1

Background information of program (policy, objectives, role and functions, activities and operational processes in general, development trends etc)

 

Social Health Protection phase.I

Policy: The constitution of the Islamic republic of Pakistan (Article 38 guarantees, as a right, the provision of social security to its all citizens. The Government of Pakistan has undertaken a number of initiatives and developed strategies that fall in the area of social protection.

The provisional Government of GB, has approved many development schemes for health sector. The Goal of the Department of Health in partnership with stakeholders, is “to improve the health status of the population in Gilgit-Baltistan through ensuring access to a high quality responsive healthcare delivery system which provides acceptable and affordable services in an equitable manner.

One of the outcomes of Government of Gilgit Baltistan health sector strategy in enhancing coverage and access to essential health services especially for the poor and vulnerable.
The population of the province living below the poverty line will have a form of social protection against catastrophic illnesses

On the request of Government of Pakistan, the German Government committed 10 million EUR as grant for Social Health Protection (SHP) in the framework of Financial Cooperation (FC). These funds are intended to support for the development of Social Health protection Pakistan in Pakistan, Especially Khyber Pakhtunkhwa and Gilgit-Baltistan. The grant will be on granted by Federal Government to the Provincial Government of GB.

Objectives

To improve access to health services by the poorest population groups in the programme region through a reduction of financial barriers and the strengthening of the quality of health service provision. At the end of the project the health status of the population in the intervention districts will have improved and its poverty levels decreased.

Specific objectives

·         21% of the poorest households in the intervention district enjoy Social Health Insurance coverage.

·         At least a further 30% of the district population purchases health insurance product so that total coverage would exceed 51% of the population.

·         Out-of–pocket expenditure by insured households for inpatient care reduced by at least 51%.

 

Functions, Activities and Operational Processes

·         The Scheme would be implemented by a PMU headed by a project Director through a third party, Insurance Company, selected through National Competitive Bidding process consistent with the government procurement rules and kfw bidding guideline.

·         It will be a two stage process, in the first stage appropriate insurance company/companies will be selected and in the second stage implementation proposals under the guidance of consultant and project Management Unit will be prepared.

·         The insurance companies will be selected according to a criteria based on their organizational capability, experience in health insurance, quality of human resource and their approach to the progamme.

·         It will be a hospitalization scheme mainly, however, maternity would be covered on non-hospitalization basis as well.

·         The insurance scheme would cover a family consisting of household head, his spouse, four children, and one elderly dependent person (parent of the family head, for example).

·         First to be enrolled is the family head and the spouse, then children beginning from youngest to oldest. After that, elderly dependent persons living in the same household may be included until seven (or fewer) are enrolled.

·         To identify households that are exempt from paying health insurance fees, the targeting mechanism developed by Benazir Income Support Programme, would be used.

·         The hospitalization component, including maternity benefits, will be limited to Rs. 25,000 per person per annum.

·         The provider payment Mechanism is a Cashless System with pre-established prices to be paid to the provider twice weekly.

·         To get the programme started the selected insurance company will propose to the Government of Gilgit –Baltistan for approval of a list of service providers for each progarmme district, that comply with national and provincial quality standards.

·         Both public and private Health care providers would be selected based on a selection criteria and would receive funds from the insurance scheme.

·         Service providers for the project will be finalized by the project steering committee.

 

 

2

Legislation and general programs and performance goals

 

It is expected that though this scheme access to health, services by the poorest population groups in the programme region would be improved through a reduction of financial barriers and the strengthening of the quality of health service provision.

Out-of-pocket expenditure by insured households for inpatient care reduced by at least 51% (21% through the social insurance and 30% through purchasing of premiums. At the project the health status of the population in the intervention districts would be improved and its poverty levels decreased.

 

3

Organizational structure and accountability relationships

 

·         The governments of
Gilgit Baltistan health department will be Executing the scheme through a project Management Unit (PMU).

·         External finance audit, to be undertaken annually in order to ascertain that funds were being used according to the project contract and budget.

·         Annual rapid assessment, including spot checks of financial records at all levels using random sampling to ensure that transferred funds has arrived as stated and that services were provided to clients as claimed.

·         Review of organizational development of the implementing organizations (every two years) to identify any significant gaps in capacity and highlight strategies for addressing them.

4

Internal and external environment and the stakeholders

 

Following are the stakeholders of the program;

1.      Health Department Government of Gilgit-Baltistan.

2.      KfW Germany

3.      Beneficiary Households

4.      Empaneled Hospitals.

5

Core service or deliverables

 

·         The insurance scheme would cover a family consisting of household head, his spouse, four children, and one elderly dependent person (parent of the family head, for example).

·         The secondary care hospitalization component, including maternity benefits, will be limited to Rs. 25,000 per person per annum

·         Transportation Charges Rs. 1000/- for maternity cases.

 

6

Internal Control System

 

Program is being implemented by Project Management Unit. Monitoring, Supervision and controlling all program related activities are the responsibility of PMU. PMU reports to Health Department on monthly basis regarding the project progress.

 

 

7

External constraints or forces affecting program delivery

 

Changes in the Political Governments and new policies adopted by the governments often effect the activities of the project.

In addition, the BISP poverty survey which was conducted in 2010 also needs to be re-visited and fresh poverty survey is need of time for smooth and sustainable implementation of Social Health Protection Programs.

8. Objectives of the audit entity or project or program in a quantified form.
S.No. Objectives Strategy Target Achieved
1 1. Verification of Poorest Households (HHs) as per BISP Data Door to door survey was conducted to verify the poorest HHs in district Gilgit 5480 HHs

5340 HHs

(97.44%)

2.   Distribution of Health Cards to verified HHs Health cards were distributed to eligible HHs through CSOs and LSOs 5340 HHs 5340 HHs (100%)

3. Awareness about usage and benefits of Health Card

 

1. Card Distribution Ceremonies at UC level. 11

11

(100%)

2. Publicity & Awareness campaign has been launched by using print and electronic media. To create awareness among 100% beneficiaries of Health Card

85% of the beneficiaries are having good knowledge about Health Card

(Ref. AKRSP Impact Study of SHP-GB)

4. Empanelment of Hospitals 1. Private Hospitals fulfilling the empanelment criteria have been contracted for treatment of SHP Insured patients 04

03

 

2. Public sector Hospitals have been empanelled for SHP.

02

(DHQ and City Hospital Gilgit)

02
6. Health Card Utilization By the Beneficiaries  

3.0%

Health Card utilization rate

2.%

Health Card utilization rate

2 1. To create awareness among communities about health insurance and its benefits. 1.      Strengthening of Community Support Organizations (CSO) and Local support organizations (LSO) 12 LSO/CSO 12 LSO/CSO
2.      Awareness sessions with community at UC levels 12 Sessions 12 Sessions
3.      Product Design for wider enrollment. Two products have been designed i.e Econo Plan and Econo plus plan ———– Two products have been designed for general public i.e Econo Plan and Econo plus plan
4.      Free medical Camps to create awareness about the Health Insurance Product

7 medical Camps in

1st Year

7 medical Camps in

2nd Year

7 Medical Camps in 3rd Year

7 medical camps

(2016-17)

7 medical camps (2017-2018)

7 Medical camps

(2018-2019)

2. Wider enrolment

(Purchase of Health Insurance Products by non-poor population)

1.      Wider enrollment

 

7828

 

6998

 

 

1.      Name of the Project

Social Health Protection Phase-II.

 

2.      Location

Districts: 1. Gilgit.

 

3.      Authorities Responsible for

a.      Sponsoring

1.      KfW Germany (Grant)

2.      Government of Gilgit-Baltistan (ADP).

 

b.      Execution

Health Department Gilgit-Baltistan, through the Project Management Unit (already established for SHPI Phase-I), under the administrative control of Secretary Health GB.

 

c.      Operation and Maintenance

Department of Health, Government of Gilgit-Baltistan.

 

d.     Concerned Federal Ministry.

Ministry of Kashmir Affairs & Gilgit-Baltistan.

4.      Plan Provision

The scheme has been reflected in Annual Development Program 2020-21.

 

5.      Project Objectives

The objectives of the project are in line with the overall objectives and outcomes of the Health Department i.e.

To improve the health status of the population in Gilgit-Baltistan by ensuring access to a high quality health care especially enhancing coverage and access to essential health services for the poor and vulnerable.

 

General Objective:

To improve access to health care services by the poorest population groups in the programme district through a reduction of financial barriers. At the end of the project the health status of the population in the intervention district will have improved and its poverty levels decreased.

 

Specific objectives:

1.      To provide Health Insurance Coverage to around 21000 poorest households in District Gilgit.

2.      To reduce out-of-pocket payments for health care services.

 

3.      To strengthen public sector hospitals as they would be permitted to retain insurance income.

4.      To promote health insurance in general population.

 

6.      Description, Justification and Technical Parameters.

i.                   Preamble.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ii. Description and Technical Parameters.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gilgit-Baltistan is one of the remotest and most economically under privileged areas of Pakistan, requiring special attention of the Federal Government and international development partners for development. The Vision 2025 of the Government of Pakistan (GoP) aims to bring this area at par with other, more developed parts of the country, by accelerating the pace of development and providing social safety projects.

Area: Gilgit-Baltistan spans over an area of 72,971 square Kilometers. Historically Gilgit, the administrative center of GB, was an important city on the old Silk Road, from which Buddhism spread from India to the rest of Asia. There are 10 districts and 110 Union Councils in GB and District Gilgit has been selected for SHP Phase-II.

Under Social Health Protection Phase-II, government of Gilgit-Baltistan with technical and financial support of KfW will pay premiums for households with BISP Proxy Means Testing (PMT) score of 32.5 or less that makes around 50% of the population of District Gilgit to be provided with Health Insurance Coverage.

 

Back ground of the Project:

German Government through KfW development bank currently supports the Social Health Protection Initiative Scheme in the District Gilgit by co-financing the inpatients care for the poorest 21% population (5340 Households). Currently 05 Hospitals have been empanelled, provision of services started in August 2016. Around 2400 patients have been provided with free treatment at empanelled hospitals during Four years of its implementation. Progress made so far in SHP Phase-I, attached as Annex: A.

The guiding principle of SHP is the ultimate goal to help the provincial Government of Gilgit-Baltistan achieving Universal Health Coverage for the most vulnerable segments of the population.

As the Phase-I of SHPI has been successfully implemented in District Gilgit, the German Government through KfW Development Bank has committed EUR 2.6 Million to launch Phase-II of SHP for which Financing agreement has been signed between EAD and KfW. Separate agreement has been also signed between Department of Health GB and KfW (Copies of agreements Attached herewith). In Phase-II the SHP scheme will be expanded in terms of population coverage and benefit package. Lessons Learnt during Phase: I and Comparison of Social Health Protection Phase: I and Phase: II is attached as Annex: B and Annex: C respectively.

 

TARGET POPULATION

1.      The scheme will be implemented in Gilgit District of Gilgit-Baltistan.

2.      Beneficiaries of this scheme will be selected on the basis of Poverty Score Card (Proxy Means Test, PMT) of Benazir Income Support Programme (BISP).

3.      The cut-off upper PMT score will be 32.50. It is estimated that there will be approximately 21,000 households under the cut-off PMT score in Gilgit district will be provided with Health Insurance coverage (Secondary & Tertiary Care).

4.      Under phase-I of this initiative, population below 16.17 PMT score is already enrolled for provision of cashless Secondary Health Care services.

5.      Tertiary Care Services will also be provided to the population below 16.17 PMT.

6.      After the completion of project life of Phase: I the population under 16.17 will be covered through Phase-II.

7.      Population under PMT Score 16.17 will be provided with OPD services.

8.      Around 5340 households under PMT 16.17 would be provided with OPD Services.

9.      The eligible population and households in the programme district is attached as Annex-D.

10.  Additional members of the household, if so desired would be covered by paying premium on individual basis.

11.  The program will cover all ages, starting at birth.

12.  The annual premium for full benefit package (Secondary and Tertiary) is estimated to be around Rs. 68.00 Million per year.

13.  The OPD premium is estimated to be around     Rs. 37.44 Million per year.

14.  The exact premium will be determined after completion of bidding process and selection of insurance firm which may vary from the estimated premiums.

15.  In case the quoted premiums are higher than the estimated premiums the deficit premiums will be met from the contingencies allocated by GoGB & KfW.

16.  Estimated premium calculations are attached vide Annex: H and Annex: I.

INSURANCE MECHANISM:

 

o   It will be a hospitalization scheme mainly, however, maternity would be covered on non-hospitalization basis as well.

o   Out Patient Department (OPD) services mainly focusing on highly prevalent diseases will be piloted in District Gilgit.(for households below 16.17 PMT).

 

BENEFIT PACKAGE (IPD):

 

o   The insurance scheme would cover a Household, consisting of household head and six other members of the household.

o   First the family head and the spouse, to be enrolled then children beginning from youngest to oldest. After that, elderly dependent persons living in the same household may be included until seven (or fewer) are enrolled.

o   The following health care services will be provided to the insured Households:

 

1.      Secondary   Care   hospital  services   normally  provided   at  secondary level   hospitals   (DHQ and THQ  Hospitals in public sector)   such   as   Medicine,  General  Surgery, Orthopedics,  Gynae  and  Obstetrics,   Pediatrics,  Ophthalmology and ENT etc.

 

 

 

 

2.      Tertiary Care  priority  diseases  coverage at tertiary care hospitals including:

 

§  Heart and Cardiovascular diseases including stunts and open heart surgeries.

§  Complications of Diabetics Mellitus.

§  Cancer Management including chemotherapy, radio therapy and surgeries.

§  Kidneys Diseases.

§  Organ failure management.

§  Neuro-surgical procedures.

§  Accidents, Emergencies and Burn care.

§  All the medical emergency care those are acute in nature requiring immediate care and management.

§  Head Injuries, all kinds of fractures, Spinal Injuries etc.

§  Costs for surgeries that are above the benefits package will be supported by other government social protection schemes like endowment fund for health by GoGB, Zakat and Bait-ul-Maal.

AGE LIMIT OF INSURED HOUSEHOLD MEMBERS:

There will be no age limits and no exclusions of pre-existing conditions (with the exception of some specific “standard exclusions” such as injuries due to suicide attempts, drug addiction or overdose, cosmetic surgery, etc)

 

PRE AND POST HOSPITALIZATION:

 

Pre and post hospitalization treatment including medicine and other necessary prescriptions up to 1 day prior to hospitalization and up to 5 days from the date of discharge from the hospital shall be part of the package rates.

 

ANNUAL INSURANCE LIMIT:

 

1.      SECONDARY COVERAGE:

Rs.25,000/- per member of the beneficiary Household per year.

 

2.      TERTIARY COVERAGE:

Rs. 300,000/- per Household per year.

 

 

 

MECHANISM IN CASE UPPER LIMIT OF TERTIARY CARE COVERAGE EXCEEDS:

            In case the upper tertiary care limit exceeds, the patient would be covered through GB Health Endowment Fund established by GoGB with an allocation of              Rs. 500.000 Million.

 

TRANSPORTATION:

 

1.      Tertiary Care Transportation Support:

Currently there is no tertiary care hospital in GB to provide Tertiary Care Services and most of the patients requiring the tertiary care services are referred to Hospitals in down country (mostly to Islamabad and Rawalpindi). Population living below the poverty line faces problems in managing/arranging the transportation charges to travel to down country for their Tertiary Care treatment.

If a referred patient requires the Ambulance Services for transportation to the Tertiary Care Hospital the selected Insurance Company will provide the Ambulance Service to the patient.

The selected insurance company will develop a mechanism with an already established Ambulance Service provider.

The insurance company could have contracts/agreements or MoUs with ambulance networks so that payment of dues on prescribed charges could be made on daily, weekly, monthly or quarterly basis.

Estimated cost for such cases is Rs. 10,000/- per Tertiary admission/referral. The estimate has been included in the benefit package.

 

2.      Secondary Care Transportation Charges:

Transportation charges amounting to Rs. 2000/- per secondary discharge will be part of the benefit package.

 

 

 

 

 

 

 

BENEFIT PACKAGE (OPD):

1.      KfW will hire an international Consultant in the first year of project implementation to design, finalize and implement the OPD approach/mechanism.

2.      Based on the recommendations of the consultant the OPD modalities and benefit package will be finalized by DoH-GB and KfW.

 

IMPLEMENTATION MODALITIES & SELECTION OF HEALTH INSURANCE COMPANY

 

1.      The Scheme will be implemented by DoH-GB through the Project Management Unit (PMU) already established for Phase: I, headed by the Project Director, through a third party, Insurance Company, selected through National Competitive Bidding process consistent with the government procurement rules (PPRA) and KfW bidding guideline.

 

2.      The insurance company will be selected by following “Single Stage Two Envelops” bidding procedure according to a criteria based on their organizational capability, experience in health insurance, quality of human resource and their approach to the programme.

SERVICE PROVIDERS:

 

1.      Inpatient secondary and priority tertiary care services will be provided on cashless basis to the insured beneficiaries by empanelled public or private health facilities.

2.      The selected insurance company will assess public and private health facilities based on predefined criteria for empanelment. The list of proposed hospitals will be submitted to the Department of Health GB for approval.

3.      Hospitals (Service providers) already empanelled for the Phase-I of the scheme will be provided to the insurance company by DoH-GB. Any changes in empanelled hospitals for the project will be approved by the project steering committee.

4.      Service providers (Both Public & Private) for the project will be finalized by the project steering committee.

5.      Empanelled Government hospitals would be permitted to retain, without loss of budget the insurance income generated from SHP insured patients.

6.      The retained insurance funds will be utilized by the Government empanelled hospitals for improvement of quality of healthcare services and payment of incentives to the hospital staff. (Detailed utilization mechanism is attached as Annex: E)

 

PROMOTION OF THE SCHEME AND PUBLIC AWARENESS:

 

1.      Government of Gilgit-Baltistan will use its authority and influence to advocate in the population for the micro health insurance scheme. It will also take steps to document and disseminate the lessons learned.

2.      The Government will undertake promotional campaigns to create public awareness amongst the population for optimum utilization of the health care services.

3.      KfW has budgeted financial support for development of public awareness messages.

 

MONITORING & EVALUATION:

 

1.      The government of Gilgit-Baltistan Health Department will execute the scheme through Project Management Unit (PMU) already established in Phase-I.

2.      To oversee the project and to take policy decisions regarding SHP, a steering committee will be formed.

3.      Composition and ToRs of Steering committee are attached as Annex-F.

4.      In order to ascertain that funds were being used according to the project contract and budget external financial audit will be undertaken annually.

5.      Annual rapid assessment, including spot checks of financial records at all levels using random sampling to ensure that transferred funds has arrived as stated and that services were provided to clients as claimed.

 

 

 

 

PROFIT SHARING OF HEALTH INSURANCE PREMIUMS:

 

            Government of GB with support from KfW has launched the scheme as a means for Social Health Protection and not as a pure commercial venture. The insurance companies / Health Insurance Organizations are expected to share a portion of the underwriting profit of the premium over the course of the program. Detailed mechanism for profit sharing is provided in Annex: P