Every year, an estimated 350,000 households in Pakistan fall into poverty because of the high costs of accessing healthcare. Public sector hospitals are often overcrowded, or unable to provide life-saving care, which means that many citizens pay out of their own pockets to meet their healthcare needs.
Pakistan has committed to achieving universal health coverage under the global sustainable development goals. Achieving the goal of health and wellbeing would require making quality healthcare available and affordable for all its 220 million citizens by 2030.
AKU’s Professor Sameen Siddiqi co-chaired the federal government’s National Advisory Committee on SDGs which was tasked with developing a universal health coverage, UHC, benefit package. Professor Siddiqi worked alongside faculty from AKU, the London School of Hygiene & Tropical Medicine and stakeholders from the federal government to devise a package of 88 essential interventions.
This package was tabled and endorsed by the federal and provincial ministers of health in October 2020 with a view towards national rollout. In this interview, Professor Siddiqi shares the key components of the package and how the University is contributing its efforts to achieve the ambition of universal health coverage in Pakistan.
Can you explain the basic elements of a UHC package and how it brings Pakistan closer to achieving targets under the Sustainable Development Goals?
Firstly, packages should cover all people, poor and non-poor, and provide access to essential services preventive, promotive, curative, and rehabilitative ones. This is where every country gets to define its own service package by looking at its disease and risk burden, cost-effectiveness of interventions, and resource availability. Services also need to be of acceptable quality. Finally, there’s the component of cost coverage through financing healthcare all the way from collecting and pooling of resources to using the funds to strategically purchase the services is included.
Goal 3 of the Sustainable Development Goals aims to ensure health and well-being for all while committing to reduce the burden of communicable and non-communicable diseases. By covering the four main components of universal coverage, Pakistan is expressing its commitment to achieving these targets under the 2030 goals.
Can you briefly explain the types of interventions being introduced and their scope?
The universal health coverage service package has 88 interventions to be implemented at the district level at three platforms – community, primary care facility, district hospital. It has been costed according to the prevalent disease burden in the country and costs US$13.0 per capita. This package is adapted from DCP3, a global initiative, and the plan is to initially implement the package in Islamabad and two districts of each province and one of each region before scaling up.
For universal coverage to be truly impactful in improving national health indicators, it will have to be adopted by all provinces. This is where I think the COVID-19 pandemic should be seen as a huge opportunity that should be seized. The pandemic has prioritised the health agenda at the national level, which previously has not been the case.
What are some of the global experiences that lower and middle-income countries can learn while introducing universal health coverage?
There are several lessons for countries to look at when developing their individual UHC packages. First and foremost, no country gets to UHC via voluntary health insurance policy. Insurance must be made mandatory together with subsidies for the poor. Secondly, we also see that all countries with universal coverage rely predominantly on government budget revenues. Finally, while the goals of UHC are shared and universal, the journey to it has to be home grown and tailored to domestic needs and challenges and for that to happen it is important to be aware that countries can’t simply purchase their way into UHC. Resources must be managed both strategically and efficiently as per the requirements and financial challenges of the country.
To what extent has AKU contributed to the development of a Universal Health Package for Pakistan?
AKU faculty - physicians, surgeons, pediatricians, oncologists, gynaecologists and other specialists have actively participated in the development of the package. They have been part of several technical working groups established by the government. Our work has been acknowledged by Pakistan’s provincial health ministries. Additionally, AKU experts in the Medical College's department of community health sciences have been heavily engaged in the costing of the package.
The mandate of universal health coverage for Pakistan is huge. What are the big factors that require key attention for the programme to be successful in the country?
There are several key considerations here. Firstly, the package covers all those who are eligible, but we know from experience that more than the eligibility, it is the entitlement that really bring populations into the fold of coverage.
Theoretically, the entire population of the country is ‘eligible’ to receive health services from public-sector facilities. However, not everyone can, and meagre resources could be siphoned off by the powerful leaving little for the poor and vulnerable. A well-implemented health insurance programme brings a sense of ‘entitlement’ to the poor, which ‘eligibility’ does not offer and is a great contribution of such schemes worldwide. Further, there is always a demand for ‘more money for health’ given Pakistan is such an under-spender, equally it needs to get ‘more health for the money’. For this, Pakistan would also need mechanisms to monitor corruption and abuse of resources to minimise leakages and loss of scarce resources for personal benefits.
This is especially important for people in Pakistan who are below the poverty line to have similar benefits of effective coverage along with those who are better off financially. Finally, there will be a lot of implementation challenges that the government will be facing regarding the provision of coverage, but designing the package is an essential step in the sense that we are seeing commitment to achieving the target of universal coverage by 2030. I believe that we will eventually achieve our goal.