The Afghan Ministry of Public Health has recently announced a User Fee Regulation under which user fees will be levied for services in secondary and tertiary public health facilities. The details of how much will be charged, for what services, and when the regulation will actually come into effect are yet to be known. What is known at the moment is that primary health care services in Afghanistan will continue to remain free of charge. Moreover, the poor, the disabled, women victims of violence, women undergoing Caesarean section, and students availing services in secondary and tertiary care facilities will be exempt from charges.

Evidence from studies in other low- and middle-income countries  show that introduction of a fee-for-service leads to reduced utilisation of health services both preventive and curative in nature. Improvement in utilisation of curative services has only been observed when there was concomitant quality improvement affected with the introduction of user fees.

The government expects that the revenue generated from the tool for improving quality is the revenue from the fees, which could be used to provide necessary drugs, equip facilities with medical technology, and train staff. Some quality improvement for public sector may include the provision of necessary drugs, equipment, and staff. It must not be forgotten that respectful behaviour towards patients will have a significant impact on the perception of quality among the public and this can be challenging from the public policy perspective.

The implementation of this new regulation will entail several challenges. First, Afghanistan has an estimated 39% poor (~12 million people), and another 36% slightly above the poverty line of $1.25 per day (~10million), meaning that only around 30% of the population may be truly eligible to pay a fee-for-service. Second, identification of the poor will be a major challenge. With some nepotism and corruption the poor could be left outside the system and unreserved. The administration of distributing some kind of ID card for the poor requires a rigorous and transparent process and this is challenging in the current scenario.

Another challenge to user-fee implementation will be the manner in which revenue is managed. A centralised system of channelling the revenue through the finance department and redistributing it to all sectors can be bureaucratic and slow process to affect the quality of services. A decentralised system may be prone to embezzlement of the revenue. One option could be to establish local accountability committees to oversee the proper spending of the newly generated revenue. Local health facility councils could play that role in rural Afghanistan.

With the introduction of the fee-for-service regulation, a small window of opportunity through generating a sustainable revenue could be opened for the Afghan Ministry of Public Health. This is crucial in terms of the country’s current debacle when it is excessively dependent on foreign aid. The Ministry, however, must be prepared for the following:

1. There will be a sharp decrease in health service utilisation, and thus a poorer health outcome in the coming months after the regulation takes effect, which could continue if the quality does not improve.
2. The expected revenue from user fees will be limited due to a large proportion of poor in the country.
3. If the revenue is not managed well, the Ministry could face a flood of criticism for local embezzlement of the new revenue or the disappearance of it in the core budget of the central government, with implications on the legitimacy of the overall government.
4. As promised, if the quality of services does not improve, the gains in health outcomes in the past decade will be significantly jeopardized and the talk of equity in health services should be thrown out the back window.

Overall, it is a bold and risky measure by the Afghan Ministry of Public Health to strengthen the health system. Yet, as they say, the devil is in the detail: it is the details of implementation that will matter. In the long run, the overall development of the country’s economy is what that will make or break the public health system in Afghanistan.

About the author: Maisam Najafizada is an Assistant Professor of Health Policy at Memorial University of Newfoundland, Canada. He tweets @mayysam 

Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare I have no conflicts of interests to declare.