ARTICLE 25 of the Universal Declaration of Human Rights states that everyone has a right to medical care and security in the event of sickness and disability. This right also figures in the constitution of the World Health Organisation.

This idea has informed debate on universal health coverage (UHC) which means that all people should enjoy equal access to a range of health services palliative, rehabilitative, preventive and treatment without incurring financial ruin in the process of accessing and paying for them.

Though this conception of universal health coverage has been termed as too narrow by some researchers, the UHC is nonetheless a good starting point to initiate discussion on the aspiration, and mechanisms of achieving health coverage by all members of society.

The need for it has arisen because of the realisation that health coverage is increasingly becoming restricted thanks to the declining commitment of governments across the world to publicly funded health provision for all and the corresponding increase in private, often expensive, health facilities.

These developments have produced unequal health access and outcomes. Like the rest of the developing world this is true of Pakistan as well where the health system runs on a dual track. There`s a publicly funded system and a private health sector, with the latter assuming an ever-larger share with each passing year.

According to one estimate about 120 million people fund medical care through outof-pocket payments of one sort or another in Pakistan. This is quite a huge number and highlights the enormity of the challenge in meeting the goal of UHC in the country.

Over the years, the public provision of health has come under great stress due to low budgetary allocations and increasing demands placed on it by a growing population. As a result, public health facilities are deteriorating. These facilities are further degraded by the exit of the middle class which is increasingly using private healthcare systems. The result is that public health facilities are being used by the poor as a measure of last resort.

In cases where the poor access the private health sector the cost of treatment is so high that it often tips families towards medical impoverishment. Consequently, a large majority of the population stays away from accessing healthcare as long as they can for fear of incurring financial ruin. In addition, between the rich and the poor, formal-sector employees are afforded considerablehealth coverage the armed forces personnel are the best covered, in this regard, from the beginning of service to the grave, with the bureaucracy coming in a close second.

There is also a network of social security hospitals to provide cover to those registered. Yet a large section of the population, employed in the informal sector falls outside this protective health cover. This unplanned and ad hoc health setting with varying levels of health coverage poses huge challenges if Pakistan is to conform to the standards of UHC.

A start can be made by setting up a highlevel committee to examine the current system of healthcare provision and to examine how it can be improved and pressed into the service of meeting the goal of UHC. (The Indian example can provide a good template in this regard). Towards this end, highlevel political commitment is a must. This commitment should cut across party lines so that UHC is made a top priority with enhanced budgetary outlays.

So far there has been no well-thought-out collective thinking on universal health provision among political parties. Political parties have not advanced beyond making promises to expand health budgets.

Most crucially, the private sector needs to be robustly regulated and made part of the government agenda on universal health coverage. This should involve private hospitals taking on non-lucrative patients as part of the UHC healthcare package.

With the health budget unlikely to rise in the foreseeable future in the face of the ever-galloping military budget, and the lack of political spine to redirect priorities, a national health insurance scheme can also help. This scheme should be run on a nonprofit basis. Currently, there are some micro-credit schemes which offer a level of health insurance. But these schemes are profit-oriented and may not help greatly in the realisation of UHC.

In some parts of the world cash transfer programmes have been made conditional on children of the poor attending health clinics. A similar move can help expand health access to the poor.

Above all, ensuring better access to social determinants of health such as education, housing and sanitation is an essential underlying requirement. Not addressing the social determinants of health can dilute the gains achieved through the policy tools mentioned.• The writer is an Islamabad-based development consultant and policy analyst.

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