Direct payments by patients at the point of health care delivery, commonly known as user fees, lead to low utilisation or exclusion of health care services on offer, difficult assessment of health needs and epidemic risks, and impoverish entire households. Vulnerable groups are particularly affected. Over the past decade, many countries transitioned away from their user fee policies in favour of free health care initiatives for all or for specific population groups, such as pregnant women, children, and people with certain illnesses.

Considering  there  is  a  worldwide  commitment  to  achieve Universal Health Coverage (UHC) by 2030, including “financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all”, one would expect free health care to be at the core of UHC policies.

However,  the  reality  witnessed  by  Médecins  Sans  Frontières (MSF)  teams  starkly contrasts the discourse around UHC. Instead of improved access to care, MSF sees a striking trend towards:

• The reintroduction of user fees and other direct payments  by  patients  within  national  health  financing strategies
• A reduction in the commitment and protection of previously accepted fee exemptions, such as those devised for:
  • populations affected by conflict, epidemics, or other crises
  • patients  with  the  need  for  (life) long,  uninterrupted, or repeated treatment and key priority health services, such as treatment for HIV, tuberculosis (TB), malaria, and maternal and child care
• A lack of commitment and support to implement free care policies that secure financial access and ensure sufficient and impactful coverage for the population’s health needs.

In most cases, the proposed policy changes coincide with the expected or announced reduction of international funds for health and a push for domestic resource mobilisation to finance the health sector. This discourse currently dominates global health policies, despite many governments lacking the resources or capacity to deliver services at the pace required without continued international support. Failure to provide this is likely to undermine previous achievements and delay progress towards UHC.

There is overwhelming evidence demonstrating that user fees in low resource and/or conflict and crisis settings exclude and deter people from seeking care, negatively affect quality of services, and exacerbate poverty and the disease burden. Indeed, these findings are mirrored by MSF’s experiences in the field and will be exemplified through several case studies. Yet, concrete measures to mitigate the negative effects of user fees are not receiving the attention they deserve in current UHC plans.

If the global health community is serious about making UHC a reality and ‘leave no one behind’, removal of user fees for essential drugs and services must be tackled as a priority. Without that first and foremost step, patients with the greatest medical needs will continue to lack access to essential health care and suffer financial distress.