Initiated with advice from Future Generations staff in 1994, Peru's Shared Administration Program transfers the management of more than 2,100 primary health care facilities directly to private, non-profit community associations known as CLAS (Local Community Associations for the Administration of Health).
With oversight from the Ministry of Health, CLAS associations create work plans and manage the health center budget. With control over their own budgets, they reinvest funds in infrastructure, health personnel, and community outreach.
This shared local governance improves the quality of health care and seeks to extend coverage to the poor and unreached.
For some time now I am familiar with the work that Future Generations is developing in Las Moras, it interested me because it makes the community participate in solving its own problems, first raising the people’s consciousness about it own needs and from that must be born the ideas to solve them and the idea that they can develop themselves.
Engineer Juan Deza Falcon Manager of Community Services of the Provincial Municipality of Huánuco On the edge of the Amazon in the Huánuco Region are some of Peru’s poorest districts. The residents of Umari live on an average daily income of $6 USD a day. Families depend largely on potato farming, leaving children and mothers especially vulnerable to malnutrition and poor health.
But, communities like Umari have some successes and local resources from which to build a better future.
The people of Umari petitioned the Ministry of Health to take ownership of their health center. Through the national Shared Administration Program, Umari formed a Local Health Administration Association (CLAS) to maintain the budget and operations of their health clinic.
This clinic, located in the town of Umari, serves 27 distant rural villages of approximately 16,000 people.
Previously, pregnant mothers and the ill traveled to the clinic only in the most dire circumstances. For some, it was a one-day journey by foot.
With support from Future Generations, the health center started an outreach program to train and supervise village women as community health agents.
Each community health agent (CHA) is elected and officially designated by the community, and is assigned 30-40 families (in towns and villages) or 10-20 families (in rural areas). CHAs learn to:
Conduct community surveys and make maps of their villages identifying families at risk (including those with pregnant women and young children)
Make monthly home visits to at-risk households to observe for danger signs using a check list
Make referrals and promote better linkages with the health clinic
Promote home-based health and sanitation practices, such as hand washing, food storage and preparation, and nutrition,Work with community leaders, mother's clubs, and other groups to develop community work plans that address priority needs, such as: garbage clean-up, reforestation, activities for youth, and health counseling.
As pregnant mothers near their time of delivery, for instance, the CHA encourages them to travel to the maternity waiting home adjacent to the Umari Health Center that is funded through the CLAS budget to house and feed mothers so they can remain under care until after their delivery.
The Umari health center works with Future Generations to monitor progress through household surveys that provide data on such indicators as child nutritional status, immunization rates, and key health practices.
With growing evidence of improved home-based health behaviors, in 2007, the Umari primary care clinic received recognition as a Best Experience in Maternal and Infant Nutrition from the Ministry of Health.
"Umari has a big advantage," says Alex Vargas, Huánuco Regional Coordinator for Future Generations Peru.
"For the last three years, staff and community members from Umari have learned new ideas and better practices through many hands-on site visits to the Las Moras community health clinic.”
With support from Future Generations Peru beginning in 2002, the CLAS-administered Las Moras Health Center was transformed into a regional innovation and learning center.
Impact evaluations from Las Moras show a decrease in childhood chronic malnutrition from 48% to 18% and a 21% increase in immunization rates.
And 21 community groups have started self-help programs to reduce gang violence among youth and leverage municipal funding for garbage collection, water systems, and electricity.
“Las Moras was the first pilot program to build local capacity and improve partnerships for integrated health and community change in Huánuco. Umari learned from Las Moras and will help to improve learning and services in more communities,” says Alex Vargas.
This learning has also spread internationally. Students from the Future Generations Master’s Degree program, from more than 22 countries worldwide, study the Las Moras and Umari experience for two weeks. In 2008, a team of three government health officials from India traveled to both health facillities as part of a Future Generations-sponsored study tour.
The level of sustained community momentum and enthusiasm in Umari is remarkable because it has been accomplished with such a minimal outside presence and monetary investment by Future Generations.
"The real value in our approach," says Dr.Laura Altobelli, Peru Country Director for Future Generations, "is linking government support services (local, regional, and national), with outside technical support directly with communities.
And at the same time, building the capacity among communities to take leadership in achieving change for themselves."
Dr. Altobelli's sentiments are echoed by the many local people participating in this process to improve community health and well-being, as exemplified by testimonials:
They called us to a meeting and they said to us that we had been selected to work with Future Generations Peru, but that they did not come to bring money but to develop the capabilities within us the people of Las Moras. That idea stuck with me, because few projects want to work in the development of the people, they only come to reach their own goals and then they go away.Mr. German Chávez President CLAS Las Moras
It is not easy to involve health personnel. It has cost us to make changes, people who never worked in the community, people who worked in hospitals, come here [to Las Moras]. Going to work with the community for them is a little shocking, but now they are enthusiastic about the process, in this work, for that reason it is necessary to continue training, to be able to transmit to the community, principally for the work of teaching the community, community work.Nurse of CLAS Las Moras
We know what happens in the health of our community, we walk, we hold meetings, we are interested in them, we give them advice, and we accompany them when they need to go to the health post. ….We are now holding demonstrations [i.e. food preparation demonstrations] because when one speaks and speaks, the mothers listen to us but they do not see/understand and sometimes they are distracted. Seeing and doing, they are going to understand better, they get enthusiastic and they are going to do it in their own homes.Community Health Agent Heroes de Jactay Sector of Las Moras