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Resource Allocation for Family Planning in Developing Countries: Report of a Meeting ECONOMIES OF SCALE One of the crucial questions facing family planning strategists concerns economies or diseconomies of scale in their operations. As the number of clients doubles in a decade or so, which costs will more than double and which will increase less than proportionally, and by how much will overall costs increase? Existing global estimates and projections such as those prepared for the International Conference on Population and Development were based on projections of numbers of users multiplied by estimates of current average expenditures per user; linearity is assumed. These suffice for their purpose, giving targets for global mobilization of resources for the Programme of Action, but they would not necessarily be useful for decisions about how best to allocate resources within a country among regions or across programs or services or groups of clients. Most existing cost studies average across clinics of different sizes or catchment areas of varying size and density of community-based distribution programs. They deal only with program operations at one time, with fixed amounts of administration, efforts at information, education, and communication, and so forth. As a result, individual studies cannot give much idea of how scale affects overall costs and particular elements of cost. Variations in costing methods and cost categories, as well as the paucity of comparable studies, make it very difficult to draw inferences on these points from comparisons across settings (Janowitz and Bratt, 1992). There are several time-series/area-level studies showing diminishing returns (in terms of fertility reduction) to intensified programs in Taiwan, Colombia, and Thailand (Schultz, 1974, 1988, 1992; Rosenzweig and Schultz, 1982). Judith Bruce has called attention to the inefficiencies inherent in current underutilization of trained providers and clinics in recently established programs in Africa and Latin America, as shown in data from the Population Council's situation analyses. There may not be a trade-off between improving the quality of services and expanding access to services, if expensive facilities and trained providers are underutilized because of remediable problems with the technical quality of services or the way clients are treated. DIVISION OF LABOR BETWEEN PUBLIC AND PRIVATE SECTORS The distinction between provision and financing of services was highlighted by Dean Jamison. Most public-sector financing of services is based on public health arguments for services for all or for the poor; whether the organizations delivering services ought to be public-or private-sector ones is a subsequent decision to be based on comparative advantages and traditions. Rodolfo Bulatao illustrated the wide variations among countries in the size and types of private organizations and practitioners providing family planning services and supplies.
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