DigiVoyager

Before anyone gets any wrong ideas, this post is not a dig at America (I say this because my main readership is 100% American, population: one) for I know fully well the gaps in quality of healthcare, the ethics, the difference in service availability (one tertiary hospital here in Peshawar does not even have a cath lab, and hence no angiographies and so on) difference in FDA regulations and trial standards, among other things, though we do have our good institutes, too. It is rather a simple thesis, one that I have observed both sides of. And my own view is that, yes, all people of all nations should get state sponsored healthcare.

Simply, whether you are the richest, or the poorest nation, state sponsored healthcare is the most direct, and biggest investment you can make in the people. I do not care for any arguments to the contrary, for they are not humane.

Now, you may wonder how I have seen both sides of it. Well, in the previous government, the forcefully ousted Prime Minister had a programme called Sehat Card, one that ensured free health care coverage of essential procedures for all (and admittedly, the only flaw in this project was that the rich exploited this too, and steps are being taken to remedy this.) Briefly, when the average Pakistani, that laborer who wages war against his own body to make less than 4 dollars a day, suffers from an MI (Myocardial Infarction, heart attack in layperson terms) it is no longer a death sentence because he cannot afford stents (and trust me, no laborer can afford any serious procedure, many even struggle to buy insulin, even though it is on the cheaper side here). There are other ventures too, like the flagship National Institute of Cardiovascular Diseases in Sindh where poor people can get state of the art treatment for free. The main hospital is in Karachi, and there are a further 9 satellite centres all over Sindh, with more to come. In fact, over 2.4 million patients, including those requiring surgeries, were treated free of cost at the National Institute of Cardiovasc­u­lar Diseases (NICVD) facilities across Sindh in 2023.¹

This is important because in Pakistan, governmental spending on healthcare per person, is quite low, lower than many developing countries, even Zimbabwe. Not only that, but the bulk of healthcare costs come from out of pocket spending, which means the poorer the person, the worse their burden.

Some data about it², to further illustrate just how much spending the Sehat Card curtailed (SCP here refers to Sehat Card Plus, all data is sourced from this report):

An independent evaluation team from Agha Khan University found that there was a significant reduction in medical care component of mean out-of-pocket expenditure for inpatient services for SCP users (PKR 1,006 ±9248) as compared with SCP nonusers (PKR 30,042 ±69014). As you can see here, the gap is astronomical. One is almost within the daily laborer's reach, the other is pronouncing a death sentence, almost.

The nonmedical component (transport etc.) was similar in both groups. The level of catastrophic health expenditure among households was significantly lower for SCP users (14%) compared to SCP nonusers (35%). The perception of economic wellbeing was higher among SCP users.

These tables should drive home just how impactful the programme is, no longer does healthcare have to eat the poor out of house and home. While the level of catastrophic health expenditure for all wealth quintiles and place of residence was significantly lower for SCP users as compared to SCP nonusers, note how those from the poorest wealth quintiles and rural areas especially are not incurring as many catastrophic health expenditures. Note also how those not availing state sponsored healthcare reported a more severe impact of hospitalizations.

I do not wish this to be a technical, jargon filled article so we will go back to the simpler side of things. Briefly, while there was poverty, there was also hope, promise of a future. With state sponsored health care, people need not die due to poverty, this was the easiest way of mobilizing the poor, downtrodden classes and it was working. However, after the ouster, the new government (let's leave aside the fact that they were not even chosen by the people) immediately froze the program for quite a while. Now, I have worked in the system for over a year (over two if we count my house job, which is an internship and three if we consider final year, which was spent in wards anyway) and I came into the system seeing the Sehat Card, saw what it did for people, and then I saw it frozen, and I saw the outcomes of it first hand. People with no money to pay, some were doomed to die due to poverty, others sold everything they had to get treatment (and that is in already subsidized government hospitals, where the government foots the bulk of the cost of most base line investigations – a basic panel consisting of a complete blood count, ESR, serum electrolytes, renal function tests, liver function tests among others, along with more specialized markers like Trop I, Trop T etc. – these cost the government way more, according to govt. hospital techs ) and many others simply avoid going to the hospital. Better misery and having some money than being left with nothing. The towering shadow of poverty cloaks every decision, and without state sponsored healthcare, it severely hurt socioeconomic mobility.

Some more stats from the previous document:

• Two-thirds of Sehat Card Plus KP users, at the time of discharge, did not report incurring out-of-pocket expenditure during admission. For the other one-third, the estimated mean expenditure was PKR 5,464 on medicines and PKR 3,519 on diagnostic tests.

• Average cost per admission was PKR 31,395, which was 20-40% higher in private hospitals. The KP government spent PKR 2.96 billion on 94,387 patients of which 0.83 billion (28.0%) were spent on treating cardiovascular diseases. The mean cost of treating cases of ischemic heart disease was PKR 89,919.

Now, government hospitals here often do not have all the facilities, they are also overcrowded, I myself did my housejob in one, and the chaos there is indescribable, we would be 10, 15 doctors dealing with over 400 patients in a day. I would often fall asleep in the doctor's room after being done with my shift at 8 PM, and go to my hostel room in the late midnight hours like 3, 4 AM despite it being a mere 5 minutes away. The real beauty of the sehat card lays in it allowing even the poorest citizen to get the best possible healthcare, at any facility of their choosing, even private.

Now, as per the report, there are concerns of its financial sustainability, but the health foundation is working on addressing those (the report is about a year old). They have gotten more aggressive with dis-empaneling of hospitals that try to exploit this, which is good to see, and started renovating more hospitals under public-private partnerships, which will be empaneled. They have even started working on upgrading the MIS (Management Information System) to integrate disease history, as well as financial means.

I will probably add more to this article someday, or I may not, part of me feels I sufficiently made my case, yet part of me wants to say much, much more, but alas there is no time nor energy. As always, Sayonara.

References: 1: Dawn News 2. https://sehatcardplus.gov.pk/wp-content/uploads/2023/05/Third-Party-Evaluation-Report-Sehat-Card-Plus-KP.pdf