Sehat Card Plus in Khyber Pakhtunkhwa: Confronting challenges, strengthening governance, ensuring financial sustainability

Objective: To conduct an in-depth policy analysis of the Sehat Card Plus (SCP), focussing on its governance, financingstructures, achievements, and long-term sustainability.Methods:A three-tiered framework was employed. At the micro-level, over 4,000 households were surveyed; at the mesolevel,readiness assessments were conducted at 38 empanelled hospitals; and at the macro-level, a policy and strategicreview of the SCP was conducted. The policy review examined (i) programme governance and coordination, including thirdpartyadministration by SLIC; (ii) current status of legislative and regulatory aspects; (iii) financing trends and sustainability;(iv) service delivery mechanisms, including beneficiary enrollment, empanellment and reimbursement mechanisms; and(v) monitoring and evaluation systems. A mixed-methods approach was used, combining literature review, technical reports,and budgetary documents with in-depth interviews conducted with provincial and federal officials, health system experts,and stakeholders. Data from interviews was collected between October and November 2022 underwent thematic deductiveanalysis.Results: Six thematic areas were identified: (i) Governance: Strong legislative commitment through the UHC Bill 2022, butwith limited citizen representation in decision-making bodies; (ii) Organizational arrangements: Limited staff anddependence on SLIC limit monitoring and strategic management; (iii) Financing: Unplanned expansion challenges financialsustainability in economic crisis, as SCP is fully funded by provincial revenues; (iv) Service purchasing: State Life InsuranceCorporation (SLIC) manages hospital empanellment and claims processing, though lack of involvement of health authorities;(v) Monitoring & evaluation: Independent monitoring systems are needed for transparency and quality assurance (vi)Communication and User Satisfaction : Beneficiary engagement and feedback mechanisms in SCP need improvement.Conclusion: SCP has expanded inpatient care and improved financial protection, but challenges remain in quality, financialsustainability, and equity, crucial for achieving UHC in Pakistan.Keywords: Universal Health Coverage (UHC), Sehat Card Plus (SCP), Khyber, Pakhtunkhwa (KP), Publicly Funded HealthInsurance, Social Health, Protection Initiative (SHPI).