This article explores the historical and contemporary problem of health care provision with a focus on the least developed countries (LDCs) and heavily indebted poor countries (HIPCs). The paper concludes that, while there may be advantages to state-run insurance systems for vulnerable populations (e.g. the indigent or the widowed elderly), there is likely a space for fee-for-service and pay-per-premium health care to develop alongside other familiar western institutions, like retail banking and telecommunications services. This discussion of financial evolution concludes with a comparison to postwar Japan and other contexts in which complex, locally unprecedented payment systems have been quick to take root and have been very successful.