Inequalities in enrollment in Nepal’s national health insurance program: An intersectional analysis of Nepal Demographic Health Survey 2022
1
School of Nursing, Midwifery, Allied and Public Health, Canterbury Christ Church University, Canterbury, United Kingdom
2
New ERA, Kathmandu, Nepal
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
BACKGROUND:
Nepal’s National Health Insurance Program (NHIP), launched in 2016, continues to show low enrolment rates and substantial socio-economic and geographical inequalities hinders the progress towards universal health coverage (UHC). This study uses a composite indicator of intersectional disadvantages to examine how multiple equity markers (wealth, education and ethnicity) interact to shape inequalities in NHIP coverage.
METHODS:
Data were drawn from 2022 Nepal Demographic and Health Survey. Independent variables included wealth status, education, ethnicity, residence, and marginalization status. A composite measure of intersectional disadvantage was constructed using three socioeconomic dimensions: wealth, educational attainment, and ethnicity. Binomial logistic regression, concentration indices, and concentration curves were used to assess the patterns of inequality in NHIP coverage.
RESULTS:
Only 10.2% of men and 10.8% of women were enrolled in the NHIP. Enrolment was disproportionately higher among wealthier, more educated, and ethnically advantaged groups. Enrolment varied markedly by province, with highest in Koshi (21.8% for men and 22.9% for women) and lowest in Madhesh (3.1% for men and 2.7% for women). Individuals experiencing triple disadvantage (poverty, illiteracy, and disadvantaged ethnicity) had substantially lower coverage (3.0% for men and 3.4% for women) than those facing no disadvantage (18.4% for men and 22.9% women). The concentration curve analysis confirmed that wealthier men and women had greater access to NHIP. Regression analysis showed that men with no disadvantages were six folds more likely (aOR= 6.4; 95% CI 2.4, 17.0) and women eight folds (aOR= 8.0, 95% CI: 4.9, 13.2) more likely, to be enrolled in NHIP compared to individuals in triple-disadvantage groups.
CONCLUSIONS:
These findings highlight ttargeted interventions are urgently required, including subsidized enrolment for low-wealth households, expansion of health facility networks in underserved provinces like Madhesh, and tailored outreach programs addressing intersection of ethnicity, gender, and education to accelerate equitable progress towards UHC.
Nepal’s National Health Insurance Program (NHIP), launched in 2016, continues to show low enrolment rates and substantial socio-economic and geographical inequalities hinders the progress towards universal health coverage (UHC). This study uses a composite indicator of intersectional disadvantages to examine how multiple equity markers (wealth, education and ethnicity) interact to shape inequalities in NHIP coverage.
METHODS:
Data were drawn from 2022 Nepal Demographic and Health Survey. Independent variables included wealth status, education, ethnicity, residence, and marginalization status. A composite measure of intersectional disadvantage was constructed using three socioeconomic dimensions: wealth, educational attainment, and ethnicity. Binomial logistic regression, concentration indices, and concentration curves were used to assess the patterns of inequality in NHIP coverage.
RESULTS:
Only 10.2% of men and 10.8% of women were enrolled in the NHIP. Enrolment was disproportionately higher among wealthier, more educated, and ethnically advantaged groups. Enrolment varied markedly by province, with highest in Koshi (21.8% for men and 22.9% for women) and lowest in Madhesh (3.1% for men and 2.7% for women). Individuals experiencing triple disadvantage (poverty, illiteracy, and disadvantaged ethnicity) had substantially lower coverage (3.0% for men and 3.4% for women) than those facing no disadvantage (18.4% for men and 22.9% women). The concentration curve analysis confirmed that wealthier men and women had greater access to NHIP. Regression analysis showed that men with no disadvantages were six folds more likely (aOR= 6.4; 95% CI 2.4, 17.0) and women eight folds (aOR= 8.0, 95% CI: 4.9, 13.2) more likely, to be enrolled in NHIP compared to individuals in triple-disadvantage groups.
CONCLUSIONS:
These findings highlight ttargeted interventions are urgently required, including subsidized enrolment for low-wealth households, expansion of health facility networks in underserved provinces like Madhesh, and tailored outreach programs addressing intersection of ethnicity, gender, and education to accelerate equitable progress towards UHC.
| eISSN: | 2654-1459 |
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