title: The effects of user fees on quality and utilization of primary health-care services in Afghanistan: a quasi-experimental health financing pilot study in a post-conflict setting.
abstract: BACKGROUND
  After the fall of the Taliban regime, most clinics in Afghanistan were charging fees to patients. The government invested in monitoring and evaluation systems for its newly rebuilt primary care system, but little was known about the effects of user fees. This study was undertaken to provide evidence on user fees' effects on quality and service utilization and to help inform development of health financing policy and strategy.
  
  
  METHODS
  A quasi-experimental health financing pilot study was implemented in 2005. Forty-seven facilities were randomized to implement a standardized user fee intervention, offer free services, or serve as controls, continuing current cost-sharing systems. Revenues were co-managed by staff and community leaders for facility improvement. Baseline and follow-up facility assessments, exit interviews, and household surveys, as well as routine data were used to evaluate user fee effects over 2 years.
  
  
  RESULTS
  Observed and perceived quality improved at most facilities but did not differ by study group. Utilization increased in all groups, but the increase was 682 to 748 visits per month larger in facilities randomized to free services compared with those randomized to fees or controls (p < 0.01).
  
  
  CONCLUSIONS
  User fees demonstrated few beneficial effects and slowed the rate of increase of service utilization in Afghanistan. In 2008, the government abolished primary care fees, citing results of this study.
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Laura C
authors.initials: LC
authors.lastname: Steinhardt
authors.forename: Krishna D
authors.initials: KD
authors.lastname: Rao
authors.forename: Peter M
authors.initials: PM
authors.lastname: Hansen
authors.forename: Sahibullah
authors.initials: S
authors.lastname: Alam
authors.forename: David H
authors.initials: DH
authors.lastname: Peters
mesh_terms: D000346:Afghanistan; D018588:Fee-for-Service Plans; D006297:Health Services Accessibility; D006801:Humans; D010865:Pilot Projects; D011320:Primary Health Care / Q000191:economics* / Q000592:standards / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000191:economics*
keywords: Afghanistan; care seeking; primary care; quality; user fees