Pakistan Bureau of Statistics National Health Accounts
23
Almost 700 million people around the world live today in extreme poverty due to cata-
strophic health expenditures. Just over half of these people live in Sub-Saharan Africa7. In
Pakistan major portion of all new entrant in poverty are also because of catastrophic health
expenditure. Pakistan has been ranked as one of the most exposed nation to poverty risk
among 43 countries of Asia-Pacific region8. To address the challenge, Sehat Sahulat Pro-
gramme is designed to provide financial health protection not only to poor families to bring
them out of poverty but also to families above poverty line in order to protection them from
falling in to poverty. At current level of maturity, the program is providing financial protection
for indoor health care coverage only.
Table 16 gives an overview of the health expenditures paid through Sehat Sahulat
Program by Federal Government in order to provide financial health protection to targeted
families in different districts of Pakistan in the FY 2021-22.
Table 16: Health expenditure paid through Sehat Sahulat Program by Federal Government 2021-22 (Million Rs.)
Region
Beneficiary District
Amount Paid
Sindh
1
135
ICT
1
250
AJK/GB
21
2,392
Total
23
2,777
The Government of Punjab is committed to the principles of Universal Health Coverage
and is approaching this goal in a phased manner. To improve access of population, especially
the poor, to good quality medical services, a phased social health protection approach has
been adopted. In the initial phase, free health insurance was provided to the population living
below the poverty line, special persons and transgender community.
Universal Health Insurance has been launched in D.G. Khan, Sahiwal, Bahawalpur,
Lahore, Rawalpindi, Multan, Faisalabad, Gujranwala, and Sargodha of Punjab, where the all-
permanent residents of 36 districts and 9 divisions of Punjab are eligible to receive health
coverage under Sehat Sahulat Program using their CNIC as health card.
Under KP Sehat Sahulat Programme, more than 7.5 million families are getting free
inpatient health services. Table 17 gives an overview of the health expenditures paid through
Sehat Sahulat Program by KP Government to targeted families in twenty-five districts of KP in
the FY 2021-22.
Table 17: Health expenditure paid through Sehat Sahulat Program by Punjab & KP Government in the FY
2021-22 (Million Rs.)
Province/Region
Number of District
covered
Total number of Families
(beneficiaries)
Amount Paid
Punjab
36
18,314 KP 25 7,469,651 18,193
7 https://www.worldbank.org/en/topic/poverty/overview 8https://phkh.nhsrc.pk/sites/default/files/2022-08/Universal%20Health%20Coverage%20Monitoring%20Report%20Paki- stan%202021.pdf
Pakistan Bureau of Statistics National Health Accounts
24
2.3.10 Development Partners/Donors
Data on health expenditures by development partners/ donor agencies has been taken
from Economic Affairs Division (EAD). All the figures are off budget figures which mean that
double counting of budget support from donors is avoided.
The data obtained from EAD only covers the off-budget expenditures/disbursements.
It means those grants/amounts which appear in the government budgetary books and in ap-
propriation accounts published by Accountant General are treated as on-budget activities,
separately.
Also, the Public Sector Development Program (PSDP) allocations are not included as
they are covered or recorded in annual appropriation accounts, and these allocations are part
of different health expenditures category which are recorded under health ministry in federal
government or under health department in provinces.
The report for the year 2021-22 covers the donors‟ expenditures/disbursements in the
four provinces of Pakistan. It does include the donors‟ expenditure in GB and AJK as their
figures are available in the data provided by EAD.
Data in the Table 18 has been made available from the respective donor agencies via
EAD as per NHA data format.
Table 18: Donor’s health expenditures 2021-22 (Million Rs.) Sector/Sub Sector Punjab Sindh KP Baluchistan ICT GB/AJK Total Family Planning (DFID) 957 72 1,002
2,031 Administration - Health and Nutrition (DFID) 1,207
1,207
2,414 Other - Health and Nutrition (DFID) 1,148
624
1,772 Total (DFID) 3,312 72 2,209
624
6,217 Mother & Child Health (USA) 6 11 2 1 1 2 23 Other - Health & Nutrition (USA)
2 5
7 Demographic & Health Surveys (USA) 1 1
2 Family Planning & Reproductive Health (USA) 1 11 3
15 Total (USA) 8 25 10 1 1 2 47 Other Health & Nutrition (WFP) 31 294 744 65
73 1,207 HIV & AIDS (UNFPA) 11
11 Maternal Health (UNFPA)
29
29 Demographic Forecasting (UNFPA)
190 2
192 Family Planning (UNFPA) 10 32 346 8
386 Total (UNFPA) 52 326 1,309 75
73
1,835
Grand Total
3,372
423
3,528
76
625
75
8,099
Source: EAD
The biggest share has been spent at KP followed by Punjab, ICT, Sindh, and Baluchi-
stan. Gilgit has the lowest share in the donors’ expenditures on health.
2.3.11 Local Non-Government Organizations
Philanthropic/Non-Government organizations (NGOs) are working in both urban and
rural areas of Pakistan. These organizations are working in multiple sectors to uplift the com-
munity by providing awareness and basic amenities of life. Philanthropic organizations are
Pakistan Bureau of Statistics National Health Accounts
25 registered under different laws whereas very few are unregistered. Philanthropic sector is dif- ferent from ‘state’ as it collects donations, charity or alms from the community and uses it for deserving communities, voluntarily. The table below shows the province-wise list of active NGOs, divided into two catego- ries on the basis of their major activities, ‘health care’ and ‘others’ organizations in order to focus on the health-related NGOs obtained from NGOs survey 2015-16 conducted under the “Change of Base of National Accounts from 2005-06 to 2015-16”. Table 19: Local Non-Government Organizations by type 2015-16 (Number of NGOs) Province Health care Others Total Punjab 856 3,703 4,559 Sindh 782 3,363 4,145 KP 56 1,023 1,079 Baluchistan 93 1,644 1,737 ICT 22 101 123 Total 1,809 9,834 11,643 Source: NGOs Survey 2015-16, Pakistan Bureau of Statistics For this purpose, expenditures data of health-related NGOs in all four provinces taken from a survey of NGOs conducted under the project of Change of Base of National Accounts (CBNA) from 2005-06 to 2015-06 by PBS. To avoid double counting, donations by interna- tional agencies have been excluded from the total health care expenditure by NGOs. These donations are already covered in financing sources. Table 20: Health Expenditures of health-related NGOs 2015-16 to 2021-22 (Million Rs.) Province Health Expenditures 2015-16 Health Expenditures 2017-18 Health Expenditures 2019-20 Health Expenditures 2021-22
Million Rs. Million Rs. Million Rs. Million Rs. 1 2 3 4 5 Punjab 10,000 32,907 39,159 45,973 Sindh 19,005 34,338 40,862 47,972 KP 11,702 2,146 2,554 2,998 Baluchistan 3,564 715 851 999 ICT
1,431 1,703 1,999 Pakistan 44,271 71,537 85,129 99,941 Health expenditures of health-related NGOs for the fiscal year 2021-22 has been esti- mated by inflating the figures of 2019-20 by the inflation rate recorded for health-related com- modities categorized as “Health Group", in the CPI of 2021-22 on the basis of 2019-20 (almost 17%). The above table shows the estimated expenditures of health-related local NGOs for fiscal years 2015-16, 2017-18, 2019-20 & 2021-22 for the four provinces as well as at the national level.
Pakistan Bureau of Statistics National Health Accounts
26 2.4 Financing sources by financing agents Matrix 1 shows the flow of funds for health expenditures in Pakistan. The rows are grouped according to financing agents while financing sources are listed in columns. The ma- trix shows the flow of funds from financing source to financing agent in Pakistan. For example, in case of federal government Ministry of Finance is the financing source and Ministry of Health, Ministry of Population Welfare, Ministry of Defense through military setup and other ministries are financing agents. In some of the cases financing sources and financing agents are the same which means that the financing sources are dedicated to own health care spend- ing exclusively and the money spent for health services (agents) is fully funded from their own resources. In Matrix 1, the “net” OOP figure for the private households has been included. The lump sum reimbursements of medical charges and Sehat Sahulat Programme figures of the federal and provincial governments’ ministries/departments have been included in the respec- tive financing agent categorized as "Other”. Whereas the reimbursements made by other em- ployers or health insurance (Military, Cantts, ESSIs and autonomous bodies etc.) to the house- holds are already included in the respective health expenditure.
Pakistan Bureau of Statistics National Health Accounts
27
Matrix 1: Current health expenditures by financing sources and financing agents in Pakistan 2021-22 (Million Rs.)
Financing Agents
Financing Sources
FS.1 Public funds
FS.2 Private funds
FS.3
ROW
Total
%
FS.1.1 Government Funds
FS.1.2 Autonomous
Bodies
FS.2.1
Em-
ployer
funds
FS.2.2
House-
hold
funds
FS.2.3
Local
NGO’s
FS.3.1
Official
donor
agen-
cies
FS.1.1.1
Fed.
Govt.
FS.1.1.2
Prov.
Govt.
FS.1.1.3
District /
Tehsil
FS.1.2.1
Federal
FS.1.2.2
Provin-
cial
HF.1
Gen-
eral
Gov-
ern-
ment
HF.1.1
Territo-
rial
Govern-
ment
HF.1.1.1
Federal
Govt.
Minis-
try:
MONHS
152,875
152,876 8.0 Other Ministries 6,547
6,547 0.4 Population Wel- fare
0.0 Military health expenditure 60,560
60,560 3.2 HF.1.1.2 Prov. Govt
Dept. of: Health
453,898
453,898 23.8 Population Wel- fare
7,742
7,742 0.4 Other
42,711
42,711
1.3
HF.1.1.3
District Bodies
District Government
131,345
131,346 6.9 Cantonments Boards
1,200
1,200
0.1
HF.1.2
Social
security
funds
HF.1.2.1 Social
Security funds
through Govt.
ESSI
15,083
15,083 0.8 Zakat health expendi- ture
625
625 0.0 Bait Ul Mal
2,223
2,223 0.1 HF.1.3 Autonomous Bodies / Corporation
18,021
18,021 0.9
1,586
1,586
0.1
HF.2
Private
Sector
HF.2.2 Other private insurance
16,260
16,260 0.9 HF.2.3 Private households' out-of-pocket payment
916,727
916,727 47.5 HF.2.4 Local NGO’s
99,941
99,941 5.2 HF.3 ROW HF.3.1 Official donor agencies
8,099 8,099 0.4 Total 219,982 504,351 132,545 18,021 1,586 31,343 919,575 99,941 8,099 1,935,443
% 11.60 25.40 7.00 1.00 0.10 1.60 47.70 5.20 0.40 100.00
Pakistan Bureau of Statistics National Health Accounts 28
2.5
Health Care Providers
2.5.1 Definition and classification
In addition to financing sources and financing agents, health care providers are the third
dimension of NHA. Health care providers are the end recipients of the health care funds. Figures
related to them answer the question of “To whom actually did the money go?” Examples of
providers include public and private hospitals, medical centers, dispensaries, solo clinics, phar-
macies, laboratories etc. Following are the three broad categories of the health care providers:
•
Public Provider
•
Private Provider
•
Non-Government Organization providers/Non-Profit Institutions
The public sector is running health care facilities for its employees and for the general
public across the country. The public sector can further be subdivided into core government,
AB/Cs and social security institutions. The providers in the core government can further be di-
vided into
➢ Providers with the civilian territorial government (Federal & Provincial) which
mainly are the health departments. The provision of health care is primarily the
responsibility of the provincial governments. This health care provision is a three-
tiered system with primary, secondary and tertiary levels of care.
➢ Providers within the military health care setup
➢ Providers run by the Cantonment Board of Pakistan
AB/Cs are providing health care services primarily to their own employees through their
own doctors, clinics and hospitals. Employees Social Security Institutions are provincial auton-
omous bodies. In Pakistan, they entertain some own health care facilities.
The public sector health care providers have been covered by data obtained from the
federal & provincial appropriation accounts, Military Accountant General, Cantonment Board of
Pakistan, Employees Social Security Institutions and a census of AB/Cs.
The main categories of private sector health care providers are:
➢ Major hospitals with specialized health facilities
➢ Other hospitals with variable quality/level of services
➢ Individually owned clinics/general practitioners including dental and eye care.
These clinics are either owned by a single person who is the sole proprietor of
the facility or they are run on a partnership basis
➢ Homeopaths, hakeems, tabibs and other traditional health providers
➢ Health care facilities from NGOs including the philanthropic organizations
➢ Ambulatory health services
➢ Facilities providing diagnostic & laboratory services
➢ Pharmacies and other retail sellers of medical goods
➢ Providers of administration and governance
The private sector has widely been covered through a survey of private health care pro-
viders and a census of big hospitals (for details see Chapter 4). The pharmacies were covered