PRB

(May 2010) Although family planning (FP) and reproductive health (RH) are critical to achieving development goals and are among the “best buys” in public health, these sectors are generally underfunded. Increasingly, advocates for RH draw on a wide range of analytic tools and data sources to strengthen the case for investments in RH programs. One approach that addresses key policy questions are RH subaccounts.

Countries can use RH subaccounts to track the flows of funds for FP/RH services through the health care system. These subaccounts provide data for critical policy issues, including who finances FP and RH services in a country; how much money is spent on FP and RH services; and where the funds go.¹ RH subaccounts incorporate information on prevention care and activities, as well as services for FP, antenatal and postpartum care, and treatment for unsafely performed abortions, sexually transmitted infections, and other gynecological problems.²

RH is one of several areas, along with malaria, HIV/AIDS, and child health, for which data are collected as part of an overall National Health Account expenditure review process. Resulting information provides critical data needed for program monitoring and for policy formulation and implementation.

Usefulness of Reproductive Health Subaccounts

RH subaccounts lead to more effective resource allocation and improved health outcomes. With the information from RH subaccounts, stakeholders can:

• Make more informed, data-driven resource allocation decisions.
• Advocate to mobilize resources from domestic and international sources.
• Inform the policy process to correct imbalances related to neglected priorities, household out-of-pocket payment burden, and absorptive capacity.
• Monitor programs more easily and effectively.
• Increase transparency and accountability.³

Through collecting and analyzing data from a variety of sources, RH subaccounts help answer specific policy questions that are critical to contraceptive security and efforts to gain momentum for FP:

• What is the burden of FP financing for households? Does income level affect use?
• Is the country dependent on donors for financing FP/RH programs?
• What is the involvement of the informal sector, for example, traditional healers and street vendors, in FP/RH service delivery?
• To what extent are FP/RH services being contracted to the private sector?
• How is spending linked to outcomes?⁴

The answers to these questions can help stakeholders more effectively advocate for increased resources for RH and develop ways to foster the sustainability of FP/RH programs. Understanding some of the broad financing issues can also contribute to a policy environment that supports a more active role of the private sector in RH and strategies that allow the public sector to focus its limited resources on those most in need.

How Reproductive Health Subaccounts Work

Researchers trace how the funds move from their sources (such as governments) through financing agents (such as ministries of health) to service providers and to service delivery (see figure). Primary and secondary data sources, such as government budgets, health information system data, Demographic and Health Surveys, and other surveys should all be used to gather the needed information.⁵ The framework for RH subaccounts is flexible enough to accommodate specific countries’ needs but standardized enough to allow cross-country comparisons.⁶ RH subaccount expenditure reviews should function as part of routine health information system data collection efforts that feed into priority setting and resource allocation. They are conducted as part of a general National Health Accounts estimation, but are usually conducted less often (every two to three years) than the general data collection exercise (every one to two years).⁷ Countries as diverse as Ethiopia, Georgia, Malawi, Mexico, Rwanda, and Uganda have undertaken RH subaccounts expenditure reviews. Malawi and Rwanda have undertaken the process more than once, giving them valuable trend data.⁸

Flow of Funds and Services in Reproductive Health Subaccounts

Source: Health Systems 2020, National Health Accounts and Public Expenditure Reviews: Redundant or Complementary Tools? (Bethesda, MD: Abt Associates, 2009).

Reproductive Health Subaccounts in Rwanda

RH subaccounts were first used in Rwanda, in 2000, 2002, and 2006. The results from 2002 showed that Rwanda was heavily dependent on donors for its FP and RH programs—80 percent of all RH spending in the country was financed by donors; governmental contributions were low. In fact, households were contributing more than the government for RH services through out-of-pocket payments. This finding led the ministry of health to successfully advocate for increased governmental support for FP and RH, from $1 million in 2002 to $2.8 million in 2006. At the same time, out-of-pocket household spending on FP and RH decreased. However, despite the absolute increase in funding, a comparison of funding levels across other priority areas showed that RH had declined in relative priority. Stakeholders used this information to advocate for and select FP/RH as one of the four priority areas in the 2008 Rwandan Joint Annual Health Work Plan. In Rwanda’s case, the data informed advocacy, resource allocation, and priority setting.⁹

Reproductive Health Subaccounts in Malawi

Malawi also benefits from RH subaccount trend data from three rounds of data collection between 2002 and 2005. RH subaccount information reveals that resources for FP/RH are inadequate, at about $12 per woman per year. While spending on RH in absolute terms has increased, it has decreased as a percentage of all health spending compared with other health priority areas—despite RH’s perceived high profile on the national health policy agenda. RH subaccount data also point to a disproportionate allocation of scarce resources across priority areas. With one of the world’s highest maternal mortality ratios—984 maternal deaths per 100,000 live births—mothers’ health is a priority for Malawi. However, little funding supports maternal health care interventions, such as training and salaries for nurses and midwives; funding drugs and medical supplies; and providing equipment and supplies for emergency obstetric, prenatal, labor and delivery, and postnatal care. In Malawi, RH subaccounts have helped identify overall funding needs and resource allocation imbalances.¹⁰

Trisha Moslin is a program administrator at the Population Reference Bureau.

References

1. Susna De, Importance of NHA Subaccounts (Bethesda, MD: Health Systems 20/20 Project, 2008).
2. Susna De and Laurel Hatt, “Reproductive and Child Health Subaccounts to Track Resource Allocations and Flows,” presentation at Scaling-Up High Impact FP/MNCH Best Practices, Bangkok, Sept. 4, 2007.
3. De, Importance of NHA Subaccounts; and De and Hatt, “Reproductive and Child Health Subaccounts to Track Resource Allocations and Flows.”
4. De, Importance of NHA Subaccounts; and USAID, “Using Reproductive Health Subaccounts to Advocate for Increased Resources for Family Planning,” Repositioning in Action E-Bulletin (August 2008), accessed at www.usaid.gov/our_work/global_health/pop/techareas/repositioning/repfp_ebulletin/080808_en.html, on Jan. 4, 2010.
5. De and Hatt, “Reproductive and Child Health Subaccounts to Track Resource Allocations and Flows.”
6. De, Importance of NHA Subaccounts.
7. De, Importance of NHA Subaccounts.
8. De, Importance of NHA Subaccounts.
9. USAID, “Using Reproductive Health Subaccounts to Advocate for Increased Resources for Family Planning”; and Health Systems 20/20 Project, “National Health Accounts Subaccounts: Tracking Health Expenditures to Meet the Millennium Development Goals,” Project Brief (2009).
10. Government of Malawi, Malawi National Health Accounts 2002-2004 With Sub-Accounts for HIV and AIDS, Reproductive and Child Health (Bethesda, MD: Partners for Health Reform Plus Project, Abt Associates Inc., 2007).