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The next series of indicators can only be calculated from the public facilities in the main study group where the complete set of questionnaires was administered.
These indicators are § presence of IEC materials in the facility, § expanded list of medicine and supply stock- outs, and § measures of supervisory practice... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
While we include the results for this single regional hospital in the tables, we do not claim that they are representative of regional hospitals as a whole.
All three of the district hospitals in the larger sample are also in this group.
5.7.1.
Information, Education, and Communi- cation (IEC) The IEC variables are ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Only one of the three district hospitals had any material advertising the availability of pre- and post-natal care and deliveries, but this is probably due to the fact that everyone knows that these services are available in hospitals.
In general, health centers surpass health posts in the display of all types of IEC ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Group Talks Offered in Public Facilities by Department, and in All Private 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Asuncion (29) Cordillera (22) Misiones (16) Central (51) Private* (19) Family Planning Maternal Health Child Health *All Private Facilities in Sample Percent of facilities Results: Facility Inventory &... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The IEC subject score variable requires some explanation.
In the questionnaire, we asked about the content of the IEC material.
If it contained informa- tion of a certain type, the facility received a score of one, and if not the facility received a zero.
The types of information examined included all contraceptive ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The maximum score was 16.
Surprisingly on this measure, health centers, with an average score of 8.7, out-performed district hospi- tals, which had an average score of 7.3 points.
Health posts had an average IEC score of 5.6 points.
The analysis by department indicates that while the public facilities in Misiones ha... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The average facility score for Misiones is less then one-half of Cordillera’s score.
Table 5.7. | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Table 5.7.
IEC Availability, by Facility Type (% of facilities) IEC Posters or Signs Available on Regional Hospital (n=1) District Hospital (n=3) Health Center (n=17) Health Post (n=31) Family Planning 100.0% 100.0% 100.0% 74.2% Antenatal Care 100.0% 33.3% 88.2% 58.1% Delivery Services 0.0% 33.3% 52.9% 19.4% Postnatal... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
IEC Availability, by Department (% of facilities) IEC Posters or Signs Available on Cordillera (n=10) Misiones (n=11) Central (n=31) Family Planning 100.0% 90.9% 77.4% Antenatal Care 90.0% 45.5% 67.7% Delivery Services 70.0% 0.0% 29.0% Postnatal Care 100.0% 63.6% 38.7% Immunizations 90.0% 63.6% 83.9% IEC Subject Score ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Supply Stock-outs The next set of variables in Tables 5.9 and 5.10 corresponds to some of the basic supplies needed to perform the basic maternal and child health services.
Note that the medicine or supply had to be normally available in the facility to be considered out of stock.
Among facility types (Table 5.9), he... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
As shown in Table 5.10, with the exception of the tetanus toxoid and BCG vaccines in Cordillera, all vaccines were continuously in stock for the last six months in 90% or more of the facilities that offered the service.
However, syringes and gloves were in considerably shorter supply, which could have easily disrupted... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Perhaps this is the driving force behind the large contraceptive injection stock-out problems presented earlier in Figures 5.3 and 5.4, though we attempted to distinguish between the availability of equipment necessary for administration and the availability of the hormonal formulation.
Note that 78% of facili- ties i... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
In general, Misiones seemed to experience the fewest problems with vaccine and ORS stock-outs, but the most problems with the availability of syringes and gloves.
Facilities in Cordillera experienced more problems with tetanus toxoid and BCG vaccine stock-outs.
Table 5.9. | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Supply Stock-Outs, by Facility Type (% of facilities) Medicine and Supplies Regional Hospital (n=1) District Hospital (n=3) Health Center (n=17) Health Post (n=31) Tetanus Toxoid Vaccine 0.0% 0.0% 12.5% 13.8% BCG Vaccine 0.0% 0.0% 7.1% 20.0% Polio Vaccine 0.0% 0.0% 0.0% 10.7% DPT Vaccine 0.0% 0.0% 0.0% 10.7% Measles Va... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Supply Stock-outs, by Department (% of facilities) Medicine and Supplies Cordillera (n=10) Misiones (n=11) Central (n=31) Tetanus Toxoid Vaccine 30.0% 0.0% 10.0% BCG Vaccine 40.0% 0.0% 7.1% Polio Vaccine 10.0% 0.0% 6.9% DPT Vaccine 10.0% 0.0% 6.9% Measles Vaccine 10.0% 0.0% 6.9% Oral Re-hydration Packet 28.6% 12.5% 37.... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Record Keeping We asked three questions in the facility observation questionnaire regarding the state and content of medical record keeping, the results of which are presented in Tables 5.11 and 5.12.
It is important to note that the responses are from the observations of the interviewer, and not those of the facility... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
In general, the results for this indica- tor are quite positive.
Except for district hospitals, 90% of facilities in every department scored a one.
The second item measured whether the facility kept a separate medical record for each patient.
Once again, the positive responses were very high – over 90% – by facility... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The guideline question for which we could most differentiate facilities was whether the facility maintained an address database with a record for each patient.
We see that most facilities maintain records of addresses, with both the health centers and posts at around 80%.
By depart- ment, public facilities in Misione... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
5.8.
Facility Supervision With the final set of variables presented in this section, we attempted to objectively measure super- visory practices.
Tables 5.13 and 5.14 present the results of the supervisory frequency questions.
Health facilities should be visited by a service supervisor for family planning, for mater... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
In the facility type breakdown (Table 5.13), all hospitals had received all types of supervisory visits in the six months preceding the survey, and most had received all supervisory visits within the three months prior to the survey.
There seems to be a problem of very infrequent, or a complete lack of, supervision in... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The problem is particularly severe in health posts, where 33% had not received a family planning supervisory visit in the six months preceding the survey and 20% had never received one.
Weak supervision for maternal and child health and immunization services also was a problem at health posts.
While about 50% of heal... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Record-Keeping Practices, by Facility Type (% of facilities) Record Keeping Practices Regional Hospital (n=1) District Hospital (n=3) Health Center (n=17) Health Post (n=31) Observation of record maintenance 100.0% 66.7% 100.0% 96.8% Separate Register for each patient 100.0% 100.0% 94.1% 100.0% Maintains address of eac... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Record Keeping Practices, by Department (% of facilities) Record Keeping Practices Cordillera (n=10) Misiones (n=11) Central (n=31) Observation of record maintenance 100.0% 90.9% 96.8% Separate Register for each patient 90.0% 100.0% 100.0% Maintains address of each patient 100.0% 10.0% 100.0% 40 received a visit more t... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
At the department level, 10% or less of the facilities in both Cordillera and Misiones had received any type of supervisory visit in the month prior to the survey, whereas over 35% of the facilities in Central had had a visit.
Most commonly, visits in Central occurred in the month prior to the survey, whereas it was i... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Half of the facilities in Cordillera had received a family plan- ning supervisory visit more than six months prior to the survey or never had a visit at all.
Infrequent or nonexistent immunization supervision affects about half of the facilities in Cordillera.
It is interesting to note that despite the remoteness of ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Maps A.12, A.13, and A.14 in Annex A present information on the public facilities in the sample that had received a supervisory visit for family planning, maternal and child health, and immunizations during the six months preceding the survey.
Table 5.13. | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Frequency of Supervisory Visits, by Facility Type (% of facilities) Health Service & Frequency of Visit Regional Hospital (n=1) District Hospital (n=3) Health Center (n=17) Health Post (n=31) Family Planning Supervisor Visit Within Last Week 0.0% 0.0% 11.8% 0.0% Within Last Month 0.0% 66.7% 23.5% 13.3% Within Last Thre... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Frequency of Supervisory Visits, by Department (% of facilities) Health Service & Frequency of Visit Cordillera (n=10) Misiones (n=11) Central (n=31) Family Planning Supervisor Visit Within Last Week 0.0% 0.0% 6.5% Within Last Month 0.0% 0.0% 32.3% Within Last Three Months 30.0% 50.0% 12.9% Within Last Six Months 20.0%... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Results: Cost of Basic Health Services Estimates of total cost provide a single measure of the total amount of resources committed to a par- ticular production activity. | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Key questions in the decentralization of a health care system include what will happen to the total amount of resources devoted to health care, will the distribution of these resources across various services change as a result of decen- tralization, and do cost estimates provide an empiri- cal basis on which these cha... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
These will be used as the basis for comparing pre- and post-decentralization service delivery costs.
This section outlines the major conceptual issues related to calculating service provision costs, provides a description of the data and estimation procedures used,9 and presents the baseline results for service provis... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The production of a good or service requires the use of various scarce resources (e.g., labor time, materials, and supplies).
Each of the resources has a “cost” or a price associated with its use (e.g., a wage rate or purchase or rental price). | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The calculation of the cost of producing a given quantity of good or services involves counting up the quantity of each type of resource used in production over some specified time period, multiplying the quantity of each resources by its unit price and adding up the results to a total. | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Thus the total cost of producing the quantity of output Q is ∑ = = n i i i x p Q TC 1 ) ( (Equation 6.1) where x1, x2, ..., xn are the quantities of each of the n inputs used in production over some specified time period and p1, p2, ..., pn are the prices per unit of 9 The estimation of service costs is a complicated m... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The conceptual issues surrounding the calculation of cost boil down to which input quanti- ties and prices to use.
There are at least six concep- tual issues that must be addressed in designing a methodology for measuring service cost.
These are discussed below.
6.1.1.
Issue 1: Which costs? | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
6.1.1.
Issue 1: Which costs?
Total cost can be viewed as the total expenditure made to purchase the resources that are used in the production of the services.10 This creates a problem because the expenditures can take place at a number of different levels in the health care system.
Some resources may be purchased at... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Some resources may be purchased at a low decentralized level, e.g., a facility paying for utility services.
Some resources, such as family planning commodities, may be donated by an external organization such as USAID.
Our approach in this study is to measure the quantity of resources used at the point where the serv... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The alternative is a “top-down” approach in which all expenditures made by any party supporting the provision of health care service are accumulated, starting with the central government and external 10 At this point we should distinguish between economic cost and what might be called actual cost.
In the theoreti- cal... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
It assumes both allocative and technical effi- ciency.
That is that the lowest cost mix of inputs consis- tent with producing the desired level of output is chosen and that these inputs are used without waste.
It also typically assumes that resources are either bought at competitive market prices or their opportunity... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Though economic cost provides an important benchmark, the questions to be addressed in this study require the use of actual cost.
44 donors and moving down toward the points of service delivery.
The “bottom-up” approach has the advantage that it makes it much easier to associate costs with particu- lar localities and... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The disadvan- tage of this approach is that it is difficult to observe the cost of administration and other support activities that occur at a high level in the health care delivery system.
We will return to this issue later in this section.
6.1.2.
Issue 2: Definition of Output While the total amount of resources de... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
In economic terms this is the average or unit cost, which is the total cost divided by the quantity of services produced.
This creates a number of problems for calculating service costs for a health care system.
Summary measures of output, e.g., total number of patients served, provide an incomplete picture of cost b... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
For example, at a given facility a patient receiving a polio immunization places an entirely different demand on health care resources than does a patient delivering a child.
Costs of service provision will vary not only with the total number of patients served, but also with the types of services provided.
For this ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
6.1.3.
Issue 3: Allocation of Costs to Specific Services: The most difficult and practical problem for gener- ating either bottom-up or top-down cost estimates, which are disaggregated by program, facility or output level, is that the production of these services often occurs in integrated programs or facilities. | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Thus, while it is fairly easy to get figures for the total staff cost or the total number of family planning or pre-natal visits performed in a facility, it is more difficult to get information on the proportion of staff time (and thus staff cost) devoted to the delivery of these two services.
Such information is cruc... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
For some types of resources the allocation process is very simple, for example if records of the quantities used are available and the resource is used in providing only one service.
Examples of this type of resource include contraceptive commodities, which are used only to provide family planning services, or vaccine... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
There are other resources that have multiple uses, but we lack information or records on the distribu- tion of these resources among their various uses.
The best example of this is staff time.
A method for allocating the cost of staff time and other resources of this type must be used.
The final type of resource is ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
6.1.4.
Issue 4: Cost and Efficiency An important aspect of cost is its use as a measure of efficiency.
All else being equal, it is preferable to provide a given quantity of a specific service at a lower cost than at a higher cost because resources for health care are scarce.
The basic economic tenant of resource sca... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
If it is possible to produce the same level of service at a lower cost, this frees funds and resources to provide more services.
6.1.5.
Issue 5: Relationship of Cost and Quality Using cost as a measure of facility performance is a double-edged sword.
On the one hand, lower cost implies a more efficient use of resour... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
We will return to the issue later.
Results: Cost of Basic Health Services 45 6.1.6.
Issue 6: Price of Inputs The selection of prices applied to the quantities of inputs also raises some issues.
Some inputs are used as they are purchased, e.g., staff time.
Staff members receive a salary for the services they provide... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Salary payments are a recurring expense.
Other types of resources, such as equipment or buildings, are paid for at one time when they are originally purchased or constructed even though they provide services over a prolonged period.
This type of expense is referred to as a capital expense.
For this study, the basic ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
To estimate the cost of staff, supplies, medicines and other inputs, we obtained the quantities used in a one-month period and their unit prices at the time of acquisition.
6.2.
Methods This section provides an overview of the basic approach that was used to calculate the total cost of service provision at the facili... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The methods of data collec- tion that were used to obtain the required informa- tion and a discussion of the issues addressed in the actual calculation of the cost data are also presented.
6.2.1.
Overview of Cost-Calculation Method This study estimated the direct recurrent cost of service delivery at the facility lev... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
This was accomplished by using a variety of data-collection strategies to identify and to quantify the quantities and cost of the various resources used to produce health care services as observed at each facility. | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The general approach of this part of the study was to measure the amounts of the various resources that were being used at each facility and to cost these resources at prices that reflected the amount of funds that were being expended in support of service provision.11 Health care, by its nature, is a very complicated ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The overriding purpose of this research is to set a baseline that will be used to evaluate the decentralization of basic health services in certain Paraguayan municipalities.
The services that are of primary interest to policymakers are primarily those for women and children.
A list of specific services of interest i... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The approach we will employ is based on the total expenditures regardless of who is making them.
Thus, donated commodities and supplies are costed based on the donors expenditures; staff costs are based on wages and salaries paid to staff regardless of who actually makes the payment.
Under a pure economic concept of ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Health Services Used in Cost Analysis Services Areas Basic Health Care Services Family Planning 1. supply of modern reversible contraceptives (IUD, oral contraceptives, condoms, injec- tions) Maternal Health 2. prenatal care 3. deliveries (normal and caesarian-section) 4. post-partum care 5. cervical cancer screening (... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
As the cost estimation strategy was designed, the evaluators made a number of decisions related to the basic conceptual issues described above.
These decisions were related primarily to choices about which outputs and costs to consider.
Cost estimates were constructed for the 10 basic health care services listed in T... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
First, the choice to limit the types of services considered in the study helps to identify the inputs to cost.
The specific services listed in Table 6.1 are almost always provided by a subset of medical staff.
While some facilities may have surgeons, dentists, anesthesiologist and other medical staff, these specializ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Various sources of information were used to identify the staff types or health personnel that provided the specific services.12 These included several catego- ries of doctors (i.e., general clinical, pediatricians, obstetricians and gynecologists), licensed nurses (including nurse obstetricians), and auxiliary nurses.
... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
We refer to the staff that provides specific health care services as the basic medical staff.
Medical staff that is not typically involved in the provision of the specific services will be referred to as other medical staff and non-medical personnel will be referred to as other staff.
In addition, while most if not a... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
We refer to these encounters as 12 Two sources of information were used to determine which staff performed the specific services.
The service statistics collected by the Ministry of Health are broken down by the staff person who provided the services.
Thus, it is possible to identify the personnel who provide family ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
other services.
Because the category of other services covers a wide range of treatments that differed significantly in the time required to provide the service, we used weights, based on the time requirements for the various other services, to construct a visit index for other services.
This was done to alleviate pr... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
A list of other services and the weights that were used in con- structing the output measure for other services are presented in Annex C. The cost estimates that follow are made for basic health care services, including other services per- formed by the basic medical staff.
Because the composition of services provided... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The timing of service provision introduces another complication into the process of allocating costs by services.
Many of the facilities have staff available 24 hours a day to provide services.
This staff provides emergency care after normal operating hours.
The primary health service provided by this "on-call" staf... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The facilities offering services around the clock have, in addition to regular staff, a “guardia” or “on-call” team that remains in the facility.
The makeup of this team varies by the type of facility. | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Because the flow of patients during normal operating hours and off-hours is likely to be very different, the availability of on-call services will likely have a substantial impact on the average cost of service provision because the number of patients served per hour of on-call staff time will likely be much lower than... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Unfortunately, the service statistics do not allow us to determine which cases were seen during normal hours of operation and which cases were treated after hours.
Two analytic approaches were used.
On the one hand, the provision of on-call services can be viewed as a part of the general overhead expense of the facil... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The other approach would be to treat on-call service provision as a separate service and Results: Cost of Basic Health Services 47 calculate the cost of the resources devoted to it.13 Throughout this section, we will note the effect that different treatments of on- call service provision has on cost and efficiency resu... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The production of the basic health care service requires five categories of resources whose con- sumption in the facility can be observed. | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
These resource categories include (1) staff time, (2) supplies, medicines and other consumables, (3) facility level administration and overhead expenses (including such items as utilities and routine mainte- nance), (4) equipment, and (5) physical space.14 The results of the use of these resources are the observ- able ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
For the first three categories of resources – staff time, supplies and medicines, and administration and overhead – the costs are incurred contemporaneously with the use of the resources and the provision of the services.
In other words, there is a relatively direct relationship between the flow of payments for the re... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Treating “on-call” service provision as a part of overhead would be correct if we could allocate it to individual services based on the proportion of those services that were provided on an on-call basis.
The absence of service statistics disaggregated between on-call and normal hours of operation cases makes this imp... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The only choices are to allocate the cost of “on-call” service in proportion to the direct cost on the individual services or allocate all of the “on-call” cost to specific services such as delivery.
Treating “on-call” costs as a separate service results in including one service with no measured output.
In fact, case... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
14 An additional category would include resources that are used to support services at the facility, but whose consumption cannot be observed at the facility level.
This category includes all resources used to provide adminis- trative support, supervision, logistic support, training and so forth that are provided by l... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
For the last two categories – equipment and physical space – there is a much more indirect relationship between expenditure on these resources and the flow of services they produce.
While a building is gener- ally paid for when it is built, it provides a flow of resources over a long period of time.
The same is true ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Data Collection Data used to estimate the cost of providing basic health services were collected from four sources: (1) facility records and knowledgeable staff, (2) health providers in the facility, (3) detailed cost case studies of a smaller sample of facilities, and (4) administra- tive levels above the facilities i... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
We will address each of these in turn.
15 Including an estimate of the capital cost of building and equipment would introduce a number of complexities and require a number of somewhat arbitrary assumptions.
The estimation of capital cost requires that a value be placed on the facility's capital stock.
That is, a mon... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
It would then be necessary to assume a useful service life for each element of the capital stock and assume an interest rate in order to construct a period cost of capital (the cost of using the capital stock for a month).
Though very basic information of the facility’s building and an inventory of the facilities medi... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
In previous cost studies (Cote d'Ivoire and the Philippines), equipment and building cost were found to be a small percentage of total cost.
It is expected that in most cases, health care will be provided from the same facilities both before and after the decentralization, thus this component is not expected to change... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Comparisons of the before and after equipment inventories will allow us to determine whether or not there has been an augmentation or depletion of the equipment stock.
48 Facility Data Collection.
The facility surveys included a number of questions related to the resources available for service provision at the facil... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
These include § A detailed staffing inventory, including the number and type of personnel and their level of effort § An inventory of family planning commodi- ties and medicines § An inventory of equipment This information was used to calculate the total staff expense and the quantity of various medicines used in the d... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Time-Allocation Log.
At each facility, a number of each type of staff (doctors, nurses, and auxiliary nurses) were asked to keep a log of their patient contacts over a period of five to six days.
For each patient contact, the starting and ending time of the contact were recorded.
The type of contact – whether it was... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
As described more fully below, these time-allocation logs were used to provide the information to allocate staff time cost to the various activities for which specific cost estimates were made.
Detailed Facility Case Studies.
The provision of health care services involves a very large number of inputs.
With the exce... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The problems and cost that would have been involved in a complete data collection effort in every facility outweighed the benefits of doing so.
To get information on the many minor expense categories, a few facilities were selected for detailed study.
The facilities that were subject to this inten- sive cost analysis... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The sample of public facilities was divided into four groups based on the characteristics of the facility.16 A representative facility from each group was chosen and an intensive analysis of the cost of minor medical and other supplies, miscellaneous operating expenses and facility administration expense was conducted.... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Estimating the cost of medical supplies and overhead expenses required data collection at levels of the health system that were above each of the health facilities.
The prices paid for many of the medical supplies used at the facility level are not known by the facility itself.
Medical supplies, for example, may not ... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
To cost these components, the purchasing agent or agency was contacted and prices of the various inputs provided to the facilities from that level were obtained.
6.2.3.
Cost Calculations Total Cost Calculations. | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
6.2.3.
Cost Calculations Total Cost Calculations.
For each public facility in the sample the total recurrent costs of basic medical services at the facility were calculated by adding the resources costs in four general categories: (1) basic medical staff costs, (2) administrative expenses, (3) specific medical suppli... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Basic Medical Staff Cost.
The cost of basic medical staff was calculated using basic medical staff information – level of effort, salary and allocation of effort – from facility records and the time-allocation logs.
To calculate the total basic medical staff cost for each facility, the wage rate17 for each category o... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
17 There were two data sources for the wage rate.
During the facility survey, facility managers were asked the typical wage rate for each category of staff.
Additionally central records were used to get actual salaries of staff at the clinic and these were cumulated by staff type and divided by the number of hours th... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Results: Cost of Basic Health Services 49 staff at a facility was multiplied by the total hours that each were engaged in providing basic medical services.
The product of this calculation was then summed for all staff types. | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
∑ = = = J j n j n j n n Hours W TSC Cost Staff Medical Basic Total 1 , , (Equation 6.2) Where Wj,n is the wage rate of staff type j (doctors, nurses, and auxiliary nurses) at facility n Hoursj,n is the number of monthly staff hours of staff type j at facility n Administrative Staff Cost.
Administrative cost is an impo... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
First, in the smaller facilities, there may be no administrative staff,18 and medical personnel, usually auxiliary nurses, may perform such administrative tasks as patient registration.
Where there is no administrative personnel, estimating the cost of administration requires that the costs associated with personnel w... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Second, in the larger facilities, services other than the basic medical services are also performed.19 In such cases it is necessary to allocate the cost of administrative personnel between basic medical services and the other activities of the facility.
Two approaches were taken to address these prob- lems.
First, w... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
The administrative expense was calculated as a percentage of the expense of basic care medical staff.
This percentage was then applied 18 Only seven of the 26 health posts reported having administrative personnel.
All health centers and hospital had administrative personnel.
19 All four of the hospital, 16 of the 17... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
to the other facilities in the same group to estimate administrative personnel expense.
The second approach was to take the reported number of hours for administrative personnel, allocate these hours between basic medical services and other medical care, and use the wage rate of administrative person- nel to calculate... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
For facilities with no administrative personnel, the time of auxiliary nurses was allocated between service provision time and administrative time to generate estimates of administration cost.
The procedures used are described in detail in Annex C. Due to the substantial variation in the uses of administrative personn... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
Cost of Specific Medicines and Supplies.
Specific medicines and supplies are those that are used only for one of the specific services.
Medicine and supply costs were estimated for family planning commodi- ties, vaccines and deliveries.
The prices of each contraceptive commodity and each vaccine were obtained from t... | https://docs-lawep.s3.us-east-2.amazonaws.com/thematic2a/pw_1/1715626783355.pdf | https://www.data4impactproject.org/wp-content/uploads/2019/09/tr-00-04-1.pdf | Paraguay |
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