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Annex 12. PERU

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Annex 12. PERU Annex 12. PERU Background An estimated 28% of Peru’s population is still living in rural areas,185 where people are not only the most neglected and disadvantaged in terms of access to quality health and education services, but also suffer most from the social, political, and economic inequities that still characterize the country. This poses formidable challenges to the state’s efforts to introduce accessible health and education services. Politically, Peru continues to experiences political unrest since its decentralization attempts beginning in 2000.186, 187 The rural inhabitants of the Andes have suffered most from this, and after several years of post-violence efforts, there remains substantial social debt that the state needs to fulfill, including effective poverty fighting and provision of health and education services. Although Peru has been classified by the World Bank as an upper-middle income economy, the real challenge will be to make particularly substantial reductions in poverty in the inner Amazon and Andean areas of the country, which have had the slowest poverty reduction rates,188, 189 indicating where the major efforts of the state should be concentrated if the country is going to become prosperous and equitable. The health system in Peru must be prepared urgently if it is going to successfully face the challenges posed by the country’s epidemiological transition characterized by an aging population, progressive reduction of communicable diseases, and sustained increase of chronic non-communicable diseases and injuries, as well as neonatal deaths and congenital malformations.190 The current country case study is focused on characterization of mid-level health workers, with the objective of highlighting advantages and limitations regarding several aspects that contribute to their deployment and performance within the Peruvian health system, as part of the efforts to achieve the health-related Millennium Development Goals (MDG) and beyond. Maldistribution of Human Resources for Health (HRH), which are scarce in these areas, is one of the equity challenges that the government must rectify to consolidate past and current achievements and ensure accomplishment of the promise of better health for all citizens. The main characteristics and drivers of the national health policy were established in the Institutional Strategic Plan 2008-2011 of the Ministry of Health of Peru.191 This Plan incorporates the state, government, and health sector policies. The driving principles of the Health Policy Guidelines include: universality, social inclusion, equity, integral profile, cross-cutting profile, efficiency, quality, solidarity, and sustainability.191 The Peruvian health system is a mixed one, as it includes the public sector, the health social security, the National Police and Armed Forces, and the private sector.192 The main insurers in the Peruvian health system are ESSALUD (including EPS); SIS (currently AUS); and private insurance companies. The MOH is a financing agency, not an insurer. By law it is supposed to cover the entire population, but in reality most public hospitals are so under-funded or payment procedures by AUS are so lengthy and bureaucratic that many patients eventually buy their own medicines, facing significant out-of pocket expenditures.193 A study published in 2008 compared healthcare spending aspects among Bolivia, Peru, and Chile, using 2004 World Bank data as the information source, and showed that Peru had the lowest total health care expenditure as a per cent of GDP. The growing weight of pooled expenditures reflects the increased public financing of the national health system, revealing the extent of improvements needed in order to achieve an acceptable level of efficiency of the health system. 208 The new decentralization process that started in 2002 meant that regional and municipal governments have been distributed growing funds and have had administrative responsibilities transferred to them, with mixed results so far, which we have highlighted in a previous section of this report.194 Other challenges that the health decentralization process needs to overcome besides capacity building at policymaking and managerial levels include the huge improvement needed in the provision of capable and motivated health workers in the poorest areas; the development of extensive infrastructure, equipment, and supplies to face the ever-changing epidemiological health profile; the improvement of accountability and governance standards which are reportedly weakest in the poor inner departments of the country; development of an effective consultation process that considers all stakeholders’ perspectives and expectations;194-196 and a definitive change to a transparent and efficient culture.196 Situational analysis of MLHW National HRH strategic plan and policy: MLHW Under the leadership of the Human Resources for Health Direction of the Peruvian Ministry of Health, the National Policy Guidelines for Development of Human Resources for Health (Lineamientos de Política Nacional para el Desarrollo de los Recursos Humanos en Salud), the National HRH Strategic Plan was unanimously approved in September 2005, after a process of analysis, discussion and consensus building with the active participation of all stakeholders involved.197 These are the guidelines that should have served as the general framework for developing and implementing the HRH specific strategies at country and sub-national levels: Guideline 1. Training of HRH based on the Integral Health Care Model, country demographic sociocultural and epidemiological profile, and taking into account the regional and local specificities. Guideline 2. Equitable strategic planning of HRH, considering the above-indicated profiles, as well as the population health needs, particularly those of the poorest segments. Guideline 3. Decentralized management of HRH, as part of management of health services, while recognizing the central and integral aspects of HRH inherent to organization development. Guideline 4. Management of effective, efficient and equitable processes for promoting capacity development of health personnel, so as to contribute to performance and quality of health care improvement Guideline 5. Acknowledgement of community health workers as valuable human resources of the Peruvian health system, as well as acknowledgement of their contribution to health and development, at local, regional and national levels. Guideline 6. Promotion of a new labour regulatory framework that considers competency and occupational profile-based entrance, public career promotion, and implementation of equitable and merit-based incentives and benefits. Guideline 7. Improvement of job conditions and promotion of motivated and committed health workers that ensure delivery of quality health services. Guideline 8. Impulse of agreement and negotiation processes in the labour relationships, based on respect to dignity of health workers, aiming at the achievement of the institutional mission. These general guidelines explicitly mention the role of community health workers, but not that of mid- level health providers such as nurses, midwives, nurse technicians, and other health cadres, although the review of specific strategies related to HRH reveal that a prominent strategy to be implemented within the framework of the Universal Health Insurance (AUS) is the development and consolidation of family health teams composed by doctors, nurses, midwives, community health workers and other 209 health professionals. Prosalud Program is notably the strategy designed by the General Management Direction for Development of Human Resources for Health as a branch of the Ministry of Health for implementing this approach that privileges primary health care and consequent promotion and prevention activities and social determinants of health.198 Prosalud also includes a package of incentives aimed at improving retention of health workers in remote and rural areas of the country, which are the main targets of AUS.198 Specific incentives proposed by Prosalud are described later in this report. It is expected that after the definitive approval of Prosalud by the Parliament and the Executive, its implementation will start rapidly progressing to an expansion phase that should cover the entire country, with primary focus on the poorest regions. Although a much-needed monitoring and evaluation plan that includes results-based budgeting components to be taken into account when implementing specific strategies of this HRH Strategic Plan has been proposed, a systematic costing procedure has yet to be formally performed. Situation analysis The functionality of the HR information systems at national and sub-national levels is still a pending issue in the agenda of strengthening the information systems in the country. Although there have been efforts to improve their resources and capacities, they are still lagging behind in their capability of providing updated, complete and accurate information about the production, deployment, migration, job and salary schemes, effects of attraction and retention strategies, among other core data needed for allowing a better planning of interventions to improve the availability of HRH across the country, as well as their performance in the provision of quality health services. The National Observatory of Human Resources for Health was established in Peru in 1999 as part of the wider development of a regional network launched through the initiative of the Pan American
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