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Abstract In present constrained economic circumstances, many governments have introduced or increased user charges for health services. This has been advocated by the World Bank, justified by reference to the raising of revenue, efficiency and, controversially, even the promotion of equity. This paper examines the impact of user charges on utilisation in the Ashanti‐Akim district of Ghana since the introduction of charges in 1985. In many ways, user charges have been a success: in recovering fees and maintaining urban utilisation. However some advantages have not materialised because the health infrastructure has not changed adequately. More importantly, equity and affordability have been problematical. For some of the population, services are no longer affordable.
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