A New Social Contract for Peru : An Agenda for Improving Education, Health Care, and the Social Safety Net

This book examines the issues of accountability in the delivery of public services. Each chapter of the book incorporates, in addition to technical, economic, and statistical analysis, an analysis of the institutional context for service delivery. A common theme that cuts across this book is the issue of accountability as developed by the World Bank in its 'World Development Report: Making Services Work for Poor People' (2004). The main conclusion of the book is that, while Peru has made significant progress in both education and health care, there remain significant challenges to achieving greater equity and better quality of services, particularly for the poor. The book finds that Peru has achieved high levels of coverage in all levels of education and in some programs of basic health care and of social assistance. Still, the average quality of most of these programs is low, and health and education outcomes are extremely inequitable. The book recommends three types of interventions: a. quality standards and quantitative goals need to be set, b. accountability chains need to be established so that providers take responsibility for their services; and c. investments are needed to create and sustain the capacity to reach these goals. Contents Foreword Acknowledgments Author Biographies Acronyms and Abbreviations 1. Improving Education, Health Care, and Social Assistance for the Poor Executive Summary and Introduction Coverage, Outcomes, and Equity Public Expenditures in Education, Health, and Social Assistance Teachers and Health Workers: A Low-level Equilibrium The Accountability Framework Attempts to Break the Low-level Equilibrium The Need for Standards of Service Conclusions and Recommendations 2. Public Expenditure in the Social Sectors Main Policy Recommendations Main Diagnostics Review of Research-based Peruvian Literature Policy Recommendations 3. Education Sector: Standards, Accountability, and Support Main Policy Recommendations The Accountability Triangle Approach in Education Issues and Analysis Good Sets of Recommendations and Research-based Diagnostics Already Exist Recommendations in Greater Detail 4. Pro-poor Policies in the Peruvian Public Health Sector Summary of Recommendations Focus of the Accountability Triangle Principal Findings Innovations and Challenges in the Management and Financing of Health Care Review of the Peruvian Literature on the Health System Recommendations Annex—Services Covered by SIS 5. The Social Safety Net Main Policy Recommendations The Accountability Triangle Approach Key Issues of the Social Safety Net Sector Review of Research-based Peruvian Literature Policy Recommendations 6. Human Resources in Public Health and Education in Peru Conclusions and Policy Implications Background Low-level Equilibrium Anti-poor Bias 7. Voice in the Accountability of Social Policy Main Policy Recommendations Conceptual Framework: The Accountability Triangle Approach Issues and Analysis Many Diagnostics and Recommendations Already Exist in Peru Specific Recommendations to Improve Voice in the Social Sectors References LIST OF TABLES 1.1. Fiscal Priority of Spending on Education, Health, and Social Assistance in Latin America 2.1. Budget for Protected Social Programs Non-salary Current and Capital Budget 2.2. Absolute Incidence of Food Program Expenditure, 2003 2.3. Relative Incidence of Health Spending by Quintile, 2003 2.4. Social Program Leakages, 2001 and 2003 2.5. Summary of Key Policy Recommendations on Compact-related Matters in the Peruvian Literature 2.6. Main National Findings on Previous Research Related to the Compact in Peru 2.7. Peru: Tasks Required to Strengthen the Compact 3.1.Official and Fe y Alegría Curricular Guidelines 3.2.Tasks Required to Implement Proper EIB in Peru 3.3.Summary of Policy Recommendations in Peruvian Literature 3.4.Factors Associated with Improved Learning Results in Peru 4.1. International Comparisons of Health Expenditure, 2000 4.2. Prevalence of Hospitalization According to Quintile in Peru, 2003 4.3. Causes of Death in Peru, 1996–2000 4.4. Selected Basic Indicators of Health for Peru and Latin America 4.5. Child Mortality in Peru According to Quintile, 1996 and 2000 4.6. Indicators of Maternal Coverage 2004 4.7. Budget Execution of MINSA and PAAG 4.8. Location of Primary Health Care Facilities According to District and Urban Poverty Levels, 2004 4.9. Comparative Indicators of Productivity: Average Number of Visits per Day by Physicians, Nurses, and Skilled Birth Attend 4.10. Comparative Indicators of Performance Using the SIS According to the Plan and Health Care Attention for Children Under 4.11. Affiliated SIS Users per Department, 2003 4.12. SIS Coverage by Plans According to Spending Quintiles, 2003 4.13. Comparison of Af filiations, Number of Consultations, and Number of Consultations per Person in SIS between 2003 and 20 4.14. Main Findings on Health Care in Peruvian Literature 5.1. Accountability Mechanisms for SSN Programs in Peru 5.2. Social Protection Spending, 2003 5.3. Circumstances Aggravating Poverty and Leading Indicators of Deprivation, by Main Age Group and Quintile 5.4. Summary of Policy Recommendations in Peruvian Literature 5.5. Summary of Impact Evaluations of SSN Programs in Peru 6.1. Education: Geographic Distribution of Teachers 6.2. Geographic Distribution of Public Health Professionals 6.3. Indexes of Fiscal Capacity and Social Service Coverage 6.4. Estimates of Prevalence of Multiple Occupations Held by Teachers 6.5. Government Teachers’ Salary as Percent of Total Household Spending According to Degree of Dependence on Official Salary 6.6. Government Health Professionals’ Salary as Percent of Total Household Spending, According to Degree of Dependence on Off 6.7. Average Net Monthly Salaries and Household Spending, in New Soles 6.8. Self-financing as Percent of MINSA Total Income 6.9. Share of Private Schools in Total Enrollment 6.10. Physicians in Private Practice as Percent Total 6.11. Education: Evolution of the number of Teachers with and without a Pedagogical Degree (PD) 6.12. Health: Components of Monthly Salaries of Doctors, 2004 6.13. Health: Monthly Salary Supplements, by Region, 2004 6.14. Teaching Career Stages and Motivations 6.15. Physician Career Stages and Motivations 7.1. Primary and Secondary Sources 7.2. Fieldwork Sites 7.3. Comparison of State Structure in 1979, Under Fujimori, and in 2005 7.4. Historical Overview of Participation in Governance and Service Delivery 7.5. New Participatory Spaces for Negotiation and Consensus Building Linked to the Social Programs 7.6. Key Mechanisms for Communication of National Voice in the Health Sector 7.7. Activity of CCLs 7.8. Incentives to Participate in CCLs 7.9. Constitution of Mesas, by Year, at each Administrative Level 7.10. Composition of Coordinators of the Mesa, December 2003 7.11. Functions of the Mesa, at Selected Fieldwork Sites 7.12. Members of Civil Society Organizations Participating in Regional and Local Mesas 7.13. Duration of Participatory Budget Cycle 7.14. PB as a Percent of the Provincial and Local Budget 7.15. Summary of Policy Recommendations in Peruvian Literature 7.16. Recommendations to Improve Inclusiveness and Effectiveness of Voice LIST OF FIGURES 1.1. Gross Enrollment Rates in Peru and Latin America, 1970–2004 1.2. Selected Health Intervention Trends in Peru and Latin America, 1990–2004 1.3. Under-5 Mortality in Peru and Latin America, 1970–2004 1.4. Infant Mortality Inequality in LAC 1.5. Stunting Rate in Peru and Latin America,1975–2002 1.6. Public Social Spending in Education, Health, and Social Assistance in LAC, as Percentage of GDP 1.7. Public Education, Health and Social Assistance Spending in Peru as Percentage of GDP, 1970–2004 1.8. Concentration Coefficients of the Social Programs, 2004 1.9. Concentration Coefficients of the Social Programs, 2004 1.10. Key Relationships of Power: The Accountability Triangle 1.11. Shocking the System through Partial Reforms 2.1. Evolution of Public Teachers’ Real Salaries,1990–2004 2.2. Budgetary Allocation and the Fiscal Space, 2002 and 2005 2.3. SNP: Contributions Received and Pensions Paid 2.4. Despite Fiscal Tightening and Lower Public Investment ...... Priority Social Spending has Remained Constant 2.5. Net Primary Enrollment and the Efficiency Frontier 2.6. DPT Immunization and the Efficiency Frontier 2.7. Absolute Incidence of Public Spending on Primary Education 2.8. Absolute Incidence of Public Spending on Secondary Education 2.9. Absolute Incidence of Public Spending on Tertiary Education 3.1. The Accountability Triangle 3.2. Real and Predicted PISA Scores 3.3. Results Variability and Socioeconomic Status 4.1. The Accountability Triangle Applied in the Health Sector 4.2. Access to Health Care 4.3. Hospitalization in MINSA Hospitals by Quintile According to Residency, 2003 4.4. Infant Mortality Rate in Peru and Latin America 4.5. Infant Mortality Rate in Peru, by Department, 2000 4.6. Evolution of the Coverage of the Main Vaccines 4.7. Per Capita SIS Expenditure by Departmental Poverty, 2003 4.8. Insurance Affiliation According to Quintile, 2003 4.9. Recommendations for Accountability Processes in the Peruvian Health Care Sector 5.1. Key Relationships of Power in the Delivery of SSN Programs 5.2. Focusing All SSN Spending toward Extreme Poor Could Reduce Their Poverty Gap by a Maximum of 40 Percent 5.3. After Rising Substantially in the 1990s, SSN Spending Declined after 1999 5.4. Peru’s SSN Spending is Low by Regional Standards 5.5. Compared to Other LAC Countries, Peru’s SSN Programs Have High Coverage, But are Not Generous 5.6. Except Vaso de Leche and Desayuno Escolar, All Other SSN Programs are Small 5.7. Only Vaso de Leche Covers a Substantial Share of its Target Group 5.8. Simulated Reduction in Extreme Poverty 5.9. Compared to Other Food Programs in LAC, Peru’s Programs Exhibit Good Targeting Performance 5.10. Compared to Cash Transfers, the Targeting Performance of Peru’s Food-based Programs is Moderate 5.11. The Simulated Impact of SSN Programs on Reducing Poverty is Small 5.12. Cumulative Geographic Distribution of Social Spending, District Level, 2004 6.1. School Enrollment and Number of Teachers 6.2. Education:Public Spending per Student, and Average Teacher Remuneration 6.3. Trends in Total Public Spending per Capita and Social Service Coverage, by Periods 6.4. Real Monthly Wage Trends for Teachers, Doctors, and Nurses 7.1. The Accountability Triangle 7.2. Political Regimes and Governance Solutions 7.3. Gross Capital Formation in Education and Health in Peru, 1968–1990 7.4. Social Expenditure by Programs 7.5. Beneficiaries by Social Programs 7.6. World Bank Institute Governance Indicators 7.7. Composition of CCRs 7.8. Civil Society Representation in CCL 7.9. Urban/Rural Participation in CCLs 7.10. Participation by Gender in CCLs 7.11. Diversity of Composition in Mesas 7.12. Household Participation in MCLCP per Quintile 7.13. Composition of Participatory Budgeting Workshops LIST OF BOXES 1.1. The Low-level Equilibrium in Education 4.1. Summary of the Status and Tendencies of Communicable Diseases in Peru 4.2. Adjustments after Personal Nombramientos in the CLAS 4.3. The Separation of Health Functions Increases Accountability 5.1. Juntos :A Conditional Cash Transfer—Cost and Potential Impact on Poverty 5.2. How Peru Achieves Good Targeting Performance This book identifies the achievements and challenges of social policy in Peru. Its objective is to provide the new presidential administration of Peru with a diagnostic of the main problems that need to be overcome to improve education, health care, and anti-poverty programs, and with recommendations on how to overcome these problems. The diagnostic uses international comparisons that put in context the achievements in coverage, quality, and equity, and presents an analysis of the evolution and distribution of public expenditures and of the service delivery institutions. In recent decades, there have been several attempts to solve some of the problems identified in this study through the introduction of reforms; the analysis of the success and limitations of these reforms is used to obtain lessons and to make recommendations. The analysis of each sector uses a combination of quantitative data from surveys and administrative information systems and qualitative information from hundreds of interviews with parents, children, teachers, nurses, doctors, and municipal, regional, and ministerial authorities in different regions of the country Daniel Cotlear Daniel Cotlear -- José R. López-Cálix Daniel Cotlear -- José R. López-Cálix -- Luis Crouch Daniel Cotlear -- José R. López-Cálix -- Luis Crouch -- Betty Alvarado Pérez and Rony Lenz Daniel Cotlear -- José R. López-Cálix -- Luis Crouch -- Betty Alvarado Pérez and Rony Lenz -- Cornelia Mihaela Tesliuc Daniel Cotlear -- José R. López-Cálix -- Luis Crouch -- Betty Alvarado Pérez and Rony Lenz -- Cornelia Mihaela Tesliuc -- Richard Webb and Sofia Valencia Daniel Cotlear-- José R. López-Cálix-- Luis Crouch-- Betty Alvarado Pérez and Rony Lenz-- Cornelia Mihaela Tesliuc-- Richard Webb and Sofia Valencia-- William Reuben and Leah Belsky. "Using the accountability framework developed by the World Development Report 2004: Making Services Work for Poor People, this book analyzes the low-level equilibrium and the numerous reforms attempted in recent decades in Peru, and, based on this analysis, proposes interventions that would facilitate the creation of a new social contract for Peru."--Jacket