Technical advisory services on the development of the National Health Insurance scheme in Nepal

Nepal has made significant progress in improving the overall health status of the population, with huge improvements in life expectancy and reductions in maternal and child mortality rates. However, access to quality healthcare remains unequal, as many citizens face barriers due to geography, socio-economic status, and economic constraints. Nepal National Health Accounts (NHA) report indicates that out-of-pocket (OOP) healthcare expenses accounted for 54.2% of total health spending in 2019/20, exceeding the South Asian average of 48.2% (WHO 2023). Government contributions to health expenditure are only 30%, which is lower than the regional average of 42% (WHO GHED 2023). A 2018 study found that 10.3% of households faced catastrophic health expenditures monthly (Ghimire et al. 2018). Furthermore, the report found that 10.7% of households spent 10% of their total household expenditure on health and 2.4% even spent 25%, implying that Nepalese households face increased vulnerability to catastrophic health expenditures risking impoverishment (ADB 2024). To achieve Universal Health Coverage (UHC), Nepal seeks to reduce OOP spending through the National Health Insurance (NHI), launched in 2016. This initiative, overseen by the Health Insurance Board (HIB), aims to provide universal access to quality health services, primarily for the informal sector. Currently, the NHI is operational in all 753 local structures across 77 districts. Though the Health Insurance Act 2017 has clearly mentioned the health insurance to be mandatory, in practice this is not yet enforced; highlighted by the fact that out of 8.1 million ever-enrolled, currently only 4.4 are actively insured as of June 2024. The increasing coverage and expansion of the NHI is a priority to the Government of Nepal (GoN) and strengthening the institution has been identified as an important action area within the strategies in both the National Health Financing Strategy (NHFS) 2022-2032 and in the National Health Sector Strategic Plan (NHSSP) 2022-2030. GIZ has been supporting the national health insurance program since 2013, on policy advisory aspects as well as technical aspects. To strengthen HIB, GIZ supported a pool of experts through the Support to Health Sector Strategy (S2HSS) program in 2023. The pool of experts supported in defining roles and responsibilities of the policy, planning and monitoring department (PPMD) and developing job descriptions for those assigned to the departments, as envisioned in the Organisation and Management (O&M) survey. In addition, the support was extended for development of crucial policy documents, strategies, guidelines, and plans. On a technical front, GIZ supported HIB for improving the open-source insurance management information system (openIMIS) to streamline core business processes: from enrollment, member verification, policy activation to claims processing and reimbursement. Meanwhile, in the current context of HIB with constrained institutional capacity despite having developed numerous strategic documents in 2023, prioritizing its execution along with implementation of necessary reforms is now critical. Additionally, increasing population coverage, contextually redefining the benefit package, enhanced claims processing, strategic purchasing, actuarial analysis for decision modelling, using data analytics for enhancing quality of care and coordination with other actors like the Social Security Fund (SSF), Employee"s Provident Fund (EPF) etc. is vital to improve efficiency and avoid redundancy in successful implementation of the health insurance program. In order to address these policy, strategy and operational level challenges, GIZ calls for a team of nine short-term and long-term experts with diverse expertise for building up the health insurance to strengthen the institutional capacities of the HIB and other social protection actors to implement the national health insurance program in Nepal. The team will consist of 2 international experts on organizational management and health insurance, 1 short-term national senior expert on health insurance, 4 national short-term experts (covering the topics insurance law, health economics, quality management and actuary analysis) and 2 national long-term experts (health economist and Monitoring & Evaluation specialist). The contract shall be managed and overseen by an international team leader and supported by a national team leader. The period of assignment of the contract will be 01 April 2025 to 31 March 2026. The tasks to be performed by the contractor have been briefly listed in the following four work packages: Work package 1: Support HIB in setting the normative and strategic structure and functions for refining the health insurance program, especially related to financial sustainability aspects. Work package 2: Harmonization of procedures and service packages of national health insurance program and other programs offering benefits in the event of illness. Work package 3: Organizational and institutional capacity development measures to improve core processes of the health insurance program. Work package 4: Provide advice to HIB on various technical matters, focusing on use of data, data analysis, evidence-based planning, and quality management. By the end of the contractual period, the experts need to develop five strategy papers relating to the financial sustainability of the national health insurance scheme, and adequately capacitate the health insurance board for major policy reforms as well as for efficiently enhanced operational functions of the program. The contractor should conduct workshops, meetings, policy dialogues etc. for the purpose. For further details on the tender, including detailed specifications of the experts, work packages and other considerations, please refer to the Terms of reference.