Health policies are crucial in delivering equitable healthcare services in a

country. Please discuss using health policy examples of your choice from
two or more countries.

Health plays notable role in an individual life and health policies plays vital
part to deliver equitable health services. The traditional view: biomedical
model defines health as absence of disease (Papas, Belar, and Rozensky,
2004). One of the organizations of United Nations defined Health as, “It is a
state of complete physical, mental, and social well being, and not merely the
absence of disease or infirmity.” (World Health Organization, 1946).This
assignment includes Health policies of Pakistan and Singapore, discuses the
lacunas and put the attention towards of the healthcare services of both
countries.

Providence of healthcare services is a huge challenge for healthcare

providers. Not only is the access to healthcare services but also equitable
providence of healthcare services a crucial task. Throughout, in the world
urbanization has boosted up and providing the healthcare services became a
daunting task for authorities, remedies became expensive in limited available
resources. This situation is creating handicaps in the healthcare system of
Pakistan.

Equity is difficult to define simply, but it is regarded as a

cornerstone not only of policy decisions, but also of ethically
legitimate social institutions (Rawls, 1999). Broadly speaking, equity
is concerned with maximizing the welfare, potentials and general
well-being of the worst-off and have-nots of a society. In the context of
universal health care (UHC), equity in access could be understood
as enhancing the prioritization of those with the greatest health
needs in order to secure for them equality of opportunity or
capability to the furthest extent possible. At the same hand, health
systems must ensure that households are not made to contribute
more than they are pay so able to that equity in financing can also
be secured. Here are the examples of states, one with lack of equity in
healthcare system and one with laudable system of health care services:
Pakistan and Singapore.

Population wise, Pakistan came at sixth number. According to the United

Nations Pakistan’s population is 2.83% of world population. It is a
developing state with fragile economy. After the 18th amendment of the
constitution of Pakistan, health department converted from federal to
provisional authorities. The central government is only responsible to make
national policies and collecting funds for health services. Health unit of
Pakistan is based on two facets: Private and Public hospitals. Health care
services are provided in three setups: primary care by rural health care
service departments and secondary care by district hospitals. Pakistan’s total
health expenditure is 3.8% of its GDP. The country is spending 0.5 to 0.8pc
of its GDP on health over the last 10 years. These percentages are less than
the WHO bench mark of at least 6pc of GDP required to provide basic and
life saving services. A Latest report says “currently Pakistan’s per capita
health spending is $36.2 which is below than the WHO’s low income
countries bench mark of $86.”(WorldHealthOrganization, 2017). The general
secretary of PMA, Dr.Qaiser Sajjad said, “The world standards demand that
there should be four nurses and eight paramedics with one doctor but the
situation is contrary to it here as we’re working with up to 40pc less support
staff.

Successive governments in Pakistan have shown neglecting attitude towards

making healthcare system based on equity. Some areas receive a lot of
attention, while others are being unaddressed. The result is appalling health
indicators, high rates of mortality and morbidity from preventable causes and
severe financial hardships for low-income households seeking access to
health services while many countries in the world, including developing
countries, are taking steps towards universal health coverage, Pakistan is
lagging far behind in this goal. According to the World Health Organization,
‘universal health coverage’ means that “all people have access to needed
health services of sufficient quality to be effective while also ensuring that
the use of these services does not expose the user to financial hardship”.

The Pakistan’s current health policy framework and the nature of its
implementation are lagging behind from the goal of universal health
coverage. Public-sector hospitals are established to provide health services to
needy people free of cost. Primary health services are offered at Basic Health
Units (BHUs) and Rural Health Centers (RHCs) are spread across districts.
District headquarter hospitals are designed to provide a range of
comprehensive healthcare services. At the top of the tier are tertiary-level
hospitals located in some of the larger cities that are meant to provide a range
of sophisticated medical services. The government employs a large cadre of
doctors and healthcare professions to staff these facilities.

This three tier system of healthcare services lacks in administration system.

The reality is the system government provides does not work. Basic health
units and rural health units barely work in Pakistan. The reason behind the
sorry mess is government does not provide enough equipments and facilities
to the administration of these units. They are being understaffed and less
funded by government.

Coming to another sorry sight, lack of facilities in rural areas and basic health
units the burden on tertiary health units became more and it become loaded
with patients. Here the paragon of example is the metropolitan of Karachi
province: Sindh where people of all nearby areas visit the hospital and face
the hurdles in their way. The case of Baluchistan province is same. Doctors
of tertiary hospitals explain mostly people die in the way to hospital.

The repercussions of low quality public sector are that people have to visit
the private hospitals. And the destitute community suffers because of this
hard reality. They cannot afford to pay the gigantic fees of private hospitals.
And resultantly, those who cannot afford the fees of private hospital they
have to sell every saving or sacrifice their lives. This is one of the reasons
that mortality rate is higher in Pakistan. Another main reason is people of the
rural areas cannot afford to travel the long way towards the secondary and
tertiary hospitals in the cities or districts. There is an estimate that about 100
million people are pushed into extreme poverty every year because of out-of-
pocket spending on healthcare. Many of them are likely to be from Pakistan.
(World Health organization, 2018).

A huge amount of patients in tertiary hospitals overburden the government to

invest more funds in tertiary hospitals which treats a few people and which
show minimum outcomes unlike primary hospitals which can impact on large
proportion of population. This is how money is being wasted, mortality rates
become more and equitable health services are being ignored in Pakistan.
Lack of coordination among primary, secondary and territory hospitals, issue
of equity in health care services is aroused. Making 90% patients visit the
primary level of healthcare services will save the overload of secondary and
tertiary where patients of grave disease should be admitted. A lot of funds
and investment can be saved by this way and the equitable providence of
healthcare services at the primary level of hospitals can be ensured.

Beyond grave effects of poor healthcare services government of Pakistan has

made no effort to overhaul the failed system. Public-private partnerships
have been initiated in some districts to fix dilapidated public hospitals.
Attempts to introduce government-supported health insurance through the
Prime Minister’s National Health Program in 2016 and the Sehat Sahulat
program of the PTI government have not been consistently implemented.
It is the pressing need to revamp the ailing system of health service in
Pakistan which entirely based on equity and justice. It stands at 154/195 in
terms of health care services (Latchet study,2018) and it stands at 152/189 in
the human development ranking (UNDP, 2018) which depicts this state
needs to boost its investment in healthcare system as well. An already debut
ridden state suffers by the powerful hands of IMF almost after every five
year, which demands to put less in human development era and more in
infrastructure. It spends only 2.6% of its GDP on healthcare despite of the
fact the WHO has estimated Pakistan has to spend 4% of its GDP in
healthcare services per the signatory of sustainable development goals.

Here comes the state with commendable health policies based on equity:
Singapore, is a country with a population
of 5.2 million, it was decolonized from British in 1819. It joined the
Malaysian Federation
in 1963 but separated two years later and became
independent. Singapore became one of
the world’s most burgeoning countries with strong
international trading links and with per capita GDP
equal to that of the leading nations of Western Europe.
It is known for its efficient and equity based
th
healthcare system. It stands at 6 number in terms of laudable healthcare
system according to WHO. It has been placed at number first state to provide
equity based health services according to Bloomberg. It’s
healthcare system consists of three pillars: firstly,
the country is expected to build a healthy population
with focus on prevention and to encourage healthy
lifestyles, Secondly Singapore also put focus on
its citizen to take responsibility towards healthy
living through the “3M” (Medisave, Medishield and
Medifund) health system. Most importantly, the government has
to keep the healthcare costs down by controlling the
supply side of the healthcare services and providing
heavy aids at public healthcare institutions.

Singapore’s health system largely put focus on self-reliance, individual

responsibility for one’s own health and collective responsibility in
keeping health care affordability. These values are consisted by
number of distinct system features and could point to a particular
conception of equity in access and finance.
Singapore has private primary health care sector.
About 80 per cent of Singapore’s primary health care needs are
met mainly by private general practitioners (GPs). These GPs
provide their own medicines, which are (along with cost of
consultation) usually fully paid for by patients, unless subsidized by
employment insurance. But public health care hospitals (or
polyclinics) provide about 20 per cent of the primary care services
to all citizens at a less rate, with certain groups of
Singaporeans (such as those under the age of 18 years or above
the age of 65 years) receiving greater subsidy. Working on the
self-reliance and individual responsibility as desirable ends, most
Singaporeans are expected to pay for their own primary health care
needs. The arrangement of finance is intended to discourage
the over-consumption of health care services. Owning health needs on their
own shoulders is also the philosophy
that underpins Medisave, a mandatory savings account scheme.

Depending on his or her age, a working Singaporean puts up

seven to 9.5 per cent of his or her monthly salary into this personal
account. Savings can boost their affordability in the health care expenses of
the account holder, including hospitalization, certain vaccinations,
health screening and other outpatient services, and home-based
hospice services. In addition, Medisave may also be drawn on to
pay the premium for MediShield, a low-cost basic medical
insurance scheme designed to meet the cost of hospitalization for
treatment of catastrophic illnesses or prolonged hospitalization in
moderate- to lower-grade wards of ‘public’ restructured hospitals.1
Claimable limits and co-payment features of MediShield, such as
co-insurance and deductibles, are similarly directed at establishing a
level of self-reliance and individual responsibility. Recently, a
severe disability insurance known as Elder Shield has been
introduced to enable risk sharing as a means of providing a level of
financial protection to those who need long-term care, especially to the aged
patients. Under certain medical diagnoses, the insured may
receive a monthly payout of S$400 over a maximum period of 72
months. Again, policy of coverage under this scheme is a huge
supplement as it is unlikely to be enough in the light of rising
costs and the very real prospect of long-term care extending
beyond six years.
Beyond the individual, families are expected to be the first line of
support. Consequently, funds in the Medisave account may also be
drawn upon to meet the health care expenses of dependents of
the account holder. Some have argued that these policies, along
with a statutory requirement for adult children to care for their
aged parents, are reflective of Confucian precepts that are deeply
embedded in Singapore’s predominantly Chinese population (Lim,
2012). While the real influence of particular ideologies on public
policy is difficult to establish with certainty, it seems clear that the
state has focused on the involvement of the private and voluntary
sectors in its ‘Many Helping Hands’ approach, through which
community based organizations are promoted as the next level of support
after the individual and the family (Lim, J., 2013; Rozario and
Rosetti, 2012). Additionally, the participation of private insurers has
been evident: insurance coverage in addition to MediShield may be
purchased from a private insurer as a Medisave-approved
Integrated Shield Plan. Premiums for this enhanced coverage may
be paid using Medisave funds. Similarly, ElderShield Supplements
may be purchased from private insurers to enhance the disability
benefits coverage provided under the ElderShield scheme.
The Community Health Assist Scheme (CHAS or the Primary Care
Partnership Scheme, as it was known until 15 January 2012) also
represents an innovative policy of public–private partnership (Ng,
2012). The public private partnership is one of the reasons which create
equity based healthcare system.

It has been boosted up in 2009, because it was extended to cover more

chronic conditions. In 2012, the qualifying age was lowered from 65 to 40
years and the income criteria aggravated from $800 to $1,500 per
capita monthly household income, significantly broadening the
pool of potential enrollees. Two subsidy tiers (the Blue Health Assist
scheme for individuals with per capita household monthly income
of less than $900 and Orange Health Assist scheme for individuals
with per capita household monthly income of more than $900 but
less than or equal to $1,500) have been added to enhance
accessibility of primary care services for more needy Singaporeans.
From January 2014, even more changes have been introduced to
expand coverage further: the qualifying age limit of 40 years have been
removed, five new chronic conditions are enlisted to
subsidised conditions and greater subsidies are provided for
specified screening tests, including those conducted by a GP. Apart
from these, charges at Specialist Outpatient Clinics in public
hospitals have been lowered for lower- and middle-income groups. a number
of changes are being considered in developing
MediShield into MediShield Life as well. These include enhancing
MediShield benefits by raising claim limits, reducing the coinsurance borne
by patients for large bills and providing lifetime
coverage. MediShield have been extended to all
Singaporeans, including those currently uninsured. For those who
are unable to pay premiums for coverage under MediShield Life,
additional government support will be provided. The state assumes
a more prominent role in meeting the acute health care needs of
citizens, as public hospitals account for about 80 per cent of
tertiary care. A majority of the public hospitals’ beds, about 81 per
cent (in moderate and lower-category wards), are heavily
subsidized. It has been reported that, in 2012, the average length
of stay in public acute care hospitals was about 5.8 days while the
average occupancy rate was around 85 per cent.4 Apart from acute
hospitals, community hospitals have more recently been introduced
for the convalescent sick and aged. For the have-nots,
Medifund has been set up as a public endowment fund to serve as
a safety net for Singaporeans who cannot afford to pay for
subsidized bill charges. In 2012, the capital sum was reported as $3
billion. In November 2007, a capital sum of $500 million was set
apart as Medifund Silver to provide aid specifically to needy, elderly
patients. Prevailing
philosophy of Singapore healthcare system is a mixture of self-reliance,
individual responsibility for
one’s own health and collective responsibility in maintaining health
care affordability, are the factors which ensure equity in access and finance.

To encapsulate, two examples of states, one with not so good health policies
and coordination: Pakistan, the other one is Singapore with equity based
health policies ensure good healthcare system and which makes it better is its
coordinated health care system and policies that are crucial to exacerbate the
human development in any state. A health is wealth; no state can run better
on the trajectory of competitive healthcare system without working on equity
based policies, Pakistan is a depiction of it which stands at 152/189 in human
development ranking (UNDP, 2018), it can follow the example of Singapore
which has better health policies and lesser mortality rate and a far better
human development rank, as it stands at 6th out of 189 sates of world (UNDP,
2020).