Millions of people are pushed into extreme poverty due to health care expenditures all across the globe. The government of Pakistan has made universal health coverage (UHC) a priority in its health sector reforms. To achieve its UHC goals, a land mark social health protection initiative of Sehat Sahulat Programme (SSP) has been started by the federal government and the participating provincial and regional governments. The programme aims at providing free of cost health insurance initially to families living below the poverty line and subsequently to the remaining families.

The covered population includes vulnerable and marginalised groups, including persons with disabilities (PWDs) and trans-gender (TG) communities, which have previously been ignored by health policy makers. Qaumi Sehat Card, Sehat Insaf Card and Sehat Card Plus are the brand names for health cards being provided by Sehat Sahulat Programme to target families in the Punjab, Azad Jammu and Kashmir (AJK), Gilgit-Baltistan (GB), Tharparker, Islamabad Capital Territory (ICT) and Khyber Pakhtunkhwa (KP), respectively.

Khyber Pakhtunkhwa, Azad Jammu and Kashmir and Tharparker district in Sindh are the programme areas where all permanent resident families, according to NADRA records, have been provided the health cards. In these districts, more than 8 million permanent resident families (43 million lives) are covered for universal health insurance coverage. In the Punjab, Gilgit-Baltistan (GB) and Islamabad Capital Territory (ICT) the programme is so far covering 6 million families (32 million lives) living below the poverty line.

The programme will be expanded to cover all 30 million permanent resident families (133 million lives) in these districts by end of the year 2021. The government of Balochistan is also targeting to cover its entire population of 1.8 million families (9.7 million lives) by the end of 2021. Thereafter, only 9 million families (48 million lives) of Sindh, excluding Tharparker district, will remain out of the health insurance ambit. The government of Sindh is likely to join the programme soon.

Sehat Sahulat Programme provides services covered under two distinct benefit packages i.e. priority / tertiary care package and secondary care package. Priority / tertiary care benefit package covers all significant high-cost critical treatments like cancer management, cardiology, accidents, ventilator support, burn, renal dialysis (renal transplant in KPK only) etc while secondary care benefit package covers all the remaining medical and surgical treatments, including abdominal surgeries, medical conditions, deliveries / C-sections etc.

The healthcare services are provided through a cash-less arrangement with more than 450 empaneled hospitals, both public and private, across Pakistan. The programme does offer inter-district and inter-provincial portability of benefits through which beneficiary of one district can access hospitalisation services from any empaneled hospital elsewhere. The programme also offers standard transport charges to families at the time of discharge from empaneled hospital and burial charges in case the patient dies in an empaneled hospital during hospitalisation.

The nuclear family is the basic unit in the Sehat Sahulat Programme. A family is composed of husband, wife and unmarried children, as per NADRA (National Database and Registration Authority) database. The unique aspect of the programme is that no beneficiary family has to apply for the health card. The entitled families are identified through NSER (National Socio-Economic Registry) data of the EHSAAS Programme. Universal coverage data is secured from the NADRA based on permanent resident record present in computerised national identify card (CNIC) of each individual. Any Pakistani citizen can check their eligibility status by texting their CNIC number to 8500.

The covered population includes the vulnerable and the marginalised groups, including persons with disabilities and trans-gender communities, which have previously been ignored by health policy makers.

The Sehat Sahulat Programme has stringent monitoring and evaluation mechanisms in place. One key component is Central Management Information System (CMIS), through which the programme management monitors the programme activities in real time. This includes patients’ admission-till-discharge activities from a service delivery aspect. All enrollment activities are being recoded and monitored through the CMIS. Sehat Sahulat Programme, in order to get independent feedback on service delivery, has also established a call centre through a third party i.e. NADRA to call each discharged patient to take their feedback on the quality of service and treatment during their admission and to check their satisfaction level. All complaints are being investigated thoroughly and satisfactory redress is made. The programme is also ensuring proper gatekeeping through patient facilitation counters in all panel hospitals to avoid unnecessary or ineligible services. A helpline (0800-09009) has been provided for beneficiaries to call for an inquiry or to register a complaint.

Sehat Sahulat Programme has a nationwide panel of hospitals, including both private and public sector health care facilities. Any hospital that wishes to join Sehat Sahulat Programme panel of hospitals can do a self-assessment using programme’s empanelment criteria available at the national programme’s website or the Khyber Pakhtunkhwa programme’s website. A self-assessment outcome with an application can either be submitted to the programme or to the contracted health insurance company directly for possible empanelment of the facility. After fulfilling the related contractual formalities, the candidate hospitals can join the programme panel.

Key lessons learned from implementing the social health insurance me in Pakistan, including provision of universal coverage in Khyber Pakhtunkhwa, Tharparker, and Azad Jammu and Kashmir are as follows:

First, no indoor health care initiative in Pakistan can be implemented without public and private sector partnership.

Second, options must reside with beneficiary families to access health care services from any hospital of their choice, public or private, without any financial constraint.

Third, federal, provincial and regional governments must allow financial independence to their public sector hospitals. This is for their empanelment in health insurance programme and in order to get financial reimbursement from insurance companies on services provided. It must also be noted that the focus should be on developing and improving standard treatment protocols. In addition, the monitoring system has to be made robust and vigilant. This is in order to improve its capacity to review the implementing process of social health insurance schemes. A vigilant monitoring system also makes for prompt redress of complaints and grievance.

Out-patient services (OPD) are a crucial component of achieving UHC in Pakistan. Communication should be focused as a prime component in Sehat Sahulat Programme. Lastly, as health insurance is a relatively new subject in the public sector, capacity building activities for public sector health care facility management are needed in areas like claim processing, reimbursement, cost management and quality assurance.

Sehat Sahulat Programme, in collaboration with its technical partners World Health Organisation (WHO) and GIZ (German Development Agency), is working on improving the programme implementing and expansion. With WHO, the programme is conducting operational research on the programme and piloting a one-year project in the ICT (Islamabad Capital Territory) where out-patient services (OPD) and reproductive health and right (SRHR) services are to be provided to enrolled families of the programme. With GIZ, it is conducting its second actuarial analysis and has developed its communication strategy. The strategy is being piloted in select districts for review and for possible expansion nationwide.

Universal health coverage, especially financial health protection against catastrophic health care expenditure, has become an essential target to be achieved. This is the most effective way to improve the socio-economic status of the families, alleviating poverty or protecting families from falling into it.

The authors are the Chief Executive Officer, the Deputy Director, and the Technical Director of the Sehat Sahulat Programme.