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Universal health coverage promises a system where everyone can access essential health care services without financial hardship. Pakistan has committed to achieve this goal by 2030. However, significant challenges remain. Despite some progress, as highlighted in the latest Service Coverage Index report released on UHC Day 2024, disparities persist across regions.
The SCI report shows that Pakistan’s overall UHC index improved from 40 percent in 2015 to 53.9 percent in 2023, indicating modest progress. Islamabad tops with a score of 63.8 percent, followed by Punjab (55.4 percent) and Sindh (50.7 percent). Balochistan lags behind at 38.4 percent, which shows stark regional inequality. These disparities underscore the need for targeted reforms to achieve equitable access to health care across the country, particularly in underserved areas.
One of the obstacles to meaningful progress is the fragmented and complex narrative around UHC, which often undermines urgency and overwhelms policymakers. As emphasized in a recent BMJ article, simplifying the UHC narrative by focusing on four actionable pillars – universality, equity, adequate financing and preparedness – can help turn aspirations into reality. But simplification must be coupled with targeted reforms to align policies with measurable results.
The Essential Package of Health Services, developed in 2020, provides a strong foundation for UHC in Pakistan. However, its success depends on effective implementation, which requires addressing systemic barriers, promoting equity and mobilizing resources.
1. Globalization: Leaving no one behind
UHC is built on the principle of universality – access to health care for all, regardless of income or geography. However, the 2024 SCI report highlights stark disparities, with rural and marginalized communities facing significant barriers to accessing healthcare.
For a family in rural Balochistan, the nearest health facility is often several hours away. A mother caring for her sick child must travel long distances and can only find an under-resourced clinic. Stories like these remind us that universalism is not just about policy. It’s about changing lives.
To address this issue, Pakistan should prioritize a phased action plan that targets the least-served areas. EPHS offers a strong foundation, but its success depends on effectively addressing systemic barriers and ensuring equitable access. An ongoing pilot project in Tando Ulyar, Sindh, has the potential to become a model for how local interventions can increase coverage and inform implementation nationwide.
Investing in community health workers (CHWs) is another important step. These frontline workers can extend primary care to remote areas, close gaps in service delivery and reduce the burden on overcrowded health facilities.
2. Equity: A health system for everyone
The SCI report reveals troubling inequalities in access to health care, with affluent urban populations benefiting from private care while rural communities rely on underfunded public facilities. For example, family planning coverage is 55.1 percent in Islamabad and 34.5 percent in Balochistan.
Equity should guide the implementation of UHC. This means ensuring that essential services are free at the point of care for vulnerable populations. Provincial heterogeneity warrants consideration of a diverse set of policy instruments that may include expansion of health insurance programs, grants/universal budgets for accredited health care institutions and other social security comprehensive health benefits. That can help protect low-income households from catastrophic spending.
Additionally, health care reform must address broader social determinants of health, such as poverty, education and gender inequality, to create a truly comprehensive system.
Achieving UHC in Pakistan is not just an ideal but a moral imperative. By simplifying the UHC narrative and adopting a goal-oriented approach, Pakistan can transform its healthcare system into one that serves all its citizens.
3. Adequate Financing: Investing in Health
Pakistan’s chronic underinvestment in health – only 1.2 percent of GDP – remains a major obstacle to UHC. The SCI report highlights the consequences of this shortage, with limited infrastructure and uneven service capacity across provinces.
However, increasing funding alone is not enough. Efficiency and accountability in health spending must also be improved. Governments should pay health care providers based on quality of care and outcomes, ensuring that resources are used efficiently. This approach can enhance both the quality and efficiency of health care delivery. Importantly, accountability should not be confused with strict financing. Flexible mechanisms, such as global budgets, when combined with effective performance management, can improve service delivery while ensuring financial security for the poorest.
In addition to domestic resource mobilisation, tax reforms and public-private partnerships, Pakistan should improve its institutional readiness to access international financing and assistance to advance its UHC goals. However, rather than relying heavily on external support, the priority should be to address inefficiencies within the current health financing system to achieve ‘more health for the same money’.
4. Preparedness: Building Resilient Health Systems
The CoVID-19 pandemic and the 2022 floods highlighted the importance of resilient health systems able to respond to public health emergencies. Pakistan’s health system, already strained by limited resources, is struggling to cope with systemic shocks, highlighting vulnerabilities that must be addressed to achieve UHC.
Investing in UHC is inherently an investment in health care. Strengthening primary health care infrastructure, expanding disease surveillance systems and ensuring strong supply chains for essential drugs and equipment are critical to building a resilient health system.
Additionally, Pakistan must prepare for the increased health impacts of climate change, which will increase the frequency and severity of public health emergencies. Integrating climate resilience into health planning and mobilizing international climate financing for health initiatives can help Pakistan build a health system resilient to future shocks.
The way forward: A unified and actionable UHC agenda.
To achieve UHC, Pakistan needs a unified narrative that emphasizes universality, equity, financing and preparedness. This narrative should resonate with political leaders, administrators, practitioners, academics, civil society and the public and should be based on local realities.
Rather than focusing solely on quick fixes, the emphasis should be on addressing systemic failures and aligning reforms with clear health goals. Continuous evaluation and adaptation is essential to ensure that reforms remain relevant and effective.
Achieving UHC in Pakistan is not just an ideal but a moral imperative. By simplifying the UHC narrative and adopting a goal-oriented approach, Pakistan can transform its health system into one that serves all its citizens. Now is the time to act—not just to promise health for all, but to deliver it.
The author, technical advisor to the International Organization for Health Financing, is a Fulbright Scholar with a master’s degree in international development studies. Email: okhan1@gwu.edu
