HIDDEN under the trite sound bites that the Pakistan Tehreek-i-Insaf’s political leadership thrives on, lies the story of a revolution that must be told.
PTI supporters should be disappointed that their leadership hasn’t effectively told the rest of the country about one of their biggest successes.
Few Pakistanis know that the party’s government in Khyber Pakhtunkhwa has successfully implemented a healthcare solution that is a blueprint for the rest of the country to follow.
No, it is not the case that KP has radically outspent everyone else. In fact, all four provinces are running neck and neck in terms of health spending as a percentage of their budgets. The claim that KP’s spending priorities are somehow vastly different than Punjab’s, which only builds metros, is a fallacy that should be removed from the PTI’s rhetorical arsenal and thrown in the wreckage left by Peshawar’s bus rapid-transit project.
What should replace it is the reality of the Sehat Sahulat Programme. Because it is innovations like these that can make widespread access to decent medical care a reality in Pakistan. And that is something worth talking about.
What should replace the PTI’s rhetorical arsenal is the reality of KP’s health programme.
Sehat Sahulat is the KP government’s flagship health insurance programme. As of now, around half of the households in the province, selected for need, based on the Benazir Income Support Programme methodology, are card-carrying members.
An expansion of coverage to 70 per cent of the population is under way. The cards, known as Sehat Insaf cards, signify that the holders are covered by health insurance, with premiums paid to State Life directly by the provincial government.
This insurance allows households to utilise up to Rs540,000 per year, for medical treatment and medicines, at public and private hospitals across the province. So, the poorest person in KP, sans a single rupee in hand, can be treated at the finest private hospital in Peshawar, just like any fee-paying patient.
The cherry on top? The insurance also pays patients lost wages, and in case of referrals from outside Peshawar, travelling money.
Premiums are surprisingly low. Currently, the KP government pays the insurance company just Rs1,500 a year per household covered. Well-placed sources confirm this will have to rise a bit, as the insurance company is currently losing money on the deal.
To keep costs low, and to combat fraud, there are a few caveats to the coverage. Outpatient care isn’t included, and there are rules relating to referrals that can be cumbersome. There is also a conscious attempt to prioritise utilisation of government hospitals, to allow them to generate revenue. Despite this, around 60 per cent of the fees paid in insurance claims, are paid to private hospitals.
Sehat Sahulat is a dramatic step towards equity in medical care. It replaces a system where a poor person requiring surgery had to choose between a lower survival probability at a crowded public hospital unable to cope with patient demand, and the certainty of financial ruin at a better equipped private hospital. It lessens the burden on public hospitals, raises the status of poor patients there (because they now represent a revenue source in the form of insurance payments), and enables people to afford private treatment that would previously have been unthinkable.
Alongside equity, Sehat Sahulat represents efficiency in spending healthcare resources. Such efficiency isn’t typically achieved by well-intentioned gentlemen in robes, poking at bed sheets, taste-testing food, ordering equipment purchases, and embarrassing the handful of highly qualified specialists who choose to make Pakistan their home.
If public hospitals across the country are hopelessly overcrowded, understaffed and under-equipped, then, yes, part of the reason is that budgetary allocations to healthcare must be raised.
But there is a more obvious reason — Pakistan is a poor country. To illustrate just how poor we are, consider this: even adjusting for purchasing power and price differences, every rupee earned by every person in the country wouldn’t be enough to publicly fund a healthcare system of the quality of, say, Norway ($5000+ per capita expenditure).
So, what we have must be spent efficiently. What KP’s brilliant initiative does is show what this might look like. By focusing more spending on insurance premiums, the state encourages a marketplace where entrepreneurs want to invest capital to build and equip new facilities that the government can’t afford upfront.
KP’s health-sector insiders confirm that this is well under way in the province. New private hospitals are being built at a rapid pace, to cater to demand from a newly insured patient base. This efficiently frees up the capital expense that would be required to build new facilities.
Some treatments are so expensive that no affordable insurance would cover them. For these, the state’s answer will have to remain specialised centres of excellence like the Pakistan Kidney and Liver Institute in Punjab, and the National Institute of Cardiovascular Diseases in Sindh. And for primary care, including the Lady Health Worker programmes and small health units, each province has lessons to learn from others. For everything else, look to KP.
A broad-based, sustainable insurance initiative including private hospitals is something that the federal government has also been working on. That programme, called the Prime Minister’s National Health Programme, still in the early phases of roll-out, covers just a few districts and offers far fewer benefits to beneficiaries. That the KP government has implemented its bold plan on the scale it has, in the time frame it has, is astounding.
That they haven’t talked about it more is shocking. The PTI would do well to change that now. And come July, each provincial government must roll the programme out in their domain.
Just as the PTI’s 100-day agenda promises — in about 10 words buried right near the end. One hopes that those supporting equity and efficiency in healthcare spending didn’t miss it.
The writer is a Lahore-based columnist and consultant with a background in finance, public and private sector strategy, and energy.
Published in Dawn, June 16th, 2018