In the era of Covid-19 healthcare should be universal and free

Categories: Care, Community Engagement, and Featured.

Covid-19 is a universal threat against the health and wellbeing of all of us and, therefore, requires universal protective measures. Our best hope is that we develop an effective vaccine, which logically should be given to everyone, to stop future outbreaks spreading and potentially eradicate the disease. But for the foreseeable future, as the virus spreads around the world and there is potential for people to be reinfected, this disease remains a threat to all of humanity.

With such a deadly disease ever-present and able to flare up quickly, it is in all our interests that there is truly universal access to a full-range of health services needed to tackle the disease. This doesn’t mean just the high-profile, intensive-care hospital services required to save the lives of people with severe illness. It also includes the vital public-health services needed to stop the spread of the virus, including testing, contact tracing and isolating cases. In addition, everyone must heed the health-promotion messages concerning hand-washing and physical distancing. There should also be universal access to compassionate palliative care for people who succumb to the virus.

Covid-19 is, therefore, perhaps the ultimate example of why we need universal health coverage ― if anyone is left out, it threatens the health security of everyone.

If the objective is to guarantee universal access to healthcare, it is vital to eliminate barriers that inhibit people accessing services and one obvious place to start is to remove financial barriers ― services should be publicly financed and provided free of charge.

Worldwide, it has been shown that healthcare-user fees dramatically reduce demand for health services ― especially preventive services, because people may not perceive that they need interventions. For example, when a $0.30 charge for preventive deworming medicines was introduced for school children in Kenya, demand fell 80%. Conversely, when countries have removed user fees, for example when the United Kingdom launched its National Health Service in 1948, they have witnessed huge increases in demand for services.

But regrettably high user fees are common in many developing countries, where up to three-quarters of healthcare expenditure is in the form of out-of-pocket payments. Furthermore, in some countries with weak governance systems, some impoverished patients are detained in hospital for months until their families can pay their bills. In addition to this being a flagrant human rights abuse, it represents a wasteful use of vital hospital beds as demand from Covid-19 patients is set to rise. In a recent newspaper article, it was even highlighted that in Ghana, patients and their relatives are charged to use hospital washrooms ― not a sensible policy in the midst of a pandemic.

Retaining health-service user fees is, therefore, likely to reduce a country’s capacity to respond to the Covid-19 pandemic, as infection rates rise because of poorer people forgoing testing and treatment. In particular, people are highly unlikely to comply with isolation or quarantine regulations in hospitals if they face mounting hospital bills. It is, therefore, encouraging that Kenya has just abolished fees it was charging for people requiring quarantine.

Simple policy solution

The policy solution to this situation is simple: countries should remove all user fees in public-health facilities and replace lost revenue and meet rising demand for services with higher levels of public financing. This can be accomplished surprisingly quickly, even in low-income settings, as shown by Uganda in 2001, when President Yoweri Museveni abolished all health-service user fees ― 10 days before a presidential election. As a result, healthcare consumption doubled practically overnight and World Bank research showed that the poor benefited disproportionately.

In providing a universal entitlement to free services, it will be important that this policy be extended beyond Covid-19-specific services, because if people suspect they have the virus but are then charged because they are diagnosed with malaria or another disease they will be discouraged from returning.

It is also important to recognise that guaranteeing access to free services in the public sector does not necessarily mean that private providers must also provide free care.  In countries with a universal free public system, it is common for richer members of society to self-select out and pay in the private sector, which improves the targeting of public subsidies on the poor. This has been crucial to the success of universal health systems in Sri Lanka and Thailand, which are weathering the Covid-19 pandemic relatively well.


Healthcare user fees have been a highly contentious topic in global health since the 1980s when they were imposed on many developing countries through the structural adjustment policies of the World Bank and the International Monetary Fund.

It is, therefore, very significant that, as part of its Covid-19 policy responses, the World Health Organisation (WHO) has now explicitly called on countries to remove all healthcare user fees and co-payments. This is a radical change in position from the days when it promoted the formalisation of user fees in Africa through the Bamako Initiative. This programme encouraged community-based financing, for example establishing revolving drug funds, which in effect meant poor people having to pay for their medicines out of pocket.

These issues are also highly relevant to South Africa’s response to Covid-19 and its long term plans to reform its health sector. After the first Covid-19 case was detected on March 4, the government acted quickly and decisively in implementing a national lockdown and mobilising a mass testing programme, involving 28 000 community health workers and 67 mobile laboratories. These services were made available to everyone free of charge. This universal, free primary-care approach was singled out for praise at the WHO daily press briefing and described as “incredible” by the epidemiologist leading the global fight against Covid-19. At the same time stories were emerging from the United States that people were being charged more than $3 000 for Covid-19 tests or being charged high fees for telephone consultations with their doctors, which not surprisingly was discouraging people from being tested.

But these successes also have implications for longer-term health-financing policies in South Africa. In particular, the superior performance of universal tax-financing over private US-style financing through user fees and private insurance, would appear to vindicate the government’s long-term goal to achieve universal health coverage through its National Health Insurance programme currently being debated by Parliament.

It would, therefore, appear that, faced with the universal threat of Covid-19, South Africa and the world is realising that it is in nobody’s interest to exclude poor people from accessing health services through charging user fees ― which, in effect, are a tax on the sick. Instead, if we are all to be protected, we must publicly finance our health systems and provide services free at the point of delivery ― for everyone. This will be an essential step in living with the ongoing threat of Covid-19 and achieving the long-term sustainable development goal target of universal health coverage.

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