Health coverage

Published December 12, 2020
The writer is professor and chair, Department of Community Health Sciences, Aga Khan University, and former director, Health System Development, WHO’s Regional Office for Eastern Mediterranean, Cairo.
The writer is professor and chair, Department of Community Health Sciences, Aga Khan University, and former director, Health System Development, WHO’s Regional Office for Eastern Mediterranean, Cairo.

IN Pakistan, annually almost 370,000 infants die before their first birthday and 10,000 women die because of pregnancy and delivery complications. This is unacceptable. With the changing disease burden, people need services for maternal and child health problems, common infectious diseases and for the rising burden of non-communicable diseases such as diabetes, heart disease, and cancer. Notwithstanding the challenges posed by Covid-19, people need access to essential health services and achieving universal health coverage (UHC) is the potential solution.

UHC has been the single most important global movement in health to which the world has committed. In 2019, the UN High Level Meeting on ‘Universal Health Coverage: Moving Together to Build a Healthier World’ was a significant achievement for countries, including Pakistan, who reaffirmed their high-level political commitment to UHC.

What does UHC mean? It means ensuring all people have access to essential health services of sufficient quality and that their use does not expose them to financial hardship. What makes UHC unique is that financial hardship is a significant barrier to ‘accessing’ healthcare. Many in Pakistan are unable to find the resources, incur catastrophic expenditure or become impoverished because of seeking healthcare for themselves or their families. A conservative estimate suggests that almost 350,000 households in Pakistan become impoverished every year while seeking healthcare. This is unfair and inequitable.

Can Pakistan achieve UHC by 2030?

Pakistan has committed to UHC in its National Health Vision 2016-25 and to raising its level of health expenditure from one per cent to 3pc of GDP. Currently, the public sector spends almost $14 per capita on health, which is among the lowest in South Asia. Despite enormous challenges, the government has made some progress on two UHC fronts.

First, it has endorsed a district-level UHC benefit package that has the nod of federal and all provincial ministers of health. It comprises 88 interventions costing $13.0 per capita. This package is adapted from DCP3, a global initiative, by a collaborative team comprising the federal national health service ministry, Aga Khan University, London School of Hygiene & Tropical Medicine, and WHO. The plan is to implement it in Islamabad, two districts of each province, one of each region before scaling up. While easier said than done, a fiscal space analysis has been initiated to determine and bridge the financial gap for implementing the package.

Second is the scale up of the Sehat Sahulat Programme in Punjab and KP with the centre’s support. The SSP, a social health insurance programme, targets providing coverage to the 65 million poor. It claims to have insured almost 10m families. Recently, Prime Minister Imran Khan committed to expanding it to the entire population in Punjab and KP for which some Rs35 billion have been allocated this year. While all sounds good, questions remain. First, despite high levels of enrolment in SSP, the utilisation rate is around 3pc, which is inadequate; second, covering the entire population of Punjab and KP would require several times more resources than what is allocated; and third, before scale-up SSP needs an independent and external evaluation.

Theoretically, the entire population of the country is ‘eligible’ to receive health services from public-sector facilities. However, not everyone can, and the meagre resources are siphoned off by the powerful leaving little for the poor and vulnerable. A well-implemented health insurance programme brings a sense of ‘entitlement’ to the poor, which ‘eligibility’ does not offer and is a great contribution of such schemes worldwide. Further, there is always a demand for ‘more money for health’ given Pakistan is such an under-spender, equally it needs to get ‘more health for the money’ available by minimising wastage, abuse of and leakages in the system.

What about Balochistan and Sindh that have not opted for social health insurance? Lower- and middle-income countries such as Egypt, Iran, Thailand, and Turkey are all moving towards or have achieved universal health insurance. It will be difficult to go against the tide for too long. All provincial and federal governments supported by academia and development partners should have an honest and informed discussion. Pakistan is far behind and has a lot of catching up to do, differences among political parties should not become the reason for delaying essential healthcare to its people.

Can Pakistan achieve UHC by 2030? It is a question worth many billions of rupees. The country has some way to go but a reasonable beginning has been made. While Covid-19 will eventually be tamed, the opportunity it has provided to raise health high on the agenda of countries like Pakistan should not be missed.

The writer is professor and chair, Department of Community Health Sciences, Aga Khan University, and former director, Health System Development, WHO’s Regional Office for Eastern Mediterranean, Cairo.

Published in Dawn, December 12th, 2020

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