One Stone: How Many Ripples?

Health care is not a small issue.  The idea of providing all people with primary health care is much bigger then making sure they have the opportunity to go to doctors and receive medicine when it is necessary.  Health care, as any public health professional will tell you, is a web of interwoven aspects that come together to allow individuals to live healthy lives.  When we think about the idea of health in terms of primary health care many individuals are likely to think that if we ensure that all people regardless of income have access to basic, primary health care then we are doing our jobs.  I am not convinced that this is the answer.

Yates, in his article “Universal Health Care and the Removal of User Fees”  (2009) talks about the importance of ensuring that all people in low and middle-income countries have access to primary health care.  He argues that, “taking money from poor people when they are sick is not a good idea” (page 2081).  I agree with this statement, but I fear that this will not be enough to ensure the health of all individuals, even on a basic level.  When we think about health it is imperative that we think about things bigger then the structures and services directly related to health care.  If we want to ensure that all people are healthy then we have many more issues to tackle.

If a woman comes into a hospital to receive pre-natal care and she is able to give birth to a healthy child that is a great step.  If she and her baby are both able to leave the facility healthy then that too is a great step.  But what happens when the mother and child return home to their village? What happens if there is no clean water or the sanitation is unreliable? What happens if there is not enough nutritious food to ensure that the child grows and develops well? What happens when the child goes to school and isn’t taught about hand washing or how to prevent the contraction of viruses such as HIV?  Yates talks about the importance of removing user fees so that individuals can seek primary health care regardless of their income.  I think that this is imperative, however it is a first very small step toward ensuring the individuals receive the health care they need.

Ensuring individuals’ health means ensuring that a community has a solid infrastructure with clean food and water.  That people receive the type of education necessary to make healthy life-choices and that individuals live in communities in which the sanitation is well functioning.  And these are just a few of the factors that need to be taken into account when thinking about the health of individuals living in low and middle-income countries.  Yates does a fantastic job of outlining the first steps that need to take place, but there is a much bigger problem here.   Additionally, Yates discusses this proposal for low and middle-income countries, but what about people living close to or below the poverty line here in the United States or other wealthy countries? Don’t they have many of the same problems? And just because they live in a wealthy country doesn’t mean that they receive the health care they need.  Is the removal of all user fees something that can and should be done in for poor individuals living in wealthy countries as well?

If the stone of user fees is no longer thrown into the water, then that will eliminate the ripple effect of primary health services in terms of doctors and treatment, but what about the much bigger ripple effect? Is this proposal really enough to ensure that all people are receiving the health care that they need? And with a problem that is as big as this, are we just biting off more then we can chew?


Yates, Rob. “Universal Health Care and the Removal of User Fees”. The Lancet. Vol 373, June 13, 2009. Pp.2078-2081.


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