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As the idealistic deadline of the Millennium Development Goals (MDGs), 2015, looms ever closer, some are calling for user fees abolition. In many African countries, this involves targeting groups considered vulnerable. However, operational problems have sur-faced in the experiences of some of the pioneering West African countries. We identified various health system bottlenecks. These challenges are also starting points and opportunities to strengthen health care systems in Africa through making changes such as significantly increasing health care funding, improving the reliability of funding, making equity a health policy priority, adopting “New Public Management” types of reforms, ensuring the supply and quality of inputs, making efforts to reinforce the systemic components of the health sector, and improving the quality and quantity of evaluations undertaken in the health sector.