KATHMANDU, July 4: Nepal's national health insurance programme, introduced to protect citizens from catastrophic medical expenses and ensure universal access to healthcare, is increasingly coming under scrutiny as patients across the country report receiving incomplete treatment despite being insured.
Reports from Lumbini, Bagmati, Sudurpashchim and Madhesh provinces paint a similar picture—patients are being forced to buy medicines from private pharmacies, endure hours-long queues, and pay out of pocket, while hospitals struggle to continue services because of delayed reimbursements from the Health Insurance Board (HIB).
The recurring complaints suggest that the programme, once envisioned as a cornerstone of Nepal's social security system, is steadily losing public confidence.
At Bheri Hospital in Banke, Ananda Dhungana of Bardiya took his wife for treatment believing their health insurance would cover the required medicines. Although the consultation was completed under the insurance scheme, the medicines prescribed by doctors were unavailable at the hospital pharmacy.
"We should receive medicines from the hospital under the insurance programme, but we had to buy them from a private pharmacy. This is not the first time," Dhungana said, adding that many insured patients are also forced to visit private laboratories because tests are unavailable at government facilities.
Pushpa Shukla of Nepalgunj echoed similar frustrations. Her family has been enrolled in the programme for several years, yet she says the promised services remain incomplete.
"All family members have health insurance, but we still have to buy many of the prescribed medicines outside the hospital," she said, describing the insurance process as more troublesome than beneficial.
Hospital authorities admit that medicine shortages have become a recurring problem but say the issue stems from delayed payments by the NIB.
According to Bheri Hospital Medical Superintendent Dr Nabin Darnal, the hospital has been unable to pay pharmaceutical suppliers because it has not received reimbursement from the board on time. As a result, suppliers have reduced deliveries, leaving hospital pharmacies short of essential medicines.
The hospital alone owes around Rs 180 million to medicine suppliers up to the previous fiscal year, with liabilities for the current fiscal year yet to be calculated. Hospital officials say delayed payments have also affected the purchase of essential medical supplies and even staff salaries.
Money laundering probe deepens as DoMLI targets promoters of ei...
The same concerns are emerging hundreds of kilometres away in Bhaktapur in Bagmati Province, where many residents say they have deliberately avoided joining the programme because they no longer trust it.
Social activist Premdhwaj Lama said his family has never enrolled in health insurance, not because of financial constraints or lack of awareness, but because of widespread complaints from beneficiaries.
"If insured patients still have to buy medicines and spend hours waiting in hospitals, I don't see the point of paying the annual premium," he said.
Families with up to five members currently pay Rs 3,500 annually for health insurance coverage, while larger families pay additional premiums for each extra member.
Even among those enrolled, dissatisfaction appears widespread.
Many patients describe the programme as "something that can neither be swallowed nor spat out," saying they spend an entire day standing in separate queues for registration, consultation, laboratory services, medicines and insurance verification.
Another frustration is that insurance coverage begins only three months after enrolment, meaning newly enrolled patients cannot immediately claim benefits even during emergencies.
HIB officials in Bagmati Province acknowledge that long waiting times and medicine shortages remain the most common complaints. Although the programme includes more than 1,100 medicines, patients say many prescribed drugs are unavailable when they visit hospitals. Several diagnostic services, including MRI, CT scans and specialized laboratory tests, are also unavailable in many facilities, forcing patients to seek treatment elsewhere.
Hospitals themselves say they are equally frustrated.
Several hospitals report waiting months or even years to receive reimbursement from the HIB. As a result, some have reduced insurance services while others have withdrawn from the programme altogether. Siddhi Smriti Academy in Bhaktapur has already stopped providing insurance services, while other institutions have warned they may follow unless outstanding payments are cleared.
In Sudurpashchim Province, insured patients report facing similar difficulties despite regularly paying insurance premiums.
Hari Devi Air, who underwent spinal surgery at Seti Provincial Hospital, said she expected the insurance programme to reduce her financial burden. However, although Rs 64,000 remained under her insurance coverage, she could not use it because her surgery bill totalled Rs 70,000.
"I even offered to pay the remaining Rs 6,000 myself, but they refused to process the insurance claim," she said.
She was also forced to purchase medicines separately, significantly increasing her treatment expenses.
Another patient, Tek Bahadur Thapa, who sought treatment for kidney disease, said only about half of his prescribed medicines were available through the hospital pharmacy.
"What is the use of health insurance if we still have to buy medicines outside?" he asked.
Officials at the HIB's Kailali office say hospitals are contractually obligated to provide services covered under the scheme. More than 1,100 medicines are officially listed under the insurance package, yet beneficiaries continue to report shortages—even of commonly used medicines.
In Madhesh Province, the government's recent decision to discontinue the insurance programme at private hospitals has shifted thousands of insured patients toward public hospitals, creating fresh challenges.
At Narayani Hospital in Birgunj, daily patient numbers have increased dramatically.
Hospital officials say the number of insured patients has risen by around 250 each day, pushing total daily patient visits from around 300–350 to nearly 600. The hospital has had to deploy additional staff to cope with the growing patient load.
Despite the increased manpower, patients complain of waiting for hours before seeing doctors. Many also report missing the hospital pharmacy's closing hours after spending much of the day in queues.
Others say medicines prescribed under the insurance scheme are frequently unavailable, forcing them to buy them from private pharmacies at their own expense. Patients also complain that diagnostic services such as MRI, CT scans, X-rays and ultrasound are not consistently available, reducing the practical benefits of insurance.
Health experts warn that unless structural weaknesses are addressed urgently, public confidence in Nepal's flagship social protection programme will continue to decline.
They argue that the government must ensure timely reimbursement to hospitals, maintain uninterrupted supplies of medicines, expand diagnostic services and strengthen monitoring to guarantee that insured patients receive the services they are entitled to.
The health insurance programme was introduced to shield households from the financial burden of illness and move Nepal closer to universal health coverage. However, experiences from hospitals across the country suggest that while citizens continue to pay annual premiums, many are still bearing substantial out-of-pocket costs when they fall ill.
For many beneficiaries, the programme has become less of a financial safety net than a source of frustration—a system that promises affordable healthcare but often fails to deliver it when it is needed most.
