This reduction of state resources has led to a variety of initiatives to lever greater community contributions.

In the 1990s, many countries introduced or intensified 'cost recovery' measures, primarily through user fees. These measures claimed a number of positive outcomes for their health systems, such as:

• increased revenue through charges on services;
• improved coverage and quality of care through spending on service improvements;
• enhanced equity through targeted spending on the poor;
• improved service utilization and referral patterns through the control of 'frivolous' demand and the use of prices to direct service use;
• increased efficiency by making providers cost conscious and encouraging cost effective techniques of providing care (Equinet Steering Committee, 1998).