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

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.