The current study showed a higher number of elderly members in the family was significantly associated with utilization of health insurance services. We found similar results in a study done in China and Taiwan.[22, 23] An increase in age elevates the vulnerability of getting ill-health, which leads to generating more health needs, resulting in high utilization of health care benefits. The another reasons for high utilization could be full waiver in contribution amount for the elderly above 70 years in health insurance program. This could motivate them to utilize the health insurance services.
Households with members suffering from chronic illness were also more likely to utilize health insurance service in this study. The higher proportion of service utilization might be because of increased health care needs for chronically ill people. Similar finding was observed in a previous study done in three districts of Nepal, which showed higher service utilization among patients suffering from chronic illnesses like diabetes and hypertension after the program's inception in the district. Also, families with chronically ill people were more likely to join the health insurance program, as evident from a study done in Illam, Nepal. Studies from the Community Based Health Insurance (CBHI) program of India  and rural China however [26, 27] did not show any association between the presence of chronic illness and health insurance utilization. In our context, a higher tendency of health insurance service utilization among chronically ill people exists. The government should address the possible selection bias by increasing population enrolment in health insurance and ensuring a larger risk pool for financial sustainability of the health insurance program.
Our study showed a significant association between health insurance utilization and membership duration of the health insurance program. The possible reason might be that members with longer duration are aware of the benefits of the health insurance program. However, the membership duration showed no association with the utilization of health insurance benefits of out-patients services in the Vietnam household living standard survey. Another study in St. Louis, USA revealed a reduction in utilization rates with increased membership duration over five years. The reasons behind this were due to centralizing health care system and long waiting lines which involved travel and time cost .
Additionally, willingness to continue the program was a significant predictor for health insurance utilization in this current study. The possible explanation for this might be the insured’s positive experience in getting health insurance benefits. High dropout rates put challenges in the reduction of insurance pool size and the negative impact on the new enrollment rate. Around 90% of the participants were willing to continue the program in the future. Given that the prevalence of service utilization was only 77.2%, this means some household are not using the service, but are willing to continuous the program. The figure showed the motivation of these subgroup .The figure is consistent with the study conducted in three districts (Kailali, Baglung and Illam) of Nepal. Similar findings were identified in a study in Ethiopia. Literature has demonstrated that the decision to continue in the program reflects the individual's risk aversion and demand for certainty as the certainty level regarding relatively good health reduces acceptance for insurance uptake and vice versa.[32–34]
In our study, family's education status, socioeconomic status, and comprehensive knowledge regarding health insurance were not significantly associated with service utilization. This study also examined the prevalence of the utilization of health insurance program, which was 77%. The dropout rate was measured as 11%, which was very low compared to the national rate, i.e., (44.5%). Although the overall performance indicator was remarkably good compared to the national rates, the comprehensive knowledge on health insurance (18.8%) was lower than the study conducted in two districts (Baglung and Kailali) of Nepal where health insurance was first implemented.
The study showed various reasons for the non-utilization of the health insurance service which included not being ill, seeking other treatment, and hearing previous bad experiences from the service users. The other reasons were having long waiting lines and over crowdedness in the health facility, bothersome procedure to get treatment and being unaware about where to go for treatment. We identified similar reasons for the non-utilization of health insurance services in studies conducted in different countries.[37–42]
The study has some limitations. The cross-sectional study was conducted in an urban setting, thus, the findings derived from this study cannot be generalized to the whole country. Similarly, the study might have encountered respondent bias despite the study team's effort to explain the purpose of the study. Nevertheless, this study is the first of its kind in Nepal, exploring the factors affecting the utilization of health insurance among the insured population.