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

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.