Daily Times

Universal health coverage means access to health for everyone without falling into poverty. If provided, this policy has the potential to transform the lives of millions of people with guaranteed improvements in education, equality, poverty reduction and economic growth. This would also help achieve the Sustainable Development Goal of good health and wellbeing.

Access to quality healthcare services remains a key development challenge for Pakistan. According to a Lancet Study (2016), among 195 countries of the world, Pakistan stands at 154th position, behind its South Asian neighbours such as Sri Lanka (71), Bangladesh (133), and India (145). Pakistan spends less than three per cent of its Gross Domestic Product on health. The latest National Nutrition Survey (2018) reveals that four out of ten children under five years of age are stunted while 17.7 per cent suffer from wasting. The rural population suffers more than their urban counterparts with 43.2 per cent stunted children than 34.8 per cent in urban areas.

Although the incumbent government of Pakistan has moved in the right direction by extending health coverage by launching Sehat Insaaf Cards, a health insurance scheme for the poor. It will be a long way to see if the benefits reach the poor. Also, the task of ensuring universal health coverage is too big to be accomplished by the government alone.

Let us look at one such study and initiative in Sindh province and some of the lessons learnt that need to be taken into consideration to ensure the benefits of such schemes including that of the Sehat Insaaf Cards reach the poor.

Micro health insurance is offered as part of the ongoing “Sindh Union Council and Economic Strengthening Support” (SUCCESS) programme in southern Pakistan. Started in 2015 and funded by the European Union, the SUCCESS would reach 600,000 rural households in eight districts of the Sindh province until 2021, an overall budget of EUR 82.13 million, including EUR 4 million for the micro health insurance (MHI) component. 25 per cent (131,0000 households) of the poorest households would be provided with the micro health insurance covering in-patient costs for each of the household members up to Pakistani Rupees 25,000/- per annum. Under the project, the insurance company is paid, on average, Pak Rs. 1,000/- for an average household of six persons per annum as premium from the project.

In a period from May 2017 to July 2018, 102,769 households including 669,184 people were insured. However, for the same period, only 2815 people, less than one per cent (0.42 per cent) of the insured people and 2.74% of the insured households utilised the insurance facility where insurance company paid the cost of treatment to the health facility or the insured person. At the time of the roll-out of this study, the claim to premium ratio was 29 per cent in July 2018 where some districts had better utilisation of MHI cards than others, relatively. Hence, this study was conducted to investigate the factors that enable or challenge the utilisation of MHI.

The MHI cards, where used, had immense benefits. The first among the enabling factors is the location of the penal hospital and the mode and cost of transportation to the hospital. Highest instance of the MHI usage in Jamshoro showed that ease of access was a key enabler for the communities to benefit from the MHI utilisation. Bakhtawar General Hospital was a convenient choice for the MHI cardholder of the union council “Morho Jabal” and settlement “Aliabad” in district Jamshoro.

The availability of MHI cards encouraged communities to access qualified doctors and rely less on quacks available nearby. Also, those who used cards have reported having saved their critical assets such as livestock and from high cost (both economic and social) borrowing from landlords and money lenders.

MHI card has been used more than 60 per cent in the cases related to gynaecology like delivery cases and more than 30 per cent in the cases of serious viral infections like Diarrhoea in children as a common disease, told by an RSP official. Here are three instances out of many where MHI cards users narrate the benefit of this facility.

The availability of MHI cards encouraged communities to access qualified doctors and rely less on quacks available nearby

Ms Fatima, an MHI cardholder of Tara CO, UC Dabhoon, village Hari camp is one of the hundreds of beneficiaries of the program, said, “Truly, I was left nowhere when I came to know about my husband’s ailment and the required money for the surgery. I was quite upset as I was not able to arrange the huge amount for the surgery but thank God I was the beneficiary of MHI. Therefore, my husband Jumo went through the surgery and treatment on the MHI card, I received under the SUCCESS programme. Now once again, he is living a normal life with the family. I have really no words to express gratitude for such great support.”

Asma Bibi, aged 25 years, a mother of six children and resident of UC Dabhoo, village Mohammad Khan, District Jamshoro. She was passing through a tough phase of her life owing to the ovarian cyst as she suffered a lot from this disease. When her relatives took her to the lady doctor, the problem of an ovarian cyst was diagnosed. The gynaecologist recommended her a surgery which cost an amount of Rs25,000. She grew despondent on the situation as she did not have money to foot the bill of the operation. She had received an MHI card under the SUCCESS programme and underwent the surgical process. She stated, “I am extremely happy and feel lucky to be a part of this programme. For me, this was not just support but perhaps a life, which enabled me to live again a healthy life with my kids.”

However, there remain challenges to better utilisation of the insurance facility. The challenges include affordability to travel to reach the panel hospital, seasonal migration, low literacy, superstition, unavailability of computerised national identity cards hindering and lack of functional coordination between the implementing Rural Support Programmes (RSPs) and the insurance provider.

The latest cumulative figures up to July 2020 show an improvement of almost four times (0.4 per cent to 1.7 per cent) of the insured people in the utilisation of the MHI insurance. The claim ratio to premium has increased from 29 per cent to 63.63 per cent, showing an increasing value for money since July 2018. This improvement is attributable partly to the payment of transportation costs as part of the insurance coverage and partly due to increased sensitisation and awareness among the MHI cardholder by the implement partners of the programme.

Partnerships with wider civil society and development organisations and integration of health coverage in the ongoing poverty reduction programmes are some of the key initiatives to help achieve universal health coverage.

Dr Abdur Rehman Cheema is a development practitioner based in Islamabad. He can be reached at arehmancheema@gmail.com. Fazal Ali Khan is Programme Manager at Rural Support Programmes Network, Islamabad. He can be reached at fazal@rspn.org.pk.