Since independence, public health care services in Ghana has been characterized by state finance. The government provides the bulk of the expenditure but donor assistance also constitutes a substantial source of funding. For example when capital expenditures are excluded, donor pooled funds in 2000 constituted 20% of public health expenditure (Arhinful 2003). Since the mid 1980's economic difficulties have compelled the introduction of user charges. Mechanisms to increase economic accessibility have led to attempts to implement health insurance and encourage generic prescribing. Recent major reforms include the creation of the Ghana Health Service.