implemented, can improve resource mobilization, equity, and efficiency, these benefits are often not achieved in practice because of indiscriminate application of user fees. The social benefits of user fees are best achieved if: (1) services with large positive externalities (such as prevention and treatment of sexually transmitted diseases) are fully exempted from fees so as not to deter demand, (2) fees are used to improve quality of care at the point of service, and (3) the poor are either exempted or face only modest fees for high-priority services.

Many investments in women's reproductive health can yield substantial improvements in health in relation to costs. Current global cost-effectiveness estimates, such as those produced for the World Development Report (World Bank, 1993), alternatives prepared for the ICPD Programme of Action, or those we have explored for the Mother-Baby Package, would benefit from a better foundation of empirical studies. But even with wide bands of uncertainty surrounding point estimates, these analyses consistently support the qualitative conclusion that reproductive health programs compare favorably to alternative health-sector investments in both poor and middle-income countries. More external assistance to reproductive health programs, particularly to delivery and neonatal care, would remedy a past imbalance among programs considered for their potential contributions to reducing the burden of disease in developing countries.

Low levels of current spending on the health sector as a whole in the low-income countries affect our recommendations for new expenditures on reproductive health. Our recommendations are designed to help in the planning for more efficient spending of resources that already are devoted to programs like family planning and mother-child health programs. But it is difficult to envision serious reforms and improvement coming with no increment in resources for the sector. Estimates prepared for India's reproductive and child health approach, for example, called for increases in public-sector recurrent spending on the order of 50-60 percent, for a relatively modest package of services (Measham and Heaver, 1996:Ch. 6). The arguments from welfare economics for public funding of health care are persuasive when applied to reproductive health, but even so, private sector funding will also have to be mobilized to achieve these goals in most countries.

Lastly, the rationale for public funding of services is not to be confused with an argument for public provision of services, still less for provision by large centralized public-sector bureaucracies. The most effective organizational forms for delivering services will vary considerably, depending on the existing institutional infrastructure. A good deal of empirical evidence will be needed to test alternative ways to deliver on the promises of the reproductive health approach.



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