The many-fold cost of care, going the wrong path

In a previous post I have summarised the Afghan national health account and the burden of health expenditure on Afghan households. In this post, I will take you through a scenario which is a composite of anecdotes of Afghan patients about the costs they incur for medical services, and a possible way to curb those costs.

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Scenario

A man in his early 50s living in a remote village in Bamyan suffers from a mild pain slightly above his stomach. The pain bothers him so much that he decides to visit a basic health center located around 10kms away from the village. He walks to the road where he can catch a vehicle, visits a basic health center. The nurse at the health center gives him a few painkillers, and advises him to visit a physician at a district hospital if it happens again. It is already late for the day to visit a district hospital. He returns home.

This is the first cost that he incurs for the trip he makes to the health facility.

The pain goes away for a few, but comes back sharper and slightly higher around the left side of his chest. He gets worried and makes the trip to the provincial hospital. The hospital is crowded, and he waits for hours to visit a physician. Finally, it is his turn. The physician asks his problem, and start checking his blood pressure like he does it to all patients. The physician diagnosis him with a heartburn and prescribes antacids. He returns home.

This is the second cost that he incurs for the trip, a minimal fee, and medication.

The next day, a sharp pain on the chest after a heavy meal makes him faint for a few minutes. He is taken to the same provincial hospital, where they he is diagnosed with a heart attack, and referred to a specialised hospital in Kabul. Two family members bring him to Kabul overnight in a private van. Physicians admit him for myocardial infarction and administer aspirin, control his pain, and recommend him to rest. He stays in the hospital for three days until he feels slightly better. He is discharged but recommended to rest as much as possible. The doctors tell him that he might need a heart surgery that can only be conducted in foreign countries.

This is the third cost he incurs for the trip, a fee for service, a lot of medication that the hospital did not have, and accommodation and trip for his accompany.

They stay in a relative’s house in Kabul and decide to visit a private hospital with the hope that the diagnosis is wrong or that if it is right, he can get some services in the country. He visits a private hospital, where he goes through a few extra laboratory exams and imaging procedures. The result from the all the procedures in private hospital is inconclusive. They say he has an abnormal electrocardiogram (ECG) but the X-ray and the blood work does not indicate any sign of heart damage. However, he does have a high cholesterol level. He returns home.

This is the fourth cost he incurs for everything.

He decides to go to India for further medical services. He gets a visa for himself and an accompany, goes to India, stays for two weeks for all the medical exams to be done, and the final diagnosis is that he has a stomach ulcer and a high cholesterol. He comes back with a backpack of medication for his ulcer and high cholesterol. Actually, his accompany also goes through a physical exam and some screening, and finds out that he has high blood pressure, and buys medication for the next six month.

This is the fifth cost he incurs.

Analysis

This was a composite of anecdotes. A poor villager might only be able to reach a provincial hospital or at best a specialized hospital in Kabul. But another patient who starts with a specialized hospital in Kabul ends up in India or Pakistan. An Afghan patient often incurs double or triple costs for a single illness. The best scenario is that the patient is taken care of in the first interaction with the health system, which does not happen often with Afghan patients.

The reason it does not happen is the quality of care. The conditions and the services of public hospitals are not better than those of basic or comprehensive health centers. In addition, patients have to pay a fee for the services in the hospital, for drugs and diagnostics, and for travel and accommodation.

The quality of services in the fancy-looking private hospitals is not better than public hospitals for the following reasons. First, all the major progress in medical services in Afghanistan (chest surgery, neurosurgery, orthopedic surgery, major diagnostic procedures using MRI and CT-scan) has first taken place in specialised public hospitals (i.e. Wazir Akbar Khan Hospital). Second, all reputable physicians and surgeons who are in the private hospitals have a government duty in the public hospital, if they really can/want to cure and care for patients; they can do it in the public hospitals. Finally, private hospitals’ first goal is to make profit. The cost of services in private hospital in Afghanistan is unimaginably high.

Therefore, the Ministry of Public Health can cut the national health expenditure by improving the quality of health care: the better the quality of care at the lower level, the lower the expenditure.

Recently, BBC Persian reported that Afghanistan was focusing on standardizing hospitals by creating another standard hospital in order to redirect around $300million that goes to medical services in foreign countries into Afghanistan.

Afghan doctors

Afghanistan already has many substandard hospitals that need to be standardized. The sensible mission would be to upgrade the current hospitals, not with technology but with professional human resources for health. Afghanistan needs better and qualified teams of physicians and surgeons. Equipment can be bought in no time, but training qualified, professional human workforce can take a long time.

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