title: Assessing the feasibility of introducing health insurance in Afghanistan: a qualitative stakeholder analysis.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Schneider Institutes for Health Policy, Heller School, Brandeis University, MS 035, Waltham, MA, 02454-9110, USA. wuzengcn@brandeis.edu.
authors.forename: Wu
authors.initials: W
authors.lastname: Zeng
authors.affiliation: Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Christine
authors.initials: C
authors.lastname: Kim
authors.affiliation: DKT International, Patna, Bihar, India.
authors.forename: Lauren
authors.initials: L
authors.lastname: Archer
authors.affiliation: Palladium Group, Kabul, Afghanistan.
authors.forename: Omarzaman
authors.initials: O
authors.lastname: Sayedi
authors.affiliation: Palladium Group, Kabul, Afghanistan.
authors.forename: Mohammad Yousuf
authors.initials: MY
authors.lastname: Jabarkhil
authors.affiliation: Palladium Group, Washington, DC, USA.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Sears
mesh_terms: D000346:Afghanistan / Q000453:epidemiology; D005240:Feasibility Studies; D017144:Focus Groups; D006077:Government Agencies; D006291:Health Policy / Q000331:legislation & jurisprudence; D006297:Health Services Accessibility / Q000191:economics; D061889:Healthcare Financing; D006801:Humans; D007348:Insurance, Health / Q000331:legislation & jurisprudence* / Q000458:organization & administration; D011050:Policy Making; D017149:Private Sector; D019472:Universal Health Insurance / Q000331:legislation & jurisprudence* / Q000458:organization & administration
keywords: Afghanistan; Feasibility; Health insurance; Stakeholder analysis; Universal Health Coverage