1. Integration of National Programs within the Health System in Peru VII Regional Forum PAHO/WHO Quito, 29-31 October 2007 Ms. Celeste Cambría

2. “Integration of National Programs within the Health System in Peru” 1. Objective 2. Methodology 3. National Programs 3. Selection Criteria 4. Results

3. Study Objective Analyze how the National Programs (NP) are integrated within the Health Systems (HS) in the countries of the Region, as well as whether NP strengthen (or weaken) HS.

4. Methodology Survey of National Program Managers Structured questionnaire of 40 questions Survey of the respondents’ opinions about 30 examples of actions related to national programs and their capacity to strengthen or weaken the health system.

5. Methodology Structured questionnaire of 40 questions Components Steering Role Organization Financing Human Resources Delivery of Services Information

6. Background The 2004 National Programs are called National Health Strategies and were created under the leadership of Minister Pilar Mazzetti Ministerial Resolution 771-2004/Ministry of Health, dated 27 July 2004

7. Steering Conduct/Lead Health situation analyses. Definition of priorities. Plans, strategies, and policies: Coordinated National Plan and 11 National Health Strategies Regulation Regulatory framework for sectoral operation. Monitoring of compliance with sectoral regulations. Development of regulatory capacity and oversight. Harmonization of health care delivery Planning the delivery of services in the country. Regulatory mechanisms on the quality of care. Incentives and organization of providers Guarantee of health insurance Definition of benefits for all inhabitants. Definition of priority populations and territories. Monitoring of compliance with insurance coverage Orientation of financing Determination of the national resource needs. Negotiation with the providers of financing. Consensus-building on criteria for resource allocation.

8. Background NHS on Immunization NHS on Prevention and Control of Metaxenic and Vector-borne Diseases NHS on Prevention and Control of Sexually Transmitted Diseases and HIV/AIDS NHS on Tuberculosis Prevention and Control NHS on Sexual and Reproductive Health NHS on Noncommunicable Diseases NHS on Mental Health and the Culture of Peace NHS on Healthy Food and Nutrition NHS on Traffic Accidents NHS on Indigenous Populations NHS on Oral Health

9. Background National Coordinators, ministerial resolutions N° 771-2004/Ministry of Health, N° 772- 2004/Ministry of Health and N° 773-2004/Ministry of Health Design, plan, program, monitor, supervise, and evaluate the implementation and execution of the National Health Strategies, as well as their internal and intersectoral organization.

10. Background Functional units General Bureau for Individual Health, Ministry of Health Standing Technical Committee National Coordinator of the National Health Strategy; a representative from the General Bureau for Health Promotion; the Bureau for Medications, Raw Materials, and Drugs; the General Office of Communications; the General Office of Epidemiology; the National Institute of Health and the General Environmental Health Bureau.

11. Background Advisory Committee Ministries (education, housing), academic institutions, international cooperation agencies, nongovernmental organizations and organizations of people affected by the National Health Strategy framework.

12. Selection criteria We divide the NHS according to their scope, importance, and available resources in the Peruvian health system, as follows: The most important include the NHS on Immunization, NHS on Vector-borne Diseases, NHS on HIV/AIDS and NHS on Tuberculosis. Those of medium importance include the NHS on Sexual and Reproductive Health, the NHS on Noncommunicable Diseases, the NHS on Mental Health and the Culture of Peace, and the NHS on Healthy Food and Nutrition. The most recent and, as a result, least developed are the NHS on Traffic Accidents, the NHS on Indigenous Populations, and the NHS on Oral Health, approved in 2007

13. Selection criteria The first two groups have characteristics that make them more comparable with programs analyzed in other countries

14. Results of the Study The description of the results from the questionnaires is presented in two parts: first, a characterization of the degree of horizontality or verticality of each NHS and, second, the most salient information from a review of the results.

15. NHS on Immunization This NHS was created by Ministerial Resolution 771-2004/Ministry of Health in July 2004. Functionally, it is an agency of the General Bureau for Individual Health, Ministry of Health. Its Immunizations Plan was approved in 2005, and falls within the framework of the Ministry of Health’s health policy guidelines, as well as the national health priorities and Millennium Development Goals. The NHS on Immunization coordinates with ESSALUD, the Ministry of Education, the Ministry of Women and Social Development, the Ministry of Defense, the Ministry of Labor, and all Regional Governments. In addition, it maintains a close relationship with other NHS such as the NHS on Sexual and Reproductive Health, HIV/AIDS, and TB. Furthermore, it coordinates periodically with CRECER. Financing for the NHS on Immunization comes from various sources, predominantly (70%) the Public Treasury. The remaining resources come from the following: 10% from donations, 5% from reimbursable external resources or loans; and the remaining 15% from others sources, including the private sector. It is noteworthy that the Regional and Local Governments are currently allocating different types of resources (human, economic, material, etc.) to the corresponding agencies of the NHS.

16. NHS on Immunization For its activities, the NHS on Immunization only has full-time personnel at the national level. Contract personnel from external resources are available. The strategy’s activities are carried out at the first, second, and third levels of care. The activities of the NHS on Immunization are part of the basic package of services (Integrated Care by Stage of Life), and include prevention and promotion activities. The NHS on Immunization does not have its own recordkeeping and information system; it uses the information generated by the General Office of Statistics and Information Technology and the General Epidemiology Bureau, from which it prepares monthly regional and quarterly national reports.

17. ComponentNHS on Immunization HV Steering120 100%0% Organization62 75%25% Financing91 90%10% HR64 60%40% Delivery of Services70 100%0% Information100 100%0% TOTAL507 88%12%

18. NHS on Mental Health Functionally, it is an agency of the General Bureau of Individual Health, Ministry of Health. In 2004, the “General Plan for the NHS on Mental Health and the Culture of Peace for 2005-2010” was approved, and in October 2006, the “National Plan of Mental Health” was approved. This plan describes specific problems, as well as the relationship of the central problem to factors such as poverty and access to services. It also identifies broad problems associated with mental health intervention. The NHS coordinates with the Ministry of Education and the Ministry of Women and Development, as well as with other entities. It employs full-time personnel for NHS activities at the regional and intermediate level; however, the subnational levels do not require approval from the national NHS for their decisions. NHS financing of comes from mixed sources, since approximately 40% of the resources come from the public treasury. Most of the additional resources come from donations from the European Union through Project PASA; these resources are administered by the Ministry of Health.

19. NHS on Mental Health The materials required by the NHS are requested through the Ministry of Health’s own system. Contract personnel from external resources are not available. Activities are carried out at the first and second levels of care. The personnel who perform this work require and receive direct training from the NHS. The strategy’s activities are integrated into the basic package of services, and include prevention and promotion activities. This NHS possesses its own recordkeeping and information system, which produces periodic reports that are used at all levels of management.

20. ComponentsNHS on Mental Health HorizontalVertical Steering120 100%0% Organization62 75%25% Financing82 80%20% HR82 80%20% Delivery of Services63 67%33% Information46 40%60% TOTAL 4415 75%25%

21. Peru: Results for each NHS Table 11 NHSHorizontalityVerticality Immunization88%12% Vector-borne diseases86%14% HIV/AIDS79%21% TB68%32% Sexual and Reproductive Health71%29% Non-communicable diseases77%23% Mental Health75%25% Food and Nutrition64%36% Oral Health69%31%

22. Peru: Characterization of each NHS Table 12 NHSApproach ImmunizationHorizontal Vector-borne diseasesHorizontal HIV/AIDSMixed, strongly horizontal TBMixed, moderately horizontal Sexual and Rep. HealthMixed, strongly horizontal Non-communicable dis.Mixed, strongly horizontal Mental HealthMixed, strongly horizontal Food and NutritionMixed, moderately horizontal Oral HealthMixed, moderately horizontal

23. Results of the Study 11 National Health Strategies were analyzed. 2 of them were described as having purely horizontal organizational strategies. (Immunization and Vector-borne diseases) The 7 remaining strategies are organized in the health system with a mixed approach that varies from moderately horizontal (three of them, TB, Food and Nutrition, and Oral Health ) to strongly horizontal (four of them, HIV, Sexual and Reproductive Health, Mental Health and Noncommunicable Diseases).

24. Results by component Components TBHIV Vector- borne diseases Immuni- zations Non- Comm. S & R Health Food and Nutrition Mental Health Oral Health TOTAL HVHVHVHVHVHVHVHVHVHV Steering 100%0%100%0%100%0%100%0%100%0%100%0%75%25%100%0%67%33% 94%6% Organization 50% 75%25%62.5%37.5%75%25%62.5%37.5%50% 100%0%75%25%62.5%37.5% 68%32% Financing 60%40%75%25%60%40%90%10%100%0%56%44%80%20%80%20%75%25% 75%25% HR 40%60% 40%100%0%60%40%75%25%60%40%60%40%80%20%100%0% 70%30% Delivery of Services 89%11%78%22%89%11%100%0%78%22%89%11%78%22%67%33%78%22% 82%18% Information 60%40%80%20%100%0%100%0%40%60% 40%0%100%40%60%25%75% 57%43% Total 68%32%79%21%86%14%88%12%77%23%71%29%64%36%75%25%69%31%75%25%

25. Results by component Steering and Delivery of Services The horizontal approach is more evident All of the NHS that were evaluated organically and administratively fall under the Ministry of Health They permit the utilization of contracts or letters of intent by subnational management levels They coordinate with other National Strategies They require an explicit ministerial resolution for approval of their standards. Furthermore, all the NHS included in the study carry out activities at the first and second levels of care, without limiting their services to these purposes. In each case, the actions of the NHS are included in a basic package of services that includes promotion and prevention activities.

26. Results by component Organization There is a greater tendency toward a vertical approach For example, in the organizational component, seven of the nine NHS that were evaluated employ full-time personnel for NHS activities at the subnational levels.

27. Results by component Financing, Human Resources, and Information The NHS showed mixed results

28. Opinion Survey 100% of the respondents believed that the following program actions strengthen the health system, with responses ranging from totally to partially strengthen. Inter-programmatic coordination of the Program Conducting surveillance studies for the Program Achievement of political commitment for the implementation and expansion of Program objectives Implementation of actions in coordination with other sectors (education, etc.) Conducting prevention and promotion activities as part of the Program’s actions

29. Opinion Survey Inclusion of the services of other health public sector providers (e.g.: Social Security) Implementation of the regional/national Program strategy Introduction of international regulations and standards for the care provided by the Program The mobilization of activists and community representatives in Program activities Community education Hiring or designating those responsible for the Program at all levels of management Supervision by the central level over the intermediate levels Establishment of incentives for health services personnel if they meet Program goals Community participation in Program activities

30. Opinion Survey We found 10 options that yielded results in which the responses ranged from totally strengthen to totally weaken the health system These reveal the doubts and differences of opinion on some key issues for the development of the National Health Strategies and for the health system as a whole

31. Opinion Survey “Supervision by the central level over the regional and local levels”, 75% agreed that this type of action strengthens the system and the other 25% believe that it weakens it. In analyzing the option, "Development of the Program’s own surveillance and information system ” the study confirmed that more than half of the respondents, 67%, stated that it strengthens the system, and the rest, 33%, that partially weakens it. This result is contradictory and reflects differences of opinion among the national coordinators on the information component. The majority of the NHS do not have their own information system but obtain information from the General Epidemiology Bureau and the General Office for Statistics and Information Technology. Similar results were found in the responses for the option “Full-time, trained staff for Program health services”, 67% answered that this type of action strengthens the system and 33% that it weakens it. “Direct administration of all financial resources by the Program” is an option in which only 50% believe that it strengthens the system and the remaining 38% believe the opposite.

32. Opinion Survey 100% of the respondents believe that the option “Financing by international cooperation of initiatives that are not sector priorities” weakens the healthcare system, with responses that vary from totally to partially weakens. The option “Implementation of a hierarchical and vertical structure for the program’s decisions and activities” is considered by 56% of the respondents as an action that weakens the system and another 33% think that it strengthens it partially. However, opinion is more unanimous on the alternative: “The existence of cooperation projects that perform the same activities as the Program” on which 75% believe that it weakens the system and 25% that it strengthens it partially. “The existence of different administration systems for managing funds disbursed for the Program” is an option related to the financing component which at all levels shows that there is still a certain vertical approach (25%), about which 56% believe that it weakens the system and 22% that it strengthens it, and 11% that it neither weakens nor strengthens it. On the option “Approval from the central level of all decisions at the intermediate and local levels” the majority considers that this weakens the system and 22% that it strengthens it partially, which shows the doubts that still persist about the current decentralization.