Introduction

Talking about equitable access to healthcare in Pakistan requires looking at global healthcare systems before turning our gaze inward. Health coverage around the world can be categorized into four main types, distinguished by two important questions: who is paying and who is covered?

1.   Universal Coverage with a Single-Payer System: Everyone is covered by a national healthcare plan fully funded by the government.

2.   Multi-Payer System with No Universal Coverage: Not everyone is insured, with those who are covered through specialized government programs or private insurance.

3.   Universal Coverage with a Multi-Payer System: Everyone is covered under a national health system with competing insurers and private options available.

4.   Out-of-Pocket System: Predominantly in developing countries, where no formal state-wide healthcare system exists, and patients pay for services directly.

These categories form the foundation for the four primary healthcare models used globally(1).

Global Healthcare Models

1.   The Beveridge Model: Funded by direct income tax deductions, with most hospitals owned and operated by the government. The UK's NHS, Spain, Cuba, and New Zealand follow this model. Despite universal access, its disadvantages prevent widespread global adoption.

2.   The Bismarck Model: Insurance payments are made by employers and employees, with ‘sickness funds’ used to pay for services. Countries like Japan, Germany, France, and Switzerland use this model, which limits access for part-time employees and non-workers.

3.   The National Health Insurance Model: Combining Beveridge and Bismarck elements, the government acts as the single payer through a state-operated insurance scheme. Most providers are private entities.

4.   The Out-of-Pocket Model: Common in developing countries, where healthcare is paid for directly by patients, systematically denying access to the socioeconomically disadvantaged.

The Need for Healthcare Reform in Pakistan

Pakistan's healthcare system is dominated by the private sector, leading to high out-of-pocket spending and systematic disparities. Socioeconomically disadvantaged groups often lack access to essential services, including antenatal care, primary childhood immunization, family planning, emergency services, and treatment for communicable diseases. This results in sub-optimal health indicators, such as maternal mortality and neonatal death rates, which, although improved, still lag behind neighboring countries in South Asia and the Eastern Mediterranean region (2).

Health Indicators and Disparities

The private sector's dominance means that high out-of-pocket spending creates systematic disparities in healthcare provision. The poor and marginalized often lack access to even basic health services. This includes antenatal care, primary childhood immunization, family planning, intrapartum and postpartum care, emergency services, and treatment for communicable diseases such as malaria and cholera. These deficiencies have led to sub-optimal health indicators such as maternal mortality and neonatal death rates. Despite some improvements over the last decade, these rates still fall short of the standards set by neighboring countries in South Asia and the Eastern Mediterranean region.

Comparative Insights from Other Low- to Middle-Income Countries

Cuba

Cuba provides free basic healthcare for all its citizens, focusing on promotion and prevention. Healthcare providers in Cuba educate citizens on healthy lifestyles as a first step toward promoting good health and longevity. Mandatory antenatal care and a high doctor-to-patient ratio contribute to good health outcomes.

Philippines

In contrast, the Philippines lacks a basic healthcare infrastructure and emphasizes privatization, making healthcare access a privilege rather than a right. High out-of-pocket expenditure poses significant health risks to the most vulnerable populations. Community health workers, trained within their communities, provide basic medical aid, but their impact is limited without governmental support and health activism.

Transforming the Dream into Reality

Pakistan can learn from countries like Cuba and the Philippines. Instead of large-scale system reforms, measured steps can enhance healthcare access:

1.   Increase Health Budget: Allocate a higher percentage of GDP to healthcare.

2.   Train Community Health Workers: Bridge the gap between populations and providers.

3.   Prioritize Prevention: Emphasize immunization and public health awareness programs.

4.   Redistribute Resources: Shift healthcare personnel and technologies from the private to public sectors.

5.   Reduce Foreign Aid Dependence: Focus on local needs and priorities.

6.   Ensure Transparency and Accountability: Hold all stakeholders responsible, from service providers to policymakers (2,3).

Specific Steps for Pakistan

1.   Increase Health Budget: Allocate a higher percentage of GDP to healthcare to ensure sufficient funding for essential services.

2.   Train Community Health Workers: Utilize community health workers to bridge the gap between healthcare providers and the population, especially in rural areas.

3.   Prioritize Prevention: Focus on immunization and public health awareness programs to prevent diseases before they occur.

4.   Redistribute Resources: Encourage the redistribution of healthcare personnel and technologies from the private sector to the public sector to ensure equitable access.

5.   Reduce Foreign Aid Dependence: Decrease reliance on foreign aid and the attached demands of foreign policy, focusing instead on local needs and priorities.

6.   Ensure Transparency and Accountability: Implement systems for transparency and accountability from all stakeholders, including service providers, managers, administrators, and policymakers.

Conclusion

The debate behind multi-payer versus single-payer universal health coverage aside, equitable access to healthcare is an ideal that Pakistan should strive for. Recognizing healthcare as a constitutionally protected human right, like education, is the first step. By doing so, the healthcare system would no longer suffer at the hands of the country’s volatile political and fiscal climate. This would entail reformations at the state level such that Pakistan’s healthcare system would retain a sturdy foundation over the course of many years, thus enabling tangible and sustainable changes to be made in healthcare provision across the country.

References

1.   World Economic Forum

2.   Shaikh, B.T., Ali, N. Universal health coverage in Pakistan: is the health system geared up to take on the challenge? Global Health 19, 4 (2023). https://doi.org/10.1186/s12992-023-00904-1

3.   Richard, L., Furler, J., Densley, K. et al. Equity of access to primary healthcare for vulnerable populations: the IMPACT international online survey of innovations. Int J Equity Health 15, 64 (2016). https://doi.org/10.1186/s12939-016-0351-7