Due to the expanding requirements of the global population, the emergence of new public health issues on a regular basis, and the diversity of population demographics, it is impossible to declare any healthcare system to be flawless. Every system requires ongoing pruning in order to analyse its strengths and weaknesses and meet the needs of its constituents. This also applies to the healthcare system in Pakistan (PHS). PHS serves a vast population of over 220 million people by combining the public and private sectors [1]. PHS faces numerous obstacles, such as insufficient finance, restricted infrastructure, the exodus of medical personnel, a dearth of emphasis on preventative healthcare (PHC), and unequal resource distribution. The first comprehensive universal health coverage (UHC) effort in Pakistan, The PHS’s Sehat Sahulat Program (SSP) is arguably its most notable accomplishment.
PHS faces numerous obstacles that make it more difficult for it to offer its residents effective and sufficient healthcare services. The lack of sufficient finance is one of the major issues. Pakistan spends a relatively small amount on healthcare per person—about 38 US dollars (USD)—compared to other developing nations [2]. In contrast to Pakistan, India, the Philippines, and Ghana, per capita healthcare expenditures are 57, 165, and 85 USD, correspondingly [2]. In 2020–2021, Pakistan allocated 1.2% of its GDP (gross domestic product) to the public health sector, up from 1.1 in 2019–2020. This rise is not noteworthy when considering the GDP percentage.An additional issue resulting from inadequate funding for the PHS is a scarcity of medical supplies, medications, medical infrastructure, and trained healthcare personnel. Despite an increase in human resources between 2014 and 2021, this expansion is insufficient to meet the demands of a population that is expanding by 2% annually (Table (Table1)1) [3]. Every year in Pakistan, about 32,879 physicians graduate; of these, 40% leave the country in search of better possibilities, primarily due to low pay, long work hours, and inequity [4]. A research done at two different medical institutions found that thirty-three percent of incoming medical students intend to go overseas to practise medicine. This brain drain places unnecessary strain on the PHS, which makes it difficult for people to receive sufficient medical care.
Another major problem PHS has is that PHC is not given enough attention. PHC encompasses health promotion and disease prevention initiatives like screenings, vaccinations, and health education. The Lady Health Workers (LHW) program, the Expanded Program on Immunisation (EPI), the Polio Eradication Initiative (PEI) Program, the Malaria Control Program (MCP), the Tuberculosis (TB) Control Program, and the establishment of basic health units (BHUs), rural health units, and rural health units (RHUs) are just a few of the actions that Pakistan’s government has taken over the years to promote PHC. Pakistan has 1,276 hospitals in 2021, along with 5,558 BHUs, 736 RHCs, 5,802 dispensaries, 780 Maternity and Child Health Centres, and 416 TB centres [3]. Nevertheless, none of these efforts have been able to significantly raise Pakistan’s health metrics. which, in comparison to its counterparts, are far poorer (Table (Table 2).2). For a population of over 220 million, these attempts are insufficient [1]. Resources in the PHC field are still scarce, and many people lack access to these services due to underdeveloped PHC centres or even the nonexistence of these centres in their area. Despite having access to these resources, the public does not practise preventive health because they are not informed about its significance to their own health and are not aware of its value. In Pakistan, a large number of people lack basic health literacy, which prevents them from having the information and abilities needed to properly access and use healthcare services.
The PHS is seriously threatened by the unequal distribution of healthcare resources. The concentration of healthcare resources, such as clinics, hospitals, and medical personnel, in metropolitan regions leaves rural areas with insufficient access to healthcare services. It causes a large gap in the outcomes and accessibility of healthcare for people living in urban and rural areas [5]. The unequal distribution of healthcare resources is reflected in the Community Health Index (CHI). CHI calculates the differences in health and well-being between various areas. The higher-tier districts in Pakistan have a 16.59 CHI inequality ratio, meaning that they are 16.59 times healthier than the lower-tier districts.There is a significant gap in resources between urban and rural areas, as evidenced by the disparity ratio, which is different by about 10 points (7.78 and 17.54, respectively). The research indicates that resources in Pakistan’s healthcare sector are not distributed fairly [5]. As a result, adequate patient diagnosis and treatment are lacking in the rural healthcare system due to a shortage of essential medical supplies, diagnostic facilities, and drugs. All of these deficiencies put more strain on urban infrastructure, which in turn causes a lack of suitable medical facilities, a shortage of doctors, and unsatisfied patients.
Program Sehat Sahulat: UHC Proposal
Universal Health Coverage (UHC) is a WHO concept that seeks to guarantee everyone has access to basic health services without financial hardship. The United Nations (UN) approved the Sustainable Development Goals (SDGs) in 2015, and UHC is one of them. Pakistan is one of the SDG signatories. As one of the SDGs, Goal 3 (health) in the UN 2030 agenda states the objective of UHC (target 3.8). The first step towards granting citizens’ fundamental rights to health care is UHC [2]. The SSP, which is a UHC effort, is the PHS’s greatest accomplishment.
The SSP is a federal and provincial health insurance program that is supported by the public sector and aims to protect all citizens’ finances from unexpected medical expenses. SSP is a historic healthcare program that is seen as a critical first step towards UHC. The Khyber Pakhtunkhwa (KPK) provincial government introduced the SSP first in 2015 with the goal of exclusively offering free health insurance coverage to the underprivileged and vulnerable. Then, in 2019, the SSP was implemented in other provinces by the Pakistani federal government working with the provincial governments. Pakistani government funds the program, which is overseen by the Ministry of National Health Services, Regulations, and Coordination.The two primary parts of the program are (i) free health insurance for qualifying families and (ii) a network of affiliated clinics and hospitals where qualifying households can get medical treatment. Originally limited to families with incomes below the poverty level, the SSP is now progressively expanding to cover all citizens. By 2022, about 44.6 million households had been reached by the SSP, which was in place in 36 districts in Punjab, 35 districts in Khyber Pakhtunkhwa, 10 districts in Azad Jammu and Kashmir (AJK), 10 districts in Gilgit Baltistan (GB), Islamabad Capital Territory (ICT), and the Hardaker district in Sindh. Premium contributions from ICT, AJK, GB, Federally Administered Tribal Areas (FATA), and Thar Parker districts are handled by the Public Sector Development Program (PSDP). Nonetheless, 100% premium contributions are funded by Punjab and KP from a variety of sources.
Households that participate in the SSP obtain health insurance cards that may be used to receive healthcare services at partner hospitals and clinics for up to one million rupees annually. A broad range of inpatient services are covered by the program, such as cardiac procedures, neurosurgical procedures, burn management, cancer management, dialysis, diabetes mellitus complications, trauma management, abdominal surgeries, fracture management, and other medical and surgical interventions [3]. payments under the program are tier-based, meaning that households with more vulnerable members—such as women, children, and the elderly—will get larger payments. Over 1030 panelled hospitals are part of the SSP’s extensive network in Pakistan. Any of these panelled hospitals can treat beneficiaries from any district.The initiative has had a favourable effect on marginalised populations’ financial security as well. Participants in this initiative were disabled individuals and transgender individuals who were registered with the National Database Regulatory Authority (NADRA). Access to UHC has been granted, which is a significant step towards the marginalised community’s integration [3]. Over sixty percent of all health costs in Pakistan are paid for out-of-pocket (OOP) [3]. At every stage of the healthcare system, the SSP has shared these costs. It also provides health insurance to 154 million Pakistanis, making it the country’s first-ever health insurance program [3]. More than 3.2 million hospital visits have been documented under the SSP’s health cards as of March 8, 2022 [1].Because of the shared health expenditure, people may now obtain medical services that they previously could not afford, which promotes wellbeing and health.
This program has certain restrictions. Numerous families have expressed dissatisfaction with the program’s limitations and the expense of care in hospitals in the private sector. The difference is intended to be paid by the patients. Due to financial difficulties, some patients have been turned away from medical care [1]. The SSP’s disrupted continuity as a result of Pakistan’s current political and economic unrest is another problem. In certain regions of the nation, it remains operational, while in others, it has been halted.