Knowledge and perception of the health insurance program among enrolled people in Ilam Municipality, Nepal

Abstract

Health insurance schemes are widely advocated as mechanisms to reduce out-of-pocket (OOP) expenditures and prevent financial catastrophe. Nepal launched its Social Health Security Program (SHSP) in 2016 with the aim of ensuring equitable and universal access to healthcare for all citizens. Despite this initiative, national enrollment coverage has remained below five percent. Despite this expansion, limited evidence exists at the municipal level on what enrolled households actually know about the scheme’s benefits and how they perceive its quality and value, a critical gap that constrains effective program implementation. This study aimed to assess the knowledge and perception of enrolled household heads about the Health Insurance Program in selected wards of Ilam Municipality. Of the 12 wards in Ilam Municipality, four wards (ward no. 4, 6, 9 and 10) were selected using a simple random sampling method. Within each ward, enrolled households were identified from the Health Insurance Board's IMIS list with help from ward-level registration assistants and were selected using systematic sampling selecting every third house from the randomly chosen starting point continuing until the required ward wise sample was obtained (Ward 4: n=64; Ward 6: n=100; Ward 9: n=131; Ward 10: n=13), yielding a total sample of 308 households. Data were collected through face-to-face structured interviews, entered in Epi- Data for validation and analyzed using IBM SPSS version 21, descriptive statistics (frequency, percentage, mean) and Chi- square tests (p<0.05) were used for analysis.   Knowledge of the basic annual premium was high (93.5%) but knowledge of the maximum annual benefit ceiling was critically low (3.2%). Perceptions across all domains were predominantly neutral (overall mean = 2.87 on a 5-point scale). Educational status (p=0.006) and occupational status (p=0.000) were significantly associated with knowledge. All respondents reported that enrollment made health service utilization easier. Targeted awareness programs covering full benefit entitlements and stronger community outreach especially for agricultural workers and those with lower education are urgently needed to improve both knowledge and utilization of the scheme.