Zeng et al.

BMC Health Services Research (2017) 17:157

DOI 10.1186/s12913-017-2081-y

RESEARCH ARTICLE Open Access

Assessing the feasibility of introducing

health insurance in Afghanistan: a
qualitative stakeholder analysis
Wu Zeng1*, Christine Kim2, Lauren Archer3, Omarzaman Sayedi4, Mohammad Yousuf Jabarkhil4
and Kathleen Sears5

Abstract
Background: In the last decade, the health status of Afghans has improved drastically. However, the health financing
system in Afghanistan remains fragile due to high out-of-pocket spending and reliance on donor funding. To address
the country’s health financing challenges, the Ministry of Public Health investigated health insurance as a mechanism
to mobilize resources for health. This paper presents stakeholders’ opinions on seven preconditions of implementing
this approach, as their understanding and buy-in to such an approach will determine its success.
Methods: Key informant interviews and focus group discussions were conducted with stakeholders. The interviews
focused on perceptions of the seven preconditions of introducing health insurance, and adapting a framework
developed by the International Labor Organization. Content analysis was conducted after interviews and discussions
were transcribed and coded.
Results: Almost all of the stakeholders from government agencies, the private sector, and development partners are
interested in introducing health insurance in Afghanistan, and they were aware of the challenges of the country’s
health financing system. Stakeholders acknowledged that health insurance could be an instrument to address these
challenges. However, stakeholders differed in their beliefs about how and when to initiate a health insurance scheme.
In addition to increasing insecurity in the country, they saw a lack of clear legal guidance, low quality of healthcare
services, poor awareness among the population, limited technical capacity, and challenges to willingness to pay as the
major barriers to establishing a successful nationwide health insurance scheme.
Conclusions: The identified barriers prevent Afghanistan from establishing health insurance in the short term.
Afghanistan must progressively address these major impediments in order to build a health insurance system.
Keywords: Health insurance, Feasibility, Stakeholder analysis, Universal Health Coverage, Afghanistan

Background The total health expenditure (THE) per capita increased

Since 2001, significant improvements have been made in from US$42 to US$56 between 2008–2009 and 2011–2012
Afghanistan’s health sector. The Basic Package of Health [3]; compared to other countries in the global arena, how-
Services (BPHS), which is free of charge and primarily ever, this level of spending is low. Households’ out-of-
supported by donors, has increased access to primary pocket (OOP) expenditures or direct payments for health
care services for the poor, especially for key maternal services are high, accounting for 73% of THE [3]. More-
and child health services [1, 2]. Despite its achievements, over, Afghanistan is heavily donor dependent, with 75% of
service delivery challenges still exist, and the country the total public health expenditure coming from external
continues to deal with a weak health financing system. aid [3] (Fig. 1).
Similar to many post-conflict developing countries,
* Correspondence: [email protected]
Afghanistan has depended on external aid to reconstruct
1
Schneider Institutes for Health Policy, Heller School, Brandeis University, MS its health system over the past decade. It has a limited
035, Waltham, MA 02454-9110, USA capacity for generating domestic revenues because the
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Zeng et al. BMC Health Services Research (2017) 17:157 Page 2 of 9

steps to move forward. This is of particular importance in

Afghanistan, where the health sector is shaped largely by
donors as funders, nongovernmental organizations (NGOs)
as providers, and the government as the steward, regulator
and provider.
In an effort to address health financing challenges, the
government of Afghanistan is interested in introducing
national health insurance, which would primarily focus
on secondary care, as a means of reducing the high fi-
nancial burden on households and improving the coun-
try’s independence regarding the funding of healthcare.
Fig. 1 Financing sources of total health expenditure in Meanwhile, health insurance is also expected to improve
Afghanistan, 2011–2012 access to health care, particularly for vulnerable popula-
tions, and ultimately improve health status and equity of
population health in Afghanistan. However, introducing
population is poor, the country has a largely informal health insurance is complex and requires a careful as-
economy, and collection of revenues for health through a sessment of its feasibility. Many feasibility studies have
broad tax base is weak [4, 5]. As external aid decreases only focused on financial viability of health insurance
and the country moves towards a model of more sustain- [15–17], and few take a holistic approach.
able governance, alternative financing mechanisms will be Guided by a feasibility assessment framework [18], this
crucial to the resilience of the existing health system and study aims to document stakeholders’ opinions on fol-
the health gains it has achieved. lowing seven preconditions for health insurance schemes
Both the high OOP expenditure and high donor de- in Afghanistan: (1) the need for health insurance, (2)
pendency in Afghanistan demand interventions to intro- political commitment, (3) legal and regulatory environ-
duce financial risk protection mechanisms, such as health ment, (4) quality of care, (5) population awareness, (6)
insurance, to move toward universal health coverage ability to pay, and (7) technical and operational capacity
(UHC). Many developing countries in sub-Saharan Africa of health insurance. It should be noted that this study
and Southeast Asia have launched ambitious national does not discuss the design of health insurance.
health insurance reforms to raise prepaid revenues for
health, pool health risks, and purchase services more effi- Methods
ciently [6, 7]. Study framework
Realizing challenges in many low- and mid-income To implement the feasibility assessment of introducing
countries to provide essential affordable quality care to health insurance, we adapted the International Labor Of-
populations, the World Health Organization (WHO) ad- fice (ILO) framework developed for strategies and tools
vocates the UHC agenda and further research on UHC for the social exclusion and poverty global program
[8–10]. One essence of UHC is to move away from dir- (STEP) on microinsurance schemes [18] and are guided
ect payment to prepayment mechanisms as a means to by the manual of planning social health insurance jointly
improve access to care (both coverage of services and developed by Asian Development Bank, ILO, WHO, and
population) and to provide financial protection of the German Technical Cooperation. The feasibility of intro-
population seeking care. Given the high OOP expend- ducing health insurance was assessed by investigating
iture and limited access to quality care, Afghanistan is in the seven preconditions of establishing health insurance
the very early stage of UHC, and needs policy changes schemes, mentioned above.
and reforms to accelerate the pace towards UHC.
Experiences from other countries show that health finan- Study participants
cing reform and the introduction of health insurance are We conducted a stakeholder assessment using both quali-
complex, long-term processes requiring strong technical tative individual key informant interviews (KIIs) and focus
and management capacity as well as political commitment group discussions (FGDs) to assess stakeholders’ interest
from various stakeholders [11–13]. There is a growing rec- in health insurance, and investigate preconditions of its
ognition that health sector stakeholders have a strong influ- introduction. In collaboration with the Health Economics
ence on policy development and moving reforms forward and Financing Directorate (HEFD) at the Ministry of Pub-
in a country [14]. The inclusion of stakeholder perceptions, lic Health (MoPH), given HEFD’s extensive knowledge of
understanding, behaviors, interests, and intentions around the healthcare system, we identified 11 stakeholder groups
health financing and health insurance will inform the feasi- for KIIs. KIIs were used to solicit information from se-
bility of introducing health insurance schemes and the next lected individuals with high-level authority and/or special
Zeng et al. BMC Health Services Research (2017) 17:157 Page 3 of 9

knowledge. KII stakeholders included high-level govern- Data analysis

ment officials from ministries and parliamentarians (i.e., All Interviews and discussions were digitally recorded and
the MoPH, Ministry of Finance [MoF], Ministry of Justice then transcribed for analysis in Atlas.ti qualitative analysis
(MoJ), Ministry of Labor and Social Affairs [MoLSA], and software. Three researchers analyzed the transcripts
Parliament); international donors and organizations (i.e., through direct content analysis, a qualitative data analysis
WHO, the European Commission [EC], USAID, and the method, using Atlas.ti software. Codes were developed pri-
World Bank); and private sector agencies (i.e., two private marily according to the seven themes (preconditions). Based
insurance companies). on the initial review and the interview guide themes accord-
We identified five stakeholder groups for participation ing to the ILO framework, we deductively organized a
in FGDs to document the perceptions, opinions, and atti- structure of initial code groups for analysis. Using this initial
tudes toward the seven preconditions amongst those who structure of codes, the researchers analyzed transcripts line
perform similar functions in the healthcare system, such by line and assigned new codes to additional emerging con-
as those in the private sector and health service providers. cepts. Atlas.ti was used to sort and organize the themes and
These groups included (1) BPHS implementing managers; to examine the patterns emerging from each of the themes.
(2) public hospital directors; (3) private hospital directors; To ensure consistency and common understanding of code
(4) organizations working on community savings projects; concepts, the analysts discussed the coding process and one
and (5) HEFD staff. senior member of the team checked the analysis results.

Results
Data collection As mentioned in the Methods section, the stakeholder
The KIIs and FGDs focused on different aspects of analysis identified seven key topics for assessment; below,
the health system as related to health insurance, de- we summarize and describe the interviews by topic.
pending on the participants’ organizational affiliations.
For example, for the MoJ and Parliamentary survey Perception of the need for health insurance
participants—entities more familiar with regulations The majority of stakeholders were aware of the health fi-
and the legal issues regarding health insurance—the nancing situation in the country, which includes high
interviews focused more on regulatory and legal con- OOP spending and reliance on donor funding, as well as
straints, and opportunities for implementing health the challenges of healthcare delivery. Stakeholders ac-
insurance. For participants from private health insur- knowledged that health financing reform (including the
ance companies, the focus of the interviews was on use of health insurance mechanisms) was needed to
understanding the insurance market, the operation of change the current situation and ensure a more sustain-
health insurance, and the capacity needed to imple- able health financing system for Afghanistan.
ment or manage health insurance. For detailed inter- Although the government states that healthcare is a right
view guide, see Additional file 1. for its citizens and reiterates its commitment to providing
Data were collected from July to August 2014, using health services for the population, participants referred to
semi-structured interview guides to frame questions and the inability to provide financial protection as a key issue
solicit stakeholders’ interests and opinions on the pre- for the current system. People sometimes have to sell their
conditions of health insurance. Interviewers explained assets or borrow from relatives and communities to seek
the purpose of the study to all participants and obtained healthcare in Afghanistan or other countries, such as India
informed verbal consent at the beginning of each inter- and Pakistan. Introducing health insurance could provide
view. They conducted all interviews in a quiet place. financial protection against catastrophic health expendi-
The KIIs and FDGs lasted approximately 60 min tures, particularly for the poor.
and were conducted in the participants’ preferred lan-
guage (English or Dari). Two experienced researchers “This [health insurance] should be our priority—to
conducted and facilitated a majority of the KIIs and promote insurance services so that we could cover or
FDGs, respectively. Both researchers are health finan- bring more people under our insurance coverage.”
cing experts with a strong understanding of the
Afghan health system. They had translation assistance Participants also pointed out that health insurance also
from national staff to conduct interviews in Dari, as could help to improve the equity of healthcare in the
needed. The translator had significant experience in country. The rising cost of health services due to new
working on health sector activities in Afghanistan and technology and changes in disease patterns has exacer-
was trained by the researchers to ensure high-quality bated inequality in the utilization of healthcare. Whereas
interviews and translations. In total, 22 KIIs and the wealthy can obtain healthcare from private health fa-
FGDs were conducted. cilities or go abroad, the poor have limited options. Health
Zeng et al. BMC Health Services Research (2017) 17:157 Page 4 of 9

insurance could be an important tool for promoting provide free means of preventive healthcare and medical
greater equity of health service utilization. treatment, and proper health facilities to all citizens of
Afghanistan in accordance with the law” [19].
Leadership and political commitment
Healthcare reform and the successful implementation of “According to the constitution, the health facilities are
health insurance schemes require strong political will and free for the people … it is clearly defined in … article
government stewardship, particularly in Afghanistan, where 52 of [the] constitution: [paraphrase of constitution]
additional challenges exist due to insecurity, poverty, and ‘The government, in accordance to the law, provides
numerous competing priorities. preventive care, treatment, and health facilities free of
charge to all the people’”.
“[Health insurance] will not be automatic because there
are a lot of priorities. There is a need, I think, for some Varying interpretations of the law and differing opinions
lobbying and advocacy. There should be some kind of exist—even among high-level government officials—about
agreement that a certain percentage [of government whether the law mandates that the government provide
revenue] will be allocated for the social sector, especially services for free to all Afghan citizens and what those ser-
for the health sector. Otherwise, the government always vices may include, or at what level. Whereas many under-
think[s] about infrastructure and security. Very often stand Article 52 as a mandate for the provision of free
the social and health sector are left out.” services, some interpret it as only requiring free facilities
(i.e., building and equipment); others believe that only cer-
A majority of stakeholders acknowledged that strong tain services must be provided free of charge. “We have
leadership, multisectoral political commitment, and ef- the constitution … but interpretation has been an issue.
fective collaboration are essential to begin implementing So far, we have not been able to interpret it.” In addition,
health insurance in Afghanistan, but noted that the “constitutionally speaking, there is a big problem at the
current political commitment should be strengthened, [presidential] level. Policymakers and politicians believe
especially at the highest levels of government. that health insurance is something that gets money from
people, which is against the law.”
“… political will and political support are very important
for establishing health insurance systems in every Quality of health services
country. But besides this, for Afghanistan especially, I Quality of care is an important precondition for
think it’s more important … because of the constitution, introducing health insurance, and health insurance is
because of the law and the regulations we currently feasible when potential health insurance beneficiaries
have, especially in terms of having all health services can access an acceptable quality of care. Interviewees
free. So we really need a very strong [political] will and identified the quality of health services as a key issue
support at different stages and in different entities of the for implementing health insurance. In Afghanistan,
government [to overcome the barriers].” the population perceives the quality of care to be low.
Although the BPHS and Essential Package of Hospital
Stakeholders acknowledged that to be successful, advo- Services (EPHS) are theoretically free of charge, pa-
cacy efforts aimed at increasing support for and political tients must purchase medications from pharmacies
commitment to health insurance must target leadership and obtain lab tests and examinations from private
across different sectors and at different levels of govern- providers because of medications stockouts and lack
ment: “It requires a lot of lobbying with Parliament, the of medical equipment and lab tests. They thus end
cabinet of Afghanistan, ministries, and the people.” Imple- up paying much higher fees: “Patients mostly pay for
mentation of health reforms in Afghanistan also will re- medicine and diagnostic examinations that are not
quire effective collaboration to design, implement, and available in [the] majority of our hospitals.”
manage a health insurance scheme. The low quality of healthcare services in Afghanistan
presents a challenge for the introduction of a health insur-
Legal and regulatory environment ance system and affects people’s willingness to participate
Stakeholders identified the legal and regulatory conditions in an insurance scheme or pay for services at any level.
for health financing as major challenges that need to be
addressed in the short term if a health insurance scheme “My suggestion, before implementing health insurance,
is to be developed in the future. In particular, the ambigu- is that first and foremost we need to strengthen our
ity of Article 52, which addresses the state’s obligation to health service performance so that our people feel that
provide healthcare to its citizens, leaves the law open to now that they have insurance, they receive quality
misinterpretation. Article 52 states “The state is obliged to health services when they need it.”
Zeng et al. BMC Health Services Research (2017) 17:157 Page 5 of 9

Poor quality of services also affects health financing as large informal economy poses a challenge to revenue gen-
a whole. For those services not available or of low qual- eration. The informal working sector also does not allow
ity, Afghan citizens leave the country, thereby spending for effective collection of taxes on small private enterprises.
those funds outside of the Afghan economy: “For some
procedures and surgeries, like laparoscopy, our people “Health insurance or life insurance is applicable when
still go to other countries, like India, Pakistan, and people have job[s], and from their income some
Turkey.” Seeking care abroad due to poor quality of ser- amount is deducted and transferred to his/her
vices often results in high levels of OOP expenditure. insurance for use when they need. However, in
Afghanistan more than 65% of population is jobless.”
Population awareness and trust
Although Afghanistan had experience with health insur- “Not all people have a regular salary and [they] don’t
ance for civil servants in the 1970s and community- know their income. In this country, the income of a
based health insurance in five districts in the early farmer is not predictable. It depends on the rain level.
2000s, health insurance, which requires prepayment It changes from year to year.”
(premiums) to allow enrollees to receive health care at Stakeholders had mixed opinions on the population’s
discounted costs or no costs when seeking care, is a new willingness to pay. On the one hand, the demand for
concept for most of the population. Many people think health insurance is increasing in the private market.
that paying money for insurance is worthless. The high Large organizations working in Afghanistan are actively
illiteracy and poverty rates pose further challenges to looking for suitable health insurance plans for their em-
educating the population about health insurance. Even ployees, largely because of the insecure working environ-
highly educated people who work in the formal sector, ment. In addition, health is often the second most
such as NGOs, would prefer to receive a medical allow- important issue for the population, after food security.
ance from their employer than to join health insurance The high poverty rate and low awareness of health in-
programs. surance limit the population’s willingness to pay. Add-
itionally, the low quality of healthcare further reduces
“We are planning to start it [health insurance] from Jan, people’s willingness to pay for health insurance: “… qual-
2015 … But we understand [that] we don’t succeed to ity again is an issue. Everyone would be willing to pay
educate the educated people to tell them why we want for quality services but [for] bad quality services, no one
this [health insurance]. Now people, even a person with would be willing to pay; at least I’m not willing to pay.”
a PhD degree, tell us no. Because if we give them Various stakeholders also expressed concerns for ensur-
medical insurance, we will cut the medical allowance … ing protection for the poor should new financing strat-
People are not familiar with the basic concept of health egies be enacted.
insurance. You educate people about the concept; it is a
very difficult job according to my experience after one Capacity to implement and manage a health insurance
year education.” system
Many stakeholders felt that there was limited technical
Our interviews found that communities lack trust not and managerial capacity to operate a health insurance
only regarding Afghan insurance systems but also more system in Afghanistan. The number of people dedicated
generally in the government. “There is reluctance from to working on insurance issues is limited to a few select
those stakeholders to contribute to [a] public insurance government units, further highlighting the current lack
scheme, because there is no equation of trust of govern- of capacity: “In all of the MoPH, only 1 or 2% [are]
ment.” This prevalent lack of trust extends to both the pri- working in health insurance.” To date, there has been
vate and public sectors, and relates to the lack of security limited capacity building and training related to health
and volatile economic situation of the country. This general insurance design and management, resulting in a lack of
distrust creates an interesting phenomenon: the govern- capacity at all levels of the government: “We don’t have
ment feels the public does not trust private health insur- the capacity to manage the scheme … and unfortunately
ance programs, and private companies feel the public does there is no capacity even at the central level.” A consen-
not trust government programs due to prevalent corruption sus exists amongst stakeholders that donor support for
and a sense that the government is unable to oversee a health insurance should focus on technical assistance
health insurance scheme effectively. and capacity building: “We need a lot of help from do-
nors and government to train us and teach us about in-
Fiscal space and willingness and ability to pay surance topics.”
Stakeholders felt that in addition to the government’s low On the contrary, some stakeholders were optimistic
institutional capacity to collect revenues, the country’s about getting young talent to engage in operating health
Zeng et al. BMC Health Services Research (2017) 17:157 Page 6 of 9

insurance schemes. Private insurance companies that country. In addition, given Afghanistan’s heavy depend-
have begun to provide health insurance products also ence on external aid and technical support, donors and
expressed willingness to support such an operation. international agencies should use their unique positions in
the health system to move health insurance onto the gov-
“In the last 13 years, … some of our workers and ernment’s agenda as a mechanism of achieving UHC.
people in Afghanistan increase their capacity. … In Stakeholders identified Article 52 of the constitution a
addition, there are many of universities in private and major legal and regulatory barrier, which stipulates that,
public sector. Many of our young generation “The state is obliged to provide free means of preventive
graduated from universities, especially in the field of healthcare and medical treatment, and proper health fa-
medicine. Graduates from universities can do and run cilities to all citizens of Afghanistan in accordance with
the health insurance program in Afghanistan.” the law.” Although the government would like to com-
mit to free care, in reality, health services are not free.
Discussion Households finance 73% of total health spending. This
Almost all of the stakeholders from government agencies, demonstrates the lack of clarity that exists related to the
private sector, donors, and UN agencies are interested in constitution—which services should be provided free of
introducing health insurance in Afghanistan, and acknow- cost and which should not, and the extent to which the
ledge the limitations in the current health system to pro- constitution would limit the use of health insurance.
vide adequate healthcare and financial protection to its High-level government officials hold different opinions
population. With the expected decline in donor funding on the correct interpretation of the law. The ambiguity
over the next ten years, gradually obtaining alternative of this article has led to a deadlock in further pursuing
sources of funding for healthcare and introducing prepay- health insurance and other alternative potential health
ment mechanisms are more imperative than ever; this fact financing mechanisms.
is reflected by the most recent health financing strategy Recent discussions have begun within the MoPH to
developed by the Afghanistan MoPH [20]. draft a revised amendment clarifying the areas of health
Despite their interest, stakeholders foresee great chal- services that should remain free of charge and those for
lenges based on the findings from this study. The major which payments can be collected. As the interviews
challenges are lack of high-level consistent commitment showed, there is general agreement that primary health-
to health insurance, ambiguity in the constitution, low care services through the BPHS should remain financially
quality of care, a low level of public awareness of health accessible to all. Additional services at the EPHS level be-
insurance, limited management capacity to run health yond the basic package may be considered chargeable, as
insurance, and limited fiscal space and willingness to pay well as secondary- and tertiary-level healthcare services.
for health insurance. Stakeholders acknowledge that Low quality of healthcare is another major concern that
many efforts, discussed in detail in this section, require prevents establishing health insurance. In Afghanistan, the
addressing these challenges to prepare the country for low quality of health services has been widely criticized as
establishing health insurance schemes. inadequate to meet the population’s health needs. Only
Similar to many health reform initiatives in Afghanistan when the quality of services improves will people be
and other developing countries, establishing health insur- confident enough to join health insurance to seek care at
ance schemes, whether public or private, requires strong contracted health facilities. Although the quality of ser-
political commitment [21–23]. It is paramount to build vices has improved substantially in the last decade
understanding and consensus among high-level govern- through the BPHS and EPHS [24], and through the intro-
ment officials that health insurance should be considered duction of the Minimum Required Standards (MRS) for
as a means to strengthen the healthcare system for in- private sector hospitals, health services need to be further
creased sustainability. strengthened and standardized. Among quality issues,
The donor community has helped the MoPH initiate ef- shortages of drugs and medical equipment are fundamen-
forts toward building political will and HEFD has advo- tal. The government already has begun working toward
cated for risk-pooling mechanisms by approaching the addressing quality issues. Several major initiatives have
MoPH and government officials from different ministries. been taken, which include (1) a program enhancing hos-
These activities have helped the government better under- pital autonomy; (2) “contracting out” service delivery to
stand the benefits and applicability of health insurance in NGOs; (3) results-based financing (RBF) pilot program to
Afghanistan. Political commitment must go beyond the reward better performance; and (4) the introduction of
MoPH. Implementing health insurance will involve mul- MRS and a certification process in the private sector.
tiple government agencies. The MoPH will need to collab- One important the step that Afghanistan is taking is
orate closely with other ministries and agencies to address aiming for accreditation of both public and private
the barriers to implementing health insurance in the health facilities for quality assurance. Initial steps are
Zeng et al. BMC Health Services Research (2017) 17:157 Page 7 of 9

underway in Afghanistan to establish an accreditation one hand, the population expects the government to
system and an accreditation oversight body. A compre- take a major role in providing and financing healthcare
hensive assessment found that that the country is ready and, on the other hand, people are concerned about the
for such an initiative and should begin the necessary implementation and effectiveness of such programs and
steps toward establishing a system immediately [25]. do not trust public programs due to the prevalent cor-
Several low- and middle-income countries, including ruption. Improving the transparency and accountability
Rwanda and Jordan, have introduced accreditation pro- of the government to the public would mitigate such
cedures and generated positive results [26–28], which concerns. The MoPH has conducted the National Health
provide valuable lessons for Afghanistan. Accounts (NHA) and Public Expenditure Tracking Sur-
Low public awareness of health insurance also poses vey (PETS), and developed the Expenditure Management
substantial challenges for Afghanistan to initiate health Information System (EMIS). These activities contribute
insurance. Interviews with private health insurance com- to anti-corruption efforts in the country and these ef-
panies showed an increasing demand for health insur- forts and their results should be communicated to the
ance in the country, particularly among the wealthy population in an easy-to-understand way.
population who work for international organizations, With limited resources for health, the government’s
banks, and NGOs. However, the concept of health insur- taxation capacity should be strengthened to increase the
ance has not been widely discussed and disseminated. fiscal space for health to allow health insurance to be
More sensitization activities on health insurance among implemented. In fact, revenue collection in Afghanistan
the population is needed to raise awareness in the coun- has increased significantly since 2002; totaling US$2.04
try about the topic. The MoPH has experience in pro- billion in 2011–12, with an annual increase of 16%,
moting anti-tobacco and health behavior messages resulting in more than nine times the level of revenue
through different means. Although the content of health collected in 2002. Revenue as a proportion of GDP was
insurance may be somewhat more complex to commu- more than 11.6% in 2011–12, up from 11.3% in 2010–11
nicate, the mechanisms for distributing messages and and 3% in 2002 [4]. However, this number remains lower
developing materials are available from the MoPH’s than the average of 15.2% in low-income countries and
Health Promotion Department. of 25.6% in lower mid-income countries in 2011 [29].
Initiating health insurance will not be possible without The MoPH should coordinate with the MoF and the
international financial and technical support. The gov- new USAID-supported tax revenue collection project to
ernment’s capacity to begin a health insurance scheme gain a better understanding of how taxation could be
remains limited—not only the capacity to design and op- strengthened and how funds could be allocated to public
erate health insurance, but also to increase the fiscal health services. Additionally, anti-corruption efforts,
space of the healthcare system and gain trust from the institutionalization and automation of tax administration
population regarding publicly funded programs. processes, and expansion of the number of taxpayers
Initial efforts to enhance health sector capacity for would improve the government’s financial situation and
managing health insurance are underway. Private health create fiscal space for healthcare, thus alleviating con-
insurance may be premature; only a few private insur- cerns caused by severe budget constraints, such as lack
ance companies have started health insurance products of medical equipment and weak health infrastructure
or acting as brokers and transferring financial risks to (i.e., poorly maintained buildings).
reinsurers outside of Afghanistan. However, given the in- We acknowledge several limitations of this study. Firstly,
creasing interest in insurance, the private sector is build- the majority of interviews were conducted in English. Des-
ing its capacity to manage health insurance schemes by pite many Afghans speaking English fluently, the interview
recruiting young talent and receiving technical support language may remain a barrier for communication, lead-
from their overseas reinsurance companies. In the public ing to the loss of some information. Similarly, for those in-
sector, few government staff are trained on how to oper- terviewees who did not speak English, the research team
ate health insurance schemes; building technical capaci- had to rely on the translator to communicate. Secondly,
ties for health insurance early in the process will be health insurance is quite a technical and complex topic
critical for the roll out and success of future insurance and requires a deep understanding of health systems and
schemes. a country’s political landscape to provide sensible informa-
Efforts to improve transparency and to build trust have tion for policymaking. Those who participated in the KIIs
been taken in the country. Often, the general population and FGDs with an understanding of health insurance
in Afghanistan has mixed feelings about public programs might not necessarily represent the stakeholder’s opinion
for healthcare. The history of ethnic and political con- as an agency, although the balance between technical and
flict and fragile governance in Afghanistan has created a political competence of the participants was considered.
mix of expectations and distrust of the government. On Despite these limitations, training for interviewers and the
Zeng et al. BMC Health Services Research (2017) 17:157 Page 8 of 9

translator, and consultation with the MoPH to select par- Funding

ticipants, may help reduce potential biases. This project was funded by the United States Agency for International
Development under the Health Policy Project (Cooperative Agreement AID-OAA-
A-10-00067). This study was made possible by the support of the American
people through the United States Agency for International Development (USAID.)
Conclusions The contents of this document are the sole responsibility of Palladium and do not
Given the existence of major barriers to health insurance, necessarily reflect the views of USAID or the United States Government.
such as legal restrictions, low quality of care, and low fiscal
Availability of data and material
space, establishment of a health insurance scheme is not The qualitative data for this study are available from the corresponding
expected in the short term (one to two years). However, author on request.
this circumstance suggests that the government and do-
Authors’ contributions
nors must work together to progressively prepare the WZ contributed to the study design, data analysis and manuscript preparation;
country for introducing health insurance. Afghanistan CK contributed to study design, data analysis and manuscript preparation; LA
could learn from the experience of some low-income contributed to data analysis and manuscript preparation; OS, MJ, KS contributed
to study design and critical review of the manuscript. All authors have read and
countries in establishing health insurance, such as Rwanda approved the final version of this manuscript.
and Ghana [8], where both community-based health insur-
ance and compulsory health insurance in the formal sector Competing interests
The authors declare that they have no competing interests.
are implemented.
The next few years will be critical in reshaping Consent for publication
Afghanistan’s healthcare system, as they will provide a Not Applicable.
limited period of donor-funded BPHS and EPHS services,
Ethics approval and consent to participate
allowing the government to develop alternative mecha- This study received permission from the institutional review board (IRB) at
nisms to generate domestic resources for healthcare. the Ministry of Public Health in Afghanistan in February 2014 (The assigned
Afghanistan will need to progressively address the major approval number is 979614). All participants were consent to participate this
study. As this study focused on individuals’ responses to policy related
concerns that impede the establishment of health insur- questions instead of individuals’ personal information and no vulnerable
ance and take an incremental approach to building a populations were included in the interview, we obtained verbal consent
health insurance system. from participants.
In the 2012–2020 Health Financing Policy, the MoPH Disclaimer
stated its intent to implement UHC in Afghanistan. If Views expressed in this article are those of the authors and do not necessarily
Afghanistan is to continue to move toward UHC, it must reflect the views of the authors’ institutions and funder of this study. None of
the authors has any financial interest in any product iscussed in this article.
address the health financing challenges that exist in the
system, particularly as donor funding declines over the Author details
1
next decade. Introducing health insurance would be a Schneider Institutes for Health Policy, Heller School, Brandeis University, MS
035, Waltham, MA 02454-9110, USA. 2Gillings School of Global Public Health,
significant step in moving the country toward UHC and University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. 3DKT
address current challenges in the system. In light of the International, Patna, Bihar, India. 4Palladium Group, Kabul, Afghanistan.
5
identified barriers to establishing health insurance in the Palladium Group, Washington, DC, USA.
country, the Afghanistan government and international Received: 2 August 2016 Accepted: 9 February 2017
partners need to work together to address those barriers
and accelerate progress toward achieving UHC.
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