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Miserable health insurance schemes for the poor

The former prime minister Nawaz Sharif has launched a state-run health insurance program and described it as the first step towards making Pakistan a welfare state. Around 1.2 million families will get free healthcare facilities in the first phase. People living below the poverty line would be able to get best possible treatment at government’s expense.

The program would benefit 3.2 million families living in Punjab, Balochistan and FATA in its two phases. Social mobilization campaign would be launched to ensure registration of all deserving people under the scheme.

Most countries in the region, including Afghanistan, have started health insurance programs on the recommendation of the World Health Organization. About 55 percent of Pakistanis earn less than $2 a day and the government has decided to provide health insurance cover to all such people in phases.

The data of the Benazir Income Support Program will be used for the purpose, according to an official. Medical insurance usually costs Rs25,000 per year, but the government would have to pay Rs1,300 for each family. “A family will get Rs50,000 for secondary care treatment which begins as soon as a patient is hospitalized,” said an official. It includes all kind of diseases. According to estimates, members of a family get admitted two or three times a year and Rs10, 000 to Rs15, 000 is spent each time.

Treatment of cancer, accidents, burns, diabetic complications, heart bypass and infection will be insured under the priority diseases category. Each family will get treatment of Rs300,000 per year and the amount will be doubled in case of emergency. Under the program, special cards would be issued to families for insurance which would be activated as soon as they were issued.

Pakistan ranks low on the social development index of child and maternal health. This reflects the level of nutrition, education and access to health services. Pakistan’s Maternal Mortality Ratio Index has slipped from 147 in 2014 to 149 in 2015. The overall maternal mortality rate is 276 per 100,000 live births.

In Balochistan the rate is as high as 785, with less than 10 percent of pregnant women receiving vaccines and immunizations. Pakistan has the third highest child (under five) mortality figures in the world, and 40 percent of these deaths occur in the neonatal period.

According to the Pakistan Demographic and Health Survey 2012-13, 45 percent of children show evidence of chronic malnutrition or stunting and 11 percent are acutely malnourished, requiring urgent treatment.

In 2014 and 2016, there were excessive deaths in children in Thar, due to endemic malnutrition and water-borne diseases. In 2014, pneumonia and diarrhoea had claimed the lives of 144,000 children nationally.

The Government of Pakistan is signatory to the Sustainable Development Goals, which call for universal health coverage by 2030. The government also makes this commitment in its health policy.

In 2017, 80 percent of Pakistan’s population is without access to primary care. Families are forced into poverty as a result of crises related to private healthcare expenditures.

In this context distributing health cards will not work. It only covers hospitalization, and these people have nowhere to get healthcare other than from the existing health facilities.

Most public facilities have consistently shown to be not usable. There are long distances to facilities, restricted hours of operations, poor facility infrastructure, lack especially doctors, equipment and supplies. Therefore there is no use of health cards. Healthcare needs huge resources, neither the government nor private organizations can take this challenge alone. In this context government has to meet the needs with private-sector offerings.

The first step could be to make public-sector facilities workable so that there is service available. The government should see that qualified doctors are available. It should provide the equipment, supplies and drugs needed to serve the citizens. At present the situation in government hospitals in Pakistan is pitiable.

The National Insurance Health Program, for the poor offering health cards to be reclaimed for hospitalization is another example of government despair. The larger issues in government institutions are poor governance, substandard human resource, lack of accountability, and lack of oversight. These shortages are a hurdle to even the full utilization of government’s own health budget.

Patients Undergoing Cancer Care in a Tertiary-Care Hospital, 2012; the authors report that the mean and median monthly cost of cancer care in Pakistan was $1093.13 and $946.42 respectively. The overall average duration for all cancers was 6.7 months. For breast cancer it was 7.8 months and for head and neck cancer 5.04 months.

In addition to direct costs for cancer treatment, there are related costs of cancer care that can require hospitalization and treatment running into the thousands. Moreover that most of the public-sector hospitals are non-functional and unusable, forcing people to seek care in private hospitals.

The inadequacies in public-sector hospitals are the responsibility of the provincial ministry of health and for them to fix. The National Health Programme, if it does nothing else, could be used as an opportunity to start this process.

Health insurance programs are complicated, requiring coordination and integrated support systems. These function best in the context of a stable overall service delivery system. Without that, this health card scheme will last only as long as donor funding.

The National Assembly Standing Committee on Planning, Development and Reform was informed that a small allocation of Rs10 billion had been proposed for the financial year of 2017-18 to widen the Health Insurance Scheme.

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