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HEALTH CARE DECENTRALIZATION IN PARAGUAY: EVALUATION OF IMPACT ON COST, EFFICIENCY, BASIC QUALITY, AND EQUITY

Baseline Report

MEASURE Evaluation Technical Report Series, No. 4

Gustavo Angeles John F. Stewart Rubén Gaete Dominic Mancini Antonio Trujillo Christina I. Fowler

The technical report series is made possible by support from USAID under the terms of Cooperative Agreement HRN-A-00-97-00018-00. The opinions expressed are those of the authors and do not necessarily reflect the views of USAID.

Printed on recycled paper

December 1999

Other Titles in the Technical Report Series

No. 1. Uganda Delivery of Improved Services for Health (DISH) Evaluation Surveys 1997. Path- finder International and MEASURE Evaluation. March 1999.

No. 2. Zambia Sexual Behaviour Survey 1998 with Selected Findings from the Quality of STD
Services Assessment. Central Statistics Office (Republic of Zambia) and MEASURE Evaluation. April 1999.

No. 3. Does Contraceptive Discontinuation Matter? Quality of Care and Fertility Consequences.
Ann K. Blanc, Siân Curtis, Trevor Croft. November 1999.

Recommended Citation:

Gustavo Angeles, John F. Stewart, Rubén Gaete, Dominic Mancini, Antonio Trujillo, Christina I. Fowler.

Health Care Decentralization in Paraguay:   Evaluation of Impact on Cost, Efficiency, Basic Quality, and

Equity. Baseline   Report. MEASURE Evaluation Technical Report Series No. 4. Carolina Population

Center, University of North Carolina at Chapel Hill. December 1999.

Acknowledgements

We would like to acknowledge the cooperation and generous support of numerous individuals and organizations that made the first phase of this study possible. We express our gratitude to the staff of 143 health facilities who cooperated with the research team to collect facility and staff data. We thank the 1,261 facility clients and the 2,150 women of reproductive age who provided information about their experiences with the health system, their health, and the health of household members. Without their cooperation and patience this study would not be possible. We thank also the regional health directors from Central, Cordillera and Misiones for their cooperation during the fieldwork.

The USAID Mission in Paraguay, which commissioned and supported the implementation of the baseline study, deserves special mention. We recognize and appreciate the cooperation of the following individuals: F. Wayne Tate (USAID/Paraguay Mission Director); Gerald Barth (Deputy Mission Director); Osvaldo Benítez (former Health Officer), Todd Sorenson (Democracy Officer); and Enrique Villalba (Program and Finance Officer). We also thank Barbara Kennedy, former USAID/Paraguay Mission Director, for her cooperation.

The technical, operational and field support of Paraguayan organizations were critical to all aspects of the study, from the initial conceptualization of the project to the collection and analysis of the data. We would also like to recognize the staff of PRODEP (Proyecto de Descentralización en Paraguay), especially Arturo Urrutia (PRODEP Director) and Carlos Mario Ramirez (PRODEP Health Consultant) who recognized the importance of assessing the impact of decentralization. We would like to thank CIRD (Centro de Información y Recursos para el Desarrollo) and its director, Agustín Carrizosa, for the use of CIRD facilities during the organization and implementation of the health facility fieldwork. This field support greatly facilitated the data collection effort. Agustín also provided valuable comments to the preliminary version of this report. At CEPEP (Centro Paraguayo de Estudios de Población), we acknowledge the important efforts of Cynthia Prieto (CEPEP Executive Director) and Mercedes Melian (CEPEP Research Director) in assisting the research team to incorporate the modules required for this study into the larger ENSMI 98 household survey. We also thank Leo Morris and Paul Stupp (both at the Centers for Disease Control and Prevention) for their valuable technical assistance in the development of the household questionnaire, the oversampling of the study areas and in the implementation of the household survey. Furthermore, we appreciate the efforts of ICA (Instituto de Comunicación y Arte) staff and Enrique Chase (ICA Executive Director) for successfully carrying out the client exit survey. We also value the efforts of ICA interviewers who conducted the facility surveys in a competent way.

In North Carolina, we drew upon the technical resources of the Carolina Population Center. Amy Ong Tsui (Director of the Carolina Population Center and former Project Director of MEASURE Evaluation) and David Guilkey (Senior Technical Advisor, MEASURE Evaluation) provided valuable technical assistance at the inception of this study and during all of its phases. We also thank Ties Boerma (Director of MEASURE Evaluation) for continuing the support to this study, and the members of MEASURE’s Technical Advisory Group for careful comments to the study proposal. The maps displaying the spatial relationships are the excellent work of Steve McGregor and John Spencer of the Carolina Population Center's Spatial Analysis Unit. Joy Fishel (Research Assistance, MEASURE Evaluation) provided valuable research and report preparation assistance. Brandon Howard (Information Officer, MEASURE Evaluation) played a key role in both the layout and production of the report. Last but not least, we acknowledge the careful and skilled translation work by Ruy Burgos.

USAID/Paraguay and the MEASURE Evaluation Project, through its Cooperative Agreement with USAID/Washington, provided funding for this study.

i
Acknowledgements

CONTENTS

Acknowledgements........................................................................................................................................ i Executive Summary.................................................................................................................................... vii 1. Introduction........................................................................................................................................... 1
1.1. Background ....................................................................................................................................... 1 1.2. Overview of Evaluation Study........................................................................................................... 2 1.3. Overview of Baseline Indicators Report............................................................................................ 2
2. Country Background............................................................................................................................. 3
2.1. Geographic Characteristics................................................................................................................ 3 2.2. Socio-Demographic Profile ............................................................................................................... 3 2.3. Health Profile .................................................................................................................................... 3 2.4. Economic & Political Profile............................................................................................................. 4 2.5. Health Care System in Paraguay ....................................................................................................... 4
2.5.1. Policy........................................................................................................................................ 4 2.5.2. Organization & Infrastructure................................................................................................... 5 2.5.3. Health Expenditure & Financing .............................................................................................. 5
3. Health Reform: Decentralization of Basic Health Services................................................................... 7
3.1. Background ....................................................................................................................................... 7 3.2. Evolution of Health Reform Initiative............................................................................................... 7
3.2.1. Phase 1: Deconcentration.......................................................................................................... 7 3.2.2. Phase 2: Decentralization.......................................................................................................... 7
3.3. Implementing the Decentralization.................................................................................................... 8
3.3.1 Roles of the Principal Actors .................................................................................................... 8
3.4. Progress of Decentralization Process................................................................................................. 9
4. Evaluation Plan................................................................................................................................... 11
4.1. Study Objectives ............................................................................................................................. 11 4.2. Study Design ................................................................................................................................... 11 4.3. Sample Selection............................................................................................................................. 11
4.3.1. Municipalities ......................................................................................................................... 11 4.3.2. Public Health Facilities........................................................................................................... 13 4.3.3. Private Health Facilities.......................................................................................................... 13 4.3.4. Health Facility Clients ............................................................................................................ 13 4.3.5. Households ............................................................................................................................. 15
4.4. Data Collection Instruments ............................................................................................................ 15
4.4.1. Facility Questionnaires ........................................................................................................... 15 4.4.2. Client Exit Questionnaire........................................................................................................ 16 4.4.3. Household Survey Questionnaire............................................................................................ 16
4.5. Survey Procedures........................................................................................................................... 17
4.5.1. Facility Survey........................................................................................................................ 17 4.5.2. Client Exit Interview Survey..................................................................................................... 18 4.5.3. Household Data ........................................................................................................................ 18
5. Results: Facility Inventory & Observation Surveys ............................................................................ 19
5.1. Availability of Health Services........................................................................................................ 19
5.1.1. Family Planning Services........................................................................................................ 19 5.1.2. Child Health Services ............................................................................................................. 23 5.1.3. Maternal Health Services........................................................................................................ 23
5.2. Weekly Service Availability............................................................................................................ 26

iii
Contents
5.3. User Fees......................................................................................................................................... 27 5.4. Staff Availability ............................................................................................................................. 32 5.5. Staff Training .................................................................................................................................. 33 5.6. Group Talks..................................................................................................................................... 34 5.7. Information, Education, and Communication (IEC), Supply Stock-outs, & Record Keeping......... 36
5.7.1. Information, Education, and Communication (IEC) ............................................................... 36 5.7.2. Supply Stock-outs.................................................................................................................. 38 5.7.3. Record Keeping ..................................................................................................................... 39
5.8. Facility Supervision......................................................................................................................... 39
6. Results: Cost of Basic Health Services ............................................................................................... 43
6.1. Conceptual Issues and Relevance.................................................................................................... 43
6.1.1. Issue 1: Which costs?.............................................................................................................. 43 6.1.2. Issue 2: Definition of Output .................................................................................................. 44 6.1.3. Issue 3: Allocation of Costs to Specific Services:................................................................... 44 6.1.4. Issue 4: Cost and Efficiency.................................................................................................... 44 6.1.5. Issue 5: Relationship of Cost and Quality............................................................................... 44 6.1.6. Issue 6: Price of Inputs............................................................................................................ 45
6.2. Methods........................................................................................................................................... 45
6.2.1. Overview of Cost-Calculation Method ................................................................................... 45 6.2.2. Data Collection ....................................................................................................................... 47 6.2.3. Cost Calculations .................................................................................................................... 48
6.3. Baseline Results .............................................................................................................................. 52
6.3.1. Facility Sample ....................................................................................................................... 52 6.3.2. Total Recurrent Cost............................................................................................................... 52 6.3.3. Service Cost per Visit ............................................................................................................. 56
7. Results: Service Efficiency ................................................................................................................. 59
7.1. Conceptual Issues............................................................................................................................ 59 7.2. Methods........................................................................................................................................... 59
7.2.1. Average Staff Productivity...................................................................................................... 60 7.2.2. Staff Utilization Rate by Type of Staff.................................................................................... 60 7.2.3. Staff Utilization Rates by Facility........................................................................................... 61 7.2.4. Utilization Rates for Inpatient Beds........................................................................................ 62
7.3. Baseline Results .............................................................................................................................. 62
7.3.1. Average Staff Productivity...................................................................................................... 62 7.3.2. Staff Utilization Rates............................................................................................................. 64 7.3.3. Utilization Rate for Inpatient Beds.......................................................................................... 65 7.3.4. Cost Recovery......................................................................................................................... 65
8. Results: Client-Exit Interview & Client Perspectives on Service Quality........................................... 69
8.1. Public Facility Clients: Characteristics............................................................................................ 70 8.2. Basic Indicators of Quality in Public Facilities ............................................................................... 70
8.2.1. Convenience of Hours of Operation ....................................................................................... 70 8.2.2. Waiting Times......................................................................................................................... 72 8.2.3. Medical Consultations ............................................................................................................ 76 8.2.4. Willingness to Return to Facility ............................................................................................ 79 8.2.5. Availability of Medicines........................................................................................................ 79 8.2.6. Facility Appearance ................................................................................................................ 79
8.3. Private-Sector Clients: Indicators of Basic Quality of Health Services ........................................... 81
8.3.1. Private Facility Client Characteristics..................................................................................... 81 8.3.2. Private-Sector Client Views on Basic Quality Indicators........................................................ 83
8.4. Findings: Basic Indicators of Equity & Other Client Characteristics .............................................. 85

iv
8.4.1. Conceptual Issues ................................................................................................................... 85 8.4.2. Equity in the Use of Health Services ...................................................................................... 86 8.4.3. Distribution & composition of health expenditure.................................................................. 88 8.4.4. Client Residence or Place of Origin........................................................................................ 91 8.4.5. Summary................................................................................................................................. 93
9. Results: Household Survey and Patterns of Service Utilization.......................................................... 95
9.1. Classification of Households by Economic Status........................................................................... 95 9.2. Prenatal Care Services..................................................................................................................... 96
9.2.1. Use of Prenatal Services ......................................................................................................... 96 9.2.2. Source of Prenatal Services..................................................................................................... 96 9.2.3. Timing and Frequency of Prenatal Services............................................................................ 97 9.2.4. Economic Determinants of Prenatal Service Use.................................................................... 98
9.3. Delivery........................................................................................................................................... 98
9.3.1. Utilization Patterns.................................................................................................................. 98 9.3.2. Birth Attendants.................................................................................................................... 100 9.3.3. Cesarean Births..................................................................................................................... 100 9.3.4. Determinants of Delivery Location....................................................................................... 100 9.3.5. Economic Determinants of Delivery Care Use ..................................................................... 102
9.4. Post-Natal Care.............................................................................................................................. 103
9.4.1. Use of Post-Natal Care.......................................................................................................... 103 9.4.2. Economic Determinants of the Use of Post-Natal Care ........................................................ 103
9.5. Vaccination ................................................................................................................................... 105
9.5.1. Utilization Patterns................................................................................................................ 105 9.5.2. Economic Determinants of Vaccination Use ........................................................................ 105
9.6. Diarrhea......................................................................................................................................... 107
9.6.1. Prevalence of diarrhea........................................................................................................... 107 9.6.2. Care-Seeking Behavior ......................................................................................................... 107 9.6.3. Economic Determinants of Diarrhea Care ............................................................................ 108
9.7. Acute Respiratory Infection (ARI) ................................................................................................ 108
9.7.1. ARI Prevalence..................................................................................................................... 108 9.7.2. Care-Seeking Behavior ......................................................................................................... 110 9.7.3. Economic Determinants of ARI Care ................................................................................... 113
9.8. Family Planning ............................................................................................................................ 114
9.8.1. Contraceptive Prevalence...................................................................................................... 114 9.8.2. Method Mix .......................................................................................................................... 115 9.8.3. Sources of Contraceptive Supply.......................................................................................... 116 9.8.4. Quality of Family Planning Services..................................................................................... 116 9.8.5. Economic Determinants of Contraceptive Use ..................................................................... 119 9.8.6. User Characteristics, Reasons for Use, and Method Preference............................................ 119
9.9. Health and Sickness Among Household Members Over Five Years of Age................................. 121
9.9.1 Sample Characteristics and Loss of Income Due to Illness or Injury.................................... 121 9.9.2. Care-Seeking Behavior ......................................................................................................... 123 9.9.3. Source of Care ...................................................................................................................... 123 9.9.4. Economic Determinants of Health Services Use................................................................... 125
9.10. Availability & Use of Health Facilities..................................................................................... 127
9.10.1. Facility of Choice ................................................................................................................ 127 9.10.2. Facility Geographic Proximity............................................................................................. 127 9.10.3. Reasons for Bypassing Closest Facility ............................................................................... 128
REFERENCES......................................................................................................................................... 131 ANNEX A: Maps

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    Andean Geology 39 (3): 541-547. September, 2012 Andean Geology doi: 10.5027/andgeoV39n3-a09 formerly Revista Geológica de Chile www.andeangeology.cl PALEONTOLOGICAL NOTE Descripción de una huella de terópodo de la Formación Misiones: primer fósil mesozoico fidedigno de Paraguay Silvina de Valais¹, Víctor Filippi², Sonia Molinas², Ricardo Souberlich² ¹ Consejo Nacional de Investigaciones Científicas y Técnicas-Instituto de Investigación en Paleobiología y Geología, Universidad Nacional de Río Negro, Isidro Lobo y Belgrano (8332),General Roca, Río Negro, Argentina. [email protected]; [email protected]. ² Laboratorio de Paleontología, Facultad de Ciencias Exactas y Naturales-Universidad Nacional de Asunción, Campus San Lorenzo, Paraguay. [email protected] RESUMEN. El registro fosilífero del Mesozoico de Paraguay es prácticamente nulo, siendo la única excepción hasta la fecha, la mención de dos rastrilladas de vertebrados -actualmente desaparecidas- en lajas de las explanadas de la Iglesia de la Catedral y de la Iglesia María Auxiliadora. Se considera que las mismas habrían procedido de la cantera San Cris- tóbal del Departamento de Misiones, al Suroeste de Asunción, perteneciente a la Formación Misiones (probablemente Cretácico Inferior). Recientemente, en una nueva laja de la explanada de la Iglesia María Auxiliadora, proveniente de la misma cantera que los especímenes desaparecidos, fue hallada una huella tridáctila de mediano tamaño, presentada y estudiada en el presente trabajo. La icnita exhibe características propias de las huellas de dinosaurios terópodos. La traza constituye la única prueba fidedigna no solo de la presencia de dinosaurios en Paraguay, sino también del primer fósil mesozoico del país. Palabras clave: Huella de vertebrado, Terópodo, Formación Misiones, Mesozoico, Paraguay.
  • CORDILLERA Autores Benjamín Grassi Fabricio Vázquez Raquel Rodríguez

    CORDILLERA Autores Benjamín Grassi Fabricio Vázquez Raquel Rodríguez

    TEKOHA HA AKÃRAPU’Ã KATUIRÃ Motenondeha Ministerio del AMBIENTE Y DESARROLLO SOSTENIBLE EVIDENCIAS CIENTÍFICAS E IMPACTOS ECONÓMICOS DEL CAMBIO CLIMÁTICO EN EL DEPARTAMENTO DE CORDILLERA Autores Benjamín Grassi Fabricio Vázquez Raquel Rodríguez Producción general Ulises Lovera Gaona, Ministerio del Ambiente y Desarrollo Sostenible Nora Clotilde Páez Ortiz, Ministerio del Ambiente y Desarrollo Sostenible Jorge González, Secretaría Técnica de Planificación del Desarrollo Económico y Social Briham Piñánez, Secretaría Técnica de Planificación del Desarrollo Económico y Social Jéssica Servín, Secretaría Técnica de Planificación del Desarrollo Económico y Social Mabel Cubilla, Secretaría Técnica de Planificación del Desarrollo Económico y Social Andrea Rodríguez, Fundación Avina Eduardo Rotela, Fundación Avina Paula Burt, Fundación Avina Paula Ellinger, Fundación Avina Virginia Scardamaglia, Fundación Avina Maquetación Nathalia Rojas Balsevich Aprobación del reporte por el Ministerio del Ambiente y Desarrollo Sostenible Agosto 2020 Se permite la reproducción total o parcial del contenido de esta publicación para propósitos académicos o sin fines de lucro, siempre y cuando la fuente sea citada inequívocamente. Para citar la fuente Grassi, B., Vázquez, F. y Rodriguez, R. 2020: Evidencias científicas e impactos económicos del cambio climático en el departamento de Cordillera. MADES-STP. Asunción, Paraguay. TEKOHA HA AKÃRAPU’Ã KATUIRÃ Motenondeha Ministerio del AMBIENTE Y DESARROLLO SOSTENIBLE EVIDENCIAS CIENTÍFICAS E IMPACTOS ECONÓMICOS DEL CAMBIO CLIMÁTICO EN EL DEPARTAMENTO DE CORDILLERA Consultores Benjamín Grassi Fabricio Vázquez Raquel Rodríguez AGRADECIMIENTOS A las personas que aportaron mucho profesionalismo a este trabajo; Lic. Diana EN EL DEL CAMBIO CLIMÁTICO ECONÓMICOS EVIDENCIAS CIENTÍFICAS E IMPACTOS Benítez (FPUNA), Lic. Sergio Méndez (IB), Lic. Héctor López (DINAC), Lic. Alcides Domínguez (FPUNA), Ana Jara (SEN) y Arnaldo Rodríguez, entre otros.
  • Epoa) Paraguay Floods

    Epoa) Paraguay Floods

    Page | 1 Emergency Plan of Action (EPoA) Paraguay Floods APPEAL Operation n° MDRPY016; GLIDE no. FL-2014-000007- PRY Date of issue: 10 July 2014 Date of disaster: 9 June 2014 Operation manager: Felipe Del Cid Point of contact: Luis Diaz de Bedoya, president of the Paraguayan Red Cross Operation start date: 9 June 2014 Expected timeframe: 12 months Overall operation budget: 1,815,467 Swiss francs Number of people affected: 46,272 families (231,360 Number of people to be assisted: 22,500 people people) (4,500 families) Host National Society: Paraguayan Red Cross Red Cross Red Crescent Movement partners actively involved in the operation: International Committee of the Red Cross (ICRC), Finnish Red Cross and Swiss Red Cross Other partner organizations actively involved in the operation: National Emergency Secretariat [Secretaría de Emergencia Nacional- SEN], Agencies of the United Nations, USAID Office of Foreign Disaster Assistance (OFDA), Oxfam A. Situation analysis Description of the disaster According to the situation report of the Ministry of Emergency of Paraguay on 5 July 2014, the intense rains in Paraguay, which started in March 2014, have been unusually intense for the season, leading to severe floods in rural communities and urban areas. The effects have continued to be felt with the flooding from the rapidly rising Paraná river and Paraguay river. To date, 46,272 families (231,360 people) from five departments in the country have been affected by the flooding and require humanitarian support. The Asunción Municipality declared a state of emergency and the National Emergency Secretariat has requested support from the Paraguayan Red Cross in terms of water and sanitation and the deployment of additional shelter support.
  • Electoral Observation Mission in Paraguay 1998

    Electoral Observation Mission in Paraguay 1998

    Electoral Observation Mission in Paraguay 1998 Unit for the Promotion of Democracy General Secretariat Organization of American States Subject to Revision and not for Release to General Public Pending Consideration by Permanent Council. Table of Contents Executive Summary .....................................................................................................................4 PART I General Context of the Electoral Observation Mission............................................................8 1. Background information on Paraguay.......................................................................................9 PART II The Electoral Observation Mission..........................................................................................11 1. Origin and mandate of the Mission..........................................................................................12 2. Start and functioning of the Mission........................................................................................14 PART III Institutional Framework.............................................................................................................16 1. Electoral Justice System.........................................................................................................17 2. Political parties.......................................................................................................................19 3. The Press ..............................................................................................................................21