Getting the basics right: Why Pakistan should focus on primary health care

01 July 2024

By Obaid Khan and Sven Engels

If policymakers in Pakistan are serious about achieving universal health coverage (UHC), it is important that smart investment decisions are made, guided by evidence. Like many countries worldwide, Pakistan has embraced the global goal of realizing UHC by 2030 as part of its commitment to the Sustainable Development Goals (SDGs). UHC means that all people can obtain the health services they require without facing financial hardship. To achieve this, prioritization of health investments is critical, especially in the context of limited fiscal space, a common struggle across many low- and middle-income countries. To maximize the impact of each rupee spent on the health care system, the focus should therefore be on the most cost-effective interventions that address the most critical health needs of the population.

The need for evidence-based prioritization of health investments in Pakistan

Recent controversies over the procurement of robotic surgical systems in Pakistan’s Sindh province highlight the issue of ‘misplaced priorities’ and the urgent need for a systematic approach to prioritizing investments in the health system. The debate over allocating billions towards robotic surgery raises the fundamental question: What should the top priorities be when investing public funds in the health system? While robotic surgery is a marvel of medical technology, its high cost and highly specific use cases raise concerns about whether it offers good value for money, particularly in a country where the basic health care needs of millions remain unmet.

Identifying high-impact health services

When budgets are tight, one should focus on the essentials. But what exactly constitutes “essential” health care? Fortunately, there is international guidance to help answer this question. The 3rd edition of Disease Control Priorities (DCP3), a periodic publication which reviews the most cost-effective health interventions, defines essential health care services as those that provide good value for money, address a significant disease burden, and are feasible to implement. In addition, these services should be delivered to the entire population in an equitable manner, in line with the principles of UHC. Based on these criteria, DCP3 identifies 218 essential health services, of which 70 percent are provided at the primary facility level, although the final selection can vary based on local context and priorities.

Developing a customized Essential Package of Health Services

In 2020, Pakistan leveraged the guidance of DCP3 to develop a national Essential Package of Health Services (EPHS), prioritizing interventions based on the country context. Subsequently, the national EPHS was customized by Pakistan’s provinces, with each province prioritizing the interventions according to their contextual realities, such as the local disease burden, special needs, and available fiscal space. As Pakistan moves forward with its UHC agenda, it will be crucial to recognize that while the development of the EPHS provides a strong foundation, the real work of transforming the health system and improving health outcomes will happen during the implementation phase, which will require a concerted effort to overcome challenges and maintain momentum.

Realizing good value for money through a focus on primary health care

Crucially, the EPHS emphasizes the importance of prioritizing interventions that can be delivered at the primary health care level, where resource needs tend to be lower but where the greatest impact on population health can be realized – offering strong value for money. Investing in primary health care therefore offers a compelling value proposition, particularly for countries with limited fiscal space, such as Pakistan. By investing in primary and community-based health services, Pakistan can target the root causes of illness, thereby also reducing the burden on secondary and tertiary care facilities.

The cost of implementing the EPHS is modest compared to the potential benefits it offers. Although it will cost only $13 per capita annually (national EPHS 2019 estimates) to implement 88 immediate priority interventions at district-level, the EPHS will benefit large parts of the population, unlike investments in niche, high-tech medical interventions like robotic surgery. In addition, the impact of investing in essential health services is far-reaching, as it improves health outcomes and reduces disparities throughout the country, thereby making real progress towards UHC. A back-of-the-envelope calculation shows that the procurement costs of four surgical robotic systems at PKR 4.25 billion (US$15m), expected to enable the delivery of a few hundred surgeries annually, could instead be used to provide a package of 88 highly cost-effective essential health services at the levels of community, PHC center, and first-level hospital to about 1.17 million people for a year.

Ensuring success and sustainability of the EPHS

The formulation of an evidence-based EPHS is certainly a vital step forward in Pakistan’s quest for UHC, but it is by no means the end of the road. The real challenge lies in its implementation, which is arguably the most complex piece of the puzzle, requiring difficult choices and trade-offs. In this regard, policymakers in Pakistan, including those at the provincial level, should consider a few key questions. How many of the 218 essential health services defined in the national EPHS can realistically be implemented given financial and institutional constraints? Do provinces have capacity to identify and address gaps between what health services are delivered in practice versus those included in the package? And how do these gaps differ across sub-provincial and district levels? Moreover, governments must continually adjust their priorities based on local evidence and available financial resources. Addressing system-level deficiencies in the health system is crucial for effective delivery of the full EPHS, and this may require mobilizing additional resources, possibly through development partners and/or private sector actors. Ensuring sustained political and administrative buy-in for these reforms is essential, as is monitoring and evaluating their progress. And ultimately, institutionalizing these initiatives in government’s budget and long-term strategic priorities is essential for their success and sustainability.

Final reflections

The formulation of the DCP3-guided national EPHS for prioritization of essential health services demonstrates Pakistan’s commitment to achieving UHC. However, the package formulation needs to be followed by a robust implementation plan to deliver these essential services. With health being a provincial subject in Pakistan, sustained political and administrative commitment at the sub-national level will be critical. The country’s limited fiscal space also necessitates a comprehensive strategy for domestic resource mobilization to finance the prioritized essential services.

Realizing the full potential of the EPHS and making strides towards UHC in Pakistan will require more than just good intentions. It will demand sustained political commitment and accountability coupled with a data-driven effort to monitor progress, identify barriers, and adapt to changing circumstances. By maintaining a sharp focus on cost-effective interventions delivered through primary health care and grounding decisions in local evidence, Pakistan can ensure that its health investments yield the greatest possible impact and drive meaningful progress towards UHC.