Strengthening Public Health Capacity in Peru

1. Dr. Arturo Hinostroza Atahualpa MINISTRY OF HEALTH Strengthening Public Health Capacity in Peru Rapid assessment at the subnational level: Decentralized Health Care in the Regions of Arequipa and Cajamarca VII REGIONAL FORUM - STRENGTHENING HEALTH SYSTEMS BASED ON PHC Quito, 29-31 October 2007

2. D IMENSIONS Public health workforce Public health information systems Public health technology Organizational and Institutional capacity for public health Financial resources for public health RAPID ASSESSMENT Beaglehole and Dal Poz define public health capacities as the components necessary to perform public health actions and achieve public health goals. They depend on the context of a specific country or region and to particular requirements to adequately meet the needs of the population. It is comprised of the following dimensions: Implementation Strengthening public health capacities requires knowing what those capacities are, their status and what the gaps are that affect the performance of the Essential Public Health Functions in Peru at both the national and regional levels.

3. ESSENTIAL PUBLIC HEALTH FUNCTIONS RESULTS IN 2001 AND 2006 1.00 Average NHA 2001 Average NHA 2006 Regional Average 2006 36% 63% 46% 0,90 0.90 0,86 0,81 0.80 0,73 0.70 0,67 0,65 0,62 0,62 0,59 0,59 0,58 0.60 0.50 0,39 0.40 0,37 0,35 0,33 0,31 0,30 0,30 0.30 0,27 0,27 0,19 0.20 0,13 0.10 0.00 EPHF 1 EPHF 2 EPHF 3 EPHF 4 EPHF 5 EPHF 6 EPHF 7 EPHF 8 EPHF 9 EPHF 10 EPHF 11 EPHF 2001 EPHF 2006 RAPID ASSESSMENT In 2005 in Peru, a Performance Evaluation of the Essential Public Health Functions was conducted at the national level and in all regions.

4. RAPID ASSESSMENT Rapid Assessment of Public Health Capacity This Rapid Assessment at the regional level in Peru is an opportunity to determine the status of public health capacity and its dimensions. To help the Health Authority improve the performance of public health functions and contribute to a sustained improvement in the health system’s response capacity, a new vision of public health that is not reactive but proactive and prospective is required. Peru is in the process of decentralizing the health sector, with regions that perform both the steering and service delivery functions. The Regions of Cajamarca and Arequipa have implemented decentralization at the regional level. At the local level, Primary Health Care management functions have been transferred from the regional to the local level, specifically the provincial and/or district levels.

5. RAPID ASSESSMENT METHODOLOGY • The dimensions or elements of public health capacity are evaluated by the Regional Health Bureaus. • Using a structured guide, interviews are conducted with key officials and personnel of the Regional Health Bureau responsible for the execution of the main activities in health—for example, the Director General; the Director of Health Services; the Director of Human Resources; and the Director of Administration. • Interviews and observations • Structured Guide

6. RAPID ASSESSMENT Structured Guide • 0= has no information or does not meet criteria • 1= there is partial information or it cannot be sustainedby evidence • 2= has the information A Structured Guide has been prepared that allows for a rapid assessment of the status of public health capacities. In order to assess the dimensions of public health capacity, the dimensions are first disaggregated into their basic characteristics or features. Then they are disaggregated by attributes related to these basic characteristics. Next, these attributes are scored according to their availability on a scale of 0, 1, and 2. The highest value is 2, which indicates the presence of the particular operational attribute. These scores are then totaled to arrive at a score for that dimension of public health capacity.

7. Basic Characteristics ELEMENTS 1 Public Health Workforce 1. Availability of Public Health jobs 2. Distribution of Public Health workers 3. Qualifications of the Public Health Workforce 4. Workers in charge of key public health processes 5. Mechanisms for upgrading public health personnel 2 Public Health Information Systems 1. Scope of Regional Health Information System 2 Sectoral Integration of the Regional Health Information System 3. Transparency of the Sectoral Health Information System 4. Qualifications of the expert support for the information system 5. Qualifications of the tech support for the information system 6. Mechanisms for strengthening the sectoral health information system 3 Public Health Technologies 1. Availability of Public Health technology 2. Evaluation of available public health technology 3. Safety of principle public health technologies 4. Qualification of expert and tech support for public health technology 5. Mechanisms for strengthening public health technology 4 Organizational and Institutional Public Health Capacities 1. Public Health Authority 2. Codification of Laws and Regulations on Public Health 3. Regional Public Health Policy and Planning 4. Decentralization of Health Care Management 5. Health Services Management 6. Mechanisms for strengthening organizational and institutional capacities in public health 5 Public Health Financial Resources 1. Investment in financing 2. Progressive Public Health spending 3. Multi-year scheduling of financing and investment in public health 4. Transparency and social control over public health spending 5. Mechanisms for strengthening financing and investment in public health RAPID ASSESSMENT Structured Guide

8. EXECUTION OF PUBLIC HEALTH CAPACITIES (482) Reflecting proper execution of the individual components of public health capacity ELEMENTS MAX. VALUE Public Health Workforce 104 Public Health Information System 86 Public Health Technology 74 Organizational and Institutional Capacities in Public Health 160 Financial Resources for Public Health 58 TOTAL 482 RAPID ASSESSMENT Structured Guide Capacity Standards Operational attributes have been defined as the standard for each capacity. Then, capacities are evaluated for specific dimensions, and this reveals any gaps in public health capacity for those dimensions.

9. Comparative Analysis Public Health Workforce Public Health Workforce 100.00% 87.50% 87.50% 100.00% 80.00% 70.00% 80.00% 63.64% 56.06% 60.00% 60.00% 37.50% 37.50% 33.33% 40.00% 40.00% 10.00% 20.00% 20.00% 0.00% 0.00% 0.00% Public Health Workforce for both regions Cajamarca y Arequipa. Year 2007 Public Health Workforce CAJAMARCA AREQUIPA Availability of public health jobs. 37.50% 87.50% Distribution of public health personnel 37.50% 87.50% Qualifications of the public health workforce 10.00% 70.00% Personnel skilled in public health processes 56.06% 63.64% Mechanisms for strengthening public health personnel 0.00% 33.33% REGIONAL AVERAGE 42.31% 64.42% Quick Evaluation in the Regions Results Obtained

10. Comparative Analysis Public Health Information System Public Health Information System 100.00% 100.00% 100.00% 83.33% 83.33% 72.22% 80.00% 73.08% 80.00% 65.38% 50.00% 60.00% 45.83% 60.00% 33.33% 33.33% 40.00% 40.00% 20.00% 20.00% 0.00% 0.00% 0.00% 0.00% Public Health Information Systems for the Regions of Cajamarca and Arequipa . Year 2007 CHARACTERISTICS CAJAMARCA AREQUIPA 1 Scope of Regional Health Information Systems 72.22% 83.33% Sectoral Integration of the Regional Health Information System 33.33% 45.83% 2 3 Transparency of the Sectoral Health Information System 83.33% 100.00% 4 Qualifications of Expert Support for the Information System 65.38% 73.08% 5 Qualifications for Tech Support for the Information System 50.00% 33.33% 6 Mechanisms for Strengthening the Sectoral Public Health Information System 0.00% 0.00% REGIONAL AVERAGE 57.50% 66.25% Quick Evaluation in the Regions Results Obtained

11. Comparative Analysis Public Health Technology Public Health Technology 100.00% 100.00% 83.33% 80.00% 80.00% 60.00% 60.00% 42.31% 42.86% 30.00% 40.00% 40.00% 16.67% 20.00% 11.54% 20.00% 20.00% 7.14% 0.00% 0.00% 0.00% 0.00% Public Health Technology in the Regions of Cajamarca and Arequipa CHARACTERISTICS CAJAMARCA AREQUIPA 1 Availability of Public Health Technologies 16.67% 83.33% 2 Evaluation of Available Public Health Technologies 11.54% 42.31% 3 Safety of Principle Public Health Technologies 30.00% 20.00% 4 Qualifications of Expert and Tech Support for Public Health Technology 7.14% 42.86% 5 Mechanisms for strengthening the Public Health Technological Management System 0.00% 0.00% REGIONAL AVERAGE 13.51 % 45.95 % Quick Evaluation in the Regions Results Obtained

12. Comparative Analysis Organizational and Institutional Public Health Capacities Organizational and Institutional Public Health Capacities 100.00% 86.67% 100.00% 96.67% 91.67% 75.00% 89.19% 100.00% 80.00% 63.51% 80.00% 65.38% 50.00% 60.00% 60.00% 40.00% 40.00% 16.67% 11.54% 20.00% 20.00% 0.00% 0.00% 0.00% Organizational and Institutional Public Health Capacity in the Regions of Cajamarca and Arequipa. Year 2007 CHARACTERISTICS CAJAMARCA AREQUIPA 1 Public Health Authority 50.00% 91.67% 2 Codification of Laws and Regulations in Public Health 75.00% 100.00% 3 Regional Public Health Policy and Planning 11.54% 65.38% 4 Decentralized Health Care Management 63.51% 89.19% 5 Health Services Management 86.67% 96.67% Mechanisms for strengthening organizational and institutional capacities in public health 6 0.00% 16.67% REGIONAL AVERAGE 56.88% 85.00% Quick Evaluation in the Regions Results Obtained

13. Comparative Analysis Financing and Investment in Public Health Financing and Investment in Public Health 100.00% 100.00% 80.00% 66.67% 58.33% 58.33% 60.00% 80.00% 66.67% 60.00% 50.00% 45.83% 60.00% 40.00% 30.00% 40.00% 20.00% 20.00% 0.00% 0.00% 0.00% 0.00% Financial Resources for Public Health Regions of Cajamarca and Arequipa. Year 2007 CHARACTERISTICS CA JAMARCA AREQUIPA Investment in Financing 1 50.00% 58.33% Progressive Public Health Spending 2 45.83% 58.33% Transparency and Social Control over Public Health Spending 3 66.67% 66.67% Multi-year Scheduling of Financing and Investment in Public Health 4 30.00% 60.00% Mechanisms for Strengthening Financing and Investment in Public Health 5 0.00% 0.00% REGIONAL AVERAGE 41.38% 53.45% Quick Evaluation in the Regions Results Obtained

14. Comparative Analysis Public Health Capacities Public Health Capacities Public Health Capacities 1.00 1.00 0.90 0.90 0.80 0.80 0.70 0.70 0.60 0.60 ORGANIZATIONAL AND INSTITUTIONAL CAPACITIES IN PUBLIC HEALTH 0.50 0.50 PUBLIC HEALTH WORKFORCE PUBLIC HEALTH INFORMATION SYSTEM FINANCIAL RESOURCES FOR PUBLIC HEALTH PUBLIC HEALTH TECHNOLOGY 0.40 0.40 0.30 0.30 0.20 0.20 0.10 0.10 0.00 Total Observed 0.00 Total Observed Execution of Public Health Capacity at the Regional Level In the Regions of Arequipa and Cajamarca. Year 2007 Cajamarca Arequipa Public Health Capacity Index Public Health Capacity Index ELEMENTS Public Health Workforce 0.4231 0.6442 Public Health Information System 0.5349 0.6163 Public Health Technology 0.1351 0 .4595 Organizational and Institutional Capacity in Public Health 0.5688 0.8500 Financial Resources for Public Health 0.4138 0.5345 TOTAL 0.4461 0.6660 Quick Evaluation in the Regions Results Obtained ORGANIZATIONAL AND INSTITUTIONAL CAPACITIES IN PUBLIC HEALTH PUBLIC HEALTH INFORMATION SYSTEM PUBLIC HEALTH WORKFORCE FINANCIAL RESOURCES FOR PUBLIC HEALTH PUBLIC HEALTH TECHNOLOGY

15. Comparative Analysis Public Health Capacities Public Health Capacities Public Health Capacities 1.00 1.00 0.90 0.90 0.80 0.80 0.70 0.70 ORGANIZATIONAL AND INSTITUTIONAL CAPACITY IN PUBLIC HEALTH 0.60 0.60 0.50 0.50 PUBLIC HEALTH WORKFORCE PUBLIC HEALTH INFORMATION SYSTEM FINANCIAL RESOURCES FOR PUBLIC HEALTH PUBLIC HEALTH TECHNOLOGY 0.40 0.40 0.30 0.30 0.20 0.20 0.10 0.10 0.00 Total Observed 0.00 Total Observed Execution of Public Health Capacities at the Regional Level in the Regions of Arequipa and Cajamarca. Year 2007 Cajamarca Arequipa Public Health Capacity Index Public Health Capacity Index ELEMENTS Public Health Workforce 0.4231 0.6442 Public Health Information System 0.5349 0.6163 Public Health Technology 0.1351 0 .4595 Organizational and Institutional Capacities in Public Health 0.5688 0.8500 Financial Resources for Public Health 0.4138 0.5345 TOTAL 0.4461 0.6660 Results of the Quick Evaluation Results Obtained ORGANIZATIONAL AND INSTITUTIONAL CAPACITY IN PUBLIC HEALTH PUBLIC HEALTH INFORMATION SYSTEM PUBLIC HEALTH WORKFORCE FINANCIAL RESOURCES FOR PUBLIC HEALTH PUBLIC HEALTH TECHNOLOGY

16. Regional Analysis Cajamarca Region Public Health Capacities 1.00 0.90 0.80 0.70 0.60 0.50 PUBLIC HEALTH INFORMATION SYTEM 0.40 ORGANIZATIONAL AND INSTITUTIONAL CAPACITY IN PUBLIC HEALTH 0.30 PUBLIC HEALTH WORKFORCE FINANCIAL RESOURCES FOR PUBLIC HEALTH 0.20 0.10 PUBLIC HEALTH TECNOLOGY 0.00 Total Observed Public Health Capacity Index Cajamarca Region. Year 2007 Total Total Public Health Capacity Index ELEMENTS Observed Expected Public Health Workforce 44 104 0.4231 Public Health Information System 46 86 0.5349 Public Health Technology 10 74 0.1351 Organizational and Institutional Capacities in Public Health 91 160 0.5688 Financial Resources for Public Health 24 58 0.4138 TOTAL 215 482 0.4461 Results of the Quick Evaluation Results Obtained

17. Comparative Analysis of Cajamarca’s Public Health Capacities and Essential Public Health Functions EVALUATION OF THE EXECUTION OF ESSENTIAL PUBLIC HEALTH FUNCTIONS Public Health Capacity CAJAMARCA REGION - 2005 1.00 1.00 0.90 0.90 0.80 0.80 0.67 0.70 0.70 0.60 0.56 0.60 0.50 0.46 0.43 0.50 0.39 0.36 0.40 PUBLIC HEALTH INFORMATION SYSTEM 0.40 0.29 ORGANIZATIONAL AND INSTITUTIONAL CAPACITY IN PUBLIC HEALTH 0.30 0.21 0.30 PUBLIC HEALTH WORKFORCE 0.20 0.17 0.20 0.16 FINANCIAL RESOURCES FOR PUBLIC HEALTH 0.20 0.10 PUBLIC HEALTH TECHNOLOGY 0.10 0.00 EPHF 1 EPHF 2 EPHF 3 EPHF 4 EPHF 5 EPHF 9 EPHF 6 EPHF 7 EPHF 8 EPHF 10 EPHF 11 0.00 Total Observed EPHF 2006 Standard ( 0 . 50 ) Regional Result ( 0.35 ) Results of the Quick Evaluation

18. Regional Capacities Arequipa Region Public Health Capacity 1.00 0.90 0.80 0.70 ORGANIZATIONAL AND INSTITUTIONAL CAPACITY IN PUBLIC HEALTH 0.60 0.50 PUBLIC HEALTH WORKFORCE PUBLIC HEALTH INFORMATION SYSTEM FINANCIAL RESOURCES FOR PUBLIC HEALTH PUBLIC HEALTH TECNOLOGY 0.40 0.30 0.20 0.10 0.00 Total Observed PUBLIC HEALTH CAPACITY INDEX FOR THE AREQUIPA REGION Total Observed Total Expected PUBLIC HEALTH CAPACITY INDEX ELEMENTS Public Health Workforce 67 104 0.6442 Public Health Information System 53 86 0.6163 Public Health Technology 34 74 0.4595 Organizational and Institutional Capacities in Public Health 136 160 0.8500 Financial Resources for Public Health 31 58 0.5345 TOTAL 321 482 0.6660 Results of the Quick Evaluation Results Obtained

19. Comparative Analysis of Arequipa’s Public Health Capacities and Essential Public Health Functions EVALUATION OF EXECUTION OF ESSENTIAL PUBLIC HEALTH FUNCTIONS Public Health Capacity AREQUIPA REGION - 2005 1.00 1.00 0.90 0.90 0.81 0.80 0.74 0.80 0.74 0.72 0.70 0.70 0.60 0.55 0.60 0.50 ORGANIZATIONAL AND INSTITUTIONAL CAPACITY IN PUBLIC HEALTH 0.46 0.50 0.42 0.48 0.38 PUBLIC HEALTH WORKFORCE PUBLIC HEALTH INFORMATION SYSTEM FINANCIAL RESOURCES FOR PUBLIC HEALTH 0.40 PUBLIC HEALTH TECHNOLOGY 0.40 0.30 0.26 0.30 0.20 0.20 0.20 0.10 0.10 0.00 EPHF 1 EPHF 2 EPHF 3 EPHF 4 EPHF 5 EPHF 6 EPHF 7 EPHF 8 EPHF 9 EPHF 10 EPHF 11 0.00 Total Observed EPHF 2006 Standard ( 0 . 50 ) Regional Result ( 0.52 ) Results of the Quick Evaluation

20. This study provides the opportunity to measure the different degrees of development in public health capacity. This study found that the instrument used allowed the establishment of a baseline for public health capacity and its five elements. It is a tool that can identify and bridge gaps in capabilities. In most cases, these gaps can be corrected by improving the decentralized management of health services. Through a precise definition of the main attributes of these elements, we have been able to construct an index to measure public health capacity, which we have called the Public Health Capacity Index. This index makes it possible for us to rapidly assess the level and degree of development in public health organizations. The comparative analysis has, in turn, revealed the differences in health management among various organizations, which has made it possible to establish a path to follow and a series of management plans that will contribute to the development of public health organizations. Conclusions drawn from the Rapid Assessment AT THE METHODOLOGICAL LEVEL

21. The Arequipa Region shows better public health capacity and also reveals a higher level of development than the Cajamarca Region. This is evident in the better organization and cohesion of Arequipa’s regional health authority, as opposed to Cajamarca’s, which is limited by the recent change of authorities at the Regional Health Bureau. The Cajamarca Region has low levels of development in the availability and distribution of public health personnel, which bears no relation to the real needs of the health management organizations or public health needs in the region. This low level of development is correlated with the poor qualifications of the personnel working in public health in the case of Cajamarca; conversely, Arequipa has one of the highest levels, expressed through the presence of plans and programs that guide the public health training processes. This situation improves when we consider the personnel responsible for the principal public health processes and activities, and those charged with the important responsibility of ensuring the capacity to respond to regional public health problems. However, this is part of a reactive approach, and it is not focused on strengthening the public health workforce in this region. It should be noted that the Regional Health Management Office for Arequipa bases several of its interventions on the improvements in the 2005 EPHF. Furthermore, it is internally a single structure with the health networks, as opposed to Cajamarca which continues to be fragmented into four subregional bureaus with different policies, plans and programs, and has kept only the regulatory unit. Conclusions drawn from the Rapid Assessment PUBLIC HEALTHWORKFORCE

22. Both Regional Healthcare Bureaus have a medium level of development, although this is an institutional and not a sectoral characteristic. The information system has a broad base and several information subsystems, which allows for greater availability of information, as it is collected from a haphazard system that is internally and sectorally fragmented. These subsystems are not integrated at all, which means that only part of the information related to goals and health outcomes is ever collected. A similar situation with respect to high performance was found in the transparency of the information system. No mechanisms have been found that help strengthen this capacity. It should be pointed out that the Arequipa Regional Healthcare Bureau, called the Regional Health Management Office, bases several of its interventions on improvements in the 2005 EPHF. However, if we consider the issue from the standpoint of available resources, we find that the Cajamarca Region is the more inefficient in allocating the financial resources it receives under the Mining Rule, and it does not invest enough in IT systems hardware through public investment. Conclusions drawn from the Rapid Assessment PUBLIC HEALTHINFORMATION SYSTEMS

23. Capacity in the two regions remains low: the Arequipa Region is at a medium-low level, and Cajamarca, at a very low level. This can be explained in part by the perception in Cajamarca that technology means only material or tangible technologies, resulting in the neglect of technologies based on models, methods, and forms of health intervention. This reveals an instrumental perception, that is, use of technology without considering whether it meets a need or its ability to improve the level of health care in the region. Both regions make no effort with regard to mechanisms intended to strengthen a technology system for public health management. The Arequipa Region has the more integrated approach to technology, which demonstrates a marked superiority, despite the fact that the occurrence of adverse events or technology failures is higher in Arequipa. This seems to be a problem of perspective, approach, and prioritization of technology, that comes from the Ministry of Health’s central offices and is expressed in poor performance in cost-effectiveness evaluations of the principal technologies, since this type of analysis is not done except in exceptional situations with respect to drugs and raw materials and quality control of public health laboratories. Conclusions drawn from the Rapid Assessment PUBLIC HEALTH TECHNOLOGIES

24. The capacity of the Arequipa Region is greater than that of Cajamarca, although in this case Cajamarca’s level is still high. The differences are based on governance and the degree of cohesion in the regional authority. In Cajamarca, we find clear differences between the Regional Government and the Regional Bureau. For the moment, these differences have been resolved through the intervention of the regional courts, which have replaced the former director of the Regional Health Bureau. The exercise of health authority in the region also rests on the legitimacy and cohesion of the regional government, which means that, although governance has improved, it has not gone hand in hand with the health leadership in either the sector or the network structure itself. In Cajamarca, there is a lower degree of health management capacity, and the strategic planning and health intervention processes are less effective. The Arequipa Region is trying to strengthen the public health system’s organizational capacity, especially in the performance of essential public health functions. It has superior performance in all aspects; and particularly stands out in Governance and Policy Planning in public health. These entities present two levels of organizational development, with the Arequipa Regional Management Office being the more uniform and advanced of the two. Both performed well in Regulation, Decentralized Health Management, and Services Management; and both performed poorly in the implementation of mechanisms aimed at strengthening organizational capacity. Conclusions drawn from the Rapid Assessment ORGANIZATIONAL AND INSTITUTIONAL CAPACITY

25. The level of development of financial resources for public health is fair, but in the case of Arequipa, we can clearly see better utilization of public resources. In fact, Cajamarca has performed poorly in multi-year programming and public investment, despite having additional resources as a result of the Mining Rule. Neither region has mechanisms in place to increase the availability of workers able to improve cost-effectiveness or to design public investment projects intended not only to improve cost-effectiveness but to boost the other capacities described above. Information on sectoral entities such as ESSALUD and Sanidad has not been collected, and there is limited coordinated action on the delivery and supply of materials. The Regional Healthcare Management Office for Arequipa has begun to develop planning and specific goals for spending by essential public health function. Even though the two regions promote social control and accountability in healthcare, there are few grassroots organizations. Conclusions drawn from the Rapid Assessment THE LEVEL OF DEVELOPMENT OF FINANCIAL RESOURCES

26. The two regions have revealed two different, intermediate levels for the exercise of public health capacities. Arequipa scored medium-high, and Cajamarca was medium-low. As we can see, the Arequipa Region presents a medium-high level of development for all elements. Arequipa has a higher level of development in organizational and institutional public health capabilities, which are affected by problems of a political nature such as those that occur in the Cajamarca Region. In all aspects, the Regional Health Management Office of Arequipa was superior. The Arequipa Region has a more highly developed approach to public health, allowing it to analyze its actual situation more clearly, which in turn can lead to better use of its financial resources. This contributes to the fact that the degree of development is more uniform in the case of Arequipa. Both regions have a similar development structure as far as their information system and financial resources are concerned; at the same time, there is little development of public health technologies, although Arequipa is still at a different level. Conclusions drawn from the Rapid Assessment EXERCISE OF PUBLIC HEALTH CAPACITY: PERFORMANCE

27. Challenges • Institutionalizing public health capacities as a tool for managing the performance of the Regional Health Authority, and for using the gaps as projects for change. This will help strengthen public health capacity to improve the performance of the Regional Health Authority. • Continuing the rapid assessment in order to provide a baseline for the execution of Public Health Capacity in the RHA. Thoroughly analyzing the results for the regions to improve outcomes of this short- and medium-term evaluation. • Providing technical support to consolidate the use of the PASC measurement instrument at the regional level. This will makes the initial experiences available as input for improving the RHA’s performance. • Refocusing cooperation efforts on the development and strengthening of Public Health Capacity, prioritizing regions with lower levels of performance.

28. Thank you