Daily Times

Pakistan’s public sector health infrastructure has not expanded much over the years, as compared to private sector infrastructure. Strengthening public sector health facilities and human resources would have improved the utilization of public health facilities as a cost-effective solution to provide quality health products to the population of Pakistan. Higher use of private health facilities utilization has resulted in high (60 per cent) Out of Pocket (OOPs) health expenditure. The general increase in health costs and OOP has adversely affected the health and economy of poor households. Sehat Sahulat Program (SSP) was conceived and initiated as targeted social health insurance for the poorest of the poor families with an income of less than $2 per day (PMT32.5) to reduce their health expenditures. Some believe that the program was politically motivated, yet, it provided a big relief to the targeted population, especially in their surgical and maternity emergency care and in cases of cardiac diseases, cancer, chronic kidney disease (such as Dialysis), etc. This program has entered its seventh year with a progressive increase in wider coverage of diseases with the inclusiveness of vulnerable populations like persons with disabilities and transgender. The program started at the national level with the idea of inclusion of all provinces.

At this time, it is fully implemented for the residents of Punjab, Khyber Pakhtunkhwa (KP), Islamabad Capital Territory (ICT), Gilgit-Baltistan (G-B), Azad Jammu & Kashmir (AJK), and Tharparker district (Sindh). The SSP has been covering a 100 per cent population in KP and Punjab since late 2021 and February 2022 respectively. In other words, it is a Universal Health Insurance provided to the whole population, free of cost. It covers hospital admission for secondary and tertiary health care and 10 priority chronic diseases. This is not Universal Health Coverage (UHC), as it does not cover primary health care, but it is a catalyst towards UHC. Though health is a provincial subject, Sindh and Balochistan provinces are still targeted programs.

SSP is being implemented through the State Life Insurance Corporation (SLIC), a public sector insurance company, through 1091 public and private empanelled hospitals with a majority of private health facilities. As a benefits package, each family registered with NADRA is eligible to get health care of PKR one million/year with a split of PKR 60,000 for secondary /tertiary and emergency hospital admissions and PKR 400,000 for treatment of around 10 priority chronic diseases, including kidney transplant and heart procedures. On exhaustion of this allocated amount, an additional amount can be utilized up to PKR 1 million.

Admissions due to cardiac problems rank as the number one use category and it takes 40 per cent share of the admission due to all other illnesses. Before the universalization of health insurance coverage during 2021-2022, the utilization rate was less than 10 per cent. Over time, the program has developed a strong monitoring system, with real-time dashboards, feedback and redressal mechanisms in place.

SSP is unique in the sense that it is the largest social health insurance fully funded by the government in the region. A comparable regional program is Ayushman Bharat Yojna, which is fully funded, but with 50 per cent population coverage. China has universal coverage partially paid by the government and Bangladesh has only contributory health insurance paid by beneficiaries.

Universalization appears to be a major driver for the enhanced use of SPP. In Punjab, in early 2022, the program was extended to 100% population. In one year, 2.5 per cent population has utilized SSP services in Punjab. In Khyber Pakhtunkhwa, where universal health insurance is completing two years, there is a ten-fold increase in its utilization and access to services and 51 per cent of the premium is utilized (KP audit report). The availability of cashless life-saving emergency services like cardiac intervention has markedly reduced out-of-pocket expenditure in line with one of the objectives of this program. According to the patient satisfaction perception surveys, 93 per cent of the population is satisfied with the services provided to citizens. A small sample survey of service providers, however, have shown concerns about the inadequacy of negotiated package for the provision of quality services.

It is encouraging that this program, with its present scope, provides secondary health care to the poor and people, by and large, are happy with this. This program is limited to medical coverage for an admitted patient, but, in Pakistan, most of the disease burden (Non- Communicated Diseases) is treated as an outdoor patient at primary health care, which is not covered, leaving out commonly found ailments such as mental health problems, hypertension, and diabetes. According to National Health Accounts 2014-15, more than 70 per cent of out-of-pocket health expenditure is on outdoor patient consultations, in the category of primary health care. Building on the success of SSP, this is high time that serious discussions are initiated on the best way to extend SSP to Primary Health Care.

(To Be Continued)

The writer is the Advisor for the Centre for Health Policy & Innovation (CHPI) at Sustainable Development Policy Institute, Islamabad.