Stewardship and governance : structuring dimensions for Implementation Primary Health Care Policies in Paraguay , 2008-2017

This study analyzes the conduction patterns of implementing Primary Health Care (PHC) in Paraguay in three government periods (2008-2012, 2012-2013 and 2013-2017) and three management levels (national, regional and local). This is a qualitative study based on grounded theory. A priori categories on PHC stewardship and governance in Paraguay were analyzed. An open-ended questionnaire was applied to a sample of social, political and technical stakeholders: ministers, coordinators, managers, consultants, and international organizations’ experts. Data were processed combining the use of Atlas Ti software and sorting findings in a structured Excel matrix. Gaps in leadership, regulatory mechanisms, technical capacities for health planning and management and financial implementation methods have affected PHC continuous expansion and strengthening process. The findings show limitations and possibilities for the implementation of this health policy in Paraguay, evidencing the need for greater qualification of management and political stability in its conduction.


Introduction
Expanded freedom in democratic contexts and access to information through new technologies has increased the participation and expectations of society vis-à-vis its health authorities, including the internal health public (professionals and health staff).This setting exposes and makes visible the conduction methods and stewardship competences of managers responsible for the management and implementation of public health policies.This study proposes the analysis of PHC stewardship and governance.
Paraguay is a unitary and decentralized republic with a political and administrative distribution organized into 17 departments and 18 health regions, including capital Asunción and 249 municipalities.The estimated population was 7,112,594 inhabitants in 2017, of which 59% speak the original alternative language "Guaraní" at home, and the illiteracy rate is 5.2%.The average life expectancy of women and men is 75.12 years and 70.83 years, respectively.The out-of-pocket expense per capita is one of the lowest in the region, with US$ 461 in relation to the Gross Domestic Product (GDP), considering the Latin American mean of US$ 718 per capita.Institutional deliveries have risen to 97%.The Human Development Index (HDI) holds the 110 th spot (0.693) and the Gini index places the country at 48.3, although Paraguay stopped being among the most inequitable countries in Latin America [1][2][3][4][5] .
The Paraguayan health system is inserted in a macroeconomic market model characterized by high segmentation and fragmentation, weak articulation and coordination among subsectors, with organizational adjustments to the system that have been incorporated through regulations of Law 1032/96 in the last 22 years.Social security covers around 17% of citizens, which is the lowest in the region, and the private subsystem does not exceed 7% 6,7 .
The Ministry of Public Health and Social Welfare (MSPBS), simultaneously develops functions of stewardship, supply and financing and assumes the responsibility of ensuring health to 100% of the population, with real coverage close to 65%, through an integrated network of services, organized by levels of care and complexity, with asymmetric decentralization processes and current trend towards centralization [8][9][10] .
In 2008, a model of care based on family health facilities and teams (USF) (ESF) was incorporated, which are integrated at the local level to provide immediate response and resolution of health problems and needs to individuals, households and communities in defined social territories, promoting a shared responsibility and management of intersectoral actions aimed at ensuring continuity of care, promoting functionality, integrality and integration of existing service networks, improving enabling conditions and environments, organization and integration of horizontal programs with a high health impact 11,12 .
This study mainly aims to analyze the influence exerted by conduction methods in the process of implementing the renewed Primary Health Care model within the framework of government changes in the last nine years, through a systemic approach to the different issues that emerge in settings of political instability that influence and affect health outcomes 13,14 .

Conceptual framework
The complexity and interdependence of political, economic and social variables underpin and influence the conduction methods and condition the course of implementation of public health policies and the ability to solve problems and needs related to the social determinants of health.In the case of PHC, governance proposes the reconfiguration of the health authority's conduct profile, readjusting the means to achieve the agreed political objectives and results and incorporating features such as professionalism, conjugation of technical and political leadership, balance between efficiency and equity and its consequences in terms of decisions, respect for the principles and regulatory, administrative and legal frameworks inherent to the public sphere, which will allow the exercise of the governing role on behalf of the government, as part of a new social pact at the service of public interest, proposing a new scheme of relationships between government and society, understood as good governance [15][16][17][18] .
In a democratic context, governance is a systemic function that facilitates adaptation and linkages between State and civil society, public administration and organizations, institutions and citizenship through exercises and dynamics of integration that progressively increase cohesion between higher and lower levels, in balance with cultural practices, openness to the application of new methods, tools, planning devices and information systems, with the purpose of influencing beyond the health field, projecting the modification of the social environment for the effective protection of an established right 19 .
It is possible to revive, in the health field, an effective model aimed at resolving conflicts, in settings of large power asymmetries, where governance can affect the equity and sustainability of egalitarian distributive policies.This conception gives rise to the idea of reflective governance, which repositions the figure of the State, responsible for the equality of economic and social conditions, to balance forces and power in decision-making 20 .
Substantive competences for PHC management are projected in the health and intersectoral realm, considering new coordination mechanisms, new strategies, different performance criteria, based on values, socio-affective attitudes, political intuition, suitability, negotiating capacity to cope with level of resistance and conflict nodes [21][22] .
The effects of governability rely on the dynamic balance between styles of government and social intelligence and capacity to achieve government responses at different levels.Governability occurs when spaces are institutionalized so that organizations enable citizens to interact with governmental levels, exercise their civil and political rights and perceive democratic incentives that protect population groups in settings of inequality or political errors 23 .
In countries with clear socioeconomic inequalities, digital gaps and access to information affect the public function's transparency and effectiveness.E-governance is an essential link to strengthen the capacities and citizen participation in the decision-making processes 24 .
In the context of PHC, the sustainable conduction method must overcome the traditional hierarchical scheme, incorporating social capital, participatory spaces, cooperation modes and flexible work styles, peer evaluations and self-evaluations, as well as considering expectations of stakeholders and shared responsibility between civil society and public authorities.It must adapt changes in structures, management procedures and power behavior for the adequate management of emerging conflicts, endorsed by the leadership of the public and political function [25][26][27] .
Interdependence between politics, governability and health outcomes has great relevance because of its effects in strengthening institutionality, when government levels, management and civil society stakeholders manage to operate together.Therefore, good governance corre-sponds to the dynamics of policy networks within a framework of responsibility in the exercise of public action, where predominance of the social and economic commitment that generates balance and the management of a code of values is recognized 28,29 .
The revised theoretical perspectives support the understanding of health management modalities, linking to research questions and contributing with ideas originated in the findings for the construction of this public policy.

Methods
This is a qualitative study based on the grounded theory by Glasser & Strauss 30 .This methodology uses the interpretation of texts and statements to approximate knowledge of the implementation of the PHC policy in Paraguay in three governmental periods (2008-2012, 2012-2013 and 2013-2017).Sampling included 24 key stakeholders who exercised leadership, management and technical advice roles in PHC.Academics, experts and consultants from international organizations, selected by convenience according to professional profile, experience and knowledge in the implementation of this public policy, from national, regional and local levels were also included.A matrix of identification of key players was drawn up, with complete information, stratifying the selected sample by institution (public and NGO), levels of care and period of government.We collected, analyzed and conceptualized contributions of respondents in the period 2015-2017.
The categories of analysis explored included knowledge and scope of the function of health stewardship, interpretation of governance methods, mechanisms for the selection of government managers and availability of evaluation tools, as well as technical capacities and skills, regulatory and financial management aspects, factors, mechanisms and interactions that facilitate or hinder governance, social cohesion, consolidation of intersectoral achievements, effective coordination of networks of people and institutions in order to achieve results within the framework of this policy.Chart 1 shows the systematization of these categories, specifying realms and sub-realms.Data processing started with the elaboration of a list of those categories, adding other emerging ones, selecting significant discursive fragments, organizing them by realms, sub-realms, concepts and constructs, generating hierarchies and specifications.It was necessary to proceed to an in-

Analysis categories
Realms Sub-realms Operational Concepts

Policy planning and formulation
Health policy agenda and strategic plans in place.

Sectoral regulatory and legislative capacity
Capacity to formulate new laws, regulations and standards that can be implemented on a national, regional and municipal basis.Financial management capacity in PHC Financial sources and flows, transfer circuits, distribution of resources (installed capacity, staffing and human resource gaps, sustainable supply of medicines and supplies).

Operational Skills
Stewardship  terpretation of the referred conduction processes regarding PHC stewardship and governance, integrating findings, context, prior knowledge and experience in that field.Output was generated through Atlas ti software, and a complementary Excel matrix was used to sort and systematically analyze the categories.Results are organized from the key messages obtained from the interviews, in segments selected according to a priori codes and some of the emerging codes.Ethical considerations, informed consent, confidentiality, anonymity and voluntary participation were taken into account.

Knowledge about Stewardship and Governance functions
The concept and functions of "health stewardship" have had several interpretations, with a predominance of a structured concept of conduct established by international organizations 31 , linked to public policymaking and exercise of health administration, formulation of plans, programs and projects, provision of services, application of laws and regulations and implementation of standards.Some stakeholders affirmed that stewardship is put to the test through the ability to overcome bureaucratic hurdles, introduction of innovations, effective response to events or diseases of collective impact, power to call for the effective participation of the community in the social management of health, continuous and coherent application of health promotion strategies that allow for the joint installation of changes and transformations.
"Governance" has been linked to the integration of referents from different institutions in decision processes, in formal participation levels.Others related this concept to the public exercise of functions on behalf of the State and some showed lack of knowledge and difficulties to understand its meaning.

Selection of leadership positions in the public sector
There was consensus in affirming that some institutions carry out merit-based and aptitude-based competitions, although in most cases the designation for the exercise of management positions builds on trust, where competences are frequently not in accordance with the challenges and responsibilities.The selection based on skills and leadership originated in a solid academic education, or respect for a public administrative career that grants leadership skills is exceptional.
In the three periods of government, the competition has been incorporated for the operational levels, but not for the managerial levels (Regional level professional, 1 st period).

Both the selection of ministers and selection of management cadres historically respond to the appointment by the Executive Power (Former Minister).
Ministers in office are surrounded by people who followed their vision not always based on suitability (Central level manager, 3 rd period).

Availability of performance evaluation tools for managers
There are no known mechanisms to evaluate the skills and abilities of high public management or senior management that allow comparing, discerning and qualifying the management and conduction of processes with guidance and results.
... Directive cadres are evaluated indirectly through citizenship opinion surveys; in other cases, performance is measured through numerical weights, which do not reflect reality (Expert, 2 nd period).

Regulatory devices
In the three periods of government, the application of regulatory tools at the first level of care was weak, both in the central and peripheral activities.The lack of specific technical evaluation and systemic analysis are confounded with control devices and the performance of specific audits, which prevent an overview of the limits of functionality of the local micro-networks where USFs are inserted.No sustained adjustments are achieved, despite available standards, manuals, protocols and guides and other operational tools, considered as a strength and indicators of stewardship.
...There is a perception that regulatory and corrective measures are installed once management problems are detected, and respond to complaints, which are followed by a passive wait for the response.(Consultant, International Organization, 3 rd period).

Evaluation activities
In the first stage, external evaluations allowed an approximation to the macro diagnosis of ongoing processes, delaying the design of tools for the systematic evaluation of this new public policy.This was attributed to the short periods between governments, the use of usual indicators used in management controls of service networks and health programs, considered inadequate due to the need to identify new performance indicators that reflect the specific introduction and functionality of PHC.
... Social control is relevant when there are no other means to detect institutional shortcomings that prevent potential beneficiaries from organizing themselves properly and access their benefits.(Former Minister).

Financing model and sustainable sources of resources
The annual projection of funds conceived at the onset of the first stage of implementation of the renewed PHC raised the annual increase of 200 USFs per year.In the last two rotations of government, financial restrictions have shown the shift of PHC as a political priority, reflected in the discontinuity of installation and functionality of new family health facilities, reaching less than 40% of expected coverage in 9 years. .

.. There is a consensus that mechanisms for allocating resources are not carried out according to a correspondence analysis with Primary Health Care's fields of action, including promotional, preventive, curative and rehabilitation activities ... (International Expert)
...There are no independent procurement processes; they are immersed in the general procurement processes of the Ministry of Health, in turn related to the complex organization and financial flow of the Ministry of Finance, which affects timely access to essential resources.The flow of PHC personnel and professionals remuneration follows its normal course, salaries credited to accounts.The financial flow for the acquisition of medicines and supplies is managed on a large scale ......It is difficult to clearly define the execution of assigned funds ... (Manager, 2 nd period of government).

Quality of technical cadres
It has been affected by the successive rotation of governments, as well as the continuity of managerial training and their competences to exercise health stewardship, reflected in the performance, communication styles, peer relationship method, negotiation and conflict resolution and comprehensive knowledge of the realms subject of conduction.
Chart 2 summarizes the results, showing the realms and sub-realms of stewardship and governance in each period of government.

Discussion
The analysis of the capacities of conduction and construction of governance in the course of implementation of the renewed Primary Health Care shows the strong link between political processes and health outcomes.The successive changes of government in settings of political instability have put to the test the stewardship capacity and other multiple variables, and autonomy, leadership of political and civil society actors and financial sustainability 32,33 were compromised.
The successive turnover of managers, technical cadres and operative personnel has influenced governance, affecting the continuity of intersectoral achievements, coordination processes of subnational teams, quality of planning and evaluation, effective coordination by levels for the implementation of strategic guidelines, commitment of technical working groups, change of priorities in the management agendas, and social cohesion has been weakened.Other effects generated have been the loss of clarity in the conduction and coordination of the guidelines established in the PHC's initial Strategic Plan, losing the focus that effectively links health problems to their social, cultural and individual causes 34 .
There is a need to concentrate State action on strategic functions for the development of human and social capital, for the strengthening of the rule of law and expanded and strengthened democracy 35,36 .
Different conduction capacities have been seen in the three periods of government, although some realms have been more affected, such as weak information system, difficulties to develop systematic evaluation processes and the continuous training of the health workforce.
With regard to regulatory capacity, this realm is cross-cutting with all other sub-realms of stewardship, considering that it is linked to political variables of power and governability 37 .Regarding the cyclical process of reorganization of public institutions and offices, after each change of government, and in particular those processes linked to the PHC strategy, the role of international Chart 2. Realms and sub-realms of the PHC Stewardship and Governance in three periods of government.financial organizations and technical cooperation agencies managed to modulate the political processes with technical rationality in the first stage, and were clearly weakened and with low influence on the following health executives and their technical teams in the subsequent stages, in which the linkage of ideological models to models of financing and conduction is made visible.None of the three periods of government was able to define an explicit financing model adapted to the requirements and oriented to decentralized management processes, rather opting for a centralized administrative model.Despite the enunciations of the current National Health Policy, there is a lack of reforms that reflect the orientation toward universality.The content of the health discourse is weak, health professional training was discontinued, emphasis was given to emergencies and conjunctures, fleeting visibility of commemorative health days, lack of analysis of MDGs versus SDGs, lack of analysis of health system performance indicators, identification of local priorities for the strengthening of the quality of personal care (HAQ) that show very low values.
Rarely does a political health process demonstrate coherence and reflect in the implementation what has ideally been formulated in its statements, as a linear, rational process from the formulation to the application of the policy.The complex settings in which health-related decisions are made rarely articulate the context, content, specific interests and objectives with the expected results as a theoretically recommendable sequence.The strengthening of strategic stakeholders for change can influence the reorganization of the health services system, facilitate institutional, structure and management changes, affecting the distribution of power and favoring PHC's vision and interests 38,39 .
Without a doubt, governance is a democratic reinforcement, a device that promotes equity, an opportunity for economic growth and social progress, around imperatives of good governance, which implies an efficient public management, with increased transparency, quality, costs and adequate financing.The existence of governance bodies favors the analysis of different dynamics and processes and are an alternative to tackle the problems as catalysts, facilitating cooperation and interaction between the State and non-state stakeholders for the implementation of policies, programs and plans 40,41 .

Conclusions
The findings suggest that the implementation of this public policy has been influenced by political instability.The successive rotation of governments in the last five years has diverted the implementation of PHC from its normal course, weakening comprehensive approaches and their potential as a State policy, reaching a coverage of 44% in nine years.
The guiding role has been tested beyond the usual performance criteria, given the challenges for overcoming various obstacles and bureaucratic hurdles to install changes and transformations around this public policy, including adaptability to complex settings, financial limitations and resolution of crises.
We identified the need to give strong impetus to training programs for managers and technical cadres that incorporate competences in a framework of demonstrated suitability according to position, area or performance organization to carry out the social development plan, and longterm projected social policies, incorporating competition for managerial positions.
Regarding governance, we note a shift between one government and another, moving from a flexible and inclusive mode to stricter hierarchy-oriented modalities.
Financial management has been affected by structural constraints, quality of spending, level of efficiency and coordination between the central government and subnational governments.The flows of resources have been insufficient to implement functions and norms, agreements and social and political dynamics, and to project sustainable changes.
Regulatory capacity was characterized in the beginning by the implementation of incentives and commitments, and in the following stages by the incorporation of oversight processes, while not of systematic evaluations to introduce improvement plans, gradually installing restrictive mechanisms that have affected social cohesion, reincorporating red tape practices.The reconstruction of governance will require considering the importance of mediation, social referents and interested parties from the public and private spheres, assuming dynamic and facilitating roles of interactions and relationships.This can exert influence to revive and maintain progress and achievements.

Collaborations
MS Cabral-Bejarano elaborated the design and the methodology, fieldwork, organization of the database, analysis, discussion of the results and drafting of the scientific paper.G Nigenda, A Arredondo and E Conill participated in the review of the design and methodology of the study and analysis and discussion of the results.

Chart 1 .
Categories of analysis: realms and sub-realms of PHC Stewardship and Governance -Paraguay.
functions Empowerment of the Health Stewardship functions.Opening to Governance as a new social pact.
Paraguay, 2008-2017.Resulting from consultation with key stakeholders, perception of sub-realms involved in PHC stewardship and governance in three periods of government.Paraguay, 2008-2017. Source: