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When user fee exemptions were introduced for children under five years of age in Niger, front-line staff in the health system were not consulted in advance, and various obstacles seriously hindered the policy's implementation. Health workers developed two types of coping strategies. The first dealt with shortcomings of the policy implementation process related to management tools, drug stocks, co-existence of the fee exemption and cost recovery systems, and, above all, supply management for medicines (ordering from private companies, issuing makeshift prescriptions). The second involved clientelism, circumvention of regulations, and misappropriation of resources. Adverse effects have arisen due to both the failings of the health system and the practices of health workers. These include a focus on the commercial management of patients, the most 'costly' of whom sometimes find themselves being refused treatment, patients roaming in search of medicines and treatment, and a decline in quality of care.

The coping strategies of front-line health workers in the context of user fee exemptions in Niger