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
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
Public and Private Health Expenditure 17
% of GDP
% of GDP
|Lower middle income
|Upper middle income
|Low & middle income
|East Asia & Pacific
|Europe & Central Asia
|Latin America & Caribbean
|Middle East & N. Africa
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 ones 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
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 centless 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
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 womens 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 questiondo 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
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.
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