To deal with difficulties in accessing care that arise in the context of cost recovery programs, many African countries are now implementing user fee exemption policies for certain vulnerable population groups. Based on a study of public policies and socio-anthropological fieldwork, this article presents a comparative analysis of the situation in Burkina Faso, Mali and Niger, which have chosen to apply relatively different exemption measures. However, the problems encountered in the design and implementation of these policies are very similar. Exemption measures are often adopted on the basis of a mix of internal political calculations and external pressures. Due to the lack of preparation, communication, effective management and most of all, adequate funding, the operation of measures is chaotic and inconsistent in most cases. Many unexpected effects were revealed by the research, notably the fact that quality of care is far from reliable due to shortages in supplies.

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