Strengthening community collaborative management of health services by building a “model” for community-based primary health care in Peru Learning for leverage by demonstrating program effectiveness Presented by Laura Altobelli, DrPH, MPH, Future Generations CORE Group Global Health Practitioner Conference – May 5-9, 2014
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Strengthening community collaborative management of health services by building a
“model” for community-based primary health care in Peru
Learning for leverage by demonstrating program effectiveness
Presented by Laura Altobelli, DrPH, MPH, Future GenerationsCORE Group Global Health Practitioner Conference – May 5-9, 2014
HypothesesHo 1: Effective improvement of PHC requires fundamental changes in management mechanisms (for financing, human resources management and commuity involvement)
Ho 2: Political sustainability of management mechanisms (for financing, human resources and community involvement) requires an effective operational model of PHC linking health services with communities to improve impact on health.
Why is it necessary?Improve EFFICIENCY of public expendituresStrengthen QUALITY & WARMTH of careEnsure EQUITY to reduce exclusión
How does this happen?SOCIAL CONTROL leading to GREATER TRANSPARENCY and ACCOUNTABILITY
Assumptions regarding community involvement in health management
FutureGenerations
Primary Health Care
FaciityNational Health
Programs
HealthServices
Network Center
Roles & functionspoorly defined
COMMUNIITES
Regional Health
Directorate
Traditional public sector primary health care in PeruTraditional public sector primary health care in Peru
MUNICIPALITY
Primary Health Care
FaciityLocal Health
Plan
Original Legal Structure of CLAS in Peru-1994Original Legal Structure of CLAS in Peru-1994
SHARED ADMINISTRATION CONTRACT
HealthServices
Network Center
Roles & functionspoorly defined
CLAS
CLAS Board of Directors
Regional Health
Directorate
CLAS - Local Health Administration Committee : a private non-profit civil association that administers public financing for one or more primary health care faciliites
MUNICIPALITY
CLAS Manager
COMMUNIITES
Elected community members
Selects, contracts, & supervisespersonnel
Prioritizes, plans, & purchases equipment and supplies
Contracts building projects and supervises them
CLAS co-manage public resources with transparency and accountability
Finances activities and incentivesfor community-based health promotion
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Wishfulthinking…
CLAS Board of Directors
I. Strengthen co-management of primary health care with a model that articulates community involvement in financial and human resources management with:
An operational model of CBPHC linking health services with communities Health promotion for behavior change – counseling in health facilities and in
homes by CHW Involvement of community leadership in MNCH Involvement of municipality in co-management of health promotion – leveraging
local resources
II. Lead and support efforts for legal stability of CLAS in the context of health reform.
Objectives in support of CLAS
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Overview – Development of PHC Approach in Peru
Seen through the lens of a Theory of Change:
SEED-SCALE Methodology
Overview – Development of PHC Approach in Peru
Scale-One – Ideally functioning local system
Scale-Squared – Use the Scale One system to teach others
Scale Cubed – Policy Environment
• SEED-SCALE concepts initially used to develop a national program for primary health care (PHC) with community involvement (Shared Administration with CLAS)
Overview – Development of PHC Approach in Peru
Scale One – Ideally functioning local system
• Establish a SCALE-One Center: create a “Model CLAS” to demonstrate how CLAS helps to strengthen the quality of PHC with sustainable links to health promotion in communities
• Build the model on successful strategies from earlier pilot PHC programs during the previous decade
Scale-Squared – Use the Scale One system to teach others
Scale Cubed – Policy Environment
• SEED-SCALE concepts initially used to develop a national program for primary health care (PHC) with community involvement (Shared Administration with CLAS)
Overview – Development of PHC Approach in Peru
Scale One – Ideally functioning local
system•Establish a SCALE-One Center: create a “Model CLAS” to demonstrate how CLAS helps to strengthen the quality of PHC with sustainable links to health promotion in communities•Build the model on successful strategies from earlier pilot PHC programs during the previous decade
Scale Squared – Use the Scale One system
to teach others•Use de “Model CLAS” as an Experimental Observation and Training Center to scale up the new model of enhanced PHC linked to communities with focus on health behavior change.
Scale Cubed – Policy Environment•SEED-SCALE concepts initially used to develop a national program for primary health care (PHC) with community involvement (Shared Administration with CLAS)
Overview – Development of PHC Approach in Peru
Scale One – Ideally functioning local
system•Establish a SCALE-One Center: créate a “Model CLAS” to demonstrate how CLAS helps to strengthen the quality of PHC with sustainable links to health promotion in communities•Build the model on successful strategies from earlier pilot PHC programs during the previous decade
Scale Squared – Use the Scale One system
to teach others•Use de “Model CLAS” as an Experimental Observation and Training Center to scale up the new model of enhanced PHC linked to communities with focus on health behavior change.
Scale Cubed – Policy Environment•SEED-SCALE concepts initially used to develop a national program for primary health care (PHC) with community involvement (Shared Administration with CLAS)•Strengthen SCALE-Cubed with a stronger legal instrument – a Law on CLAS
Overview – Development of PHC Approach in Peru
Scale One – Ideally functioning local
system•Establish a SCALE-One Center: créate a “Model CLAS” to demonstrate how CLAS helps to strengthen the quality of PHC with sustainable links to health promotion in communities•Build the model on successful strategies from earlier pilot PHC programs during the previous decade
Scale Squared – Use the Scale One system
to teach others•Use de “Model CLAS” as an Experimental Observation and Training Center to scale up the new model of enhanced PHC linked to communities with focus on health behavior change.•Continue to innovate•Develop other “Model CLAS” with local adaptations.•Promote visits to Scale-Squared Centers
Scale Cubed – Policy Environment•SEED-SCALE concepts initially used to develop a national program for primary health care (PHC) with community involvement (Shared Administration with CLAS)•Strengthen SCALE-Cubed with a stronger legal instrument – a Law on CLAS
Overview – Development of PHC Approach in Peru
Scale One – Ideally functioning local
system•Establish a SCALE-One Center: créate a “Model CLAS” to demonstrate how CLAS helps to strengthen the quality of PHC with sustainable links to health promotion in communities•Build the model on successful strategies from earlier pilot PHC programs during the previous decade
Scale Squared – Use the Scale One system
to teach others•Use de “Model CLAS” as an Experimental Observation and Training Center to scale up the new model of enhanced PHC linked to communities with focus on health behavior change.•Continue to innovate•Develop other “Model CLAS” with local adaptations•Promote visits to Scale-Squared Centers
Scale Cubed – Policy Environment•SEED-SCALE concepts initially used to develop a national program for primary health care (PHC) with community involvement (Shared Administration with CLAS)•Strengthen SCALE-Cubed with a stronger legal instrument – a Law on CLAS•Disseminate strategies and results, advocate for policy continuation & improvements
Regional Health
Directorate
CLAS
Primary Health Care
FaciityLocal Health
Plan
SCALE-ONE: Define and improve quality of relationships around CLAS
SCALE-ONE: Define and improve quality of relationships around CLAS
SECTORIZATION STRATEGY
COMMUNIITES
COMMUNITY WORK PLANS
CLAS Board of Directors
COMMUNIITES
CWP
HealthServices
Network Center
Then, SCALE-SQUARED: Observational learning/teaching center
Then, SCALE-SQUARED: Observational learning/teaching center
CHW ASSOCIATIONS
Blue interventions: Changeagent (FG) introduces newstrategies to improve quality, build ownership & sustainability.
MUNICIPALITY
Regional Health
Directorate
CLAS
Primary Health Care
FaciityLocal Health
Plan
SCALE-CUBED: New CLAS Law in Peru 2007SCALE-CUBED: New CLAS Law in Peru 2007
MUNICIPALITY
Regional Government
COMUNSA- Club de madres- Vaso de leche-- APAFA-- Promotor
COMUNA- Club de madres- Vaso de leche-- APAFA-- Promotor
COMUNSA- Club de madres- Vaso de leche-- APAFA-- Promotor
COMMUNITY
- Community leader- -CHW
COMANAGEMENT AGREEMENT
HealthServices
Network Center
Roles & functionspoorly defined
Community-based
Organizations
COMMUNIITES
CLAS Board of Directors
New national law on CLASstrengthens the range of participation for government and community collaborative management of primary health care services.
-Be trained in sectorization-Self assess PHC organization & management-Assign team responsible for sectorization
-Identify sectors-Categorize risk of each sector-Map each sector-Training materials-Monitoring forms-Train personnel-Assign sectorists to sectors
-Tutors train CHW-Create situation room-Deliver basic package of integrated health services-Organize admission system-Develop schedule for community visits
Monthly tasks: Each Sectorist
Quarterly tasks Sectorization leaders
Community
-Sectorist meets community leaders-Each community elects their CHW
-CF and WL implement the community monitoring system
GOAL: SCALE-Squared with National Norms to Scale-Up CLAS with Improved Quality of CB-PHCGOAL: SCALE-Squared with National Norms to Scale-Up CLAS with Improved Quality of CB-PHC
MUNICIPALITY
Regional Government
COMUNSA- Club de madres- Vaso de leche-- APAFA-- Promotor
COMUNA- Club de madres- Vaso de leche-- APAFA-- Promotor
COMUNSA- Club de madres- Vaso de leche-- APAFA-- Promotor
COMMUNITY
- Community leader- -CHW
COMANAGEMENT AGREEMENT
HealthServices
Network Center
Community-based
Organizations
COMMUNIITES
CLAS Board of Directors
SECTORIZATION STRATEGY
CWPCOMMUNITY WORK PLANS
CHW ASSOCIATION853 CLAS committees nowco-manage 1/3 of all primary health care facilitiesin Peru (2139 out of 7000)
Decentralization laws:• Confusion in roles and responsibilities for health - each regional government
strengthens (or not) CLAS according to its own decision.
Health sector financing issues:• Results-Based Budgeting – in reality this re-centralizes management
responsability for public funds.• Fewer funds are transferred to CLAS with the justification that CLAS are
“private” and have their own resources. • Budget cuts removed CLAS Regional Technical Support Teams with untoward
consequences for CLAS.
Policy Environment - Challenges
FutureGenerations
Policy Environment - Challenges
Ministry of Health has had weak leadership in role clarification:• Confusion on decision-making authority between regional health offices,
subregional health management micro-networks and networks, and CLAS. • Erroneous perception that “CLAS is autonomous”, therefore the network
Budget units do not send reimbursements, budgets, or supplies/equipment to CLAS, placing in jeopardy the ability of CLAS to provide quality services.
• The MOH has not emitted clear directives (which it is legally obliged to do) to orient regional governments on the procedures to re-structure existing CLAS and expand new CLAS.
• Weakening perception of the importance of community participation and social control of primary care services.
FutureGenerations
Policy Environment - Challenges
Opposition of interest groups to CLAS:• Medical Federation was opposed to the non-public payroll options for
contracting physicians.• Medical Federation was opposed the idea of physicians having to work with or
respond to community members.Regional administrators of government health budgets opposed transfer of funds
directly to CLAS for local administration.
Health Promotion continues to be underprioritized:• Relegation of CHW to municipal control.• No clear health sector strategy on CHW work and support.
FutureGenerations
Policy Environment – Ways to influence
Involvement of Government Partners at every step of Project - Regional Government and Municipalities
Interest Group on CLAS - Advocacy group founded and led by Future Generations
National Health Council – Committee on Health ServicesFuture Generations is the representative of Civil Society Organizations on this committeeWorking on Regulations to new Law on Integrated Health Networks – includes CLAS
Initiative Against Child MalnutritionConsortium of 17 NGOs and donor agencies for policy advocacy on chronic malnutrition and anemia
Roundtable to Articulate the Fight Against Poverty (quasi-governmental oversight entity)Group on Maternal-Newborn Budgetary Program
Group on Articulated Nutrition Budgetary Program FutureGenerations
Thank you!
For more reading on CLAS in Peru:
L. Altobelli and C. Acosta (2011) Local Health Administration Committees (CLAS): opportunity and empowerment for equity in health in Peru. In: Erik Blas, Johannes Sommerfeld & Anand Sivasankara Kurup (Eds.) Social Determinants Approaches to Public Health: from concept to practice. Geneva: World Health Organization.