The protection gap under a social health protection initiative in the COVID-19 pandemic: A case study from Khyber Pakhtunkhwa, Pakistan.

Background Sehat Sahulat Programme (SSP) is a Social Health Protection (SHP) initiative by the Government of Khyber Pakhtunkhwa (GoKP), covering inpatient services for 100% of the provinces population. In this paper, we describe SSPs role in GoKPs COVID-19 response and draw inferences for similar programmes in Pakistan. Methodology and methods We conceptualised SSP as an instrumental case study and collected three complementary data sources. First, we studied GoKPs official documents to understand SSPs benefits package. Then we undertook in-depth interviews and collected non-participant observations at the SSP policy and implementation levels. We recruited participants through direct (verbal and email) and indirect (invitation posters) methods. Use of maximum variation sampling enabled us to understand contrasting views from various stakeholders on SSPs policy dimensions (i.e., coverage and financing), tensions between the policy directions (i.e., whether or not to cover COVID-19) and how policy decisions were made and implemented. We collected data from March 2021 to December 2021. Thematic analysis was conducted with the help of Nvivo12. Findings Throughout 2020, SSP did not cover COVID-19 treatment. The insurer and GoKP officials considered the pandemic a standard exclusion to insurance coverage. One SSP official said: "COVID-19 is not covered and not relevant to us". GoKP had stopped non-emergency services at all hospitals. When routine services restarted, the insurer did not cover COVID-19 screening tests, which were mandatory prior to hospital admission. In 2021, GoKP engaged 10 private SSP hospitals for COVID-19 treatment. The SSP Reserve Fund, rather than insurance pooled money, was used. The Reserve Fund was originally meant to cover high-cost organ transplants. In 2021, SSP had 1,002 COVID-19-related admissions, which represented 0.2% of all hospital admissions (N=544,841). An advocacy group representative called the COVID-19 care under SSP "too little too late". In contrast, SSP officials suggested their insurance database and funds flow mechanism could help GoKP in future health emergencies. Conclusion The commercially focused interpretation of SHP arrangements led to a protection gap in the context of COVID-19. SSP and similar programmes in other provinces of Pakistan should emphasise the notion of protection and not let commercial interests lead to protection gaps.