The Ministry of Health follows a “centre-periphery” model. Smaller health posts (called “puestos de salud”) provide care for the peripheral (and more rural) populations. The size and complexity of facilities increases closer to the center, where health centers (“centro de salud”), district hospitals (“hospital districtal”) and central hospitals (“hospital central”) are responsible for medical care. Finally, IPS facilities are predominantly in urban areas, where most of the population with regular employment lives and are similar to MoH facilities located in the same areas (World Bank 2006).

# _The Data_

The data are from a survey of 292 doctors in 98 facilities in four departments of the country— Asuncion, Cordillera, Misiones and Central. These facilities were picked randomly from a list of public facilities in these provinces administered by the MoH and the IPS.

There were four different parts to the data collection. In every facility, CIRD completed a facility survey and a roster of all doctors. We then observed interactions between doctors and patients for a set of doctors randomly chosen from the roster—depending on the size of the facility, the total number of doctors observed varied between 1 and 10, yielding a total of 292 doctors who were observed at least once.<sup>3</sup> For this sample of 292 doctors, there are 11 interactions on average for each doctor, yielding a total of 2271 doctor-patient interactions. As the patient left the clinic, a second surveyor standing outside completed an exit-interview with detailed socio-demographic information on education, wealth, age and employment; health status including self-reported health status and a health measure based on activities of daily-living as well as satisfaction with the service.

Finally, we were concerned that observing the doctor-patient interaction would itself change the way that the doctor behaved—this is the well-known Hawthorne effect, discussed for instance in Leonard (2006). To gauge the extent to which this happened, patients who had visited the facility in the last week were surveyed at home and completed a questionnaire similar to that administered in the exit survey. This part of the survey was not completed for all the facilities, but for a sub-sample of 64 facilities administered by the MOH. The households surveyed were predominately within a 15 minute walk from the facility. Although the patients interviewed through the exit survey are _not_ the same as the patients interviewed at home, it is likely that the two samples are comparable: Since we chose the day of the facility visit randomly, there is no _a priori_ reason to believe that the patients interviewed at home are very different from those interviewed at the facility, once we restrict attention to those who came to the clinic from within a 15-minute radius.

Table 1 summarizes basic characteristics of doctors, patients, and reported satisfaction for the full sample (Table 1, Column A), the sub-sample of facilities where the additional household survey was administered (Table 1, Column B) and for respondents from the household survey itself (Table 1, Column C). On average, patients visiting the facilities are in their mid-thirties (parents were interviewed when the patient was a child), report at least primary education and just under 20 percent report arriving in very good health (SRHS). The doctors who see these patients tend to be female (55 percent), middle-aged and with an average of 17 years of experience on the job. As in most other surveys, patients report a high level of satisfaction: Although the question on satisfaction allowed for 5 options ranging from “very dissatisfied” to “very satisfied”, 90 percent responded that they were either “satisfied” or “very satisfied”, a finding that is standard in the literature (Williams, B et all 1998). For our analysis, we restrict ourselves to two options—“very satisfied” and “others”; for the full sample, 59 percent fall in the former category.<sup>4</sup> 3 A small number of doctors (42) were observed in multiple facilities as part of a study trying to understand the impact of contracting regimes on performance. These doctors were over-sampled from the random population and their inclusion (or exclusion) does not alter the results.

4 This categorization does not affect our results; in alternative specifications using 4 possible values for satisfaction and an ordinal probit specification, we obtain very similar relationships. Collapsing the 4 4