A Comparative Cost-Effectiveness Analysis of Four family Planning Service Delivery Agencies in Nepal

by Ram P. Risal, Master of Arts in Demography (1986)

The study sought to examine cost-effectiveness of main four family planning service delivery agencies in Nepal, namely, Family Planning/ Maternal and Child Health Project (FP/MCH)/ Integrated community Health Services Development Project (ICSDHP), Family Planning Association of Nepal (FPAN), and Nepal Contraceptive Retail Sales Company (NCRSC). More specifically, the study aimed to measure and analyze a) cost and output performances, b) effects of processes in achievements of outputs, c) efficiency of each agency through the years, d) relative efficiency across agencies and e) fertility impact of contraception and changes in fertility on national level. The relevant time periods taken into consideration for the analysis were FY 1974/75, 1979/80 and 19882/83.

Analytical explorations were guided by the following hypothesized relationships: a) input mix applied for the delivery of services directly varies with maturity and scale odf and contraceptive method mix offered by the agency; b) generation of outputs is contingent on processes in service delivery; c) outputs produced and effects created differ in accordance with emphasis placed for promoting and delivering contraceptive method method-specific services; d) variations in inputs applied for in various processes to produce varying desired outputs and in turn to create different effects result I some variations in cost-effectiveness of agencies in delivering services; e) some variations in cost-effectiveness and thereby in relative efficiency across agencies result from differences in distribution of service points and, recruitment and deployment of clinic personnel and outreach workers in the family planning program, the more cost-effective the agency and consequently more efficient in the delivery of family planning services.

The study found out that expenditure of the four agencies in aggregate (or total program cost0 was increasing with an accelerating momentum through the years. The largest proportion of total was maintained by FP/MCH and the smallest FPAN, if NCRSC is not included in the comparison due to its highly subsidized operations and distinct service delivery structure.

A dramatic rise in FP/MCH expenditures in the recent period was attributable to increasing emphasis placed in promoting sterilization program while the slowest pace of FPAN spending to steady pace in expanding service delivery in the rural areas.

Input mix or expenditure of the agency on different line items was directly related with the maturity and scale of and contraceptive method mix offered and emphasis placed by the agency in the promotion and delivery of method-specific services.

The longer the agency has been delivering the services the negligible capital costs of the agency. Such agency is FP/MCH. The greater the emphasis placed in the promotion of sterilization program, the larger the proportion of recruited sterilization acceptors in the methods mix of new acceptors but the rapid rate of increase in the direct costs of the agency. The agency referred to is FPAN.

The effects of processes in service delivery on achievements of outputs were clearly visible. FP/MCH appeared to have a longer clinic hour, more balanced and productive time use patterns of clinic and field personnel and thus, the greater inflow of FP clients than ICDHSDP. The higher the concentration of service delivery of the agency in more accessible regions of the country the more efficient its outreach workers. This specifically refers to FPAN, specifically its paid motivators.

The process analysis further disclosed that: a) motivating couples for sterilization was costlier than to motivate for reversible methods; b) integration of FP with other health services in ICHSDP health posts has not been an effective FP service delivery mechanism. Nonetheless, on the whole a very low inflow of FP clients has been observed in such agencies. The chief reason for the low inflow of FP clients was the provision of FP services being confined to pills and condoms in the majority of both FP/MCH clinics and ICHSDP health posts.

Cost-effectiveness analysis showed that when it comes to the recruitment of new acceptors FP/MCH was the most cost-effective/efficient agency and FPAN the least. This can be explained by the variations in the method-specific acceptors recruited. FC/MPH has been recruiting large numbers of condom and pill acceptors. On the other, FPAN has been recruiting more sterilization acceptors. It is obvious that the cost to generate pill and condom acceptors is much lower than the cost to generate sterilization acceptors. In terms of CYP and FBA indicators which are the better indicators of effectiveness, FPAN stood out as the most cost-effective agency and ICHSDP the least.

In effect, the larger the proportion of sterilization acceptors in the methods mix of new acceptors recruited by the agency, the higher the cost per new acceptor but the more cost-effective the agency. The other factor which might have made FPAN the most cost-effective agency in terms of the CYP and FBA was its concentration of service delivery in more accessible regions of the country and thuis its most efficient outreach workers i.e. paid motivators. On the other, ICHSDP has remained as a very low profile with all program indicators under consideration. Possible reasons for the explanation of relatively low performance of ICHSDP which the study has not empirically investigated were the following: a) main thrust being initially directed to health services with FP services integrated only in the later years; b) its outreach workers having very wide areas of coverage, and c) its substantial overlap in service delivery with FP/MCH. With respect to NCRSC, it appeared to have been not only more cost-effective over time but also, an effective supplement to channels of contraceptive distribution of free distributing agencies.

Finally, the national FPP emerged not to have been so effective in reaching the eligible couples in general and the younger ones in particular despite the accelerating momentum in expenditures through the years. In effect, it appeared that contraception has been resorted to by Nepalese women at older ages, with high parity, who are closed to the end of child bearing. Hence, the fertility impact of contraceptive used remained minimal as shown in the negligible reduction of marital general fertility rate, a clear indication that the national FPP has been very slow in attainment of its ultimate goal. Thus, reducing fertility through family planning program in Nepal poses a great challenge to both program managers and policy makers in that it may take a long way to attain some measurable reductions.