However, because of the cost of care, such savings accounts are often insufficient and seen from the overall point of view of society, are inefficient for funding care in most countries. Since the 1980s, user fees have been introduced in many developing countries as alternative way of financing health care in response to declining public expenditures. Such fees have been introduced in Central African Republic, the Democratic Republic of the Congo, Ghana, Honduras, Jamaica, Liberia, Peru, Senegal and Uganda as part of structural adjustment programmes on the assumption that they would extend the coverage of services and promote the appropriate use of care. In other countries, such as Bolivia, the Dominican Republic and El Salvador , user fees have been introduced more locally because of continuous cost crises. In some countries, such as Canada and Denmark , employee or private insurance schemes cover expenses not reimbursed by national or local care schemes.
User fees have their down side.
Such fees have been found to reduce use of health care in countries like Ghana and Zaire . Research in the United States and other OECD countries, as well as in developing nations, has shown that the adverse health consequences of user fees are greatest for sick people who are poor. In contrast, a study in Cameroon, where user fees were introduced in line with the Bamako Initiative, showed that when quality improvements accompanied the introduction of user fees, utilization of health centres increased. Some low-income countries remain dependent on e xternal funding as a means of financing health care. In recent years, the nature of external funding has changed, with overall levels of support reduced and a shift towards imposing specific conditions on receiving governments.