Factors affecting the Utilization of Social Health Insurance by the General Population in Bhaktapur Municipality

Introduction: Lack of proper financing system puts the vulnerable population at health risk with high level in rural setting. For the reduction of financial burden and to achieve universal health care, Government of Nepal launched a security program called as Social Health Insurance Program. This study aimed to find the factors associated with the utilization of the social health insurance scheme. Methods: Descriptive cross-sectional study was conducted in the Bhaktapur Municipality ward no 2. 422 households were chosen using systematic random sampling. Questionnaires were used to measure the factors affecting the utilization. The collected data was entered in Epidata and analyzed in SPSS version 16. The data were presented in the frequency and percentage. Bivariate analysis was done to identify factors utilizing social health insurance. Factors having p value less than 0.05 was taken as significantly associated. Multivariate analysis was done to examine the association between the outcome variables. Results: Almost half of the general population (42.4 %) were utilizing social health insurance scheme and reason for not utilizing includes lack of confidence in the scheme and the services of the scheme, followed by high premium cost. Age (p=0.044), occupation (p= 0.049), wealth quintiles (p=<0.001) were found to be significantly associated with utilization of social health insurance. Logistic regression analysis showed that the odds of enrollment among very rich population group were lower than the medium (AOR 0.550, 95% CI 0.305-0.993) and rich population (AOR 0.557, 95% CI 0.316-0.981). Conclusions: Multiple factors were found to be associated with the utilization of the health insurance scheme which includes age of the household head, occupation of the household head, economic status, availability of the drugs and charge paid during their visit in the health care services, behavior showed by the health care provider, confidence in the scheme, satisfaction in the services that have been providing and source of the information.


INTRODUCTION
Health of the vulnerable population is at risk due to the lack of proper financing system. Out of pocket payments along with the lack of access to health care services, disease shift from communicable to non communicable disease puts the vulnerable population at health risk. 1 Only 2/3 rd of population have easy access to health care facilities with 59% in rural setting and 86% in urban setting. 2 For the reduction of financial burden and to achieve universal health care, Government of Nepal launched a security program called as Social Health Insurance Program. The program was started as a pilot program in 2072/73 in Kailali, Baglung and Illam and in year 2073/09/01 it was started in Bhaktapur district. 3 Karanjit et al. Factors affecting the Utilization of Social Health Insurance by the ... Social health insurance is playing a crucial role in addressing the burden of sickness funds and helped to establish link between social stratification and insurance status. 4 Thus, the objective of this study was to identify the factors associated with utilization of social health insurance program by general population in Bhaktapur Municipality.

METHODS
Descriptive cross-sectional study was conducted among the general population of Ward no. 2, Bhaktapur Municipality, Nepal. Sample for the study includes population both insured and non insured population. Systematic random sampling was done using the sample frame of Bhaktapur Municipality.

RESULTS
About two out of five population (42.4%) had been utilizing the social health insurance scheme. Three out of four of the respondents (74.30%) had renewed their insurance scheme. It was found that one fifth of the respondents (21.81% ) had less confidence in the scheme and the services the scheme had been providing followed by high premium cost of the scheme(20.16%). The main reason for renewal of the scheme was reduction of out of pocket payments (66.16%). Out of non-renewed population, almost half of the population did not renew the scheme due to the long queue (43.47%) and lack of care from the health care providers (39.13%). Social health insurance utilization was significantly associated with age, occupation and wealth quintile. Similarly, Social health insurance utilization was associated with availability of the services, charge paid during each visit, behaviour of health care provider, satisfaction of the services, confidence in services and source of information. The logistic regression analysis didn't show a significant association between age and occupation while there seemed to be a significant association between utilization of the social health insurance scheme and wealth quintile of the participants. An estimate from the logistic regression analysis indicated that the odds of utilizing the social health insurance scheme among rich population group were halves than the odds of the very rich population group. The study showed that the marital status plays significant role in utilizing social health insurance scheme and married household were more utilizing the schemes than the singles. 8 Indicators like ethnicity, religion showed no significant relationship in the enrollment of the social health insurance scheme as it basically focus on the household level than the individual level.
Educational status of the household head and family they had been residing plays no significant role in the utilization of the social health insurance (0. 5  Lastly my study revealed, 72.06% of the services were available at free of cost and found that the renewal of social health insurance scheme was highly associated with availability of the services (0.000 at 95% CI), 64.25% of the population had been paying less than 500 during each visit which also showed significant association with charge paid during each visit (0.007 at 95% CI), 83.8% of the health care service provider were polite showing significant association between behaviour of the health care provider and utilization of the services (0.003 at 95% CI) and confidence in the services (0.006 at 95% CI). 76% were satisfied with the services they had been using which showed significant association between satisfaction with the services and utilization of health insurance scheme (0.000 at 95% CI).

CONCLUSIONS
According to study, almost half of the respondents were found to be utilizing the health insurance scheme. Utilization was found to be higher in population with poor wealth quintile. Association between utilization was found with age, occupation of the participant, wealth quintile, availability of the services, charge paid during each visit, behavior of the health care provider, confidence in the scheme, satisfaction in the services that had been providing and source of the information. Various reasons were found for the renewal and non renewal of the services. The reason for the renewal of the services includes reduction of out of pocket payment, available of free services and better services. The reason for non renewal of the services were refusal from the spouse, long queue and lack of care were established by this study.
Hence, it could be concluded that utilization of the health insurance scheme could be increased by providing awareness to the general population regarding the services that have been providing by the health insurance scheme as well as proper management provision of continuous supply of medicine.