UHC monitoring in Pakistan
UNIVERSAL Health Coverage is always a work in progress. This is why ‘advancing UHC’ is better phrasing than ‘achieving UHC’. As I have written previously on these pages, despite a multidimensional public health crisis in the country, there have been some important developments with regard to UHC in Pakistan, including the development of the Essential Package of Health Services at the national and provincial level, and health insurance in the form of the Sehat Sahulat programme, albeit limited to hospitalisation. UHC’s third important element is regular monitoring, which is my topic today.
Monitoring UHC is complex; at best, it indicates its advancement in various dimensions. It is important, first of all, to be mindful of what UHC consists of. The WHO’s definition of UHC bears repeating: “when all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.”
Do we have such a composite reliable metric covering all these varied and interlinked aspects of UHC? The answer is no. But then, ‘perfect’ is the enemy of ‘good’. We cannot be perfect, but we can still monitor some aspects by employing improvisations, and using indicators as well as selective and piecemeal methods and then bring all these together to see how we are faring in UHC.
In 2015, a watershed Sustainable Development Agenda was approved by all heads of states at the UN. UHC became target 3.8 under the third SDG. The same year, the WHO and World Bank together produced the “first global monitoring report” on “tracking universal health coverage”. Since then, both agencies have jointly produced seven reports, the last one in 2023.
Pakistan has started to systematically produce an annual national UHC monitoring report.
Pakistan is one of the few countries to have systematically started producing an annual national UHC monitoring report. The first was in 2023, while the 2024 report was published last month — thanks to the team at the Health Planning, System Strengthening and Information Analysis Unit of the health ministry and the support of the UK Foreign Commonwealth & Development Office.
The report presents the service coverage index (SCI) from 2015 for the entire country. It is a standard methodology developed by the WHO and World Bank in which eight health services — including mother and child health, communicable diseases and non-communicable diseases (NCDs), and four values from “service capacity and access” — are factored in.
Nationally, by the end of 2023, the SCI stood at 53.9 (it ranges from one to 100) which is 35.8 per cent higher than in 2015 and 2.2pc than in 2022. The improvement is predominantly seen in reproductive, maternal and child health, while there are issues of data availability for NCDs. Islamabad Capital Territory ranked the highest with a score of 63.9, followed by Punjab at 55.5. Balochistan has the lowest SCI of 38.4. In nominal terms, it means that around 114 million individuals in Pakistan are not even able to access essential health services either through the public or private sector. Pakistan has a lower SCI than Bangladesh, China, India, Iran, Sri Lanka, Lebanon and even Syria, which has been constantly in a state of war.
The report provides detailed changes that have taken place in each of the 14 services and system indicators, including adolescent health, family planning, antenatal care visits, child immunisation, polio, acute respiratory infections and diarrhoea, HIV, hepatitis, malaria, antimicrobial resistance, cardiovascular diseases, cancers, diabetes, risk factors of NCDs, tobacco use, availability of hospital beds, essential health workforce, and the status of implementation of international health regulations.
On the financial protection side, in 2023, around 13.4m people risked poverty due to catastrophic health expenditures exceeding 10pc of the household income, with current health expenditure predominantly affecting the poor and escalating amidst high inflation. Out-of-pocket payments constitute 46.86pc of the total health expenditure in Pakistan, which is less than earlier estimates but still far exceeds the global average of 15pc. Balochistan faces severe financial protection challenges. This situation is the result of low public financing and lack of social health insurance at the primary healthcare level in the private sector.
A unique feature of the 2024 report is the breakdown of UHC-related statistics at the district level, which are presented for the first time. Some figures are eye-opening. A listing of all districts in Pakistan with reference to inequities and systemic inefficiencies shows that per capita Government Health Expenditure in Lahore is above $70 and less than $1 in 24 out of 36 districts in Punjab. There is obviously a low corresponding SCI in these districts. In Sindh, the per capita GHE in Karachi is almost $25, whereas four districts spent less than $1, and 17 out of 24 districts spent less than $10. In KP, the figures are $51.5 for Peshawar and $21 for Abbottabad. However, out of 32 districts, none is in the red, ie, less than $1, though 25 districts receive less than $10 per capita. The SCI situation is really bad in erstwhile Fata (Newly Merged Districts), and as low as 23 in Kohistan district. Of all the provinces, Balochistan is the worst off in terms of SCI, though not as bad in terms of GHE. This basically indicates huge systemic inefficiencies. Out of 33 districts, GHE in 24 districts is less than $10, whereas the same is 37.2 for the provincial capital Quetta and 25.7 for Lorelai. Only four districts in Balochistan have an SCI above 40. Dera Bugti has a service coverage of 18 and Killa Abdullah around 20. The situation in Gilgit-Baltistan and Azad Kashmir is relatively better. In Islamabad, per capita GHE is 79, the highest in the country, and so is the SCI, which is 64.
The report even goes into cross-cutting intersectoral areas that affect health, and provides important information on poverty, nutrition, gender equality, water and sanitation, employment, and urbanisation, and identifies policy and data gaps while making important recommendations.
This is easily the best national report I have read on UHC. I hope this annual monitoring and reporting practice continues in future, and with the government’s own funding.
The writer, a former health minister, is currently a professor of health systems & population health at Shifa Tameer-i-Millat University.
Published in Dawn, January 10th, 2025