The Association for Voluntary Surgical Contraception retrospectively examined the impact of funding decreases on access to sterilization services at 20 nongovernmental family planning clinics in Mexico, the Dominican Republic, and Brazil. Clinic staff were asked questions about client fees, caseloads, availability of comparable low-cost or free services nearby, cost-recovery activities, and the socioeconomic profile of clients before, during the time, and after subsidies were lowered or eliminated. Funding reductions were followed by decreased caseloads at 14 of the 20 sites studied. Of the six others, four experienced an increase in caseloads, one saw no perceptible change, and one experienced a decrease only as a result of management policy to cut the caseload to improve quality. The most common response to the decrease in funding (shared by 17 sites) was an increase in client fees. In all but three of the 17 clinics, the increase in fees was met with a decline in caseloads. Moreover, at nine of these 17 sites, the fee increase effected a change in client mix; anecdotal evidence suggests that more middle-income and fewer lower-income clients were using sterilization services. Four lessons can be drawn from this study: Donors need to plan funding phase-outs carefully, in conjunction with grantees; grantees need to assess the costs of the procedure realistically, and assign fees accordingly; management needs to seek alternative funding sources in lieu of, or in addition to, increasing fees; and caseloads can be increased and costs recovered by diversifying services.
PIP: The objective of this 1989-90 policy impact study of sterilization services was to review how access and quality were affected by the decreases or withdrawal of subsidies and general decline in financial support for sterilization programs in Brazil, the Dominican Republic and Mexico. The focus is on cost-recovery strategies used by nongovernmental organization (NGOs) when faced with reduced donor support from the Association for Voluntary Surgical Contraception (AVSC). 4 recommendation are provided. In the brief background discussion there is reference to the following findings: there are few differences in demand between free and moderately priced FP services; user fees rarely cover all costs; wide variation exists in estimating cost methodologies; and sliding fee scales are difficult to administer. Questionnaire on financing and service statistics, client profiles, alternative service sites, and referral for services were obtained from clinic staff. The findings were that there was a sharp decline in caseload at 14 of the 20 sites examined. 4 sites at least 1 in each country had an increased caseload; 1 had no change and 1 had a decrease due to management policy to do so. These 6 reflect strategies for continuance of the program and self-reliance. Of the 17 clinics which responded with an increase in fees, only 3 did not have a decline in caseload. There was same evidence that increased fees brought more middle income clients. Successful strategies included securing other funding and diversifying services. In locations where other low or no cost services were available, most clinics increasing fees lost clients. Recommendations identified the following elements for sustainability: 1) the need for careful planning, 2) the ability to identify costs and set elastic fees, 3) the existence of an entrepreneurial spirit that guides organization effort in seeking alternative funding sources, and 4) diversification of services. There was proof at some sites that sustainability was compatible with accessibility with the condition that self-reliance is planned for and other than fee increasing strategies are employed.