The poor are especially vulnerable to the consequences of not being able to afford high healthcare costs at private hospitals. Public sector hospitals, away from major urban cities, are also not a sufficient option for the poor as they are often not fully functional and are rarely trusted to provide high quality services.  

Micro-health insurance schemes, or MHIs, involve the use of empaneled private and public sector hospitals to offer healthcare services that protect the poor from falling into poverty due to the expense of unforeseen medical emergencies.

Dr Shehla Zaidi, an associate professor of health policy and systems in community health sciences at AKU, and her team recently undertook a study on government purchase of services from private health organisations to revitalise the government’s primary health center network in Sindh’s rural and peri-urban areas. She had earlier assessed focal initiatives to contract the private sector and she recently supported a major development network, Pakistan’s Rural Support Programmes Network, RSPN, to analyse experiences of a large European Union-funded micro-health insurance programme implemented by the RSPN in rural Sindh. Dr Zaidi is also working as a policy adviser to the World Health Organization on improving private sector engagement for universal health coverage (UHC) in the region.

In this interview, Dr Zaidi highlights key lessons from emerging home-grown initiatives in Sindh to promote healthcare access. She highlights strategic policy arrangements to harness private health providers for expanding access to universal health coverage and comments on ‘best buys’ for policy.

What can be learnt from experiences of contracting the private sector to manage primary health care services? 

Contracting of private provider services for primary health care is a very popular tool in Sindh and almost the entire primary and secondary health network has been contracted out to private providers. In Khyber Pakhtunkhwa, contracting of secondary hospitals is being attempted in crisis-hit districts. The imperative is very similar in both provinces: to revitalise the government health network by using professional services of private health organisations and their positive image to build trust in communities. 

In Sindh there is an ample private, organised sector ranging from medical charities to private commercial organisations and NGOs, whereas KP benefits from the established presence of international humanitarian relief organisations who have been working in the province for several years. 

Contracting with private providers can arguably improve staff presence, medicine availability, service functionality and operating hours of health facilities. It can also provide room for innovations, which the private sector can quickly take forward. Our earlier work on a contracting pilot under district devolution showed positive changes, with higher utilisation indicated in those health centers where preventive care services to be delivered in surrounding villages were also contracted. We are currently studying these aspects in Sindh through a joint research project between AKU’s community health sciences department and AKU’s Center for Excellence in Women and Child Health in coordination with the World Bank. We will be planning a lesson learning event this year.

Contracting of health service delivery is a complex area worldwide. It is not like infrastructure concessional contracts which Pakistan is more used to doing in transport and other sectors. 

Provincial governments started off with good but perhaps naïve expectations of extending infrastructure contract experience to the health sector which is where it is struggling. My earlier study on country wide contracting of NGOs for HIV control highlighted considerable capacity gaps to contracting of private providers as well as for in-bred resistance.

We have moved on since then and there is growing buying in within the higher policy circles but the government needs to be assisted to develop the expertise, skills sets and systems to do this well. Pricing of contracts to avoid over-paying and under-paying private providers, speedy e-commerce systems linked to performance results, and standardised independent monitoring are best buys for skills investment for the government. 

Another area that I would like to point out is that the exclusive policy focus in Pakistan remains on contracting private sector to improve the government health network. But even achieving the best possible quality in government hospitals will not be enough to meet the volume of health services required for universal health service coverage. Hence, there is a critical need to purchase health services from private hospitals, clinics and diagnostic centres to supplement government services for meeting UHC. To do this requires strategic use of different financing arrangements.

Since 2005, Pakistan has seen the launch of at least five micro-insurance schemes aimed at covering the costs of hospitalisation, run by large development networks such as the RSPN and the Aga Khan Rural Support Programme. In 2015, Pakistan’s federal government also launched a national health insurance initiative, Sehat Sahulat Programme (formerly known as the PM’s national health insurance programme) which currently covers hospitalisation for 6.7 million households, in provinces other than Sindh. Both the MHI initiatives and Sehat Sahulat are similar in design as they use poverty-based scorecards to offer cover to the poorest citizens and focus on inpatient services.    

MHIs provide a subsidised package of health services to low-income communities in regions that are yet to develop government-led national insurance schemes. They work at the level of the community unlike national health insurance schemes, which are verticalised and government-led.

The obvious advantage of MHIs is in providing preparatory ground for roll-out of national health insurance schemes by mobilising poorly literate communities for seeking insurance and by developing a local pool of community resources. MHIs can also work alongside private and national health insurance schemes to help mobilise community resources to meet transport costs to healthcare facilities, which are often high and to offer continued support to purchase medicines or cover for lost wages. 

The disadvantage is that coverage through MHIs will be comparatively small, compared to national health insurance schemes. Also, MHIs have usually relied on donor or project funding and can be unsustainable for scale-up. 

Studies from Pakistan show low utilisation of successive micro-insurance schemes despite widespread distribution of health cards. Also, the services utilised are a random mix driven by a wish list of patients rather than consumption of priority health services. Another longstanding issue is that private hospitals empaneled for insurance services are sparse, located in urban centers of districts, and communities face high transportation costs and loss of daily wage income in accessing far-off care. 

These issues were flagged by us nearly 10 years ago when exploring result-based financing options for maternal and child health in Sindh through a NORAD-UNICEF study​.

 

RSPN-AKU analysis also showed poor insurance literacy amongst both communities as well as attitudinal issues for poor patient empaneled providers. And importantly, all of these micro-insurance schemes supported by donors and government development funds come to an end, so you get an increasing listing of dead projects. 

There are common core issues to be addressed for national health insurance initiatives underway nationally as well as in northern parts of Pakistan. Sustainable financing will be when both citizens, employers and government pool funds into a single insurance pool and cross-subsidise the poor. The easiest starting point is in urban centers where there is higher ability to pay for premiums, more of formal workforce whose salaries can be contributed towards an insurance pool and greater availability of health infrastructure. 

Starting insurance in rural remote locations is not suited to the contextual realities of these regions. It may score a political goal, but certainly will not deliver meaningfully. In fact, it is the contracting of health NGOs, provision of vouchers and conditional cash transfers that are the payment modalities used worldwide for remote areas. 

Another must have for insurance schemes is expansion from hospital admission to inclusion of out-patient care. Primary care satellite clinics must serve a gatekeeping function for hospital referrals otherwise there will be unnecessary admissions into hospitals and a growing cost tab. Luckily in Pakistan efforts are now underway to provide an evidence-based service package to which another team at AKU is contributing. 

A third point is to prevent uneven quality of care across hospitals a ‘must have’ quality assurance link is needed. Instead of each insurance provider doing their own thing, a licensing relationship should be in place with a provincial regulatory commission to accredit and license hospitals before they can provide services. 

Communication of insurance is very important to unpack how to avail insurance in simple terms for the common public. We must move away from sole reliance on community support organisations (CSOs) to an expanded use of digital communication platforms that are popularly used even by the poor in South Asia. We should remember that heavy investment in CSO networks for insurance have a cost that adds to the final tab of insurance costs.