What does this research mean for the field?

Enrollment in Nepal's National Health Insurance Program is highly inequitable, with individuals facing an intersection of poverty, illiteracy, and disadvantaged ethnicity having substantially lower coverage compared to those with no such disadvantages. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This research aims to analyze socio-economic and geographical inequalities in enrollment in Nepal's National Health Insurance Program.

April 19, 2026Open Access

Inequalities in Enrollment in Nepal’s National Health Insurance Program: An Intersectional Analysis of Nepal Demographic Health Survey 2022

Puntos clave

This research aims to analyze socio-economic and geographical inequalities in enrollment in Nepal's National Health Insurance Program.
Used data from the 2022 Nepal Demographic and Health Survey
Created a composite measure of intersectional disadvantage
Employed binary logistic regression and concentration indices
Examined variations in enrollment by wealth, education, ethnicity, and region
Only 10.2% of men and 10.8% of women were enrolled in NHIP
Enrollment rates varied significantly by province, with Koshi at 21.8% for men and 22.9% for women
Triple disadvantaged groups had substantially lower enrollment rates (3.0% for men and 3.4% for women)
Concentration curve analysis confirmed higher access for wealthier individuals

Resumen

Nepal’s National Health Insurance Program (NHIP), launched in 2016, continues to show low enrollment rates and substantial socio-economic and geographical inequalities hinder the progress towards universal health coverage (UHC). This study uses a composite indicator of intersectional disadvantages to examine how multiple equity markers (wealth quintile, education status and ethnicity) interact to shape inequalities in NHIP coverage. Data were drawn from the nationally representative 2022 Nepal Demographic and Health Survey. Key predictors are wealth status, education, ethnicity, residence, province, ecological zone and marginalization status. A composite measure of intersectional disadvantage was constructed using three socioeconomic dimensions: wealth, education, and ethnicity. Binary logistic regression, concentration indices, and concentration curves were used to assess the patterns of inequality in NHIP coverage. Results show that only 10.2% of men and 10.8% of women were enrolled in the NHIP. Enrollment 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). Enrollment was disproportionately higher among wealthier, more educated, and ethnically advantaged groups. This disparity is starkest for those with an intersection of triple disadvantage (poor, illiterate, and disadvantaged ethnicity) and had substantially lower coverage (3.0% for men and 3.4% for women) compared to those facing no disadvantage (18.4% for men and 22.9% women). The concentration curve analysis confirmed that wealthier women and men had greater access to NHIP. Multivariable analysis showed that women and men with no disadvantages were more likely to be enrolled in NHIP than individuals in triple-disadvantage groups. These findings highlight persistent inequities in NHIP, which undermine its contribution to financial risk protection. Targeted interventions are urgently required, including effective implementation of existing subsidies for poor households, expansion of health facility networks in underserved provinces like Madhesh, and tailored outreach programs that address the intersection of ethnicity, wealth, and education in both genders to accelerate equitable progress towards UHC.

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