UNIVERSAL HEALTH COVERAGE IN THE PAKISTANI CONTEXT

Universal Health Coverage (UHC) is a health care system goal aimed at ensuring that all individuals and communities receive the health services they need without suffering financial hardship. UHC encompasses a wide range of health services, including health promotion, prevention, treatment, rehabilitation, and palliative care, which are accessible to all people regardless of their financial status.

Key Components of UHC:

Access to Quality Health Services:

UHC aims to provide comprehensive health services that are of high quality and cover a broad spectrum of care needs. This includes everything from basic health screenings and immunizations to advanced surgical procedures and chronic disease management.

Financial Protection:

One of the primary goals of UHC is to protect individuals from the financial risks associated with paying for health services out-of-pocket. This involves reducing or eliminating the need for direct payments at the point of service, thus preventing people from falling into poverty due to health expenses.

Equity in Health Coverage:

UHC strives for equity in health services, ensuring that everyone, particularly the most vulnerable and marginalized populations, has access to the health care they need. This includes addressing disparities based on income, geography, gender, and other social determinants of health.

Benefits of UHC:

Improved Health Outcomes:

By ensuring access to essential health services, UHC can lead to better health outcomes, reducing morbidity and mortality rates and improving quality of life.

Economic Benefits:

UHC can contribute to economic growth by enhancing productivity through a healthier workforce and reducing the economic burden of diseases.

Social Stability:

UHC promotes social cohesion and stability by reducing inequalities and ensuring that all citizens can access health care.

Global and National Implementation

Global Commitment:

UHC is a key target under the United Nations Sustainable Development Goals (SDG 3.8), which calls for achieving UHC, including financial risk protection, access to quality essential health-care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all by 2030.The Universal Health Coverage (UHC) Monitoring Report 2021 for Pakistan highlights several key areas of focus and challenges in the country's health system as it strives to achieve comprehensive health coverage for all its citizens.

Universal Health Coverage is the main outcome of health-related SDGs and is measured with two targets, one for essential service delivery (3.8.1) and other for financial protection (3.8.2).

NATIONAL HEALTH VISION

‘To improve the health of all Pakistanis, particularly women and children by providing universal access to affordable, quality essential health services which are delivered through a resilient and responsive health system, capable of attaining the Sustainable Development Goals and fulfilling its other global health responsibilities’

Health is centrally positioned within the 2030 sustainable development agenda, with one comprehensive goal of ‘Good Health’ (SDG 3) and its 13 targets (and more than 27 indicators) covering major health priorities, and links to targets in many of the other goals.

The UHC framework embodies three related objectives:

a)???????? Equity in access to essential healthcare services - everyone who needs services should get them, not only those who can pay.

b)???????? The quality of health services should be good enough to improve the health of those receiving services; and

c)???????? People should be protected against financial risk, ensuring that the cost of using services does not put people at risk of financial harm.

UHC ensures that all people and communities have access to needed promotive, preventive, curative, rehabilitative and palliative health services of optimum quality without risk of financial hardships, cuts across the health targets and contributes to promoting health security and equity. Progress towards UHC also ensures positive change in other health-related targets across different sectors. Good health allows children to learn and adults to earn, helps lift people from poverty, addresses social and gender inequities and provides the basis for well-being, social cohesion, health security and long-term economic development.

SDG target for UHC 3.8 has two indicators:

3.8.1 on coverage of essential health services measured through UHC Service Coverage Index (SCI); and

3.8.2 on the proportion of a country’s population with catastrophic spending on health, defined as large household expenditure on health as a share of household total consumption or income

Both must be measured together to obtain a clear picture of those who are unable to access health care and those who face financial hardship due to spending on health care.

3.8.1??? UHC Service Coverage Index (SCI) is a composite indicator and is defined as the average coverage of essential health services based on sixteen tracer interventions in four groups that include reproductive, maternal, newborn and child health; infectious diseases; non-communicable diseases; and services capacity and access.

The UHC prioritizes four groups of integrated essential health care services at all five levels of health care delivery system (i.e., community, primary healthcare centre, first level hospital, tertiary hospital, and population levels) and through both public and private sectors, to address the burden of diseases in an effective and efficient way.

As defined by World Bank (WB) and World Health Organization (WHO), four groups and sixteen proxy interventions for UHC SCI monitoring are as following:

a: Reproductive, maternal, new-born, child, and adolescent health & nutrition

·???????? Family Planning;

·???????? Antenatal and Delivery care;

·???????? Child Immunization;

·???????? Health Seeking behaviors for Child Illness (Pneumonia)

b: Infectious diseases

·???????? Tuberculosis Effective Treatment;

·???????? HIV & AIDS Anti-Retroviral Treatment;

·???????? Insecticide Treated Nets Coverage for Malaria;

·???????? Adequate Water and Sanitation

c: Non-communicable diseases

·???????? Blood Pressure;

·???????? Diabetes Mellitus;

·???????? Cervical Cancer Screening;

·???????? Tobacco Control

d: Service capacity and access

·???????? Hospital Beds Density;

·???????? Essential Health Workforce Density;

·???????? Access to Essential Medicines, Vaccines and Commodities;

·???????? Capacities for International Health Regulations (IHR)

3.8.2 Financial risk protection is another dimension of the UHC. The affordability of healthcare is a key issue especially in low- and middle-income countries, where a large number of people lack sufficient financial means to access health care services. Worldwide, millions of people are pushed into vicious cycle of poverty every year due to compelling needs to pay for health care services.

Investment in health improves health outcomes, reduces poverty, and contributes to promoting economic growth. Better health and improved health systems also enable a country to tackle health emergencies and ensure national security. With poor health status in Pakistan, another major challenge during 2021 was the continuing negative impact of COVID-19 epidemic, particularly for those who are poor or vulnerable, women and children, youth, persons with disabilities, people living with diseases, older people, refugees, internally displaced persons, and migrants.

PAKISTANI CONTEXT

Pakistan is currently going through epidemiological and demographic transitions. However, both transitions in Pakistan are slow compared to other countries in the region. Epidemiological transition considers patterns of mortality change and causes of death (and sometimes ill health) from patterns dominated by maternal & child health and infectious diseases to those in which chronic, degenerative physical ailments predominate with increasingly non-communicable and mental ill-health conditions.

Demographic transition refers to the shift in vital rates within population groups at various geographical scales from a pattern of high birth (fertility) and death (mortality) rates to one of low rates. Paralleling both these transitions are recognized related changes such as “nutrition transition” and “ageing transition”. All these patterns are evident in Pakistan, and it is recognized that they may not be unidirectional. Indeed, different “speeds” of transition may occur in different places and sometimes reverses, or mixed patterns are observed.

Burden of Disease (BoD) is “A systematic, scientific effort to quantify the comparative magnitude of health loss from all major diseases, injuries, and risk factors by age, sex, and population and over time”. The preferable unit for quantification of BoD is Disability-Adjusted Life Years (DALYs), which measures the number of years of healthy life lost to premature death and disability.

Hence, DALYs are the sum of years of life lost due to premature death (YLLs) and years lived with disability (YLDs).

According to Institute of Health Metrics & Evaluation (IHME)10, the annual rate of DALYs lost per 100,000 population indicates that Pakistan has very high BoD among the regional countries i.e., 42,059 DALYs/ 100,000 population in 2019.

Neonatal and maternal disorders constitute the largest disease group of disease burden, followed by cardio- vascular diseases and then respiratory infections & TB.

Maternal Health:

The maternal mortality ratio (MMR) decreased from 276 per 100,000 live births in 2006-07 to 186 per 100,000 live births in 2019. However, to achieve the Sustainable Development Goal (SDG) target of 70 per 100,000 live births by 2030, the rate of decrease needs to more than double.

Child Health:

Under-five mortality has steadily declined at an annual rate of about 3%, reaching 67 per 1,000 live births by 2019. Despite this progress, neonatal causes account for 65% of under-five deaths.

Neonatal mortality and stillbirth rates have decreased at an annual rate of just 2% over the last decade, indicating a need for improved quality of care during birth and enhanced neonatal care services

Service Coverage and Health Interventions:

Pakistan has seen improvements in antenatal care, skilled birth attendance, and immunization coverage. However, these advancements have not been sufficient to meet the SDG targets due to slow reductions in mortality rates and stagnant contraceptive prevalence

CHALLENGES IN UHC

Some of the key challenges in the health sector and more specifically to achieve UHC in Pakistan include the following:

Health Governance

·???????? Limited institutional capacity

·???????? Provincial/ Area level - policy analysis, planning, coordination, outsourcing, regulation

·???????? District level - monitoring, supervision, operational planning

·???????? Weak culture of accountability and transparency

·???????? Inadequate engagement of the private sector

·???????? Limited capacity for ensuring effective decentralization – central, provincial, district levels

·???????? Weak health sector and inter-sectoral coordination

·???????? Need to regularly review implementation of policy documents

·???????? Need to strengthen regulatory bodies and implementation of legislations

Service Delivery

·???????? Availability: Shortage of health facilities, inequity, limited availability of essential health services; Weak engagement with the Private sector/ General physicians for delivery of EPHS

·???????? Accessibility: Physical, financial, social barriers

·???????? Quality: Quality standards and regulatory systems

·???????? Demand: Low awareness and demand

·???????? Coverage: Limited coverage of essential services, biased towards rich and well-off areas – equity issues

·???????? Utilization: Low utilization of PHC health services leading to burden on hospitals; poor referral system

·???????? Humanitarian - Development Nexus to be developed for effective response during emergencies while ensuring sustainability

Human Resources for Health

·???????? Acute shortage - 1.69 essential health force /1000 pop (Target- 4.45 by 2030)

·???????? Inequitable distribution- Urban/Rural and declining number of LHWs

·???????? Inadequate skill mix

·???????? Weak HRH management: inadequate incentives, disparities, weak supervision, limited employment capacity

·???????? Weak technical capacity: No proper system of In-service training

·???????? Weak HRH information: HRH registry needs to be standardized and integrate for appropriate planning and HRH management

·???????? Growth of private sector health educational institutions with weak regulation

Health Financing

·???????? Data constraints on health financing, including out-of-pocket expenditure and delayed mechanism to update

·???????? Predictable and adequate financing for health

·???????? Health emergencies and epidemics needing huge investments

·???????? No health financing strategy with limited allocation & expenditure

·???????? Need to close financing gap to ensure provision of services, along with a pre-payment mechanism to reduce catastrophic/out-of-pocket health expenditure

·???????? Public financial management reforms in health sector, aligned to cross-sectoral public financial management reforms

·???????? Need to strengthen rules/procedures for purchase of goods and services in public sector while ensuring efficiencies

·???????? Need to ensure strong accountability system in public sector

Health Information

·???????? Accessibility to information – Infrequent availability of survey results at national, provincial and district level

·???????? Poor comparability of different surveys’ results

·???????? HIS of vertical programs, surveillance systems to be integrated fully in Pakistan Health Information System (PHIS) Dashboard

·???????? Questionable quality of data reported through Health Management Information System (HMIS)

·???????? Limited use of information for decision making

·???????? System of Civil Registration and Vital Statistics not in place

·???????? Limited use of technology and innovation

Essential Medicines and Health Technologies

·???????? Need to have a robust mechanism to monitor availability of quality essential medicines, commodities, and supplies - with regular consumption analysis to check frequent stock-out

·???????? Unused equipment/technologies to be disposed of regularly

·???????? Inappropriate stock management should be addressed at all levels

·???????? Strengthening of national, provincial and district procurement system, including regulation

·???????? Check on inflow of counterfeit drugs

WAY FORWARD

Pakistan's journey towards UHC is complex but crucial for improving national health outcomes. Strengthening the health system at all levels, ensuring adequate financing, and maintaining political commitment are essential steps to achieving comprehensive health coverage by 2030

The 2021 Universal Health Coverage (UHC) Monitoring Report for Pakistan highlights several key aspects of child health as part of its broader assessment of health coverage. Key areas of focus include:

Child Immunization: Immunization coverage is a crucial indicator for child health within the UHC framework. The report emphasizes the importance of maintaining and improving immunization rates to protect children from vaccine-preventable diseases. This includes efforts to ensure widespread access to vaccines, especially in remote and underserved areas.

Maternal and Newborn Health: The report underscores the significance of maternal health services, which directly impact child health outcomes. This includes antenatal care, skilled birth attendance, and postnatal care, which are critical for reducing maternal and neonatal mortality rates.

Nutrition: Addressing malnutrition is a key component of child health. The report discusses efforts to improve nutritional status through programs aimed at combating both undernutrition and micronutrient deficiencies among children. These initiatives are vital for ensuring healthy growth and development.

Community Health Workers: The role of community-based health workers, such as Lady Health Workers (LHWs), is highlighted. These workers are instrumental in providing essential maternal, newborn, and child health services, particularly in rural and hard-to-reach areas. They help bridge gaps in healthcare access and ensure that basic health services are delivered at the community level.

Health System Strengthening: The report emphasizes the need for strengthening the health system at all levels, including improving infrastructure, enhancing the capacity of health workers, and ensuring the availability of essential medicines and supplies. This is crucial for delivering comprehensive child health services.

These focus areas align with the broader goals of achieving universal health coverage by ensuring that all children have access to essential health services without financial hardship. The report calls for continued investment and policy efforts to address these critical aspects of child health within the UHC framework.

The 2021 Universal Health Coverage (UHC) Monitoring Report for Pakistan covers various aspects of public health, reflecting both achievements and ongoing challenges in the country's health system.