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

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: http://www.who.int/health_financing/strategy/dimensions/en/

[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.