Charging patients in poor countries for medical care compromises the health and lives of large numbers of people

Mit Philips is health policy analyst for Medecins Sans Frontieres, based in Brussels. Over the past years, Philips has been studying the effects of asking patients to pay for health care they cannot afford. Here, she explains why it is urgently needed to make medical care free of charge for poor populations.

"There are many adverse effects of charging poor patients for health care. We have seen in our projects and our research that large numbers of people simply cannot afford to see a doctor when they need to, and stay away from the clinics. Others only arrive after they have been able to gather the money they need, selling cattle or borrowing from relatives and the delay in their treatment can lead to serious complications.

"In general, if you are asking people to further impoverish themselves for medical treatment, you are contributing to a spiral of poverty that most likely will affect their health status in the long run. For organisations like ours, it simply does not make any sense to put barriers between patients and the medical care they need, and financial barriers are particularly prohibitive. Luckily, more and more actors in the field of health care now recognise this."

Can you give concrete examples of what the effects of patients fees can be?

Free health care in Liberia with MSF

© Sofie Stevens/MSF (2007) -

"I can give you many examples. Recently, there was a 12-year-old boy in Liberia who was run over by a car and was left with a complicated fracture, with bone sticking out of his leg. His parents gathered all the money they could for hiring a taxi, but found that they had nothing left at the hospital for paying the compulsory registration fee. They took their son home again. His condition deteriorated, his wound got infected with tetanus and he came to the point where he could not eat any more. Neighbours then told the parents that health care was free in the MSF clinic. It took us two full month to repair the damage done not only by the accident but also by the delay in treatment.

One of the excesses that I find particularly disturbing is when patients are not allowed to leave the hospital as long as they have not paid the full charge. We've seen in Burundi and the Democratic Republic of the Congo how women, after having given birth through a ceasarian section, a costly operation in those countries, were effectively held hostage with their babies while their relatives and friends were trying to get the money together."

What happens if you stop asking patients to pay?

"We have seen in a number of projects that the effect can be immediate and huge. People who previously stayed away from clinics all of a sudden start coming forward in large numbers. And they come with serious medical issues.

"In Mali, for instance, we introduced free care in an area where malaria is rife. Almost instantly, the number of infected people we saw tripled. It made us wonder just how many people, children mainly, had gone undetected for the disease and untreated, how many had been dying needlessly in their homes before. Simply because they did not have the money they needed in the clinics and had no means for getting the money. I mean, if one of your children has fever and needs medical care but all of them need food, what are you going to spend your money on if you cannot afford both? The choices were often that stark."

So which countries should be making health care free?

Free health care in Liberia with MSF

© Sofie Stevens/MSF (2007) -

"Let's be clear: there is no such thing as free health care. Someone has to foot the bill. But in poor countries it should not be the patients, as this works against what a health system is trying to achieve.

"When we speak of not charging patients, we are talking about two groups of countries. There are those where free care is already the policy, but due to lack of financial or other means the authorities cannot implement it for the majority of their people. Obviously, a policy that exists only on paper will not save one single life.

"And then there are other countries, mainly in sub-Saharan Africa, that have very bad health indicators, including low life expectancy and high mortality rates, and where the majority of people are very poor. These countries should move to introducing free care as a matter of urgency, too."

What should governments be doing?

"The governments of the concerned countries must come forward with a clear message: we cannot afford to charge our people for the care they need. At the same time, international organisations and donor governments have to wake up to the reality that patients fees in poor countries exclude large numbers of people from medical care without solving the problems of funding for the health system. They need to dramatically step up their technical and financial support.

"A common mistake has been to look at the issues around health care financing from a macro-economic perspective only. At MSF, our approach comes from being among people who are ill or injured every day; we want to treat people who need medical care and will always try to break down barriers that keep patients away from our services. Likewise, policy makers have to understand what their decisions could mean for a young boy in Liberia, a woman giving birth in Burundi and scores of other people when they need medical care."