ceptives through commercial outlets in all 27 Indonesian provinces. In 1992 the Gold Circle program was begun to include a wider range of contraceptive supplies and services. While these programs have been growing, another program has also been in place, providing free contraceptive supplies for distribution by doctors and midwives working on their own account and in-kind subsidies of other sorts to private clinics and providers. Other policy changes include encouraging large employers to include family planning among health services provided by their company clinics and creating the legal structure for prepaid health care plans that would offer family planning. In the public sector, there is some recovery of costs from clients: the 1991 Demographic and Health Survey showed that 42 percent of clients paid something for public-sector services.

Thailand provides a useful example of successful efforts to make a program both equitable and sustainable on several dimensions. The Thai program received a great deal of foreign assistance in the 1970s and early 1980s, but this aid was phased out and replaced by Thai government funds during the 1980s. The rapid increase of government funds to replace what had previously been given by donors allowed continued rapid expansion of the program, so that contraceptive use is now common even among the poor and uneducated. The program charged fees for pills, IUDs, and sterilization during its early years (1970-1976), when family planning users were typically women of higher socioeconomic status (OPTIONS Project, 1994: 9; Knodel et al., 1984). In 1976, fees were eliminated for most services and most clients in public-sector outlets, although urban women in particular were still most likely to pay something for pills. Many urban women obtain supplies from private-sector outlets, perhaps because of differences in waiting time or perceived differences in quality of attendant services. This demonstrates that Thais are willing to pay for family planning and could serve as an example of rationing subsidized supplies and services by allowing the private sector to meet the demand of those to whom convenience matters more (although many would also argue that public-sector managers would need to be sure that poor quality and excessive waiting times are not driving clients away). In the public sector, fees have been charged in such a way as to provide the heaviest subsidy to the methods deemed most cost-effective from the program's point of view, namely IUD insertions and sterilization, although it is not clear that this was done on efficiency or equity grounds or both (Sanderson and Tan, 1992).

CONCLUSION

The case studies presented in detail, as well as other cases discussed in more cursory fashion during the meeting, gave grounds for cautious optimism about the ability of family planning programs to adapt to a new environment by changing the mix of subsidies for family planning and related health services and by lowering average levels of subsidy. Many programs have already adapted in different ways, moving from fees to universal free services and back to partial



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Resource Allocation for Family Planning in Developing Countries: Report of a Meeting ceptives through commercial outlets in all 27 Indonesian provinces. In 1992 the Gold Circle program was begun to include a wider range of contraceptive supplies and services. While these programs have been growing, another program has also been in place, providing free contraceptive supplies for distribution by doctors and midwives working on their own account and in-kind subsidies of other sorts to private clinics and providers. Other policy changes include encouraging large employers to include family planning among health services provided by their company clinics and creating the legal structure for prepaid health care plans that would offer family planning. In the public sector, there is some recovery of costs from clients: the 1991 Demographic and Health Survey showed that 42 percent of clients paid something for public-sector services. Thailand provides a useful example of successful efforts to make a program both equitable and sustainable on several dimensions. The Thai program received a great deal of foreign assistance in the 1970s and early 1980s, but this aid was phased out and replaced by Thai government funds during the 1980s. The rapid increase of government funds to replace what had previously been given by donors allowed continued rapid expansion of the program, so that contraceptive use is now common even among the poor and uneducated. The program charged fees for pills, IUDs, and sterilization during its early years (1970-1976), when family planning users were typically women of higher socioeconomic status (OPTIONS Project, 1994: 9; Knodel et al., 1984). In 1976, fees were eliminated for most services and most clients in public-sector outlets, although urban women in particular were still most likely to pay something for pills. Many urban women obtain supplies from private-sector outlets, perhaps because of differences in waiting time or perceived differences in quality of attendant services. This demonstrates that Thais are willing to pay for family planning and could serve as an example of rationing subsidized supplies and services by allowing the private sector to meet the demand of those to whom convenience matters more (although many would also argue that public-sector managers would need to be sure that poor quality and excessive waiting times are not driving clients away). In the public sector, fees have been charged in such a way as to provide the heaviest subsidy to the methods deemed most cost-effective from the program's point of view, namely IUD insertions and sterilization, although it is not clear that this was done on efficiency or equity grounds or both (Sanderson and Tan, 1992). CONCLUSION The case studies presented in detail, as well as other cases discussed in more cursory fashion during the meeting, gave grounds for cautious optimism about the ability of family planning programs to adapt to a new environment by changing the mix of subsidies for family planning and related health services and by lowering average levels of subsidy. Many programs have already adapted in different ways, moving from fees to universal free services and back to partial

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Resource Allocation for Family Planning in Developing Countries: Report of a Meeting fees again, or encouraging private-sector participation in varying degrees. Thailand provides an encouraging example of a program surviving very well the rapid decrease of foreign assistance in a short period of time. The crucial question is the extent to which that success can be replicated in part in countries with lower rates of growth of incomes and public revenue. All the countries studied appear to have managed to operate mixed systems for long periods of time; this suggests that public versus private sector and free care versus full cost recovery need not be all-or-nothing choices. There is an increasing amount of research useful for examining the differential impact on the poor of reduced subsidies. In the middle-income Asian countries best studied (Indonesia and the Philippines), the effects of higher prices on the use of contraceptives by the poor are discernible, but not large. These relatively small price effects could explain the apparent lack of acrimony in donor-government discussions of family planning financing and its lack of salience in domestic political discussion, especially compared with the high-stakes debates over the financing of curative health care. Targeting family planning subsidies more to the rural poor seems to be feasible and could mitigate the impact of efforts to increase the revenue from clients. One attractive option for reducing the required levels of subsidy is to reduce costs through improved management, the scope for which has not been sufficiently explored. The Programme of Action of the 1994 International Conference on Population and Development urges that the governments of developing countries themselves take responsibility for keeping this subject at the fore: “Recipient countries should ensure that international assistance for population and development activities is used effectively . . . so as to assist donors to secure commitment to further resources for programmes” (United Nations, 1994: para. 14.12). Increasing efficiency may not be an alternative to raising more funds for the sector, but rather a prerequisite for doing so. Finally, participants noted many instances in which data are simply insufficient to answer questions of great policy importance. Gaps that are worth more attention from implementing agencies and research funders include the lack of micro-level, preferably longitudinal data for estimating program impacts, and the lack of facility-level cost data. Many of the crucial questions now facing policy makers in family planning involve joint consideration of what will happen to program costs, service quality, and contraceptive use if various changes are made to reduce average subsidies, and analysts are not confident about their ability to make precise estimates of either costs or effectiveness.