Universal Health Coverage in Pakistan: A call for Health System Reforms

Introduction

The sustainable development goal 3.8, adopted in 2015 by the United Nations advocated the need for ‘Universal Health Coverage’ (UHC), a roadmap promising that all people, particularly those in need, have access to essential health services when and where they need, without any financial hardship. 1 UHC is not a new lexicon, it was outlined in the founding constitution of the World Health Organization (WHO) that has stipulated health as a fundamental and universal right of every human being without distinction of race, religion and political belief, economic and social condition. 2 WHO defines ‘maximum’ population coverage, health service coverage, and financial protection, as three dimensions of UHC. The first dimension is relatively simpler to understand: what proportion of the people in the catchment of a health facility are covered for health services, and how many are left out. The second dimension delineates the range of essential health services made available to the people e.g. immunization, family planning, antenatal care, delivery by skilled birth attendant, treatment of common ailments, and services for HIV/AIDS, tuberculosis and malaria etc. Third dimension is about the expenditure incurred while seeking the healthcare, especially the out of pocket expenditure or the cost sharing by the patient, which is supposed to be minimal or zero at the point of service delivery.³
The question is whether the health system in Pakistan is ready and responsive to pursue the ambitious agenda of UHC. All three dimensions would ned reforms as pre-requisites to make genuine progress towards UHC. With the GDP allocation consistently of less than 1% for health 4 , Pakistan’s health indicators have improved in the last one decade miraculously; yet the progress is diminutive vis-à-vis other neighbouring and regional countries. COVID-19 pandemic has further contributed in worsening of the health indicators particularly those related to maternal, new-born and child health. Although the country has a vast health system infrastructure, the operationalization of primary health care remains a challenge due to shortage of health workforce and lack of conducive environment to work. ⁵ Amidst this state of affairs, the private sector in Pakistan has taken over as the preferred health service provider of all levels of health care, of course with a price tag. ⁶ When the OOP is almost 2/3 rd of the total expenditure on health ⁷ , it is likely to compound impoverishment of the already poor families, subjecting them to health shocks. The current social health protection program of the government presents a silver lining,
henceforth. This program must sustain and should be given a legal cover through parliamentary legislation. Contrary to the present design of the program, health system should move towards the implementation of a progressive income-rated contributions to health financing, with focus on need based entitlements to health services, and pursuit of the concept of income and risk cross- subsidization, whereby the rich cross-subsidize the poor, whilst the healthy cross-subsidize the sick. This approach will ensure the element of equity and fairness in health. Otherwise, the health status variance between the different socioeconomic population groups, and limited access to primary education, safe drinking water, sanitation and hygiene conditions are some of the daunting challenges.
For improving the state of public sector health service delivery, the district health system must be strengthened and empowered, administratively as well as financially. ⁸ UHC requires a new leadership agenda for public health action, through the creation of an effective mechanism of training and supportive supervision in the district health system, forging the necessary inter-sectoral collaboration and coordination at all operational levels, including a meaningful participation of the community-the ultimate beneficiary of the health system. ⁹
Improvement in access to essential health care necessitate establishing 24/7 basic health care units, and the gaps in the human resource for health can be addressed to some extent through task shifting and expansion of the lady health workers and community midwives network in the uncovered areas of Pakistan. Moreover, it is important to increase the budgetary allocation for health as percentage of GDP to fulfil the mandate of effective service delivery. The reform of public health financing should be focused on the district health system, instituting output based budgeting and promoting performance based budgeting. Policy makers need to understand the drivers of health seeking behaviour of the population in an increasingly pluralistic health care system. There is no denial on the significance of achieving UHC, however, optimal utilization of health services will happen only with ensuring adequate human resource and quality health care. It is to be noted that social health protection and UHC contribute not only to health; but also to poverty reduction and to the advancement of many SDGs that are linked with health.¹⁰
Government of Pakistan has announced that it will implement the UHC reforms agenda on fast track basis once the pandemic is in control. It is needless to say that in present times it is not only the virus which was killing people, it’s the poverty, lack of access and years and years of living with health conditions and health systems which have not been properly managed. The health disparities have widened because of the socio-economic class and many other factors which pushed people below the poverty line. Progress towards UHC is directly linked to country's health budget allocated for public sector health care delivery as well as health insurance scheme in years to come. 11 COVID-19 pandemic has unearthed the capacity of not only developing but many developed countries i.e., failure to deliver an equitable healthcare and to acknowledge that health security is not a non- figurative concept, it is about fairness and equity. Hope, Pakistan will soon come out of this pandemic crisis, safeguarding its poor segments of population by expanding its safety net for health, and thus achieving the UHC agenda by 2030.