Unlike the situation with food or medical care subsidies, the amounts of money involved in reducing subsidies for family planning would be relatively small, even as proportions of the spending of poor people. But providers in many countries, particularly the medical profession, are politically influential organized groups whose interests would either be threatened or advanced by any major reforms. Susan Cochrane gave the example of Japan, where organized physicians managed to keep a ban on hormonal contraception, ostensibly because of safety concerns, but probably also because of financial incentives encouraging them to perform abortions. If Japanese women had more political influence, the range of contraceptive methods practically available would likely be wider.

The literature on sectoral reform mainly includes ex post studies describing how various interests defeated or transformed new policies. Reich has been working on guidelines for ex ante political assessment of reform proposals, to help in the design stage, both for local governments in the United States and for governments of developing countries (Reich, 1994b).

IMPLEMENTATION OF REFORMS TO INCREASE FINANCIAL SUSTAINABILITY

Perhaps the most effective way to devise a strategy for sustainability is to study the experience of programs that have had to adjust to reductions or withdrawals of foreign assistance to the population sector. “Sustainability” is usually defined to include aspects of institutional self-sufficiency not discussed at length at this meeting. But much of the anxiety propelling the research on sustainability comes from considerations of the need to decrease costs or transfer the burden of family planning subsidies.

John Ross argued that aid donors should avoid monolithic strategies for promoting financial sustainability in countries with very different levels of program maturity and administrative traditions. Many African countries, among the world's poorest and with very new family planning programs, will need large amounts of assistance for some years. In other countries, such as Colombia, there have been interesting local experiments on which any future strategy can build. In the Philippines and Kenya, there are major drives to decentralize administration and policy making; family planning programs could usefully follow along.

Three case studies were presented in the meeting, one by Ojeda, concerning an affiliate of the International Planned Parenthood Federation, PROFAMILIA in Colombia, in a context of declining foreign assistance; another by Tsai, concerning the national family planning program of Taiwan, in a context of rapid economic growth and increasing public expenditure. Ratna Tjaja discussed the experience of the National Family Planning Board (BKKBN) in Indonesia, which has made a major effort to involve private-sector providers and transfer some responsibility for resources to communities in a mature national program that has offered universally subsidized services. All three national programs have had to



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OCR for page 19
Resource Allocation for Family Planning in Developing Countries: Report of a Meeting Unlike the situation with food or medical care subsidies, the amounts of money involved in reducing subsidies for family planning would be relatively small, even as proportions of the spending of poor people. But providers in many countries, particularly the medical profession, are politically influential organized groups whose interests would either be threatened or advanced by any major reforms. Susan Cochrane gave the example of Japan, where organized physicians managed to keep a ban on hormonal contraception, ostensibly because of safety concerns, but probably also because of financial incentives encouraging them to perform abortions. If Japanese women had more political influence, the range of contraceptive methods practically available would likely be wider. The literature on sectoral reform mainly includes ex post studies describing how various interests defeated or transformed new policies. Reich has been working on guidelines for ex ante political assessment of reform proposals, to help in the design stage, both for local governments in the United States and for governments of developing countries (Reich, 1994b). IMPLEMENTATION OF REFORMS TO INCREASE FINANCIAL SUSTAINABILITY Perhaps the most effective way to devise a strategy for sustainability is to study the experience of programs that have had to adjust to reductions or withdrawals of foreign assistance to the population sector. “Sustainability” is usually defined to include aspects of institutional self-sufficiency not discussed at length at this meeting. But much of the anxiety propelling the research on sustainability comes from considerations of the need to decrease costs or transfer the burden of family planning subsidies. John Ross argued that aid donors should avoid monolithic strategies for promoting financial sustainability in countries with very different levels of program maturity and administrative traditions. Many African countries, among the world's poorest and with very new family planning programs, will need large amounts of assistance for some years. In other countries, such as Colombia, there have been interesting local experiments on which any future strategy can build. In the Philippines and Kenya, there are major drives to decentralize administration and policy making; family planning programs could usefully follow along. Three case studies were presented in the meeting, one by Ojeda, concerning an affiliate of the International Planned Parenthood Federation, PROFAMILIA in Colombia, in a context of declining foreign assistance; another by Tsai, concerning the national family planning program of Taiwan, in a context of rapid economic growth and increasing public expenditure. Ratna Tjaja discussed the experience of the National Family Planning Board (BKKBN) in Indonesia, which has made a major effort to involve private-sector providers and transfer some responsibility for resources to communities in a mature national program that has offered universally subsidized services. All three national programs have had to

OCR for page 19
Resource Allocation for Family Planning in Developing Countries: Report of a Meeting deal with issues of financial sustainability of family planning programs, balanced against concerns about access to services and the quality of services. Ruth Levine presented case studies prepared for the OPTIONS project, comparing results of an evaluation of sustainability of the Thailand National Family Planning Program with those of studies of Indonesia and Colombia (OPTIONS Project, 1994). The experience of the family planning program in Taiwan gave an encouraging glimpse of possibilities for programs currently sustained by large amounts of foreign assistance. The program in Taiwan was designed from the outset without expectation of much foreign assistance or local allocations for a separate free-standing system. The health care infrastructure and personnel were used for family planning; the conflict between health and family planning, which has been solved in so many countries by duplication of facilities and organizations, was considered simply unaffordable. User fees, albeit small ones, were charged from the beginning, so clients were familiar with the idea and providers had experience in implementing sliding-scale fees. With assistance from the Population Council, a considerable effort was made in program experimentation, leading to such changes as a coupon system for contraceptive supplies and involvement of private physicians that probably improved cost-effectiveness (see also Cernada, 1982). Satia pointed out that few programs had responded to the external pressure caused by reduced assistance from foreign donors with a balanced plan, involving elements of both user fees, the generation of new local resources, and cost reduction. Ojeda presented plans and early results of the efforts of PROFAMILIA to implement such a balanced approach. One of PROFAMILIA's strategies is to raise funds by “diversification,” by which they mean offering valued clinical services at fees high enough to cover costs and generate cross-subsidies for contraceptive services. The examples included Pap smears, sonography, pregnancy testing, and other reproductive health and general medical services. This option would have to be considered in light of a country's overall plans for reproductive health services and rationales for public financing of health care, since it could well be that some of these services should themselves be offered at subsidized rates. Tjaja gave an overview of Indonesia's policy of KB Mandiri, meaning self-reliance in family planning, adopted in 1987. At the national level, the Indonesian government estimates that its funds already cover between 80 and 90 percent of the cost of the family planning program. Self-reliance is supposed to be manifested at the household and community as well as national levels. The aim is to differentiate between households able to pay for services themselves, those that still require partial subsidy, and poor households for whom family planning services should continue to be free of charge. One long-term goal is to increase private-sector provision of contraceptives to 50 percent by the year 2000. The Blue Circle social marketing program initiated in 1987 promotes sales of contra-