<\/p>\n
Pakistan\u2019s Sehat Sahulat Program (SSP) is one of the most ambitious public health interventions in the country\u2019s history. By providing cost-free inpatient care for families living below the poverty line, it seeks to protect vulnerable citizens from catastrophic health expenditures. The clinical intent is commendable: the government pays the premium, the State Life Insurance Corporation of Pakistan (SLIC) manages claims, and disadvantaged families gain access to life-saving medical treatment.
\nHowever, as every sound health-financing framework demonstrates, clinical intent without a robust procurement strategy remains incomplete. At present, the financial architecture of SSP contains a critical structural weakness.
\nThe system activates only when a patient becomes ill enough to require hospitalization. By significantly expanding tertiary-care coverage to PKR 400,000 without establishing a strong primary-care \u201cgatekeeping\u201d mechanism, the program is effectively underwriting the most expensive tier of healthcare while neglecting the far less costly preventive and outpatient care that could keep patients out of hospitals altogether.
\nCurrently, SSP operates on a fee-for-service (FFS) reimbursement model, under which hospitals are paid according to the procedures they perform. In health economics, this is widely recognized as a driver of \u201cmoral hazard\u201d: when payment is linked to volume, utilization predictably increases.
\nThe warning signs are already visible. A 2019 actuarial assessment conducted by the International Labour Organization (ILO) and Deutsche Gesellschaft f\u00fcr Internationale Zusammenarbeit (GIZ) cautioned that rising utilization rates and escalating hospital costs would eventually exceed the government\u2019s flat premium contributions. This projection is increasingly becoming reality.
\nAcross many low- and middle-income countries, patients frequently bypass local clinics and overcrowd tertiary hospitals for conditions that could easily be managed at the primary-care level. Because SSP lacks a structured referral filter, highly specialized hospital infrastructure is being used to treat illnesses that a local General Practitioner (GP) could address at a fraction of the cost.
\nUnder Pakistan\u2019s Public Financial Management (PFM) framework, financing an open-ended tertiary-care system without strong expenditure controls or clinical auditing mechanisms is fiscally unsustainable. Instead of funding preventive diabetic care and insulin management through primary physicians, the system often ends up paying for amputations and advanced complications.
\nFlipping the Financial Model: Primary Capitation
\nTo contain unchecked expenditure growth and align with national Universal Health Coverage (UHC) priorities, Pakistan must fundamentally reform how healthcare is purchased. The system should transition from passive fee-for-service reimbursement toward active primary-care capitation.
\nCapitation refers to a payment model in which healthcare providers receive a fixed prospective payment \u2014 commonly called a Per Member Per Month (PMPM) fee \u2014 to manage routine patient care. Importantly, catastrophic hospitalization costs would remain within the centralized SSP risk pool; only routine and preventive care responsibilities would shift to primary-care providers.
\nUnder such a model, GPs become financial stakeholders in preventive health outcomes. A predictable monthly revenue stream incentivizes physicians to manage chronic illnesses early, improve continuity of care, and prevent avoidable disease progression that ultimately triggers expensive tertiary claims.
\nThe Evidence-to-Execution Framework
\nOperationalizing this reform within Pakistan\u2019s Public Procurement Regulatory Authority (PPRA) framework would require a structured five-step integration strategy:
\n1. Actuarial Risk Stratification
\nA uniform PMPM rate would be ineffective and inequitable. A healthy 20-year-old requires significantly fewer healthcare resources than a 60-year-old patient with hypertension or diabetes. Using data from Benazir Income Support Programme (BISP) and national disease registries, patients should be assigned clinical risk scores. Higher-risk individuals would correspond to higher PMPM reimbursements, ensuring fair compensation for providers managing more complex cases.
\n2. The Referral Gatekeeping Mechanism
\nThis would serve as the program\u2019s principal regulatory control. SSP tertiary-care claims should only be reimbursable by SLIC when accompanied by a digitally verified referral code issued by a registered GP, except in strictly verifiable emergency situations. Such a mechanism would ensure that patients first engage with the primary-care system before escalating to tertiary facilities.
\n3. Quality-Based Withholds
\nTo prevent under-treatment, a percentage \u2014 ideally 10% to 15% \u2014 of the provider\u2019s PMPM payment should be withheld and released only after achieving measurable quality indicators. These may include vaccination coverage, diabetes screening rates, maternal health referrals, and preventive-care benchmarks. Ghana successfully implemented a similar quality-withhold mechanism within its National Health Insurance Scheme in 2012 to discourage under-service delivery.
\n4. Digital Identity Integration
\nThe GP network must be rigorously credentialed and integrated with the National Database and Registration Authority (NADRA) biometric verification system. This would significantly reduce fraud, eliminate ghost beneficiaries, and prevent duplicate billing.
\n5. Phased Pilot Rollout
\nNationwide implementation on day one would carry excessive operational risk. Instead, the model should first be tested through a localized Randomized Controlled Trial (RCT) in a high-density SSP district such as Rawalpindi or Peshawar to evaluate the financial sustainability and operational feasibility of the PMPM formula.
\nThe Reality Check
\nImplementation will not be frictionless. Rural Pakistan continues to face a severe shortage of qualified primary-care providers, making capitation difficult in underserved districts where provider networks remain weak or nonexistent. Additionally, restructuring the current hospital-centric financing ecosystem is likely to encounter significant resistance from stakeholders benefiting from high-volume tertiary billing.
\nInstitutionally, the State Life Insurance Corporation of Pakistan would also need to evolve from a passive claims-processing entity into an active population-health manager.
\nYet the alternative is long-term fiscal exhaustion.
\nSSP remains a landmark achievement in Pakistan\u2019s social protection landscape. However, financing healthcare exclusively at the catastrophic stage effectively subsidizes inefficiency rather than prevention. By strategically procuring primary care through a risk-adjusted capitation model, Pakistan can transform preventive healthcare into a financially sustainable public investment.
\nIt is time for Pakistan to stop merely funding hospitals \u2014 and start systematically procuring health.<\/p>\n","protected":false},"excerpt":{"rendered":"
Pakistan\u2019s Sehat Sahulat Program (SSP) is one of the most ambitious public health interventions in the country\u2019s history. By providing cost-free inpatient care for families living below the poverty line, it seeks to protect vulnerable citizens from catastrophic health expenditures. The clinical intent is commendable: the government pays the premium, the State Life Insurance […]<\/p>\n","protected":false},"author":1,"featured_media":337933,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[63,7],"tags":[],"class_list":["post-337932","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-63","category-pakistan-news"],"_links":{"self":[{"href":"https:\/\/sapeher.dailysapehertimes.com.pk\/index.php?rest_route=\/wp\/v2\/posts\/337932","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sapeher.dailysapehertimes.com.pk\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/sapeher.dailysapehertimes.com.pk\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/sapeher.dailysapehertimes.com.pk\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/sapeher.dailysapehertimes.com.pk\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=337932"}],"version-history":[{"count":1,"href":"https:\/\/sapeher.dailysapehertimes.com.pk\/index.php?rest_route=\/wp\/v2\/posts\/337932\/revisions"}],"predecessor-version":[{"id":337934,"href":"https:\/\/sapeher.dailysapehertimes.com.pk\/index.php?rest_route=\/wp\/v2\/posts\/337932\/revisions\/337934"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/sapeher.dailysapehertimes.com.pk\/index.php?rest_route=\/wp\/v2\/media\/337933"}],"wp:attachment":[{"href":"https:\/\/sapeher.dailysapehertimes.com.pk\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=337932"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/sapeher.dailysapehertimes.com.pk\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=337932"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/sapeher.dailysapehertimes.com.pk\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=337932"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}