Overview
In 2018, Pakistan became a signatory to the UHC Global Compact to achieve UHC by 2030, and the development of a UHC essential package of health services (EPHS) is a critical element of Pakistan's roadmap to reach that goal, as outlined in its National Vision 2016-2025. Funded by the Canadian government and under the leadership of the Pakistan Ministry of Health, WHO is piloting the implementation of Pakistan's Essential Package of Health Services (EPHS) using a PHC oriented Model of Care, working closely with a collaboration of thirteen global health, development, and humanitarian agencies under a Global Action Plan for Healthy Lives and Well-being for All (SDG3 -GAP). The pilot is being implemented in Islamabad Capital Territory and Charsadda districts (1 April 2021 - 30 September 2022).
As Pakistan begins to operationalize the EPHS, the issue attracting the most attention is how to close the gap between available resources and the estimated cost of the EPHS. pending the expansion of the fiscal space to allow full implementation of the EPHS, Pakistan has approved the limited national Package for immediate district-level implementation at $12.98 per person per year.
WHO Head of Mission Pakistan, Dr Palitha Mahipala, monitoring the implementation of the EPHS PHC-oriented model of care implementation in March 2022, Charsadda (Khyber-Pakhtunkhwa). ©WHO/Pakistan
Moving planning to results to sustainably finance PHC for UHC
SDG-GAP partners are mobilizing across institutions, sectors, communities, and people to address this issue and put structures for sustainable financing for PHC.
The Government of Pakistan, the WHO country office, with support from the WHO Office for the Eastern Mediterranean Region, co-hosted a policy dialogue forum PHC for UHC mission in March 2021 for stakeholders to review the status of PHC and sustainable health financing and advise on a model of care to ensure effective implementation of the UHC-Benefit Package. Participants included the federal and provincial governments, GAVI, GFF, Global Fund, UNAIDS, UNFPA, UNICEF, the World Bank, other local and international development partners, and civil society organizations. The mission concluded with a high-level national "PHC4UHC" Forum, where representatives from federal and provincial levels and SDG-GAP partners signed a Joint statement in support of enhancing PHC towards UHC in Pakistan.
As signatories of this joint statement, the partners committed to align their approach toward "PHC for UHC" and work together to build a sustainable PHC model for integrated service delivery. Since then, SDG3-GAP partners have developed and implemented joint commitment and action plans. An SDG3-GAP Coordination Committee, led by the WHO Head of Mission, is constituted at the country level to align the support for PHC strengthening and sustainable health financing.
SDG-GAP partners are collaborating to develop a national and provincial level health-financing framework and health-financing strategy for UHC to move the effort forward. The World Bank supports the strategy by conducting a health system financing assessment and a fiscal space analysis; the WHO is providing technical support & assistance (TA) for developing a health financing strategy, while GAVI, Global Fund and WHO are conducting cross-programmatic efficiency analysis of selected vertical programs (TB, Malaria, HIV/AIDS, EPI) to identify inefficiencies across the selected health programmes and their implications on the overall health system. In addition, the Global Financing Facility (GFF) supports the World Bank in conducting resource mapping and expenditure tracking (RMET), as well as detailed analysis of public financial management (PFM) at the district level. The RMET and PFM analyses will close data gaps in primary healthcare financing at the district level. The GFF, UNICEF, World Bank, and WHO have promoted political buy-in of the EPHS by developing a UHC investment case based on six priority reforms and coverage targets of critical PHC-based EPHS interventions. The investment case is estimated at US$ 17.40 per capita.
Emerging opportunities being discussed to finance PHC-based EPHS include the upcoming National Health Support Project supported (NHSP) by the World Bank, GFF, GAVI, GFTAM and Bill Melinda Gates Foundation, building on the success of the National Immunisation Support Project (NISP) co-funded by the Bill and Melinda Gates Foundation, GAVI, USAID and the World Bank. High-impact financing instruments for the World Bank's NHSP include Disbursement-Linked Indicator (DLI) mechanism to promote integrated programming with existing programs and promote equitable access in remote, marginalized areas. Such equity approaches have also been built into the review of the Federal Expanded Program on Immunization (EPI) and the development of the Lady Health Worker (LHW) National Strategic Plan (2022–2026) with WHO and UNICEF support. The equity approach puts Pakistan on the path to reaching children with zero dose immunization in accelerated districts with the lowest coverage.
SDG-GAP partners recognize that country ownership is essential for sustainable financing to be achieved for UHC. They have, therefore, engaged in broad consultation at the national and provincial levels to promote localization of the EPHS into national and provincial plans and budgets to move forward towards implementation. After the national endorsement of the UHC-Benefit Package/Essential Package of Health Services (EPHS) in October 2020, SDG3-GAP have engaged in broad consultation to localize the Package into provincial plans. As a result, as of May 2022, all provinces except Punjab have localized the EPHS within their plans and budgets.
Shahid Waheed (left), Shagufta Shahid (centre) and Rabia Farhan (right) sit in the waiting area at Family Health Hospital in Lahore, Pakistan. ©WHO/Blink media - Saiyna Bashir.
Learning for participatory governance in sustainably financing PHC for UHC
SDG-GAP Partners recognize that a PHC-oriented model of care is a dynamic process as lessons are learnt and necessary adjustments are made to address issues identified during the pilot. Learning is fundamental to these processes. Therefore, SDG-GAP partners continue strengthening the capacity for collaborative learning towards generating and using knowledge to monitor and improve EPHS implementation. Part of the effort includes strengthening existing coordination platforms, especially assisting Pakistan's government in establishing a unified national health sector coordination mechanism. In November 2021, the National Advisory Committee (NAC) endorsed Standard Operating Procedures (SOP) to set up a new governance structure for the National Health Sector Coordination. The NAC also endorsed forming a dedicated national working group on Health systems. To further unify and align their support to government systems, SDG3-GAP signatories have also merged their two SDG3-GAP accelerator working groups in Pakistan (PHC and Sustainable Financing for Health) into a working group called the PHC Service Delivery and Financing group.
Putting people at the centre
To accelerate progress to UHC, citizens and communities must be at the heart of any transformation in health systems and services. Therefore, SDG3-GAP partners support community engagement and empowering efforts to enable meaningful involvement from citizens and communities. One example of this effort is the "UHC literacy" campaign led by WHO to create awareness of UHC. Part of the effort includes the development of training modules for the capacity building of community health committees. Since June 2022, UNICEF and WHO, working closely with UK-AID are supporting district planning and budgeting exercise, starting with priority districts in Sindh, Khyber Pakhtunkhwa, Punjab, and Baluchistan.
Looking ahead
As Pakistan progresses toward universal health coverage (UHC), more joined-up efforts are required to resolve the continued fiscal challenges limiting health spending, ensuring effective alignment of the EPHS with other ongoing social protection initiatives (e.g., the Sehat Sahulat) and engaging more meaningfully with the private sector. SDG3-GAP partners' commitment and the increased political will of the government of Pakistan to sustainably finance PHC for UHC are already equipping the country with the knowledge and experience to overcome these challenges on its path to the ambitious yet achievable goals of healthy lives and wellbeing for all.
What is the SDG3 GAP?
The Global Action Plan for Healthy Lives and Wellbeing for All (SDG3 GAP) is a set of commitments by 13 agencies that play significant roles in health, development and humanitarian responses to help countries accelerate progress on the health-related SDG targets.
The added value of the SDG3 GAP lies in strengthening collaboration across the agencies to take joint action and provide more coordinated support aligned to country owned and led national plans and strategies. A “recovery strategy” (Oct 2021) serves as a strategic update on the SDG3 GAP in the context of achieving an equitable and resilient recovery from the COVID-19 pandemic to the health-related SDG targets.
The purpose of GAP case studies is to monitor SDG3 GAP implementation at country level.