Health care for sale?

Considering patients to be consumers of health leads to the question of cost for commodity (health care). This cost is often debated and removal of user fees is one of the more recent suggested trends in health coverage solutions among low-income countries (Yates, 2009; WHO, 2010).

According to the World Health Organization (WHO), each year 100 million people become impoverished due to point of service health care costs (WHO news release, 2010).  The urgency of finding a viable solution to health care access has been expressed by Dr. Margaret Chan, current director of the WHO, who stated, “If health systems do not find the right answers now, the bill further down the line is going to keep getting higher and bigger” (2010).  These difficult problems are important for the future of global public health.  The structure of a given health system can greatly affect healthcare outcomes (Bennet, Ozawa & Rao, 2010).  Clearly, health care cost for the consumer is an important issue.

In his article arguing for universal health care coverage (UHC), Rob Yates argues that “user fees have been an ineffective, inefficient, and inequitable financing mechanism” that essentially target poor people (2009). He cites several studies indicating that user fees discouraged health system use among the poor (Yates, 2009). He makes his case suggesting that the WHO should set a timetable for UHC and calls for increased aid.

However, in defense of user fees, Ir and Bigdeli refute Yate’s arguments instead suggesting that in certain cases (Cambodia, in this case) user fees might indeed help to ensure quality of care and access to care (2009). They also stress a point Yates himself initially brought up cautioning that removal of user fees does not remove other barriers to care including “travel costs, informal fees, and low quality of services” (Yates, 2009; Ir & Bigdeli, 2009).  Kruk et al further exemplify this in their article focusing on pregnant women who bypass the closest health facility for a further facility in Tanzania, perhaps perceiving the further facility to be of better quality (2009). The concern about the quality of services is an important one- no matter how accessible health care services become, if they are of poor quality, then all efforts to make the services accessible are futile (Kruk et al, 2009).

In reading about the debates surrounding UHC, whether to apply it, and if so, how- I can’t help but come back to the importance of cultural relevance. Since each country, including poor countries, each have their own set of circumstances involving different levels of infrastructure, community arrangements, etc, it would be foolish to assume that the same approach would work for each situation. Again, coming back to viewing patients as consumers, wouldn’t it be better customer service to tailor the commodity to the patient’s, or community’s, unique needs?


Bennet, S., Ozawa, S. & Rao, K. (2010). Which path to universal health coverage?  Perspectives on the World Health Report 2010. PLoS Med, 7 (11).

Ir, P. & Bigdeli, M. (2009). Removal of user fees and universal health-care coverage. The Lancet, 374 (9690), p 608.

Kruk, M., Mbaruku, G., McCord, C., Moran, M., Rockers, P. & Galea, S. (2009). Bypassing primary care facilities for childbirth: a population-based study in rural Tanzania.  Health Policy and Planning, 24, p 279-288.

World Health Organization [WHO] (2010). WHO urges all countries to strengthen health financing so more people can use services. Retrieved 10/2/11 from

Yates, R. (2009). Universal health care and the removal of user fees. The Lancet, 373 (2078).


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