The return on investment in the health sector is very high. The calculation of social return on investment includes not only financial returns, but also aspects such as empowerment, social cohesion and political participation, which are assessed in different quantitative and qualitative ways. It examines the returns generated not only for the investor but also for the company as a whole. Historical economic analysis has shown that between 1970 and 2000, at least 11% of economic growth in low- and middle-income countries was just a consequence of the reduction in adult mortality during this period.
From the perspective of universal health coverage, essential health services must cover the entire population, without discrimination, giving priority to the most vulnerable. In mixed health systems like ours, public health expenditure is well below the lowest international threshold. Therefore, about 60 percent of health expenditure constitutes direct expenditure. With about half of the population living in poverty, the direct spending of the poor can be catastrophic.
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If a member of a poor family falls ill and has to be hospitalized, the family quickly goes bankrupt. Those slightly above the poverty line slide into extreme poverty and for the already poor it is a disaster. The WHO and the World Bank have jointly declared that 100 million people around the world are pushed into extreme poverty every year because of health care spending.
The sudden realization of the situation led the previous government and the current government to invest in this area. The Sehat Sahulat program has not only supported political change, but has grown over the past three years. It was a sign of maturity that what was called the Prime Minister’s National Health Program became the Sehat Sahulat program and what was called the Sehat Insaf Card became the National Health Card or Qaumi Sehat Card. .
Essential health services must cover the entire population, giving priority to the most vulnerable.
Social health insurance in Pakistan began by protecting the poor from out-of-pocket expenses through a prepaid deal. The KP made it universal and the federal government took positive steps by making it available to the entire population of Tharparkar, Azad Kashmir and former Fata. As of June 2021, about 18 million poor and non-poor families, or about 81 million people (37 percent) in Pakistan, had been enrolled in the program. Families living below the poverty line are identified using the Benazir Income Support Program National Socio-Economic Registry Poverty Database, which is linked to Nadra.
The Sehat Sahulat program currently only offers health insurance to those who need to be hospitalized. The program covers a wide range of treatments ranging from minor ailments to major problems, including heart surgery, dialysis, cancers and hospital deliveries. The range of services is very generous. In fact, with the exception of dentistry, cosmetic surgery, implants and organ transplantation (although this is covered by the KP), almost all other treatments for which hospitalization is required are covered.
The program also represents a major public-private partnership. More than 500 private and public hospitals across the country have been recruited and insurance benefits are available for all hospitals in the panel. The government has entrusted the management of the program to the State Life Insurance Corporation to which the Federal and Punjab governments pay a premium of Rs1,998 per family per year while the KP government pays a premium of Rs2,849. The company hires hospitals and reimburses them for the cost of treating patients. The insurance limit of federal and Punjab programs can reach Rs 720,000 per family per year, while that of the KP program can reach Rs 1 million. The program is fully publicly funded. So far, more than one million hospitalized patients have benefited from it and the general satisfaction of patients and their families is at the rendezvous.
Besides the poor, there are many other marginalized and voiceless groups such as people with disabilities, transgender community, informal sector, workers, people living in remote areas, etc. The program is gradually expanding to include them as well. People with disabilities and trans people are already included, provided they are registered with Nadra.
Tharparkar, Azad Kashmir, KP (also including former areas of Fata) and seven districts of Sahiwal and Dera Ghazi Khan division in Punjab now have universal health insurance, meaning that all permanent residents of these areas can benefit from the program. Plans have been announced to provide social health insurance to all permanent residents of the Punjab, Islamabad Capital Territory and Gilgit-Baltistan by December 2021. It is questionable whether the entire population should benefit from free health care. Going forward, middle-income households should be considered for a co-payment system and the rich should pay in full.
The government is showing financial commitment. Each fiscal year, the allocations for the program are increased. For example, the largest province, Punjab, allocated 2 billion rupees in fiscal year 2019-21 and increased it to 23 billion rupees in fiscal year 2020-21 and increased it to 80 billion rupees in the current fiscal year. The corresponding figures for KP are Rs5.8 billion, Rs13.7 billion and Rs22 billion. Sindh withdrew from the program giving untenable explanations. In reality, it was for political reasons. Recently, the cabinet of Balochistan finally approved the implementation of the social health insurance program. Provincial leaders must transcend political issues instead of denying their populations financial protection for essential health care.
Pakistan has made great strides. Social health insurance systems evolve over decades. Germany, for example, took more than a century to develop its health insurance system. Sehat Sahulat needs an additional political firewall. Small project teams from the Federal, Punjab and KP governments have done a tremendous job in developing and implementing the Sehat Sahulat program. The latter must now move from a project to a national health insurance organization that will continue to conduct research and calibrate programs to meet the health needs of the country. The Sehat Sahulat program is indeed a success and the Pakistani government and people can be justifiably proud of it.
The author is a former SAPM in health and currently serves as WHO adviser on universal health coverage.
Posted in Dawn, July 9, 2021