(dog barks) (dramatic music) - [rita] this is dua fatima. at just six months old, she's been diagnosed with a life-threatening condition. she needs multiple surgeries to stand any chance of living beyond infancy. - (speaking foreign language)

- [rita] for her parents, mohammed and madiha, wanting healthcare for their daughter is a given, but paying for it is another matter. the care they so desperately need is beyond their means. - (speaking foreign language) - [rita] at home in their remote village of kallar syedan, mohammed works as a laborer earning just $200 a month. there is very little healthcare provision in poor rural communities like the one mohammed calls home. - (speaking foreign language)

- [rita] without some kind of help, his daughter will not survive. it's a story that plays out in so many countries across the globe in poverty, deprivation, and covid, preventing millions from accessing life-saving healthcare they so desperately need. but mohammed and his family have one ray of hope. here in pakistan, a groundbreaking health financing system has been developed to help those in need. the brainchild of a physician turned policy maker. - (speaking foreign language) - [rita] 10 years ago, dr. sania nishtar set out on a mission to modernize health financing in desperate need of reform. the challenge was immense, but dr. nishtar discovered that the flaw in pakistan's healthcare system was the system itself.

it is 2015, and dr. sania is on one of her regular visits to a local hospital where she encounters a family with an all too familiar problem. - she's developed an abscess in the brain. if the operation is not done now, she will most certainly not survive. they'll have to sell a piece of their land or they'll have to borrow from a family or community. they will end up being indebted for life. - [rita] with less than 2% of pakistan's gdp spent on health, the system was failing to provide basic coverage and it was the poorest who were suffering. - i think that it's tragic because you're dealing with people's lives. i mean, if these places were functioning

if hospitals were functioning, if medicines were available on the shelf, if functionaries were in place, people could have been served. the quality of care could have been better. (horn honking) - [rita] dr. sania believes healthcare should be available like drinking water, a reliable pure life-giving essential piped to us when we need it, wherever we are. but she discovered that in pakistan, the pipe that delivers healthcare is often choked or leaking. like many low and middle income countries, pakistan has inherited two systems that operate separately. first, a creaking public health system funded by taxes which has three tiers. a local basic health unit. next, a secondary hospital in the nearby town, and third, a major tertiary hospital in the provincial capital.

alongside this, a private system funded either through insurance premiums or out-of-pocket payments. these two systems can function together in higher income countries to provide near universal coverage. but in pakistan, most people work informally and are not covered by tax or insurance. - 27% of the country's population which comes to around 50 million individuals have health coverage in pakistan. but the rest, which is a staggering 165 million, do not. it is the mixed health system, which serves them and they run the risk of spending catastrophically on healthcare or foregoing healthcare altogether or getting into financial ruin when they are confronted with a major medical illness. - [rita] it was a desire to help others that led dr. sania to become the first female cardiologist in pakistan.

she quickly rose to the top of her profession but from a position of power, the disparities in her country's healthcare system became all too apparent. - i could have been a cardiologist for the rest of my life giving quality care to the rich and just turning my eye away from those who couldn't afford it. but what i saw in hospitals was very distressing. you'd see patients on stretchers outside. you'd see individuals waiting for wheelchairs to come. you'd see people with broken legs, the elderly with stroke and little children with fever and expectant mothers and overwhelmed doctors and the reality of the overload. and that's what led me to forego my clinical career as a cardiologist and embark on this journey to find a solution. - [rita] what dr. sania discovered was a public healthcare system in disarray, ripe

for exploitation and rife with inefficiencies and misuse. - so this is a district hospital. it is at the center of a very large population and here is its medical ward. i was expecting to see throngs of patients here but i'm shocked yet again to see a ward completely empty. - [rita] local residents were quick to air their grievances. - (speaking foreign language) - (speaking foreign language) - (speaking foreign language) - (speaking foreign language) - (speaking foreign language) - [rita] they were angry because a fully functioning hospital was only a stone's throw away. - i'm showing you something typical of the mixed health system syndrome. here, i'm standing on public property. this is a district hospital. it's abandoned. it's completely underutilized, but the building across is a thriving private hospital. there are throngs of patients there

and if you have the money, you can just walk across and seek care. - [rita] and the problem wasn't just confined to large hospitals. remote rural health centers were victims of exploitation and neglect as well. - this basic health unit was not meant to be right up on the hill. it was meant to be bang on the roadside but that roadside property has a lot of commercial value. so if you look across the road, you would see this hotel beautifully placed and the basic health unit is right up there. so imagine a woman who's about to deliver or an elderly person with a stroke having to come up all this way. it would be excruciating for them and i'm not surprised that it's underutilized. - [rita] the lack of use wasn't solely down to the location. the facility was simply unfit for purpose. - there never has been any running water in this facility.

there are electricity blackouts for 10 hours running. this basic health unit looks like a ghost health facility. in terms of brick and mortar, it has all the right elements, but it's hardly ever used. there is an ambulance that the facility owns but it's standing behind locked gates. i doubt if it's ever been used here. - the old system had two significant weaknesses. one was it had elements of corruption, and secondly all it did was transfer cash. whereas actually poverty isn't just about how much money you've got, it's about the opportunities you've got. it's about how are your children getting into school? it's about have you got the healthcare when you come to some catastrophic moment? all of those things make up poverty and so you have to think of poverty in the round. - [rita] dr. sania brought all of her evidence of systemic failure together in an analysis that would become a classic. "choked pipes" described pakistan's inequitable system

where public and private healthcare coexist. but reliance on taxation or insurance to fund the system fails to provide for the majority. it's the same picture across many low to middle income countries. - most developing countries that have poorly funded public systems and unregulated burgeoning private sector interplay in health actually suffer from the mixed health system syndrome. so when i wrote the first draft of "choked pipes" and sent it to some colleagues, especially in africa they called me back and said, "are you sure you've got the country right? because what you've described is actually what is playing out right here in our country." - [rita] dr. sania hoped that "choked pipes" would build such a strong case against the existing system that government would have to accept the reforms she was proposing. but in 2010, the government of pakistan gutted the health ministry and devolved power

to regional government. health was taken off the national agenda. - the ministry of health was abolished. the doors were locked and the business was just shut, one fine morning. for me, it was personally very shocking. - [rita] three years later, a new government reinstated the health ministry and dr. sania was appointed federal minister. a move welcomed both in pakistan and abroad. - mr. president, i'm pleased to report that earlier this month, we reestablished a federal level ministry of health in pakistan. the manner in which democracies and governance function has implications for health systems. - [rita] dr. sania rebuilt the national ministry of health to fix problems at the federal level, but the provincial health systems remained largely unchanged. she realized a new approach was needed.

- i just thought to myself, i've gotta do something practical. i can't be writing books and papers all my life and advocating for change. i have to demonstrate how change actually takes place on ground. tinkering at the margin is not an option anymore. we require some major decisions to overhaul this system. - [rita] her vision was to create a system that would help patients with no funds and nowhere left to turn to offer them a lifeline. but to do this required a completely new approach. - the health systems should be there to produce healthcare services and public health services that are effective and efficient that provide value for money and services that are equitable and responsive to needs of citizens, and to change in context in order to provide financial protection so everyone benefits. - a health system has to satisfy people

to equally cater to the needs of the rich and poor and it should ensure that patients do not face financial catastrophe when they fall ill. i would see while working in the emergency room, women being taken away from the hospital, bedridden for life because families did not have the money to pay for their hip operations. laborers on construction sites falling from the fourth floor, fracturing a leg and their relatives scurrying back to their villages to sell their only cow, their only mean of livelihood to pay for the operation. it was totally unacceptable. - [rita] in 2011, in pakistan's capital islamabad, dr. sania's heartfile organization was growing. she established a prototype third health system focusing on catastrophic health expenditure. her ambition was to grow a fund large enough to help the 73% who were left out of the mixed health finance system.

her new third system targeted cases individually with care being purchased from the best provider, whether public or private, plugging the gap and raising standards across the board. for four years, the project helped over 5,000 people access life-saving medical care without having to face financial ruin to pay for their treatment. - medical bankruptcies happen even in the most advanced countries of the world. so i focused on the issue of catastrophic health expenditure and catastrophic health expenditure is most pronounced in mixed health systems. - [rita] the heartfile health financing project harnessed emerging digital technologies such as sms rather than the slow paper-based bureaucracy used by the public health sector. it proved to be a lifeline for those most in need and laid the foundation for a system that would revolutionize social care.

back in 2015, little marwa bibi was facing a medical crisis which if left untreated, could prove fatal. - she's three. she'll be three years old just after it. she walks around during the summer, but during winter, she stays in bed. the doctor said, "when she reaches nine months, take her to peshawar for an x-ray. hopefully, they'll be able to give her an operation because without it, she'll die. they said the operation could cost three to 400,000 rupees. - [rita] paying for the operation would impoverish the entire extended family - (speaking foreign language) - [rita] unable to find treatment for her heart condition locally, marwa and her mother traveled the long distance to islamabad, hoping for a better chance of success.

- bed 17? (speaking foreign language) - [sana] (speaking foreign language) - [dr. mahrukh] (speaking foreign language) - [sana] (speaking foreign language) - marwa is a two and a half year old girl. she comes from a very poor background. she has got a hole in her heart. for this, she's gonna need an open heart surgery otherwise leaving her just like that, this child might not make it in a few years so she needs this surgery right away. - [rita] marwa was lucky. dr. mahrukh was one of a growing network of doctors working with heartfile health financing. the processing of marwa's case began. just 24 hours later, an assessor arrived. she had to be sure that the case was genuine - [assessor] (speaking foreign language) - [sana] (speaking foreign language) - [rita] using skype, another independent inspector

also witnessed the assessment. - [assessor] (speaking foreign language) - [shahzaad] (speaking foreign language) - [assessor] (speaking foreign language) - [rita] marwa's mother had 48 hours to wait while a panel of experts made the final decision on whether to fund her care. - [assessor] so the priority score is 23 and eligibility is 76. the system says that we can provide a full assistance. (machine beeping) - [rita] marwa's lifesaving operation took place within days. the cost of the procedure was negotiated directly with the hospital that excelled in heart surgery. payment was made only after the operation was completed successfully. this innovative use of digital technology directly undermined fraud

by ensuring that the grant could only be spent on the medical treatment itself. the model was so effective, it received worldwide attention at the world economic forum and clinton global initiative. it also became a case study at the harvard school of public health. - what sania did is to completely transform and create in effect a parallel, well functioning digital system which they were able to scale up very rapidly with the aim of providing affordable high quality access when care was needed. - [rita] in the seven years since marwa got her treatment, much has changed in pakistan. in 2019, the government launched a wide ranging social protection plan. sania joined the cabinet to execute the plan. called ehsaas, it was a radical new model for poverty reduction and reached out to more than 15 million households.

- that program came to be known as ehsaas which means compassion in our local language, urdu. ehsaas was a multi-component program. it had cash transfer services, care services for various categories of disadvantaged individuals and it had initiatives aimed at graduating individuals out of poverty by providing them with opportunities to build their livelihood. so there were these three large buckets of interventions within ehsaas. - ehsaas didn't just cover cash transfers. it didn't just cover education. it didn't just cover health. it covered things like nutrition of young children which is fundamentally important. so it was truly comprehensive and i think probably the most comprehensive anti-poverty program that i've ever seen. - (speaking foreign language) - [rita] dr. sania's heartfile health financing was copied as one of the pillars of the ehsaas system known as ehsaas tahafuz.

this third system has been pivotal in alleviating poverty for many. - so the third health systems model essentially purchases services from hospitals and from laboratories for individuals based on certain eligibility criteria where targeting comes into play, where rules come into play rather than purchasing services in hospital in bulk. - [rita] mohammed and madiha have brought their daughter, dua fatima to a hospital near rawalpindi. they hope she will get the surgery she so desperately needs. - (speaking foreign language) - [mohammed] (speaking foreign language) - (speaking foreign language) - [mohammed] (speaking foreign language) - (speaking foreign language) - [mohammed] (speaking foreign language) - (speaking foreign language) - [mohammed] (speaking foreign language) - (speaking foreign language) the baby, dua fatima has an increasing size of head

so we have to treat it urgently. that is a urgent matter. if they don't undergo the surgery, they can't increase up to the size of a football and they usually die after one and a half year. - [rita] dua fatima is lucky. her parents brought her in for treatment early but there's still the question of cost. - this is a disease of the poor people. they are usually 15 to 20,000 per month and the shunt costs 50,000. they can't afford it, so they usually don't go with the surgery and the patient dies. (speaking foreign language) - [rita] using a smartphone app, dr. umar can apply directly to ehsaas tahafuz for funding. once identities are crosschecked to weed out fraud, if dua fatima's father meets the criteria, he'll receive a text confirming the funding

for her operation. - before the the tahafuz program, many patients died because of their poor background. but after this program, the patients are coming in a very good flow and the the surgeries are performed well in time. if they come to the hospital early, we usually have 90 to 100% success - by bringing together the welfare system with the health system, she's really emphasized development of the social welfare program. sania's creating the basis for a universal health coverage that provides not just access to healthcare, effective healthcare but also financial protection when it's needed. - [dr. umar] (speaking foreign language) - (speaking foreign language) - what sania nishtar was able to do crucially was transfer money direct from government to the mobile phone of an intended beneficiary.

so the technology was absolutely fundamental 'cause it cut out all of the potential middle people who might be at risk of redirecting the money. - [rita] dua fatima's parents have the green light for her treatment. she will be operated on today to give her the best possible chance of a full recovery. - [dr. umar] (speaking foreign language) - [rita] the human story is still at the center of dr. sania's work. she's determined to enable the poorest in society to access free healthcare and to make sure it is provided in a coherent, transparent and above all, dignified manner. - i don't think the ehsaas program would've made the progress it has or have the comprehensive vision as well as activity it has without sania.

she's been truly awesome. - [rita] it's been seven years since marwa bibi had her lifesaving operation. she's now a happy, lively 10 year old. - (speaking foreign language) - [rita] the life-threatening heart defect that her parents couldn't afford to treat was healed thanks to dr. sania's pioneering scheme. - [sana] (speaking foreign language) - [rita] and baby dua fatima has had both of her life-saving operations completed successfully.

- (speaking foreign language) - one of my long-term ambitions is to ensure universal social protection for everyone, everywhere and health is a very important component of that. i want to play a small part in ensuring that no one pays catastrophically for healthcare. no one risks medical impoverishment. no one is driven to forego healthcare because they are unable to pay for it. - [rita] for decades, countries around the world have struggled with the divide between public and private healthcare. will sania's third system become the new normal for mixed health systems everywhere? global healthcare experts certainly hope so. (upbeat music)

[announcer] funding for this documentary was provided in part by the maryland forestry foundation. stewardship is caring. (lilting piano music) ♪ forest her: the next wave of conservation. (piano music continues) ♪ [narrator] mother earth is communicating with her waters and trees. our ecosystem depends on trees to filter water, reduce sedimentation, provide oxygen, and grow food. (trees rustling in the wind)