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RHO archives : Topics : Family Planning Program Issues
Annotated Bibliography
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Financial management and sustainability
Arends-Kuenning, M. Reconsidering the doorstep-delivery
system in the Bangladesh family planning program. Studies in Family
Planning 33(1):87–102 (March 2002).
Based on an analysis of longitudinal data from the Maternal and Child Health-Family
Planning Extension Project, the author questions two recommendations made
to increase the cost-effectiveness of family planning services in Bangladesh.
The first recommendation is to encourage women to switch from nonclinical
to clinical methods. Womens preferences for temporary nonclinical methods
are reasonable, however, given the context of high child mortality, high
infection risks, and limited availability of clinical services. The second
recommendation is for field workers to focus on motivating nonusers to adopt
a method rather than on resupplying continuing users. Data show, however,
that resupply visits will have the larger impact on contraceptive prevalence.
Results also suggest that field workers will be most effective if they target
their visits to women who are uneducated or live in poor areas.
Barberis, M. and Harvey, P.D. Costs of family
planning programmes in fourteen developing countries by method of service
delivery. Journal of Biosocial Science 29:219–233 (1997).
This article analyzes the cost-effectiveness of different modes of service
delivery in 14 countries, based on cost per couple-year of protection (CYP)
in 1991 and 1992. Sterilization services had the lowest cost per CYP (US$1.85),
followed by social marketing programs (US$2.14), and clinic-based services
other than sterilization (US$6.10). The highest costs were for community-based
distribution projects (US$9.93) and clinic-based services with a community-based
distribution component (US$14.00). While no single mode of service delivery
is appropriate for all settings, the authors conclude that social marketing
shows special promise as a cost-effective way to reach large numbers of
people.
Barnett, B. Do
client fees help or hurt? Network 18(2):6–11 (1998).
Available at: www.fhi.org/en/fp/fppubs/network/v18-2/nt1822.html.
While charging for services may limit access to contraception, the revenues
generated by fees may lead to improvements in quality of care and increases
in financial sustainability for individual programs. Program managers must
consider the impact of pricing systems both on client demand and on clinic
resources. Before establishing a fee system, managers need to measure the
unit costs of the services offered, decide whether and how to subsidize
services for clients who cannot afford to pay, and give plenty of warning
to clients. One approach that preserves access to family planning is cross-subsidization,
in which charges for health services such as lab tests are used to subsidize
family planning services.
Bratt, J.H. et al. The impact of price changes
on demand for family planning and reproductive health services in Ecuador.
Health Policy and Planning 17(3):281–287 (2002).
This study measured the impact of price increases on (1) the utilization
and revenues of family planning clinics in Ecuador and (2) access to services
by poor clients. The authors compared price increases of different amounts
at different clinics for IUD insertions, IUD revisits, gynecology visits,
and prenatal visits. Their findings suggest that demand for the IUD and
prenatal services was inelastic, so that price increases would boost clinic
revenue without greatly reducing utilization. In addition, there was no
consistent association between higher prices and loss of low-income clients.
Bratt, J.H. et al. Three strategies to promote
sustainability of CEMOPLAF clinics in Ecuador. Studies in Family
Planning 29(1):58–68 (1998).
Separate studies were conducted to analyze the impact of three strategies
to increase the sustainability of a private organization operating 20 reproductive
health clinics in Ecuador. Reducing the number of follow-up visits for IUD
users during the first year from four to one liberated provider time for
gynecological consultations and saved money for IUD users with little impact
on quality of care. A survey of clients found that CEMOPLAF fees are low
relative to clients' income and could be increased, although measures should
be taken to protect truly need clients. A cost projection determined that
ultrasound machines would be a profitable investment of scarce resources
at only 3 of 19 potential sites. The authors conclude that, individually,
none of the interventions would make a large impact on CEMOPLAF's cost-recovery
ratio, but together they could improve the agency's financial situation.
Ciszewski, R.L. and Harvey, P.D. Contraceptive
price changes: the impact on sales in Bangladesh. International Family
Planning Perspectives 21:150–154 (1995).
This article examines the impact of price changes in the price of condoms
and pills sold by a social marketing program in Bangladesh. Retailers, wholesalers,
and consumers resisted a steep price increase, and condom sales dropped
by 29 percent and pill sales by 12 percent. When sales had not returned
to previous levels two years later, prices were lowered and sales increased,
reaching and then exceeding earlier levels. The authors conclude that large
increases in contraceptive prices dampen demand.
Donaldson, D. et al. (eds). Using
cost and revenue analysis tools. The Family Planning Manager
2(1)(1993). Available in English
at: http://erc.msh.org/mainpage.cfm?file=2.1.1.htm&module=finance&language=English,
in French
at: http://erc.msh.org/readroom/francais/coreisfr.htm, and in Spanish
at: http://erc.msh.org/mainpage.cfm?file=core.htm&module=toolkit&language=spanish.
Conducting cost and revenue analyses helps managers understand how staffing
patterns, service mix, service practices, and procurement affect resource
use. Results of these analyses can prompt managers to consider different
ways of delivering services to reduce costs and/or increase revenues. Managers
can use the results to decide whether to change service practices, add new
services or facilities, or use some services to subsidize others. Three
spreadsheet tools are presented: Cost-Analysis Methodology for Clinic-Based
Family Planning Methods, Cost and Revenue Analysis Tool (CORE),
and A Supply-Demand Model of Health Care Financing.
Finger, W.R. Commercial
sector can improve access. Network 18(2) (1998). Available
at: www.fhi.org/en/fp/fppubs/network/v18-2/nt1825.html.
Public resources can be focused more effectively on low-income clients if
people who are able to pay shift to the commercial sector. This requires
convincing consumers that private-sector services are affordable and have
advantages over public services (for example, convenience, easier access,
greater confidentiality, and better quality). Free public services, lack
of information and training, and legal restrictions have slowed down the
expansion of the commercial sector into family planning, but some donor
agencies and government health ministries are helping train private-sector
providers in family planning, including pharmacists, midwives, and private
physicians. Social marketing has successfully involved the private sector
in contraceptive distribution.
Fleischman Foreit, K.G. Source
of maternal and child health care as an indicator of ability to pay for
family planning. International Family Planning Perspectives 28(3):167–169
(September 2002). Available at: www.guttmacher.org/pubs/journals/2816702.html.
Using data from the Demographic and Health Survey from eight developing
countries, this research note estimates how many women can afford to purchase
contraceptives from the private sector, thus reducing the burden on government
family planning funding and allowing governments to target their subsidies
to needier clients. The percentage of female contraceptive users who receive
private maternal and child health care (used as a proxy to estimate who
has the economic resources and information needed to purchase contraceptives
from the commercial sector) ranged from 5 percent in Peru and Zimbabwe to
22 percent in Colombia. A further analysis calculated the impact if all
pill users in Indonesia, the Philippines, and Zimbabwe who had children
aged five and younger and who paid for private maternal and child health
care purchased their pills from commercial sources. The private sectors
share of the oral contraceptive market would increase by 22 to 26 percent,
while the governments financial burden would decline by 3 to 7 percent.
Hanson, K. et al. Ends versus means: what is
the role of markets in expanding access to contraceptives? Health
Policy and Planning 16(2):125–136 (2001).
This economic analysis examines the trade-offs between public- and private-sector
supply of contraceptives. Where the private sector is the only source of
contraceptives, market failures may keep contraceptive coverage lower than
socially desirable. Providing free or subsidized contraceptives, however,
may inhibit the development of the commercial sector. Evidence is mixed
on the extent to which price influences the demand for contraceptives. The
authors conclude that strategies must be tailored to the local context,
and a market assessment should be an important part of the decision-making
process. Four key variables are: contraceptive prevalence rates (market-based
strategies are more appropriate where contraceptive use is high), HIV prevalence
(the ready supply of condoms to high-risk groups must take priority over
all else where HIV prevalence is high), income level of country (market-based
strategies are more appropriate in middle-income than poor countries), and
size and geographic spread of private-sector development (care must be taken
not to undercut a well-established private sector with subsidized goods).
Hubacher, D. et al. Increasing
efficiency to meet future demand: family planning services provided by the
Mexican Ministry of Health. International Family Planning Perspectives
25(3):119–124, 138 (1999). Available at: www.guttmacher.org/pubs/journals/2511999.html.
By correcting inefficiencies in the delivery of family planning services,
the Mexican Ministry of Health potentially could meet rising demand for
services without expanding current programs. Increasing the length of the
providers workday (currently less than six and one-half hours) and the
proportion of time providers spend with clients (37 percent for nurses and
47 percent for doctors) would increase efficiency as would dispensing more
contraceptives at each visit. For example, doubling the number of pill cycles
distributed during a visit reduces the cost per couple-year of protection
from US$27 to US$19. Implementing all three suggestions would reduce the
overall cost per couple-year of protection from the 1995 level of US$29
to US$22 by 2010.
Janowitz, B. et al. Excess
capacity and the cost of adding services at family planning clinics in Zimbabwe.
International Family Planning Perspectives 28(2):58–66
(2002). Available at: www.guttmacher.org/pubs/journals/2805802.html.
This study used mini-situation analyses and time-motion studies to determine
the impact of adding a new service (syndromic management of reproductive
tract infections) on provider time and service costs. Following retraining,
the median length of visits for new acceptors increased from 20 to 27 minutes
and more clients were offered syndromic management services. Despite these
additional demands on their time, providers spent less than 40 percent of
their time with clients after retraining and had substantial amounts of
unoccupied time in the early morning and late afternoon. The authors conclude
that family planning clinics in the developing world can provide additional
services at little extra cost if providers simply spend more time with clients.
However, providers may require incentives to increase their workload.
Janowitz, B. et al. Community-based
distribution in Tanzania: costs and impacts of alternative strategies to
improve worker performance. International Family Planning Perspectives
26(4):158–160, 193–195 (2000). Available at: www.guttmacher.org/pubs/journals/2615800.html.
This article compares costs and worker performance at three community-based
distribution programs in Tanzania. Compensation, supervision, and training
costs vary widely between the three programs, and all three contribute to
the cost per visit. The program that paid CBD agents the most ($398) had
the highest cost per agent ($701), but also had the highest number of visits
per agent (425). Because of high training and supervision costs, the program
that paid agents the least ($33) still had high costs per agent ($558),
and its agents made the fewest visits (105). The third program had by far
the lowest total cost per agent ($155) because compensation, supervision,
and training costs all were low, and its agents made an intermediate number
of visits (132). The authors conclude that increasing the pay of CBD agents
actually reduces the cost per visit, because it increases the number of
visits they make and spreads the costs of training and supervision over
more visits. Spending less on training or supervision, however, may reduce
costs without reducing the number of visits.
Janowitz, B. et al. Issues
in the Financing of Family Planning Services in Sub-Saharan Africa.
Research Triangle Park, NC: Family Health International (1999). Available
at: www.fhi.org/en/ReproductiveHealth/Publications/booksReports/fpfinancing/index.htm.
This extensive report analyzes all available information, both published
and unpublished, on financing family planning services in sub-Saharan Africa.
It is addressed to policy makers and program managers and identifies gaps
in the information needed to facilitate policy and program change. To calculate
the shortfall in funding, the report presents information on the current
and projected needs for family planning services, the estimated cost of
meeting those needs, and current government and donor expenditures. The
authors then closely examine the potential of three different strategies
in the African context: (1) charging fees so that users pay a greater share
of service costs, in combination with a system of means-testing to protect
the poor; (2) encouraging the growth of the commercial sector, including
for-profit providers, retailers, social marketing, managed care, and employer-based
family planning programs; and (3) reducing the cost of family planning services
by mobilizing underutilized capacity, eliminating unnecessary medical barriers,
and integrating family planning and other reproductive health services that
are currently offered by separate vertical programs.
Janowitz, B. What do we really know about the
impact of price changes on contraceptive use? International Family
Planning Perspectives 22(1):38–40 (1996).
Charging user fees for family planning services is controversial, since
fees may reduce access to services among poor women and lead to declines
in contraceptive prevalence. This article reviews econometric modeling and
experimental studies on the impact of price changes on demand for family
planning services. The author concludes that various methodological problems
undermine the validity of all of the studies, so that the potential of user
fees remains unclear. Well-designed experimental studies are needed to assess
all of clients potential responses to price increases: paying the higher
prices, switching to a lower-cost method or provider, and discontinuing
family planning.
Lande, R.E. and Geller, J.S. Paying for family
planning. Population Reports Series J, Number 39. Baltimore,
Maryland: Johns Hopkins University Population Information Program (November
1991).
As demand for family planning continues to grow, paying for services is
becoming a greater challenge. While governments and donors may pay more,
new approaches are looking toward users, employers, and insurers to bear
a greater share of the burden. Potential approaches include removing constraints
on retail sales, training and promoting private providers, expanding social
marketing programs that sell subsidized contraceptives through retail outlets,
charging small fees for improved government services, setting up workplace
family planning services with employer support, including family planning
in health insurance coverage, cross-subsidizing family planning for the
poor, and increasing efficiency in service delivery.
Levin, A. et al. Cost-effectiveness of family
planning and maternal health service delivery strategies in rural Bangladesh.
International Journal of Health Planning and Management 14:219–233
(1999).
This article assesses two alternative service delivery strategies that were
designed to improve the effectiveness and efficiency of service delivery
in rural Bangladesh. While delivering services at a centrally located neighborhood
spot reduced travel time for providers, the approach was less cost-effective
compared with home delivery of services because clients attendance was
low. Increasing the frequency of outreach clinics and adding immunization
to the services offered generally did prove more cost-effective than static
clinics, probably because of increased demand for services.
Mitchell, M.D. et al. Costing
of reproductive health services. International Family Planning
Perspectives 25 (Suppl.):S17–S21, S29 (1999). Available at: www.guttmacher.org/pubs/journals/25s1799.html.
Cost data were collected from the Zimbabwe National Family Planning Council
(ZNFPC) and MEXFAM and disaggregated to calculate the cost of individual
services. Costs were consistently lower at ZNFPC, largely due to the use
of specially trained nurse-midwives rather than doctors to provide most
family planning and reproductive health care. Because labor accounts for
most of the cost of reproductive health services, adding clients does not
necessarily reduce the cost per client. However, staff, equipment, and facilities
at most health and family planning programs operate below capacity. In this
situation, the cost of adding clients or services is low. The authors conclude
that the simple methodology they propose can help managers understand the
financial and programmatic implications of alternative service delivery
strategies.
Musau, S. (ed). Charging
fees for family planning services. Family Planning Manager 1(3):1–12
(1992). Available online in English
at: http://erc.msh.org/mainpage.cfm?file=2.1.3.htm&module=finance&language=English,
in French at:
http://erc.msh.org/readroom/francais/fees.htm, and in Spanish
at http://erc.msh.org/readroom/espanol/fees.htm.
This article examines the pros and cons of charging fees for family planning
services. Before deciding to charge such fees, managers must consider the
objective for the fees, whether clients are willing and able to pay for
services, client perceptions of the quality of services offered, policy
and regulatory restrictions on a fee-for-service program, the cost of the
services offered, and the cost of implementing a user fee system. The article
offers advice on how to overcome staff and client resistance to introducing
fees, and provides practical tips on deciding what kind of fee to introduce,
determining how much to charge, developing a system of controls for fee
collection, and developing a system of exemptions and waivers.
Nanda, P. Gender dimensions of user fees: implications
for women’s utilization of health care. Reproductive Health
Matters 10(20):127–134 (2002).
This gender-based analysis of user fees for health services reviews recent
literature from Africa. Evidence suggests that utilization of women’s
health care services drops when user fees are introduced. Evidence also
questions whether the small amount of revenue generated by user fees enhances
the quality of health services, given the administrative costs of the system,
although fees may have a positive impact if they are retained at the local
level. Women are less able than men to pay for health care, and systems
to exempt women, especially the poor, from user fees typically are inconsistently
applied and poorly executed. The author recommends that user fees not be
implemented on a broader scale until there is evidence, including gender-disaggregated
data, that such fees improve resources without reducing utilization or hurting
poor women.
Schuler, S.R. et al. Paying for reproductive
health services in Bangladesh: intersections between cost, quality, and
culture. Health Policy and Planning 17(3):273–280 (2002).
Using data from 500 in-depth, semi-structured interviews, this article examines
clients response to a shift by NGOs in their service delivery strategy
in Bangladesh. Clients are required to travel further and pay more for services,
but higher quality services are offered. The goal is to increase access
while maximizing cost recovery. Findings suggest that attitudes related
to charging and paying for services are as important as an appropriate pricing
structure in achieving these objectives. Gender, class, and ideas about
entitlements, the role of government, the status of NGOs, and obligations
among people all affect the ability and willingness of people to pay for
health services. The poor may expect the government to provide free services
and drugs, consider themselves unfairly exploited when charged even nominal
sums by NGOs, and equate free cost with service quality.
Schuler, S.R. et al. Reconciling
cost recovery with health equity concerns in a context of gender inequality
and poverty: findings from a new family health initiative in Bangladesh.
International Family Planning Perspectives 28(4):196–204 (2002).
Available at: www.guttmacher.org/pubs/journals/2819602.html.
A new model of service delivery in Bangladesh has expanded the range and
quality of women’s health services, but the emphasis on cost recovery
means higher costs for clients. This study gathered qualitative information
on the response to the new model through individual interviews with clients,
husbands, community members, and service providers; group interviews; and
observations at clinics. Economic constraints limit access to health services
and shape the health-seeking strategies of the poor. The new service model
has created problems for poor women by undermining the informal system of
credit they used to rely upon. While fee waivers for the poor are part of
official policy, staff do not provide them openly and systematically out
of concern that it will discourage other clients from paying. The authors
conclude that a transparent system for providing credit and fee exemptions
based on need would help NGOS in Bangladesh and elsewhere maintain access
to services while maximizing cost recovery.
Schuler, S.R. et al. The
persistence of a service delivery culture: findings from a qualitative
study in Bangladesh. International Family Planning Perspectives
27(4):194–200 (2001). Available at: www.guttmacher.org/pubs/journals/2719401.html.
A combination of interviews and observations were used to investigate how
clients, communities, and program staff were adapting to a shift from door-to-door
contraceptive distribution in Bangladesh to clinic-based delivery of a broader
package of health services. While client and community reactions are generally
favorable, indicating a willingness to adapt, the old family planning service
delivery culture persists and creates obstacles to change. These include
clients expectations of discounted or free services and compensation for
adopting clinical methods; suspicion of clinical methods and providers
motives for offering them; and holding providers who supply a method responsible
for treating subsequent health problems and side effects free of charge.
Smith, E. Evaluations
suggest better ways to use resources: economic analysis of programs can
improve productivity and quality of care. Network 21(3):21–25
(2002). Available at: www.fhi.org/en/fp/fppubs/network/v21-3/nt2133.html.
Economic analysis of program can help managers identify revenue-producing
services that can subsidize other activities, evaluate clients ability
to pay for services, discover whether certain services or products are draining
resources, determine if clinics in different regions should charge different
prices, and evaluate staff productivity. Economic analyses conducted in
El Salvador, Ecuador, Jamaica, and Tanzania illustrate the contributions
this approach can make to family planning program management.
Wolff, J.A. et al., eds. "Making your Program
Sustainable." In: The Family Planning Manager's Handbook: Basic
Skills and Tools for Managing Family Planning Programs. West Hartford,
Connecticut: Kumarian Press (1991). Available in English
at: http://erc.msh.org/fpmh_english/chp10/index.html, in French
at: http://erc.msh.org/fpmh_french/chp10/index.html, and in Spanish
at: http://erc.msh.org/fpmh_spanish/chp10/index.html.
The three keys to organizational sustainability are a stable organization,
creating demand for services, and achieving greater control over resources.
Programs can develop organizational stability by articulating a clear mission,
developing strong leadership, recruiting and rewarding excellent staff,
strengthening management systems, and being responsive to changing environments
and client needs. Increasing demand calls for understanding client needs
and how to meet them, providing high-quality services, and marketing family
planning services effectively. Programs can achieve greater control over
resources by broadening the resource based, finding ways to reduce costs,
gathering information on program costs, planning and monitoring expenditures,
and basing decisions on actual program results. Cross-subsidies (between
services, between clinics, and between clients) also can contribute to sustainability.
Wolff, J.A. et al., eds. "Managing your
Finances." In: The Family Planning Manager's Handbook: Basic
Skills and Tools for Managing Family Planning Programs. West Hartford,
Connecticut: Kumarian Press (1991). Available in English
at: http://erc.msh.org/fpmh_english/chp9/index.html, in French
at: http://erc.msh.org/fpmh_french/chp9/index.html, and in Spanish
at: http://erc.msh.org/fpmh_spanish/chp9/index.html.
Family planning managers must have basic financial management skills so
that they can ensure their program's resources are used responsibly and
appropriately. The financial management cycle consists of providing services,
receiving cash, paying for expenses, and reporting to donors and other outside
sources of the use of funds provided. This chapter provides practical advice
on how to prepare a budget for the work plan, project revenues and monitor
cash flow, control and manage funds, compare program results with budget
projections, determine and compare the cost of services, meet institutional
reporting requirements, and understand and use financial reports for decision
making.
Yeboah, D.A. Strategies
adopted by Caribbean family planning associations to address declining international
funding. International Family Planning Perspectives 28(2):122–125
(2002). Available at: http://www.guttmacher.org/pubs/journals/2812202.html.
In recent years, Caribbean family planning associations (FPAs) have lost
international funding because their need has been rated as lower than other
regions of the world. To understand how the FPAs are adapting to this loss
of funding, the authors sent a questionnaire to five countries. They found
that Caribbean FPAs have adopted many new strategies to deal with the loss
of funding, including strict financial management and restructuring to increase
efficiency, business development and purchase of their buildings to improve
sustainability, expansion of services and revision of fee structures to
increase revenues, use of volunteers to reduce costs, and membership and
fundraising drives to provide additional revenue.
Policy making
Ashford, L.S. New
population policies: advancing womens health and rights. Population
Bulletin 56(1) (March 2001). Available at: www.prb.org/Template.cfm?Section=PRB&template=/ContentManagement/ContentDisplay.cfm&ContentID=3697.
This article reviews the evolution of national population policies, particularly
following the historic 1994 Cairo conference. It describes the new focus
on improving reproductive health and women's rights and how governments
have tried to incorporate this new approach in their policies and programs.
The Bulletin also looks at possible new directions for population policies.
Bertrand, J.T. Et al. Indicators to measure the policy environment. In Handbook of Indicators for Family Planning Evaluation, Chapter 2, pp. 25–44. Chapel Hill, North Carolina: EVALUATION Project (December 1994). Available in English, French, and Spanish at: www.cpc.unc.edu/measure/publications/manuals/handbook/handbook.html. This chapter provides a conceptual framework for evaluating the policy environment of family planning programs, based on the standard input-process-output-outcomes model. Five indicators are proposed to assess the process of policy planning and policy development that modifies the policy environment over time. Eleven indicators are proposed to assess the outputs of this process, including measures of political support, national policy, and operational policy. The handbook sets out the operational definition, data requirements, data sources, and purpose of each indicator.
Center for Reproductive Law and Policy. Reproductive Rights 2000: Moving Forward. New York (CRLP) (June 2000). Available in English and Spanish at: www.crlp.org/pub_bo_rr2k.html.To ensure that international declarations on womens reproductive rights are meaningful, women must work toward the adoption and enforcement of national laws and policies reflecting their principles. This book examines legal and policy developments since the Cairo and Beijing conferences in eight areas: population, reproductive health, and family planning; contraception; abortion; HIV/AIDS and other sexually transmissible infections; harmful traditional practices affecting reproductive health; rape and other sexual violence; marriage and family law; and reproductive rights of adolescents. Each chapter also includes recommendations for further government action.
Finkle, J.L. and McIntosh, C.A. United Nations
population conferences: shaping the policy agenda for the twenty-first century.
Studies in Family Planning 33(1):11–23 (March 2002).
This article reviews the population conferences sponsored by the UN, beginning
in Rome in 1954, and shows how their priorities have shifted from scientific
to political considerations. At the same time, participants have changed.
First, independent experts were replaced by national delegations selected
by and representing their governments. More recently, nongovernmental organizations
representing civil society have begun to play an active role at the conferences.
Because of the broader range of participants, the population field has grown
in scope and complexity and is in danger of losing its focus. Increasingly,
population issues are linked with broader questions of poverty, the environment,
human rights, economic development, globalization and the like. The authors
suggest that smaller regional or thematic meetings may be a good way to
rationalize the conference process in the years to come.
Hardee, K. and Smith, J. Implementing
reproductive health services in an era of health sector reform. The
POLICY Project Occasional Paper 4 (March 2000). Available at: www.policyproject.com/pubs/occasional/op-04.pdf.
This paper reviews the impact on reproductive health care of various health
sector reform initiatives, including decentralization, integration, essential
services packages, streamlining operational policies, cost recovery, and
encouraging private sector participation. There is too little evidence as
yet to determine whether health sector reform will promote efficient, effective,
and equitable reproductive health care delivery or whether it will lead
to neglect of reproductive health in favor of more pressing health issues.
Reform process must be monitored and evaluated, especially their impact
on issues of equity and access.
Hardee, K. et al. Reproductive
health policies and programs in eight countries: progress since Cairo.
International Family Planning Perspectives 25 (Suppl.):S1–S9
(1999). Available at: www.agi-usa.org/pubs/journals/25s0299.html.
To examine progress in implementing the ICPD Program of Action, stakeholders
were interviewed in Bangladesh, India, Nepal, Jordan, Ghana, Senegal, Jamaica,
and Peru. While all of the countries have begun formulating policies to
reflect the new emphasis on reproductive health care, program implementation
has only just begun. Moving from policy to programs faces several challenges,
including disseminating the message of Cairo to a wider base of stakeholders,
planning for the complexity of integrated services, increasing human and
financial resources, improving the quality of care, and viewing Cairo as
a long-term process. The authors conclude that setting priorities and phasing
in interventions are the key to progress.
Hoodfar, H. and Assadpour, S. The politics of
population policy in the Islamic Republic of Iran. Studies in Family
Planning 31(1):19–34 (2000).
This case study examines the different phases of population policy in Iran,
especially after the 1979 revolution, based on informal interviews with
officials, medical personnel, family planning clients, and religious leaders.
It focuses on the formal and informal strategies adopted by political experts,
the media, religious authorities, and the government to bring about a reversal
in policy toward family planning in what seemed to be an unfavorable environment.
Jacobson, J.L. Transforming family planning
programmes: toward a framework for advancing the reproductive rights agenda.
Reproductive Health Matters 8(15): 21–32 (2000).
New approaches to family planning and reproductive health call for the application
of human rights as well as public health principles, but these are not easily
reconciled. The reproductive rights agenda focuses on the process as well
as the outcome of program activities; addresses the gender dynamics of sex,
which are rooted in cultural and social norms; addresses sexual coercion
and infection as well as unwanted pregnancy; and seeks to instill a sense
of entitlement among clients and a rights-based ethos among programs. Obstacles
to change include: social, economic, and political conditions, such as poverty,
that undermine rights and entitlement; weak support for the rights agenda
at the national level; continuing program focus on reduced fertility; vague
definitions of key concepts; rapid health care reforms; and limited capacity
in the womens movement at the local level.
Jain, A. et al. Do Population Policies Matter?
Fertility and Politics in Egypt, India, Kenya, and Mexico. New York:
Population Council (1998).
The four case studies in this book illustrate how and why the formulation,
implementation, and effectiveness of population policies vary over time,
within, and between countries. The book concludes that population policies
must go beyond family planning programs, following the ICPD Programme of
Action. The authors recommend the involvement of non-health sectors to reduce
gender and other disparities; the involvement of health as well as family
planning departments in the delivery of reproductive health services; making
the improvement of individual well-being the sole objective of fertility-reduction
and population policies; and increasing public advocacy for change.
Langer, A. et al. Health
sector reform and reproductive health in Latin America and the Caribbean:
strengthening the links. Bulletin of the World Health Organization
78(5): 667–676 (2000). Available at: www.who.int/docstore/bulletin/pdf/2000/issue5/bu0560.pdf.
In many countries of Latin America and the Caribbean, the health sector
is being reformed to increase its effectiveness and efficiency while simultaneously
being asked to adopt the ICPD model of broad-based reproductive health care.
This article examines how common approaches to health sector reform (decentralization
of management, changes in financing to increase sustainability, and increasing
the role of the private sector) have helped or hindered efforts to improve
reproductive health care. Despite the rhetoric, actual change has so far
been limited. However, the authors warn that if health reforms are driven
exclusively by financial and political considerations, the quality of reproductive
health care may suffer. They recommend specific strategies to improve reproductive
health in a health reform environment.
Lee, K. et al. Family planning policies and programmes
in eight low-income countries: a comparative policy analysis. Social
Science & Medicine 47(7):949–959 (1998).
In order to understand why some countries adopt effective family planning
policies and programs while others do not, four pairs of low-income countries
were analyzed: Bangladesh and Pakistan, Zimbabwe and Zambia, Thailand and
the Philippines, and Tunisia and Algeria. Each pair differed in the strength
of their family planning programs but was matched socioeconomically and
culturally. Policy analyses of all eight countries found three factors that
promoted strong population policies and family planning programs: the formation
of broad-based coalitions among policy elites in support of family planning,
the spread of policy risk beyond a single individual or group, and stability
of the institutional home and funding for family planning programs. The
study suggests that the process of making and implementing national family
planning policies is as important as the content of those policies to the
success of family planning programs.
Lubben, M. et al. Reproductive
health and health sector reform in developing countries: establishing a
framework for dialogue. Bulletin of the World Health Organization
80(8):667–674 (2002). Available at: www.who.int/docstore/bulletin/pdf/2002/bul-8-E-2002/bu1060.pdf.
Lack of dialogue between the areas of reproductive health and health sector
reform has led to disjointed policymaking in developing countries. Different
participants, with different priorities and ideologies, operating in different
policy environments have contributed to the divide. The authors propose
a framework that encourages a productive dialogue between the two areas.
The first step is to identify stakeholders in both policy areas and develop
collaborative links between them. The next step is to introduce a common
understanding around relevant policy contexts. Then the key participants
must agree on a common purpose. The final step is to identify causal links
between policy content in reproductive health and health sector change as
a basis for evidence-based policy making.
Lush, L. et al. Politics and fertility: a new approach
to population policy analysis. Population Research and Policy Review
19: 1–28 (2000).
Demographic and policy change over a 30-year period was analyzed in four
pairs of developing countries: Algeria and Tunisia, Bangladesh and Pakistan,
Zambia and Zimbabwe, and the Philippines and Thailand. In the first three
pairs of countries, evidence suggests that state policies and programs explain
much of the difference in the timing and extent of fertility declines, while
cultural contrasts are more important in the final pair. Policies and programs
were more successful in countries that identified a coherent rationale for
reducing population growth and in which strong and financially secure coalitions
of policy elites shared the political risks associated with population policies.
Pachauri, S., ed. Implementing
a Reproductive Health Agenda in India: The Beginning. New Delhi:
Population Council, South & East Asia Regional Office (1999). (Introductory
essay and order form available online at www.popcouncil.org/reprohealthagenda/implementingreprohealth.html.
Following the ICPD Program of Action, the Indian Ministry of Health and
Family Welfare made a fundamental shift in policy, moving from method-specific
contraceptive targets to providing client-centered, good quality, reproductive
health services. The first eight chapters in this book examine how this
policy change came about, its implementation, and the impact on program
performance and field operations. The next four chapters discuss whether
the changed policy environment is helping reach neglected population groups,
including young people and men. The final seven chapters discuss the challenges
of addressing specific reproductive health problems, including HIV/AIDS,
reproductive tract infections, abortion, safe motherhood, and sexuality.
Population Council. What
Can Be Done to Foster Multisectoral Population Policies: Summary Report
of a Seminar. New York: Population Council (1998). Available
at: www.popcouncil.org/multisectoral/multisectoral.html.
Speakers at a 1997 conference strongly endorsed a multisectoral approach
to population policy that goes beyond family planning services to engage
other sectors, such as education and employment, and that focuses on individual
welfare, human rights, gender equity, and broad-based socioeconomic equity.
They discussed how to move policy thinkers to realize that many factors
over and above family planning availability are at issue, what institutional
barriers exist, and the relative roles of donors, ministries, coordinating
processes, and constituents.
Population Reference Bureau. Reproductive
Health in Policy & Practice: Case Studies from Brazil, India, Morocco,
and Uganda. Washington, DC : Population Reference Bureau (2001).
Available at: www.prb.org/Template.cfm?Section=PRB&template=/ContentManagement/ContentDisplay.cfm&ContentID=5934.
To assess how the ICPD Program of Action is being implemented in diverse
settings, researchers in Brazil, India, Morocco, and Uganda investigated
changes in reproductive health policies and services, as well as in the
political and social environment in which initiatives are carried out. Not
surprisingly, progress on reproductive health and women's status is uneven
across and within countries, and none of the countries have addressed all
of the Cairo goals. However, the studies reveal major changes in the political,
social, and economic environment in which reproductive health goals are
pursued. In all of the countries studied, there is greater openness in political
decision-making, growth in NGO activity, increasing visibility and influence
of the womens rights movement, increasing decentralization of authority
from national to local governments and some major reforms in the way that
health systems operate. At the service level, attempts have been made to
improve the quality of services, to increase the integration of family planning
and other health services, and to expand services to under-served groups.
Seltzer, J.R. The
Origins and Evolution of Family Planning Programs in Developing Countries.
Santa Monica, CA: RAND (2002). Available at: www.rand.org/publications/MR/MR1276.
This book discusses the three public policy objectives that have underpinned
family planning programs—the demographic, public health, and human
rights rationales—and the criticisms associated with each. The author
reviews the research evidence to assess the validity of each criticism and
describes how programs have evolved in response to them. Important lessons
for guiding policy can be drawn from the criticisms and controversies surrounding
international family planning programs. Programs must continue to evolve
in response to valid criticisms, and they must adapt to new global challenges,
such as the enormous cohort of adolescents moving into its childbearing
years. Adapting the health care rationale to current global conditions requires
new organizational and financing arrangements and a reconfiguration of services.
Continuing support of womens groups and health advocates is important,
since their criticisms have contributed to improvements in policy and program
design; research is also important.
Tantchou, J. and Wilson, E. Post-Cairo reproductive
health policies and programs: a study of five Francophone African countries.
POLICY Occasional Papers No. 6. Washington, DC : The POLICY Project
(August 2000). Available in English
at: www.policyproject.com/pubs/occasional/op-06.pdf, and in French
at: www.policyproject.com/pubs/occasional/op-06fr.pdf.
This summary examines reproductive health policy in Benin, Burkina Faso,
Cameroon, Cote dIvoire, and Mali following the ICPD and 1996 Ouagadougou
Forum. While all five countries have adopted the ICPD definition of reproductive
health, they are still in the process of developing comprehensive policies
and program implementation lags behind. Shared challenges include: garnering
broad support for reproductive health; coordinating reproductive health
and population policies and programs; systematically determining reproductive
health priorities; encouraging NGO involvement; and using resources more
efficiently and effectively.
Visaria, L. et al. From
family planning to reproductive health: challenges facing India. International
Family Planning Perspectives 25 (Suppl.): S44–S49 (1999). Available
at: www.guttmacher.org/pubs/journals/25s4499.html.
In the 1990s the government of India rejected demographic goals for its
family planning program in favor of addressing more comprehensive reproductive
and child health needs. This article analyzes the reasons behind this dramatic
change in policy, its reception in India, and challenges in implementing
it. The authors conclude that the success of the new approach depends on
convincing stakeholders, both providers and clients, of its importance.
Advocacy
Center for Development and Population Activities
(CEDPA). Advocacy:
Building Skills for NGO Leaders. CEDPA Training Manual Series
vol. IX. Washington, DC : CEDPA (1999). Available at: www.cedpa.org/publications/pdf/advocacy.htm.
This manual, which is available in English, French, and Spanish, provides
the basis for a three-day workshop to build the capacity of NGO leaders
to advocate effectively for reproductive health issues. It is written for
experienced trainers and utilizes participatory methodologies. The six sessions
teach: how the advocacy process contributes to policy change; how to select
advocacy issues, set policy-focused objectives, and identify sources of
support and opposition; how to identify audiences and analyze their interests;
how to develop compelling messages and deliver them to policy makers; how
to use networking and coalition-building as a tool for effective advocacy;
and how to develop an advocacy implementation plan.
Gillespie DG. Whatever
happened to family planning and, for that matter, reproductive health?
International Family Planning Perspectives. 2004;30(1):34–38.
Available at: www.agi-usa.org/pubs/journals/3003404.html.
This commentary urges advocates to revisit the Cairo Programme of Action
and reconsider their messages in order to reverse the current trend towards
declining political support and funding for reproductive health and family
planning. New messages are needed that focus on problems policy makers consider
important and that present a clear course of action. Best bets are averting
mother-to-child HIV transmission, reducing abortion, and expanding access
to family planning services for the poor.
BOND, a British network of NGOs engaged in international development and development education, originally compiled this material for a training course on advocacy. This series of guidance notes discusses how developing country NGOs can advocate to change polices that affect the lives of disadvantaged people and how NGOs in the developed world can support them. Each note outlines essential steps in the advocacy process, offers practical tips, and lists lessons learned. One note also discusses how to monitor and evaluate advocacy programs and suggests appropriate indicators.
International Planned Parenthood Federation (IPPF).
Advocacy
Guide for Sexual and Reproductive Health and Rights.
London: IPPF (2001). Available at: www.ippf.org/pubs/advocacyguide/index.htm.
This user-friendly guidebook offers clear and practical advice on how to
advocate for sexual and reproductive health, including family planning,
no matter how large or small an organizations resources and ambitions may
be. It discusses how to: establish goals, objectives and activities; expand
your base of support through networking and coalition-building; frame issues
and shape messages for target audiences; reach the general public; work
with the media; use the Internet; develop print materials, conduct public
education; lobby policy makers; hold conferences to educate colleagues;
and deal with the opposition.
Johns Hopkins University Center for Communication
Programs (JHU/CCP). "A"
Frame for Advocacy. Baltimore: JHU/CCP (1999). Available at: www.jhuccp.org/pr/advocacy/.
This pamphlet summarizes a six-step process for public policy advocacy to
guide interested programs and personnel. Accompanying each step (analysis,
strategy, mobilization, action, evaluation, and continuity) is a list of
specific activities that need to be accomplished.
Ketting, E., ed. Advocacy for reproductive health.
Planned Parenthood Challenges 1(1996).
In the mid 1990s, IPPF placed a new priority on advocacy to explain, promote,
and defend the ICPD Programme of Action. This special issue of Planned
Parenthood Challenges highlights the efforts of IPPF and its member
family planning associations to generate public awareness and advocate for
change around the world. Articles describe regional efforts as well as specific
country programs advocating change in Palestine, safeguarding individual
rights in China, combating opposition in the Philippines, speaking out for
youth in Kenya, raising the issue of unsafe abortion in Mauritius, and working
with the media in Peru.
Sharma, R.R. An
Introduction to Advocacy: Training Guide. Washington, DC : Support
for Analysis and Research in Africa (SARA) Project, Academy for Educational
Development, (no date). Available in English
at: www.dec.org/pdf_docs/PNABZ919.pdf, and in French
at: www.dec.org/pdf_docs/PNACB277.pdf.
This training guide was prompted by the recognition that systematic and
iterative advocacy is as important to policy and program change as identifying
problems and finding solutions. The guide is designed to inform a diverse
audience about advocacy and its methods, give them the basic skills and
confidence they need to proceed, and increase the use of available data
to inform the advocacy process. Ten training modules cover the meaning of
advocacy, identifying policy issues, selecting an advocacy objective, researching
audiences, developing and delivering messages, understanding the decision-making
process, building alliances, making effective presentations, fundraising,
and improving advocacy. It is illustrated with case studies in reproductive
health from Africa.
Singh S et al. Adding
It Up: The Benefits of Investing in Sexual and Reproductive Health Care.
New York: Alan Guttmacher Institute and UNFPA; 2003. Available at: www.guttmacher.org/pubs/addingitup.html.
This report makes the case for increased funding for sexual and reproductive
health services, including family planning, in developing countries. It
takes a broader approach to measuring the costs, benefits, and return on
investment of these services by analyzing how sexual and reproductive health
services contribute to economic growth, societal and gender equity, and
democratic governance as well as health. The authors argue that policy makers
need a fuller accounting of these broad benefits as well as more complete
information about costs in order to appreciate the substantial returns on
sexual and reproductive health investments.
Upadhyay, U. and Robey, B. Why
family planning matters. Population Reports, Series J, Number
49 (July 1999). Available in English, French, and Spanish at: www.infoforhealth.com/pr/online.shtml#j)
Advocacy is essential if family planning programs are to receive the leadership
commitment and financial resources they need to meet rising demand for family
planning. This report summarizes key evidence in support of family planning
and family planning programs for use in advocacy campaigns. Family planning
programs offer numerous benefits; they meet demand for family planning,
saves womens and childrens lives, offers women choices, encourages safer
sex, reaches out to youth, involves men, protects the environment, and aids
development.
Van Kampen, J. Dealing
with Advocacy: A Practical Guide. Hanover, Germany: RHI ComNet,
EC/UNFPA Initiative for Reproductive Health in Asia (no date). Available
at: www.asia-initiative.org/pdfs/advocacy_guide.pdf.
This brief guide explains the importance of advocacy for reproductive health
and provides an overview of the advocacy process. It is an excellent introduction
to the field.
Financial management and sustainability
Arends-Kuenning, M. Reconsidering the doorstep-delivery
system in the Bangladesh family planning program. Studies in Family
Planning 33(1):87–102 (March 2002).
Based on an analysis of longitudinal data from the Maternal and Child Health-Family
Planning Extension Project, the author questions two recommendations made
to increase the cost-effectiveness of family planning services in Bangladesh.
The first recommendation is to encourage women to switch from nonclinical
to clinical methods. Womens preferences for temporary nonclinical methods
are reasonable, however, given the context of high child mortality, high
infection risks, and limited availability of clinical services. The second
recommendation is for field workers to focus on motivating nonusers to adopt
a method rather than on resupplying continuing users. Data show, however,
that resupply visits will have the larger impact on contraceptive prevalence.
Results also suggest that field workers will be most effective if they target
their visits to women who are uneducated or live in poor areas.
Barberis, M. and Harvey, P.D. Costs of family
planning programmes in fourteen developing countries by method of service
delivery. Journal of Biosocial Science 29:219–233 (1997).
This article analyzes the cost-effectiveness of different modes of service
delivery in 14 countries, based on cost per couple-year of protection (CYP)
in 1991 and 1992. Sterilization services had the lowest cost per CYP (US$1.85),
followed by social marketing programs (US$2.14), and clinic-based services
other than sterilization (US$6.10). The highest costs were for community-based
distribution projects (US$9.93) and clinic-based services with a community-based
distribution component (US$14.00). While no single mode of service delivery
is appropriate for all settings, the authors conclude that social marketing
shows special promise as a cost-effective way to reach large numbers of
people.
Barnett, B. Do
client fees help or hurt? Network 18(2):6–11 (1998).
Available at: www.fhi.org/en/fp/fppubs/network/v18-2/nt1822.html.
While charging for services may limit access to contraception, the revenues
generated by fees may lead to improvements in quality of care and increases
in financial sustainability for individual programs. Program managers must
consider the impact of pricing systems both on client demand and on clinic
resources. Before establishing a fee system, managers need to measure the
unit costs of the services offered, decide whether and how to subsidize
services for clients who cannot afford to pay, and give plenty of warning
to clients. One approach that preserves access to family planning is cross-subsidization,
in which charges for health services such as lab tests are used to subsidize
family planning services.
Bratt, J.H. et al. The impact of price changes
on demand for family planning and reproductive health services in Ecuador.
Health Policy and Planning 17(3):281–287 (2002).
This study measured the impact of price increases on (1) the utilization
and revenues of family planning clinics in Ecuador and (2) access to services
by poor clients. The authors compared price increases of different amounts
at different clinics for IUD insertions, IUD revisits, gynecology visits,
and prenatal visits. Their findings suggest that demand for the IUD and
prenatal services was inelastic, so that price increases would boost clinic
revenue without greatly reducing utilization. In addition, there was no
consistent association between higher prices and loss of low-income clients.
Bratt, J.H. et al. Three strategies to promote
sustainability of CEMOPLAF clinics in Ecuador. Studies in Family
Planning 29(1):58–68 (1998).
Separate studies were conducted to analyze the impact of three strategies
to increase the sustainability of a private organization operating 20 reproductive
health clinics in Ecuador. Reducing the number of follow-up visits for IUD
users during the first year from four to one liberated provider time for
gynecological consultations and saved money for IUD users with little impact
on quality of care. A survey of clients found that CEMOPLAF fees are low
relative to clients' income and could be increased, although measures should
be taken to protect truly need clients. A cost projection determined that
ultrasound machines would be a profitable investment of scarce resources
at only 3 of 19 potential sites. The authors conclude that, individually,
none of the interventions would make a large impact on CEMOPLAF's cost-recovery
ratio, but together they could improve the agency's financial situation.
Ciszewski, R.L. and Harvey, P.D. Contraceptive
price changes: the impact on sales in Bangladesh. International Family
Planning Perspectives 21:150–154 (1995).
This article examines the impact of price changes in the price of condoms
and pills sold by a social marketing program in Bangladesh. Retailers, wholesalers,
and consumers resisted a steep price increase, and condom sales dropped
by 29 percent and pill sales by 12 percent. When sales had not returned
to previous levels two years later, prices were lowered and sales increased,
reaching and then exceeding earlier levels. The authors conclude that large
increases in contraceptive prices dampen demand.
Donaldson, D. et al. (eds). Using
cost and revenue analysis tools. The Family Planning Manager
2(1)(1993). Available in English
at: http://erc.msh.org/mainpage.cfm?file=2.1.1.htm&module=finance&language=English,
in French
at: http://erc.msh.org/readroom/francais/coreisfr.htm, and in Spanish
at: http://erc.msh.org/mainpage.cfm?file=core.htm&module=toolkit&language=spanish.
Conducting cost and revenue analyses helps managers understand how staffing
patterns, service mix, service practices, and procurement affect resource
use. Results of these analyses can prompt managers to consider different
ways of delivering services to reduce costs and/or increase revenues. Managers
can use the results to decide whether to change service practices, add new
services or facilities, or use some services to subsidize others. Three
spreadsheet tools are presented: Cost-Analysis Methodology for Clinic-Based
Family Planning Methods, Cost and Revenue Analysis Tool (CORE),
and A Supply-Demand Model of Health Care Financing.
Finger, W.R. Commercial
sector can improve access. Network 18(2) (1998). Available
at: www.fhi.org/en/fp/fppubs/network/v18-2/nt1825.html.
Public resources can be focused more effectively on low-income clients if
people who are able to pay shift to the commercial sector. This requires
convincing consumers that private-sector services are affordable and have
advantages over public services (for example, convenience, easier access,
greater confidentiality, and better quality). Free public services, lack
of information and training, and legal restrictions have slowed down the
expansion of the commercial sector into family planning, but some donor
agencies and government health ministries are helping train private-sector
providers in family planning, including pharmacists, midwives, and private
physicians. Social marketing has successfully involved the private sector
in contraceptive distribution.
Fleischman Foreit, K.G. Source
of maternal and child health care as an indicator of ability to pay for
family planning. International Family Planning Perspectives 28(3):167–169
(September 2002). Available at: www.guttmacher.org/pubs/journals/2816702.html.
Using data from the Demographic and Health Survey from eight developing
countries, this research note estimates how many women can afford to purchase
contraceptives from the private sector, thus reducing the burden on government
family planning funding and allowing governments to target their subsidies
to needier clients. The percentage of female contraceptive users who receive
private maternal and child health care (used as a proxy to estimate who
has the economic resources and information needed to purchase contraceptives
from the commercial sector) ranged from 5 percent in Peru and Zimbabwe to
22 percent in Colombia. A further analysis calculated the impact if all
pill users in Indonesia, the Philippines, and Zimbabwe who had children
aged five and younger and who paid for private maternal and child health
care purchased their pills from commercial sources. The private sectors
share of the oral contraceptive market would increase by 22 to 26 percent,
while the governments financial burden would decline by 3 to 7 percent.
Hanson, K. et al. Ends versus means: what is
the role of markets in expanding access to contraceptives? Health
Policy and Planning 16(2):125–136 (2001).
This economic analysis examines the trade-offs between public- and private-sector
supply of contraceptives. Where the private sector is the only source of
contraceptives, market failures may keep contraceptive coverage lower than
socially desirable. Providing free or subsidized contraceptives, however,
may inhibit the development of the commercial sector. Evidence is mixed
on the extent to which price influences the demand for contraceptives. The
authors conclude that strategies must be tailored to the local context,
and a market assessment should be an important part of the decision-making
process. Four key variables are: contraceptive prevalence rates (market-based
strategies are more appropriate where contraceptive use is high), HIV prevalence
(the ready supply of condoms to high-risk groups must take priority over
all else where HIV prevalence is high), income level of country (market-based
strategies are more appropriate in middle-income than poor countries), and
size and geographic spread of private-sector development (care must be taken
not to undercut a well-established private sector with subsidized goods).
Hubacher, D. et al. Increasing
efficiency to meet future demand: family planning services provided by the
Mexican Ministry of Health. International Family Planning Perspectives
25(3):119–124, 138 (1999). Available at: www.guttmacher.org/pubs/journals/2511999.html.
By correcting inefficiencies in the delivery of family planning services,
the Mexican Ministry of Health potentially could meet rising demand for
services without expanding current programs. Increasing the length of the
providers workday (currently less than six and one-half hours) and the
proportion of time providers spend with clients (37 percent for nurses and
47 percent for doctors) would increase efficiency as would dispensing more
contraceptives at each visit. For example, doubling the number of pill cycles
distributed during a visit reduces the cost per couple-year of protection
from US$27 to US$19. Implementing all three suggestions would reduce the
overall cost per couple-year of protection from the 1995 level of US$29
to US$22 by 2010.
Janowitz, B. et al. Excess
capacity and the cost of adding services at family planning clinics in Zimbabwe.
International Family Planning Perspectives 28(2):58–66
(2002). Available at: www.guttmacher.org/pubs/journals/2805802.html.
This study used mini-situation analyses and time-motion studies to determine
the impact of adding a new service (syndromic management of reproductive
tract infections) on provider time and service costs. Following retraining,
the median length of visits for new acceptors increased from 20 to 27 minutes
and more clients were offered syndromic management services. Despite these
additional demands on their time, providers spent less than 40 percent of
their time with clients after retraining and had substantial amounts of
unoccupied time in the early morning and late afternoon. The authors conclude
that family planning clinics in the developing world can provide additional
services at little extra cost if providers simply spend more time with clients.
However, providers may require incentives to increase their workload.
Janowitz, B. et al. Community-based
distribution in Tanzania: costs and impacts of alternative strategies to
improve worker performance. International Family Planning Perspectives
26(4):158–160, 193–195 (2000). Available at: www.guttmacher.org/pubs/journals/2615800.html.
This article compares costs and worker performance at three community-based
distribution programs in Tanzania. Compensation, supervision, and training
costs vary widely between the three programs, and all three contribute to
the cost per visit. The program that paid CBD agents the most ($398) had
the highest cost per agent ($701), but also had the highest number of visits
per agent (425). Because of high training and supervision costs, the program
that paid agents the least ($33) still had high costs per agent ($558),
and its agents made the fewest visits (105). The third program had by far
the lowest total cost per agent ($155) because compensation, supervision,
and training costs all were low, and its agents made an intermediate number
of visits (132). The authors conclude that increasing the pay of CBD agents
actually reduces the cost per visit, because it increases the number of
visits they make and spreads the costs of training and supervision over
more visits. Spending less on training or supervision, however, may reduce
costs without reducing the number of visits.
Janowitz, B. et al. Issues
in the Financing of Family Planning Services in Sub-Saharan Africa.
Research Triangle Park, NC: Family Health International (1999). Available
at: www.fhi.org/en/ReproductiveHealth/Publications/booksReports/fpfinancing/index.htm.
This extensive report analyzes all available information, both published
and unpublished, on financing family planning services in sub-Saharan Africa.
It is addressed to policy makers and program managers and identifies gaps
in the information needed to facilitate policy and program change. To calculate
the shortfall in funding, the report presents information on the current
and projected needs for family planning services, the estimated cost of
meeting those needs, and current government and donor expenditures. The
authors then closely examine the potential of three different strategies
in the African context: (1) charging fees so that users pay a greater share
of service costs, in combination with a system of means-testing to protect
the poor; (2) encouraging the growth of the commercial sector, including
for-profit providers, retailers, social marketing, managed care, and employer-based
family planning programs; and (3) reducing the cost of family planning services
by mobilizing underutilized capacity, eliminating unnecessary medical barriers,
and integrating family planning and other reproductive health services that
are currently offered by separate vertical programs.
Janowitz, B. What do we really know about the
impact of price changes on contraceptive use? International Family
Planning Perspectives 22(1):38–40 (1996).
Charging user fees for family planning services is controversial, since
fees may reduce access to services among poor women and lead to declines
in contraceptive prevalence. This article reviews econometric modeling and
experimental studies on the impact of price changes on demand for family
planning services. The author concludes that various methodological problems
undermine the validity of all of the studies, so that the potential of user
fees remains unclear. Well-designed experimental studies are needed to assess
all of clients potential responses to price increases: paying the higher
prices, switching to a lower-cost method or provider, and discontinuing
family planning.
Lande, R.E. and Geller, J.S. Paying for family
planning. Population Reports Series J, Number 39. Baltimore,
Maryland: Johns Hopkins University Population Information Program (November
1991).
As demand for family planning continues to grow, paying for services is
becoming a greater challenge. While governments and donors may pay more,
new approaches are looking toward users, employers, and insurers to bear
a greater share of the burden. Potential approaches include removing constraints
on retail sales, training and promoting private providers, expanding social
marketing programs that sell subsidized contraceptives through retail outlets,
charging small fees for improved government services, setting up workplace
family planning services with employer support, including family planning
in health insurance coverage, cross-subsidizing family planning for the
poor, and increasing efficiency in service delivery.
Levin, A. et al. Cost-effectiveness of family
planning and maternal health service delivery strategies in rural Bangladesh.
International Journal of Health Planning and Management 14:219–233
(1999).
This article assesses two alternative service delivery strategies that were
designed to improve the effectiveness and efficiency of service delivery
in rural Bangladesh. While delivering services at a centrally located neighborhood
spot reduced travel time for providers, the approach was less cost-effective
compared with home delivery of services because clients attendance was
low. Increasing the frequency of outreach clinics and adding immunization
to the services offered generally did prove more cost-effective than static
clinics, probably because of increased demand for services.
Mitchell, M.D. et al. Costing
of reproductive health services. International Family Planning
Perspectives 25 (Suppl.):S17–S21, S29 (1999). Available at: www.guttmacher.org/pubs/journals/25s1799.html.
Cost data were collected from the Zimbabwe National Family Planning Council
(ZNFPC) and MEXFAM and disaggregated to calculate the cost of individual
services. Costs were consistently lower at ZNFPC, largely due to the use
of specially trained nurse-midwives rather than doctors to provide most
family planning and reproductive health care. Because labor accounts for
most of the cost of reproductive health services, adding clients does not
necessarily reduce the cost per client. However, staff, equipment, and facilities
at most health and family planning programs operate below capacity. In this
situation, the cost of adding clients or services is low. The authors conclude
that the simple methodology they propose can help managers understand the
financial and programmatic implications of alternative service delivery
strategies.
Musau, S. (ed). Charging
fees for family planning services. Family Planning Manager 1(3):1–12
(1992). Available online in English
at: http://erc.msh.org/mainpage.cfm?file=2.1.3.htm&module=finance&language=English,
in French at:
http://erc.msh.org/readroom/francais/fees.htm, and in Spanish
at http://erc.msh.org/readroom/espanol/fees.htm.
This article examines the pros and cons of charging fees for family planning
services. Before deciding to charge such fees, managers must consider the
objective for the fees, whether clients are willing and able to pay for
services, client perceptions of the quality of services offered, policy
and regulatory restrictions on a fee-for-service program, the cost of the
services offered, and the cost of implementing a user fee system. The article
offers advice on how to overcome staff and client resistance to introducing
fees, and provides practical tips on deciding what kind of fee to introduce,
determining how much to charge, developing a system of controls for fee
collection, and developing a system of exemptions and waivers.
Nanda, P. Gender dimensions of user fees: implications
for women’s utilization of health care. Reproductive Health
Matters 10(20):127–134 (2002).
This gender-based analysis of user fees for health services reviews recent
literature from Africa. Evidence suggests that utilization of women’s
health care services drops when user fees are introduced. Evidence also
questions whether the small amount of revenue generated by user fees enhances
the quality of health services, given the administrative costs of the system,
although fees may have a positive impact if they are retained at the local
level. Women are less able than men to pay for health care, and systems
to exempt women, especially the poor, from user fees typically are inconsistently
applied and poorly executed. The author recommends that user fees not be
implemented on a broader scale until there is evidence, including gender-disaggregated
data, that such fees improve resources without reducing utilization or hurting
poor women.
Schuler, S.R. et al. Paying for reproductive
health services in Bangladesh: intersections between cost, quality, and
culture. Health Policy and Planning 17(3):273–280 (2002).
Using data from 500 in-depth, semi-structured interviews, this article examines
clients response to a shift by NGOs in their service delivery strategy
in Bangladesh. Clients are required to travel further and pay more for services,
but higher quality services are offered. The goal is to increase access
while maximizing cost recovery. Findings suggest that attitudes related
to charging and paying for services are as important as an appropriate pricing
structure in achieving these objectives. Gender, class, and ideas about
entitlements, the role of government, the status of NGOs, and obligations
among people all affect the ability and willingness of people to pay for
health services. The poor may expect the government to provide free services
and drugs, consider themselves unfairly exploited when charged even nominal
sums by NGOs, and equate free cost with service quality.
Schuler, S.R. et al. Reconciling
cost recovery with health equity concerns in a context of gender inequality
and poverty: findings from a new family health initiative in Bangladesh.
International Family Planning Perspectives 28(4):196–204 (2002).
Available at: www.guttmacher.org/pubs/journals/2819602.html.
A new model of service delivery in Bangladesh has expanded the range and
quality of women’s health services, but the emphasis on cost recovery
means higher costs for clients. This study gathered qualitative information
on the response to the new model through individual interviews with clients,
husbands, community members, and service providers; group interviews; and
observations at clinics. Economic constraints limit access to health services
and shape the health-seeking strategies of the poor. The new service model
has created problems for poor women by undermining the informal system of
credit they used to rely upon. While fee waivers for the poor are part of
official policy, staff do not provide them openly and systematically out
of concern that it will discourage other clients from paying. The authors
conclude that a transparent system for providing credit and fee exemptions
based on need would help NGOS in Bangladesh and elsewhere maintain access
to services while maximizing cost recovery.
Schuler, S.R. et al. The
persistence of a service delivery culture: findings from a qualitative
study in Bangladesh. International Family Planning Perspectives
27(4):194–200 (2001). Available at: www.guttmacher.org/pubs/journals/2719401.html.
A combination of interviews and observations were used to investigate how
clients, communities, and program staff were adapting to a shift from door-to-door
contraceptive distribution in Bangladesh to clinic-based delivery of a broader
package of health services. While client and community reactions are generally
favorable, indicating a willingness to adapt, the old family planning service
delivery culture persists and creates obstacles to change. These include
clients expectations of discounted or free services and compensation for
adopting clinical methods; suspicion of clinical methods and providers
motives for offering them; and holding providers who supply a method responsible
for treating subsequent health problems and side effects free of charge.
Smith, E. Evaluations
suggest better ways to use resources: economic analysis of programs can
improve productivity and quality of care. Network 21(3):21–25
(2002). Available at: www.fhi.org/en/fp/fppubs/network/v21-3/nt2133.html.
Economic analysis of program can help managers identify revenue-producing
services that can subsidize other activities, evaluate clients ability
to pay for services, discover whether certain services or products are draining
resources, determine if clinics in different regions should charge different
prices, and evaluate staff productivity. Economic analyses conducted in
El Salvador, Ecuador, Jamaica, and Tanzania illustrate the contributions
this approach can make to family planning program management.
Wolff, J.A. et al., eds. "Making your Program
Sustainable." In: The Family Planning Manager's Handbook: Basic
Skills and Tools for Managing Family Planning Programs. West Hartford,
Connecticut: Kumarian Press (1991). Available in English
at: http://erc.msh.org/fpmh_english/chp10/index.html, in French
at: http://erc.msh.org/fpmh_french/chp10/index.html, and in Spanish
at: http://erc.msh.org/fpmh_spanish/chp10/index.html.
The three keys to organizational sustainability are a stable organization,
creating demand for services, and achieving greater control over resources.
Programs can develop organizational stability by articulating a clear mission,
developing strong leadership, recruiting and rewarding excellent staff,
strengthening management systems, and being responsive to changing environments
and client needs. Increasing demand calls for understanding client needs
and how to meet them, providing high-quality services, and marketing family
planning services effectively. Programs can achieve greater control over
resources by broadening the resource based, finding ways to reduce costs,
gathering information on program costs, planning and monitoring expenditures,
and basing decisions on actual program results. Cross-subsidies (between
services, between clinics, and between clients) also can contribute to sustainability.
Wolff, J.A. et al., eds. "Managing your
Finances." In: The Family Planning Manager's Handbook: Basic
Skills and Tools for Managing Family Planning Programs. West Hartford,
Connecticut: Kumarian Press (1991). Available in English
at: http://erc.msh.org/fpmh_english/chp9/index.html, in French
at: http://erc.msh.org/fpmh_french/chp9/index.html, and in Spanish
at: http://erc.msh.org/fpmh_spanish/chp9/index.html.
Family planning managers must have basic financial management skills so
that they can ensure their program's resources are used responsibly and
appropriately. The financial management cycle consists of providing services,
receiving cash, paying for expenses, and reporting to donors and other outside
sources of the use of funds provided. This chapter provides practical advice
on how to prepare a budget for the work plan, project revenues and monitor
cash flow, control and manage funds, compare program results with budget
projections, determine and compare the cost of services, meet institutional
reporting requirements, and understand and use financial reports for decision
making.
Yeboah, D.A. Strategies
adopted by Caribbean family planning associations to address declining international
funding. International Family Planning Perspectives 28(2):122–125
(2002). Available at: http://www.guttmacher.org/pubs/journals/2812202.html.
In recent years, Caribbean family planning associations (FPAs) have lost
international funding because their need has been rated as lower than other
regions of the world. To understand how the FPAs are adapting to this loss
of funding, the authors sent a questionnaire to five countries. They found
that Caribbean FPAs have adopted many new strategies to deal with the loss
of funding, including strict financial management and restructuring to increase
efficiency, business development and purchase of their buildings to improve
sustainability, expansion of services and revision of fee structures to
increase revenues, use of volunteers to reduce costs, and membership and
fundraising drives to provide additional revenue.
