C H A P T E R   5
Finding the Resources

The consensus of governments and civil society alike is that ensuring access to health is primarily a public sector concern. At the same time, there is a discussion about the place of the private sector.

The ICPD Programme of Action recognizes that providing reproductive health services necessarily requires a partnership in which many institutions must participate. Assigning appropriate roles to different public and private sources, either as providers or as financiers of reproductive health services, is a matter for both principled debate and practical experimentation.11

Who Pays: How Should We Decide?
The World Bank estimates that less-developed countries not only spend less on health than higher-income countries, but often fund a smaller proportion of their health expenditure through public financing.

Recent studies of national health accounts in the Philippines 12 and Bangladesh 13 have confirmed that private out-of-pocket expenditures for reproductive health are larger than previously recognized and can exceed public expenditures. Much health expenditure, public or private, goes to curative care; if money is needed in a medical crisis, people do whatever they can to find it. Reproductive health care on the other hand is largely preventive so there is less willingness to pay for it, and family planning prevents not disease but pregnancy.

Reliance on private resources for reproductive health services varies considerably. In such countries as Brazil and Colombia, for example, non-governmental organizations play a major role in reproductive health service delivery. In other Latin American countries, state involvement is limited by cultural and political considerations, or the private sector is preferred. More than half of all health expenditures in Latin America may be financed from private allocations,14 and the proportion of reproductive health care privately financed is probably even larger. In Africa and in many Asian countries, the state is a major provider of services.15

The arguments for government and official donor funding of reproductive health services, and other development strategies of the Programme of Action, are fundamental.16 Governments and donors should subsidize:

• Services to which society believes each individual should have access regardless of their ability to pay;

• Activities to benefit not only the individual but society as a whole;

• Services the private sector has little or no incentive to provide;

• Services that help reduce poverty. Finding the Resources

TABLE 2
Public and Private Health Expenditure 17

Source: The World Bank 1999. World Development Indicators 1999.
Washington D.C.: The World Bank.

The first of these arguments is based on principles of equity and rights. The right to health, the right to non-discrimination with regard to gender, and the right to choose the number and spacing of one’s children are basic parts of existing human rights.18 The second recognizes general benefits to society. These include, for example: reduced social impact of sexually transmitted diseases; lower public costs as the result of population growth and associated environ-mental degradation; and faster development as the result of the increased participation of women.

The third justifies investments in reproductive health service regulation and monitoring, testing, research and development. It also justifies support for information on reproductive health, which can help generate demand that can allow private-sector approaches to develop. However, the Programme of Action leaves it up to countries to decide the principles for allocating responsibilities to different actors. Similarly, the importance of a comprehensive set of integrated services is clearly stated but no blueprint is provided. This approach recognizes national priorities and provides a place for local inputs, capacities, perspectives, values and ingenuity.

The final argument recognizes the special susceptibility of the poor to ill-health and unwanted pregnancy, which makes it more difficult for poor people to escape poverty.

Making Sure Reproductive Health Services Reach the Poor
For many, the logical approach would be to ask those who can to pay, and to provide public services only to the poor. However, such a restriction risks undermining political support: if only the poor benefit from a programme, decision makers may reduce budgetary provision for it, particularly in the context of shrinking government budgets.19

It is difficult, moreover, to direct public inputs successfully. Political pressures bias services in favour of elite or urban populations, which accounts for the large share of health budgets going to city hospitals. Even without such pressures, the better-educated and better-off are better informed and more confident in dealing with public bureaucracies. Poor and marginalized people get little attention from public servants.

Public money can be saved if those who are able to pay do so, either through being shifted to private providers or by paying fees for public service. However, setting maximum income levels and administering means tests for service recipients is politically risky, time-consuming, and may cost more than it saves.

Evidence about service use by different population groups is clearer in family planning than in other areas of reproductive health care. Studies in Viet Nam, the Philippines and Indonesia show that the poorest fifth of the population receives about 15 per cent of the service benefits from public investment in family planning, and the poorest two fifths nearly 36 per cent—less in each case than their share of the population.

Increased reliance on the private sector must not deprive
the poor of health services.

However, the poorest fifth get less than 9 per cent of national income, and the poorest two fifths get only 22 per cent; so that when compared to income distribution, family planning subsidies do transfer resources to the poor. Also, a large share of the health benefits going to higher income groups are accounted for by their disproportionate use of more costly hospital providers. Charging for these services would further help to direct public benefits to poorer people.

In Mexico, NGOs have had better success than the government programme in directing services to the poor because they can select their target population. The clients of FEMAP (Federación Mexicana de Asociaciones Privadas de Salud y Desarrollo Comunitario, AC), for example, include a higher proportion of poor people on the urban fringes than do government programmes.20

Drawing more revenue from those able to pay for use of higher-cost services, and working with NGOs and the private sector to reach selected populations, can improve the effectiveness of public services and provide the resources for improvements in quality — for example, for training staff to provide better service.

Many analysts have recommended increased reliance on the private sector for the most efficient delivery of reproductive health services. The challenge is to do this without depriving the many people in developing countries who cannot pay. A successful shift calls for more, not less, investment in reproductive health, to test different options for service delivery and finance and understand their impacts on quality and equity. It means more, not less, need for external resources to provide specialized technical assistance.

The donor community must accept its responsibility and remember their own systems of subsidized care and the development of their own public/private balance. Private initiatives are important but not at the expense of services for the poor. Faster development and improvements in health depend on greater access to services.

At the same time, communities are able and willing to share risks and costs to improve reproductive health services. One project in the Philippines has started a social insurance system to share the considerable costs of emergency obstetric care for the one pregnancy in 10 in which complications occur. An insurance scheme would cost $2.48 per insured pregnancy, but the expected economic benefit of the scheme would be nearly twice these costs.21 Direct beneficiaries must still find part of the true costs, which remains a heavy burden on the poorest; but individuals and families are willing to do whatever is needed to find the money for life-saving care, and the scheme lowers the cost for all.

In Nepal, some communities have also pooled their resources to finance emergency transportation for obstetric care.22 Combined with education for husbands in the risks, in the danger signs of complications and in support of prompt care, emergency referral can save many women’s lives.

Community contributions may also take the form of repair, maintenance and general upkeep. Communities can often provide materials or construction to supplement public provision of staff and salaries.

Fees for service can help maintain programmes, but there is a question—do fees reduce access and discourage use of health services? The evidence is mixed: some studies have found that service use falls off when fees are first imposed, but may recover over time. Some studies show that fees are more acceptable when a part is directed towards improvements in service quality, and may be followed by increased service use.23

Conclusion

Despite tight resources and other constraints, both developed and developing countries have built new partnerships among governments and civil society for population and development, created integrated programmes for sexual and reproductive health, and advanced the empowerment of women. This progress shows that the ICPD goals are seen as necessary and practical.

In an age of globalization, providing basic social services is a global responsibility. The alternative to assistance for long-term investment in development, including population, is the increasing likelihood of social breakdown and an increasing demand for short-term relief. Addressing the effects of social breakdown will save lives, but addressing the causes will allow people, and nations, to build lives of their own.

| MAIN MENU | CONTENTS | NEXT |

For more information:
United Nations Population Fund
Information and External Relations Division
220 E. 42nd Street, New York, NY 10017, U.S.A.
Tel. 212-297-5020; fax: 212-557-6416
E-mail: ryanw@unfpa.org. Web site: www.unfpa.org