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

330 Pages·2006·2.213 MB·English

by  Daniel Cotlear

35037
A W O R L D B A N K C O U N T R Y S T U D Y
A New Social Contract
for Peru
An Agenda for Improving Education,
Health Care, and the Social Safety Net
Edited by Daniel Cotlear
THE WORLD BANK

A W O R L D B A N K C O U N T R Y S T U D Y
A New Social Contract for Peru
An Agenda for Improving Education,
Health Care, and the Social Safety Net
Edited by Daniel Cotlear
THE WORLD BANK
Washington, D.C.
Copyright © 2006
The International Bank for Reconstruction and Development/The World Bank
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Manufactured in the United States ofAmerica
First Printing: January 2006
printed on recycled paper
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ISBN-10:0-8213-6567-3 ISBN-13:978-0-8213-6567-0
eISBN:0-8213-6568-1
ISSN: 0253-2123 DOI: 10.1596/978-0-8213-6567-0
Cover photos by RECURSO team,The World Bank.
Library ofCongress Cataloging-in-Publication Data has been requested.
Contents
Foreword xi
Acknowledgments xiii
Author Biographies xvii
Acronyms and Abbreviations xix
1. Improving Education,Health Care,and Social Assistance for the Poor 1
Daniel Cotlear
Executive Summary and Introduction 1
Coverage,Outcomes,and Equity 4
Public Expenditures in Education,Health,and Social Assistance 9
Teachers and Health Workers:A Low-level Equilibrium 18
The Accountability Framework 20
Attempts to Break the Low-level Equilibrium 24
The Need for Standards ofService 35
Conclusions and Recommendations 37
2. Public Expenditure in the Social Sectors 43
José R.López-Cálix
Main Policy Recommendations 45
Main Diagnostics 47
Review ofResearch-based Peruvian Literature 61
Policy Recommendations 69
3. Education Sector:Standards,Accountability,and Support 71
Luis Crouch
Main Policy Recommendations 71
The Accountability Triangle Approach in Education 73
Issues and Analysis 75
Good Sets ofRecommendations and Research-based Diagnostics
Already Exist 94
Recommendations in Greater Detail 101
iii
iv Contents
4. Pro-poor Policies in the Peruvian Public Health Sector 107
Betty Alvarado Pérez and Rony Lenz
Summary ofRecommendations 108
Focus ofthe Accountability Triangle 110
Principal Findings 112
Innovations and Challenges in the Management and Financing
ofHealth Care 123
Review ofthe Peruvian Literature on the Health System 144
Recommendations 144
Annex—Services Covered by SIS 152
5. The Social Safety Net 153
Cornelia Mihaela Tesliuc
Main Policy Recommendations 154
The Accountability Triangle Approach 156
Key Issues ofthe Social Safety Net Sector 159
Review ofResearch-based Peruvian Literature 179
Policy Recommendations 186
6. Human Resources in Public Health and Education in Peru 191
Richard Webb and Sofía Valencia
Conclusions and Policy Implications 192
Background 197
Low-level Equilibrium 201
Anti-poor Bias 238
7. Voice in the Accountability ofSocial Policy 245
William Reuben and Leah Belsky
Main Policy Recommendations 245
Conceptual Framework:The Accountability Triangle Approach 247
Issues and Analysis 251
Many Diagnostics and Recommendations Already Exist in Peru 284
Specific Recommendations to Improve Voice in the Social Sectors 284
References 291
Contents v
LISTOFTABLES
1.1. Fiscal Priority ofSpending on Education,Health,
and Social Assistance in Latin America 12
2.1. Budget for Protected Social Programs Non-salary Current
and Capital Budget 55
2.2. Absolute Incidence ofFood Program Expenditure,2003 60
2.3. Relative Incidence ofHealth Spending by Quintile,2003 60
2.4. Social Program Leakages,2001 and 2003 61
2.5. Summary ofKey Policy Recommendations on Compact-related
Matters in the Peruvian Literature 62
2.6. Main National Findings on Previous Research Related
to the Compact in Peru 63
2.7. Peru:Tasks Required to Strengthen the Compact 66
3.1. Official and Fe y Alegría Curricular Guidelines 83
3.2. Tasks Required to Implement Proper EIB in Peru 90
3.3. Summary ofPolicy Recommendations in Peruvian Literature 95
3.4. Factors Associated with Improved Learning Results in Peru 98
4.1. International Comparisons ofHealth Expenditure,2000 113
4.2. Prevalence ofHospitalization According to Quintile in Peru,2003 115
4.3. Causes ofDeath in Peru,1996–2000 117
4.4. Selected Basic Indicators ofHealth for Peru and Latin America 118
4.5. Child Mortality in Peru According to Quintile,1996 and 2000 120
4.6. Indicators ofMaternal Coverage 2004 122
4.7. Budget Execution ofMINSA and PAAG 126
4.8. Location ofPrimary Health Care Facilities According to District
and Urban Poverty Levels,2004 127
4.9. Comparative Indicators ofProductivity:Average Number ofVisits
per Day by Physicians,Nurses,and Skilled Birth Attendants,2004 129
4.10. Comparative Indicators ofPerformance Using the SIS According
to the Plan and Health Care Attention for Children Under 5 130
4.11. Affiliated SIS Users per Department,2003 135
4.12. SIS Coverage by Plans According to Spending Quintiles,2003 136
4.13. Comparison ofAffiliations,Number ofConsultations,and Number
ofConsultations per Person in SIS between 2003 and 2004 137
4.14. Main Findings on Health Care in Peruvian Literature 145
5.1. Accountability Mechanisms for SSN Programs in Peru 158
5.2. Social Protection Spending,2003 160
5.3. Circumstances Aggravating Poverty and Leading Indicators
ofDeprivation,by Main Age Group and Quintile 164
vi Contents
5.4. Summary ofPolicy Recommendations in Peruvian Literature 180
5.5. Summary ofImpact Evaluations ofSSN Programs in Peru 182
6.1. Education:Geographic Distribution ofTeachers 199
6.2. Geographic Distribution ofPublic Health Professionals 200
6.3. Indexes ofFiscal Capacity and Social Service Coverage 204
6.4. Estimates ofPrevalence ofMultiple Occupations Held by Teachers 214
6.5. Government Teachers’Salary as Percent ofTotal Household Spending
According to Degree ofDependence on Official Salary 215
6.6. Government Health Professionals’Salary as Percent ofTotal Household
Spending,According to Degree ofDependence on Official Salary 215
6.7. Average Net Monthly Salaries and Household Spending,in New Soles 216
6.8. Self-financing as Percent ofMINSA Total Income 222
6.9. Share ofPrivate Schools in Total Enrollment 226
6.10. Physicians in Private Practice as Percent Total 227
6.11. Education: Evolution ofthe number ofTeachers with and without
a Pedagogical Degree (PD) 229
6.12. Health:Components ofMonthly Salaries ofDoctors,2004 231
6.13. Health:Monthly Salary Supplements,by Region,2004 232
6.14. Teaching Career Stages and Motivations 236
6.15. Physician Career Stages and Motivations 236
7.1. Primary and Secondary Sources 250
7.2. Fieldwork Sites 250
7.3. Comparison ofState Structure in 1979,Under Fujimori,
and in 2005 256
7.4. Historical Overview ofParticipation in Governance
and Service Delivery 258
7.5. New Participatory Spaces for Negotiation and Consensus
Building Linked to the Social Programs 259
7.6. Key Mechanisms for Communication ofNational Voice
in the Health Sector 263
7.7. Activity ofCCLs 271
7.8. Incentives to Participate in CCLs 274
7.9. Constitution ofMesas,by Year,at each Administrative Level 275
7.10. Composition ofCoordinators ofthe Mesa,December 2003 275
7.11. Functions ofthe Mesa,at Selected Fieldwork Sites 276
7.12. Members ofCivil Society Organizations Participating
in Regional and Local Mesas 277
7.13. Duration ofParticipatory Budget Cycle 278
Contents vii
7.14. PB as a Percent ofthe Provincial and Local Budget 282
7.15. Summary ofPolicy Recommendations in Peruvian Literature 285
7.16. Recommendations to Improve Inclusiveness and Effectiveness
of Voice 288
LISTOFFIGURES
1.1. Gross Enrollment Rates in Peru and Latin America,1970–2004 5
1.2. Selected Health Intervention Trends in Peru
and Latin America,1990–2004 7
1.3. Under-5 Mortality in Peru and Latin America,1970–2004 7
1.4. Infant Mortality Inequality in LAC 8
1.5. Stunting Rate in Peru and Latin America,1975–2002 9
1.6. Public Social Spending in Education,Health,and Social Assistance
in LAC,as Percentage ofGDP 10
1.7. Public Education,Health and Social Assistance Spending
in Peru as Percentage ofGDP,1970–2004 13
1.8. Concentration Coefficients ofthe Social Programs,2004 15
1.9. Concentration Coefficients ofthe Social Programs,2004 16
1.10. Key Relationships ofPower:The Accountability Triangle 23
1.11. Shocking the System through Partial Reforms 25
2.1. Evolution ofPublic Teachers’Real Salaries,1990–2004 50
2.2. Budgetary Allocation and the Fiscal Space,2002 and 2005 50
2.3. SNP:Contributions Received and Pensions Paid 52
2.4. Despite Fiscal Tightening and Lower Public Investment…… Priority
Social Spending has Remained Constant 54
2.5. Net Primary Enrollment and the Efficiency Frontier 56
2.6. DPT Immunization and the Efficiency Frontier 57
2.7. Absolute Incidence ofPublic Spending on Primary Education 58
2.8. Absolute Incidence ofPublic Spending on Secondary Education 58
2.9. Absolute Incidence ofPublic Spending on Tertiary Education 59
3.1. The Accountability Triangle 74
3.2. Real and Predicted PISA Scores 76
3.3. Results Variability and Socioeconomic Status 77
4.1. The Accountability Triangle Applied in the Health Sector 111
4.2. Access to Health Care 114
4.3. Hospitalization in MINSA Hospitals by Quintile According
to Residency,2003 115
4.4. Infant Mortality Rate in Peru and Latin America 119
viii Contents
4.5. Infant Mortality Rate in Peru,by Department,2000 119
4.6. Evolution ofthe Coverage ofthe Main Vaccines 122
4.7. Per Capita SIS Expenditure by Departmental Poverty,2003 135
4.8. Insurance Affiliation According to Quintile,2003 137
4.9. Recommendations for Accountability Processes in the Peruvian
Health Care Sector 148
5.1. Key Relationships ofPower in the Delivery ofSSN Programs 157
5.2. Focusing All SSN Spending toward Extreme Poor Could Reduce
Their Poverty Gap by a Maximum of40 Percent 167
5.3. After Rising Substantially in the 1990s,SSN Spending
Declined after 1999 168
5.4. Peru’s SSN Spending is Low by Regional Standards 168
5.5. Compared to Other LAC Countries,Peru’s SSN Programs
Have High Coverage,But are Not Generous 169
5.6. Except Vaso de Leche and Desayuno Escolar,All Other
SSN Programs are Small 170
5.7. Only Vaso de LecheCovers a Substantial Share ofits Target Group 172
5.8. Simulated Reduction in Extreme Poverty 173
5.9. Compared to Other Food Programs in LAC,Peru’s Programs
Exhibit Good Targeting Performance 174
5.10. Compared to Cash Transfers,the Targeting Performance
ofPeru’s Food-based Programs is Moderate 175
5.11. The Simulated Impact ofSSN Programs on Reducing
Poverty is Small 175
5.12. Cumulative Geographic Distribution ofSocial Spending,
District Level,2004 178
6.1. School Enrollment and Number ofTeachers 203
6.2. Education:Public Spending per Student,and Average
Teacher Remuneration 204
6.3. Trends in Total Public Spending per Capita and Social Service
Coverage,by Periods 205
6.4. Real Monthly Wage Trends for Teachers,Doctors,and Nurses 206
7.1. The Accountability Triangle 248
7.2. Political Regimes and Governance Solutions 249
7.3. Gross Capital Formation in Education and Health
in Peru,1968–1990 253
7.4. Social Expenditure by Programs 254
7.5. Beneficiaries by Social Programs 254
7.6. World Bank Institute Governance Indicators 257