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With the expense of providing reproductive health services increasing, information on how staff members spend their time can help program managers determine whether there is sufficient downtime to add new services at minimal additional cost. METHODS: Providers in Zimbabwe were retrained in syndromic management of reproductive tract infections. Before and after retraining, mini-situation analyses were performed at several clinics to determine how staff spent their contact time with clients. The mean length of visits was calculated, as was the amount of time spent on risk assessments, pelvic exams and collection of lab specimens. Time-motion studies were conducted to determine how providers spent their time following retraining, including client services, administrative activities and unoccupied time. RESULTS: The median length of visits for new acceptors was longer following retraining (27 minutes) than it was before (20 minutes), and the proportion of such clients who received various syndromic management services increased. Yet even after retraining, providers spent less than 40% of their time with clients. Observation revealed substantial unoccupied time in early morning and late afternoon. If more clients received services, time spent with clients would increase and unoccupied time would decrease; thus, the labor cost of a clinic visit could be cut-at one clinic, by almost one-half. Overall, the average provider cost of family planning visits could be reduced by more than one-third if providers increased the share of time spent with clients from 40% to 60%. CONCLUSIONS: Reduction of provider downtime (time absent from the clinic, time spent unoccupied or time not otherwise used productively) at family planning clinics in the developing world could increase capacity to provide services with a minimal rise in costs. Poorly paid providers, however, may require financial incentives to increase their workload.

This paper describes the efforts of Family Health International to develop a simple, standard and replicable methodology to estimate expenditures on family planning in developing countries. The study found that it is not possible, at least at this time, to develop such a methodology. Numerous problems were encountered in making expenditure estimates. First and most important, expenditure accounts are not always readily available. Even when these accounts are available, they may require some adjustments. In some instances, for example, the salaries of health workers who also provide family planning are in the health accounts, whereas in other cases the workers covered in the family planning accounts spend some of their time providing health services. Allocation variables then must be developed to separate spending on family planning from that on health. In some instances allocation variables were developed and used to separate family planning from health expenditures, but in this case allocation variables were not available and a cost analysis was performed. It is concluded that it takes considerable time and effort to estimate expenditures, and that the approach that was followed varied by country, reflecting the data available to make estimates.