Findings from National Health Accounts Investing in Reproductive

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

Outline p Background p Method p Results p Next steps

Background

Background Achieving the Millennium Development Goals p Addressing the principles causes of the burden of disease Maternal health indicators p Reproductive health (RH) more broadly p p Managing for results

Background “We manage what we measure” p Support sound policy decisions by tracking: p p 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? r Hospitals vs. ambulatory care facilities r Curative care vs. prevention programs Who benefits from spending for RH? r Socio-economic groups r Gender r Geographic distribution

Method

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

Definition of reproductive health expenditures (continued) p Other reproductive health services p p p STI RTI Gynecological services Oncology Infertility IEC, public awareness, health education campaigns p Training p Research p

Method Reproductive Health Accounts: Countries covered Egypt Years Jordan Rwanda RH subanalysis 2001 2000 1998 2002 2000 1998 preliminary (2002) General NHA 2002 1995 1991 (2001, 2000) (2002) HIV/AIDS subanalysis p Ongoing in Mexico, Karnataka (India) p 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 birth control method 53. 9% 41. 2% 4% Use of antenatal care (% of births) 52. 9% 98. 6% 92% % of births delivered in a health care facility 48. 2% 96. 9% 27% % 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 = USD $10. 9 M or $5. 31 / WRA Total Health Expenditures Jordan = USD $127. 6 M or $98. 14 / WRA Total Health Expenditures

Reproductive health results Where do reproductive health dollars come from? Rwanda Egypt Jordan 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 4% 37% Egypt 6% 12% Jordan 16% 17% Donor funding is concentrated on RH and HIV/AIDS in Rwanda

Reproductive health results Who is managing reproductive health funds? Rwanda Jordan 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 25% 85% 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? % of THE for HIV/ADS 2002 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

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 % of FP commodity expenditure 2002

Reproductive health results : family planning Utilization vs OOP expenditure on commodities % of use/OOP expenditure for each FP commodity Injectables Oral Contraceptives Condoms

Reproductive health results : family planning Utilization of commodities by quintile DHS 2000

Reproductive health results Conclusion of RH subanalysis p Dependence on donors to finance RH p Low government contribution to RH p In fact, households finance more than the government p Households contribute close to half of all curative RH expenditures p Donor expenditures are primarily targeted for prevention and public health programs

Reproductive health results Conclusion (cont’d) p Optimal mix of spending on curative versus prevention? p p Curative = 18% of total RH expenditures Prevention and public health programs = 66% of total RH exp p Little is being spent on maternal health care services p Financial burden on households p Households pay to obtain donated contraceptives given to the government r r p 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 r r 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