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									Findings from National Health Accounts:
    Investing in Reproductive Health


                              Tania Dmytraczenko
                       Senior Health Economist, PHRplus


                  Global Health Council Conference
                            1 June 2005

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
Acknowledgements


   Egypt
       Driss Zine Eddine El Idrissi
       Samir Fouad
       Manjiri Bhawalker
       Osmat Azzam
   Jordan
       Fatina Halawani
       Patricia Hernandez
   Rwanda
       Susna De
       Emmanuel Kabanda
       Vianney Nizeyimana
Outline


 Background


 Method


 Results


 Next   steps
Background
Background

Achieving the Millennium
Development Goals

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

 Managing   for results
Background


“We manage what we measure”

   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
Method
Definition of reproductive health
expenditures

   Family planning services
       Outpatient counseling and issuance of contraceptive
        commodities
       Female and male surgical sterilization
       Retail sale of family planning commodities
   Maternal health services
       Antenatal care
       Deliveries
       Emergency obstetric care
       Postnatal care
Definition of reproductive health
expenditures (continued)

   Other reproductive health services
       STI
       RTI
       Gynecological services
       Oncology
       Infertility
   IEC, public awareness, health education
    campaigns
   Training
   Research
Method

Reproductive Health Accounts:
Countries covered

                           Egypt            Jordan         Rwanda
Years                              2002           2001        2002
                                   1995           2000        2000
                                   1991           1998        1998
General NHA                                                    

RH subanalysis              preliminary                        
                                   (2002)   (2001, 2000)      (2002)

HIV/AIDS subanalysis                                             

   Ongoing in Mexico, Karnataka (India)
   Bangladesh, Nepal, Sri Lanka, India (2 states)
Results
Reproductive health results


Reproductive 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             53.9%       41.2%        4%
 birth control method
 Use of antenatal care (% of births)            52.9%       98.6%       92%

 % of births delivered in a health care         48.2%       96.9%       27%
 facility
 % 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%

*subsequent to discharge
Source: DHS 2000, 2002
Reproductive health results

Reproductive health within context of
general health care
      RH spending as a percentage of total health expenditures


        Rwanda                               Jordan
   RH expenditures = USD $10.9M        RH expenditures = USD $127.6M
        15.7%     or $5.31 / WRA            15.3%    or $98.14 / WRA




                     Total Health                    Total Health
                    Expenditures                    Expenditures
    Reproductive health results

    Where do reproductive health dollars
    come from?

   Rwanda                         Egypt                               Jordan
       Other private                                         Other private
                                  Other private
           2% Households              2%                         11%              Households
Public
                     10%                                                             46%
 8%

                                                    Households
                        Public                         45%
                         50%


                                                                 Public
                                                                  38%        Donors
       Donors                              Donors
                                             3%                                5%
        80%

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

Public versus donor priorities in
resource allocation
               Rwanda             Egypt        Jordan
              4%       37%       6%    12%    16%    17%
    100%
     90%
     80%
     70%
     60%
     50%
     40%
     30%
     20%
     10%
      0%
            Public    Donor    Public Donor Public   Donor
                              RH General health
Donor funding is concentrated on RH and HIV/AIDS in Rwanda
    Reproductive health results

    Who is managing reproductive
    health funds?

           Rwanda                                     Jordan
                                                         NGOS
                                                         3.6%
      NGOs
                                      Household OOP
      35.8%                                                           Public entities
                                          39.6%
                                                                         45.7%


                                  Public entities
                                     51.8%

Household OOP
    10.0%         Other private
                                                      Other private
                      2.4%
                                                         11.1%

  Public entities are the largest payer / purchaser of RH
Reproductive health results

Who is financing reproductive health
expenditures by public entities?
Origin of funds managed by public entities in Rwanda

                                                                                     Donor sources
General health       25%                                                             Public sources




           RH        85%


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

                                          USD (in '000)

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


                        What types of RH services are being
                        funded and by whom in Rwanda?
                       70%                                    2002                    Public Sources
                                                        6%
                       60%                                                            Donors (incl. NGOs)
                                                                                      Households
% of THE for HIV/ADS




                       50%                                                            Private Companies

                       40%

                       30%                              60%


                       20%
                                        1%
                                        6%
                       10%
                                        8%                                 1%
                                       2%                                   2%                6%              6%
                       0%
                             Curative Care   Prevention and     Pharmaceuticals       Health        Other (6% )
                                (18% )        public health        and other       administration
                                                 (66% )        nondurables (3% )       (7% )



                       Households finance half of all curative care while donor funds go
                       principally towards prevention programs
Reproductive health results

Breakdown by RH categories in
Rwanda
                                  2002
                            Other (NSK)
                                6%        Maternal health
           Administration
                                               15%
               7%


                                               FP commodities and
                                                   consultation
                                                       6%




        Prevention and public
         health programs on
            MCH and FP
                 66%
Reproductive health results : maternal health

Deliveries


      Expenditure/ delivery in a facility         $7.59

      Number of deliveries in a facility         99,201
      Number of deliveries at home              268,210


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

Breakdown of expenditures by
method mix
                                                          Households
      40%                           2002
                                                          Donors via NGO
      35%                                                 Donors via MoH

      30%
                                                 12%
      25%          16%             22%
      20%

      15%          3%
                                                 18%
      10%
                   13%             12%
        5%
                                                  3%
        0%
               Injectables         Oral         Condoms
                              contraceptives
 Reproductive health results : family planning

 Utilization vs OOP expenditure on
 commodities
              100                                    1
                                                                   6           5             6
                       10                12
               90                                17
                                                                                                  Other Providers
               80
                                                                                                  Private Providers
               70                                                                                 Public Providers
% of           60
use/OOP                                                                    78
               50                        72                        87
expenditure                                                                                  94
for each FP            90
               40                                82
commodity
               30
               20
               10                        15                                17
                                                                   7
                0
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                                               Oral
                      Injectables                                          Condoms
                                               Contraceptives
Reproductive health results : family planning

Utilization of commodities by
quintile
    100

     90

     80

     70              63.6                                    Highest Quintile
                                    73.3
     60                                              83.1
                                                             Fourth Quintile
                                                             Third Quintile
     50
                                                             Second Quintile
     40                                                      Lowest Quintile

     30              17.4
                                     10
     20
                     10.7             5              5.6
     10                                              8.5
                     6.6             10

      0              1.7             1.7             2.8

               Injectables   Oral contraceptives   Condoms
          DHS 2000
Reproductive health results

Conclusion of RH subanalysis

   Dependence on donors to finance RH

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

   Households contribute close to half of all
    curative RH expenditures
        Donor expenditures are primarily targeted for
         prevention and public health programs
    Reproductive health results

    Conclusion (cont’d)

   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 services

   Financial 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)
   Thank You



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




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

								
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