An analysis of family planning program costs can be performed for different reasons. A
cost analysis might be used to make major decisions about a national family planning
program, for example, or even to compare the benefits of a national family planning
program with other social programs.
Cost analyses can also be tailored to examine smaller issues, such as comparing
different services within a program or clinic. Examples of these studies include an
analysis of adding Norplant to family planning programs in Thailand and whether to change
the number of follow-up office visits for intrauterine device (IUD) users in Ecuador.
Cost studies need to consider all resources involved, especially the use of staff. Some
costs are relatively easy to measure, such as the cost of supplies. However, determining
the cost of staff time needed for a specific service involves on-site research.
"You need to find out how staff members spend their time," says Dr. Barbara
Janowitz, who directs economics research at FHI. "The only way to do that is to go to
the clinic or delivery site. This is the critical element in a cost approach that sees the
program as a system -- using specific resources to produce desired services." Dr.
Janowitz and her colleagues developed a guidebook to assist program managers in using such
a system analysis framework.1
Better use of staff
The Mexican government, working with FHI, analyzed a national system that provides 16
percent of all family planning services in Mexico. A more efficient use of staff could
substantially increase the number of clients served, the study suggests.
The study found that nurses work an average of about 6.5 hours a day and physicians
about 6.25 hours a day, totals that include personal break time. Government officials say
a reasonable work day should be eight hours. Also, the health workers spend less than half
of their time providing direct services to clients (nurses, 38 percent; doctors, 47
percent). Meetings, administrative duties, unoccupied work time and personal time account
for much of the remainder.
By increasing the workday to eight hours and increasing the portion of time with
clients to two-thirds of a provider's work day, "efficiency can be increased to
accommodate growing demand within the current service delivery system up to the year
2010," the study concluded. This would allow the system to expand services from the
current 1.5 million couple years of protection (CYPs) to 1.8 million CYPs in 2010 without
additional staff. The CYP cost averaged for all contraceptive methods would decline from
about U.S. $26.40 in 1995 to about U.S. $24 in 2010.
The study showed "how the Ministry of Health can contain program costs while
continuing to meet the needs of a population that is still growing," says Dr.
Gregorio Pérez-Palacios, director general of reproductive health for the Mexican Ministry
of Health. The study also found that CYP costs could be reduced by increasing the number
of contraceptive units (oral contraceptives and condoms) provided at each clinic visit and
by switching from a one-month injectable to a three-month injectable.2
Ten research teams observed physicians and nurses in hospitals, urban and rural health
centers and health auxiliary units. The cost of provider labor was estimated, and this
cost, plus costs for capital, commodities and other expenses, allowed calculation of CYP
costs for different contraceptive methods.
Like Mexico, contraceptive prevalence has grown rapidly in Bangladesh, from 8 percent
in the 1970s to 45 percent in the current decade. Bangladesh officials, working with FHI,
examined the capacity of its family planning outreach and clinic systems, assuming a
continuing increase in the demand for services.
As in Mexico, this study observed how staff spend their time, using that and other data
to calculate the CYP cost for each method. Government field workers spent about 3.75 hours
a day working, with about two-thirds of that time traveling and one-third with clients.
Unauthorized leave accounts for about 20 percent of the cost of a field worker providing
family planning services, based on a surveillance of whether field workers actually worked
and, if so, the length of time they worked.
If field workers eliminated absenteeism and increased the time they worked each day by
one hour, the labor cost per CYP for the pill would decline by about one-third, from U.S.
$3.05 to U.S. $1.97. With this better use of staff time, the number of field workers
needed by the year 2004 would be only 17,118, a decline from the 23,500 employed in 1994.
However, each worker would be responsible for almost twice as many couples, to 1,382
couples from the current 719 couples to visit per year. With no change in work patterns,
the program would have to increase the number of field workers by more than a third, to
32,861 field workers, with the cost going from U.S. $24 million to U.S. $33 million.
"Increased productivity would enable the existing systems to meet the projected
demand in 2004," concludes an FHI study. But maintaining good quality services and
good management approaches are also critical, the study says. "An important question
is whether these changes are realistic, in that they assume an increased work effort on
the part of field workers."3 The study does not address
how absenteeism would be reduced and added work time increased by the government. It
points out, however, that a similar study found that field workers at nongovernmental
organizations (NGOs), whose salaries are similar to government field workers, were absent
less often and spent more time making home visits than the government workers.4
This suggests that NGOs may offer motivation factors that could be duplicated among
government workers, encouraging better performance.
Specific decisions
Cost studies can also be done on specific issues facing program planners or
policy-makers, such as whether to introduce a new method or revise guidelines for an
existing method.
A study in Thailand found that the labor, supply and commodity costs of the
contraceptive implant Norplant would total U.S. $9.40 per CYP, compared to about U.S. $5
for injectables and U.S. $1.40 for the IUD. Moreover, almost all of the new Norplant
acceptors interviewed in the study indicated they would have used another modern method if
they did not have access to Norplant. Hence, it would be less expensive for the government
to supply injectables and IUDs instead of Norplant. The government had to decide whether
to purchase Norplant for widespread distribution, even though less costly alternatives
were available; charge users higher prices; or limit Norplant to certain groups, such as
women in remote areas or to those who had completed their families and did not want to be
sterilized.5
"Soon after the introduction of the method, the policy was to provide the implants
to a few target groups of users in remote areas, not nationwide," says Dr. Kanchana
Kanchanasinith of the Thailand Ministry of Public Health. The policy was influenced by
limited supplies and high demand. More recently, enough supplies have been available to
serve all appropriate clients who requested Norplant. Women pay about 20 percent of the
cost of the device (about U.S. $4.27 of the $19.25 commodity cost).
Analysts have pointed out weaknesses in depending entirely upon the CYP measurement
when making decisions about services. CYP does not take into account the different failure
rates during normal use from one method to the next, for example, nor do they consider
other important aspects, such as a client's need to use condoms or other barrier methods
to protect against sexually transmitted diseases or clients' perceptions and preferences.6
A study in Ecuador with Centro Médico de Orientación y Planificación Familiar
(CEMOPLAF) examined potential cost savings in reducing the number of required follow-up
visits for IUD users without endangering a woman's health. The study, which interviewed
some 5,000 women, found that one follow-up visit would detect 66 percent of the health
problems, while the required four visits would detect 73 percent of the problems. Changing
to a one-visit standard allowed substantial savings.7 CEMOPLAF
made the change, allowing staff to provide other services, including more care to clients
who experience problems. At the same time, the program emphasized to IUD users that they
should return for a follow-up visit if they noticed any abdominal pain.
In Honduras, the Asociación Hondureña de Planificación de Familia (ASHONPLAFA),
working with FHI, found that its two largest clinics produced 68 percent of the clinical
services provided in 1991. Four smaller clinics accounted for the remaining use and
generally had the same fixed costs. This meant the average cost per client was much higher
in smaller clinics. Finding ways to increase utilization of the four smaller clinics would
spread out the fixed costs among more visits and thus reduce average costs.8
Compared to other services
Some cost studies compare the value of family planning to other health costs.
A cost-benefit analysis in Mexico examined whether the Instituto Mexicano de Seguro
Social (IMSS)'s family planning services saved IMSS money by reducing the load on its
maternal and infant care service. The study used cost data from 37 IMSS hospitals and 16
clinics. The study found that for every peso IMSS spent on family planning services in its
urban population during a 12-year period, it saved nine pesos on maternal and infant care
services, averting 3.6 million births during the study period.9
A recent study in the United States compared the costs of 15 different contraceptive
methods to the health costs of using no method, and found that all methods were less
costly compared to the health costs of unintended pregnancies when using no method. The
study also concluded that "up-front acquisition costs are inaccurate predictors of
the total economic costs of competing contraceptive methods."10
A recent study in Great Britain found a similar result, reporting that all
contraceptive methods resulted in net savings to the National Health Service because
family planning services are less expensive than all outcomes from unplanned pregnancy,
with additional savings through the avoidance of income maintenance and social welfare
provision arising from unplanned pregnancies.11
These studies included insurance costs for healthcare associated with unwanted
pregnancies, which involved insurance systems that are unique to the United States and
Great Britain. Even so, the studies have implications for developing countries, where many
governments essentially pay the health-care costs that private insurance supports in some
western countries.
Other reproductive health issues have also been examined. In a recent study in
Tanzania, researchers from the London School of Hygiene and Tropical Medicine and
elsewhere concluded that the cost-effectiveness of intervention to prevent HIV infections
compared favorably with other successful preventive medicine programs, such as childhood
immunization efforts. The scientists compared the costs of intervention to the number of
HIV infections prevented to reach this conclusion.12
-- William R. Finger
References
- Janowitz B, Bratt JH. Methods for Costing Family
Planning Services. Durham, NC: United Nations Population Fund and Family Health
International, 1994.
- Hubacher D, Holtman M, Fuentes M, et al. Family
Planning Services at the Mexican Ministry of Health: Current Costs and Future
Considerations. Final Report. Durham: Family Health International, 1997.
- Janowitz B, Holtman M, Hubacher D, et al. Can the
Bangladeshi family planning program meet rising needs without raising costs? Int Fam
Plann Perspect 1997;23(3):116-21,145.
- Janowitz B, Jamil K, Chowdhury J, et al. Productivity
and Costs for Family Planning Service Delivery in Bangladesh: The NGO Program. Durham,
NC: Family Health International, 1996.
- Janowitz B, Kanchanasinith K, Auamkul N, et al.
Introducing the contraceptive implant in Thailand: impact on method use and costs. Int
Fam Plann Perspect 1994;20(4):131-36.
- Shelton JD. What's wrong with CYP? Stud Fam Plann
1991;22(5):332-35.
- Foreit J, Bratt J, Foreit K, et al. Cost control, access
and quality of care: the impact of IUD revisit norms in Ecuador. Unpublished paper.
Population Council, 1994.
- Bratt JH, Suazo M, Santos H. Costs of Family Planning
Services Delivered Through ASHONPLAFA Programs. Final Report. Durham: Family Health
International, 1993.
- Nortman DL, Halvas J, Rabago A. A cost-benefit analysis
of the Mexican Social Security Administration's family planning program. Stud in Fam
Plann 1986;17(1):1-6.
- 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.
- McGuire A, Hughes D, Walsh J, et al. The economics of
family planning services. Unpublished paper. London Family Planning Association, 1995.
- Gilson L, Mkanje R, Grosskurth H, et al.
Cost-effectiveness of improved treatment services for sexually transmitted diseases in
preventing HIV-1 infection in Mwanza region, Tanzania. Lancet
1997;350(9094):1805-9.
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