||This paper reviews the experience of implementing user fees in Africa. It describes the two main approaches to implementing user fees that have been applied in African Countries, the standard and the Bamako Initiative models, and their common objectives. It summarizes the evidence concerning the impact of fees on equity, efficiency, and system sustainability (as opposed to financial sustainability), and the key bottlenecks to their effective implementation. On teh 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 impacts of fees on their objectives; and how to strengthen the process of implementation. If introduced by themselves, fees are unlikely to achieve equity, efficiency or sustainability objectives. They should, therefore, be seen as only one element in a broader health care financing package that shoudl include some more of risk-sharing. This financing package is important in limiting the potential equity dangers clearly associated with fees. There is a greater potential role for fees within hospitals rather than primary facilities. Achievement of equity, efficiency, and, in particular, sustainabilityy will also require the implementation of complementary interventions to develop the skills, systems, and mechanisms of accountability critical to ensure effective implemntation. Finanly, the process of policy development and implementation it itself an important influence over effective implementation.