ISLAMABAD: The Poverty Alleviation and Social Safety Division (PASSD) has sought cabinet approval for Catastrophic Healthcare Expenditure Policy (Ehsaas Tahafuz), envisaging to cater only to catastrophic expenditure and targets beneficiaries that are either not covered under existing programmes, or that have utilized their Sehat Sahulat Program (SSP) limits, or are in hospitals that are not covered under SSP and provide coverage for all essential treatments (including outpatient).
The division has moved a summary to the cabinet, a copy of which is available with Business Recorder, stated that the government has embraced universal health coverage as one of its important policy objectives. This is in alignment with the government’s commitment to the UN’s1 sustainable developments goals.
To deliver on this policy objective, the Sehat Sahulat Program was launched and is being up scaled. The SSP is making a significant contribution to protect people from catastrophic health expenditures. However, there are certain limitations inherent to the adoption of insurance in mixed health systems that need to be addressed.
Given the importance of protecting the most vulnerable in the society, there was a need for a program to complement Sehat Sahulat that addresses potential gaps and ensures no one falls into poverty due to healthcare expenses.
To address this need, Ehsaas Tahafuz was designed as Pakistan’s first-ever shock-oriented safety net programme under the Ehsaas framework. Ehsaas Tahafuz has defined its coverage principles to complement the Sehat Sahulat Program.
Ehsaas Tahafuz Project Management Unit launched
The program caters only to catastrophic expenditure and targets beneficiaries that are either not covered under existing programs, or that have utilized their SSP limits, or are in hospitals that are not covered under SSP and provide coverage for all essential treatments (including outpatient).
The Tahafuz system is paperless, mobile-phone centered and technology-based. Its automated workflows, accounting mechanisms and pre-configured rules for eligibility ascertainment help avoid abuse and mistargeting of social protection funds. To ensure efficient use of public resources and to build synergies between complementary programs, the Division has developed a Catastrophic Healthcare Expenditure Policy (CHE). Consultations have been held with the Ministry of National Health Services Regulation and Coordination in this regard.
The summary noted that WHO defines CHE as out-of-pocket (OOP) spending for healthcare that exceeds 40 percent of household income net of subsistence needs. Estimates suggest that 1-2 percent of the world population suffers from financial catastrophes due to OOP medical costs each year.
CHE is an equally significant challenge in Pakistan. There are financial gaps in the current healthcare system leading to 56 percent of healthcare expenses being out-of-pocket in Pakistan (compared to 44 percent for low-income countries and 41 percent for heavily indebted poor countries). It is estimated that one percent of the population in Pakistan is pushed below the poverty line each year due to out-of-pocket health care expenditure.
To address this challenge, the government introduced the SSP to improve financial access to good quality medical services through a health insurance scheme. The program provides coverage to 7.7 million families across 1500 treatment packages (covering secondary care and priority treatment) at 450 medical facilities across the country.
The SSP plans to expand its current selected beneficiary coverage to universal health coverage across Punjab, ICT, and GB in the coming months based on the prime minister’s directive. In addition to this, KP scaled up the program across its province as SSP plus, to provide universal health coverage to all KP residents (6.5 million families).
While the SSP has been able to provide significant cover to the population, there are certain limitations inherent to the adoption of insurance in Mixed Health Systems that need to be addressed. These include the following: (1) Limitation of health insurance to address catastrophic health expenditure in all cases currently, families can avail health services of Rs 360,000 - 1,000,000 per year. While this level of coverage is sufficient to protect beneficiaries against most health expenses, it does not provide a safety net for households with catastrophic health expenses beyond this range (e.g., cancer treatment, transplants, cardiac surgeries, etc.), leaving many households at the risk of facing financial distress. (2) Few of public sector hospitals in Pakistan have not been covered under the existing programs so far, due to hospital on boarding challenges. This has led to many patients in public sector hospitals being exposed to significant out-of-pocket expenditure in the public healthcare system. (3) a large number of individuals remain undocumented, and whilst they may be the most vulnerable, the government is unable to pay premiums on their behalf. (4) Geographic - in addition, Sehat Sahulat is currently not operational in Sindh and Balochistan. (5) Out-patient services Sehat Sahulat does not cover outpatient services. (6) Hospitals not empanelled with SSP – Sehat Sahulat has empanelled specific hospitals as per their empanelment criteria therefore, there are beneficiaries at non-SSP empanelled hospitals who are not protected against health expenses.
While the government aims to expand SSP to all provinces in a similar manner to KP, only the gap of lack of universal coverage will be resolved. The gaps around annual limits, lack of public sector hospital coverage etc will remain and need to be addressed.
A fund-based solution can complement the existing insurance-based SSP to provide Universal Health Coverage in such contexts. A fund-based system refers to a strategic purchasing system that buys/purchases services from hospitals based on a set of eligibility criteria and rules (This does not refer to the fund-based system that makes payments to hospitals based on DRGs)
Given the current landscape and the importance of protecting the vulnerable, there was a need for a program, designed to act as a complementary initiative to the current programs, which addresses the gaps to ensure no one falls into poverty due to healthcare expenses.
To address this need, Ehsaas Tahafuz was designed as Pakistan’s first-ever shock-oriented safety net program to provide coverage specifically against catastrophic health expenditures to vulnerable communities. The program works in partnership with service providers (hospitals) that identify patients requiring financial support. Patients identified are then assessed by Tahafuz against an eligibility criterion. For eligible patients, hospitals are directly reimbursed for pre-defined treatment costs.
Tahafuz has defined its coverage principles to complement already existing SSP and plug in any gaps. The program was built keeping in mind five key principles: (1) Provides universal access -Offers coverage to every citizen of Pakistan regardless of race, gender, socio-economic class, provincial residence etc. Tahafuz operates as a universal program supporting all beneficiaries as long as the health expense is catastrophic in nature and/or not covered under SSP. (2) Cater to only catastrophic expenditure- Provides coverage for health expenses that are catastrophic in nature and not covered in the existing SSP system,(3) Complements existing insurance programs - Prevents duplication of efforts and costs with the existing programs by serving patients. (4) Coverage for all essential treatments - Ensures all required health treatments, services and products are available to eligible beneficiaries including outdoor services. (5) Promotes accountability and improvement - Uses digital mechanisms to monitor and evaluate beneficiary experience and service provider performance. This allows tapping donors and private philanthropists more meaningfully.
Patient qualifies for step 2 if Hospital is not empanelled by SSP/KP Sehat Plus or, the patient is not enrolled in Sehat Sahulat, or patient is enrolled in Sehat Sahulat but: Patient has exceeded coverage provided by SSP/KP Sehat Plus, or Condition is not covered under Sehat Sahulat, or Unable to access support through SSP due to any circumstance subject to prior confirmation by SSP desk at empanelled hospital.
Patient is eligible for Tahafuz if cost of treatment required is more than 40 percent of patient’s estimated monthly income less food costs (WHO definition).
The eligibility criteria ensure that the funds are only used to address needs of deserving patients who would otherwise remain neglected and unserved. The Tahafuz system is currently operational in four cities and is being scaled up. Its automated workflows, supply-chain management, tracking and time-shaping, and pre-configured rules for eligibility ascertainment, help overcome abuse and mistargeting of social protection funds. These features have made the system responsive and accountable. The system turns around patient requests for assistance within 24-72 hours. In addition, micro-transaction alerts and personalized login credentials for web viewing enable transparency and accountability. Ehsaas Tahafuz will run as per the parameters outlined in this policy to complement Sehat Sahulat to ensure efficient use of public resources and to build synergies between complementary programs.
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