The United States is not the only country locked in an intense debate over health care reform. In many other countries, it’s also a matter of life and death.

Take Liberia. Liberians endured decades of brutal war that only ended in 2003 and left much of the country’s infrastructure in ruins. The wreckage wrought to its health care system was particularly severe, and is reflected in today’s health indicators, among the lowest in the world.

In addition to the traumatic legacy of war, today most Liberians struggle to survive crippling impoverishment. More than 90 percent of the country’s 3.6 million people live on less than $2 a day, which means that any costs required to obtain health care — no matter how small — are prohibitively expensive.

Doctors Without Borders/Medecins Sans Frontieres (MSF) has been providing medical care in Liberia since 1990, including emergency surgical care during some of the worst times of the conflict. When the war ended, MSF committed to supporting health care centers until 2010, and today, we provide free support at several health structures and hospitals in the capital, Monrovia.

MSF documented years of our work in a recent report, “Wanted: Increased Health Coverage,” in order to contribute to the current health policy and financing discussions taking place in the country. Our experience in Liberia, and elsewhere, clearly shows that “user fees” at health structures deter many Liberians from seeking medical care until a health concern becomes an emergency.

Women tell our staff of the impossible choices they have to make day in and day out between feeding their family and taking a sick child to see a doctor. Just last month, we had to send four-year-old David for an amputation of his right arm. David cut his arm while climbing up a tree, but his family treated him at home because they could not afford medical care. Sadly, one month later his parents rushed him to our hospital with an infection so advanced it was impossible to treat with antibiotics.

The government of Liberia also recognizes the need to provide free health care, and in 2005 suspended the “user fee” system. But there is a big difference between policy goals and practice, and even though the government has taken important measures to improve access, free care is still simply not a reality for far too many Liberians.

As the health care debate in Liberia continues, the issue of introducing “user fees” is once again being considered. MSF strongly believes that the burden of financing Liberia’s health care system should not fall on those least able to bear it.

If Liberia is to even have a chance of serving the population’s health needs, health care must be subsidized. The cost of medicines, diagnostics, staff salaries, and clinics and hospitals can only be shouldered by the national government and international donors like USAID and the European Union.

In a positive first step, the U.N. General Assembly announced last month that six developing countries, including Liberia, would receive funds to help them provide free health care to women and children.

There are no easy solutions, and the government of Liberia faces daunting challenges as it tries to rebuild the country after decades of war. But ensuring that financial barriers do not prevent Liberians from getting essential health care deserves sustained support.

In the United States, 44,000 people die a year because there is no guaranteed health care. In Liberia and many other countries, the death toll is even higher. We need to insist that people deserve access to quality, affordable health care, whether in the United States or around the world.

Robin Vincent-Smith is head of mission in Liberia of the Nobel Peace Prize-winning Doctors Without Borders/Medecins Sans Frontieres. He can be reached at pmproj [at] progressive [dot] org.