95115 ANALYSIS OF THE HEALTH CARE LABOR MARKET IN PERU DISCUSSION PAPER J ANU ARY 2015 Michelle Jiménez Eduardo Mantilla Carlos Huayanay Michael Mego Christel Vermeersch ANALYSIS OF THE HEALTH CARE LABOR MARKET IN PERU Michelle Jiménez, Eduardo Mantilla, Carlos Huayanay, Michael Mego, and Christel Vermeersch January 2015 i Health, Nutrition, and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population (HNP) Family of the World Bank's Human Development Network (HDN). The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For information regarding the HNP Discussion Paper Series, please contact the Editor, Martin Lutalo at mlutalo@worldbank.org or Erika Yanick at eyanick@worldbank.org. © 2015 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. i Health, Nutrition, and Population (HNP) Discussion Paper Analysis of the Health Care Labor Market in Peru Michelle Jiménez,a Eduardo Mantilla,b Carlos Huayanay,c Michael Mego,d and Christel Vermeersche a CRONICAS, Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru b Universidad ESAN, Lima, Peru c CRONICAS, Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru d Universidad ESAN, Lima, Peru e The World Bank, Washington, DC This paper was prepared with funding from the Japan-World Bank Partnership Program for Universal Health Coverage and from the World Bank’s Non-Lending Technical Assistance Project (P147195) to Peru. Abstract: This report aims to provide an updated analysis of labor market trends for the health workforce in Peru, focusing on the basic health team —physician, nurse, and midwife—and other health professionals related to current priorities. Peru has been labeled as a country with a shortage of health professionals (that is, with less than 25 professionals per 10,000 inhabitants), and although the most recent numbers indicate that the situation has improved, the shortages are bound to become more acute as the country aims to achieve Universal Health Coverage. We found that the country trains both in public and private universities a large number of professionals, but that the majority of trained professionals do not then go on to work for the public sector. This dynamic had not been described before and challenges current assumptions of human resources needs and availability. There is very little reliable data on numbers, type and work conditions for human resources working outside the public sector, including the social security insurance health system (EsSalud), other health insurance providers, and the private sector, and as a result no detailed information can be obtained about the distribution of health professionals outside the public sector. For policy purposes, it is necessary to improve the quality and integration of HRH information across the sector. Keywords: Human Resources in Health Disclaimer: The findings, interpretations, and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Michelle Jimenez, CRONICAS, Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, Avenida Armendáriz 497, 2do Piso, Miraflores, Lima 18, Perú. Tel. +51 1 241 69 78, cronicas@oficinas-upch.pe, www.cronicas-upch.pe ii T ABLE OF CONTENTS Acknowledgments ........................................................................................................................................ vi Acronyms and Abbreviations .......................................................................................................................vii List of Figures .............................................................................................................................................. viii List of Tables ................................................................................................................................................ ix Executive Summary ...................................................................................................................................... x Training of Health Professionals .............................................................................................................. xi Transition of Graduates to the Labor Market ........................................................................................... xi Contracting of Health Professionals in the Public Sector .........................................................................xii Migration ...................................................................................................................................................xii Retention ................................................................................................................................................. xiii Postgraduate Training ............................................................................................................................. xiii Recommendations ...................................................................................................................................xiv Relevance of skills of health professionals ..........................................................................................xiv Contracting, compensation, and retention policies within realistic budgetary scenarios .....................xiv Quality of information on HRH .............................................................................................................xiv Research to inform the policies for implementation ............................................................................. xv Limitations ............................................................................................................................................... xv Introduction.................................................................................................................................................... 1 Justification ................................................................................................................................................ 1 Objectives .................................................................................................................................................. 1 Background and Conceptual Framework .................................................................................................. 2 Methodology .............................................................................................................................................. 4 1. Training of Health Professionals ............................................................................................................ 5 Data Sources ............................................................................................................................................. 5 Supply of Health Training Programs ......................................................................................................... 5 Applications and Admissions to Training Programs .................................................................................. 6 Graduates from Health Training Programs and Certification .................................................................... 8 Comparison Between Training Curricula, Professional Association Profiles, CONEAU’s Standard Number 25, and MINSA Profiles ............................................................................................................... 9 Physicians ............................................................................................................................................ 10 Nurses .................................................................................................................................................. 10 Midwives .............................................................................................................................................. 11 Discussion ............................................................................................................................................... 11 2. Transition of Graduates to the Labor Market ....................................................................................... 12 Sources of Data ....................................................................................................................................... 12 The Rural and Urban-Marginal Internship Program ................................................................................ 12 iii The Transition between Universities and the SERUMS Program ........................................................... 13 The Transition from SERUMS to the Public Sector Health Labor Market ............................................... 18 Discussion ............................................................................................................................................... 24 3. Contracting of Health Professionals in the Public Sector .................................................................... 25 Data Sources ........................................................................................................................................... 25 Distribution of Health Professionals by Subsector .................................................................................. 25 Contract Regimes to Hire Health Human Resources in the Public Sector ............................................. 26 The Health Workforce Gap in MINSA and Regional Governments’ Health Care Establishments — 2013 ................................................................................................................................................................. 27 Projection of the Health Workforce Gap .................................................................................................. 31 Discussion ............................................................................................................................................... 32 4. Migration .............................................................................................................................................. 33 Data Sources ........................................................................................................................................... 33 Students’ Intention to Migrate .................................................................................................................. 33 Discussion ............................................................................................................................................... 35 5. Retention .............................................................................................................................................. 36 Data Sources ........................................................................................................................................... 36 Human Resources for Health Aspirations, Expectations, and Needs ..................................................... 36 Health Facility Employee Satisfaction ..................................................................................................... 37 Discussion ............................................................................................................................................... 38 6. Postgraduate Training: Medical Specialties ........................................................................................ 38 Data Sources ........................................................................................................................................... 38 Organization of Postgraduate Training for Medical Specialties .............................................................. 38 Postgraduate Training of Medical Specialties: Supply and Demand ...................................................... 39 Distribution of Medical Specialists within the System ............................................................................. 40 Deficit of Medical Specialists ................................................................................................................... 41 Resident Training Dynamics and Incorporation into the Public Sector ................................................... 42 Discussion ............................................................................................................................................... 42 Conclusions ................................................................................................................................................. 43 Recommendations ...................................................................................................................................... 44 Relevance of skills of health professionals .......................................................................................... 44 Contracting, compensation, and retention policies within realistic budgetary scenarios ..................... 45 Quality of information on HRH ............................................................................................................. 45 Research to inform the policies for implementation ............................................................................. 45 Limitations ............................................................................................................................................... 46 References .................................................................................................................................................. 47 Annexes ...................................................................................................................................................... 49 Annex 1: Data and Information Sources Used in This Report ................................................................ 49 iv Annex 2: Curricula of Training Programs of Universities with 4 Percent or More Number of Students in the Basic Health Team Professions ........................................................................................................ 50 Annex 3: Universities That Have Registered Training Programs for Health Professionals with CONEAU ................................................................................................................................................................. 54 Annex 4: Comparison of Competency Profiles ....................................................................................... 56 Annex 5: Human Resource in Health Gap in the Public Sector (2013) .................................................. 61 Annex 6: Projections of the Human Resources in Health Gap in the Public Sector, 2013 –50 ............... 63 Annex 7: CONAREME Standard No. 25 ................................................................................................. 65 v ACKNOWLEDGMENTS This study was conducted pursuant to the Memorandum of Understanding signed by the Peruvian Ministry of Health (Ministerio de Salud—MINSA) and the World Bank, and was developed with funds from the Japanese government under the Japan-World Bank Partnership Program for Universal Health Coverage. The approach and parameters of this study were defined on the basis of discussions with the General Director’s Office for Management of Human Resources Development (Dirección General de Gestión del Desarrollo de Recursos Humanos—DGGDRRHH) at MINSA, with inputs from PARSALUD and the World Bank. The authors are grateful to the World Bank for publishing this report as an HNP Discussion Paper and to ESIT Traducciones for their work on translating the original document. The study benefited from inputs and comments provided by Hernán Garcia, Karina Gil, Gabriela Samillán, Walter Vigo, Rosanna Oleachea-Geng, Enrique Velasquez, Joana Godinho, Akiko Maeda, Edson Araujo, and Andre Medici. The authors thank Gabriela Moreno Zevallos and Sara Burga for their outstanding administrative support. vi ACRONYMS AND ABBREVIATIONS ANR Asamblea Nacional de Rectores / National Assembly of Rectors ASPEFAM Asociación Peruana de Facultades de Medicina / Peruvian Association of Medical Schools UHC Universal Health Coverage CAS Contrato Administrativo de Servicios / Administrative Contract for Services (a temporary employment agreement to work in the public sector) CONAREME Comité Nacional de Residentado Médico / National Committee of Medical Residency CONEAU Comisión Nacional de Evaluación y Acreditación Universitaria / National Council of University Evaluation, Accreditation and Certification DGGDRRHH Dirección General de Gestión del Desarrollo de Recursos Humanos / General Director’s Office for Management of Human Resources Development DIGEMIN Dirección General de Migraciones y Naturalización / Bureau of Immigration and Naturalization DIRESA Dirección Regional de Salud / Regional Health Directorate EsSalud Seguro Social de Salud del Perú / Social Health Insurance of Peru FFAA Fuerzas Armadas de la República del Perú / The Peruvian Military Forces FONCODES Fondo de Cooperación para el Desarrollo Social / Social Compensation and Development Fund HIV/AIDS Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome HRH Human Resources for Health INEI Instituto Nacional de Estadística e Informática / National Institute of Statistics and Informatics MINSA Ministerio de Salud / Ministry of Health NCD Noncommunicable Disease PAHO Pan-American Health Organization PARSALUD Programa de Apoyo a la Reforma del Sector Salud / Program to support health sector reform PEAS Plan Esencial de Aseguramiento en Salud / Health Insurance Essential Plan PNP Policía Nacional del Perú / Peruvian National Police SERUMS Servicio Rural y Urbano Marginal de Salud / Rural and Urban Marginal Health Service SIS Seguro Integral de Salud / Comprehensive Health Insurance Scheme SISOL Sistema Metropolitano de la Solidaridad / Metropolitan Solidarity System SNP Servicios no Personales / Non-personal Services (a temporary employment agreement to work in the public sector; it has been replaced by CAS) UHC Universal Health Coverage WHO World Health Organization vii LIST OF FIGURES Figure 1.1 Conceptual Framework of the Study ........................................................................................... x Figure 1.2 Number of Doctors, Nurses, and Midwives in Peru, 1975–2012 ................................................. 2 Figure 1.3 Conceptual Framework of the Study ........................................................................................... 4 Figure 1.4 Medical Training Supply and Demand, Public vs. Private Universities, 2007 –11 ....................... 7 Figure 1.5 Nursing Training Supply and Demand, Public vs. Private Universities ....................................... 7 Figure 1.6 SERUMS Applicants from Medical Schools per University of Origin, 2013 .............................. 16 Figure 1.7 SERUMS Applicants for Midwifery, by University of Origin, 2013 ............................................. 18 Figure 1.8 Health Professionals Join the Public Sector after Completing SERUMS .................................. 19 Figure 1.9 Dynamics of Training, SERUMS, and Entry into the Public System for Physicians .................. 20 Figure 1.10 Dynamics of Training, SERUMS, and Entry into the System for Nurses ................................ 20 Figure 1.11 Dynamics of Training, SERUMS, and Entry into the System for Midwives ............................. 21 Figure 1.12 Dynamics of Training, SERUMS, and Entry into the System for Dentists ............................... 21 Figure 1.13 Dynamics of Training, SERUMS, and Entry into the System for Nutritionists ......................... 22 Figure 1.14 Dynamics of Training, SERUMS, and Entry into the System for Psychologists ...................... 22 Figure 1.15 Dynamics of Training, SERUMS, and Entry into the System for Pharmacists and Biochemists .................................................................................................................................................................... 23 Figure 1.16 Dynamics of Training, SERUMS, and Entry into the System for Medical Technologists ........ 23 Figure 1.17 Methodology Used to Calculate Health Workforce Gaps ........................................................ 28 Figure 1.18 Number of Medical and Nursing Degrees Recognized in Spain, by Country of Origin of the Migrant ........................................................................................................................................................ 35 viii LIST OF TABLES Table 1.1 Registration and Accreditation of Health Training Programs with CONEAU ................................ 6 Table 1.2 Demand and Supply of Training in Midwifery, Dentistry, Nutrition, Psychology, Dentistry, Pharmacy and Biochemistry, and Medical Technology ................................................................................ 8 Table 1.3 Number of Graduates by Profession, 2007 –11 ............................................................................ 9 Table 1.4 Number of SERUMS Positions by Year (2007–13) and Source of Financing ........................... 13 Table 1.5 Number of Graduated Health Professionals and Number of SERUM Entrants ......................... 14 Table 1.6 SERUM Applicants, All Professions, per University of Origin, 2008 –13..................................... 15 Table 1.7 Nursing SERUMS Applicants per University of Origin, 2013 ...................................................... 17 Table 1.8 Type of Contract for Public Sector Employees Who Completed SERUMS in 2007 –11 ............. 24 Table 1.9 Distribution of Health Professionals by Health System Subsector ............................................. 26 Table 1.10 Human Resources for Health per Contract Regime Nationwide (Public Sector Only) ............. 27 Table 1.11 Number of Graduates and Ratio of Graduates/ Entrants ......................................................... 29 Table 1.12 Projections of the Number of Graduated Professionals 2012 –15 ............................................ 30 Table 1.13 Projection of the Number of Professionals Entering SERUMS ................................................ 31 Table 1.14 Projection of the Number of Professionals Entering the Public Health System ....................... 31 Table 1.15 Summary of Gap Closure Simulations ...................................................................................... 32 Table 1.17 Plans to Migrate Abroad after Graduation, 2010 University Census ........................................ 34 Table 1.18 Results of Organizational Climate Survey (2011 –13) ............................................................... 37 Table 1.19 Number of Entrants to Priority Specialties ................................................................................ 39 Table 1.20 Distribution of Priority Medical Specialists by Department ....................................................... 40 Table 1.21 Distribution of Priority Medical Specialists according to Health Establishment Category ........ 41 Table 1.22 Absorption of 2009/10 Medical Residents in the Public Sector, 2013 ...................................... 42 ix EXECUTIVE SUMMARY This report aims to provide an updated analysis of labor market trends for the health workforce in Peru, focusing on the basic health team—physician, nurse, and midwife—other professionals related to health priorities—specifically nutritionists, psychologists, pharmaceutical chemists, dentists, and medical technologists—as well as main medical specialists—anesthesiologists, family and community doctors, general surgeons, internists, obstetricians/gynecologists, and pediatricians. Moreover, the study reviews and synthesizes the existing peer-reviewed and grey literature on human resources for health (HRH) in Peru and provides guidance on potential policy interventions and management changes focused on these professions that may improve the current situation of human resources for health in the country. The study’s main limitation is that it is focused mainly on public employees, that is, those hired by the Ministry of Health (MINSA) and the regional governments. The information (for instance, the number, type, and distribution of professionals) of human resources working in the social security health insurance (EsSalud) and the private subsector is limited to current data held by the MINSA’s National Observatory on Human Resources for Health, which is provided voluntarily and not necessarily on a regular basis. Lack of information on current salary levels and how these compare across subsectors, as well as unemployment rates for these professionals are other limitations of this study. We used three main strategies for data analysis: (1) Reviewing documents, reports, or academic literature published by MINSA, other national and international organizations, or published by research groups in scientific journals; (2) using data from primary sources without merging them with other data; and (3) merging and/or combining data from different sources. Unfortunately, we were unable to obtain reliable primary data for our migration and retention analyses. This study is organized according to a conceptual framework that seeks to represent specific characteristics of the flow of human resources for health through the Peruvian labor market (Figure 1.1). The report is organized in six sections, each one of which corresponds to one component of the framework: training of health professionals, transition of graduates to the labor market, contracting, migration, retention, and postgraduate training. Figure 1.1 Conceptual Framework of the Study Source: MINSA, DGGDRRHH 2014. x TRAINING OF HEALTH PROFESSIONALS We analyzed the current state of supply and demand for training of health professionals, and the number of graduates. Overall, there is a high interest in, and demand for, training at a professional level for careers that form the basic health team, and more than 70 percent of this training1 is supplied by private universities. We also reviewed the competency profiles of trained professionals as evidenced by: (a) the curricula of the medical, nursing, and midwifery training programs with the highest number of students; (b) the standards prepared by the National Council of University Evaluation, Accreditation and Certification (CONEAU) that are used to accredit education programs for these professions; (c) the competency profiles developed by the respective professional associations for the purpose of certifying graduates. These curricula and profiles were compared to the prioritized competency profiles of primary care physicians, nurses, and midwives prepared by MINSA. The objective was to determine whether the current training programs prepare professionals to work at the primary care level—as defined by the MINSA competency profile. Results showed a clear disparity between the profiles of health professionals at the training/graduate stage and the one required by MINSA at the primary care level, which is the main employer of health professionals in the country. In particular, physicians and nurses appear to lack preparation to work at the primary care level. Furthermore, we find that MINSA’s profiles for professionals in the basic health team lack skills related to prevention, health promotion, and management. For example, MINSA’s competency profile for nurses only requires them to provide adult care in the case of tuberculosis and HIV/AIDS, while the full burden of preventing and treating NCDs is assigned to physicians. MINSA’s approach to NCDs at the primary care level may result in a lack of appropriate attention to the prevention and treatment of people with early symptoms of NCDs who need to implement lifestyle changes (diet, exercise) to prevent progression of the disease. CONEAU is the institution responsible for accrediting training programs and certifying professionals, and it has established a process to regulate and guarantee the quality of university education. However, the accreditation process has advanced slowly: as of July 2013, 45 universities had registered for accreditation 234 training programs for the professions (physicians, nurses, midwives, nutritionists, psychologists, pharmaceutical chemists, dentists, and medical technologists) included in this report, but only 2 of these programs had completed the accreditation process. TRANSITION OF GRADUATES TO THE LABOR MARKET In the second section of the report, we review data on the transition of graduates to the labor market via the Rural and Urban Marginal Health Service (Servicio Rural y Urbano Marginal en Salud—SERUMS). SERUMS is one of the strategies used by MINSA to increase coverage of primary health care professionals in rural and marginal areas, and is a requirement for those health professionals who would like to work in the public sector. The vast majority of health professionals who enroll in SERUMS spend a year working at the primary care level in rural or urban-marginal areas. We reviewed data on the number of SERUMS positions, applicants’ profiles (that is, the university they graduated from), number of graduates who take up SERUMS positions, number of those completing SERUMS who start to work for the public sector in subsequent year, and the conditions of their employment. 1. Measured by the average number of entrants. xi For most professions included in this study, except for physicians, a significant number of graduates do not to take up a SERUMS position. This finding indicates that currently the labor market of human resources for health in Peru offers other job opportunities that do not require previous SERUMS experience. After completion of SERUMS, only 25 percent of professionals are incorporated into (hired by) the public sector the subsequent year. Furthermore, those who do join the public sector after completing SERUMS do so mainly under temporary employment agreements. Considering the data reviewed, we conclude that the market offers other job opportunities to these professionals that are more attractive than SERUMS and public sector employment. CONTRACTING OF HEALTH PROFESSIONALS IN THE PUBLIC SECTOR In this section we present the distribution of health professionals within the public sector at a national level, and provide information on the contracting modalities used within this subsector. The information on HRH working outside the public sector (contracted by either MINSA or the regional governments) is incomplete and therefore it was not possible to review contracting of health professionals in the labor market outside of the public sector or make any comparisons. The public sector has at least 10 contract modalities or labor conditions; we presume there is a great variability in salaries though we had no access to data of salary levels for this study. Even though salary may not be the only factor shaping workers’ decisions about a job position, such salary variability is probably an obstacle in attracting and retaining high-quality and motivated professionals to the public sector. We also estimate the number of health professionals that the public sector needs to provide services compared to the number of professionals in the current health workforce, the time needed to reduce the health workforce gap in the public sector, and the measures that may be adopted to accelerate that process.2 We find that in a scenario in which the number of professionals incorporated into the system is doubled, the gap of physicians required by MINSA3 could be closed by 2020; alternatively, if the absorption rate stays at the current level, such a gap would be closed by 2027. The respective numbers for nurses, at the absorption rates described, would be 2019 and 2024. For midwives, our calculations show that the gap may be resolved by 2017 with the current hiring rate. It is worth mentioning that these calculations are based on relatively simplistic assumptions and do not control for the increased need of HRH related to population increases or an increase of the elderly population, natural attrition, or workforce turnover and retirement for instance. MIGRATION We examined published information on migration of Peruvian health professionals, as well as health professions students’ intentions to migrate abroad. Data from the university census carried out in 2010 showed that a majority of students reported that they intended to migrate to practice their profession (78 percent of medical students, 67 percent of nursing students, and 60 percent of midwifery students). Other 2. The gaps are based on the actual demand of medical procedures of the Essential Health Insurance Plan (Plan Esencial de Aseguramiento en Salud—PEAS), as well as other administrative and training activities that are part of the labor duties of these professionals at the primary care level. 3 This gap is estimated by quantifying the difference between the need for and the availability of human resources for health care services. The need for human resources is estimated using an estimate of the time required to provide the medical services of the Essential Health Insurance Plan ( Plan Esencial de Aseguramiento en Salud —PEAS) as well as other health care activities not considered in PEAS, and management and training activities that are part of job duties in the primary care level. The unit that is used to calculate the human resource gap for health care services of the primary care level is the health micro-network. xii reports show that many professionals, particularly physicians and nurses, do indeed migrate, and the loss for the country, especially of professionals trained by public universities, is high. This section highlights the need for improved information on migration flows of Peruvian health professionals to gain an understanding of the migration situation and design policies to respond to it. RETENTION In this section, we summarize and discuss the few available studies on incentives to attract and retain health professionals. These studies show that very few physicians expect or aspire to work at the community level or in rural areas. Furthermore, many have already migrated to larger urban areas to pursue their studies. A discrete choice experiment of job preferences related to remaining in working placements located in rural Ayacucho highlights the significance of incentive packages, and how they can change according to profession, years of experience, and gender. Data collected by MINSA’s Quality Office show that the majority of health workers consider their job environment could be improved, which could be an indicator of job satisfaction. However, the available information for analysis is limited, since there are no labor force surveys, for instance, or more information about salaries and benefits in other subsectors. POSTGRADUATE TRAINING We describe the supply and demand for specialized physician training focused on specialties related to health priorities: anesthesiology, family and community medicine, general surgery, internal medicine, obstetrics and gynecology, and pediatrics. Furthermore, we present the distribution of those specialists per level of care and department, and analyze the demand for specialists’ training and their integration into the public sector workforce once they have completed their residency. We find a high demand for training in these priority medical specialties. In 2013, more than 43 percent of physicians beginning their residencies were associated with them. We find that the distribution of specialists between the different levels 4 of health establishments is relatively appropriate as it responds to requirements established by MINSA; however, geographic distribution is extremely unbalanced with more than half of the specialists being located in Lima. The National Committee of Medical Residency (CONAREME), which regulates medical specialist training in Peru has developed competency profiles for each specialty. We examined the profiles of priority specialties to determine the extent of priority or approach given to the primary care level. We find that only the gynecology and obstetrics, and the family and community medicine specialties, give some priority to primary or community care. Although, primary care training might not be expected for general surgeons, internists and anesthesiologists, as they would not be expected to perform necessarily at primary care levels, it could be expected that some consideration would be included in pediatricians’ training, given that they might be providing care at primary care level. The analysis of the resident training dynamics and of the incorporation of specialists into the public sector shows that only 10 percent of specialists start working for the public sector in the first two years after completing their residencies, indicating that a significant number of specialized human resources are not 4. Health establishments are categorized according to the level of care that they can provide —from the least complex to the most complex. xiii used in the public sector. Unfortunately, little is known about where these specialists choose to work, how many migrate (from/to where), or how to attract a larger number of them to work in the public sector. RECOMMENDATIONS Our recommendations can be grouped in four areas: (i) the relevance of skills of health professionals; (ii) contracting, compensation, and retention policies to improve absorption and retention of health professionals in the public sector; (iii) the quality of information on HRH; and (iv) research to inform the policies for implementation. Relevance of skills of health professionals  We recommend that MINSA’s General Director’s Office for Management of Human Resources Development (Dirección General de Gestión del Desarrollo de Recursos Humanos—DGGDRRHH) work with public and private universities to review existing training programs and develop new programs focused on training professionals to work specifically at the primary care level. Programs could look beyond the currently available programs and include shorter, more community-oriented courses. If these shorter courses are associated with a high likelihood of employment after completion, they may be well received in a market with a high demand for training. Considering that private institutions currently provide the majority of training in the health professions, they would play an essential role in the development of new training programs. In addition, it would be important to offer these courses in the local regions close to student residences, as students from rural areas may be more likely to enroll and work in their region of origin.  The accreditation process for training programs will need to be made more agile if it is to guarantee training quality. We recommend a more detailed assessment of CONEAU’s processes to understand the difficulties and propose steps that could speed up the certification process.  Professional associations are already playing a role in certifying professionals; however, this process does not add value or improve a professional’s employment opportunities in the labor market, and it is unclear whether it includes any assessment of skills. The certification process should be widened to include an assessment of skills that would guarantee professional quality and improve job opportunities.  MINSA’s profiles for the basic health team would need to be updated to adjust responsibilities for caring for NCDs and adult conditions. Nurses need to assume a larger role in the prevention and management of chronic conditions. Furthermore, other skills such as administrative management, and public health prevention and promotion need to be considered within these profiles. Contracting, compensation, and retention policies within realistic budgetary scenarios  In terms of contracting, the public sector relies on a multitude of contract regimes, which seem to be paired with wide divergences in salary. We recommend that MINSA take a global look at contractual regimes and payment schemes and strategically review compensation mechanisms.  The SERUMS program has been successful at ensuring the presence of health professionals in rural and remote areas; however, it is not accompanied by a mechanism to retain these professionals in the public sector. We recommend that SERUMS be complemented with a retention strategy, based on a more complete assessment that includes studies that explore the job aspirations and expectations of new graduates. Post-SERUMS professionals signaled their interest in working for the public sector by enrolling in SERUMS—the public sector should capitalize on this knowledge in its attempts to hire and retain professionals. Quality of information on HRH  There is a fragmentation in the information systems between MINSA, EsSalud, the other health insurance providers and the private sector, and as a result, no comprehensive information can be xiv obtained about the distribution of health professionals by subsector. For policy purposes, it is necessary to improve the quality and integration of HRH information both in the public sector and outside of it. To achieve this, there is a need for strategic alliances with entities that routinely collect data on human resources in these subsectors, such as EsSalud, private insurance providers, professional associations, and corporations managing clinics and private hospitals. The challenge would be to create a relationship in which there is common interest in sharing this information. Such information will strengthen subsequent studies on the employment market of HRH as it provides a more complete vision of the entire sector.  In regards to migration, there are still many unanswered questions. For instance, there is little information on how many professionals leave the country to work, how many continue studying, how many come back, and when. There are outstanding questions as to when more aggressive retention strategies should be applied, for example, before or after SERUMS, before or after the residency? To be able to answer some of these questions, MINSA will need to work with the Bureau of Immigration and Naturalization (DIGEMIN) to improve the quality of information on health professional migration. Research to inform the policies for implementation  Professional incorporation into the public sector will require the development of contractual, incentive, and retention packages that are based on better understanding of health professionals’ aspirations, expectations, and needs. Studies on new graduates, those who complete their SERUMS, current public sector workers, other subsectors workers, and unemployed health professionals may provide information on job expectations, relative options in the market, and salary and social benefit expectations, which we were not able to analyze in this study. Some methodologies that may be used include surveys, discrete choice studies, and focus groups, among others.  In our analysis of the dynamics of medical specialist training and absorption of specialists by the public sector, we find that absorption by the public sector is minimal, at approximately 10 percent. It would be important to research the flow of medical specialists within the market and understand what happens with them, where they end up working, and why. Moreover, we need to understand how MINSA can manage to attract and retain more specialists within its budgetary limitations. LIMITATIONS This study has several main limitations:  The discussion of human resources in health that is presented in this report focuses on the public sector, and this limitation was mainly driven by availability of data. At the same time, the discussion on human resources in health should be framed within a broader discussion on the role of the public sector in health service delivery, and the role of other providers including EsSalud, the other insurance/provisions institutions like the Metropolitan Solidarity System (Sistema Metropolitano de la Solidaridad—SISOL) and the private sector providers.  Even within the public sector, our analysis is limited by availability of data in several areas. xv INTRODUCTION JUSTIFICATION In 2011, Japan celebrated the 50th anniversary of its own achievement of Universal Health Coverage (UHC). On this occasion, the government of Japan and the World Bank conceived the idea of undertaking a multicountry study to share country experiences from countries at different stages of adopting and implementing UHC strategies, including Japan itself. This led to the formation of the Japan-World Bank Partnership Program for Universal Health Coverage. A total of 11 countries participated in the study, including Bangladesh, Brazil, Ethiopia, France, Ghana, Indonesia, Peru, Thailand, Turkey, and Vietnam. (Ikegami et al. 2014) This report is a background report to the Peru Country Summary Report that was prepared by the World Bank. This study also is part of the implementation of a September 2013 Memorandum of Understanding between the Peruvian Ministry of Health and the World Bank, which outlines a program of cooperation and technical assistance between the two institutions. The Peruvian government has started implementing Supreme Resolution No. 001-2013-SA, and it has proposed a series of guidelines and reform mechanisms for the health sector (July 2013). 5 Of particular importance among these are the following: strengthening the health public sector, encouragement of health promotion actions; protection of individuals and families by extending the current insurance coverage until universality is achieved; upgrading of health professionals’ work conditions to support prop er conditions for their development and for carrying out their duties; improving regulation of and access to quality medicines; and improving the use of health resources, reducing household out-of-pocket expenses, and increasing public funding for health. Therefore, this study aims to meet the objectives of the Japan-World Bank Partnership Program for Universal Health Coverage, as well as MINSA’s needs, within the context of the abovementioned reform. This study was carried out in collaboration with the General Director’s Office for Management of Human Resources Development (Dirección General de Gestión del Desarrollo de Recursos Humanos — DGGDRRHH) of MINSA, PARSALUD, and the World Bank. OBJECTIVES The objectives of this report are the following:  Analyze recent trends of the health labor market in Peru for the basic health team professionals (physician, nurse, and midwife) and other professionals related to health priorities, specifically nutritionists, psychologists, pharmaceutical chemists, dentists, and medical technologists, as well as how they impact the UHC strategy implementation in the country.  Review and synthetize existing literature on the health workforce situation in Peru to provide context to the labor market analysis.  Provide guidance on potential political interventions and management changes focused on these professions, which may improve the current situation of human resources for health in the country. 5... http://www.minsa.gob.pe/portada/Especiales/2013/reforma/documentos/documentoreforma11122013.pdf. 1 BACKGROUND AND CONCEPTUAL FRAMEWORK Achieving the goal of UHC requires an expansion of benefits and coverage that generally requires an investment in the health workforce. Countries that embark upon UHC face increasing pressures to ensure that there are sufficient health workers to respond to the growing demand for appropriate and effective health services. The WHO estimates that a health workforce density of 22.8 skilled health professionals per 10,000 people is the lower level needed to achieve relatively high coverage for essential health interventions. (WHO 2006) According to the World Development Indicators, the number of doctors, nurses and midwives in Peru has increased in recent years to reach 26.5 per 10,000 people in 2012, from 18.4 in 1999, mainly due to an increase in the number of nurses and midwives (Figure 1.2). So while the density of skilled health professionals may no longer be at critical levels according to the WHO definition, it is low compared to other countries that have achieved UHC or are close to achieving it. For example, Japan and France have 63.3 and 126.6 skilled health professionals per 10,000 people respectively, while Brazil has 81.4 and Turkey has 41.1 (Maeda et al. 2014). Figure 1.2 Number of Doctors, Nurses, and Midwives in Peru, 1975–2012 30.0 25.0 20.0 Nurses and midwives (per 15.1 10,000 people) 15.0 6.7 12.7 Physicians (per 10,000 people) 10.0 WHO Threshold (22.8 per 10,000 people) 5.0 10.6 11.7 11.3 9.3 9.2 7.2 5.3 0.0 1975* 1980* 1985* 1990* 1999 2009 2012 Source: World Development Indicators (WDI), 2014. *The WDI do not contain data on nurses and midwives for 1970–90. Human resources for health in Peru include all professionals and workers of the sector, including administrative staff, as well as physicians in training in a clinical specialty (known as residents), who are hired during their training period (usually three years), and professionals working in the Rural and Urban Marginal Internship Program (Servicio Rural Y Urbano Marginal de Salud—SERUMS). This study focuses on the basic health team professionals (physician, nurse, and midwife) and other professionals related to the priorities outlined by MINSA during the preparing of this report, specifically dentists, nutritionists, psychologists, pharmaceutical chemists, and medical technologists. At the postgraduate level we also included those specialties that are related to the health priorities—that is, anesthesiology, family and community medicine, general surgery, internal medicine, gynecology and obstetrics, and pediatrics. 2 The Peruvian health sector is divided into five distinct groups of service providers: (a) The public subsector, which includes the Ministry of Health (Ministerio de Salud—MINSA) and the regional governments; (b) Social Health Insurance (EsSalud); (c) the Armed Forces and National Police health service; (d) the Metropolitan Solidarity System (Sistema Metropolitano de la Solidaridad—SISOL), which provides services within the Lima metropolitan area; and (e) the private subsector. 6 Due to lack of availability of data, this study focuses mostly on the public subsector. The labor market is the economic environment in which the supply of labor—formed by the population’s ability and willingness to work certain numbers of hours in particular paid activities—and demand for labor— constituted by job opportunities—interact. The supply is the workforce that is available, whereas the demand is formed by employers looking for workers. The degree of balance between these two factors determines the market conditions at a given time. This study evaluates the current labor market conditions and trends for human resources in health (HRH) in Peru. This study is organized according to a conceptual framework that seeks to represent specific dynamics of the Peruvian labor market for the health sector (Figure 1.3). The important flows of Human Resources in Peru include the following: Professionals are initially trained in public and private universities. After training, graduates transition to the labor market; if they are interested in working for the public sector or (in the case of physicians in specialist training)—they must complete the SERUMS internship program. After the SERUMS, transition of graduates into the public sector can happen through various contracting regimes, but graduates are also able to work in other sectors (social security insurance, private sector, etc.). At the same time, the Peruvian health labor market is characterized by high rates of out-migration and difficulties in retaining employees in rural and remote locations. Following the outlined dynamics, the report has been organized in six sections, each corresponding to a specific part of the framework: training, transition of graduates to the labor market (SERUMS), health labor contracting in the public sector, migration, retention, and postgraduate studies (that is, specialist training for physicians). 6. By and large, the arrangement of service providers mirrors financing arrangements: The public sector is financed by general taxation resources from the Ministry of Finance and by resources from the Comprehensive Health Insurance Scheme (Seguro Integral de Salud—SIS). EsSalud is an integrated entity that insures and provides services to mostly formal sector workers using its own providers, financed by payroll taxes. The Armed Forces and National Police health service have their own financing and service provision network. Finally the Metropolitan Solidarity System is a public- private partnership that provides care on a out-of-pocket fee-for-service basis, albeit at affordable rates. There are various relatively limited arrangements between the service provision networks to finance and provide services across networks. 3 Figure 1.3 Conceptual Framework of the Study Source: MINSA, DGGDRRHH 2014. METHODOLOGY This study is focused mainly on public workers who work in the service delivery networks managed by MINSA and the regional governments. A significant limitation for this study is that the information on human resources working for EsSalud, other service providers, and the private subsector is limited only to the current data held by the MINSA’s National Observatory for Human Resources for Health. Another limitation is the lack of information on salaries7 and levels of unemployment.8 This study used existing data and information from different sources, which are listed in annex 1. Three strategies were used for data analysis: (1) Reviewing documents, reports, or academic literature published by MINSA, other national and international organizations or scientific journals; (2) Using data from primary sources, that is, without mixing them with other data; and (3) Combining and handling data from different sources. Each section specifies the data and information sources. Data and information from primary sources in the Migration and Retention sections are limited so the analysis is mainly a summary of already published information. 7. This data was not included in the databases that MINSA shared with the group carrying out the study. 8. To the knowledge of the group there were no recent, publicly available labor market surveys that could have informed this component. 4 1. TRAINING OF HEALTH PROFESSIONALS In this section we analyze the current state of supply and demand of training for the health professions and the number of graduates. We also analyze the profile of the basic health team professionals currently in the market, through (a) an analysis of the curricula of training programs for members of the basic health team (physicians, nurses, and midwives) in those universities with the largest number of students, according to the 2010 University Census; (b) an analysis of competency profiles prepared by professional associations for the certification of professionals; and (c) an analysis of the standard used by the National Council of University Evaluation, Accreditation and Certification (CONEAU) to accredit education programs for these professions. These profiles were then compared to the prioritized competency profiles of primary care physicians, nurses, and midwives prepared by MINSA to determine whether the current market offers the professional profile most needed by MINSA. DATA S OURCES The data and information sources used for this section are the following:  National Council of University Evaluation and Accreditation (Comisión Nacional de Evaluación y Acreditación Universitaria—CONEAU): Progress of training programs’ accreditation, and authorization of professional associations to certify them.  National Assembly of Rectors (Asamblea Nacional de Rectores—ANR): Information on how many students apply, enroll, and graduate from health training programs.  Professional associations: Competency profiles used to certify professionals.  National Institute of Statistics and Informatics (Instituto Nacional de Estadística e Informática—INEI): 2010 National University Census.  Public and private universities: Training programs’ curricula of the basic health team ( physicians, nurses, and midwives) from universities that train at least 4 percent of the student population belonging to these professions, according to the 2010 University Census.  MINSA: Prioritized competency profiles of primary care physicians, nurses, and midwives. SUPPLY OF HEALTH TRAINING PROGRAMS Peru has a wide array of health training programs at the university level, both public and private. Out of the 100 universities that participated in the 2010 University Census, 78 offered training programs in the professions covered by this report: medicine, nursing, midwifery, nutrition, psychology, pharmaceutical chemistry, dentistry, and medical technology. The 2010 census included 33 medical schools and 58 nursing training programs, whereas in 1960 there were only 3 medical schools and 8 nursing schools (MINSA 2011), which shows a rapid growth in the supply of training. The programs are provided by both public and private universities, though the latter offer a larger number of programs and take in more students. Of those universities with a larger number of medical students (defined in this report as 4 percent or more of registered students in accordance with the 2010 University Census), seven were private universities (with 11,214 registered students) and two were public universities (with 1,767 students). For nursing and midwifery, the universities with a larger number of registered students were all private, five for nursing and four for midwifery. The training programs of these universities are summarized in annex 2, and are discussed in more detail below. The National Council of University Evaluation and Accreditation (CONEAU) is responsible for registering and accrediting university education in Peru. CONEAU data show that, as of July 2013, 45 universities had 5 registered 234 training programs for the professions covered by this report (see annex 3 for the list of universities that have registered programs). The number of programs is particularly high because universities that have several campuses register the programs by campus rather than in a centralized manner. For instance, Alas Peruanas University registered its nursing program 14 times since it is offered in 14 different campuses. Table 1.1 shows the number of universities with registered training programs, the total number of registered training programs (counting all campuses), the number of training programs that have started the accreditation process, and the number that have completed it. As of November 2013, only two undergraduate health training programs had been accredited by CONEAU: dentistry at the Universidad Peruana Cayetano Heredia, and nursing at the Universidad Católica Los Angeles de Chimbote. As is clear from Table 1.1, there is a large pending agenda in terms of accreditation of training programs. Based on the information collected for this study, it is not possible to comment specifically on possible hurdles in the accreditation process. However, the apparent need to accredit training programs separately by campus appears to be a requirement that may cause delays without providing clear benefits. Table 1.1 Registration and Accreditation of Health Training Programs with CONEAU Program Number of Total number of Accreditation Accreditation universities with registered training process initiated process registered training programs (number of completed programs (counting all training programs) (number of campuses) training programs) Medicine 21 22 17 0 Nursing 35 58 47 1 Midwifery 18 25 17 0 Dentistry 22 37 27 1 Nutrition 10 10 9 0 Psychology 20 38 32 0 Pharmaceutical 10 13 10 0 chemistry Medical technology 7 31 27 0 Source: Progress in training programs accreditation processes, July 2013 (http://aca-evaluamos.blogspot.com/). APPLICATIONS AND ADMISSIONS TO TRAINING PROGRAMS Overall, there appears to be a large interest from potential students in health training programs, and the number of applicants vastly exceeds the number of admissions. Figure 1.4 presents applications and admissions to professional training in the areas of medicine and nursing. According to the information provided by the National Assembly of Rectors (Asamblea Nacional de Rectores —ANR), in recent years approximately 20 percent of applicants to nursing programs at public universities ended up entering the programs, whereas for private universities the admission rate is close to 90 percent. In medical training, 5 percent of applicants to public universities entered the programs, whereas 26 percent of those applying to private institutions were admitted 9 (Figure 1.4 and Figure 1.5). Similar gaps between the supply and 9. Applicants to several programs would be counted for each program to which they apply. However, applications are done separately to each university, with separate admission exams, and there is no information as to extent to which applicant pools overlap. 6 demand of professional training can be observed in other health-related professions; in those areas as well, there are similar difference between public and private universities (Table 1.2). Figure 1.4 Medical Training Supply and Demand, Public vs. Private Universities, 2007–11 30,000 30,000 Public universities Private universities 25,000 25,000 20,000 20,000 15,000 15,000 10,000 10,000 5,000 5,000 - - 2007 2008 2009 2010 2011 2007 2008 2009 2010 2011 Admissions Non-admitted applicants Admissions Non-admitted applicants Source: National Assembly of Rectors (ANR) 2007–11. Authors’ calculations. Figure 1.5 Nursing Training Supply and Demand, Public vs. Private Universities 15,000 15,000 Public universities Private universities 10,000 10,000 5,000 5,000 - - 2007 2008 2009 2010 2011 2007 2008 2009 2010 2011 Admissions Non-admitted applicants Admissions Non-admitted applicants Source: National Assembly of Rectors (ANR) 2007–11. Authors’ calculations. 7 Table 1.2 Demand and Supply of Training in Midwifery, Dentistry, Nutrition, Psychology, Dentistry, Pharmacy and Biochemistry, and Medical Technology Profession Candidates / Admissions 2007 2008 2009 2010 2011 Average Applicants Public Universities 3,663 2,753 2,618 3,191 3,612 3,167 Admissions Public Universities 637 663 509 815 730 671 Ratio 0.17 0.24 0.19 0.26 0.20 0.21 Midwifery Applicants Private Universities 1,811 2,507 2,035 2,281 2,742 2,275 Admissions Private Universities 1,604 2,231 1,943 2,187 2,418 2,077 Ratio 0.89 0.89 0.95 0.96 0.88 0.91 Profession Candidates / Admissions 2007 2008 2009 2010 2011 Average Applicants Public Universities 6,074 5,591 3,686 5,256 5,177 5,157 Admissions Public Universities 587 602 492 673 665 604 Ratio 0.10 0.11 0.13 0.13 0.13 0.12 Dentistry Applicants Private Universities 4,788 6,377 5,127 5,671 5,966 5,586 Admissions Private Universities 3,865 5,472 4,829 4,921 4,791 4,776 Ratio 0.81 0.86 0.94 0.87 0.80 0.86 Profession Candidates / Admissions 2007 2008 2009 2010 2011 Average Applicants Public Universities 2,125 2,036 905 1,612 1,615 1,659 Admissions Public Universities 332 442 260 403 400 367 Nutrition and Food Ratio 0.16 0.22 0.29 0.25 0.25 0.23 Science Applicants Private Universities 417 320 209 224 381 310 Admissions Private Universities 279 308 197 220 329 267 Ratio 0.67 0.96 0.94 0.98 0.86 0.88 Profession Candidates / Admissions 2007 2008 2009 2010 2011 Average Applicants Public Universities 5,307 4,491 2,255 4,531 4,259 4,169 Admissions Public Universities 448 594 232 717 406 479 Ratio 0.08 0.13 0.10 0.16 0.10 0.11 Psychology Applicants Private Universities 5,533 6,949 6,891 8,076 9,969 7,484 Admissions Private Universities 4,456 5,917 5,646 7,953 8,149 6,424 Ratio 0.81 0.85 0.82 0.98 0.82 0.86 Profession Candidates / Admissions 2007 2008 2009 2010 2011 Average Applicants Public Universities 3,779 3,263 2,620 2,837 2,759 3,052 Admissions Public Universities 396 603 577 568 629 555 Pharmacy and Ratio 0.10 0.18 0.22 0.20 0.23 0.19 Biochemistry Applicants Private Universities 1,008 1,341 980 1,827 2,328 1,497 Admissions Private Universities 975 1,300 1,002 1,785 2,112 1,435 Ratio 0.97 0.97 1.02 0.98 0.91 0.97 Profession Candidates / Admissions 2007 2008 2009 2010 2011 Average Applicants Public Universities 1,475 2,122 1,610 2,179 2,313 1,940 Admissions Public Universities 223 393 223 370 319 306 Ratio 0.15 0.19 0.14 0.17 0.14 0.16 Medical Technology Applicants Private Universities 1,171 1,479 1,747 1,677 2,513 1,717 Admissions Private Universities 1,087 1,465 1,802 1,852 2,497 1,741 Ratio 0.93 0.99 1.03 1.10 0.99 1.01 Source: National Assembly of Rectors (ANR) 2007–11. Authors’ calculations. GRADUATES FROM HEALTH TRAINING PROGRAMS AND CERTIFICATION To estimate the number of entrants into the health labor market, we estimated the graduation rates for training in the health professions within the established time period of training (for example, seven years for physicians and five years for nurses and midwives). Using data on the number of applicants, entrants, and graduates during 2007–11, we estimate that in this period an average of 6,579 students per year entered nursing training, whereas in that same period, the average yearly number of graduates was 2,814. Likewise, in medical training we observe an average of 3,353 entrants per year, whereas the annual average number of graduates was 1,784 (Table 1.3). Overall, of those students admitted to medical and 8 nursing schools, an estimated 43 percent and 53 percent, respectively, actually graduated within the established training period. Before graduates are allowed to exercise their professions, they must be certified by their respective professional associations, which are themselves authorized by CONEAU. All professional associations related to the professions analyzed in this report are authorized to issue certifications.10 Table 1.3 Number of Graduates by Profession, 2007–11 Profession Graduates 2007 2008 2009 2010 2011 Total Public Universities 551 819 720 881 751 3,722 Medicine Private Universities 693 844 938 1,462 1,260 5,197 Total 1,244 1,663 1,658 2,343 2,011 8,919 Public Universities 1,039 1,472 1,298 1,732 1,480 7,021 Nursing Private Universities 972 1,206 1,101 1,774 1,997 7,050 Total 2,011 2,678 2,399 3,506 3,477 14,071 Public Universities 271 413 303 557 392 1,936 Midwifery Private Universities 689 495 445 589 683 2,901 Total 960 908 748 1,146 1,075 4,837 Public Universities 221 440 307 288 332 1,588 Dentistry Private Universities 665 1,142 921 1,311 1,650 5,689 Total 886 1,582 1,228 1,599 1,982 7,277 Public Universities 105 171 132 199 158 765 Nutrition and Food Science Private Universities 27 38 18 46 46 175 Total 132 209 150 245 204 940 Public Universities 139 267 276 362 311 1,355 Psychology Private Universities 779 861 874 1,448 1,828 5,790 Total 918 1,128 1,150 1,810 2,139 7,145 Public Universities 202 310 247 394 396 1,549 Pharmacy and Biochemistry Private Universities 206 304 110 322 445 1,387 Total 408 614 357 716 841 2,936 Public Universities 76 182 289 253 307 1,107 Medical Technology Private Universities 38 94 115 145 254 646 Total 114 276 404 398 561 1,753 Sources: National Assembly of Rectors (ANR) 2007–11. Authors’ calculations. COMPARISON BETWEEN TRAINING CURRICULA, PROFESSIONAL ASSOCIATION PROFILES , CONEAU’S STANDARD NUMBER 25, AND MINSA P ROFILES In this section, we aim to determine whether health professionals entering the labor market upon completion of their training have the necessary competency profile to function at the primary care level. We analyze the curricula of universities that enrolled at least 4 percent of medicine, nursing, and midwifery students, according the 2010 University Census. We then compare the curricula to the profiles created by professional associations for the purpose of certifying graduates so they can exercise their professions, 10. Data on the number of professionals who do not seek certification was not available to be included in this study. 9 and to the standards prepared by CONEAU to accredit the training programs for these professions. Accreditation of training programs consists of assessment on 98 standards (CONEAU 2010). To make the analysis easier, this study focused on standard no. 25, which is used to assess the curricula. The curricula, professional association profiles, and CONEAU’s standard No. 25 were then assessed against the profiles developed by MINSA for the basic health team at the primary care level. Annex 4 presents the profiles prepared by MINSA, those prepared by professional associations, and CONEAU standard no. 25. Physicians Our analysis suggests that medical training programs recognize the importance of the primary care level since they include it in their graduates’ profile and offer community/public health courses and community health externships. The training programs of the Santa Maria Catholic University and Antenor Orrego Private University are exceptions, since they mainly have a clinical approach and offer no community externships. Nevertheless, none of the curricula we analyzed are specifically oriented toward the primary care level. For instance, the number of credits related to primary care-related courses and community externships varies from 4 to 11, out of a total (average) of 298 credits required to graduate, which evidences a relatively low priority afforded to this care level in the analyzed curricula. We then compare the prioritized competency profile of the primary care physician prepared by MINSA, the profile prepared by the Peruvian Medical Association, and Standard no. 25 of CONEAU (table A4.1, annex 4). The profile prepared by the Peruvian Medical Association includes management, critical data assessment, and public health/prevention skills. It also makes clear that physicians are responsible for planning, directing, and assessing health teams’ work. This type of skill is strikingly absent from the MINSA profile. However, an important area specified in MINSA’s profile is the treatment of people suffering from depression, alcoholism, or violence. This shows an acknowledgment of the high prevalence of these conditions (Prince et al. 2007) and the importance of providing services for them at the primary care level. The profile of the Peruvian Medical Association does not include specific mental health–related skills. Regarding disease coverage, it is worth highlighting that in MINSA’s profile for physicians puts them in charge of addressing the entire burden of care for noncommunicable diseases (NCDs), while the nurse profile does not include any skills related to these diseases. Standard no. 25 includes knowledge of primary care, public health, and health management—all relevant for the profile required by MINSA. However, this is only one of eight requirements, and the other requirements are related to developing professionals who work in other care levels as well. Considering the curricula and profiles that we analyzed, we conclude that professionals that enter the labor market will not be specifically prepared to work at the primary care level. Nurses Our analysis of the nursing training curricula shows that some of them have more of a community-based approach than others, though none has a predominantly community-based approach (annex 2, table A2.1) The curriculum of San Juan Bautista University stands out because it emphasizes community care in its profile; it also includes community-based courses and a community internship program. The curricula of Los Angeles de Chimbote University, the only one accredited by CONEAU, also stands out: it requires the approval of 322 credits for graduation, as compared to an average 220-credit requirement in other universities. We then compare the competency profile for primary care nurses prepared by MINSA, the profile prepared by the Peruvian Nursing Association, and CONEAU’s standard no. 25, which is used to accredit nurse training programs (annex 4, table A4.2). MINSA’s profile focuses mainly on medical care for infants and children; for adults, nurses’ duties are linked specifically to TB and HIV-related care. An important finding is that MINSA’s profile has a purely clinical care–oriented approach, which does not include management, 10 prevention/promotion, and evaluation skills, which are in fact included in the Peruvian Nursing Association’s profile. By contrast, the profile of the Peruvian Nursing Association is more general, which makes sense given that it is used to certify nurses who also work in the secondary and tertiary care levels. At the same time, the PNS profile does include management, activity planning, evaluation, and prevention and promotion skills, which are key at the primary care level. CONEAU’s standard no. 25 presents a list of the subjects that the curricula should include for the training program to be accredited, but none of the subjects on this list is directly related to community health or to the primary care level. In addition, there is no other standard requiring, for instance, an internship at this level. This analysis shows that while CONEAU does not require that training programs include community health–related knowledge and/or internships, in reality most of the curricula analyzed do include them. However, as is the case with physicians, the graduate nurses entering the labor market will not be specifically prepared to work at the primary care level. Midwives Our analysis of midwifery curricula shows that Los Angeles de Chimbote University and San Martin de Porres University have courses focused on community health; however, these universities do not include a community health rotation (table A2.2, annex 2). Alas Peruanas University, on the other hand, does have community rotations. While it is beyond this study’s scope to comment on the implications of this difference, it is worth mentioning that CONEAU does not have a standard to guide this aspect of training programs. We then compare the prioritized competency profile of the primary care midwife prepared by MINSA, the profile prepared by the Peruvian Midwifery Association, and CONEAU’s standard no. 25, which is used to accredit midwifery training programs (annex 4, table A4.3). These three profiles are very similar, except that the Midwifery Association’s profile includes reproductive health–related skills with a community-level approach, as well as planning and implementation of promotion and prevention activities, while MINSA’s profile does not include this type of preventive activity. Standard no. 25 of CONEAU presents a list of subjects that need to be included in the curricula, including public health and community midwifery, which are both relevant for the primary care level. Overall, we conclude that the curricula, as well as the Midwifery Association and CONEAU standards include community health skills, which contrasts with the medicine and nursing training programs. DISCUSSION Overall, we find that there is a high supply and demand for training in health-related professions in Peru. CONEAU has initiated regulation and accreditation so as to guarantee training quality; however, this process is slow and is far from being completed; therefore it is difficult to objectively assess the quality of available training. However, we cannot immediately conclude that lack of accreditation means low quality, as some institutions have nationally and internationally recognized training programs that have trained capable and effective professionals for decades. For the purpose of our analysis of the labor market for health professionals, what is important is the existing commitment to training regulation and to guaranteeing a minimum standard, which we think is necessary because it could eventually be reflected in the type of graduates from these programs and in the quality of human resources in health. However, this is a long- term goal and much remains to be done in the short and medium run. The profiles created by MINSA are specific for the primary care level, which should fill 70 to 80 percent of the population’s health service needs, and therefore these positions are key for the government to meet its UHC commitment. Nevertheless, we find that the university curricula, professional association profiles, and CONEAU’s standard no. 25 to accredit training programs are all such that professionals entering the labor market are not necessarily or specifically trained to work at the primary care level. Therefore, there is a low 11 likelihood that MINSA would be able to get the number and type of professionals it needs to work at the primary care level. Professional associations could play a role in certifying professionals; however, it is not clear whether certification also includes an assessment of professionals’ skills, since traditionally the associations have required registration and membership fee collection, rather than competency assessment. However, the existence of the profiles represents an opportunity to integrate professional associations to HRH management. For MINSA and regional governments to find primary care–trained professionals in the market, it is necessary to create programs specifically focused on training professionals to work at this level, and simultaneously work with professional associations to specifically certify these professionals. MINSA and regional governments, as the largest employers, have the opportunity to work with training institutions, which, for the most part, are private. Finally, we find significant gaps in MINSA’s profiles for professionals in the basic health team: specifically (i) the profiles lack skills related to prevention, promotion, and management; (ii) MINSA’s profile for nurses only includes a limited number of skills related to adult care (only two related to tuberculosis and HIV/AIDS), and profiles assign the full burden of preventing and treating NCDs to physicians. Internationally, a discussion is ongoing around the need to widen the nonclinical services that are provided by health staff (WHO 2010). Yet MINSA’s clinical approach to NCDs may result in a lack of appropriate attention at the primary care level for people with early symptoms of NCDs who need to implement lifestyle changes (diet, exercise) to prevent progression of the disease. 2. TRANSITION OF GRADUATES TO THE LABOR M ARKET In this section we analyze the dynamics of integration of recent graduates into the labor market. In particular, we analyze the availability of Rural and Urban-Marginal Internship (SERUMS) positions, SERUMS professionals’ university of origin, the number of graduated professionals taking up SERUMS positions, the number of SERUMS graduates who join the public sector, and the conditions of their employment. SOURCES OF DATA The sources of information for this section are the following:  MINSA: a. Database of the National Observatory on Human Resources for Health b. Database of SERUMS (2007–13), including information of applicants’ university of origin  ANR: Information about the number of graduates from health training programs THE RURAL AND URBAN-MARGINAL INTERNSHIP PROGRAM One of the strategies used by MINSA to increase coverage of primary health care professionals is the Rural and Urban-Marginal Internship Program (Servicio Rural y Urbano Marginal en Salud— SERUMS). This internship is a requirement for those health professionals who would like to work in the public sector, and for physicians who would like to go on to specialist training. Health professionals who enroll in SERUMS spend a year working at the primary care level in rural or urban-marginal areas. In 2009, the SERUMS 12 system started using the Poverty Map prepared by the Social Compensation and Development Fund (FONCODES) to prioritize the poorest districts for SERUMS positions (MINSA 2011). There has also been a significant increase in the number of available positions: Table 1.4 presents the number of positions by source of financing in the years 2007 to 2013. Table 1.4 Number of SERUMS Positions by Year (2007–13) and Source of Financing Source of Financing 2007 2008 2009 2010 2011 2012 2013 EsSalud 489 584 603 601 598 610 617 MINSA 3,185 3,766 4,749 4,696 5,471 5,698 5,387 Private sector 41 55 75 73 43 46 65 Juntos program 701 Other 234 182 210 335 335 302 315 Total 4,650 4,587 5,637 5,705 6,447 6,656 6,384 Sources: MINSA, DGGDRRHH 2007–13. Authors’ calculations. Currently it is mandatory that all SERUMS take place at the primary or secondary care level. The regional governments are in charge of deciding the localities and establishments, with advice from DGGDRRHH. Data from 2011 show that this strategy has been effective at increasing the presence of health professionals in the most remote and disadvantaged locations. For instance, in 2008 among the poorest 800 districts in the country, only 53 percent had at least one SERUMS physician; by 2011 this had increased to 89. Furthermore, in the three poorest regions of Peru, the presence of physicians increased significantly to 95 percent of the districts in Ayacucho, 97 percent in Apurimac, and 95 percent in Huancavelica (MINSA 2011). THE TRANSITION BETWEEN UNIVERSITIES AND THE SERUMS PROGRAM Even though SERUMS is a requirement to work in the public sector, not all graduates of university training programs apply immediately. Table 1.5 shows estimations on the number of graduates in 2010 and 2011, and SERUMS positions taken in 2011 and 2012, respectively. For physicians, the number of SERUMs tracks closely the number of graduates from the previous year, though we observe that in some years graduates appear to delay the take-up of a SERUM, which can result in a higher number of SERUMs in subsequent years. For example, 2,011 professionals graduated from medical school in 2011, but the number of SERUMS positions taken up in 2012 was 2,496. For all other health-related professions, the number of professionals taking up a SERUMS position is lower than the number of graduates in the previous year, which may indicate an oversupply of graduates, a limited number of SERUMS positions for these professions, or alternative job opportunities. 11 11. The data obtained do not allow us to distinguish those professions where there might be a lack of applicants to SERUMS from those professions where there might be a lack of SERUMS positions. 13 Table 1.5 Number of Graduated Health Professionals and Number of SERUM Entrants 2010 2011 2011 2012 Profession Graduates SERUMS Graduates SERUMS Medicine 2,343 2,182 2,011 2,496 Nursing 3,506 1,918 3,477 1,983 Midwifery 1,146 967 1,075 862 Dentistry 1,599 556 1,982 455 Nutrition and food science 245 131 204 127 Psychology 1,810 275 2,139 285 Pharmacy and biochemistry 716 127 841 125 Medical technology 398 93 561 110 Total 11,763 6,249 12,290 6,443 Source: ANR, and MINSA, DGGDRRHH 2010–12. Authors’ calculations. According to information provided by MINSA, in 2013 the number of SERUMS applicants across all professions had increased 62 percent compared to 2008 (Table 1.6). In addition, the distribution of universities of origin has substantially changed in that period: in 2008 the San Marcos National University and San Martin de Porres Private University provided the largest number of applicants; in 2013 Inca Garcilaso de la Vega Private University and Alas Peruanas University (private) had overtaken them in terms of the number of SERUM applicants. 14 Table 1.6 SERUM Applicants, All Professions, per University of Origin, 2008–13 University 2008 2009 2010 2011 2012 2013 (% ) (% ) (% ) (% ) (% ) (% ) U.P. Inca Garcilaso De La Vega 5 7 8 10 12 10 U. Alas Peruanas 1 2 4 4 5 U. De San Martin De Porres 8 9 8 8 7 6 U.N. Federico Villarreal 5 5 6 4 5 4 U.N. Mayor De San Marcos 8 7 6 5 4 4 U.N. De Trujillo 2 3 4 3 3 3 Asociación U. Privada San Juan 1 1 2 2 3 3 Bautista U. Los Ángeles De Chimbote 2 2 3 2 3 3 U.N. San Luis Gonzaga—Ica 5 4 3 3 2 3 U. P. César Vallejo 2 2 2 3 3 3 U. Peruana Cayetano Heredia 3 3 3 3 2 3 U. Peruana Los Andes 5 4 4 4 3 2 U. Católica Santa Maria 4 4 4 3 4 2 U. Norbert Wiener 3 2 2 2 2 2 U. Andina Del Cuzco 3 4 3 2 1 2 U.N. De San Agustin 4 4 3 3 3 2 U.N. Daniel Alcides Carrion 3 3 2 2 1 1 U.N. De San Antonio De Abad Del 2 2 1 2 1 1 Cusco Other universities 35 34 32 37 36 38 Number of applicants (Total) 9,570 12,326 16,217 13,716 14,182 15,539 Sources: MINSA, DGGDRRHH 2008–13. Authors’ calculations. For the medical profession, the following medical schools provided the largest share of SERUMS applicants in 2013: San Martin de Porres Private University (11 percent), Latin-American School of Medicine (7 percent), Antenor Orrego Private University (7 percent), and San Juan Bautista Private University (7 percent). The Latin-American School of Medicine is a Cuban institution that trains students from many Latin American countries, who then return to their countries, and thus has started to provide a representative percentage of SERUMS applicants (Figure 1.6). 15 Figure 1.6 SERUMS Applicants from Medical Schools per University of Origin, 2013 U. De San Martín De Porres 11% Escuela Other Latinoamericana De U. Priv. Antenor Orrego Medicina 40% 7% 7% As. U. Priv. San Juan Bautista 7% U.C. Sta U. Ricardo Palma U. De Aquino María 6% 3% 4% U. Peruana U.N.M. De San Marcos U.N. De Trujillo- Unt Cayetano Heredia U.N. De San Agustín 5% 3% 3% 4% Sources: MINSA, DGGDRRHH 2013. Authors’ calculations. For nursing training programs, the distribution of universities is more even. Inca Garcilaso de la Vega Private University and Alas Peruanas Private University lead in the number of SERUMS applicants, with 7 percent of applicants each (Table 1.7). 16 Table 1.7 Nursing SERUMS Applicants per University of Origin, 2013 University Number of SERUMS Percent of total applicants (%) U. Inca Garcilaso De La Vega 308 7 U. Alas Peruanas 307 7 Asociación U. Privada San Juan Bautista 248 6 U. Los Ángeles De Chimbote 173 4 U. Andina Néstor Cáceres Velásquez 170 4 U. N. De Trujillo- Unt 158 4 U. N. Del Callao 140 3 U. P. San Pedro 132 3 U. N. De Cajamarca 126 3 U. N. San Luis Gonzaga De Ica 114 3 U.C. Sto Toribio De Mogrovejo 112 3 U. Andina Del Cusco 108 3 U. De San Martín De Porres 103 2 Others 1.931 47 TOTAL 4.130 100 Sources: MINSA, DGGDRRHH 2013. Authors’ calculations. For the midwifery profession, a university located in a region, Los Angeles de Chimbote University, has the largest number of SERUMS applicants (9 percent), followed by Alas Peruanas University (8 percent), and San Martin de Porres Private University (8 percent) (Figure 1.7). 17 Figure 1.7 SERUMS Applicants for Midwifery, by University of Origin, 2013 U. Los Ángeles De Chimbote 9% U. Alas Peruanas 8% Other U. De San Martín De 45% Porres 8% U. N. Daniel Alcides Carrión 7% U. N. Hermilio Valdizán 6% U. Peruana Los Andes 5% U. P. Norbert Wiener U. N. Jorge Basadre 4% Grohmann U. N. De Cajamarca 4% 4% Sources: MINSA, DGGDRRHH 2013. Authors’ calculations. THE TRANSITION FROM SERUMS TO THE PUBLIC SECTOR HEALTH LABOR MARKET In this section, we analyze the transition of SERUMS graduates to the public sector, by using MINSA- provided information on professionals who took up a SERUMS position between 2007 and 2012, as well as professionals who were working in the public sector as of September 2013. 12 Figure 1.8 shows that most SERUMS graduates do not enter the public sector health labor market after completing the SERUMS. The gap represents professionals who went to work in EsSalud, in the private sector or independently, those who are underemployed or unemployed, and those who migrated. So even though the SERUMS program has proved effective at increasing the presence of health professionals in rural and remote areas, participation in SERUMS is not necessarily the immediate preceding step to gaining employment in the public sector. Finally those who do join the public sector after completing SERUMS do so mainly under a temporary agreement (Table 1.10). We also observe that 10 percent of SERUMS graduates enter the system as residents (see section 6). 12. Note that health professionals currently in SERUMS (that is, in the 2012-II and 2013-I cohorts) are considered a part of the current workforce, and therefore it is not possible to analyze their transition to the public sector health labor market. 18 Figure 1.8 Health Professionals Join the Public Sector after Completing SERUMS 7,000 6,447 5,637 5,705 6,000 4,650 4,587 5,000 4,000 Number of SERUMS 3,000 Public Sector Entrants 2,104 1,984 1,637 1,676 1,476 2,000 1,000 - 2007 2008 2009 2010 2011 Sources: MINSA, DGGDRRHH 2013. Authors’ calculations. Furthermore, it is possible to identify the dynamics of different professions in terms of entering the public sector. Figure 1.9 to Figure 1.16 illustrate the number of graduated professionals each year, the number of people taking up SERUMS positions, and the number of these who join the public sector in the following year. For those joining the health sector we were able to carry out an individual match from the SERUMS database to the database of the National Observatory on Human Resources for Health. It is worth highlighting that in the case of physicians in recent years (Figure 1.9), the number of people taking up SERUMS positions is higher than the number of graduated professionals; this is possible because graduates do not necessarily apply to SERUMS immediately upon graduation from their training programs. For all professions other than physicians, there are a significant number of graduates who do not take up SERUMS positions, and many of those who do, do not necessarily join the public sector workforce. 19 Figure 1.9 Dynamics of Training, SERUMS, and Entry into the Public System for Physicians 2013 Public System Entrants 613 2012 SERUMS 2,496 2011 Graduates 2,011 2012 Public System Entrants 372 2011 SERUMS 2,182 2010 Graduates 2,343 2011 Public System Entrants 599 2010 SERUMS 1905 2009 Graduates 1658 2010 Public System Entrants 686 2009 SERUMS 2001 2008 Graduates 1663 2009 Public System Entrants 564 2008 SERUMS 1719 2007 Graduates 1244 0 500 1000 1500 2000 2500 3000 Number of Medicine Professionals Sources: National Assembly of Rectors (ANR); and MINSA, DGGDRRHH 2007–13. Authors’ calculations. Figure 1.10 Dynamics of Training, SERUMS, and Entry into the System for Nurses 2013 Public System Entrants 265 2012 SERUMS 1,983 2011 Graduates 3,477 2012 Public System Entrants 605 2011 SERUMS 1,918 2010 Graduates 3,506 2011 Public System Entrants 731 2010 SERUMS 1761 2009 Graduates 2399 2010 Public System Entrants 844 2009 SERUMS 1775 2008 Graduates 2678 2009 Public System Entrants 623 2008 SERUMS 1244 2007 Graduates 2011 0 500 1000 1500 2000 2500 3000 3500 4000 Number of Nursing Professionals Sources: National Assembly of Rectors (ANR); and MINSA, DGGDRRHH 2007–13. Authors’ calculations. 20 Figure 1.11 Dynamics of Training, SERUMS, and Entry into the System for Midwives 2013 Public System Entrants 252 2012 SERUMS 862 2011 Graduates 1,075 2012 Public System Entrants 269 2011 SERUMS 967 2010 Graduates 1,146 2011 Public System Entrants 256 2010 SERUMS 898 2009 Graduates 748 2010 Public System Entrants 316 2009 SERUMS 793 2008 Graduates 908 2009 Public System Entrants 278 2008 SERUMS 724 2007 Graduates 960 0 200 400 600 800 1000 1200 1400 Number of Midwifery Professionals Sources: National Assembly of Rectors (ANR); and MINSA, DGGDRRHH 2007–13. Authors’ calculations. Figure 1.12 Dynamics of Training, SERUMS, and Entry into the System for Dentists 2013 Public System Entrants 93 2012 SERUMS 455 2011 Graduates 1,982 2012 Public System Entrants 54 2011 SERUMS 556 2010 Graduates 1,599 2011 Public System Entrants 66 2010 SERUMS 501 2009 Graduates 1228 2010 Public System Entrants 53 2009 SERUMS 435 2008 Graduates 1582 2009 Public System Entrants 51 2008 SERUMS 343 2007 Graduates 886 0 500 1000 1500 2000 2500 Number of Dentistry Professionals Sources: National Assembly of Rectors (ANR); and MINSA, DGGDRRHH 2007–13. Authors’ calculations. 21 Figure 1.13 Dynamics of Training, SERUMS, and Entry into the System for Nutritionists 2013 Public System Entrants 19 2012 SERUMS 127 2011 Graduates 204 2012 Public System Entrants 20 2011 SERUMS 131 2010 Graduates 245 2011 Public System Entrants 34 2010 SERUMS 109 2009 Graduates 150 2010 Public System Entrants 27 2009 SERUMS 115 2008 Graduates 209 2009 Public System Entrants 16 2008 SERUMS 102 2007 Graduates 132 0 50 100 150 200 250 300 Number of Nutrition and Food Science Professionals Sources: National Assembly of Rectors (ANR); and MINSA, DGGDRRHH 2007–13. Authors’ calculations. Figure 1.14 Dynamics of Training, SERUMS, and Entry into the System for Psychologists 2013 Public System Entrants 47 2012 SERUMS 285 2011 Graduates 2,139 2012 Public System Entrants 56 2011 SERUMS 275 2010 Graduates 1,810 2011 Public System Entrants 62 2010 SERUMS 221 2009 Graduates 1150 2010 Public System Entrants 44 2009 SERUMS 207 2008 Graduates 1128 2009 Public System Entrants 20 2008 SERUMS 144 2007 Graduates 918 0 500 1000 1500 2000 2500 Number of Psychology Professionals Sources: National Assembly of Rectors (ANR); and MINSA, DGGDRRHH 2007–13. Authors’ calculations. 22 Figure 1.15 Dynamics of Training, SERUMS, and Entry into the System for Pharmacists and Biochemists 2013 Public System Entrants 21 2012 SERUMS 125 2011 Graduates 841 2012 Public System Entrants 14 2011 SERUMS 127 2010 Graduates 716 2011 Public System Entrants 17 2010 SERUMS 91 2009 Graduates 357 2010 Public System Entrants 12 2009 SERUMS 92 2008 Graduates 614 2009 Public System Entrants 19 2008 SERUMS 92 2007 Graduates 408 0 100 200 300 400 500 600 700 800 900 Number of Pharmacy and Biochemistry Professionals Sources: National Assembly of Rectors (ANR); and MINSA, DGGDRRHH 2007–13. Authors’ calculations. Figure 1.16 Dynamics of Training, SERUMS, and Entry into the System for Medical Technologists 2013 Public System Entrants 2 2012 SERUMS 110 2011 Graduates 561 2012 Public System Entrants 12 2011 SERUMS 93 2010 Graduates 398 2011 Public System Entrants 15 2010 SERUMS 64 2009 Graduates 404 2010 Public System Entrants 16 2009 SERUMS 81 2008 Graduates 276 2009 Public System Entrants 21 2008 SERUMS 88 2007 Graduates 114 0 100 200 300 400 500 600 Number of Medical Technology Professionals Sources: National Assembly of Rectors (ANR); and MINSA, DGGDRRHH 2007–13. Authors’ calculations. 23 Table 1.8 Type of Contract for Public Sector Employees Who Completed SERUMS in 2007–11 Contract type Number of workers Share of total (% ) CAS 6,802 76.89 Resident 883 9.98 Contract type 276 531 6.00 Payroll 272 3.07 Third party 134 1.51 Contract type 728 127 1.44 Not specified 87 0.98 Municipal contract 7 0.08 Redeployed 3 0.03 Total 8,846 100 Sources: MINSA, DGGDRRHH 2013. Authors’ calculations. DISCUSSION The results presented in the last section show that for the health professions included in the study, except for medicine, there are a significant number of graduates who decide not to take up a SERUMS position— a prerequisite for work in the public sector and for ongoing specialist training in the case of physicians. This may indicate that the labor market is offering opportunities for which SERUMS is not a requirement. There is also an increase in the number of graduates from private universities —for example, Inca Garcilaso de la Vega Private University and Alas Peruanas University—who take up SERUMS positions, whereas the number of graduates from public universities, for example, San Marcos National University, has been steadily decreasing. Finally, the public sector fails to absorb the majority of professionals completing SERUMS, and the vast majority of those graduates who are hired into the public sector, work under temporary contracts. This analysis indicated that the deficit of health professionals in the public sector is not due to the lack of trained professionals in the market, but instead to the inability of the public sector to absorb them. The government has relied on SERUMS as a strategy to ensure human resources for health in rural and remote areas, and evidence shows that this has been a successful strategy. However, given that the insertion level of SERUMS graduates into the public sector is rather low, and that most of those who do get inserted, do so under temporary agreements ( 24 Table 1.8), we conclude that SERUMS and public sector employment do not compete with other job opportunities provided by the market to these professionals. 13 Therefore, it is necessary to develop deployment policies that go beyond SERUMS and make sure that MINSA and regional governments have access to the necessary budget to attract and retain health professionals in the public sector. To develop these retention policies it is necessary to conduct a more complete assessment, including studies with new graduates to explore and acquire a deeper understanding of their employment aspirations and expectations, and job features that they appreciate the most, and to contrast this with a market assessment and an exploration of the other opportunities that are available to these new graduates. In addition, it is necessary to investigate the reasons why many professionals who complete SERUMS do not pursue their profession in the public sector, despite being qualified to do so. It would be critical to understand what could make the public sector an attractive or feasible job option for some graduates once they complete their SERUMS, and what measures could be implemented to attract and retain these professionals, for example flexibility to extend and renew SERUMS contracts and not have gaps in between contracts. 3. CONTRACTING OF HEALTH PROFESSIONALS IN THE PUBLIC SECTOR In this section we analyze how the public sector contracts health professionals, how these professionals are distributed within the sector, and which contract regimes are used. Furthermore, we evaluate the time required to close the health workforce gap and the measures that may be adopted to speed up this process. DATA S OURCES We reviewed the literature and analyzed the following data:  MINSA: o Database of the National Observatory on Human Resources for Health o Calculation of health workforce gaps, using a methodology updated to 2013  ANR: Information of how many people graduate from professional health training programs  INEI: Population projection nationwide as of June 2013 DISTRIBUTION OF HEALTH PROFESSIONALS BY SUBSECTOR Information on health professionals working within the different subsectors of the health care system is shown in Table 1.9. Data on human resources working in the public sector is much more accessible and complete than that available for other subsectors. Even though the National Observatory on Human Resources for Health is in charge of collecting information from all subsectors, this is not complete enough to allow analysis beyond the overall numbers that are presented in Table 1.9. This in itself points to a major challenge for HRH policies in Peru: there is no information system that provides a complete picture of human resources across the subsectors, and as a result, no comprehensive information can be obtained about the distribution of health professionals. 13. With the available data, it is difficult to distinguish whether the lack of absorption is due to lack of openings to work in the public sector, or lack of applicants to available positions. 25 Table 1.9 Distribution of Health Professionals by Health System Subsector Police MINSA and (PNP) and Private Profession regional EsSalud SISOL14 Total military sector governments (FFAA) Physician 18,220 9,210 1,901 749 3,589 33,669 Nurse 20,939 9,515 2,140 206 691 33,491 Midwife 10,032 1,178 189 59 75 11,533 Dentist 2,610 778 461 18 604 4,471 Nutritionist 933 318* 40 17 29 1,337 Psychologist 1,320 283* 328 18 70 2,019 Pharmaceutical 1,385 372* 86 1 46 1,890 chemist Medical 1,512 2,033 227 4 163 3,939 technologist Total 56,951 23,687 5,372 1,072 5,267 92,349 % 61.7 25.6 5.8 1.2 5.7 Source: MINSA, DGGDRRHH, 2013, except items marked with * for which source is http://www.essalud.gob.pe/transparencia/pdf/informacion/clasificador_cargos_2t_2013.pdf. CONTRACT REGIMES TO HIRE HEALTH HUMAN RESOURCES IN THE PUBLIC SECTOR Health professionals in the public sector are hired under many different contractual regimes, leading to a wide variation in salary levels and benefits. Workers hired under permanent contracts, as described by Legislative Decree 276, may receive up to twice the salary of those under temporary contracts, such as the Administrative Contract for Services (Contrato Administrativo de Servicios—CAS). The salary differences are especially large for physicians; for other professional categories, although there are differences, these are smaller (MINSA 2011). The CAS was created in 2008 with the intention of improving the hiring system, suppressing Non-personal Services Agreements (Servicios No Personales—SNP), a previous type of temporary contract, and establishing a contract that has a specific term, schedule, job description, provides social benefits through EsSalud, and contributes to the pension system. Since the creation of CAS, all SNP employees became CAS employees; however, the temporary character of the CAS still leads to instability in employment (MINSA 2011). Table 1.10 presents information on HRH currently working in the public sector and their contract regimes. Overall, 53 percent of human resources have permanent appointments; 32 percent work under temporary CAS agreements; and 11 percent are working in a SERUMS position. SERUMS positions are more prevalent in predominantly rural regions such as Huánuco, Huancavelica, Pasco, and Tumbes, where they account for approximately 25 percent of health professionals (data not shown). 14. Metropolitan Solidarity System (Sistema Metropolitano de la Solidaridad). 26 Table 1.10 Human Resources for Health per Contract Regime Nationwide (Public Sector Only) Contractual Health Health Health Total regime professionals technicians assistants # % # % # % # % Payroll 28,388 47 24,510 61 2,464 71 55,362 53 CAS 20,008 33 12,489 31 775 22 33,272 32 SERUMS 2013 – I 5,387 9 — 0 — 0 5,387 5 Contract type 276 2,391 4 1,478 4 127 4 3,996 4 Contract type 728 566 1 882 2 3 0 1,451 1 Resident 1,450 2 — 0 — 0 1,450 1 SERUMS 2012 – II 1,421 2 — 0 — 0 1,421 1 Third party 682 1 400 1 58 2 1,140 1 Redeployed 564 1 321 1 28 1 913 1 Not specified 123 0 63 0 1 0 187 0 Municipal contract 19 0 121 0 2 0 142 0 Total 60,999 100 40,264 100 3,458 100 104,721 100 Source: MINSA, DGGDRRHH 2013. When one compares health professionals working in the public sector with those working in EsSalud, the difference is even larger especially for professionals who are not physicians: public employees receiving up to S/. 19,000 less in salaries and benefits per year (MINSA 2011). In 2006, Webb and Valencia estimated that physicians’ salaries in the public sector fell by 75 percent in real value between 1976 and 2004 (from S/. 7,974 in 1976, to S/. 1,919 in 2004, adjusted to the 2001 value of nuevos soles). Finally, we encountered some anecdotal evidence that suggests that many physicians are engaged in dual practice between the public and private sectors—however, we could not find any information or data on this topic so we are unable to verify the extent to which this happens. THE HEALTH WORKFORCE G AP IN MINSA AND REGIONAL G OVERNMENTS’ HEALTH C ARE ESTABLISHMENTS —2013 We reestimated the health workforce gaps for basic health team professionals (physicians, nurses, and midwives), using a methodology developed by MINSA to quantify the difference between the need for and the availability of human resources for health care services. The need for human resources is estimated using an estimate of the time required to provide the medical services of the Essential Health Insurance Plan (Plan Esencial de Aseguramiento en Salud—PEAS) as well as other health care activities not considered in PEAS, and management and training activities that are part of job duties in the primary care level. The unit that is used to calculate the human resource gap for health care services of the primary care level is health micro-network. The methodology is summarized in Figure 1.17. 27 Figure 1.17 Methodology Used to Calculate Health Workforce Gaps Step 1: Calculate HRH needs Step 2: Calculate HRH availability Identify the population that is assigned to each micro-network Step 3: Calculate HRH gap -> Estimate the demand for PEAS Gather and organize information services on HRH availability -> Validate information on HRH Subtract HRH availability estimate -> Estimate the amount of time from HRH needs estimate needed to provide the PEAS availability package as well as other required activities, by profession => ESTIMATE OF HRH NEEDS => ESTIMATE OF HRH AVAILABILITY => ESTIMATE OF HRH GAP Source: Authors’ calculations. We calculated that in 2013 Peru has a deficit of 11,779 physicians, 8,780 nurses, 4,950 midwives, and 27,515 dentists (annex 5). On the positive side though, the gap for some human resources has been closed in a number of regions. The deficit for dentists is not surprising, since the number of dentists entering the system is minimal. Compared with 2009, we observe a significant increase in the gap for physicians (30 percent) and for dentists (26 percent), whereas the gap for nurses and midwives remained constant. We use this gap information, together with INEI’s population growth projections, and projections on the number of health professionals to assess in how much time the estimated gaps could potentially be filled, depending on the absorption rate of graduates into the public sector. Using the information available from the ANR, we first calculate the ratio of graduates to the number of entrants five years earlier15 (Table 1.11) After applying the calculated ratio to the number of students entering public and private universities from 2008 to 2011, it is possible to project number of graduates from those universities for the period 2012 to 2015.16 Table 1.12 summarizes these results. 15. In this case, we made the calculation for five years of study, since the available information corresponds to such period of time. It is worth indicating, however, that medical training lasts seven years. 16. It is worth specifying that as of the date of this report, the National Assembly of Rectors only had information for the 2007–11 period. Thus, we will work with the projection for 2012. 28 Table 1.11 Number of Graduates and Ratio of Graduates/ Entrants Number of Graduates Graduates to Type of Profession admissions ratio University 2007 2008 2009 2010 2011 (5 years) Public 551 819 720 881 751 0.79 Medicine Private 693 844 938 1,462 1,260 0.58 Total 1,244 1,663 1,658 2,343 2,011 0.64 Public 1,039 1,472 1,298 1,732 1,480 0.76 Nursing Private 972 1,206 1,101 1,774 1,997 0.52 Total 2,011 2,678 2,399 3,506 3,477 0.60 Public 271 413 303 557 392 0.62 Midwifery Private 689 495 445 589 683 0.43 Total 960 908 748 1,146 1,075 0.48 Public 221 440 307 288 332 0.57 Dentistry Private 665 1,142 921 1,311 1,650 0.43 Total 886 1,582 1,228 1,599 1,982 0.45 Nutrition and Public 105 171 132 199 158 0.48 Food Science Private 27 38 18 46 46 0.16 Total 132 209 150 245 204 0.33 Public 139 267 276 362 311 0.69 Psychology Private 779 861 874 1,448 1,828 0.41 Total 918 1,128 1,150 1,810 2,139 0.44 Pharmacy and Public 202 310 247 394 396 1.00 Biochemistry Private 206 304 110 322 445 0.46 Total 408 614 357 716 841 0.61 Medical Public 76 182 289 253 307 1.38 Technology Private 38 94 115 145 254 0.23 Total 114 276 404 398 561 0.43 Source: National Assembly of Rectors (ANR) 2013. 29 Table 1.12 Projections of the Number of Graduated Professionals 2012 –15 Type of Projected Number of Graduates Profession University 2012 2013 2014 2015 Public 776 605 867 1,005 Medicine Private 1,166 1,322 1,523 1,527 Total 1,942 1,927 2,390 2,531 Public 1,518 1,204 1,594 1,481 Nursing Private 2,752 2,020 2,446 2,833 Total 4,270 3,224 4,041 4,314 Public 408 313 502 449 Midwifery Private 950 827 931 1,030 Total 1,358 1,141 1,433 1,479 Public 340 278 381 376 Dentistry Private 2,336 2,062 2,101 2,045 Total 2,677 2,340 2,481 2,421 Nutrition and Public 210 124 192 190 Food Science Private 51 32 36 54 Total 261 156 228 245 Public 412 161 498 282 Psychology Private 2,427 2,316 3,263 3,343 Total 2,840 2,477 3,760 3,625 Pharmacy and Public 396 396 396 396 Biochemistry Private 445 445 445 445 Total 841 841 841 841 Medical Public 307 307 307 307 Technology Private 254 254 254 254 Total 561 561 561 561 Source: Authors’ calculations. Furthermore, using information on the dynamics of professionals and their entry into SERUMS, as presented in Figure 1.9 to Figure 1.16, it is possible to calculate an average ratio (percentage) of those who take up a SERUMS position and of those who stay in the system. Using this ratio, it is possible to project the number of professionals who would enter SERUMS and then the public sector (Table 1.13 and Table 1.14). 30 Table 1.13 Projection of the Number of Professionals Entering SERUMS Profession 2013 2014 2015 2016 Medicine 2,291 2,274 2,820 2,987 Nursing 2,690 2,031 2,546 2,718 Midwifery 1,209 1,015 1,275 1,316 Dentistry 883 772 819 799 Nutrition and food science 167 100 146 157 Psychology 454 396 602 580 Pharmacy and biochemistry 227 197 263 303 Medical technology 292 240 311 337 Source: Authors’ calculations. Table 1.14 Projection of the Number of Professionals Entering the Public Health System Profession 2014 2015 2016 2017 Medicine 641 637 790 836 Nursing 995 751 942 1,006 Midwifery 399 335 421 434 Dentistry 124 108 115 112 Nutrition and food science 33 20 29 31 Psychology 91 79 120 116 Pharmacy and biochemistry 36 31 42 48 Medical technology 47 38 50 54 Source: Authors’ calculations. PROJECTION OF THE HEALTH WORKFORCE G AP Finally, we calculated a projection of the health workforce gap for 2013–40 (annex 6, table A6.1). For this projection, we assumed that, starting in 2016, the number of professionals taking up SERUMS positions would stay constant and be equal to the projections for that year. It is worth mentioning that even though we expect an increase in the number of new professionals, we should also consider that every year a certain number quit, so we are using a conservative assumption that the number of additional entries into SERUMS meets the number of those who complete or quit SERUMS. Furthermore, we assume that the ratio of professionals who keep working in the public system also remains constant. Under those assumptions, we estimated that the gap of physicians would be closed in 2027, the gap of nurses in 2024, and the gap of midwives in 2017. By contrast, the gap of dentists would not be closed in the indicated term, which is to be expected because of the low ratio of dentists entering the public system through SERUMS (annex 6, table A6.1). We also carried out a simulation with different scenarios, in which we varied the percentage of professionals who join the public sector after completing SERUMS and calculated the year in which the gap would be closed (Table 1.15). Increasing the rate of absorption into the public system by 10 percent would reduce the time to close the gap by no more than three years. By doubling the rate of absorption (100 percent increase), it would be possible to close the gaps between 2016 and 2020. 31 Table 1.15 Summary of Gap Closure Simulations Higher system absorption rate scenarios Physicians Nurses Midwives Psychologists Dentists Starting condition: Ratios 0.28 0.37 0.33 0.2 0.14 0% Year gap closes 2027 2024 2017 2045 >2050 Ratios 0.31 0.41 0.36 0.22 0.15 Scenario 1: +10% Year gap closes 2025 2023 2017 2042 2049 Ratios 0.34 0.44 0.40 0.24 0.17 Scenario 2: +20% Year gap closes 2024 2023 2017 2040 2046 Ratios 0.36 0.48 0.44 0.26 0.18 Scenario 3: +30% Year gap closes 2024 2022 2017 2038 2043 Ratios 0.39 0.52 0.46 0.28 0.20 Scenario 4: +40% Year gap closes 2023 2021 2016 2036 2039 Ratios 0.42 0.56 0.50 0.30 0.21 Scenario 5: +50% Year gap closes 2022 2021 2016 2035 2039 Ratios 0.56 0.74 0.66 0.40 0.28 Scenario 6: +100% Year gap closes 2020 2019 2016 2030 2033 Source: Authors’ calculations. DISCUSSION MINSA and the regional governments are the largest employers of the health sector in Peru, and this gives them substantial weight in influencing the health labor market. On the other hand, there is only limited available information on human resources working outside the public sector (MINSA and regional governments). The little comparative information available indicates that public sector salaries are lower than those offered by other subsectors such as EsSalud. In addition, the public sector relies on a large number of contract regimes for hiring HRH, which is associated with large discrepancies in terms of salary. In addition, most new hires into the public sector are done on the basis of temporary CAS contracts. Although it has been proven that salary is not the only factor considered by workers in employment decisions, these salary differences and temporary employment conditions are an obstacle to attracting high- quality, motivated employees to the public sector. The Peruvian government is promoting basic health teams—physician, nurse, midwife—as the basis for primary care services and as a means to guarantee universal health coverage. In practice, however, filling those positions is not straightforward. Our analysis shows that a significant number of graduates do not take up SERUMS positions and thus do not join the public sector and that this is in part related to the lack of labor stability and the lower salaries offered in the public sector. Our projections show that if the government were able to double the absorption of physicians into the public system after their SERUMS internship, it would close the gap by 2020, seven years earlier than if the absorption ratio remains constant; for nurses it might be 2019 versus 2024. Regarding midwives, the 32 calculations show that the gap might be closed in 2017 with the current absorption ratios. This type of information is important in developing incentive policies to increase the level of human resource absorption into the public sector. 4. MIGRATION In this section, we analyze migration patterns of health professionals. DATA S OURCES Unfortunately, we were unable to obtain records of migratory flows of health professionals into and out of Peru. The following are the data and information sources used in this section:  Publications related to human resources for health in Peru and the region found by searching in Google Scholar (http://scholar.google.com/) and PubMed (http://www.ncbi.nlm.nih.gov/pubmed)  2010 National University Census STUDENTS’ INTENTION TO MIGRATE Given that there is no accurate information about actual flows of migration to other countries, we have to rely on other sources of information. There are two studies that look at students’ desire to migrate. The 2010 University Census asked students about their desire to migrate to another country after finishing professional studies. Table 1.16 shows the responses for health professionals. The intention to migrate is highest among medical students (78 percent) and is significantly higher than in 2008 according to Mayta- Tristán (Mayta-Tristán, 2008). In this previous study, medical interns at San Marcos National University were asked about their intention to migrate for work reasons. The results showed that 38.1 percent of interns had the intention to migrate, and of these, 70 percent planned to migrate to Europe and 23 percent to North America. The main reason was better economic prospects, and students were more likely to intend to migrate if they had an extracurricular rotation, or if they had presented at least one scientific paper at a student congress. This difference between the two studies in the intention to migrate may be due to the fact that the census sample included private as well as public university students, while the Mayta-Tristán study was limited to one public university. 33 Table 1.16 Plans to Migrate Abroad after Graduation, 2010 University Census Profession Number of students Respondents planning to surveyed migrate after graduation (%) Medicine 21,333 78 Nursing 31,879 67 Midwifery 11,643 60 Dentistry 21,770 69 Nutrition and food science 3,254 64 Psychology 24,413 60 Pharmacy and biochemistry 7,963 65 Medical technology 6,537 66 Biology 7,801 74 Source: National Institute of Statistics and Informatics (INEI) 2010. A 2013 report published by the Pan-American Health Organization (PAHO), “Migration of Qualified Health Professionals, Financial Impact, Recognition of Diplomas: Challenges and Perspective in Andean Countries”, documents that Peru has the highest number of migrating physicians and nurses in the region, losing an average 588 physicians and 881 nurses annually, thereby accounting for 44.7 percent of doctor and nurse migrations in the region. The outflow of Peruvian nurses is particularly alarming, since they represent 68.1 percent of the total nurse migration of the region. The PAHO report estimated that the cost of this migration would be between 13.3 and 25.7 percent of the total value of exports, depending on whether the professionals were trained in private or public universities. The report concluded that human resources’ migration costs are significant for the region and have an impact on the amount and quality of local supply. Two publications study the migration of Peruvian physicians (Bernardini-Zambrini et al. 2011) and of physicians and nurses of the Andean region, to Spain in particular (Álvarez Velasco 2012), using migration data provided by Spanish authorities. Both studies report that Peru contributes a significant and progressively increasing number of professionals to the Spanish health system. Figure 1.18 was adapted from Álvarez Velasco (2012) and shows an increase in the number of official recognitions of physicians and nurses’ degrees from the region. The Bernardini-Zambrini report, on the other hand, finds that two out of every five Peruvian physicians who migrated to Spain chose a family medicine position. 34 Figure 1.18 Number of Medical and Nursing Degrees Recognized in Spain, by Country of Origin of the Migrant Number of Medical Degrees Recognized 2000 Bolivia 1500 Chile 1000 Colombia Ecuador 500 Peru Venezuela 0 2002 2003 2004 2005 2006 2007 2008 2009 Number of Nursing Degrees Recognized 600 500 Bolivia 400 Chile 300 Colombia 200 Ecuador Peru 100 Venezuela 0 2002 2003 2004 2005 2006 2007 2008 2009 Source: Álvarez Velasco 2012; Spain, Ministry of Education, General Sub-Director’s Office for Degrees and Qualification Recognition 2012. DISCUSSION We conclude that there is a high intention to migrate among students in the health professions, and that many professionals eventually fulfill their intention, especially physicians and nurses, from whom we had more information. The losses for the country, particularly if those professionals were trained in public universities, are high. Overall, it would be helpful to have more information on migratory flows of health professionals into and out of Peru. 35 5. RETENTION In order to develop incentive policies to attract and retain health employees, it is essential to have first – hand information on employee preferences and motivations. However, obtaining such information is not straightforward. Very few studies survey preferences and motivations directly, and those that do cannot necessarily be generalized outside of the original sample, that is, to other geographical areas, to people trained in other professions, or to other phases in their careers (new graduates vs. more experienced personnel). In this section we summarize the results of the available studies and present recent information from MINSA’s Quality Office on employee satisfaction. DATA S OURCES The data and information sources used in this section are the following:  MINSA’s Quality Office—survey on internal user satisfaction  Publications related to human resources for health in Peru and the region, found by searching in Google Scholar (http://scholar.google.com/) and PubMed (http://www.ncbi.nlm.nih.gov/pubmed) HUMAN RESOURCES FOR HEALTH ASPIRATIONS , EXPECTATIONS , AND NEEDS A study about the current situation and professional perspectives of medical students in nine Latin American countries (Mayta-Tristán et al. 2010) found that 37 percent of them study in a place other than where they were born, whereas 82 percent plan to work in hospitals, and only 2.3 percent in health care centers. 47.6 percent agree that the average salary received by physicians in their countries is insufficient. Among Peruvian students, 47.7 percent intend to migrate to practice their profession, and only Colombia and El Salvador have larger percentages. Another study in Peru surveyed physicians who were undergoing the Peruvian Medical Association registration process (n=782) on job projections, and found that 7.0 percent planned to work in the interior of the country and only 0.5 percent in rural areas. This intention was positively related to having both parents living outside of Lima, knowing Quechua, and having done their internship outside of Lima (Mayta-Tristán et al. 2011). Three publications report the results of a discrete choice experiment conducted with physicians, nurses, and midwives working in Ayacucho. Different job packages were presented to them, with different combinations of salaries and benefits, to understand what conditions would encourage them to choose to continue to work in a rural area. For nurses and midwives, the likelihood of choosing an urban position was almost 15 times higher than for choosing a rural position. The top reasons to choose a rural job included a salary increase, an assignment to a “better” type of health center, and scholarships to continue their professional training. Increasing the number of years to secure a permanent contract appeared to be a disincentive for both rural and urban jobs. Simulations showed that a package that includes a 75 percent increase in salary and more scholarships for specialization could increase the percentage of nurses and midwives accepting a rural job from 36.4 to 60.0 percent (Huicho et al. 2012a). On the other hand, physicians were five times more likely to choose an urban position than a job in a rural community. A salary increase and bonus points for specialization would serve as incentives to choose a rural area, whereas an increase in the number of years required to secure a permanent position would be a disincentive. Being male and currently employed at a hospital considerably reduces the likelihood of accepting a rural job. Simulations showed that a package with a salary increase of 75 percent, permanent contract after two years in the rural area, and bonus points for specialization would increase the percentage of physicians accepting a rural job from 21 to 77 percent. A package with a 50 percent salary increase, plus bonus points for 36 specialization would also increase the probability of physicians accepting a rural job from 21 to 52 percent (Miranda et al. 2012). A qualitative study that was conducted as a part of this experiment identified that the job conditions of many health professionals were hard, and that there is no systematic incentive strategy for attracting and retaining employees in rural areas. The main incentives requested by the employees included—besides the abovementioned—more contractual stability and labor benefits, infrastructure enhancement, equipment and supplies for health professionals, training opportunities, better housing, better food, and better care and recognition (Huicho et al. 2012b). Bobbio and Ramos (2010) surveyed the job satisfaction of physicians, nurses, midwives, and nursing technicians in the Dos de Mayo National Hospital. They show that 22.7 percent of physicians, 26.2 percent of nurses and midwives, and 49.4 percent of nursing technicians were satisfied with their jobs. The multivariate analysis shows that for physicians, factors associated with job satisfaction included the hygiene and tidiness of the job environment, and satisfaction with department heads; for nurses and midwives, the factors were appropriate workload, and proper promotion opportunities; and finally for nursing technicians, these factors were satisfaction with their monthly salary and satisfaction with job supervision. HEALTH FACILITY EMPLOYEE S ATISFACTION MINSA makes use of a continuous survey to assess the organizational climate of health centers, which we were able to access for this study. The survey assesses the internal users’ (that is, health facility employees) satisfaction. The survey has 28 questions in which the users have to respond on a 1 to 4 point scale, with 4 being the “healthiest” score. Thus, the overall score that can be obtained varies from 28 to 112. If the overall score is more than 84, the organizational climate is labeled as “healthy”; between 56 and 84, the climate is considered to need improvement, while if the score is lower than 56, the organizational climate is labeled as unhealthy (MINSA 2013). In accordance with the results obtained in the last surveys conducted in 2011 to 2013, none of the health care centers show an unhealthy environment. However, the largest number of health care centers have a score between 56 and 84 (to be improved), and less than 10 percent show a healthy climate (Table 1.17). Even though it is true that in health care centers where the organizational climate needs to be improved, the average score is not too low (over 70); it is still important to highlight that the number of organizations that lack a healthy environment is high—almost comprising the 90.5 percent of surveyed institutions during this period. Table 1.17 Results of Organizational Climate Survey (2011–13) Organizational Number of Average Number of Average Number of Average climate health care score health care score health care score centers centers centers (2011) (2012) (2013) Unhealthy 0 n.a. 0 n.a. To be improved 42 73.1 155 74.7 63 73.3 Healthy 0 n.a. 21 88.7 6 86.8 Total 42 73.1 176 76.4 69 74.5 Source: Health Quality Office, MINSA 2013. Note: n.a. = not applicable. 37 DISCUSSION The 2011 study by Mayta-Tristán et al. indicate that very few physicians expect or aspire to work at the community level or in rural areas. Besides, many have already migrated for study reasons. The discrete choice experiment in Ayacucho highlights the significance of incentives to retain health professionals working in rural areas. Information about organizational climate shows that for the majority of health employees there is a need to improve their working environment. This may be an indicator of labor satisfaction. Nevertheless, the available information for analysis in this section is limited, and more studies are necessary to better understand what incentives are needed to attract and retain health professionals to the primary care level within the public sector. 6. POSTGRADUATE TRAINING: M EDICAL SPECIALTIES In this section, we look into the organization, supply and demand of postgraduate training for medical specialties. We analyze the distribution of specialists within the system and the dynamics of incorporating these specialists into the public sector. DATA S OURCES The data sources used in this section are the following:  MINSA: Database of the National Observatory of Human Resources for Health  CONAREME: o Profiles to recognize priority specialists: http://www.conareme.org.pe/ o Entrants to Medical Residency from 2009–10 and 2013, per specialty  Publications related to human resources for health in Peru and the region, found by using Google Scholar (http://scholar.google.com/) and PubMed (http://www.ncbi.nlm.nih.gov/pubmed) ORGANIZATION OF POSTGRADUATE TRAINING FOR MEDICAL SPECIALTIES The admission process to medical residency is managed by medical schools and financed by the MINSA. To apply for admission, applicants must be physicians, belong to the Peruvian Medical Association, be accredited by the medical association to practice medicine, and have completed a SERUMS. Applicants can only apply to one medical school, and the selection process is conducted annually and simultaneously for each medical residency program. The admission exam is prepared by the Peruvian Association of Medical Schools (ASPEFAM, http://aspefam.org.pe/), application is by clinical, surgical, or subspecialty area; and positions are allocated in strict order of results among the approved applicants. Herrera-Añazco et al. (2012) note that universities play a smaller role during medical residencies, as training is the responsibility of the teaching hospitals. Some teaching hospitals do not include scientific and academic activities in their training program, while others do but often do not conduct the corresponding activities due to the fact that residents are needed to fill in for the lack of assistant specialist doctors. Galán- Rodas et al. surveyed 416 physicians that applied to a residency program and found that this was not the first application for more than half of these applicants. Among those interviewed, 67.5 percent favored a single national exam, while 39.2 percent preferred a separate selection process by specialization. Moreover, 78.1 percent disagreed with MINSA’s proposal of implementing additional mandatory time of service in the medical residency in the less developed regions of the country. 38 This section describes the supply and demand for medical specialist training focused on the specializations linked to health priorities: internal medicine, pediatrics, surgery, anesthesiology, gynecology, and midwifery, and family and community medicine. Additionally, it describes the distribution of these specialists within the public sector and analyzes the training and absorption dynamics of the public sector. POSTGRADUATE T RAINING OF MEDICAL SPECIALTIES : SUPPLY AND DEMAND The number of available openings for training of medical specialists is mostly limited by the capacity of teaching hospitals and health centers, while the number of candidates depends on the number of graduated physicians who have completed SERUMS (since this is a requirement to access the medical residency) and their interest in pursuing a specialization. According to CONAREME, 2,036 physicians entered the medical residency in 2013, with 1,968 admitted for specialization and 68 for sub-specialization. Table 1.18 shows the number of candidates that applied for admission as well as the number of actual admissions. The lowest admissions-to-candidates ratio can be found in general surgery and pediatrics, where the demand is high and only about 30 percent of applicants get a resident position. Also, the data for family and community medicine show the number of applicants is lower than the number of entrants, which results from a DGGDRRHH strategy to increase the number of positions for residents. Table 1.18 Number of Entrants to Priority Specialties Specialization Candidates Admissions Admissions to 2013 2013 candidates ratio Anesthesiology 281 143 0.51 Family and community 112 149 1.33 medicine General surgery 383 116 0.30 Gynecology and obstetrics 463 164 0.35 Internal medicine 125 103 0.82 Pediatrics 558 178 0.32 Total (for these 776 853 1.10 specializations) Source: CONAREME 2013. CONAREME determines the minimum training standards for priority specialties, including anesthesiology, pediatrics, gynecology and obstetrics, internal medicine, general surgery, and family and community medicine. Annex 7 presents a summary of these standards. We examined the standards to determine whether they included developing competencies related to the primary care level, since health facilities at level I-2 and above can include a physician with a specialty, and health facilities at level I-4 and above should have a specialist.17 The CONAREME standards show that the only specialties with community care- oriented skills are gynecology and obstetrics, and family and community medicine. 17. Primary health facilities are labeled level I-1 to I-4, secondary facilities are labeled II-1, II-2, and II-E (specialist secondary level facility), and tertiary level facilities are labeled III-1, III-2, and III-E. 39 DISTRIBUTION OF MEDICAL SPECIALISTS WITHIN THE SYSTEM In November 2012, MINSA estimated that there were 7,048 specialists in the public health sector, of which 4,063 or 57.6 percent were concentrated in Lima (MINSA 2012). Among the 4,069 medical specialists in the 6 priority areas, 53 percent were concentrated in Lima. Table 1.19 shows the unbalanced distribution of priority medical specialists by department. Table 1.19: Distribution of Priority Medical Specialists by Department Department Anesthesi Family and General Gynecolo Internal Pediatric Total o-logy community surgery gy and medicine s medicine obstetrics Amazonas 6 1 6 7 1 6 27 Ancash 7 1 22 28 11 26 95 Apurimac 4 6 6 6 5 6 33 Arequipa 29 5 45 36 33 48 196 Ayacucho 8 2 6 14 5 7 42 Cajamarca 5 1 15 16 4 12 53 Callao 38 5 44 65 40 69 261 Cusco 16 0 24 30 17 24 111 Huancavelic 6 0 6 4 4 5 25 a Huánuco 12 0 6 21 5 10 54 Ica 33 1 39 44 32 47 196 Junín 13 0 25 22 9 13 82 Libertad 41 1 46 68 36 60 252 Lambayequ 14 1 23 21 10 20 89 e Lima 312 24 316 554 302 640 2148 Loreto 8 0 6 14 9 12 49 Madre De 2 1 1 2 0 2 8 Dios Moquegua 3 2 5 5 1 5 21 Pasco 6 0 12 14 4 8 44 Piura 14 2 13 32 6 25 92 Puno 8 2 11 27 5 13 66 San Martín 4 1 7 10 2 5 29 Tacna 8 0 11 14 8 12 53 Tumbes 2 2 7 4 4 5 24 Ucayali n.a. n.a. n.a. n.a. n.a. n.a. n.a. Total 601 58 708 1066 557 1,089 4,079 Source: MINSA, DGGDRRHH 2013. Note: n.a.= not applicable. 40 We also analyze the distribution of priority medical professionals by health establishment category. Table 1.20 shows that there some specialists at primary levels I-3 and I-4, particularly for gynecology and obstetrics and pediatrics; however, they are mostly concentrated at the secondary and tertiary care levels. The table also shows that there are only a few (n=58) specialists in family and community medicine within the system, even at the primary care level. Table 1.20 Distribution of Priority Medical Specialists according to Health Establishment Category Category Anesthesio- Family and General Gynecology Internal Pediatrics Total logy community surgery and medicine medicine obstetrics I-1 1 0 0 1 0 0 2 I-2 4 1 3 5 4 6 23 I-3 8 12 13 28 10 27 98 I-4 9 15 14 57 9 33 137 II-1 94 7 118 171 65 107 562 II-2 122 7 202 265 115 213 924 II-E 1 1 1 0 1 0 4 III-1 264 9 307 412 331 486 1,809 III-2 87 0 28 106 6 203 430 III-E 9 0 14 13 4 6 46 Decentralized 0 3 1 3 1 3 11 health directorates MINSA 2 0 1 2 4 2 11 Other 0 3 6 3 7 3 22 administrative entities Grand total 601 58 708 1,066 557 1,089 4,079 Source: MINSA, DGGDRRHH 2013. DEFICIT OF MEDICAL S PECIALISTS The deficit of specialists in Peru is not new, but it has become more salient within the context of universal health coverage—which has increased the demand for health services and for infrastructure and equipment—and given the high rate of migration of physicians. In 2011 Zevallos et al. analyzed the need for medical specialists based on two methodologies: the required number of specialists according to the categorization standard of health establishments, and the number required according to the epidemiological and demographical profile of the population. The difference between the calculated need and the number of practicing specialists defined the gap of medical specialists. According to the categorization standard, there was a total need for 11,176 medical specialists, and according to the epidemiological and demographical profile the need was 11,738. The number of specialists in the public sector at that time was 6,074; thus the estimated gaps nationwide are similar with both methods. The gap is largest in gynecology and obstetrics, pediatrics, internal medicine, and general surgery. 41 RESIDENT TRAINING DYNAMICS AND INCORPORATION INTO THE PUBLIC SECTOR To analyze the dynamics of medical specialist training and incorporation into the system, we looked at information on physicians entering residency in 2009 and 2010, who would complete their residency in 2012 and 2013. These individuals were compared to those who currently work in the public sector. We find that only 9.9 percent of the total specialists who completed their specialties in the last two years currently work for the public sector. The highest absorption percentage is for general surgeons, followed by pediatricians and anesthesiologists. It is telling that out of the 75 residents who entered the family and community medicine specialty in 2009 and 2010, only one specialist currently works in the public sector (Table 1.21). Table 1.21 Absorption of 2009/10 Medical Residents in the Public Sector, 2013 Specialization Admissions to MINSA employees Absorption residency (%) 2010 2009 Total 2010 2009 Total Anesthesiology 87 72 159 5 23 28 17.6 Family and community 42 33 75 1 1 1.3 medicine General surgery 78 65 143 8 20 28 19.6 Gynecology and obstetrics 117 87 204 4 16 20 9.8 Internal medicine 78 59 137 5 11 16 11.7 Pediatrics 118 88 206 15 22 37 18.0 Overall total 1,156 924 2,080 58 148 206 9.9 Sources: CONAREME; and MINSA, DGGDRRHH 2013. Authors’ calculations. DISCUSSION This section shows that there is a high demand for training for priority medical specialties. In 2013 more than 43 percent of total residents were associated with those specialties. The competency profiles prepared by CONAREME show that only the programs in gynecology and obstetrics, and family and community medicine give attention to the primary care level. The number of family and community medicine residencies has increased considerably, yet their current number within the system is low (n=58), and absorption of new graduates of this specialty into the public system seems virtually inexistent. On the other hand, although the distribution of specialists according to the health facility level appears appropriate, the geographical distribution is extremely unbalanced; more than half the specialists are concentrated in Lima, and there is still a significant deficit within the system. The resident training and specialist absorption dynamics show that a great number of professionals do not start working for the public sector in the first two years after finishing their residency. This indicates a significant loss of specialized human resources and training investment. This analysis is based on two relatively recent years, however, and information on entrants in former years may better inform these dynamics. If in fact this low absorption of specialists into the system is confirmed, it would be important to study where these specialists work, how often they migrate, and how to attract a larger number of them to work within the public sector. 42 CONCLUSIONS In this report, we used existing data and information, so the strength of the results and conclusions reached depend on the quality of the corresponding data. The sections with better data are training of health professionals, transition of graduates to the labor market, contracting of health professionals, and postgraduate training. The migration and retention sections mainly summarize previous publications. The Training section shows that there is a high demand for training in the basic health team professions and other professions related to health in Peru, and that most of the training supply is provided by private universities. Even though there is a commitment to standardize training and assure its quality, the process— managed by CONEAU—has been slow and still needs work. It is hard to objectively discuss the present quality of training in Peru, so long as this process fails to make additional progress. The comparison of MINSA’s competency profile for the basic health team in the primary care level and the professional profiles in the market highlights that basic health team graduates are not specifically prepared to work in the primary care level. Therefore, there is a low likelihood that MINSA would find the type and number of professionals it requires to work in the primary care level. For MINSA and the regional governments to find the professional profile for primary care level in the market, it is necessary to create training programs focused specifically on training professionals to work at this level and—at the same time—work with professional associations to certify these professionals. There is an opportunity for MINSA and the regional governments—as the majority employers—to work with training institutions, most of which are private, to influence the content of the training and the certification process. In the analysis of the SERUMS program, we observed that for most of the professions included in the study, except for medicine, take-up of SERUMS is lower than the actual number of graduates. There are a significant number of graduates who choose not to participate in SERUMS, which is an indicator that the labor market is offering other opportunities that do not insist on SERUMS as a prerequisite. Furthermore, the analysis shows that the public sector fails to absorb the majority of professionals completing SERUMS, which indicates that the deficit of health professionals in the public sector is not due to the lack of professionals in the market, but rather to the fact that there is no mechanism complementing SERUMS to enable incorporation of these professionals into the public sector, and possibly because there are other more attractive employment opportunities in the market. Though there is evidence that SERUMS has been effective at assuring the presence of human resources in rural and remote areas, the question arises of how to retain those professionals who complete SERUMS. In other words, what retention policies and budgetary changes must be implemented to assure the incorporation of more professionals into the public sector? These training dynamics followed by SERUMS and the low number of graduated professionals joining the public sector show that the health professional gap in the system is not a result of a lack of trained professionals, but of the low level of absorption into the public sector. We used projections of training and incorporation into the system to simulate the amount of time necessary to fill MINSA’s estimated gaps. Calculations show that if we double the number of professionals joining the system, the gap for physicians might be filled by 2020, seven years earlier than if we were to continue at the present absorption rate; for nurses it would be five years earlier (2019 vs. 2024). Regarding midwives, the calculations show the gap might be closed in 2017 with the current absorption rates. This type of information is significant for developing incentive policies to increase the absorption level of human resources into the public sector. 43 Intention to migrate among health professions students is high, and many professionals currently fulfill such intentions. However, it is necessary to improve the quality of available information on migratory flows from Peru to develop a more robust analysis. To improve the incorporation of health professionals into the public sector, it is necessary to explore and understand their aspirations, expectations, and needs—not only of new graduates but also the more experienced professionals—since their motivations would be different. Available data are still insufficient to develop effective incentive packages. Resident training and specialist absorption dynamics presented in section 6 are based on only two years of data. Analyses show that the vast majority of specialists do not start working for the public sector in the first two years after completing their residencies, indicating a significant loss of specialized human resources and training investment, which is financed entirely by the government. It is necessary to conduct a more detailed study to understand what happens with those specialists—where do they end up working, and how many of them migrate—in order to develop effective retention policies. It is noteworthy that the lack of information on health professionals who work outside the public sector (MINSA and regional governments), on prevailing salary levels and on unemployment among health workers are the most significant limitations for this study. RECOMMENDATIONS Our recommendations can be grouped in four areas: (i) the relevance of skills of health professionals; (ii) contracting, compensation, and retention policies to improve absorption and retention of health professionals in the public sector; (iii) the quality of information on HRH; and (iv) research to inform the policies for implementation. Relevance of skills of health professionals  We recommend that MINSA’s General Director’s Office for Management of Human Resources Development (Dirección General de Gestión del Desarrollo de Recursos Humanos— DGGDRRHH) work with public and private universities to review existing training programs and develop new programs focused on training professionals to work specifically at the primary care level. Programs could look beyond the currently available programs and include shorter, more community- oriented courses. If these shorter courses are associated with a high likelihood of employment after completion, they may be well received in a market with a high demand for training. Considering that private institutions currently provide the majority of training in the health professions, they would play an essential role in the development of new training programs. In addition, it would be important to offer these courses in the regions, as students from rural areas may be more likely to enroll and work in their region of origin.  The accreditation process for training programs will need to be made more agile if it is to guarantee training quality. We recommend a more detailed assessment of CONEAU’s processes to understand the difficulties and propose steps that could speed up the certification process.  Professional associations are already playing a role in certifying professionals; however, this process does not add value or improve a professional’s employment opportunities in the labor market, and it is unclear whether it includes any assessment of skills. The certification process should be widened to include an assessment of skills that would guarantee professional quality and improve job opportunities.  MINSA’s profiles for the basic health team would need to be updated to adjust responsibilities for caring for NCDs and adult conditions. Nurses need to assume a larger role in the prevention and management 44 of chronic conditions. Furthermore, other skills such as administrative management, and public health prevention and promotion need to be considered within these profiles. Contracting, compensation, and retention policies within realistic budgetary scenarios  In terms of contracting, the public sector relies on a multitude of contract regimes, which seem to be paired with wide divergences in salary. We recommend that MINSA take a global look at contractual regimes and payment schemes and strategically review compensation mechanisms.  The SERUMS program has been successful at ensuring the presence of health professionals in rural and remote areas; however, it is not accompanied by a mechanism to retain these professionals in the public sector. We recommend that SERUMS be complemented with a retention strategy, based on a more complete assessment that includes studies that explore the job aspirations and expectations of new graduates. Post-SERUMS professionals signaled their interest in working for the public sector by enrolling in SERUMS—the public sector should capitalize on this knowledge in its attempts to hire and retain professionals. Quality of information on HRH  There is a fragmentation in the information systems between MINSA, EsSalud, the other health insurance providers and the private sector, and as a result, no comprehensive information can be obtained about the distribution of health professionals by subsector. For policy purposes, it is necessary to improve the quality and integration of HRH information both in the public sector and outside of it. To achieve this, there is a need for strategic alliances with entities that routinely collect data on human resources in these subsectors, such as EsSalud, private insurance providers, professional associations, and corporations managing clinics and private hospitals. The challenge would be to create a relationship in which there is common interest in sharing this information. Such information will strengthen subsequent studies on the employment market of HRH as it provides a more complete vision of the entire sector.  In regards to migration, there are still many unanswered questions. For instance, there is little information on how many professionals leave the country to work, how many continue studying, how many come back, and when. There are outstanding questions as to when more aggressive retention strategies should be applied, for example, before or after SERUMS, before or after the residency? To be able to answer some of these questions, MINSA will need to work with the Bureau of Immigration and Naturalization (DIGEMIN) to improve the quality of information on health professional migration. Research to inform the policies for implementation  Professional incorporation into the public sector will require the development of contractual, incentive, and retention packages that are based on better understanding of health professionals’ aspirati ons, expectations, and needs. Studies on new graduates, those who complete their SERUMS, current public sector workers, other subsectors workers, and unemployed health professionals may provide information on job expectations, relative options in the market, and salary and social benefit expectations, which we were not able to analyze in this study. Some methodologies that may be used include surveys, discrete choice studies, and focus groups, among others.  In our analysis of the dynamics of medical specialist training and absorption of specialists by the public sector, we find that absorption by the public sector is minimal, at approximately 10 percent. It would be important to research the flow of medical specialists within the market and understand what happens with them, where they end up working, and why. Moreover, we need to understand how MINSA can manage to attract and retain more specialists within its budgetary limitations. 45 LIMITATIONS This study has several main limitations:  The discussion of human resources in health that is presented in this report focuses on the public sector, and this limitation was mainly driven by availability of data. At the same time, the discussion on human resources in health should be framed within a broader discussion on the role of the public sector in health service delivery, and the role of other providers including EsSalud, the other insurance/provisions institutions like the Metropolitan Solidarity System (Sistema Metropolitano de la Solidaridad—SISOL) and the private sector providers.  Even within the public sector, our analysis is limited by availability of data in several areas. 46 REFERENCES Álvarez Velasco, S. 2012. “Emigración de Médicos-as y Enfermeros-as de la Región Andina Hacia España: Complejas Consecuencias Para el Desarrollo Local.” ANDINA-MIGRANTE. Boletín del Sistema de Información sobre Migraciones Andinas — FLACSO Ecuador 14 (November). Alwan, A., D. R. Maclean, L. M. Riley, E. T. d'Espaignet, C. D. Mathers, G. A. Stevens, and D. 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Maselko, M. R. Phillips, and A. Rahman. 2007. “No Health without Mental Health.” The Lancet 370 (9590): 859–77. Webb, R., and S. Valencia. 2006. “Human Resources in Public Health and Education in Peru.” In A New Social Contract for Peru: An Agenda for Improving Education, Health Care, and the Social Safety Net, ed. D. Cotlear, 191–244. Washington, DC: World Bank. WHO (World Health Organization). 2011. Global Status Report on Non-Communicable Diseases 2010. Geneva: WHO, 176. Zevallos, L., R. Pastor, and B. Moscoso. 2011. “Oferta y demanda de médicos especialistas en los establecimientos de salud del Ministerio de Salud: Brechas a nivel nacional, por regiones y por tipo de especialidad.” Rev Peru Med Exp Salud Pública 28 (2): 177–85. 48 ANNEXES ANNEX 1: DATA AND INFORMATION S OURCES USED IN THIS REPORT Source Provided information Report Methodology section General  Profiles of the basic health team (physicians, nurses, 1, 2, 3, 6  Reviewing the Director’s Office midwives, nursing technicians) for the primary care level literature for Human  List of medical specialists linked to health priorities: internal  Use of primary Resources medicine, surgery, Obgyn, pediatrics, anesthesiology, and sources Development family medicine  Combination of Management,  Publications of the National Human Resources for Health data and sources Ministry of Observatory Health  National Human Resources for Health Observatory database (2007, 2009, 2010, 2012)—or National System of Information on Human Resources for Health (INFORHUS - http://minsa- drupal.tmp.vis-hosting.com/app/inforhus/).  SERUMS database (2007–13) Quality Office,  Survey of internal users’ satisfaction 5  Use of primary Ministry of sources Health National Council  Progress made in accreditation processes of health training 1  Use of primary of University programs. Last progress published July 7, 2013 (http://aca- sources Evaluation, evaluamos.blogspot.com/) Accreditation  Progress in certification of health professionals through and Certification professional associations (CONEAU) (http://www.coneau.gob.pe/certificacion/proceso-de- certificacion/entidades-certificadoras-autorizadas.html) National  2010 National University Census (CENAUN) 1, 2, 3, 4  Use of primary Institute of  Projection of inhabitants nationwide for June 2013 sources Statistics and  Combination of Informatics data and sources (INEI) National  Data related to the number of students applying, entering, and 1, 2, 3  Use of primary Assembly of graduating from the following university professions: medicine, sources Rectors (ANR) nursing, obstetrics, nutrition, dentistry, psychology,  Combination of pharmaceutical chemistry, and medical technology (2007–11) data and sources Professional  Profiles created to certify professionals: 1  Use of primary associations o Peruvian Medical Association* (http://www.cmp.org.pe/) sources o Peruvian Nursing Association (http://www.cep.org.pe/) o Peruvian Midwifery Association (http://www.colegiodeobstetrasdelperu.org/portal/index.php) National  Profiles to recognize priority specialists: 6  Use of primary Committee of http://www.conareme.org.pe/ sources Medical  Medical residency entrants for 2009–10, by specialty  Combination of Residency data and sources (CONAREME) Public and  Curricula of the basic health team training programs 1  Use of primary private (physicians, nurses, and midwives) of universities with at least sources universities 4 percent of the student population of these professions, according to the 2010 University Census Scientific  Publications related to human resources for health in Peru and 1, 2, 3, 4,  Reviewing the journals, the region via Google Scholar (http://scholar.google.com/) and 5, 6 literature reports, and PubMed (http://www.ncbi.nlm.nih.gov/pubmed) searches other publications *We had access to the professional associations’ profiles through their website s in November 2013, except for those marked with *, which were accessed by other means. 49 ANNEX 2: CURRICULA OF TRAINING PROGRAMS OF UNIVERSITIES WITH 4 PERCENT OR MORE NUMBER OF STUDENTS IN THE BASIC HEALTH TEAM P ROFESSIONS Table 2A.1 Nursing Curricula University San Pedro Private University San Juan Bautista Private Alas Peruanas Los Ángeles de Chimbote Catholic (Chimbote) University University University What is the profile? Profile focused on prevention Profile focused on medical Profile focused on Profile focused on medical care. With and health promotion. With care. With skills for the medical care. With skills skills for the development of skills in community care of development of prevention for the development of prevention and health promotion individual, family, and and health promotion prevention and health programs in the community. Also with community in relation to programs in the community. promotion programs in a strong approach on project and existing risk factors in the Also project management the community. Also research development, planning, and natural environment, and and research. project and research management. research skills development, planning, and management. Is there a primary There is a focus on primary There is a focus on primary There is a focus on There is a focus on primary care. It care approach? care. It includes relevant care. It includes relevant primary care. It includes includes relevant courses starting courses starting from the first courses starting from the relevant courses starting from the first semesters. semesters. first semesters. from the first semesters. Courses prior to the In the 2nd year: In the 1st year: (1) In the 2nd year: (1) In the 3rd year: (1) Nursing Care for internship (1) Community Disease I (4 Community Health (6 cr.) Nursing for Family and Family Health (4 cr.) cr.) Community Health Care In the 4th year: (2) Nursing Care for In the 4th year: (4 cr.) Community health (7 cr.) (2) Community Disease II (7 cr.) Total credits 11 credits 6 credits 4 credits 11 credits Community Not specified Marginal Urban and Rural Not specified (1) Family and Community Health I (6 internship Internship (22 credits) (6 credits) months) (2) Family and Community Health II (6 credits) Total credits n.a. 22 credits n.a. 12 credits 50 University San Pedro Private University San Juan Bautista Private Alas Peruanas Los Ángeles de Chimbote Catholic (Chimbote) University University University Health management In the 2nd year: In the 4th year: In the 4th year: In the 3rd year: (1) Nursing care management (1) Health Management (10 (1) Economics applied to (1) Marketing Techniques (2 credits) (4 credits) credits) health (4 credits). (2) Administration, Health In the 4th year: Management and Nursing (2) Health Nursing Management (3 (6 credits). credits) (3) Projects and Budgets (2 credits) (4) Nursing Management (4 credits) (5) Logistic Administration (2 credits) Credits 4 credits 10 credits 10 credits 13 credits Research In the 1st year: (1) Bio- In the 1st year: (1) Statistics In the 2nd year: (1) In the 1st year: (1) Statistics (4 cr.) statistics (3 cr.) and Demographics (3 cr.) Statistics (3 cr.). In the 2nd year: (2) Nursing In the 2nd year: (2) In the 2nd year: (2) Basic In the 3rd year: (2) Bio- Epidemiology (3 cr.); (3) Bio-statistics Epidemiology (4 cr.); (3) Epidemiology (2 cr.) statistics (3 cr.); (3) (4 cr.) Research Methodology (3 cr.) In the 3rd year: (3) Research Research Methodology (3 In the 3rd year: (4) Thesis I (3 cr.); (5) In the 4th year: (4) Nursing Methodology (3 cr.) cr.); (4) Epidemiology (4 Qualitative Research (2 cr.); (6) Research I (3 cr.); (5) Nursing In the 4th year: (4) Research cr.); (5) Preparation of Thesis II (3 cr.). Research II (3 cr.) Project Preparation (3 cr.); Research Projects (5 cr.) In the 4th year: (7) Thesis III (3 cr.); 8) (5) Implementing Research In the 4th year: (6) Thesis IV (3 cr.). Projects (3 cr.) Research Project Implementation (5 cr.) Credits 16 credits 14 credits 23 credits 25 credits Sources: Public and private universities. Authors' calculations. Note: One additional university has over 4 percent of nursing students (Néstor Cáceres Andean University); however, the authors were unable to obtain a copy of the curricula; n.a. = not applicable. 51 Table 2A.2: Midwifery Curricula San Martín de Porres University Alas Peruanas University Los Angeles de Chimbote Catholic University What is the profile? Profile focused on maternal care Maternal care approach (prenatal, Maternal care approach (prenatal, (prenatal, intranatal and postnatal). intranatal and postnatal). With skills for intranatal, and postnatal). Skills for Skills in community health, health project development in the community community health, health management, and research and research. management. and research. Primary care approach? There is a primary care approach. There is a primary care approach. Rural There is a primary care approach. Courses from the first year internship, one-semester long. Courses from the first years Courses prior to the internship In the first year: (1) Public Health (3 None In 2nd year: (1) Community Obstetrics and externship credits) I (3 credits). In the 2nd year: (2) Community In the 3rd year: (2) Community Obstetrics (4 credits) Obstetrics II (4 credits). In the 5th year: (3) Community Externship (4 credits). Total credits 7 credits 0 credits 11 credits Type of internship In the 4th year (IX semester): (1) You have a 3-semester-internship. The Internship I (10 credits). first semester is a community internship, In the 5th year: (1) Hospital Internship In the 5th year: (2) Internship II (20 with 2 modules of 20 (credits): (12 credits) credits); (3) Internship III (20 (1) Community projection activities and credits). expanded program of immunizations (primary care level); (2) administrative and primary care–level activities Total credits 50 credits 20 credits 12 credits Health management In the 3rd year: (1) Health In the 3rd year: (1) Management and In the 4th year: (1) Entrepreneurial Administration and Management I (3 Marketing (4 credits) Leadership (2 credits) credits). In the 5th year: (2) Public investment In the 4th year: (2) Health Projects (2 credits); 3) Marketing Administration and Management II Techniques (2 credits); 4) Labor Law (2 credits). (2 credits). Credits 5 credits 4 credits 8 credits 52 San Martín de Porres University Alas Peruanas University Los Angeles de Chimbote Catholic University Research In the 1st year: (1) Bio-statistics (3 In the 1st year: (1) Bio-statistics (3 In the 1st year: (1) Statistics (4 credits); (2) Epidemiology (4 credits) credits). credits). In the 2nd year: (3) Research I (3 In the 2nd year: (2) Epidemiology (3 In the 2nd year: (2) Bio-statistics (4 credits) credits) credits). In the 3rd year: (4) Research II (3 In the 3rd year: (3) Research In the 3rd year: (3) Thesis I (3 credits) credits) Methodology (3 credits); (4) Writing and In the 4th year: (4) Thesis II (3 credits); In the 4th year: (5) Research III (3 Dissertation (2 credits); (5) Thesis (5) Thesis III (3 credits) credits) Seminar (2 credits) In the 5th year: (6) Thesis IV (3 credits) In the 4th year: (6) Thesis Development (2 credits) Credits 16 credits 15 credits 20 credits Total credits to receive degree 240 credits Nonspecified 234 credits Sources: Public and private universities. Authors' calculations. Note: One additional university has over 4 percent of nursing students (Néstor Cáceres Andean University;. however, the authors were unable to obtain a copy of the curricula. 53 ANNEX 3: UNIVERSITIES THAT H AVE REGISTERED TRAINING PROGRAMS FOR HEALTH PROFESSIONALS WITH CONEAU Table 3A.1 Universities That Have Registered Training Programs for Health Professionals With CONEAU No. NAME OF UNIVERSITY 1 ASOCIACION UNIVERSIDAD PRIVADA SAN JUAN BAUTISTA 2 UNIVERSIDAD ALAS PERUANAS 3 UNIVERSIDAD ANDINA DEL CUSCO 4 UNIVERSIDAD ANDINA NESTOR CACERES VELASQUEZ 5 UNIVERSIDAD CATOLICA DE SANTA MARIA 6 UNIVERSIDAD CATOLICA DE TRUJILLO 7 UNIVERSIDAD CATOLICA LOS ANGELES DE CHIMBOTE 8 UNIVERSIDAD CATOLICA SAN PABLO 9 UNIVERSIDAD CATOLICA SANTO TORIBIO DE MOGROVEJO 10 UNIVERSIDAD CIENTIFICA DEL SUR 11 UNIVERSIDAD FEMENINA DEL SAGRADO CORAZON 12 UNIVERSIDAD JOSE CARLOS MARIATEGUI 13 UNIVERSIDAD NACIONAL AGRARIA LA MOLINA 14 UNIVERSIDAD NACIONAL DANIEL ALCIDES CARRION 15 UNIVERSIDAD NACIONAL DE CAJAMARCA 16 UNIVERSIDAD NACIONAL DE HUANCAVELICA 17 UNIVERSIDAD NACIONAL DE LA AMAZONIA PERUANA 18 UNIVERSIDAD NACIONAL DE PIURA 19 UNIVERSIDAD NACIONAL DE SAN MARTIN 20 UNIVERSIDAD NACIONAL DE TRUJILLO 21 UNIVERSIDAD NACIONAL DE TUMBES 22 UNIVERSIDAD NACIONAL DE UCAYALI 23 UNIVERSIDAD NACIONAL DEL SANTA 24 UNIVERSIDAD NACIONAL DEL ALTIPLANO 25 UNIVERSIDAD NACIONAL DEL CALLAO 26 UNIVERSIDAD NACIONAL DEL CENTRO DEL PERU 27 UNIVERSIDAD NACIONAL FEDERICO VILLARREAL 28 UNIVERSIDAD NACIONAL HERMILIO VALDIZAN 29 UNIVERSIDAD NACIONAL JOSE FAUSTINO SANCHEZ CARRION 30 UNIVERSIDAD NACIONAL MAYOR DE SAN MARCOS 31 UNIVERSIDAD NACIONAL PEDRO RUIZ GALLO 32 UNIVERSIDAD NACIONAL SAN LUIS GONZAGA 33 UNIVERSIDAD NACIONAL SANTIAGO ANTUNEZ DE MAYOLO 34 UNIVERSIDAD PERUANA CAYETANO HEREDIA 54 No. NAME OF UNIVERSITY 35 UNIVERSIDAD PERUANA DE CIENCIAS APLICADAS 36 UNIVERSIDAD PERUANA LOS ANDES 37 UNIVERSIDAD PERUANA UNION 38 UNIVERSIDAD PRIVADA ANTENOR ORREGO 39 UNIVERSIDAD PRIVADA CESAR VALLEJO 40 UNIVERSIDAD PRIVADA DE TACNA 41 UNIVERSIDAD PRIVADA NORBERT WIENER 42 UNIVERSIDAD PRIVADA SAN IGNACIO DE LOYOLA 43 UNIVERSIDAD PRIVADA SAN PEDRO 44 UNIVERSIDAD RICARDO PALMA 45 UNIVERSIDAD SEÑOR DE SIPAN Sources: CONEAU, July 2013 (http://aca-evaluamos.blogspot.com/). Authors’ calculations. 55 ANNEX 4: COMPARISON OF COMPETENCY PROFILES Table 4A.1: Comparison of MINSA’s Official Profile for Primary Care–Level Physicians with the Profile Made by the Peruvian Medical Association and Standard No. 25 of CONEAU to Accredit Medical Training Programs No. Prioritized competency profile of the primary care level Profile prepared by the Peruvian Medical Standard No. 25 of CONEAU surgeon prepared by MINSA Association 1 HEALTH CARE SKILLS The curricula shall include: 1.1 Prenatal care during first consultation, prioritizing in the He/she manages the basic principles of Contents of anatomy, histology, embryology, third quarter, pursuant the current regulations. reasoning and clinic diagnosis pursuant the biochemistry, genetics, physiology, current regulations. microbiology, parasitology and immunology, pathology, pharmacology and therapeutic base, preventive medicine. 1.2 Taking care of noncomplicated horizontal delivery with He/she takes care of the healthy newborn, Training in basic sciences, lab practices, or appropriate intercultural attention pursuant the pursuant the regulations into force. other opportunities for direct application of the regulations into force. scientific method, safe observation of biomedical phenomenon, and critical data analysis. 1.3 Taking care of women in the puerperal period, within He/she provides medical care for healthy Preclinical and clinical training of all organic two hours and up to the 24 hours after delivery, children and adolescents, pursuant the systems, including significant ethical and bio- pursuant the regulations into force. regulations into force. ethical aspects, prevention aspects, acute and chronic diseases, rehabilitation, and terminal care. 1.4 Taking care of sexual and reproductive health issues in He/she comprehensively manages prevailing Experience in primary care, epidemiology, adolescents, pursuant the regulations into force. noncommunicable diseases of children and public health, and health management. adolescents, the more prevailing are the priority, pursuant the regulations into force. 1.5 Taking care of women for quarterly injectable He/she comprehensively manages prevailing Clinical experiences in family medicine, contraception, pursuant the regulations into force. infections of children and adolescents, internal medicine, obstetrics and gynecology, pursuant the regulations into force. pediatrics, psychiatry, and surgery. 1.6 Taking care of women for prevention and detection of Conducting the prenatal control of the low risk Having experiences both with hospitalized cervical and breast cancer, pursuant the regulations expectant mother, deriving opportunities when and nonhospitalized patients. into force. required, pursuant the regulations into force. 1.7 Immediate care for the full-term newborn, pursuant the Taking care of normal delivery and immediate Available training opportunities in regulations into force. puerperium, pursuant the regulations into multidisciplinary areas, such as emergency force. care, geriatrics and disciplines to help 56 No. Prioritized competency profile of the primary care level Profile prepared by the Peruvian Medical Standard No. 25 of CONEAU surgeon prepared by MINSA Association diagnosing, such as radiology and clinical pathology. 1.8 Taking care of children with acute respiratory infection, Initial care of labor complications and Specific training in communication skills, with obstructive bronchitis syndrome and asthma, pursuant immediate puerperium and its early reference, patients, relatives, colleagues, and other the regulations into force. pursuant the regulations into force. health professionals. 1.9 Taking care of children with acute diarrheal disease, Taking care of noncomplicated gynecologists- pursuant the regulations into force. obstetrics infections, pursuant the regulations into force. 1.10 Taking care of children with anemia, pursuant the He/she manages adults’ noncommunicable regulations into force. diseases with emphasis in the more prevailing ones, pursuant the regulations into force. 1.11 Taking care of children with chronic malnutrition, He/she prescribes commonly used drugs pursuant the regulations into force. according to their instructions, interactions, and adverse side effects. 1.12 Taking care of children with parasitic diseases, He/she provides initial care to the pursuant the regulations into force. politraumatized patient pursuant regulations into force. 1.13 Taking care of smear positive respiratory symptoms, Initial care of the surgical acute abdomen and pursuant the regulations into force. its referral, pursuant the regulations into force. 1.14 Taking care of people with sexually transmitted He/she early identifies more frequent surgical infections, HIV/AIDS, pursuant the regulations into diseases for timely referral. force. 1.15 Taking care of people with He/she conducts emergency and low depression/violence/alcoholism issues, pursuant the complexity surgical procedures. regulations into force. 1.16 Taking care of people with diabetes mellitus, pursuant the regulations into force. 1.17 Taking care of people with high blood pressure, pursuant the regulations into force. 1.18 Taking care of people with obesity issues, pursuant the regulations into force. 2 MANAGEMENT SKILLS He/she conducts an analysis of the health situation within his/her scope. He/she prepares operational plans based on his/her analysis. 57 No. Profile prepared by the Peruvian Medical Prioritized competency profile of the primary care level Standard No. 25 of CONEAU surgeon prepared by MINSA Association He/she organizes health-team work and the work with social actors of his/her scope. He/she directs health-team work. He/she assesses that the prepared plan is met. 3 ASSESSMENT AND INVESTIGATION SKILLS He/she prepares and reports the results of health investigation projects. He/she critically evaluates the results of investigations to improve his/her professional practice. 4 PROMOTION AND PREVENTION SKILLS He/she implements health-related training and advising activities prioritizing the more prevailing health problems. He/she conducts comprehensive clinical analysis on people with no symptoms to identify risk factors, early detection of health problems, and health certification, pursuant the regulations into force. Sources: MINSA, Peruvian Medical Association, CONEAU. Authors’ calculations, 2014. 58 Table 4A.2 Comparison of Competency Standards and CONEAU Standard for Nursing No. Prioritized competency profile of the primary care Profile prepared by the Peruvian Nursing Association Standard No. 25 of CONEAU level nurse prepared by MINSA 1 Providing immediate nursing care to full-term Assessing growth and development of newborns, children, The plan shall include: newborns in the delivery room, pursuant the and adolescents, pursuant the regulations into force  Discipline epistemology. regulations into force. • Assessing the bio-psycho-social status of newborns, children,  Care technologies. Providing nursing care to newborns in the joint or adolescents, detecting risks or harms, pursuant the  Adult and elderly nursing. sojourn, pursuant the regulations into force. regulations into force  Mental health nursing. • Planning nursing care for newborns, children, or adolescents,  Nursing in maternal and Assessing growth and development of children less pursuant the regulations into force than one-year old, pursuant the regulations into childcare. • Implementing and assessing plan-related actions, as well as  Nursing in child and force. early stimulation-related actions with newborns and children, adolescent care. Providing nursing care to children with acute pursuant the regulations into force respiratory infection, acute obstructive bronchitis  Women health care. • Educating and informing the mother or the person syndrome, and asthma, pursuant the regulations into  Family and community accompanying the newborn, child, or adolescent, based on the force. nursing. care plan and documenting this under the established format, Providing nursing care for children with acute  Nursing research. pursuant the regulations into force. diarrheal diagnosed, pursuant the regulations into  Nursing education. force.  Management of hospital Providing nursing care to children diagnosed with and community nursing anemia, pursuant the regulations into force. services. 2 Providing nursing care to people infected with Providing comprehensive care to healthy or sick people  Biological sciences. pulmonary TB under medical treatment, pursuant the considering life stages, applying guidelines and protocols  Microbiology and regulations into force. of care and the regulations into force parasitology. Providing nursing care to people with STD-HIV/AIDS, • Preparing the nursing care plan, based on prioritized needs or  Nutrition and diet therapy. pursuant the regulations into force. problems of healthy or sick people, considering protective  Pharmacology. factors, risk factors, and intercultural factors.  Anatomy. •Managing nursing care with the health tem, based in  Physiology. institutional regulations and quality indicators  Sociology. • Implementing and assessing the nursing care plan, based on  Anthropology. scientific evidence, guidelines, care protocols, institutional  Psychology. regulations, and quality indicators  Philosophy. 3 Developing specific prevention actions by life stages, Managing the national immunization strategy, pursuant the  Ethics. prioritizing children less than five-year old through regulations into force and quality indicators  Professional ethics. safe vaccination, pursuant the regulations into force. • Preparing the vaccination plan in its jurisdictional scope, pursuant the regulations into force •Administering the vaccine in accordance to the vaccination calendar into force and the regulations of the immunization national strategy and quality indicators •Assessing the health immunization strategy of the local scope applying quality indicators Sources: MINSA, Peruvian Nursing Association, CONEAU. Authors’ calculations, 2014. 59 Table 4A.3 Comparison of Competency Standards and CONEAU Standard for Midwifery No. Prioritized competency profile of the primary care Profile prepared by the Peruvian Midwifery Standard No. 25 of CONEAU level midwife prepared by MINSA Association 1 Providing monitoring prenatal care, pursuant the Taking care of the expectant mother and the child The curricula includes the following aspects: regulations into force. to be born, pursuant the regulations into force.  Human Anatomy.  Anthropology.  Bio-statistics. 2 Taking care of noncomplicated horizontal delivery, Conducting the labor and delivery process, in its  Cell and Molecular Biology. with appropriate intercultural attention, pursuant the different stages, with appropriate intercultural  Obstetric Minor Surgery and Instrumentation. regulations into force. attention, pursuant the regulations into force.  Health Education. 3 Taking care of women in the puerperal period within Taking care of women and partner and their  Embryology and Genetics. two and up to 24 hours after delivery, pursuant the demands and needs for birth control, pursuant the  Intercurrent Diseases in Midwifery. regulations into force. regulations into force.  Epidemiology. 4 Taking care of adolescents in sexual and Implementing community actions to address  Ethics and Professional Ethics. reproductive health–related issues, pursuant the sexual and reproductive health needs, pursuant  Pharmacology. regulations into force. the regulations into force.  Human Physiology. 5 Taking care of women using quarterly injectable Planning activities of sexual and reproductive  Physiopathology. hormonal contraception, pursuant the regulations health organizations and services, pursuant the  Health Management. into force. regulations into force.  Gynecology. 6 Taking care of women for prevention and detection  Histology. of cervical and breast cancer, pursuant the  Clinical Laboratory. regulations into force.  Legal Medicine.  Microbiology and Parasitology.  Neonatology.  Nutrition and Dietetics.  Midwifery.  Integrative Midwifery.  Community Midwifery.  Pediatrics and Childcare.  Comprehensive Preparation for Labor and Delivery.  Development Psychology.  Chemistry, Biochemistry.  Public Health.  Sexual and Reproductive Health.  General and Obstetric Semiology.  Clinical Midwifery/Obstetric Care Techniques.  Obstetric Therapeutics. Sources: MINSA, Peruvian Midwifery Association, and CONEAU. Authors’ calculations, 2014. 60 ANNEX 5: HUMAN RESOURCES IN HEALTH G AP IN THE PUBLIC SECTOR (2013) Table 5A.1 Estimate of the Human Resource in Health Gap in Public Sector Establishments (MINSA and Regional Governments), 2013 Region Needs assessment Availability Gap (Need - Availability) Phys. Nurse Midw. Dent. Nutr. Psych. Tech. Phys. Nurse Midw. Dent. Nutr. Psych. Tech. Phys. Nurse Midw. Dent. Nutr. Psych. Tech. 279 314 127 114 44 79 117 157 210 204 40 2 14 29 122 104 -77 74 42 65 88 ANCASH 726 812 301 269 67 187 218 233 313 259 51 5 5 1 493 499 42 218 62 182 217 APURIMAC 291 109 123 109 28 77 91 256 544 270 124 21 37 28 35 -435 -147 -15 7 40 63 AREQUIPA 742 826 308 264 65 182 206 420 551 373 140 28 37 61 322 275 -65 124 37 145 145 AYACUCHO 451 501 186 162 36 113 128 225 596 360 97 1 24 73 226 -95 -174 65 35 89 55 CAJAMARCA 860 949 357 316 80 221 257 388 738 466 67 8 16 54 472 211 -109 249 72 205 203 CUSCO 844 944 342 299 60 200 210 385 646 422 121 16 32 81 459 298 -80 178 44 168 129 HUANUCO 637 706 261 229 43 155 162 214 438 285 43 13 22 1 423 268 -24 186 30 133 161 HUANCAVELICA 357 397 149 133 33 90 109 273 454 329 97 14 41 34 84 -57 -180 36 19 49 75 ICA 367 412 148 130 26 87 87 205 180 106 73 12 20 8 162 232 42 57 14 67 79 JUNIN 779 871 319 276 53 186 195 323 614 373 78 3 13 3 456 257 -54 198 50 173 192 LA LIBERTAD 852 947 348 308 71 210 233 352 398 362 45 22 7 25 500 549 -14 263 49 203 208 LAMBAYEQUE 591 661 245 213 41 140 149 249 321 273 49 18 53 49 342 340 -28 164 23 87 100 LIMA REGION 491 551 203 179 47 125 143 334 292 236 96 23 26 1 157 259 -33 83 24 99 142 LORETO 642 711 263 226 49 155 172 174 225 221 56 0 8 20 468 486 42 170 49 147 152 MADRE DE 75 83 32 30 10 20 26 80 80 67 22 0 12 0 -5 3 -35 8 10 8 26 DIOS MOQUEGUA 104 116 43 38 8 24 28 85 130 76 40 11 22 3 19 -14 -33 -2 -3 2 25 PASCO 152 169 65 57 15 39 49 109 142 119 31 4 17 8 43 27 -54 26 11 22 41 PIURA 996 1,114 398 346 59 228 224 449 460 462 85 8 33 6 547 654 -64 261 51 195 218 PUNO 894 995 375 325 78 222 260 406 679 320 79 25 6 32 488 316 55 246 53 216 228 SAN MARTIN 393 449 163 154 53 116 135 205 212 260 43 2 15 2 188 237 -97 111 51 101 133 TACNA 213 238 88 77 16 51 55 126 201 138 43 8 16 8 87 37 -50 34 8 35 47 61 Region Needs assessment Availability Gap (Need - Availability) Phys. Nurse Midw. Dent. Nutr. Psych. Tech. Phys. Nurse Midw. Dent. Nutr. Psych. Tech. Phys. Nurse Midw. Dent. Nutr. Psych. Tech. TUMBES 106 119 42 37 7 25 25 90 82 65 18 5 9 2 16 37 -23 19 2 16 23 UCAYALI 307 343 126 110 24 72 79 106 166 135 29 6 11 16 201 177 -9 81 18 61 63 CALLAO 496 552 199 175 28 114 114 197 119 109 61 15 36 8 299 433 90 114 13 78 106 LIMA EAST 1,498 1,668 601 523 79 340 319 355 249 254 133 31 30 5 1,143 1,419 347 390 48 310 314 SIDE LIMA SOUTH 1,536 1,710 617 537 84 349 330 415 232 265 119 26 40 5 1,121 1,478 352 418 58 309 325 SIDE LIMA METRO 2,117 2,360 855 744 109 485 452 542 309 272 160 28 69 9 1,575 2,051 583 584 81 416 443 TOTAL 17,796 19,627 7,284 6,380 1,313 4,292 4,573 7,353 9,581 7,081 2,040 355 671 572 10,448 10,647 1,553 4,357 961 3,621 4,001 Sources: Ministry of Health and authors’ calculations, 2014. Note: The gap has been calculated as the difference between human resources need and availability, in which the difference results being negative (excess of job supply) has not considered the total sum, because it distorts the real gap calculation. This methodology is similar to the one applied by the Ministry of Health, when calculating the gap by Healthcare Center. 62 ANNEX 6: PROJECTIONS OF THE HUMAN RESOURCES IN HEALTH G AP IN THE PUBLIC SECTOR , 2013–50 Table 6A.1 Projection of the Human Resources in Health Gap in the Public Sector (MINSA and Regional Governments), 2013 –50 YEAR NEW ENTRANTS TO THE HEALTH PROFESSIONS WORKFORCE HEALTH HUMAN RESOURCE GAP Medical Medical Physician Nurse Midwife Dentist Nutritionist Psychologist Physician Nurse Midwife Dentist Nutritionist Psychologist Technologist Technologist 2013 10,448 1,553 961 3,621 4,001 2014 33 91 47 9,807 10,647 1,154 4,357 928 3,530 3,954 2015 641 995 399 124 20 79 38 9,170 9,652 819 4,233 908 3,451 3,916 2016 637 751 335 108 29 120 50 8,380 8,900 398 4,125 878 3,331 3,866 2017 790 942 421 115 31 116 54 7,544 7,958 -36 4,011 847 3,215 3,812 2018 836 1,006 434 112 31 116 54 6,707 6,953 -470 3,899 816 3,099 3,758 2019 836 1,006 434 112 31 116 54 5,871 5,947 -905 3,787 784 2,983 3,704 2020 836 1,006 434 112 31 116 54 5,035 4,942 -1,339 3,675 753 2,867 3,650 2021 836 1,006 434 112 31 116 54 4,198 3,936 -1,773 3,563 722 2,751 3,596 2022 836 1,006 434 112 31 116 54 3,362 2,930 -2,208 3,451 691 2,635 3,542 2023 836 1,006 434 112 31 116 54 2,525 1,925 -2,642 3,339 659 2,519 3,488 2024 836 1,006 434 112 31 116 54 1,689 919 -3,076 3,228 628 2,403 3,434 2025 836 1,006 434 112 31 116 54 853 -86 - -3,511 3,116 597 2,287 3,380 2026 836 1,006 434 112 31 116 54 16 1,092 - -3,945 3,004 565 2,171 3,326 2027 836 1,006 434 112 31 116 54 -820 2,098 - -4,379 2,892 534 2,055 3,272 2028 836 1,006 434 112 31 116 54 -1,657 3,103 - -4,814 2,780 503 1,939 3,218 2029 836 1,006 434 112 31 116 54 -2,493 4,109 - -5,248 2,668 471 1,823 3,164 2030 836 1,006 434 112 31 116 54 -3,329 5,114 - -5,682 2,556 440 1,707 3,110 2031 836 1,006 434 112 31 116 54 -4,166 6,120 - -6,117 2,444 409 1,591 3,056 2032 836 1,006 434 112 31 116 54 -5,002 7,126 - -6,551 2,333 377 1,475 3,002 2033 836 1,006 434 112 31 116 54 -5,839 8,131 - -6,985 2,221 346 1,359 2,948 2034 836 1,006 434 112 31 116 54 -6,675 9,137 - -7,420 2,109 315 1,243 2,894 2035 836 1,006 434 112 31 116 54 -7,511 10,142 - -7,854 1,997 284 1,127 2,840 2036 836 1,006 434 112 31 116 54 -8,348 11,148 - -8,288 1,885 252 1,011 2,786 2037 836 1,006 434 112 31 116 54 -9,184 12,154 - -8,723 1,773 221 895 2,732 2038 836 1,006 434 112 31 116 54 -10,021 13,159 - -9,157 1,661 190 779 2,678 2039 836 1,006 434 112 31 116 54 -10,857 14,165 - -9,591 1,549 158 663 2,624 2040 836 1,006 434 112 31 116 54 -11,693 15,170 - -10,026 1,438 127 547 2,570 2041 836 1,006 434 112 31 116 54 -12,530 16,176 - -10,460 1,326 96 431 2,516 2042 836 1,006 434 112 31 116 54 -13,366 17,182 - -10,894 1,214 64 315 2,462 2043 836 1,006 434 112 31 116 54 -14,203 18,187 - -11,329 1,102 33 199 2,408 2044 836 1,006 434 112 31 116 54 -15,039 19,193 - -11,763 990 2 83 2,354 2045 836 1,006 434 112 31 116 54 -15,875 20,198 - -12,197 878 -30 -33 2,300 836 1,006 434 112 21,204 766 63 YEAR NEW ENTRANTS TO THE HEALTH PROFESSIONS WORKFORCE HEALTH HUMAN RESOURCE GAP Medical Medical Physician Nurse Midwife Dentist Nutritionist Psychologist Physician Nurse Midwife Dentist Nutritionist Psychologist Technologist Technologist 2046 31 116 54 -16,712 - -12,632 -61 -149 2,246 2047 836 1,006 434 112 31 116 54 -17,548 22,210 - -13,066 655 -92 -265 2,192 2048 836 1,006 434 112 31 116 54 -18,385 23,215 - -13,501 543 -124 -381 2,138 2049 836 1,006 434 112 31 116 54 -19,221 24,221 - -13,935 431 -155 -497 2,084 2050 836 1,006 434 112 31 116 54 -20,057 25,226 - -14,369 319 -186 -613 2,030 836 1,006 434 112 26,232 207 Year gap closes at present absorption rate Year gap closes at 50 percent higher absorption rate Year gap closes at 100 percent higher absorption rate 64 ANNEX 7: CONAREME STANDARD NO. 25 Table7A.1 Minimum Training Standards For Priority Medical Specialists, as Prepared by CONAREME Profile ANESTHESIOLOGY FAMILY MEDICINE AND GENERAL GYNECOLOGY INTERNAL PEDIATRICS (summary) COMMUNITY HEALTH SURGERY AND MEDICINE OBSTETRICS HEALTH CARE (1) Diagnosing the health (1) Developing health (1) Solving (1) Conducting (1) Knowledge, (1) Knowledge, status of patients who will promotion and protection medical and healthy women skills, and skills, and be subject of surgical activities; activities for surgical controls; as well competencies competencies on diagnosis procedures, preventing medical-surgical problems with as diagnosing and on pathology prevention, care, treatment, and prognosis. and mental health diseases high mortality treating gyneco- diagnosis, care, and (2) Preparing equipment of a higher prevalence in the rates due to its obstetric management, comprehensive and medicines that will be country. prevalence pathologies. Thus, and treatment management of used during anesthetic (2) Promoting nutrition: rates. using clinical and related to adult child's health act, for all types of prioritizing children, (2) Conducting updated diagnosis health care surgery. expecting mothers, and elective and assistance (3) Preventing, elderly. emergency procedures. diagnosing, and providing (3) Providing comprehensive abdomen and appropriate solutions for care considering that most digestive tract all anesthesia-related relevant diseases surgery, and complications that may determining factors need to optionally the arise. be modified by actions with a more frequent (4) Taking care of the bio-psycho-social approach emergencies in patient for as long as targeting the individual, other specialties. necessary in the family, community, and immediate postsurgery environment. stage. (4) Diagnosing and treating (5) Assuring patient the patient and his/her family discharge from the with acute and chronic Recovery Unit, under the diseases, of a higher minimum safety prevalence in different life standards according to stages, in areas of medicine, the scales used in such surgery, gynecology- unit. obstetrics, pediatrics, and (6) Directing the CPR psychiatry (mental health). team. 65 Profile ANESTHESIOLOGY FAMILY MEDICINE AND GENERAL GYNECOLOGY INTERNAL PEDIATRICS (summary) COMMUNITY HEALTH SURGERY AND MEDICINE OBSTETRICS SOCIAL (1) Planning, (1) Permanently promoting (1) Participating (1) Participating in (1) Participating (1) Participating PROJECTION implementing, and programming, executing and in several stages reproductive in the several in the several assessing health actions assessing as a team health of child health health promotion stages of child stages of child at the community level. promotion actions targeting promotion and maintenance, promotion health promotion (2) Participating or the individual, family, programs, at a including those programs at a programs at a organizing health community, and the local, regional, related to ethics local, regional, local, regional, campaigns at the environment, working with and national policies and legal or national level. and national community level. the organized community level. (2) regulations into (2) Participating level. (2) and its health agents. (2) Participating or force. (2) in the design, Participating or Developing intersectoral and organizing Developing organization, organizing health interinstitutional actions to specialty-related reproductive and execution of campaigns control health risks, health disorder health contributing to promoting healthy campaigns. prevention, campaigns reducing child environments and practices. including contributing to mortality. (3) Coordinating health mammary adult mortality actions with local pathology and reduction. organizations of civil society. interrelated (4) Participating in diseases. emergency situation and disaster solutions, coordinating with the local committee of civil defense. 66 This report aims to provide an updated analysis of labor market trends for the health workforce in Peru, focusing on the basic health team —physician, nurse, and midwife—and other health professionals related to current priorities. Peru has been labeled as a country with a shortage of health professionals (that is, with less than 25 professionals per 10,000 inhabitants), and although the most recent numbers indicate that the situation has improved, the shortages are bound to become more acute as the country aims to achieve Universal Health Coverage. We found that the country trains both in public and private universities a large number of professionals, but that the majority of trained professionals do not then go on to work for the public sector. This dynamic had not been described before and challenges current assumptions of human resources needs and availability. There is very little reliable data on numbers, type and work conditions for human resources working outside the public sector, including the social security insurance health system (EsSalud), other health insurance providers, and the private sector, and as a result no detailed information can be obtained about the distribution of health professionals outside the public sector. For policy purposes, it is necessary to improve the quality and integration of HRH information across the sector. ABOUT THIS SERIES: This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual author/s whose name appears on the paper. Enquiries about the series and submissions should be made directly to the Editor Martin Lutalo (mlutalo@ worldbank.org) or HNP Advisory Service (healthpop@worldbank.org, tel 202 473-2256). For more information, see also www.worldbank.org/hnppublications. 1818 H Street, NW Washington, DC USA 20433 Telephone: 202 473 1000 Facsimile: 202 477 6391 Internet: www.worldbank.org E-mail: feedback@worldbank.org