Global Resources Required to Expand Family Planning Services in Low- and Middle-Income Countries John Stover, Eva Weissman, September 2010 John Ross
Purpose and Approach Purpose To understand the resources needed to expand family planning services and the sources of funding Approach Estimate unit costs for each method Project numbers of FP users by method Add program support costs
Unit Costs: Literature Review Much of our information on the unit costs of family planning is quite old. Most studies from Bangladesh, Guatemala, Kenya, the Philippines, and Zambia.
Estimates of Cost per CYP Lit Review: Weissman, E. 2007. Cost of Family Planning Literature Review. USAID Health Policy Initiative. UNFPA: As reported in Vlassoff, M. et al. 2004. Assessing the Costs and Benefits of Sexual and Reproductive Health Interventions. New York: Alan Guttmacher Institute.
New Data Collection Efforts The USAID Health Policy Initiative, Task Order 1 conducted a unit cost study in Ethiopia, Jordan, Kenya, and Mali in 2009. Marie Stopes International is currently undertaking a costing study on its services in Ethiopia, Pakistan, and Uganda. DKT continues to update its costs per CYP.
Country-level Costs The following results are from the Health Policy Initiative s four-country study: Ethiopia Jordan Kenya Mali
Commodity costs are similar except for Jordan Ethiopia Mali Kenya Jordan Comments Pill $3.99 $4.57 $4.28 $13.29 13 cycles Condom $4.68 $6.00 $4.68 $2.48 100 condoms Injectable $3.93 $4.46 $4.50 $3.49 4 injections IUD $0.55 $1.15 $0.83 $4.99 IUD + supplies for insertion and removal Implant $26.10 $34.36 $37.51 Implant + supplies for insertion and removal Sterilization $22.40 $22.40 $22.40 $31.70 Drugs and supplies for procedure $40 $35 $30 $25 $20 $15 $10 $5 $0 Commodity Cost Ethiopia Mali Kenya Jordan Pill Condom Injectable IUD Implant Sterilization
Personnel costs vary with salary and type of worker delivering service Average annual salaries differ by personnel type and country but, more importantly, the type of personnel delivering services varies by county. As a result, the personnel costs per user per year are lowest in Ethiopia and highest in Jordan. $80.00 Ethiopia Mali Kenya Jordan Physician $3,000 $21,500 $12,000 Clinical Officer $7,500 Midwife $1,800 $7,000 Nurse $880 $1,200 $6,500 Health Extension Worker $640 Ethiopia Mali Kenya Jordan Pill $0.72 $1.90 $3.42 $11.55 Condom $0.88 $1.91 $8.27 Injectable $1.29 $2.50 $3.86 $8.71 IUD $0.67 $2.77 $3.21 $15.09 Implant $26.11 $35.81 $36.69 Female Sterilization $26.85 $36.19 $72.08 Government Health Facility - Initial Visit $70.00 $60.00 $50.00 $40.00 Ethiopia Mali Kenya Jordan $30.00 $20.00 $10.00 $0.00 Pill Condom Injectable IUD Implant Sterilization
Direct costs per CYP vary substantially across countries Results from four-country study conducted by USAID Health Policy Initiative, Task Order 1, 2009
Direct costs per CYP from this study are similar to other results Health Policy Initiative: Ethiopia, Mali, Kenya, and Jordan: Four Country Study, 2009 Guttmacher: Vlassoff, M. et al. 2004. Assessing Costs and Benefits of Sexual and RH Interventions. FHI: Ligation, Excision, Occlusion, Oh My! March 28, 2010.
Factors affecting unit costs Level of development Higher incomes = higher wages = higher service delivery cost Source of commodities Donated commodities may be less expensive than selfpurchase Who delivers service Community health worker, midwife, nurse, physician
Overhead Costs Include facility costs, transportation, maintenance, supervision, training, administration, slack time May be the largest component of total costs May be more important to average cost than to marginal cost, particularly for government services Method Overhead Pills 82% Injections 77% IUD 72% Female Ster. 23% Condom 50% Source: Vlassoff, M. et al. 2004. Assessing Costs and Benefits of Sexual and Reproductive Health Interventions. New York: Alan Guttmacher Institute.
There are many barriers to family planning expansion Jordan Kenya Mali Ethiopia Solutions Source Commodities Lack of funding x Increase donor awareness Health Policy Initiative Poor logistics x x x Strengthen logistics system DELIVER Human Resources Lack of trained staff x x x Provider training Capacity/RESPOND High turnover x Health Policy Initiative Lack of female physicians x Regulations, personnel policies Health Policy Initiative Poor provider attitudes x Training Capacity/RESPOND Physical access Lack of rural access x x x Expansion of CBD and outreach programs PATHFINDER Demand side Rumors and misconceptions x x x x IEC/Research C-Change/FRONTIERS Male attitudes x IEC/Research Cultural and religious barriers x x x IEC/Research Side effects/discontinuation x Provider training Capacity/RESPOND
Support activities can address barriers to use Support Activities Barriers Policy and advocacy Stockouts Evaluation Lack of funding Logistics Lack of trained staff Communication Negative provider attitudes Research Lack of rural access Training Rumors and misconceptions Discontinuation
Typical annual support costs estimated by USAIDsupported projects Function Typical Annual Cost Project Policy $1,500,000 Health Policy Initiative Training $800,000 Access FP, Capacity Plus Research (OR) $700,000 PROGRESS, CRTU Research (DHS) $150,000 MEASURE DHS Management $700,000 Leadership, Management and Sustainability Logistics $1,000,000 - $3,500,000 DELIVER Communication $1,400,000 C-Change M&E $150,000 MEASURE Evaluation TOTAL $6,400,000 - $9,900,000
Methods for Global Cost Estimates Estimates made for each of 134 low- and middle- income countries; 59 depend on donors for more than 10% of commodity needs Women of reproductive age (WRA) from UN Population Division Estimates and Projections Contraceptive prevalence rate (CPR) linearly interpolated from latest value to current CPR + unmet need by 2015, constant to 2020 These estimates result in close to 150 million new modern method users between 2008 and 2015, the proposed MDG-5b target Method mix evolves from current mix to international pattern as TFR drops to replacement level Number of modern method users = WRA x CPR x Method Mix
Historical rates of increase in modern method CPR have averaged just under 1 percentage point per year but annual growth of 2.0-2.3 percentage points per year will be needed to meet the proposed goal for MDG 5b.
Evolution of method mix by method 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 Trad Mster Fster Condom VFT IUD Injection Pill CPR Key: IUD = intrauterine device, VFT = vaginal foaming tablets, Fster = female sterilization, Mster = vasectomy, Trad = traditional methods
Evolution of method mix by type of method Key: LAPM = long=acting and permanent methods, Trad = traditional methods
Assumptions on sources of funding Donor funding includes Commodity costs in donor-dependent countries for public sector clients NGO service delivery and overhead costs in donordependent countries Program support costs in countries with CPR < 50% 50 dropping to 30 Government and out-of-pocket funding includes Service delivery and overhead costs in donor-dependent countries All commodity, service delivery, and overhead costs in nondonor-dependent countries
Assumptions for global estimate Method Commodity Cost Service Delivery Cost Pills $0.212 $2.31 82% Injections $0.866 $2.13 77% IUD $0.368 $3.69 72% Female Ster. $9.090 $29.81 23% Male Ster. $4.950 $29.81 23% Condom $0.025 $4.49 50% Implant $5-20 $3.69 72% Overhead Commodity cost: average of UNFPA and USAID costs Service delivery cost: based on Health Policy Initiative four-country study and Vlassoff, M. et al. 2004. Assessing Costs and Benefits of Sexual and Reproductive Health Interventions. Overhead: Vlassoff, M. et al. 2004. Assessing Costs and Benefits of Sexual and Reproductive Health Interventions.
Total Costs of Family Planning Services to Meet Need 800,000 Modern Method Users by Method to Meet Unmet Need by 2015 700,000 600,000 500,000 400,000 300,000 200,000 Implant Condom Mster Fster IUD Injection Pill 100,000 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Billions $6 Total Cost of Family Planning by Component $5 $4 $3 $2 Support Overhead Service Delivery Commodities $1 $0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Billions $6 Cost of Family Planning Programs by Source of Funding $5 $4 $3 $2 Donors Out of Pocket National Governments $1 $0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Final Points Results are similar to those published by the Guttmacher Institute but are lower in the future, especially for program support costs. Methods are implemented in a spreadsheet that countries can use for estimating their own costs. The model was used at Kigali workshop. Methods and assumptions will also be added to FamPlan and Reality Check. These results are being reviewed by a technical committee in preparation for the Millennium Development Summit in September 2010.