Title : Willingness to pay and enrollment in the national health insurance program in a remote district of Karnali province, Nepal: A community-based study
Abstract:
Background: Nepal continues to face challenges in achieving universal health coverage, with out-of-pocket expenditure accounting for over 54% of total health spending and catastrophic health expenditure concentrated among the poorest households, particularly in Karnali Province. Despite nearly a decade of implementation, the National Health Insurance Program (NHIP) suffers from low enrollment, high dropout rates, and a large gap between stated willingness to participate and actual coverage, especially in remote mountain districts. Evidence on the determinants of willingness to pay (WTP) and enrollment from such rural settings remains absent from the literature. This is the first community-based WTP study from a remote Karnali mountain district, filling a critical gap in NHIP evidence from Nepal's most resource-constrained settings.
Methods: A community-based cross-sectional study was conducted in Jumla District, Karnali Province, from October 2025 to March 2026 among 422 households following ethical approval from IRC-KAHS. 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.
Conclusion: A large gap between stated willingness to enroll and actual enrollment persists in Jumla, driven primarily by premium unaffordability, income instability, and geographic inequity rather than lack of demand. 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 and sustainability in remote settings.
