social health security programme: standard operating...

Social Health Security Programme: Standard Operating Procedures 2016

Government of Nepal Social Health Security Development Committee

Contents

Acronyms III

About these Standard Operating Procedures V

Part 1. Structure, Benefit Package and Provider Payment Mechanisms 1-12

Chapter 1. Introduction 3

Chapter 2. Organisational structure 5

Central level 5

District level 7

VDCs/municipality level 8

Chapter 3. Benefit package and member contribution 9

Benefit package 9

Member contribution 9

Chapter 4. Provider payment mechanisms 11

Health posts 11

Primary health centres 11

Hospitals 12

Payment for drugs 12

Part 2. Standard Operating Procedures 13-48

Chapter 5. Communication strategy 15

Chapter 6. Enrolment process 17

Chapter 7. Membership renewal process 23

Chapter 8. Replacing lost ID cards 27

Chapter 9. Change of first service point 29

Chapter 10. Health service utilisation 31

Health post 31

Primary health centre 32

Hospital or referral centre 36

Chapter 11. Claims from health facility 45

Claim entry 45

Medical review 46

System accountability 47

Annex 1: Terms of Reference of District manager 49

Annex 2: Terms of Reference of Enrolment officers 51

Annex 3: List of drugs provided through SHSP 53

Annex 4: Details of the Benefit Package Available through Social Health Security Programme 57

Annex 5: Enrolment form 69

Annex 6: Membership ID card 71

Annex 7: Receipt 73

Annex 8: Progress and Monitoring Form 75

Annex 9: Change of health facility form 77

Annex 10: General health check-up form 79

Annex 11: Referral form 81

Annex 12: OPD/ Emergency Ticket 83

Annex 13: Family member renewal form 85

Annex 14: Notification of payment 87

DDC district development committee

DM district manager

DSHSCC district social health security coordination committee

EA enrolment assistant

ECG electrocardiogram

EO enrolment officer

FCHV female community health volunteer

GON government of nepal

HDC hospital development committee

HFOMC health facility operation and management committee

IMIS insurance management information system

IPD in-patient department

MoH ministry of health

NHI national health insurance

OPD out-patient department

PHC primary health centre

SHS social health security

SHSDC social health security development committee

SHSP social health security programme

SOP standard operating procedures

USG ultrasonography

VDC village development committee

Acronyms

About these Standard Operating Procedures

This document contains the Standard Operating Procedures (SOP) for the implementation and operationalization of the Social Health Security Programme (SHSP). Part 1 contains a short introduction to the SHSP before explaining the structure of the programme, the benefit package and provider payment mechanisms.

Part 2 contains a step-by step guide to the business processes of the programme. It is designed for use by everyone involved in the running the SHSP at the central, district and community levels, including enrolment assistants, health facility management, staff and committees, staff of the district office of the SHSDC (district manager, accounts officer, enrolment officers, data entry clerk), the Social Health Security Development Committee, the District Social Health Security Coordination Committee, and the Ministry of Health. Part 2 is broken up into processes related to the communication strategy, enrolment, membership renewal, replacing lost cards, change of first service point, health service utilisation, and claims, for which step by step guidance is given, together with useful infographics explaining the involved processes.

1

Part 1

Structure, Benefit Package and Provider Payment mechaniSmS

this part provides a general overview of the Social health Security Programme, including its organisational structure, benefit package and provider payment mechanisms as background information to the Standard operating Procedures contained in Part 2.

3

chaPter 1.

IntroductIon

Nepal remains committed to achieving universal health coverage, as seen in the new constitution, which was promulgated in 2015. Although gradual progress has been made in terms of access to health services, much remains to be done. Out-of-pocket expenditure by households is still high, putting vulnerable populations at risk. Such out-of-pocket payments prevent a substantial proportion of the population from accessing health care services and puts them at risk of impoverishment from catastrophic spending. The various social health protection interventions in place are fragmented, often fail to provide the necessary financial protection against catastrophic spending and are not always based on medical need. Thus, there was a felt need for a mechanism in the health financing system to enhance pre-payment and risk pooling to minimise financial hardship and impoverishment arising from the use of health care services in Nepal.

National Health Insurance Programme got impetus following the budget allocation for the fiscal year 2012 (2068/2069 BS). Subsequently, Government of Nepal (GoN) adopted ‘National Health Insurance (NHI) Policy 2014 (2071 BS). as a key policy guide with a vision to ensure Universal Health Coverage. As envisioned by the policy on NHI, the Government of Nepal established a semi-autonomous body, Social Health Security Development Committee (SHSDC) in 2015 (2071 BS), as an implementer of the NHI. SHSDC chaired by the Secretary of the Ministry of Health, is composed of representatives from the Ministry of Finance, Ministry of Health, and Department of Health Services, along with experts. The SHS Program (Operating) Rules was endorsed by the MOH in 2015 (2072 BS), which set the legal foundation for the implementation; and Standard Operating Procedures (SOP) has also been approved by the committee in 2016 (2072 BS). The SHS program has been rolled out in three districts (Kailali, Baglung and Ilam) by 2016 (2072/2073 BS) and is planned to be subsequently expanded nationwide.

Intr

oduc

tion

4

National Health Insurance Policy

Long Term Goal

The long term goal is to improve the overall health status of Nepalese Citizens.

Main Objective

To ensure Universal Health Coverage by increasing access to, and utilization of necessary

quality health services.

Specific objectives

1) To increase the financial protection of the public by promoting pre-payment and risk

pooling in the health sector;

2) To mobilize financial resources in an equitable manner; and

3) To improve the effectiveness, efficiency, accountability and quality of care in the delivery

of health care services.

Goal and objectives of the policy are depicted in the following box:

5

chaPter 2.

organIsatIonal structure

The Social Health Security Programme (SHSP) is a social protection programme of the Government of Nepal that aims to enable its citizens to access quality health care services without placing a financial burden on them. The SHSP is a family-based health insurance scheme implemented by the Social Health Security Development Committee, which has a presence at two levels: a central office in Kathmandu and district offices in all implementation districts. It is also represented by enrolment assistants at the community [village development committee (VDCs) municipality] level. Health facility operations and management committees are also an integral part of the SHSP and are involved in tasks such as the selection of enrolment assistants and ensuring that services and drugs available through SHSP are available at the facility. Figure 1 illustrates the various organisational bodies and stakeholders involved in the administration, governance and provision of health services under the SHSP and their relationship with each other.

Central level

At the central level, the SHSP is implemented by the Social Health Security Development Committee (SHSDC), which is located in Kathmandu. The SHSDC, which was formed through the Social Health Security Development Committee Formation Order 2071 BS (2014 AD), is responsible for implementing the SHSP in Nepal. The SHSDC, led by the Secretary of the Ministry of Health as Chairman, includes representatives from the Ministry of Finance, Ministry of Health, and Department of Health Services, along with various subject experts (in the fields of medicine, health and health economics).

The SHSDC is tasked with making policy decisions on the benefit package, contribution amounts, developing mechanisms for providing subsidies to those identified as poor, as well as negotiating with service providers (public and private) on the provision of services, their costs and payment mechanisms.

For implementation of the programme, a diverse team of public health experts, medical doctors, paramedics, public administrators and IT experts are present at the central level of SHSDC, led by the executive director of the SHSDC. Until the Organisation & Management survey is complete, the executive director will be the GON’s gazetted first class officer or equivalent, seconded to the committee; thereafter, the executive director will be selected using a competitive process. This team at the central level is supported by the district team present at the headquarters of each implementation district.

org

anis

atio

nal

stru

ctur

e

6

Co

mm

un

ity

Cent

ral

Dist

rict

VD

C/

mu

nic

ipa

lity

Hea

lth

post

En

rol

Fig

ure

1: S

ocia

l Hea

lth

Sec

uri

ty P

rog

ram

me O

rga

niz

atio

na

l Str

uct

ure

So

cia

l Hea

lth

Sec

uri

ty P

rog

ram

me

(SH

SP)

Org

an

isat

ion

al S

tru

ctu

re

Leg

en

d

So

cia

l Hea

lth

Sec

uri

ty

Dev

elo

pm

ent

Co

mm

itte

e (S

HS

DC

)M

inist

ry o

fH

ealt

h (

MO

H)

SH

SD

Cd

istri

ctof

fice

SH

SD

Cce

ntra

lof

fice

Vo

lunt

eers

En

rolm

ent

ass

ista

nt En

rolm

ent

of

fice

r

Dist

rict

SH

S C

oo

rdin

atio

nC

om

mit

tee

Ad

min

istra

tio

nReg

ula

tio

nS

erv

ice p

rov

isio

n

No

min

ate &

sup

erv

ise

Prim

ary

hea

lth

cent

re

Nat

ion

al/ce

ntra

lh

osp

ita

l

Reg

ion

al/

zon

al/

dist

rict

hosp

ita

l

Serv

ice

uti

lisat

ion

Co

ord

inat

e

HFO

MC

Ref

err

al

Cla

im

Co

ord

inat

e

Su

pp

ort

7

District level

District offices

The district offices of the SHSDC are the representatives of the SHSP at the district level. Led by a district manager, the district offices are responsible for raising awareness about the insurance scheme among the public, coordinating and managing the memberships (enrolment, renewals), and liaising with the service providers in the district. The district offices are the first contact point for anyone looking for information on insurance and related issues.

District manager: A district manager leads the SHSDC district offices and is responsible for the overall implementation of the SHSP in the district. The district manager's focus is on coordinating with local governing bodies, communities, and service providers for the successful implementation of the SHSP. A detailed job description for the district manager can be found in Annex 1.

Enrolment officers: The enrolment officers form a link between the SHSP district office and the enrolment assistants at the community level. They are responsible for collecting the completed enrolment forms together with the contribution amounts from the enrolment assistants and bringing them back to the district offices for verification and entry into the Insurance Management Information System (IMIS). In addition, they are responsible for providing enrolment supplies and information related to renewals and feedback collection to the enrolment assistants. A detailed job description for the enrolment officer can be found in Annex 2.

Accounts officer: As the name suggests, the accounts officer is responsible for all accounting related matters for the district office. This includes managing the contribution amounts for enrolment and renewals as well as conducting accounting tasks of the district office.

Data entry clerk: The data entry clerk is tasked with entering the information on the enrolment forms collected by the enrolment officer into the IMIS.

District Social Health Security Coordination Committee

A District Social Health Security Coordination Committee (DSHSCC) is present in all SHSP implementing districts as the coordinating body that brings the programme together with other public institutions and with representatives from civil society. The major function of this committee is to smooth the work of SHSDC in the districts, raise awareness, and provide feedback on how to make the programme more effective in the districts. The following are the specific responsibilities of the DSHSCC:

• To coordinate the SHSP for smooth service delivery;

• To assist people from low income groups to access social security through the SHSP;

• To assist health facilities to improve their infrastructure;

org

anis

atio

nal

stru

ctur

e

8

• To monitor health security-related programmes within the district in coordination with the SHSDC district office; and

• To increase the participation of all stakeholders in the SHSP.

VDCs/municipality level

Health facility management committee

The health facility management committee coordinates the implementation of the SHSP in each health facility. In public health facilities, this committee is called the health facility operation and management committee (HFOMC) or hospital development committee (HDC). Private facilities have similar committees. It is envisioned that the health facility management committee includes two SHSP members (including one woman).

Enrolment assistants

The enrolment assistants are the representatives of the programme at the household level. Enrolment assistants go door-to-door to raise awareness of the insurance programme, enrol families and provide them with any information they need regarding the programme.

The management committees of a public facility recommend community members to the SHSDC to be selected as enrolment assistants. Based on this recommendation, the SHSDC district office selects enrolment assistants for the SHSP, such that there is one enrolment assistant per 1,000 families and an additional two enrolment assistants as back-up. After being trained on the various aspects of the SHSP, including the use of the IMIS, the enrolment assistants go back to their respective VDCs/municipalities equipped with a smartphone and information, education and communication (IEC) materials, prepared to enrol families into the programme.

Health facilities

During enrolment, SHSP members are given a choice to select their first service point, which is the most accessible health facility they would usually go to in order to seek health services. The first service point could be a primary health centre (PHC) or a hospital.

These health facilities provide health services to SHSP members using very similar procedures to what they follow for non-SHSP members. Health facilities are responsible for identifying if a particular person who has come to seek services is a member of the SHSP, providing health services and drugs according to the provisions spelled out by the agreement between the health facility and the SHSDC, and referring them to a higher-level facility (if required). The SHSP envisions a cashless system for SHSP members at the health facility (except for the 15% co-payment for drugs). The health facility claims the agreed upon amounts from SHSDC after providing services to the member.

9

chaPter 3.

BenefIt Package and memBer contrIButIon

Benefit package

The benefit package is the services and drugs that are available to SHSP members at health facilities under the SHSP. These include emergency services, out-patient services, select in-patient services, select diagnostic services and select drugs, in addition to any free services and drugs available at public health facilities through other programmes. The services and drugs in the benefit package have a standardised price, which is the basis for determining the deductions to the ceilings for the SHSP members after receiving services. The maximum ceiling available to SHSP members is based on the size of the family (see Table 1). The list of drugs and services available under the SHSP is presented in Annexes 3 and 4 respectively.

Member contribution

The member contribution (or contribution amount) is the yearly amount a family has to pay for membership in the SHSP. The annual contribution amount depends on the size of the family (see Table 1). The contribution amount has to be paid, in full, during the time of enrolment.

Table 1. Annual member contribution amount and ceiling

Family size Annual contribution amount per family

Maximum ceiling per family per year

Families with up to 5 members

NPR 2,500 NPR 50,000

Each additional member of the family

NPR 425 per additional member

NPR 10,000 per additional member but a maximum ceiling of 100,000 per family

Children born within a family’s valid coverage period are covered by the SHSP for that period without paying any additional contribution amount. However, they must be enrolled in the SHSP at the time of renewal by paying the contribution amount, like other members of the family.

Ben

efit

pac

kage

and

m

embe

r co

ntri

buti

on

11

chaPter 4.

ProvIder Payment mechanIsms

The SHSP is designed to be cash-less system for members seeking health services. Upon presenting their SHSP membership ID card at a health facility, members are able to receive the health services and drugs covered by the benefit package without having to pay at any stage, except when receiving drugs (for which a co-payment of 15% is required) and if they bypass the first service point in non-emergency case (in which case a co-payment of 50% is required).

This effectively means that service providers have to provide services to members free of cost initially and then claim reimbursement from the SHSDC according to the agreed rates. The IMIS streamlines this claims process for health facilities, while providing a convenient claim review mechanism for the SHSDC. Upon a successful review of a claim, the claimed amount is paid to the health facility by the SHSDC at pre-defined intervals. The SHSDC has opted for a case based payment mechanism, in which a fixed rate is paid for each out patient emergency service provided. For inpatient care, SHSDC pays a fixed rate according to the diagnosis (diagnosis specific costs have been calculated by the SHSDC).

Health posts

Even though health posts are not assigned as the first service point, they do provide basic health services to SHSP members. In particular, they provide SHSP members in their catchment area who are above the age of 40 with a yearly health check-up. Health posts can claim for reimbursement of such services from SHSDC, according to the previously agreed rates.

Primary health centres

Primary health care centres (PHCs) are the first service point for SHSP members and provide emergency and out-patient services including required drugs. After providing services to members, PHCs can claim the cost of providing services covered in the benefit package from the SHSDC, which reviews the claim and judges if it is in accordance with the agreement between the two parties. Once approved, the SHSDC reimburses the PHC for the amount claimed.

Prov

ider

pay

men

t m

echa

nism

s

12

Only 85% of the amount claimed for drugs will be reimbursed by the SHSDC, as facilities are responsible for collecting 15% as a co-payment from the member.

The facility cannot claim for reimbursement for follow-up visits for an OPD service within 7 days of the initial consultation.

Hospitals

The mode of payment for hospitals is similar to that for PHCs; hospitals provide services to SHSP members free of cost initially and claim reimbursement from the SHSDC later. Compared to PHCs, there are more services available to members at hospitals, such as in-patient services and more sophisticated diagnostic services.

Payment for drugs

Although the SHSP has been designed as a cash-less system, a co-payment is required from the SHSP member for drugs. While 85% of the cost of drugs is deducted from the member's benefit ceiling, 15% of the cost must be paid by the member to the pharmacy in cash at the time when the drug is dispensed. Therefore, health facilities will only be reimbursed for 85% of the cost of drugs claimed, as the SHSDC expects the health facility/pharmacy to collect the remaining 15% directly from the member.

The only exception to this co-payment is if the member has been classified as either of the three categories: ultra-poor, poor or vulnerable, by the SHSDC during enrolment. In such a case, no co-payment is required.

The list of drugs available through the SHSP is given in Annex 3.

13

Part 2

Standard oPerating ProcedureS

this part contains the standard operating procedures and is designed to be used by practitioners of ShSP and health facilities as a practical step-by-step guide to the processes involved in the ShSP from enrolment through to claims processing.

15

chaPter 5.

communIcatIon strategy

Public awareness raising (sensitisation) about the objectives, concepts and modalities of the SHSP needs to be carried at three levels (central, district and community) to sensitise the population on the benefits of SHSP and encourage enrolment. At the central level, mass media will be used as the chief means of raising public awareness. A circular will be issued containing the guidelines for sensitisation, radio broadcasts will be made and sensitisation materials distributed. Coordination will be established with institutional stakeholders, such as large employers, cooperatives, microfinance institutions, non-government organisations (NGOs) and unions, for the purpose of including them in the sensitisation campaign. The SHSDC may also seek the assistance of other institutions for its sensitisation campaign.

Other ministries will also be coordinated with regarding sensitisation. For example, efforts will be made to anchor information on the utility of the SHSP in the health curricula of schools, in coordination with the Ministry of Education.

At the district level, the DSHSCC will coordinate with other ministries and stakeholders. The SHSP district offices will conduct and coordinate SHSP sensitisation activities on appropriate occasions (e.g., at local festivals/jatras, at harvest time, and during exhibitions, etc.).

At the community level, apart from enrolment assistants, female community health volunteers (FCHVs), social mobilisers and teachers may also be mobilised for sensitisation activities. It is the responsibility of the DSHSCC to ensure that sufficient sensitisation materials (such as leaflets and posters) are produced and distributed at the community level to the concerned stakeholders.

com

mun

icat

ion

stra

tegy

17

chaPter 6.

enrolment Process

Families can enrol in the SHSP at any time of the year, with services starting on one of the four appointed policy start dates: 1 Bhadra, 1 Mangsir, 1 Falgun or 1 Jestha, depending on the day of enrolment. The policy is valid for 1 year starting from the policy start date. The enrolment period and corresponding policy start dates are presented in Table 2.

Table 2. Policy start dates for different enrolment months

Enrolment month Policy start date

Magh to Chaitra (Approx. 15 Jan–14 Apr) 1 Jestha (Approx. 15 May)Baisakh to Asadh (Approx. 15 Apr–14 Jul) 1 Bhadra (Approx. 15 August)Shrawan to Ashwin (Approx. 15 Jul–14 Oct) 1 Mangsir (Approx. 15 November)Kartik to Poush (Approx. 15 Oct–14 Dec) 1 Falgun (Approx. 15 February)

The following are the steps to be followed in the enrolment process.

Step 1: The enrolment assistants inform people about the SHSP and its benefits at various social gatherings (such as local festivals, school parent-teacher days, meetings of mothers’ groups and health camps) and at sessions organised at health facilities to provide information on the SHSP and its benefits. The enrolment assistants distribute information, education and communication (IEC) materials to families and encourage them to enrol in the programme.

Step 2: The enrolment assistant visits potential families and provides details of the benefit package and contribution amount and answers any questions about enrolment. During visits, the enrolment assistant informs the family how much they have to pay to enrol in the programme, depending on the size of their family and their poverty status.

Step 3: Once families are ready to enrol, the enrolment assistant fills out an enrolment form for each member of the family, collects the contribution amount and provides a receipt.

enro

lmen

t pr

oces

s

18

If any family claims to be poor, the enrolment related assistant takes the following steps:

• If the family is poor, ultra-poor or marginalised and has an identity card provided by Ministry of Cooperatives and Poverty Alleviation of the Government of Nepal, the enrolment assistant records the serial number of the card on the enrolment form and calculates the amount accordingly.

Step 4: Using the Enrolment App on the SHSDC provided mobile phone, the enrolment assistant scans the QR code on the completed enrolment form and takes a picture of the associated family member. This process is repeated for each family member. In this way the QR code on a particular form is associated with the picture of the member whose details appear on the form.

Step 5: On the receipt provided to the new member, the enrolment assistant records that it is a new enrolment and writes the serial number of the receipt on the family head’s enrolment form. All of the documents generated during the process of enrolling a family (forms, copies of receipts) are stapled together and filed by the enrolment assistant.

As the SHSP is for Nepali citizens only, proof of Nepali citizenship of any one of the family members must be provided to the enrolment assistant during enrolment.

Step 6: After the enrolment process, the enrolment assistant issues an insurance membership ID card for each member of the family. The enrolment assistant informs the family of the policy start date.

Step 7: If there is no Internet access during enrolment at the household, the enrolment assistant uploads the photographs in one of two ways:

• from the phone once the Internet is available, or

• by transferring the photographs to the laptop of the enrolment officer on their next visit.

Step 8: The enrolment officer visits each VDCs/municipality every two weeks to monitor various aspects of the programme, as well as to collect documents and contribution amounts from enrolment assistants. During this visit, the enrolment assistant hands over the completed enrolment forms and contribution amounts to the enrolment officer who records the same on the progress and monitoring form. It is at this meeting that any remaining photographs are transferred from the enrolment assistant’s phone to the enrolment officer's laptop for uploading into the IMIS at the district office.

Step 9: The enrolment assistant follows the following steps while handing over the documents and contribution amount to the enrolment officer.

• The enrolment assistant fills in the progress and monitoring form.

• The enrolment officer checks the completeness of all enrolment form-related documents.

19

• The enrolment officer accepts the contribution amount after crosschecking against the number of families (and members) being enrolled.

• The enrolment officer includes details of the incentive to be provided to the enrolment assistant and record the details of this amount on the progress and monitoring form.

• Both the enrolment assistant and the enrolment officer sign the progress and monitoring form.

• The enrolment assistant and the enrolment officer each keep a copy of the form.

The incentive amounts due to the enrolment assistant for enrolling new members are deposited into the enrolment assistant’s bank account by the district office of the SHSDC.

Step 10: The enrolment officer hands over all documents and contribution amounts to the accounts officer of the district office, or provides a deposit slip to the accounts officer to show that the contribution amounts have been deposited into the SHSDC bank account (and keeps a written record of this).

Step 11: The accounts officer crosschecks the contribution amount paid by each family (cash or bank deposit voucher) with the amount mentioned in the receipt. If it matches, the accounts officer receives the receipts and cash/deposit slips and signs a summary form. If there are any discrepancies, the following steps are taken:

• The accounts officer directs the enrolment officer to correct the discrepancy between the description of the families enrolled in the SHSP and the contribution amount.

• If the description of individual families enrolled in the SHSP and their respective contribution amount match, but a discrepancy is found in the total amount, the accounts officer resolves the discrepancy with the enrolment officer.

Step 12: The accounts officer deposits the collected contribution amount to the SHSDC bank account and keeps a record of the amount deposited (including details of the amount handed over by the enrolment officer). The deposit slip is filed by the accounts officer after being checked by the district manager. If the enrolment officer has deposited the collected money and made the deposit slip available, the district manager tallies the deposit slip with the bank statement. If there is any discrepancy between the two, the district manager resolves it with the concerned enrolment officer.

Step 13: After confirming the financial accuracy of the contribution amounts, the accounts officer hands over the enrolment forms to the district manager. The district manager checks all of the documents and details submitted by the accounts officer.

• If the collected documents and details are not complete or inaccurate, the district manager instructs the enrolment officer to collect/correct the documents or details.

enro

lmen

t pr

oces

s

20

Step 14: After obtaining all enrolment related documents and details of families, the district manager sends these to the data entry clerk for entry into the IMIS.

During this process, the membership ID number for each family member is linked to the membership ID number of the family head.

Tables 3 and 4 list some of the important personnel and documents/supplies needed in the enrolment process.

Table 3. Important actors in the enrolment process

Important actors

Head of family

Member of family

Enrolment assistant

District manager

Enrolment officer

Accounts officer

Data entry clerk

Table 4. Important documents/supplies for the enrolment process

Important documents/supplies Remarks

Enrolment form with membership ID card One for each family member (see Annex 5)

ID card cover For each enrolee

(Smart) mobile phone For each enrolment assistant

Receipt (for collecting contribution amounts and internal transactions)

For each enrolment officer and enrolment assistant (See Annex 7)

Progress and monitoring form For each enrolment officer and enrolment assistant (See Annex 8)

Laptop For enrolment officer

Bag For each enrolment officer and enrolment assistant to keep supplies and documents

Motorbike For enrolment officer

Stapler For each enrolment officer and enrolment assistant

Pens For each enrolment officer and enrolment assistant

21Figure 2: Enrolment process

Fill inEnrolment Form

NoYes

Collect contributionamount and

provide receipt

Visit household

Submitthrough app

Submit

Check pooridentity

card

Distribute membership card

to each family member

Fill in monitoring and progress form

Provide newforms & materials

NO

Documents & amountcomplete?

Collectdocuments

andContribution

amount

Return to EA for correction

YES

YES

Enrolmentassistant

(EA)

Enrolmentofficer(EO)

(Hands over filled Enrolment Forms,

contribution amount, vouchers

and receipts)

(Transfers unsubmitted Photos

to EO’s phone/ laptop)

Meetat a designated

location(every 15 days)


Acc

ount

ant Accountant

Districtmanager

(DM)

Submits documents and

contribution amount

Hand over documents

Return toEO for correction

Deposit moneyin bank

Keep account of transactions

Accountant checks

documents& amount

are complete

NO

YES

NO

DM checksdocuments

& amounts are complete

Return documentsto accountant

Hand over approved

documents toaccountant

Enrolment Process

Inform,advise and

convince

Does familyhave poor

identity card?

With app in mobile:

-Scan QR code of all

Enrolmentforms

-Take photo of each member

Data entry clerk enters

data into IMIS



NoYes


provide receipt

Visit household

Submitthrough app

Submit

Check pooridentity

card





NO


Collectdocuments

andContribution

amount


YES

YES

Enrolmentassistant

(EA)




and receipts)



Meetat a designated



Acc

ount

ant Accountant

Districtmanager

(DM)


contribution amount

Hand over documents




Accountant checks

documents& amount

are complete

NO

YES

NO

DM checksdocuments



Hand over approved


Enrolment Process

Inform,advise and

convince


identity card?

With app in mobile:


Enrolmentforms



data into IMIS



NoYes


provide receipt

Visit household

Submitthrough app

Submit

Check pooridentity

card





NO


Collectdocuments

andContribution

amount


YES

YES

Enrolmentassistant

(EA)




and receipts)



Meetat a designated



Acc

ount

ant Accountant

Districtmanager

(DM)


contribution amount

Hand over documents




Accountant checks

documents& amount

are complete

NO

YES

NO

DM checksdocuments



Hand over approved


Enrolment Process

Inform,advise and

convince


identity card?

With app in mobile:


Enrolmentforms



data into IMIS

chaPter 7.

memBershIP renewal Process

The renewal process starts 2 months before the date of expiry of the SHSP membership. The following are the steps to be followed in the membership renewal process.

Step 1: The district manager generates a list of upcoming renewals using the IMIS. This list is disaggregated into VDCs/municipalities and wards.

Step 2: The enrolment officer takes the list of all families due for renewal when visiting the VDCs/municipalities to monitor and collect documents and contribution amounts.

Step 3: The enrolment officer provides the list of families due for renewal to the enrolment assistant during his/her regular visit to the VDCs/municipalities and provides details of which members need (new) photographs taken, if any.

Step 4: The enrolment assistant informs the members listed of the need to renew their membership.

Step 5: If family agrees to renew:

• The enrolment assistant renews the membership by filling out a membership renewal form for the family. If any of the members need a new photograph, the enrolment assistant takes the photograph on his/her mobile phone.

• The enrolment assistant collects the contribution amount from the family after the renewal process (including the contribution amount for any new family members), based on the SHSP provisions, and issues a receipt marked ‘renewal’.

• If the family is poor, ultra-poor, or marginalized and has a poor identity card provided by the Ministry of Cooperative and Poverty Alleviation after the previous enrolment or renewal process, the enrolment assistant records the serial number of the verification documents on the renewal form and calculates the contribution amount accordingly.

The validity and status of the poverty card has to be determined every year during renewal, and contributions calculated accordingly.

mem

bers

hip

rene

wal

pr

oces

s

24

The classification of poor families is determined by the Ministry of Cooperatives and Poverty Alleviation.

Step 6: If the description of the family has changed (e.g., new members added or members removed), the form is filled in based on the new description. For each new member, a new enrolment form is filled in, QR code scanned and photograph taken using the Enrolment App.

Step 7: The new member is issued a membership ID card. If necessary, the enrolment assistant updates other members’ photographs. The enrolment assistant compiles all documents of a single family together.

Step 8: The enrolment assistant scans and sends details of the family using the Renewal app on his/her mobile phone.

Step 9: The enrolment assistant hands over all documents and any contribution amounts to the enrolment officer at the next meeting. While handing over documents and amounts the following steps are taken:

• Along with the renewal details, the enrolment assistant fills in a progress and monitoring form.

• The enrolment officer checks the completeness of the renewal form-related documents.

• The enrolment officer accepts the contribution amount for renewal after crosschecking against the number of families (and members) being renewed.

• The enrolment officer includes the details of the incentive to be provided to the enrolment assistant and records the details of this amount on the progress and monitoring form.

• Both the enrolment officer and enrolment assistant sign the progress and monitoring form.

• The enrolment officer and enrolment assistant each keep one copy of the form.

Step 11: If there are any photographs remaining to be uploaded from the enrolment assistant's smartphone (due to the lack of Internet connection), the enrolment officer transfers the photographs to his/her laptop for uploading into the IMIS. Photographs are then deleted from the enrolment assistant’s smart mobile, but only after ensuring that photographs are secured on the server.

The incentive amounts due to the enrolment assistant for renewing members are deposited into the enrolment assistant’s bank account by the district office of the SHSP.

Step 12: The enrolment officer hands over all documents and contribution amounts to the accounts officer of the district office, or provides the original deposit slip to the accounts officer to show that the contribution amounts have been paid into the SHSDC bank account (and keeps a written record of this).

25

Step 13: The accounts officer crosschecks the contribution amount paid by each family (cash or bank deposit voucher) with the amount mentioned in the receipt. If it matches, the accounts officer receives the receipts and cash/deposit slips and signs a summary form. If there are any discrepancies, the following steps are taken:

• The accounts officer directs the enrolment officer to correct the discrepancy between the description of families enrolled in the SHSP and the contribution amount.

• If the description of individual families enrolled in the SHSP and their respective contribution amount match, but a discrepancy is found in the total amount, the accounts officer resolves the discrepancy with the enrolment officer.

Step 14: The accounts officer deposits the collected contribution amount to the SHSP bank account and keeps a record of the amount deposited (including details of the amount handed over by enrolment officer). The deposit slip is filed by the accounts officer after being checked by the district manager. If the enrolment officer has deposited the collected money and made the deposit slip available, the district manager tallies the deposit slip with the bank statement. If there is any discrepancy between the two, the district manager resolves the discrepancy with the concerned enrolment officer.

Step 15: After confirming the financial accuracy of the contribution and renewal amounts, the accounts officer hands over the renewal forms to the district manager.

• The district manager checks all of the documents and details submitted by the accounts officer.

• If the documents and details are not complete, the district manager instructs the enrolment officer to collect the remaining documents or details.

Step 16: After obtaining all renewal related documents and details of families, they are sent to the data entry clerk for entry into the IMIS.

During this process, the membership numbers for each family member are linked to the membership number of the family head.

Tables 5 and 6 list some of the important personnel and documents/supplies needed in the renewal process.

mem

bers

hip

rene

wal

pr

oces

s

26

Table 5. Important actors in the renewal process

Important actors

Head of family

Member of family

Enrolment assistant

Enrolment officer

Accounts officer

District manager

Data entry clerk

Table 6. Important documents/supplies for the renewal business process

Important documents/supplies Remarks

Membership Renewal form See Annex 13

(Smart) mobile phone For enrolment assistant



Progress and monitoring form For each enrolment assistant and enrolment officer (See Annex 8)

Laptop For enrolment officer

Motorbike For enrolment officer

Stapler For each enrolment assistant and enrolment officer

Pens For each enrolment assistant and enrolment officer

Bag For each enrolment officer & enrolment assistant to keep supplies and documents

27

chaPter 8.

rePlacIng lost Id cards

If any SHSP member requires a replacement membership ID card, the following steps are followed.

Step 1: Any member requiring a replacement membership ID card is required to contact the enrolment assistant of the respective VDCs/municipalities or the district office of the SHSP and present the membership ID card of the head of family (or other family member). If the membership ID cards of all members of a family are lost or destroyed, the details are checked in the records of the IMIS. The enrolment assistant should provide the details of the member (name, VDCs/municipalities, name of household) to the enrolment officer and find out the ID number of the member.

Step 2: The enrolment assistant fills in a new enrolment form for the member and marks it with ‘replacement membership ID card’. The identification number of the family head (or other family member) is recorded on the form. In case the family head does not have a membership ID card, the identification number of another member of the family is recorded on the form.

Step 3: The enrolment assistant scans the QR code on the enrolment form with the enrolment app on his/her mobile phone, takes a photograph of the member with the phone and gives the replacement membership ID card to the member. The enrolment assistant then provides a receipt to the member after taking NPR 20 for the replacement membership ID card.

Step 4: The enrolment assistant hands over the enrolment form and the contribution amount collected for the replacement membership ID card to the enrolment officer in the next meeting, who records the same on the progress and monitoring form.

Step 5: The enrolment officer hands over all documents and contribution amounts to the accounts officer of the district office, or provides a deposit slip to show that the contribution amounts have been paid into the SHSDC bank account (and keeps a written record of this).

Step 6: The accounts officer crosschecks the contribution amount paid by the member for the replacement membership ID card with the amount mentioned in the receipt. If it matches, the accounts officer signs the form. If there is a discrepancy, the accounts officer mentions this on the form.

repl

acin

g lo

st I

d

card

s

28

Step 7: After confirming the financial accuracy of the contribution amount, the accounts officer hands over the enrolment form to the district manager. The district manager checks all of the documents and details submitted by the accounts officer. If the collected details and documents are not complete, the district manager instructs the enrolment officer to collect the remaining details or documents.

Step 8: The designated personnel changes the membership ID number of the person issued with a replacement membership ID card in the IMIS.

Note: If any person issued with a replacement ID card is not already registered in the programme, the documents are resent to the enrolment assistant. In such cases, the enrolment assistant is instructed to hand over the contribution amount, all documents and the receipt.

Tables 6 and 7 list some of the important personnel and the documents/supplies needed in the replacement of membership ID card process.

Table 7. Important actors in replacement of membership ID card process

Important actorsHead of family

Member of family

District manager

Accounts officer

Enrolment assistant

Enrolment officer

Data entry clerk

Table 8. Important documents/supplies in the replacement of membership ID card process

Important documents/supplies REMARkS

Enrolment form with membership ID card For each enrole (See Annex 5)

ID card Cover For each family member (see Annex 6)

(Smart) mobile phone For each enrolment assistant and enrolment officer

Progress and monitoring form For each enrolment assistant and enrolment officer (see Annex 8)



Bag For each enrolment officer and enrolment assistant to keep supplies and documents

Laptop For enrolment officer to use IMIS

Pens For each enrolment officer & enrolment assistant

29

chaPter 9.

change of fIrst servIce PoInt

If any SHSP member wishes to change the health facility that serves as his/her first service point, the following steps are followed.

Step 1: If the health facility designated as the first service point needs to be changed, the family member wishing to make the change contacts a nearby enrolment assistant or the district office of the SHSDC and informs them of the need to change the first service point.

Step 2: The enrolment assistant visits the member and fills in a change form, indicating the change to the first service point. The enrolment assistant then submits this form to the enrolment officer.

Step 3: The enrolment officer then submits all documents to the district manager and keeps a written record of this.

Step 4: If the documents and details collected are not complete, the district manager instructs the enrolment officer to collect the remaining details and documents.

Step 5: After receiving all details and documents needed to change the health facility designated as the first service point, the change form is approved and sent to the data entry clerk for entry into the IMIS.

Step 6: The data entry clerk enters the details of the change into the IMIS.

Tables 9 and 10 list some of the important personnel and documents/supplies needed in the change of health facility process.

chan

ge o

f fi

rst

se

rvic

e po

int

30

Table 9. Important actors in change of health facility process

Important actors

Head of family

Member of family

District manager

Enrolment officer

Enrolment assistant

Data entry clerk

Table 10. Important documents/supplies for changing health facilities

Important supplies/ documents Remarks

Change form See Annex 9

(Smart) mobile phone For each enrolment assistant

Bag For each enrolment assistant and enrolment officer to keep supplies and documents

Laptop For each enrolment officer

31

chaPter 10.

health servIce utIlIsatIon

During enrolment, members are allowed to select their first service point, which is the health facility they would go to first when seeking health services. The first service point is the closest primary health care centre (PHC) or hospital to the member's home.

These health facilities provide health services to SHSP members, using very similar procedures to those followed for non-SHSP members. Health facilities are responsible for identifying if a particular person who has come to seek services is a member of the SHSP, providing the services and drugs according to the provisions spelled out by the agreement between the facility and the SHSDC, and referring the SHSP member to a higher level facility (if required). The SHSP envisions a cashless system at the health service provider (except for the 15% co-payment for drugs and 50% co-payment for bypassing the first service point). The health facility claim reimbursement of the agreed upon amounts from SHSDC after providing services to the SHSP member.

Health post

Even though health posts are not defined as the first service point for members of the SHSP, they are required to provide any treatment services deemed necessary by the Government of Nepal free of charge, as they currently do for the general public (including non-SHSP members). There are no deductions to the benefit package ceiling for services received by SHSP members from a health post. If the required health services are not available at the health post, a referral is made to the member’s first service point. However, the health post must provide health screening once in a year to the SHSP members in their catchment area who are above 40 years of age. This service can be claimed for reimbursement from the SHSDC.

Step 1: Health posts provide a general health screening to SHSP members above 40 years of age once a year. The services to be provided under the general health screening are defined in Annex 7 of the Social Health Security Programme (Operating) Rules 2014.

Step 2: The health post then claims reimbursement for each health screening service provided to an SHSP member. The SHSDC reimburses the health post at the rate mentioned in Social Health Security Programme Operating Rules 2014.

hea

lth

serv

ice

util

isat

ion

32

Tables 11 and 12 list some of the important personnel and documents/supplies needed in health service utilisation process.

Table 11. Important actors in the utilisation of health services at a health post

Important actors

SHSP members above 40 years of age

Health professionals at health posts

Table 12. Important documents/supplies in the utilisation of health services at a health post


Membership ID card For identification at the health facility (see Annex 6)

General health screening form For health screening (see Annex 10)

Referral form In case referral has to be made (see Annex 11)

(Smart) Mobile phone To use IMIS

Primary health centre

An SHSP member should initially seek health care services from the first service point selected during enrolment. The first service point is generally a PHC or hospital in the district of enrolment.

Step 1: Except in cases of emergency, health facility staff at the registration counter should check to determine if the person seeking health services is a member of the SHSP or not.

In case of emergency, medical services are provided before trying to determine SHSP membership.

Step 2: To determine membership, the health facility staff at the registration counter should take the following steps:

• Use the IMIS Enquire app by scanning the QR Code of the membership ID card. An alternative is to enter the membership ID number into the IMIS search (on the computer). The IMIS will provide the picture, membership active period, and first service point, as well as the remaining ceiling of the SHSP member. Using this information, the health facility staff at registration should determine the ownership and validity of the SHSP membership.

• If an internet connection is not available, the IMIS should be used through the smartphone only. The Enquiry app will run in 'offline mode' and display all the information required to determine ownership and validity.

Step 3: If any problems occur with the verification process, the health facility staff will coordinate with the designated SHSP office.

33

Step 4: If the person seeking services has no membership ID card, but claims to be an SHSP member, the health facility registration staff will ask him/her to wait while their membership is confirmed.

Membership can be determined by searching the IMIS (only computer based), using information such as the service seeker's name, VDCs/municipality, ward and gender.

Step 5: If the member has a low balance (less than 10%) remaining on the ceiling, the health facility staff will inform the member of the following:

• The possibility that the balance may be exhausted during service utilisation; and

• The requirement to pay any remainder if the balance is exhausted.

Step 6: After determining membership, the health facility staff member at the registration desk records the SHSP member’s name, membership ID number, and health facility code, on the OPD ticket (Service utilization form) (Annex 12). Health facility staffs are to ensure that the three copies of the OPD ticket (one original and two automated carbon copies) are intact.

If the policy of the SHSP member is not active and the ceiling amount has been exhuausted, the health service utilisation process is the same as for someone who is not a member of SHSP.

Step 7: The health facility staff member asks the member if any other family member is receiving services through their SHSP membership at the same time. If another member of the family is also receiving services and if the balance is unlikely to be enough for both services, the health facility staff member will inform the SHSP member of:

• the possibility that the balance may be exhausted during service utilisation; and

• the requirement to pay any remainder if the balance is exhausted.

Step 8: The SHSP member is then directed towards the OPD with the OPD ticket (3 copies) filled in by the health facility staff member.

Step 9: At the OPD, the health worker fills out the OPD ticket form with information such as the complaint, required diagnostic tests, and required medication and follow up required.

Processes required for other information systems such as HMIS – filling out OPD register etc. still need to be continued even for SHSP members.

Step 10: If the patient only requires counselling/advice and does not need drugs or further diagnostic services, the health worker:

• Provides the required advice and counselling

• Gives the original OPD ticket (white copy) to the patient and keeps two copies of the form

• Hands over two copies (red and yellow) of the OPD ticket to the appropriate health facility staff member at a pre-defined time (e.g., end of OPD visiting time)

hea

lth

serv

ice

util

isat

ion

34

Step 11: If the patient requires drugs:

• The health worker provides the necessary advice and counselling and directs the member to the pharmacy with all three copies of the OPD ticket.

• At the pharmacy, the patient gives all three copies of the OPD ticket to the attendant.

• If the prescribed drugs are among the government mandated free drugs, the pharmacy provides the drugs free of charge to the patient.

• If the prescribed drugs are among the drugs provided by SHSP, the pharmacy provides the drugs after collecting the 15% co-payment from the patient. The amount of the co-payment is recorded on the OPD ticket and stamped by the pharmacy. (The remaining 85% is reimbursed by the SHSDC.)

• The pharmacy provides the stamped original OPD ticket (white copy) to the member and keeps the other two.

• At a pre-defined time (e.g., end of OPD visiting time), the pharmacy hands over the copy of the form to the concerned health facility staff member.

Step 12: If the SHSP member utilising the health services needs diagnostic services:

• The health worker provides the necessary advice and counselling and directs the member to the registration/billing counter with three copies of the OPD ticket.

• The member gives all three copies of the health OPD ticket to the health facility staff member at the registration/billing counter.

• The health facility staff member at the registration/billing counter issues the invoice for the diagnostic services (lab, X-ray, USG, etc.) and marks that the service has been provided through the SHSP.

• The patient takes this invoice and proceeds to the appropriate diagnostic room (lab, X-ray, USG, etc.). All three copies of the OPD ticket are kept at the registration counter.

• If any of the services ordered by the health worker are not available, it is clearly mentioned on the OPD ticket.

• The SHSP member gives the invoice to the health facility staff member at the diagnostic room.

• The health facility staff member at the diagnostic room provides the required services as mentioned in the invoice and information regarding report collection.

• All diagnostic test reports are collected from the reception/billing counter, along with the three copies of the OPD ticket left there previously. Once the report is ready, the SHSP member utilising the service consults the doctor with the report and the OPD ticket, which is collected from the registration/billing counter.

• The health worker provides the services to the SHSP member (as mentioned in Step 9).

35



Step 13: If the SHSP member utilising the health services needs both drugs and diagnostic services:

• The health worker, after providing the necessary advice and counselling, gives the three copies of the OPD ticket (with information regarding the drugs and the diagnostic test requirements), and directs the member to collect the drugs from the pharmacy first and then go to the registration/billing counter for diagnostic services.

• The member gives all three copies of OPD ticket to the pharmacy.

• The pharmacy provides the drugs by taking the co-payment amount (15% of the cost of drugs covered by SHSP) from the SHSP member. The co-payment amount is recorded on the OPD ticket.

• The pharmacy stamps all three copies of OPD ticket, gives all of them to the member and asks the member to take them to the billing counter. For their internal book-keeping, the pharmacy keeps a record of the drugs dispensed.

• The member gives all three copies of the form to the billing/registration counter.

• The health facility staff member at the registration/billing counter issues the invoice for the diagnostic services (lab, X-ray, USG, etc.) and marks that the service has been provided through the SHSP.

• The patient takes this invoice and proceeds to the appropriate diagnostic room (lab, X-ray, USG, etc.). All three copies of OPD ticket are kept at the registration counter.



• The health facility staff member at the diagnostic room provides the services mentioned in the invoice and the necessary information regarding report collection.

• All diagnostic test reports are collected from the registration/billing counter, along with the three copies of the OPD ticket left there previously. Once the report is ready, the patient consults the doctor with the report and the OPD ticket, which is collected from the registration/billing counter. The health facility staff member at the diagnostic room keeps a record of the reports, either in the computer or in the register.

• The health worker provides services to the member (as mentioned in Step 9).



hea

lth

serv

ice

util

isat

ion

36

Step 14: If the member seeking the health services requires more services from a higher-level health facility:

• The doctor refers the member to a higher-level health facility by filling in a referral form (Annex 11).

• The white copy of the OPD ticket, a referral letter and other related documents are handed over to the SHSP member with instructions to go to the assigned higher-level facility.

• The health facility informs the referral case to the higher level health facility where the patient is referred

• Once at the higher-level health facility, the member follows the same steps as they did when visiting their first service point – at registration, they should present their referral form along with the membership ID card.

Step 15: The health facility staff member submits a claims for reimbursement of the services rendered from the SHSDC, in accordance with the OPD ticket (service utilisation form), using the IMIS.

Step 16: During the regular visit of the enrolment officer to the health facility, one copy of all accumulated copies of the claim forms and the IMIS generated claim summary sheet are handed over by the health facility to the enrolment officer.

Hospital or referral centre

The SHSP member is required to seek health care services from the health facility designated as the first service point during enrolment. While utilising health services from a hospital or referral centre, the following steps are followed.

Step 1: Except in cases of emergency, health facility staff at the registration counter should check to determine if the person seeking health services is a member of SHSP or not before providing the medical services.

In case of emergency, medical services are provided before trying to determine SHSP membership.

Step 2: To determine membership, the health facility staff at the registration counter should take the following steps:

• Use the IMIS Enquire app by scanning the QR Code of the membership ID card. An alternative is to enter the membership ID number into the IMIS search (on the computer). The IMIS will provide the picture, membership active period, and first service point, as well as the remaining ceiling of the SHSP member. Using this information, the health facility staff at registration should determine the ownership and validity of the SHSP membership.

37

• If an internet connection is not available, the IMIS should be used through the smartphone only. The Enquiry app will run in 'offline mode' and display all the information required to determine ownership and validity.

Step 3: If any problems occur with the verification process, the health facility staff will coordinate with the designated SHSP office.

Step 4: If the person seeking services has no membership ID card but claims to be an SHSP member, health facility registration staff asks him/her to wait while their membership is confirmed. Membership can be determined by searching the IMIS (only computer based), using information such as the service seeker's name, VDCs/municipality, ward and gender.

Step 5: If the member has a low balance (less than 10%) remaining on the ceiling, the health facility staff informs the member of:



Step 6: After determining membership, the health facility staff member at the registration desk records the SHSP member’s name, membership ID number, and health facility code, on the OPD ticket (service utilisation form) (Annex 12). Health facility staff are to ensure that the three copies of the OPD ticket (one original and two automated carbon copies) are intact.

If the policy of the SHSP member is not active, the health service utilisation process is the same as for someone who is not a member of SHSP.

Step 7: The health facility staff member asks the member if any other family member is receiving services through their SHSP membership at the same time. If another member of the family is also receiving services and if the balance is unlikely to be enough for both services, the health facility staff member will inform the SHSP member of:



Step 8: The SHSP member is then directed towards the OPD with the OPD ticket filled in by the health facility staff member (in Step 7).

Step 9: At the OPD, the health worker fills out the OPD ticket with information such as the complaint, required diagnostic tests and required medication.

Processes required for other information systems such as HMIS – filling out OPD register etc. still need to be continued even for SHSP members.

hea

lth

serv

ice

util

isat

ion

38

Step 10: If the patient only requires counselling/advice and does not need drugs or further diagnostic services, the health worker:

• Provides the required advice and counselling



Step 11: If the patient requires drugs:

• The health worker provides necessary advice and counselling and directs the member to the pharmacy with all three copies of the health OPD ticket.

• At the pharmacy, the patient gives all three copies of the OPD ticket to the attendant.

• If the prescribed drugs are among the government mandated free drugs, the pharmacy provides the drugs free of charge to the patient.

• If the prescribed drugs are among drugs provided by the SHSP, the pharmacy provides the drugs after collecting the 15% co-payment from the patient. The amount of the co-payment is recorded on the OPD ticket and stamped by the pharmacy. (The remaining 85% is reimbursed by the SHSDC.)

• The pharmacy provides the stamped original OPD ticket (white copy) to the member and keeps the other two.

• At a pre-defined time (e.g., end of OPD visiting time), the pharmacy hands over the copy of the form to the concerned health facility staff member.

Step 12: If the SHSP member utilising the health services needs diagnostic services:

• The health worker provides the necessary advice and counselling and directs the member to the registration/billing counter with three copies of the OPD ticket.

• The member gives all three copies of the health OPD ticket to the health facility staff member at the registration/billing counter.

• The health facility staff member at the registration counter issues the invoice for the diagnostic services (lab, X-ray, USG, etc.) and marks that the service has been provided through the SHSP.

• The patient takes this invoice and proceeds to the appropriate diagnostic room (lab, X-ray, USG, etc.). All three copies of the OPD ticket are kept at the registration counter.



• The health facility staff member at the diagnostic room provides the required services as mentioned in the invoice and information regarding report collection.

39

• All diagnostic test reports are collected from the reception/billing counter, along with the three copies of the OPD ticket left there previously. Once the report is ready, the SHSP member utilising the service consults the doctor with the report and the OPD ticket, which is collected from the registration counter.

• The health worker provides the services to the SHSP member (as mentioned in Step 9).



Step 13: If the SHSP member utilising the health services needs both drugs and diagnostic services:

• The health worker, after providing the necessary advice and counselling, gives the three copies of the OPD ticket (with information regarding the drugs and the diagnostic test requirements), and directs the member to collect the drugs from the pharmacy first and then go to the registration/billing counter for diagnostic services.

• The member gives all three forms to the pharmacy.

• The pharmacy provides the drugs by taking the co-payment amount (15% of the cost of drugs covered by SHSP) from the SHSP member. The co-payment amount is recorded on the OPD ticket.

• The pharmacy stamps all three copies of OPD ticket, gives all of them to the member and asks the member to take them to the billing counter. For their internal book-keeping, the pharmacy keeps a record of the drugs dispensed.

• The member gives all three copies of the form to the billing/registration counter.

• The health facility staff member at the registration counter issues the invoice for the diagnostic services (lab, X-ray, USG, etc.) and marks that the service has been provided through the SHSP.

• The patient takes this invoice and proceeds to the appropriate diagnostic room (lab, X-ray, USG, etc.). All three copies of OPD ticket are kept at the registration counter.



• The health facility staff member at the diagnostic room provides the services mentioned in the invoice and the necessary information regarding report collection.

• All diagnostic test reports are collected from the reception/billing counter, along with the three copies of the OPD ticket left there previously. Once the report is ready, the patient consults the doctor with the report and the OPD ticket, which is collected from the registration counter. The health facility staff member at the diagnostic room keeps a record of the reports, either in the computer or in the register.

hea

lth

serv

ice

util

isat

ion

40

• The health worker provides services to the member (as mentioned in Step 9).



Step 14: If the member seeking the health services requires admission as an inpatient for additional treatment:

• The member utilising the service is admitted in the relevant ward with three copies of the OPD ticket.

• The concerned ward provides the required services to the member.

• If another member of the family is also receiving services and if the balance is unlikely to be enough for both services, the health facility staff member will inform the SHSP member that, after the balance is exhausted, the treatment process is the same as for someone who is not a member and they will be required to pay any remainder.

• The member’s complaint(s) and any diagnostic and other services provided are written on the OPD ticket.

The pharmacy keeps a record of the drugs distributed, either in the computer or in the register.

After the report is ready, the health facility staff member at the diagnostic room keeps a record of the report, either in the computer or in the register.

Step 15: If the member seeking the health services requires more services from a higher-level health facility:

• The doctor refer the member to a higher-level health facility by filling in a referral form (Annex 11).

• The white copy of the OPD ticket, a referral letter and other related documents are handed over to the SHSP member with instructions to go to the assigned higher-level facility.

• Once at the higher-level health facility, the member follows the same steps as they did while visiting their first service point – at registration, they should present their referral form along with the membership card.

Step 16: The health facility staff member submits a claim for reimbursement of the services rendered from the SHSDC, in accordance with the OPD ticket (service utilisation form) using the IMIS.

Step 17: During the regular visit of the enrolment officer to the health facility, one copy of all accumulated copies of the claim forms and the IMIS generated claim summary sheet are handed over by the health facility to the enrolment officer.

The service utilization process is illustrated in the Figure 3.

41

Inform member aboutremaining benefit package

Health facility personnelfills Service

Utilisation Form

Member goes toDoctor

Does not require drugs or

diagnostic services

Requiresdrugs

Requiresdiagnostic

services

Doctor refers member to appropriate health facility with Health Utilisation Form and Referal Form

Patient goes to billing counter, collects diagnostic service invoice and leaves3 copies of Service Utilisation Form

Presents serviceinvoice in diagnostic room

Presents invoice and usesservices in diagnostic room

Requiresin-patient services

Referral

Counselling

Discharge

Health Workerinvestigates

Follow up

Follow up

Only for drugsnot providedfree bygoverment


Leave 2 formsat pharmacy

Leave 2 formsat ward

Leave 2 formsto doctor

Collect Service Utilisation Form from billing counter and visit doctor for follow up

Take 1 form home

Show Social Health

Security programmembership card

First pointof contact *

Follow procedure as of non member

Verify membershipthrough MIS

Figure 3: Health Service Utilisation Process

* In case of emergency, visit nearest

health facility where the needed

service is available

Health Service Utilisation Process

NO YES

NO

YES

Pharmacy

Pharmacy

BillingCounter

BillingCounter

HospitalWARD

Does memberrequire referral?

Diagnostic room

Diagnosticroom

Admitin relevant

ward

Requires drugs and diagnstic services Patient goes to billing counter,

collects diagnostic service invoice and leaves 3 copies of Service Utilisation Form

42

Inform member aboutremaining benefit package

Health facility personnelfills Service

Utilisation Form

Member goes toDoctor

Does not require drugs or

diagnostic services

Requiresdrugs

Requiresdiagnostic

services

Doctor refers member to appropriate health facility with Health Utilisation Form and Referal Form

Patient goes to billing counter, collects diagnostic service invoice and leaves3 copies of Service Utilisation Form

Presents serviceinvoice in diagnostic room

Presents invoice and usesservices in diagnostic room

Requiresin-patient services

Referral

Counselling

Discharge

Health Workerinvestigates

Follow up

Follow up



Leave 2 formsat pharmacy

Leave 2 formsat ward

Leave 2 formsto doctor

Collect Service Utilisation Form from billing counter and visit doctor for follow up

Take 1 form home

Show Social Health

Security programmembership card

First pointof contact *

Follow procedure as of non member

Verify membershipthrough MIS

Figure 3: Health Service Utilisation Process

* In case of emergency, visit nearest

health facility where the needed

service is available

Health Service Utilisation Process

NO YES

NO

YES

Pharmacy

Pharmacy

BillingCounter

BillingCounter

HospitalWARD

Does memberrequire referral?

Diagnostic room

Diagnosticroom

Admitin relevant

ward

Requires drugs and diagnstic services Patient goes to billing counter,

collects diagnostic service invoice and leaves 3 copies of Service Utilisation Form

43

Tables 13 and 14 list some of the important personnel and documents/supplies needed in the utilisation of health services from a hospital or referral centre process.

Table 13. Important actors in the utilisation of health services from a hospital or referral centre

Important actors

SHSP member

Health professionals

Registration, billing and enquiry staff

Enrolment officer

Health facility cashier/accountant

Pharmacy dispenser

Staff of diagnostic room

Health facility member (Claim Administrator)

Table 14. Important documents/supplies used during service utilisation from a hospital or referral centre


Membership ID card Required for all family members (See Annex 6)

(Smart) mobile phone or computer For enrolment assistant

OPD ticket (Service utilization form) See Annex 12 Referral form See Annex 11Payment notification form See Annex 15 IMIS

hea

lth

serv

ice

util

isat

ion

45

chaPter 11.

claIms from health facIlIty

Claim entry

Every health facility that provides health services to members of the SHSP is required to submit a claim to the SHSDC to receive reimbursement for the services rendered, in accordance with the contract signed between the facility and the SHSDC. Claims can only be submitted through the IMIS. When an SHSP member receives services from a health facility, two copies of the service utilisation form always remain at the health facility. The information on these forms is the basis for the facility to claim for the services rendered to that particular SHSP member.

The following is the process to be followed by a health facility when submitting a claim to SHSDC:

Step 1: Once logged into the IMIS the claim administrator assigned by the health facility1 navigates to the 'Health Facility Claims' section and follows the instructions in the 'Service Provider Manual' to enter in a new claim to be sent to the SHSDC.

The claim administrator should ensure that the 'Claim ID' that appears on the top right-hand corner of the service utilisation form is entered properly into the IMIS – this ID is unique to every service utilisation form and should never be repeated when entering claims into the IMIS.

Step 2: If there are multiple claims that need to be entered into the IMIS, the claim administrator follows the same procedure outlined above for each claim.

Once a claim has been submitted by a health facility, no changes can be made to it.

Step 3: The IMIS performs a checks to ensure that the claim is compliant with the agreement between the facility and SHSDC. In particular, the following checks are automatically done by the IMIS:

1 Claim administrators are nominated by the respective health facilities. Once the SHSDC is informed of this nomination, a distinct username and password is issued to the claim administrator via SMS.

clai

ms

from

hea

lth

faci

lity

46

• Validity of SHSP membership of patient for whom services were provided

• Validity of OPD visits – e.g., if it is a follow-up visit within 7 days of initial visit2

• If certain services are not applicable according to gender

Step 4: If the claim passes all the checks in the IMIS, a medical review of the claim is done by the SHSDC medical officers. The reimbursement amount to the health facilities is based on the medical review.

Medical review

Step 1: The SHSP medical review team at the national level selects, through the IMIS, a sample of all claims for a thorough medical review.

Step 2: The medical review team then checks the formal and factual correctness of the sample claims, as well as whether or not the claimed services are justified according to the diagnosis entered (ICD). The medical review team also checks the appropriateness of the claimed drugs against the services rendered.

Step 3: If any clarifications are required to process the claim, the medical officer can directly contact the concerned person at the health facility.

Step 4: Using all the information available, the medical officer either fully accepts, partially accepts, or fully rejects the claim.

Step 5: Using the IMIS, the accounts officer at the central SHSDC office generates a report outlining the number of claims submitted by a particular facility and the corresponding number of accepted/rejected claims along with their value.

Step 6: Using the information in this report, the accounts officer issues reimbursement payments to the health facilities. The report is provided to the respective health facility along with the payment.

Step 7: If the administrator of the health facility has an objection, it can appeal to the appeals review committee of the SHSP central office.

Step 8: The appeal is reviewed by the committee and, based on the decision, the accounts officer either confirms the previous evaluation or adjusts it accordingly.

2 No reimbursement is made for follow-up visits within 7 days of initial visit.

47

System accountability

System accountability refers to the structured collection of member feedback to strengthen the purchaser role of the SHSP. As a representative of its members, the SHSP can give members a stronger voice in the health sector. Member feedback can help health providers and managers (district public health officers) to focus on improving the health system.

Feedback mechanism

The IMIS allows the collection of feedback from SHSP members regarding the services they have received at health facilities. This feedback acts as very important information for both the SHSDC and the service providers in order to understand the public perception of the services being provided and any avenues of improvement. The steps involved in the feedback mechanism process are as follows.

Step 1: During the medical review of claims, the medical officer can choose certain claims from the list of all claims to receive feedback from members.

The claims that have been selected for feedback from members can only be valuated, and reimbursed to the health facility after the feedback has been received.

Step 2: The district managers generated a report outlining the claims and details of the SHSP member selected for feedback in their district using the IMIS. This report is categorised according to VDCs/municipality and disaggregated by ward.

Step 3: This report is handed over to the relevant enrolment officer, who identifies the enrolment assistants in the particular areas where feedback is to be gathered. The enrolment officer informs the enrolment assistants of the need to collect feedback.

Step 4: The enrolment assistants go to the house of the SHSP member whose claim was selected for feedback and fill out the form in the Feedback app according to the process described in the IMIS Mobile Phone Application User Manual.

Step 5: Once the form has been completed, it is sent via the Internet, or through the enrolment officers if there is no Internet connectivity, to the IMIS.

Step 6: The medical review team then evaluates the particular claim based on the feedback received from the SHSP member.

Inquiry and complaint management

The SHSP has an inquiry and complaint hotline at the central level. Complaints received are sent to the respective district for necessary action. Apart from holidays, the hotline is open every day from 10 am till 5 pm. Outside of consultation hours, an automatic announcement asks callers to phone again during consultation hours (and announces those hours).

clai

ms

from

hea

lth

faci

lity

48

Operators use special software for recording individual caller details and problems. Callers searching for general information on the SHSP are captured in this software to allow analysis of hotline calls. The steps for operating the inquiry and complaint hotline are as follows.

Step 1: Incoming calls are accepted by the hotline operator in a standardised manner, i.e., with a greeting and identification of the hotline operator (e.g., ‘Welcome to the SHSP hotline; my name is [operator name]; how can I help you?’).

Step 2: The hotline operator opens a case in the SHSP complaint software, selects the category of the information query/complaint and fills in the details.

Step 3: The hotline operator enquires whether or not this complaint is linked to a prior complaint. If so, the complaint number of the prior complaint is noted down.

Step 4: If the issue cannot be resolved on the phone, the hotline operator provides the caller with the complaint number and informs the caller about the next steps to be taken by the SHSP (e.g., the forwarding of the complaint to a district manager for complaint handling or the possibility of immediate settlement of the complaint).

Step 5: The hotline operator then ends the call.

Step 6: If the complaint has to be handled locally or by another department, the operator assigns the claim to a district manager or an SHSP central office employee.

Step 7: The assigned staff member is informed about the pending case by an auto-generated email with a link to the pending case. He/she then initiates the necessary action to solve the case.

Step 8: When the case is solved, the assigned staff member closes the case in the information system.

Step 9: At the end of each week, the operator checks the status of all open claims and follows up on those pending for an unduly long time.

Step 10: At the end of each month, the operator creates an analysis of all calls received.

49

annex 1 terms of reference dIstrIct manager The district manager shall supervise all staff within the SHSP district office. Among other things, he/she shall be responsible for establishing and supervising a ‘movement plan’ for enrolment officers to enable them to cover all VDCs/municipalities in the district at least twice a month in a cost-effective way. The following shall be the other responsibilities of the district manager:

(a) To coordinate with local bodies and communities for the implementation of the SHSP including to interact/communicate with local communities or make available necessary information to them to ensure optimum participation in this programme;

(b) To resolve any disputes regarding membership identification and request the SHSDC to resolve disputes that cannot be resolved;

(c) To make recommendations to the SHSDC management body on policy matters related and the technological aspects of membership enrolment;

(d) To conduct orientation programmes or seminars about the SHSP;

(e) To monitor and supervise the personnel in the district office;

(f) To work as member secretary of the District Social Health Security Coordination Committee;

(g) To monitor, supervise and evaluate the SHSP in the district and make necessary recommendations;

(h) To adopt all methods to ensure the transparency of the programme;

(i) To arrange public hearings to inform all stakeholders of the SHSP about this programme

(j) To undertake the financial administration of the district office including maintaining records of income and expenditure, spending funds or causing funds to be spent, having records audited, and resolving or recovering any arrears ;

(k) To carry out daily administrative work; and

To carry out other work assigned by the central office.

ann

ex 1

: ter

ms

of r

efer

ence

di

stri

ct m

anag

er

51

annex 2 terms of reference enrolment offIcers

The enrolment officers shall form a link between the SHSP district office and the enrolment assistants at the community level. They shall travel to the VDCs/municipality level at least twice a month to carry out the following functions:

(a) To arrange, or cause to be arranged, membership enrolment and renewal by collecting the contribution money as per the Social Health Security Programme Operating Rules (2014);

(b) To identify the individuals or families who have no access to, or have been left out of, the SHSP and enrol them, or cause them to be enrolled, as members;

(c) To identify the members whose renewal is due and arrange for their renewal;

(d) To conduct public awareness programmes about the SHSP;

(e) To resolve any disputes regarding membership identification and request the SHSDC to resolve disputes that cannot be resolved;

(f) To make recommendations to the SHSDC management body on policy matters and the technological aspects of membership enrolment;

(g) To mobilise enrolment assistants for the enrolment and renewal of members and/or other work related thereto;

(h) To monitor and evaluate the work of the enrolment assistants; and

(i) To carry out other work assigned by the SHSDC or the bodies thereunder (e.g., the District Social Health Security Coordination Committee – DSHSCC).

ann

ex 2

: ter

ms

of r

efer

ence

en

rolm

ent

offi

cers

53

annex 3 lIst of drugs ProvIded through shsP

Government of NepalSocial Health Security Development Committee

List of drugs provided through SHSP(Related to Rule 30)

(These drugs are provided through SHSP from PHCs and Hospitals.)

SN NAME OF MEDICINE DOSAGE FORM TYPES OF DRUGS

1 Amphotericin B INJECTION ANTIFUNGAL

2 Amoxycillin 125 mg/5ml,60ml SUSPENSION ANTIBIOTIC

Amoxycillin 500 mg TABLET ANTIBIOTIC

3 Amoxycillin + Clavulanate 375mg/625mg/1.2gm

TABLET ANTIBIOTIC

4 Ampicillin 500mg INJECTION ANTIBIOTIC

5 Azithromycin 100mg/5ml,15ml SUSPENSION ANTIBIOTIC

6 Bismuth Iodoform PASTE ENT

7 Ceftriaxone 250 mg/500mg INJECTION ANTIBIOTIC

8 Cefixime 100mg TABLET ANTIBIOTIC

Cefixime 200mg DISPERSIBLE TABLET ANTIBIOTIC

Cefixime DS DRY SYRUP ANTIBIOTIC

9 Chlorampheicol Eye Applicap 1 %,5ML DROPS ANTIBIOTIC

10 Flucloxacillin 500mg CAPSULE ANTIBIOTIC

11 Clathrithromycin 250mg/500mg

TABLET ANTIBIOTIC

12 Clindamycin 150mg CAPSULE ANTIBIOTIC

Clindamycin 300mg/600 mg INJECTION ANTIBIOTIC

13 Gentamicin 40mg/ml,80 mg/ml INJECTION ANTIBIOTIC

14 Erythromycin 125mg/5ml,60ml SUSPENSION ANTIBIOTIC

Erythromycin 250mg/500mg TABLET ANTIBIOTIC

15 Levofloxacin 500mg/750mg TABLET ANTIBIOTIC

16 Ichthamol in Glycerine Ear Drops DROPS ANTIINFLAMMATORY & ANTIMICROBIAL

17 Moxifloxacin 400mg TABLET ANTIBIOTIC

Moxifloxacin 400mg/100ml SUSPENSION ANTIBIOTIC

ann

ex 3

: lis

t of

dru

gs

prov

ided

thr

ough

sh

sP

54


18 Ofloxacin DT 100mg TABLET ANTIBIOTIC

Ofloxacin 200mg/400mg TABLET ANTIBIOTIC

Ofloxacin 50mg/5ml, 30ml SUSPENSION ANTIBIOTIC

Ofloxacin 200mg/100ml INJECTION ANTIBIOTIC

19 Piperazine Citrate SYRUP ASCARIASIS

20 Permerthin TOPICAL SCABIES,LICE

21 Spironolactone 12.5mg/25mg/100mg TABLET DIURETIC

22 Chlorpheniramine maleate 1mg/10mg TABLET ANTIHISTAMINICS

23 PheniramineTab 1mg/4mg/25mg TABLET ANTIHISTAMINICS

24 Salbutamol ,100 ml SYRUP BRONCHODILATORS

Salbutamol 2mg TABLET BRONCHODILATORS

25 Chlorpromazine 25 mg TABLET ANTIDEPRESSANTS

26 Fluoxetine 10mg/20mg CAPSULE ANTIDEPRESSANT

27 Fluphenazine Decanoate(Prolinate) 25mg/ml, 1ml

INJECTION ANTIDEPRESSANT

28 Haloperidol 0.25mg/1.5mg TABLET ANTIDEPRESSANT

29 Diazepam 5mg/10mg TABLET ANTIANXIETY

30. Dexamethasone 0.5mg TABLET ANTIINFLAMMATORY AGENTS

31. Diclofenac 50mg/100mg TABLET NSAIDS

32. Enalapril 2.5mg/5mg/10mg TABLET ANTIHYPERTENSIVES

33. Nifedipine5mg/ 10mg TABLET ANTIHYPERTENSIVES

34. Bisacodyl 5mg TABLET LAXATIVE

Bisacodyl 5mg/10mg SUPPOSITORY LAXATIVE

35. Hepatitis B Vaccine INJECTION VACCINE

36. Mefenamic Acid,250mg/500mg TABLET ANTISPASMOLYTICS

37. Metformin 850mg TABLET ANTIDIABETIC

38. Clopropamide 100mg / 250mg TABLET ANTIDIABETIC

39. Glimpiride 1mg/2mg/3mg/4mg TABLET ANTIDIABETIC

40. Methotrexate 2.5mg / 7.5mg TABLET RHEUMATID ARTHRITIS

41. Probenecid 500mg TABLET URICOSURIC AGENTS

42. Tranexamic acid 250mg TABLET ANTIFRIBINOLYTICS

43. Warfarin1mg / 2mg / 3mg / 5mg TABLET ORAL ANTICOAGULANTS

44. Atorvastatin 5mg/10mg/20mg TABLET LIPID LOWERING AGENT

55


45. Cholecalciferol 250mg TABLET VITAMIN D

Cholecalciferol 200ml SUSPENSION VITAMIN D

46. Ascorbic acid 500mg TABLET/CAPSULE VITAMIN C

Ascorbic acid,15ML DROPS VITAMIN C

47. Calcium acetate 667mg TABLET CALCIUM SALTS

48. PARACETAMOL CHLORPHENIRAMINE MALEATE + PSEUDOEPHEDRINE HYDROCHLORIDE

TABLET ALLERGY COUGH & COLD

49. + CHLORPHENIRAMINE MALEATE + PSEUDOEPHEDRINE HYDROCHLORIDE, 60ml

SYRUP ALLERGY COUGH & COLD

50. Probenecid 500mg TABLET URICOSURIC AGENTS

51. Omeprazole 20mg TABLET ANTISECRECTORY AGENTS

52. Penicillin G 10 Lac IU INJECTION ANTIBACTERIAL

Penicillin G 400,000 IU INJECTION ANTIBACTERIAL



53. Spectinomycin POWDER ANTIBACTERIAL

54. Permethin 30gm/5%w/v SOLUTION SCABIES

55. Phenobarbitone 30 mg TABLET ANTISEIZURE

56 Pyridoxine 10mg/40mg/60mg/100mg TABLET PYRIDOXINE DEFICIENCY

57. Podophyllin Tincture Benzoin TINCTURE ANO GENITAL WARTS

58. Sulphacetamide 10% Eye DROPS,10ml DROPS BACTERIAL INFECTIONS

Suphacetamide 20% Eye Drops DROPS BACTERIAL INFECTIONS

Suphacetamide 30% Eye Drops DROPS BACTERIAL INFECTIONS

59. Tetracycline Eye Ointment 1%,5mg OINTMENT ANTIINFECTIVES

60. Trihexiphenidyl 1.5mg/5mg TABLET ANTIPARKINSONIANS

Trihexiphenidyl 2mg CAPSULE ANTIPARKINSONIANS

61. Valacyclovir 200mg/400mg/800mg TABLET ANTIVIRAL

62. Zinc Sulphate 10mg/20mg TABLET MINERALS

ann

ex 3

: lis

t of

dru

gs

prov

ided

thr

ough

sh

sP

57

annex 4 detaIls of the BenefIt Package avaIlaBle through socIal health securIty Programme

(Relating to Rule 14(1) Government of Nepal

Social Health Security Development Committee

Details of the Benefit Package Available through Social Health Security Programme

1. Laboratory diagnostic services

(a) List of laboratory tests provided free/subsidised through the Government of Nepal’s vertical health programmes NOT through the Social Health Security Programme)

SN Name of test Programme Primary health centre

Up to 25-bed hospital

50-bed or above

EM OPD IPD

1 K-39 test Kala-azar √ √ √ √ √

2 Peripheral smear / RDT for MP

Malaria √ √ √ √ √

3 CD4 count HIV x x x x *

4 Viral load HIV x x x x *

5 AFB stain Tuberculosis √ √ √ √ √

6 Gene expert Tuberculosis x x x x *

7 Influenza PCR Outbreak/ surveillance

x x x x *

8 Smear for Lepra Leprosy √ √ √ √ √

Note: √: Available at the health facility; X: NOT available at the health facility; *: Available only if the service is catered from respective health facility

ann

ex 4

: det

ails

of

the

Ben

efit

Pac

kage

58

(b) List of laboratory tests provided through the Social Health Security Programme of the Government of Nepal



50 bed or above

EM OPD IPD

Biochemistry

1 S. Glucose F/R/PP SHS √ √ √ √ √

2 24 hour urine protein SHS x √ √ √ √

3 CPK SHS x x x x √

4 CPK MB SHS x x x x √

5 LFT SHS x * * * √

6 - S. Bilirubin T & D SHS x * * * √

7 - S. Alkaline Phos SHS x * * * √

8 - S.GPT SHS x * * * √

9 - Total protein SHS x * * * √

10 - S. Albumin SHS x * * * √

11 SGOT SHS x * * * √

12 S. Alpha amylase SHS x * * * √

13 S. Uric acid SHS x √ √ √ √

14 A/G ratio SHS x * * * √

15 Lipid profile - S. cholesterol - S. triglyceride - HDL - LDL

SHS x x x x √

SHS x x x x √

SHS x x x x √

SHS x x x x √

16 S. Creatinine SHS √ √ √ √ √

17 S. Urea SHS √ √ √ √ √

18 S. Electrolytes (Na/K) SHS x x x x √

Haematology

19 Absolute cell count SHS x * * * √

20 - Eosinophil SHS x * * * √

21 - Neutrophil SHS x * * * √

22 - Lymphocyte SHS x * * * √

23 - Monocyte SHS x * * * √

24 - Basophil SHS x * * * √

25 Aldehyde test SHS x * * * √

26 BT / CT SHS x * * * √

27 CBC (TC/DC/Hb) SHS √ √ √ √ √

28 ESR SHS √ √ √ √ √

29 PCV(HCT) SHS x * * * √

30 Platelet count SHS x * * * √

31 Reticulocyte count SHS x * * * √

32 Comment on Peripheral smear

SHS x * * * √

59



50 bed or above

EM OPD IPD

33 Bone marrow study (ME)

SHS x x x x *

34 Prothrombin time (PT)

SHS x x x x *

35 HbA1C (max twice/year)

SHS x x x x *

Histo/cyto pathology

36 Biopsy (Endo + colonoscopy)

SHS x x x x *

37 Fluid cytology SHS x x x x *

38 FNAC SHS x x x x *

40 Histo biopsy (major) SHS x x x x *

41 Histo biopsy (minor) SHS x x x x *

42 Pap smear SHS x x x x *

Immunology

43 ASO SHS x * * * √

44 Blood group &Rh typing

SHS √ √ √ √ √

45 Brucella SHS x * * * √

46 CRP SHS x * * * √

47 Pregnancy test urine SHS √ √ √ √ √

48 RA test SHS x * * * √

49 TPHA SHS x * * * √

50 VDRL/RPR SHS √ √ √ √ √

51 Tumour marker

CA 125

PSA

SHS x x x x *

SHS x x x x *

SHS x x x x *

52 Cross-match (where blood bank available)

SHS x * * * *

Virology

53 HIV (in pre-surgical screening)

SHS √ √ √ √ √

54 HBsAg SHS x √ √ √ √

55 HCV SHS x * * * *

56 HEV SHS x * * * *

57 Dengue SHS x * * * √

Endocrinology

58 Thyroid function:T3, T4, TSH* (not more than twice a year)

SHS x x x x *

ann

ex 4

: det

ails

of

the

Ben

efit

Pac

kage

60



50 bed or above

EM OPD IPD

Microbiology

59 Blood culture SHS x x x x √

60 CSF culture SHS x x x x √

61 CSF R/E SHS x x x x √

62 Gram stain SHS √ √ √ √ √

63 KOH preparation SHS √ √ √ √ √

64 Pus culture SHS x x x x √

65 Sputum/throat swab/ urine/stool culture

SHS x x x x √

66 Urethral/cervical swab culture

SHS x x x x √

67 Widal SHS x * * * √

Parasitology

68 Stool: R/E SHS √ √ √ √ √

69 Urine: R/E SHS √ √ √ √ √

Note: SHS = Social Health Security Programme


61

2. Radiological/ Other diagnostic services (covered under diagnostic services):

(a) List of diagnostic services provided free/subsidised through Government of Nepal’s vertical health programmes) - None

(b) List of diagnostic services provided free through Social Health Security Programme (within the ceiling defined by the Programme)

SN Name of service Programme Primary health centre


50 or above bedEM OPD IPD

1 X-ray plain SHS √ √ √ √ √

2 Ultrasound for (acute

abdominal pain, 1

time for ANC)

SHS √ √ √ √ √

3 ECG SHS √ √ √ √ √

4 Gastro-endoscopy SHS x √ √ √ √

5 Vision test SHS √ √ √ √ √

6 Colour blindness SHS √ √ √ √ √

7 Hearing test (tradi-tional method)

SHS √ √ √ √ √

8 Plain CT scan of skull (once a year)

SHS x x x x *

9 Echo cardiogram SHS x x x x *

10 Angiography SHS x x x x *


ann

ex 4

: det

ails

of

the

Ben

efit

Pac

kage

62

3. Services relating to diseases or conditions of diseases(a) List of diseases/conditions made free by Government of Nepal (at health centres

identified by the government)

SN Name of disease/condition

Programme Primary Health Centre

Up to 25 beds

50 beds or above

Immunisation

1 Vaccination (NIP covered) Extended Programme of immunization

√ √ √

2 Rabies vaccine Extended Programme of immunization

* * *

3 Japanese encephalitis vaccine Extended Programme of immunization

* * *

Infectious Diseases

2 Diarrhoea (mild dehydration) Child Health Programme √ √ √

3 ARI pneumonia Child Health Programme √ √ √

4 Treatment of all TB cases Disease Control √ √ √

5 Multi drug resistant TB cases √ √ √

6 Extensive drug resistant TB cases

x √ √

7 Leprosy treatment Disease Control √ √ √

8 Leprosy treatment reaction x √ √

9 Leprosy rehabilitation care x x √

10 Simple malaria case management

Disease Control √ √ √

11 Complicated malaria case management

√ √ √

12 Kala-azar Disease Control √ √ √

13 Japanese encephalitis Disease Control √ √ √

14 First line therapy HIV/AID Disease Control √ √ √

15 Second line therapy HIV x √ √

16 RTIs/STIs (including cervical erosion)

√ √ √

17 VCT counselling * * *

Family planning

18 Family planning Family planning

19 i. Condoms √ √ √

20 ii. Minilap √ √ √

21 iii. Vasectomy √ √ √

Others:

22 Snake bite (antivenin) Disease control √ √ x


63

(B) List of diseases/conditions for which free treatment is provided through Social Health Security Programme



Up to 25 beds

50 beds or above

Infectious diseases

1 Diarrhoea with severe dehydration

SHS √ √ √

2 Dysentery SHS √ √ √

3 ARI - severe pneumonia SHS √ √ √

4 Seasonal flu SHS √ √ √

5 Treatment for Hep A/Hep B and Hep E

SHS √ √ √

6 Enteric fever SHS √ √ √

7 Dengue fever SHS √ √ √

8 Dengue haemorrhagic fever SHS √ √ √

9 Tetanus (only tetanus vaccine TT covered)

SHS √ √ √

10 Meningitis SHS √ √ √

Paediatrics

11 Birth asphyxia SHS √ √ √

12 Neonatal sepsis SHS √ √ √

13 Low birth weight √ √ √

Less than 1,8001,800–2,500 g

SHS √ √ √

SHS √ √ √

14 Malnutrition (severe) SHS √ √ √

Gynaecology/obstetrics

15 Puerperal sepsis SHS √ √ √

16 Septic abortion SHS x √ √

17 ANC SHS √ √ √

18 Normal delivery SHS √ √ √

19 Assisted delivery (vacuum, forceps use etc.)

SHS √ √ √

20 Caesarean section x x √

21 Post-natal care (up to 7 days)

SHS √ √ √

22 Pelvic organ prolapse (POP) screening & conservative management

SHS √ √ √

23 Uterine prolapse surgical management

SHS x x √

24 Premature rupture of membrane

SHS √ √ √

25 Antepartum haemorrhage SHS √ √ √

26 Postpartum haemorrhage SHS √ √ √

27 Severe anaemia SHS √ √ √

ann

ex 4

: det

ails

of

the

Ben

efit

Pac

kage

64



Up to 25 beds

50 beds or above

28 Eclampsia SHS √ √ √

29 Cx cancer cryo therapy SHS √ √ √

30 Medical examination for breast cancer screening

SHS √ √ √

31 Dysfunctional uterine bleeding (DUB)

SHS x √ √

32 Perimenopausal syndrome (osteoporosis management)

SHS √ √ √

33 Post Abortion Care SHS √ √ √

34 Ectopic pregnancy SHS x X √

ENT/ophthalmology

35 Eye check-up/diabetic retinopathy

SHS

36 Cataract surgery operations SHS x √ √

37 Refraction check up SHS √ √ √

38 Simple infection (conjunctivitis, sty)

SHS √ √ √

39 Acute otitis media SHS √ √ √

40 Chronic otitis media SHS √ √ √

41 Hearing test (audiogram) SHS √ √ √

42 Rhinitis SHS √ √ √

43 Sinusitis SHS √ √ √

44 Foreign body in eye, nose, ear and throat

SHS √ √ √

45 Epistaxis SHS √ √ √

46 Pharyngitis SHS √ √ √

47 Tonsillitis SHS √ √ √

48 Laryngitis SHS √ √ √

49 URTI SHS √ √ √

Lung/chest diseases

50 Bronchitis SHS √ √ √

51 ARI SHS √ √ √

52 Asthma (acute – emergency and routine drugs)

SHS √ √ √

53 Chronic obstructive pulmonary disease (up to OPD management – nebuliser during emergency)

SHS √ √ √

54 Pneumothorax SHS √ √ √

55 Pleural effusion SHS √ √ √

Cardiac

56 Coronary artery disease – conservative management

SHS √ √ √

57 Rheumatic heart disease – conservative management

SHS √ √ √

65



Up to 25 beds

50 beds or above

58 Acute hypertensive stroke (conservative)

SHS √ √ √

59 Myocardial infarction (medical treatment)

SHS x √ √

60 Primary treatment for congestive cardiac failure

SHS x √ √

61 Arrhythmia SHS √ √ √

Gastro

62 Acid peptic disorder SHS √ √ √

63 Cholecystitis SHS √ √ √

64 Pancreatitis (conservative management)

SHS √ √ √

65 Treatment of appendicitis SHS √ √ √

66 Intestinal obstruction (conservative management)

SHS √ √ √

67 Peritonitis (conservative management)

SHS √ √ √

68 Appendectomy SHS x x √

69 Cholecystectomy DHS x x √

Nephrology

70 Acute nephritis SHS √ √ √

71 Nephrotic syndrome (medical management)

SHS √ √ √

72 Urinary tract infection SHS √ √ √

73 Urinary bladder calculus SHS x x √

RTI/conditions (male)

74 Orchitic SHS √ √ √

75 Phimosis/paraphimosis SHS √ √ √

76 Hydrocele surgical management

SHS x x √

Ortho

77 Osteomyelitis (medical treatment)

SHS √ √ √

78 Gout/RA/osteoarthritis (medical treatment)

SHS √ √ √

79 Muscle pain/torticollis/back pain

SHS √ √ √

80 Management of fracture (simple)

SHS √ √ √

81 Cervical /lumber spondylosis (conservative management)

SHS √ √ √

ann

ex 4

: det

ails

of

the

Ben

efit

Pac

kage

66



Up to 25 beds

50 beds or above

Dental

82 Oral and dental check up SHS √ √ √

83 Filling SHS √ √ √

84 Simple extraction SHS √ √ √

NCDs

85 Migraine headache SHS √ √ √

86 Hypertension SHS √ √ √

87 Diabetes mellitus SHS √ √ √

88 Anxiety SHS √ √ √

89 Depression SHS √ √ √

90 Schizophrenia SHS √ √ √

91 bipolar disorders SHS √ √ √

92 Common mental disorders (including psychosis)

SHS √ √ √

93 Child & adolescent psychiatric disorders

SHS √ √ √

94 Geriatric problems including dementia

SHS √ √ √

95 Epilepsy SHS √ √ √

Injury/surgery

96 Conservative management of head injury

SHS √ √ √

97 Minor injuries including falls SHS √ √ √

98 Other minor ailments (like aches, scabies, worms, boils)

SHS √ √ √

99 Burn management SHS √ √ √

100 Suture SHS √ √ √

101 Shoulder, elbow and hip dislocation

SHS √ √ √

102 Amputation SHS x x √

103 Burn clean dressing and graft SHS √ √ √

104 Incision and drainage SHS √ √ √

105 Incision and drainage (e.g., Osteomyelitis)

SHS x √ √

106 Cyst, lump, lipoma SHS √ √ √

107 Impacted nail SHS √ √ √

Others

108 Poisoning (lavage and antidote)

SHS √ √ √

109 Circumcision SHS x √ √

110 Hernia SHS x √ √

111 Haemorrhoid excision SHS x √ √

112 Polyp (nasal, cervical, simple rectal)/kharsutra

SHS x √ √

67



Up to 25 beds

50 beds or above

113 Ear lobe repair (*cosmetic purpose not included)

SHS x √ √

114 Palliative care for cancer patients

SHS x √ √

115 Physiotherapy SHS √ √ √

116 Counselling SHS √ √ √

Note: SHS = Social Health Security ProgrammeNote: √: Available at the health facility; X: Not available at the health facility*: Available only if the service is catered from respective health facility

ann

ex 4

: det

ails

of

the

Ben

efit

Pac

kage

69

annex 5 enrolment form

(Relating to Rule 3(5))

Government of Nepal


Enrolment Form

New enrolment Name of householder Relationship with the household head

Membership no. of the household head

Member to be added

No. of family members

I hereby request enrolment of me/my family in the Social Health Security Programme.

Personal details:

Name: ………………………Sex: Female o Male o Other o Date of birth………………………

Current address: ………………………District………………………Municipality/

VDC………………………Ward number……… Tol/street………………………House number ..............

Phone/mobile number: ……………………Email...................................................................................

Photo identification number/Types ………………………

2) The facility chosen as first point of service from …………………….. Primary health post/ hospital

3) Date of enrolment:

Date of service coming into effect o Bhadra 1 o Mangsir 1 o Falgun 1 o Jestha 1

4) Do you have a poor ID card? Yes o No o

If yes, identification card number……. Ultra poor o poor o marginalised o

5) Enrolment fee.............. NPR………………..In words……......................……....................................................

Receipt number…………..

Membership No.044466600

ann

ex 5

: enr

olm

ent

form

70

6) Consent: All details mentioned above are correct. In case they prove to the contrary, I am ready to

be subject to the punishment determined by Social Health Security Programme (Operating) Rules

2072 .

Right Left

Signature of the applicant ……………………Date………………

For official use

1) Signature of collector Name/surname : Code number:

2) Approved by

Name/date:

Signature/date of the person who enters (data) in computer

ID card Issued on:

If anyone finds this ID card, please return it to the nearest Social Security District Office or the police

post.



Individual Identity Card

Name......................................................................................

Date of birth................................ Membership of house

owner......................................

Address.............................District......................................

Municipality/VDC......................................Ward Number

Sex: Female o Maleo Other o

The member himself/herself shall be answerable in case this identification card is misused or wrongly used

Signature of the member

Right left

Contact number:

71

ID card Issued on:

If anyone finds this ID card, please return it to the nearest Social Security District Office or the police

post.

Contact number:



Individual Identity Card

Name......................................................................................

Date of birth................................ Membership of house

owner......................................

Address.............................District......................................

Municipality/VDC......................................Ward Number

Sex: Female o Male o Other o

The member himself/herself shall be answerable in case this identification card is misused or wrongly used

Signature of the member

Right left

annex 6 memBershIP Id card

ann

ex 6

: mem

bers

hip

Id

car

d

73

annex 7 receIPt

Government of NepalSocial Health Security Development Committee

Receipt

Annex 10.1Ma. Le. Pa. Pha. No. 11

Received an amount of NRS ………………….. in word

………………………………………… for ……………...............

Receipt No.

Date:

Received by:

Position:

Received from:

Symbol No:

S.N Particular Amount

Cash Voucher Total

Total

ann

ex 7

: rec

eipt

75


Progress and Monitoring Form

Date:………….. Name or registering authority:…..

Enrolment assistant:…………. VDC/municipality code no……..

Enrolment assistant code:…………….

Details of materials/goods

Particulars Received by enrolment assistant Received by enrolment officer

Enrolment form

Family number change form

Membership renewal form

Feedback details (attached) Not needed

ID Card Cover Not needed

Receipt Not needed

Details of the contribution money collected

Membership registered family number

Number of family members

Number of Members

Total Amount Incentives

Capable of paying

Marginalized

Poor

Ultra poor

Details about information and data dissemination

Information disseminated by enrolment assistant

Number

Number of new registration

Number of renewal

Number of changes in family size

Feedback

…………………………….. ………………………….

Enrolment assistant Enrolment officerSignature Signature

annex 8 Progress and monItorIng form

ann

ex 8

: Pro

gres

s an

d m

onit

orin

g fo

rm

77

annex 9 change of health facIlIty form

(Relating to Rule 9 (5))Government of Nepal

Social Health Security Development Committee Mr/Ms…………..,

Reference: Regarding changing of health facility I request Social Health Security Development Committee to change the health facility operated by this committee. Name: Membership number of the family head: ………………………… Membership number:

The current first service point: …………………..Primary health post/hospital District: ………………

Change sought: New health facility: …………. Primary health post/hospital District: ……………

Reason for changing first health facility: (1) Migration (2) Marriage (3) Migration for study purpose (4) Transfer (5) Other…..

Documents attached: 1.……………… 2.…………….

Signature of applicant ……………………………………………………………………………………………………………… On behalf of the Committee It appears justifiable to change the first health facility as sought by the applicant upon assessing details mentioned above.

………………………………….. The signature of the recommender Applicant’s contribution money is not due. ……………………………………….. ……………………………………….. Department of Financial Administration Approved by

ann

ex 9

: cha

nge

of

heal

th f

acil

ity

form

79

(Relating to rule 15(1)

Government of Nepal


General Health Check-up Form

Number of the main member of Social Health Security Programme (family head):

Membership no. of the member (examinee):

Name: Age: Sex: Female Male Other

Occupation:

Contact no…

Medical history of chronic disease/conditions

Medical condition Status Use of drugs Name of the drugs under use

Yes No Taken Not taken

Diabetes High blood pressure Any psycho-social problems Any other chronic disease

Family history

Medical condition Status

Yes Yes

Diabetes High blood pressure Any psycho-social problems Any other chronic disease

annex 10 general health check-uP form

ann

ex 1

0: g

ener

al h

ealt

h ch

eck-

up f

orm

80

Present medical condition

Wt: ………………..Kg Height: Inches

Blood pressure: Systolic Diastolic

Blood /urine sugar level …….. mg/dl or micro mole

BMI

S. (reatimire ……………. mg)

Risk behaviours

Smoking Yes No

Alcohol: Daily or frequently Occasionally

Never

Light drinking Moderate drinking Heavy drinking

Physical activity < 30 minutes

30–60 minute

> 60 minutes

Dietary habit: Vegetarian Non-vegetarian

Daily fat consumption ………………………..

Prescribed advice:

Signature

Chief of health facility or health worker

81

annex 11 referral form

(Relating to Rule 18 (1))

Government of Nepal Ministry of Health

Department of Health Services Health Management Information System

Referral Form

Date: ../../……

1. Health Facility Name and Address 2. Contact No.

3. Name, surname of client 4. Sex 5. Age

6. Address District VDC/Municipality Ward No

7. Service being utilized 8. Proposed date of visit

9. Condition BP Pulse Temp Respiration Weight (KG)

Ht(cm)

MUAC (mm)

Edema on both feet

(+,++,+++)

10. Treatment Procedure:

11. Drugs used:

12. Mention if other tests required

13. Reason for shift/referral

14. Remarks

_____________________

_____________________

A client seeking health service from this health facility with above mentioned detail is referred for necessary health service. You are requested to notify once contacted.

Referred by: …………………… Position: …………………………….

Note : This form should be used when a client has to be referred for required health services.

ann

ex 1

1: r

efer

ral f

orm

83

annex 12 oPd/emergency tIcket (health servIce utlIzatIon form)Related to HMIS 1.2 Claim Code (S.N).


District: _____________ Name of Health Facility: __________

Health Facility Code: ___________

Master Register No.

Name, Surname Ethnic Code Sex Age

Membership No.

Health Service Card(OPD/Emergency Service)

Address District VDC/ Municipality Ward No. Contact No.

Date(DD/MM/YY)

OPD Registration No History and Diagnosis ICD

CodeTreatment and Advice

ann

ex 1

2: o

Pd/e

mer

genc

y ti

cket

85

annex 13 famIly memBer renewal form

(Relating to Rule 5 (2))


Family Member Renewal Form

I request membership renewal for myself and my family under the Social Health Security Programme.

Details/particulars of members

SN Full name Membership number

Contribution money Whether earlier

condition has been changed or not

Reason if

changed

personal committee total

1.

2.

3.

4.

5.

For official use

Money received against membership renewal NPR ………….. in words (………………………) Re-ceipt number (bank voucher number): ……………..

The account number to which it is deposited: ……………… Date: ………………..

………… ………….. Cash collector Verifying authority

ann

ex 1

3: f

amil

y m

embe

r re

new

al f

orm

87

annex 14 notIfIcatIon of Payment

(Relating to Rule 18(1))

Government of Nepal


Notification of Payment

M/S ………………………..

As per the request made by ……………..for payment of NPR………(in words……..) marked

with reimbursement payment no…..., this amount, that comes to be a payable remainder after

necessary scrutiny and the subsequent deduction of the amount found non-payable according to

Directive, has been paid to that health facility. Please notify upon receiving the same.

On behalf of Treasury:

……………………..

ann

ex 1

4: n

otif

icat

ion

of

paym

ent

Contact :

Government of Nepal Social Health Security Development Committee Teku, KathmanduPhone : 977-1-4100223, 4100224Fax : 977-1-4100223Website : www.shs.gov.npEmail : [email protected]