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Despite recent progress, as a region, sub-Saharan Africa has the highest rates of maternal, infant, and child mortality in the world. From 2009 to 2012, researchers led by Niger’s Laboratoire d'études et de recherches sur les dynamiques sociales et le développement local (LASDEL) analyzed government efforts in Burkina Faso, Mali, and Niger to increase access to health care by removing user fees.

In the 1980s, with advice from international organizations, most African countries adopted direct payment for health services as the primary means to finance their health systems. Patients had to pay for health services out-of-pocket, severely hindering access to services for the most vulnerable. New recommendations in the 2000s called for African countries to offer subsidies or abolish payments for certain health services and groups. Until now, the impacts of these reforms in francophone West Africa have not been documented.