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The effects of commercialised health care in embedding, exacerbating and legitimating social and economic inequality are at the root of widespread and recurrent resistance to commercialisation in health. In low income developing countries suffering generalised poverty, and notably in Sub-Saharan Africa, liberalisation of largely unregulated clinical provision has created a substantially informalised, fee-for-service primary health sector which is exclusionary, low quality and under stress. This article argues against a policy assumption that health systems constitute a sector that can benefit like other commodities from liberalisation. Health care is better understood as a ‘fictional commodity’ in the Polanyian sense: inappropriate for full commodification, producing intensely perverse effects when provided on competitive markets, and therefore requiring planning and social constraint. If managed effectively, integrated health systems—like redistributive land reform and effective labour protection—can support a broader economic transition that avoids extremes of inequality; conversely if treated simply as a transitional sector, health systems can make exclusion and inequality much worse. Copyright © 2006 John Wiley & Sons, Ltd.