Financing and Sustainability Postabortion Care Services March 2002

Financial Sustainability  What does it take?  Not about numbers only  But numbers do count  Not “business as usual”

Not About Numbers Only  Sustainability plan included in strategic plan  Business plans also for NGOs?  Change of attitude  Efficiency in service delivery  Awareness of cost implications of quality  Costs of high vs. poor quality

Numbers Do Count  How much does it cost to provide services: current level and at scale?  What price to charge for PAC services  If no cost recovery, who pays for any subsidies offered?  Budgetary recognition and allocation by ministries of health

Not Business As Usual  Organizational sustainability  Need business-like approach  Leadership  Strategic partnerships/collaboration  External relations – creatively managed

Business-like Approach  “Not-For-Profit is not a management style, but a tax status” (P. Drucker)  Relevant business-type principles:  Use of financial management information  Cost analysis  Synergy through integration  Customer/patient/client focus

Leadership  Born or taught?  Need for champions to promote  Political will creates enabling environment

Partnerships  Training – who has comparative advantage?  Logistics for MVA and other supplies  Procurement of supplies

External Relations  These need to be managed well  Costs/burden of donor support  Weaning out of donor dependence – is this in the sustainability plan?

Cost of PAC Services  Availability of information on cost  Some studies on cost effectiveness of MVA vs. D&C  Little information on the costs involved in scaling up of PAC services  What cost information is relevant?

Scaling Up: What Costs Are Relevant?  Incremental costs only:  MVA or D&C supplies  Additional staff time costs  Other supplies and equipment required

Relevant Costs (cont)  Opportunity costs of scaling up PAC services  What happens to funding for other RH services  Scaling up FP reduces need for PAC; Unwanted pregnancy implies failure in FP

Cost Estimation  Step 1: Strategic mapping to identify what exists and service delivery gaps  Step 2: Estimation of demand.  Step 3: Incremental resources needed over time.  Step 4: Cost of additional resources

Costing Tools  CORE (Cost and Revenue analysis tool developed by MSH)  Cost Estimate Strategy (developed by MSH)  Cost Analysis Tool (developed by EngenderHealth)  A Guide to Assessing Resource Use for the Treatment of Incomplete Abortion (Developed by Ipas)

Scaling Up: Cost Determinants  Capital costs – Buildings, equipment, initial training  Takes into account existing infrastructure  Projected demand for services  Treatment protocols  Ease of replication of pilot

Cost Drivers The key cost drivers include:  Treatment protocols, e.g.  The re-use of canulla  Length of stay/Discharge from hospital  Drugs and medical supplies and staff time are the most significant costs  Need to control the key cost drivers.

Financing PAC Services  User fees  Community health funds  Health insurance  Cost savings through:  Lower hospital stay  Use of MVA where possible as this has been proven to be more cost effective than D&C  Public funds (taxation)  External assistance

Policy Considerations  Financing issues  Service sustainability  Staff capacity  Continued availability of supplies  Support for PAC at policy level  Budgetary support  Clarity on legal issues to enhance use  Classification of PAC services as “emergency” care?

Conclusions  Importance of financing and sustainability in PAC  Complex subject  Cost effectiveness of MVA vs. D&C  Need to do more research on issues of financing and sustainability in scaling up PAC