Document of
The World Bank
Report No: ICR00003691
IMPLEMENTATION COMPLETION AND RESULTS REPORT
(IBRD-76430)
ON A
LOAN
IN THE AMOUNT OF US$15.0 MILLION
TO THE
REPUBLIC OF PERU
FOR A
SECOND PHASE OF THE HEALTH REFORM PROGRAM
June 30, 2016
Health, Nutrition and Population
Bolivia, Ecuador, Peru and Venezuela Country Management Unit
Latin America and the Caribbean Region
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CURRENCY EQUIVALENTS
(Exchange Rate Effective December 31, 2015)
Currency Unit = Peruvian Nuevo Sol
PEN 300.35 = US$ 1.00
US$ 1.00 = PEN 3.33
FISCAL YEAR
January 1 – December 31
ABBREVIATIONS AND ACRONYMS
APL Adaptable Program Loan
AUS Aseguramiento Universal en Salud –
Universal Health Insurance
CPS Country Partnership Strategy
CRED Control de Crecimiento y Desarrollo
CRVS Civil Registration and Vital Statistics
DIA Derecho a la Identidad y
Aseguramiento
DIRESA Dirección Regional de Salud
EA Environmental Assessment
EDA Extreme Diarrhea
ENDES Encuesta Demográfica y de Salud
Familiar
EPPES Estrategia de Promoción de Práctica
y Entornos Saludables
FS Feasibility Study
GOP Government of Peru
IADB Inter-American Development Bank
ICR Implementation Completion and
Results Report
IMR Infant Mortality Rate
INT Department of Institutional Integrity
IOI Intermediate Outcome Indicator IPP Indigenous People Plan
ISR Implementation Status and Results
Report
KPI Key Performance Indicator
M Million
M&E Monitory and Evaluation
MA Management Agreement
MEF Ministerio de Economía y Finanzas
– Ministry of Economy and Finance
MINSA Ministerio de Salud de Perú –
Ministry of Health of Peru
MMR Maternal Mortality Rate
PAD Project Appraisal Document
PARSALUD Programa de Apoyo a la
Reforma del Sector Salud
PDO Project Development Objective
PIU Project Implementation Unit
PRONIS Programa Nacional de Inversión de
Salud
QUALY Quality Adjusted Life Years
RF Results Framework
SIAF Sistema Integrado de Administración
Financiera
SIS Seguro Integral de Salud –
Comprehensive Health Insurance
SNIP Sistema Nacional de Inversión
Publica
SUNASA Superintendencia Nacional de Salud
Senior Global Practice Director: Timothy G. Evans
Practice Manager: Daniel Dulitzky
Project Team Leader: Andre Medici
ICR Team Leader/Author: Federica Secci
iii
PERU
Second Phase of the Health Reform Program (P095563)
TABLE OF CONTENTS
Data Sheet
B. Key Dates .................................................................................................................. iv C. Ratings Summary ...................................................................................................... iv D. Sector and Theme Codes ........................................................................................... v
E. Bank Staff ................................................................................................................... v
F. Results Framework Analysis ...................................................................................... v
G. Ratings of Project Performance in ISRs .................................................................... x H. Restructuring .............................................................................................................. x I. Disbursement Profile ................................................................................................. xi
1. Project Context, Development Objectives and Design ............................................... 1
2. Key Factors Affecting Implementation and Outcomes .............................................. 5 3. Assessment of Outcomes .......................................................................................... 12 4. Assessment of Risk to Development Outcome ......................................................... 22
5. Assessment of Bank and Borrower Performance ..................................................... 23 6. Lessons Learned ....................................................................................................... 26
7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 27 Annex 1. Project Costs and Financing .......................................................................... 29
Annex 2. Outputs by Component ................................................................................. 30 Annex 3. Economic and Financial Analysis ................................................................. 39
Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 45 Annex 5. Beneficiary Survey Results ........................................................................... 47 Annex 6. Stakeholder Workshop Report and Results ................................................... 48
Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ..................... 49 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 71 Annex 9. List of Supporting Documents ...................................................................... 72 Annex 10: Analysis of PDO Achievement ................................................................... 73
Annex 11: Loan Amount Allocation ............................................................................ 77
Annex 12: Organization of PARSALUD II Project Implementation Unit (PIU) ......... 78
MAP .............................................................................................................................. 79
iv
Data Sheet
A. Basic Information
Country: Peru Project Name: PE- (APL2) Health
Reform Program
Project ID: P095563 L/C/TF Number(s): IBRD-76430
ICR Date: 06/30/2016 ICR Type: Core ICR
Lending Instrument: APL Borrower: GOVERNMENT OF
PERU
Original Total
Commitment: USD 15.00M Disbursed Amount: USD 11.98M
Revised Amount: USD 15.00M
Environmental Category: B
Implementing Agencies: PARSALUD
Cofinanciers and Other External Partners: Inter-American Development Bank (IADB)
B. Key Dates
Process Date Process Original Date Revised / Actual
Date(s)
Concept Review: 11/02/2005 Effectiveness: 12/14/2009 12/15/2009
Appraisal: 12/11/2008 Restructuring(s): 06/20/2011
08/25/2014
Approval: 02/17/2009 Mid-term Review: 10/30/2012 02/26/2013
Closing: 01/31/2015 12/31/2015
C. Ratings Summary
C.1 Performance Rating by ICR
Outcomes: Moderately Satisfactory
Risk to Development Outcome: Moderate
Bank Performance: Moderately Satisfactory
Borrower Performance: Moderately Satisfactory
C.2 Detailed Ratings of Bank and Borrower Performance (by ICR)
Bank Ratings Borrower Ratings
Quality at Entry: Moderately
Unsatisfactory Government:
Moderately
Unsatisfactory
Quality of Supervision: Moderately Satisfactory Implementing
Agency/Agencies: Moderately Satisfactory
Overall Bank
Performance: Moderately Satisfactory
Overall Borrower
Performance: Moderately Satisfactory
v
C.3 Quality at Entry and Implementation Performance Indicators
Implementation
Performance Indicators
QAG Assessments
(if any) Rating
Potential Problem Project
at any time (Yes/No): No
Quality at Entry
(QEA): None
Problem Project at any
time (Yes/No): No
Quality of
Supervision (QSA): None
DO rating before
Closing/Inactive status:
Moderately
Satisfactory
D. Sector and Theme Codes
Original Actual
Sector Code (as % of total Bank financing)
Compulsory health finance 4 4
Health 62 62
Public administration- Health 34 34
Theme Code (as % of total Bank financing)
Child health 30 30
Health system performance 30 30
Indigenous peoples 10 10
Population and reproductive health 30 30
E. Bank Staff
Positions At ICR At Approval
Vice President: Jorge Familiar Pamela Cox
Country Director: Alberto Rodriguez Carlos Felipe Jaramillo
Practice Manager: Daniel Dulitzky Keith E. Hansen
Project Team Leader: Andre C. Medici Fernando Lavadenz
ICR Team Leader: Federica Secci
ICR Primary Author: Federica Secci
F. Results Framework Analysis
Project Development Objectives (from Project Appraisal Document) Framed within the long-term objective of the Health Reform Program (APL in all its
phases) to reduce maternal and infant mortality rates in Peru’s nine poorest regions of the
country (Amazonas, Huánuco, Huancavelica, Ayacucho, Apurimac, Cusco, Cajamarca,
Ucayali, and Puno); the specific APL 2 Project Development Objectives are to: (i)
improve family care practices for women (during pregnancy, delivery and breast-feeding),
vi
and children under the age of three; (ii) strengthen health services networks with capacity
to solve obstetric, neonatal and infant emergencies and to provide comprehensive health
services to women (during pregnancy, delivery and breast-feeding) and children under
the age of three; and (iii) support MINSA's governance functions of regulation, quality,
efficiency and equity for improving the new health delivery model of maternal and child
health care in a decentralized environment (same as in the Loan Agreement).
Revised Project Development Objectives (as approved by original approving authority)
The PDOs, the Key Performance Indicators (KPIs) and the outcome targets were not
revised. However, some targets were revised during the 2014 project restructuring for the
Intermediate Outcome Indicators (IOIs) (see below).
(a) PDO Indicator(s)
Achievement of targets was assessed as follows:
Target Surpassed: the value of the indicator at the end of the project (December 2015, based
on 2014 data) is higher than the target
Target Achieved: the value of the indicator at the end of the project (December 2015, based
on 2014 data) is equal to the target, or it is equal to or greater than 85% of the target
Target Partially achieved: the value of the indicator at the end of the project (December
2015, based on 2014 data) is equal to or greater than 65% and lower than 85% of the target
Target Not Achieved: the value of the indicator at the end of the project (December 2015,
based on 2014 data) is equal to or lower than 64% of the target
Not evaluated: no data is available to assess the achievement of the target and/or the value of
the indicator.
Indicator Baseline Value
Original Target
Values (from
approval
documents)
Formally
Revised
Target
Values
Actual Value
Achieved at
Completion or
Target Years
Overall program indicator: Reduce infant mortality rate
Value: 42 25 17
Date: 2005 January 2015
(2013 data)
December 2015
(2014 data)
Comments: Target Surpassed
Overall program indicator: Reduce chronic malnutrition of children under the age of 5
Value: 38.2 30.2 23.7%
Date: 2005 January 2015
(2013 data)
December 2015
(2014 data)
Comments: Target Surpassed
KPI #1: Increase the proportion of institutional deliveries in rural areas of the nine selected
Regions from 44% (2005) to 78% (2013) – proxy indicator for Maternal Mortality
Value: 44% 78% 74.2%
Date: 2005 January 2015
(2013 data)
December 2015
(2014 data)
vii
Comments: Target Achieved (89%).
KPI #2: Reduce the prevalence of anemia among children under age in the nine regions from
69.5% (2005) to 60% (2013)
Value: 69.5% 60% 57.3%
Date: 2005 January 2015
(2013 data)
December 2015
(2014 data)
Comments: Target Surpassed
KPI #3: Increase from 64% to 80% the share of children in the nine selected regions who are
exclusively breastfed until 6 months of age
Value: 64% 80% 87%
Date: 2005 January 2015
(2013 data)
December 2015
(2014 data)
Comments: Target Surpassed
KPI #4: Reduce the prevalence of anemia among pregnant women in the nine Regions from
41.5% (2005) to 35% (2013)
Value: 41.5% 35% 36.4%
Date: 2005 January 2015
(2013 data)
December 2015
(2014 data)
Comments: Target Partially Achieved (78%).
KPI #5: Reduce the hospital lethality rate among neonates in the nine selected Regions from
9.5% (2005) to 5% (2013)
Value: 9.5% 5% 5%
Date: 2005 January 2015
(2013 data)
December 2015
(2014 data)
Comments: Target Achieved (100%).
KPI #6: Increase in the proportion of pregnant women of the nine regions with at least 1 prenatal
control during the first trimester of pregnancy from 20% (2005) to 45% (2013)
Value: 20% 45% 69.1%
Date: 2005 January 2015
(2013 data)
December 2015
(2014 data)
Comments: Target Surpassed
viii
(b) Intermediate Outcome Indicator(s)
The rating scale is the same as the one above used for the PDO Indicators.
Indicator Baseline Value
Original Target
Values (from
approval
documents)
Formally
Revised
Target Values
Actual Value
Achieved at
Completion or
Target Years
IOI #1: Percentage of SIS affiliated children who received growth and development controls
(CRED) according to their age
Value 34% 66% 56.8%
Date 2005
January 2015
(2013 data)
December 2015
(2014 data)
Comments: Target Partially Achieved (71%).
IOI #2: Percentage of health facilities with improvement in infrastructure (minor construction,
rehabilitation and/or new equipment)
Value 0 104 Dropped 104
Date 2005
January 2015
(2013 data) 2014
December 2015
(2014 data)
Comments: Target Achieved (100%) (dropped at the 2014 restructuring but reintroduced for the
ICR, based on government’s data).
IOI #3: Percentage of SIS affiliated rural pregnant women with laboratory tests on hemoglobin,
urine and syphilis
Value 37% 80% 53.5% 69%
Date
2005 January 2015
(2013 data)
December
2015
(2014 data)
December 2015
(2014 data)
Comments: Surpassed against revised target; 74% achievement against original target.
IOI #4: Percentage of pregnant women under SIS that receive iron and folic acid supplements
Value 37% 80% 60% 55%
Date
2005 January 2015
(2013 data)
December
2015
(2014 data)
December 2015
(2014 data)
Comments: Revised Target Partially Achieved (78%); 42% achievement against original
target.
IOI #5: Percentage of women satisfied with the services in selected facilities by confidence index
Value N/A 25% Dropped 74.4%
Date 2005
January 2015
(2013 data) 2014
December 2015
(2014 data)
Comments: Surpassed (dropped at 2014 restructuring, but reintroduced for the ICR). Based on
ISR data, the target was 25% and the value after the survey was conducted was 74.4%.
IOI #6: Percentage of cesareans in SIS affiliated pregnant rural women
Value 3% 5% 10% 9.5%
Date
2005 January 2015
(2013 data)
December
2015
(2014 data)
December 2015
(2014 data)
Comments: Revised Target Achieved (93%); surpassed against original target.
IOI #7: Percentage of references among SIS-affiliated women (during pregnancy and
puerperium) and neonates
ix
Value N/A 5% Dropped N/A
Date 2005
January 2015
(2013 data) 2014
December 2015
(2014 data)
Comments: Not evaluated. Indicator not monitored throughout the project and dropped at
restructuring (2014)
IOI #8: Percentage of SIS affiliated households that make out-of-pocket expenditures in
medicines
Value 67.3% 25% 55% 56%
Date
2005 January 2015
(2013 data)
December
2015
(2014 data)
December 2015
(2014 data)
Comments: Revised Target Achieved (92%); 27% achievement against original target.
IOI #9: Number of accredited health establishment by type of resolution
Value 80 169 Dropped N/A
Date 2005
January 2015
(2013 data) 2014
December 2015
(2014 data)
Comments: Not evaluated. Indicator not monitored throughout the project and dropped at
restructuring (2014)
IOI #10: Number of Management Agreements in place
Value N/A N/A Dropped N/A
Date 2005
January 2015
(2013 data) 2014
December 2015
(2014 data)
Comments: Not evaluated. Indicator not monitored throughout the project and dropped at
restructuring (2014)
IOI #11: Number of health personnel and community health workers trained within the behavior
change campaign (EPPES)
Value 0 758 1178
Date 2005
January 2015
(2013 data)
December 2015
(2014 data)
Comments: Surpassed (added for the ICR - based on Government data)
IOI #12: Number of health facilities improved
Value 0 73 69
Date 2005
January 2015
(2013 data)
December 2015
(2014 data)
Comments: Achieved (95%) (added for the ICR - based on Government data). This indicator
measured the number of facilities that were either built, re-built or expanded by the project (i.e.
major constructions).
IOI #13: Norms and regulations to improve efficiency and equity of the health delivery system
prepared
Value 0 27 32
Date 2005
January 2015
(2013 data)
December 2015
(2014 data)
Comments: Surpassed (added for the ICR - based on Government data)
IOI #14: Clinical pathways and corresponding financing systems designed
Value 0 11 16
Date 2005
January 2015
(2013 data)
December 2015
(2014 data)
x
Comments: Surpassed (added for the ICR - based on Government data)
IOI #15: Periodic evaluations of the performance of the health networks prepared
Value 0 17 19
Date 2005
January 2015
(2013 data)
December 2015
(2014 data)
Comments: Surpassed (added for the ICR - based on Government data)
G. Ratings of Project Performance in ISRs
No. Date ISR
Archived DO IP
Actual
Disbursements
(USD millions)
1 06/19/2009 Satisfactory Satisfactory 0.00
2 12/11/2009 Satisfactory Satisfactory 0.00
3 06/28/2010 Satisfactory Satisfactory 0.00
4 02/23/2011 Satisfactory Satisfactory 0.86
5 08/05/2011 Satisfactory Satisfactory 1.20
6 01/23/2012 Satisfactory Satisfactory 3.48
7 09/22/2012 Satisfactory Satisfactory 4.05
8 05/10/2013 Satisfactory Moderately Satisfactory 5.65
9 12/21/2013 Satisfactory Moderately Satisfactory 7.40
10 07/12/2014 Satisfactory Moderately Satisfactory 7.96
11 12/19/2014 Satisfactory Moderately Satisfactory 9.27
12 06/17/2015 Satisfactory Moderately Satisfactory 9.73
13 12/30/2015 Moderately Satisfactory Moderately Satisfactory 11.98
H. Restructuring
Restructuring
Date(s)
Board
Approved
PDO Change
ISR Ratings at
Restructuring
Amount
Disbursed at
Restructuring
in USD
millions
Reason for Restructuring &
Key Changes Made DO IP
06/20/2011 No S S 1.20
Reallocation of funds to
increase funds allocated to
Component 2 and reduce those
for Components 1 and 3.
08/25/2014 No S MS 8.58
Based on the MTR, the
restructuring (a) revised the
results framework; (b) extended
the Closing Date of the Project
to Dec 31, 2015; (c) increased
the threshold for firm contracts
to US$300,000; and (d) changed
the disbursement estimates.
xi
I. Disbursement Profile
1
1. Project Context, Development Objectives and Design
1.1 Context at Appraisal
1. Peru was a growing economy, but with persistent inequalities, and undergoing a
demographic transition. At appraisal, it had registered strong economic growth, with a
7.6% GDP growth in 2006, 9.0% in 2007 and 9.3% in 2008. This progress contributed to
a substantial reduction of poverty. The national poverty rate dropped from 48.6% in 2004
to 39.3% in 2007, while extreme poverty fell from 17.1% to 13.7%. However,
inequalities and disparities across regions remained a challenge. Extreme poverty was
3.5% in urban areas and 32.9% in rural areas in 2007. From being heavily rural in 1950
with 33% of the population living in urban areas, by 2007 this proportion had increased
to 76%. In terms of age structure, of a population of more than 27 million in 2007, 33%
were less than 15 years old and 4.8% over 65.
2. By appraisal, Peru had advanced on some health-related MDG outcome indicators;
yet, improvements were not uniform ― across all socio-economic groups, regions, and
between rural and urban settings, revealing persistent inequalities. Despite its overall
decrease, in 2006 the infant mortality rate (IMR) varied from 5 per 1,000 live births in the
richest quintile to 45 in the poorest; Lima had a low IMR of 20, but Cusco has the highest
at 84. While mortality in the post-neonatal period decreased, the relative share of
perinatal mortality as a cause of infant deaths increased. This was due to conditions
related to both demand and supply side factors (e.g. low institutional delivery rate, lack of
immediate attention for newborns) and strongly linked with maternal malnutrition – more
than a quarter of pregnant women, age 15 to 49, suffered from anemia (ENDES 2000-1).
Despite progress on nutrition outcomes, one-quarter of Peruvian children under five
suffered from chronic malnutrition, while 69% of children under two suffered from
anemia. Located at high altitude, the regions of Huancavelica, Huánuco, and Ayacucho,
among the poorest of Peru, were the ones with the highest stunting levels (more than 40
percent). At 164 deaths per 100,000 live births, Peru’s maternal mortality ratio (MMR)
was almost double the Latin American average. In 2006, institutional delivery in urban
areas was 92% and only 44% in rural areas. Finally, financial obstacles still represented a
significant barrier to access. In the poorest quintile, 34% of individuals reported they had
no access to health care for lack of money, while in the richest quintile only 6% did
(ENAHO 2006).
3. Evolving health system. The Ministry of Health (Ministerio de Salud, MINSA) had
taken some steps to strengthen accountability within a fragmented health care system in
an increasingly decentralized environment. Management Agreements (MAs) were
adopted to set goals for the Regions/municipalities’ health networks and results-based
budgeting was increasingly used. The Comprehensive Health Insurance (Seguro Integral
de Salud, SIS), created in 2001 and covering over 16% of the population, reimbursed
MINSA public providers based on agreed upon health plans and covered predominantly
vulnerable population living in poverty or extreme poverty, although not all in need.
2
4. Rationale for Bank assistance. The project evaluated in this ICR was part of a two-
phase Adaptable Program Loan (APL) to support the Government of Peru (GOP)’s
Health Reform Program (Programa de Apoyo a la Reforma del Sector Salud –
PARSALUD). In both its phases, the overall PARSALUD program aimed at improving
maternal and child health outcomes in Peru. The APL series was built on an ongoing
dialogue with the Government of Peru (GOP) and on prior analytical work (e.g.
RECURSO) and lending operations in the health sector (e.g. Basic Health and Nutrition
Project – P008048).
5. The first phase (APL 1) in support of PARSALUD I was the Mother and Child Insurance
and Decentralization of Health Services Project – P062932, which started in July 2001
and closed in June 2006. The planned investment under PARSALUD I amounted to
US$239 M, jointly funded by the International Bank for Reconstruction and
Development (IBRD, i.e. the Bank) (US$ 87 M), the Inter-American Development Bank
(IADB) (US$ 87 M), the GOP (US$ 64.3 M), and the OPEC Fund (US$ 8 M); the total
actual investment was US$232 M ― GOP (US$ 176.80 M), Bank (US$ 27 M), and
IADB (US$ 28 M). The objective of the first phase of the program was to improve
maternal and child health and to help reduce morbidity and deaths of the poor from
communicable diseases and environmental conditions. The specific objective of the APL
1 was to increase access of the poor to better quality health programs and services.
PARSALUD I was successful in reducing perinatal mortality and IMR and increasing
skilled birth attendance by strengthening the demand and improving the quality of the
supply of health programs and services. APL 1 contributed to the success of the overall
program and its ICR (ICR000073) rated efficacy as substantial and the overall project as
satisfactory ― confirmed by the IEG evaluation. Finally, a set of nine triggers was
agreed on to demonstrate readiness for transition from phase I to phase II. All triggers
were met at the end of phase I, with the exception of one, due to changes in regulatory
framework, independent from PARSALUD1.
6. The project evaluated by this ICR (P095563) supported the second phase of the GOP’s
PARSALUD and intended to sustain the achievements of the first phase. The overall
objective of the second phase of the program was to reduce maternal and infant mortality
and reduce chronic malnutrition of children under the age of 5. The specific objective of
the APL 2 are described in section 1.2. The total planned investment under PARSALUD
II amounted to US$162.40 M, funded largely by GOP (US$ 132.40 M) and co-funded by
the Bank and the IADB (US$ 15 M each); the total actual investment was US$165 M ―
GOP (US$ 138 M), Bank (US$ 11.98 M), and IADB (US$ 15 M). The project
represented a small portion of domestic financing; yet, there was considerable demand
from the GOP for the Bank’s support to policy reforms and for its fiduciary contributions
to leverage an expeditious and efficient execution of policies and investments. The
project also did provide additional funding for regional governments for investments and
1 A summary of triggers is reported in the PAD, pp 10-11. The trigger that was not achieved was the separation of
financing and service provision within the Social Security Fund (ESSALUD). Changes in the regulatory framework
granted more autonomy to ESSALUD and reduced the ability of MINSA to influence its institutional processes.
Eventually, ESSALUD started piloting a separation of functions, but this was decided independently from the
PARSALUD trigger.
3
interventions not covered by budgetary allocations. Finally, the project was aligned with
the national and sector policies and with the Bank’s Country Partnership Strategy (CPS)
for Peru for FY12-16, as well as with the Ministry of Economy and Finance (MEF)’s
efforts towards results-based budgeting.
1.2 Original Project Development Objectives (PDO) and Key Indicators
7. This project was the second of the APL series to continue supporting the broader GOP
program (PARSALD II). The specific program objective was to reduce maternal and
infant mortality and reducing chronic malnutrition of children under the age of 5. The
program indicators were: MMR2, IMR and chronic malnutrition of children under 5.
8. The stated objectives of APL2 were to continue supporting the Borrower’s effort to
reduce maternal and infant mortality rates in intervened rural areas in Selected Regions in
the Borrower’s territory, in particular through: (i) the improvement of family care
practices for women (during pregnancy, delivery and breast-feeding), and children under
the age of three; (ii) the strengthening of health services networks with capacity to solve
obstetric, neonatal and infant emergencies and to provide comprehensive health services
to women (during pregnancy, delivery and breast-feeding) and children under the age of
three; and (iii) the supporting of MINSA's governance functions of regulation, quality,
efficiency and equity for improving the new health delivery model of maternal and child
health care in a decentralized environment. The objectives were aligned between the
Loan Agreement and the PAD.
The PDO-level indicators (Key Performance Indicators, KPIs #1-6) were:
a) Increase the proportion of institutional deliveries in rural areas of the nine selected
Regions from 44% (2005) to 78% (2013)
b) Reduce the prevalence of anemia among children under age 3 in the nine regions
from 69.5% to 60%
c) Increase from 64% to 80% the share of children in the nine selected regions who
are exclusively breastfed until 6 months of age
d) Reduce the prevalence of anemia among pregnant women in the nine Regions
from 41.5% (2005) to 35% (2013)
e) Reduce the hospital lethality rate among neonates in the nine selected Regions
from 9.5% (2005) to 5% (2013)
f) Increase in the proportion of pregnant women of the nine regions with at least 1
prenatal control during the first trimester of pregnancy from 20% (2005) to 45%
(2013).
1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and
reasons/justification
2 Due to difficulties in monitoring MMR, institutional delivery was used as a proxy for maternal mortality by
PARSALUD.
4
9. Neither the PDO nor the PDO indicators were revised. However, as per restructuring
paper dated August 20, 2014, the Results Framework (RF) was revised to reflect the new
proposed end date of the project, which was moved from January 31, 2015 to December
31, 2015. The targets of some Intermediate Outcome Indicators (IOIs) were revised and
some IOIs were dropped (IOIs # 2, 5, 7, 9, 10). No additional indicators were added.
1.4 Main Beneficiaries,
10. The main beneficiaries were meant to be families (preponderantly rural) with pregnant
women and children under age of three in the nine poorest regions in the country:
Amazonas, Huánuco, Huancavelica, Ayacucho, Apurimac, Cusco, Puno, Cajamarca and
Ucayali. The last two regions were also prioritized due to slow advances on IMR and
MMR. Particular attention was to be targeted on indigenous populations as part of
vulnerable and poor groups. Other beneficiaries included health professionals who
benefited from training and improved infrastructure; local health managers, who
benefited from training, tools, and technical assistance; and MINSA who benefited from
technical assistance for enhancing government capacities, regulatory framework for local
services, and M&E functions.
1.5 Original Components
11. The project consisted of four components:
Component 1 (total estimated costs US$6.00 million). Improving health practices at
the household level for women (during pregnancy, delivery and breastfeeding) and
children under the age of three in rural areas of selected Regions (demand-side
interventions), by: a) design, implementation and monitoring of a behavioral change
communication and education program to promote healthy practices at the household
level, including increased demand for health services (Estrategia de Promocion de
Practica y Entornos Saludables, EPPES); and b) promotion of SIS enrollment rights and
identity rights of the targeted population (Derecho a la Identidad y Aseguramiento, DIA).
Component 2 (total estimated costs US$142.30 million). Increasing the capacity to
provide better maternal and child health services for the poor (supply-side
interventions); through: a) the improvement of the quality of services in health facilities
of the nine regions; and b) the provision of support for the integrated health delivery
model and the development of support systems to raise the efficiency and effectiveness of
health networks.
Component 3 (total estimated costs US$5.20 million). Strengthening government
capacities to offer more equitable and efficient health system in a decentralized
environment (governance and financing) by: (a) supporting a regulatory framework and
increasing quality in the provision of health services, (b) expanding the health insurance
system (SIS) enrollment; (c) strengthening data monitoring and accountability in the
system; and (d) supporting the decentralization of health services.
5
Component 4 (total estimated costs US$8.9 million) Project Coordination and
Monitoring and Evaluation (M&E), through the provision of technical assistance,
financing of incremental operating costs, and external and concurrent audits.
1.6 Revised Components
12. During the 2011 restructuring, the reallocation of Loan proceeds among disbursement
categories was revised, as shown in Annex 11. The contribution to Components 1 and 3
was halved (from 50% of program costs to 25%), while the contribution to Component 2
was increased (from 6% of program costs to 8%). No changes were made to Component
4.
1.7 Other significant changes
13. The project underwent two level 2 restructurings. The first, in June 2011, changed
funding allocations among components and supported more timely disbursement. It was
motivated by the fact that, at the onset of the project, the GOP used domestic resources to
advance expenditures for technical assistance activities originally planned to be financed
with the loan funds, given that the budget allocation for the loan had not yet been
approved by the borrower.
14. The second restructuring, in August 2014:
a) Extended the Closing Date to December 31, 2015, to complete all Project
activities and to ensure full disbursement of loan proceeds, focusing on
component 2 and 3;
b) Revised the RF to increase clarity, improve the accuracy of indicator definitions
and data, and revised project targets in line with available evidence and feasibility
of achieving targets. The indicator target dates were also adjusted to the new
Closing Date;
c) Changed disbursement estimates to reflect the new action plan and respective
procurement plan, and
d) Increased procurement threshold for prior review for consulting firms from
US$100,000 to US$300,000.
2. Key Factors Affecting Implementation and Outcomes
2.1 Project Preparation, Design and Quality at Entry
15. Project Design. The project design was based on the lessons of APL 1 outlined in its
ICR (ICR000073). In particular, it was emphasized that: (1) the lack of a clear
implementation strategy that would ensure results, among other factors, caused
difficulties in the first phase of the program, which were overcome by using evidence-
based research to focus on results; (2) political volatility was detrimental on project
implementation and impact and, while ministerial influence was necessary; it was also
important to implement project activities in coordination with the areas of MINSA
6
responsible for specific project components; (3) there was a need to build institutional
and managerial capacity at regional level before transfer funds directly to these local
management units; and (4) intercultural strategies were vital when beneficiaries belonged
to diverse indigenous groups and community participation was key to ensure
sustainability. In addition, the second phase of the program, including its activities and
the Results Framework (RF), was informed by a comprehensive feasibility study
finalized in 2008 (with a baseline for the indicators taken in 2005).
16. Due to a strong interest of the GOP at the time of appraisal on infrastructure investment,
the project was largely focus on upgrading health facilities in the nine regions, where lack
of infrastructure was identified as an important barrier to service access. Yet, these
infrastructure investments were used as entry point to promote broader sectoral reforms
and the use of evidence-based policy. These “soft interventions”, which were at the core
of PARSALUD I, were less prominent in PARSALUD II; however, they are fundamental
in ensuring sustainability of progress.
17. Project Preparation. Preparation of APL 2 started promptly, even before the closing of
APL 1. As was the case for the first phase, APL 2 was also co-financed by the World
Bank and the IADB, and therefore, project preparation was conducted in close
collaboration with the IADB team3. However, a three years gap stands between the end of
phase I and the effectiveness of the project supporting phase II. Changes in political
priorities and leadership due to frequent changes in Government were the main causes of
this delay. When a new Minister of Health was appointed in October 2008, an
opportunity window opened up and project preparation regained traction. The project was
negotiated in December 2008 and approved by the Board of Directors on February 17,
2009. The signing of the Loan Agreement only happened 9 months later, on November
16, 2009 and the project was declared effective on December 15, 2009.
18. Quality Enhancement Review (QER) and Decision Review Meeting (DM). The
project underwent a QER in May 2006; the DM was held in December 2008. During both
meetings, the element of the project that was mostly appreciated by the reviewers was the
cultural adaptation of all the planned activities. Some of the issues and recommendations
raised during these meetings not only revealed to be crucial to determine quality at entry,
but were eventually found to be critical during implementation. These included:
a) Establishing clearer links with the previous APL and, more broadly, better explaining
how the new operation would fit within the Peruvian institutional environment, which
had changed from the end of the first phase of the program and, even more, from its
original conceptualization;
3 The IADB project and the Bank project in support of PARSALUD II were aligned in terms of development objective,
timeline and resources committed (US$15 million each). The results frameworks of the two projects slightly differed
on some of the KPIs and IOIs. While the Mid-Term Review was conducted jointly and communications between the
two teams was maintained throughout the life of the projects, supervision missions were largely carried out separately by the two co-founders.
7
b) Strengthening the M&E system by: (i) reducing the number of indicators, but
establishing a clear results chain from activities to outputs and outcomes; (ii) reducing
the number of data sources from which the indicators would be derived; and (iii)
ensuring that the counterpart had the capacity to monitor the RF;
c) Assessing more realistically the risks deriving from the institutional environment
which are outside the scope of the project, especially with regard to the links with SIS
and the dependence upon approvals from the National Investment System (Sistema
Nacional de Inversión Pública, SNIP). During implementation, it became clear that
SIS had gain much more independence than anticipated and coordination with
PARSALUD gradually reduced. SNIP, which was created in Peru in the early 2000s,
was rather rigid in its conceptualization of investment projects, with a non-
participatory decision-making process and long approval time of programs, thereby
compromising the possibility to efficiently make any changes to the projects during
implementation. Furthermore, its clear preference for financing infrastructure
investment left very little margin to incorporate other investment approaches, such as
those adopted by APL 1, despite their proven effectiveness.
2.2 Implementation
19. Implementation of the project did not suffer from any major complications. The
project had a slow start. While activities related to Components 1 and 3 started
immediately, delays in disbursement and execution related mainly with the infrastructure
investments under Component 2. Once construction works began and medical equipment
started being purchased in 2011, project disbursement picked up towards the end of 2012.
20. As a result of the nature of the activities, project implementation was characterized
by a high volume of transactions. Given the commitment to co-finance all civil works
of the PARSALUD program with 6% funding coming from loan resources (i.e. 3% from
the Bank and 3% from the IADB) and the remaining 94% from domestic resources, all
procurement processes followed the Bank’s procedures. This was highly desirable from
the perspective of MINSA, given the stricter Bank procurement guidelines, and it
reflected a general trend in Peru at that time ― when the GOP was seeking external
resources to fund rather small portions of broader national investment programs to benefit
from streamlined procurement processes and technical assistance. Yet, this posed stress
on the task team for the supervision of all transactions related to the program, efforts that
were, therefore, disproportionate with respect to the resources committed with the loan.
21. While the program was successful in achieving its broader goals of reducing
maternal and infant mortality and chronic malnutrition in children under 5,
progress on the indicators in the RF was mixed during the life of the project. Some
of the targets were achieved even before the MTR in February 2013, while others had a
more fluctuating trajectory. To some extent, this was related to the delays in construction
works, which shortened the time horizon available to see the impact of the infrastructure
investments on the selected health outcomes and outputs. In other cases, the trend of
some indicators reflected those at the national level, such as in the case of the prevalence
of anemia among pregnant women. The delays in progress on some indicators motivated
the downgrade of the Overall Project Implementation (IP) rating from satisfactory to
8
moderately satisfactory in 2013, rating which was then kept in consideration of the
disbursement delays ― eventually, the project disbursed 80% of the planned amount.
22. The Mid-Term Review (MTR) in February 2013 identified some of the challenges
and correcting measures, including the needs to better coordinate with other relevant
units within the MINSA and regional governments, strengthen M&E, increase loan
disbursement (by then only 35%), modify the RF to reflect the actual starting and end
date of the project, and support the reform process within MINSA by increasing capacity
of and coordination with the regional and levels. Some of these recommendations were
immediately taken on board, including for example strengthening the M&E function
within PARSALUD. Others were only partially addressed during the life of the project.
Overall, the following implementation strengths were identified:
(i) Project Implementation Unit (PIU)’s capacity and commitment. The
PARSALUD PIU was reconstituted in 2009, after a period of two years from its
closure after the program’s first phase. The capacity of the PIU for project
coordination was assessed as satisfactory and the unit was generally appropriately
staffed (see Annex 12). The role of project coordinator was stable (two main
coordinators and two acting for a very brief period of time). The project coordinators
and many of the key personnel were very committed and remained within the team
throughout project implementation, ensuring continuity and supporting improved
capacity of the PIU. The PIU was found to be very proactive in a number of areas.
For example, the PIU accepted all communications and documents to be sent
electronically to the IADB and the Bank, which is not common practice in Peru. The
PIU developed and made available checklists to constructors to ensure environmental
safeguards were abided by and monitored compliance independently. Finally, the PIU
worked closely with each Direccion Regional de Salud (DIRESA) to support local
and regional-level interventions (such as the EPPES) and to strengthen capacity at the
regional and local level based on the needs of each region.
(ii) Cultural adaptation of interventions. The systematic strengthening of health rights
and empowerment of the population in rural areas about social participation in health
through the EPPES and DIA campaigns were very well received by the local
communities. These initiatives, together with the prior consultations held with local
communities before the start of all civil works under PARSALUD, helped regional
administrations build capacity for intercultural strategies, including communication in
local languages (e.g. Quechua and Aymara). As a result of those culturally-sensitive
interventions, coverage from SIS increased in the lowest quintiles in the Project areas.
(iii)Contribution to the Identity and Insurance Rights movement. PARSALUD was
very active in catalyzing efforts to support the Derecho a la Identidad y
Aseguramiento (DIA) for the health sector. This was an intersectoral initiative, in
collaboration with the RENIEC and civil society, and with a strong regional and local
commitment, to which PARSALUD contributed by supporting a campaign to
promote the issuance of the Live Birth Certificate to children under 3 years of age and
the National Identity Document to pregnant women and mothers.
The following implementation weaknesses were identified:
9
(i) Political changes within MINSA and regional governments. Four Ministers of
Health changed during project implementation. Despite posing some concerns about
stability of political commitment for the project and its key staff, eventually political
changes at the national level did not substantially impact on project implementation.
On the other hand, frequent political changes in the regional governments meant that
PARSALUD PIU had to constantly re-engage with new administrators and staff,
requiring duplication of efforts for capacity building at the local level.
(ii) Delays in civil works and consultancies. As of December 2012, after 2 years of
implementation, about 27% of project's civil works were delivered, with
heterogeneous patterns among the regions. Logistic difficulties for timely civil works
completion were associated with difficult climate and access to sites, as well as with a
few cases of collusion, properly addressed by the counterpart. Delays in hiring
consultants were due to, among others, frequent changes in regional administration,
scarcity of professionals adequately qualified for some tasks, delays in approval
processes from the regions, and political attention diverted to sudden public health
emergencies (e.g. pneumonia in Puno and dengue in Ucayali). Despite all delays,
almost all planned civil works were completed before the project closing date, with a
few being delivered in 2016.
(iii)Underestimation of the impact of other programs or initiatives on progress on
the PARSALUD indicators. In some cases, project indicators showed irregular
progress. This was partially due to other government programs providing incentives
contrasting with those provided by PARSALUD (e.g. distribution of formula milk
which at times affected exclusive breastfeeding of infants), and partially with changes
in procedures for the registration with SIS (e.g. requirement of national identification
document to register with SIS, which negatively affected the number of affiliates).
2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization
23. Design. The project’s Results Framework (RF) was derived from the PARSALUD
program RF, which was based on a feasibility study (FS) finalized in 20084 and approved
as the program proposal by the SNIP.
24. The indicators in the RF reflected all parts of the PDO. The PDO-level indicators (Key
Performance Indicators, KPIs) focused on improving practices at the household level
(PDO 1) and on strengthening the health service network (PDO 2). The Intermediate
Outcome Indicators (IOIs) focused on PDO 2 and 3 (supporting MINSA’s government
functions). The first three components of the project were also aligned with the three
parts of the PDO. Given the funds allocation, KPIs and IOIs focused largely on PDO 2
and Component 2 (strengthening of health services networks – supply side). Component
3 (governance and financing) is reflected by a small number of IOIs, most of which were
dropped in 2014.
4 Segunda fase del Programa de Apoyo a la Reforma del Sector Salud - PARSALUD II. ESTUDIO DE
FACTIBILIDAD. Nov 2008
10
25. Baseline data as of 2005 was available for all but three indicators, based on the FS.
Targets were set against that baseline by imposing improvements greater than the
expected improvements based on historical trends. However, delays in project
preparation and effectiveness made the baseline and the targets outdated, but neither of
these were revised. If unable to change the baseline and/or the targets at the time of
appraisal, due to time constraints and lengthy government processes, within the context
of the first restructuring in 2011, when data from 2009 was becoming available, these
should have been used to update the baseline and the targets.
26. Implementation. The project indicators were monitored using government’s systems and
surveys. This had the advantage of not creating a parallel system. However, the PIU had
to request or download data from different institutions responsible for data collection
before being able to analyze it. There was a time lag of one year between the data
collection and the data availability, so that data for a given year became available only in
the following calendar year.
27. Due to unavailability of data at the time of the ISRs, two KPIs only started being
monitored in December 2014 (ISR 11, with data of December 2013). Given that they had
not been monitored, five IOIs were dropped during the restructuring in 2014. However,
data was available for two of those, which were reintroduced for the purpose of the ICR.
The other three indicators had not been clearly defined and monitoring was therefore
problematic. Unfortunately, all three of those IOIs measured progress against the same
part of the PDO (3). Since the PARSALUD PIU monitored more indicators than those
monitored by the Bank, additional intermediate indicators might have introduced to
replace the problematic IOIs to better assess improvements on PDO 3 ― for example
during the first restructuring in 2011 or immediately after the MTR in 2013.
28. Within the PIU the M&E Unit originally included two specialists, one focused on
Monitoring and the other on Evaluation. Following suggestions from the MTR, the M&E
function was strengthened and the original unit was split into two to focus and strengthen
each area ― supervision of program performance, and management of scientific evidence
for enhanced effectiveness of the overall program (see Annex 12).
29. Utilization. Once data was processed, the M&E team analyzed data for each indicator
and informed the technical team of the trends. If needed, the local coordinators within the
DIRESA were contacted to understand the reasons for the variation in the indicators,
especially with regard to birth, death and maternal anemia. However, given the
difficulties in monitoring the full results chain and the delay in obtaining information on
the indicators, data was not used by the local level to inform decision-making or revise
practices and procedures in real time. It was used by the PIU to promote studies that
supported increased knowledge and evidence-base policy, informing the design of
technical guidelines and regulations that improved MINSA’s regulatory capacity.
2.4 Safeguard and Fiduciary Compliance
30. Safeguards. Given that the project (environmental category B) triggered the
Environmental Assessment (OP/BP/GP 4.01) and the Indigenous People Safeguard
11
Policies (OP 4.10), environmental and social safeguards were monitored. The
Environmental Assessment was conducted in 2005; the Indigenous People Plan (IPP) was
prepared in 2006. In 2013, specific missions assessed the compliance with environmental
and social safeguards and proposed corrective recommendations where needed. More
targeted safeguards supervision missions were conducted in 2013 to review
implementation of the action plans in line with the EA and the IPP. The implementation
of the activities under an intercultural approach related to Component 1 (including the
EPPES, the DIA, and the prior consultations to IP for infrastructure construction) were
rated as satisfactory. Similarly, the implementation of environmental safeguards was
rated satisfactory, given the proactivity of the PIU in promoting the use of checklists for
solid waste and water management during infrastructure construction under Component 2.
31. Financial Management. The counterpart’s financial management performance was
considered generally satisfactory. The PIU was appropriately staffed from the start and,
despite delays in systematically adopting the official system for managing transactions
used in all implementation units in the public sector (Sistema Integrado de
Administración Financiera, SIAF), financial reports were timely and were found to be of
satisfactory quality. Audit reports were provided on time and there were no qualified
opinions. Until 2013, disbursement was very slow (39% in August 2013). Problems were
related to a number of factors, including previous delays in civil works as a consequence
of inadequate planning and due to the remote project locations, which did not offer
incentives for enterprises to participate in the bidding process; and the contractors’
noncompliance with contractual clauses. The GOP established a condition of Pari-Passu
for all civil works (6% of external resources), which limited the scope for accelerating
disbursement of the loan. Finally, deferred payments for civil works at the end of the
project (Ocongate Health Center and Health Center Chuquibambilla) and the cancelation
of the scheduled execution of large amounts of consulting services (i.e. Diplomado APS
PROFAM and Sistema Nacional de Sangre Segura) expected to be contracted before the
project closing and executed during the project grace period, negatively impacted
disbursement. As a result, total disbursement reached 80% at project closing.
32. Procurement. Given that the entire Government program followed the Bank’s
procurement guidelines, the Bank reviewed and approved a large volume of transactions.
The initial delays due to lack of planning by the counterpart and long processing time for
No Objections by the Bank were addressed and resolved after the first two years of
project implementation. Procurement delays remained associated mainly with the scarcity
of qualified contractors and remoteness of the work sites.
2.5 Post-completion Operation/Next Phase
33. Building on the PARSALUD know-how, a follow on GOP investment program, the
Programa Nacional de Inversion de Salud (PRONIS) was approved in 2015 and is now
operational. In line with the decentralization, PRONIS allows regions to set their own
priorities and request funding from the central level. The possibility of a follow-on Bank-
funded operation to support this new investment strategy has been discussed. MINSA and
PARSALUD presented concrete proposals to MEF and the Bank (including a logic
framework for the new operation). Discussions are still ongoing until the political
12
situation stabilizes after the national elections which are taking place between April and
June 2016.
3. Assessment of Outcomes
3.1 Relevance of Objectives, Design and Implementation
The Overall Relevance Rating is: Substantial.
34. Relevance of Objectives: Rating High. The project was fully aligned with the CPS for
FY12-16 for Peru (February 1, 2012; p.21) and with the priorities of MINSA for an
investment program with a strong focus on reducing maternal mortality, infant mortality
and undernutrition, and an interest in improving equity in access to services. Today,
reduction of maternal mortality and especially of infant mortality remain important, while
non-communicable diseases are increasingly capturing attention and funding due to
increased burden. Malnutrition and anemia still remain very high on the Government
agenda given that progress has been fluctuating, not only in the project areas, but more
generally across the country. In addition, poverty and inequalities, especially in the
project areas, are still far from being resolved. The World Bank is currently undertaking
the first Systematic Country Diagnostics for Peru (the review meeting will be held before
the end of FY16) and will start working on the Country Partnership Framework in the
first quarter of FY17. Addressing inequalities, support to effective decentralization, and
improved nutrition, all of which were at the core of PARSALUD, still remain highly
relevant.
35. Relevance of Design: Rating Substantial. Given that this project supported phase II of
the program and all triggers were met at the end of phase I, the APL design was
maintained. MINSA gained experience in managing APL fiduciary rules and believed
these would help reinforce accountability, expressing preference for this lending
instrument.
36. The project design appropriately aimed to address both demand and supply side factors to
improve maternal and child health outcomes in the nine regions, as well as to increase the
capacity of the government at the national and local level. It had a strong intercultural
footprint, which was very appropriate given the areas of focus under the program. It was
also designed in parallel and to build synergies with another Bank-financed project aimed
at improving nutrition outcomes by using conditional-cash transfers, the Juntos Results
for Nutrition Project (P117310), approved in 2011.
37. As mentioned above, the RF was aligned with the project components and reflected the
different parts of the PDO. At approval, the design of the RF still reflected baseline data
of 2005, which could have been updated with more recent data, either at that stage or at
the first restructuring in 2011. Data for some IOIs was not available and five indicators
were dropped at the 2014 restructuring. More effort could have gone to incorporate in the
project’s RF some IOIs included in the program’s RF to better assess progress with
Component 1 and 3; to compensate for these weaknesses, several IOIs were included at
the time of the ICR.
13
3.2 Achievement of Project Development Objectives
The Efficacy Rating is: Substantial. The overall efficacy rating is the result of the assessment of
achievement of the three parts of the PDO, all of which are rated substantial.
Assessment of achievement of the program’s objectives
38. The project objective was to contribute to the overall GOP’s effort to reduce maternal
and child mortality and improve chronic malnutrition in children ― and, as explained
below, the project did contribute to this. A comprehensive impact evaluation would be
needed to demonstrate the attribution of the achievement of the program objectives and
of the PDO-level indicators the project. However, the case for project contribution to the
achievement of the PDO, is supported by progress on the intermediate outcome indicators
that are more directly attributable to the project.
39. In terms of the overall results of the program, between 2009 and 2014, Peru was able to
reduce IMR from 42 to 17 against a target of 25, and chronic malnutrition of children
under 5 years of age from 38.2% to 23.7%, against a target of 30.2% (last PARSALUD
progress report). MMR per se was not monitored by the program due to uncertainty about
the reliability of data; however, the indicator on institutional deliveries was used as a
proxy. As seen below, this indicator moved from 62.2% to 74.2% against a target of 78%,
between 2009 and 2014. The total number of maternal deaths was also reduced from 186
to 159 in the project areas, against a national average of 481 and 411 between 2009 and
2014. Hence, overall, PARSALUD was successful in reducing MMR and IMR and
chronic malnutrition in children under 5 years of age. More detailed program results are
found in Annex 3.
Assessment of achievement of the project’s objectives
40. In terms of the three specific project objectives, the ICR assesses the original
indicators as well as additional indicators added at the time of the ICR to introduce
additional evidence in support of the results chain to the PDO. All indicators were
related to the three parts of the PDO statement, as follows:
(i) Improvement of family care practices for women (during pregnancy, delivery and
breast-feeding), and children under the age of three:
KPIs# 1, 2, 3, 4, 6; IOIs # 1, 11
(ii) Strengthening of health services networks with capacity to solve obstetric, neonatal
and infant emergencies and to provide comprehensive health services to women
(during pregnancy, delivery and breast-feeding) and children under the age of three:
KPIs# 1, 2, 4, 5, 6; IOIs # 2, 3, 4, 5, 6 and 12 (added)
(iii) Supporting MINSA's governance functions of regulation, quality, efficiency and
equity for improving the new health delivery model of maternal and child health
care in a decentralized environment
IOIs # 7, 8, 9, 10; and 13, 14, 15 (added).
41. IOIs #2 and 5 (PDO 2), 7, 9 and 10 (PDO 3) were dropped at the 2014 restructuring. At
the time of the ICR data was only available to support IOIs #2 and 5, which were
14
therefore reintroduced. Additional qualitative data was collected to support the analysis
of PDO 3.
42. When assessed against the original baseline, all the indicators have surpassed,
achieved or partially achieved the targets at the end of the project, which supports
achievement of all parts of the PDO (Table 1). Also, notably, the final percentage of
achievement does not reflect that roughly half of all indicators surpassed their targets.
Therefore, the actual level of achievement is far greater than the table suggests.
Table 1: Achievement of PDO (targets against original 2005 baseline)
Program
level
PDO
level Intermediate PDO 1* PDO 2* PDO 3
Target surpassed 2 3 6 4 4 3
Target achieved or
substantially achieved
(>=85% met)
2 4 1 5 1
Target partially achieved
(65%-84% met)
1 2 2 2 0
Target not achieved
(<65% met)
0 0 0 0 0
Unknown
0 3 0 0 3
Total 2 6 15 7 11 7
% surpassed and
achieved 100% 83% 83% 71% 82% 100% * Note: The table double-counts some indicators to assess PDO 1 and 2.
43. Given the fact that the baseline for this project which was approved in 2009 actually used
2005 data (for reasons explained above), the ICR team reviewed achievement of project
indicators against the 2009 baseline (see Annex 10). Notably, many of the indicators
already registered improvements in 2009 compared with the baseline values of 2005.
This overall trend continued during project implementation, with all but one indicator
(prevalence of anemia in pregnant women) following the positive trajectory. This
supports the positive contribution of the project to the achievement of the PDO. In
addition, many of the indicators for the project regions showed performance at least in
line with the national average (see Annex 3), a very positive result considering the
geographical and socio-economic conditions of the project regions.
15
44. The assessment below is based on the official 2005 baseline data, and when appropriate,
also uses revised targets for IOIs.
PDO 1: improvement of family care practices for women (during pregnancy,
delivery and breast-feeding), and children under the age of three. Rating:
Substantial.
KPI #1: Increase the proportion of institutional deliveries in rural areas of the nine
selected Regions from 44% (2005) to 78% (2014) – Achieved
KPI #2: Reduce the prevalence of anemia among children under the age of 3 in the nine
regions from 69.5% (2005) to 60% (2014) – Surpassed
KPI #3: Increase from 64% to 80% the share of children in the nine selected regions who
are exclusively breastfed until 6 months of age – Surpassed
KPI #4: Reduce the prevalence of anemia among pregnant women in the nine Regions
from 41.5% (2005) to 35% (2014) – Partially Achieved
KPI #6: Increase in the proportion of pregnant women of the nine regions with at least 1
prenatal control during the first trimester of pregnancy from 20% (2005) to 45% (2014) –
Surpassed
IOI #1: Percentage of SIS affiliated children who received growth and development
controls (CRED) according to their age – Partially Achieved
IOI #11: Number of health personnel and community health workers trained within the
behavior change campaign (EPPES) – Surpassed
45. The project contributed to the increase of breastfeeding practices, one of the most
important indicators for Component 1. Exclusive breastfeeding has been low in Peru,
although in the project areas it was higher than the national average in 2009 (82.2% vs.
68.5%). The project greatly contributed to the uptake of breastfeeding practices in the
nine regions, since the share of exclusive breastfed children in project areas rose to 87%,
while the national average remained flat at 68.4%. This was in line with other GOP
programs such as Juntos, although other programs aimed at providing food and formula
supplements to poor families; therefore, achievements under the project seem to be
remarkable.
46. Progress on anemia in the nine regions has been slow, reflecting national trends.
Anemia has traditionally been a problem in Peru, often associated with lack of
knowledge. Anemia in children under 3 has been stable between 2009 and 2014 in the
project areas, while it has slightly declined as a national average (50.4 and 46.8). Anemia
in pregnant women declined between 2005 and 2014 but it did not follow a steady
trajectory. The prevalence of anemia, higher in the nine regions compared to national
average, was relatively stable at the beginning of the project, at around 30%. However,
after dropping to 24.3% in 2013, well below the national average of 28%, it started rising
again to levels higher than the national average (36.4% vs 32.5%). In the project regions,
the reasons for this trend seems to be related more to demand-side factors than supply-
side factors. The availability of iron supplements at facility level has increased over time
and the proportion of women who receives those supplements has also increased.
According to PARSALUD staff, women admit that they are not taking iron supplements
16
due to their bad taste, color and smell. New supplements have recently been purchased to
overcome this issue; their effectiveness is yet to be assessed once the data for 2015
becomes available. The slow progress on the prevalence of anemia in women in Peru
requires additional efforts to ensure stable and sustainable improvements.
47. The achievement of PDO 1 is supported by successful progress on a number of IOIs.
All facilities that needed to be provided with audiovisual equipment to support the
behavior change campaigns were in fact provided one (1,423). The project trained more a
total of 1,178 health personnel and community health workers within the communication
and behavior change campaign (400 more than planned). According to SIS data, the
biggest increase in the number of services provided to SIS-enrolled beneficiaries between
2011 and 2015 was for primary care services, which demonstrates greater accessibility of
basic services for the poor, with a sharp increase in prevention as opposed to curative
services. Finally, the campaign promoting identity and insurance rights (Derecho a la
Identidad y Aseguramiento, DIA) was conducted twice in every region for 3 months each
time, for a total of 6 months of campaing in every region ― 3 months less than originally
planned.
48. PDO 2: strengthening of health services networks with capacity to solve obstetric,
neonatal and infant emergencies and to provide comprehensive health services to
women (during pregnancy, delivery and breast-feeding) and children under the age
of three. Rating: Substantial.
KPI #1: Increase the proportion of institutional deliveries in rural areas of the nine
selected Regions from 44% (2005) to 78% (2014) –Achieved
KPI #2: Reduce the prevalence of anemia among children under age in the nine regions
from 69.5% (2005) to 60% (2014) – Surpassed
KPI #4: Reduce the prevalence of anemia among pregnant women in the nine Regions
from 41.5% (2005) to 35% (2014) – Partially Achieved
KPI #5: Reduce the hospital lethality rate among neonates in the nine selected Regions
from 9.5% (2005) to 5% (2014) – Achieved
KPI #6: Increase in the proportion of pregnant women of the nine regions with at least 1
prenatal control during the first trimester of pregnancy from 20% (2005) to 45% (2014) –
Surpassed
IOI #2: Percentage of health facilities with improvement in infrastructure (minor
construction and/or equipment) -- Achieved
IOI #3: Percentage of SIS affiliated rural pregnant women with laboratory tests on
hemoglobin, urine and syphilis – Surpassed
IOI #4: Percentage of pregnant women under SIS that receive iron and folic acid
supplements – Partially Achieved
IOI #5: Percentage of women satisfied with the services in selected facilities by
confidence index – Surpassed
IOI #6: Percentage of cesareans in SIS affiliated pregnant rural women – Achieved
IOI #12: Number of health facilities improved – Achieved
17
49. Health infrastructure improved in the nine regions. The project supported the
construction and/or renovation of 695 out of the planned 73 hospitals and basic health
centers that offered obstetric and neonatal services; the remaining 4 are being completed
in 2016, financed by GOP. It provided all of the 104 pre-identified health centers with
medical equipment for maternal and child care and installed IT systems in 55 centers to
support the implementation of the e-Health plans (planned 54).
50. The project delivered capacity building programs for different groups of health
professionals using a culturally-sensitive approach. The project contributed to the
training of 956 health workers (nearly 300 more than planned) on maternal and child care
and specifically of 282 doctors and midwives on the vertical delivery (Parto Vertical) in
7 health facilities located in 4 regions within PARSALUD. Together with improved
infrastructure and training, cultural adaptation of health facilities for the provision of
vertical deliveries and support to Maternal Waiting Homes (Casas Maternas) were key in
improving rates of institutional deliveries among indigenous populations. This includes
the creation, dissemination, and systematization of knowledge around vertical delivery
practices among health care providers and the institutionalization of this method in both
regions: in the Amazon and Cusco, 54% and 33% of all deliveries were vertical,
respectively, in 2012. The Casas Maternas, communal space managed, built, and
maintained by communities and local governments, helped address the physical and
cultural barriers faced by indigenous women residing far from health centers. There are
475 operational Casas Maternas throughout the country, with Cusco, Puno, Huancavelica
and Apurimac the most important areas of reference.
51. The project strengthened the networks of services and improved quality of care and
access to emergency services. In order to ensure a more effective network of services,
all 9 regions elaborated a plan for the improvement of the referral and counter-referral
system. The project also trained key health personnel in management of human and
financial resources (1,336 actual vs. 1,143 planned).
52. On quality of care, the project funded a specific training and implementation program to
reduce maternal pre- and post-partum bleeding through the introduction of a supervised
medical protocol based on the use of specific evidence-based interventions and medicines,
which has been shown to reduce post-partum hemorrhage. According to a survey done in
2012, the reported satisfaction among women who used the services was 75%.
53. The rates of C-sections in women affiliated with SIS increased in line with the intention
of ensuring that women in need were actually able to access this service. While the
national average has increased to 12%, in the PARSALUD region it seems to have been
stable since 2012. This seems to suggest that while excessive use of those services might
5 More precisely, one health center underwent two types of renovations and received two sets of equipment; hence
although technically the number of health centers renovated and equipped was 68 and 103 respectively, the number of
renovation works done and sets of equipment delivered was 69 and 104 respectively.
18
be starting in Peru, as it is already common practice across Latin America, in the project
area those services are provided only when required.
54. PDO 3: supporting MINSA's governance functions of regulation, quality, efficiency
and equity for improving the new health delivery model of maternal and child
health care in a decentralized environment. Rating: Substantial.
KPI #8: Percentage of SIS affiliated households that make out-of-pocket expenditures in
medicines – Partially Achieved
KPI #13: Norms and regulations to improve efficiency and equity of the health delivery
system prepared – Surpassed
KPI #14: Clinical pathways and corresponding financing systems designed – Surpassed
KPI #15: Periodic evaluations of the performance of the health networks – Surpassed
55. The achievement of the IOIs suggests that progress towards PDO 3 was significant. PARSALUD II developed 32 proposals for norms and legal acts to improve efficiency
and equity of the health system for approval by MINSA, when they had only planned for
27. The design of the clinical pathways and corresponding financing system was also
finalized by the project (16 actual vs 11 planned). The capacity of analyzing performance
of the health system also improved through the completion of regular performance
reports (19 produced vs. 17 planned) – although the majority of those were released in
2015, rather than being released constantly throughout the project and periodically
updated.
56. PARSALUD II supported MINSA in reformulating its regulatory framework to
ensure better quality of the health delivery system, in particular on purchasing,
prescribing, and monitoring the quality of pharmaceuticals. Peru’s consolidation of a
purchasing system for essential medicines lowered their costs for the country. In addition,
a comprehensive training system in essential drug prescriptions was implemented in the
project’s health facilities, and support was provided for improving the regulatory
framework for quality control using SUNASA (Superintendencia Nacional de Salud).
57. The project strengthened the regional management capabilities on MCH through
specialized training in neonatal and obstetric competencies for health professionals and
managerial capacities for the Health Regional Directorates (DIRESA). Budget executions
for functions related to maternal and child care and especially nutrition improved in the
nine regions following capacity building interventions between 2012 and 2014 (e.g.
Cusco moved from 88.7% in 2012 to 97% budget execution in 2014 on maternal and
child health, while Amazonas moved from 77.5% in 2012 to 91.6% in 2014 on nutrition)
58. Additional qualitative information supports significant progress on PDO 3. This
information was collected during the ICR mission and triangulated with findings by
PARSALUD evaluations derived from focus group discussions and individual interviews
conducted with informants at MINSA, PARSALUD team, regional administrators, health
professionals, and beneficiaries. The technical assistance provided by PARSALUD
supported a cultural change within the regional administrations and health professionals
19
towards an approach that recognizes the human right of pregnant women and children to
be treated fairly and with dignity, which has been appreciated by the beneficiaries. The
project assisted the decentralization process by providing targeted assistance to the
regions that needed more specific support with the regulation function. Topics of focus
varied depending on the needs of each region, ranging from human resources to supply
chain management. Progress were made on enhancing transparency, with a portal and
website created for PARSALUD. In addition, central planning for civil works was
strengthened as delays in starting and concluding civil works at the beginning of the
project reduced over time. Overall, this evidence suggests that PARSALUD promoted
significant progress in improving the government capacity on regulation, quality, equity,
and efficiency.
3.3 Efficiency
The Efficiency Rating is: Modest
59. Rather than carrying out a separate economic analysis, the PAD referred to the one done
in the FS. The ICR could not update the analysis done in the FS; instead, a more
qualitative assessment of project efficiency and cost-effectiveness was undertaken (see
Annex 3).
60. Cost-effectiveness was overall substantial, especially considering that the Bank loan
leveraged a much more significant amount of domestic resources; on balance, in
consideration of the delays and the disbursement level, efficiency is considered modest.
Allocative efficiency
61. Maternal, newborn and child health (MNCH) interventions are recognized by the
literature as highly cost-effective investments. Particularly effective interventions in
MNCH packages would be management of labor and delivery, care of preterm births, and
treatment of serious infectious diseases and acute malnutrition 6 ― all key focus of
PARSALUD. Such MNCH interventions, targeted to those most in need, can prevent
maternal and infant deaths and reduce the healthy years of life lost due to disability,
thereby benefiting the health sector and society as a whole 7,8,9
.
62. Lack of infrastructure and professional attention, under registration of beneficiaries on
the public health insurance (SIS) and poor managerial and logistic capacity on local
health units were identified as barriers to health service availability for women and
children in rural areas. Therefore, closing the gap in health care access required targeting
6 Black R, Levin C, Walker N, Chou D, Liu L, and others. 2016. "Reproductive, Maternal, Newborn, and Child Health:
Key Messages from Disease Control Priorities, 3rd Edition." The Lancet. Published online 9 April 2016 7 World Health Organization the case for Asia and the Pacific, Investing in Maternal Newborn and Child Health,
Geneva, Switzerland. 8 Bill and Melinda Gates Foundation, Maternal, Newborn and Child Health Strategy Overview,
www.gatesfoundation.org. 9 Black R, Laxminarayan R, Temmerman M, and Walker N. editors. 2016. “Reproductive, Maternal, Newborn, and
Child Health. Disease Control Priorities, third edition, volume 2”. Washington, DC: World Bank. doi:10.1596/978-1-
4648-0348-2. License: Creative Commons Attribution CC BY 3.0 IGO
20
resources on the identified barriers and on vulnerable rural populations. The return on
infrastructure investments have clear long-term benefits, which facilitate improvements
in the provision of quality services. In addition to infrastructure investments, the project
funded some important and highly cost-effective demand-side interventions under
Component 1. These evidence-based interventions supported the growing health service
demand, improved the quality of care and were at the core of PARSALUD I; a stronger
focus on similar interventions would have further increased the cost-effectiveness of
PARSALUD II.
Efficiency of project preparation and implementation
63. Project preparation was characterized by delays leading to a three-year gap
between the end of APL 1 and APL 2 effectiveness. Delays were largely due to the
political economy in the country. Once the project gained political traction, it was rapidly
appraised and negotiated.
64. The project was implemented within the time period originally planned. The project
was extended by 11 months, which balanced the 10-month gap between Bank approval
and effectiveness. However, despite the extension, the project disbursed 80% of the
planned amount, due to delays in procurement and civil works10
.
65. Given the nature of the project, the evaluation of Project efficiency should consider
the Bank’s overall program financial contribution. In this sense, the project was
extremely cost-effective, since by supporting less than 10% of the total program’s costs,
it leveraged nearly US$ 140 million of domestic resources, in addition to the US$ 15
million provided by the IADB. Despite the initial civil works delays and the 80% final
loan disbursement ratio, the program’s actual costs were fundamentally in line with the
amount of resources identified at appraisal.
66. The implementation efficiency of the overall Government program was leveraged by
the project funds and the use of Bank fiduciary safeguards that provided cover for
the weaker Government systems and processes. The Bank project team reviewed
procurement bidding documents and contracts for civil works, consultancy services and
provision of training for the overall program. This effort increased the leverage of
technical and fiduciary implementation support beyond the loan funds and enhanced the
technical skills of the PARSALUD technical and fiduciary team.
Fiscal impact and sustainability
67. The fiscal impact of the project was marginal, limiting sustainability concerns.
Project implementation did not have a major impact on the MINSA budget, as it weighed
an average of 0.08 percent throughout the period analyzed. Once the facilities were built,
10 Until three months before the project closing date, the PARSALUD team assured that the project would disburse
100% of the loan. However, this did not materialize due to legal problems with regard to a big consultancy contract and
delays in civil works, which are being funded by domestic resources.
21
improved or better equipped through the program’s funds, the responsibility for the
management of those was transferred to the regional government. By signing the
Convenios (contracts between PARSALUD and each of the nine regions), regional
governments committed to allocate budget for maintenance of the upgraded facilities as a
condition for starting civil works in pre-identified facilities in that specific region.
3.4 Justification of Overall Outcome Rating
The Overall Outcome Rating is: Moderately Satisfactory. This rating takes into account
that the project is the second in a series of two APLs to support a broader GOP program
that has been largely successful in achieving its goal of improving maternal and child
health.
Table 6: Summary of Outcome Ratings
Project Outcome Ratings
Relevance Substantial
Efficacy Substantial
Efficiency Modest
Overall Outcome Rating Moderately Satisfactory
3.5 Overarching Themes, Other Outcomes and Impacts
(a) Poverty Impacts, Gender Aspects, and Social Development
68. The project targeted specifically nine of the poorest regions, home of indigenous people
and isolated communities, and within those communities focused on the most vulnerable
groups ― women and children in the early years of life. The equity dimension was
important in conceptualizing the project, which contributed to social inclusion and
promoted a solid basis for personal identification and for the affiliation to the SIS. The
project was mindful of local identities and practices and successfully built on those to
select interventions that were culturally appropriate for a specific context, such as the
parto vertical. This was key in ensuring that people were more comfortable in accessing
the services, with the aim of sustaining improvements in access to basic services.
(b) Institutional Change/Strengthening
69. The project showed progress in building capacity at the central level and most
importantly at the regional and local levels, benefiting government representative and
different categories of health professionals. For example, PARSALUD II contributed to
the local and regional capabilities to conduct social dialogue with various stakeholders
prior to project implementation. The prior consultations on project’s infrastructure (to
build, improve and equip the health facilities for obstetric and neonatal care), was a
coordinated effort involving indigenous populations, regional and local governments,
which strengthened the ability of local and regional actors to seek consensus on health
infrastructure building.
22
(c) Other Unintended Outcomes and Impacts (positive or negative)
70. The project contributed to increased inclusion of indigenous communities and to provide
space for communities and especially women to be heard, increasing accountability of the
system. At the end of 2013, the project organized a South-South Knowledge workshop on
intercultural interventions in health aimed to showcasing PARSALUD’s best lessons
learned and bringing regional experiences that informed and strengthened PARSALUD’s
intercultural agenda. The main attendants to the workshop were representatives of the
Pan American Health Organization (PAHO), the National Autonomous University of
Mexico, the Ministry of Health of Venezuela and the Ministry of Cultures of Peru, among
others.
71. The project had a pivotal role in fostering and guiding the identity rights movement in the
health sector and in creating a platform for dialogue of different actors at the national and
local levels. The systematic introduction of birth certificates as the first means of personal
identification provided the legal basis for the registration to the SIS as well as other GOP
programs and access to the related benefits.
72. The project improved awareness of environmental issues, helped create a conducive
institutional environment to ensure environmental hazards are considered and dealt with,
and built capacity at the central, regional and local level.
3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops
Not available.
4. Assessment of Risk to Development Outcome
Risk to Development Outcome Rating: Moderate
73. The follow-on GOP program, Programa Nacional de Inversion de Salud (PRONIS), built
on the lessons learned and know-how from PARSALUD. Financial sustainability of the
program does not seem to be a concern, given that PARSALUD was already largely
funded by domestic resources and funds have already been allocated for the new program
investments. While the Project Coordinator and the Technical Coordinator have been
transferred, many of the key PARSALUD personnel are now working on PRONIS,
ensuring greater continuity of the follow-on investment program with PARSALUD.
PRONIS is also supervising the completion of the outstanding PARSALUD
consultancies and civil works to be delivered in 2016.
74. PRONIS focuses on 748 key health centers and facilities, many of which PARSALUD
rehabilitated or improved. However, contrary to PARSALUD, PRONIS is not
specifically targeted to the poorest regions and it does not support an explicit, a priori
objective or topic. The regions will identify the specific outcomes of focus for the
23
investments depending on their demographic and epidemiological characteristics and
political priorities.
75. PARSALUD put in place systems to ensure sustainability at the local level, by promoting
and supporting decentralization of responsibilities and functions and building capacity for
better use of resources for maternal and child services, which would benefit the regions
even in the context of PRONIS. However, the high turnover of staff in the regional
administrations and the irregular progress of some of the indicators pose some questions
on sustainability of achieved results if a systematic strategy to address those is not
adopted. Nutrition and anemia in particular remain problematic at the national level.
Therefore, ensuring more systematic progress on those indicators, especially among the
most vulnerable population, would require alignment of national, regional and local
commitment.
5. Assessment of Bank and Borrower Performance
5.1 Bank Performance
(a) Bank Performance in Ensuring Quality at Entry
Quality at Entry rating is: Moderately Unsatisfactory.
76. The project suffered from a long preparation time. The Concept Note review was held
in November 2005, but appraisal and negotiations were only conducted in December
2008. However, the time gap between the end of PARSALUD I and the beginning of
phase II was mainly due to changes in the political arena and consequent inconsistent
commitment from the GOP to maternal and child health and nutrition through the
program. When the project regained political traction, the project was appraised,
negotiated and approved by the Board of Directors within 3 months (December 2008-
February 2009). Once approved by the GOP, the Loan Agreement was signed in
November 2009 and declared effective in December 2009.
77. The long preparation time might have been used more effectively for persuading the
GOP to incorporate more of the “soft interventions” that characterized
PARSALUD I. The main focus of the APL 2 was on infrastructure investment, reflecting
a strong interest of the GOP. This was used as an entry point to incorporate some
activities to support a reform agenda, evidence-based interventions and changes of
practices at the individual and local level. These were in line with the highly effective
activities promoted by PARSALUD I, although in PARSALUD II they had lost the
prominence they had in phase I.
78. Finally, more effort could have been placed to address suggestions from the QER
and the DM, which proved to be important during implementation. Concerns were
raised during the QER and DM with regard to the need to strengthen the M&E capacity
of the counterpart and the M&E design, and to better assess the project’s fit with the new
institutional environment, evaluating the risks that this entailed. These concerns were
24
only partially addressed. Additional measures to strengthen M&E capacity of the
counterpart had to be taken during the MTR. The RF reflected a baseline which was
outdated by the time the project started and it included a high number of indicators; yet it
could have more clearly incorporated some IOIs to support the achievement of PDO 1.
Institutional constraints, such as the rigidity of the SNIP, were underestimated by the
project. Given that the project supported a broader program, any substantial changes
would have required additional approvals by SNIP causing further details; hence, the RF
was never revised during preparation, reflecting a baseline taken in 2005 and targets set
against that baseline.
(b) Quality of Supervision
The quality of supervision is rated Moderately Satisfactory.
79. The task team conducted regular supervision missions approximately every six
months to monitor the implementation of the project. Financial management
supervision missions were at times held separately. In addition to formal missions, the
team was in close communication with the PIU. Records of ISRs and Aide Memoire were
kept, although in some instances these were not available in the Bank’s online system.
80. The ISRs reported progress on most of the indicators, although data on two PDO
indicators only became available in late 2014, at which time five IOIs were dropped. The
team was aware of the outdated baseline and targets and repeatedly asked the counterpart
to update the RF; however, while changes were made to the RF, the counterpart did not
agree to revise the baseline. The team could have taken the opportunity of the
restructuring in 2011 to address this issue so as to better be able to monitor the
performance of the project.
81. Given that the project triggered the Environmental Assessment (EA) (OP/BP/GP 4.01)
and the Indigenous People Safeguard Policies (OP 4.10), environmental and social
safeguards were monitored. An environmental safeguard mission carried out in June
2013, reported that, although the EA’s recommendations were not fully met, the
seriousness of the counterpart on environmental issues and on their proactivity was
remarkable. The mission produced a series of recommendations aimed to systematize the
PIU’s efforts, which were ratified and implemented by the counterpart. A social
safeguard supervision mission carried out on May 2013, made recommendations to
improve the use of waiting homes for deliveries (casas de espera) and to increase the
sustainability of the mobile health care teams (mobile brigades), both of which were
adopted by the counterpart.
(c) Justification of Rating for Overall Bank Performance
82. On balance, the overall Bank performance is rated as Moderately Satisfactory.
5.2 Borrower Performance
25
(a) Government Performance
Government Performance: Moderately Unsatisfactory
83. The project could not count on constant political support. After a long preparation
period in which government commitment to the project was variable, an incoming
Minister of Health in October 2008 ensured that MINSA supported the investment
program during its implementation, since it aligned well with the new political priorities.
Throughout the life of the project, four ministers of health were in power. Laws and
regulations were approved timely and Management Agreement with the regions were
also finalized and implemented in line with the decentralization. While support from the
highest levels of the Ministry was more stable, commitment from the Sub-Ministry level
was more variable, requiring additional efforts from the PARSALUD team and the co-
founders to keep momentum and ensure continuity of implementation.
The political economy of the investment system in Peru and the relationship
between MINSA and MEF/SNIP posed some difficulties for both project design and
implementation. At the time of project preparation, MEF and SNIP, which had recently
been instituted, were strongly focused on hard investments rather than incorporate soft
elements in investment program. Unfortunately, given the SNIP requirements at the time,
options to adjust the project in line with “soft” interventions were very limited for
MINSA. For the same reasons, even though aware that the RFs for the project and for the
program should have been improved, MINSA could not support the request to update the
baseline, given that it would have required additional political approvals by SNIP. During
the last supervision mission in December 2015, the team was informed that MEF had not
secured funds for key PARSALUD personnel to be in place during the grace period (until
April 2016); the task team urged MINSA to address this issue. In addition, while in 2013
MEF had in principle agreed on increasing the proportion of loan resources to be used
under Component 2 (which was supposed to be 6% for the Pari-Passu), this commitment
never materialized and MINSA was not successful in its negotiations with MEF on this
aspect. As documented in the ISRs, financial planning and coordination between MINSA
and MEF remained an issue throughout the project.
84. Coordination between MINSA and the project team was variable depending upon
the political changes within MINSA. Tensions reached the highest levels in 2012, when
the Project Coordinator left the PIU, but overall improved after the appointment of a new
Minister of Health in the same year. In addition to informal and ongoing dialogue
between MINSA and the PARSALUD team, representative of MINSA participated in the
Steering Committee that regularly reviewed progress of the program, together with MEF,
PARSALUD, and regional representatives. From 2011, improved planning and
coordination between MINSA and the project team allowed for a reduction in the number
of requests for No Objections and a smother processing of the same by the Bank, which
resulted in less delays in implementation of Component 2.
(b) Implementing Agency or Agencies Performance
Implementing Agency Performance Rating: Moderately Satisfactory
26
85. PARSALUD PIU, an independent unit created within and by MINSA, was responsible
for the technical coordination, planning, M&E, financing and administration, including
procurement, contracting and payments, and accountability for the program; however, it
had limited decision making power. The execution of the technical component remained
under the relevant Directories of MINSA. The coordination capacity of the unit was
assessed as satisfactory from the start, given prior experience with coordination of the
first phase of the program and with the related Bank procedures.
86. The unit was adequately staffed. It included approximately 70 employees in 2015, in
addition to some consultants. Its key personnel have been pretty stable throughout the life
of the project. The Project Coordinator changed in 2012, after a political change in
MINSA. The new coordinator used to be the Technical Coordinator of PARSALUD,
which ensured institutional memory and consistent support to the initiative. Some issues
of coordination and dialogue between different teams within the unit could be detected.
87. The PIU complied with financial management procedures and reporting. The
Finance and Administration Unit was appropriately staffed (6 employees) since the start
of the project. For the first two years, integration of the information system and the
improvement of the TASK POA to issue Interim Financial Reports and Statement of
Expenditures was not complete. However, the PIU was still able to provide timely and
reliable information for project monitoring through Excel. Transactions were well
documented and financial reporting done in accordance with Bank requirements, as the
financial audits confirmed.
88. The unit was proactive in flagging any suspected cases of collusion in procurement.
For example, an INT case was opened in April 2011 on risks during execution of works
in the Region of Huancavelica. PARSALUD II timely identified and corrected fraudulent
practices from an enterprise and it responded positively to all requests made by the Bank,
designing and implementing a Governance and Anti-Corruption Action Plan.
89. The unit was very active in addressing social and environmental safeguards. For
example, even before the supervision mission in 2013, the unit had a dedicated and
growing team that not only monitored compliance with the EA, but had also developed
practical tools to be used during construction works to appropriately deal with solid waste
and water management. The unit had a system to ensure these checklists were available
to the construction companies and it monitored timeliness of use and compliance. The
unit supported the development of a technical norm on liquid waste management, training,
and the adoption and monitoring of plans for adequate solid waste and water management
in facilities already constructed and those being constructed.
(c) Justification of Rating for Overall Borrower Performance
90. On balance, the overall rating for the Borrower Performance is: Moderately Satisfactory.
6. Lessons Learned
27
91. Some of the lessons learned and reflections that emerge from the ex-post evaluation of
the project, considering the strengths and weaknesses of design and implementation,
include:
The importance of culturally-sensitive interventions to ensure effective access of
indigenous populations to health services (e.g. vertical delivery and casas de espera);
this requires action on the demand as well as on the supply side, since both families
and healthcare professionals need to understand their respective roles and
perceptions;
The pivotal role of the health system in promoting civil registration and vital statistics
(CRVS) through awareness campaigns and through its network of clinics and
hospitals, so that, from birth, individuals can be identified ― with benefits that go
beyond the sector; this requires a strong coordination between the Ministry of Health
and the authorities in charge of coordinating and administering CRVS programs. The
health sector is well positioned to pioneer innovative ways of engaging with
marginalized communities to this purpose, given the privileged entry point that health
services offer;
The crucial role of M&E systems to monitor project performance and to ensure
correction measures can be taken in a timely fashion and at the appropriate level;
particularly, being able to recognize and address the weaknesses of M&E design early
on and having a strong and meaningful RF from the start, which can be revised as
needed to reflect the project’s success and implementation pace. The RF should
reflect appropriate baseline and targets, identify indicators for outcomes and outputs
directly attributable to the project and those to which the project only contributes, and
present a clear results chain of PDO, outputs and project activities;
The importance of ensuring continuity of projects when financing a programmatic
series; institutional environment and contextual factors can change substantially in the
time frame of APL or DPL (Development Policy Lending) operations and keeping the
momentum when transitioning from one phase of investments to the next is crucial
for the relevance of the series of operations;
The difficult balance between the importance of maintaining ongoing dialogue and
long-term engagement with a country, on the one hand, and the efficiency in the use
of scares resources when pursuing relatively small investments in projects that require
substantial levels of supervisions and high volumes of transactions, on the other. In
this project, supervision efforts to oversee all program’s transactions were
disproportionate compared to the size of the loan, which accounted for less than 10%
of the program resources. As many countries transition from low-middle income to
higher income levels, this questions becomes more and more relevant for Bank
operations.
7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies
Comments were received by the PIU on June 17 and 21, 2016 and were further discussed
between the PIU team and the ICR Task Team Leader on June 21, 2016. Where
28
appropriate, comments were incorporated in the main text of the ICR. All comments
provided by the PIU are reported, as received, in Annex 7 after the executive summary of
the Borrower’s ICR.
(b) Cofinanciers
No comments were received from the IADB.
29
Annex 1. Project Costs and Financing
(a) Project Cost by Component (in USD Million equivalent)
Components Appraisal Estimate
(USD millions)
Actual/Latest
Estimate (USD
millions)
Percentage of
Appraisal
Strengthening of demand 6.00 6.43 107%
Improvement of service
delivery network 142.30 138.54
97%
Government and Financing 5.20 3.25 62%
M&E and Administration 8.90 16.86 189%
Total Baseline Cost 162.40 165.08 102%
Total Financing Required 162.40 165.08 102%
(b) Financing
Source of Funds Type of
Cofinancing
Appraisal
Estimate
(USD
millions)
Actual/Late
st Estimate
(USD
millions)
Percentage
of Appraisal
Borrower 132.40 138.23 104%
Inter-American Development
Bank 15.00 15.00 100%
International Bank for
Reconstruction and Development 15.00 11.98 80%
30
Annex 2. Outputs by Component
1. Component 1. Improving health practices at the household level for women (during
pregnancy, delivery and breastfeeding) and children under the age of three in rural
areas of selected Regions
a) Design, implementation and monitoring of a behavioral change communication and
education program to promote healthy practices at the household level, including
increased demand for health services (Estrategia de Promoción de Práctica y Entornos
Saludables, EPPES);
(i) Identification of specific practices to be promoted, including antenatal care,
institutional delivery, neonatal visits, exclusive breastfeeding, newborn feeding, care for
sick newborns at home, feeding a sick newborn; within the affiliation to SIS and the
health care rights and responsibilities.
(ii) Development and implementation of tailored EPPES strategies by region, focused on
202 districts.
(iii) Development, validation, and production of culturally sensitive printed and audio-
visual materials (radio spots, soap operas, videos, etc.) in different languages, including
Spanish, Quechan, Aymara, Awaji, Shipibo, and Wampi; for example, 13 modules of
radio soap opera “Mi derecho a crecer” (My right to grow), and 5 short videos on healthy
practices.
(iv) Behavior change campaign being featured in 45 radio channels and 18 television
regional or local channels in local languages.
(v) Distribution of equipment for basic training and dissemination (PCs, data display
devices, TVs, DVD) in 1,423 health centers;
(vi) Training of 380 community leaders, 412 local authorities, 720 healthcare personnel,
and 720 community/civil society agents for the local implementation of the EPPES;
b) Promotion of SIS enrollment rights and identity rights of the targeted population
(Derecho a la Identidad y Aseguramiento, DIA)
(i) 666,993 children under 3 years old and 1,888,531 women have been provided with the
live birth certificate, national identification document and affiliation with SIS.
(ii) Design, production and dissemination of materials promoting SIS rights and identity
rights for all nine Regions in Spanish, Quechuan, Aymara, Shipibo and Awaji.
31
(iii) Design and implementation of a campaign promoting SIS rights and identity rights,
carried out twice (in 2011 and in 2013-2014) in the nine regions for the duration of three
months each, focused on mothers, fathers, and careers.
(iv) Implementation of the Live Birth Registry and support to the Auxiliary Registry
Offices for the prompt registration in six regions (Amazonas, Apurímac, Ayacucho,
Cajamarca, Huánuco, and Huancavelica).
(v) Online system of birth registration in hospitals and more complex health centers in
eighth regions (Amazonas, Ayacucho, Apurímac, Cajamarca, Cusco, Huancavelica, Puno
and Ucayali).
(vi) Thirty six Auxiliary Registry Offices were installed in seven regions (Amazonas,
Apurimac, Ayacucho, Cajamarca, Huánuco, Huancavelica, and Ucayali) and training
workshops were organized for midwifes and RENIEC and SIS registrars.
(vii) Creation and strengthening of spaces for intercultural dialogue (Grupos Impulsores
del Derecho a la Identidad y Aseguramiento) in the nine regions, with representatives of
the regional Directorates of Social Development; RENIEC; JUNTOS Program; local
government representatives for the sectors: Education, Health, and Women and
Vulnerable Groups; and other NGOs and civil society organizations.
(viii) Seven regions approved regional directives for the issuance of the Live Birth
Certificate (Amazonas, Apurímac, Ayacucho, Cusco, Huánuco, Huancavelica, and
Ucayali).
(ix) All nine regions adopted regulations related to the timely and free-of-charge issuance
of the Live Birth Certificate.
2. Component 2. Increasing the capacity to provide better maternal and child health
services for the poor
a) Improvement of the quality of services in health facilities of the nine regions;
(i) Sixty nine health facilities were improved; these included new constructions and
expansion or remodeling of existing facilities in the nine regions; the remaining four
prioritized facilities will be delivered in 2016.
(ii) One hundred and four facilities were provided with new medical equipment in the
nine regions.
(iii) Technical assistance to ensure proper use and maintenance of the new infrastructure
and equipment for the administrators and the health teams.
(vi) All construction sites used the approved tools for environmental managements.
32
(vii) Fifty Environmental Impact Studies certified by DIGESA.
(viii) Evaluation of environmental liabilities and elaboration of Environmental
Management Plan for 22 projects implemented.
(ix) Capacity building to 805 staff in comprehensive solid waste management
in 104 health facilities.
(x) Design of the Technical Standard proposal "Integrated Management of fluid
waste in health facilities and medical support services”.
(xi) Technical assistance to DIRESA for simplification of procedures related to
authorization of septic tanks and infiltration and approval of the Program of Adequacy
and Environmental Management for the transfer, treatment and disposal of solid waste.
(xii) Implementation of an Internship program for Emergency Obstetrics and Neonatal
Care for a total of 674 participants, including 382 interns in diagnosis, stabilization and
referral of obstetrics and neonatal emergencies (FONB), 256 interns in basic emergency
obstetrics and neonatal care (FONE), and 36 interns in intensive care (FONI).
(xiii) Technical assistance to 11 hospitals in the nine regions to be qualified to host
interns.
(xiv) Training of 282 health professionals in the prioritized health facilities (FONB) on
vertical delivery, with 33 tutors and 6 training sites in 5 regions (Ayacucho (2),
Cajamarca, Cusco, Huancavelica, and Ucayali).
(xv) Development and distribution of 180 DVDs with videos promoting vertical delivery
across health centers in Ayacucho.
(xvi) Training of 440 health professionals in intercultural communication with Quechua-
speaking population in Ayacucho, Apurímac, Cusco, Huancavelica, and Puno.
(xvii) Twenty four initiatives implemented though an ad-hoc fund (Fondo Concursable)
in 167 health centers in the nine regions, by providing technical assistance to 24 technical
teams to strengthen both technical and managerial skills to implement 333 activities
identified in the action plans – benefiting a population of more than 370,000.
b) Provision of support for the integrated health delivery model and the development of
support systems to raise the efficiency and effectiveness of health networks.
(i) Proposals for improving the referral and counter-referral system, in particular for
maternal and neonatal service referrals, finalized in Puno and Ucayali and under
development in Amazonas, Ayacucho, Apurímac, Cajamarca, Cusco, Huánuco y
Huancavelica.
33
(ii) Technical assistance provided to DIRESAs and the health networks in the nine
regions to improve budget execution by better planning for maternal and child health and
nutrition between 2012 and 2014.
(iii) Training provided to 1,007 pharmacists and personnel responsible for
pharmaceuticals on stock management and good storage practices for pharmaceutical
products, medical devices and medical devices.
(iv) Implementation of the redesign of network storage and distribution of pharmaceutical
products, medical devices and medical devices in eighth regions.
(v) Software developed for the regions to monitor the availability of pharmaceuticals and
medical devices in the health centers.
(vi) Implementation of the Health Care Standards in 128 health centers by conducting
793 visits to provide technical assistance.
(vii) Implementation of the e-Health Network model of teleconsultations and tele-training,
using a platform installed in two centers acting as national reference points (Nacional
Materno Perinatal y Hospital Nacional Docente Madre Niño San Bartolomé) and in the
Regional Hospital and health centers in the regions of Amazonas, Huanuco and Ucayali
and Amazon, for a total of 48 primary care centers connected. Ongoing plans to establish
the e-Health model in Huancavelica, Apurímac y Ayacucho.
(viii) Started the development of the interoperable national system of Registry of
Teleconsultations.
c) Inclusion of intercultural focus in service provision
(i) Consultations in 12 districts in the nine regions through Intercultural Dialogues whose
purpose was to promote cultural understanding and participatory decision-making in
relation to the implementation of the program’s civil works.
(ii) Technical meetings for the analysis of maternal and neonatal health indicators with
representatives of DIRESAs, Directorate of Social Development, Ombudsmen,
universities, professional associations, CUNA MAS, UDR - SIS.
d) Increasing knowledge of effective delivery systems
(i) Study of prescribing practices in health facilities FONB and FONE in Huánuco and
Cajamarca.
(ii) Mixed-method study on the provision of health care to children under 3 years of age
in health facilities in 9 poor regions, Peru. 2013.
(iii) Qualitative evaluation of neonatal mortality in the regions of Huánuco y Ucayali,
Peru. Biomedica: Revista del Instituto Nacional de Salud (Colombia)
34
(iv) Cause-effect analysis of hospital neonatal mortality in two Andean-Amazonian
departments of Peru. Revista Panamericana de Salud Pública (OPS).
(v) Neonatal mortality, analysis of surveillance registries and clinical histories for
neonates in 2011 in Huánuco and Ucayali, Peru. Rev. Peru Med. Exp. Salud Pública.
2014.
(vi) Study of factors related to anemia in children under 3 years of age in Peru: analysis
of data from ENDES 2007-2013. Biomedica: Revista del Instituto Nacional de Salud
(Colombia).
(vii) Four studies on users’ perceptions on drugs and their use in medical facilities.
(viii) Determinants of the use of contraceptives in adolescent and young girls who are
sexually active, Peru 2012.
(ix) Analysis of the impact of investing in health facilities on maternal health indicators
in regions under PARSALUD II.
(x) Study of knowledge, perceptions, and attitudes towards C-sections and blood
transfusion in rural areas of the regions under PARSALUD II.
3. Component 3. Strengthening government capacities to offer more equitable and
efficient health system in a decentralized environment.
This component aimed at: a) Supporting a regulatory framework and increasing quality
in the provision of health services; b) Expanding the health insurance system (SIS)
enrollment; c) strengthening data monitoring and accountability in the system; d)
supporting the decentralization of health services
Component 3 outputs:
(i) Preparation of 32 technical norms and regulations for: (a) the accreditation and
certification system, currently proposed by the law but not regulated, (b) infrastructure
maintenance systems, (c) a reference laboratory system, (d) hemotherapy (e) hospital
financing, (f) pharmaceutical purchasing and logistics system, and (g) a health
communication and promotion system.
Proposal for the regulatory framework for Universal Health Coverage
Policy guidelines on citizen participation and oversight under the Universal
Health Insurance. In 2011 the Guidelines for Citizen Oversight prepared in 2010,
were approved
Proposed technical standards on Obstetric and Neonatal functions in health
facilities
35
Inspection manual and guide of good practices in manufacturing pharmaceutical
products (and validation)
Project for regulating organization and functions of SUNASA
Technical standards of the Service Delivery Unit, Obstetric Center
Regulation of the organization and functions of SIS – Personnel Allocation Table
Regulation for the registry, control and surveillance of pharmaceutical products
and medical devices
SIS regulations under the Universal Health Insurance
Analysis of the national health policy framework in line with the regulations of
transferred functions (decentralization)
Operationalization of the model of comprehensive health care at the primary care
level
Document defining physical targets for 2012 for the Strategic Programs for
Maternal and Child Health and Nutrition, through the implementation of the
IPMF (adjusted with recommendations of the MEF and MINSA) at the level of
the DIRESAs, UE, Networks, Micro-networks and health facilities
Bill of law on financing for the subsidized and semi-contributory insurance
Proposal for the salary scale of the MINSA and Regional Government personnel
in the Medical Career track
Roadmap of the decentralization process
Criteria to estimate the needs for pharmaceutical products and medical devices
used for the Health Priorities
Supreme decree on the Mobile System for Emergency Care
Clinical guideline for emergency obstetric care according to the level of care (x2)
Strategic Plan of the AUS
Manual of the organization and functions for the regulatory framework on
Universal Health Insurance and its regulations
New LOF of MINSA
Proposal for the Users’ Committee of the SUNASA; health norm (maternal,
newborn and child care); regional norm on the care for newborn and children
under 3 years of age in the region of Huancavelica
Regulation related to the law on financing for the subsidized and semi-
contributory system
Whitepaper on Identity and Insurance Rights
Technical standards for the Service Delivery Unit for Intensive and Intermediate
Newborn Care
Norm of SISMED
Proposal for the standard identifier for medical devices
Proposal for local decentralization
Criteria for the Definition of Health Care Networks, with emphasis on maternal-
neonatal care
Update of the technical standards for the vertical delivery (2015)
Proposal for the regulation of telecare – remote diagnostics (2015)
Accreditation model of the IPRESS, which includes:
36
o product 2: (i) proposal of whitepaper: model of quality health care
accreditation by IPRESS, and (ii) proposal of health standards: manual of
quality health care accreditation by IPRESS in Peru
o product 3: (i) proposal of regulation for the accreditation by IPRESS in
Peru; (ii) Proposal of regulation for the certification of the agents qualified
for certifying accreditation by IPRESS in Peru
o product 4: (i) proposal of methodology and clinical guidelines and tools
for the accreditation by IPRESS (including the model of supervision of
accreditation by IPRESS); (ii) proposal of the financing model for
accreditation by IPRESS in Peru; and (iii) proposal for the model of
information management for accreditation by IPRESS in Peru
(ii) Technical assistance supporting SIS and the decentralization of responsibilities in
health care
Redesign of the Technical Document on Quality in Health, in the context of the
National Policy on Quality in Health, Decentralization, and Universal Health
Insurance, which sets the guidelines for the design and implementation of the
Quality Management System in the health facilities
Systematization of the implementation process of the Universal Health Insurance
in the MINSA and in the regions of Ayacucho, Apurímac and Huancavelica
Systematization of the evaluation of the exercise of the functions transferred to
the regions, based on the application of MED
Technical and financial assistance for the development of the model for the
supervision of SUNASA
Systematization of the M&E implementation process of the decentralization
aimed at improving performance of the health functions
Computer application that automate the analysis and reporting of information
from the monitoring system of availability of medicines and supplies for the
delivery and obstetrics and neonatal emergencies (available on the PARSALUD II
website)
Technical assistance for the proposal for the evaluation of results and monitoring
of the implementation of the universal health insurance, which includes a set of
indicators for the AUS baseline and the design of the evaluation
Technical and financial assistance for the development of the model for
implementing the National System of Conciliation and Arbitration in Health
Design of the model for evaluation of staff and monitoring of the supervisions to
IPRESS and the Management Units (2015)
Strengthening of the management of multi-year investments in health (2015)
Proposal of the Coverage of the Benefit Package of FISSAL (2015)
Design of the management model of FISSAL (including tax policy, relationships
with providers, payment mechanisms and incentives) (2015)
Proposal for the baseline, evaluation of results and monitoring of activities for the
implementation of the AUS, presented to CTIN and SETEC
Cost-benefit analysis of pre-hospital emergency and urgent care of the Mobile
System for Emergency Care National Program
37
Study of the status of transfer (of functions) from SIS to the implementing units
Elaboration of the Annual Report to the Congress of the Republic of Peru on the
progress with the implementation of the AUS
Evaluation of the potential impact of measures for the protection of intellectual
property in the access to biological products
Analysis, identification and proposal for the legal regulations to support the
activities of the innovative model of Telemedicine
Diagnosis of the care provided to SIS patients in pharmacies, both public and
private, in the context of the implementation of Inclusive Pharmacies
(iii) Support to capacity development through the creation of ad-hoc training programs,
including:
Government and Management in Health (176 tutors and 332 health professionals
trained in the I edition and 346 in the II edition, including doctors, nurses,
obstetricians, and pharmacists), consisting of a Master in Government and
Management in Health, Diplomas in different areas (Strategic Planning and
Public Investment Programs, Health Management and Administration,
Management of Health Networks, Hospital Management), and certificates for
specific modules
Diploma in Information management for Health Interventions (76 tutors and 266
health professionals trained, including doctors, nurses, obstetricians, nutritionists,
psychologists, and biologists)
(iv) Studies supporting the implementation of the PARSALUD program and the
development of technical documents and proposals for regulations:
Analysis of factors associated with out-of-pocket spending in health, among the
poor population, in a context of a progressively increasing funding for
comprehensive health insurance
Diagnostics of the information system in the nine regions
Evaluation of the implementation of the accreditation process of health services
within the scope of PARSALUD II and proposal for improvement
Evaluation of maternal and child care practices in areas of extreme poverty in
Peru, 2012 (Published in Rev. Peru Med. Exp. Salud Pública. 2014; 31(2):243-53)
Systematic review on effectiveness of community interventions on the reduction
of neonatal mortality. Revista Peruana de Medicina Experimental y Salud Pública
Systematic review on effectiveness of community interventions on the growth and
development of children under 5 years of age in rural areas. Revista Cadernos de
Saude Pública – Brasil
Technical document generated from the International Conference “Towards
Universal Health Coverage” (Hacia la Cobertura Universal de Salud)
Literature review on Comprehensive Health Care Networks
38
Literature review on the efficacy or effectiveness of pharmaceutical policies
which contribute to improve access to essential drugs for the population
Review and development of proposals for improvement to the document
“Guidelines and measures for the reform of the health sector”
E-Health in Peru: systematization of the experiences from 2002 to 2013.
E-Health in maternal and neonatal services in the Peruvian Amazonia: towards an
integrated model.
Evaluation and redesign of the health care model for dispersed populations
Systematization of the experience with the behavior change campaign Estrategia
de Promoción de Practica y Entornos Saludables (EPPES) in PARSALUD II
Systematization of the experience with the strategy for the Derecho a la Identidad y
Aseguramiento (DIA) in PARSALUD II
Systematization of the experience with the Fund (Fondo Concursable) for the
selection and implementation of interventions in PARSALUD II
Systematization of the experience with the strategy for Prior Consultations and
Intercultural Dialogue implemented by PARSALUD II
Systematization of the experience with the management of PARSALUD II
Systematization of the experience with the implementation of the training
program via internships on obstetrics and neonatal emergencies and vertical
delivery
Systematization of the experience with community participation and transparency:
strategies for citizen oversight and accountability
Systematization of the experience with the improvement of infrastructure and
equipment of the health facilities classified as FONB and FONE, developed under
the investment framework within PARSALUD II
4. Component 4. Project Coordination and Monitoring and Evaluation (M&E),
through the provision of technical assistance, financing of incremental operating
costs, and external and concurrent audits.
(i) PARSALUD PIU operating costs.
(ii) Mid-Term Evaluation of PARSALUD program.
(iii) Final evaluation of the PARSALUD program.
(iv) Yearly external financial audits.
(v) Elaboration and implementation of risk mitigation plans related to procurement and
contracting.
39
Annex 3. Economic and Financial Analysis
Introduction
1. Peru’s (APL2) Health Reform Program Project sought to reduce maternal and infant
mortality rates in Peru’s nine poorest, largely rural and indigenous, regions. The targeted
regions (Amazonas, Huánuco, Huancavelica, Ayacucho, Apurimac, Cusco, Cajamarca,
Ucayali and Puno) are characterized by greater population dispersion, fewer health
facilities, lower service demand and generally a higher incidence of infant and maternal
morbidity and mortality. Therefore, the interventions targeted by the Project improved
maternal and infant mortality in the regions where health improvements are more difficult
to achieve.
2. Higher maternal and infant mortality rates and malnutrition in children under 5 are
associated with higher poverty levels and lower access to health services.11
According to
data from ENDES 2005-2007 neonatal mortality was 11 times higher among newborns of
the poorest income quintiles (23 per 1000 live births) compared to those of the richest
income quintiles (2 per 1,000 live births). Likewise chronic malnutrition has a very
unequal geographic and income distribution.12
Maternal mortality, double the LAC
average also reflects wide disparities in Peru, with Lima measuring an MMR of 52 in
2000 while the MMR for Huancavelica and Puno were 302 and 361, respectively in the
same year. In these two regions only 21 and 27.8 percent of the total births were
professionally attended.
3. Studies have demonstrated that public spending on rural infrastructure is one of the most
powerful instruments that governments can use to promote economic growth and poverty
reduction.13,14
In particular, maternal, newborn and child health (MNCH) interventions
are recognized by the literature as highly cost-effective investments. Particularly effective
interventions in MNCH packages include labor and delivery management, preterm birth
care, and serious infectious diseases and acute malnutrition treatment 15
― all key focus
of PARSALUD. Many maternal and infant deaths can be prevented with cost-effective
health interventions and services targeted at those most in need.16,17
Studies show that the
11In 2005 a rural sick child affiliated to SIS had a 2.9 higher likelihood to demand health services than a sick rural child
with no SIS affiliation (http://www.parsalud.gob.pe/factibilidad-del-programa, Estudio de Factibilidad: Modulo III:
Formulacion, pag 434). 12 In 2004 (INEI, 2006) malnutrition was almost four times higher among children living in the rural areas (39 percent)
than for those living in urban areas (10 percent). The regions of Huancavelica, Huánuco and Ayacucho, among the
poorest in Peru, have more than 40 percent stunting levels. 13 Fan, Shenggen, Infrastructure and Pro-poor Growth, Paper prepared for the OECD DACT POVNET Agriculture and
Pro-poor Growth, Helsibki Workshop, 17-18 June 2004. 14 Many of the health complications women face during childbirth could be prevented with better access to skilled
health care professionals during labor (World Health Organization). 15 Black R, Levin C, Walker N, Chou D, Liu L, and others. 2016. "Reproductive, Maternal, Newborn, and Child
Health: Key Messages from Disease Control Priorities, 3rd Edition." The Lancet. Published online 9 April 2016 16 World Health Organization the case for Asia and the Pacific, Investing in Maternal Newborn and Child Health,
Geneva, Switzerland. 17 Bill and Melinda Gates Foundation, Maternal, Newborn and Child Health Strategy Overview,
www.gatesfoundation.org.
40
direct health benefits of investing in family planning and maternal and newborn health
services is dramatic, reducing the healthy years of life lost due to disability and pre-
mature death. Furthermore, the implementation of cost effective MNCH interventions not
only has direct benefits for women and children but also for the health sector and
societies as a whole.18
Targeted investments can support the response of health systems to
other urgent medical needs, curb sexually transmitted diseases, while reduce unplanned
births and family size, thereby improving educational and employment opportunities for
women, saving public-sector spending for health, water, sanitation and social services
and reducing pressure on scarce natural resources.
Project Costs
4. Lack of infrastructure and medical personnel attention are an obstacle to health service
provision for women and children in rural areas. Closing the gap in health care access
requires targeting resources on those least likely to be receiving care, such as the
indigenous and rural population in Peru. Investment in health care infrastructure is cost
effective and supports the improvement of health outcomes in rural and poor areas. A
recent study prepared by Juan Jose Diaz and Miguel Jaramillo evaluating Peru’s
PARSALUD program found infrastructure investments (and training) cost effective
through the prevention of blood loss.19
Eighty three percent of Peru’s Health Reform
project funds (USD$138 million) went to fund Component 2 (demand side interventions),
which was one of the most effective in terms of PDO achievement.20
Table 1: Component Effectiveness21
PDO 1 PDO 2 PDO 3
PDO Achievement 0.70 0.79 0.94
Costs for related component 5,861,770.32 138,555,014.74 3,262,626.36
Indirect costs per related
component 4,522,123.35 4,522,123.35 7,787,229.78
Total costs for related component 10,383,893.67 143,077,138.09 11,049,856.14
Feasibility Study Benefits
5. The GOP conducted a feasibility study (FS) during project preparation evaluating two
project investment options. The project was selected for its low cost-effectiveness ratio
vis-à-vis alternative projects. Though the FS was not updated during the ICR, the
assumptions made regarding the estimation of Project costs and effectiveness for the
18 Black R, Laxminarayan R, Temmerman M, and Walker N. editors. 2016. “Reproductive, Maternal, Newborn, and
Child Health. Disease Control Priorities, third edition, volume 2”. Washington, DC: World Bank. doi:10.1596/978-1-
4648-0348-2. License: Creative Commons Attribution CC BY 3.0 IGO 19 The study found that infrastructure investments and training supported the prevention of blood loss (above 500
milimeters) for an average cost of US$3328 per case (and US$29,897 for a case with blood loss above 3,000 mililiters).
Evaluating Interventions to reduce maternal mortality: evidence from Peru’s PARSalud program, Journal of
Development Effectiveness, Volume 1, Issue 4, 2009). 20 See annex 2 for detailed information on indicator achievement. 21 This chart does not include the almost USD$17 million spent on monitoring, evaluation, administration and auditing.
41
feasibility study appear adequate. The economic valuation was undertaken following
accepted international standards for estimating the present value of future costs avoided
in the target population. The Project’s costs were assumed to be US$162.4 million, the
discount rate 11 percent in soles and the benefit of Project implementation USD$4.45
million. The actual project cost was USD$164 million, (USD$13 million World Bank
financed, USD$15 million IADB financed and USD$138 million GOP financed). The
benefits were estimated applying the methodology of Quality Adjusted Life Years
(QUALY). Measuring benefits through QUALY’s not only measures the number of years
gained due to loss of mortality but also as a result of the decrease in chronic or temporary
incapacity due to chronic illnesses.22
The method considered the following effectiveness
indicators: the number of avoided deaths; the number of avoided disease cases and the
number of days that an individual is prevented from of being ill due to the project effects.
Chart 2 includes some of the main health benefits assumed and quantified from project
implementation.
6. In order to evaluate the study’s assumptions we compared (when possible) the actual
change in indicators impacted by the targeted interventions. The interventions used in the
FS study for applying the QUALY methodology (and for which a reduction in deaths or
cases is assumed) are similar to those targeted in the Project. Generally the assumptions
regarding health improvements (and years of life gained due to reduction in deaths and
incapacities) were reflected in health improvements in the Project regions though the
actual number of death avoided/cases is difficult to compare. The largest benefits (in
economic terms) from the interventions assumed in the study stem from the leading
causes of maternal and infant mortality (hemorrhages and preeclampsia/eclampsia, and
delayed fetal growth, fetal malnutrition, short gestations and low birth rate, respectively),
since one year of premature death is the equivalent of one year of healthy life lost (see
Table 2).
Table 2: Feasibility Study Calculated Benefits
Source: FS Module IV: Evaluation
22 The method converts the loss of mortality/incapacity avoided years into years of life gained.
42
7. The FS assumed project interventions would result in a reduction in maternal death cases,
from 321 cases if the project was implemented to 237 without the project (difference of
84).23
The actual decrease in maternal deaths in the Project areas was of 75 women
between 2007 and 2015.24
A FS-assumed reduction in anemia cases was reflected in an
actual reduction of anemia among children under the age of 5 in the nine project regions
(PDO 2) from 69.5 percent (2005) to 57.3 percent (December 2014) and among pregnant
women in the same area (PDO 4) from 41.5 percent (2005) to 36.4 percent (2014).25
The
availability of iron/folic acid supplements during Project implementation in the targeted
regions also suggests that the use of iron/folic acid supplements increased with Project
implementation (as indicated in the FS study) thereby boosting maternal nutrition (with
associated impacts on infant deaths).
8. The FS study assumed a significant reduction in infant deaths with a high associated
monetary benefit due to the prevention of considerable years of healthy life lost. The
main targeted interventions (which are the main causes of infant mortality) are related to
the diagnosis and treatment of asphyxia, sepsis, prematurity, low birthrate, neonatal
hospitalization and postpartum control. The projected number of deaths avoided
according to the FS due to various interventions ranged from 24,200 without the Project
to 28,531 if the Project was implemented (difference of 4331). Though the Project did not
measure infant mortality, one of the Project PDO indicators (PDO indicator 5) measured
the hospital lethality rate among neonates in the nine selected Regions, which fell from
9.5 percent (2005) to 5 percent (2014). The under-5 mortality rate (per 1,000 live births)
in Peru fell from 22.1 in 2009 to 16.9 in 2015, also displaying a downward trend.26
In
addition to the interventions targeted, the project also lowered chronic malnutrition in
children under 5 from 36.6 percent of the Project population to 23.7 percent. This was
supported by an increase in exclusive breastfeeding in children under 6 months from 79.7
percent to 87 percent and in hand washing (for mothers) from 36.3 percent to 44.1
percent (project data). These interventions support the prevention of diarrhea, pneumonia,
and respiratory diseases, all common causes of child illnesses.
Comparison among regions
9. An experimental approach comparing the regions with and without Project intervention
reveal substantial effectiveness due to favorable results in Project implemented regions.
The fall in malnutrition and maternal mortality were greater in the Project regions than in
the non-project regions. This is particularly significant when one takes into account the
lag in health service demand in the project regions, partly due to the associated service
access difficulties. A study prepared by the GOP revealed that (pre-project) only 57
23 The study focuses on: complicated abortion, normal birth, hemorrhaging, eclampsia, sepsis and obstructed cesarean. 24 National Epidemiological Network 25 At the time of project preparation more than ¼ of women between 15 and 49 suffered from anemia largely because
of inadequate nutrition.. 26 Estimates developed by the UN Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, World Bank,
UN DESA Population Division) at www.childmortality.org.
43
percent of the poorest quintile had physical access to the obstetric network less than 2
hours from their residence.27
.
10. Malnutrition fell 12.8
percentage points in the project
areas, compared to 6.9
percentage points in the non-
project regions. The fall in the
project areas narrowed the gap
between the project and national
averages from 12.8 percent in
2009 to 9.1 percent in 2014.
Decreases in the rural project
areas (13.5 percent) were
significantly higher than in urban areas (7.9 percentage points). Furthermore, as hoped,
the fall in malnutrition was higher for the lower income quintile (14.5 for quintile 1 and
16.7 for quintile 2 compared to no change in the superior quintile)
11. Malnutrition and infant mortality outcomes were driven by a number of improvements in
interventions supported by the project. The proportion of exclusively breastfeed children
in the project areas increased 7.3 percentage points while remaining practically the same
in the non-project areas. However, in the project areas the increase was driven by the
urban and higher quintile population (since approximately 90 percent of the lower
quintile already exclusively breastfeed). Changes measuring the prevalence of anemia
and EDA (extreme diarrhea) in children under 3 for the years 2009-2014 were similar for
project and non-project areas. Both project and non-project areas experienced an increase
in hand washing, 7.8 percentage points and 11.4 percentage points respectively,
supporting a reduction in diarrhea and other illnesses. In the Project areas the increase
was higher in the rural and lower income quintile populations. The proportion of children
under 3 with health child appointment (control de crecimiento y desarollo – CRED)
increased significantly in both the project areas and nationally.
Maternal mortality in the project areas fell by 38 percent between 2007 and 2015,
compared with a 28 percent drop in the non-project areas suggesting that the project had
an important impact. This is
particularly true when comparing
the more difficult terrain and
poorer access to services, in
project versus non-project areas.
The proportion of institutional
births in Peru, a proxy for
maternal mortality, increased 13.3
in the project areas, 16.3 in the
non-project areas and 14.3
27 (http://www.parsalud.gob.pe/factibilidad-del-programa, Estudio de Factibilidad: Resumen Ejecutivo, p. XIII).
44
nationally between 2009 and 2014. The increase was most marked in rural project areas
(13.3 percent increase) and in the lower income quintile (16.2 percent for quintile 1 and
14.5 percent for 2). The proportion of rural pregnant women that have an appointment
within the first trimester increased for both groups. Though the neonatal mortality did not
reach the target for 2014 of 3.8 it decreased slightly from 5.6 in 2009 to 5.02 in 2014.
Fiscal Impact and Sustainability
13. The fiscal impact of the project was marginal limiting any sustainability concerns. As
identified during project preparation and as revealed in Table 3 project implementation
did not have a major impact on the MINSA budget, as it weighed an average of 0.08
percent throughout the period analyzed.
Table 3: Project Financial and Sustainability Analysis
Source: World Bank DataBank, at 2010 constant price
45
Annex 4. Bank Lending and Implementation Support/Supervision Processes
(a) Task Team members
Names Title Unit
Lending
Fernando Lavadenz Senior Health Specialist GHN04
Amparo Elena Gordillo-Tobar Sr Economist (Health) GHN04
Nelson Gutierrez Sr Social Protection Specialist GSP04
Alessandra Marini Senior Economist GSP03
Jose Pablo Gomez-Meza Senior Economist (Health) LCSHH
Livia M. Benavides Country Operations Adviser LCC6C
Patricia Mc Kenzie Practice Manager GGOPR
Rocio Schmunis Operations Officer GHN05
Mariana Montiel Senior Counsel LEGLE
Fabiola Altimari Senior Counsel LEGLE
Keisgner De Jesus Alfaro Senior Procurement Specialist GGODR
Patricia de la Fuente Hoyes Senior Financial Management Specialist GGO22
Tomas Socias Senior Procurement Specialist LCSPT
Xiomara Morel Lead Financial Management Specialist GGO22
Lourdes Linares Senior Financial Management Specialist GGO22
Nelly Ikeda Financial Management Specialist GGO22
Robert Leonard O'Leary Senior Finance Officer WFAFO
Monique Francine Mrazek Senior Investment Officer CMGCS
Alonso Zarzar Casis Sr Social Scientist GSURR
Isabel Tomadin Social Sector Specialist GSURR
Pablo Lavado Junior Professional Associate LCSHS
Carmen Rosa Osorio Junior Professional Associate LCSHE
Claudia Sanchez Junior Professional Associate LCSHE
Patricia Bernedo Senior Program Assistant GSP04
Luisa Yesquen Program Assistant LCC6C
Erika Bazan Lavanda Program Assistant LCSHD
Natalia Moncada Senior Executive Assistance GSUSD
Julia Nanucci Language Program Assistant LCSHD
Zulma Ortiz Consultant LCSHH
Silvana Vargas Consultant LCSHS
Pablo Augusto Lavado Consultant GMFDR
Supervision/ICR
Fernando Lavadenz Senior Health Specialist GHN04
Andre Medici Senior Economist (Health) GHN04
46
Nelson Gutierrez Sr Social Protection Specialist GSP04
Omar S. Arias Diaz Lead Economist GSPDR
Amparo Elena Gordillo -Tobar Sr Economist (Health) GHN04
Alvaro Larrea Lead Procurement Specialist GGO04
Rocio La Vera Procurement Specialist GGO04
Patricia de la Fuente Hoyes Senior Financial Management Specialist GGO22
Nelly Ikeda Financial Management Specialist GGO22
Monica Tambucho Senior Finance Officer WFALN
Maria Virginia Hormazabal Finance Officer WFALN
Renata Pantoja Financial Analyst WFALN
Mariana Montiel Senior Counsel LEGLE
Rocio Schmunis Operations Officer GHN05
Federica Secci Health Specialist GHNGE
Claudia Sanchez Lanning Junior Professional Associate GSPDR
Carmen Cornejo Junior Professional Associate LCSHD
Gabriela Moreno Zevallos Program Assistant GHN04
Sara Burga Program Assistant LCC6C
Cristian Pereira Stambuk Consultant GEDDR
Fernanda Bahia Consultant LCSHH
Isabella Bablumian Consultant GHNDR
(b) Staff Time and Cost
Stage of Project Cycle
Staff Time and Cost (Bank Budget Only)
No. of staff weeks USD Thousands (including
travel and consultant costs)
Lending
FY06 36.18 184.20
FY07 24.35 85.85
FY08 37.94 140.46
FY09 43.55 144.57
Total: 142.02 555.08
Supervision/ICR
FY09 12.94 41.70
FY10 32.17 93.30
FY11 41.00 137.90
FY12 47.00 196.22
FY13 51.78 215.81
FY14 60.35 254.61
FY15 28.56 152.98
FY16 10.94 78.14
Total: 284.74 1170.66
47
Annex 5. Beneficiary Survey Results
Not applicable
48
Annex 6. Stakeholder Workshop Report and Results
Not applicable
49
Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR
1. The evaluation of the PARSALUD II program was conducted in 2015 by the Peruvian
University of Cayetano Heredia and the National Institute of Mexican Public Health. An
English summary of the main findings of the evaluation is reported below and the
original Executive Summary of the evaluation report follows (in Spanish)
2. PARSALUD II was established as a program to support the modernization process and
reform of the health system, while seeking to improve the health and lower the mortality
and morbidity of the maternal and infant population in the 9 poorest regions of Peru.
Project design included various components targeting health service demand and supply,
health sector regulations and national and regional management aspects.
3. The objectives of the evaluations were the following:
Determine program design relevance in terms of PDO achievement.
Determine target achievement in relation to program activities/components and
achievement of objectives and targets in relation to the baseline and the intermediate
evaluation
Identify the Project’s main limitations, successes and lessons learned in order to
provide recommendations.
4. Results and Conclusions:
PARSALUD II targets were aligned with Peru’s national health strategy.
Interventions prioritized rural and areas with greater poverty levels where
maternal and infant mortality rates were greater than in the rest of the country.
Program design was relevant, appropriate, and had a logical structure.
Indicators were partially in line with the Program’s strategic actions and
components.
Project expenditure was 100% efficiency in 6 of the 14 analyzed activities.
Some of the most notable program successes include: (a) a reduction in the
prevalence of malnutrition in children under 3 (from 37 to 21%), (b) the
institutionalization of the care of women’s health during pregnancy, birth and
during the postpartum period, and (c) the promotion of good health practices
related to children.
When comparing Project implementation and non-Project implementation regions,
the evaluation found that the project regions presented better health conditions
regarding indicators measuring prenatal care attention and quality of attention and
institutional births. However, women in these regions also presented greater
complications during the postpartum period.
In terms of the health of infants 3 years and younger the greatest advances were
related to nutritional indicators. The reduction in chronic malnutrition was almost
12 percentage points in both groups between 2009 and 2014.
Though the results reveal changes that favor the improvement of health in
population groups exposed to PARSALUD2 it is difficult to directly attribute the
positive impacts to the Project.
50
“ESTUDIO DE EVALUACIÓN FINAL DE LA SEGUNDA FASE DEL
PROGRAMA DE APOYO A LA REFORMA DEL SECTOR SALUD -
PARSALUD II” (Resumen Ejecutivo)
INTRODUCCIÓN
5. PARSALUD II se crea como programa para apoyar el proceso de modernización y
reforma del sistema de salud, buscando mejorar el estado de salud de la población
materno – infantil, mediante el incremento del uso de servicios de salud materno
infantiles y la reducción de la morbilidad de los niños y niñas menores de 3 años de
familias de la zona rural de 09 regiones más pobres del Perú (Amazonas, Apurímac,
Ayacucho, Cajamarca, Cusco, Huancavelica, Huánuco, Puno y Ucayali).
6. PARSALUD II combina varios componentes que se relacionan y actúan tanto en la oferta
como en la demanda de servicios de salud, así como a nivel normativo y de gestión a
nivel nacional y regional. Para cumplir con los objetivos, el Programa se ha organizado
sobre la base de tres componentes que han sido considerados como fundamentales:
Fortalecimiento de la demanda, fortalecimiento de la oferta y gobierno, y financiamiento
y adicionalmente un componente transversal de gestión que incluye administración,
evaluación, monitoreo y auditoría.
7. La Universidad Peruana Cayetano Heredia con el Instituto Nacional de Salud Pública de
México realizaron la evaluación final de PARSALUD II en el 2015, desde una
perspectiva integral de todo el ciclo de la acción: Planificación, implementación
resultados e impactos, utilizando la teoría del cambio.
8. Los objetivos específicos de la evaluación son los siguientes:
1. Determinar la pertinencia, relevancia y suficiencia del diseño del Programa en relación
al logro de los objetivos.
2. Determinar el grado de cumplimiento de las metas previstas con relación a las
actividades y componentes del Programa.
3. Evaluar el nivel de cumplimiento de los objetivos y metas a nivel de resultado y
evaluar su tendencia contrastándolos con los de la línea de base y evaluación
intermedia.
4. Identificar las principales limitaciones y los factores de éxito y lecciones aprendidas
del Programa y formular recomendaciones para la mejora del cumplimiento de sus
objetivos.
METODOLOGÍA
9. En la evaluación del diseño para la evaluación de la pertinencia se revisaron
documentos proporcionados por PARSALUD II; estos son: Resumen Ejecutivo, Módulo
51
I: Aspectos generales, Módulo II Identificación: Definición del problema, Módulo II
Identificación: Diagnóstico del contexto, definición del problema, Módulo III
Formulación: Análisis de la demanda- Análisis de la oferta-Descripción de la alternativa.
Se revisaron adicionalmente las ENDES 2000, 2004, 2005, 2006, informes de la
Organización Mundial de la Salud, Organización Panamericana de la Salud, Informes del
Instituto Nacional de Estadística e Informática de Perú. Así como lineamientos de
política nacional, normas y documentos técnicos en el campo de la salud materna infantil.
Con base en la revisión de documentos, se elaboraron informes por categorías de análisis
vinculadas a la pertinencia.
10. Para la evaluación de coherencia del diseño de PARSALUD II, se utilizó el análisis de
teoría causal y teoría de cambio del Programa, para lo cual se retomó el árbol de
problemas28
y el árbol de objetivos propuestos por PARSALUD II.29
Se organizaron
diagramas de causalidad con la finalidad de dar un ordenamiento lógico a la teoría causal.
11. Para identificar la relevancia de las intervenciones de PARSALUD II para atender el
problema de salud materno infantil en zonas rurales se realizó una búsqueda intencionada
de propuestas para abordar la problemática en la literatura utilizada para construir la
teoría causal y la teoría de cambio del Programa que fuera publicada entre 2000 a 2006.
Se elaboró una matriz con el resumen de cada uno de los artículos a partir de la cual se
elaboró el informe.
12. Para evaluar la suficiencia en el diseño de PARSALUD II, se evaluó la lógica vertical y
la lógica horizontal del marco lógico del Programa. En la lógica vertical del Programa se
realizó una evaluación de la suficiencia de las actividades (cantidad, oportunidad y
concentración en función a la población beneficiaria) para generar un determinado
producto y en qué medida los productos producidos por las actividades permiten alcanzar
el componente del Programa. Este tipo de evaluación se realizó para cada uno de los
componentes considerados en el Programa, igualmente se realizó una evaluación de la
suficiencia de los componentes para producir el propósito del Programa y de éste como
contribuye al fin. El análisis de la lógica vertical respondió a las siguientes preguntas:
¿Las metas a nivel de acciones son adecuadas para alcanzar las actividades
principales?
¿Las actividades especificadas para cada componente son las necesarias para
producir el componente?
¿Los componentes son necesarios para lograr el Propósito del Programa?
¿El Propósito del Programa contribuye al fin?
13. Con respecto a la evaluación de desempeño y eficiencia, se realizó un análisis
comparativo de la programación y la ejecución de los productos relacionados a los
componentes del Programa en tres dimensiones: cantidades producidas, tiempos de
producción y monto gastado; buscando identificar los factores relacionados a la eficiencia.
28 PARSALUD II. Módulo II: Identificación, definición del problema y sus causas. pág 344. 29 PARSALUD II. Módulo II: Identificación, objetivos del proyecto pág. 377
52
Las fuentes de información utilizadas fueron las siguientes: los estudios de factibilidad
del Programa (nacional y regionales), Planes Operativos Anuales (POA), Matrices del
Progress Monitoring Report para el BID, Reportes del SIAF (MEF) y SIMAF
(PARSALUD) II, Informes de Evaluación, Convenios con Regiones, Actas de Sesiones
del Comité Directivo de PARSALUD II, entre otros. La estrategia de análisis tomó en
cuenta los lineamientos del Ministerio de Economía y Finanzas para la evaluación Ex -
post de proyectos de inversión (general y en salud) y constó de tres etapas. La primera
fue dirigida a la recopilación y procesamiento de información, que incluyó trabajo de
campo en Perú, así como la definición de los productos por componente a trabajar. La
segunda etapa constó de un análisis cuantitativo de los datos de producción, tiempo de
ejecución y gasto; generándose medidas de eficiencia a partir de razones entre lo
planeado y lo realmente obtenido. Finalmente, la tercera etapa estuvo encaminada a
identificar los factores relacionados a la eficiencia del Programa, a partir de revisión
documental y compilación de información brindada en reuniones con el grupo de tarea.
Para sistematizar esta información se consideraron cuatro categorías: factores políticos,
económicos, sociales y tecnológicos (PEST).
14. En relación al análisis del logro de los resultados, se ha aplicado el análisis siguiendo el
enfoque del marco lógico. Hasta donde ha sido posible, se han vuelto a estimar los
indicadores a partir de información primaria. En la interpretación de los resultados se
consideró no solamente la diferencia aritmética entre el valor proyectado y el valor
observado, sino el significado de la diferencia considerando dos criterios: la naturaleza
dinámica interna de los procesos que requiere una adecuación periódica de las metas y el
ambiente externo cambiante que implica también una adecuación periódica de las metas.
Se recurrió en lo posible a fuentes de información y, en su defecto, a fuentes secundarias.
15. PARSALUD II, midió en ¿qué medida las intervenciones de PARSALUD II han
contribuido en el mejoramiento de los indicadores intermedios de salud materna e infantil
en las regiones establecidas como prioritarias por el propio Programa? e identificó si el
efecto sobre los indicadores intermedios de salud depende del grado de exposición que
tiene la población de interés al Programa, entendiendo como exposición al número de
intervenciones realizadas en un distrito o provincia en un tiempo determinado.
16. El análisis de efectos se basó en un diseño observacional pre-post con grupo de
comparación. Se llevó a cabo un análisis intención al tratamiento de diferencias en
diferencias tomando como línea base la información disponible en 2009 y como
información post-intervención la disponible en 2014. A partir de la utilización de pruebas
estadísticas de diferencias de medias se decidió que el grupo control esté conformado por
los distritos no expuestos al programa de las nueve regiones donde interviene
PARSALUD. Los indicadores de resultados planteados en la presente evaluación se
encuentran relacionados a los indicadores de propósito y componente del PARSALUD II.
17. Con el fin de explorar diferencias de efecto según intensidad del tratamiento, se
conformaron los siguientes grupos de comparación: P1: Hogares residentes de distritos
con una acción PARSALUD II entre 2009 y 2014, P2: Hogares residentes de distritos con
53
más de una acción PARSALUD II entre 2009 y 2014 y C: Hogares residentes de distritos
en las regiones PARSALUD II pero sin acciones del Programa entre 2009 y 2014.
18. En el análisis se utilizó un modelo de regresión multivariada, ajustándose por la edad de
la madre, si tuvo algún aborto, nivel de escolaridad, condición laboral, edad del jefe del
hogar, estado conyugal, edad de la mujer en el primer nacimiento, lengua indígena, total
de niños que alguna vez nacieron, nivel de riqueza30
, conformación del hogar,
urbano/rural, y si tiene la cultura de lavado de manos. En el caso de los indicadores de
salud de niños menores de tres años, adicionalmente se ajustó por las siguientes variables:
si al momento del nacimiento hubo contacto piel a piel con la madre, lugar del parto, y
tamaño del niño al nacer. En el caso del análisis de los indicadores de gasto en salud, en
el análisis de se controló por: sexo, edad y educación del jefe del hogar, algunas
características demográficas del hogar como la presencia de niños pequeños, adultos
mayores o mujeres en edad fértil, también se controló por el nivel de pobreza del hogar y
otras condiciones sociales y de saneamiento en la vivienda. Con excepción de la variable
que identifica a los hogares con gasto catastrófico en salud, las variables de gasto fueron
transformadas en logaritmos.
19. La aproximación cualitativa buscó caracterizar la implementación de PARSALUD II,
describir los resultados de este Programa, las lecciones aprendidas, los principales retos y
los factores de éxito de éste, desde la perspectiva de los actores del MINSA, PARSALUD
II, las agencias financiadoras y la población beneficiaria. La metodología de esta
aproximación consistió en entrevistas a decisores de política a nivel nacional, regional y
local, a operadores de EESS y a gestantes, puérperas y madres de niños menores de 3
años de las regiones Amazonas, Apurímac y Cajamarca, las cuales fueron seleccionadas
en razón de que cuentan con un gran número de estrategias implementadas y en base a
que presentan diversos niveles de eficiencia (alto, medio y bajo). Asimismo, se realizó un
grupo focal con los nueve coordinadores zonales de PARSALUD II. La información
recolectada y grabada fue transcrita y analizada.
20. Entre las limitaciones identificadas resalta el corto tiempo programado para realizar la
presente evaluación, asimismo, el periodo de corte establecido (2009 hasta agosto 2015),
no hizo posible una evaluación que incluya las actividades desarrollas hasta el cierre del
Programa en diciembre del 2015.
21. Finalmente, el que el Programa no contemplara en el documento de factibilidad el diseño
de una evaluación de efecto dificulta establecer categóricamente en qué medida los
resultados identificados en la mejora de la salud materno infantil se deben al Programa.
RESULTADOS
30 El nivel de riqueza es un indicador disponible para su uso en las bases de datos de la ENDES. De acuerdo a su
metodología, se construye a partir de los activos de los hogares, siguiendo la metodología de Shea Rutstein y Kiersten
Johnson de Macro Internacional Inc. y Deon Filmer y Lant Pritchett del Banco Mundial (The DHS Wealth Index:
Approaches for Rural and Urban Areas. DHS Working Papers.USAID. 2008)
54
22. En cuanto la pertinencia del diseño, El PARSALUD II propuso como problema central
para la intervención del Programa el “Bajo acceso a servicios de salud materna, alta
morbilidad infantil y deficiente ingesta de micronutrientes de los niños y las niñas
menores de 3 años de familias de zona rural de 09 regiones. Como se puede observar
existen tres problemas; el bajo acceso es un problema relacionado con la atención de
servicios de salud, la morbilidad infantil relacionada con el estado de salud y la deficiente
ingesta de micronutrientes es la ausencia de una solución que debe integrarse como parte
de la atención integral del niño. En consecuencia, los otros dos problemas requieren de un
análisis de causa efecto y de un marco lógico específico que permita definir con claridad
el propósito del sector salud en el caso de las IRA y EDA en niños menores de tres años
ya que la mayoría de factores explicativos para este problema están fuera del sector salud.
Consideramos que el problema más importante a resolver en la población rural en 2006
se expresa en el “Bajo acceso a servicios de salud maternos y en niños y las niñas
menores de 3 años de familias de zona rural de 9 regiones.
23. Según los documentos revisados en torno a las metas a alcanzar en salud materno infantil,
se aprecia que PARSALUD II se alinea perfectamente a las metas estratégicas nacionales
propuestas por el gobierno peruano. Por otro lado también se priorizó la intervención de
ámbitos rurales, dispersos y con la mayor pobreza. Se seleccionó las regiones para su
intervención en base a indicadores con mayores desventajas sociales y sanitarias. Es
evidente que intervinieron en regiones con mayor pobreza y ruralidad en las cuales la
razón de mortalidad materna e infantil fue superior al resto de regiones del país. Para la
formulación del PARSALUD II convocaron a diversas instituciones, lo que hace inferir
que su formulación se realizó desde una perspectiva intersectorial. Para la
implementación del Programa se consideraron instancias vinculadas al MINSA, las
regiones y sus organismos públicos descentralizados.
24. En relación a la evaluación de la coherencia, existen actividades que se contemplaron en
el diseño del Programa, pero que no se incluyeron en los planes. Así como actividades
que son parte de los planes, pero que no se contemplaron en el diseño de la alternativa
seleccionada. Las actividades de diseño se contemplaron acertadamente en los tres
primeros años del Programa; no obstante algunas actividades de evaluación se
programaron antes de haber terminado las acciones de ejecución.
25. El análisis de la teoría causal fue elaborado utilizándose la evidencia científica antes que
el MEF contará con los programas basados en la lógica de los presupuestos por resultados.
Por lo que el 31% de ellas fueron publicadas antes de 1996 y 54% antes del 2000. En
cuanto a la documentación de evidencia para la causalidad del problema central
relacionado con el bajo acceso de servicios de salud de la población rural sólo utilizaron
un documento del año 1991, lo que podría calificarse como una revisión insuficiente para
el contexto actual. La mayoría de documentos revisados dan cuenta de las IRA, EDA y
desnutrición.
26. En cuanto la evaluación de la relevancia, en el diseño se incluyó aspectos claves para
mejorar el acceso de la población rural a los servicios de salud materno infantiles
55
reportados en la literatura. Abordó aspectos como: fortalecimiento de las competencias
del personal de salud para la atención integral de la gestante, del niño menor de 3 años así
como para la atención de la emergencia. Incluyó acciones para dotación de equipos,
materiales e insumos a los establecimientos de salud así como la construcción de
establecimientos de salud para garantizar mayor accesibilidad de la población a un
paquete de servicios de salud. Contempló el fortalecimiento de las acciones que realiza el
SIS en cuanto al aseguramiento en salud, otras instancias del MINSA, SUSALUD (Ex
SUNASA), y finalmente desarrolló estrategias para la adecuación cultural de los servicios
de salud
27. Con respecto a la evaluación de suficiencia, se observó que a nivel de la lógica vertical
del programa los componentes se alinearon perfectamente con el propósito y éste con el
fin. No obstante, las acciones estratégicas (propósitos) y actividades (acciones)
requirieron revisarse para alinearse totalmente, al igual que la unidad de medida y la
cantidad a producir de las metas de las acciones estratégicas. En cuanto a los
componentes los resultados a alcanzar fueron los adecuados.
28. Los indicadores se alinearon parcialmente a la medición de las acciones estratégicas y
componentes del Programa.
29. En términos del desempeño del Programa en cuanto al cumplimiento de actividades y
logro de productos, y el gasto ejercido por producto, se observó que el Programa fue
eficiente en niveles de 100% o más en 6 de los 14 productos analizados. El componente
con mayor eficiencia fue el Componente III de Gobierno, destacando la generación de
propuestas de normas y disposiciones legales, y el diseño de sistemas de seguimiento.
Otro componente con producción eficiente fue el Componente I de Demanda, donde
destaca la producción de personal capacitado en el Programa de Comunicación y
Educación para la Salud. Se debe mencionar también que la producción de capacitación
de personal en gestión de recursos humanos (PREG, Parto Vertical, Emergencias
obstétricas y neonatales, Quechua) y en atención materno neonatal, del Componente II
de Oferta, presentaron procesos eficientes. No obstante, entre los productos generados
con menos eficiencia se encuentran: los relacionados a infraestructura, debido al retraso
en el desarrollo de las obras y el equipamiento en Telesalud, en este último caso por el
punto de corte de la evaluación.
30. Entre los hallazgos relacionados al cumplimiento de objetivos y metas a nivel de los
resultados destaca el logro en cuanto a la reducción de la prevalencia de la desnutrición
en menores de 3 años (37 a 21%); destacan también los logros en la institucionalización
del cuidado de la salud de la madre durante el embarazo, el parto y el puerperio, así como
en la promoción de las prácticas del cuidado de la salud del niño; pero se advierte aún
una diferencia rural urbana importante.
31. Con relación a la evaluación del efecto, cuando se realiza una comparación simple de los
indicadores intermedios de salud materna e infantil en regiones atendidas por
PARSALUD II y regiones sin atención, entre 2009 y 2014, se encuentra que el grupo de
56
comparación presentó mejores condiciones de salud en los indicadores de atención
prenatal, atención prenatal ajustada por calidad y parto institucional. No obstante, se
observó que las mujeres del grupo de comparación presentaron mayor porcentaje de
complicaciones durante el puerperio. Al analizar los indicadores con la información de
2014, se observó que en algunos de los indicadores las brechas entre los grupos de
exposición y de comparación se redujeron, sin embargo en la mayoría, las diferencias
entre los grupos se mantiene. Los indicadores de salud relacionados con la atención
prenatal, lugar del parto y situación de salud durante el puerperio mejoraron entre 2009 y
2014 en toda la región PARSALUD II, tanto en el grupo de expuestos como en los no
expuestos a las acciones del Programa.
32. Con relación a la salud de los niños de 3 años y menores, los mayores avances se dieron
en los indicadores nutricionales, sobre todo en el indicador de desnutrición crónica y
anemia. La reducción de la prevalencia de la desnutrición crónica, entre 2009 y 2014, fue
de casi 12 puntos porcentuales en ambos grupos. Con relación a las variables de gasto en
salud de los hogares, se encontraron cambios en los niveles observados en 2009 y 2014.
33. Si bien los resultados anteriores muestran algunos cambios que parecen favorecer las
condiciones de salud en el grupo de hogares expuestos a PARSALUD II, no es posible
argumentar si los cambios observados responden a las acciones implementadas por el
Programa o a otros factores. Por ello se realiza un análisis para la estimación de efectos,
controlando por otros factores que inciden en los resultados de salud analizados, de tal
manera que podamos aproximarnos al verdadero efecto del PARSALUD II sobre los
indicadores de interés. Los resultados de este ejercicio muestran que, con excepción del
indicador de parto institucional donde se encontró un ligero efecto del programa, en las
demás variables analizadas no se halló evidencia de que el Programa tuviera un efecto
significativo en mejorar la atención prenatal, en reducir las complicaciones durante el
puerperio, en mejorar algunas de las condiciones nutricionales de los niños menores de 3
años, o en reducir el gasto que realizan los hogares en salud.
34. Finalmente, hubo consenso en señalar que el PARSALUD II cumplió con su objetivo de
apoyar la reforma del sistema de salud de Perú, favoreciendo el aseguramiento público, el
desarrollo de infraestructura, así como la capacitación del personal y el equipamiento de
establecimientos de salud. Se destacó su diseño organizacional y administrativo como
una de sus fortalezas más importantes. Para las Regiones el PARSALUD II es
considerado que, más allá de su acción financiadora, es un valioso apoyo técnico
estratégico. Se reconocieron problemas de retraso de obras y la necesidad de mejorar la
coordinación entre el Programa y el MINSA. La transparencia y el diseño organizacional
han sido factores de éxito. En la relación intercultural si bien gestantes y puérperas
valoran el “aliento”, la “importancia” y el “encariñamiento” en la atención a sus procesos
de parto y puerperio, aún es débil el reconocimiento de su derecho a comprender todos
los procedimientos (resultados de análisis, revisión de su gestación, asistencia a casas
maternas, cesárea y lactancia) a los que están sujetas para tranquilizarlas y no infundirles
temor.
57
35. La posibilidad del rol municipal en la Promoción de la salud es más bien una perspectiva
a desarrollar. Lo avanzado con gobiernos municipales ha demostrado ser valioso,
requiere persistir en restablecer vínculos que aseguren la aún débil articulación con este
actor público.
CONCLUSIONES
1. Respecto a la pertinencia del Programa, la formulación tiene un alto valor que recoge
la problemática y plantea la solución de manera adecuada
2. Respecto a la coherencia responde parcialmente a una teoría causal
3. El Programa es relevante porque incluyó la formulación las acciones de intervención
relacionadas en la literatura científica consideradas relevantes para problemas
similares.
4. Respecto a la suficiencia, la lógica vertical del programa se alinean perfectamente los
componentes, con el propósito y este con el fin y que las acciones estratégicas
(actividades) y actividades( acciones) requieren revisarse para alinearse
adecuadamente necesita mejorar el sentido de la lógica horizontal más que la lógica
vertical
5. PARSALUD II se planteó generar 14 productos relacionados a actividades dentro de
sus componentes, para así lograr los objetivos del Programa. En su logro fue eficiente
para los componentes de Gobierno y Demanda; y parcialmente eficiente para el
componente de Oferta, principalmente por el retraso en el inicio de obras así como
problemas con las empresas contratistas. A pesar que el desarrollo del Programa se
dio en un periodo con constantes cambios políticos y ante la carencia de postores
competentes para llevar a cabo las acciones encomendadas; el PARSALUD II logró
coordinación con los gobiernos regionales para llevar a cabo su labor, desarrolló
sistemas de monitoreo e información que facilitaron la detección de problemas de
ejecución, así como procesos administrativos para agilizar la gestión financiera.
6. Los resultados de los indicadores en términos de la diferencia entre lo proyectado y lo
observado, en números absolutos y resultados, muestran que el Programa ha
alcanzado los logros que se había propuesto.
7. El Programa coadyuvó a objetivos de la reforma del sistema de salud en la atención
del embarazo, parto y la salud infantil, a la vez que favoreció el desarrollo de
innovaciones gerenciales en la gestión gubernamental, lo que hace necesario
conservar lo aprendido en futuras intervenciones del MINSA.
8. En las regiones hay un reconocimiento del importante apoyo de la asistencia técnica
para producir ordenamientos organizacionales y capacitar al personal de salud que
debe acompañar la inversión en infraestructura.
9. Se reconoce un avance significativo en todas las regiones acerca del reconocimiento
del derecho de las mujeres gestantes, puérperas y madres a ser tratadas con igualdad,
quedan aún desafíos para el MINSA para avanzar en una relación cívica de
reconocimiento a sus derechos y que no experimenten que se el servicio “les está
haciendo un favor” como señalaba una decisora del nivel nacional.
RECOMENDACIONES
58
1. Las propuestas de implementación de programas de salud deben responder a
necesidades de salud de la población a quien se pretende beneficiar, las mismas que
deben estar respaldadas en fuentes de información locales y los lineamientos de
política de salud nacional. PARSALUD II en este sentido puede constituirse en un
referente nacional para formular intervenciones de salud en poblaciones rurales.
2. El análisis de teoría causal para la elaboración del marco lógico de PARSALUD II,
utilizó artículos científicos, no obstante algunos de ellos con una temporalidad de
publicación de más de diez años previos a la implementación del programa, dado el
retraso en su inicio. Por lo cual se sugiere que en estos procesos las evidencias
utilizadas deben ser el más actuales y procedente de países con el mismo nivel de
ingresos.
3. La coherencia interna de los niveles de causalidad en la formulación de programas de
salud deben revisarse con la finalidad de proponer estrategias y acciones altamente
vinculadas con los componentes del programa y así alcanzar el propósito del mismo.
4. Los indicadores deben seleccionarse en base a su especificidad para medir los
componentes del Programa y debe contemplarse la mejor fuente de información, ya
sea esta primaria o secundaria para su medición desde el inicio del Programa. Por lo
cual como parte del diseño los programas deben contemplar presupuesto para la
evaluación integral del mismo.
5. Los indicadores de las actividades deben ser definidos como una cantidad a ejecutar y
los indicadores de componentes y propósito como resultados a alcanzar.
6. Rescatar y replicar formas de gestión, como el Monitoreo de la Gestión Financiera,
que permite un mejor desempeño del Programa y una identificación temprana de
problemas de ejecución.
7. Establecer mecanismos que limiten la vulnerabilidad de la operación del Programa
ante factores externos como la inestabilidad política y de personal. Es importante
desarrollar una masa crítica y de técnicos que aseguren la continuidad a las acciones
del Programa.
8. En términos del diseño para la evaluación del impacto de futuros programas, se
recomienda planear un diseño de evaluación de impacto con asignación aleatoria de
los grupos de exposición o intervención y de control, que permita estimar el efecto
del programa en la población que realmente recibe los beneficios de éste, y que
permita, además, controlar por aspectos como la calidad de la atención.
9. Retomar la experiencia gerencial desarrollada en materia de buenas prácticas y
gestión por resultados.
10. Fortalecer el vínculo con los Municipios en planes concertados para la vigilancia y
disminuir la desnutrición infantil.
11. Reforzar la relación social de cuidado y encuentro cultural con gestantes y madres
que solicitan explicaciones para comprender cómo los procedimientos que susciten
confianza y no temor.
59
COMENTARIOS SOBRE EL REPORTE DE IMPLEMENTACION,
FINALIZACION Y RESULTADOS (BIRF-76430)
SEGUNDA FASE DEL PROGRAMA DE APOYO A LA REFORMA DEL
SECTOR SALUD
AVANCE DE INFORMACION 1
17 junio del 2016
UNIDAD EJECUTORA 123
PROGRAMA NACIONAL DE INVERSION EN SALUD - PRONIS
Equipo de Gestión PRONIS
1. Rocío Espino Goycochea, Coordinadora General (e) del PRONIS.
2. Francisco Solís Coronado, Coordinador (e) de la Unidad de Planeamiento, Calidad y
Desarrollo.
3. Ana Cano Bobadilla, Coordinadora de la Unidad de Pre Inversión.
4. Juan Manuel Pizarro Garcés, Coordinador (e) de la Unidad de Estudios Definitivos.
5. Carlos López Chamorro, Coordinador (e) de la Unidad de Obras.
6. Bárbara Lem Conde, Coordinadora de la Unidad de Administración y Finanzas.
7. Elizabeth Martínez Galván, Coordinadora de la Unidad Asesoría Legal.
8. Paola Tamayo Medina, Coordinadora de la Unidad de Relaciones Institucionales y de
Comunicación.
UNIDAD EJECUTORA 123
Av. Javier Prado Oeste 2108 - San Isidro Lima – Perú
60
www.pronis.gob.pe
Teléfono: 611-8181
Lima - Perú
61
2.2 Implementation (page 7)
19. Implementation of the project did not suffer from any major complications.
The project had a slow start. While activities related to Components 1 and 3 started
immediately, delays in disbursement and execution related mainly with the infrastructure
investments under Component 2. Once construction works began and medical equipment
started being purchased in 2011, project disbursement picked up towards the end of 2012.
Comentario:
Respecto al contrato de obras debemos indicar que el primer contrato se suscribió el 12
de mayo de 2010 correspondiente a la ejecución de obras de la región Apurímac; y que
respecto a los contratos de equipamiento debemos indicar que el primer contrato se
suscribió en diciembre del 2010.
Asimismo, se registra pagos en obras con recursos de endeudamiento externo de
aproximadamente 5 millones de nuevos soles y es importante destacar que el MEF no
autorizo el reembolso de US$ 731,22.7 de gastos efectuados con Recursos Ordinarios del
Tesoro Público y que inicialmente estaban programados a financiarse con Recursos de
Endeudamiento Externo.
21. While the program was successful in achieving its broader goals of reducing
maternal and infant mortality and chronic malnutrition in children under 5,
progress on the indicators in the RF was mixed during the life of the project. Some
of the targets were achieved even before the MTR in February 2013, while others had a
more fluctuating trajectory. To some extent, this was related to the delays in construction
works, which shortened the time horizon available to see the impact of the infrastructure
investments on the selected health outcomes and outputs. In other cases, the trend of
some indicators reflected those at the national level, such as in the case of the prevalence
of anemia among pregnant women. The delays in progress on some indicators motivated
the downgrade of the Overall Project Implementation (IP) rating from satisfactory to
moderately satisfactory in 2013, rating which was then kept in consideration of the
disbursement delays ― eventually, the project disbursed 80% of the planned amount.
Comentario:
En el PARSALUD II, los indicadores no fueron evaluados relacionando el retraso en las
obras de construcción ni con los retrasos en los desembolsos. Para relacionarlos tendría
que hacerse la evaluación de impacto.
22. The Mid-Term Review (MTR) in February 2013 identified some of the
challenges and correcting measures (page 8) (ii) Delays in civil works and consultancies. As of December 2012, after 2 years of
implementation, about 27% of project's civil works were delivered, with heterogeneous
patterns among the regions. Logistic difficulties for timely civil works completion were
associated with difficult climate and access to sites, as well as with a few cases of
collusion, properly addressed by the counterpart. Delays in hiring consultants were due to,
among others, frequent changes in regional administration, scarcity of professionals
62
adequately qualified for some tasks, delays in approval processes from the regions, and
political attention diverted to sudden public health emergencies (e.g. pneumonia in Puno
and dengue in Ucayali). Despite all delays, almost all planned civil works were
completed before the project closing date, with a few being delivered in 2016.
Comentario:
El término dificultades logísticas, es general y puede inducir a pensar que estos fueron
problemas atribuibles a la entidad, se sugiere modificar e indicar directamente que las
obras civiles presentaron retrasos por diversos factores entre ellos: factores climaticos,
rutas de acceso así como también por problemas de colusión.
2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization -
Implementation. (page 10)
27. Due to unavailability of data, two of the six KPIs only started being measured in
December 2014 (ISR 11, with data of December 2013). Given that they had not been
monitored, five of the intermediate indicators were dropped during the restructuring in
2014. However, data was available for two of those, which were reintroduced for the
purpose of the ICR. The other three indicators had not been clearly defined and
monitoring was therefore problematic. Unfortunately, all three of those IOIs measured
progress against the same part of the PDO (3). Since the PARSALUD PIU monitored
more indicators than those monitored by the Bank, additional intermediate indicators
might have introduced to replace the problematic IOIs to better assess improvements on
PDO 3 ― for example during the first restructuring in 2011 or immediately after the
MTR in 2013.
Comentarios:
Todos los indicadores que solicitó el banco, se presentaban lo avances en los informes de
progreso semestrales. Cuáles son los dos indicadores de los seis que de acuerdo a lo que
se señala se midieron a partir de diciembre 2014.
Según lo afirmado en el reporte son 5 indicadores eliminados y la entidad tiene
identificado 6; los que se retiraron por lo descrito en la columna de Comentarios en la
siguiente tabla, de acuerdo a lo coordinado con el responsable del BM y el equipo de
AEGE del PARSALUD II.
Indicadores de
Resultados de Nivel ODP Protocolo
Fuente de
Información Comentarios
Componente 2:
% de establecimientos de
salud con mejora en
infraestructura
(construcción menor y
nuevo equipamiento)
NO HAY SISTEMA DE
INFORMACIÓN QUE
SOPORTE ESTE DATO
% de mujeres (gestantes,
parturientas y lactantes)
que reportan satisfacción
con la atención recibida
NO HAY SISTEMA DE
INFORMACIÓN QUE
SOPORTE ESTE DATO
63
Indicadores de
Resultados de Nivel ODP Protocolo
Fuente de
Información Comentarios
% de establecimientos de
salud con mejora en
infraestructura
(construcción menor y
nuevo equipamiento)
NO HAY SISTEMA DE
INFORMACIÓN QUE
SOPORTE ESTE DATO
Componente 3:
% de referencias
correspondientes a mujeres
(gestante, parturienta,
puérpera) o neonatos
afiliados al SIS
NO HAY SISTEMA DE
INFORMACIÓN QUE
SOPORTE ESTE DATO
Número de
establecimientos de salud
acreditados por tipo de
resolución
NO HAY SISTEMA DE
INFORMACIÓN QUE
SOPORTE ESTE DATO
Número de acuerdos de
gestión
NO HAY SISTEMA DE
INFORMACIÓN QUE
SOPORTE ESTE DATO
28. Within the PIU and, specifically, within the Technical Coordination Unit, the M&E
Unit originally included two specialists, one focused on Monitoring and the other on
Evaluation. Following suggestions from the MTR, the M&E function was strengthened
and the original unit was split into two to focus and strengthen each area ― supervision
of program performance, and management of scientific evidence for enhanced
effectiveness of the overall program (see Annex 12).
Comentario:
La Unidad de Monitoreo y Evaluación no dependía de la Unidad de Coordinación
Técnica. Además el organigrama según el Manual es el siguiente, debiéndose modificar
el presentado en el reporte.
64
2.4 Safeguard and Fiduciary Compliance (page 11)
31. Financial Management. The counterpart’s financial management performance was
considered generally satisfactory. The PIU was appropriately staffed from the start and,
despite delays in systematically adopting the official system for managing transactions
used in all implementation units in the public sector (Sistema Integrado de
Administración Financiera, SIAF), financial reports were timely and were found to be of
satisfactory quality. Audit reports were provided on time and there were no qualified
opinions. Until 2013, disbursement was very slow (39% in August 2013). Problems were
related to a number of factors, including previous delays in civil works as a consequence
of inadequate planning and due to the remote project locations, which did not offer
incentives for enterprises to participate in the bidding process; and the contractors’
noncompliance with contractual clauses. The GOP established a condition of Pari-Passu
for all civil works (6% of external resources), which limited the scope for accelerating
disbursement of the loan. Finally, deferred payments for civil works at the end of the
project (Ocongate Health Center and Health Center Chuquibambilla) and the cancelation
of the scheduled execution of large amounts of consulting services expected to be
contracted before the project closing and executed during the project grace period,
negatively impacted disbursement. As a result, total disbursement reached 80% at project
closing.
Comentario:
Respecto a los retrasos iniciales debido a la falta de planificación, el informe debería
precisar que un elemento importante que explica el retraso fue la demora en la firma del
contrato de préstamo.
Además mencionar, que no se concretó el financiamiento de una consultoría programada
las (Diplomado APS PROFAM) y la recisión del contrato de otra consultoría sobre el
Sistema Nacional de Sangre Segura; junto a las obras ya mencionadas en este párrafo.
En relación al porcentaje de desembolsos a finales del 2013, tenemos registrado 49.33%
con respecto a los fondos provenientes del Banco Mundial. Se sugiere indicar la fuente
para verificar la data.
32. Procurement (page 11). Given that the entire Government program followed the
Bank’s procurement guidelines, the Bank reviewed and approved a large volume of
transactions. The initial delays due to lack of planning by the counterpart and long
processing time for No Objections by the Bank were addressed and resolved after the first
two years of project implementation. Procurement delays remained associated mainly
with the scarcity of qualified contractors and remoteness of the work sites.
Comentario:
Respecto a los retrasos iniciales debido a la falta de planificación, el informe debería
precisar que el retraso se debió a la demora en la firma de los contratos de préstamo (16
de noviembre del 2009); lo que no permitió solicitar los créditos presupuestales
oportunamente ni para el 2009 ni el 2010 debido a los plazos que fijan las normas de
presupuesto.
65
Con respecto a la lejanía de los centros de trabajo, se debería de modificar la expresión,
a que las intervenciones se realizaban en lugares de difícil acceso y que el problema de
la planificación se debió a esto y a la calidad de los contratistas y la baja participación
de los mismos.
3.2 Achievement of Project Development Objectives
42. When assessed against the original baseline, all the indicators have surpassed,
achieved or partially achieved the targets at the end of the project, which supports
achievement of all parts of the PDO (Table 1). Also, notably, the final percentage of
achievement does not reflect that roughly half of all indicators surpassed their targets.
Therefore, the actual level of achievement is far greater than the table suggests.
Table 1: Achievement of PDO (targets against original 2005 baseline)
Program
level
PDO
level Intermediate PDO 1* PDO 2* PDO 3
Target surpassed 2 3 6 4 4 3
Target achieved or
substantially achieved
(>=85% met)
2 4 1 5 1
Target partially achieved
(65%-84% met)
1 2 2 2 0
Target not achieved
(<65% met)
0 0 0 0 0
Unknown
0 3 0 0 3
Total 2 6 15 7 11 7
% surpassed and
achieved 100% 83% 83% 71% 82% 100%
Comentario:
Se requiere la tabla con los cálculos realizados para la elaboración de la Tabla 1 del
Informe.
49. Health infrastructure improved in the nine regions (page 16). The project
supported the construction and/or renovation of 69 out of the planned 73 hospitals and
basic health centers that offered obstetric and neonatal services; the remaining 4 are being
completed in 2016, financed by GOP. It provided all of the 104 pre-identified health
centers with medical equipment for maternal and child care and installed IT systems in 55
(planned 54).
Comentario:
Hasta el año 2015 se culminó las obras en 68 establecimientos de salud (en un
establecimiento se realizaron 2 obras). Para este año 2016 se deben culminar 5
Establecimientos de Salud adicionales. Asimismo, el equipamiento médico y mobiliario
se distribuyó en 103 establecimientos de salud.
66
Finalmente se sugiere que con respecto a las TI señaladas, se debe especificar que esto
se refiere al equipamiento para la implementación de la estrategia de Telesalud.
50. The project delivered capacity building programs for different groups of
health professionals using a culturally-sensitive approach. The project contributed to
the training of 956 health workers (nearly 300 more than planned) on maternal and child
care and specifically of 282 doctors and midwives on the vertical delivery (Parto
Vertical) in 7 health facilities located in 4 regions within PARSALUD. Together with
improved infrastructure and training, cultural adaptation of health facilities for the
provision of vertical deliveries and support to Maternal Waiting Homes (Casas
Maternas) were key in improving rates of institutional deliveries among indigenous
populations. This includes the creation, dissemination, and systematization of knowledge
around vertical delivery practices among health care providers and the institutionalization
of this method in both regions: in the Amazon and Cusco, 54% and 33% of all deliveries
were vertical, respectively, in 2012. The Casas Maternas, communal space managed,
built, and maintained by communities and local governments, helped address the physical
and cultural barriers faced by indigenous women residing far from health centers. There
are 475 operational Casas Maternas throughout the country, with Cusco, Puno,
Huancavelica and Apurimac the most important areas of reference.
Comentario:
Cuál es la Fuente de las 475 casas maternas?
3.3 Efficiency
Efficiency of project preparation and implementation (page 19)
64. The project was implemented within the time period originally planned. The
project was extended by 11 months, which balanced the 10-month gap between Bank
approval and effectiveness. However, despite the extension, the project disbursed 80% of
the planned amount, due to delays in procurement and civil works.
Comentario: El proyecto desembolsó el 80% del préstamo programado por el Banco, ello debido a
que no se concretó el financiamiento de una consultoría programada (Diplomado APS
PROFAM) ya la rescisión del contrato de otra consultoría(Sistema Nacional de Sangre
Segura), por causal atribuible al contratista, por un total de aproximadamente
US$1,900,000.
Adicionalmente, se debió a la postergación de los pagos por la ejecución de obras que
estaban financiándose con los recursos del préstamo, debido a que su ejecución excedía
el plazo de vigencia del Programa (31 de diciembre de 2015), como es el caso del Centro
de Salud Ocongate y Centro de Salud Chuquibambilla por un importe aproximado de
US$ 925,945.59
Adicionalmente, el retraso de las contrataciones y ejecución se debió a que inicialmente
fue necesario resolver contratos de obras, por situaciones atribuibles a los contratistas.
67
Efficiency of project preparation and implementation (page 20)
66. The implementation efficiency of the overall Government program was leveraged
by the project funds and the use of Bank fiduciary safeguards that provided cover for the
weaker Government systems and processes. The Bank project team reviewed all
procurement bidding documents and contracts for civil works, consultancy services and
provision of training. This effort increased the leverage of technical and fiduciary
implementation support beyond the loan funds and enhanced the technical skills of the
PARSALUD technical and fiduciary team.
Comentario:
No todos los documentos de licitación y contratos para obras, fueron revisados por los
bancos. En tal sentido, se debería precisar que se efectuaron las revisiones de
losdocumentos de licitación y contratos para las obras, según el tipo de revisión, en este
caso, la revisión ex ante, otorgándoselas No Objeciones correspondientes. En los casos
de procesos con revisión ex post, las revisiones fueron aleatorias en las misiones
fiduciarias del propio banco, además de las revisiones de la Auditoría Externa.
4. Assessment of Risk to Development Outcome (page 22)
74. PRONIS focuses on about 800 key health centers and facilities, many of which
PARSALUD rehabilitated or improved. However, contrary to PARSALUD, PRONIS is
not specifically targeted to the poorest regions and it does not support an explicit, a priori
objective or topic. The regions will identify the specific outcomes of focus for the
investments depending on their demographic and epidemiological characteristics and
political priorities.
Comentario:
El número de Establecimientos de Salud Estratégicos que el MINSA ha definido son 748.
5.2 Borrower Performance
(b) Implementing Agency or Agencies Performance (page 25)
89. The unit was proactive in flagging any suspected cases of collusion in
procurement. For example, an INT case was opened in April 2011 on risks during
execution of works in the Region of Huancavelica. PARSALUD II timely identified
and corrected fraudulent practices from an enterprise and it responded positively to all
requests made by the Bank, designing and implementing a Governance and Anti-
Corruption Action Plan.
Comentario:
Cabe señalar que la primera denuncia de práctica fraudulenta se efectuó ante el Banco
Mundial el 12 de noviembre de 2010, en el marco del contrato suscrito para la ejecución
68
de obras de la región Huancavelica entre el PARSALUD y el Consorcio Huancavelica.
Por lo tanto, se deberá precisar que el caso de dicha denuncia se efectúo en Noviembre
de 2010.
ANNEX 1. Projects Costs and Financing (page 28)
(a) Project Cost by Component (in USD Million equivalent)
Components
Appraisal
Estimate (USD
millions)
Actual/Latest
Estimate (USD
millions)
Percentage of
Appraisal
Strengthening of demand 6.00 6.43 107%
Improvement of service
delivery network 142.30 138.54
97%
Government and Financing 5.20 3.25 62%
M&E and Administration 8.90 16.86 189%
Total Baseline Cost 162.40 165.08 102%
Total Financing Required 162.40 165.08 102%
(b) Financing
Source of Funds Type of
Cofinancing
Appraisal
Estimate
(USD
millions)
Actual/Late
st Estimate
(USD
millions)
Percentage
of Appraisal
Borrower 132.40 138.09 104%
Inter-American Development
Bank 15.00 15.00 100%
International Bank for
Reconstruction and Development 15.00 11.98 80%
Comentarios:
Sobre el cuadro a)
El 03 de octubre del 2013 el PARSALUD envía al Ministerio de Economía y Finanzas el
documento donde se señala la Modificatoria en la Estructura de Financiamiento de los
contratos de préstamo (OFICIO N° 0740-2013-PARSALUD/CG) en donde se adjunta el
OFICIO N° 0275-2013-PARSALUD/CG que anexa la propuesta de modificación.
69
El Ministerio de Economía y Finanzas con Oficio 1457-2013-EF/52.04 del 26 de
diciembre del 2013 envía la Nueva Estructura de Financiamiento de los contratos de
préstamo aprobada de acuerdo al OFICIO N° 0740-2013-PARSALUD/CG.
Con documento Re. Loan N° 7643 – PE – Health Reform Program (APL 12) –
PARSALUD Project Restructuring del 26 de agosto del 2014, el Banco Mundial da
opinión favorable a la propuesta de estructura de financiamiento de acuerdo al Oficio
1457-2013-EF/52.04, la misma que hace referencia a la modificatoria del 2013.
Por lo que se solicita considerar la información del siguiente cuadro – En la Columna
Modificado.
Distribución por componente, Montos originales (Viabilidad) VS última
reasignación aprobada (Año: 2014)
Components
Appraisal
Estimate
(USD
millions)
Actual/Latest
Estimate
(USD
millions)
Percentage
of
Appraisal
Strengthening of demand 5.98 5.9 99%
Improvement of service delivery
network 142.25 141.8 100%
Government and Financing 5.19 4.83 93%
M&E and Administration 8.96 17.17 192%
Total Baseline Cost 162.38 169.7 105%
Total Financing Required 162.38 169.7 105%
Al respecto, se adjunta los documentos en PDF del Sustento de Modificación de la
Estructura de Financiamiento Aprobada.
Sobre el cuadro b)
Igualmente se observa una diferencia en la data del cuadro enviado, la información que
tiene la entidad es la siguiente:
Source of Funds
Type of
Cofinan
cing
Appraisal
Estimate
(USD
millions)
Actual/Late
st Estimate
(USD
millions)
Percentage
of Appraisal
Borrower 132.40 138.23 104%
Inter-American Development Bank 15.00 15.00 100%
International Bank for Reconstruction
and Development 15.00 11.98 80%
ANEXO 7: Estudio de Evaluación Final de la Segunda Fase del Programa de Apoyo
a la Reforma del Sector Salud – PARSALUD II (Resumen Ejecutivo)
Punto 29 RESULTADOS (página 54)
En términos del desempeño del Programa en cuanto al cumplimiento de actividades y
logro de productos, y el gasto ejercido por producto, se observó que el Programa fue
70
eficiente en niveles de 100% o más en 6 de los 14 productos analizados. El componente
con mayor eficiencia fue el Componente III de Gobierno, destacando la generación de
propuestas de normas y disposiciones legales, y el diseño de sistemas de seguimiento.
Otro componente con producción eficiente fue el Componente I de Demanda, donde
destaca la producción de personal capacitado en el Programa de Comunicación y
Educación para la Salud. Se debe mencionar también que la producción de capacitación
de personal en gestión de recursos humanos (PREG, Parto Vertical, Emergencias
obstétricas y neonatales, quechua) y en atención materno neonatal, del Componente II de
Oferta, presentaron procesos eficientes. No obstante, entre los productos generados con
menos eficiencia se encuentran: los relacionados a infraestructura, debido al retraso en el
desarrollo de las obras y el equipamiento en Telesalud, en este último caso por el punto
de corte de la evaluación.
Comentario:
1. Las actividades de Telesalud solo fueron financiadas con recursos del BID y
Recursos Ordinarios. No hubo recursos ni actividades asignadas al presupuesto
del Banco Mundial.
2. Con referencia a lo colocado en el informe: “entre los productos generados con
menos eficiencia se encuentran: los relacionados a infraestructura, debido al
retraso en el desarrollo de las obras y el equipamiento en Telesalud, en este
último caso por el punto de corte de la evaluación”
a. No hubo ningún retraso ni incumplimiento de las actividades ni productos
programados en la línea de Telesalud del PARSALUD II.
b. En relación a la última entrega de equipos adquiridos para las DIRESA’s, en
diciembre del 2015 se realizaron: (i) Las entregas a las Direcciones Regionales
de Salud de Amazonas, Huánuco y Ucayali; (ii) Se entregaron las pecosas y actas
con la conformidad de pago final a la UAF del Programa.
c. El giro al proveedor se efectuó en este ejercicio presupuestal 2016.
71
Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders
72
Annex 9. List of Supporting Documents
Project Appraisal Document, January 22, 2009
Minutes of Concept Note Review Meeting, November 2, 2005
Minutes of Quality Enhancement Review Meeting, May 4, 2006
Minutes of Decision Review Meeting and Matrix of Comments and Team
Reponses, December 8, 2008
Loan Agreement between Republic of Peru and International Bank for
Reconstruction and Development (7643-PE), signed November 16, 2009
Minutes of Negotiations, December 15, 2008
Implementation Completion Report of Health Reform Program (Programa de
Apoyo a la Reforma del Sector Salud - PARSALUD I; First Phase: Mother and
Child Insurance and Decentralization of Health Services), dated March 30, 2006
(ICR000073)
Feasibility Study of PARSALUD II (Segunda fase del Programa de Apoyo a la
Reforma del Sector Salud - PARSALUD II. Estudio de Factibilidad), November
2008
Restructuring Papers:
a) Restructuring Paper (level 2), dated May 17, 2011, approved June 20, 2011
b) Restructuring Paper (level 2), dated August 20, 2014, approved August 26,
2014
Implementation Documents:
a) Implementation Status and Results Reports
b) Aide Memoires
c) Mid-Term Review Report (Revisión de Medio Término de la Segunda Fase
del Programa de Apoyo a la Reforma del Sector Salud (PARSALUD II) en el
Perú, April 2013)
d) Financial Audits Reports
e) PARSALUD Progress Reports
f) Government’s Final Evaluation of PARSALUD (Estudio de Evaluación Final
de la Segunda Fase del Programa de Apoyo a la Reforma del Sector Salud ―
PARSALUD II, December 2015)
PARSALUD Studies:
a) Sistematización de la Estrategia de Promoción de Practica y Entornos
Saludables (EPPES) por el PARSALUD II
b) Sistematización de la Estrategia de Derecho a la Identidad y Aseguramiento-
DIA del PARSALUD II
c) Sistematización del Fondo Concursable para la Selección e implementación
de las iniciativas en el ámbito de intervención del PARSALUD II
d) Sistematización de la Experiencia en Consulta Previa y Diálogos
Interculturales, Implementadas por el PARSALUD II
73
Annex 10: Analysis of PDO Achievement
# Indicator 2005 2009 2014
End
target
Average
annual
growth
rate 2005-
2009
Average
annual
growth
rate 2009-
2014 Ratings
End target
met (100%
achieved or
surpassed)?
In/
before
2009?
Indicator
going in
desired
direction
in 2009-
2014?
Annual
growth
rate
>=0.5%
?
1 Infant mortality rate 42
17 25
Surpassed Yes
Yes
2
Prevalence of chronic
malnutrition in children
under 5 years of age 38.20% 23.70% 30.20% Surpassed Yes Yes
3
Increase the proportion of
institutional deliveries in
rural areas of the nine
selected Regions from 44%
(2005) to 78% (2014) 44.00% 58.80% 74.20% 78.00% 3.70% 2.20%
Partially
achieved No
Yes Yes
4
Reduce the prevalence of
anemia among children
under age in the nine
regions from 69.5% (2005)
to 60% (2014) 69.50% 58.20% 57.30% 60.00% -2.83% -0.13%
Partially
achieved Yes Yes Yes No
5
Increase from 64% to 80%
the share of children in the
nine selected regions who
are exclusively breastfed
until 6 months of age 64.00% 82.20% 87.00% 80.00% 4.55% 0.69% Achieved Yes Yes Yes Yes
6
Reduce the prevalence of
anemia among pregnant
women in the nine Regions
from 41.5% (2005) to 35%
(2014) 41.50% 31.80% 36.40% 35.00% -2.43% 0.66%
Not
Achieved No No
74
# Indicator 2005 2009 2014
End
target
Average
annual
growth
rate 2005-
2009
Average
annual
growth
rate 2009-
2014 Ratings
End target
met (100%
achieved or
surpassed)?
In/
before
2009?
Indicator
going in
desired
direction
in 2009-
2014?
Annual
growth
rate
>=0.5%
?
7
Reduce the hospital lethality
rate among neonates in the
nine selected Regions from
9.5% (2005) to 5% (2014) 9.50% 9.50% 5.00% 5.00% 0.00% -0.64% Achieved Yes
Yes Yes
8
Increase in the proportion of
pregnant women of the nine
regions with at least 1
prenatal control during the
first trimester of pregnancy
from 20% (2005) to 45%
(2014) 20.00% 63.90% 69.10% 45.00% 10.98% 0.74% Achieved Yes Yes Yes Yes
9
Percentage of SIS affiliated
children who received
growth and development
controls (CRED) according
to their age 34.00% 28.80% 56.80% 66.00% -1.30% 4.00%
Partially
achieved No
Yes Yes
10
Percentage of health
facilities with improvement
in infrastructure (minor
construction, rehabilitation
and/or new equipment) 0.00 0.00 103.00 103.00 0.00% 1471.43% Achieved Yes No Yes Yes
11
Percentage of SIS affiliated
rural pregnant women with
laboratory tests on
hemoglobin, urine and
syphilis 37.00% 42.00% 69.00% 53.50% 1.25% 3.86% Surpassed Yes No Yes Yes
12
Percentage of pregnant
women under SIS that 37.00% 49.90% 55.00% 60.00% 3.23% 0.73%
Partially
achieved No Yes Yes
75
# Indicator 2005 2009 2014
End
target
Average
annual
growth
rate 2005-
2009
Average
annual
growth
rate 2009-
2014 Ratings
End target
met (100%
achieved or
surpassed)?
In/
before
2009?
Indicator
going in
desired
direction
in 2009-
2014?
Annual
growth
rate
>=0.5%
?
receive iron and folic acid
supplements
13
Percentage of women
satisfied with the services in
selected facilities by
confidence index 0.00% 1.00% 74.40% 25.00% 0.25% 10.49% Surpassed Yes No
14
Percentage of cesareans in
SIS affiliated pregnant rural
women 3.00% 3.50% 9.50% 10.00% 0.13% 0.86%
Partially
achieved No Yes Yes
15
Percentage of references
among SIS-affiliated
women (during pregnancy
and puerperium) and
neonates N/A N/A
Droppe
d Dropped Dropped Dropped
16
Percentage of SIS affiliated
households that make out-
of-pocket expenditures in
medicines 67.30% 62.00% 56.00% 55.00% -1.33% -0.86%
Partially
achieved No Yes Yes
17
Number of accredited health
establishment by type of
resolution 80.00 N/A
Droppe
d Dropped Dropped Dropped
18
Number of Management
Agreements in place N/A N/A
Droppe
d Dropped Dropped Dropped
19
Number of health personnel
and community health
workers trained within the
behavior change campaign
(EPPES) 0.00 0.00 1178.00 758.00 0.00% 16828.57% Surpassed Yes No Yes Yes
76
# Indicator 2005 2009 2014
End
target
Average
annual
growth
rate 2005-
2009
Average
annual
growth
rate 2009-
2014 Ratings
End target
met (100%
achieved or
surpassed)?
In/
before
2009?
Indicator
going in
desired
direction
in 2009-
2014?
Annual
growth
rate
>=0.5%
?
20
Number of health facilities
improved 0.00 0.00 69.00 73.00 0.00% 985.71%
Partially
achieved No
Yes Yes
21
Norms and regulations to
improve efficiency and
equity of the health delivery
system prepared 0.00 0.00 32.00 27.00 0.00% 457.14% Surpassed Yes No Yes Yes
22
Clinical pathways and
corresponding financing
systems designed 0.00 0.00 16.00 11.00 0.00% 228.57% Surpassed Yes No Yes Yes
23
Periodic evaluations of the
performance of the health
networks 0.00 0.00 19.00 17.00 0.00% 271.43% Surpassed Yes No Yes Yes
* Explanation of Ratings:
Surpassed: end target achieved/surpassed and indicator value at the start of the project lower than the end target;
Achieved: end target met/surpassed (at any point in time), growth rate during the project going in desired direction and >=0.5%;
Partially Achieved: end target not met, growth rate during the project going in desired direction and >=0.5% OR end target met before 2009, growth rate during
the project going in desired direction and <0.5%;
Not Achieved: end target not met and undesired trajectory of indicator
77
Annex 11: Loan Amount Allocation
Loan Amount Allocation (in millions of US$)
Approved Revised Actual
(1) Goods, works,
consultant’s services and
Training under Part 1 of the
Project
2.99 1.49 0.52
(2) Goods, works,
consultant’s services and
Training under Part 2 of the
Project
9.16 11.96 10.32
(3) Goods, works,
consultant’s services and
Training under Part 3 of the
Project
2.59 1.30 0.88
(4) Goods, consultant’s
services including audit and
Operating Costs
0.25 0.25 0.25
78
Annex 12: Organization of PARSALUD II Project Implementation Unit (PIU)
Source: http://www.parsalud.gob.pe/organizacion
General Coordinator: Dr Walter Vigo Valdez
Technical Coordinator: Dr Rosa Ines Bejar Caceres
Financial Administration Coordinator: Mr Fernando Masumura Tanaka
79
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