Decentralization of health care in Paraguay: A contribution to gender equality?
Objective To understand the dynamics of the processes of decentralization of health services carried out between 1996 and 2008 and their impact on women’s well-being and gender equity.
Methodology Qualitative and quantitative data collection techniques were used in 10 case studies, which were analyzed using the Decision SpacePrincipal Agent model proposed by Bossert (1998).
Results In Paraguay, health care was one of the sectors that was most expanded towards local spaces. This was due to the increasing demands of a constantly growing population, but also to the interests of some local governments that took the decentralization of health services as an opportunity to deal with delayed and critical needs of their communities. This process was anchored in the Local Health Councils (LHC), devices designed for public health management, with the participation of civil society. The LHC were empowered to promote interagency partnerships, manage resources and guide actions jointly with the authorities of health establishments and the municipality. Representatives of local institutions, indigenous and women’s organizations were integrated in the process. Participation in the LHC was implemented without further methodological guidelines or protocols to facilitate the inclusion of historically excluded sectors, such as women. Considering that a great part of their members were women, it was assumed that this would be an opportunity to discuss their health related rights. This assumption was not observed in all cases and, oddly enough, in those cases in which there were initiatives proposed in this regard, it was not women who drove them - at least not deliberately. The case studies showed that the decentralized system reported to the central level, with little margin for the LHC, local health staff and inhabitants to play a part in the local service supply. Any possible innovations that they could implement depended on the increase in their own resources, derived from charges to the community, which led to patients’ greater out-of-pocket expenses, with the subsequent constraints to reversing the system’s exclusion gaps.
25