dr ally r memon
When the PM Health Insurance Scheme was approved back in June 2014, it was suggested through official sources that the programme was to cover 100 million of Pakistan’s deprived population. With the national health insurance programme recently launched and inaugurated by the premier, information emerging from reported sources tells us of the scope and coverage of the scheme. In its first phase, it intends to initially cover 15 districts and be gradually extended to 23 districts providing 1.2 million families with free healthcare treatment. The second phase of the programme will lead to 3.2 million families living below the poverty line being covered.
With health being a devolved matter, Sindh and KP provincial governments opted out of the scheme, we may have bought a big sigh of relief for a few sitting in the capital since the Rs 9.2 billion budget eventually allocated for this programme would have hypothetically amounted to Rs 92 of health-cover-per-person for the initially proposed 100 million people if all provinces had participated. Of course one would have factored in Sindh and KP contributions to the pot had they joined in. Now shedding the load Sindh and KP may have put on the programme, we can say that the gods are with us as this in theory, amounts to a health treatment cover of Rs 2875 per family or Rs 480 per individual if you take Pakistan’s average family size of 6 perhousehold across the participating provinces. Mind you, this is just probably enough to get some basic medicine dispensed and an X-ray scan taken if you’re lucky.
It is further baffling when you consider the salient features of this national health programme announced by the federal health minister, which are that sequentially as an individualised health care treatment pathway, Rs 50,000 are made available and capped on the PM’s health card for treating common illness while Rs 300,000 are made available and capped for treatment of a serious medical condition, which may be extended to Rs 600,000. Further details provided on this by the health ministry and the Prime Minister’s office declares that those covered under the scheme will be eligible for free treatment of chronic illnesses including heart disease, diabetes, kidney disease, hepatitis and liver disease.
The idea of treating such chronic illnesses seems far-fetched with Rs 480 available per individual per targeted household. Without doubting the intentions of the government, the case may very well be that individuals will genuinely be provided for as per need up to the suggested cover amounts. That for instance, someone with kidney disease gets covered upto Rs 300,000 for dialysis treatment or another gets covered upto Rs 600,000 for cardiac bypass surgery and post-operative treatment. This would of course be gratifying and fulfilling on part of the government. But then if this is the case, the expected population coverage of the programme should be realistically predicted rather than giving farce projections of the numbers of people or families that can be covered.
If we consider that even aRs 50,000 basic cover for common illness is provided to treatan entire family, then the allocated Rs9.2 billion budget suffices support for a maximum 46,000 households across the country. Or if you take up the Rs 300,000 cover for treating only one individual per family with a chronic illness leaving other family members aside, then the budget suffices support for a maximum 30, 600 families across the country. And even these are optimistic projections since we are not yet accounting for the bulky administrative and resourcing costs typically associated with administering a healthcare programme. One remains bemused therefore as to how all this is planned for or how the economics of it is worked out by the government. Maybe it is just that we are not as logical or enlightened as they are.
Furthermore, the PM health insurance programme wishfully includes the private health sector and private hospitals as service providers in this scheme whereby people can avail private treatment which the insurance scheme will cover. We are left wondering as to what contractual or subsidiary arrangements the government has negotiated with private healthcare providers for this scheme and with whom? Private healthcare providers exist both in institutional and consortium forms across Pakistan and it is no secret that they operate unregulated and have free will to charge for services given the fact that demand for reliable healthcare treatment far exceeds its supply. If the case is that private healthcare organisations had bid under some tendering process (e.g. submissions of PC1’s) during the planning and contracting phase of the scheme, then it would be useful to know the process and criteria by which they have come on board and more importantly, to know what the costing and subsidising arrangements are under the scheme.
We must keep in mind that given the lack of healthcare service provision in rural areas, the provision of health cards will bring a large influx of patients in to urban government-run hospitals and centres that are already overworked, under-resourced and inadequately staffed. For this reason, it is of interest to determine if any money from this programme will feature an element of primary care and public awareness initiatives rather than only funding secondary and tertiary care. This is important since research evidence would suggest that primary healthcare initiatives in communities and public health education campaigns have a wider and larger impact on improving health in the long run.
The crux of the matter is that this PM Health Insurance programme, like many other health initiatives of the past, is overly hyped and under resourced. The problem gets taken back to the drawing board. That no matter how wishful, well-intended or theoretically innovative a public health scheme may be, it simply won’t have an impact on improving public health unless more money and resource are allocated to health. Neither will devolution of health policy and implementation to provinces make any difference as the last seven years of devolution have demonstrated. Any new healthcare blueprint for Pakistan needs enormously increased health funding in the face of a growing population crisis. If Pakistan continues to allocate a dire 1 percent of its annual budget spending to health, then the health crisis can only prevail.
— The author is a faculty member at Kingston University, UK and teaches on the MSc Leadership and Management in Health Programme.