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Reproductive Health |
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Issues in the Financing of Family Planning Services in Sub-Saharan AfricaChapter VI: Conclusion |
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This report has addressed major issues related to the financing of family planning services in sub-Saharan Africa by consolidating available information, much of which is not published or readily available. It has also identified gaps in the information base that will need to be filled to facilitate policy and program change. The Resource Gap As illustrated in Chapter II, the need for family planning services is high and rising. While trends in donor funding for family planning have been quite positive over the last decade, the most recent data must be interpreted with caution, given changes in the definitions of funding categories. Specifically, it appears that a substantial proportion of recent funding increases for family planning and other elements of reproductive health care has been designated for the latter. Funding for family planning alone may have even declined. While the global emphasis on prioritizing broader reproductive health issues is laudable and long overdue, its potential negative impact on funding for family planning alone should not be underestimated. Eventually, countries will need to replace donor funds for both family planning and other elements of reproductive health care with in-country resources. Failure to take these realities into account encourages the development of service delivery systems that are neither efficient nor sustainable. While estimating current levels of government expenditure is a colossal task and results in a broad array of estimates of limited accuracy, one fact is clear: Governments in sub-Saharan Africa contribute significantly less toward overall family planning expenditures than those in other regions, and this is unlikely to change. While donor funds are increasingly directed at broader reproductive health care, and government expenditure on family planning remains minimal, resource requirements for family planning will increase dramatically in the future. There is, therefore, an urgent need to mobilize alternative sources of funding for family planning. This will be necessary even to sustain current, inadequate levels of service provision. Meeting high and rising levels of unmet need increases the need for additional resources substantially. Alternatively, or additionally, resources can be conserved by providing services more efficiently. There are several options available to mobilize or conserve revenue. Unfortunately, the information base on the potential of these strategies is limited. Most have not been attempted with great success, particularly in the sub-Saharan context; those that have been attempted have not been evaluated, or their evaluations have questionable results due to methodological flaws. The development of a coherent, systematic regional family planning financing strategy must be preceded by targeted efforts to improve this information base. Conclusions about each strategy -- based on the limited information available -- and recommendations for further research are presented for each approach later in this chapter. Key issues A meaningful regional strategy for family planning finance will depend on the development of an improved information base on family planning needs and expenditures. Policy-makers need relevant, practical information that could be obtained from:
Key areas for action Some actions can be taken immediately to address the growing resource gap. These include the following: 1. The sub-Saharan region has high levels of unmet need for family planning services, as well as a large gap between user needs and both actual and potential resources. As a result, this region should continue to receive a disproportionate share of donor resources in the short and medium term. 2. In the short term, donors should increase their support to African family planning programs in order to sustain them in the face of increasing demand for services. In order to prevent dependence and to minimize host-country displacement of resources, donors should set clear time frames for phase-out of increased assistance and assist countries to develop their own plans for domestic resource mobilization. 3. The resources needed to implement the broad Programme of Action from the ICPD in Cairo are not available. Donors must prioritize among the various elements of the Programme. Care must be taken to ensure that funding for family planning services is not diminished as implementation of the Cairo agenda moves forward. Charging Fees for Services Chapter III presented available information on the potential for raising revenue by charging or increasing fees to users of public sector and NGO service outlets, so that users pay a higher share of service costs. Information was also presented on the impact of this strategy on access to services, particularly among vulnerable groups. The pricing literature for sub-Saharan Africa is very limited and does not provide a sufficient base upon which to make decisions about instituting or increasing prices. It does suggest that marginal increases in currently low (or zero) fees might raise a limited amount of revenue without seriously compromising access to care. Available studies also find that higher, private sector prices do have a negative impact on demand. This may imply that efforts to raise public sector or NGO prices to levels high enough to generate the significant resources needed would probably dampen demand to the extent that both users' access and revenue potential would be compromised. Key research questions A careful examination of options for sustainable financing of family planning services would include study of the following questions:
Key areas for action Many issues must be taken into account in the development of research and policies on user fees for family planning. Although additional research will be useful in determining what actions to take regarding cost recovery, there are some steps that can be taken immediately: 1. Government and NGO programs should consider introducing limited fees for family planning services. Without some level of cost recovery, programs will be unable to expand services to meet high and growing levels of demand for services, make urgently needed quality improvements, or expand their service base to include elements of the ICPD Programme of Action. Indeed, the inadequate, existing service base will be increasingly under threat unless some cost recovery is instituted. 2. Means testing cannot be relied upon as a strategy to ensure that the poor and other vulnerable groups have access to services in a fee-charging system. Available evidence suggests that means testing -- as currently implemented -- is extremely costly and fails to protect many who need protection, while providing exemptions for those who are able to pay. The imperfect, short-term solution may be to charge fees at a very low level, and to use simple targeting strategies that do not require means testing, such as targeting by geographic area, facility type, etc. This implies accepting both limited cost recovery and mistargeted exemptions as inevitable until more is known about ways to institute effective means testing in the circumstances that prevail in the region, at reasonable cost. At that time, higher fee levels, and more effective, specific means testing systems, can be instituted. 3. At least some fee revenues should be retained by the service delivery outlets that collect them and, to the extent possible, used to improve service quality. This will enhance revenue collection and may mitigate the demand-dampening effects of fees. Quality improvements are also important in their own right. Mobilizing the Commercial Sector As discussed in Chapter IV, the commercial sector plays a limited role in family planning in sub-Saharan Africa, particularly in comparison to other regions. Given the concern that high fees may deter contraceptive use coupled with the poor performance of means testing, greater attention should be given to encouraging the growth of the commercial sector. Programs should center their resource mobilization efforts on strategies such as encouraging public sector users with the ability to pay to use commercial sector services, and creating an environment conducive to commercial sector growth. There appears to be ample room for mobilizing a greater commercial sector role, particularly in the provision of re-supply methods. There is also evidence that a substantial proportion of the public sector subsidy is being used by individuals who appear to have the ability to pay for commercial sector services. Many of the factors that stymie commercial sector growth are not amenable to short-term policy intervention. There is evidence that such factors as income and urbanization levels, for example, are significantly correlated with commercial market share in sub-Saharan Africa. On the other hand, there are several areas where intervention could have an effect. Unfortunately, available evidence suggests that resources have been used to support those interventions with the least promise in terms of reducing the pressure on the public purse. One of the major constraints to commercial sector growth is, in fact, donor and government funding of low- or no-cost public and NGO services -- since the commercial sector cannot compete in this environment. Charging fees for these services would stimulate commercial sector growth. Other promising interventions include general efforts to minimize and simplify the regulations, taxes, and import duties that currently make family planning service delivery a burdensome venture. A range of interventions to promote a greater role for private health-care providers and pharmacists should also be considered. Interventions to expand employer-based family planning services have received perhaps the most attention. However, it is not clear that this approach can play a major role in family planning service delivery in the region. The small size of the formal employment sector, the limited involvement of women in this sector, and the small number of companies large enough to consider providing such services limit its overall potential. Its potential for shifting users out of the public sector is even more limited, since formal sector employees are among those most likely to be using commercial services already. Interventions to promote the role of managed care in family planning financing are also receiving growing attention. Again, however, this approach has very limited potential for freeing public sector resources, since potential beneficiaries are already least likely to be using public services. One promising approach to increasing the commercial sector is social marketing. These programs are expected to decrease reliance on African government and donor funds by inducing users to switch from more to less highly subsidized services. However, evaluations of whether social marketing programs accomplish this goal are lacking in the sub-Saharan Africa region. Key research questions Research in the following general areas would facilitate the development of a strategic plan for commercial sector mobilization:
Key areas for action Immediate policy actions include the following: 1. Many clients who use free or low-cost public services can afford to pay (or pay more) for services. Mechanisms should be developed to shift such individuals to commercial sector sources. Governments should develop explicit policy statements describing their target clientele (i.e., market segmentation). Urban markets are likely to offer the greatest potential for commercial sector growth. As a result, policy-makers should first devote attention to segmenting the urban market and promoting urban-based commercial sector development. 2. Governments should create incentives for commercial sector growth, particularly in urban areas, e.g., by reducing associated taxes, liberalizing regulations, and reducing or eliminating other barriers to market entry -- while taking care to ensure service safety and quality, as well as vigorous and fair competition. 3. Employers have limited incentives to provide family planning services. Insurance companies and other managed care arrangements have even less incentive to cover family planning services. Further investment in these approaches should be undertaken cautiously; it is likely that the limited resources available for commercial sector promotion could be used to far greater effect in other areas. 4. Governments should create incentives for commercial sector growth, particularly in urban areas. Programs need to determine whether they should devote additional resources to social marketing in order to stimulate the growth of the commercial sector. Reducing the Cost of Services Chapter V examined prospects for reducing the costs of family planning services. Reducing service costs is one way to narrow the gap between needs and resources. Too often, we focus almost exclusively on increasing resources, and little, if at all, on the efficiency with which services are provided. Key research questions Key decision points and information gaps include the following:
Key areas for action Immediate policy actions include the following: 1. Efforts should be made to mobilize underused capacity in family planning services in the region. This capacity is substantial, and could be used both to expand services and improve their quality, without substantial new resources. However, the costs, financial and otherwise, of capacity mobilization should not be underestimated. 2. In light of the potentially high costs but low effectiveness of treating family planning clients for cervical infections based on risk assessment or the syndromic approach, these approaches should either be revised and re-tested or should be phased out. Priority should be given instead to the promotion of behavior change and condom distribution. 3. A major effort should be made to develop and promote standards and guidelines for family planning service provision, with an emphasis on eliminating unnecessary or outdated tests and procedures. Existing, updated international standards should be assessed, modified, and implemented at the national and local levels, based on local circumstances. Such an effort will not only reduce the costs of service provision, it will also enhance access. 4. While individuals should be given a choice of contraceptive methods, the costs of methods cannot be ignored in determining the method mix. Given limited resources, the universal provision of methods based on demand and without regard to cost will restrict the number of individuals whose need for family planning services can be met. 5. Non-physician personnel should be trained and mobilized to play a greater role in family planning service provision, with due regard for safety and quality. There is evidence that nurses can be trained to insert IUDs safely and effectively. Similarly, lower level personnel can provide oral contraceptives and injectables. Not only will this approach diminish service costs, it will also enhance access. Final Comments There is potential for mobilizing revenues to finance current and future needs for family planning in the region. Each strategy, however, must be implemented based on information about its impact on revenues, access to care, reproductive choice, and many other issues. The information gaps in this document should be prioritized by decision makers in the region. This priority-setting exercise should be followed by targeted research, the results of which should be widely disseminated to promote financing reform through rational family planning pricing policies, targeted commercial sector mobilization, and cost-minimizing strategies. However, some actions can be taken immediately to recover costs, promote the development of the commercial sector and reduce costs. Policy-makers need to draw up action plans to implement the immediate actions that we have outlined in this chapter. Without research on financial issues coupled with some immediate policy actions, it will be difficult to maintain current, inadequate levels of service provision. Meeting unmet needs for family planning and broader reproductive health care -- today and in the future -- will remain unattainable goals. |
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