User fees are once again a topic of hot policy debate in Africa. They were introduced relatively recently in many countries box 1;: but the current call is for their removal, particularly at primary care level.2 As analysts who have consistently argued against user fees, we broadly support this call. However, we recognise that this action cannot be introduced overnight and, if weakly implemented, may exacerbate the problems facing African health systems. We outline both why we believe African countries should move away from user fees, and what actions should accompany their removal to ensure that this policy change strengthens rather than undermines healthcare provision. Our suggestions are based on the experience of countries such as South Africa and Uganda that have already removed some or all fees, as well as wider experience of policy change.
British Medical Journal (2005) 331 (7591) 762-765 [doi:10.1136/bmj.331.7519.762]