Prioritizing Healthcare Equity: The Road to Universal Health Coverage in Pakistan

The Pakistan Health Financing System Assessment highlights the country’s challenges in achieving Universal Health Coverage, including low public health spending, reliance on out-of-pocket costs, and systemic inequities. It recommends reforms to prioritize primary healthcare, expand financial protection, and improve resource allocation for equitable and efficient health services.

The Pakistan Health Financing System Assessment, a joint effort by the World Bank Group, the Ministry of National Health Services, Regulations and Coordination, and provincial health departments, critically evaluates the country’s health financing landscape. This report highlights Pakistan’s strides toward Universal Health Coverage (UHC) while addressing the systemic challenges hindering its progress. Initiatives like the Essential Package of Health Services (EPHS) and the Sehat Sahulat Program (SSP) represent significant advancements. The EPHS ensures access to primary healthcare, while the SSP provides tax-funded health insurance to low-income households. Despite these efforts, financial sustainability and systemic inefficiencies remain obstacles to the equitable delivery of healthcare services.

A Stark Deficit in Health Expenditures

Pakistan’s health spending remains critically low, with provincial per capita expenditures ranging from $7.8 in Khyber Pakhtunkhwa (KP) to $10 in Punjab and Sindh. These figures fall far short of the South Asia regional average of $17.5 and the lower-middle-income country benchmark of $27.1. Although there has been some growth in public health financing over the past decade, the disparity among provinces is notable. For instance, Punjab allocates 16.8% of its health budget to primary healthcare (PHC), compared to KP’s 6%. This inequity underscores the need for a more strategic allocation of resources, emphasizing preventive and primary care services to achieve equitable health outcomes.

Out-of-Pocket Spending: A Crisis of Equity

Out-of-pocket (OOP) expenditures account for a staggering 60% of Pakistan’s current health expenditures, significantly higher than the low- and middle-income country average of 48% and far exceeding the World Health Organization's target of 15–20%. The primary driver of OOP costs is the price of medicines, which makes up the largest portion of health expenditures across all provinces. For example, in Punjab, medicines account for 54% of OOP health spending. This overreliance on private spending exposes households to catastrophic health expenditures, pushing many into poverty. Addressing this issue will require expanding public health insurance under SSP and ensuring affordable access to medicines and vaccines.

Structural Inequities in Health Infrastructure

The report highlights stark disparities in resource allocation between districts. Rawalpindi, with a population of 5.4 million, spent nearly four times more on health services in 2018 than Sargodha, which has a population of 3.7 million. This discrepancy arises from Rawalpindi’s focus on tertiary care facilities, while Sargodha emphasizes primary healthcare. The reliance on historical budgeting practices rather than needs-based or performance-oriented approaches exacerbates these inequities. Reforming budget allocation mechanisms to reflect population needs and healthcare performance is essential to ensure equitable access to resources and services across districts.

Building a Sustainable Path to UHC

Achieving UHC in Pakistan requires significant reforms in resource mobilization, allocation efficiency, and equity-focused interventions. The report estimates that implementing a comprehensive EPHS would require $25.4 per capita annually for high-priority interventions, rising to over $28 with medium-priority ones. Current spending, however, remains at $14 per capita, reflecting a substantial resource gap. Policymakers are urged to increase health expenditures to 1.5% of GDP by 2025, up from the current 1.08%. Alternative revenue streams, such as pro-health taxes on tobacco and sugary beverages, could generate additional funds to support PHC and social protection programs.

Expanding programs like SSP and EPHS is vital to providing financial protection and ensuring access to essential healthcare services. Targeted reforms should also address inefficiencies in hospital care, which consumes over 50% of public health budgets in every province. By directing more resources toward PHC, Pakistan can achieve significant cost-effectiveness while addressing the rising burden of non-communicable diseases.

While marked by significant progress, Pakistan’s journey toward UHC remains fraught with challenges. Low public health spending, reliance on OOP expenditures, and structural inequities in resource allocation are critical barriers. By prioritizing primary healthcare, adopting needs-based budget allocation, and mobilizing additional resources through innovative revenue streams, the country can build a more equitable and efficient health financing system. With sustained efforts and strategic reforms, Pakistan has the opportunity to improve health outcomes for its population and make UHC a tangible reality.