Printer Friendly

Stewardship and governance: structuring dimensions for Implementation Primary Health Care Policies in Paraguay, 2008-2017.

Introduction

Expanded freedom in democratic contexts and access to information through new technologies has increased the participation and expectations of society vis-a-vis its health authorities, including the internal health public (professionals and health staff). This setting exposes and makes visible the conduction methods and stewardship competences of managers responsible for the management and implementation of public health policies. This study proposes the analysis of PHC stewardship and governance.

Paraguay is a unitary and decentralized republic with a political and administrative distribution organized into 17 departments and 18 health regions, including capital Asuncion and 249 municipalities. The estimated population was 7,112,594 inhabitants in 2017, of which 59% speak the original alternative language "Guarani" at home, and the illiteracy rate is 5.2%. The average life expectancy of women and men is 75.12 years and 70.83 years, respectively. The out-of-pocket expense per capita is one of the lowest in the region, with US$ 461 in relation to the Gross Domestic Product (GDP), considering the Latin American mean of US$ 718 per capita. Institutional deliveries have risen to 97%. The Human Development Index (HDI) holds the 110th spot (0.693) and the Gini index places the country at 48.3, although Paraguay stopped being among the most inequitable countries in Latin America (1-5).

The Paraguayan health system is inserted in a macroeconomic market model characterized by high segmentation and fragmentation, weak articulation and coordination among subsectors, with organizational adjustments to the system that have been incorporated through regulations of Law 1032/96 in the last 22 years. Social security covers around 17% of citizens, which is the lowest in the region, and the private subsystem does not exceed 7% (6,7).

The Ministry of Public Health and Social Welfare (MSPBS), simultaneously develops functions of stewardship, supply and financing and assumes the responsibility of ensuring health to 100% of the population, with real coverage close to 65%, through an integrated network of services, organized by levels of care and complexity, with asymmetric decentralization processes and current trend towards centralization (8-10).

In 2008, a model of care based on family health facilities and teams (USF) (ESF) was incorporated, which are integrated at the local level to provide immediate response and resolution of health problems and needs to individuals, households and communities in defined social territories, promoting a shared responsibility and management of intersectoral actions aimed at ensuring continuity of care, promoting functionality, integrality and integration of existing service networks, improving enabling conditions and environments, organization and integration of horizontal programs with a high health impact (11,12).

This study mainly aims to analyze the influence exerted by conduction methods in the process of implementing the renewed Primary Health Care model within the framework of government changes in the last nine years, through a systemic approach to the different issues that emerge in settings of political instability that influence and affect health outcomes (13,14).

Conceptual framework

The complexity and interdependence of political, economic and social variables underpin and influence the conduction methods and condition the course of implementation of public health policies and the ability to solve problems and needs related to the social determinants of health. In the case of PHC, governance proposes the reconfiguration of the health authority's conduct profile, readjusting the means to achieve the agreed political objectives and results and incorporating features such as professionalism, conjugation of technical and political leadership, balance between efficiency and equity and its consequences in terms of decisions, respect for the principles and regulatory, administrative and legal frameworks inherent to the public sphere, which will allow the exercise of the governing role on behalf of the government, as part of a new social pact at the service of public interest, proposing a new scheme of relationships between government and society, understood as good governance (15-18).

In a democratic context, governance is a systemic function that facilitates adaptation and linkages between State and civil society, public administration and organizations, institutions and citizenship through exercises and dynamics of integration that progressively increase cohesion between higher and lower levels, in balance with cultural practices, openness to the application of new methods, tools, planning devices and information systems, with the purpose of influencing beyond the health field, projecting the modification of the social environment for the effective protection of an established right (19).

It is possible to revive, in the health field, an effective model aimed at resolving conflicts, in settings of large power asymmetries, where governance can affect the equity and sustainability of egalitarian distributive policies. This conception gives rise to the idea of reflective governance, which repositions the figure of the State, responsible for the equality of economic and social conditions, to balance forces and power in decision-making (20).

Substantive competences for PHC management are projected in the health and intersectoral realm, considering new coordination mechanisms, new strategies, different performance criteria, based on values, socio-affective attitudes, political intuition, suitability, negotiating capacity to cope with level of resistance and conflict nodes (21-22).

The effects of governability rely on the dynamic balance between styles of government and social intelligence and capacity to achieve government responses at different levels. Governability occurs when spaces are institutionalized so that organizations enable citizens to interact with governmental levels, exercise their civil and political rights and perceive democratic incentives that protect population groups in settings of inequality or political errors (23).

In countries with clear socioeconomic inequalities, digital gaps and access to information affect the public function's transparency and effectiveness. E-governance is an essential link to strengthen the capacities and citizen participation in the decision-making processes (24).

In the context of PHC, the sustainable conduction method must overcome the traditional hierarchical scheme, incorporating social capital, participatory spaces, cooperation modes and flexible work styles, peer evaluations and self-evaluations, as well as considering expectations of stakeholders and shared responsibility between civil society and public authorities. It must adapt changes in structures, management procedures and power behavior for the adequate management of emerging conflicts, endorsed by the leadership of the public and political function (25-27).

Interdependence between politics, governability and health outcomes has great relevance because of its effects in strengthening institutionality, when government levels, management and civil society stakeholders manage to operate together. Therefore, good governance corresponds to the dynamics of policy networks within a framework of responsibility in the exercise of public action, where predominance of the social and economic commitment that generates balance and the management of a code of values is recognized (28,29).

The revised theoretical perspectives support the understanding of health management modalities, linking to research questions and contributing with ideas originated in the findings for the construction of this public policy.

Methods

This is a qualitative study based on the grounded theory by Glasser & Strauss (30). This methodology uses the interpretation of texts and statements to approximate knowledge of the implementation of the PHC policy in Paraguay in three governmental periods (2008-2012, 2012-2013 and 2013-2017). Sampling included 24 key stakeholders who exercised leadership, management and technical advice roles in PHC. Academics, experts and consultants from international organizations, selected by convenience according to professional profile, experience and knowledge in the implementation of this public policy, from national, regional and local levels were also included. A matrix of identification of key players was drawn up, with complete information, stratifying the selected sample by institution (public and NGO), levels of care and period of government. We collected, analyzed and conceptualized contributions of respondents in the period 2015-2017.

The categories of analysis explored included knowledge and scope of the function of health stewardship, interpretation of governance methods, mechanisms for the selection of government managers and availability of evaluation tools, as well as technical capacities and skills, regulatory and financial management aspects, factors, mechanisms and interactions that facilitate or hinder governance, social cohesion, consolidation of intersectoral achievements, effective coordination of networks of people and institutions in order to achieve results within the framework of this policy. Chart 1 shows the systematization of these categories, specifying realms and sub-realms. Data processing started with the elaboration of a list of those categories, adding other emerging ones, selecting significant discursive fragments, organizing them by realms, sub-realms, concepts and constructs, generating hierarchies and specifications. It was necessary to proceed to an interpretation of the referred conduction processes regarding PHC stewardship and governance, integrating findings, context, prior knowledge and experience in that field. Output was generated through Atlas ti software, and a complementary Excel matrix was used to sort and systematically analyze the categories. Results are organized from the key messages obtained from the interviews, in segments selected according to a priori codes and some of the emerging codes. Ethical considerations, informed consent, confidentiality, anonymity and voluntary participation were taken into account.

Results

Knowledge about Stewardship and Governance functions

The concept and functions of "health stewardship" have had several interpretations, with a predominance of a structured concept of conduct established by international organizations (31), linked to public policymaking and exercise of health administration, formulation of plans, programs and projects, provision of services, application of laws and regulations and implementation of standards. Some stakeholders affirmed that stewardship is put to the test through the ability to overcome bureaucratic hurdles, introduction of innovations, effective response to events or diseases of collective impact, power to call for the effective participation of the community in the social management of health, continuous and coherent application of health promotion strategies that allow for the joint installation of changes and transformations.

"Governance" has been linked to the integration of referents from different institutions in decision processes, in formal participation levels. Others related this concept to the public exercise of functions on behalf of the State and some showed lack of knowledge and difficulties to understand its meaning.

Selection of leadership positions in the public sector

There was consensus in affirming that some institutions carry out merit-based and aptitude-based competitions, although in most cases the designation for the exercise of management positions builds on trust, where competences are frequently not in accordance with the challenges and responsibilities. The selection based on skills and leadership originated in a solid academic education, or respect for a public administrative career that grants leadership skills is exceptional.

In the three periods of government, the competition has been incorporated for the operational levels, but not for the managerial levels (Regional level professional, 1st period).

Both the selection of ministers and selection of management cadres historically respond to the appointment by the Executive Power (Former Minister).

Ministers in office are surrounded by people who followed their vision not always based on suitability (Central level manager, 3rd period).

Availability of performance evaluation tools for managers

There are no known mechanisms to evaluate the skills and abilities of high public management or senior management that allow comparing, discerning and qualifying the management and conduction of processes with guidance and results.

... Directive cadres are evaluated indirectly through citizenship opinion surveys; in other cases, performance is measured through numerical weights, which do not reflect reality (Expert, 2nd period).

Regulatory devices

In the three periods of government, the application of regulatory tools at the first level of care was weak, both in the central and peripheral activities. The lack of specific technical evaluation and systemic analysis are confounded with control devices and the performance of specific audits, which prevent an overview of the limits of functionality of the local micro-networks where USFs are inserted. No sustained adjustments are achieved, despite available standards, manuals, protocols and guides and other operational tools, considered as a strength and indicators of stewardship.

... There is a perception that regulatory and corrective measures are installed once management problems are detected, and respond to complaints, which are followed by a passive wait for the response. (Consultant, International Organization, 3rd period).

Evaluation activities

In the first stage, external evaluations allowed an approximation to the macro diagnosis of ongoing processes, delaying the design of tools for the systematic evaluation of this new public policy. This was attributed to the short periods between governments, the use of usual indicators used in management controls of service networks and health programs, considered inadequate due to the need to identify new performance indicators that reflect the specific introduction and functionality of PHC.

... Social control is relevant when there are no other means to detect institutional shortcomings that prevent potential beneficiaries from organizing themselves properly and access their benefits. (Former Minister).

Financing model and sustainable sources of resources

The annual projection of funds conceived at the onset of the first stage of implementation of the renewed PHC raised the annual increase of 200 USFs per year. In the last two rotations of government, financial restrictions have shown the shift of PHC as a political priority, reflected in the discontinuity of installation and functionality of new family health facilities, reaching less than 40% of expected coverage in 9 years.

... There is a consensus that mechanisms for allocating resources are not carried out according to a correspondence analysis with Primary Health Care's fields of action, including promotional, preventive, curative and rehabilitation activities ... (International Expert)

... There are no independent procurement processes; they are immersed in the general procurement processes of the Ministry of Health, in turn related to the complex organization and financial flow of the Ministry of Finance, which affects timely access to essential resources. The flow of PHC personnel and professionals remuneration follows its normal course, salaries credited to accounts. The financial flow for the acquisition of medicines and supplies is managed on a large scale.... It is difficult to clearly define the execution of assigned funds ... (Manager, 2nd period of government).

Quality of technical cadres

It has been affected by the successive rotation of governments, as well as the continuity of managerial training and their competences to exercise health stewardship, reflected in the performance, communication styles, peer relationship method, negotiation and conflict resolution and comprehensive knowledge of the realms subject of conduction.

Chart 2 summarizes the results, showing the realms and sub-realms of stewardship and governance in each period of government.

Discussion

The analysis of the capacities of conduction and construction of governance in the course of implementation of the renewed Primary Health Care shows the strong link between political processes and health outcomes. The successive changes of government in settings of political instability have put to the test the stewardship capacity and other multiple variables, and autonomy, leadership of political and civil society actors and financial sustainability (32,33) were compromised.

The successive turnover of managers, technical cadres and operative personnel has influenced governance, affecting the continuity of intersectoral achievements, coordination processes of subnational teams, quality of planning and evaluation, effective coordination by levels for the implementation of strategic guidelines, commitment of technical working groups, change of priorities in the management agendas, and social cohesion has been weakened. Other effects generated have been the loss of clarity in the conduction and coordination of the guidelines established in the PHC's initial Strategic Plan, losing the focus that effectively links health problems to their social, cultural and individual causes (34).

There is a need to concentrate State action on strategic functions for the development of human and social capital, for the strengthening of the rule of law and expanded and strengthened democracy (35,36).

Different conduction capacities have been seen in the three periods of government, although some realms have been more affected, such as weak information system, difficulties to develop systematic evaluation processes and the continuous training of the health workforce.

With regard to regulatory capacity, this realm is cross-cutting with all other sub-realms of stewardship, considering that it is linked to political variables of power and governability (37). Regarding the cyclical process of reorganization of public institutions and offices, after each change of government, and in particular those processes linked to the PHC strategy, the role of international financial organizations and technical cooperation agencies managed to modulate the political processes with technical rationality in the first stage, and were clearly weakened and with low influence on the following health executives and their technical teams in the subsequent stages, in which the linkage of ideological models to models of financing and conduction is made visible.

None of the three periods of government was able to define an explicit financing model adapted to the requirements and oriented to decentralized management processes, rather opting for a centralized administrative model. Despite the enunciations of the current National Health Policy, there is a lack of reforms that reflect the orientation toward universality. The content of the health discourse is weak, health professional training was discontinued, emphasis was given to emergencies and conjunctures, fleeting visibility of commemorative health days, lack of analysis of MDGs versus SDGs, lack of analysis of health system performance indicators, identification of local priorities for the strengthening of the quality of personal care (HAQ) that show very low values.

Rarely does a political health process demonstrate coherence and reflect in the implementation what has ideally been formulated in its statements, as a linear, rational process from the formulation to the application of the policy. The complex settings in which health-related decisions are made rarely articulate the context, content, specific interests and objectives with the expected results as a theoretically recommendable sequence. The strengthening of strategic stakeholders for change can influence the reorganization of the health services system, facilitate institutional, structure and management changes, affecting the distribution of power and favoring PHC's vision and interests (38,39).

Without a doubt, governance is a democratic reinforcement, a device that promotes equity, an opportunity for economic growth and social progress, around imperatives of good governance, which implies an efficient public management, with increased transparency, quality, costs and adequate financing. The existence of governance bodies favors the analysis of different dynamics and processes and are an alternative to tackle the problems as catalysts, facilitating cooperation and interaction between the State and non-state stakeholders for the implementation of policies, programs and plans (40,41).

Conclusions

The findings suggest that the implementation of this public policy has been influenced by political instability. The successive rotation of governments in the last five years has diverted the implementation of PHC from its normal course, weakening comprehensive approaches and their potential as a State policy, reaching a coverage of 44% in nine years.

The guiding role has been tested beyond the usual performance criteria, given the challenges for overcoming various obstacles and bureaucratic hurdles to install changes and transformations around this public policy, including adaptability to complex settings, financial limitations and resolution of crises.

We identified the need to give strong impetus to training programs for managers and technical cadres that incorporate competences in a framework of demonstrated suitability according to position, area or performance organization to carry out the social development plan, and long-term projected social policies, incorporating competition for managerial positions.

Regarding governance, we note a shift between one government and another, moving from a flexible and inclusive mode to stricter hierarchy-oriented modalities.

Financial management has been affected by structural constraints, quality of spending, level of efficiency and coordination between the central government and subnational governments. The flows of resources have been insufficient to implement functions and norms, agreements and social and political dynamics, and to project sustainable changes.

Regulatory capacity was characterized in the beginning by the implementation of incentives and commitments, and in the following stages by the incorporation of oversight processes, while not of systematic evaluations to introduce improvement plans, gradually installing restrictive mechanisms that have affected social cohesion, reincorporating red tape practices. The reconstruction of governance will require considering the importance of mediation, social referents and interested parties from the public and private spheres, assuming dynamic and facilitating roles of interactions and relationships. This can exert influence to revive and maintain progress and achievements.

DOI: 10.1590/1413-81232018237.09242018

Collaborations

MS Cabral-Bejarano elaborated the design and the methodology, fieldwork, organization of the database, analysis, discussion of the results and drafting of the scientific paper. G Nigenda, A Arredondo and E Conill participated in the review of the design and methodology of the study and analysis and discussion of the results.

References

(1.) Direccion General de Encuestas, Estadisticas y Censos (DGEEyC). Encuesta Permanente de Hogares. Paraguay, 2016. [Online]. [consultado 2016 Dic 12]. Disponible en: www.dgeec.gov.py/microdatos/

(2.) Dullak R, Rodriguez-Riveros MI, Bursztyn I, Cabral-Bejarano MS, Ruoti M, Paredes ME, Wildberger C, Molinas F. Primary Health care in Paraguay: overview and prospect. Cien Saude Colet 2011; 16(6):2865-2875.

(3.) Paraguay. Ministerio de Salud Publica y Bienestar Social. Direccion General de Descentralizacion. Informe Descentralizacion Sanitaria 2010. [Online]. [consultado 24 de mayo de 2014] Disponible en: http://www.mspbs. gov.py/dependencias/Direccion General de Descentralizacion/Informe Descentralizacion 2010

(4.) Benitez G. Informe Paraguay: Distribucion del gasto en salud y gastos de bolsillo, principales resultados. Asuncion: Centro de analisis y difusion de la Economia Paraguaya; 2014.

(5.) Gimenez Caballero E, Rodriguez JC, Ocampos G, Flores L. Composicion del gasto de bolsillo en el sistema de salud del Paraguay. Mem. Inst. Investig. Cienc. Salud 2017; 15(3):64-72

(6.) Rodriguez-Riveros MI, Bursztyn I, Ruoti M, Dullak R, Paez M, Orue E, Sequera M, Lampert N, Gimenez G, Velazquez S. Evaluacion de la Atencion Primaria de Salud en un contexto urbano: percepcion de actores involucrados. Saude Debate 2012; 36(94):449-460.

(7.) Monroy Peralta JG, Villagra Carron J, Molinas Maldonado MM, Biedermann Villagra, TM. Informe de Evaluacion a Programas Publicos. Programa de Atencion Primaria de Salud y Unidades de Salud de la Familia. Sistema de seguimiento y evaluacion en el marco del presupuesto por resultados. Paraguay 2011. [Online] [consultado 2014 Mar 3]. Disponible en: http://www.mspbs. gov.py/planificacion/wp-content/uploads/2012/06/ Evaluacion_APS_Monroy2011.pdf

(8.) Paraguay. Ley N[degrees] 3007/06. Que modifica y amplia la Ley 1032/96. 2006. [Online] [consultado 2015 Jun 20]. Disponible en: http://www.cird.org.py/salud/descarga. php?docs_id=299

(9.) Espelt A, Borrell C, Rodriguez-Sanz M, Muntaner C, Pasarin MI, Benach J, Schaap M, Kunst AE, Navarro V. Inequalities in health by social class dimensions in European countries of different political traditions. Int J Epidemiol 2008; 37(5):1095-1105.

(10.) Republica del Paraguay. Ley 1032 que crea el Sistema Nacional de Salud. Paraguay; 1996. [Online]. [consultado 2014 Feb 2]. Disponible en: http://www.mic.gov. py/v1/sites/172.30.9.105/files/Ley%2048.pdf

(11.) Organizacion Panamericana de Salud (OPS), Organizacion Mundial de la Salud (OMS). La Atencion Primaria de Salud mas necesaria que nunca. Informe sobre la Salud en el mundo 2008. [Online] [consultado 2014 Mar 10]. Disponible en: http://www.who.int/ whr/2008/08_report_es.pdf

(12.) Organizacion Panamericana de la Salud (OPS). Consulta Regional de Montevideo--Uruguay (Declaracion Regional de APS) presentada en la 46 asamblea de la CD. Montevideo: OPS; 2005.

(13.) Organizacion Panamericana de la Salud (OPS). Documento de posicion de la APS sobre el legado de Alma Ata, lecciones aprendidas y experiencias extraidas de los procesos de reforma de los sistemas de salud. Washington: OPS; 2005.

(14.) Conill EM, Fausto MCR, Giovanella L. The contribution of comparative analysis to a comprehensive evaluation framework for primary care systems in Latin America. Rev. Bras. Saude Matern. Infant. 2010; 10(Supl. 1):S15-S27.

(15.) Conill E. Politicas de atencao primaria e reformas sanitarias: discutindo a avaliacao a partir da analise do Programa Saude da Familia em Florianopolis 1994-2000. Cad Saude Publica 2002; 18(Supl.):191-202.

(16.) Macinko J, Montenegro H, Nebot Adell C, Etienne C y Grupo de Trabajo de Atencion Primaria de Salud de la Organizacion Panamericana de la Salud. La renovacion de la atencion primaria de salud en las Americas. Rev Panam Salud Publica 2007; 21(2/3):73-84.

(17.) Meneu R, Ortun V. Transparencia y buen gobierno en sanidad: Tambien para salir de la crisis. Gaceta Sanitaria 2011; 25(4):333-338.

(18.) Arredondo Lopez AA, Orozco E. Temas selectos en Sistemas de Salud. Costos, Financiamiento, Equidad y Gobernanza: Conceptos, Tendencias y Evidencias. Mexico: UAG; 2009.

(19.) Flores W. Los principios eticos y los enfoques asociados a la investigacion de la gobernanza en los sistemas de salud: implicaciones conceptuales y metodologicas. Rev. Salud Publica 2010; 12(Supl. 1):28-38.

(20.) Magrini Pigatto JAM, Cacciamali MJ, Jorge MJ. Primary Health Care Governance: Case Studies in Argentina and Brazil. Journal on Business Review 2012; 2(2):77-84.

(21.) Bambra C, Joyce KE, Maryon-Davies A. Strategic review of health inequalities in England post-2010 (Marmot Review): Task Group 8: priority public health conditions: final report. London: University College London: 2009.

(22.) Saltman RB, Ferroussier-Davis O. The concept of stewardship in health policy. Bull World Health Organ 2000; 78(6):732-739.

(23.) Exworthy M. Policy to tackle the social determinants of health: using conceptual models to understand the policy process. Health Policy Plan 2008; 23(5):318-327.

(24.) Cunill Grau N. Las politicas con enfoque de derechos y su incidencia en la institucionalidad publica. Revista del CLAD Reforma y Democracia 2010; 46:43-72.

(25.) Ortuzar MG. El desplazamiento del poder en Salud. Astrolabio 2017; 20:47-63.

(26.) Ortuzar MG. "Gobernanza" y "Gobernanza en Salud": Una nueva forma de privatizar el poder politico? Revista Internacional de Etica y Politica 2014; 5:63-86.

(27.) Prats J. Gobernabilidad democratica para el desarrollo humano. Marco conceptual y analitico. Revista Instituciones y Desarrollo 2001; 10:103-148

(28.) De la Torre R. Medicion del bienestar y progreso social: una perspectiva de desarrollo humano. Revista Internacional de Estadistica y Geografia 2011; 2(1):18-35.

(29.) Arredondo Lopez A, Orozco Nunez E, Wallace S, Rodriguez M. Indicadores de gobernanza para el desarrollo de estrategias binacionales de proteccion social en la salud de los migrantes. Saude Soc 22(2):310-327.

(30.) Hernandez Carrera RM. Qualitative research trough interviews: Its analysis by Grounded Theory. Cuestiones Pedagogicas 23:187-210

(31.) Organizacion Panamericana de Salud (OPS), Organizacion Mundial de la Salud (OMS). Salud en las Americas. Rectoria y Gobernanza para la Cobertura Universal. Washington: OPS, OMS; 2017.

(32.) Perez Andres C. Sobre la Metodologia Cualitativa. Rev Esp Salud Publica 2002; 76(5):373-380.

(33.) Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet 2001; 358(9280):483-488.

(34.) Sandoval CA. Investigacion Cualitativa. In: Programa de Especializacion en Teoria, Metodos y Tecnicas de Investigacion Social. Bogota: Instituto Colombiano para el fomento de la Educacion Superior; 1997. p. 187. Modulo IV.

(35.) Marin J. Fortalecimiento de la funcion rectora de las autoridades sanitarias en las reformas del sector de la salud. Rev Panam Salud Publica 2000; 8(1-2):21-32.

(36.) Nigenda G, Alcalde-Rabanal J, Gonzalez-Robledo LM, Servan-Mori E, Garcia-Saiso S, Lozano R. Eficiencia de los recursos humanos en salud: una aproximacion a su analisis en Mexico. Salud publica de Mexico 2016; 58(5):533-542

(37.) Rodriguez C, Lamothe L, Barten F, Haggerty J. Governance and health: meaning and implications in Latin America. Rev Salud Publica 2010; 12(Supl. 1):151-159.

(38.) Prats J. Servicio Civil y Gobernabilidad Democratica. Administracion & Ciudadania 2009; 3(3):65-94.

(39.) Paraguay. Ministerio de Salud Publica. Organizacion Panamericana de Salud (OPS)/Organizacion Mundial de la Salud (OMS). Exclusion Social en Salud Paraguay; 2006. [cited 2013 Feb 27]. Available from: http://www. paho.org/hq/dmdocuments/2010/Exclusion_Salud_ Paraguay_2007.pdf

(40.) Declaracion de Alma Ata. [Online]. [cited 2013 Feb 27]. Available from: http://www.alma-a.es/declaraciondealmaata/declaraciondealma

(41.) Bascolo E. Gobernanza y economia politica de las politicas de APS en America Latina. Cien Saude Colet 2011; 16(6):2763-2772.

Article submitted 15/02/2018

Approved 12/03/2018

Final version submitted 05/04/2018

Maria Stella Cabral-Bejarano [1]

Gustavo Nigenda [2]

Armando Arredondo [3]

Eleonor Conill [4]

[1] Direccion General de Desarrollo de Servicios y Redes de Salud, Centro de Investigacion en Politicas, Sistemas y Servicios de Salud, Universidad Catolica Ntra. Sra. de la Asuncion. Olegario Andrade 3078, LA Herrera. Asuncion Paraguay. cabralbejarano. mariastella@gmail.com

[2] Partners in Health. Boston MA EUA.

[3] Centro de Investigacion en Sistemas de Salud, Instituto Nacional de Salud Publica de Mexico. Mexico DF Mexico.

[4] Observatorio Iberoamericano de Politicas e Sistemas de Saude, Universidade Federal de Santa Catarina. Florianopolis SC Brasil.
Chart 1. Categories of analysis: realms and sub-realms of PHC
Stewardship and Governance--Paraguay.

                       Themes        Analysis            Realms
Sub-realms                           categories

Policy planning and    STEWARDSHIP   Competences         Political
formulation                                              Skills

Sectoral regulatory
and legislative
capacity

Financial management
capacity in PHC

Stewardship                                              Operational
functions                                                Skills

Health system

PHC strategy

RIISS                                                    Operational
                                                         Skills

USFs

HR-PHC

Training and                                             Managerial
leadership                                               Skills

Empowerment and
Responsibility

Rights approach                      Principles          Transparency
                                     and Values
Voice and
accountability

Fight against
corruption

Political Ethics

Coordination           GOVERNANCE    Intersectoriality   Co-conduction
Mechanisms

Areas of influence

Participation in                                         Intersectoral
decision-making,                                         Participation
regulation and
accountability
processes

Participation in
ASIS and social
management processes

Sub-realms             Operational Concepts

Policy planning and    Health policy agenda and strategic plans in
formulation            place.

Sectoral regulatory    Capacity to formulate new laws, regulations and
and legislative        standards that can be implemented on a
capacity               national, regional and municipal basis.

Financial management   Financial sources and flows, transfer circuits,
capacity in PHC        distribution of resources (installed capacity,
                       staffing and human resource gaps, sustainable
                       supply of medicines and supplies).

Stewardship            Empowerment of the Health Stewardship
functions              functions. Opening to Governance as a new
                       social pact.

Health system          Knowledge about the Paraguayan Health System
                       and its recent reforms.

PHC strategy           Knowledge about the PHC strategy: current
                       definition and interpretation.

RIISS                  Compliance with the organization and
                       structuring processes of the RIISS, through the
                       coordination lines.

USFs                   Effective insertion and organization of USFs in
                       local networks through a control panel.

HR-PHC                 Balance, staffing according to gaps,
                       identification of financial protection
                       mechanisms, expanded recruitment of community
                       workers and priority disciplines and their
                       training.

Training and           Training of managers in health administration
leadership             and governance, type of selection of management
                       personnel, labor and salary
                       regimen of managers.

Empowerment and
Responsibility

Rights approach        Existence of mechanisms, spaces and indicators
                       of transparent management with facilitated
Voice and              accessibility to all strata of society and
accountability         public opinion--Transparency in the handling of
                       information.

Fight against
corruption

Political Ethics

Coordination           Coordination mechanisms State, Private Sector,
Mechanisms             Third Sector, Community Organizations.

Areas of influence     Influence in formulating policies, plans and
                       administrative decisions.

                       Influence in the production of services and
                       financing.

Participation in       Levels of participation and influence in health
decision-making,       decision-making. Knowledge and management of
regulation and         legal changes and regulatory mechanisms.
accountability
processes              Knowledge and use of transparency and
                       accountability mechanisms.

Participation in       Contribution in dynamics of development and
ASIS and social        strengthening of social and environmental
management processes   management processes, Decentralization and
                       analysis of health situation.

Chart 2. Realms and sub-realms of the PHC Stewardship and
Governance in three periods of government. Paraguay, 2008-2017.

    REALMS        SUB-REALMS               1st PERIOD
                                           2008-2012

STEWARDSHIP AND   Knowledge and scope      Incorporation
GOVERNANCE OF     of the term              of the social
PUBLIC HEALTH     stewardship              perspective into
POLICIES                                   the other functions
                                           and roles
GOVERNANCE,
GOVERNABILITY
AND GOOD
GOVERNANCE
                  Reinterpretation         Adds social
                  of the stewardship       cohesion and
                  concept                  aligns government
                                           and development
                                           policies

                  Mechanisms for           Trust positions,
                  the selection of         transfer of
                  government officials     experts from
                                           other government
                                           secretaries

                  Existence of             They are evaluated
                  management               by management
                  assessment tools         results and the
                                           Executive evaluates
                                           the ministers.

                  Level of consensus       High
                  achieved

                  Model (Political         Synergic model
                  conduct)

                  Participation            Mixed decisional
                  of a diversity of        networks
                  stakeholders:
                  Intersectoriality

                  Perception of society    Balance of
                  and governability        authority,
                                           legitimacy of
                                           values and social
                                           norms

                  Planning and             Strengthening
                  Implementation of        strategic
                  Policies                 stakeholders vs
                                           Weak evaluative
                                           processes

                  Financial Management,    Free services
                  quality of
                  expenditure,
                  efficiency, central
                  government/subnational
                  levels coordination

    REALMS        SUB-REALMS               2nd PERIOD
                                           2012-2013

STEWARDSHIP AND   Knowledge and scope      Normative
GOVERNANCE OF     of the term              and traditional
PUBLIC HEALTH     stewardship              health services
POLICIES                                   provision
                                           function
GOVERNANCE,
GOVERNABILITY
AND GOOD
GOVERNANCE
                  Reinterpretation         Overcomes
                  of the stewardship       bureaucratic
                  concept                  barriers,
                                           facilitates
                                           structuring
                                           between upper
                                           and lower levels

                  Mechanisms for           They do not
                  the selection of         respond to
                  government officials     merits, some
                                           managers remain

                  Existence of             There are no
                  management               tools to assess
                  assessment tools         skills and abilities
                                           of managers, but
                                           rather of middle
                                           managers

                  Level of consensus       Median
                  achieved

                  Model (Political         Mixed
                  conduct)

                  Participation            Median
                  of a diversity of
                  stakeholders:
                  Intersectoriality

                  Perception of society    Transition,
                  and governability        tendency to
                                           centralization

                  Planning and             Insufficient
                  Implementation of        political and
                  Policies                 technical times.

                  Financial Management,    Management
                  quality of               evaluation
                  expenditure,             similar to the rest
                  efficiency, central      of the programs
                  government/subnational
                  levels coordination

    REALMS        SUB-REALMS               3rd PERIOD
                                           2013-2017

STEWARDSHIP AND   Knowledge and scope      Compliance
GOVERNANCE OF     of the term              with Rules,
PUBLIC HEALTH     stewardship              Regulations
POLICIES                                   and Laws

GOVERNANCE,
GOVERNABILITY
AND GOOD
GOVERNANCE
                  Reinterpretation         Incorporates
                  of the stewardship       adjustments
                  concept                  and
                                           adaptations
                                           into
                                           changes and
                                           organizational
                                           innovations

                  Mechanisms for           Global
                  the selection of         rotation of HR,
                  government officials     managers and
                                           technicians
                                           from all health
                                           authorities

                  Existence of             Popularity level
                  management               is measured as
                  assessment tools         a synonym of
                                           management
                                           acceptance

                  Level of consensus       Low
                  achieved

                  Model (Political         Hierarchical
                  conduct)                 model

                  Participation            Weak
                  of a diversity of
                  stakeholders:
                  Intersectoriality

                  Perception of society    Centralized,
                  and governability        bureaucratic
                                           management

                  Planning and             Institutional
                  Implementation of        Strategic Plan
                  Policies

                  Financial Management,    Rotation
                  quality of               of qualified
                  expenditure,             stakeholders
                  efficiency, central      that
                  government/subnational   affected the
                  levels coordination      institutionality

    REALMS        SUB-REALMS               OBSERVATIONS

STEWARDSHIP AND   Knowledge and scope      Strict conduction methods
GOVERNANCE OF     of the term              coexist, adherence to
PUBLIC HEALTH     stewardship              rigorous standards,
POLICIES                                   decreases integration of
                                           new stakeholders, paralyzes
GOVERNANCE,                                work teams, alienates
GOVERNABILITY                              organizations and fragments
AND GOOD                                   the provision of services.
GOVERNANCE
                  Reinterpretation         The governing role should
                  of the stewardship       broaden its scope,
                  concept                  incorporate organizational
                                           innovations, adaptability,
                                           agility, leadership,
                                           specialization, it should
                                           promote governance,
                                           exercise the role of
                                           organizing and articulating
                                           of stakeholders,
                                           institutions and
                                           organizations.

                  Mechanisms for           Only in some cases, the HR
                  the selection of         profile is characterized by
                  government officials     aptitude, suitability,
                                           leadership, training,
                                           skills and conduction
                                           abilities.

                  Existence of             In general, they are
                  management               evaluated by the results of
                  assessment tools         management, through opinion
                                           surveys to the public
                                           (successful processes,
                                           cohesion of executives).

                  Level of consensus       Balance of authority,
                  achieved                 legitimacy of values and
                                           social norms.

                  Model (Political         Trust-based cooperation is
                  conduct)                 more effective than
                                           authority-based
                                           cooperation.

                  Participation            Multiple mechanisms and
                  of a diversity of        initiatives for the direct
                  stakeholders:            participation of society
                  Intersectoriality        and communities in the
                                           management of public
                                           policies.

                  Perception of society    Good governance: Mission to
                  and governability        guide, within the framework
                                           of a comprehensive and
                                           sustainable development,
                                           the primary goals and
                                           objectives of health,
                                           quality of life and
                                           well-being.

                  Planning and             Planning must incorporate
                  Implementation of        the rights, values and
                  Policies                 practices approach, as a
                                           support for the regulatory
                                           framework designed to
                                           implement the policies.

                  Financial Management,    Changes in care and
                  quality of               organizational models are
                  expenditure,             restricted due to lack of
                  efficiency, central      financial guarantees.
                  government/subnational
                  levels coordination

Source: Resulting from consultation with key stakeholders, perception
of sub-realms involved in PHC stewardship and governance in three
periods of government. Paraguay, 2008-2017.
COPYRIGHT 2018 Associacao Brasileira de Pos-Graduacao em Saude Coletiva - ABRASCO
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2018 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Cabral-Bejarano, Maria Stella; Nigenda, Gustavo; Arredondo, Armando; Conill, Eleonor
Publication:Ciencia & Saude Coletiva
Date:Jul 1, 2018
Words:5764
Previous Article:Network integration and care coordination: the case of Chile's health system.
Next Article:Decentralization and regionalization of health policy: a historical-comparative approach between Brazil and Spain/Descentralizacao e regionalizacao...
Topics:

Terms of use | Privacy policy | Copyright © 2022 Farlex, Inc. | Feedback | For webmasters |