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Introduction: In recent years, a number of African countries, including Niger, have adopted policies abolishing user fees at point of service, targeting categories of people or services. These policies do not take account of geographical and financial accessibility for cases that require medical evacuation from primary to secondary level. This paper documents an experiment illustrating the importance of considering the place of medical evacuation in fee exemption schemes for vulnerable population groups. Methods: Quantitative analysis of routine statistical data was performed pre- and post-experiment. The data was taken from monthly activity and financial reports supplied by the 16 IHCs , the district hospital and the regional hospital for the period from 2008 to 2010, and was analyzed using MS Excel. Results: A medical evacuation reserve fund was set up, with 77% of it made up of “extra centime” payments from the free-healthcare target groups. A large increase (more than twofold) was recorded in the number of cases evacuated, from 191 in 2008 to 460 in 2009. Detailed analysis shows that more than 72% of the people evacuated belong to the free-healthcare target groups. The average transportation cost for an evacuation is about €37. Conclusion: The introduction of a solidarity-based financing mechanism resulted in an increase in the number of evacuations, for which the average cost was too high for most rural households. Policies aimed at abolishing direct user fees by integrating the cost of medical evacuations offer an effective strategy for health risk coverage and for counteracting the impoverishment caused by ill health.