TORs: National Senior STTA –  Legal Expert
Sustainable Financial Model of Sehat Sahulat Programme(A Universal Health Insurance Scheme) 

Programme

Evidence for Health (E4H) is a Foreign, Commonwealth & Development Office (FCDO)-funded programme aimed at strengthening Pakistan's healthcare system, thereby decreasing the burden of illness and saving lives. E4H provides technical assistance (TA) to the Federal, Khyber Pakhtunkhwa (KP), and Punjab governments, and is being implemented by Palladium along with Oxford Policy Management (OPM).

Through its flexible, embedded, and demand-driven model, E4H supports the government to achieve a resilient health system that is prepared for health emergencies, responsive to the latest evidence, and delivers equitable, quality, and efficient healthcare services. Specifically, E4H delivers TA across three outputs:

Output 1: Strengthened integrated health security, with a focus on preparing and responding to health emergencies, including pandemics.

Output 2: Strengthened evidence-based decision-making to drive health sector performance and accountability.

Output 3: Improved implementation of Universal Health Coverage, with a focus on ending preventable deaths.

Background and Problem Statement

In 2016, the Government of Punjab launched the Prime Minister’s National Health Programme (PMNHP), a health insurance initiative for vulnerable persons responding to rising healthcare costs and the associated risk of poverty from catastrophic medical expenses. This social health protection programme provided coverage for in-patient medical expenses. Initially targeting economically vulnerable individuals (through a proxy means test (PMT) score below 32.5 in the National Socio-Economic Registry (NSER) , the programme's successful pilot led to its universal expansion in Punjab in 2021 through Sehat Sahulat Programme (SSP). With over 31 million families covered  (127 million people), this is significant progress towards providing in-patient health service delivery in Punjab, contributing to the Universal Health Coverage (UHC) indicator of service capacity and access. However, the programme's expansion has brought financial sustainability challenges to the forefront due to economic challenges and constrained fiscal space and lack of buy-in from relevant government counterparts.

Punjab: According to the contractual schedule, the provincial government could not pay its share of the premium to the State Life Insurance Company of Pakistan (SLIC). Shortly into the contract, the government shifted from paying the agreed premium amounts to paying estimated claims due plus administrative fees. In June 2023, the government implemented austerity measures to further reduce claim costs, restricting access to programme benefits.

Khyber Pakhtunkhwa (KP): The SSP in Khyber Pakhtunkhwa was suspended multiple times throughout 2023 due to non-payment of premiums. Ultimately, the programme was suspended. Currently, the SSP in KPK was made operational soon after the new government took charge and made partial outstanding payments to SLIC.

Federal Government: The Federal Government of Pakistan (GoP) has failed to pay any premium since the contract's inception. Services were not suspended due to the joint nature of the contract. Essentially, the GoPb was paying the GoP premium share. This arrangement has now ceased, with Punjab not footing the bill anymore as it is struggling itself.

Currently, there are ongoing discussions within the provincial government about the scope of the benefit package itself, as well as the beneficiaries and the empanelled hospitals. The P&SHD is committed to providing health coverage to as many people as possible, but given economic and fiscal constraints, the beneficiaries entitled to the package have been revised to those that score below 40-45 on the PMT.  Changes have also been proposed and/or already made to the benefit package, with c-sections and normal deliveries now only available in public sector hospitals. Furthermore, there are co-payment mechanisms for surgical procedures that require patients to contribute up to 50 per cent of the cost if they opt for treatment in private sector hospitals. There is also a push to include a greater number of public sector hospitals compared to private sector establishments. At the moment, there are just over 200 public facilities as opposed to 165 private healthcare facilities empanelled. The push factor for this is to make drive most of the funds into public sector hospitals to bring costs down for the government.

Objective

The overall objective of phase 1 of the TA will be to provide the department with a report on the province's current fiscal situation. Decision-makers will assess the current financial problems, the urgency of financial reform, and the requirement—if any—of reforms to the benefit package and circumventing legal barriers to achieve this.

Scope of Work and Methodology

The Scope of Work and Methodology for the Technical Assistance assignment is designed to ensure the development and facilitation of actionable recommendations.

Step 1:

• Develop a stakeholder engagement plan identifying key stakeholders, including government agencies, healthcare providers, policymakers, and beneficiary representatives. Schedule initial meetings to understand their perspectives and gather preliminary data.
• Next, the team is expected to collect detailed financial data on health expenditures from the Finance Department and financial management cell of the P&SHD and Specialised and Medical Education Department along with the Punjab Health Initiative Management Company. The team is expected to use WHO or IMF guidelines for fiscal space analysis preferably .   The team is also expected to collect health insurance claim data from SLIC and comprehensively analyse what services are being claimed, distributed across private and public sector establishments, and cross-referenced with claimant PMT scores (if applicable). The team will also document the rationale for the criteria of PMT score 40 and/or below, adopted for beneficiaries. 
• The consultants are expected to collect and analyse demographic projections and economic growth data from the Pakistan Bureau of Statistics and other relevant government and non-government institutions. Analyse data on current debt levels and fiscal policies affecting health financing. The team will also incorporate findings from the TA on review of Punjab Health Sector Strategy (2019-2030)
• The team is expected to review all relevant laws and regulations to assess the level of compliance of SSP financing mechanisms. These would include the Constitution (1973), Public Financial Management Act (2019), Provincial Finance Acts, Taxation Statuses, Insurance Ordinance (200), SECP Insurance Rules (2002), and any other relevant laws. 

Checkpoint 1: Complete the inception report with identified stakeholders and initial data collection with a rapid review of the current situation. 

Step 2:

• Conduct a detailed analysis of the costs of the current health insurance benefit package on Punjab’s budget (using its costings and understand what costing mechanisms have been used).
• Evaluate how health expenditures align with or exceed budget allocations and the implications for fiscal sustainability.
• Explore forecasting tools to provide a range of projections, highlighting potential fiscal pressures.
• Assess the overall budget structure, revenue streams, and expenditures across sectors to determine the available fiscal space for health spending on UHI.
• Explore opportunities for reallocating funds or increasing health spending efficiency.
• Conduct forecasting based on the current benefit package to understand the sustainability of funding these benefits in the long term under various economic conditions.
• Assess the fiscal space specifically in sustaining the current health insurance benefits, analysing revenue and spending to determine the feasibility of continued funding without additions or deletions.Assess the legal space to identify any barriers and obstacles in the current financing models, in order to reduce the risk of future legal challenges that may disrupt the programme.
• Do a fiscal analysis on how a budget can be pivoted from the tertiary and secondary healthcare facilities to the primary health care facilities.
• Analyse the efficiency savings by using more public facilities for treatment than private facilities. 

Step 3:

• Inception Report: This should outline the scope of the TA, the objectives, the methodology, tools, frameworks used, the literature review conducted, and a detailed timeline.
• Budget Impact Analysis Report (Draft): This report should analyse how the existing benefit package impacts Punjab’s health budget, detailing expenditures and budget alignment. It should also include an assessment of the long-term sustainability of the current benefit package, including fiscal space analysis, financial forecasting, and debt sustainability analysis.
• Final Report: This report should comprehensively analyse all findings and recommendations and lay a roadmap for the next steps. It is expected that the consultants will include an analysis section on what the economic risks will be if the current financing model is continued, what may happen in the event of a fiscal shock or economic downturn, and what impact it may have on the health sector service delivery and UHC SCI scores if there is a collapse or further damage is done in such events. The report should also include the next steps for conducting subsequent TA, including the recommended scope and objectives for phases 2 and 3, elaborated at the beginning of this document.

Conduct analysis of legal space, ensure legal compliance and mitigate risks, facilitate approvals, and secure stakeholder buy-in.

Timeline and LOE
The level of effort for the role is 28 working days, from September 2024 to -January 2025.

Requirements 

Educational Background
Bachelor’s and Master’s degree in Law, with specialization in public sector law, health law, or related fields. 

Experience:

• Minimum of ten years of experience in legal advisory roles within the public sector in Pakistan, ideally with a focus on health or social protection programs.
• Proven ability to navigate complex legal frameworks and provide actionable legal advice on large-scale public sector initiatives.
• Experience engaging with government legal advisors and stakeholders.

Technical Expertise & Competencies:

• In-depth knowledge of Pakistani laws and regulations, particularly those related to healthcare financing, social protection, and public sector governance.
• Strong analytical skills with the ability to identify legal risks and propose effective mitigations.
• Effective communication skills for interfacing with government legal advisors and ensuring that legal considerations are fully integrated into the program’s financial strategies.

Deliverables/KPIs

• Conduct a comprehensive review of the legal and regulatory framework governing the SSP, identifying any legal barriers to the proposed financial models.
• Ensure that all proposals comply with national and provincial laws, including but not limited to the Constitution of Pakistan, Public Finance Management Act 2019, Provincial Finance Acts, Insurance Ordinance 2000, and others as relevant.
• Draft necessary amendments to laws or regulations to support the SSP’s financial sustainability.
• Act as a liaison between the project team and government legal advisors to address any legal concerns and facilitate approvals.
• Identify potential legal risks and provide strategies for mitigation to ensure smooth implementation of the program.
• Contribute to the final report by providing a section that outlines the legal review findings, recommended amendments, and the legal viability of the proposed financing models.