The notion of access to health care in a large-scale social health protection initiative: a case study of ‘Sehat Sahulat Programme’ at Khyber Pakhtunkhwa, Pakistan

Sehat Sahulat Programme (SSP), a health insurance initiative, was launched by the Government of Khyber Pakhtunkhwa (GoKP) in Pakistan to improve access to quality health services. In this paper, we describe the notion of access under SSP, present stakeholders’ views on access-related challenges, and suggest ways forward to realise SSP’s access-related objective in the broader context of its contribution towards Pakistan’s drive to achieve Universal Health Coverage (UHC). We employed a case study design approach using three data sources. We used official GoKP programme documents to capture the chronology of events (policy interventions), in-depth interviews to explore the drivers behind the events and non-participant observations to understand the decision-making and implementation processes. We employed maximum variation sampling. Access to documents and observation sites was gained through the SSP director. We recruited interviewees through direct and indirect approaches and conducted thematic analysis. GoKP engaged the State Life Insurance Corporation (SLIC) of Pakistan as a purchaser. SLIC purchased services from public and private hospitals for SSP patients, up to 600,000 Pakistani Rupees (PKR) per family per year. Considering this insurance coverage, GoKP officials claimed SSP made health care accessible, which the development partners contested. Instead of the narrow finance-centric definition by GoKP, the development partners highlighted the broader dimensions of access, including the services’ acceptability and availability. Tensions existed between the interpretation of the stakeholders on different dimensions of access. For instance, GoKP and SLIC claimed that including private hospitals in SSP improved services’ availability, but development partners noted an under-supply of private providers in remote districts of the province. Bridging such an undersupply, SLIC made inter-district referrals, which the patient advocates noted led to travel costs and geographical barriers. Similarly, GoKP officials claimed SSP had good acceptability. The providers noted that SSP’s acceptability was damaged by limited patient choice, low package rates, and delayed claims payments. This analysis suggests that SSP had challenges with the acceptability and geographical dimensions of access which GoKP needed to address. A key transferrable lesson is that demand-side intervention (insurance) might not improve access with a weak supply side. Therefore, countries contemplating improving access to services enroute to achieving UHC need to address both supply and demand-side considerations.