PERU: STRENGTHENING GOVERNANCE IN THE CONTEXT OF DECENTRALIZATION

1. PERU: STRENGTHENING GOVERNANCE IN THE CONTEXT OF DECENTRALIZATION VII Regional PAHO/WHO Forum Quito, 29-31 October 2007 Dr. Oscar Ugarte

2. I. THE HEALTH SYSTEM IN PERU

3. SEGMENTATION OF THE HEALTH SYSTEM Source: National Household Survey, 2005.

4. SEGMENTATION OF HEALTH FINANCING Source: National Health Accounts, 2000.

5. FRAGMENTATION OF HEALTH SERVICES Source: III Census of Sanitary Infrastructure, 2005.

6. POPULATION INSURED IN HEALTH

7. RESULTS OF SEGMENTATIONAND FRAGMENTATION • Lack of coordination among the different providers exacerbates inequity in the delivery of care to the population. • Cross-subsidies increase institutional costs. • Irrationality in the investments of each subsector. • Inefficiency of the entire health system.

8. II. DECENTRALIZATION IN HEALTH

9. THE PROCESS OF DECENTRALIZATIONIN HEALTH Organic Law of Regional Governments Regional Government National Government CONSENSUS-BUILDING Organic Law of Municipalities Municipal Government Organic Law of Municipalities Law 27783: Bases for Decentralization

10. DIMENSIONS OF THE STEERING ROLE

11. SPECIFIC FUNCTIONS OF THEREGIONAL GOVERNMENTS IN HEALTH l. Carry out infrastructure projects a. Approve and carry out regional policies f. Organize levels of care and administration m. Information to the population about the sector b. Regional Health Development Plan g. Organize and maintain health services h. Supervise public and private health services c. Coordinate comprehensive health actions n. Promote human resources development d. Participate in National Coordinated & Decentralized Health System (SNCDS) i. Prevention and control of emergencies and disasters o. Periodically evaluate achievements p. Raise nutrition levels e. Health promotion and prevention activities j. Control the production and supply of drugs k. Promote environmental health Source: Organic Law of Regional Governments, Article 49.

12. CURRENT SITUATION • Since 2003, 26regional governments have been established in 24 departments in the country, Callao Province, and Metropolitan Lima. • By Supreme Decree 068 of 2006, transfers to the regional governments established in the 2006-10 Medium-term Plan will be completed by 31 December 2007. • Since 2004, there have been three opportunities forinterregional coordination in health: the Northern Macro-Region (10 Regional Health Bureaus), the Central Macro-Region (7 Regional Health Bureaus), and the Southern Macro-Region (8 Regional Health Bureaus).

13. SPECIFIC FUNCTIONS OFMUNICIPAL GOVERNMENTS IN SANITATION AND HEALTH 1. Administer water, sanitation and solid waste services 2. Provincial municipalities grant services through concessions 3. Provide rural health services 4. Promote environmental sanitation 5. Carry out preventive medicine campaigns 6. Manage primary health care Source: Organic Law of Municipalities, Article 80.

14. CURRENT SITUATION • In accordance with Supreme Decree 077 of 2006, the transfer of management of primary health care to the local governments begins as of January 1, 2007. • The form of transfer is through pilot projects, respecting the service networks and micro networks. The micro network is the minimum unit for transfer. • The design of 14 pilot projects at the district or multidistrict levels is in progress (Municipal Association).

15. DEFINITION OF MANAGEMENT OF PRIMARY HEALTH CARE* Art. 1. - The management of primary health care involves health care provided by health facilities, categories I-1, I-2, I-3, and I-4, in aspects of the protection and recovery of the health of the population; as well as health promotion interventions and actions related to health determinants carried out with active citizen participation and multisectoral coordination. *Ministerial Resolution 1204-2006-SA.

16. III. PRINCIPAL MECHANISMS OF STEERING IN HEALTH

17. THE COORDINATED NATIONALHEALTH PLAN 1. Approved in July 2007, integratingnational and regional priorities. 2. Health priorities: maternal mortality, infant mortality, malnutrition, communicable diseases, mental health, chronic degenerative diseases, accidents, disabilities, and oral health. 3. Priorities of the system: universal insurance,decentralization, improving the delivery and quality of services, development of human resources, drugs, results-based financing, governance, and citizen participation. 4. Priorities in health determinants: water and sanitation,social exclusion, environment, occupational health, food security, public safety, education.

18. UNIVERSAL INSURANCE IN HEALTH 1. Draft legislation for universal insurance presented to the National Congress has multiparty support. 2. Progressive increase in public insurance (Comprehensive Health Insurance): from $90 million to $350 million in 2011, until the entire poor population (50% of the total) is covered. 3. The linchpin of the insurance system is public coordination (SIS and ESSALUD), to which private insurance is added. 4. Guaranteed health plan for the entirepopulation.

19. GUARANTEE THE DECENTRALIZATION OF PUBLIC FINANCING IN HEALTH Percentage of the Public Health Budget 66.7 65.3 64.5 63.5 36.5 35.5 33.3 34.7 2004 2007 2005 2006

20. STRENGTHENING OF SERVICE NETWORKS ANDMICRO NETWORKS 1. Coordinate service networks and micro networks based on public services in the context of pilot projects for local decentralization, strengthening the regional and local health authority. Territorial or sectoral government? 2. Strengthen Regional and Local Health Plans within the framework of the National Consultative Plan. 3. Guarantee financing for supply and demand through the regional government and the SIS budget. 4. Train human resources and determine the regimen for hiring personnel. 5. Adoption of performance incentives and their use in relations with public and private providers. 6. Citizen participation: Local health action committees and other forms.

21. NECESSARY CONDITIONS FOR THESTEERING ROLE • Policy-making at the national level. • Clear objectives in public health policy. • Intergovernmental consensus-building: National, regional, and local. • Sectoral and intersectoral consensus-building. • Citizen participation.

22. III. OPPORTUNITIES FOR STEERING IN HEALTH

23. INTERGOVERNMENTAL CONSENSUS-BUILDING National Government • SHARED STEERING • FUNCTIONS IN HEALTH: • National, regional, and local • planning. • Policy-making. • Strengthening the capacity • of government. • Decentralized financing • of supply and demand. • Strengthening networks and • micro networks. • Human resources development. • Public-private coordination. Regional Government Municipal Government

24. COORDINATED NATIONAL ANDDECENTRALIZED HEALTH SYSTEM* National Health Council: Ministry of Health, ESSALUD, health systems, private universities, medical school, trade associations, health VMs, municipalities, civil society. National Government: MINISTRY OF HEALTH Regional Health Council: DIRESA, ESSALUD, health systems, private universities, professional associations trade associations, civil society and other institutions. Intersectoral coordination Regional Government: DIRESA (Regional Health Bureau) Provincial Health Council: Mayor’s Office, ESSALUD, health systems, private professional schools, trade associations, civil society and other institutions. Intersectoral coordination Municipal Government: Health Committee * Law 27813: Coordinated National and Decentralized Health System

25. ougarte@praes.org