Percent of government health budget allocated to family planning and reproductive health

Definition:

Budget allocated to family planning (FP) and reproductive health (RH) programs include the following resources: financial, human, physical infrastructure, and material support at all levels of government. Resources may be expressed in monetary forms, such as local currency budgets or US dollar conversions; other units, such as number of staff or staff time assigned to RH, are also possible.

To calculate this indicator:

(Amount of money in the government health budget allocated to FP and RH/Total amount of health budget) x 100

This indicator builds on another FP Financing indicator which looks at Types of financing mechanisms for delivery of family planning/reproductive health goods and/or services identified, tested, and officially adopted.

Data Requirement:

Evidence of allocations to FP and RH such as a budget line item, by the government.

Data Sources:

National and sub-national expenditure budget documents with evidence of approval; national and sub-national accounts; invoices, and other evidence of expenditures; personnel or staff assignment rosters.

Another source of information on national funding is Track 20 data on total government expenditure on FP, by country.

Indicator Type:

Percent

Purpose:

This indicator measures the commitment of government resources at the national or decentralized sub-national level to the FP and RH program. Evaluators must carefully define this indicator before they apply it to a country. First, they must define the realm of expenditures by determining which government services are being tracked. Second, evaluators must decide how to treat the source of public funds. For example, they may exclude donor grants but may include loan funds. Third, evaluators may track separately capital expenditures (for new or renovated facilities, equipment) and recurrent expenditures for program operations (salaries, supplies, maintenance). Capital budgets may fluctuate widely from year to year, rising to cover construction of new facilities and falling when construction is complete. Thus, a decreased capital budget may not demonstrate or indicate a worsened policy environment. On the other hand, recurrent budgets should show at least maintenance or preferably steady increases over time, to cover growing populations and expanded and/or higher quality services.

Issues:

Particularly in countries that provide FP/RH services along with other maternal child health or primary health care services, evaluators may have trouble identifying and linking the line item in the budget of the appropriate ministry/organization to FP/RH. Moreover, when personnel provide other health services in addition to FP/RH, evaluators may have difficulty determining the proportion of time and resources devoted to FP/RH.

In such cases, evaluators have the following options. First, the most commonly used, though least reliable approach, is to interview supervisors and health workers, asking them to estimate the percentage of their time spent providing FP/RH services. This percentage can then serve as a basis for allocating labor and other joint costs.

Second, evaluators can conduct a time-use survey of a sample of facilities, using either the technique of patient flow analysis or direct observation of health workers at specified intervals (i.e., work sampling). However, patient flow analysis is more effective at identifying patient flow patterns (e.g., wait times and total attendance times) for informing service delivery improvements (Dixon, et. al, 2015) than estimating the percent of time providers are spending providing FP/RH services.

Third, another commonly used indicator of government resource commitment to RH is the share of the total national budget allocated to FP/RH. The main problem with this alternative is that RH programs are often financed by several levels of government (e.g., national, state, local). Another problem is that such an indicator is sensitive to variations in the size of the national budget due to political, ideological, or national security considerations.

Fourth, some evaluators convert total expenditures to a per capita measure. This conversion permits cross-country comparisons and at the country level may complement, rather than replace, the total resources indicator.

Fifth, as a precursor to this indicator, evaluators may track, on an interim basis, newly enacted plans or policies (either at the government, organizational, or programmatic level) that attempt to increase resources for RH services. Examples include new, separate budget line items for RH services in national and local ministry of health budgets, or a directive that insurance plans must cover RH services. Planning to increase resources for RH services may signal an increased recognition of the importance of such services.

Finally, the government can enhance resource adequacy by spending existing resources more efficiently. An important question regarding implementation is whether funds or other resources allocated are actually expended to provide RH services. Many governments fall short of implementing their published budgets. When assessing implementation, evaluators must confirm that the resources allocated to RH programs actually flow to the operational units in the field providing the services. In practice, most evaluations will not be able to follow the money trail down to the operational level.

Reference:

Dixon CA, Punguyire D, Mahabee-Gittens M, Ho M, Lindsell CJ. Patient flow analysis in resource-limited settings: a practical tutorial and case study. Global Health: Science and Practice. 2015;3(1):126-134. http://dx.doi.org/10.9745/GHSP-D-14-00121