Question 1 What is the issue, and why does it matter?
Citing the Health Insurance Board, the Auditor General reports that only 7.58 per cent of Madhesh's population were active insured members, the lowest of the seven provinces (the highest was Gandaki at 35.72 per cent), and says this raises questions about access, awareness and service availability in the province with the second-largest population.1
The choice is how to improve outcomes in this province, who benefits first, and which institution can act. The figures below belong to the stated reporting period; they are not a real-time measure of today’s conditions.
Question 2 What do current law and policy say?
Basic and secondary education and basic health are local powers (Schedule 8, items 8 and 9); health services and higher education are provincial (Schedule 6, items 8 and 9); health policy and national hospitals are federal (Schedule 5, item 16); education and health are concurrent for all three levels (Schedule 9, items 2 and 3).2
Agriculture, factories and industrialisation are provincial (Schedule 6, item 20); province-level irrigation is provincial (Schedule 6, item 7); central-level large irrigation projects such as Sunkoshi–Marin are federal (Schedule 5, item 14); local roads, agro-roads and irrigation, and agriculture and agro-product management, are local (Schedule 8, items 11 and 15); agriculture and irrigation services are concurrent for all three levels (Schedule 9, items 4 and 5).2
Water supply services are provincial (Schedule 6, item 7) and local (Schedule 8, item 19); water supply and sanitation are federal–provincial concurrent (Schedule 7, item 18); water uses and environment are concurrent for all three levels (Schedule 9, item 7); water-resources policy is federal (Schedule 5, item 11).2
Provincial executive power rests with the Council of Ministers. The Chief of Province (governor) performs constitutional and legal functions, generally on the Council’s recommendation and consent; the governor is not the department delivering these services. Provincial revenue and expenditure estimates go to the Provincial Assembly.3
Question 3 What is known, uncertain or disputed?
Known
Citing the Health Insurance Board, the Auditor General reports that only 7.58 per cent of Madhesh's population were active insured members, the lowest of the seven provinces (the highest was Gandaki at 35.72 per cent), and says this raises questions about access, awareness and service availability in the province with the second-largest population.1
The federal FY 2083/84 budget continues a child nutrition allowance in 25 districts 'mainly across Madhesh, Karnali, and Sudurpashchim provinces, which have high poverty'.4
Uncertain
A province-wide number does not identify the worst-served wards or prove the same problem in every municipality. Before spending, establish a current local baseline, service quality, staffing, access barriers and the full operating cost.
Disputed
The policy choice is how to balance universal access, concentrated investment, affordability and fiscal sustainability. The alternatives below are Policy Nepal’s discussion options derived from the problem evidence, not claims that officials or parties have endorsed them.
Questions 4–5 What are the options, and what do they cost and achieve?
Options are listed in no particular order. Policy Nepal does not recommend one; real policies often combine them.
A
Fix the service and referral pathway14
Check staffing, medicines, diagnostics, opening hours and referrals alongside enrolment or facility counts.
Benefits
- Focuses on completed care rather than registration alone.
Costs
- Requires reliable supplies, clinical staff and referral transport.
Trade-offs
- Expanding demand without provider capacity can increase waiting time.
What does implementation require?
- Publish service standards and anonymised waiting, stock-out and referral data; protect medical records.
Make financial protection usable14
Help eligible households understand benefits, renew coverage and navigate claims while checking whether providers can deliver covered services.
Benefits
- Can reduce paperwork barriers and avoidable out-of-pocket costs.
Costs
- Needs outreach, claims support and sustainable provider payment.
Trade-offs
- Insurance registration is not proof that care is available or affordable.
What does implementation require?
- Track renewal, rejected claims, waiting time and household costs separately; refer financing issues to the legally responsible level.
Combining options
Start with a verified baseline and maintenance of functioning services, then test additional investment against the same outcomes. Publish who pays for capital costs, recurring costs and any household charges; an unfunded operating plan is not a sustainable solution.
Question 6 Who is responsible?
Shared
Schools and healthBasic and secondary education and basic health are local powers (Schedule 8, items 8 and 9); health services and higher education are provincial (Schedule 6, items 8 and 9); health policy and national hospitals are federal (Schedule 5, item 16); education and health are concurrent for all three levels (Schedule 9, items 2 and 3).2
Shared
Farming, irrigation and agro-processingAgriculture, factories and industrialisation are provincial (Schedule 6, item 20); province-level irrigation is provincial (Schedule 6, item 7); central-level large irrigation projects such as Sunkoshi–Marin are federal (Schedule 5, item 14); local roads, agro-roads and irrigation, and agriculture and agro-product management, are local (Schedule 8, items 11 and 15); agriculture and irrigation services are concurrent for all three levels (Schedule 9, items 4 and 5).2
Shared
Drinking water and groundwaterWater supply services are provincial (Schedule 6, item 7) and local (Schedule 8, item 19); water supply and sanitation are federal–provincial concurrent (Schedule 7, item 18); water uses and environment are concurrent for all three levels (Schedule 9, item 7); water-resources policy is federal (Schedule 5, item 11).2
Provincial
Chief Minister, Council of Ministers and Provincial AssemblyProvincial executive power rests with the Council of Ministers. The Chief of Province (governor) performs constitutional and legal functions, generally on the Council’s recommendation and consent; the governor is not the department delivering these services. Provincial revenue and expenditure estimates go to the Provincial Assembly.3
Question 7 What have parties and leaders said and done?
What was said or promised is shown apart from what was recorded as done. Every entry needs a dated source. A missing entry means the position is not established, not that someone opposes or is neutral.
This dossier presents official evidence and research options. It does not assign a position to a chief minister, governor, mayor or political party without a dated source specific to this issue.
Said or promised
Position not established in reviewed sources.
Recorded actions and outcomes
Position not established in reviewed sources.
Question 8 What would progress look like, and when do we check again?
IndicatorLatest official figureOfficial targetRevisit
Completed care and referrals, with waiting times and medicine availability14
Not established
No official target found
2026-10-20
Renewal, claim rejection and household out-of-pocket expenditure14
Not established
No official target found
2026-10-20
Sources
Grouped by type of evidence. Government plans show what government intends; they are not proof of results. Party material shows what a party says.
Constitution & law
- The Constitution of Nepal (English translation, incl. first and second amendments), Schedules 5–9 — Nepal Law Commission, Government of Nepal, Gazette publication 20 September 2015 (2072/06/03); amended 2016 and 2020. Schedule 5 (federal powers), pp. 193–195; Schedule 6 (provincial powers), pp. 196–197; Schedule 7 (federal–provincial concurrent powers), pp. 198–199; Schedule 8 (local powers), pp. 200–201; Schedule 9 (concurrent powers of all three levels), p. 202. Item numbers are given in each statement that cites this source.. Checked 2026-10-11
- Constitution of Nepal, English translation with first and second amendments — Nepal Law Commission. Articles 162, 166, 207–208; Schedules 6–9. English translation; Nepali text authoritative.. Checked 2026-10-13
Government plans & policy
- Budget Speech for Fiscal Year 2026/27 (2083/84) (unofficial English translation) — Ministry of Finance, Government of Nepal, 2083 Jestha 15 (29 May 2026). Para 21(a), (d), (e) (Mid-Madhesh Quadrangle; northern eco-trade destinations; Koshi Corridor), pp. 9–10; para 34 (child nutrition allowance in 25 districts), p. 16; para 41(k), (q) (Galchhi–Syaphrubesi–Rasuwagadhi road; Bathnaha–Biratnagar and Janakpur–Jayanagar–Bardibas railway), p. 19; para 42(a)–(b) (Terai/Madhesh drinking water and 'Arsenic-Free Terai'; Yangri–Larke diversion to Melamchi), p. 21; para 43(b)–(i) (hydropower projects, transmission lines, Hetauda green hydrogen pilot, Kathmandu Valley battery storage), pp. 22–23; para 44(d)–(e) (Sunkoshi–Marin; irrigation of 122,000 ha in Bara, Rautahat, Sarlahi, Mahottari and Dhanusha), p. 23; para 50(d) (mango processing in Siraha and Saptari; tomato processing in Sarlahi), p. 30; para 52(b), (e), (f) (Janakpur; World Heritage initiative; provincial tourism corridors), pp. 32–33; para 69(d)–(e) (Nepali liquor brands; microbreweries; excise on alcohol), pp. 44–45; para 73(d) (agro-processing tax exemption; VAT exemption on cold-storage machinery), p. 47. Checked 2026-10-11
Change history
- 2026-10-13 — Expanded the province challenge into the same eight-question format as national issues. (Regional issues deserve equally accessible evidence, options, responsibilities and tracking. Original dates and sources retained; policy options are editorial proposals.)
