pISSN 2671-6925   eISSN 2671-6933
Open Access, Peer-reviewed
    J Glob Health Sci. 2019 Dec;1(2):e46. English.
    Published online Nov 28, 2019.
    https://doi.org/10.35500/jghs.2019.1.e46
    © 2019 Korean Society of Global Health.
    Original Article

    Lessons learned for reducing out of pocket health payment in Afghanistan: a comparative case study of three Asian countries

    Fatima Akbari,1 Munehito Machida,1,2 Hiroyuki Nakamura,3 Keisuke Nagase,4 Aya Goto,5 and Akinori Hara3
      • 1Department of Global Health, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan.
      • 2The Partnership Project for Global Health and Universal Health Coverage (GLO+UHC), Japan International Cooperation Agency (JICA) Thailand Office, Bangkok, Thailand.
      • 3Department of Environmental and Preventive Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan.
      • 4Department of Corporate Planning, Kanazawa University Hospital, Kanazawa, Japan.
      • 5Center for Integrated Science and Humanities, Fukushima Medical University, Fukushima, Japan.
    • Correspondence to Fatima Akbari. Department of Global Health, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa 920-8640, Japan. Email: Fatima.akbari111@gmail.com
    Received November 01, 2019; Accepted November 21, 2019.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Abstract

    Background

    In Afghanistan, out-of-pocket (OOP) health costs provoke inequities of access and have pushed 2.55% of the population below the poverty line.

    Methods

    This multiple case study consists of 3 countries' experience in OOP reduction (Afghanistan, Korea, and Thailand). Our analysis is based on “The Five Control Knobs” first proposed in 1997.

    Results

    In the financing knob, government domestic revenue is the most important contributor to health financing in Korea and in Thailand, where OOP has been replaced. While relying on foreign donations for OOP reduction, household OOP remains the most important source of healthcare revenue in Afghanistan. As for the payment knob, OOP reduction is assisted by the following reforms in the 3 countries: 1) abolition of user fees in Afghanistan, 2) unification of health insurance agencies in Korea, and 3) introduction of a Universal Coverage Scheme (UCS) in Thailand. In regard to the organization knob, increasing the number of health care facilities and expanding available health services have significantly contributed to reducing OOP in all cases. In relation to the regulation knob, the following reforms have reduced OOP burdens: regulation of the private health sector in Afghanistan, separation of drug dispensing from prescribing in Korea, and introduction of the UCS in Thailand. As for the behavior knob, further improvements require patients to behave differently, as encouraged by social marketing, access to reliable health information, and effective complaint management.

    Conclusion

    Reduction of OOP in Afghanistan could result from coordination among several reforms in the control knobs. Increasing government participation and earmarking surplus taxes for health, replacing passive provider payment methods to active ones, and including needed health services in the public standardized health packages, are actions that Afghanistan could adopt, and adapt, from the experience of Korea and Thailand for further success.

    Keywords
    Out-of-pocket payments; Health policy; Health care reform; Case study; Universal health coverage

    INTRODUCTION

    Discourse about using insurance schemes to promulgate healthcare services go back to at least 1883.1 In 2005, the concept of universal health coverage (UHC) was endorsed at the 58th World Health Assembly,2 and health insurance has become a hot topic in the global health community. Subsequently, UHC became an important endpoint among the Sustainable Development Goals (SDGs) proposed in 2015 at the United Nations General Assembly.3 UHC means “people in any part of a country can receive the required healthcare services of sufficient quality, without facing any financial difficulties.” This definition reflects three dimensions of coverage: population coverage, service coverage, and financial coverage.4 The financial aspect of UHC emphasizes reducing the percentage burden of peoples' out-of-pocket (OOP) healthcare expenses. Fear of catastrophic financial burden arising from OOP expenses discourages poor people from seeking healthcare services. This lack of equity and financial risk protection stands in the way of achieving UHC.5 In spite of global efforts toward UHC, at least half of the world's population still does not have access to essential health services, and 100 million people are being pushed annually into extreme poverty due to catastrophic healthcare debt.6

    Years of civil war and Taliban dominance in Afghanistan destroyed infrastructure in all sectors, including the health service delivery system. After defeating the Taliban and establishing a new government, Afghanistan started on its path to UHC by introducing the Basic Package of Health Services (BPHS) in 2003, a package of services necessary to address major health problems.7 However, Afghanistan still has a long way to go before achieving UHC, including the need to address health inequities between urban and rural areas,8 dependence on donors to sustain health service delivery, and OOP payments, which account for more than 70% of health service costs.9 Many studies have correlated high OOP with major health problems in Afghanistan, highlighting the seriousness of this issue and the urgent need to address it. For example, a 2016 report found that household OOP is a major barrier to accessing BPHS in Afghanistan,10 with high costs and inability to pay being reasons for not seeking treatment in 50% of those who responded to a survey in 2004–2005.11 Wealth quintile has been identified as the strongest predictor of health-care-seeking behavior in Afghanistan.11 Also, the Afghanistan Multiple Indicator Cluster Survey (AMICS 2011-12) showed a huge difference in access to and utilization of healthcare services between poor and rich families.8

    Korea, a high income country, is noteworthy for its introduction of a stable unique health insurance scheme, and, after 12 years of sustained effort, successful achievement of Universal Insurance Coverage for all citizens.12 Thailand, a middle income country, implemented a Universal Coverage Scheme (UCS) that includes citizens of its informal sector (currently around 75% of the Thai population), within 2 years, based on long-term public health activities. Thailand is well known globally for achieving Universal Insurance Coverage for all citizens in 2002.13 These prominent achievements in Korea and Thailand provide lessons to be learned for low- and middle-income countries seeking paradigms of Universal Insurance Coverage achievement, including Afghanistan, which has a relatively low Gross Domestic Product (GDP).

    The aim of this study is to identify plausible health system reforms that reduce OOP in Afghanistan, by analyzing experiences in Korea and Thailand that led to OOP reduction in the years that followed reforms in each country.

    METHODS

    Study design

    This study is an embedded multiple case study with a literal replication design,14 pertaining to the experience of 3 countries (Afghanistan, 2008–2009; Korea, 2000–2001; and Thailand, 2005–2006) to significantly reduce OOP contribution to total health expenditure (THE). This multiple embedded case study contains more than 1 sub-unit by using “control knobs” in analysis, which allows for integrating quantitative and qualitative methods within one unit. The literal replication in this study means that the cases were selected to corroborate each other with regard to the OOP reduction.

    Data sources

    The World Health Organization (WHO)'s Global Health Expenditure Database and Global Health Observatory (GHO) provided health-financing data. Local and international reports were found via PubMed, Web of Science, and Oxford Academic with search logic ([“health system” OR “Out of Pocket” OR “financial risk protection” OR “UHC”] AND “Afghanistan”). Afghan Ministry of Public Health (MoPH) officials also provided valuable information.

    Analysis framework

    To guide data collection and analysis, the units of our analysis framework were defined according to “The Five Control Knobs” (Financing, Payment, Organization, Regulation, and Behavior), as initially proposed by William Hsiao in 1997.15 In order to achieve a desired result in a complex system, the performance of different inputs must be modified to produce specific outputs. This concept can be applied to health care delivery systems. Five control knobs (Financing, Payment, Organization, Regulation, and Behavior) are defined as the primary inputs for producing intermediate outputs. Control knobs are key features that influence the performance of a health care delivery system and can be changed by policy.15 By exploring delivery system control knobs, a health sector reformer can undertake a diagnostic journey, and determine the causes for health care delivery system outcomes.15 In this study, our target outcome for health care delivery was OOP reduction. We assessed reforms in the 5 control knobs over the years preceding the year in which the OOP was substantially reduced in each country to determine which factors played significant roles. After comparing reforms among all cases, this study proposes health system reforms to reduce the health OOP burden in Afghanistan. For assessing each control knob, we formulated a question for each one to inform and guide our efforts (Table 1).

    Table 1
    Brief description of each control knob and its associated question

    Analysis procedures

    First, the “Questions” in Table 1 were drafted and revised until agreement was reached through discussions among members of the research collaborating group in the MoPH in Afghanistan. During these discussion, we concluded that OOP payment reduction will enable all citizens, regardless of income, to access and purchase health services. So, we set the question “What are the financing options that can successfully substitute OOP?” in the Financing control knob. We analyzed country-specific data on healthcare reforms in each control knob for each case separately, to determine the most significant contributors to OOP reduction. The researchers discussed data collected from previously mentioned sources and the conclusions among themselves, and consulted with experts in each area and inside the target countries, in order to improve the data interpretation. We then compared the results for the 3 cases to make final recommendations according to the main study goals.

    RESULTS

    Indicators and trends in OOPs

    Comparison of the general healthcare financing indicators among Afghanistan, Korea, and Thailand (Table 2) indicates that the highest healthcare expenditures overall (15,282 million USD) and per capita (217.1 USD) are in Korea, and the lowest are in Afghanistan (1,984 million USD and 60.1 USD, respectively). Although Korea shows the highest percentage of people who spend a considerable amount of their income on healthcare services, the percentage of people pushed below the poverty line by healthcare payments is almost zero; this percentage is higher in Thailand, and highest in Afghanistan. The percentage of domestic general government expenditures for healthcare is highest in Thailand and lowest in Afghanistan, but the percentage of private healthcare expenditure and OOP are the opposite in these countries.

    Table 2
    General and health financing indicators of the 3 countries

    In all 3 cases, the percentage of OOP contributing to THE has decreased significantly. The reduction started in different years: 2008–2009 in Afghanistan, 2000–2001 in Korea, and 2005–2006 in Thailand (Fig. 1). We focused on each of these OOP-changing transitions and presented case study findings in terms of current status, reforms in each control knob, and OOP trend affected by reforms, to evaluate and compare the influential issues in the reforms in all cases (Table 3).

    Fig. 1
    The percentage of OOP participation in THE in all cases.
    The database does not include data from Afghanistan prior to 2002.

    OOP = out-of-pocket; THE = total health expenditure.

    Table 3
    Current situation and major reforms in each country

    Experiences in reducing OOP

    Financing

    Household OOP is the main source of health care revenue in Afghanistan, while social insurance contributions and government domestic revenue predominate in Korea and Thailand, respectively. OOP reduction in each case was attempted by different financing options. In Afghanistan, when the OOP contribution to THE fell by 10% between 2008–2009, it was replaced by direct donations from foreign-aid agencies to the healthcare sector. In Korea, when the OOP contribution to THE fell by almost 5% between 2000–2001, it was replaced by social health insurance (SHI) and transfers by the government on behalf of specific groups (e.g., payments to SHI on behalf of specific population groups such as children, and the elderly). On the other hand, in Thailand, when the OOP contribution to THE fell by almost 10% between 2005–2006, it was mainly supplanted by government domestic revenue payments (Fig. 2).

    Fig. 2
    CHE by the percentage of revenue of health care financing schemes (source: Global Health Expenditure Database).
    CHE = current health expenditure; SHI = social health insurance.

    Payment

    1) Payment methods to healthcare professionals

    In Afghanistan, a monthly salary is the most common payment method for professionals in the healthcare sector.16, 17 This is also true for Korean health professionals working in hospitals and public institutions, but others in primary and ambulatory care are paid on a fee-for-service (FFS) basis.18 In Thailand, salary and salary plus bonus are the common payment methods.19, 20 From 3 countries' experience, no OOP reduction can be traced to how healthcare professionals are paid.

    2) Providers' payment mechanism

    In Afghanistan, since the introduction of BPHS7 and Essential Package of Hospital Services (EPHS; a standardized package of secondary health services provided by provincial and regional hospitals throughout the country),21 a capitation payment system had been used to pay contracted non-governmental organizations (NGOs) for delivering the covered healthcare services.17 However, during the 2010s, a global budget payment method was introduced, in which organizations must meet predetermined outcome targets before getting their budget allocation; organizations that exceed their targets will be paid more, with freedom to reassign budget lines.22 However, this reform does not seem to affect the OOP trend significantly because non-contracted BPHS and EPHS facilities were still assigned to predetermined, unmodifiable budget lines.22 Furthermore, since 2010, result-based financing has been applied to incentivize health service delivery.23

    In Korea, FFS had been the most common way to pay health care facilities since the establishment of the current health system in 1961.18, 24 However, efforts were made to replace it with a resource-based relative value scale (RBRVS), which determines payments for outpatient care based on the cost of the resources for providing the services,25 and prospective payments for inpatient care, according to a Diagnosis-Related Group (DRG) scheme.18 Efforts led to implementation of the RBRVS in 200126 and implementation of DRGs for acute care providers under 7 disease categories in 2013.27 Yet, the trend of OOP contribution to THE has not significantly changed since 2001.

    In Thailand, provider payment methods since 2002 have differed among 3 major health services purchasers: the National Health Security Office (NHSO), the Comptroller General Department (CGD), and the Social Security Office (SSO).28 The NHSO reimburses the UCS based on age-adjusted capitation for outpatient services, and DRGs for inpatient services.29 The CGD has reimbursed the Civil Servants Medical Benefits Scheme (CSMBS) for monthly outpatient bills since 2007, and replaced FFS with DRGs for inpatients in 2007.30 The SSO uses inclusive capitation for outpatients,29 and applies DRGs partly for inpatient services to reimburse SHI providers.31 Through the reforms above, OOP burden has gradually decreased.

    3) Patients' payment methods

    In Afghanistan, during the first years of BPHS and EPHS implementation, there was no formal cost-sharing policy between patients and the government, and most NGOs were charging patients point-of-care user fees.32 This policy was abolished in 2008, based on a health financing study from 2005,33 and OOP contribution to THE fell by 10% the following year. Ever since, BPHS and EPHS are available free of charge, while patients have to pay high user fees for other medical services sought from private healthcare providers.34

    In Korea, for services included among National Health Insurance (NHI) benefits, people are required to make a copayment that varies according to the level of the healthcare services facility. For services not covered by the NHI benefit, people have to pay FFS.35 Vulnerable and low income earners (3.8% of the population in 2009), are covered by a Medical Aid Program funded through general tax revenue, and those persons pay no or discounted fees for health services.36 Before health insurance reform in the early 1990s, different insurers had different methods to assess the contributions of the participants.35 Since 1998, the National Health Insurance Corporation (NHIC) has managed all insurers, and after 2000, when the OOP contribution to THE trended down by almost 5%, all insurance agencies were unified under the NHIC, and the contributions and co-payment rates became similar for all beneficiaries.37

    In Thailand, after the introduction of UCS in 2002, a small copayment of 30 baht (0.96 USD) per visit was required, but this requirement was discontinued in 2006, after which the OOP contribution to THE trended down almost 3% the next year).38 Also, coverage of services by the UCS has expanded; for example, antiretroviral drugs began to be covered in 2004, after which the OOP contribution to THE trended up 1% but significantly declined by 10% in 2005, and renal replacement therapy for end stage renal disease began to be covered in 2008, after which the OOP contribution to THE dropped gently by almost 1.5%.39 Currently, the services covered under all insurance schemes are entirely free,19 unless people buy non-prescription medication, visit private health facilities whose charges are not covered by insurance, or bypass the required steps for seeking health care at specific facilities.20

    Organization

    1) Mix of healthcare service delivery organizations

    In Afghanistan, mainly NGOs are in charge of public health facilities (BPHS- and EPHS-delivering facilities) with the MoPH overseeing their activities.16 Although data about the private health facilities are still insufficient,40 60% of Afghans reported that private health facilities were their first referral point.40, 41 Between 2001 and 2010, the number of public health delivery facilities increased 3-fold,42, 43 and between 2004 and 2011, the number of BPHS facilities increased more than 2-fold. The OOP contribution to THE trended down from almost 89% to 74% between 2004–2011.40

    Korean health care, by tradition, came from private sector practitioners,35 and the government strongly promoted privatization of health service delivery during the 1960s.23 While in 1962, 41.8% of all hospital beds were in the private-for-profit sector,35 this increased to 76.8% in the 1990s35 and to 94% in the 2000s.18 Privatization and promotion of competition have resulted in a tremendous increase in the number of health care facilities over the past decade.44 For example, between 2000 and 2013, the number of health care facilities in Korea increased from 61,776 to 84,971, during which OOP contribution to THE trended down from about 41% to 35%.45

    In Thailand, health services are delivered mainly in the public sector, with almost 70% of hospital beds owned by the government.19 While the private sector controls almost 20% of hospital beds,19 most large hospitals are concentrated in big cities like Bangkok,46 and some public institutions, such as the military, have their own health facilities.19 Since 2002 after the implementation of UCS, the number of public health facilities has increased,46 and OOP contribution to THE trended abruptly down in the years that followed.

    2) Division of activities among healthcare service delivery organizations

    In Afghanistan, primary health care is provided by the BPHS via 6 types of standardized health facilities: Health Posts (with 2 community health workers and no beds), Health Sub Centers, Basic Health Centers, Comprehensive Health Centers, Mobile Health Teams, and District Hospitals (which have at least 4 medical doctors).7 Secondary health services are provided by the EPHS via 2 levels of hospitals in provinces and regions.21 In addition, there are 22 specialized national hospitals in Kabul city,22 and private healthcare facilities provide different levels of service.47 After its initial development, the BPHS was revised in 2005 and 2010 to include services such as mental health, disability, and primary eye care. New facilities were launched, such as Health Sub Centers and Mobile Health Teams, and special populations like nomads and prisoners became eligible for BPHS.22, 48 OOP contributions to THE trended down by 4% between 2005–2006, then trended up almost 5% in 2011, followed by a drop of 8% in 2012. The EPHS was revised in 2013 to describe standards for delivering secondary healthcare in Afghanistan. While district hospitals were EPHS facilities before the revision in 2010, they began to be identified as BPHS facilities after the revision.22, 48

    In Korea, there are 4 levels of health care facilities: clinics (0–30 beds), small hospitals (31–100 beds), general hospitals (> 100 beds), and specialized general hospitals.27 Emergency care is provided by emergency departments through a mix of private and public hospitals. The emergency care system is separate from the general healthcare system and is mainly composed of regional and local referral centers.27

    In Thailand, health care delivery facilities are structured as follows: health centers and primary care units (PCUs) with no beds, community hospitals (10–90 beds), and central/regional hospitals (300–1000 beds).49 All prevention and promotion services were being provided free of charge by the MoPH to the whole population until the UCS was introduced to take responsibility for providing these services. Furthermore, the Thai Health Promotion Foundation (ThaiHealth, financed by a 2% excise tax on tobacco and alcohol), established in 2001, supports health promotion activities.19 The National Institute for Emergency Medicine (NIEM) was established in 2008 and took over the entire responsibility of delivering prehospital emergency care from the NHSO.19, 50

    3) Interactions among healthcare service delivery organizations and their relationship with the rest of the political and economic system

    In Afghanistan, the MoPH contracts out BPHS and EPHS service delivery to NGOs, which compete with each other for contracts.51 Private facilities compete for patients who pay FFS for all their private care.47 In Korea, health care organizations compete for resources and revenue, since health service delivery is owned privately, and for services not covered by NHI, people have to pay FFS. On the other hand, people are free to choose their desired health facility.52 In 1997, the government planned to implement a hospital performance evaluation program and publish the results so that people could make informed choices and to create incentives for hospitals to compete by improving the quality of their services.24 The hospital performance evaluation program was finally implemented in 2004.31 In Thailand, health care organizations rely on contracts with health services purchasers for service delivery. UCS and SHI members must choose from a network of registered health facilities, while members of CSMBS can choose from any public provider.30 Furthermore, CSMBS members can choose any level of public health facility,53 whereas the UCS and SHI members have to pay FFS for care at secondary hospitals unless they have a referral letter from a primary care provider.30

    4) Internal administrative structure of healthcare service delivery organizations

    In Afghanistan, the BPHS- and EPHS-providing NGOs practice autonomous decision-making patterns,22 while all the decisions of facilities managed by the MoPH are made centrally by the ministry.16, 22 In 2011, all 14 national specialty hospitals were given autonomy and granted the authority of managing their own budgets.54, 55 In Korea, historically all health care policy decisions were made centrally by the Ministry of Health, while administration of public health, medical aid programs, and long-term care insurance were totally or partially decentralized to local government control for decades. Nevertheless, hospital management is autonomous, and hospital owners have the freedom to manage their facilities without restrictions.18 In Thailand, the Decentralization Act (1999), was endorsed in accordance with the Thai Constitution of 1997, and mandated the transfer of health services responsibilities from the central government to local governments, which also necessitated the transfer of related budget and personnel.56 Thereafter, a series of agencies was established to decentralize different activities from the ministry. Health promotion activities were decentralized to ThaiHealth (2001). The NHSO (2002) now manages the UCS, and the Health Accreditation Institute (2009) is in charge of quality control of health services and the certification of hospitals and health centers.19

    Regulation

    1) Public health and health services regulations

    In Afghanistan, an increase of unregulated private for-profit organizations prompted the MoPH, in 2008, to start developing policies, regulations, and strategies aimed at the private for-profit sector. OOP contributions to THE trended down by 10% in the following year. The aim of these regulatory efforts was to improve the quality of health services, encourage private investment in the health sector, and achieve sustainability.57 In Korea, until 2000, both physicians and pharmacists were dispensing and prescribing medicine. Overuse and misuse of medicines made pharmaceutical costs the major factor behind increased health expenditures. Reforms to separate drug dispensing from prescribing were implemented by the Korean government in 2000, and OOP contributions to THE trended down 5% the following year).58 In Thailand, ThaiHealth was established in 2001 as an independent public agency. ThaiHealth supports state and non-state actors, in particular civil society, to promote the well-being of citizens by acting as a funding catalyst to support programs and actions that change social values, lifestyles and environments.19

    2) Health insurance regulations

    In Afghanistan, a civil servant SHI program was in effect during the 1970s, but it became defunct during the years of civil war and Taliban invasion.59 Thereafter, a Community Based Health Insurance (CBHI) was piloted by the MoPH between 2005 and 2006 in selected BPHS facilities in 5 provinces; the main goal was to assess the feasibility of CBHI in Afghanistan.34 This pilot indicated that insecurity was the main barrier for implementing health insurance in Afghanistan.34 Currently, there is no legally binding health insurance scheme in Afghanistan. In Korea, mandatory health insurance was implemented in 1977 after amendment of the health insurance law. The National Health Insurance Act implemented in 2000 led to the integration of health insurance agencies.60 OOP contributions to THE trended down by 5% the following year, suggesting that these 2 major health insurance regulatory reforms were implemented successfully. In Thailand, there were 4 health insurance programs: the CSMBS for government employees and their dependents, the Social Security Scheme (SSS) for private employees, the Medical Welfare Scheme (MWS, a government subsidy for the poor), and the Voluntary Health Card Scheme (VHCS, an option for people not eligible for other insurance programs).13 Due to operational problems in the MWS and VHCS, 30% of the population remaining uninsured13 until 2002, when the National Health Security Act was approved by the parliament and UCS was introduced. OOP contributions to THE had remained almost constant until 2005, then sharply dropped by 10%.61

    Behavior

    An Afghan social marketing organization was launched in 2008, offering services in reproductive health, family planning, and primary care for women, and children younger than 5 years of age, in rural areas. The overall goal of the organization is to improve access to quality healthcare and enable people to make informed decisions. Different social marketing approaches are used for achieving the overall goals, such as provision of information through billboards, product branding, radio and TV commercials, and mobile cinemas.62 In Korea, the NHIC provides a wide range of health-related resources to the general population, patients, and ethnic minorities, including: health education, online information about health centers, distribution of leaflets containing health information, provision of health information to high-risk groups with follow-up case management, provision of medical consultation through service counters located in major hospitals, and health education activities for patients and the general public in hospitals.18 In Thailand, a 24-hour call center is a part of UCS, and the 2 main tasks of this call center are to provide information and manage complaints. Calls from anywhere in Thailand are charged at a flat rate of 3 baht (0.096 USD) per call.20 Additionally, Thai citizens are provided health information through various media, such as television, newspapers, radio, magazines, village broadcasting services, leaflets, and posters.19

    DISCUSSION

    The results of this study can be discussed from 2 standpoints: 1) Trends in OOPs and OOP reduction experience, and 2) Lessons learned for Afghanistan from the case studies.

    After answering the questions associated with each control knob (Table 1), by analyzing the reforms in each case and comparing reforms in the control knobs among all the cases (Table 3), it became evident from this study that the trends of OOP contributions to THE could be traced to reforms in different control knobs. In Afghanistan, the abolition of user fees for public health services and the adoption of new policies and regulations for the private sector (Payment and Regulation control knobs) in 2008 were the main antecedents to OOP reduction, with OOP contributions to THE trending down by 10% between 2008 and 2009. In Korea, OOP was reduced after separating drug dispensing and prescribing, and after integrating health insurance agencies (Payment and Regulation control knobs) in 2000. OOP contributions to THE trended down by 5% between 2000 and 2001. In Thailand, OOP reduction was accelerated by extending the benefits of UCS, for example, including antiretroviral therapy in 2004 and adding kidney transplantation as an option for end-stage renal disease in 2008 (Payment and Organization control knobs). OOP contributions to THE trended down by 10% between 2005 and 2006. Furthermore, increasing the number of health facilities, expanding access to health services, and extending the range of available and affordable health services (Payment and Organization control knobs) were common reforms in all cases.

    Findings pertaining to the control knob of “financing” in the current study suggest that increasing government contributions and prepayment revenues to THE can reduce OOP. According to a study that reviewed health insurance patterns over a 30-year period in Korea, achieving universal health insurance coverage is not feasible in low- and middle-income countries without government subsidies for poor persons and those working in informal sectors.63 It has been reported that the OOP is inversely correlated with the contributions of SSS and other government agencies to THE in 122 countries.64 WHO has reported that earmarking taxes on harmful products can generate sustainable resources for health activities.65 For example, health promotion activities are financed by a 2% surcharge on tobacco taxes in Thailand. Likewise, earmarking taxes for health has made the implementation or expansion of health insurance programs possible in Ghana, Ethiopia, and Philippines.66

    The findings in relation to the control knob of “payment” suggest that providers' and patients' payment methods as incentives have a very strong potential to affect the performance of the healthcare system and OOP. The line item budgeting applied for payments to non-contracted health facilities and national specialized hospitals in Afghanistan, represents supply-side financing,22 which provides little incentive for facilities to be innovative, provide more services, or pay much attention to patient satisfaction and health outcomes.16 Conversely, shifting to strategies that focus on the performance of health facilities would create positive incentives for those facilities to improve system outcomes. Strategic purchasing has contributed to equitable access and financial risk protection in Thailand.53

    The findings pertaining to the Organization control knob in this study suggest that increasing the number of health facilities and increasing affordable and available services reduces OOP. The inclusion of some new services in BPHS and EPHS and efforts to ensure the availability of included services can reduce OOP in Afghanistan, just as availability of comprehensive packages that were free at the point of delivery resulted in a high level of financial protection in Thailand.53 Provision of services outside of the BPHS and EPHS, by public-private partnership (PPP) in public facilities, may be another way in Afghanistan. This will increase the number of available services in public facilities and create incentives for public health facilities to improve patient satisfaction, besides generating additional revenue for the health centers. PPP in the field of hospital services has improved the quality of public health services and reduced costs in 9 countries in Asia, Europe, North America, and Africa.67

    Political will and regulations from governments are key to reducing OOP; governments need to use their influence to ensure transparency, accountability, and good administration of health facilities and insurance agencies. Close coordination between insurance agencies and the Ministry of Health has helped to advance government health goals in Korea,63 and regulation of the fee schedule by the government has resulted in cost containment in both Korea62 and Japan.68 Government subsidies have further played a major role in expanding health insurance coverage in other Asia-Pacific countries.69

    Changes in the health system require patients to behave differently; this could be promoted through social marketing, making reliable health information readily available, and clarifying reasons and incentives brought about by adjusting payment or regulation control knobs. In Korea, for example, to prevent patients from directly visiting hospital outpatient departments without first being seen at a clinic, co-payments are higher when patients visit hospital outpatient departments directly.63 Social marketing has influenced health behaviors and health outcome in targeted areas in low- and middle-income countries.70 Further evaluations are needed in Afghanistan to determine the influence of the current system on the peoples' healthcare-seeking behaviors.

    In conclusion, in order to reduce OOP for health and accelerate Afghanistan's movement towards UHC, reforms in different health system control knobs are needed, all of which require political will and enforceable regulations. To these ends, it is essential to assume a stable, sustainable political environment and economic development. With these assumptions, suggested policy agendas to be implemented include: increasing domestic health revenue by increasing government contributions to THE, generating additional domestic revenue for health by earmarking taxes on products harmful to health, shifting from passive provider payment to more strategic methods, increasing health service availability by increasing the number of health facilities, and utilizing PPP to increase available services in public health facilities and to create positive incentives for them. These changes need to be coordinated at the community level by effectively disseminating of information and encouraging active local involvement in the reforms. We dare to imagine Afghanistan learning by example now, and becoming an example for others in the future.

    Notes

    Conflict of Interest:No potential conflict of interest relevant to this article was reported.

    Author Contributions:

    • Conceptualization: Akbari F, Machida M, Goto A, Hara A.

    • Data curation: Akbari F, Machida M.

    • Formal analysis: Akbari F, Machida M.

    • Investigation: Akbari F, Machida M, Hara A, Goto A.

    • Methodology: Akbari F, Goto A, Machida M.

    • Validation: Goto A, Nagase K, Nakamura H.

    • Writing - original draft: Akbari F, Machida M, Hara A, Goto A.

    • Writing - review & editing: Machida M, Hara A, Goto A, Nagase K, Nakamura H.

    ACKNOWLEDGEMENTS

    We express our sincere thanks to Dr. Farhad Farewar (Ministry of Public Health, Afghanistan), Mr. Minkyu Kang (Ministry of Health and Welfare, Republic of Korea), Dr Borwornson Leerapan (Mahidol University, Thailand) and Dr. Nobuyuki Hamajima (Nagoya University, Japan), for generously providing access to their expertise during the conduct of our research. We also acknowledge Prof. Kenneth E. Nollet (Fukushima Medical University, Japan) for initial project and final manuscript advice. This work received an International Participant Award (IPA 2019) from the Japan Society of Public Health.

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    MeSH Terms
    Afghanistan*
    Asian Continental Ancestry Group*
    Delivery of Health Care
    Family Characteristics
    Fees and Charges
    Health Care Costs
    Health Care Reform
    Health Expenditures
    Health Policy
    Health Services
    Healthcare Financing
    Humans
    Insurance, Health
    Korea
    Poverty
    Social Marketing
    Taxes
    Thailand
    Universal Health Insurance
    Metrics
    Share
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