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Health Care Decentralization in Paraguay 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. December 1999 Printed on recycled paper 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 organiza- tions 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. Acknowledgements i 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
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