2013年-世界发展银行全球_Improving_Access_to_Health_Care_Services_through_the_Expansion_of_Coverage_Program___The_Case_of_Guatemala_42页_1mb

Summary of the Document: Improving Access to Health Care Services through the Expansion of Coverage Program (PEC) in Guatemala

Core Content

The document presents a case study on the Expansion of Coverage Program (PEC) in Guatemala, part of the World Bank's Universal Health Coverage Studies Series (UNICO Study Series). It examines the PEC's role in expanding health and nutrition services to poor, rural, and indigenous populations, analyzing its institutional arrangements, financial mechanisms, service delivery processes, and the challenges it has faced.

The PEC was established in 1997 by the Ministry of Public Health and Social Assistance (MOH) with government support, aiming to improve access to health care in underserved areas. The program has expanded significantly over the years, covering 20 of Guatemala's 22 departments and 206 of its 334 municipalities, reaching 4.3 million people by 2012. The MOH estimates that the PEC serves 54% of the rural population.

Main Objectives

• To improve access to health and nutrition services in poor, rural, and indigenous communities.
• To strengthen the primary health care (PHC) system through alternative service delivery models.
• To provide a basic package of services through mobile health teams and NGOs.

Key Policies and Implementation

1. Institutional Arrangements

• The PEC is coordinated by the Integrated Health Care System Directorate (SIAS) at the central level.
• At the local level, the Health Area Directorate monitors and supervises PEC providers based on 28 indicators.
• The PEC operates through contracting with NGOs, particularly for service provision and health services administration.
• NGOs are responsible for managing mobile health teams and coordinating with public health facilities.

2. Service Delivery and Coverage

• PEC services are classified as primary care, with more complex cases referred to secondary or tertiary level facilities.
• The basic health team includes a doctor or nurse, community facilitator, traditional birth attendants, and health and nutrition educators in some areas.
• The Community Center is a key institution in each jurisdiction, with a target population of 500 to 2,000 people.

3. Accreditation Process for NGOs

• NGOs must go through a two-stage accreditation process:
  • Preselection: Involves calls for proposals, form submission, and committee formation and training.
  • Selection: Includes bid opening, qualification, and awarding based on technical and financial criteria.
• The final approval is given by the Integrated Health Care System (SIAS) at the central level.

4. Financing and Budget Trends

• The PEC is highly dependent on government funding, with only 15% coming from external sources.
• The annual budget has fluctuated over the years, as shown in Table 5.
• The budget and actual funds released show a decline from 2008 to 2011, due to political and fiscal constraints.
• Figure 2 shows the estimated population covered by the PEC, increasing from 0.46 million in 1997 to 4.3 million in 2012.

5. Performance and Challenges

• The PEC has been credited with improving access and strengthening PHC through:
  • Introduction of planning and monitoring tools.
  • Administrative efficiency improvements.
  • Use of alternative personnel (e.g., auxiliary nurses, community volunteers) to address staffing shortages.
• Despite its contributions, the PEC has been affected by political and economic factors, with support fluctuating based on government priorities.
• The MOH has limited resources and capacity to oversee, monitor, and evaluate the program, leading to limited evidence on its long-term impact.
• Chronic underfinancing and variable political support have constrained the program's ability to expand and maintain quality.

Key Information

1. Health System Overview

• The Guatemalan health system includes both public and private providers.
• The MOH covers 71% of the population, while the IGSS covers 18%.
• Out-of-pocket payments account for 54% of total health expenditures in 2010, which is higher than the LAC regional average of 72%.
• Public health expenditure as a share of GDP is 2.6% in 2010, among the lowest in the region.

2. Program Evolution

• The PEC started with three departments and expanded to 20 departments and 206 municipalities.
• It has been successful in expanding coverage, especially in rural and indigenous areas.
• The program has also adapted its service package over time, including new services and target adjustments.

3. NGO Role and Contracting

• The PEC uses NGOs to provide services in remote areas where public infrastructure is lacking.
• Two types of contracts were initially used:
  • Service provision.
  • Health services administration.
• After 2010, the second type of contract was no longer used due to administrative and financial issues.

4. Current Status and Future Needs

• The PEC is highly dependent on political support and fiscal capacity.
• The program has limited capacity for monitoring and evaluation.
• Sustained and significant expansion will require more government resources and commitment.
• A phased, costed strategy and action plan for improving access and quality is essential for future success.

Conclusion

The PEC has played a critical role in improving health access in Guatemala, particularly in rural and indigenous communities. However, its sustainability and effectiveness are limited by political and financial constraints. The program has contributed to the strengthening of primary health care, but further improvements require greater government investment, institutional capacity, and consistent political support. The UNICO Study Series aims to support UHC implementation by providing operational tools and insights from the PEC experience.