FutureGenerations

The International Budget Partnership published the following article by Laura C. Altobelli, Country Director for Future Generations Peru, in their most recent newsletter.  The IBP is a leading advocate of openness and public accountability, in order to make government budgets more responsive to the needs of low-income people.  You can read the full article text here, or in the IBP e-newsletter:

Health care in the community of Las Moras in Huánuco, Peru, consisted of a poorly equipped one-room health post staffed by an auxiliary nurse and visited by few patients. Then in 1994, the primary health care facility in Las Moras and about 250 others throughout the country were incorporated into a new government-community partnership for the delivery, management, financing and monitoring of primary health care services, called the Shared Administration Program. The program formed committees of locally elected community members, called Comunidades Locales de Administración de Salud (CLAS), into private non-profit associations to collaboratively manage government funds for primary health care services. This gave communities not just a voice in priority-setting and oversight but also direct control over public funds for expenditures on infrastructure, equipment and human resources. Since the inception of CLAS, Future Generations, a private non-profit organization, has worked with the government, civil society and local communities to design the CLAS system and build the capacity of communities to thrive within the CLAS framework.

As a result of participating in the CLAS partnership, the Las Moras Health Center built additional consultation rooms and a birth center, purchased necessary equipment and supplies in a timely manner and increased the staff to 36 members, including doctors. It now supports a system of community health promoters, who are trained and supervised by health personnel to do monthly visits to families with pregnant women and children under two years old for check ups, referrals, and health education. This system of outreach and support has quadrupled the level of coverage for maternal and child health care.

Las Moras is not an isolated success story, CLAS has spread across the country, improving health care coverage and the efficiency of service delivery. CLAS committees now oversee one-third of all government primary health services. CLAS is supported by the national government’s health sector financial and administrative systems and is also able to mobilize — through participatory budgeting, donations, prepayment schemes, or other means —complementary resources from local municipalities and other governmental and non-governmental entities to meet health sector goals. This unique strategy of direct community involvement has resulted in more public and private funds for local health facilities and greater efficiency in the use of these resources to increase the quality and utilization of health services. Studies show that CLAS achieves greater coverage of key health services for mothers and children, greater equity and higher levels of satisfaction than traditionally operated public primary care services.

Although the CLAS system does not cover the entire country, recent legislation has given municipal governments the responsibility of managing primary health care and requires them to open their budget processes to the public. In the context of decentralization, the central government of Peru is concerned with increasing the role and capacities of municipal governments, many of which serve small rural or peri-urban districts. Municipal governments have historically invested their small budgets in local infrastructure with little accountability to their constituents. Extending municipal governments’ purview to include primary health care delivery heightened these concerns about capacity and accountability which is reflected in the legislation’s requirements for municipalities to open their budget processes to public participation and to produce results-oriented budgets. Even with the broader health care mandate, only a portion of municipalities’ revenues are currently distributed through participatory budgeting. There is little information about how well this process is actually working, but there are indications that the process is evolving.

Future Generations supports the CLAS system’s participatory budgeting and local collaborative management by linking both of these functions more effectively with the communities served by CLAS and thereby helping the health system to strengthen its relationship with local municipalities. The goal is to develop an effective and efficient community-oriented health model based on incorporating participatory and results-oriented budget processes into municipal oversight of primary health care service delivery.

Future Generations trains teams of municipal officials, health sector personnel and community representatives to work with local communities to develop a strategic vision based on local data and community priorities and a work plan to implement the vision.  For community priorities that require resources from outside the community, projects are presented in the annual participatory budgeting process. Municipal officials have found this an ideal method for ensuring that they satisfy community needs and demands as required by law and learning community organizing skills that bring them closer to their constituents.

The effort to increase transparency by opening public decision making and social control to public participation contributes to decentralization in Peru. The aim of programs like CLAS is to empower citizens, communities, and institutions to collaboratively manage the use of public resources, achieving the goals of equity and sustainability through shared local governance of social services and development investments. Following these principles, the Las Moras community in Huánuco has significantly reduced chronic childhood malnutrition, won recognition from the Ministry of Health. and the National Society of Industries in Peru , and serves as a national observation and training center for replicating the CLAS model in other regions of the country and abroad.