What factors influence enrolment in Nepal’s National Health Insurance Program? A community-based cross-sectional study using the Health Belief Model

Introduction Despite government efforts to improve healthcare access through the National Health Insurance Program (NHIP) in Nepal, enrolment rates remain suboptimal. Understanding the behavioural, psychological and social drivers of enrolment is necessary to inform targeted intervention. This study assessed factors influencing NHIP enrolment using the Health Belief Model (HBM). Methods A community-based cross-sectional study was conducted among 360 randomly selected households in Panini Rural Municipality of Arghakhanchi district from July to August 2022. Data were collected through face-to-face interviews using an HBM-guided semi-structured questionnaire via KoboToolbox. Logistic regression analysis was performed using SPSS 22 to identify facilitators and barriers. Results Perceived susceptibility and severity of illness significantly influenced enrolment. Households perceiving poor family health had higher odds of enrolment (AOR 4.06, 95% CI 1.00 to 16.41), as did those with recent illness experience (AOR 2.51, 95% CI 1.09 to 5.75). Good knowledge about NHIP strongly predicted enrolment (AOR 6.61, 95% CI 3.09 to 14.13), along with perceived affordability of premium payments (AOR 4.51, 95% CI 1.12 to 18.19). Social cues were powerful motivators; peer enrolment (AOR 4.00, 95% CI 1.86 to 8.60), neighbour encouragement (AOR 7.95, 95% CI 3.63 to 17.39) and family agreement (AOR 4.72, 95% CI 1.56 to 14.34) markedly increased the likelihood of enrolment. Perceived benefits, however, were not significant predictors. Among the 180 non-enrolled households, common barriers included inappropriate premium collection timing (53.9%), belief that insurance was unnecessary (43.9%), limited service points (29.4%) and referral card requirements (19.4%). Conclusions These findings emphasise the need for targeted interventions that improve awareness by leveraging social networks. Affordability and referral card requirements were reported as barriers to enrolment underscoring a need for further exploration of flexible payment mechanisms and referral processes.