INSPIRE Pakistan

Informing the Social Health Protection Initiative through Rigorous Evidence



What is SHPI?

In Pakistan, where more than 48 million people live under the national poverty line, health-related expenditures are a major cause of economic shock for poor families. More than half of all the money spent on health comes out of patients’ own pockets. In the absence of social health protection schemes which make health services affordable, many of Pakistan’s poorest citizens simply do not seek care when they fall ill.

The Government of Pakistan is committed to changing this situation and has been taking major strides to ensure that all its citizens have access to good quality health services without incurring financial hardship. Since 2015, the Social Health Protection Initiative (SHPI) aims at increasing access of the poor to health services in selected districts of Pakistan’s Khyber Pakhtunkhwa (KP) province and the Gilgit Baltistan (GB) area, beginning to move towards Universal Health Coverage. To this end, the project takes a demand-side approach and removes financial barriers by providing a subsidized health insurance.

Home to the world’s oldest national social health insurance system, Germany has been a trusted partner in Pakistan’s efforts to expand social health protection. As the SHPI has emerged as the cornerstone of Pakistan’s strategy to achieve Universal Health Coverage (UHC), Germany has financially supported the initiative through the KfW Development Bank and has worked closely with partners at the federal and provincial level to design suitable schemes and to develop the capacities needed to implement these at scale.

Our research team

KfW selected our research consortium consisting of Friedrich-Alexander University Erlangen-Nürnberg (FAU), the Heidelberg Institute of Global Health of the Heidelberg University’s Medical Faculty (HIGH), and the Khyber Medical University (KMU), to provide additional evidence in support of the implementation. The research component covers 1) preparatory studies in support of the design of the scheme, 2) implementation research throughout the project cycle, 3) outcome and impact evaluation, and 4) additional research on out-of-pocket (OOP) expenditures for inpatient care services (IPD) under Phase 1.

The research focus is on timely provision of scientific evidence, which is supposed to feed back into and enhance ongoing implementation. Close cooperation with all stakeholders involved is therefore just as crucial as a flexible needs-based research approach. The general research output should include:

  1. Health needs and care and insurance preferences of the target population (benefit package, providers, accountability mechanisms);
  2. Bottlenecks in implementation (utilization, effects on IPD scheme, impact on target group and providers);
  3. Recommendations for optimization (in line with evidence, budget and local policies);
  4. Impact on health system and social health protection system (OOP expenditure, quality, capacity);
  5. Impact on target group (OOP expenditure, equity, health, satisfaction).

SHPI Phase 1

Since the inception of the SHPI, the German Development Bank (KfW) has supported the program financially and through technical assistance. Phase 1 of the KfW programme saw the enrolment of approximately 100,000 households with a total of approximately 800,000 people in selected districts in KP and GB in 2016. Insured households can obtain inpatient services on a cashless basis in 18 selected public and private hospitals in KP and 5 hospitals in GB. Notably, the insurance premiums are fully subsidized under the KfW program for the poorest 21% of the population.

Following the pilot phase, the Department of Health in KP has rolled out the program province-wide, increasing coverage not only geographically but also socially to include 69% of the population. However, even after the pilot phase, benefits remained restricted to inpatient care services (IPD). Phase 1 is still being implemented and expected to be completed soon, with a possible extension.

SHPI phase 2

Given the aim of achieving Universal Health Coverage, Phase 2 is now extending coverage to include outpatient services (OPD), which should increase financial protection for beneficiaries. The KfW support in this second phase is again limited to the 21% poorest households, which corresponds to a poverty cut-off score of 16.17. It is also expected that the inclusion of OPD services shifts the focus more to rural/ non-urban areas. In parallel, KfW is preparing Phase 3 of the SHPI, which will focus on digital services.

Besides providing funding for insurance premiums, KfW supports the second phase through technical assistance. For this purpose, the consulting firm Management for Health (m4h) has been selected to assist the respective DoH designing the benefit package, selecting an insurance company, empanelling providers, and setting up the necessary infrastructure.