While there are still some commentators who seem stuck on the question of whether removing fees for health care in poor countries is a good idea at all – thankfully there are others who have moved on to the much more critical question of not whether this should happen – but how.
The recent World Health Report on Health Financing for Universal Coverage leaves no doubt that user fees are a bad idea. In the Director General’s own words, they constitute “by far the greatest obstacle to progress” on the path to universal access.
Learning how to successfully remove fees is best done by looking at those countries that have made that bold step forward. The introduction of free care for pregnant women and children in 2010 in Sierra Leone – a post-conflict nation with a crumbling and severely under-resourced health system and one of the highest rates of maternal deaths in the world – provides very relevant lessons for the numerous other low-income countries facing similar challenges.
Let’s look at the impact first. Before free care for pregnant women and children was introduced in Sierra Leone, 88% of citizens said that their inability to pay was by far the greatest barrier to accessing care when sick. Just 12 months after the introduction of free care, medical care for children under five has increased by 214% and the proportion of children getting approved treatment for diagnosed malaria increased from 51% to 90%. For pregnant women, deliveries in formal clinics and hospitals increased by 45% and uptake of modern family planning methods went up 140%. More importantly, the number of delivery complications treated in health units increased 150% and the fatality rate in these cases fell by 61%. This shows us clearly that more women in need of emergency obstetric care are accessing it earlier and that this is making a difference. These positive results recently made it on to the front page of the New York Times.
How did this remarkable change happen? Donnelly’s recent article in The Lancet highlights the key factors. No rocket science here: a high level of political commitment and leadership from the President of Sierra Leone and key staff within the Ministry of Health; health worker reform including the elimination of 850 ghost workers from the payroll; salary increases of at least 100% for all staff; over 1000 additional workers hired; upgrading of a number of facilities to provide a fuller range and better quality of services, and; a desperately needed injection of resources and effort into sorting out the key issue of medicines supply.
Of course there remain big challenges. Of concern is a recent drop off in vaccination coverage likely caused by a breakdown in the medicine cold-chain systems and a potential reduction in primary health care outreach activities. Health worker numbers are still way short of what’s needed; there are concerns in some areas that pregnant women are still paying for services; and there is insufficient infrastructure to build an effective referral system across the country.
But do these challenges mean that free care should not have been introduced? The impact figures cited above challenge anyone who argues that. They suggest that efforts must in fact be redoubled to address long-standing problems that have naturally been exacerbated by a very welcome increase in demand. We need to focus on creating a virtuous rather than vicious circle.
Many commentators suggest conditions must be perfect before fee removal can be considered. In the vast majority of countries this would mean an indefinite wait that put very simply – costs lives.
Instead, the Sierra Leone experience along with others shows that the free care policy itself can be instrumental in bringing needed political attention to long failing elements of the health system, like workers and medicines. Government monitoring of access and quality of services, while still falling far short of what is needed, also seems to have improved relative to before.
The free care policy also achieved something that must be the envy of many other low-income countries – donor co-ordination. Government leadership and determination on this policy forced many of the donors into action, sometimes against their will. Reports from Sierra Leone on the preparation period also confirm that the World Bank supported the introduction of free health care and was a partner to the government in the preparations.
Countries that want to implement free health care shouldn’t have to wait for donors to get their house in order. Rather they should take courage from the example of Sierra Leone and kick start progressive policies in the interests of their citizens which donors should be forced to follow.
 Government of Sierra Leone, Ministry of Health and Sanitation (2011) ‘Health Information Bulletin’ Volume 2, Number 3.
 Information provided by correspondence with Save the Children UK and to be included in a forthcoming report