Health Reform, Community Participation, and Social Inclusion: The Shared Administration Program

Executive Summary

The experience of the Shared Administration Program (PAC – ‘Programa de Administración Compartida’), created in 1994, has been the most important expression of the health sector reform to this date, since it fosters the three major premises of the reform: quality, efficiency, and equity in health services. The PAC program is distinguished by the aspect of co-management of health services by the community through a committee of elected community members called CLAS (‘Comité Local de Administración de Salud’). The CLAS receives and manages financial resources transferred from the public treasury for the purpose of providing health services to the community.

A CLAS is a private, non-profit entity that is legally registered, composed of three members elected by the community and three community members selected by the health facility manager. The seventh member is the health facility manager, usually the chief physician, who participates in all decisions of the CLAS and completes the scheme of co-management. By virtue of a legal contract between the CLAS and the Ministry of Health, CLAS are held responsible for ensuring the implementation of a Local Health Program that is developed annually on the basis of a community health diagnosis. This responsibility of CLAS translates into social control of the quality and efficiency of health services delivered. CLAS are given the power to contract health personnel and other workers for the health facility; therefore CLAS can and do require personnel to treat community members well. CLAS are given the power to make decisions on how funds (whether transferred public treasury funds or fees–paid-for-services) should be utilized. They therefore tend to use resources more efficiently, since they can better determine the needs and priorities of their own community and have an incentive to obtain more for less. CLAS are composed of community members who know best which families in the community are the most needy, therefore CLAS also have the capacity to improve equity in health care delivery, although some need orientation to this important aspect. As a local institution, CLAS helps to ensure the sustainability of health and other social development programs in the community.

PAC now covers over ten percent of peripheral health facilities in the country (611 of approximately 5000 health centers and health posts). Its administration at the central level of the Ministry of Health has recently progressed from being isolated and nearly independent, to being incorporated into the mainline administration of PAAG (‘Programa de Administración de Acuerdos de Gestión’) along with PSBPT (‘Programa de Salud Básica para Todos’). PAC is now endowed with growing political support and good perspectives for future expansion.

The present document is a qualitative and quantitative analysis of PAC, which has been conducted in the framework of the mid-term review of the cooperation of Peru-UNICEF 1996-2000. The mid-term review provides UNICEF an opportunity to reinforce strategic alliances and achieve a more effective collaboration with the country. Since the early design phases of program design, UNICEF has provided support to PAC: first, through provision of theoretical orientation via the Bamako Initiative; and later, through a variety of specific points of critical support for training, events, printing and dissemination of important program publications, and others.

The qualitative methodology utilized for this program analysis included: review of previous studies and evaluations of PAC; interviews with key officials in the Ministry of Health; and a review of the development of PAC in two Health Sub-Regions (Ayacucho and Chincha/Ica), including interviews with key officials and visits to CLAS utilizing interview guides. A quantitative analysis of national survey data from ENNIV 97 (National Survey of Living Standards, Instituto Cuánto, S.A.) was also conducted to compare sampling clusters with and without CLAS on a series of health care utilization and health expenditure variables.