Evaluating the Grievance Redressal System in Public Driven Health Insurance Program: Lessons and Learning for Pakistan

Abstract

Introduction The supply-driven public sector health insurance programs often face a lower utilization of health services due to an incompetent grievance redressal (GR) system, flawed design and burecratic hurdles. Resultantly, the targeted population faces poor quality of services, especially when their grievances are not addressed appropriately.
Methods This paper evaluates the efficiency and effectiveness of the GR system in the Sehat Sahulat Program (SSP)—a universal health insurance (UHI) initiative in Pakistan. Our research comprises both qualitative and quantitative components, where we conducted in-depth interviews with the supply-side stakeholders, patients, complainants and citizens.
Results We found that the program lacks an integrated case management system (ICMS). The complaints, registered through the call center, are only monitored. However, the call center lacks an automated system and hospital integration. Most of the population needs more knowledge about the program's features and how to register complaints. Despite being a universal health insurance (UHI) initiative, the program requires a clearer policy on the GR system, and there is a limited technical capacity to analyze the complaints.
Conclusion Currently, the inpatient utilization rate of health services is below 3%. An efficient GR system along with improvement in program design can raise the inpatient utilization rate to 8-10%. The program requires a robust communication strategy, an integrated case management system (ICMS), a referral system, a hospital tracking android application, and regular monitoring, which will effectively use the taxpayer’s money.