Pakistan has made significant strides in advancing universal health coverage (UHC) since signing the UHC 2030 Global Compact in 2018. It became the first country to develop a UHC benefit package, based on the Disease Control Priorities, 3rd edition (DCP3). The country has begun phased implementation in 12 prioritized districts after the development of a UHC benefit package in 2020, with the support of the Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP) partners, including Gavi, the Vaccine Alliance, Global Financing Facility (GFF), Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Children's Fund (UNICEF), United Nations Development Programme (UNDP), United Nations Population Fund (UNFPA), World Bank (WB) and World Health Organization (WHO). The SDG3 GAP coordination and alignment committee at country level has played a catalytic role in streamlining and enhancing coordination among development partners for primary healthcare (PHC) and health financing accelerators to drive UHC implementation.
The effectiveness of the SDG3 GAP coordination and alignment committee became evident during the summer of 2022 when Pakistan experienced catastrophic floods resulting from heavy rains, glacial melt and landslides. Approximately 33 million people were affected, with nearly eight million people displaced and 1700 fatalities. The floods damaged the health infrastructure and impacted the health workforce, leading to the disruption of 13% of health facilities. The delivery of healthcare services from the community to the district level was markedly affected. Due to the disruption of services, the immediate focus shifted to the formidable task of conducting a post-disaster needs assessment (PDNA). WHO led the health cluster for the PDNA, involving 22 national and international experts from seven entities, including the Asian Development Bank (ADB), UNAIDS, UNICEF, UNDP, UNFPA, WB, and WHO. Most of these organizations were already collaborating under the SDG3 GAP committee and these connections proved instrumental in bringing all relevant partners together for the assessment and in sharing updates on their ongoing and planned activities in response to the floods.
Visit to flood-affected area, Larkana, Pakistan, 12 September 2022. ©WHO Pakistan/Hamid Inam
The PDNA involved a meticulous analysis of the flood's impact on the population, physical assets and healthcare services. Through a combination of quantitative and qualitative analyses, it identified the necessary response measures to restore essential and non-essential services as well as provided estimates for short-, medium- and long-term needs for infrastructure reconstruction and service delivery restoration. The total cost of damages in the health sector was estimated at US$109 million, with losses amounting to US$34 million. The projected costs for recovery and reconstruction were estimated at US$188 million.
The PDNA report served as the baseline to develop the Resilient Recovery, Rehabilitation and Reconstruction Framework (4RF), which, in turn, became Pakistan's blueprint for planning, financing, implementation and monitoring at national and provincial levels. The 4RF outlines key priorities for policy and operational reforms, including short-term plans to ensure uninterrupted health service delivery and to address social determinants as well as medium-term strategies, involving UHC and coordinated mechanisms, disease surveillance, health information systems and stable public financing. It was developed through consultation with key stakeholders, including federal and provincial governments and international development partners. The dynamic nature of the 4RF allows for regular updates to align with changing priorities and availability of resources, playing a vital role in monitoring and evaluating the recovery programme's progress and effectiveness.
Medical camp supported by WHO, Sukkur, Pakistan, 12 September 2022. ©WHO Pakistan/Hamid Inam
The PDNA and 4RF played a pivotal role in offering evidence-based estimates and strategies at the International Conference on Climate Resilient Pakistan, co-hosted by the Government of Pakistan and the UN in January 2023, in Geneva. The global conference served as a platform to secure international support and establish enduring partnerships, aimed at enhancing Pakistan’s climate resilience and adaptation efforts. This success highlighted the remarkable collaboration among partners, which proved invaluable in working cohesively on the PDNA and 4RF. It stands as a noteworthy example of practical endeavors that can be replicated at the implementation level within the health sector, through joint work plans and comprehensive monitoring and evaluation processes.
Under the flood rehabilitation plan, development partners are supporting the Government of Pakistan through a resilient recovery, by reconstructing damaged health facilities and building the capacity of the health workforce. WHO Pakistan is working with the government to reconstruct the health sector infrastructure to provide essential health services. This includes the refurbishment of 464 PHC facilities, the strengthening of 169 basic emergency obstetric care (EmOC) service centers and the establishment of 88 nutrition stabilization centers in flood- affected districts. UNICEF provided essential PHC services to 6 083 267 flood-affected people through outreach and static facilities, refurbished 112 damaged facilities and supported 5000 lady health workers with essential supplies and basic equipment for community outreach. The GFATM provided financial support of US $48.25 million to support uninterrupted availability of lifesaving health products, thereby ensuring the continued access to free malaria and tuberculosis (TB) diagnostic and treatment services for communities during the humanitarian response phase. The funds have also been used to renovate health facilities and replace destroyed equipment in laboratories for building resilient health systems.
Building on previous milestones
As featured in the 2022 Country Case Study, the SDG3 GAP partners supported the strengthening of PHC and health financing to facilitate the implementation of the UHC benefit package for integrated service delivery. However, the floods in 2022 severely damaged the health infrastructure, disrupting health service delivery, and there is a risk of a reversal of previous gains on the path to achieving UHC.
Resilient health systems are vital foundations for robust and productive communities, delivering health services in an equitable, sustainable and effective manner. WHO, with GFATM’s support, provided technical assistance to the government to develop a resilient health systems component in the GFATM funding request 2024-26. The consultative process engaged federal and provincial governments, SDG3 GAP partners (UNAIDS, UNICEF, GFATM, UNFPA, UNDP), development partners and private sector representatives. The interventions outlined in the resilient health systems plan are primarily centered around PHC and community engagement. They aim to facilitate integrated service delivery, eliminate duplications, optimize resource allocation and enhance efficiency within programs associated with HIV, TB and Malaria. Further, this offers a significant opportunity for coordinated endeavors between the government and partners, including SDG3 GAP allies, with the potential to enhance collaboration during implementation and establish a robust resilient health systems framework for integrated service delivery, aligned to the National Health Support Project (NHSP).
To address the issue of suboptimal coordination among partners, as reported by the Government in the SDG3 GAP monitoring framework survey, the SDG3 GAP coordination committee is actively working to strengthen coordination and collaboration among partners, both in the planning and implementation phases, to avoid fragmented efforts in their support to the Government. Over the past few years, this collaborative effort has witnessed many landmark developments, such as the joint high-level mission for “primary healthcare for universal health coverage” (PHC4UHC). The mission involved eight SDG3 GAP agencies and regular engagement through the SDG3 GAP coordination committee and technical working groups. The active participation of all partners in key initiatives, including the NHSP, the Model of Care, the resilient health systems component on the request for funding from GFATM, cross-programmatic efficiency analysis of selected vertical programs, the PDNA and the 4RF, among others.
What is the SDG3 GAP?
The Global Action Plan for Healthy Lives and Wellbeing for All (SDG3 GAP) is a set of commitments by 13 agencies that play significant roles in health, development, and humanitarian responses to help countries accelerate progress on the health-related SDG targets. The added value of the SDG3 GAP lies in strengthening collaboration across the agencies to take joint action and provide more coordinated support aligned to country owned and led national plans and strategies.