1. 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.orghttp://www.phrplus.org Findings from National Health Accounts: Investing in Reproductive Health Tania Dmytraczenko Senior Health Economist, PHRplus Global Health Council Conference 1 June 2005

2. 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

3. Outline  Background  Method  Results  Next steps

4. Background

5. 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

6. “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 Background

7. Method

8. 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

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

10. Reproductive Health Accounts: Countries covered EgyptJordanRwanda Years200219951991200120001998200220001998 General NHA  RH subanalysis preliminary  ( 2002)  (2001, 2000) (2002) HIV/AIDS subanalysis  Method  Ongoing in Mexico, Karnataka (India)  Bangladesh, Nepal, Sri Lanka, India (2 states)

11. Results

12. Reproductive health indicators EgyptJordanRwanda Maternal mortality (per 100,000 live births)170411071 Total fertility rate3.53.75.8 % 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 attendant60.9%99.5%30% Use of postnatal care (% of births)52.5%96.9/28%*1.1% Source: DHS 2000, 2002 Reproductive health results *subsequent to discharge

13. Reproductive health within context of general health care Total Health Expenditures RH spending as a percentage of total health expenditures Reproductive health results Total Health Expenditures JordanRwanda = USD $10.9M or $5.31 / WRA = USD $127.6M or $98.14 / WRA

14. Where do reproductive health dollars come from? JordanEgyptRwanda RH is being financed mostly by either: donors (Rwanda) or government and households (Egypt, Jordan) Reproductive health results

15. Public versus donor priorities in resource allocation 4%37% Rwanda 16%17%Jordan 6%12%Egypt Donor funding is concentrated on RH and HIV/AIDS in Rwanda Reproductive health results

16. Who is managing reproductive health funds? Public entities are the largest payer / purchaser of RH RwandaJordan Reproductive health results

17. Who is financing reproductive health expenditures by public entities? Donors finance a large share of RH expenditures by public entities and 100% of spending by NGOs 25% 85% Origin of funds managed by public entities in Rwanda Reproductive health results

18. What types of RH services are being funded and by whom in Rwanda? % of THE for HIV/ADS Reproductive health results 2002 Households finance half of all curative care while donor funds go principally towards prevention programs

19. Breakdown by RH categories in Rwanda Reproductive health results 2002

20. 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 : maternal health

21. Breakdown of expenditures by method mix % of FP commodity expenditure 2002 Reproductive health results : family planning

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

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

24. 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

25. 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) Reproductive health results

26. 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.orghttp://www.phrplus.org Thank You Reports related to this presentation are available at www.phrplus.org