In-depth enquiry into the implementation of a large-scale social health protection scheme in the context of the drive towards universal health coverage in Khyber Pakhtunkhwa, Pakistan

Abstract

BACKGROUND: In the wake of Goal 3 (ensuring healthy lives and promoting well-being for all at all ages) of the Sustainable Development Goals (SDGs) and the resulting push for Universal Health Coverage (UHC), Pakistan’s Federal and Provincial Governments launched three large-scale social health protection (SHP) schemes. Sehat Sahulat Programme (SSP), Sehat Hifazat Programme (SHiP) and the Prime Minister’s National Health Programme (PMNHP) were initiated by the provincial governments of Khyber Pakhtunkhwa (GoKP), Gilgit Baltistan (GB) and the Federal Government of Pakistan (GOP), respectively.

SSP was publicly inaugurated on 15 December 2015, while SHiP and PMNHP started in June and November 2016, respectively. The Federal and Gilgit Baltistan schemes implemented the SSP model. On 20 August 2020, SSP was expanded to cover 100% of the population of KP. GoKP considered SSP an important pillar in achieving UHC in the province. There was a dearth of research about the key drivers behind the initiation and expansion of the programme, the challenges it faced and its contextualisation in the province’s strides towards achieving UHC.

I sought to describe the evolution of SSP in KP through stakeholders’ accounts and explore potential ways for leveraging SSP to contribute towards achieving UHC in the province. SSP was selected as a case study for its advanced stage of implementation and its influence on the design of SHiP and PMNHP.

METHODOLOGY AND METHODS: I used an instrumental case study design. My study received ethics approval from the University of Edinburgh (Scotland, UK) and Khyber Medical University (Pakistan). I complied with the ethics regulations of informed consent, participants’ autonomy, confidentiality, and their right to withdraw. I used three complementary data collection methods. First, I collected official programme documents. I then conducted in-depth interviews and non-participant observations.

Programme documents were used to describe the chronology of events in SSP evolution and the changes in its policy parameters - for example, population, services and financial coverage. I acquired the documents from the SSP head office and its official website. The included documents were either authored or commissioned by GoKP, including Planning Commission Form 1 (PC-1) and the contracts between GoKP and the insurance company implementing SSP.

I used purposive (maximum variation) sampling for conducting interviews and observations in order to compare and contrast views from various stakeholders on the programme’s strategy and implementation. Through these interviews with diverse stakeholders, I explored the reasons behind changes in the policy parameters, their practical implications and the future directions to harness the programme’s role in achieving UHC. These stakeholders were the officials who attended the policy meetings or were involved with the programme implementation. These included officials from GoKP, the insurer, providers (hospitals), public advocacy groups and international development agencies (partners). I recruited participants through direct (face-to-face or emails) and open invitations (displaying a poster at the stakeholder offices).

I conducted policy level observations at meetings convened by the SSP head office and implementation level observations at SSP desks in the programme hospitals. Entry to the observation sites was facilitated by the gatekeeper, i.e., the Director of SSP. Equal representation was ensured by the type of hospital (public and private) and level of care (secondary and tertiary).The observations enabled me to explore how SSP policy decisions were made and how they were (or were not) translated into implementation practices.

I collected data from March 2021 to December 2021. I stopped data collection when data saturation was achieved. I conducted thematic analysis of these data. The Multiple Streams Theory (MST), the UHC Box and the Health Systems Strengthening (HSS) Frameworks informed my initial coding and major themes. I refined the broader themes through repeated iterations of the data analysis. I analysed the data with the help of NVivo 12. Using the World Health Organization’s (WHO) UHC Box Framework, I explored the coverage components of SSP, while MST helped me tease out the problem and policy streams that led to SSP initiation and the potential policy options to address its current problems. The HSS Framework enabled me to understand how SSP and the broader health system influenced each other.

FINDINGS: My final dataset comprised of 20 official documents, transcripts of 62 interviews and field notes from 63 hours of observations. The PC-1 defined SSP as an insurance programme designed for improving the population’s health status and poverty reduction. Interviewees credited the German Development Bank (KfW) as the major driving force behind SSP for its advocacy, technical assistance and financial support. Other reasons leading to SSP, as described by the respondents, were poor health indicators, rising health care costs, widespread poverty and the pessimism of the supply-side health care financing. GoKP paid an annual premium to the insurer, who purchased health services for the covered population from both public and private hospitals.

SSP had set three stated objectives, i.e., improving access to care, quality of services and financial protection for the covered population. These objectives resonated with the UHC definition by WHO, i.e., access to health services of sufficient quality to be effective without financial hardships. The development partners and advocacy groups suggested that SSP improved the affordability and availability components of access, but that challenges with geographical accessibility and acceptability persisted. The programme documents (PC-1 and contracts) showed an incremental enhancement in the population, services and cost coverage, making inpatient health care affordable (free).

In Phase 1 (2015), SSP covered 3% of the province population for secondary care. Each family had financial protection of up to 240,000/- Pakistani Rupees (PKR) per year. In Phases 2 and 3, population coverage was expanded to 51% and 69% of the province population, respectively. Tertiary care was added, and the financial coverage was enhanced to PKR 540,000/ per family per annum. In Phase 4 (2020), coverage was extended to 100% population; organ transplants were added to the benefits package and financial coverage was increased to PKR 600,000/ per family per annum.

The basic design features of SSP, as proposed by KfW, were solidarity, subsidiarity, and equity. SSP had plans to provide free health insurance to low-income families and raise revenue through paid enrollment of the wealthy (solidarity). GoKP deviated from this model and covered the entire population of KP free of cost. Through SSP, GoKP envisaged service provision through private hospitals (subsidiarity). However, in Year 3, GoKP included public sector hospitals in the programme. According to the advocacy groups, what started as social protection initiative for the poor was extended to 100% population with 100% subsidy. The advocacy groups noted that they perceived the rich to be subsidised by the poor. They expressed fear that the rich, as a result of their connections and better understanding of the health system, would crowd out the poor.

The stakeholders (GoKP, development partners and the insurer) had different interpretations of the programme’s rapid expansion. GoKP officials called the 100% population coverage a success, but the partners called it overdoing (in terms of financial implications for GoKP). The development partners noted that the rapid expansion of the programme compromised its financial viability and implementation feasibility. The insurer likened the rapid expansion to riding a roller-coaster, allowing them little time to establish the implementation processes. During my field observations, I saw the insurance staff at SSP desks struggling with enrollment and verification of patients. Similarly, the partners (especially the WHO representatives) considered the benefits package concerning, as it covered costly surgeries like cardiac bypass, but excluded mental health and primary care (which the partners considered cost-effective). Moreover, despite its claim to protect against catastrophic inpatient expenditure, SSP had protection gaps, as reported by the advocacy groups and the insurance officials. For example, the insurer informed they refused services to coronavirus disease 2019 (COVID-19) patients, arguing that pandemics were not covered.

The providers and the partners suggested that for meaningful improvement in access, quality of care and contribution towards UHC, GoKP needed to address the deficiency of human resources for health, improve its regulatory oversight and strengthen the services’ availability in remote districts. Considering the limited inpatient model, stakeholders noted that SSP had a limited contribution towards UHC. Moreover, the programme did not report on the internationally comparable UHC tracer or UHC effective coverage indicators.

CONCLUSIONS: The findings from this in-depth qualitative enquiry suggest that international development assistance and policy entrepreneurship can play a vital role in promoting global health objectives like UHC. However, the implementation of an innovative intervention was shaped by the constraints of the implementing system. My work further suggested that introducing a demand-side intervention did not cure the supply-side weaknesses. Insurance programmes like SSP should be considered a step towards UHC and not the ultimate panacea.

SPP’s expansion to 100% population coverage provided two transferrable lessons: (i) As the PMNHP and SHiP deliberate on 100% population coverage, policymakers need to consider pro-poor safeguards (like a transparent, online patient scheduling and workflow management) in place, and (ii) policy entrepreneurs need policy levers, for example, disbursement-linked indicators, to keep the basic design elements intact.

The stakeholders (apart from GoKP and the insurer) argued that the narrative of excluding pandemics fitted more with commercial insurance than social protection, highlighting the need for a better understanding and design of such programmes. Finally, initiatives like SSP were seen as contributing towards UHC, but how much is the question. SSP and related initiatives, in view of the development partners, should report on globally recognised and comparable indicators.