WILLINGNESS TO PAY AND ENROLLMENT IN THE NATIONAL HEALTH INSURANCE PROGRAM AMONG HOUSEHOLDS IN A REMOTE DISTRICT OF NEPAL: A COMMUNITY-BASED STUDY FROM JUMLA
Author(s)
Manish Rokaya, Master of Public Health (MPH)1, Dr.Seshananda Sanjel, phD in Occupational health2, Nishant Lama, Masters of public health nutrition2, Om prakash kafle, Masters of public health2, Harihar Adhikari, Doctor of medicine in Dermatology2, Ganes Yogi, Bachelor of public health student2.
1Department of Public Health, Karnali Academy ot Health Sciences, Jumla, Chandananth-2, Jumla, Karnali Province, Nepal, 2Karnali Academy ot Health Sciences, Jumla, Jumla, Nepal.
1Department of Public Health, Karnali Academy ot Health Sciences, Jumla, Chandananth-2, Jumla, Karnali Province, Nepal, 2Karnali Academy ot Health Sciences, Jumla, Jumla, Nepal.
OBJECTIVES: Nepal continues to face challenges in achieving universal health coverage, with out-of-pocket expenditure accounting for over 54% of total health expenditure. Despite nearly a decade of implementation, the National Health Insurance Program (NHIP) suffers from low enrolment and high dropout rates especially in remote mountain districts. This is the first community-based Willingness to Pay (WTP) study from a remote Karnali which aims to assess WTP for NHIP and its associated factors
METHODS: A community-based cross-sectional study was conducted in Jumla District from October 2025 to March 2026 among 422 households. Households were selected using multistage stratified random sampling with urban and rural strata, followed by systematic sampling within each stratum. Household heads or spouses were interviewed face to face using a pretested semi-structured questionnaire. WTP for the current NHIP was assessed using circular payment card and open-ended contingent valuation methods. WTP for a hypothetically improved scheme with enhanced service quality was assessed using a double-bounded dichotomous choice approach. Logistic, linear, and interval regression models were used to identify factors associated with enrollment and WTP.
RESULTS: Most respondents (91.5%) expressed willingness to enroll in the NHIP, yet actual enrollment was only 67.5%, with a significant urban-rural disparity (78.8% vs 50.3%, p<0.001). Among non-enrolled households, 47.4% cited unaffordability of the premium as the primary reason. Mean WTP for the current scheme was NPR 2,024, approximately 37% below the official premium of NPR 3,500. Under the improved service scenario, mean WTP increased to NPR 2,132. Education, place of residence, income stability, and occupation were significant predictors of both enrollment and WTP.
CONCLUSIONS: Although nearly nine out of ten households expressed willingness to join, enrollment remained lower. Transitioning from the current flat-rate premium to an income-based sliding-scale model, alongside targeted improvements in medicine availability, diagnostic services, and rural enrollment infrastructure, is essential for improving NHIP coverage.
METHODS: A community-based cross-sectional study was conducted in Jumla District from October 2025 to March 2026 among 422 households. Households were selected using multistage stratified random sampling with urban and rural strata, followed by systematic sampling within each stratum. Household heads or spouses were interviewed face to face using a pretested semi-structured questionnaire. WTP for the current NHIP was assessed using circular payment card and open-ended contingent valuation methods. WTP for a hypothetically improved scheme with enhanced service quality was assessed using a double-bounded dichotomous choice approach. Logistic, linear, and interval regression models were used to identify factors associated with enrollment and WTP.
RESULTS: Most respondents (91.5%) expressed willingness to enroll in the NHIP, yet actual enrollment was only 67.5%, with a significant urban-rural disparity (78.8% vs 50.3%, p<0.001). Among non-enrolled households, 47.4% cited unaffordability of the premium as the primary reason. Mean WTP for the current scheme was NPR 2,024, approximately 37% below the official premium of NPR 3,500. Under the improved service scenario, mean WTP increased to NPR 2,132. Education, place of residence, income stability, and occupation were significant predictors of both enrollment and WTP.
CONCLUSIONS: Although nearly nine out of ten households expressed willingness to join, enrollment remained lower. Transitioning from the current flat-rate premium to an income-based sliding-scale model, alongside targeted improvements in medicine availability, diagnostic services, and rural enrollment infrastructure, is essential for improving NHIP coverage.
Conference/Value in Health Info
2026-11, ISPOR Europe 2026, Vienna, Austria
Value in Health, Volume 29, Issue 12S
Code
HPR42
Topic
Health Policy & Regulatory
Topic Subcategory
Health Disparities & Equity
Disease
No Additional Disease & Conditions/Specialized Treatment Areas