This paper reviews the experience of implementing user fees in Africa.
it describes the two main approaches to implementing user fees that h
ave been applied in African countries, the standard and the Bamako Ini
tiative models, and their common objectives. It summarizes the evidenc
e concerning the impact of fees on equity, efficiency and system susta
inability (as opposed to financial sustainability), and the key bottle
necks to their effective implementation. On the basis of this evidence
it then draws out three main sets of lessons, focusing on: where and
when to implement fees; how to enhance the impact of fees on their obj
ectives; and how to strengthen the process of implementation. if intro
duced by themselves, fees are unlikely to achieve equity, efficiency o
r sustainability objectives. They should, therefore, be seen as only o
ne element in a broader health care financing package that should incl
ude some form of risk-sharing. This financing package is important in
limiting the potential equity dangers clearly associated with fees. Th
ere is a greater potential role for fees within hospitals rather than
primary facilities. Achievement of equity, efficiency and, in particul
ar, sustainability will also require the implementation of complementa
ry interventions to develop the skills, systems and mechanisms of acco
untability critical to ensure effective implementation. Finally, the p
rocess of policy development and implementation is itself an important
influence over effective implementation.