The momentum towards achieving the United Nations Millennium Development Goals re-invigorated concerns around sustainable health care financing and the adequacy of the financing arrangements in many lowresource settings. Accordingly, this necessitated the institution of user-fees as part of health financing reform in many countries in sub-Saharan Africa. These fees are charges levied at the point of service with the intent of reducing 'frivolous' consumption of health services, increasing the quality of services available and at the same time increasing coverage and utilisation of services. Likewise, as a 'decisive' policy to cushion the existing challenges facing health care financing in the region, a critical assessment of the assertions of proponents of user fees who use the principle of cost recovery and revenue mobilization to drive the concept of rational utilization, efficiency and equitable distribution of health care services is often exaggerated. As it were, the available evidence suggests that user fees alone will not likely accomplish equity, efficiency, or the sustainability objectives in health services in the region. What is critical is that user fees should be linked to the broader package of financing -such as insurance coverage-and with a view to averting any form of equity danger that may thus arise.

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International developmental support in sub-Saharan Africa has been quite remarkable in helping to address a number of challenges bedevilling healthcare delivery in the region. However, these humanitarian actions have just being a part of the developmental picture, as there is the need for more robust activities by these actors to support local policies particularly in the area of community health financing. As it were, this will involve building and supporting workable and sustainable 'pre-payment' schemes, supporting national governments to obtain the necessary information through more robust methods in data collection and in local research on health care financing in order to provide accurate information to inform policy on both the costs and benefits of alternatives of community health financing. Furthermore, as these now come to bear, donor support for community health financing will not only improve on access to health care delivery amongst the poorest of the poor in sub-Saharan Africa but will create a platform for these donor recipient countries to be self-sufficient and self reliant, and should these agencies cease to continue or run out of funding the consequences for the region will not be dire.

Strengthening health systems, improving health outcomes, as well as finding answers to the competing alternatives of healthcare financing are critical issues that continue to bother health policy makers. Irrespective of the options, the choice of health care financing should mobilize resources for health and improve access to quality care at the same time. Notably, the health financing policy in Nigeria provides a framework for establishing health insurance schemes so as to expand coverage in health care delivery for the formal and informal sectors as a strategy towards universal access to healthcare. Accordingly, the authors, through this review, systematically assess the evidence of the extent to which health insurance impacts on access to services and quality of primary healthcare in Nigeria. While this comes to bear, the findings reveal an evidence of moderate-to-high strength that health insurance increases access to care and improves the quality of care received; however, it remains equivocal in some instances. The review therefore contributes to the literature on healthcare financing by extending and qualifying existing knowledge and advocating for accelerated reforms if universal coverage will be achieved.

Objective: To assess how user-fees policy impacts on clienteles' access to care, willingness to utilize health services and their satisfaction with the quality of healthcare, having to pay at the point of service in a tertiary health facility. Method: This was a cross-sectional descriptive study. The instrument was a pre-tested, semistructured self administered questionnaire. Descriptive statistics as well as chi-square test and regression analysis were done to show statistically significant associations. Results: The findings reveal different modes money was made available for payment for health services. On the whole, about 98% of payment were through 'formal' out-of pocket spending (user-fees) with most respondents having to source for funds from own money. It was shown that user-fees increases 'rational' demand for services and at the same time decreasing the willingness to seek such level of care. However, it is associated with better quality service delivery. Conclusion: The findings from this study has brought to the fore that user-fee policy is an effective mechanism for achieving desired health outcomes in tertiary care. However, there remain the problems of inequities in tertiary healthcare coverage. The evidence so far suggests that user fees alone will not accomplish the sustainability objectives in health financing in the country. This suggests that charges levied for tertiary health services should therefore be linked to the broader package of financing through health insurance coverage.