CLIENT CHOICE THROUGH DEMAND-SIDE FINANCING

Marie Stopes International (MSI) is globally recognized as one of the leading family planning organizations. The organization uses deman-dside financing to improve access to family planning, sexually transmitted infection (STI) services, and safe motherhood services, using a range of innovative financing models. MSI is currently running voucher schemes and outputs-based aid (OBA) financing in several countries, including Kenya, Uganda, Tanzania, Cambodia, and Yemen. This chapter explores MSI's global experiences with demand-side financing for sexual and reproductive health services.

WHY DEMAND-SIDE FINANCING?

In some settings, limited government capacity challenges the ability to design and implement effective public health service delivery mechanisms (Eichler 2006). Historically, financial input into health systems has focused on the supply side (infrastructure, staff, salaries, etc.), often, though not exclusively, through the government/public sector. This approach is failing to impact significantly on health outcomes as a result of inefficiencies, inflexibility, and monopolies inherent in many public sector systems (Sandiford et al. 2005; Bhatia & Gorter 2007; Bhatia et al. 2006).

A large proportion of health care in developing countries is delivered through the non-state sector. In Pakistan, for example, 80 per cent of total health expenditure is out-of-pocket payments by individuals for curative services provided by independent, private health care providers (Pakistan Medical Research Council 1998). The scale of this private sector reflects on public services — both the shortage of public health care facilities in rural areas and urban slums, and the perceived low quality of their services by clients.

The existence of a large private sector in developing countries presents an opportunity to increase the poor's access to key health services. However, harnessing the private sector to provide services to low-income groups and thereby contribute to public health objectives presents a number of challenges. The quality of private service provision is often poorly regulated by the state and hence can be low or varied. The services may be biased towards those that maximize revenue rather than those that offer the best public health outcomes, such as long-term family planning methods, bed nets, and other preventive services.

SEXUAL AND REPRODUCTIVE HEALTH

Sexual and reproductive health is underresourced in many developing countries.