A CLAS act? Community-based organizations, health service decentralization and primary care development in Peru

Abstract

In 1994 Peru embarked on a programme of health service reform, which combined primary care development and community participation through Local Committees for Health Administration (CLAS). They are responsible for carrying out local health needs assessments and identifying unmet health needs through regular household surveys. These enable them to determine local health provision and tailor services to local requirements. CLAS build on grassroots self-help circles that developed during the economic and political crises of the 1980s, and in which women have been prominent. However, they function under a 3 year contract with the Ministry of Health and within a framework of centrally determined guidelines and regulations. These reforms were implemented in the context of neo-liberal economic policies, which stressed financial deregulation and fiscal and monetary restraint, and were aimed at reducing foreign indebtedness and inflation. We evaluate the achievements of the CLAS and analyse the relationship between health and economic policy in Peru, with the aid of two contrasting models of the role of the state - 'agency' and 'stewardship'. We argue that Peru's experience holds valuable lessons for other countries seeking to foster community involvement. These include the need for community capacity building and partnership between community organizations and state (and other civil) agencies.

Comprehensive Primary Health Care in South America: contexts, achievements and policy implications

“…100 in Colombia in 1993 20,21,22 . Other selective primary health care models emerged because of the formation of specific programs or projects such as the Comités Locales de Administración de Salud in Peru 23 and cost-effective nutrition programs in Argentina 24 . Other elements identified as important to the shaping of primary health care definitions in South America during this period included model family and community medicine programs or policies 25,26,27 with an emphasis on the intercultural capacity of primary health care 15. Progressive health system reforms informed only 17% of the definitions of primary health care.…”

“…• Problems with primary health care financing include unreliable national sources of funding, lack of sustainability of programs tied to external donors or lenders, and corruption leading to the misuse of funds 17,23,50,68 .…”

International sources of learning for the organisation of primary care

“…There are over 800 of these Comunidades Locales de Administracion de Salud in Peru, and their performance and resources appear to outstrip centrally managed alternatives. 7,8 For the UK, the level of public and patient participation, in particular, is both an aspiration and an inspiration.…”

Improving Health in Ucayali, Peru: A Multisector and Multilevel Analysis

“…The rationale behind the establishment of the CLAS by the central government was that ÔÔresource allocation decisions would be improved if they were made jointly by those responsible for allocating budgets and the communities that were to benefit from themÕÕ (Iwami and Petchey, 2002, p. 248). The amount and coverage of CLAS has increased significantly; since the program's inception in 1993, the number of CLAS-operated health facilities has increased from 133 to 1242 (Iwami and Petchey, 2002). CLAS receive transfers from MINSA for the management of facilities and generate additional funding with revenues obtained from payments for health services.…”

“…CLAS receive transfers from MINSA for the management of facilities and generate additional funding with revenues obtained from payments for health services. The CLAS management committee consists of six members, three of whom are volunteers elected by the community, and the director of the local health center or health post (Iwami and Petchey, 2002). So far, in communities where CLAS have been established, improvements in health services and community participation have been reported relative to those where CLAS have not been formed.…”