PRESENTATION HEALTH:

INTRODUCTION:

Improvements in health services cause increase in longevity, improve in health outcomes and
increase in productivity.

A third of the welfare gains in developed countries can be attributed to this

Despite this fact millions of individuals in developing countries remain without access to health
care services.

HACER VER A LA GENTE QUE EN NUESTRA OPINION ERA NECESARIO UN PROGRAMA COMO
ESTOS PARA AYUDAR A LA GENTE. DATOS DEL WORLD BANK? COMPARAR ESTOS CON UN PAIS
AFRICANO?

One popular policy option to improve health outcomes is contracting the provision of health
services to the private sector.

Previous studies attempted to answer the following questions.

1. do these programs improve coverage of health services?

2. do these programs generate better health outcomes using the same level of resources
when compared with public provision of services? (are they more efficient than public
ones?)

But the empirical evidence has not provided definite answers to those questions.

EN LA PRESENTACION METER UN POCO DE DONDE ESTA GUATEMALA Y SU SITUACION ACTUAL

YA QUE MUCHA GENTE NI SABRÁ LOCALIZARLA EN EL MAPA. Y DECIR UN POCO SOBRE LAS
MALAS CONDICIONES DE VIDA ALLA PARA TOCAR EL CORAZONZITO DE LA PEÑITA.

BACKGROUND: THE GUATAEMALAN HEALTH SYSTEM:

The Guatemalan health system, like many other health systems in developing countries, is
highly segmented and fragmented, and the lack of coordination among services often leads to
duplication.

It is structured and organized in such a way that a large percentage of the population is left
without access to health services.

This system is characterized by a tripartite organization composed of the Ministry of Health

(responsible of provide curative and preventive care for the entire population at practically no
charge), the Guatemalan Social Security Institute (IGSS) (provides retirement benefits and
health services to workers in the formal “legal” sector and their families, and it runs its own
health facilities, which are separate from those of the Ministry of Health) and the private
sector.

The remaining health services in Guatemala are provided by the armed forces and police
health network, by NGOs and charitable organizations, and by the private, for-profit sector

There are two types of private, for-profit providers: (i) folk healers, herbalists, and other
practitioners of traditional medicine; and (ii) providers in the modern private sector, which has
grown primarily in urban areas, fueled by rising incomes and dissatisfaction with the quality of
public sector care

Regarding spending, total health expenditure per capita was $96 in 2000, while public health
expenditure per capita amounted to $39. (aqui puedes buscar por ejemplo cual es la media
mundial en world bank statistics). The problems of access to basic health services in Guatemala
are found not only on the supply side, but also on the demand side. Indigenous peoples, who
constitute more than 40% of the population, tend to rely heavily on traditional medicine.
Limited efforts have been done to adapt indigenous populations to modern medicine with
other problems such as costs of transportation and medicine having importance.

These supply and demand problems are reflected in basic health indicators, which show large
inequalities between rural, poor, and indigenous populations and urban, affluent, and non-
indigenous populations. For instance, maternal mortality for indigenous women was
211/100,000, compared to 70/ 100,000 for non-indigenous mothers. (ver si el % de indigenous
se podría asemejar al de algún país africano para hacer una comparativa).

The plan

NGOs were assigned to provide services to delimited geographical áreas.

The NGOs’ delivery strategy relied on mobile medical teams (to reach areas difficult to access)
composed of a physician, an auxiliary nurse, and an institutional facilitator (rural health
technician or nurse) that traveled at least once a month to “convergence centers” or meeting
places for the local population where services were provided.

At the community level, community facilitators would recruit and supervise local staff,
generally traditional midwives and community health promoters, who assisted with the
logistics of service provision.

WHY 1996 was a Good starting point for the plan

two joint conditions for the successful implementation of the extension program were in
place: a number of NGOs that specialized in health already existed in Guatemala, and the
government was committed to being a reliable payer for these NGOs.
Contracting in, contracting out model, include it?

Two types of program implementation.

Contracting out provides full flexibility to NGOs regarding clinical and administrative functions.
(in other word full private?)

Contracting in NGOs focused on administrative tasks and employed public workers to provide
health services.

(combination of public and private)

WHICH OF THEM DO YOU THINK WORKED BETTER?

Results show that the contracting-in model seems to have performed slightly better than the
contracting-out model, especially regarding the utilization of nurses and physicians for
prenatal care.

One of the reasons is that while some NGOs under the contracting-out model had to start from
scratch in terms of recruiting, hiring, and training personnel, the contracting-in model used
Ministry of Health personnel with ample experience in rural health delivery.

Or that the use of rural technicians who were already known to the targeted population
probably helped to reduce demand barriers

The study

WHAT IS THE PURPOSE OF THE STUDY

Stages of the plan

The history of the PEC can be broken down into four phases.

1. 1996–2000 rapid expansion within a management environment that was weak in

terms of planning, supervision, and monitoring.
2. 2000–04 deep Budget cuts due to new government in power resulted in a slight
increase in enrolment in PEC
3. 2004–08 Another government in power that envisioned PEC as one of its key
programs. Population coverage started to increase and per capita spending recovered.
Also promoted initiatives to the monitoring and supervision of contracted NGOs.
4. 2008–12 New Budget cuts and delayed payments to NGOs.

Results:

Results indicate that both models have produced statistically significant positive effects on
some aspects. For instance, results show that the contracting-in model has produced a 12
percentage point increase in coverage of the first dose of tetanus vaccine and also a similar
reduction in the fraction of women reporting that their prenatal care check-ups took place at
their homes or at the homes of traditional birth attendants

POLICY LESSONS FROM THE PEC EXPERIENCE:

As we have mentioned in the first expansion we found that contracting in model worked
slightly better.

WHY CONTRACTING OUT MODEL CONTINUED IF CONTRAXTING IN WAS BETTER? I think

because of the new government that came supported more the contracting out but if they ask,
ask ariadna.

Second expansion

indicate that during the second expansion the contracting-out modality increased first-dose
vaccination rates by about 13–21 percentage points and third-dose vaccination by about 30
percentage points

Why?

Learning of the health mobile teams might be a reason and also of patients.

A more plausible explanation is the substantial learning acquired at the central level regarding
how to effectively manage the contracting process. (to add to the contracting-out model some
of the favorable features of contracting in that we have pointed out, such as integrating the
mobile teams with the Ministry of Health’s formal network of providers)

Strarting at a small scale and gradually developing knowledge and procedures could have set
up s more solid basis for the program to expand.

LONG TERM SUSTAINABILITY OF THE PLAN:

As government changes hands, programs without broad support are undermined and, as a
result, they may be discontinued or underfunded.

While the PEC has suffered heavy budget cuts when political support has faltered, these cuts
have not reduced the level of beneficiaries covered by the program, although they have
affected the quality of services.

Maybe the PEC is “too big to close” (4,600,000 beneficiaries). However, in other countries
there have been instances in which a lack of political support brought about the total
discontinuation of similar programs. This was the case, for instance, in countries such as Peru
or Honduras, where contracting-out programs that were providing basic health services to
poor and rural populations were completely discontinued after governmental changes, leaving
those populations without health coverage.

In order to achieve long-term sustainability, it seems necessary to compromise, that is, to

implement interventions that are effective and have a positive impact while drawing on broad
political and societal support that includes key stakeholders such as health workers’ unions
(Kaufman & Nelson, 2004).
CONCLUSIONS:

Using a difference-in-difference model, we estimate the impact that each of these strategies
had on key children’s and women’s health outputs, and found slightly better results for the
contracting-in model.

However, the documented effects are limited and are substantially smaller than those
documented during the second expansion of the program (2004–07).

Policy implications:

 results point to the critical role played by the capacity of program administrators to
manage the contracting process effectively. One option to ensure the development of
that capacity consists of starting at a small scale and gradually developing knowledge
and procedures before scaling up the program. In the case of Guatemala, a more
gradual approach might have set up a more solid basis for the program to expand and
generate results at scale sooner.
 Second, program design should aim to generate not only large effects on health
outputs, but also long-term political sustainability. Political support seems key for
allowing programs to develop capacity and for avoiding costly policy reversals.

Limitations of the study:

because of data limitations, we are unable to assess effects on final health outcomes such as
infant mortality.

Because of the discontinuity of the contracting in they could not compare both systems with
data of the first and second expansion.