Leadership Case Study. ONE PAGE.

Leadership Case Study

Writing Assignment #2 – ONE PAGE. Apply principles of leadership, governance and management to the CLAS Case Study of Peru. Formulate your own strategy that addresses the needs of the community. Refer to the reading and website linked above to choose among the strategies (empowerment, coalitions, media advocacy, etc.)

Running Head: CASE STUDY OF CLAS IN PERU: OPPORTUNITY AND EMPOWERMENT IN HEALTH EQUITY

Case Study of CLAS in Peru: Opportunity and Empowerment in Health Equity

MPH STUDENT

University

Purpose: With collaboration of the local government, private non-profit Comunidad Local de Administracion de Salud (CLAS) received funds to provide primary health care (PHC) services to the public in Peru. Peru is one of the few countries in the world with a legalized, regulated, recognized, community-based healthcare program.

Vision of project: To illustrate the significant and sustainable achievements in the community when people work together and create a powerful social awareness.

Community empowerment: community empowerment identified key components which promote an innervation for a better healthcare system to the public. “Community-based participatory research is a promising approach to reducing health disparities. It empowers individuals and communities to become the major players in solving their own health problems” ((Molina, Viswanath, Warnecke, Prelip, August 1, 2016).

Collaboration decision-making: strongly evidence suggest social participation and empowerment have a positive effect on health outcomes and reduction of inequalities. Social determinants of health (SDH) are conditions in which people are born, raise, live, work, and age. SDH are determined by level of income, power, and resources. Poverty have limit access to healthcare and resources. While wealthy individuals can obtain the best and most advance medical care. Social participation on CLAS allowed surveillance and control of health services in an effort to promote community development, promotion of health, and health equity.
Strategies: when communities are legally involved in managing public resources those programs tend to generate resistance and ensure sustainability.

References

Altobelli, L. (2008). Case Study of CLAS in Peru: Opportunity and Empowerment in Health Equity., 37.

Thompson, B., Molina, Y., Viswanath, K., Warnecke, R., & Prelip, M. L. (2016, August 1).

Strategies To Empower Communities To Reduce Health Disparities. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5554943/

Leadership Case Study

Writing Assignment #2 – ONE PAGE. Apply principles of leadership, governance and management to the CLAS Case Study of Peru. Formulate your own strategy that addresses the needs of the community. Refer to the reading and website linked above to choose among the strategies (empowerment, coalitions, media advocacy, etc.)

Read the case study below:

· Case Study of CLAS in Peru: Opportunity and Empowerment for Health Equity

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Case Study of CLAS in Peru: Opportunity and Empowerment for Health Equity
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Case Study of CLAS in PeruSAMPLE x

Case Study of CLAS in PeruSAMPLE2 x

Hide Rubrics

Rubric Name: Community Empowerment

Print Rubric

This table lists criteria and criteria group names in the first column. The first row lists level names and includes scores if the rubric uses a numeric scoring method. You can give feedback on each criterion by tabbing to the add feedback buttons in the table.Criteria

Outstanding Achievement

Commendable Achievement

Marginal Achievement

Unsatisfactory

Failing

Criterion Score

Target Community

5.25 points

Empowerment needs are based on collaboration between and participation by community members, representatives of community-based organizations, and researchers to achieve health equity through social action. Identifies community assets on which to build interventions, and it facilitates the exchange of knowledge between researchers and community members. Includes: a long-term partnership that is focused on a local health issue and involves co-learning, capacity building, shared decision making, mutual ownership of research findings, and dissemination of results, and balances power among the partners, and helps translate research into policy and practice.

4.6725 points

Most components are included.

4.1475 points

Some components are included.

Case Study of CLAS

n Peru:

Opportunity and Empowerment for Health Equity

Prepared by:

Laura C Altobelli, Future Generations
www.future.org , laura@future.org

August

This paper was prepared for “Case Studies of Programmes Addressing Social Determinants of Health and
Equity” organized by the Priority Public Health Conditions – Knowledge Network (PPHC-KN) of the
World Health Organization Commission on Social Determinants of Health, with support from the Alliance
for Health Policy and Systems Research, World Health Organization

Geneva 2

Switzerland

Home

mailto:laura@future.org

ABSTRACT

Local Health Administration Communities (CLAS) in Peru are private non-profit civil
associations that enter into agreements with government and receive public funds to administer
primary health care (PHC) services applying private sector law for purchasing and contracting.
CLAS is an example of a government strategy that effectively addresses social determinants of
health (SDH), referring to the social, cultural, and economic barriers at the local level that keep
people from obtaining services. Bottom-up approaches such as empowerment strategies and
community participation have become important paradigms in public health and development
efforts to address these local barriers and are becoming part of the discourse on SDH. Citizen
participation is essential as a path to empowerment, and evidence is now available showing that
empowerment strategies do have a positive effect on health outcomes and in reducing inequalities
in health. Initially through a Supreme Decree, and now a national law on CLAS, the Peruvian
government provides the opportunity structure for more flexible financial management with
social participation that gives citizens direct control in the transparent management of primary
health services, in planning and as facilitator of community development, and in promotion of
healthy behaviors and lifestyles of individuals in the community, thereby building agency and
empowerment. Evidence is presented showing the effectiveness, efficiency, equity, and
coverage of CLAS as compared to PHC services that are administered through the cumbersome
traditional public system that still operates in 70% of the Ministry of Health PHC system.
“Peru´s CLAS program…is one of the world’s best demonstrations of rapid expansion with
decentralization of the Alma Ata model of community-based primary health care.” (from report
by H. Mahler et al. 2001).

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru

ACRONYMS

CHA Community Health Agents
CLAS Comunidad Local de Administración de Salud

Local Community Health Administration Association
DHS Demographic and Heath Survey
DISA Dirección de Salud

Regional Health Office
DIRESA Dirección Regional de Salud

Regional Health Office
ENDES Encuesta Demográfica y de Salud Familiar
Demographic and Health Survey
FONCODES Fondo de Compensación para el Desarrollo Social

Compensation Fund for Social Development
GOP Government of Peru
IBRD International Bank for Reconstruction and Development (World Bank)
IADB InterAmerican Development Bank
MOH Ministry of Health of Peru
NGO Non-governmental organization
PAC Programa de Administración Compartida
Shared Administration Program
PAHO Pan American Health Organization
PARSalud Proyecto de Apoyo a la Reforma de Salud
Health Reform Support Project
PHC Primary health care
PRORESEP Programa de Revitalización de Servicios Periféricos
Program for Revitalization of Peripheral Health Services
PSBPT Programa de Salud Básica para Todos
Basic Health for All Program
PSL Plan de Salud Local
Local Health Plan
PSNB Programa de Salud y Nutrición Básica
Basic Health and Nutrition Program
RM Resolución Ministerial
Ministerial Resolution
SEG Seguro Escolar Gratuíto
Free Health Insurance for School Children
SIS Seguro Integral de Salud
Integrated Health Insurance
SMI Seguro Materno-Infantil
Maternal-Infant Health Insurance
SUTEP Sindicato Unico de Trabajadores de Educación del Perú
Unique Union for Peruvian Education Workers
WHO World Health Organization

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru

TABLE OF CONTENTS

Abstract i
Acronyms ii
Table of contents

iii

1. Background 1

1.1 How CLAS effectively address social determinants of health
1.2 How CLAS operate
1.

Objectives of Shared Administration and CLAS
1.

Geographic distribution of CLAS in the primary health care

system of the Ministry of Health
1.

Past evidence on the effects of CLAS on the health system and

on health of the population

2. Case Study Method 6

3. Findings 6

3.1 Mechanisms by which CLAS improve equity of access,
quality of service, and social capital

3.2 Key political processes to establish and expand CLAS

4. Discussion

4.1 Going to scale
4.2 Managing policy change
4.3 Managing intersectoral processes
4.4 Adjusting design
4.5 Ensuring sustainability

5. Conclusions

6. Acknowledgements 1

7. References

8. Graphs 1-7

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
iii

1 BACKGROUND

Peru has been successful in reducing its infant mortality to a par with the Latin American
average. However, maternal mortality and chronic child malnutrition are still excessively high,
and inequities in access and quality remain associated with large gaps in income. The country has
one of the lowest per capita expenditures on health, $

0, as compared to an average of $

2 in
Latin America (Alvarado and Mrazek, 2006), and the distribution of this expenditure has been
highly inequitable.

Peru delivers health care through a mix of providers. The Social Security Institute (EsSalud)
provides obligatory employee health insurance with payroll deduction, serving 20 % of the
population with formal employment. The Armed Forces has its own system of care for military
families comprising 3 % of the population. The wealthiest

% utilizes private services and the
private health insurance industry. The poorest 65% of the population is covered the Ministry of
Health (MOH) network of primary health care (PHC) services and hospitals. Of this group about
45% have access and 20% remain excluded due to geographic, social, cultural, and economic
barriers. This case study refers to the 65% nominally covered by the MOH health system,
focusing on the primary level of care where 80% of all health care needs can be attended.

Peru is among the few countries in the world that has a government health program with
legalized, regulated, and institutionalized community participation. The Shared Administration
Program, formalized in April of

94 by Supreme Decree 01-94-SA, gives responsibility and
decision-making power over the management of public resources for the administration of,
currently,

% of the Ministry of Health (MOH) primary health care (PHC) system. Despite the
fact that community participation is now universally accepted as a basic strategy for primary
health care, the legalized form of participation established in the Shared Administration Program
is a rare phenomenon in the Latin American region and in the world. Participation is based on
specific law and regulations, and a contract signed between the community non-profit entity
(called the CLAS) and the Regional Health Department. This private-public contract is based on
a local health plan: the CLAS is obligated to supervise its administration and completion, and the
MOH takes responsibility for financing implementation of the plan.

This program for co-management of MOH PHC services was initiated in 1994 in the upswing
from a decade-long downturn of terrorism, hyperinflation, and collapse of the health sector.
Decentralization was entering political discourse on governance but without clear strategies.
Most Peruvian communities have strong traditions of internal organization, though their
relationship with government has swung between dependency, independence, and mistrust. In
the few years following the Alma Ata Declaration on Primary Health Care in 1978, the initial
projects promoting PHC were better defined as community manipulation than community
participation. MOH PHC services were medicalized and dominated by physicians.
Government and health sector politics and the strong influence of physicians´ and health workers
unions were forces affecting the development of the CLAS from its beginnings.

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru

1.1 HOW CLAS EFFECTIVELY ADDRESS SOCIAL DETERMINANTS OF HEALTH

This case study describes the ways in which CLAS is an example of a government strategy for
managing PHC services that effectively addresses social determinants of health (SDH). SDH
frequently refer to factors outside the reach of the health care sector that affect health status,
particularly in regard to the social and economic conditions in which people live that affect their
health. Other aspects of SDH refer to the social, cultural, and economic barriers at the
community level that keep people from obtaining the services they need. Bottom-up approaches
such as empowerment strategies and community participation have become important paradigms
in public health and development efforts to address these local barriers and are becoming part of
the discourse on SDH.

There is consensus in the literature that citizen participation is essential as a path to
empowerment, given the type of participation. Experiences with development programs around
the world are providing evidence that when people are assisted to assess their situation and select
their own priorities based on local data and to build leadership capacity, they are able to identify
creative solutions that are unique to their needs and resources and become empowered to
implement and maintain the solutions on a long-term basis (Taylor-Ide and Taylor, 2002).

Evidence is now available showing that empowerment strategies do have a positive effect on
health outcomes and in reducing inequalities in health (Wallerstein, 2006). Social participation
and empowerment have been adopted as basic concepts by the World Bank, the InterAmerican
Development Bank, the United Nations system, and bilateral agencies. The World Bank
considers two attributes of empowerment: agency, in terms of the exercise of choice by
marginalized communities; and opportunity structure, in terms of the design of government
programs that allows people to create effective action (World Bank, 2001). CLAS provides the
opportunity structure which allows for development of agency through formalized social
participation in health.

Social participation in CLAS allows critical roles in the surveillance and control of health
services, in planning and as facilitator of community development, and in promotion of health
behaviors and lifestyles of individuals in the community, therefore building agency and
empowerment. Furthermore, these roles depend on the public sector to provide the opportunity
structure to promote and facilitate capacity-building, especially among the poorest members of
the community and women, a view promoted by Amartya Sen (2000).

As will be described in this chapter, CLAS in Peru are composed of community members who
are given legal authority to administer public funds for organizing and delivering health care.
Evidence will be presented that shows how much better CLAS work in delivering services
effectively and efficiently, of better quality, greater equity, and with greater health impact as
compared to PHC services that are administered through the cumbersome traditional public
system that still operates in 70% of the MOH PHC system.

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru

1.3. HOW CLAS OPERATE

From 1994 to 2008 when new regulations went into effect, CLAS have been formed of six
elected community members, organized as non-profit civil associations under rules of the
Peruvian Civil Code. Candidates are nominated by community members, and democratic voting
takes place for the six community members of the General Assembly in the presence of
municipal and Regional Health Directorate (DIRESA) representatives. The six elected
Association members have a two-year term, and among themselves vote on three members to
form the Board of Directors with president, secretary, and treasurer who have a one-year term.
The health facility medical chief is CLAS Manager.

The relationship between CLAS and the government through the regional DIRESA is formalized
with a Shared Administration Contract, with responsibilities on both sides specified in detail. An
annual operational plan and budget called the Local Health Plan (Spanish acronym – PSL), is a
key instrument for co-management beyond standard clinical services to include community-
identified needs.

CLAS-run health services depend primarily on government funding through: (1) direct cash
transfers from the public treasury, (2) cash reimbursements from the government health insurance
program (SIS) for the poor and, (3) in-kind receipt of medicines and some supplies purchased in
bulk by the DIRESA. Fees collected from patients for non-covered health services are
administered by CLAS as opposed to non-CLAS health services who do not control funds. Cash
transfers from the public treasury and public health insurance reimbursements go into a
commercial private bank account controlled by CLAS. All funds are publicly owned but under
the joint stewardship of DIRESA and CLAS, which provide monthly financial reports to the
DIRESA. Expenditures of public funds for acquisitions and infrastructure are faster and simpler
under the CLAS system. CLAS are not required to adhere to cumbersome rules of public
administration that were set up to avoid misuse of funds and instead create incapacity to spend,
forcing return of funds to the central government at the end of each fiscal year. Success of CLAS
is importantly due to their agility in financial management with more efficient spending on
priority and community-identified needs for better quality of health care. For example, CLAS
can purchase laboratory equipment or contract lab services to third parties, renovate the health
facility, hire more personnel, purchase security equipment and personnel to prevent thefts, and
make other improvements that increase the perception of quality of care which increases demand
for services. Misuse of funds in CLAS has not been an issue: social control by the community
promotes transparency.

Social control over health personnel is exercised by CLAS and the general population who are
empowered to feel ownership of health services and demand accountability by health personnel.
Personnel are hired and fired by CLAS under private labor contracts. In contrast, government
payroll personnel’s labor regimen provides permanent job stability, a six-hour work day, one-
month vacation, health insurance, and a full public pension. Entitlements and lack of
accountability create a shield for minimal productivity and many refuse to do work they find
disagreeable such as going into communities (Webb and Valencia, 2006). The new law on CLAS
signed in 2007 includes a clause to correct this problem.

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru

1.3. OBJECTIVES OF SHARED ADMINISTRATION AND CLAS

The objectives of CLAS are being achieved as much for its unique legal structure as the favorable
inclination of communities to become empowered. These objectives include: Contribute to
modernization of public health administration by incorporating private sector law in the
administration of State resources. Decentralize by allocating state resources directly to the place
of budget execution. Involve elected community members in exercising management and social
control of public funds, directly administering their use for contracting personnel, construction
and maintenance of infrastructure, and purchase of equipment, medicines, and supplies. Improve
quality and quantity of health services through a Local Health Plan based on community
decisions. Improve equality by determining fee scales and identifying excluded community
members who need exoneration of fees and/or increased efforts to reach them. Promote more
public and private investment in public health services by expanding possible sources of funding.

1.4 GEOGRAPHIC DISTRIBUTION OF CLAS AMONG PRIMARY HEALTH CARE
FACILITIES OF THE MINISTRY OF HEALTH

Of 6,871 PHC facilities of the MOH, 2,133 (31%) are administered by 783 CLAS. Individual
CLAS administer one facility, and aggregate CLAS can administer two or more PHC facilities.
The PHC system has five categories of care. These are, in descending order, Level I-3 and I-4
health centers (more than one physician, full staff, no in-patient care except normal maternity
services), Level I-2 health posts (one physician, few other staff), Level I-1 or I-0 health posts (no
physician). Graph 1 shows the distribution of CLAS and non-CLAS PHC facilities
disaggregated by rural/urban areas and level of categorization in the year 2006. CLAS comprise
42% to 52% of large health centers in rural and urban areas, respectively, and 43% of larger rural
health posts. Among small health posts in rural and urban areas, CLAS administer only 26 to

% of them, respectively. Of the larger health posts (Level I-2) in urban areas, 33% are
administered by CLAS. When the CLAS program initiated in 1994, the early CLAS tended to
be small health posts with one doctor. These have been able to develop over time into larger
facilities with more personnel, more infrastructure and equipment, and greater demand for
services due in large part to their flexible management structure, as compared to non-CLAS.

1.5 PAST EVIDENCE ON THE EFFECTS OF CLAS ON THE HEALTH SYSTEM AND
ON HEALTH OF THE POPULATION

Prior studies comparing CLAS and non-CLAS have findings that by and large show positive
impacts of CLAS on equity, quality, and coverage of health services (Altobelli, 1998a, 1998b;
Cortez 1998; Vicuña et al, 2000; Altobelli and Pancorvo, 2000; Altobelli and Sovero, 2004).

Impact on Equity

Research on equity of access in CLAS-administered primary care facilities has provided evidence
that the program is more effective in delivering affordable services to the poor. One of these
studies was conducted on national data from the 1997 National Living Standards Survey in Peru.
As shown on Graph 2, CLAS provided significantly more full or partial exoneration of fees in
each of the three lowest income quintiles in rural area, as compared to non-CLAS facilities.

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru

These data were collected just as the school health insurance program was put into place, and
prior to the maternal-child health insurance program, so those programs should not have
influenced the findings on this table.

Impact on Efficiency

Graphs 3 and 4 illustrate the greater efficiency of CLAS versus non-CLAS PHC services by
showing the number of physicians and productivity of patient care. Graph 3 shows the mean
number of physicians working in CLAS and non-CLAS health posts and health centers in both
rural and urban areas. Among health posts, rural CLAS have more than twice the number of
physicians than rural non-CLAS (.41 vs .

); the number of physicians is similar in urban health
posts whether CLAS (.63) or non-CLAS (.74). On the other hand, urban health centers that non-
CLAS have significantly more doctors on average (3.62) than either rural non-CLAS (2.8) or
rural and urban CLAS (2.63 and 2.40, respectively).

Graph 4 shows coverage of health services for children from data on Integrated Health Insurance
(SIS) reimbursements which was abstracted manually from records of all 675 health facilities,
200 CLAS and 475 non-CLAS in three of

Regions of Peru – Cusco, Huánuco, and La
Libertad. Results show the number of visits per child in Plan A (0-4 years) in relation to the total
number of children 0-4 years of age living in the jurisdiction of each health facility by whether it
is CLAS or non-CLAS, urban or rural. CLAS in both rural and urban areas have twice or nearly
twice the average number of visits per child as compared to non-CLAS.

Impact on Demand

Evidence of differential utilization of health services for children in CLAS as compared to non-
CLAS was assessed from Peru National Demographic and Health Survey-DHS data from 2000.
As shown on Graph 5, three variables showed differences between populations living in CLAS
and non-CLAS jurisdictions on utilization of health services for sick children. This graph
suggests that CLAS has a positive influence on intermediate variables of access and utilization
for children, and confirms findings from the year 2002 shown in Graph 4.

Impact on chronic malnutrition in children

Using maternal education as a proxy indicator for socioeconomic status, the Peru DHS data
showed that CLAS populations in rural areas were on average poorer than non-CLAS
populations (Altobelli, 2006). Furthermore, maternal education and socio-economic status as
defined by household expenditure is the most significant predictor of chronic malnutrition in
children (Mercer, 1988). This can be seen clearly in Graph 6. In order to remove the effect of
distributional socio-economic differences in the interpretation of the data, data on chronic
malnutrition in children under age five were analyzed by stratified categories of maternal
education. Results in Graph 6 show that among children whose mothers had any primary
schooling, chronic malnutrition was 40.8% in those living in CLAS jurisdictions, and 44% in
those living in non-CLAS jurisdictions. The difference is significant. This educational stratum is
most likely to use Ministry of Health services, being neither the very poorest stratum of mothers
who are frequently excluded from any use of health services (No Education category), nor the
better-educated stratum that is more likely to use sources of health care other than the Ministry of

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
5

Health (Any Secondary or More category). This difference is not explained by higher
educational levels of mothers in the CLAS groups.

2 CASE STUDY METHOD

This case study focuses on the process of implementation, with five types of processes of
particular interest: (1) going to scale – the challenges faced in moving from small pilot program
to a widespread intervention; (2) managing policy change – in terms of policy formulation
toward policies that are likely to benefit the poor and vulnerable, the influence of the political
environment, the role of individuals as policy champions, managing opposing professional views;
(3) managing intersectoral processes – including stewardship challenges in working with other
sectors, difficulties in coordination, etc.; (4) adjusting design – adjustments made to the original
program design during implementation, issues of sequencing elements of the program, effects of
stakeholder views upon design; (5) ensuring sustainability – issues in securing ongoing financial
support for the program, as well as promoting institutional sustainability.

Data collection for this study combined several methods of data collection. Qualitative data was
collected through semi-structured interviews with a series of stake-holders on their retrospective
and current knowledge and opinions, listed by name and title in the acknowledgements.
Interviews were tape recorded, if permitted by the respondent, and transcribed.

Further qualitative data was collected through semi-structured interviews with members of

CLAS to determine how CLAS influence equity and social determinants of health. Three regions
were selected for interviews on the basis of geographic distribution (coast, mountains, high
jungle) and level of regional support to CLAS (high, low, medium). In each were selected three
“good” CLAS and three “poor” CLAS utilizing the MOH classification based on management
criteria. Random selection of CLAS was attenuated by accessibility so as to facilitate the field
work.

Specific documentation reviewed for this case study included government legislation (law
decrees, supreme decrees, regulations, administrative directives, etc.) relating to (i) the Shared
Administration Program, (ii) co-management and community participation in health, and (iii)
decentralization; at least 10 published and unpublished reports and evaluations on the Shared
Administration Program, including quantitative analyses of program performance comparing
CLAS and non-CLAS PHC facilities.

3 FINDINGS

Presentation of findings on the case study of CLAS revolve around two questions. Firstly, what
is the agency of CLAS in regard to mechanisms they use to improve access to care through
promoting equity and quality of care. The second question looks at key political processes in the
development of government policy on CLAS.

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
6

3.1 MECHANISMS BY WHICH CLAS IMPROVE EQUITY OF ACCESS, QUALITY OF
SERVICE, AND SOCIAL CAPITAL

a. CLAS Role to Promote Equity of Access

Fees-for-services: Nearly all CLAS interviewed for this case study reported having a sliding
scale of fees-for-services for the purpose of increasing access by the poor. In cases where no
differential fees are allowed, it was considered that the SIS insurance program is doing the job to
ensure coverage of the poor. CLAS members interviewed did not generally report having a role
in deciding which families could pay less. This decision was left mainly to the CLAS manager,
sometimes in conjunction with social workers and CHA.
Excluded populations: All CLAS interviewed, either alone or in coordination with the CLAS
manager and health management team, made decisions on the need for and design of a strategy
for providing health services to isolated and hard-to-reach communities.
SIS affiliations: All CLAS interviewed participate in strategies to increase affiliations of mothers
and children in the Integrated Health Insurance (SIS) program, both to attend more patients,
especially the poor. One of the main motivating factors is to increase the income of the health
facility.
Community health agents (CHA): Nearly all PHC facilities, both CLAS and non-CLAS, have
volunteer CHA who are generally trained and supervised by a health center nurse in period
meetings at the health center. In few cases do health personnel work in communities alongside
CHA. CLAS reported a variety of ways in which they provide incentives or support to the work
of CHA, such as: accreditation, providing ID cards, providing refreshments during work
sessions, giving gifts on special occasions, recognizing CHA as partners of CLAS, financing
rotating employment of CHA in cleaning or laundry work of the health facility, ensuring free
medical care to CHA, ensuring that CHA obtain training. CHA work is generally supported on
an ad-hoc basis; much more systematic support is needed to sustain the work of CHA.

b. CLAS Role in Promoting Quality Of Care

CLAS members defined quality of care as shorter waiting times, nondiscrimination, no
mistreatment, longer hours of attendance, having sufficient health personnel particularly medical
specialists, having enough medicines, and others. Ways in which CLAS promoted quality of care
included the following:
Improvements in personnel, equipment, and infrastructure: CLAS members made management
decisions to: (1) motivate health personnel by increasing wages, (2) orient expenditures to
improvements in infrastructure and equipment, (3) present proposals to regional or local
government for financing of infrastructure and other projects, and (4) improve their own
management capabilities by obtaining training in legal norms for PAC.
Improving patient-provider relationships: CLAS members report that relationships are
improved since health personnel are accountable to them. They encourage personnel to be more
enthusiastic and energetic with patients, and sanction any who mistreat patients or are
irresponsible in completing their work (i.e. arrive late, leave early).
Channelling community feedback: Requests by the community for changes or improvements in
health services are generally channeled through CLAS Association members. In the case a
patient is mistreated, the line of decision-making is not standard, but nearly always involves a

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
7

collaborative decision between CLAS members and the CLAS manager, with final action
sometimes referred to the DISA/DIRESA for solution.

CLAS Role in Building Social Capital

Leadership development: CLAS members consider membership to be an honor, that their role is
highly respected by the community, and that they are seen as having power to change what needs
changing to improve health services. All report that people come to them to discuss or complain
about the health services. CLAS members often go on to take other leadership roles such as
elected or appointed positions in local municipal government.
Leadership development for women: In all CLAS interviewed, the number of female members of
the General Assembly had increased over time. One-third of CLAS interviewed had a majority
(4 or more of 6 members) of members who are female. Female CLAS members were referred to
as being more responsible, more transparent, not easy to manipulate, and more knowledgeable
about health, especially that of children.

3.2 KEY POLITICAL PROCESSES TO ESTABLISH AND EXPAND CLAS

Primary health care (PHC) was placed on the health policy agenda for the first time in Peru in
1985 by then Health Minister Dr. David Tejada, ex Deputy Secretary of WHO under Dr. Halfdan
Mahler. Though many were enthused by the PHC approach, there was little support for the
strategy either technically, administratively, or financially in the centralist and hospital-oriented
health sector. As a result, the initial thrust for PHC faded within a year or two. Hyperinflation,
Shining Path terrorist activity, and government estrangement from international financing eroded
public health services to the point of total health sector collapse by 1990.

With the change of government in 1990, budgetary deficiencies and terrorist activity continued in
rural areas. Also, the cholera epidemic of 1991 diverted health sector attention. Following
capture of the Shining Path leader in September, 1992, Peru began to move rapidly toward a new
economic model that slowed inflation and stimulated greater international investment and donor
financing. A trend toward privatization was emerging. The Ministry of Economy and Finance
(MEF) initiated the “Peruvian Government Reform Project” and within that the “Health Sector
Reform”. The MEF commissioned development of legal norms to modernize the health sector,
applying concepts of social-oriented market economics and democracy (Vera, 1994).

There was a new orientation to poverty reduction and growing political commitment to
decentralization as part of the regional trend in Latin America. Dr. Jaime Freundt entered as
Minister of Health in mid-1993 with the intention of strengthening PHC services: only

0 out of
3,800 health centers and posts were operational (MOH, 1992). Innovative solutions were
required. A new major program financed by the public treasury, the Basic Health for All
Program (Spanish acronym – PSBPT) had the goal to rapidly increase PHC coverage to the
neediest populations. Over 3,000 PHC facilities were reactivated with human and material
resources administered through a special quasi-public program.

Dr. Freundt saw the need for an alternative form of administration for PHC that would begin to
solve the problems of lack of resources and poor quality. Decentralization had no specific
proposals for implementation, and the MOH thought they could contribute to this process.

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Privatization was becoming acceptable. The idea was to design a program that would involve
community participation, recognizing that the State could not manage everything, that “things
work when those who are most interested in having it work well are involved” (Freundt, 2007).

Dr. Freundt sought advice from international expert on community participation, Dr. Carl E.
Taylor1, who was in the process of developing an evidence-based theory of community change
which incorporates new roles for empowered communities, government, and outside change
agents (Taylor and Taylor, 1985 and 2002). In January 1994, Carl Taylor and two Peruvian
experts, Juan Jose Vera and Patricia Paredes, visited mountain communities where the Shining
Path was active to find out why villages did not want to reopen MOH services. They found,
listening to villagers, that doctors treated them as ignorant, were uncaring, and mainly wanted to
return to the city. Villagers wanted to have medical care, but on their own terms and with a say
in it.

As the legal framework for the new program in the process of design, the Peruvian Civil Code
and its articles for creation of civil associations were seen as ideal for building the model of
community-based health administration committees. Most relevant of prior experiences was that
of the Program for Revitalization of Peripheral Health Services (Spanish acronym – PRORESEP),
UNICEF-supported, that applied principals of the Bamako Initiative to a community-
administered rotating drug fund.

From January to April 1994, the legal and institutional framework of the new program was
drafted by a team2 of experts. A Supreme Decree Nº 01-SA-94 was signed by the President on
May 5, 1994, that created the Shared Administration Program (Spanish acronym – PAC) with the
formation of Local Health Administration Committees (Spanish acronym – CLAS), and the
Shared Administration Program for Pharmaceuticals (PACFARM). PAC was set up as a sub-
program of PSBPT. The PAC technical team began the identification, formation, and training of
regional health staff, PHC facility personnel, and communities. The first pilots of CLAS were
inaugurated in July 1994 with thirteen PHC facilities in Ayacucho, home of the Shining Path, and
coastal Ica.

By the end of the first year, 250 health facilities were incorporated into the program each with a
CLAS Association. CLAS expansion continued at a rapid pace. Two evaluations of CLAS were
conducted in 1995 and early 1996 that had very positive findings on the progress and value of
CLAS (O´Brien and Barnechea, 1996; Taylor, 1996). By mid-1997, ten percent of all MOH
PHC facilities in Peru were administered by CLAS: 558 CLAS administered 611 health facilities
(out of about 6000 total facilities) in 26 out of 33 Health Regions of Peru.

An important health sector reform that contributed to decentralization and improved equity was
the development of two government health insurance programs that were eventually combined
into the SIS (Spanish acronym for Integrated Health Insurance) program. Free School Insurance
(Spanish acronym – SEG) was created in 1996 to fulfill Fujimori’s 1995 reelection campaign

1 Founding Chair and Professor Emeritus of the International Health Department at The Johns Hopkins University
School of Hygiene and Public Health (now Bloomberg School of Public Health).
2 Team members were Engineer Juan José Vera, Dr. Patricia Paredes, Dr. Nicolas Velarde, Carlos Bendezú, y Nurse
Roxana Pajuelo, with support from Dr. Jaime Freundt, Econ. José Carlos Vera and Dr. Augusto Meloni.

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promise to provide public schoolchildren with free medical and dental care. Health facilities
became quickly overwhelmed since they received no reimbursements for hiring additional
personnel to meet the increased demand for health services by schoolchildren.

The second public insurance scheme began in 1997 with a pilot for the Maternal-Child Insurance
Program (Spanish acronym – SMI) focused on reducing cost barriers for preventive services and
childbirth. The pilot was implemented in three areas where CLAS were already well in place3
building on the fact that CLAS were able to receive directly insurance reimbursements. SMI
pilots proved successful in the context of CLAS financial management since CLAS could hire
more personnel and enhance services to meet the increased demand. Non-CLAS facilities were
not considered in the SMI pilots. This fact was not widely known or understood as a major
factor in the success of the SMI pilots

By the end of 1997, resistance to CLAS was building from different sectors. Groups of regional-
level health administrators complained of CLAS, physician unions and health worker unions
complained and called for boycotts of CLAS, and groups of officials and technical advisors in the
central Ministry diminished the value of CLAS. Technical teams working on the design of health
management “networks and micronetworks” saw no way to incorporate CLAS into their proposal
that in effect was consolidating the inefficiencies of traditional public administration. Under
pressure to close CLAS, Minister of Health Marina Costa-Bauer, sociologist by training, decided
to freeze CLAS expansion and commissioned an internal program evaluation (Vicuña et al 1999).
At that point, over

0 additional CLAS were organized and waiting to be recognized, and
another 200 were in stages of formation.

The IMF and World Bank were starting to take an interest in CLAS as a strategy for modernizing
the public sector, improving transparency and social control of public expenditure. Other
agencies were also taking an interest in CLAS and commissioned papers on the program,
including the Inter American Development Bank (Altobelli, 1998a), IDRC/IADB (Cortez, 1998),
and UNICEF (Altobelli, 1998b). All papers demonstrated comparative results with non-CLAS
on health care coverage and equity with findings highly favorable in support of CLAS.

In January 1999, the CLAS program was reinstated. A new strategy was designed for rapid
program expansion, incorporating additional health facilities into existing CLAS. These were
referred to as “aggregate CLAS”, whereby one CLAS administered more than one health facility.
Some had up to 40 facilities under one CLAS. The pros and cons of the aggregate CLAS model
were addressed in a case management paper which suggested that community involvement
declined with aggregate CLAS, though efficiency could increase (Altobelli and Pancorvo, 2000).
Thereafter, it was decided to partition larger aggregate CLAS into smaller ones.

Scaling-up of the SMI insurance program also began in 1999. Now non-CLAS were included in
SMI, but they could not receive directly the insurance reimbursements. In CLAS, on the other
hand, SMI reimbursements were received directly into their co-managed bank accounts and
became a boon to improvements in staffing, infrastructure, and equipment which allowed CLAS
to enter an upward spiral of improved supply and demand.

3 SMI was piloted in CLAS-administered networks in the Regions of Tacna and Arequipa, and the Moyobamba
province in the Region of San Martin.

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The decision to rapidly scale-up of both CLAS and SMI in 1999 was a direct result of the IBRD
Programmatic Social Reform Loan to Peru using a new mechanism in which policy decisions and
benchmarks were agreed on with government social sectors (health, education, food assistance,
justice) as conditionalities for loan disbursements. CLAS initiated an expansion phase to go from
10% to 33% of primary level facilities over a period of three years. See Graph 7.

Funding for SMI expansion reimbursement payments was part of a proposed 1999 funding
package for $264 million U.S. dollars from IBRD, IADB, and a consortium of bilateral funders
(Britain, Canada, Japan, and others). The package was intended to subsidize all recurrent costs of
the SMI for three years, after which it was expected that the GOP would begin to take over the
costs. This funding proposal, in addition to the IBRD conditionalities in the health sector,
reflected the close coordination among agencies to promote major progress in decentralization
and improving health services to the poor.

Unfortunately, the transitional government in 2000-200

wanted to put the SMI expansion loan
package on hold until the next elected government was in place, but the delay resulted in donor
withdrawal. Without these loans, the SMI insurance reimbursements were left under
responsibility of the public treasury. The lack of secure financing for SMI affected CLAS by
limiting the newly-found source of fresh funds reimbursed to CLAS that was utilized for
improving quality of PHC services. Nor was there technical support for CLAS from the IBRD-
funded technical assistance project, PARSalud, due to perceived wavering of political
commitment to CLAS. Nevertheless, the dedicated national technical team of Shared
Administration was a constant that provided the underpinning technical support to keep CLAS
alive during this time.

A dramatic increase in CLAS during 2001-2002 can be attributed to the IBRD-PSRL
conditionalities, in addition to the committed advocacy of the National Coordinator of Shared
Administration, Dr. Victor Baccini, who was able to convince the Minister to not detain CLAS
expansion. This was a major achievement in spite of the conservative orientation of the then
Health Minister Dr. Solari who, together with his Vice Minister Dr. Carbone, represented a
religious sect and reversed gains in women’s access to health services (Coe, 2004). Both Drs.
Solari and Carbone had a health policy discourse in support of community participation.
However, when Dr. Carbone became Minister in 2002, he took overt action to detain CLAS
expansion.

Under Dr. Carbone, the MOH commissioned an evaluation of CLAS with the call to propose
“other models of co-management”. The evaluation reports provided a positive assessment of
CLAS with useful recommendations (Sobrevilla et al, 2002; Velarde and Sobrevilla, 2002).
Ignoring these papers, the MOH went ahead smoothing the road toward closure of CLAS through
a series of Ministerial Resolutions5 in late 2002. The only donor agencies at that time with a
technical interest in CLAS were DFID and USAID, though they provided little financial support.
Given the political and financial environment for CLAS, it is remarkable that the whole program
did not collapse. Possible reasons it did not included the solid legal basis created at the outset of

4 Installed as a result of the fraudulent Presidential elections of 2000.
5 R.M. Nº 895, R.M. Nº 1743, and R.M. Nº 1793.

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the program in 1994, the committed technical support by the MOH Shared Administration team,
and the on-going advocacy by external public health specialists.

Given the blockage of communication with external agencies promoted by Dr. Carbone, efforts
were initiated by the private non-profit, Future Generations, in January 2003 to work directly
with the Commission on Health, Population, Families and Disabled Persons of the Peruvian
Congress to advocate for a law on CLAS that would provide greater legal stability and protection
from the fluctuating levels of support provided by rotating leadership teams in the MOH. By the
end of the year, a consortium of development agencies and NGOs, public health experts, and
MOH officials6 was assembled by Congressman Dr. Daniel Robles, President of the Health
Commission. A “Sub-Commission for the Study of CLAS” was formed and an initial draft of the
law was discussed in a series of three macroregional meetings in December 2003 and January
2004. Numerous subsequent drafts were produced during 2004 and through October 2005, but
work on the law was put on hold as the 2006 Presidential election campaigns drew near and the
political climate became uncertain as to how the new government would want to deal with CLAS
(Future Generations, 2008).

Work on the CLAS law proposal in the Health Commission of Congress stimulated a parallel
effort within the MOH, which felt that it was their role to create the law proposal. For a time,
there were two parallel and competing CLAS law proposals in course.

Overt resistance to CLAS was building particularly from the Medical Federation who feared the
permanence of a potential CLAS law. A national physicians strike led by the Medical
Federation in late 2003 to early 2004 included the derogation of CLAS as one of their demands.
Another demand was to place on government payroll all physicians working on short-term
contracts in government health services. By that time the Ministry of Health leadership had
passed to Dr. Álvaro Vidal who was a supporter of the physician unions, and under whom the
physicians´ strike began. It fell to his successor, Dr. Pilar Mazzetti, a research neurologist, to
resolve the strike, which she did by agreeing to the demand for government employment of all
physicians in April of 2004. One expert described this as “the most regressive policy decision in
public health to occur in the last ten or fifteen years”, damaging the health system and the health
reform process. Many feared that CLAS would be debilitated by loss of social control over
physician performance.

CLAS had survived the physician’s strike, but PAC was progressively dismantled as funding was
cut and the PAC technical team was reduced from 35 persons to five over a period of 2-3 years. In
December 2005, the remaining PAC team was transferred from PAAG to the Executive Office of
Health Services Management in the MOH, with final transition of CLAS financial management to
the traditionally inefficient MOH General Accounting Office. While it was widely feared that PAC
could suffer in administrative efficiency and lose technical guidance from this move, this was also
seen as positive action toward main-streaming PAC into general work of the MOH. On the down
side, regional DIRESAs remained without a specific office in charge of regional CLAS
management. Responsibility for CLAS continued to be assigned in an ad-hoc manner in each
region.

6 Consortium included Future Generations Peru, MOH, MEF, PAHO, UNICEF, DFID, USAID, CARE Peru, PHR
Plus, Policy Project, and Pathfinder.

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In his inaugural speech on July

, 2006, Alan Garcia stated that he would extend the experience
of CLAS during his presidency to the education sector. Consequently in October 2007 the
Peruvian Congress approved a new “Law on Co-Management and Citizen Participation in Health
for Health Facilities at the Primary Level of Care of the Ministry of Health and the Regions,”
culminating five years of advocacy on CLAS from within the MOH and from outside change
agents.

4 DISCUSSION

Five themes addressed by this case study are discussed separately in this section. Within each
theme are discussed the issues and challenges, what was done to address them, and the outcomes.

4.1. GOING TO SCALE: CHALLENGES IN MOVING FROM SMALL PILOT TO
WIDESPREAD INTERVENTION

The process of incorporating health facilities into PAC is illustrative of a shared management
process. Communities played a role in deciding whether or not to enter the program or were
approached by the MOH for strategic reasons. Once the initial group of CLAS was functioning
they served as demonstration sites encouraging other communities to choose to enter the
program, thus maintaining the self-selection process that was an important feature of successful
implementation. The scaling-up process was demand-driven since community decision-making
had to be involved from the beginning.

CLAS owes much to Dr. Freundt who was so convinced of the need to go forward with CLAS
that he bypassed two signatures in the MOH before sending the original Supreme Decree on
CLAS to the President in May 1994; his leadership on CLAS was unwavering though surrounded
by disbelievers in the MOH. A highly-qualified multidisciplinary technical team was assembled
that was committed to the idea of community participation. The first national coordinator, Ing.
Juan José Vera, had significant experience working with community groups in co-managing
agricultural programs, and his sustained dedication to CLAS was exemplary. Carlos Bendezú
had held the highest governing role in the region where the Shining Path had been most active,
bringing political astuteness and a deep understanding of community needs to the team. Together
with a public health physician, Dr. Patricia Paredes, the initial group for the first four program
years was a key to successful implementation, even with changes of Health Ministers and
national politics. Their longevity facilitated scaling-up CLAS to the first 10 percent of all PHC
services by 1997. Later national coordinators of Shared Administration were physicians with
field experience as CLAS managers who could provide operational guidance to other physicians
around the country who were managing CLAS on the ground.

The program was initially conducted with minimal publicity as a strategy implemented by the
CLAS management team to avoid the fate of a similar community-controlled program in the
education sector in 1993 which had been widely publicized, seen as a threat to teacher autonomy,
and quickly brought down by the powerful teacher’s union SUTEP, which had seen the program
as a threat (Ortiz de Zevallos et al, 1999). Repeating that same history though in the health
sector, physicians were the ones who opposed CLAS, adducing that doctors should not be

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obligated to respond to the communities they serve. Physicians also complained of the double
work involved in co-management with copious reporting requirements. There was truth in the
latter issue as there was a temporary “dual” reporting system as PHC policy shifted from the old
model to the CLAS model.

The Ministry of Economy and Finance was a player with little direct decision in expansion of
CLAS with the major exception of the conditionalities it accepted as part of the IBRD
Programmatic Social Reform Loan, whereby MEF placed pressure on the MOH to comply with
the agreed policy changes. These included expanding CLAS by a specified percent each year for
three years between 1999 and 2002, as one of the conditionalities for loan disbursement to MEF.

Overall, donors have played a critical role in support of CLAS at different points in time, ranging
from technical support to research to policy change conditionalities for CLAS expansion. The
latter, incorporated into the IBRD loan program, qualifies as one of the most important supports
to the scaling-up of CLAS. It is important to note that no major donor-funded PHC projects in
the first ten years of CLAS provided technical support to CLAS, such as the major PHC projects
funded by USAID, IBRD, and the European Commission. These were important lost
opportunities that could have resulted in a faster scaling-up process and less political and
professional resistance to CLAS. The IADB was instrumental in financing the small technical
team in the MOH that established and managed the Shared Administration Program. After that,
no donor agency provided recurrent cost support to CLAS.

Non-governmental organizations by and large played a small role in support of CLAS, with one
exception. Most were worked on projects funded by donors that did not address CLAS.
Eventually Pathfinder and CARE Peru incorporated some support to CLAS in the way of
technical assistance, field work, manuals, or model development as part of larger projects on
reproductive health or health rights programs. Future Generations was the only non-
governmental organization that provided technical support to CLAS throughout the life of the
program. Dr. Carl Taylor, founder and senior advisor of Future Generations, was involved from
the design stage and throughout the years of CLAS development. In 2001 the organization
created an affiliate in Peru with the mission to strengthen CLAS.

A health advocacy group representing civil society, comprised of health professionals and health-
related NGOs and established in 2003, called ForoSalud, included CLAS in regional fora as part
of civil society groups involved in health at the regional level. ForoSalud in general supported
CLAS, though they could have been more proactive.

As an individual, Dr. Halfdan Mahler, ex-Secretary General of WHO, had an impact on
professional opinion of CLAS when he visited Peru in early 2002, made site visits to several
CLAS, and spoke highly in favor of CLAS to dignitaries of the medical profession and MOH.

4.2 MANAGING POLICY CHANGE

Despite the rapid expansion, increasing community demand and success of CLAS in delivering
health care, resistance grew from the medical profession, regional DIRESAs, and health worker
unions. The Medical Federation considered CLAS as a move toward privatization of health, thus

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jeopardizing their goal to have all physicians appointed to the government payroll. Physicians
have long sought what they consider their lawful rights that physicians should be hired
competitively for public sector jobs and that once accepted they should enter as permanent public
servants with government pension to the grave. A study in Uruguay showed that doctors on
government payroll are significantly less productive on the job than contracted personnel, since
they have no incentives for efficiency (Webb and Valencia, 2006; Das and Pave, 2007). Equally
damaging is the loss of hours worked when a contracted physician switches over to the
government payroll which requires only a six-hour work day.

Resistance also came from officials in administrative units of DISA/DIRESAs who lose control
over resources as a result of the CLAS system that transfers funds directly to CLAS bank
accounts. In addition, the use of low-cost short-term no-benefit contracts by CLAS has generated
resistance especially from the non-physician health workers union FENUTSA.7 CLAS are caught
between needing to hire more personnel and receiving little financial support to meet the need,
having to rely on fees-for–services or SIS reimbursements to hire personnel. Many
DISA/DIRESAs had been working under the erroneous assumption that SIS reimbursements to
CLAS cannot be utilized to finance private labor contracts that would pay benefits; so they use
SIS funds only for short-term no-benefit contracts.

By not admitting that a decentralized model was functioning through CLAS, teams of consultants
charged with designing a decentralized model omitted CLAS from their decentralization design
frameworks. Instead they preferred the idea of handing primary health care services over to
management by local municipalities. As a compromise, the new law on CLAS incorporates local
municipal government as one of three signatories on the co-management agreement, thereby
satisfying the goal to articulate primary care services with local government while maintaining a
good share of community control.

Health reform teams also designed a model called the “health management network” in which
PHC facilities were regrouped into networks and smaller micro-networks related by geographic
accessibility and provision for referral to a center with a higher resolutive capacity, centralizing
laboratory and information systems, and serving as a “budgetary executing unit”. This program
was superimposed over CLAS, creating a competing organizational model that lacked the
financial and human resource administration capabilities that were already consolidated in CLAS.

An error in management of PAC was its early placement in regional DISA/DIRESA Community
Participation Units, frequently staffed by non-health professionals such as sociologists and
anthropologists who were experts in community participation but had difficulty comprehending
the decentralized financial and human resource management aspects of PAC, and were therefore
ineffective in correctly representing the program to the rest of the MOH. These offices were
sometimes the main source of criticism of CLAS, particularly in the first years of CLAS when
power struggles occurred between communities and government as both learned new roles and
ways to share power in decision-making and control over resources. Health sector employees
expected to see communities easily begin to “participate”: this concept became for many a
criteria for evaluation of CLAS, and they judged that CLAS did not meet the “criteria”.
Criticisms flourished on the basis that CLAS was “not true community participation.” A

7 Federación NacionalUnico de Trabajadoesr de Salud- FENUTSA

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population-based study of CLAS showing that 80% of those surveyed did not know what CLAS
was, was taken as evidence that the community did not participate in PAC, and that CLAS was
“not valid” as a program for community participation (Cortez, 1998). A policy paper attempted to
clarify the concept of community participation and CLAS, after which there seemed to be less
negative discussion of CLAS along these lines.

4.3 ADJUSTING DESIGN: LAWS, REGULATIONS, AND RESOLUTIONS ON CLAS

A major strength of the CLAS program was that it was founded on the basis of a Supreme
Decree, just below the level of a Congressional law, and structured on the Civil Code, both
aspects that provided a strong legal framework for operating new financial and contractual
arrangements in the health sector. There were virtually no major adjustments made in the laws
and regulations guiding CLAS from 1994 up to the year 2007 given ten Ministerial Resolutions
emitted throughout that period which modified only minor details of the program. Three
disastrous Ministerial Resolutions in late 2002 reduced the autonomy of CLAS, delineating how
the MOH could close down a CLAS, and creating a commission to revise its legal framework.
This stimulated Future Generations in January of 2003 to initiate advocacy with the Health
Commission of Congress on developing a new law decree to provide legal stability to CLAS that
was finalized four years and 10 months later.

The new “Law on Co-Management and Citizen Participation in the Primary Level of Care of the
Ministry of Health and the Regions” that goes a long way to resolve issues that have arisen and
lessons learned since program initiation in 1994. It provides for wider participation from each
community and representation of government on the CLAS Association, and for orientation and
training of government officials, health providers, and community members who are associated
with CLAS to ensure the quality of participation. CLAS addresses social determinants of health
through enhancement of democratic governance.

4.4. ENSURING SUSTAINABILITY OF CLAS

To ensure the program’s sustainability it would be necessary to demonstrate that CLAS was an
essential component of a strengthened primary health care model, and that it would have to
articulate with local government. The strategy was to start with the most successful CLAS in
each region and build their capacity as Self-help Centers of Action Learning and
Experimentation, using them as training centers for scaling-up. Future Generations became the
first organization to develop a pilot ´Model CLAS´ in the poor urban settlement of Las Moras in
Huánuco Region on the eastern slope of the Andes beginning in late 2002. In Las Moras, PHC
facility work is better organized with community leaders, volunteer health promoters, and
community organizations. Promotion of home-based health behavior change is improved with
check-lists for community volunteers to monitor mothers and children, and materials to extend
health education and prevention to the home. The model works with a methodology of
community empowerment for strengthening social control and transparency of health
management, with capacity building of all actors to strengthen social capital and local ownership
of the development process. Las Moras has been awarded several prizes and recognition in
national competitions on quality improvement, and serves now as a model site and Self-help
Center of Action learning as it was set up to do. ´Model CLAS´ are serving their goal of helping

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politicians and health officials see the value of CLAS to improve primary health care, keeping
alive the idea of CLAS through periods when there was little other support, and now serving as
guides and training centers to scale-up improved overall quality of primary health care services.

5 CONCLUSIONS

Summary of findings on CLAS:

1. Latin American governments have historically lacked transparency and participation of

the citizenry in decision-making and the oversight of public programs. The CLAS
program in Peru was among the first to provide the increased transparency, participation,
and social control that had become priorities of the population by the beginning of the
twenty-first century. Political and bureaucratic resistance to CLAS was slowly toppled
through research, advocacy, and ´Model CLAS´ to finally reach a political acceptance
with signing of the Law on Co-Management in October, 2007.

2. Power struggles between the health sector and communities, and between medical and
health worker unions and the health sector were a necessary component of maturation of
each set of actors as new governing roles were learned and incorporated. To date, the
unions continue their resistance against CLAS.

3. Expansion of CLAS was favored by the important role played by both internal and
external champions. Internal champions were the relatively stable and committed
technical team in the Ministry of Health. External champions were UNICEF, IBRD, and
IADB, as well as public health researchers and several NGOs.

4. CLAS demonstrate that social participation is essential for the efficient implementation of
primary health care. The watch-dog role of citizens in CLAS over use of public resources
not only empowers the community, but helps to ensure transparency and efficiency. This
includes the social control that citizens exert over the quality of care through the pressure
placed on health care providers at the point of service delivery.

Lessons learned for public health to be drawn from CLAS experience are:

1. Trusting in the community as an active and empowered member of a co-managed “health
team” promotes agency, builds social capital, and provides mechanisms to involve
women and the most vulnerable groups in both utilization of the health system and in
community organizing for local planning and action in health and development.

2. When communities are legally involved in managing public resources, the programs are

certain to generate resistance from interest groups that stand to lose power. The lesson
from CLAS is that community involvement is the surest way to ensure sustainability, in
spite of resistance, as long as even a few key government officials continue to support the
program and, importantly, that outside agencies are helped by donors to play a role in
policy research, advocacy, and technical assistance.

3. The power struggles and difficult political pressures on CLAS over time could be one of

the factors that counter-intuitively, but importantly, contributed to their success as they
learned to survive under pressure. If this lesson is generalized, then it should be expected

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that a longer development period is essential to achieve sustainable programs with
community empowerment. A legislated health reform that provides the “opportunity
structure” should not be expected to achieve the effective “agency” needed for successful
participatory models from one day to the next.

4. Primary health care systems that provide the opportunity structure and facilitate

community agency for empowerment can be best scaled-up after initial formation of
model “Centers for Active Learning and Experimentation” that successfully apply the
concepts of community empowerment in alliance with government, facilitated by outside
change agents who contribute to capacity building and advocacy. These model centers
with adaptations to each geo-political area can serve as useful learning centers for rapid
scaling-up to other sites within the area.

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6 ACKNOWLEDGEMENTS

The author acknowledges the collaboration of Julio Puntriano, Advisor to the Minister of Health
of Peru and Head of the Decentralization Unit of the MOH during the first part of this study.
Many thanks are given especially to Sara Bennett and Erik Blas of WHO for supervising the case
study, providing incisive comments and help on earlier drafts of this paper. The author is
grateful to the following persons who reviewed and commented on this case study: Carl E.
Taylor, Luis Espejo, Alejandro Vargas, José Cabrejos, and Nicholas Velarde. Thanks are given
to the Alliance for Health Policy and Systems Research for funding support. Special
acknowledgement is given to the following persons interviewed for this case study who
generously shared aspects of their direct experience with CLAS during different periods in the
history of CLAS. These are listed below by name and title held during the period in which each
was associated with CLAS and the Shared Administration Program:

Present Member of Congress
Dr. Daniel Robles, Congressman and past President of the Congressional Commission on Health,

Population, Families and Persons with Disabilities

Past Health Minister
Dr. Jaime Freundt, ex Minister of Health (1994-1995)

Past and Present National Coordinators of the Shared Administration Program
Dra. Jackeline De La Cruz, current National Coordinator of Shared Administration Program

(2006-present)
Dr. Victor Bacini, ex National Coordinator of Shared Administration Program (2000-2003)
Dr. Ricardo Díaz, ex National Coordinator of Shared Administration Program (1999-2000)
Dr. Nicolas Velarde, ex Interim National Coordinator of Shared Administration Program (1998)
Ing. Juan José Vera, ex National Coordinator of Shared Administration Program (1994-1998)

Past and Present General and Executive Directors in the Ministry of Health
Dr. Carlos Acosta, Executive Director of Health Services Management, General Directorate of

Personal Health, Ministry of Health (2005-present)
Dr. Luisa Hidalgo, ex General Director of Personal Health, Ministry of Health (2002-2003)
Dr. Oswaldo Lazo, ex General Director of Personal Health, Ministry of Health (2001-2002)
Dr. Augusto Meloni, ex General Director of Office of International Cooperation and Finance,

Ministry of Health (1994-1999), ex Advisor to the Minister of Health (1993-1994)

Past Program Coordinators and Government Advisors
Dr. Danilo Fernández , ex National Coordinator of Program for Administration of Management

Agreements and Basic Health for All Program, Ministry of Health (1996-2000)
Dr. Carlos Ricse, ex General Coordinator of PARSalud Project
Dr. Wilfredo Solis, ex Advisor, National Council on Decentralization (2007)
Sr. Felix Valencia, Insurance Expert, SIS (2007)
Econ. José Carlos Vera, ex Advisor to the Minister of Health (1993-1994)
Dr. Arturo Yglesias, ex Advisor to the Minister of Health (1993)

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
19

Past and Present Leaders of the Physician Union and Association
Dr. Julio Castro, past and current Dean of the Peruvian Medical Association (Colegio Médico)
Dr. Julio Vargas, current President of the Peruvian Medical Federation (Federación Médica)

Past and Present International Consultants and Advisors
Dr. Carl E. Taylor, Professor Emeritus, The Johns Hopkins University, and co-Founder and

Senior Advisor for Future Generations
Dr. Rigoberto Centeno, Consultant in Health Services, Pan American Health Organization

CLAS Associations
CLAS Panao, Huánuco Sr. Glicerio Aquino, President

Dr. José Salas, Manager
CLAS San Francisco de Cayrán, Huánuco Sr. Jorge Lazaro, President

Dra. Helen Trujillo, Manager
CLAS Huancapallac, Huánuco Sr. Kleber Sánchez, President

Lic. Cleopatra Cervantes, Manager
CLAS Perú Corea, Huánuco Sra. Haide Malpartido, President

Dr. Edwin Morales, Manager
CLAS Umari, Huánuco Sr. Victor Inocencio, President

Dr. Dennys Talenos, Manager
CLAS Pillco Marca Sra. Rosario Guzman, President

Dr. José Rodriguez, Manager
CLAS Wanchaq, Cusco Sr. Elio Cárdenas, President

Dra. Carolina Letona, Manager
CLAS Quiquijana, Cusco Sra. Elsa Ojeda, President

Dr. Wilbert Polo, Manager
CLAS Urcos, Cusco Sra. Angélica Gonzáles, President

Dr. Dario Navarro, Manager
CLAS Ttio, Cusco Sr. Mario Aparicio, President

Dr. William Loayza, Manager
CLAS Pisac, Cusco Sr. Francisco Rojas, President

Dr. Arturo Jara, Manager
CLAS Chinchero, Cusco Sr. Constantino Sallo, President

Dr. Gabriele Bermudez, Manager
CLAS San Francisco, Tacna Sr. Luis Llosa, President

Dr. Jaime Miranda, Manager
CLAS Intiorko, Tacna Sra. Tania Palco, President

Dra. Luisa Maria Maldonado, Manager
CLAS Vista Alegre, Tacna Sra. Justina Ramos, President

Dr. Benjamin Núñez, Manager
CLAS Ciudad Nueva, Tacna Sr. Roberto Hualpa, President

Dr. José Medina, Manager
CLAS Alto de la Alianza, Tacna Ing. Martin Paucara, President

Dr. Renán Neira, Manager
CLAS Cono Norte, Tacna Sr. Alejandro Tuyo, President

Dra. Carolina Davalos, Manager

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru

7 REFERENCES

Altobelli, LC (1998a) ´Comparative analysis of primary health care facilities with civil society

participation in Venezuela and Peru.´ Prepared for the seminar, Social Programs,
Poverty, and Citizen Participation, March 12-13, 1998. Cartagena, Colombia: Inter-
American Development Bank. http://www.future.org/publications/comparative-
analysis-primary-health-care-facilities-with-participation-civil-society-ve

Altobelli, LC (1998b) ´Health Reform, Community Participation, and Social Inclusion: the

Shared Administration Program.´ Paper prepared for the Mid-term Evaluation of the
UNICEF-Peru Cooperation. August, 1998. http://www.future.org/publications/health-
reform-community-participation-and-social-inclusion-shared-administration-progra

Altobelli, LC & Pancorvo, J (2000) ´The Shared Administration Program and the Local Health

Administration Committees: Case study of Peru.´ Case study prepared for the III
Forum for Europe and the Americas on Health Sector Reform, San José, Costa Rica.
World Bank. http://www.future.org/publications/shared-administration-program-and-
local-health-administration-associations-clas-peru

Altobelli, LC (2002) ´Participación comunitaria en la salud: La experiencia peruana en las

CLAS.” In: J. Arroyo (Ed.) La Salud Peruana en el Siglo XXI: Retos y Propuestas de
Política, Lima: Consorcio de Investigación Económica y Social/ DFID/ Policy Project.
pp. 303-354.

Altobelli, LC & Sovero, J (2004) ´Cost-efficiency of CLAS Associations.´ Lima: Future

Generations, Mulago Foundation, DFID. http://www.future.org/publications/cost-
efficiency-clas-associations-primary-health-care-peru

Altobelli, LC (2006) ´Comparative Analysis of Health Impact and Health Services Utilization in

CLAS and Non-CLAS Primary Health Care Services in Peru,´ Lima: Future Generations
Peru.

Alvarado, B & Mrazek, M (2006) ´Salud.´ In: Marcelo M. Guigale, Vicente Fretes-Cibils, and

John L. Newman, Peru: Opportunity for a Different Country – Prosperous, Equitable,
and Governable. Washington, DC: International Bank for Reconstruction / World Bank.

Coe, AB (2004) ´From Anti-Natalist to Ultraconservative: Restricting Reproductive Choice in

Peru´, Reproductive Health Matters 12(24): 56-69.

Cortez, R (1998) ´Equidad y calidad de los servicios de salud: el caso de los CLAS.´ Lima:

Research Center of the Universidad del Pacífico, Working Documento Nº 33.

Cortez, R & Phumpiu, P (1999) ´La Entrega de Servicios de Salud en los Centros de

Administración Compartida (CLAS): el caso del Perú.´ Lima: Universidad del Pacífico,
International Development Research Center (IDRC/CIDA), Inter-American Development
Bank (IADB).

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
21

http://www.future.org/publications/comparative-analysis-primary-health-care-facilities-with-participation-civil-society-ve

http://www.future.org/publications/health-reform-community-participation-and-social-inclusion-shared-administration-progra

http://www.future.org/publications/shared-administration-program-and-local-health-administration-associations-clas-peru

http://www.future.org/publications/cost-efficiency-clas-associations-primary-health-care-peru

Das, J & Pave Sohnesen, T (2007) ´Variations in Doctor Effort: Evidence from Paraguay.´

Health Affairs 26 (3): w324-w337

Díaz J, Altobelli LC, Espejo L, Cabrejos J, & Vargas A (2006) ´Pilot Project SCALE-Squared

Training Center, CLAS Las Moras – Huánuco: Mid-Term Evaluation 2003-2005,´
Lima: Future Generations, Mulago Foundation, Duane Stranahan Charitable Trust.

Enge, K et al (1984) ´Evaluation of the Health Promoter Program,´ Lima: Ministry of Health.

Espejo, L et al (2001) ´Modelo para el Desarrollo de Capacidades Locales en la Promoción de la

Salud de las Comunidades,´ Serie: Lección Nº 2, Lima: CARE Peru.

Freundt, J (2007) Personal communication.

Future Generations (2008) ´Development of the “Law That Establishes Co-management and

Citizen Participation in Primary Health Care Facilities of the Ministry of Health and the
Regions”: A Documented Chronology 2003 to 2007.´ Prepared to commemorate the
approval by the Peruvian Congress on October 5, 2007 and the promulgation by the
President on October 30, 2007 of Law Nº

124. January 15, 2008.

Mahler, Halfdan, Carl E Taylor, Daniel Taylor, Omak Apang (2001) Memorandum on Findings

and Recommendations for Peru´s National System of Community Co-Managed Primary
Health Care. Franklin, WV: Future Generations.
http://www.future.org/publications/memorandum-findings-and-recommendations-perus-
national-system-community-co-managed-prim

Meloni, A (2007) Personal communication.

Mercer, MA (1987) ´Social Class Determinants of Growth Stunting in the Peruvian Sierra,´

Doctor of Public Health Thesis, The Johns Hopkins University School of Hygiene and
Public Health, Baltimore, Maryland.

Ministry of Health (1992) ´National Inventory of Health Infrastructure,´ Lima: Ministry of

Health.

O`Brien, E & Barnachea, M (1996) ´Informe Final: Evaluación del Programa de Focalización de

Gasto Social Básico: Sub Programa Administración Compartida,´ Lima: Ministry of
Health and Program for Analysis, Planning, and Implementation (PAPI)-USAID.

Ortiz de Zevallos G, Eyzaguirre H, Palacios RM, & Pollarolo P (1999) ´The Political Economy

of Institutional Reforms in Peru: the cases of education, health, and pensions.´ Lima:
Instituto Apoyo, Inter-American Development Bank. Working Document R-348.

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http://www.future.org/publications/memorandum-findings-and-recommendations-perus-national-system-community-co-managed-prim

Puntriano, J (2002) ´Análisis del Modelo de Co-Gestión Vigente: Análisis critica de la
normatividad nacional que regula o incide en el diseño y el funcionamiento del Modelo de
Cogestión CLAS.´ Lima: Ministry of Health

Salazar F, Carrasco V, Arroyo J, & Mendoza W (no date) ´El Programa de Salud Básica para

Todos y los Comités Locales de Administración de Salud: Dos Modelos de Reforma
para la Red Periférica. Peru 1994-1996,´ Investigaciones en Salud Pública. Lima:
Universidad Peruana Cayetano Heredia.

Sen, Amartya (2000) Development as Freedom. New York: Alfred A. Knopf.

Sobrevilla A (2002) ´Proposals for Improvement of Co-management of Public Health Services,´

Lima: Ministry of Health.

Taylor, C (1996) ´Evaluation and Report on Strengthening a National Co-Managed System of

Primary Health: Report to the Honorable Minister of Health,´ Lima: Pan American
Health Organization. http://www.future.org/publications/evaluation-and-report-
strengthening-national-system-community-co-managed-primary-health

Taylor-Ide, D & Taylor, CE (1995) Community-Based Sustainable Human Development: A

Proposal for Going to Scale with Self-Reliant Social Development, New York:
UNICEF Environment Section. http://www.future.org/publications/community-based-
sustainable-human-development

Taylor-Ide, D & Taylor, CE (2002) Just and Lasting Change: When Communities Own Their

Future, Baltimore: The Johns Hopkins University Press in collaboration with Future
Generations. http://www.future.org/publications/just-and-lasting-change

Valdivia, M (2002) ´Public health infrastructure and equity in the utilization of outpatient health
care services in Peru,´ Health Policy and Planning 17(Supple): 12-19.

Velarde, N & Sobrevilla, A (2002) ´Proposals for Adjustments to the CLAS Model and for the

Development of Other Experiences of Co-Management in Health,´ Lima: Ministry of
Health.

Vera, JC (1994) ´Modernization and opening of health services to participation of the private

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Vera, JC (2007) Personal communication.

Vicuña, M, Ampuero S, & Murillo J (2000) ´Analysis of Effective Demand and Its Relation to

the Management Model in Primary Health Care Facilities: Evaluation of the Shared
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Future Generations/Peru and Ministry of Health of Peru

http://www.future.org/publications/evaluation-and-report-strengthening-national-system-community-co-managed-primary-health

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Wallerstein, N (2006) What is the evidence of effectiveness of empowerment to improve health?
Copenhagen, WHO Regional Office for Europe (Health Evidence Network Report;
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Webb, R & Valencia, S (2006) ´Human resources in health and public education in Peru,´ In:

Cotlear, Daniel (Ed.) A New Social Contract for Peru: How to achieve a better
educated, healthier, and more solidary country? Washington, D.C.: World Bank.

World Bank (2001) Report on the World Development 2000.

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
24

Graph 1: Proportional distribution of 6,871 Ministry of Health primary health
care facilities by level of categorization and whether CLAS or non-CLAS: 2006

3.3
1.4

3.6 4.3
5.4

37.2

4.4
1.3

9.9 8.6 7.6

0
5

10
15
20
25

Rural Health Post –
no doctor (I-1)

Rural Health Post –
with doctor (I-2)

Rural Health Cente

– full staff

(I-3)

Urban Health Post –
no doctor (I-1)

Urban Health Post –
with doctor (I-2)

Urban Health
Center – full staff

(I-3)

%
o

f a
ll

pr
im

ar
y

ca
re

fa
ci

lit
ie

CLAS Non-

CLAS

Source: Prepared by author. Data from 2006 National Inventory of Infrastructure, Equipment, and Human
Resources. Lima, Peru: Ministry of Health). (Category I-3 includes I-3 and I-4)

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
25

Graph 2: Percent of patients in three lowest income quintiles with full or partial
exoneration of fees, by type of rural facility

87.8

697

1.5

56.555.1

38.8

CLAS

Non-CLAS

Type of Rural Health Facility

%
w

ith
fu

ll
or

p
ar

tia
l e

xo
ne

ra
tio

n
of

fe
es

Quintile I
Quintile II
Quintile III

Source: L. Altobelli (1998) Health reform, community participation, and social inclusion: the Shared Administration Program. Lima, Peru:
UNICEF. (Data used from the 1997 National Living Standards Survey in Peru)

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
26

Graph 3: Mean number of physicians per facility by whether CLAS or non-CLAS,
rural or urban: 2006

Health Pos ts , 0.41
Health Pos ts , 0.16

Health Pos ts , 0.63 Health Pos ts , 0.74

Health Centers , 2.63
Health Centers , 2.8

Health Centers , 2.4

Health Centers , 3.62

0.5

1
1.5
2

2.5

3.5

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

Area and Type of Health Facility

M
ea

n
nu

m
be

r o
f

oc
to

rs
p

er
h

ea
lth

fa
ci

lit
y

Source: Prepared by author. Data from 2006 National Inventory of Infrastructure, Equipment, and Human Resources. Lima, Peru:
Ministry of Health).

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
27

2.32

1.32

2.94

1.73

0
0.5
1
1.5
2
2.5
3
M
ea
n
nu
m
be

r
of

v
is

its
p

er
c

hi
ld

p
er

y
ea

Rural CLAS Rural Non-CLAS Urban CLAS Urban Non-CLAS
Jurisdiction and Area of Residence

Graph 4: Average number of annual clinic visits per child by residence in a jurisdiction of CLAS
or non-CLAS, rural or urban: Cusco, Huánuco, La Libertad Regions 2002

Source: Altobelli, L and A. Sovero (2004) Cost-Efficiency of CLAS Associations. Lima: Future Generations with support from DFID.
www.future.org (Data based on Integrated Health Insurance (SIS) reimbursements for Plan A – Children 0-4 Years of Age 2002)

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
28

Home

Graph 5: Percent of rural mothers seeking health care for a
sick child under age five, by residence in a jurisdiction of

CLAS or non-CLAS: 1996-

2000

68.1

41.7

55.7

64.1

36.2

51.1

20
40

Child with
diarrhea treated

with ORT

Child with
diarrhea taken to
formal

provider

Child with ARI
taken to formal

provider
%
o

c
hi

ld
re

n
w

ith
c

on
di

tio
n

CLAS
Non-CLAS

Source: Altobelli, L (2006) Comparative Analysis of Health Impact and Health Services Utilization in CLAS and Non-CLAS Primary Health
Care Services in Peru. Lima: Future Generations www.future.org (Data source: Peru Demographic and Health Survey IV, 2000)

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
29

Home

Significant
Difference

p< .01

N=306 N=397 N=1315 N=1584 N=427 N=682

Graph 6: Percent of rural children under age five with chronic malnutrition by education
of mother and by res idence in a juris diction of CLAS or non-CLAS: 1996-2000

54.6

40.8

24.6

54.4

25.2

20
30
40

No Educat ion Any P rimary Any Secondary or More

MAT ERNAL EDUCAT ION

%
r

ur
al

c
hi
ld
re

n
ch

ro
ni

ca
lly

m
al

no
ur

is
he

d
CLAS
Non-CLAS

W
F

HO Case Study on CLAS in Peru
uture Generations/Peru and Ministry of Health of Peru

Home

Graph 7: Growth of CLAS and Number of Primary Health Care
Facilities Administered by CLAS from 1994 to present.

500

1000

1500

2000

2500

94 95 96 97 98 99 00 01 02 03 04 05 06 07

CLAS CLAS Facilities

Source: Ministry of Health of Peru, 2007.

WHO Case Study on CLAS in Peru
Future Generations/Peru and Ministry of Health of Peru
31

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