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G Assessing Program Effectiveness and Cost-Effectiveness
Pages 338-366

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From page 338...
... In this area, a good deal can be learned from the literature on family planning programs in developing countries. Once given a set of programs whose effectiveness has been demonstrated, a second evaluation objective then comes into play: to determine their costeffectiveness.
From page 339...
... Only the most rudimentary forms of cost-effectiveness analysis have been applied to family planning programs, whether in the United States or in developing countries. As is made clear in what follows, perhaps the most informative literature on these issues is that concerned with health care costs in the United States, also reviewed in the second main section.
From page 340...
... are important, not only because of the obvious connections to contraceptive motivation, but also because of the fact that in the United States, access to service subsidies is conditioned on income. Under the current system of public funding, a woman's income relative to the poverty line determines the fee schedule that she faces for services in Title X clinics and establishes her rights to free services through Medicaid.3 In choosing among alternative providers, a woman will rely on the information available to her regarding the characteristics Xpnv of private physicians or other non-program sources of contraceptive methods and the outof-pocket prices of these methods Ppnv(Y)
From page 342...
... 7Although the desire to avoid conception is something that is expressed in the current decision period, a woman's expectations about future events figure into this desire. Consider a woman who, at present, wishes to avert conception altogether.
From page 343...
... , not all women who wish to delay or avert pregnancy make use of a contraceptive method.9 This disjuncture between expressed preferences and behavior has been termed a "KAP-gap." Women who act on their stated preferences may obtain contraceptive methods either from program sourcesthese are mainly family planning clinics or from non-program sources-these are mainly private physicians in the case of prescription methods, and pharmacies for the non-prescription methods such as condoms and foam. Users of contraception face some risk of conception, as do non-users, although of course method users enjoy a greater degree of protection.
From page 344...
... , the woman will have accumulated information about contraceptive methods and related aspects of reproductive health, will have enjoyed a certain amount of cumulative protection from unintended pregnancy, and will currently use or not use a method. Each of the programs will have made some contribution to her accumulated knowledge, contraceptive protection, and current use.
From page 345...
... Note that when access and fees for service are income-conditioned, as they are for Title X clinics and Medicaid services, predictions about net program effects depend on the priceresponsiveness of demands for contraception among women of differing income levels. The committee is not aware of any detailed data concerning such issues for the United States, although there are data available for developing countries.
From page 346...
... To sum up this much-abbreviated discussion, it is no simple matter to document program effectiveness in a context of multiple programs and individual self-selection among programs. The evaluation literature can provide some guidance on these issues, but much depends on the availability of data at both the individual and the areal level.
From page 347...
... Here x is defined principally in terms of protection from unintended pregnancy, but other dimensions will also prove to be of interest. The ranking is expressed in terms of the full social costs C(xJ of the resources used to produce x, with these costs being denominated in money terms.
From page 348...
... Programs differing in scale or output mix can only be compared indirectly through the device of cost functions, which provide a statistical means of predicting what social costs would be if the programs generated the same level of output or had the same output mix. Thus, the estimation of cost functions a difficult task-is central to an evaluation of program cost-effectiveness.
From page 349...
... The response on the part of many clinics, according to Donovan, was to increase reliance on fees for family planning and other services, and to reduce the range of services supplied inhouse. The increasing use of referral by clinics, as opposed to direct service provision, has implications for the level and mix of output x, the total social costs Cfx)
From page 350...
... represents total costs under an integrated service delivery scheme, and C, and C2 represent costs when the services are not integrated. i3 To put it differently, economies of scope exist if there are potential cost savings to be secured by integrating service delivery in some fashion.~4 If these savings exist, or if the savings are believed to be possible under an alternative organization of the health system, then q and r should be considered jointly in a proper cost-effectiveness evaluation.
From page 351...
... First, they are concerned with prevention, and in this case, mainly with the prevention of unintended pregnancy. Second, family planning programs produce what should be regarded as intermediate outputs, as opposed to final outputs x, in that they provide interested clients with contraceptive methods accompanied by information on their use, the potential side-effects, and so on.
From page 352...
... How should the contribution of the program be assessed in this instance? Wantedness status is to a great degree an individual matter, something Hat lies beyond the reach and He responsibilities of family planning programs.
From page 353...
... The degree of use-effectiveness depends on Me socioeconomic characteristics and motivations of the user, and on We information that has been made available to her. In providing contraceptive methods, a program produces an intermediate output Cat must be, as it were, further processed by Me client to yield a final output: the level of protection against unintended pregnancy.
From page 354...
... Total services supplied are therefore Nl, NO, and NR.) The total social costs associated with these services may be summarized in a cost function Ci˘O,N,I, Q,R;w)
From page 356...
... The distinction between the costs borne by clients and the costs tallied in program accounts is important, because different forms of program organization imply different divisions of social costs between the program and its clients. For example, a program that does little in the way of community outreach reduces its own administrative costs in comparison to more ambitious programs, but in so doing might increase total social costs.
From page 357...
... Translating Service Statistics into Measures of Contraceptive Protection A long-standing problem in the evaluation of family planning programs concerns the link between program service statistics, which are represented in this document by (O,N,I,Q,R) , and protection from unintended pregnancy.
From page 358...
... or she may have a change of heart in respect to wontedness, discontinue the method, and hope to conceive (a path indicated by the dashed lines showing a transition at a2 to state 2~. Three transition rates govern the movements among states: r,2 and r2, determine transitions between the wantedness statuses, and r,3 represents the method failure rate.
From page 359...
... The use-effectiveness measure retains We assumption of fixed wantedness status, but allows contraceptive failure rates r,3 to depend on We characteristics of the client served (her subgroup k, In this document) and permits the failure rates to vary (at least In principled with the information provided by the program.
From page 360...
... The conceptual experiment is to imagine a health system much like the current system, except that the program of interest has been removed, scaled back, or otherwise altered. What would be the service level and mix x, and total social costs C(x)
From page 361...
... Each data point provides information on total social costs C and the level and mix of services provided, whether these are expressed in terms of service statistics (O,N,I,Q,R) or, for the contraceptive component of services, in more refined measures of services such as En and E2 discussed above.
From page 362...
... specify cost functions that incorporate shift factors representing different forms of organization, as for example, not-for-profit versus proprietary hospitals. With such data in hand, one then selects a functional form for the cost function Ci(O,N,I,Q,R;w)
From page 363...
... But in the absence of supporting evidence-the committee finds none in the literature these strong assumptions are not well justified and may be misleading as a guide to policy. CONCLUSIONS This discussion and analysis has attempted to provide an introduction or guide to the evaluation literature on effectiveness and cost-effectiveness, with emphasis on those issues which are central to family planning programs.
From page 364...
... Cost-effectiveness and financial sustainability in family planning operations research. In Operations Research: Helping Family Planning Programs Work Better.
From page 365...
... Manual IX: The methodology of measuring the impact of family planning programs on fertility. Popul Stud.


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