Background

In 2016, Pakistan’s Khyber Pakhtunkhwa province embarked on a pilot initiative introducing a social health protection (SHP) scheme in four of its 26 districts. Funded by the German government through KfW Development Bank with technical support from the consulting firm Oxford Policy Management (OPM), the initiative aimed at providing access to cash-free in-patient services to the poorest 21% of the population of the four pilot districts. Less than a year later and before the pilot was complete and evaluated, the provincial government decided to invest its own budget to expand coverage to all districts and to the poorest 50% of the entire population. In November 2017, prior to a further expansion of the programme, the provincial government, supported by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH and AOK International Consulting, conducted a progress review.

Method

The Joint Review was based on available documentation, interviews with representatives of government, NGOs supporting the enrolment of targeted beneficiaries, the contracted insurance company and participating hospitals, and on focus group discussions with beneficiaries. The SHP scheme was critically examined in relation to the three core functions of a healthcare system: health service provision, health financing and regulation.  In a final workshop with key stakeholders, findings were discussed and recommendations formulated.

Findings

In the pilot initiative, some 85% of the targeted households received an SHP card, and the contracted insurance company successfully designed and managed the beneficiary registration system as well as claims processing from the hospitals. A remaining challenge was to standardise diagnoses and treatments among the hospitals. Government contributions to the scheme, based on a lump sum per enrolled household, were assessed as sufficient, while uptake of benefits, at ca. 2.2%, were below the expected benchmark of 3%. Negotiation of provider contracts with the insurance company was well accepted by both public and private hospitals, revealing a potential for improved enforcement of quality standards. The Joint Review recommended introducing cross-subsidisation with the addition of population groups that could pay for insurance, for risk pooling and financial sustainability, and reinforcing the stewardship functions of the SHP scheme through better coordination of the different technical and political actors involved in regulation. It was recommended to reassess the financial sustainability of the scheme before proceeding with further expansion.