The PHRplus Project is funded by U.S. Agency for International Development and implemented by:

Abt Associates Inc. and partners, Development Associates, Inc.; Emory University Rollins School of Public Health; Philoxenia International Travel, Inc. Program for Appropriate Technology in Health; SAG Corp.; Social Sectors Development Strategies, Inc.; Training Resources Group; Tulane University School of Public Health and Tropical Medicine; University Research Co., LLC.

URL: http://www.phrplus.org

Findings from National Health Accounts: Findings from National Health Accounts: Investing in Reproductive HealthInvesting in Reproductive Health

Tania DmytraczenkoTania DmytraczenkoSenior Health Economist, PHRSenior Health Economist, PHRplusplus

Global Health Council ConferenceGlobal Health Council Conference

1 June 20051 June 2005

AcknowledgementsAcknowledgements

EgyptEgypt Driss Zine Eddine El Idrissi Samir Fouad Manjiri Bhawalker Osmat Azzam

JordanJordan Fatina Halawani Patricia Hernandez

RwandaRwanda Susna De Emmanuel Kabanda Vianney Nizeyimana

OutlineOutline

BackgroundBackground

MethodMethod

ResultsResults

Next stepsNext steps

BackgroundBackground

Achieving the Millennium Achieving the Millennium Development GoalsDevelopment Goals

Addressing the principles causes of the Addressing the principles causes of the burden of diseaseburden of disease Maternal health indicators Reproductive health (RH) more broadly

Managing for resultsManaging for results

Background

““We manage what we measure”We manage what we measure”

Support sound policy decisions by tracking:Support sound policy decisions by tracking: Who finances RH services and programs? How much do they spend? Where do RH funds go, i.e., what is the distribution

among providers and ultimately among services provided?

Hospitals vs. ambulatory care facilities Curative care vs. prevention programs

Who benefits from spending for RH? Socio-economic groups Gender Geographic distribution

Background

MethodMethod

Definition of reproductive health Definition of reproductive health expendituresexpenditures

Family planning servicesFamily planning services Outpatient counseling and issuance of contraceptive

commodities Female and male surgical sterilization Retail sale of family planning commodities

Maternal health servicesMaternal health services Antenatal care Deliveries Emergency obstetric care Postnatal care

Definition of reproductive health Definition of reproductive health expenditures (continued)expenditures (continued)

Other reproductive health servicesOther reproductive health services STI RTI Gynecological services Oncology Infertility

IEC, public awareness, health education IEC, public awareness, health education campaignscampaigns

TrainingTraining ResearchResearch

Reproductive Health Accounts: Reproductive Health Accounts: Countries coveredCountries covered

EgyptEgypt JordanJordan RwandaRwanda

YearsYears 20022002

19951995

19911991

20012001

20002000

19981998

20022002

20002000

19981998

General NHAGeneral NHA

RH subanalysisRH subanalysis preliminary preliminary ((2002)2002)

(2001, 2000)(2001, 2000)

(2002)(2002)

HIV/AIDS subanalysisHIV/AIDS subanalysis

Method

Ongoing in Mexico, Karnataka (India) Ongoing in Mexico, Karnataka (India) Bangladesh, Nepal, Sri Lanka, India (2 states)Bangladesh, Nepal, Sri Lanka, India (2 states)

ResultsResults

Reproductive health indicatorsReproductive health indicators

Egypt Jordan Rwanda

Maternal mortality (per 100,000 live births) 170 41 1071

Total fertility rate 3.5 3.7 5.8

% of women in union using a modern birth control method

53.9% 41.2% 4%

Use of antenatal care (% of births) 52.9% 98.6% 92%

% of births delivered in a health care facility

48.2% 96.9% 27%

% of births with a trained birth attendant 60.9% 99.5% 30%

Use of postnatal care (% of births) 52.5% 96.9/28%* 1.1%

Source: DHS 2000, 2002Source: DHS 2000, 2002

Reproductive health results

*subsequent to discharge

RH expenditures15.3%

Reproductive health within context of Reproductive health within context of general health caregeneral health care

RH expenditures15.7%

Total Health Expenditures

RH spending as a percentage of total health expendituresRH spending as a percentage of total health expenditures

Reproductive health results

Total Health Expenditures

JordanJordanRwandaRwanda= USD $10.9M

or $5.31 / WRAor $5.31 / WRA

= USD $127.6M

or $98.14 / WRAor $98.14 / WRA

Public8%

Households10%

Donors80%

Other private2%

Other private11%

Donors5%

Public38%

Households46%

Where do reproductive health dollarsWhere do reproductive health dollarscome from?come from?

Donors3%

Public50%

Other private2%

Households45%

JordanJordanEgyptEgyptRwandaRwanda

RH is being financed mostly by either: donors (Rwanda)RH is being financed mostly by either: donors (Rwanda)or government and households (Egypt, Jordan)or government and households (Egypt, Jordan)

Reproductive health results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Public Donor Public Donor Public DonorRH General health

Public versus donor priorities in Public versus donor priorities in resource allocationresource allocation

4% 37%RwandaRwanda

16% 17%JordanJordan

6% 12%EgyptEgypt

Donor funding is concentrated on RH and HIV/AIDS in RwandaDonor funding is concentrated on RH and HIV/AIDS in Rwanda

Reproductive health results

Other private11.1%

NGOS3.6%

Public entities45.7%

Household OOP39.6%

Who is managing reproductive Who is managing reproductive health funds?health funds?

Other private2.4%

NGOs35.8%

Public entities51.8%

Household OOP10.0%

Public entities are the largest payer / purchaser of RHPublic entities are the largest payer / purchaser of RH

RwandaRwanda JordanJordan

Reproductive health results

0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000

RH

General health

USD (in '000)

Donor sources

Public sources

Who is financing reproductive health Who is financing reproductive health expenditures by public entities?expenditures by public entities?

Donors finance a large share of RH expenditures by Donors finance a large share of RH expenditures by public entities and 100% of spending by NGOspublic entities and 100% of spending by NGOs

25%25%

85%85%

Origin of funds managed by public entities in Rwanda

Reproductive health results

What types of RH services are being What types of RH services are being funded and by whom in Rwanda?funded and by whom in Rwanda?

2%

8%

2%

1%6% 6%

60%

6%

1%

6%

0%

10%

20%

30%

40%

50%

60%

70%

Curative Care(18%)

Prevention andpublic health

(66%)

Pharmaceuticalsand other

nondurables (3%)

Healthadministration

(7%)

Other (6%)

Public SourcesDonors (incl. NGOs)HouseholdsPrivate Companies

% o

f T

HE

fo

r H

IV/A

DS

Reproductive health results

20022002

Households finance half of all curative care while donor funds go Households finance half of all curative care while donor funds go principally towards prevention programsprincipally towards prevention programs

Breakdown by RH categories in Breakdown by RH categories in RwandaRwanda

Other (NSK)6%

FP commodities and consultation

6%

Administration7%

Maternal health15%

Prevention and public health programs on

MCH and FP66%

Reproductive health results

20022002

DeliveriesDeliveries

Expenditure/ delivery in a facilityExpenditure/ delivery in a facility $7.59$7.59

Number of deliveries in a facilityNumber of deliveries in a facility 99,20199,201

Number of deliveries at homeNumber of deliveries at home 268,210268,210

If all deliveries were to take place at facilities, current If all deliveries were to take place at facilities, current expenditures (60% of which are financed by households) on expenditures (60% of which are financed by households) on deliveries would need to increase by deliveries would need to increase by 3 fold3 fold

Reproductive health results : maternal health

Breakdown of expenditures by Breakdown of expenditures by method mixmethod mix

13% 12%

3%

3%18%

16% 22%

12%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Injectables Oralcontraceptives

Condoms

Households

Donors via NGO

Donors via MoH

% o

f F

P c

om

mo

dit

y ex

pen

dit

ure

20022002

Reproductive health results : family planning

Utilization vs OOP expenditure on Utilization vs OOP expenditure on commoditiescommodities

90

15

82

717

10

72

17

8778

94

126 5 6

1

0

10

20

30

40

50

60

70

80

90

100

Use

OOP Expe

nditure Use

OOP exp

enditu

re Use

OOP exp

enditu

re

Other Providers

Private Providers

Public Providers% of use/OOP expenditure for each FP commodity

InjectablesOral Contraceptives

Condoms

Reproductive health results : family planning

Utilization of commodities by Utilization of commodities by quintilequintile

1.7 1.76.6 10

17.4

10

5.6

63.6

73.3

83.1

2.8

8.5

510.7

0

10

20

30

40

50

60

70

80

90

100

Injectables Oral contraceptives Condoms

Highest Quintile

Fourth Quintile

Third Quintile

Second Quintile

Lowest Quintile

DHS 2000

Reproductive health results : family planning

Conclusion of RH subanalysisConclusion of RH subanalysis

Dependence on donors to finance RHDependence on donors to finance RH

Low government contribution to RHLow government contribution to RH In fact, households finance more than the

government

Households contribute close to half of all Households contribute close to half of all curative RH expenditurescurative RH expenditures Donor expenditures are primarily targeted for

prevention and public health programs

Reproductive health results

Conclusion (cont’d)Conclusion (cont’d)

Optimal mix of spending on curative versus prevention?Optimal mix of spending on curative versus prevention? Curative = 18% of total RH expenditures Prevention and public health programs = 66% of total RH exp

Little is being spent on maternal health care servicesLittle is being spent on maternal health care services

Financial burden on householdsFinancial burden on households Households pay to obtain donated contraceptives given to the

government Consultation fees Anecdotal evidence that fees may be charged by some facilities for the commodity

itself* In some service delivery points, households payments exceed price of

donated commodities Oral contraceptives (households pay twice as much) Injections (households pay the same amount)

Reproductive health results

The PHRplus Project is funded by U.S. Agency for International Development and implemented by:

Abt Associates Inc. and partners, Development Associates, Inc.; Emory University Rollins School of Public Health; Philoxenia International Travel, Inc. Program for Appropriate Technology in Health; SAG Corp.; Social Sectors Development Strategies, Inc.; Training Resources Group; Tulane University School of Public Health and Tropical Medicine; University Research Co., LLC.

URL: http://www.phrplus.org

Thank You

Reports related to this presentation Reports related to this presentation are available at www.phrplus.orgare available at www.phrplus.org