Seminar in Peru: Health Policies and Systems Research

The CRONICAS Center of Excellence in Chronic Diseases is sharing knowledge, building capacity and mutual understanding of health Policy and Systems Research.

Given the growing emphasis on health systems research and the role of health policy in the health of populations, the Peruvian team of COHESION, CRONICAS recently held a seminar on the topic.

Here is an overview of what took place and what the main and most important messages were:

On July 03 2017, the Institute of National Health (INS) and CRONICAS Center of Excellence in Chronic Diseases with the support of The Alliance for Health Policy and System Research- WHO, held the seminar “Health Policies and Systems Research” at the headquarters of the INS.  The objective was to show and discuss a new area of research that can be used for the implementation of policies.

Dr. Hans Vasquez from the “General office of Research and Technology Transfer” opened the seminar and stressed the importance of moving forward from diagnostic research to doing research that can have a bigger impact on health. In countries like Peru there is little research on policies, health systems or implementation.

The first presentation was provided by Nhan Tran, manager of “The Alliance for Health Policy and Systems Research (AHPSR)”. He said that the current challenge is to ensure health interventions are effectively integrated into health systems and are designed to be scaled up in different contexts. He pointed out that one of the reasons why implementation is so difficult is because implementation is about change (asking organizations to behave differently, people to do things differently, etc.). That is why it is important to think implementation as a process of change. Finally, he emphasized three main important shifts on how to do implementation: 1) applying a more systems perspective, 2) thinking about research as part of the implementation research, and 3) having local investment in implementation.

(Left to right Dr. Hhan Tran and Dr. Hans Vásquez; picture from INS

The next two presentations were from representatives of the public sector, Dr. Manuel Catacora Villasante from the “Institute of assessment in technologies in Health and Research” of the Social Security; and Bio Gisely Hijar Guerra from the “National Center of Public Health-INS”. They talked about the prioritized research subjects of their institutions, gave some examples of research being developed and pointed out some opportunities of funding.

The fourth presentation was given by Dr. Ludovic Reveiz from the Pan American Organization, where he explained how there is still too little information on how to do implementation research in policies. He showed the work the program iPIER is developing in Latin America and the Caribbean, which aims to facilitate improvements in program implementation through implementation research. An important part of this program is a workshop where the grant recipients receive a basic understanding of the research methodologies in implementation research.

The fifth presentation was from Dr. Fernando Llanos of the Universidad Peruana Cayetano Heredia. He talked about his research in health systems at primary care and universal coverage. He explained some conceptual frameworks, the methodology of the study and some final conclusions. He highlighted two important conclusions; first that before thinking in primary health care, there should be a clear definition of what is considered primary health care in Peru, and second, that talking about universal coverage meant to think of the system as a whole, because in the Peruvian context there are several subsystems.

Mg. Gerardo Seminario of “Salud sin Limites” gave the final presentation where he spoke about the process of making an agenda for public policies for the health of indigenous populations in Peru. He pointed out that a policy agenda is not necessarily a rational decision but derives from other factors like power roles, negotiations, institutional frames, etc. The making of an agenda consists on the concurrence of 4 factors: a problem, a possible solution, stakeholders and a window of opportunity. He concluded that the policies for the health of indigenous populations is still fragile, because the response for intercultural health is accepted but only on the surface, because the network of experts is not consolidated, because politicians change frequently as do their interests, because the vertical structure of the health system does not facilitate an intercultural health, and because the window of opportunities is narrowing.

(Picture from INS

At the end of the seminar there were two panel discussions. One, about the priorities of research policies and health systems, included the participation of Dr. Maria del Carmen Calle Dávila (General Directorate of Strategic Interventions in Public Health) and Dr. Hans Vasquez (INS). The second panel was about funding opportunities for research in policies and health systems, and included Dr. Franco Romani (INS) and Dr. Alexander Tarev (General Directorate of Strategic Interventions in Public Health). The discussions brought to our attention the efforts of the public sector to do research, and though these efforts are few and recent, the road is being build. There is still the need that the research community meets the demands of the public sector. In that sense it is necessary that the public sector opens more opportunities where policy makers and researchers can encounter each other.

This seminar was a good opportunity for the dialog between the research community, policy makers and civil organizations. For the COHESION team, it was a good moment for engagement and to gain an update of the research being done in in health policies and systems.

CRONICAS and Health Systems Research:

At CRONICAS Center of Excellence in Chronic Diseases there have been past and ongoing research projects related to the assessment of health systems. Through 2012-2013 the project “Barriers” financed by the AHPSR, piloted for the first time in Peru a research implementation manual for the evaluation of healthcare systems’ responses to chronic non-communicable diseases. Currently the COHESION project has as objective to improving the health system response for attending the double burden of Noncommunicable and Neglected Tropical Diseases. Initiatives like these are in the path to look for solutions for the current health issues the health systems face.

Additional information:

COHESION team meets in Nepal

Two members of the Swiss COHESION team (Sarah Lachat and Jorge Correia) traveled to Nepal
recently where they worked for 15 days with the local COHESION team (Nilambar Jha,
Suman Sing and Sanjib Sharma) at the B.P. Koirala Institute for Health Science.
The aim of the visit was to support the planning and implementation of the three
elements of the COHESION research project (policy analysis, health system assessment, community
perception study). In addition to working session at the BP Koirala, the selected sites of intervention
Itahari (urban) and Banyani (rural) were visited, including a visit of the two related Primary
Health Care centers and meetings with the local stakeholders (VCD committee members, staff from
the PHC centers, etc.). The current management of NCDs and leprosy was discussed, as well as perceptions regarding both types of diseases and related needs.
Another major aim of the visit was to perform a situational analysis of the management of patients affected by leprosy in Nepal, with a focus on therapeutic patient education, led by Dr.
Correia. This study was conducted in three sites, selected due to the number of leprosy patients that attend and the expertise of the institutions: B.P Koirala Institute of Health Sciences, Lalgadh Leprosy
Hospital and Services Center and the Anandaban Leprosy Hospital. More than 20 interviews were conducted with patients, caregivers, expert patients, health workers and program managers. Educational sessions were also observed.
Preliminary results show how stigma and social exclusion remain vivid, a source of distress for those who suffer from the disease. Many beliefs regarding the illness remain prevalent, still viewed by many patients as a curse or divine punishment despite the numerous education campaigns aimed at improving the understanding of the disease. Furthermore, treatment of leprosy and its reactions were discussed in-depth, and most importantly, the capital role of self-care to prevent disability. Different models of existing therapeutic education programs were analyzed. These were very well set up in the two specialized institutions visited, and limited in other health centers. Policy interviews with  program managers from three main NGOs involved in leprosy management were conducted jointly by the Swiss and Nepalese COHESION team members.
Before leaving the country, the joint team also paid a visit to the office of the Swiss Cooperation
Agency (SDC) and built a promising partnership with local officers. A brief policy interview on NCD
management was also performed with the WHO focal point of national Health Sector in Kathmandu.
A lot was done in little time. The main success was undeniably the opportunity to work together!

Swiss team goes to Mozambique

The COHESION team meets in Mozambique. Three members of the Swiss team (Dr. David Beran, Dr. Claire Somerville and Mrs. Sarah Lachat) join the Mozambique team this week at Eduardo Mondlane University.

Policy Analysis and gender are at the top of the agenda, but the team will not miss the opportunity to advance the community and health system assessments and reporting.

The team is grateful to be able to profit from face to face time in the country.

Community Health Perceptions Study in Peru

The Community Health Perceptions Study is one of the baseline studies of the COHESION project. It consists of a community mapping, focus groups and in-depth interviews with the aim to understand the community’s perceptions on healthcare services, health problems, (especially those related to diabetes, hypertension, and neurocysticercosis), as well as the implications of NCDs and NTDs at the individual, family and community level.

The community mapping in Peru was conducted in November 2016 in rural and peri-urban communities located in Northern Peru, namely: Ayabaca, Montero, Pingola and Sicacate. The fieldwork team was composed of one representative of CRONICAS Center of Excellence in Chronic Diseases (Silvana Pérez León) and a member of its local partner Centro de Salud Global of Universidad Peruana Cayetano Heredia (Fernando Urizar). They visited the selected communities and identified relevant actors to engage with in future COHESION activities.

This first visit helped to gain an overall understanding of the communities as well as to plan the data collection process, which took place earlier this year (February 1-21). Data were collected by two teams comprised of a man and  woman with social sciences degrees. They were joined by Nathaly Aya Pastrana, the COHESION PhD student from Università della Svizzera italiana in Lugano Switzerland. Nathaly participated in interviewing patients, caregivers and community leaders, as well as conducting focus groups with community members.

Data collection during the rainy season was challenging as the heavy rains made it difficult to access remote areas and to recruit participants for the focus groups. Intense rainfalls and floods continued until April 2017, creating public health concerns in the region, such as the spread of infectious diseases like dengue (Ministerio de Salud del Perú 2017). Fieldworkers (Gabriela Rengifo Briceño and Jorge Tuanama Álvarez) shared the following testimony of their fieldwork experience in the area:

“The dispersion of the population and the rains represented a challenge, but we learned that these are everyday conditions that people must solve when going to work, going to the health post for a checkup or for an emergency. Some are critical of the health service but it is the nearest alternative. Besides, going to other providers is expensive in time and money. Therefore, it was difficult to talk about health without offering in exchange attention, medicines or information.”

Ms. Aya Pastrana collected additional data through 1) interviews with representatives of communication channels, 2) recorded radio programs, 3) collected samples of printed communication material from local primary health care centers, and 4) documented observations of her field experience. The findings will provide additional insights to design interventions at the community level.

Preliminary analyses of the Community Health Perceptions Study show differences in the awareness about chronic conditions. People seem more aware of hypertension, with little knowledge of diabetes and neurocysticercosis. (see COHESION Newsletter Vol.1 Ed. 1)


Ministerio de Salud del Perú (2017)  Aprueban “Lineamientos Para El Manejo Del Dengue En Zonas de Desastres Perú 2017.”, accessed July 20, 2017.

Interview with patient for the Community Health Perceptions Study, Sicacate, Northern Peru.

Focus groups with old women for the Community Health Perceptions Study. Pingola, Northern Peru.


Recruiting participants for the Community Health Perceptions Study. Montero, Northern Peru.


Recruiting participants for the Community Health Perceptions Study. Montero, Northern Peru.


Preliminary results from Household Survey in Nepal

Preliminary findings of the household survey in Nepal show that a total of 6245 people lived in 1209 households with an average family size of 5.17 ±2.02. Females were lesser in proportion (48.8%) than males and most of the people were living in nuclear families (64%). About one fourth of them were illiterate. The main source of drinking water was tube well among majority (97%) of the households and most of the households (68.2%) used firewood as a source of fuel for cooking. A quarter of households still practiced open field defecation. More than three fourth of them (78.1%) living below the poverty line.

About 66% of the households consulted a health care institution for health problems in the past one year. Among those who had visited PHC (41.4%) for consultation, 93.8% reported of having received information about their health problems; however 20.6% of them did not get sufficient time to ask for clarification. Although 47% of them were referred to other health institutions, almost half of them rated the service of PHC to be good. Most of them (70.5%) could reach the PHC by walking and about 29% of them were not accompanied by anybody during the visit to the PHC.

Among the health problems reported, there were two cases of leprosy, more than 8% were diabetes and about 9% were hypertension.


Apart from health workers such as doctors, nurses, health assistants and auxiliary health workers, and female community health volunteer, people also seek advice regarding health problems from their friends (10.6%), relatives (23%), neighbor (7.1%) and traditional healers (12%). None of the people had any form of health insurance.



Household Survey in Nepal

For the first time, in the rural area, Baniyani VDC, Jhapa district, South-western Nepal, a major household survey on several health issues was conducted by the Nepalese COHESION team during the last week of November 2016. The aim of the survey was to collect baseline information needed to assess the level of NCDs and NTD prevalence and related health care in one of the two selected site for COHESION intervention in Nepal.

The Household survey was conducted in the framework of the Interdisciplinary “Community Diagnosis Program” organized by School of Public Health and Community Medicine which comprises of two weeks of residential posting in rural setting for 1st Year MBBS, BDS and B.Sc. Nursing students. More than 200 students took part to the survey, supervised by 30 postgraduates and teachers, to collect data of more than 1200 households.

The questionnaires used are an innovative mixture of closed and open-ended questions concerning the socio-demographic profile of the community, reported health problems, health seeking behaviour and access to health facility and services at PHC level from a consumer perspective.

An orientation program was first organized at the B. P. Koirala Institute of Health Sciences (BPKIHS) to deliver lectures for the students on the different methods to be used. A meeting with local authorities including VDC heads, health worker, leaders, school teachers, Female Community Health Volunteers and others was also organized the week before field work, to inform the community of Baniyani VDC about the program and its aim.

The total of 201 medical graduate and nursing students under the supervision of 26 supervisors, including MD/MPH/MSc. nursing students were grouped in nine groups in accordance with the total number of wards of Baniyani VDC and performed house to house visits during 7 full days and collected more than 1200 households using semi-structured questionnaires regarding the above mentioned issues.

All households of the VDC were visited. The local communities were very cooperative in general. However, some resisted for the interview which could be due to mistrust towards health institutions or business. Others could not be assessed because of locked houses, probably due to the harvesting season or migration for work. Some members of household questioned about benefits of the survey: the fact that we were holding a health camp in parallel (day program of on the spot consultations offered by the MDs/faculties from B. P. Koirala Institute) helped a lot in this regard. At the end of the data collection exercise preliminary findings were shared with the community representatives, which also fostered mobilization of the villagers.

A challenge of the survey was to visit the place of study from the place of residence with such a huge group of students. We had to travel for more than an hour by bus. We all were very busy during the data collection with regard to visiting different households by walking. In every evening, attendance of students and briefing of status of data collection was organized.

In general, this survey was a success. Not only data were collected, but because all students had the opportunity to gain a lot of valuable experience.