The German Development Bank as a policy entrepreneur for social health protection: a case study of the development and implementation of the ‘Sehat Sahulat Programme’ in Khyber Pakhtunkhwa, Pakistan

Background The German Development Bank (KfW) supported the Government of Khyber Pakhtunkhwa (GoKP) to design and implement its first social health protection (SHP) scheme, named the Sehat Sahulat Programme (SSP). We described the role of KfW in the evolution of SSP with a view to identifying transferrable lessons for international development agencies working on similar initiatives in socioeconomically comparable contexts. Methods We employed a qualitative instrumental case study design approach. First, we obtained and analysed key programme documents to describe the chronology of events and policy changes. We then undertook in-depth interviews to understand factors influencing policy changes. Finally, we carried out non-participant observations to understand how policy decisions were made and implemented. We employed maximum variation sampling to recruit participants and conducted a thematic analysis of data. Results SSP was described by GoKP officials as an innovative financing strategy and a flagship project of the government formed by the Pakistan Tehreek-i-Insaf (PTI). First, programme officials reported that KfW was instrumental in both designing and financing SSP, which had plans to provide free health insurance to low-income families and raise revenue through paid enrollment of the wealthy (solidarity). Second, GoKP deviated from this model and covered the entire population of KP free of cost. Through SSP, GoKP envisaged service provision through private hospitals (subsidiarity). In the third year, GoKP included public sector hospitals in the programme. Although planned supplementary insurance products might result in inequitable utilisation, KfW continued supporting SSP and committed funding for piloting outpatient department services for two years, 2023 and 2024. Conclusions This in-depth case study has highlighted the potentially positive role of international development assistance in introducing innovative financing strategies to promote universal health coverage. However, development partners might have limited control over how things evolve.