As the blog by Rhona MacDonald Encouraging developments for universal access to health care emphasized developing countries continue their march towards achieving universal coverage. An essential step towards this goal is the abolition of user fees. Indeed, a global consensus has been reached at the international and African level (UNGA side event September 2009): user fees are hardly cost effective, the amount of revenue raised at the national level is low, they hamper the ability of poor people to access healthcare and push others into debt or poverty . User fees therefore fare badly on efficiency and equity grounds. This has prompted their original proponents to announce their support for countries wishing to remove user fees , if sustainable
What does sustainability mean? It is generally understood in its narrowest sense, i.e. fiscal self sufficiency  as in the reply by Obermann . Yet sustainability should be recognised as a complex process which encompasses considerations of social structures (organisational routines and institutional standards) as well as temporality issues . The Sierra Leonean government has been working on alternative financing mechanisms since this policy reform started being developed in September 2009, hence posing the question of sustainability, fiscal and systems/ social’ wide, from its very inception. This is in line with the academic proposal that sustainability starts first ,.
This brings us to the second main crux of the debate: whose responsibility is it to ensure sustainability? Should it sit solely with national governments still highly dependent on foreign aid? We argue that whilst national governments do have a duty to increase the budget allocated to health, and find ways to raise funds that are more progressive and allow pooling and cross subsidisation at a national level, the responsibility does not stop there. A broader political consensus is necessary so that the population also accepts the idea of national solidarity and subsidisation across wealth quintiles, hence accepting to pay taxes.
Moreover, if the global health community is serious about achieving the health MDGs and global solidarity, this responsibility should be shared across all health actors. Donors should provide long-term funding, allowing for the development of domestic mechanisms such as tax financed systems. In the past few years the UK government alone seemed to have championed the removal of user fees – although how far the current government will continue to support this agenda remains unclear- with other actors timidly contributing (UNICEF, World Bank for example). Researchers should also invest in analysing the processes through which the implementation of user fees removal succeeds and can be sustained.
 WHO ( 2010), The world health report – Health systems financing: the path to universal coverage, accessed on 03 August 2011, available at http://www.who.int/whr/2010/en/index.html
 World Bank (2007) , Healthy Development -The World Bank Strategy for Health, Nutrition, and Population Results, , accessed on 03 August 2011, available at siteresources.worldbank.org/…/HNPStrategyFINALApril302007.pdf
 Schieber et al (2006), Financing health systems in the 21st century, Disease Control Priorities in Developing Countries. 2nd edition.Jamison DT, Breman JG, Measham AR, et al., editors, Washington (DC): World Bank; 2006, available at files.dcp2.org/pdf/DCP/DCP12.pdf , accessed on 03 August 2011
 Obermann K (2011) Free health care in Sierra Leone: a mite too optimistic?, The Lancet, Volume 378, Issue 9789, Pages 400 – 401, 30 July 2011, accessed on 03 August 2011, available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61209-9/fulltext
 Pluye, P., et al. (2004). Making public health programs last: conceptualizing sustainability. Evaluation and Program Planning, 27(2), 121-133
 Pluye, P., et al (2005). Program sustainability begins with the first events. Evaluation and Program Planning, 28(2), 123-137
 Scheirer, M. A. (2005). Is sustainability Possible ? A review and commentary on empirical studies of program sustainability. Americanl Journal of Evaluation, 26(3), 320-347
 Ridde, V., & Morestin, F. (2011). A scoping review of the literature on the abolition of user fees in heathcare services in Africa. Health Policy and Planning, 26(1), 1-11
Guest post written by Nouria Brikci (Save the Children UK, London) and Valéry Riddé (University of Montréal/CRCHUM, Montréal, Canada)
Conflicts of interest: We declare that we have no conflicts of interest
Correspondence to: Nouria Brikci (firstname.lastname@example.org)