No cash, no care: How user fees are blocking universal health coverage

Tuesday, December 19, 2017 — At a Malawian health care centre, a mother receives only half of the pills she needs to treat her child for malaria as she is unable to pay the full amount (equivalent to 9 USD), putting the child’s life at risk. In the Central African Republic (CAR), a pregnant woman is asked to pay the equivalent of 2.7 USD for an HIV test but she cannot afford it. When she encounters complications during pregnancy, she is prescribed with fluids that cost 1.8 USD per day. To cover the fees, she asks her neighbours for money. She now repays them little by little but is still in debt. A refugee in Jordan stopped treatment for her non-communicable disease (NCD) because she cannot afford the fees (23 USD per consultation). In a rural area of the Democratic Republic of Congo (DRC), a mother and her baby are not allowed to leave the hospital until they pay 38 USD for an emergency C-section that saved their lives.

While these are just a few examples witnessed by MSF, millions of people face situations like this every day when trying to access essential health care. Deterred from seeking care, the ill simply stay at home and hope for a merciful death. Others delay going to the health facility until their condition worsens, at which point, it is often too late. Many desperate families are forced to take loans or sell their belongings to pay for care, leading to further impoverishment. Health workers, often lacking adequate remuneration, prescribe substandard or unnecessary treatments based on what they think patients can afford and what will generate the most profit. In epidemic outbreaks, the deterring effect of user fees has weakened surveillance and response, as patients die in the community and go unreported.

Over the past decade, many countries addressed these issues by transitioning to free healthcare, either for the entire population or for specific groups, such as pregnant women, children, and people with certain illnesses. Yet, in Guinea, CAR, Jordan, DRC, and other countries, direct patient payments at the point of delivery continue to be demanded from the most vulnerable groups, including refugees, displaced populations, and patients with HIV, TB, NCDs, and malaria. Troublingly, user fees are currently being expanded or (re)introduced in countries that had previously removed financial barriers for patients, such as Afghanistan, Mozambique, and Malawi. Funding cuts now also threaten Sierra Leone’s Free Health Care Initiative for women and children.

Cutbacks in international health grants are putting countries under increasing pressure to rely on domestic resources to maintain and expand health coverage. This has resulted in the (re)introduction of user fees as a method of domestic resource mobilization (DRM), despite overwhelming evidence that out-of-pocket payments are not only unable to generate sufficient revenue but also have detrimental effects for the population, such as limiting access to care, exacerbating poverty, and “punishing the poor”[1].

Consultants and advisors are conveniently ignoring this evidence, including the inefficiency of individual ‘poverty’ exemptions (i.e. whether a person qualifies as indigent). Moreover, international agencies such as the World Bank, WHO, donors, and national governments are failing to uphold their previous commitments to support elimination of user fees, with negative consequences for all three Universal Health Coverage (UHC) dimensions.[2] Failure to transition away from patient fees carries a high human cost and undermines the credibility of commitments to achieve UHC by 2030.  

Any serious engagement to translate UHC from rhetoric to reality should start with the removal of direct patient payments. This implies dedicated resources to pay for services instead of patients shouldering the cost. The effective abolition of user fees will require remuneration of health workers to compensate for the loss of revenue from patient payments and reinforcement of services and supplies to cope with the increased demand.

In 2005 user fees were recognized as ‘an unnecessary evil’[3], and by 2009, all stakeholders were called upon “to act by making health care free in poor countries”.[4] Almost a decade later, we can only highlight the intolerable consequences of these harmful practices. We urge leaders in global health, including national governments, to enforce and support existing free care policies and remove user fees from health financing strategies as a matter of priority. To avoid continued lack of access to essential services and needless financial distress, taxing the ill must come to an end.

[1] Statement by Dr Margaret Chan, former WHO General Director, in 2009.

[2] The three UHC dimensions are the overall utilization rates of services; the range and quality of services provided; and protection against financial hardship. For more information on this topic, see:

[3] Sophie Witter. An unnecessary evil? User fees for health care in low-income countries. Save the Children, January 2005.

[4] “Your money or your life –Will leaders act now to save lives and make health care free in poor countries?”, 2009. Produced under the leadership of Oxfam and endorsed by 60 organizations including MSF. 

Ms Marie-Josée Yakité, MSF midwife at the Castors HRUB since 2014<br/><br/>"I’ve been working here with MSF at Castors since 2014. For 20 years, I worked at Castors before the arrival of MSF, and also at the Hôpital de l’Amitié – a big hospital in Bangui, the capital of the Central African Republic.<br/>We often look after patients who can’t get treatment elsewhere because they don’t have the money. People know that here we offer quality care to everyone, free of charge. In health centres that are not managed by international organisations like MSF, you have to pay for everything. If a patient can’t pay, they send them here. I remember one lady who was referred to us from one of the main hospitals in Bangui. This woman had already been monitored for pre-eclampsia. When the medical staff realised that there was foetal distress, they referred her to us. Not because the hospital couldn’t treat this kind of complication – it was just a matter of money.<br/>In the health centres where patients have to pay for their care, when women arrive in labour, the staff make an assessment of all the tests and the procedures that need to be performed, and an estimate of how much it will cost. And then they make them pay. And if they realise that the woman doesn’t have the money, and that she needs treatment she can’t afford, they prefer to refer her here at Castors because we don’t ask for any money for our services.<br/>We also have women who show up here ready to give birth, but who, for lack of money, have not had any prenatal examinations or tests, for syphilis, toxoplasmosis or HIV for example. We see this very often, especially women who are HIV-positive. These women come to us in labour, without having had a prenatal HIV test. And in theory this test should be free, as it is covered by the Global Fund. Yet sometimes they force women to pay for a whole raft of prenatal tests and they refuse to do the HIV test if the women don’t do the other tests, for which they have to pay. They ask them to pay for the medical supplies, the gloves, the health card, everything.<br/>Because of these financial questions, some people refuse to go to hospital. They prefer to stay at home and rely on traditional medicine. Not long ago, we treated a young woman of 19 who had taken traditional oxytocics. She wanted to give birth at home, she didn’t want to go to a health centre because she didn’t have the money to pay. But the dose of the medicine she took was too high – she ruptured her uterus and her baby died. When the family saw she had suffered a haemorrhagic shock, she was taken to the health centre near her home, which then referred her here to Castors. By the time she came here, three days had already passed. Luckily we managed to save her, but we had to carry out a hysterectomy. She already has a healthy child, but sadly for her, she can’t have any more.<br/>It’s the referrals from other health centres that are the most complicated. Very often, these women come to us in a very serious condition. Sometimes they bring us a woman on the back of a motorbike, and she dies before making it to the door. I suspect that sometimes the health centres keep patients longer than they should in the hope that they might still squeeze something out of them. I tell all the women to come here to Castors as soon as they feel their first labour pains. Here we have qualified staff who can guarantee high-quality care to all patients, irrespective of who they are and where they come from." Photogrpaher: Sandra Smiley
Raissa, 35 years old, shopkeeper, and Maiva, 18 months,<br/>Single, with spouse<br/>Malimaka neighbourhood, district 5, Bangui<br/><br/>"I have six children: the oldest is 19 and the youngest, Maiva, is now 18 months. I live here in Bangui, in the Malimaka neighbourhood, in district 5. <br/>During the events of 2013, I fled with almost all my neighbours to the IDP camp at M’Poko airport. Seleka set up here in the neighbourhood in March that year (Author’s note: this is when Seleka, a coalition of armed men under former-President Michel Djotodia, took Bangui by force). There was a Seleka house just on the corner there, and there was another other that way. There were also many of them in the mosque. Those men would do whatever they wanted. When you crossed the road, you had to watch out to make sure you weren’t shot at. They would turn up at houses in the neighbourhood, break down the door and steal everything. Sometimes, to get people to leave, they would fire into the air, and even at people – they killed women by the road behind where we are sitting now. Once the shots started, everyone would start running and the Seleka fighters would make take advantage of this to carry off our things, even our beds. Anti-Balaka fighters chased them off in December 2013 and then set up here themselves. For us, the people living here, not much changed. They also harassed us, which ultimately drove us to leave. <br/>Before the troubles, we had better lives. During, and just after, I no longer had the means to continue my business. Now, it is quiet, we no longer hear gunfire. It still isn’t easy to earn a living here, but I have to try. I have six children: I can’t just sit here and do nothing. <br/>When I was living at the M’Poko IDP camp, we were living in poor conditions: my five children and I lived under the same tarpaulin. I became pregnant with Maiva while we were there. I didn’t go to many prenatal consultations, but that was more due to the lack of security in the camp and city, rather than money problems. Ultimately, we left in December last year, when the government closed and tore down the camp. They gave money to some people to help them leave and get back on with their lives. Unfortunately, I didn’t get anything. <br/>I gave birth to Maiva in Castors, in district 5. For the other children, I gave birth at one of the major hospitals in Bangui. There, they ask for a lot of money. At every step, they ask you for money. For every procedure, you have to pay the healthcare staff directly in cash. They don’t even ask you to go to the counter. The staff do not look after the patients, their top priority is the money. When I went to the hospital to give birth to my second son, I gave birth alone on the floor in the waiting room. If you want the midwife to come to you, you have to spend a lot of money first."<br/><br/>Prenatal consultation for her previous pregnancies: CFA 2,000 <br/>Spending CFA 2,000 on oranges from the market, Raissa could make CFA 2,000 in profit by reselling them. Photographer: Sandra Smiley
Prisca, 20 years old, shopkeeper, and Darlan, 1 year old<br/>Single<br/>Kaya neighbourhood, district 5, Bangui<br/><br/>"I gave birth to my first child a year ago. I went for prenatal consultations at the local health centre. They asked for CFA 15,000 for all the examinations, but I was unable to pay for them. So, I negotiated with them at the counter, explaining that my husband had left and that I was short of money. Fortunately, the staff sympathised and cut the price to CFA 7,000. <br/>When I went into labour, I immediately set off to Castors hospital. I knew that you can safely give birth there, free of charge. They sent me to the delivery room, but it was no use, the baby was not descending. The staff realised that the baby was presenting feet first. This is a complication that could have been identified at prenatal consultations. They immediately sent me to the operating theatre for a caesarean section. <br/>I went through all this a year ago. Unfortunately, I still have money problems. Sometimes I can make ends meet, sometimes not. I have to manage somehow because there is no one to take care of me. As I told them, my husband left Bangui when I became pregnant and since then, I only rarely hear from him. My family is also poor. They have their own problems and can’t help me out. <br/>I do not want any more children: I’d rather take care of my son properly with what I have. You also have to pay for family planning services at pharmacies, hospitals and health centres, but fortunately there are international organisations here who provide them to women for free."<br/><br/>Caesarean section at the hospital: CFA 50,000 to 60,000<br/>Food for four or five people for a month CFA 60,000<br/>Private school fees for one year: CFA 50,000<br/>Motorbike journey in Bangui: CFA 500<br/>A chicken: CFA 3.500<br/>A bowl of cassava (enough for a family for two weeks): CFA 3.000<br/>One kilogram of rice: CFA 500. Photographer: Sandra Smiley
Maryse, aged 29, student, and Osias, aged three months, born at the Castors Health Centre<br/>Unmarried, with partner <br/>Malimaka neighbourhood, 5th arrondissement, Bangui<br/><br/>"I became pregnant with my second baby Osias almost a year ago. During my pregnancy, I had all my prenatal consultations at the local state-run health centre. I had six prenatal consultations and I had to pay for them all. On top of that I also had some prenatal tests, but not all of them, because I didn’t have the money to pay for them, and at the local health centre the tests cost CFA 1,500, CFA 2,000, and sometimes even more. I didn’t do the HIV test for example. They asked me to pay CFA 1,500 for that one, and I just didn’t have the money [note: in principle, HIV tests should be free at all health centres in the CAR].<br/>In the sixth month of my pregnancy, my waters were leaking slowly. At the health centre, they prescribed a treatment with an infusion, twice a day. This was costing me CFA 1,000 a day. I had to ask my neighbours for money to cover the costs; I’m paying back what I borrowed, little by little, but I still owe them money.<br/>In spite of this treatment, my waters carried on leaking for another month. Then suddenly in my seventh month, I went into labour. I got on a motorbike at once to go to the Castors Health Centre, which my friends had told me about – they had given birth there and told me that MSF offered free care there. When I arrived I gave birth to a premature baby.<br/>Osias was tiny, and needed to grow before we could bring him home. I stayed there with him for a month and a week, the time it took for him to put on enough weight to be able to leave. It was a positive experience: we had everything we needed, the staff looked after us really well, and everything was free.<br/>It’s not always easy to start a family here in Bangui. I have two children with my partner, but we’re not married. Nowadays in Bangui, couples live together without getting married because weddings are expensive, costing more than most people can afford these days. My partner is a technician, but he doesn’t have a steady job. I am a student: I am studying for my baccalaureate.<br/>I had to interrupt my studies because of what happened in the last few years, and so my studies fell behind. When I am at school, I can’t work and earn money for the family. But I’m trying to hang in there. I think of my future, of my children’s future. I would like one day to work in healthcare, so I can help people around me."<br/><br/>Maryse’s school fees for one year: CFA 6,000 for her school uniform + CFA 2,500 for insurance = CFA 8,500<br/>Cost of giving birth in one of the major hospitals in Bangui: CFA 6,000 for giving birth + CFA 9,000 for medicine + CFA 6,000 for admission (2 days) = CFA 21,000. Photographer: Sandra Smiley
Jeski, aged 27, economics and maths teacher, currently unemployed<br/>His daughter Jesblim, aged 14 days, born at the Centre de Santé de Castors <br/>Combattants neighbourhood, Bangui<br/><br/>"My wife, Sublime, gave birth to our first child, a girl called Jesblim, two weeks ago. We had our prenatal check-ups at the Hôpital Communautaire, one of the big hospitals in Bangui. When my wife became pregnant, we knew she had to be seen at a medical centre, but as it was our first child everything was new, and we didn’t know where to look for the best care, or what prices we would have to pay.<br/>My wife first went to the hospital, where they said she had to undergo various prenatal examinations. I managed to pull together the money that we needed for what had to be done: examinations, consultations, buying a health card, etc. Whenever I managed to get some money, I paid for some tests. Then, when I earned a bit more, I came back to pay for some more. In total I paid CFA 45,000. You can do quite a bit with that much money: it pays for a month’s worth of food for a family of four, a year of school for our child at a good private school…<br/>Sublime carried on following the various steps until the eighth month of her pregnancy, when we realised that her treatment was not appropriate, even though we were paying for it, and paying a lot. My wife therefore decided to go to the Centre de Castors.<br/>Sublime went for a consultation, and they told her to come back once she went into labour. When the day came, she was able to give birth without problem, but she had to have a caesarean section. There’s no way she could have had this operation anywhere else, because an operation is expensive, and I am unemployed, I don’t have any money, I just to odd jobs here and there.<br/>It’s hard for people here to afford these expenses, and I am no exception. Sometimes you have money, sometimes you don’t; and when you don’t, you can’t get treatment. You have to jump through hoops to be able to go to the hospital.<br/>For young people today, it’s not easy to find a job. When you go into the neighbourhoods, you’ll see the young people. They are there early in the morning. At midday they are still there, under the mango tree. They are there until the evening.<br/>I finished my studies a long time ago, but I found it difficult to get a steady job. I give maths and economics lessons at people’s homes. It’s OK, but sometimes it isn’t. Often, I agree a price with a client, he accepts, I teach his child well, his results are good, but come the end of the month the boss tells me he has financial problems, that he can’t pay me. And I have to feed my family at home. I have to keep 10 people going at home: my mother, my family and my younger brother’s family. All those people depend on me.<br/>Would we like to have more children? We have to be realistic. It costs money to have children. Yes, the treatment at MSF is free, but will MSF always be around? What will happen to us tomorrow if MSF is not there anymore? If you don’t have money in your pocket to pay the CFA 100 for pills that will save you, you just die. That’s scary. So you can’t just have children for the pleasure of having them. You have to be realistic first." Photographer: Sandra Smiley