# **3.3 OIA and BIA on public health care**

For the countries in this study, the BIA and OIA for public health care spending is only applied to Paraguay, for which there is sufficient information on the demand for health care, access to health care facilities, and household private spending by types of health services.<sup>26</sup> In particular, Paraguay’s Permanent Household Survey allows identification of households in which a child suffered an illness or accident (within the last 90 days) that was considered serious enough to seek medical attention. Among those cases, the analysis further identifies those who responded that although they were willing to receive attention, they did not seek it because medical services were not close by, were too expensive, or were not considered by individuals sufficiently good to effectively demand them . This group is categorized as being excluded from public and private health services. Those who visited a healer<sup>27</sup> or a relative are not considered to enjoy the public health care opportunity.<sup>28</sup> Consequently, those who suffered an illness or accident in the last 90 days, considered it sufficiently important to seek attention and were not subject to supply, costs, and quality restrictions are categorized as enjoying the opportunity of timely and affordable access to health care services. Public provision of health care refers to services provided by the Ministry of Health and Social Welfare ( _Ministerio de Salud Publica y Bienestar Social_ ) and the Institute of Social Security ( _Instituto de Prevision Social_ ). Public care services are further divided into those provided in a health center ( _centro_ or _posta de salud_ ) and those provided in hospitals.<sup>29</sup> No further disaggregation is possible given the available administrative and household survey data. Private health care corresponds to services provided by pharmacies and private professionals and medical institutions. All of this information is available at the departmental level.

The distribution of net unitary benefits from health care is neither progressive nor regressive in Paraguay. The average _aggregate_ benefit from health care neither systematically increases nor decreases along with income levels (figure 9a). Household out-of-pocket contributions do not seem to follow a monotone trend either, although beneficiaries in the bottom 40 percent incur less out-of-pocket contributions in absolute terms on a systematic basis. The result is a net benefit for those in the top

> 26 Other studies talk of health opportunities in the form of health and nutrition outcomes (see footnote 15). However, as health and nutrition outcomes are a function of many different factors interacting complexly, it is believed that access to public health services is a more accurate representation of the opportunity, in the same way that access to public education captures educational opportunities. This does not deny, of course, that health and nutrition status—like education status—constitute important intermediate inputs for current and future well-being and welfare.

> 27 It is possible that the family preferred the attention of a healer instead of that of standard health services, even if the latter were available and affordable. In this case, the analysis would be overestimating exclusion to health care. However, the percentage of the ill who visited a healer or a relative was 1.49 percent in 2010.

> 28 Self-medicated are also considered as excluded from health services. However, the analysis was conducted assuming that selfmedication is considered as not seeking health services. Results—available upon request—did not change substantially.

> 29 Under health centers, primary and secondary health services are provided by _postas de salud_ and _clinicas de salud_ . Secondary and tertiary health services provided by regional and central hospitals and by MSPyBS and IPS hospitals are grouped under hospital services.

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