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

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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.

Posts, 0.41Posts, 0.16

Posts, 0.63 Posts, 0.74

Centers, 2.63Centers, 2.8

Centers, 2.4

Centers, 3.62

Rural CLAS Rural Non-CLAS Urban CLAS Urban Non-CLAS

TYPE OF PRIMARY CARE FACILITY

Ave

rage

n°

of p

hys

icia

ns

Source: Altobelli L. Data from National Inventory of Infrastructure, Equipment, and Human Resources 2006. Lima, Peru: Future Generations.

Average nº of physicians per primary care facility

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2.32

1.32

2.94

1.73

1

1.5

2

2.5

3

Ave

rage

nº

visi

ts p

er c

hild

per

yea

r

Rural CLAS Rural Non-CLAS Urban CLAS Urban Non-CLAS

TYPE OF PRIMARY CARE FACILTY

Average n° consultations children 0-4 yrs-old – public health

insurance (SIS)

Source: Altobelli L and A Sovero (2004) Cost-Efficiency of CLAS. Lima: Future Generations. (Data from SIS Plan A, 2002)

Results on CLAS versus Non-CLAS: productivity and efficiency

2011 201250.0

55.0

60.0

65.0

70.0

75.0

80.0

69.8 72.0

64.5 59.2

Process: Family planning

Health facility performance in 28 CLAS (solid line) and 77 Non-CLAS (dotted line) Ucayali Region-Peru. 2011, 2012. % completion of best practices

2011 201250.0

55.0

60.0

65.0

70.0

75.0

80.073.0

79.8

64.3 62.2

Process: First prenatal visit

2011 201250.0

55.0

60.0

65.0

70.0

75.0

80.0

72.679.9

65.2 60.7

Process: Prenatal care follow-up

2011 201215.0

20.0

25.0

30.0

35.0

40.0

45.040.2

37.6

35.629.3

Process: Community actions

2011 201250.0

55.0

60.0

65.0

70.0

75.0

80.0 78.377.1

69.8

71.3

Process: Healthy and sick child care

2011 201260.0

65.0

70.0

75.0

80.0

85.0

90.0

73.677.7

65.7

86.1

Process: TB care

Results on CLAS versus Non-CLAS: performance

Source: Project USAID | Quality Health Care, 2013 FutureGenerations

3 Sectorization Strategy

• DEFINED TASKS FOR HEALTH SYSTEM STRENGTHENING

2 Modified

Care Group

Strategy• NEW HUMAN RESOURCES AND MATERIALS FOR TRAINING CHW

1 CHW Strategy

• DEFINED TASKS, INSTRUMENTS & HEALTH PROMOTION MATERIALS

Three Linked Strategies for Strengthening Primary Health Care

1 CHW strategy for MNCH

CHWROLES

TASKS

INSTRU-MENTS

Train for community monitoring/

education

Learn to change health

behaviors.

8 Facilitator Manuals

for training in

MNCH. ng-

Learning Methods

.

Know the community

Household census.Mapping.Identify

info. desires of

family

Family census form.

Map of household

s.Three

Question Survey.

Monitor risk groups (first 1000 days)

Monthly home visits.

Identify danger signs.Refer cases.

Checklists to

monitor danger signs.

Referral slips.

Educate mothers on best health

practices

Teach mothers.

7 flipcharts.Checklists

to monitor

behaviors. Birth Plan

card.

Report community information

Report births & deaths. Report

activities.

Forms to notify

births & deaths.

CHW report form.

Supervision form.

Teaching /Learning Methods

“Community Facilitator”

Roles: Reinforce training, supervision,

and support

“Women Leader” (CHW)

Health staff - “Tutors for Promotion of

MNCH”

Roles: Training,

supervision, and support

Pregnant women and mothers of children under two

2 Modified Care Group Strategy for MNCH

Group of 15-30 households

Care Group

Level Preparatory Phase

InitialPhase

Implementation Phase

Monitoring Phase

Health sector Management

-Be trained in Sectorization

-Train Tutors for MNCH* Promotion

Weekly tasks

Primary Care

HealthFacility

-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

-Develop Community Work Plans

Monthly tasks: -Community Facilitator-CHW -WomenLeader

District Municipality

-Finance health promotion Yearly tasks for TDI Technology

MNCH = Maternal, Neonatal, and Child Health

-CF and WL implement community edu. & monitoring

3 Sectorization Strategy for MNCH

- Tutors train CF and CHW

- Pay CF stipends

Sectorization Strategy organizes health personnel work in communities

Interdisciplinary team work: health facility & community2-stage community mapping and monitoring

Huánuco adopts Sectorization Strategy

Public eventon MAMproject

Pathway to Integration: Learning for Leverage

TA, studies, articles on CLAS

Nationalpolicies

Regional& district policies

FGprojects

& activities

1994 2002 03 04 05 06 07 08 09 10 11 12 13 14

MOH establishes & scales-upCLAS

CLAS law passed

CLAS regulationspassed

MOH stops CLAS expansion

Health reform – laws

Regulations on new laws

Visits to MAM Project by MOH-MEF

Cusco regiónadoptsSectorizationStrategy

Pilot “Model CLAS” USAID CSHGP - NEXOS ProjectUSAID CSHGP – MAM Project

Awards

New MOH health promotionstrategy builds on“Model CLAS”

Municipal ordinances : recognize CF & WL – Pay CF stipend & trng. costs

Legislative advocacy for CLAS

Advice to MOHon communityparticipation in PHC

Evaluations of PHCpilot projects

Sharing Histories

cRCT Project

FG publishesSectorization Strategy

Huánuco printing flipcharts

CLAS pays CF & WL training costs

Advocacy on CLAS and PHC strategy

Regional Health

Directorate

CLAS

Primary Health Care

FaciityLocal Health

Plan

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

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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.

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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.

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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.

http://bit.ly/jGKRYq

FutureGenerations