The Profamilia Family Planning Program, Colombia : an economic perspective

Pollcy, Research, and External Affalrs J WORKING PAPERS.- Population, Health, and Nutrition Population and Human Resources Department The World Bank August 1991 WPS 759 The Profam lla Family Planning Program, uolinibia An Economic Perspective Jesus Amadeo Dov Chernichovsky and Gabriel Ojeda Profamilia, an affiliate of the International Planned Parenthood Federation, provides n,ore than 60 percent of Colombia's family planning services. In 1986, Profamilia recovered more tlhan half of its costs, which is rare for family pianning services. But it could have provided more protection for the same amount of money. The Policy. Rescarch, and Extema! Affairs Compicx disnhbutes PR I: Working I'dpers to dtsscmmalc thc findingiol scirk in progress and to encourage the cxchangc of idcas among Ilank staff and all otlhcrs inicrctcd mn devclopmcnt issues I hsc papers carry thc ndnfle. of the authors, reflect only thcir views, and should hc used and citLd accordmngly T'he finduLgs, intcrpretrions. and conclusions arc thc authors' own '[hey should not be attnhutci to the W'orld lBank, its Board of Directors, its managcncnt, or any of its mcmcbr countrncs  Plc,Research, and External Affairs Population, Health, and Nutrition WPS 759 This paper - a product of the Population, Health, and Nutrition Division, Population and Human Resources Department- is part of a largereffort in PRE to examine the relative importance of constraints of demand and supply on the usc of contraception. Copies are available free from the World Bank, 1818 lI Street NW. Washington, DC 20433. Please contact Otilia Nadora, room S6-065, extension 31091 (113 pages, with tables). Profamilia, an affiliate of the Intemational run than this study found to be truc for the short Planned Parenthood Federation, provides more term.) than 60 percent of Colombia's family planning services. o The clinical program (delivering mainly the IUD) and the outreach program (delivering Profamilia's outreach effort (CBD) dclivers mainly the pill) are the most cost-effective. The mainly pills in rural and outlying urban areas, voluntary sterilization program is the least cost- through 100 field workers. Its two clinic-based effective because of the higher cost of steriliza- programs provide (1) voluntary sterilization and tion, the hcavy subsidy for sterilization, and the (2) clinical scrvices: gynecological consultation, higher mean age of clients who are sterilized. It intrauterine devicc (IUD) services, and over-thc- might be more efficient to shift emphasis from counter sales of contraceptives. sterilization to the other two programs. In 1986, these threc programs delivcred o Fees for service should be seriously consid- more than I million "couple years of protection" ered, and more research done on the issue. More (CYP) at a cost of about US$6.43 million. The demand could be met with more workers, and sterilization program provided the most protec- higher prices - particularly for slerilization- tioIn. The clinical and CBD programs each might not reduce revenucs. provided about 43 percent of revenues. Tlhe outreach programn accounted for 31 percent of e More resources should be targeted to areas costs, the clinical program 39 percent, and the where there are proportionately more mothers voluntary sterilization program 30 percent. and where people are better educated (and hence more receptive to family planping). Aniadeo, Chemichovsky, and Ojeda address the question: Could Profamilia have provided o Experienced and married workers sell more more protection with the same resources? They in the outreach program than their junior, found that: unmarried colleagues. Experienced workers tend to be paid more than inexperienced workers, but o Operations tend to be constrained by limited married workers tend to be paid less than unmar- personnel and supplies. With more of each, ried workers. It would pay to retain experienced more protection could be delivered. staff (who are more likely to be married). o The labor costs and unit costs of contracep - In both the clinical and surgical programs, tion are lower in the outreach and clinical output would increase if there were proportion- programs, which can be expanded with available ately more nurses and fewer doctors. infrastructure. Thc marginal unit cost of volun- tary sterilization is higher partly because sur- The underlying hypothesis of this study geons are paid "by the piece." (But the effects of (which remains untested) is that there is suffi- educating the people about sterilization may cient demand for the various operations to make sterilization more cost-effective in the long expand. The PRE Working Paper Series disseminates [he findings of work under way in thc Bank's Policy, Rcsearch, and Extemal i AffairsComplcx. An objecctivc ofthc scries is to get thesc findings out quickly, even ifpresentations arc less than fully xolished. Thc findings, interpretations, and conclusions in thcse papers do not necessarily r.present official Bank policy. Produced by the PRE Dissemination Center  TABLE OF ONTF[ E=aXUrIVE SUMMARY PREFACE 1. INDU ON .. .. .. ....... ...** 0 1 2. PLATIONAD FALYPLLANNING IN C4BIA . ...0...... 3 2.1. The Population: Size, Grwth, ar Distribution 2.2. Poplxation Policy and Family Planning 3. PROFAXELIA . . .......... . . . . . . . . . . 0 8 3.1. Brief History 3.2. The Commmity-Based Distribution (CD) Program 3.3. The Clinic-Based Progranm 3.3.1. The Clinical Program 3.3.2. The Voluntary Sterilization Program 4. PROGRAM EFFICIENY: TE ISSUJES AND ANALYTIC FRAMEWORK .. ...... 21 4.1. Introduction 4.2. The Efficiency Issue 4.3. Costs, Reource Productivity and Internal Allocation of Resurces 4.4. Alloation Across Programs and Across Methods within Programs 4.5. Statistical Approach 5. IIE BD . . .. . . . . .. . . . . 37 5.1. Objectives and Framwork of Analysis 5.2. Field Worker Operations: A Model and Hypotheses 5.3. Data 5.5. Productivity and Effectiveness of Field Workers 5.6. Contraceptive Prices 5.7. Program costs and wage [etermination 5.8. Cost-effectiveness of Field Wrker Operations 5.9. Method Mix 5.10.Conclusions: the CBD Sub-Program 6. I{ CLMIC-BAS PRAS . . . . . . . . .. ......... . . . 73 6.1. Objective anid Franrk of An&aysis 6.2. Clinics Resources, Envirament, and ProductivitV: Data 6.3. Costs of Clinic-Based Operations 6.4. Estimticn Procedure 6.5. Ptriuctivity and EffectiveneSS of Clinical Operations 6.6. Variable Labor Costs and EfficiencY of WOrker Allocation 6.7. Fixed Capital Costs and Scale 6.8, Method Mix 6.9. nclusions: The Clinic-Based Sub-ProgramB 7. P-WTIVE (SUB) PRGRA EFFICIENCY .0. .0. .0 . .0 . . . . . . . . . 97 8. KCLJIIS .* * 0 0 . 0 . 0 . . . . . . . . . . 99  List of Tables and Figures Table 2.1: Pop.latiotr Characteristics by Region . . . . . . . . . . . . 4 Table 2.2: Distribution of Contraceptive Users by Source of Supply . . . 7 Table 3.1: Basic Characteristics of Field Wbrkers . . . . . . . . . . 11 Table 3.2: CbD Program Prices to Consumer . . . . . . . . . . . . . . . 11 Table 3.3: Profamilia CBD Program, 1986 . . . . . . . . . . . . . . . . 13 Table 3.4: Clinic Area, Consultations and Surgeries by Type of Clinic, 1986. . . . . . . . . . . . . . . . . . . . . 17 Table 3.5: Estimated Prices for the Surgical and Clinical Sub-Programs, 1986 . ......... 17 Table 3.6: Profamilia Clinic-BEzsed Sub-Programe, 1986 ... ... . . . 18 Table 5.1: List of Variables by Operational Category and Coxnptual Relationship .. . . . . . . . . . . . .53 Table 5.2: Regression Coefficients (Natural Logarithm) Quantity of Sales of Contraceptives, Regional-Level Estimates for CBD Program . 54 Table 5.3: Regression Coefficients: (Natural Logarithm) of Contraceptive Sales, Individual Worker-Level Estimates for CBD Program . . 56 Table 5.4: Regression Coefficients (Natural Logarithm) of Worker Wages 66 Table 5.5: Adjusted Tbtal CYP Gained by Investment in any Method in the CBD Program . . . . . . . . . . . . . . . . . . . . . 70 Table 6.1: Cost Components of Clinical operations . . . . . . . . . . . 77 Table 6.2: Regression Coefficients (Natural Logarithms) of Clinical Sub-Program. . . . . . . . . . . . . . . . . 83 Table 6.3: Regression Coefficients (Natural Logarithms) of Surgical Program . . . . . . . . . . . . . . ....... . 84 Table 6.4: Percentage Changes in Clinical Personnel to Produce a 10% Increase in Output with No Budgetary COmsequences . . . . 87 Table 6.5: Regression Coefficients of Program Oost . . . . . . . . . . 89 Table 6.6: Marginal Oost and Marginal Revene by Method ....... . 93 Table 6.7: Clinical Program: Adjusted Tbtal CYP and Relevant Data by Method in Clinic-Based Programs (per 100 pesos invested) . . . 94 Table 7.1: Adjusted Total CYP and Relevant Data for Profamilia Sub- Programs . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Figure 4.1: Shares in CYP, Gross Value of Sales and Costs, by Sub-Program 23 Figure 4.2: CYP, and Value of Sales (x 1000) per 1000 Pesos by subp . . . . . 34 Figure 5.1: Field Worker Productivity: Interaction between Supply and Demand in a Catchmeent Area . . . . . . . . . . . . . . . . . 45  EFAN N ESU1 . . . . . e . . . . . . . . . . . . . . . . . . . . * . . . . 104 ANNEX :Clinics ty . . . . . . ......................... 105 AM 2: The Worker's Optiml Time Allocation betwemn Delivery and Resource Mobilization .. . . . . . . . . . . . . . . 106 ANNEX 3: Potential Bias in Dend EAsticity Estimates . . . . a . . . . 108 ANNEX 4: Allocation of Nurses to Clinical Operations . .. . . 109 ANNEX 5: Reallocation of Ms and Nurse for Higher otput withot Budgetary Cmsequeanos. . . . . . . . . . . . . . . . .111 ANNEX 6: Marginal Consultation Cost of IUD, Surgeries and Sales of Contraoeptives . . . . . .. . a . . . . . . . . . 113  i EXBUEXVE SUMMR Profamilia, an affiliate of the International Planned ParEnthood Federation (IPPF) in Colaibia, is a migvemental, nt-for-profit organizaticn providing more than sixty percent of the country's family planning services. fhe ireminder is provided by the governmeqt and the private swtor. Profamilia's program is vertically organized; it provides mainly family plannng ard closely related services, and does nat provide services sucih as maternal and child care. Profamilia's outreadi effort, the Crmunity-Based Distribution (D) sub- program, delivers mainly pills in rural and outlying uran areas. It is run by about 100 field v -cers. Te agency has two clinic-nised (sub-) programs, administered throuh sam 38 clinics with a stf of abt 500.