programme with specialization to meet the growing market demands. 2013-01-01T00:00:00Z https://hdl.handle.net/20.500.14356/650 Title: A research study on indoor admission form in Kanti Children's Hospital Authors: Lamsal, Madhab, Dr. 2013-01-01T00:00:00Z