Health Care System Reform Research Articles

Economic and health impacts of China’s comprehensive health care system reform

Economic and health impacts of China’s comprehensive health care system reform

Can China’s national comprehensive medical reform increase medical resources and reduce healthcare burden: evidence from Chinese provinces

ObjectivesChina’s national comprehensive medical reform (NCMR) is an important attempt in the reform of healthcare system, and quantitative evaluation of its effect is of great significance for continuously deepening medical reform, grasping the reform direction, and building a healthy China. Therefore, focusing on medical resources and medical burden, this study aims to systematically explore the policy effectiveness and the provincial heterogeneity of NCMR, as well as the potential influencing factors.MethodsUtilizing the collected multi-period panel data of 31 provinces in mainland China in 2006–2021, we regarded the release of the two batches of pilot provinces in NCMR as a quasi-natural experiment and comprehensively adopted a Staggered difference-in-differences (DID) model and Synthetic Control Method (SCM), combined with word frequency statistics and grouping regression analysis.ResultsNCMR can effectively increase the number of licensed physicians by 12.6% and reduce the per capita medical expense for in-patients by 7.2% in the pilot provinces. Furthermore, the NCMR policy effect in different pilot provinces shows various characteristics, and only Jiangsu, Zhejiang, and Chongqing achieve both the growth of medical resources and the reduction of medical expenditure. Meanwhile, word frequency statistics are conducted based on related policy descriptions and news reports on the official websites, so as to summarize the specific policy means in the three provinces, and provide a reference for other provinces to practice the healthcare reforms. Besides, extensibility analysis shows that the effect of NCMR is affected by the population aging and health status. Groups with low degree of population aging (low-AG)/high population health status (high-HE) performed a more obvious reform effect.ConclusionThis study provides beneficial policy implications for increasing medical resources, reducing medical burden, and promoting medical reform process.

Analysis of rational prescription of medicines by village clinics: a repeated cross-sectional study of a province in eastern China.

To analyse the rational prescription of medicines by village clinics following China's implementation of the New Healthcare System Reform (NHCSR). Retrospective study. Village clinics in a province in eastern China. Our evaluation was based on the core drug use indicators reported in the study 'How to Investigate Drug Use in Health Facilities: Selected Drug Use Indicators'. The level of rational use of medicines (RUMs) in village clinics improved in 2018 compared with 2009; the average number of drugs per prescription decreased from 3.66 to 2.77, the percentage of prescriptions including antibiotics decreased from 65.40% to 46.00%, and the percentage of prescriptions including injections decreased from 55.75% to 37.48% (all p<0.01), whereas the percentage of drugs prescribed from the list of essential medicines increased from 66.50% to 80.34%, and the percentage of drugs prescribed by generic names increased from 61.29% to 70.65% (all p<0.01). The level of RUMs improved after the implementation of the NHCSR, however, it was found that there was still a gap between the level of RUMs in 2018 and the international reference value. Financial investments, electronic prescription systems, improved supervision and regular training are essential actions that must be implemented.

Community mental health care in Croatia: Mobile team for psychosocial support in the community

Abstract The Republic of Croatia has initiated numerous reforms in the mental health care system in the community. Within the framework of EU JA Implement, a mobile team was formed to provide interventions in the community, that is, in the homes of persons discharged from psychiatric hospitals. The mobile team was formed during 2023. The team includes: one psychiatrist, leader and coordinator of the mobile team, three graduate nurses, a case manager, a social worker, three experienced experts who are employed in the team as peer workers, and one social pedagogue and psychologist. The wider composition of the team includes a psychiatrist who provides outpatient psychiatric treatment, who is familiar with the individual recovery plan and, if necessary, participates in the development of the plan. The goal of establishing a mobile team is to implement an individual recovery plan in the community, that is, in the patient’s home, using biopsychosocial interventions, with the aim of better and faster recovery of the user and inclusion in the community, as well as prevention of rehospitalization and disability. Before the patients home visits, the experts in the team were trained. 15 patients were included in the pilot project, with whom 96 home visits or interventions were carried out in the time period from the establishment of the team to April 2024. As a result of the effectiveness of the pilot project, in 2024, in accordance with the Strategic Framework for the Development of Mental Health until 2030, the Republic of Croatia adopted a new network of health institutions, within which 30 mobile psychiatric teams and 24 psychological teams at the primary level of health care are planned. Empowerment of users, engagement of people with experience in the implementation of interventions, increase in mental health literacy of the population and destigmatization are additional results of the implementation of mental health protection in the community through JA impleMENTAL.

Experiences of parents with very premature-born children at risk of neurodevelopmental disorders: A qualitative study.

Premature birth is a traumatic and stressful situation for parents who are immediately separated from their infant because of the newborn's need for specialized care. The staff of these units are in charge of following the principles of family-centred care and practices for neonates at risk of neurodevelopmental disorders, including providing training to the family during their hospital stay and after being discharged. The aim of this study is to explore the perceptions of parents of premature children at risk of neurodevelopmental disorders in regard to care, interventions and assistance provided during the first months of their child's life. A qualitative descriptive study was carried out through individual interviews. The data analysis was conducted through a thematic analysis. The methodology and results were reported following the standards for preparing qualitative research reports and recommendations. Twenty-one parents of premature children were interviewed. From these interviews, three main themes emerged: (i) parents' perspectives on preterm birth risk communication, (ii) navigating parental support and early interventions in preterm birth and (iii) perceptions of preterm birth protective and challenging factors. The parents of premature children need to receive better communication about the care and interventions for their child, and it is necessary that health personnel are better trained in terms of management and administration of public resources. Strategies must be implemented that continuously guide parents on the follow-up and care of their premature child not only during their first moments of life but also after being discharged from the hospital. This study highlights the need to improve care for parents with premature infants at risk, emphasizing the necessity for health care system reforms and support structures, allowing health care professionals to enhance attention and care.

Healthcare Access for Patients With Inflammatory Bowel Disease in the United States: A Survey by the Crohn's & Colitis Foundation.

A prior survey disseminated in 2017 identified that healthcare access barriers exist and significantly affect patients with inflammatory bowel disease (IBD). We sought to identify, through an updated survey, the healthcare access barriers that patients continue to face, with a focus on socioeconomic factors and patient awareness of resources to navigate existing barriers. A 52-question online survey evaluating (1) access to healthcare professionals, medications, and procedures; (2) associated financial challenges; and (3) patient awareness of education and advocacy tools to navigate IBD care barriers, was disseminated through multiple channels to IBD patients and their caregivers. Of the 2281 completed responses, patients on advanced specialty medications, younger than 65 years of age, or on employer insurance experienced significantly greater issues with insurance barriers to accessing medications and coverage of medically necessary tests/treatments. Patients who live in areas of concentrated poverty were more likely to experience poor health outcomes when subjected to step therapy compared to patients who did not. Additionally, patients were more likely to experience one or more financial barriers or trade-offs if the patient used an advanced specialty medicine or lived in an area with concentrated poverty. While there have been significant and numerous advancements in IBD treatments, patients with IBD continue to experience barriers to healthcare access and treatment and financial struggles. Ongoing awareness and advocacy efforts focused on healthcare system reform and related policies to further minimize care disparities and barriers remain vital.

EXPERIENCE IN IMPLEMENTING PROJECTS ON THE INTRODUCTION OF VALUE-BASED HEALTHCARE IN FOREIGN COUNTRIES

The introduction of value-based healthcare is considered as the most promising area of healthcare system reform in different countries, regardless of the level of their socio-economic development. The definition of value-based in healthcare is defined by M. Porter and E. Tysberg, which is formulated as the ratio of the results that are important to patients to the costs incurred to achieve these results. The purpose of this study is to study the experience of foreign medical organizations in the implementation of value-based healthcare and generalize the main stages and factors influencing its implementation.

Medical and social aspects of euthanasia of palliative patients in Ukraine, Switzerland, Canada, the USA and Israel

Medical Assistance in Dying (MAiD) is legally used in such countries as the Netherlands, Belgium, Luxembourg, Switzerland, Colombia, Canada, Australia, Spain, Germany, and the USA. Portugal and New Zealand are considering legal euthanasia laws. MAiD is performed by injecting a lethal substance into a terminally ill person by a doctor or the patient himself. Euthanasia is one of the services that palliative patients need in the last months and days of their lives. The availability of MAiD increases the country's ranking in the Quality of Death Index and reduces the need for euthanasia tourism. Ukraine needs the legalization of MAiD, as well as the improvement of the palliative and hospice care system in general. The research was conducted using the methods of systematic analysis, the comparative method and the bibliosemantic method with the search for literary sources and legal acts in Google, Google Scholar and PubMed, with an emphasis on Ukraine, Switzerland, the USA, Canada and Israel. During the comparative analysis, it was concluded that the Canadian model of the MAiD is optimal for Ukraine, taking into account the experience of its construction, society's perception and problems related to the application of the legislative norms of the MAiD. The Canadian health care system, the MAiD practice is guided by the social perception of its work models. Legislators respond sensitively to thorough scientific research and court decisions, which respect state and social institutions. The analyzed results of scientific research in Switzerland, the USA and Israel warn researchers and legislators against possible abuses in the implementation of MAiD. But at the same time, they attest to the importance of an accessible MAiD procedure for terminally ill palliative patients, which should be available for the realization of the right to a dignified death along with quality palliative medicine for the realization of the right to a dignified life. Keywords: palliative and hospice care, health care system reform, Medical Assistance in Dying, Quality of Death Index, right to life, right to die.

Impact of Diagnostic-Related Groups Healthcare Payment Reform on Public Hospitals

The increasing reform of diagnosis-related groups (DRG) healthcare payment plays a crucial role in the reform of the medical and healthcare system, accelerating the high-quality development of public hospitals and serving as a critical path for their reform. The innovation of DRG healthcare payment methods can balance the financial income and expenditure of public hospitals, while also achieving a more harmonized balance of interests among hospitals, patients, and health insurance. This reform effectively controls the operating costs of hospitals, strictly regulates medical behaviors and quality management, and optimizes the patient treatment process. To quickly adapt to this reform trend, public hospitals need to seize the opportunities of healthcare system reform, adopt corresponding strategies to address the impact of DRG payment reform and achieve their own sustainable development goals in health.

On certain issues of modern health care system development

Nowadays, the reforming of health care system in the Russian Federation is the most actual since country survives difficult economic conditions and is in need of development of new enhanced scientific and methodological approaches to various aspects of public health and health care, targeting increase of all types of efficiency in this system (medical, social, economic ones). For proper functioning of health care system, not only physicians, but also such specialists as physicists, engineers, mathematicians, biologists, chemists, lawyers, economists, psychologists, teachers and others are to be involved in process of developing new approaches. The multidisciplinary approach and effective interdisciplinary interaction can input into improvement of health care system based on needs of patients. To achieve the highest benefit for patient, development of comfortable conditions for all participants of diagnostic and treatment process, appropriate quality of medical care and maximal level of satisfaction of subjects in given system, it is necessary to consider segmentation of medical services market i.e. characteristics of consumers and providers. The systematic approach is to be applied to achieve this target, involving organizations of private and public sector of practical health care and scientific and educational organizations. it is needed to develop methods of early diagnostic, disease prevention programs and training of personnel in health care system, taking into account approaches of integrative and preventive medicine.

Revisiting the Policy Implications of Medical Tourism in the Post-COVID-19 Pandemic From a Malaysian Perspective: A Qualitative Study.

Background Malaysia has been one of the most prominent destination countries for medical tourism. The industry received significant government support to create a conducive environment for its growth, such as the provision of an investment tax allowance for the facilities participating in medical tourism and the establishment of the Malaysia Healthcare Travel Council (MHTC) to coordinate collaboration between various industry stakeholders to promote medical tourism activities at the international level and facilitate inbound medical tourists. The establishment of the MHTC facilitates collaboration between various industry stakeholders. In addition to facilitating medical tourism activities, MHTC is also involved in analysing relevant data, including but not limited to the socio-demography of medical tourists, the trend of their healthcare service utilisation, revenue generated, and market intelligence to promote the industry's growth. The council serves as a medium to facilitate the collaboration of stakeholders such as the hospitals participating in medical tourism, the Association of Private Hospitals Malaysia, the Malaysian Society for Quality in Health, and various government agencies, including the Ministry of Health and the Department of Immigration, Malaysia. We explore the policy-related implications of medical tourism and its relationship with the Malaysian national healthcare system. Methodology We revisited Pocock and Phua's conceptual framework of policy implications for medical tourism to explore its relevance after more than a decade of intensive government support and the aftermath of the COVID-19 pandemic. We employed a qualitative case study design using semi-structured, in-depth interviews with stakeholders from the Ministry of Health Malaysia, the private health sector, professional bodies, academics, and health-related civil society organisations. Results Our study found that many issues identified in the original framework remain relevant after over a decade. However, we also identified additional implications, such as the role of insurance portability in encouraging the growth of international hospital accreditation and the issue of equitable access to healthcare within the context of the current Malaysian healthcare system in the aftermath of COVID-19. Conclusion Due to its vulnerability, there is a need to develop a strategic collaboration that includes incorporating medical tourism activities into a broader framework, such as promoting aged care within the retirement destinations package for expatriates, which could ensure its sustainability instead of relying solely on medical tourism activities. In the meantime, policy implications arising from the industry remain relevant and should be addressed through a comprehensive structural reform of the national healthcare system involving stakeholders from the public and private health sectors.

National charitable fundraising for the NHS, 1948–2023

AbstractWhether charitable fundraising might play a part in funding Britain's ostensibly tax‐funded NHS has been a longstanding dilemma, which until recently has received only occasional scholarly attention. In 1946, Aneurin Bevan argued that one of the main goals of the reformed health care system was to liberate health care from the ‘caprice of private charity’. Seven decades later, NHS Charities Together's Urgent Covid‐19 Appeal became a powerful societal rallying cry in the health emergency of the pandemic and raised £150 million in the process. This paper draws together findings from new archival research, a witness seminar with key actors in the NHS charity sector, and qualitative research based on interviews with NHS charity staff and trustees (N = 13), all conducted between 2021 and 2023. We investigate the way in which national appeals have been proposed, debated and implemented at different times in the NHS's history. We trace the recurrence of conflicting ideas about the acceptability of national fundraising for the NHS, about whether public loyalties are to their local services or the national ‘brand’ and about the introduction of national appeals into a complex ecology of local NHS charities. The history of charitable fundraising for the NHS is, we argue, neither a simple story of spontaneous public generosity, nor often of formal policy reform, but is an artefact of more complex dynamics between a changing cast of local and national actors over the last 75 years.

The global patient-reported outcomes for multiple sclerosis initiative: bridging the gap between clinical research and care - updates at the 2023 plenary event.

Significant advancements have been achieved in delineating the progress of the Global PROMS (PROMS) Initiative. The PROMS Initiative, a collaborative endeavor by the European Charcot Foundation and the Multiple Sclerosis International Federation, strives to amplify the influence of patient input on MS care and establish a cohesive perspective on Patient-Reported Outcomes (PROs) for diverse stakeholders. This initiative has established an expansive, participatory governance framework launching four dedicated working groups that have made substantive contributions to research, clinical management, eHealth, and healthcare system reform. The initiative prioritizes the global integration of patient (For the purposes of the Global PROMS Initiative, the term "patient" refers to the people with the disease (aka People with Multiple Sclerosis - pwMS): any individual with lived experience of the disease. People affected by the disease/Multiple Sclerosis: any individual or group that is affected by the disease: E.g., family members, caregivers will be also engaged as the other stakeholders in the initiative). insights into the management of MS care. It merges subjective PROs with objective clinical metrics, thereby addressing the complex variability of disease presentation and progression. Following the completion of its second phase, the initiative aims to help increasing the uptake of eHealth tools and passive PROs within research and clinical settings, affirming its unwavering dedication to the progressive refinement of MS care. Looking forward, the initiative is poised to continue enhancing global surveys, rethinking to the relevant statistical approaches in clinical trials, and cultivating a unified stance among 'industry', regulatory bodies and health policy making regarding the application of PROs in MS healthcare strategies.

Patient empowerment in public healthcare funding system reform: a power network perspective

ABSTRACT This paper examines a reform of the French healthcare system that aimed to empower patients and improve their access to care but led to various adverse consequences for patients. Specifically, already socio-economically disadvantaged groups of patients found their positions becoming even more precarious. Conceptually, we draw upon Emerson’s power dependence theory and find that, rather than empowering patients, the reform resulted in private health insurance providers emerging as critical actors and primary beneficiaries of power network changes. This healthcare system-level analysis highlights the need for patients to be the direct focus of healthcare system reform and the importance of considering their position within the power network for understanding reform outcomes. This attention to the power network adds to the extant theorisation on the effects of funding mechanism reform on the nature of patient empowerment and access to healthcare.

THE ROLE OF PEDAGOGY IN THE PROFESSIONAL ACTIVITY OF A MODERN DOCTOR

The relevance of the study of the role of pedagogical knowledge in the professional activity of a modern doctor is due to the reform of the domestic health care system and the reorientation of medical workers from the treatment of diseases to preventive medicine and the promotion of a healthy lifestyle. The purpose of the work is to consider the role of pedagogy in the professional activity of a modern doctor. The article discusses the directions of building a model of interaction between a doctor and a patient. In conclusion, it is concluded that the achievements of pedagogical science, ensuring the harmonious development of personality, are also important for their use in the practical professional activity of a modern doctor, especially from the point of view of teaching patients and educating them to self-preservation behavior. Therefore, pedagogy today plays an important role in the system of training medical personnel and acts as a subject, the study of aspects of which is aimed at integrating pedagogical knowledge into the process of training a modern doctor.

Moral economy and moral capital: A new approach to understanding health systems

Healthcare systems can be considered moral economies in which moral capital in the form of expectations toward norms, values, and virtues are exchanged and traded. Moral capital, as a concept, is an extension of Bourdieu's forms of symbolic, and in particular, cultural capital. This research set out to identify forms of moral capital evident in the accounts of health professionals and patients within the distinctive healthcare systems of Germany, New Zealand, and the Unites States. Here, we provide an overview of 15 forms of moral capital that were identified. An important form of moral capital is equality. The global coronavirus pandemic has illuminated inequalities in healthcare systems across the world. We suggest considering moral capital as a useful tool to reform healthcare systems and make the provision of healthcare a more equitable enterprise.

DIFFERENTIAL DIAGNOSIS OF TUBERCULOSIS AND NON-SPECIFIC PULMONARY INFILTRATS (Lecture)

Following the reformation of healthcare system and the dissolution of the specialty "Phthisiology," the extensive anti-tuberculosis efforts in Ukraine now fall under the purview of family doctors and specialists across various fields. According to the Law of Ukraine “On Overcoming Tuberculosis in Ukraine”, enacted on 14.07.2023 under No. 3269-IX, Paragraph 4 (Article 4), individuals afflicted with tuberculosis or latent tuberculosis infection are entitled to specialized medical care. This includes the treatment of all forms of tuberculosis and associated conditions across a spectrum of healthcare institutions. Compliance with this legal mandate necessitates that doctors of various specialties possess not only proficiency in contemporary tuberculosis treatment methods, which will be facilitated by the regional tuberculosis control center, but also competence in diagnosing tuberculosis in its various presentations. When health issues arise, patients typically seek assistance first from primary care specialists. The “Pulmonary infiltrate syndrome” is an X-ray syndrome characterized by the presence of shadows in the lungs exceeding 1 cm in diameter. There are numerous causes for such changes in the lungs. Given that the lungs are the most common site for tuberculosis, particularly in the form of infiltrative shadows, which may signify not only tuberculosis but also pneumonia, tumors, lung infarction, eosinophilic infiltrate, and other conditions, the question of their differential diagnosis becomes quite relevant. The increasing frequency and subtle clinical presentation of the “Pulmonary infiltrate syndrome” necessitate proficiency in the clinical aspects and diagnosis of its most common manifestations. The key differential diagnostic features that distinguish infiltrative pulmonary tuberculosis from other nonspecific infiltrates include contact with a tuberculosis patient or a history of tuberculosis, often subacute onset, heterogeneous infiltrative shadow in 1, 2, or 6 segments with a connection to the lung root, moderate leukocytosis, lymphopenia, elevated ESR, presence of acid-fast bacilli in sputum or bronchial lavage, specific endobronchitis, positive response to antitubercular therapy, and lack of improvement with other nonspecific treatment methods.

Key aspects of the Saudi healthcare system reform and the potential impact on the main stakeholders: A qualitative study

ObjectivesTo explore and understand KSA’s fundamental healthcare system reform, the potential changes and challenges, and their impacts on major stakeholders. MethodologyTo gain in-depth insights into healthcare leaders’ perspectives regarding healthcare system reform in KSA, a qualitative research approach was used. Ten participants from diverse backgrounds were selected, representing various sectors in KSA: private, public, executive, consulting, and regulatory. This study was conducted between august 2022 and June 2023. FindingsThe findings revealed four key themes that shed light on healthcare system transformation in KSA and its effects: healthcare system reform, the impact of corporatization/privatization on healthcare providers, the impact of corporatization/privatization on health insurance, and the impact of corporatization/privatization on the workforce. Furthermore, the findings indicated that the ongoing transformation of the public sector toward privatization in KSA faces various challenges that affect most, if not all, stakeholders in the sector. However, the private sector possesses several strengths that can aid in addressing the challenges associated with the rapid transformation of the system. These strengths include familiarity with the market, robust financial management, extensive experience in coding and billing payers and insurance companies, efficient decision-making processes, flexibility, and maturity. ConclusionThe study facilitated comprehensive insights into the transformation of KSA’s healthcare system and the public sector’s shift toward corporatization/privatization. The sector must enhance its capabilities by establishing specialized units and recruiting talent. Further studies are also needed to gain a deeper understanding of the obstacles hindering the transformation.

Identifying gaps in healthcare: a qualitative study of Ukrainian refugee experiences in the German system, uncovering differences, information and support needs

BackgroundThe 5.8 million Ukrainian refugees arriving in European countries must navigate varying healthcare systems and different and often unknown languages in their respective host countries. To date, there has been little exploration of the experiences, perceived differences, information and support needs of these refugees regarding the use of healthcare in Germany.MethodsWe conducted ten qualitative interviews with Ukrainian refugees living in Germany from February to May 2023, using Ukrainian, English and German language. The transcribed interviews were analysed using the qualitative content analysis method according to Kuckartz and Rädiker with the MAXQDA software.ResultsIn general, participants consistently had a positive experience of the German healthcare system, particularly regarding the quality of treatments and insurance. Differences have been reported in the structure of the healthcare systems. The Ukrainian healthcare system is divided into private and state sectors, with no mandatory insurance and frequent out-of-pocket payments. Pathways differ and tend to focus more on clinics and private doctors. General practitioners, often working in less well-equipped offices, have only recently gained prominence due to healthcare system reforms. Initiating contact with doctors is often easier, with much shorter waiting times compared to Germany. Interviewees often found the prescription requirements for many medications in Germany to be unusual. However, the mentioned differences in healthcare result in unmet information needs among the refugees, especially related to communication, navigating the healthcare system, health insurance, waiting times and medication access. These needs were often addressed through personal internet research and informal (social media) networks because of lacking official information provided during or after their arrival.ConclusionsDespite the positive experiences of Ukrainian refugees in the German healthcare system, differences in the systems and language barriers led to barriers using healthcare and information needs among refugees. The dissemination of information regarding characteristics of the German health care system is crucial for successful integration but is currently lacking.Trial RegistrationGerman Clinical Trials Register: DRKS00030942, date of registration: 29.12.2022.

Exploring barriers to access to care following the 2021 socio-political changes in Afghanistan: a qualitative study

BackgroundFollowing the change of government in August 2021, the social and economic landscape of Afghanistan deteriorated into an economic and humanitarian crisis. Afghans continue to struggle to access basic healthcare services, making Universal Health Coverage (UHC) in the country a major challenge. The aim of this study was to perform a qualitative investigation into the main access to care challenges in Afghanistan and whether these challenges have been influenced by the recent socio-political developments, by examining the perspectives of health professionals and hospital directors working in the country.MethodsHealth professionals working in facilities run by an international non-government organisation, which has maintained continuous operations since 1999 and has become a key health reference point for the population, alongside the public health system, and hospital directors working in government hospitals were recruited to participate in an in-depth qualitative study using semi-structured interviews.ResultsA total of 43 participants from ten provinces were interviewed in this study. Four issues were identified as critical barriers to achieving UHC in Afghanistan: (1) the lack of quality human resources; (2) the suboptimal management of chronic diseases and trauma; (3) the inaccessibility of necessary health services due to financial hardship; (4) the unequal accessibility of care for different demographic groups.ConclusionsHealth professionals and hospital directors shed light on weaknesses in the Afghan health system highlighting chronic issues and issues that have deteriorated as a result of the 2021 socio-political changes. In order to improve access to care, future healthcare system reforms should consider the perspectives of Afghan professionals working in the country, who are in close contact with Afghan patients and communities.