It is 7 am in New Kru Town in the Liberian capital, Monrovia, and Redemption Hospital does not open for another hour. But a long line is already forming outside the doors. Some patients have travelled up to 60 kilometres to benefit from the free treatment.

In February Liberia's Ministry of Health eliminated all user fees at Redemption and other government-run hospitals and clinics in the country, after several months of charging fees, which put health care out of the reach of many.

Liberia, slowly rebuilding from 14 years of war, has a poor, largely unemployed population and a devastated infrastructure. And it is confronting the question in this post-conflict setting of how to sustain the health sector – user fees or some other mechanism.

The World Bank and other international institutions are working with the government to come up with the best answer. World Bank economist in Liberia, Alex Preker, said the Bank is committed to finding sustainable healthcare solutions for Liberia if funding for free care from donors runs out.

"Illness has a potentially devastating impact on low-income and other vulnerable populations,” Preker told IRIN. He pointed to a range of options – including subsidies to providers who treat vulnerable groups and insurance or prepayment schemes for those who can afford to contribute to such plans – “that have been shown to lower the financial burden of illness.”

Alternative healthcare mechanisms could include imposing taxes or providing affordable health insurance, health experts say. Save the Children UK and the UN Children’s Fund (UNICEF) will soon begin gathering empirical data on the feasibility of imposing nominal health fees or offering insurance to the public. They hope to release a report detailing the findings in January.

"Liberia needed both short-term and long-term strategies,” said Judah Morris, Save the Children’s health manager in Liberia. “In the short-term, the answer was to suspend user fees. In the long term, we have to identify alternative health care mechanisms."

Liberia allocated 5.48 percent of the national budget to health care in 2007-08. Negotiations for the 2008-09 budget are underway. The World Health Organization (WHO) recommends that countries spend 15 percent of GDP on the health sector.

At Redemption Hospital, while free care might be encouraging people to seek medical treatment, it is likely not sustainable without some means of support.

When the medical aid group Médecins Sans Frontières left the hospital in May 2006 – having provided free health care there for years – the government began charging for services. Hospital beds and waiting rooms emptied out. Then with funding from the World Bank and other international donors, the Health Ministry was able to increase its budget from US$6 million in 2006-07 to US$10 million in 2007-08. The extra funding paid for the salaries of medical staff and meant that patients no longer had to pay.

Mixed views

Free equals good for some, but Liberians are divided on the issue of free health care and whether it can be maintained.

"Since the Ministry of Health received funding in February, there have been free services here - everything from A to Z is free,” said Benson Poka, a physician's assistant at Redemption Hospital. "But some people are wondering how long funding for free healthcare will last."

Some Liberians say it might be better to impose a nominal fee than offer free healthcare that the government might not be able to sustain.

"Liberia needs continuity. It would be devastating if free health care… was suddenly removed,” said Bet Kalimar during a visit to Redemption Hospital.

Liberia’s Health Minister, Walter T. Gwenigale, echoed her concerns. "The last thing we want to see is affordable health care taken away from people,” he told IRIN.

For now, at least, with the exception of pathology results, X-rays and rare medication, all services are free at government-run facilities like Redemption Hospital and Telaware Hospital in Voinjama.

At Monrovia's other large hospital, John F Kennedy, which is autonomous but is granted 1 percent of the health budget, user fees have been cut but not abolished. There, adults pay just under $1 to register each time they seek treatment. Children pay 50 cents. Emergency treatment is more expensive and an appointment with a consultant costs $4.

Around 80 percent of people in Liberia have no formal employment. Those who manage to find jobs earn an average of $30 to $150 a month.

So it is no surprise that the waiting room at Redemption is much busier than that at John F Kennedy.

Deterred by user fees at John F Kennedy Hospital, Yassa Bernar said she had walked for two hours while suffering from stomach pains to reach Redemption Hospital. "I don't have a job or much money, so I couldn't afford to pay for treatment. I'm glad health care is free here" she said.

But Eugene Nyarko, WHO representative in Liberia, said when health care is free to the consumer, “that doesn't mean it's free to the government… We have to look at other options.”