A Roadmap for Universal Health Coverage

Although the Sehat Sahulat Program is an important step towards providing universal health coverage to the citizens of Pakistan, the government will have to invest in healthcare infrastructure to achieve sustainable success.

When his physician told Rehman Gull, 42, that he needed a minor surgical procedure to cure his back pain, he didn’t have to worry about how to cover his hospital expenditures, surgeon fees, lab tests and medicines. The next morning, he checked into a private hospital in Peshawar, underwent the procedure and returned home after three days without paying a single paisa.

“I just had to produce my CNIC to prove that I am a permanent resident of Khyber Pakhtunkhwa (KPK) to avail the facility of free hospitalisation and treatment,” says Gull, a resident of Jhagra village, who works as an office attendant at a media company in Peshawar.

KPK’s Sehat Sahulat Program (SSP) provides universal access to healthcare to permanent residents of Pakistan’s North-Western province like Gull and their families, which they could not otherwise afford. The program entitles 7.2 million families free in-patient treatment for up to one million rupees per family a year. “They only need to present their CNIC at the SSP counters set up at the 400 ‘empanelled’ private and public-sector hospitals across the province – and in Islamabad, Punjab and Karachi for non-resident families,” says Zain Raza, an analyst working with the Internal Support Unit of the provincial Health and Finance Department.

Gull is not the only one from his extended family to have availed the free health facility. His sister-in-law was recently treated for heart issues. Another family member underwent a minor procedure two months earlier. “This is an amazing facility for the poor and low-income people like myself,” says Gull, the father of four children. “Now we don’t have to worry about money when we need hospitalisation.”

How It Began

In 2012, the Federal Government introduced a micro health insurance scheme for the beneficiaries of its flagship social protection program, the Benazir Income Support Programme (BISP, recently rebranded by the PTI government as Ehsaas) under which the poorest of the poor and their families were provided monthly stipends. Taking a cue from this, Punjab rolled out its own initiative and enrolled 75,000 poor families between 2012 and 2014. In 2015, the Federal Government launched a national health programme in the former FATA districts of KPK – with Punjab, Sindh and Balochistan adopting it later. This programme has been extended to Azad Kashmir and Gilgit-Baltistan.

PTI-led KPK, however, chose to independently launch and pursue its own project in four districts with support from Germany and then expanded the scope to the entire population, with the government assuming the costs for all citizens. This decision was made to avoid ‘exclusion and inclusion errors’ owing to the outdated BISP 2011 poverty survey data.

“Setting up a social health protection scheme is a step-by-step process. KPK launched its pilot in 2015, targeting the poorest 21% in four districts. A year later, the Provincial Government decided to invest its own money to expand the coverage to all districts and the poorest 50% of the population. And from November 2020, the health insurance scheme has been available to every resident and non-resident citizen of the province, irrespective of their income,” says Riaz Tanoli, Project Director for the provincial SSP.

“In addition to the provincial programme, a similar federal facility is being provided to the 1.2 million people of the former FATA districts where each family is entitled to free treatment worth Rs 750,000 per year.” According to Tanoli, the province plans to expand the health insurance coverage to liver and kidney transplants. “For this we are in the process of signing an agreement with a hospital in Islamabad.”

How the Program Works

To avoid complications, KPK adopted a single-payer model, whereby it fully subsidises the annual premium of Rs 2,849 per family from its health budget and contracted the State Life Insurance Company (SLIC) to manage the healthcare expenditure as a third-party administrator. The insurer negotiates provider contracts with the empanelled hospitals, including the treatment packages and the amount of reimbursement. Data on the beneficiaries and their use of services are managed by NADRA and SLIC, which is also responsible for monitoring and evaluating the performance of the empanelled hospitals and excluding poor performers from the contracts.

“The contract has been awarded to SLIC through national competitive bidding. Eight firms applied and three were shortlisted,” Tanoli says. “The premium is paid through the government budget. We allocated Rs 10 billion for the ongoing financial year. The premium amount is likely to rise to Rs 21 billion in the next fiscal year.” According to him, at least 75,000 people have so far taken advantage of this health insurance, whichspared them a combined expenditure of two billion rupees between November 2020 and February 2021.

Tanoli says that the government paid the insurance company the entire premium for the year in a lump sum. “Under the contract, the company is entitled to keep 15% of the saving (unspent amount from the total premium) and return the remaining 85% to the government at the end of the year. If the expenditure crosses the agreed premium amount, the risk is borne by the insurer.”

The Provincial Government feels that it can easily manage the costs for the next three years. “After that period, we will have a fair idea of the rate of increase in expenditure, as more people become aware of the scheme and begin using it,” contends Tanoli. He is of the view that the scheme will ultimately reduce government expenditure on public-sector hospitals going forward, as they start earning money from their contracts with the insurer, leading to a significant reduction in the subsidy amount the government has to pay them from its budget.

Punjab Lags Behind

Pursuing the KPK model, the Usman Buzdar government plans to extend the coverage of its health insurance project to the entire population of Punjab by the end of 2021, although so far it lags behind KPK. According to officials, Punjab has so far succeeded in bringing health coverage to the 5.3 million out of nine million families living below the poverty line in 28 districts in two years. “We are increasing the scope of the scheme and issuing health insurance cards to eligible families. So far, 290,000 in-patients have availed free medical treatment and we are quickly moving towards universal health coverage,” says a health department official. In Punjab, the government is paying SLIC a premium of Rs 1,998 per family to provide health coverage of Rs 720,000 per family per year. “Once we achieve universal coverage, the premium will go up and the expenditure ceiling for each family will be enhanced to one million rupees.”

The publicly funded SSP is an important step towards universal health coverage that delivers healthcare to everyone equally and free of cost. However, it is unlikely to meet its goal unless the provinces start investing in health infrastructure, bringing modern diagnostic and treatment facilities closer to the areas where the poor and vulnerable targeted under the scheme actually live. Unless the infrastructure is created, the majority of the people will remain excluded from the so-called universal health coverage.

Nasir Jamal is Chief Reporter, Dawn Lahore.
nasirjamal65@gmail.com