Predictors of health insurance enrolment and wealth-related inequality in Nepal: evidence from Multiple Indicator Cluster Survey (MICS) 2019

Objectives We analysed predictors of health insurance enrolment in Nepal, measured wealth-related inequality and decomposed inequality into its contributing factors. Design Cross-sectional study. Setting We used nationally representative data based on Nepal Multiple Indicator Cluster Survey 2019. Out of 10 958 households included in this study, 6.95% households were enroled in at least one health insurance scheme. Primary outcome measures health insurance (of any type) enrolment. Results Households were more likely to have health insurance membership when household head have higher secondary education or above compared with households without formal education (adjusted OR 1.87; 95% CI: 1.32 to 2.64)). Households with mass media exposure were nearly three times more likely to get enroled into the schemes compared with their counterparts (adjusted OR 2.96; 95% CI 2.03 to 4.31). Hindus had greater odds of being enroled (adjusted OR 1.82; 95% CI 1.20 to 2.77) compared with non-Hindus. Dalits were less likely to get enroled compared with Brahmin, Chhetri and Madhesi (adjusted OR 0.66; 95% CI 0.47 to 0.94). Households from province 2, Bagmati and Sudurpaschim were less likely to have membership compared with households from province 1. Households from Richer and Richest wealth quintiles were more than two times more likely to have health insurance membership compared with households from the poorest wealth quintile. A positive concentration index 0.25 (95% CI 0.21 to 0.30; p<0.001) indicated disproportionately higher health insurance enrolment among wealthy households. Conclusions Education of household head, exposure to mass media, religious and ethnic background, geographical location (province) and wealth status were key predictors of health insurance enrolment in Nepal. There was a significant wealth-related inequality in health insurance affiliation. The study recommends regular monitoring of inequality in health insurance enrolment across demographic and socioeconomic groups to ensure progress towards Universal Health Coverage.