Despite multiple post-conflict challenges, including extreme poverty, destroyed infrastructure, insecurity, and difficult terrain, Afghanistan has successfully expanded a standardized package of primary care services to rural areas, where 80% of the population lives. Afghanistan's preliminary accomplishments have been hailed as a best-practice model, but in-depth analysis on whether the population has equitable access to care is warranted.

This dissertation analyzes determinants of access to primary care in rural Afghanistan, focusing on geographic and financial factors, which can be especially inequitable in post-conflict settings. The main data sources include a cross-sectional rural household survey conducted in 2006 and quantitative and qualitative data collected at baseline (2004) and end-line (2007) of a pilot study on user fees at primary care facilities.

Geographic access, measured by households' reported travel time to the nearest facility, showed strong associations with interventions requiring contact with the formal health system, including appropriate care-seeking for children with pneumonia signs and DPT3 immunization. Use of oral rehydration therapy for children with diarrhea was used significantly more by wealthier households, regardless of facility distance.

User fees demonstrated few beneficial effects on observed or perceived quality when they were collected and used at facilities, and they appeared to suppress utilization. However, facility staff and community leaders cited their benefits as sources of discretionary income and their ability to ensure only "real" patients come.

Fee waiver cards distributed to vulnerable households in catchment areas of user fee facilities were associated with increased likelihood of seeking care when sick and with using facility delivery services. Community nomination of beneficiary households was well received and appeared to be pro-poor, using wealth scores from an asset index to measure poverty, despite leakage to wealthier households and high under-coverage of poor households.

Afghanistan abolished user fees for primary care in 2008, citing results of this research. Other positive developments include new initiatives to expand geographic access through mobile teams and sub-centers and experimentation with demand-side financing to encourage utilization. Continued donor funding and Afghan support for the health system, along with mechanisms to monitor equity of primary care, will help further expand access to the population.