“Health protection is an important economic topic”
Interview with FAU professor Andreas Landmann on health care provision in Pakistan
Health insurance is something we take for granted in Europe, but for many people all over the world, it is simply unaffordable. Pakistan is one of the countries that does not have a social health protection scheme. To change this, Prof. Dr. Andreas Landmann from the Institute of Economics at FAU is collaborating on a project that is hoping to secure outpatient health care services in the country. In this interview, he talks about his role as an economist and that of his team in the project and what he does during his research stays in Pakistan.
You’re working on the INSPIRE project and have spent time in Pakistan for the project. What is INSPIRE about?
The acronym INSPIRE stands for “Informing the Social Health Protection Initiative through Rigorous Evidence” and the project aims to secure social health protection in Pakistan, specifically outpatient health care services. We were involved in planning and implementing state run health insurance for hospitals in our first project, but there are no schemes as yet for outpatient treatment. This area is more complex, as outpatient health care providers are smaller, more diverse and more difficult to monitor and have fewer administrative resources and less infrastructure. In addition, the use of outpatient health care depends to a greater extent on the costs involved, which means it can quickly become expensive if many more people visit the doctor. This makes it an unpredictable financial risk for the cost-bearing institution who is providing the health insurance.
Health care isn’t necessarily the first thing you would associate with economics. What do both areas have in common?
I actually conduct research on risk and insurance, which is one of the core issues of economics, because the subject deals with how to secure against financial risks and explores which incentive and economic problems exist. This is the case for all types of insurance, also in health care. Poor health is the greatest financial risk for people all over the world and this is especially the case in developing countries.
This is the reason why health protection is so important and the reason why it is a key issue in economics, for example when trying to answer questions such as why poverty and health are mutually dependent. Our work at INSPIRE is interdisciplinary and we have researchers with a medical background as well as some from the public health sector.
What are your tasks in the project?
I am the principal investigator, which means I am the spokesperson for the consortium. This means I am responsible for organizing the project and I coordinate the activities of the three universities involved. I also represent the project to third parties and I am responsible for communicating with project partners, the Ministry of Health in Pakistan and the Kreditanstalt für Wiederaufbau (KfW) (KfW Development Bank). But my main task, of course, is our research agenda and supervising my doctoral candidates and postdoctoral researchers.
How did you get involved in the project?
I have been involved in research into health insurance in Pakistan for 11 years. My contact with the KfW came about much earlier though, as I won a prize for practical research for my doctoral thesis. I used the opportunity to talk to the KfW about their plans for the health sector and I thought the project for setting up a social health protection scheme in Pakistan sounded really interesting.
From 2014 onwards, I started working on the project for hospital health insurance I mentioned earlier and it made sense to start another innovative pilot project after that, focusing this time on outpatient health care as the first one was such a huge political success. We spent many years preparing the INSPIRE project and it started officially in 2021.
How exactly are you involved in the project?
We conduct a great deal of accompanying research. Before implementation, which is scheduled for the end of this year, we will ascertain the needs of the population and incorporate this information into the project. We will also outline the framework conditions of the health care providers. As soon as health care provision has been secured, we will collect data on the effects this has and highlight any potential for improvement.
What was it like in the country itself? Pakistan is not necessarily a conventional holiday destination.
In some ways it’s more complex, or more dangerous if you want to put it in a more direct way. It’s no coincidence that some parts of the country are marked red on the risk map. But there are some parts of the country where it is possible to lead what we would call a normal life, in the capital city Islamabad, for example.
Fortunately, I have several good local contacts who I can rely on and who offer good advice on which areas are safe. There is also an official document known as a “no objection certificate”. Before traveling, you have to say where you are going and then you need this certificate, depending on your destination, that says that there are no security concerns, or that security will be provided. In some cases, this could mean that you receive a heavily armed police escort. But this is something I would prefer to avoid as it’s a bit strange and attracts more attention than if you are traveling in a normal unmarked car (laughs).
Is it easy to get to know people under these conditions?
Pakistan is a great country with unbelievably welcoming people. I always look forward to the food each time I go there. I’ve been there 12 times already and have got to know the country and its culture very well. The large number of personal contacts I have there have made getting to know the country much easier, of course. And that is what you were referring to in your question. The fact that travel is more complicated also means that it’s not always easy to travel to villages and talk to people spontaneously. The interviews with focus groups always involve a great deal of organization. This means it’s not really that easy to get to know people. But we do get to know the project partners really well.
We’ve already completed one very important step, which is to create a needs assessment for outpatient care from the perspective of the general population. We’re currently evaluating the provider side, which means we’re looking at outpatient clinics in hospitals, doctors and local health stations. We’re looking at if and how they can provide health care, and we will put the information into a policy brief for our partners. We have almost completed this step.
In addition, we will also collect data on households on the one hand, and on providers on the other, so that we have some up to date information just before implementation. The provision of outpatient health care is to be implemented this year and we will accompany the project afterwards in order to investigate which changes it brings about or which changes are necessary.
The project is a very good basis for further projects. We have already been awarded another grant and I think there is a great deal of potential for further research in this area.
The project's blog: https://blogs.fau.de/inspirepakistan/
Follow-up funding awarded
Prof. Landmann and Prof. Helmsmüller from Hochschule Bonn-Rhein-Sieg have been awarded funding by the German Institute for Development Evaluation (Deutsches Evaluierungsinstitut der Entwicklungszusammenarbeit - DEval) and the Federal Ministry for Economic Cooperation and Development (BMZ). In the project called Impact evaluation of the OPD health insurance in Northern Pakistan, they will conduct a rigorous quantitative measurement of the effects of outpatient health insurance. The funding period runs from March 1, 2023 until September 30, 2025.
Further information about the DEval RIE funding: https://rie.deval.org/de/rie-foerderprogramm/das-rie-foerderprogramm/foerderprogramm
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