Achieving universal health coverage

At the current population growth rate, public sector will never be able to provide healthcare to all

Dr Ali M Mir March 28, 2019
The writer is a Public Health Specialist with experience of working both in the public and private sectors

Among the 17 Sustainable Development Goals that Pakistan has committed to achieving by 2030, the Goal 3 relates to providing Universal Health Coverage (UHC) to all citizens. It is an ambitious, yet achievable target, provided we can introduce major structural changes in the current healthcare delivery system. We can benefit from four basic healthcare models being practised globally.

The Beveridge Model: Under this model, the government is responsible for financing and providing free of cost healthcare. The system is financed through tax revenues. The government controls expenditures. Compared to per-capita healthcare expenditures in other developed countries, the model is more cost-effective.

The Bismarck model: This system is financed jointly by employers and employees who pay into a sickness fund through payroll deduction. All citizens are covered even those who are not employed, and services are purchased from private hospitals and private providers who are regulated by the government.

The National Health Insurance model: This model uses private-sector providers, but payment comes from a government-run insurance programme that all citizens fund through an insurance premium. It is practised in Canada, South Korea and a few other industrialised countries.

Out of Pocket model: This is widely practised in most developing countries with weak health systems like in Africa and South East Asia, where citizens are compelled to purchase healthcare from private providers. Those who cannot afford go without services.

Pakistan is an example where all four models function in an uncoordinated manner. Theoretically, the government is responsible for providing free healthcare — but not so in practice. Public sector facilities are overcrowded, understaffed and ill-equipped.

Meagre healthcare budgets, low salaries, weak accountability and poor governance further exacerbate the situation. At the current population growth rate, the public sector infrastructure will never be in a position to keep pace in providing healthcare to all, as there will be a perennial shortage of hospital beds, doctors, nurses, equipment and supplies.

According to World Bank estimates, the share of out of pocket expenditures of the total health expenditures is 66%. For many, medical expenditures can be impoverishing.

To offset out of pocket expenditures and help the poor access healthcare, the federal and provincial governments have recently introduced health insurance schemes for the poor to obtain medical care for certain conditions from empaneled public and private hospitals.

Culling the positive aspects of all the four models, Pakistan can introduce a hybrid that can help achieve UHC in an abridged timeframe. Employing the Beveridge model, the government may use its existing infrastructure and focus entirely on providing free of cost preventive and promotive healthcare in the form of compulsory immunisation, maternal neonatal child health and family planning services, health education campaigns and programmes for prevention of communicable and non-communicable diseases and other community-oriented programmes.

Following the Bismarck model, curative care can be purchased from a well-regulated private sector. Privatising large public facilities including tertiary care hospitals may be an option to consider. The existing healthcare commissions should be empowered to enforce standards allowing the same level of care to the rich and the poor as well as the ability to regulate the cost of services.

Funding mechanism can be through multi-payer, not-for-profit insurance programmes to which all who are employed or earn an independent income pay through payroll deductions or individual contribution, with the government pitching in for those who cannot afford or are unemployed.

All in all, the rich should have the option of making out of pocket payments for receiving expedited services for non-urgent routine procedures, and such payments should further help subsidise costs for the poor.

Published in The Express Tribune, March 28th, 2019.

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