Peru
THE STORY
In a study that compares health system efficiency within Latin American and OECD countries based on eight key indicators (such as life expectancy and specialised delivery care), Peru ranks 61 out of 69 countries (Izquierdo et al, 2018). There is a human resources capacity gap when it comes to healthcare budget administration at the national and subnational governments; this is especially acute at the regional level, which is responsible for 40% of public spending on health (Movimiento Salud 2030, 2020). With 64% of the Peruvian population dependent on the public system to access healthcare (SUSALUD/MINSA, 2019), budget management challenges and fragmentation within the system have a major effect on Peruvians’ access to quality and timely healthcare.
Movement Health 2030 is enhancing regional governments’ budget management capacities by developing a pilot in the Cusco region in collaboration with the change organisation Delivery Associates. This project will involve the creation of a dashboard that will give healthcare officials visibility over regional healthcare key performance indicators for early childhood development and average waiting times via real-time data (continuous monitoring) and readily available insights, thereby improving the efficiency and effectiveness of healthcare spending.
Driving public management innovation at the regional level, Movement Health is working to transform the Peruvian health system and improve the multi-level governance of healthcare in Peru. With a plan to eventually scale the solution across Peru’s regions - and possibly beyond - Movement Health’s work could help to deliver equitable and quality healthcare to all Peruvians.
THE CHALLENGE
Peru faces many challenges when it comes to the planning and efficiency of healthcare budget allocation and spending across governmental levels. This translates into inequities in access to and quality of care and, overall, lower healthcare coverage for the population.
COUNTRY STATS:
• Since 2010, execution of health expenditure has been 85% on average (MEF, 2021).
• Health expenditure as a percentage of GDP in Peru was no more than 5.2% in 2018, in comparison with 12.5% in OECD countries and almost 8% in LATAM and the Caribbean (World Bank, 2019).
• In Peru, 680 USD are spent per citizen every year, compared to the LATAM average of 1026 USD (OECD, 2020).
• Between the years 2003 and 2016, almost one fifth of deaths were attributed to cancer in Peru. During this time, deaths attributed to cancer increased from 15.4% of all deaths in 2003 to 18.1% in 2016, and this number is still growing (Zafra-Tanaka et al, 2020). Despite this, each year, the Ministry of Health returns around 65 million soles (US$ 17 MM approx.) of the budget for cancer care. This represents around 40% of the cancer care budget (SIAF-MEF, 2021).
THE APPROACH: HOW DID WE IDENTIFY THE CHALLENGE?
The Movement Health Team engaged in a 5-step process to identify Peru’s main healthcare challenge and create a plan to address it. This involved:
High level policy meetings with key stakeholders, including representatives from the National Ministries of Economy and Health and the National Assembly of Regional Governments.
In-depth interviews with high level officials involved in healthcare (17 senior officials, who were or had been Ministers of State, vice ministers, directors of the sector in both the central government and the regional governments).
A literature review of research on budget execution in Peru and Latin America.
Cross-analysis of the information by a multidisciplinary local team and a comprehensive budget review. From this, the team formulated recommendations to improve the efficiency of planning and health spending at the legal, programmatic, and operational levels from 2021 onwards.
Open and closed events to validate key findings with key stakeholders, opinion leaders and national/subnational authorities.
Implementation of a regional government pilot to validate the impact of these findings and improve indicators within key specific health care areas, such as early childhood development and average waiting times.
The partners involved in this process were: the Camara de Comercio de Peru, the Regional Government of Cusco, Copenhagen Institute for Future Studies, Civium (the local partner), Delivery Associates, Dr. Rifat Atun (global board member of Movement Health 2030), and Roche.
AMBITION AND VISION: HOW ARE WE ADDRESSING THE CHALLENGE?
To begin to address the challenge identified and validate the recommendations created by the Peru Movement Health team with key local stakeholders, a pilot is now being developed in collaboration with the Cusco Regional Government and Delivery Associates. An innovative public management method has been developed to enhance regional health officials’ capacity to turn financial resources into healthcare results. This method will also be supported by a dashboard to improve information management and connectivity between the different regional institutional actors who are responsible for healthcare administration. The pilot is being deployed in 89 clinics and hospitals within the primary health network (Red Salud Norte), which serves approximately 500,000 citizens in the region.
PROJECTED RESULTS AND DELIVERABLES:
Improvement of regional healthcare officials’ planning and strategy capacities to facilitate the successful decentralisation (from the national to the regional level) of healthcare management and expenditure.
Better knowledge management and data-driven budget decision-making across institutional healthcare actors.
Higher-quality, more accessible and more timely healthcare for Peruvian citizens.
A radical improvement in key performance indicators, particularly for early childhood development and health personnel productivity, without needing to increase budget spending.
A simple yet innovative model that can be used by any regional government in Peru to implement key strategic public policy interventions, such as early childhood development, oncology care and telemedicine.
NEXT STEPS: HOW COULD THE APPROACH AND SOLUTION BE SCALED?
As the budget execution challenges and multi-level governance issues identified by Movement Health are very similar across all 26 regions of Peru, the regional-level model developed in Cusco could be replicated in other regions by analysing the local stakeholders and drawing upon the knowledge and alliances built during the initial pilot.
The model could be presented to the Ministry of Health and the Ministry of Finance as an initiative to facilitate health decentralisation and improve regional capacity to provide healthcare.
The Peruvian model could also be presented to key stakeholders of multilateral organisations to identify possible partners to scale-up the experience and export it to other countries.
REFERENCES
World Health Organisation. (2017). Primary health care systems (PRIMASYS): case study from Peru, abridged version. Geneva. Licence: CC BY-NC-SA 3.0 IGO [online]. Available at: https://www.who.int/alliance-hpsr/projects/alliancehpsr_peruabridgedprimasys.pdf?ua=1
OECD. (2020). Gasto en salud per cápita y en relación al PIB [online]. Available at: https://www.oecd-ilibrary.org/sites/b01ad37f-es/index.html?itemId=/content/component/b01ad37f-es
Ministerio de Economía y Finanzas, Peru. (2021). Estructura Programática de Programas Presupuestales, MEF, 2012-2020 [online]. Available at: https://www.mef.gob.pe/es/?option=com_content&language=es-ES&Itemid=101530&view=article&catid=211&id=2768&lang=es-ES#2021
Zafra-Tanaka, J. H., Tenorio-Mucha, J., Villarreal-Zegarra, D., Carrillo-Larco, R., & Bernabe-Ortiz, A. (2020). Cancer-related mortality in Peru: Trends from 2003 to 2016. PloS one, 15(2), e0228867 [online]. Available at: https://doi.org/10.1371/journal.pone.0228867
Izquierdo, A.; C. Pessino & G. Vuletin (2018). Mejor gasto para mejores vidas. Cómo América Latina y el Caribe puede hacer más con menos. Washington D.C. BID [online]. Available at: https://imgcdn.larepublica.co/cms/2018/09/21211810/DIA-2018-Mejor-gasto-para-mejores-vidas-PRENSA.pdf
Jack, W. & M. Lewis (2009). Health Investments and Economic Growth: Macroeconomic Evidence and Microeconomic Foundations. World Bank [online]. Available at: https://openknowledge.worldbank.org/handle/10986/4072
Durand, F., et al. (2020). Patologías del Sistema de Salud Peruano. Fondo Editorial PUCP: Lima [online]. Available at: https://www.fondoeditorial.pucp.edu.pe/ciencia-politica/1141-patologias-del-sistema-de-salud-peruano.html
Ministerio de Salud, Peru (2019). SuSalud Portal [online]. Available at: https://www.minsa.gob.pe/reunis/data/poblacion_asegurada.asp
Movement Health 2030. (2020). Available at: https://es.movimientosalud2030.com/peru
World Bank. (2019) Current health expenditure as a % of GDP, Peru, World Health Organisation Global Health Expenditure Database [online]. Available at: https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=PE
World Bank. (2019). Current health expenditure as a % of GDP, OECD Members, World Health Organisation Global Health Expenditure Database [online]. Available at: https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=OE
World Bank. (2019). Current health expenditure as a % of GDP, Latin America and The Caribbean, World Health Organisation Global Health Expenditure Database [online]. Available at: https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=ZJ