Free healthcare in Sub-Saharan Africa: clearing up the misconceptions

This document introduces a series of nine evidence-based fact sheets showing how certain ideas about free healthcare repeatedly expressed in our knowledge transfer activities actually represent “lazy thinking” (1).


In 2010, the African Union called for full exemption from healthcare costs of children under five and pregnant women [2]. Postapartheid South Africa pioneered this exemption in 1994. That initiative was founded on strong political will to make healthcare as widely accessible as possible, especially to the poorest. Since the early 2000s, a great many African countries have followed suit by instituting user fees exemption policies, or “free healthcare”, for certain categories of patients (3). Download introduction [pdf]

This series, Free healthcare in sub-Saharan Africa: clearing up the misconceptions, consists of nine fact sheets dealing with the following misconceptions:

1 : « A financial contribution, however small, must be required! »

Requiring any financial contribution, however small, restricts access to healthcare by the poorest. While there are other determinants of use (location, quality of care, etc.), the primary reason why patients do not use health services is that they cannot afford them. Download fact sheet [pdf]

2 : « Free healthcare doesn’t benefit those who need it most! »

The most advantaged populations (the least poor, urban populations, etc.) do not monopolize the benefits of free healthcare. The most disadvantaged profit from it just as much, and sometimes even more. Of course, free healthcare alone cannot be expected to correct all the existing inequalities in health systems. Download fact sheet [pdf]

3 : « Free healthcare takes away people’s sense of responsibility and is not valued enough! »

Free healthcare makes people responsible by enabling them to play an active part in managing their own health. People’s perceptions of the value of healthcare are not affected by whether the services are free. On the contrary, making healthcare free may serve as a strategy to bolster people’s confidence in health services and professionals. Download fact sheet [pdf]

4 : « Free healthcare is substandard care! »

Quality of care is a very complex concept. In the documented cases, the parameters studied do not demonstrate any deterioration in quality of care where free care is well implemented. They do show the importance of accompanying measures when free care is introduced. Download fact sheet [pdf]

5 : « Free healthcare is impossible because it creates excessive workloads for health workers! »

Measuring healthcare workloads produces varying results, which are closely dependent on context. Measurement makes it possible to distinguish between health workers’ perceptions of increases in workload and actual overloads. Most often, health human resources exceed the need. Therefore, the increased use of health centres generated by free healthcare makes the system much more efficient by using resources more effectively. If demand does grow to exceed supply, it is up to the health system to adjust to meet the needs that up to then were not recognized because of the constraints imposed by user fees. Download fact sheet [pdf]

6 : « Free healthcare will bankrupt health centres! »

Free healthcare is perfectly compatible with the cost recovery system. It helps financial centres expand their financial capacities, provided it is sufficiently funded and properly implemented with a third-party payer. It can also further empower members of health centre management committees and the general population. Download fact sheet [pdf]

7 : « Making deliveries free will lead to more births! »

Free healthcare increases the number of assisted deliveries by qualified personnel and ultimately saves lives. Free deliveries and family planning are complementary. Both deal with reproductive health, respond to health needs, are aimed at reducing poverty, and promote the enforcement of sexual and reproductive rights. Download fact sheet [pdf]

8 : « African states are incapable of implementing free healthcare! »

There are many examples to show that, given sufficient political will and proper adherence to the various stages of planning and financing, African states are in a position to implement effective free healthcare policies. Download fact sheet [pdf]

9 : « African countries can’t afford free healthcare! »

In most cases, free healthcare policies for children and pregnant women already in place in Africa are funded by national budgets, of which the share devoted to health remains woefully insufficient. National and international resources are available to finance free healthcare policies, provided African governments and their partners give them the required priority. Download fact sheet [pdf]