While community-based distribution of family planning services can be a cost-effective approach, some studies have found other delivery approaches are often less expensive. Cost, however, is only one factor. Without a community distribution strategy, experts say, some people in many countries would receive no services at all.
"Comparing costs of clinics and CBD (community-based distribution) programs is not useful unless the programs serve the same audience," says Dr. Barbara Janowitz, an FHI economist who has studied community programs in Tanzania, Bangladesh and other countries. "Generally, you need CBD because you cannot reach the population through a clinic program."
Many studies of CBD program costs have used couple years of protection (CYPs), a traditional family planning measurement. Distributing 13 cycles of oral contraceptives produces one CYP, for example, since that many pills provide one year of protection.
A study of family planning programs in 14 developing countries comparing costs this way found community distribution to be among the most expensive options. Clinic-based sterilization cost only U.S. $1.85 per CYP in two countries, while community-based distribution programs in five countries averaged $9.93.1
The CYP measurement has important limitations. While all program costs are generally included, the cost burden to clients, such as travel expenses to a clinic, are not. Also, CYP cost calculations do not take into account different failure rates among methods, client preferences, informed choice, or a client's need to use condoms for disease prevention.
Some experts suggest that other indicators are more useful, such as ways to measure access to an expanded method mix.2
For example, the Planned Parenthood Association of South Africa included the costs clients pay (travel and time lost from work) to evaluate clinic and community-based distribution costs. Clinics provided only injectables, oral contraceptives and condoms, not methods that result in a high number of CYPs -- such as sterilization and intrauterine devices -- which would skew calculations in favor of clinics. CBD workers provided pills and condoms. When client costs were included, CBD was cheaper, about U.S. $42 per CYP compared to U.S. $44 per CYP at clinics. Also, the CBD cost declined to U.S. $25 per CYP in the second year, since community agents often provide only information during initial visits. The study did not attempt to calculate the value of supplying information.3
"CBD is comparable in cost to clinic provision, and may, in fact, provide significant money savings," concluded Edina Sinanovic, a health economist at the University of Cape Town Medical School, who conducted the study. The study found that CBD services may also save money by allowing professional clinic staff to devote more time to services that require more expertise.
Other evaluations examine the cost per visit to a household. A study in Kenya compared cost effectiveness of seven CBD models serving rural and urban areas, examining both the cost per client met or visited and cost per CYP. Three urban programs used agents working from clinics, while the four other programs served rural areas with home visits or village-based CBD workers. Although costs varied, the location served was not a significant factor in costs per visit or CYP. "Rural and urban CBD programs can achieve similar levels of cost effectiveness," the study found. "For the less cost-effective programs, the reason is not because of where they operate."4
In another analysis, the Population Council and FHI worked with Centro Médico de Orientación y Planificación Familiar (CEMOPLAF) in Ecuador to evaluate the cost of outreach services to remote rural areas. CEMOPLAF had found that rural residents are reluctant to spend the time and money to visit clinics in distant towns. CEMOPLAF developed a system in which providers from two clinics traveled to remote areas. Providers from one clinic attracted enough clients to reduce average costs below the level achieved before the outreach effort began. Providers from the other clinic did not, primarily because of competition from commercial providers and because their services were offered at an inconvenient location.5
Asociación Probienestar de la Familia Colombiana (PROFAMILIA), the International Planned Parenthood Federation affiliate in Colombia, examined three CBD approaches. One used social marketing, supplying small rural drugstores at wholesale prices. In the second approach, CBD instructors serving about 70 CBD posts received wage incentives. The third approach used two-person teams (each with a man and woman), who promoted family planning at health posts, hospitals and schools rather than making household visits.
From a cost perspective, all three strategies were effective. The social marketing experiment actually resulted in a profit, although government and pharmaceutical company decisions have limited its usefulness. A Population Council study of the approaches recommended using such commercial approaches when there is sufficient demand for services.6
-- William R. Finger
References
- Barberis M, Harvey PD. Costs of family planning programs in fourteen developing countries by method of service delivery. J Biosoc Sci 1997;29(2):219-33.
- Fort AL. More evils of CYP. Stud Fam Plann 1996;27(4):228-31.
- Sinanovic E. Cost-effectiveness analysis of couple years of protection provision by community-based distribution of contraceptive services in selected areas of Khayelitsha. Unpublished paper. Planned Parenthood Association of South Africa Western Cape, 1998.
- Chege JN, Askew I. An Assessment of Community-based Family Planning Programmes in Kenya. Nairobi: Population Council, 1997.
- De Vargas T, Roy K, Bratt J, et al. Extension of Reproductive Health Services to Rural Indigenous Communities of Ecuador. New York: Population Council, 1998.
- Vernon R, Ojeda G, Townsend M. Contraceptive social marketing and community-based distribution systems in Colombia. Stud Fam Plann 1988;19(6):354-60; Townsend J, Ojeda G, Townsend M. Alternative strategies to improve the cost-effectiveness of the Profamilia CBD program in Colombia: wage incentive versus specialized IEC teams. Presentation at the Population Association of America meeting, San Francisco, CA, April 3-5, 1986.
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