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Limited resources require family planning programs to choose among competing
priorities, such as adding a contraceptive method, improving counseling, expanding
community-based delivery systems into hard-to-reach rural areas, expanding clinical
programs and broadening services to include sexually transmitted diseases. Program
managers need information on costs and benefits of services to make better informed
decisions about these services.
"What do you get and what does it cost?" asks Dr. Barbara Janowitz, who directs
FHI's Service Delivery Research Division. "These are the two questions to ask when
introducing a new contraceptive method or expanding the availability of a method. The same
two questions hold when a program considers adding a new service in the reproductive
health field. To make logical choices, managers need to know what various services cost as
well as what impact a specific change in program function will have."
She and her colleagues have developed a manual to assist program managers to undertake
such studies. It describes the way a program can calculate the costs of its services and
then use that information to evaluate whether to add or expand contraceptive choices and
make other types of changes in service delivery. Governments and nongovernmental
organizations (NGOs) in Bangladesh, the Dominican Republic, Ecuador, Mexico and other
countries have worked with FHI using this approach.1
"The manual considers only the fertility reduction outcomes of family planning
programs," says Dr. Janowitz, "but the approach can be expanded to include
impacts on other aspects of women's lives or those of their families. For example,
outcomes could also include reductions in high-risk pregnancies and fewer sexually
transmitted infections because of increased condom use."
Most cost studies rely on the cost of providing a couple-year of protection (CYP) -- the
level of contraceptive use equal to one year of contraceptive protection. CYP, however,
does not take into account failure rates during normal use nor does it consider the
broader ways that contraception might affect a person, including protection from sexually
transmitted diseases.2
Other organizations have begun to develop cost analysis methodologies. For example,
Management Sciences for Health, a U.S.-based organization, suggests a simple, step-by-step
process that can determine the costs of each type of visit to a clinic using only
personnel and commodities costs. These are usually two of the largest cost items. Expenses
for training, maintenance, information and other items are not included in this model.3
Among the cost issues that the FHI manual and other similar methodologies can help
managers address are: the cost of adding a contraceptive method or expanding its use; how
to assess the cost effectiveness of various service delivery systems; and how to increase
contraceptive access by reallocating limited resources through changes in unnecessary
practices or regulations.
Method choices
When a family planning program considers changes in the kinds of contraceptives it
provides, many factors, including cost, play a role. For example, a new technology that
may attract new clients could become available, such as the hormonal implant Norplant. The
increase in HIV/STDs may prompt more interest in promoting condoms and other barrier
methods at family planning clinics. Interest in involving men could lead to campaigns to
inform them about vasectomy, as has been done in Kenya, Brazil and other countries.
If a method attracts new users or meets an identifiable need, such as STD prevention or
involvement of men, then program managers might consider reducing or eliminating one
service to provide another.
A study in Thailand, coordinated by the National Family Planning Program (NFPP) and FHI,
compared the incremental cost of Norplant with IUDs and injectables. It also examined how
adding Norplant might increase overall contraceptive use. Providing three years of
protection with Norplant cost U.S. $9.40 per year, compared with about U.S. $5 for
injectables and U.S. $1.40 for the IUD. Of the 550 new Norplant acceptors interviewed, 96
percent of the women said they would have used another modern method if the implant had
not been available. "Thus introducing the implant or significantly expanding its use
in Thailand will cost more than expanding the use of the IUD or injectables,"
concluded Dr. Janowitz and her colleagues in the study.4
The study included only additional or marginal costs related to the specific methods
(commodities, supplies and labor providing the services). Since the expansion was
implemented within the existing hospital structure, no infrastructure costs were included.
Also, costs to the client such as travel and lost wages were not included, although these
can be important considerations from the users' point of view.
The NFPP in principle wants to offer Norplant as an additional method in its national
network of community hospitals, where it traditionally has provided contraceptives at
subsidized prices. The study identified three choices the NFPP can make: spend limited
resources to subsidize this method, charge users higher prices, or limit its use to women
who have completed their families and do not want to be sterilized.
In Ecuador, a study examined the cost of adding the injectable DMPA in the clinics of a
nongovernmental organization. The study found that when injected by a nurse, DMPA cost
about half as much to deliver as the pill, U.S. $6.68 a year compared to U.S. $12.88 for
the pill. The calculation included only marginal costs specific to the method --
commodities, supplies and labor providing the services. (The DMPA cost was higher when
injected by doctors, whose salaries are higher than those of nurses.) The difference in
cost to the clinic was mainly due to the cost of the commodities to the program.
The clinic charged the same for DMPA and the pill, U.S. $22 per year. The part of the fee
not needed for method-specific costs went toward the overall program expenses, such as the
clinic facility and administrative costs. Thus, a DMPA user contributed U.S. $15.32 per
year toward these other clinic costs, compared with U.S. $9.12 for the pill user. In the
case of this Ecuador NGO, DMPA was a good source of revenue.
Circumstances in a country often make it misleading to compare costs from one country to
another.5 The situation in Ecuador, for example, differed
substantially from that in Thailand described earlier, so the numbers in these two studies
should not be compared.
In Nyeri, Kenya, the Provincial General Hospital began a postpartum IUD program in the
early 1990s but did not know whether to continue it. An FHI study compared the cost of
immediate post-placental insertion (IPPI), which is performed within 10 minutes after the
placenta is expelled, and insertion at a maternal and child health clinic, which is done
at least six weeks after the birth.
The study compared incremental costs for the two types of insertions and found that for
one year of protection, costs were 41 percent higher when the IUD was inserted at the
clinic (U.S. $4.75), compared with insertion done in the delivery room (U.S. $3.37). The
major additional cost was the time spent on preparation for sterile conditions at the
clinic, conditions that were already present in the delivery room. This study contributed
to the hospital's decision to continue its postpartum IUD program.6
Improving delivery systems
Many programs must decide how to divide limited resources among clinical and
community-based services, while also making each system as efficient and high-quality as
possible. Working with the National Family Planning Program in Bangladesh, FHI is
conducting a nationwide cost study, examining clinical and outreach programs administered
by the government and by NGOs. In the last seven years, the government has nearly doubled
the number of outreach workers, from 13,000 to 23,000, and now spends U.S. $22 million a
year on salaries alone, including the services of 4,500 supervisors.
This commitment to a community-based distribution system has contributed to a sharp
increase in contraceptive use, particularly among pill users. Over the last decade in
Bangladesh, the proportion of married women of reproductive age using contraception has
more than doubled, from 19 percent to 45 percent, and pill use has jumped six-fold, from 3
percent to 17 percent. The portion of users getting their pills from outreach workers has
gone from 45 percent to 70 percent.
Preliminary results from the FHI studies indicate that while the existing systems have
been successful, they can serve even more users without major cost increases. The studies
have gathered data by accompanying workers on home visits, analyzing records, monitoring
when supervisors and outreach workers went to work, calculating time spent with a client,
and other approaches.
"The community-based workers could meet a lot of increased demand without any
additional costs," says Dr. Janowitz, who is coordinating the Bangladesh studies.
"Some outreach workers work shorter hours than they are supposed to work."
Regarding the clinics, preliminary results indicate that many are under-utilized, and
hence many more people could also be served at the clinics without major cost increases.
A study in Nigeria, Tanzania and Zimbabwe also showed the importance of using a clinical
system efficiently. In each country, about one-fourth of the clinics served approximately
80 percent of the new clients, concluded a research team led by the Population Council.
Considerable room exists "for expanding services in the large number of facilities
that have relatively few clients," the study found. "Alternatively, resources
could be concentrated in the most heavily used service-delivery points."7
Contraceptive cost studies generally do not include costs to the user. If a woman has to
visit a clinic for a resupply of a method, such as pills or injectables, she incurs the
cost of transportation. A woman visited by a community-based worker does not have
transportation costs, but the outreach program does have that additional cost.
"The program costs of a clinic-based and an outreach program may appear to be the
same but the costs to the user may be different," explains Dr. Janowitz. "You
have to consider both the cost of programs in providing a method and the cost to the user
in getting the method. Cost to the user may affect demand for contraception and cannot be
ignored."
Different service delivery systems often use information campaigns when attempting to
expand contraceptive services. Few data show how much it costs to change a person's
behavior through such an effort, but studies have compared the value of different
promotion approaches. An analysis of a male motivation campaign in Zimbabwe, for example,
found that "radio was by far the most cost-effective in reaching people and
encouraging them to use family planning." The study found the cost of using radio was
U.S. $2.41 per new family planning user, while the cost of pamphlets was U.S. $28.06 per
new user, although the radio program had been available longer than the pamphlets. While
the radio campaign cost almost twice as much as the pamphlets (U.S. $93,000 compared to
U.S. $50,000), it resulted in more than 20 times more new users.8
Unnecessary regulations
Some requirements for using contraceptives add unnecessary costs, which can limit
access to potential users. Examples include the number of follow-up visits recommended for
IUD users and mandatory laboratory tests prior to receiving oral contraceptives.
Some programs recommend up to three or four follow-up visits for IUD users. To determine
whether so many visits are needed for women with no or mild symptoms, FHI researchers
analyzed records from clinical trials of IUDs involving 11,000 women in nine countries.
The study found that less than 1 percent of follow-up visits by women with no or mild
symptoms had a health risk that would not have been detected without the follow-up visits.9 "It makes sense not to have so many visits and let the
staff do something more useful," says Dr. Janowitz, who led the study.
In Ecuador, Centros Medicos de Orientación y Planificación Familiar (CEMOPLAF) wanted to
know if it could reduce its norm of four return visits for IUD acceptors without
endangering a woman's health. A study by FHI and the Population Council compared four
return visits to one visit, interviewing some 5,000 women. It concluded that one follow-up
visit would detect 66 percent of the health problems, and four visits would uncover 73
percent. But by changing to a one-visit norm, CEMOPLAF would save about U.S. $33,000 per
year.10
"We implemented the one-visit follow-up norm at 15 days after insertion, the time
when most problems occur with an IUD," says Teresa de Vargas, executive director of
CEMOPLAF. Following this change, from 1992 to 1993, the number of revisits declined by a
third. "We have used the increased staff time to provide expanded gynecological and
prenatal services."
Another expensive practice followed by some countries, particularly in francophone Africa,
is to require a set of laboratory tests before providing oral contraceptives. Commonly
required lab tests are used to detect cervical cancer, diabetes, high cholesterol, anemia
and liver function problems. In a prospective study of 410 women in an urban area of
Senegal, such tests indicated possible contraindications for pill use in only 20 women,
nine of whom returned for a second test. Of those nine, only one had a confirmed
contraindication. The cost of such mandatory tests in Senegal ranges from U.S. $55 to
$216, depending on the type of lab a woman chooses, as much as five times the monthly per
capita income in Senegal.11
The study led to a new national policy to eliminate the tests. "Even though the
government of Senegal no longer requires these tests, many doctors and midwives still
do," says John Stanback of FHI, who led the study. "Because of the expense, the
tests have the potential for keeping thousands of women in urban areas from using the
pill."
When unnecessary regulations limit access to contraceptive methods for some users, women
in particular may suffer. Unwanted pregnancies can result in maternal mortalities and
chronic maternal morbidities. Other problems include the issues of stress and time lost
from work because of poor health that may be linked to lack of access to good quality
family planning services.
Providing adequate access to contraception can also reduce health-care costs for unwanted
pregnancies. A recent study in the United States compared the costs of 15 different
contraceptive methods to the health costs of not using any contraception. Based on U.S.
data, including insurance costs for the healthcare associated with unwanted pregnancies,
it found that all 15 methods were less costly when compared with using no method. While
the study applies to the health-care system used in United States, it has implications for
all countries. "The message is simple: regardless of payment mechanism or
contraceptive method, contraception saves money," the study concluded.12
In many countries, governments essentially pay the health-care costs that the insurance
system supports in the United States. "An important question for all governments to
consider is, 'What does it cost not to use a method?'" says Dr. Janowitz.
-- William R. Finger
Footnotes
- Janowitz B, Bratt JH. Methods for Costing Family
Planning Services (Durham: FHI and UNFPA, 1994).
- Shelton JD. What's wrong with CYP? Stud Fam Plann
1991; 22(5): 332-35.
- Analyzing costs for management decisions. The Family
Planning Manager 1993; 2(2).
- Janowitz B, Kanchanasinith K, Auamkul N, et al.
Introducing the contraceptive implant in Thailand: impact on method use and cost. Int
Fam Plann Perspect 1994; 20(4): 131-36.
- Janowitz B, Bratt JH. Costs of family planning services:
A critique of literature. Int Fam Plann Perspect 1992; 18(4): 137-44.
- Hubacher D, Janowitz B, Mate EM, et al. Comparing the
Costs of Two IUD Programs in a Kenyan Hospital. Paper delivered at APHA Annual Meeting,
1992.
- Mensch B, Fisher A, Askie I, et al. Using situation
analysis data to assess the functioning of family planning clinics in Niger, Tanzania and
Zimbabwe. Stud Fam Plann 1994; 25(1): 18-31.
- Piotrow PT, Treiman KA, Rimon JG, et al. Strategies
for Family Planning Promotion -- World Bank Technical Paper Number 223. (Washington:
The World Bank, 1994).
- Janowitz B, Hubacher D, Petrick T, et al. Should the
recommended number of IUD revisits be reduced? Stud Fam Plann 1994; 25(6): 362-67.
- Foreit F, Bratt J, Foreit K, et al. Cost control,
access and quality of care: the impact of IUD revisit norms in Ecuador. Unpublished paper.
1994.
- Stanback J, Smith JB, Janowitz B, et al. Safe provision
of oral contraceptives: the effectiveness of systematic laboratory testing in Senegal. Int
Fam Plann Perspect 1994; 20(4): 147-49.
- Trussell J, Leveque JA, Koenig JD, et al. The economic
value of contraception: A comparison of 15 methods. Am J Public Health 1995:
85(4):494-503.
For more information, visit Family Health International's Website at www.fhi.org
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