Policy columnist for The Diplomat Magazine and guest blogger, Hannan Hussain, explores the potential of Universal Healthcare in Pakistan with a government-run health protection initiative being piloted in the country’s northern most province, Khyber Pakhtunkhwa.
Development of a quality healthcare system has served as a popular reference point in Pakistani politics and activism. Yet, successive leaderships have struggled to achieve any significant impact in terms of equitable health. Mass disparities in its distribution and accessibility, inadequate budgets, and a soaring population growth rate have jointly compounded Pakistan’s pursuits for health-intensive development, while regional powers continue to make headway.
However, early signs of Universal Healthcare are beginning to show in Pakistan’s Northern most province. Khyber Pakhtunkhwa is home to the Sehat Sahulat Program, a government-run health protection initiative that provides below poverty line segments significant financial coverage, and province-wide accessibility to secondary and tertiary treatment facilities.
Ever since the launch of Sehat Sahulat’s services in 2016, thousands of citizens below the poverty line have undergone treatments, with majority of them opting for tertiary care – the most specialized and costly bracket of health procedures. Some of these include angioplasty, cardiovascular treatments, and organ failures. The PTI-led Khyber Pakhtunkhwa government has operationalized services across 75% of the province’s 35 districts, and is now preparing to launch the scheme on a nationwide scale. As efforts get underway, five elements become central to our understanding of the Sehat Sahulat Program’s functioning, its characteristics, and early success.
Resonance at the grass-roots
Interviews with 80 families, comprising of 400 Sehat Sahulat enrollees across 15 cities, revealed a high level of patient satisfaction with public hospital treatment. “I am suffering from severe chest burns”, says a 55-year old enrollee undergoing treatment at Lady Reading Hospital, Khyber Pakhtunkhwa’s largest public hospital. “If something was to go wrong with my kidneys, I could not afford the costs without the Sehat Sahulat card.”
Another patient, a father of three from the rural district of Swabi, underlined the utility of the insurance scheme for his family. “For my children and wife, when they get sick or need urgent treatment, it is usually beyond my reach to ensure healthcare for them. I am even able to save some remaining funds in the Sehat Sahulat card for our future treatments.”
Challenges of excessive administrative autonomy among public hospitals, and growing patient referrals from rural to urban hospitals are certainly some areas of concern for the provincial government. However, in the three years since the commencement of its services, Sehat Sahulat offers a much-needed financial cover for the poverty-stricken segments of Khyber Pakhtunkhwa, facilitating their expectations of meeting healthcare exigencies.
Sehat Sahulat’s origins stem from India’s 2008 Rashtriya Swasthya Bima Yojana (RSBY) Insurance Programme. Under this model, the Indian government aimed to increase below poverty line (BPL) access to in-patient medical care (patients who require admission to hospitals), across both public and private health facilities. In 2011, the Sehat Sahulat team conducted a feasibility study which found RSBY to be the most compatible health insurance model for Pakistan, based on the understanding that Indian states faced similar socioeconomic and urban-rural dynamics as Pakistan.
The provincial government of Khyber Pakhtunkhwa went on to embrace RSBY’s central emphasis on out-of-pocket payment reduction (reduction of personal costs on healthcare) among India’s poor – while augmenting it with new features: A provincially-approved “funds retention formula”, and cross-sectoral public-private health partnerships.
Revenue through “Fund Retention”
Amid a struggling economy, how does the government of Khyber Pakhtunkhwa sustain healthcare revenue? To address this dilemma, the Sehat Sahulat team had a “Fund Retention Formula” approved by the Chief Minister of Khyber Pakhtunkhwa in 2016. The formula empowered provincial public hospitals to retain a certain percentage of income generated from their treatments. The retained amount is divided into two portions: 25% is transferred to the provincial government, and the remaining 75% of the amount is held by the hospital for service quality improvement, and doctors’ share.
Dr. Muhammad Riaz Tanoli, Director of the Sehat Sahulat Program, considers the formula to be an important intervention for retaining competent doctors in the province’s public sector. “Since many of our doctors practice in private as well, they encourage patients to go to private hospitals for a quick, overnight treatment. To deter such an occurrence, the fund retention formula incentivizes hospitals in such a way that if a private practice yields PKR 10,000 a day for the doctor, he receives PKR 4,000 extra from public hospitals. This way, we strike a financial compromise.”
Equitable Access: Public-Private Partnerships
The “Health Foundation of Khyber Pakhtunkhwa”, a legal body created through the 2016 Khyber Pakhtunkhwa Assembly Act, is used by Sehat Sahulat to bolster partnerships in underdeveloped districts. Its mandate is to involve the private sector in the dispensation of health services to the masses. “The end goal is to have sufficient amounts of health services so that these health facilities are accessible to the population”, states Dr. Shahid Younas, Chief of Khyber Pakhtunkhwa’s Health Sector Reform Unit. “For that we have to make certain policy decisions. Currently, there are three districts where the public and private health sector remains underdeveloped – Kohistan, Tora Bora and Tang. It is here that the role of the Khyber Pakhtunkhwa Health Foundation becomes critical in looping in the private sector, and aligning it with the public sector for maximum service accessibility.”
Meeting Health Security Targets: Sustainable Development Goal 3.8
The Sehat Sahulat model is built in alignment with Pakistan’s commitment to Universal Health Coverage (UHC) by 2030. The commitment, listed as part of Sustainable Development Goal target 3.8, calls for achieving UHC that includes “financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”
The Sehat Sahulat Program currently offers a 540,000 PKR per-head lump sum to below poverty line segments, applicable across both secondary care (specialist care) and tertiary care (post-hospitalization) brackets.
“Eradicating financial barriers is one of the objectives of the Sehat Sahulat Program”, says Dr. Shahid Younas. “We are taking care of catastrophic health expenditure in the province, in a bid to extend financial protection to 69% of Khyber Pakhtunkhwa’s population. Neglected transgender segments are also being included. So efforts towards achieving Universal Health Coverage are clearly under way.”
Ultimately, the program’s execution in Khyber Pakhtunkhwa offers a blueprint for developing public-private healthcare collaborations effectively in larger provinces, such as Punjab. Moreover, if the end goal is to make healthcare truly universal in Pakistan, the government must encourage a culture of bottom-up legislation, so that provinces can continue to produce interventions such as the Funds Retention Formula.
Hannan Hussain (@hannanhussain7) is a research analyst at the Islamabad Policy Research Institute (IPRI), and a policy columnist for The Diplomat Magazine. His writings have focused on development and economic issues in Malaysia, Venezuela, China, Pakistan and the wider South Asian region.
The views expressed in this post are those of the author and in no way reflect those of the International Development LSE blog or the London School of Economics and Political Science.