The experience of implementing a social health insurance programme at health facilities in Khyber-Pakhtunkhwa, Pakistan

Abstract

Objective:To explore the experiences of key stakeholders, including hospital managers, clinicians, and hospital-based StateLife Insurance Corporation (SLIC) representatives, SCP's implementation challenges and successes.Methods: A qualitative descriptive exploratory design was employed across 38 empanelled public and private facilities inKP. Key informant interviews (n=103) were conducted until data saturation was reached, exploring barriers and facilitatorswithin the SCP's operational framework. Data were analyzed using NVivo software, applying a mix of deductive and inductiveapproaches.Results: Strengths and enablers included a comprehensive benefits package design, a robust third-party administrativesystem, and the digitization of health management information systems for efficiency. Implementation barriers includedlow reimbursement rates affecting service quality at health facilities, documentation issues hindering patient access, unevenavailability of services causing patient frustration, resource-intensive claim preparation with a slow reimbursement process,and a lack of quality assurance mechanisms.Conclusion: This study provides a nuanced understanding of the SCP implementation, highlighting the need for revisitingreimbursement rates, addressing documentation challenges, ensuring service availability, streamlining reimbursementprocesses, and strengthening quality assurance mechanisms. The SCP's comprehensive benefits package, effectivepurchaser-provider relationships, and digitization efforts emerge as key strengths that contribute to its success.Keywords: Sehat Card Program (SCP), Social Health Insurance, Implementation Challenges. Stakeholder Perspectives,Reimbursement Processes, Khyber Pakhtunkhwa