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Many African countries, confronted by healthcare access and payment collection problems now promote policies that exempt some low-income persons from paying for healthcare services. This article draws on a review of public policies and on sociological and anthropological field interviews in Burkina Faso, Mali and Niger. It compares each country's relatively different free-medical-care system and their rather similar design and operational problems. Governments often bow to internal political calculations and external pressures in determining which payment exemption measures to pursue. The resulting systems usually prove unwieldy and inconsistent because of poor preparation, communication and management, and a lack of funding. This article reveals many unintended consequences. In particular, quality care remains out of reach for many because of shortages of medicine and other supplies.