In a recent meeting of Insaf Doctors Forum at Aiwan-e-Iqbal, Prime Minister Imran Khan talked about his government’s commitment towards providing citizens Universal Health Coverage (UHC) and their expansion plans in Punjab and KP, set to be achieved in phases within a year.
UHC, as a broad concept, primarily calls for access to quality health for every citizen without pushing them into financial hardships. Under this, every citizen, above or below the poverty line, can avail free healthcare. Developed, as well as developing countries all over the world, struggle with providing UHC to its citizens.
When it comes to Pakistan, we have a complex healthcare delivery system. It is jointly administered by the federal and provincial governments and consists of the private and public sectors. The 18th Amendment passed on April 8, 2010, consisted of the devolution of about 22 federal ministries to the four federating units, including the health ministry. Under it, the federal ministry of health was abolished giving way to lack of coordination between the federal and provincial governments on health care initiatives, as can be seen from the Sehat Sahulat Program (SSP). The difference of vision and incoherence between the federal and provincial governments has proved to show different results in respective provinces.
Launched in 2015 as the Sehat Sahulat Program in KP by their provincial government and the PM’s National Health Program across the country (both are named Sehat Sahulat Program since 2018), the Program is a micro health insurance scheme, fully subsidized by the government to improve access of the poor population to good quality medical services.
It provides free of cost indoor healthcare services to people below the poverty line, persons with disabilities, and the transgender community who are registered in NADRA and have specialized CNICs’. Citizens can SMS their National Identity Card number to 8500 or check online on the SSP website to check their eligibility in the Program.
Once eligible, the Sehat Insaf Card, now known as Qaumi Sehat card, is issued to families to use as part of the Program (although physical card not needed – CNIC is enough to show eligibility). The cards are mainly to create a proper database of citizens. The Program has inter-district and inter-provincial compatibility where patients can go to any of the 380 hospitals on the panel across the country. The utilization percentage is between 3 – 8 percent, which is the average uptake of such services across the world.
All indoor hospital services, including, dialysis, eye surgeries, appendix, cesarean, etc. except liver transplants, are covered in the Program. Currently, all people living below poverty, i.e. earning less than $2/day in Punjab, KPK, AJK, GB and 100% population coverage for newly merged districts of KP and District Tharparkar (Sindh) are covered. Persons with disabilities (in AJK, GB, ICT, Punjab) and transgender community (across Pakistan), who are registered in NADRA and have special CNIC are also covered.
Under SSP, each family will receive health coverage of Rs. 720,000 per year (In KP this is around Rs. 1 million under their universal health coverage program – their premium is around Rs. 2,800). This accounts for all medical and surgical procedures, excluding liver transplants. The average cost of treatment so far has been calculated at around Rs. 30,000 with the most common procedures being cardiology and cancer management related.
The SSP is an ambitious program. It is sustainable and will produce a competitive environment for public and private hospitals as it will motivate the public sector to keep up with their quality and improve their health services to compete with private-sector hospitals. Many stakeholders view the SSP as a key building block as Pakistan moves towards Universal Health Coverage.
The Sehat Sahulat Program and UHC in KP
Prime Minister Imran Khan has long been a champion of taking initiatives to provide quality healthcare in Pakistan. Before politics, he built the Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC), a cancer centre to make cancer treatment accessible in Pakistan.
The vision of the cancer centre reads, “To act as a model institution to alleviate the suffering of patients with cancer through the application of modern methods of curative and palliative therapy irrespective of their ability to pay, the education of health care professionals and the public and perform research into the causes and treatment of cancer”.
When his provincial government launched SSP in 2015, it was quick to show historical results in the province since its inception where it was extended in phases. The first phase of the Program was launched in 2015; covering three percent of the population (100,000 families in four districts) of KP. In its second phase in 2016, the Program was extended to 51 percent of the population (1,791,930 families in all KP districts). The third phase of the Program started in 2017, covering 64 percent of the population (3,200,000 families). Finally, in the fourth phase, all families in KP will be covered by the end of 2020.
The government currently pays a fixed premium, around Rs. 2,000, per eligible family (average family assumed to be 5.7 people) to State Life Insurance Company, which in turn manages members’ healthcare expenditure.
Taimur Saleem Jhagra, the KP Health, and Finance Minister has worked towards smooth execution of the Program despite opposition from other factions. PTI provincial government implemented the Program despite budgetary constraints. The SSPs’ success in KP and the Prime Minister’s vision of UHC in Pakistan prompted the government to further extend the equity of healthcare in the province.
In August 2020, it was announced that SSP would move towards providing universal health coverage in the entire province. Unlike before, every citizen under this now, above or below the poverty line, will have access to free health care. Its preparations are set in motion, and its implementation will start from October 31, 2020, in some parts of the province, and by January 31, 2021, every citizen of KP will receive free healthcare.
Upon its successful implementation, every citizen in the province will avail free health care services. This would be a feat for the province and a testament of their priority towards healthcare. KP could be an example for all other provinces, especially Punjab and Sindh, which are relatively more developed than KP and have flatlands and better roads and infrastructure.
The Sehat Sahulat Program and UHC in Punjab
The PML-N government in 2015 launched the PM’s National Health Program, which targeted all citizens falling under the poverty line as per the World Health Organization’s standards. This Program was later named Sehat Sahulat Program in 2018 and is similar in structure as KP’s SSP. The SSP’s objective is to improve access of the poor population to good quality medical services, through a micro health insurance scheme.
So far, the Program, expected to be completed in three phases has been expanded in all 36 districts to 5.2 million families of Punjab in its first phase, with Sehat Insaf Cards being distributed to these families. Data of families belonging to different demographics is being collected, which will help the government identify deserving families. However, unlike KP, Punjab has failed to achieve the desired targets of the SSP in terms of outcome. Out of the 5.2 million families, only 93,000 people could benefit from the SSP within one year, making the success rate of the Program only two percent.
Furthermore, The Punjab Health Initiative Management Company (PHIMC) which was mandated by the Specialized Health Care and Medical Education Department for implementation of SSP on its behalf has demanded an additional amount of Rs. 5 billion to sustain the Sehat Sahulat Program. It is currently being run on an ad hoc basis with no leadership, generating internal problems.
Unlike the KP government, Punjab’s team is lagging in proper and timely execution of the Program. Despite, the Prime Minister plans to transition SSP in Punjab on the KP model from selective healthcare eligibility to the entire province getting free healthcare. He said in August that he would push the idea in Punjab, where the Pakistan Tehreek-e-Insaf (PTI) is in power.
Earlier in September 2020, Punjab Health Minister, Dr Yasmin Rashid announced that she would look into launching universal health coverage in the province, starting in two of Punjab’s major cities after being directed by the Prime Minister.
The Prime Minister in October said, “I have asked Dr Yasmin Rashid to implement the provision of health card to everyone in Punjab in phases to bring about a revolution in the healthcare system of the country”. He further added that the Punjab Health Minister was reluctant to commit to achieving the gigantic task considering the large population of the province.
The province of Punjab has different dynamics when it comes to its healthcare sector. It is bigger in size with a population of around 110 million people but comparatively more developed than all other provinces of the country. That is a huge number compared to KP’s 40 million people and requires better management and implementation of the Program. Punjab can test run the UHC model in selective cities while working on SSP in its proper expansion across the province.
The Sehat Sahulat Program and UHC in Sindh and Balochistan
The Prime Minister considers UHC to be of paramount importance and plans to provide it to every citizen in Pakistan. After KP and Punjab, where his party is in power, he plans to push Balochistan and Sindh towards it where his party and government has less power.
He said in August that he would suggest the Balochistan government to launch a similar initiative in the province. Once the populations of the three provinces have access to free healthcare, he said, the people in Sindh will demand the provincial government to introduce a similar program which would ultimately put the opposition-led Sindh government under pressure to extend the facility to its people.
So far, SSP is only launched in Tharparkar. The SSP and UHC have a long way to go in the southern provinces of Pakistan. It depends on the provincial and federal governments to work closely towards healthcare initiatives despite their political differences to achieve substantial results in the healthcare sector.
UHC around the world
UHC has long been provided in many parts of the developed world for decades. Developing countries in Africa and Asia have also transitioned to the system. Still, many countries, including the biggest economy in the world, are far behind in the realization of this healthcare system. The United States remains one of the only advanced industrialized nations without a comprehensive national health insurance system.
India was five years ahead of Pakistan in launching an ambitious target of achieving UHC for all citizens in October 2010 to provide easily accessible and affordable healthcare to all Indians. In delivery, India is far behind in achieving UHC as much needs to be done as the Indian healthcare system is fragmented and lacks coordination among the different stakeholders involved in the delivery of healthcare services.
Bangladesh in its road towards UHC struggles with an outdated public financial management structure, along with sociocultural disinclination, lack of citizen empowerment, and demand. Inadequate political commitment and decision making power and poor governance are the main challenges towards implementing UHC in Nepal. WHO has identified that poor government stewardship, governance, and health delivery system are the main challenges in developing countries.
The KP government will start implementing UHC from today. The KP team has achieved monumental success, and upon the Program’s implementation completion, other provinces in the country will likely follow its healthcare model. For a developing country like Pakistan to achieve UHC, ahead of bigger economies and developed countries, KP can serve as a role model not just for our own provinces, but to countries that are planning to achieve UHC as well.
GVS News Desk