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Risk Pooling in Afghanistan

2010 –2012 || U.S. Agency for International Development


Out-of-pocket expenditures for health constitute approximately 75 percent1 of total health expenditures in Afghanistan - despite the availability of the Basic Package of Health Services (BPHS), which includes essential preventative and curative care services. Distance from facilities and loss of income makes accessing health services very difficult for those living in remote areas. Informal payments are also standard practice at both central and peripheral health facilities. Fear of these costs has dissuaded many households from seeking health care until it is too late, driving up expenses further. High out-of-pocket health costs can place an enormous financial burden on families and push people deeper into poverty. As part of USAID's Health Systems 20/20 project, Deloitte is exploring the feasibility of introducing a financial risk protection mechanism in Afghanistan that will provide financial protection to those covered by the plan.

The Challenge

Afghanistan is beset with political and civil instability, which has had detrimental effects on the country's health system. Health infrastructure is weak, access to health care is low, and out-of-pocket expenditures for health, particularly among the poor, are high. Afghanistan's National Strategy on Health Care Financing and Sustainability 2009-2014, has highlighted the need to introduce financial risk protection mechanisms to help control out-of-pocket expenditures. Insurance schemes have been piloted previously in Afghanistan but faced significant challenges: instability of wages meant instable premium contributions leading to insolvency, lack of awareness contributed to low enrollment, and low quality of services and participating providers led to low demand. However, much in Afghanistan has changed and there may be opportunities to design an insurance scheme that is feasible within the Afghanistan context.

How We Helped

Under Health Systems 20/20, Deloitte is conducting a feasibility study to examine the possibilities for developing and implementing an effective health insurance scheme designed to overcome challenges previously faced; and to provide options to the Government of Afghanistan to initiate health insurance given the context and health system landscape. In doing so, we are looking at specific components that are required for a health insurance scheme to be effective: the regulatory environment, the financial resources available to support a scheme, the administrative functions and options for management of the scheme, the benefits package, the provider environment, and the social and cultural factors that will impact how a scheme may be designed and rolled out.


Deloitte has significant experience in providing guidance and assistance to countries as they consider health insurance implementation and scale-up. We understand the various factors that should be considered given the specific national context and work with stakeholders to design an approach that is tailored to the country's needs. In Afghanistan, our long history of working in the country and awareness of the particular challenges it faces are informing the design of the study and will be important to helping develop a road map for moving forward.

1 Government of the Islamic Republic of Afghanistan Ministry of Public Health (Forthcoming). National Health Accounts Afghanistan 2008-2009. Kabul, Afghanistan

Deloitte’s work in Afghanistan under the Health Systems 20/20 project is carried out under a subcontract with Abt Associates Inc., prime contractor for the Health Systems 20/20 cooperative agreement. Health Systems 20/20 is funded through the generous support of the American people through the U.S. Agency for International Development (USAID). Health Systems 20/20 helps USAID-supported countries address health system barriers to the use of life-saving priority health services. In the process, the project works to strengthen health systems through integrated approaches to improving financing, governance, and operations, and building sustainable capacity of local institutions.

As used in this document, “Deloitte” means Deloitte Consulting LLP, which provides strategy, operations, technology, and human capital consulting services, Deloitte Financial Advisory Services LLP, which provides financial advisory services, and Deloitte & Touche LLP which provides governance and risk oversight and reporting advisory services. These entities are separate subsidiaries of Deloitte LLP. Please see for a detailed description of the legal structure of Deloitte LLP and its subsidiaries. Certain services may not be available to attest clients under the rules and regulations of public accounting.

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