Utilization Challenges of Public Health Insurance Initiatives: Evidences from Sehat Sahulat Program (SSP) in Pakistan
Executive Summary
Healthcare utilization largely depends on both demand and supply-side factors. On the supply side, health infrastructure could be better to serve the population’s needs, whereas, on the demand side, affordability is the main challenge, especially for poor households. Health insurance provides an opportunity to avail of decent health facilities. The government of Pakistan launched the Sehat Sahulat Program (SSP) to provide equitable and affordable indoor health services through public-driven health insurance.
The current study has analyzed the SSP by focusing on the factors that may reduce the in-door utilization of health services. Besides secondary analysis, we have managed the qualitative and quantitative field survey by conducting in-depth interviews with all the supply and demand side stakeholders. A household survey is also carried out with the beneficiaries.
Our analysis found that the program has been facing the issues of lower utilization due to various factors, including lack of awareness and a limited number of empanel hospitals. In some districts, there is only one hospital to cater to the needs of 73,000 families. The program also requires focus to ensure 100% enrolment of all the eligible families, as in study districts, the pending cases range from 22% to 74%, with an average of 39%. Around 7% of the inpatients are deprived of seeking indoor treatment, either due to lack of hospital or lack of facility in the hospital or denial of services by the empanel hospital.
The program requires improving the environment of the empanel hospital by ensuring the availability of communication material, the 24/7 presence of a front desk person (HFO), and the availability of the operational manual. On the demand side, we found that most beneficiaries need more proper knowledge about various program features, including where they should go for treatment, package amount, type of treatment covered in the package, and whom to contact for information.
Despite the low utilization rate, a heartening element is the high satisfaction level of the beneficiaries who had received treatment. As a way forward, we recommend the following:
First, the program may ensure every citizen receives in-door health treatment by improving accessibility and availability of health services and easing the documentation requirement.
Second, there must be a sufficient number of empanel hospitals, and offered packages against a treatment must be attractive to avoid the ‘pick and choose’ option by the hospitals. The entire government health infrastructure must be on the pool of SSP. It should be mandatory that all private hospitals be a part of the SSP.
Third, the authorities must ensure that HFOs should be available in hospitals 24/7. The hospital list should be publicly available through various sources, including the website and dedicated SMS service. Moreover, the program should introduce some Android applications to find the nearest hospital to a patient.
Fourth, there is a need for a grassroots-level communication strategy, especially in districts where the program is universal. The key messages must be disseminated at the doorsteps of beneficiaries. For this, the program may involve local notables, education and health departments, and other social safety net departments having a ground-level presence (i.e., BISP, Zakat, Pakistan Bait-ul-Mal, and various provincial social protection/security authorities). Overall, the communication strategy must be heterogeneous, considering the population’s needs.
1. Introduction
1.1. Introduction
Healthcare utilization largely depends on both demand and supply-side factors. In developed countries, it is mostly determined by the demand-side factors as these countries have well-structured supply-side facilities and financing elements, including health insurance systems [1, 2]. However, in low-income countries, access to health facilities and quality of health services are the major concerns, as poor individuals cannot utilize the health facilities due to the availability and affordability challenges [3].
Most low-income countries, including Pakistan, face supply and demand-side constraints on effective health financing tools. On the supply side, they lack high-quality health infrastructure—uniformly available to all the population segments. On the demand side, the informal markets, and health insurance mechanisms are inadequate and accessible only to a limited population segment. The social protection programs also cannot ensure health financing for vulnerable and low-income families. As a result, most of the population has to finance their expenses from their pockets [4]. The heavy health expenditures raise their present vulnerability, i.e., compromise on low or forgo treatment, and push them into chronic and intergenerational poverty. As a coping strategy, they mostly borrow, cut down on consumption, sell assets, and curtail other investments, including that on child education [5].
Health insurance provides an opportunity to avail adequate health facilities [6]. Different health insurance models are operatable around the globe, including single-payer, multiple insurers, government-sponsored and employer-sponsored insurance, etc [7]. However, such models could be more mature and operational in developing countries by targeting most of the population due to various socio-economic imperfections, including informal economy, lack of affordability, absence of competitive health insurance companies, and cultural, religious, and other beliefs. For example, various religious segments in Pakistan consider health insurance as ‘haram’.
Health insurance helps the public, especially the poor, to afford equitable health facilities; therefore, insurance schemes can enhance the health utilization rate across various socio-economic groups, including inpatient, outpatient, and emergency services [6]. Multiple governments in developing countries have devised health insurance schemes for the poor segments to facilitate them through in-door/out-door services, i.e., Rashtriya Swasthya Bima Yojana (RSBY) and PMJAY in India [8], National Health Insurance (NHI) in South Africa [9], and National Hospital Insurance Fund (NHIF) in Kenya [10]. Some programs are non-contributory, where the government fully pays the health premium, whereas some are contributory.
There are various challenges in the supply-driven health insurance programs for the poor segments. For example, the need for more awareness about health insurance schemes plays a vital role in influencing the coverage and acceptability of the schemes amongst the beneficiaries, leading to lesser effective utilization of health care services and, consequently, poorer health outcomes. Although the public sector programs offer free health insurance to the poor and vulnerable segments, they mostly face coverage issues and lower utilization. The program may also need better awareness among beneficiaries, lack robust planning, delays and irregularities, etc.[8]. Several determinants of poor understanding include political factors, social/cultural norms, and economic factors [8, 11]. Supply-side factors include hospital access, lack of requisite facilities, denial of services by empanelled hospitals, and lower health insurance limits [9, 12]. Sometimes, the poor beneficiaries have to purchase medicine out-of-pocket due to the non-availability of ensured treatment in empanelled hospitals or because the scheme does not cover prescribed drugs [13, 14]. Regular awareness campaigns, automated health insurance systems, and efficient complaint management systems significantly improve health insurance utilization care [15].
