Universal Health Coverage and Pakistan

How we fared and what we should do

“May Allah Almighty protect you against all diseases!” This is the sentence almost everyone of us wish to our fellow human beings. In Pakistan, saying this to every other person seems more appropriate because for most people in this country, seeking health facilities is synonymous with inequality, economic burden, bribery, reference and quackery. It is especially because the available health facilities, their quality as well as utility are creating inequality and discrimination at geographical, socio-economic and social levels.

Although the fundamental right to health pertains to the provision of, and access to, low-cost, reliable health facilities in the form of hospitals, clinics, medicine and medics, the prevailing situation in Pakistan in this context suggests that we still have a lot to do in terms of ensuring Universal Health Coverage as a basic human right. It is because Pakistan, with a score of 40, stands at a miserable 162nd place among 183 countries on Service Coverage Index of the Universal Health Coverage target of the Sustainable Development Goal 3. Moreover, according to a report titled “Tracking Universal Health Coverage: 2017 Global Monitoring Report” of the World Health Organization and World Bank, Pakistan has scored lower than the average South Asian score of 53 and even that of Africa which was 46 – world average is 64. No country has been able to achieve a cent per cent score because more than half the world population does not have access to essential health services and more than 100 million people have to pay dearly for healthcare and almost 800 million people spend nearly 10 percent of their household budgets on health issues. So, in order to call the attention of the world to these and such other problems, the world will be observing the International Universal Health Coverage Day on 12 December under the theme “Unite For Universal Health Coverage: Now is the time for collective action.”

Universal Health Coverage (UHC) means that 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. UHC does not mean free coverage for all possible health interventions, regardless of the cost, as no country can provide all services free of charge on a sustainable basis; rather financial burden incurred by availing themselves of health facilities is alleviated. This minimizes the problems created by paying from their own pockets and reduces the risks of their being trapped in poverty because unexpected ailments often compel people to spend all their savings and they are left with no option but to sell their assets or seek loans to meet the expenses which put their and their children’s future in jeopardy. But, it is not all about finances; rather UHC bridges the gulf of inequality. In this configuration, achieving universal health coverage, 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 are ensured. Hence, UHC is an important element of efforts on ensuring healthy lives, alleviating poverty alleviation and reducing social inequality under the Sustainable Development Goals (SDGs) of the United Nations. And, Target 3.8 of the SDG 3 – Ensure healthy lives and promote wellbeing for all at all ages – is related to it. It has two indicators: the first 3.8.1 is related to essential health services while the second, 3.8.2 is about the segment of population that makes catastrophic spending on health. The first is about population coverage under the UHC while the second is about financial security.

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The performance of countries in terms of these two indicators can be measured in two ways:

(1) the ratio of population that has access to needed and quality health care facilities; and

(2) the ratio of population that spends huge household budgets on health issues.

The WHO has developed a framework to track the progress of UHC by monitoring both the categories, taking into account both the overall level and the extent to which UHC is equitable. These categories and the matters they take into account are as follows:

With the help of these indicators, the ratio of population covered under the UHC is determined. If we see in the context of Pakistan, the situation is not encouraging. According to the indicators on which Pakistan has been analyzed in WHO and World Bank’s “Tracking Universal Health Coverage: 2017 Global Monitoring Report,” Pakistan’s position on the first is 49 percent.

Similarly, if we analyze the situation on Target 3.8.2, that is, about economic security aspect of the UHC, we take guide from “Financing Global Health 2016: Development Assistance, Public and Private Health Spending for the Pursuit of Universal Health Coverage,” of the Institute for Health Metrics and Evaluation (IHME). This report says that Pakistan, with a spending of 2.7 percent of GDP, was at 177th place out of 184 countries in 2014. While on the indicator ‘Out-of-pocket spending as share of total percentage’ the country was at 15th place with a ratio of 55.4 percent. These facts and figures clearly depict that our percentage of GDP spending on health sector is much lower than that of other countries of the world. And, in fine, it means that most Pakistanis have to pay for health facilities by themselves.

In this state of affairs, Pakistan’s progress on the SDG related to Universal Health Coverage has been stagnant, i.e. below the required level of 50 percent. This is the picture portrayed in 2018 SDG Index and Dashboards report of the Sustainable Solution Network in which performance of all countries on SDGs has been measured. As per the report, with a score of 54.9, Pakistan was ranked 126 among 156 countries.

Universal Health Coverage is all about the expansion of healthcare services, financial security and availability of more resources. And healthcare services are directly related to a robust infrastructure of health facilities and increase in the number of medics. According to the Economic Survey of Pakistan 2017-18, total number of health facilities (hospitals, dispensaries, rural health centres, TB centres, basic health units, maternity homes, etc.) is 14,261 with an average of one facility serving 14,570 people spanning an area of 55 square kilometres. Similarly, there are only 368,244 registered medical professionals (doctors, nurses, midwives, and lady health visitors) each serving, on an average, 564 people. In Pakistan, one doctor is serving 957 people while one nurse provides medical care to 2002 persons. It, in effect, means that one registered medical practitioner serves nearly 2.3 sq km of Pakistan. In addition, the number of beds available in all public sector health facilities is 126,019, that is, one bed for 1,649 individuals.

When we analyze the situation from the second aspect, i.e. financial security and availability of more and more resources, we find that, as per a report titled “National Health Accounts Pakistan 2015-16,” published by Pakistan Bureau of Statistics, the amount spent on providing healthcare facilities to the people was only 908 billion rupees, i.e. 3.1 percent of the national GDP – minimum benchmark set by WHO is 6 percent. Similarly, during the said year, per-capita spending on health was recorded at US$ 45 as against the WHO’s threshold of US$ 86 – Pakistan spent lower even than the South Asian countries like India and Sri Lanka that spent 75 and 127 dollars respectively. Moreover, out of the total spending on health in Pakistan, 523 billion rupees, or 58 percent, came out of people’s own pockets. According to a research paper Healthcare System of Pakistan (published in International Journal of Advanced Research and Publications), “Only 27% of the population benefitted from full healthcare coverage which includes mostly government employees and members of armed forces, and remaining 73% depends on out of pocket payments.” According to another report, 50 percent of this amount goes to purchase of medicines.

To ameliorate this situation, a number of encouraging steps are being taken by the government of Pakistan with “Prime Minister’s National Health Program” as its mainstay. The programme would benefit 3.2 million families living in Punjab, Balochistan and FATA in its two phases and a social mobilization campaign would be launched to ensure registration of all deserving people under the scheme.

Notwithstanding this prevailing state of affairs in Pakistan, if we have a look at the WHO’s standards, there should be 5 beds for a 1000 population. But, in Pakistan, there were only 104,740 beds in 1,201 public sector hospital – 0.54 beds per 1000 population, as per PBS’s Pakistan Statistical Yearbook 2016 – as against the demand of 977,000 beds calculated on the above-mentioned WHO criterion. It means we have only 11 percent of the required number of beds (89 percent deficiency). Moreover, in order to assess the performance of countries in terms of provision of UHC, the WHO has set some benchmarks in its “Global Strategy on Human Resources for Health: Workforce 2030” report according to which there should be 4.45 physicians, nurses and midwives per 1000 population. As per the data provided in Pakistan Economic Survey 2017-18, total number of medics (doctors, nurses and midwives) in Pakistan is 349,844 as against the WHO-recommended number of 924,597, which means that for an approximately 227.7 million population of the country, their per capita availability comes out to be 1.68. It means we have a deficiency of 62 percent.

The whole discussion can be concluded by saying that although we should be always praying to Almighty Allah for better health of people, especially those belonging to middle and lower middle class of our society, we should, at the same time, ensure that we make all efforts to achieve the goal of Universal Health Coverage.