Peru Second Phase of Health Reform Program Implementation Completion and Results Report

Annex 2. Outputs by Component

1. 
   Component 1. Improving health practices at the household level for women (during pregnancy, delivery and breastfeeding) and children under the age of three in rural areas of selected Regions
   

a) Design, implementation and monitoring of a behavioral change communication and education program to promote healthy practices at the household level, including increased demand for health services (Estrategia de Promoción de Práctica y Entornos Saludables, EPPES);
(i) Identification of specific practices to be promoted, including antenatal care, institutional delivery, neonatal visits, exclusive breastfeeding, newborn feeding, care for sick newborns at home, feeding a sick newborn; within the affiliation to SIS and the health care rights and responsibilities.
(ii) Development and implementation of tailored EPPES strategies by region, focused on 202 districts.
(iii) Development, validation, and production of culturally sensitive printed and audio-visual materials (radio spots, soap operas, videos, etc.) in different languages, including Spanish, Quechan, Aymara, Awaji, Shipibo, and Wampi; for example, 13 modules of radio soap opera “Mi derecho a crecer” (My right to grow), and 5 short videos on healthy practices.
(iv) Behavior change campaign being featured in 45 radio channels and 18 television regional or local channels in local languages.
(v) Distribution of equipment for basic training and dissemination (PCs, data display devices, TVs, DVD) in 1,423 health centers;
(vi) Training of 380 community leaders, 412 local authorities, 720 healthcare personnel, and 720 community/civil society agents for the local implementation of the EPPES;

b) Promotion of SIS enrollment rights and identity rights of the targeted population (Derecho a la Identidad y Aseguramiento, DIA)
(i) 666,993 children under 3 years old and 1,888,531 women have been provided with the live birth certificate, national identification document and affiliation with SIS.
(ii) Design, production and dissemination of materials promoting SIS rights and identity rights for all nine Regions in Spanish, Quechuan, Aymara, Shipibo and Awaji.
(iii) Design and implementation of a campaign promoting SIS rights and identity rights, carried out twice (in 2011 and in 2013-2014) in the nine regions for the duration of three months each, focused on mothers, fathers, and careers.
(iv) Implementation of the Live Birth Registry and support to the Auxiliary Registry Offices for the prompt registration in six regions (Amazonas, Apurímac, Ayacucho, Cajamarca, Huánuco, and Huancavelica).
(v) Online system of birth registration in hospitals and more complex health centers in eighth regions (Amazonas, Ayacucho, Apurímac, Cajamarca, Cusco, Huancavelica, Puno and Ucayali).
(vi) Thirty six Auxiliary Registry Offices were installed in seven regions (Amazonas, Apurimac, Ayacucho, Cajamarca, Huánuco, Huancavelica, and Ucayali) and training workshops were organized for midwifes and RENIEC and SIS registrars.
(vii) Creation and strengthening of spaces for intercultural dialogue (Grupos Impulsores del Derecho a la Identidad y Aseguramiento) in the nine regions, with representatives of the regional Directorates of Social Development; RENIEC; JUNTOS Program; local government representatives for the sectors: Education, Health, and Women and Vulnerable Groups; and other NGOs and civil society organizations.
(viii) Seven regions approved regional directives for the issuance of the Live Birth Certificate (Amazonas, Apurímac, Ayacucho, Cusco, Huánuco, Huancavelica, and Ucayali).
(ix) All nine regions adopted regulations related to the timely and free-of-charge issuance of the Live Birth Certificate.

2. 
   Component 2. Increasing the capacity to provide better maternal and child health services for the poor
   

a) Improvement of the quality of services in health facilities of the nine regions;
(i) Sixty nine health facilities were improved; these included new constructions and expansion or remodeling of existing facilities in the nine regions; the remaining four prioritized facilities will be delivered in 2016.
(ii) One hundred and four facilities were provided with new medical equipment in the nine regions.
(iii) Technical assistance to ensure proper use and maintenance of the new infrastructure and equipment for the administrators and the health teams.
(vi) All construction sites used the approved tools for environmental managements.

(vii) Fifty Environmental Impact Studies certified by DIGESA.

(viii) Evaluation of environmental liabilities and elaboration of Environmental Management Plan for 22 projects implemented.

(ix) Capacity building to 805 staff in comprehensive solid waste management

in 104 health facilities.

(x) Design of the Technical Standard proposal "Integrated Management of fluid

waste in health facilities and medical support services”.
(xi) Technical assistance to DIRESA for simplification of procedures related to authorization of septic tanks and infiltration and approval of the Program of Adequacy and Environmental Management for the transfer, treatment and disposal of solid waste.
(xii) Implementation of an Internship program for Emergency Obstetrics and Neonatal Care for a total of 674 participants, including 382 interns in diagnosis, stabilization and referral of obstetrics and neonatal emergencies (FONB), 256 interns in basic emergency obstetrics and neonatal care (FONE), and 36 interns in intensive care (FONI).
(xiii) Technical assistance to 11 hospitals in the nine regions to be qualified to host interns.
(xiv) Training of 282 health professionals in the prioritized health facilities (FONB) on vertical delivery, with 33 tutors and 6 training sites in 5 regions (Ayacucho (2), Cajamarca, Cusco, Huancavelica, and Ucayali).
(xv) Development and distribution of 180 DVDs with videos promoting vertical delivery across health centers in Ayacucho.
(xvi) Training of 440 health professionals in intercultural communication with Quechua-speaking population in Ayacucho, Apurímac, Cusco, Huancavelica, and Puno.
(xvii) Twenty four initiatives implemented though an ad-hoc fund (Fondo Concursable) in 167 health centers in the nine regions, by providing technical assistance to 24 technical teams to strengthen both technical and managerial skills to implement 333 activities identified in the action plans – benefiting a population of more than 370,000.

b) Provision of support for the integrated health delivery model and the development of support systems to raise the efficiency and effectiveness of health networks.
(i) Proposals for improving the referral and counter-referral system, in particular for maternal and neonatal service referrals, finalized in Puno and Ucayali and under development in Amazonas, Ayacucho, Apurímac, Cajamarca, Cusco, Huánuco y Huancavelica.
(ii) Technical assistance provided to DIRESAs and the health networks in the nine regions to improve budget execution by better planning for maternal and child health and nutrition between 2012 and 2014.
(iii) Training provided to 1,007 pharmacists and personnel responsible for pharmaceuticals on stock management and good storage practices for pharmaceutical products, medical devices and medical devices.
(iv) Implementation of the redesign of network storage and distribution of pharmaceutical products, medical devices and medical devices in eighth regions.
(v) Software developed for the regions to monitor the availability of pharmaceuticals and medical devices in the health centers.
(vi) Implementation of the Health Care Standards in 128 health centers by conducting 793 visits to provide technical assistance.
(vii) Implementation of the e-Health Network model of teleconsultations and tele-training, using a platform installed in two centers acting as national reference points (Nacional Materno Perinatal y Hospital Nacional Docente Madre Niño San Bartolomé) and in the Regional Hospital and health centers in the regions of Amazonas, Huanuco and Ucayali and Amazon, for a total of 48 primary care centers connected. Ongoing plans to establish the e-Health model in Huancavelica, Apurímac y Ayacucho.
(viii) Started the development of the interoperable national system of Registry of Teleconsultations.
c) Inclusion of intercultural focus in service provision
(i) Consultations in 12 districts in the nine regions through Intercultural Dialogues whose purpose was to promote cultural understanding and participatory decision-making in relation to the implementation of the program’s civil works.
(ii) Technical meetings for the analysis of maternal and neonatal health indicators with representatives of DIRESAs, Directorate of Social Development, Ombudsmen, universities, professional associations, CUNA MAS, UDR - SIS.
d) Increasing knowledge of effective delivery systems
(i) Study of prescribing practices in health facilities FONB and FONE in Huánuco and Cajamarca.
(ii) Mixed-method study on the provision of health care to children under 3 years of age in health facilities in 9 poor regions, Peru. 2013.
(iii) Qualitative evaluation of neonatal mortality in the regions of Huánuco y Ucayali, Peru. Biomedica: Revista del Instituto Nacional de Salud (Colombia)
(iv) Cause-effect analysis of hospital neonatal mortality in two Andean-Amazonian departments of Peru. Revista Panamericana de Salud Pública (OPS).
(v) Neonatal mortality, analysis of surveillance registries and clinical histories for neonates in 2011 in Huánuco and Ucayali, Peru. Rev. Peru Med. Exp. Salud Pública. 2014.
(vi) Study of factors related to anemia in children under 3 years of age in Peru: analysis of data from ENDES 2007-2013. Biomedica: Revista del Instituto Nacional de Salud (Colombia).
(vii) Four studies on users’ perceptions on drugs and their use in medical facilities.
(viii) Determinants of the use of contraceptives in adolescent and young girls who are sexually active, Peru 2012.
(ix) Analysis of the impact of investing in health facilities on maternal health indicators in regions under PARSALUD II.
(x) Study of knowledge, perceptions, and attitudes towards C-sections and blood transfusion in rural areas of the regions under PARSALUD II.

3. 
   Component 3. Strengthening government capacities to offer more equitable and efficient health system in a decentralized environment.
   

This component aimed at: a) Supporting a regulatory framework and increasing quality in the provision of health services; b) Expanding the health insurance system (SIS) enrollment; c) strengthening data monitoring and accountability in the system; d) supporting the decentralization of health services
Component 3 outputs:
(i) Preparation of 32 technical norms and regulations for: (a) the accreditation and certification system, currently proposed by the law but not regulated, (b) infrastructure maintenance systems, (c) a reference laboratory system, (d) hemotherapy (e) hospital financing, (f) pharmaceutical purchasing and logistics system, and (g) a health communication and promotion system.

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  Proposal for the regulatory framework for Universal Health Coverage
  
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  Policy guidelines on citizen participation and oversight under the Universal Health Insurance. In 2011 the Guidelines for Citizen Oversight prepared in 2010, were approved
  
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  Proposed technical standards on Obstetric and Neonatal functions in health facilities
  
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  Inspection manual and guide of good practices in manufacturing pharmaceutical products (and validation)
  
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  Project for regulating organization and functions of SUNASA
  
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  Technical standards of the Service Delivery Unit, Obstetric Center
  
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  Regulation of the organization and functions of SIS – Personnel Allocation Table
  
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  Regulation for the registry, control and surveillance of pharmaceutical products and medical devices
  
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  SIS regulations under the Universal Health Insurance
  
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  Analysis of the national health policy framework in line with the regulations of transferred functions (decentralization)
  
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  Operationalization of the model of comprehensive health care at the primary care level
  
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  Document defining physical targets for 2012 for the Strategic Programs for Maternal and Child Health and Nutrition, through the implementation of the IPMF (adjusted with recommendations of the MEF and MINSA) at the level of the DIRESAs, UE, Networks, Micro-networks and health facilities
  
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  Bill of law on financing for the subsidized and semi-contributory insurance
  
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  Proposal for the salary scale of the MINSA and Regional Government personnel in the Medical Career track
  
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  Roadmap of the decentralization process
  
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  Criteria to estimate the needs for pharmaceutical products and medical devices used for the Health Priorities
  
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  Supreme decree on the Mobile System for Emergency Care
  
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  Clinical guideline for emergency obstetric care according to the level of care (x2)
  
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  Strategic Plan of the AUS
  
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  Manual of the organization and functions for the regulatory framework on Universal Health Insurance and its regulations
  
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  New LOF of MINSA
  
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  Proposal for the Users’ Committee of the SUNASA; health norm (maternal, newborn and child care); regional norm on the care for newborn and children under 3 years of age in the region of Huancavelica
  
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  Regulation related to the law on financing for the subsidized and semi-contributory system
  
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  Whitepaper on Identity and Insurance Rights
  
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  Technical standards for the Service Delivery Unit for Intensive and Intermediate Newborn Care
  
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  Norm of SISMED
  
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  Proposal for the standard identifier for medical devices
  
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  Proposal for local decentralization
  
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  Criteria for the Definition of Health Care Networks, with emphasis on maternal-neonatal care
  
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  Update of the technical standards for the vertical delivery (2015)
  
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  Proposal for the regulation of telecare – remote diagnostics (2015)
  
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  Accreditation model of the IPRESS, which includes:
  
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    product 2: (i) proposal of whitepaper: model of quality health care accreditation by IPRESS, and (ii) proposal of health standards: manual of quality health care accreditation by IPRESS in Peru
    
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    product 3: (i) proposal of regulation for the accreditation by IPRESS in Peru; (ii) Proposal of regulation for the certification of the agents qualified for certifying accreditation by IPRESS in Peru
    
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    product 4: (i) proposal of methodology and clinical guidelines and tools for the accreditation by IPRESS (including the model of supervision of accreditation by IPRESS); (ii) proposal of the financing model for accreditation by IPRESS in Peru; and (iii) proposal for the model of information management for accreditation by IPRESS in Peru
    

(ii) Technical assistance supporting SIS and the decentralization of responsibilities in health care

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  Redesign of the Technical Document on Quality in Health, in the context of the National Policy on Quality in Health, Decentralization, and Universal Health Insurance, which sets the guidelines for the design and implementation of the Quality Management System in the health facilities
  
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  Systematization of the implementation process of the Universal Health Insurance in the MINSA and in the regions of Ayacucho, Apurímac and Huancavelica
  
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  Systematization of the evaluation of the exercise of the functions transferred to the regions, based on the application of MED
  
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  Technical and financial assistance for the development of the model for the supervision of SUNASA
  
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  Systematization of the M&E implementation process of the decentralization aimed at improving performance of the health functions
  
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  Computer application that automate the analysis and reporting of information from the monitoring system of availability of medicines and supplies for the delivery and obstetrics and neonatal emergencies (available on the PARSALUD II website)
  
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  Technical assistance for the proposal for the evaluation of results and monitoring of the implementation of the universal health insurance, which includes a set of indicators for the AUS baseline and the design of the evaluation
  
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  Technical and financial assistance for the development of the model for implementing the National System of Conciliation and Arbitration in Health
  
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  Design of the model for evaluation of staff and monitoring of the supervisions to IPRESS and the Management Units (2015)
  
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  Strengthening of the management of multi-year investments in health (2015)
  
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  Proposal of the Coverage of the Benefit Package of FISSAL (2015)
  
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  Design of the management model of FISSAL (including tax policy, relationships with providers, payment mechanisms and incentives) (2015)
  
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  Proposal for the baseline, evaluation of results and monitoring of activities for the implementation of the AUS, presented to CTIN and SETEC
  
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  Cost-benefit analysis of pre-hospital emergency and urgent care of the Mobile System for Emergency Care National Program
  
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  Study of the status of transfer (of functions) from SIS to the implementing units
  
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  Elaboration of the Annual Report to the Congress of the Republic of Peru on the progress with the implementation of the AUS
  
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  Evaluation of the potential impact of measures for the protection of intellectual property in the access to biological products
  
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  Analysis, identification and proposal for the legal regulations to support the activities of the innovative model of Telemedicine
  
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  Diagnosis of the care provided to SIS patients in pharmacies, both public and private, in the context of the implementation of Inclusive Pharmacies
  

(iii) Support to capacity development through the creation of ad-hoc training programs, including:

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  Government and Management in Health (176 tutors and 332 health professionals trained in the I edition and 346 in the II edition, including doctors, nurses, obstetricians, and pharmacists), consisting of a Master in Government and Management in Health, Diplomas in different areas (Strategic Planning and Public Investment Programs, Health Management and Administration, Management of Health Networks, Hospital Management), and certificates for specific modules
  
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  Diploma in Information management for Health Interventions (76 tutors and 266 health professionals trained, including doctors, nurses, obstetricians, nutritionists, psychologists, and biologists)
  

(iv) Studies supporting the implementation of the PARSALUD program and the development of technical documents and proposals for regulations:

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  Analysis of factors associated with out-of-pocket spending in health, among the
  poor population, in a context of a progressively increasing funding for comprehensive health insurance
  Diagnostics of the information system in the nine regions
  
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  Evaluation of the implementation of the accreditation process of health services
  within the scope of PARSALUD II and proposal for improvement
  
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  Evaluation of maternal and child care practices in areas of extreme poverty in Peru, 2012 (Published in Rev. Peru Med. Exp. Salud Pública. 2014; 31(2):243-53)
  
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  Systematic review on effectiveness of community interventions on the reduction of neonatal mortality. Revista Peruana de Medicina Experimental y Salud Pública
  
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  Systematic review on effectiveness of community interventions on the growth and development of children under 5 years of age in rural areas. Revista Cadernos de Saude Pública – Brasil
  
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  Technical document generated from the International Conference “Towards Universal Health Coverage” (Hacia la Cobertura Universal de Salud)
  
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  Literature review on Comprehensive Health Care Networks
  
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  Literature review on the efficacy or effectiveness of pharmaceutical policies which contribute to improve access to essential drugs for the population
  
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  Review and development of proposals for improvement to the document “Guidelines and measures for the reform of the health sector”
  
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  E-Health in Peru: systematization of the experiences from 2002 to 2013.
  
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  E-Health in maternal and neonatal services in the Peruvian Amazonia: towards an integrated model.
  
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  Evaluation and redesign of the health care model for dispersed populations
  
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  Systematization of the experience with the behavior change campaign Estrategia de Promoción de Practica y Entornos Saludables (EPPES) in PARSALUD II
  
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  Systematization of the experience with the strategy for the Derecho a la Identidad y Aseguramiento (DIA) in PARSALUD II
  
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  Systematization of the experience with the Fund (Fondo Concursable) for the selection and implementation of interventions in PARSALUD II
  
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  Systematization of the experience with the strategy for Prior Consultations and Intercultural Dialogue implemented by PARSALUD II
  
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  Systematization of the experience with the management of PARSALUD II
  
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  Systematization of the experience with the implementation of the training program via internships on obstetrics and neonatal emergencies and vertical delivery
  
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  Systematization of the experience with community participation and transparency: strategies for citizen oversight and accountability
  
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  Systematization of the experience with the improvement of infrastructure and equipment of the health facilities classified as FONB and FONE, developed under the investment framework within PARSALUD II
  

4. 
   Component 4. Project Coordination and Monitoring and Evaluation (M&E), through the provision of technical assistance, financing of incremental operating costs, and external and concurrent audits.
   

(i) PARSALUD PIU operating costs.
(ii) Mid-Term Evaluation of PARSALUD program.
(iii) Final evaluation of the PARSALUD program.
(iv) Yearly external financial audits.
(v) Elaboration and implementation of risk mitigation plans related to procurement and contracting.