DECEMBER 12 is Universal Health Coverage Day. It commemorates the resolution on ‘Global Health and Foreign Policy’, adopted by the UN General Assembly in 2012, urging countries to accelerate progress on UHC. To recall: “UHC means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.”
UHC is no longer a mere slogan or rhetoric. It has developed into a new science at the crossroads of medicine, public health, health systems and social sciences. A UHC index has been developed, and WHO and the World Bank together issue a periodic report on how regions and countries are performing on improving access to essential health services and ensuring financial protection for the poor and vulnerable.
On the occasion of UHC Day, I have listed 10 key priorities to advance UHC in Pakistan. With our abysmal mother and child indicators, high prevalence of preventable communicable and non-communicable diseases, low health budget, dominant and loosely regulated private health sector and increasing frequency of health emergencies, healthcare priorities can be many and varied. The list below has been developed for the steady and sustainable advancement of UHC.
We need a paradigm shift where primary healthcare is concerned.
UHC is the realisation of the right to health. However, it is not clearly established in Pakistan’s Constitution. The right to health, like the right to education, needs to be established as a constitutional right. All political parties should work towards such a constitutional amendment.
Pakistan has made huge progress in the last four years in terms of developing a cost-effective and costed National Essential Health Services Package and provincial EHSPs. The integrated delivery of 88 high-priority health services at the district level can address most prevalent health risks and diseases. The EHSP should be the centrepiece of healthcare, guiding the reorientation and strengthening of all the building blocks of the healthcare system — governance and regulation; training and deployment of health workers; financing; health information systems; and provision of medicines and health technologies.
We have also made a gigantic leap by establishing the Sehat Sahulat Programme, which has survived three governments. However, what started off as a financial protection mechanism for vulnerable groups in case of hospitalisation has been universalised for political reasons. This is neither sustainable nor the best use of public money in a declining economy. The original goal of the programme needs to be restored by limiting Sehat Sahulat to poor and vulnerable groups and expanding it to cover ambulatory care.
We need to seriously prioritise primary healthcare. Up to 70 per cent of health needs can be taken care of at the PHC level. No country has been able to improve its vital health indicators without improving PHC. We have to shift our investments from big hospitals to quality PHC. Our public-sector tertiary hospitals are overly crowded because our PHC is not working. PHC in Pakistan has become synonymous with poor healthcare for the poor. When was the last time any one of us took a loved one to a BHU or RHC? We need a paradigm shift on PHC at the policy level, where allocations and operations are concerned.
Prevention is not only better but also cheaper than cure. Effectively managing risks to, and the determinants of health spares us misery and expense. Ensuring safe blood transfusions and injection safety, for example, will drastically reduce the spread of HIV and hepatitis C. We have to strengthen preventive, promotive and rehabilitative healthcare.
With around 60pc of out-of-pocket health expenditure primarily going to the private health sector, UHC cannot advance at the national level without improving and involving private care, especially general practitioners who provide the bulk of PHC. Medical colleges — public and private — should develop PHC facilities along with hospitals for providing quality healthcare, as well as for training their students. The capitation-based Sehat Sahulat Programme needs to be extended to the PHC level for private-sector GPs who should be trained as family physicians so that they can provide quality PHC.
UHC means covering everyone, but the way our population has swelled and continues to grow unchecked, no surge in resources can meet the people’s healthcare needs. We now have the world’s fifth largest population. With over four million unwanted pregnancies every year, we are clearly not being able to ensure the availability of contraceptives. The government must pay constant attention to population control by overhauling the Lady Health Workers Programme and ensuring the availability of contraceptives.
Our health workforce’s education and training aren’t aligned with our healthcare needs. The average fresh medical graduate has no idea about our disease burden, the organisation of the healthcare system or health policies. He or she has never been exposed to primary healthcare during training. There is an urgent need to reform our medical and public health curricula and (re)train the workforce where needed.
Healthcare includes health security in the face of sudden adversity. Readiness to respond to health emergencies through strengthening essential public health functions is very much a part of UHC. Pakistan is prone to emergencies, and climate change-induced catastrophes are on the rise. The Covid-19 experience has proven the importance of a reliable surveillance system to pick early warning signals of disease outbreaks and of data-based response decisions. Though Pakistan has responded well to Covid-19, its lessons should guide the strengthening of relevant policies and institutions.
Seventy per cent of our disease burden is now made up of non-communicable diseases — blood pressure, diabetes, mental health problems, cancer, etc. These conditions need to be prevented in the first place; once they develop, lifelong treatment is required. Our healthcare system is not organised to provide long-term care. Linking each individual’s digital medical record to his or her CNIC is the way to ensure that the doctor can examine a patient’s history before prescribing a new set of expensive diagnostic tests and medicines.
With technological innovations and the use of telemedicine, expanding healthcare coverage is not an unattainable dream. UHC is progressive but its pace and direction is in our hands.
The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University and WHO adviser on UHC.
Published in Dawn, December 16th, 2022