USAID/Peru/Health Policy. Contract No. GHS-I December 15, 2013

Transcripción

1 Report on and assessment of the human resources management system, including activities undertaken to strengthen the system and recommendations for use in other regions USAID/Peru/Health Policy Contract No. December 15, 2013 Prepared for: Armando Cotrina, COR USAID/Peru Health Office Av. Encalada s/n Lima - Peru Submitted by: Abt Associates Inc Montgomery Avenue Suite 800 North Bethesda, MD 20814

2 This document has been drafted by the USAID PERU Health Policy Project, financed by the United States Agency for International Development (USAID) under contract #GHS-I The author s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States government.

3 Table of Contents Acronyms... iv Executive Summary... vi Introduction Legal and conceptual framework for the development of Human Resources Management System in health institutions SERVIR and Civil Service Reform Background of the civil service in Peru[2] The Civil Service Law Ministry of Health: Proposal on Human Resources Management System for Health Institutions HHR policy and strategic planning Work organization Employment management Performance management Development and training management Compensation management Managing human and social relations Assessment of the Human Resources Management System Performance Evaluation of the Entire HRMS in Health Institutions Tools and methodologies to assess HRMS implementation Human Resources Management System in SMT-RHD Human Resources Management System in other regions HHR Policy and Strategic Planning: Progress Results of the assessment in San Martin Regional Health Directorate Results of the assessment in other regions Work Organization: Progress Results of the assessment in San Martin Regional Health Directorate Results of the assessment in other regions Employment Management: Progress Abt Associates Inc. Table of Contents pg. i

4 2.4.1 Results of the assessment in San Martin Regional Health Directorate Results of the assessment in other regions Performance Management: Progress Results of the assessment in San Martin Regional Health Directorate Results of the assessment in other regions Development and Training Management: Progress Results of the assessment in San Martin Regional Health Directorate Results of the assessment in other regions Compensation Management: Progress Results of the assessment in SMT-RHD Results of the assessment in other regions Managing Human and Labor Relations: Progress Results of the assessment in San Martin Regional Health Directorate Results of the assessment in other regions Activities undertaken to strengthen the HRMS in health institutions Activities undertaken to estimate staffing needs Activities undertaken to define job profiles Activities undertaken to define managerial competencies Activities undertaken to design salary scales Activities undertaken to develop competencies at micronetwork level Activities undertaken to assess management performance Performance evaluation method Performance evaluation implementation Competencies evaluation definition and criteria Analysis of results obtained in the evaluation of goals attained and competencies Activities undertaken to improve recruit and selection processes Conclusions Recommendations to implement the HRMS at regional level References Abt Associates Inc. Table of Contents pg. ii

5 7. Annex Questionnaire to assess the implementation of the HRMS in health institutions Qualitative assessment of HRMS conducted by PARSALUD II in 4 Regions SMT-RHD: HHR regional policies National agenda for research in HHR ASEGURA software for HHR requirements calculations Using the spreadsheet to facilitate calculations Survey to determine the available working time in the first-level-of-care Detailed table of "available working time" for health facilities Available working time to provide PEAS in first-level-of-care health facilities Ministry of health: General competencies for the health sector CONEAU: Managerial competencies for health professionals Human resources management competencies Transversal managerial competencies Abt Associates Inc. Table of Contents pg. iii

6 Acronyms AETA CAFAE CAS CAP CDC CGP CLAS CONEAU CTS DGGDRH DIRESA DL HP HR HHR HRMS ILO JNE LMEP MAPRO MOF MoF MoH PAHO PAP PARSALUD II PCM PDP PEAS PLAME RG Asignación Extraordinaria por Trabajo Asistencial / Extraordinary Assignment for Health Care Work Comité de Administración del Fondo de Asistencia y Estímulo / Management Committees for the Stimulus and Assistance Fund Contrato administrativo de servicios / Administrative services contract Cuadro de asignación de personal / Staffing Table Competencies Development Centers Civil service managers Comités Locales de Administración de Salud / Health Administration Local Committees Consejo de evaluación, acreditación y certificación de la calidad de la educación superior universitaria / Council for the Quality of Professional Education Compensación por Tiempo de Servicios / Compensation for time of service Department of Human Resources Development Management Dirección Regional de Salud / Region Health Directorate Legislative Decree Health Policy Human resources Health human resources Human Resources Management System International Labour Organization National Jury of Elections Ley marco del empleo público / Framework law for public employment Manual de procesos / Procedures Manual Manual of Organizations and Functions Ministry of Finance Ministry of Health Pan American Health Organization Presupuesto analítico de personal / Staff budget Programa de Apoyo a la Reforma del Sector Salud / Program for Health Reform Support Presidency of the Council of Ministers Personal Development Plan Plan esencial de aseguramiento universal / Essential package Planilla mensual de pagos / Monthly payroll Regional governments Abt Associates Inc. Acronyms pg. iv

7 RHD RIT RNSDD ROF SERUMS SERVIR SMT-RHD TA UE UHI UNDP USAID WHO WISN Regional health directorate Reglamento interno de trabajo / Internal rules Registro Nacional de Sanciones de Destitución y Despido / National Registry of Sanctions and Dismissals Regulation of Organization and Functions Servicio Rural y Urbano Marginal en Salud / Civil Health Service in Rural and Marginal Urban Areas National Civil Service Authority San Martin Regional Health Directorate Technical Assistance Unidades ejecutoras de presupuesto / Budget spending units Universal health insurance United Nations Development Programme United States Agency for International Development World Health Organization Workload Indicators of Staffing Need Abt Associates Inc. Acronyms pg. v

8 Executive Summary In June 2008, the National Civil Service Authority (SERVIR) was created as the leading agency in managing the Human Resources Management System for public institutions. Complementarily, the Ministry of Health defined a basic structure for this system to be implemented in health institutions. This structure contains seven components or sub-systems with 29 processes. Based on this structure, the Health Policy (HP) project designed a tool to assess the level of implementation for all 29 processes at the regional level. This assessment instrument was applied to Cajamarca and San Martin regional health directorates, and as results collected by the Program to Support Health Reform (PARSALUD II) in 4 additional regions. Evidence from these six regions confirms that human resource offices only perform administrative activities related to monitoring staff attendance; recruiting, selection and hiring; managing payrolls; and relations with unions. Almost no progress was seen in the performance evaluation and planning components, while some modest progress was observed in processes related to organization of work; capacity development; and management of human and social relations. The few processes that are developing display technical shortcomings. The challenge is to make these offices move away from personnel administration towards a more comprehensive human resource management approach. The poor performance of human resource offices is mainly due to the fact that these offices are staffed with non-professional personnel who are not trained in human resource management. Additionally, offices are not able to take on new responsibilities under the regulatory framework of the human resources management system. Another difficulty related to the management of human resources is the variety of personnel policies, many of which are duplicates of or are in conflict with other policies. This confusion over policies prevents processes from being carried out according to norms; causes frequent staff turnover; contributes to a lack of clarity in team member roles and the lack of a responsible part for managing processes; engenders the existence of various remunerative norms that provoke dissatisfaction and inequity; and impedes the creation of reliable human resources information to formulate sound decisions. Additionally, not all processes are managed by a single organizational unit. A key factor in this situation is that the health authorities do not give much importance to human resource management. In some cases, authorities have designated untrained employees as heads of human resources offices. In another case, authorities have hired a lawyer to manage the office to have a legal advisor to manage institutional relationships with unions. For the health sector, the lack of a proper human resource planning process generates that specific human resource needs to meet the population s health needs are unknown. The lack of job profiles favours selection processes that are based on subjective criteria rather than the needs of the position. Recruitment and selection processes are carried out without taking into account key regulatory aspects such as adequate dissemination for competitive recruitment; and objective assessment of the candidates. The lack of objective performance assessments based on job profiles generates that staff do not know if what they are doing is right. Lack of performance incentives generates a lack of motivation. The lack of a fair and equitable salary scale not only generates dissatisfaction but also results in a shortage of human resources where they are needed most. To tackle these problems, USAID has contributed to the design and validation of tools aimed at the implementation of key processes for managing health human resources. The tools designed include the following: Methodology and tools to define human resource requirements at the first level of care. Methodology and tools for the design of job profiles. Abt Associates Inc. Executive Summary pg. vi

9 Methodology for the design of labor competencies and performance standards. Methodology and tools for designing salary scales for staff recruitment at the first level of care. Methodology and tools for competency development for health personnel responsible for the growth and development of children under five years through the implementation of competency development centers at the first level of care. Methodology and flowcharts for recruitment, selection and hiring processes based on job profiles. Methodology and tools for evaluating the performance of health network managers. Implementing these tools at the regional level depends fundamentally on whether regional authorities understand the link between improvement in health indicators and the performance of health human resources. Improving organizational performance depends on how many human resources are required for the achievement of regional health goals and the individual performance of each health worker. To improve individual performance, it is necessary to define what is expected of each health worker; measure the performance gap; implement incentive mechanisms for good performance or capacity building programs; and establish an appropriate working environment. This report presents detailed information about the results of the human resources management system assessment as well as an explanation of the tools that were designed and implemented to strengthen the system. Abt Associates Inc. Executive Summary pg. vii

10 Introduction The enactment of Legislative Decree (DL) 1023 in June 2008 created the National Civil Service Authority (Autoridad Nacional del Servicio Civil - SERVIR) as the governing body of the Human Resources Management System (HRMS). The Presidency of the Council of Ministers (Presidencia del Consejo de Ministros PCM) confers SERVIR with the legal power and national authority to improve public administration by strengthening the civil service at national scope. The HRMS provides, develops and implements government policies related to the civil service, including the rules, principles, resources, methods, procedures and techniques used by all public sector entities in the management of human resources (HR). The HRMS is composed of: a) SERVIR, which formulates civil service national policy, governs the system and resolves disputes. b) State-level human resources offices, or those acting in their place, which are responsible for implementing the rules, principles, methods, procedures and techniques of the system as part of the decentralization process. According to DL 1023, the system comprises the following processes: Planning of HR policies Work organization Employment management Performance management Compensation management Development management and training Managing relationships Resolution of disputes In addition, Article Six of Law No [1], the Civil Service Law passed in July 2013, establishes the following functions for the HR office in public institutions: a) Executes and implements arrangements, guidelines and management tools provided by SERVIR and the respective public institution. b) Develops guidelines and policies for the development of the personnel management plan and the optimal functioning of the HRMS, including the application of indicators. c) Supervises, develops and implements continuous improvement initiatives in the processes that comprise the HRMS. d) Conducts research as well as quantitative and qualitative analysis of staff provision, according to institutional needs. e) Manages job profiles. f) Manages and updates, in the scope of its competence, the National Registry of Civil Service Personnel (Registro Nacional de Personas del Servicio Civil) and the National Registry of Dismissal and Sanctions (Registro Nacional de Sanciones de Destitución y Despido RNSDD). g) Other functions that are established through regulations by the governing body of the system. Abt Associates Inc. Introduction pg. 1

11 Through this framework, the Ministry of Health (MoH) proposes a scheme to support health institutions in the implementation of a system for health human resources (HHR). This report presents the current operating status of the HRMS in six regional health directorates; activities that have been developed to strengthen HRMS implementation in health institutions; and recommendations to improve implementation and replicate successes in other regions. Abt Associates Inc. Introduction pg. 2

12 1. Legal and conceptual framework for the development of Human Resources Management System in health institutions This chapter delineates the legal framework governing HRMS implementation in public institutions and the HRMS structure, which was designed by the MoH for health institutions nationwide. 1.1 SERVIR and Civil Service Reform Background of the civil service in Peru[2] The civil service in Peru has been characterized as very complex with large deficits in planning and organization capacity. Most especially, however, the civil service has been criticized for lacking a clear authority to conduct the processes required to satisfy workers needs and improve performance. Most of the obstacles toward achieving a just and equitable civil service are related to the coexistence of different working regimes, distortions in remunerative schemes, temporary contracts, the lack of a governing body, and most especially the lack of a national civil service policy. There have been various reform processes over the past 20 years, including the following: a) In 1990, the reform process was characterized by downsizing and the redefinition of the state s role in HR issues. The following initiatives illustrate this process: reducing staff through incentives to resign; closing entry into the civil service; creating a private activity labor regime (DL 728); contracting "non-personnel services" to prevent the entry of permanent staff; hiring senior officials from UNDP and the Management Support Fund; and creating alternative mechanisms to increase worker incomes such as the Management Committees for the Stimulus and Assistance Fund (Comités de Administración del Fondo de Asistencia y Estímulo - CAFAE). b) In 1995, the reform process concentrated on modernizing the state and encouraging the flexibility of administrative systems. However, the process lacked political support, and progress was limited to the enactment of the following laws: Law of State Procurements (Ley de Contrataciones del Estado); Diplomatic Service Law; and the law that prohibits recruitment and employment in case of kinship. c) In 2000, the reform process sought to overcome citizens distrust of public institutions through the creation of spaces for dialogue. A new process of decentralization was initiated in 2002, and the Framework Law for Public Employment (Ley Marco del Empleo Público - LMEP) was enacted in d) In 2008, the current civil service reform process started. At the outset, there were 500 civil service regulations, more than 102 salary scales in 82 public institutions, over 400 rules to regulate payment of public employees, and more than 198 remunerative and nonremunerative types of payments. The Peruvian state employed approximately 1,300,000 public servants, and each year 42,000 new employees were being hired without a clear purpose or need. SERVIR was created at this time 1 as the administrative governing body for HRM and responsible for civil service development. Several of the laws related to civil service reform[2] are shown in the following table: 1 DL 1023 Abt Associates Inc. Legal and conceptual framework for HRMS pg. 3

13 Table 1: Problems that are trying to be solved by new civil service laws. Problem Proposal Law Lack of governing body in HRM Creation and implementation of SERVIR DL 1023 Lack of formal recruitment for highly qualified professionals Lack of a performance assessment system Lack of training programs and policies Limitations in rationalizing staff especially in regions and municipalities SOURCE: SERVIR Creation and regulation of the Public Managers Corps Permanent evaluation: To train underperforming workers To recognize and reward efficient workers To have qualified staff Approval of training procedures and a training fund Establishment of a special regime that allows local and regional governments to implement comprehensive modernization processes DL 1024 DLDL 1025 DL 1025 DL 1026 These regulations have been integrated into one law, which will regulate incorporation, retention, promotion and termination of civil servants The Civil Service Law After several attempts to improve civil service in Perú, Law No [1], the Civil Service Law, was enacted on July 4, 2013 to establish a unique regime for individuals who are employed by the government and are responsible for its management, the exercise of its authority, and the provision of services. According to the rule, the guiding principles of the civil service according to the law are: general interest; effectiveness and efficiency; equal opportunity; merit; budgetary provision; legal and regulatory expertise; transparency; management accountability; probity and public ethics; flexibility; and protection against the arbitrary end of the civil service. Civil servants in public entities will be classified by the following groups when the law is implemented: a) Public Official: Political representative or political office representative who exercises government functions in state organizations. Directs a unit and approves policies and standards. Public officials are classified as: Public official from a direct and universal election (president, vice president, congressmen, regional councilors, mayors, aldermen) Public official whose designation and removal is regulated (ombudsman; comptroller general of the republic; public prosecutor; chairman of the supreme court; president of the National Jury of Elections (JNE); and rectors and vice rectors of public universities, among others) Public official whose designation and removal is based on trust (ministers; vice ministers; general manager of regional government; and municipal manager). They must have higher education or experience and meet the job profile requirements. b) Public Directors: Civil servant who runs a body, program or special project. Admission is by open competition based on merit and fulfillment of the respective job profile. Public directors can remain in their position for three years renewable up to two terms depending Abt Associates Inc. Legal and conceptual framework for HRMS pg. 4

14 on the fulfillment of annual goals. Their performance evaluations are based on compliance with goals. Only 20% of public directors can have the status of trusted servants 2. c) Career civil servant: Civil servant with functions directly related to compliance of key substantive functions. This is a unique and integrated system, which does not include officers; public officials; trusted officials; or complementary activities civil servants. These positions are not filled on a temporary basis. Hiring is done by open or public competition based on merit, fulfilling the respective job profile. d) Complementary activities civil servant: Civil servant with functions indirectly related to compliance of key substantive functions. Hiring is done by open competition based on merit, fulfilling the respective job profile. They can be hired through a contract for an indefinite period or a fixed-term contract. This law also reaffirms the organization of the civil service through the Administrative System of Human Resource Management, which includes SERVIR, the HR offices of public institutions and the Civil Service Tribunal. HR offices or those serving in their stead are responsible for the HRM and have the following functions: a) Implements HR management guidelines provided by SERVIR and its unit. b) Designs guidelines and policies for the development of a people management plan and the optimal functioning of the HRMS, including the application of indicators. c) Supervises, develops and implements continuous improvement initiatives in the HRMS. d) Analyzes quantitative and qualitative staffing according to institutional needs. e) Manages job profiles. f) Maintains the National Registry of Civil Service Personnel and the National Registry of Sanctions and Dismissals (RNSDD). Major criticisms of the law originate from the workers union, which believes: 1. The law creates a new labor regime in the state. 2. The law did not collect the opinions of workers, who are directly involved. 3. The law restricts union rights and eliminates collective negotiation as well as the right to strike and join a union. 4. Assessments would bring mass dismissals of workers, affecting labor stability. 5. It is unknown whether civil service salaries will be better. 6. The ability to relax the rules facilitates dismissal. 7. The law eliminates special assignments and subsidies. Since passage of the law, the workers union has organized strikes and mobilizations against implementation of the law, arguing that the "There is a great fear that the law can generate massive layoffs, but we have repeatedly clarified that this reform cannot be compared with that made in the nineties. Nancy Laos, Minister of Labor, July 31st, The law defines "trusted servant" (cargo de confianza) as a civil servant who is part of the direct and immediate environment of public officials or public directors, and whose tenure in the civil service is subject to the confidence of the person who supervises him. The number of trusted servants in no one case should be greater than 5% of total posts provided by the institution, with a minimum of two and a maximum of 50, with the head of the unit determining the location of trusted servants. Abt Associates Inc. Legal and conceptual framework for HRMS pg. 5

15 law eliminates work stability. The Minister of Labor has appeased labor unions by proposing a series of "locks" to ensure stability required for state workers. Encouragingly, a survey conducted between June 7-8, 2013[3] by a renowned polling company produced the following results: 84% of the population agrees with meritocracy as the core of the reform, and 88% supported annual evaluations of public servants. 74% approve the termination of personnel who has received negative performance evaluations for two consecutive years. 36% have heard of this reform. Among this group, 56% approve of it. Support increases to 78% after the components of the reform are fully explained. According to the law, the new labor regime is meritocratic: hiring is carried out by publicized, competitive examination, and job retention and promotion are secured through evaluations. Perhaps the greatest error in rollout of the law was the lack of discussion to explain the scope of the new law. Regarding collective negotiation, the law states the following: Collective rights of civil servants are specified in Convention 151 of the International Labour Organization (ILO) and the Constitution of Peru. The law also stipulates that the right to strike is exercised after the failure of any mechanisms for negotiation, and if workers decide to use this right, they must give 15 days of advance notice to allow time for hiring temporary staff to ensure the provision of minimum services. The law does not explicitly mention dismissal as a result of evaluations. The law says that a worker who receives a negative review, specifically "performance under observation", should be trained; if the result of a second evaluation is again "performance under observation", the rating will become unsatisfactory. However, the law does not state what will happen with employees who receive disapproving. There is currently no information on the contents of the law s regulations. Meanwhile, union protests continue. 1.2 Ministry of Health: Proposal on Human Resources Management System for Health Institutions Under the legal framework established by SERVIR and according to the Civil Service Law, public institutions must implement their HRMS. To facilitate its implementation, the MoH has developed a proposal for the structure of HRMS which defines subsystems, processes and functions. The expected results of HRMS implementation in health institutions are: a) Adequate health workers properly situated and properly performing their duties. b) Attract and retain competent staff. The following inputs are necessary to implement HRMS in health institutions: a) Health policies and strategies to align staff performance. b) Models of health care, management and health services organization to define competency profiles, HR allocation, and HR compensation, among others. c) Health service portfolios to define individual goals. d) Civil Service Law as a legal framework for HRMS implementation. Abt Associates Inc. Legal and conceptual framework for HRMS pg. 6

16 e) Regulation of organization and functions (ROF) to define job profiles, recruitment, assessment, etc. The following graph displays this structure: Graphic 1: HRMS in health institutions: MoH proposed structure. I. HHR Policy and Strategic Planning HR needs, Strategies to cover HR gap Health Policy Strategies Healthcare Model Management Model Organizational Model Healthservice portfolio Civil,Service Law ROF II. Work Organization Job profiles Identification of labor competencies Job Rating III. Employment Management Recruitment, selection, incorporation and induction Staff mobidity Disciplinary process Staff retirement and retirement IV. Performance Management Performance planning Supervision Performance evaluation Feedback Plans for Individual performance improvement VI. Development Management Career progression Capacity building Teaching &Service Regulation V. Compensation Management Salary scales Payroll Benefits, bonuses, pensions Incentives Having adequate workers, placed in appropriate places, doing well what they have to do. Attract and retain competent staff VII. Managing human and social relationships Organizational Climate and Culture; Labor relation; Workplace health, safety and welfare. The following subsections explain the operational definitions of each process within the HRMS for health institutions HHR policy and strategic planning This subsystem is primarily responsible for HRM alignment to national and regional policies; national health strategies; and the comprehensive care model. It also enables coordination among all HRM processes to ensure suitable and competent workers where they are needed. The processes involved in this subsystem are: HHR policies and strategies. This process consists of developing HRM policies and strategies that will attract and retain competent staff. Operational research development. It is necessary to have evidence in order to define policies and strategies for HR management and development that are relevant and cost-effective. This process seeks to promote research studies focused on factors that will attract and retain competent staff as well as research to support HR policy design. HHR information management. To ensure proper management, it is necessary to have reliable and update-to-date HHR information at both the institutional and sectoral levels. HR observatories are an excellent mechanism to maintain HHR quantitative information, and information system records or specific databases, including staff competencies, performance evaluations, and incentives, complement quantitative information. All information must be updated to allow informed HRM decisions. HHR management control. This process is aimed at supporting health managers at different levels, as well as those responsible for other subsystems, in monitoring HRM indicators, Abt Associates Inc. Legal and conceptual framework for HRMS pg. 7

17 analyzing results and defining necessary corrective measures. It also includes annual evaluations of HRMS processes and manager performance. HHR strategic planning. This process includes all actions related to quantitative and qualitative HHR requirements and needs at all levels in the short, medium and long term at both institutional and sectoral levels. This process also addresses necessary actions to fill the HHR gap. HHR planning should be closely linked and coordinated with national and regional health policies; institutional strategies; and health provision approaches (e.g. the family health care model). Challenges to the planning process include high internal and external migration of health workers as well as high staff turnover. HHR financing. This process includes the necessary actions to ensure a sufficient budget to provide adequate HHR for proper health facility operation Work organization This subsystem exists to optimize HHR working capacity by specifying the content of functions, activities and tasks, as well as the staff qualifications to achieve them. The main goal of this subsystem is to establish a set of policies and standards regarding work specialization that forms the "job"; the job profile includes a work description, including objectives, relationships, roles, responsibilities and working conditions; and the position requirements, including educational background, experience and competencies. As an additional part of the job profile, competency profiles articulate staff abilities in regard to institutional objectives, goals and organizational culture. The processes involved in this subsystem are: Job profile design. Based on the "general functions" established in the institutional ROF, each organizational unit designs its positions and the specific functions of each position. The functions of each position are outlined in the Manual of Organization and Functions (MOF). Based on the MOF, each unit defines its "job profile", which has two major components: Job description: Defines the characteristics of the job, including the job title; location within the organization; relationships with other positions, including supervisory, managerial, and collaborative roles; purpose; functions to be performed; and working conditions (e.g physical such as equipment; normative, as the regulatory framework to be used) for good job performance. Job analysis: This refers to the characteristics of ideal job candidate in relation to the job requirements. This section establishes required academic training, experience, knowledge and skills. Identification of labor competencies. This process identifies specific and general competencies for each position. Job rating. This process analyzes and compares the contents of jobs to define their relative importance within the organization; place them in hierarchical order as the basis of the remuneration system; and aid in the development of career plans within health institutions. Job design alone is not enough to trigger HRM processes and it is also necessary to rank and value jobs in relation to their importance within the organization. The position must be assessed and not the person who occupies it. Abt Associates Inc. Legal and conceptual framework for HRMS pg. 8

18 1.2.3 Employment management Employment management seeks to establish a set of policies and standards to optimize inflows, movement and exit of staff in health care organizations. These policies and standards should be based on job profiles and competencies established by the employer and should foster the achievement of sectoral health objectives. The processes involved in this subsystem are: Recruitment. This process allows health care organizations, based on HHR needs identified in the planning process, to attract candidates to participate in selection processes. The recruitment process uses internal (within the organization) or external sources. Selection. In this process, the institution examines whether candidates meet the job requirements, which are described in the job profile, and then selects the candidate who has the necessary skills for successful performance. This process also involves the formation of selection committees and defines the criteria, standards, procedures and tools for evaluating candidates in the selection process. Incorporation. This process formalizes the entry of the selected candidate into health organizations and establishes the characteristics, conditions, restrictions and penalties related to employment. This process includes compliance with standards for each of the modalities of incorporation (stable or contracted) and the definition of the duties and rights of HHR. Induction. This is a general orientation process prior to the start of work activity. This process provides basic information about the institution, including norms, policies and organizational characteristics; explains the nature of the position; and indicates requisite functions and roles. In addition, the new employee receives relevant information to help achieve satisfactory performance. Staff mobility. This process defines workplace assignment changes that HHR can perform both inside and outside health institutions. These changes balance the needs identified in the target unit and the availability of the worker (in the origin institutional source) as well as the worker's own need, under current regulations. The regulation defines the types of workplace assignment change, displacement criteria, and administrative procedures to be followed for each type of mobility. Management of personnel files, control of attendance. This process consists of conservation, renovation, veracity and legality of the documents maintained by institution staff, as well as compliance with rules for the submission of affidavits. It also includes the management and control of the working day, permissions, holidays, leave, etc. Administration of disciplinary process. In this process, the institution determines the level of staff responsibility in certain administrative acts, including compliance with disciplinary procedures in accordance with applicable regulations; the classification of fault; the design of internal rules (reglamento interno de trabajo - RIT); and the registration and updating of the RNSDD. Staff termination and retirement. In this process, the institution regulates the term of employment between staff and the institution. In compliance with labor rights and under current regulations, disengagement may be voluntary or involuntary. There are currently several forms of disengagement: resignation, removal, dismissal, and termination, among others. This process includes the enforcement of laws on the causes for dismissal; termination of employment procedures and requirements; and standards and criteria for the termination of employment. Abt Associates Inc. Legal and conceptual framework for HRMS pg. 9

19 1.2.4 Performance management The performance management subsystem aligns the strategy of the institution with the individual objectives of HHR to continuously improve staff performance and hence institutional performance. Performance evaluation is part of performance management, which allows each member of the institution to know at all times specific employee expectations in terms of quantitative and qualitative attributes for a given period. The aim of the evaluation is to establish strategies for solving performance problems motivate employees and encourage personal development. The performance management subsystem defines and measures competency standards and performance targets to be achieved by health personnel in order to promote and maintain the highest possible level of performance based on recognition of merit, ability and equal opportunities. Performance management is mainly aimed at establishing a set of policies and rules regarding standards of competence and performance goals of health workers.achievement of these goals is linked to various incentive and personal development mechanisms, which promote continuous improvement processes in HHR and, consequently, in health institutions. The processes involved in this subsystem are: Performance planning. This consists of defining competencies, standards and individual performance goals to be achieved in line with institutional priorities, strategies and objectives. This process also includes the definition of the methodology for performance evaluation as well as the design of the necessary assessment tools for an objective measurement of staff competence and compliance with established performance goals. Supervision. This consists of continuous and systematic support to health workers to improve their performance based on the observation that immediate supervisors do to promote continuous improvement of skills. This process is also driven by leaders. Performance evaluation. This consists of an objective and transparent measurement of health staff skills and institutional goals obtained during a defined time period and following a predefined methodology. Results should be compared to competency standards and goals established in the performance planning process. Feedback and design of plans for individual performance improvement. In this process, plans are designed for individual performance improvement based on results from the performance evaluation. Leaders define performance objectives for each employee in the following year Development and training management The development and training management subsystem defines practices to encourage professional and job development opportunities by providing learning opportunities as well as career path planning within the organization. The processes involved in this subsystem are: Labor advancement (promotion and career path). This process is responsible for the policies and procedures governing HHR promotion and occupational group change within an institution. It also manages the assumption of duties and responsibilities of greater difficulty or complexity in comparison to the previous level. The labor process includes both horizontal progression, which is a progression in degree, category, or step that can be established without shifting the workplace or occupational group to which the worker belongs; and vertical progression, which is promotion within the structure of the organization to a higher level. Abt Associates Inc. Legal and conceptual framework for HRMS pg. 10

20 Capacity building. This process is responsible for providing tools and resources to facilitate individual and collective learning and further develop staff labor competencies. The term "labor competency" refers to the knowledge and skills demonstrated at work and reflect the worker's contribution to the objectives of the organization. Regulation of the teaching - service process. This process involves a set of actions needed to articulate HHR training and education activities within health services. The teaching and service provision relationship refers to the simultaneous occurrence of health service provision and specialized educational opportunities for health personnel in health facilities. The dual nature of these training areas requires the regulation and enforcement of standards to ensure the quality of both health and education services Compensation management Compensation management relates to remuneration provided by the organization in return for work done. Compensation can take several different forms: pay or base salary, which is a fixed amount that is paid hourly or monthly; monetary and non-monetary incentives related to performance recognition; and benefits, which are established by law and serve as additional payments awarded by the institution. The processes involved in this subsystem are: Design of salary scales. This process defines salary scales based on job profile and job classification by levels. Management of payroll and salaries. This process manages compliance with the rules and procedures which establish and maintain fair and equitable salary structures in the organization. In this process, the organization defines the remunerative and non-remunerative compensation as well as electronic payroll management: monthly payroll (Planilla Mensual de Pagos - PLAME); registration of labor information (Registro de información laboral T Registro); and social benefits settlement, such as compensation for time of service (Compensación por Tiempo de Servicios - CTS), gratuities and bonuses. This process also involves the regular registration of income, both on the dependent category (fifth category) and the independent category (fourth category). Administration of benefits and bonuses. This process administers extra-pay benefits including holidays, life insurance, subsidized transportation, subsidized food and health insurance. Incentive management. This process enforces the rules and instruments that are established and applied by the institution to recognize worker achievements. This recognition has no permanent wage effects and can be monetary and non-monetary. Pension management. This process manages the recognition and granting of pensions; survival verification; and the application of legislation for pension payment Managing human and social relations This subsystem seeks to regulate and harmonize interactions between individuals, focusing on the collective dimension. It includes policies and practices related to organizational climate; labor relations; social welfare; and safety at work. This subsystem supports all of the subsystems mentioned above and guarantees conditions conducive to satisfactory productivity and performance. Abt Associates Inc. Legal and conceptual framework for HRMS pg. 11

21 The processes involved in this subsystem are: Management of the organizational climate and culture. This process is aimed at maintaining or improving the perception of collective satisfaction. Organizational climate is defined as the set of qualities, attributes or relatively permanent properties of a particular work environment, which are perceived, felt or experienced by workers who make up the organization. The organizational climate influences individual behavior. Management of labor relations. This process governs relations between the head of an organization and social partners, including unions and associations, which represent workers or group of workers. This process also involves collective negotiation of wages and working conditions to appropriately manage conflicts. Workplace health, safety and welfare. This process includes two groups of activities: Social welfare: This activity affects the quality of life of staff and their extended family and fosters a peaceful and enjoyable workplace experience. Social welfare programs include the promotion of sports activities; event celebrations; cafe or restaurant services; educational support; financial services; daycare; and care for elderly people, among others. Health and safety at work: This activity refers to a set of rules; procedures; and technical, educational, medical and psychological measures to protect employees physical and mental integrity. These measures prevent health risks inherent to job tasks and the physical working environment. This activity also seeks to diagnose and prevent occupational diseases based on the study of two variables: man and his work environment. Abt Associates Inc. Legal and conceptual framework for HRMS pg. 12

22 2. Assessment of the Human Resources Management System In 2012, the Program for Health Reform Support (Programa de Apoyo a la Reforma del Sector Salud PARSALUD II) led the development of a technical report entitled "Developing a Health Model for Decentralized Regional HRMS: Ayacucho, Cajamarca, Cusco, Huanuco and Ucayali and their Respective Action Plans"[4]. This document includes a diagnosis of HRMS performance at various levels of management, including the Regional Health Directorate (RHD), networks, micro-networks and hospitals. Both PARSALUD II and the project developed the HRMS diagnosis, which was based on the HRMS structure as defined by the MoH. To gather the information, PARSALUD II designed a survey for examining each of the subsystems defined by the MOH. The project reviewed PARSALUD II s survey and incorporated the latest developments in the HRMS structure. The project also worked with the MoH to expand the survey to examine all processes involved in the HRMS. In this chapter, the methodology developed by the project to gather information in San Martin Regional Health Directorate (SMT-RHD) will be presented. In addition, the results of the survey conducted in SMT-RHD for each of the HRMS processes will also be presented. Based on the PARSALUD II technical report, a comparative chart was compiled to display each subsystem s operations in regions where PARSALUD II works. Since the instruments used by PARSALUD II and the project are different, the results are not comparable. Given this, the project gathered information from Cajamarca using the instruments applied in San Martin to compare results obtained. This comparison is presented in a table showing the performance of HRMS in these two regions. 2.1 Performance Evaluation of the Entire HRMS in Health Institutions Tools and methodologies to assess HRMS implementation In order to gather the necessary information to determine the level of HRMS implementation, the project employed the following tools, which were developed by the USAID Peru Health Policy Project: a) A list of questions for each of the processes in each HRMS subsystem 3. The questionnaire consists of several closed questions whose answers are YES or NO. The following are several examples: 3 See the questionaire in Annex 7.1 Abt Associates Inc. Assessment of the Human Resources Management System pg. 13

23 1. Does your institution have human resources management and development policies? ( ) YES ( ) NO If the answer is yes, please answer the following questions. Otherwise, skip to the next section. 2. Are the human resources management and development approved? ( ) YES ( ) NO Do you have the specifics of at least 60% of job the profiles for the following levels written down? Question Level N 1 Regional Health Directorate 2 Network 3 Operational Office 4 Micro-network YES 60% of job profiles NO There are also open questions that allow qualitative information or more specific information, including the following examples: According to the current ROF, which governing bodies are involved in estimating human resource requirements and design staffing plans in your institution? Level RHD Network Micro-network Is involved? In case of participating YES NO Name of the responsible body Specific function In relation to the selection process conducted during the past year, provide the following information: Month # Days to publicize the vacancy Achieved Results of selection process Process with Invalid objections b) A spreadsheet to record the answers of every closed question. The spreadsheet immediately allows the aggregation of results into tables and graphs for easy analysis. Additionally, each question has been weighted according to its strategic importance in proper HRMS functioning. The project used the following ratings to analyze the results: High development: > 80% complete Moderate development: 40% - 80% complete Abt Associates Inc. Assessment of the Human Resources Management System pg. 14

24 Little Development: <40% complete The processes considered in the analysis were identified by the MoH as important to include. Table 2: Key processes for each HRMS subsystem in health institutions. Subsystem HHR policy and strategic planning Work organization Employment management Development and training management Performance management Compensation management Managing human and social relations Key Processes Policies and strategies for HHR management and development Development of operational research HHR information management HHR management control HHR strategic planning HHR financing Design of job profiles Identification of labor competencies Job rating Recruitment, selection, incorporation and induction Staff mobility Management of personnel files, control of attendance Administration of disciplinary process Staff termination and retirement Labor advancement (promotion and career path) Capacity building Regulation of the teaching-service process Performance planning Supervision Performance evaluation Feedback and design of plans for individual performance improvement Design of salary scales Management of payroll and salaries Administration of benefits and bonuses Incentive management Pension management Management of the organizational climate and culture Management of labor relations Workplace health, safety and welfare To gather information on the implementation of the HRMS in SMT-RHD, the director of the HR Management Directorate developed a workshop for responsible parties of HRM processes at different organizational levels. Working groups were formed to analyze each subsystem. The project made a conceptual presentation of the processes in each subsystem for each working group to facilitate understanding of survey questions Human Resources Management System in SMT-RHD The new organizational structure of SMT-RHD[5] has considered the functioning of two normative units, which must maintain close coordination, to lead HRMS implementation: Abt Associates Inc. Assessment of the Human Resources Management System pg. 15

25 Human Resource Management and Development Directorate (HRM Directorate) - This body executes exclusive regulatory functions in HHR management and is primarily responsible for the following subsystems: policy and planning; work organization; performance management; development and training management; and some processes related to compensation and labor relations management. Operations Directorate This body manages regulatory functions for all administrative systems, including personnel administration. It is primarily responsible for the job management subsystem and some processes of compensation and labor relations management. The implementing units of HRMS are: Health networks, which are responsible for implementing the processes regulated by the HRM Directorate. Operations Offices, which are responsible for implementing the processes regulated by the Operations Directorate. These inter-relationships are presented in the following graph: Graphic 2: Staff of the Human Resources Management and Development Directorate: Number of workers by labor regimen, San Martin REGIONALGENERAL MANAGEMENT Regional Office of Planning and Busget Regional Office of Administration Regional Office of Legal Consulting Persons Management Office Accounting and Treasury Office Logistics Office Estate Control Office Office of information Technology Regional Management of Social Development Regional Health Directorate Office of Sectoral Legal Consulting Office of Planning and Health Intelligence Regional Office of Regional Defense ad Disaster Risk Management HRMS Governing at regional level Responsible for HR development processes Responsible for personnel administration processes Operations Management - Health Directorate of Human Resource Development No Comprehensive Health Direction Department of Regulation and Control in Health Sector Operations Offices (05) Health Networks Management (10) Hospitals and Regional Services Administrative Management Unit Budget Management Unit Referential Hospital Tarapoto Referential Laboratory Blood Bank Normative Units Implementing Units SOURCE: SMT technical report Abt Associates Inc. Assessment of the Human Resources Management System pg. 16

26 The new ROF is currently under implementation so the region s units are not fully deploying their functions. As of July 2013, the HRM Directorate only has five employees, including four professionals and one technician; two of the professionals have permanent positions, while the other staff members were hired through an administrative services contract (Contrato Administrativo de Servicios CAS)[6]. The quantity and composition of staff members is insufficient to lead, regulate, monitor and control the implementation of HRM processes. Table 3: HRM Directorate staff: Number of workers by labor regimen, San Martin Occupational group Total 276 Regimen 728 Regimen CAS Full-time independ ent contracto r Professional Administrative Technician Administrative Assistant TOTAL SOURCE: SMT technical report Listed below are results from the diagnostic tools. Other Graphic 3: Results for each subsystem, San Martin San Martin: HRMS in Health Institutions Sub-System: Managing human and social relations Sub-System: Compensation Management Sub-System: HHR Policy and Strategic Planning 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Sub-System: Work Organization Sub-system: Employment Management Sub-System: Performance Management Sub-System: Development and Training Management SOURCE: SMT technical report[7] Abt Associates Inc. Assessment of the Human Resources Management System pg. 17

27 Table 4: Results for each subsystem, San Martin Human Resource Management System % complete Result Subsystem: HHR policy and strategic planning 65.0% Moderate development Subsystem: Work organization 32.0% Low development Subsystem: Employment management 37.5% Low development Subsystem: Development and training management 62.2% Moderate development Subsystem: Performance management 14.0% Low development Subsystem: Compensation management 57.7% Moderate development Subsystem: Managing human and social relations 64.3% Moderate development HUMAN RESOURCE MANAGEMENT SYSTEM 47.5% SOURCE: SMT technical report Moderate development Table 4 shows that SMT-RHD has, on average, achieved a 48% progress rate in HRMS implementation. The subsystems that are more developed include HHR policy and strategic planning; managing human and social relations; and development and training management. On the opposite end, the performance management subsystem is the least developed Human Resources Management System in other regions Graphic 4: Results for each subsystem, Cajamarca Cajamarca HRMS Sub-System: Managing human and social relations Sub-System: Compensation Management Sub-System: HHR Policy and Strategic Planning 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Sub-System: Work Organization Sub-system: Employment Management Sub-System: Performance Management Sub-System: Development and Training Management SOURCE: Cajamarca technical report Abt Associates Inc. Assessment of the Human Resources Management System pg. 18

28 Table 5: Results for each subsystem, Cajamarca Human Resources Management System % completed Result HHR policy and strategic planning 48.0% Moderate development Work organization 10.0% Little development Employment management 35.0% Little development Development and training management 29.6% Little development Performance management 1.8% Little development Compensation management 57.7% Moderate development Managing human and social relations 21.4% Little development Human Resources Management System 29.1% Little development SOURCE: Cajamarca technical report Table 5 shows that Cajamarca has not reached optimal levels for proper HRM. The weaker subsystems include performance management; work organization; and management of human relations. These weaknesses are concerning since these subsystems are integral to achieving the objectives, goals and outcomes of the health care model in the region. Regional management documents are outdated and are not aligned with the decentralization process, much less with the current care model. Given this situation, processes within the HR policy and strategic planning subsystem have not been developed. Comparative chart The project created a table of results obtained by PARSALUD II from Ucayali, Cusco, Ucayali, Cajamarca and Huánuco to compare RHD performance on HRMS implementation. Other results from Cajamarca and San Martin, which were obtained by applying diagnostic tools designed by the project, are also included to make additional comparisons. Analysis of some processes has not been considered in the PARSALUD II evaluation because the information is too qualitative. To elaborate this matrix, the project examined information from the PARSALUD II technical report 4 to compare the results and formulated the following conclusions: All PARSALUD II RHDs, with the exception of Ucayali which shows little development in all subsystems, show the same results in each of the subsystems. PARSALUD II survey does not cover all processes in its analysis. The project s survey explores in greater detail HRMS processes. Comparing Cajamarca results from both surveys, differences in application, analysis and results are apparent. By comparing San Martin and Cajamarca performance with the application of HP project survey, better results are apparent in San Martin in all the subsystems. 4 See the results of qualitative assessmemnt in PARSALUD regions in Annex 7.2 Abt Associates Inc. Assessment of the Human Resources Management System pg. 19

29 Table 6: Comparative table of HRMS level of implementation in six regions. N.c.= Not considered in PARSALUD II assessment; N.i.= No information HRMS HHR policy and strategic planning Policies and strategies for HHR management and development Development of operational research Ucayali * Cusco * Huanuco Cajamarc Ayacuc * a* ho * San Martín ** Cajamarca ** 65% Moderate 48% Modera te N.c. N.c. N.c. N.c. N.c. 73% Moderate 0% Little N.c. N.c. N.c. N.c. N.c. 0% Little 0% Little HHR information management Little Little Little Little Little 76% Moderate 90% High HHR management control HHR strategic planning HHR financing N.c. N.c. N.c. N.c. N.c. 0% Little 50% Moderat e Little Little Little Little Little 82% High 57% Moderat e N.c. N.c. N.c. N.c. N.c. 100 % High 86% High Work organization 32% Little 10% Little Design of job profiles Identification of labor competencies Little Little Moderate Moderate Moderate Moderat e Moderate Moderate Moderate Moderat e 38% Little 18% Little 38% Little 0% Little Job rating N.c. N.c. N.c. N.c. N.c. 10% Little 0% Little Employment management 37% Little 36% Little Recruitment, selection, incorporation and induction Little High High High High 38% Little 38% Little Staff mobility N.i. N.i. N.i. N.i. N.i. 0% Little 0% Little Management of staff files and attendance control Administration of disciplinary process Staff termination and retirement Development and training management Labor advancement (promotion and career path) N.c. N.c. N.c. N.c. N.c. 40% Moderate 25% Little N.c. N.c. N.c. N.c. N.c. 43% Moderate 43% Moderat e Little Little Little Little Little 0% Little 67% Moderat e Little Moderate Moderate Moderate Moderat e 60% Medium 30% Little 76% Moderate 19% Little Capacity building Little Little Little Little Little 58% Moderate 40% Little Regulation of the teaching & service process N.c. N.c. N.c. N.c. N.c. 35% Little 30% Little Performance management 14% Little 2% Little Performance planning Little Little Little Little Little 16% Little 12% Little Supervision Little Little Little Little Little 0% Little 0% Little Performance evaluation Little Little Little Little Little 22% Little 0% Little Feedback and design of plans for individual performance improvement N.c. N.c. N.c. N.c. N.c. 0% Little 0% Little Abt Associates Inc. Assessment of the Human Resources Management System pg. 20

30 HRMS Compensation management Design of salary scales Management of payroll and salaries Administration of benefits and bonuses Incentive management Pension management Managing human and social relations Workplace health, safety and welfare Management of labor relations Management of the organizational climate and culture HUMAN RESOURCES MANAGEMENT SYSTEM Ucayali * Cusco * Huanuco Cajamarc Ayacuc * a* ho * San Martín ** Cajamarca ** 61% Moderate 58% Modera te Little Little Little Little Little 63% Moderate 41% Moderat e Little Little Little Little Little Little Little Little Little Little 100 % 100 % High High 100 % 100 % High High Little Little Little Little Little 44% Moderate 56% Moderat e Little Little Little Little Little 100 % High 100 % High 70% Moderate 21% Little Little Little Little Little Little 63% Moderate 34% Little N.i. Moderate Moderate Moderate Moderat e 100 % High 22% Little Little Little Little Little Little 69% Moderate 29% Little 48% Moderate 29% Little SOURCE: (*) PARSALUD II technical report. (**) HP project assessment. Abt Associates Inc. Assessment of the Human Resources Management System pg. 21

31 2.2 HHR Policy and Strategic Planning: Progress Results of the assessment in San Martin Regional Health Directorate The following graph shows the results of five of the processes that are within this subsystem. On average, implementation of this subsystem is 65% completed, which indicates moderate development. It has been noted that some processes are not working, including development of operational research and HHR management control. According to what was reported, HHR financing is functioning adequately. Graphic 5: San Martin HHR policy and strategic planning: Results by key processes. San Martin: HHR Policy and Strategic Planning HHR Financing Policies and Strategies for HHR Management 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Development of operational research HHR Strategic Planning HHR information management HHR Management Control SOURCE: SMT technical report Abt Associates Inc. Assessment of HRMS pg. 22

32 Table 7: San Martin HHR policy and strategic planning: Results by key processes. KEY PROCESSES Expected result Obtained result % Complete Result Policies and strategies for HHR management and development % Moderate development Development of operational research 4 0 0% Little development HHR information management % Moderate development HHR management control % Little development HHR strategic planning % High development HHR financing % High development Average % Moderate development SOURCE: SMT technical report Below are key findings for each of the processes within this subsystem: Formulation of policies and strategies for management and HHR development This process shows 73% success, mainly due to the following developments: The HRM directorate is responsible for developing HR policies for the SMT region. In October 2008, SMT-RHD led the signing of a memorandum of commitment to all institutions in the regional health system approving a set of regional policies for HHR management and development. These policies are aimed at improving the performance of HR and working conditions to "have adequate health workers properly situated, properly performing their duties". Currently, these policies are not approved. 5 The USAID Peru Health Policy Project is working closely with the SMT-RHD management team to implement these policies. Progress and specific advances are presented in the following table: Table 8: San Martin human resources regional policies: Progress. Policy Progress Ongoing Policy 3. - HHR strategic planning based on actual needs to properly allocate HHR according to demographic, cultural and epidemiological profiles of the region, highlighting health priorities of excluded populations. Policy 6. - Implementation of a new regulatory framework based on labor competency profiles; compensation and incentive systems; recruitment and staffing processes; applying public career promotion; and considering rights, duties, gender equity and respect for diversity. Methodology to determine HR requirements and gaps for the first level of care. Determination of HR needs at micronetwork level for the short, medium and long term. Baseline assessment of HRMS functioning in SMT-RHD. Contributions to the MoH proposal of designing a decentralized management system in HHR in the context of SERVIR. Job profiles of RHD units. Job profiles of networks. Job profiles for first level of care. Strategies to fill the gaps. Institutional planning system for HHR. Recruitment and selection processes based on job profiles. Definition of non-monetary incentives. 5 See HHR regional policies in Annex 7.3 Abt Associates Inc. Assessment of HRMS pg. 23

33 Policy Progress Ongoing Policy 2. - Managing training processes linked to institutional development projects using the Continuing Education in Health (Educación Permanente en Salud EPS) and competencies approach to strengthen job performance, characterized by respect for rights, gender equity and cultural relevance of the population. SOURCE: SMT technical report Salary scale for staff employed in firstlevel-of-care facilities. Definition of RHD management competencies to assume functions transferred in the decentralization process. Definition of managerial competencies for networks. Proposal for job performance evaluation of network management teams based on job competencies. Implement a job performance evaluation system of network management teams based on individual goals and job competencies. Despite advances in the design and implementation of regional HR policies, problems that have been encountered in this process are outlined in the following table: Table 9: Constraints in the formulation of policies and strategies for HHR management and development. San Martin, Problem Constraints Consequences Proposal for improvement HR policies have not been approved. Designed policies have nothing explicitly related to health and safety at work. Changes in regional authorities slow the approval process. This aspect was not prioritized at the outset due to lack of information and awareness regarding its importance. Lack of a regulatory framework for HHR actions in RHD. Administrative sanctions for failure to comply. Review and update policies to bring into alignment with Civil Service Law. There are aspects of designed policies which are not yet implemented, including skills development; motivation and incentives; and workplace health, safety and welfare. Lack of a policy framework and competent teams to design policy implementation strategies. SOURCE: SMT technical report The Civil Service Law includes the following statement to describe one function of the HR office or corresponding body: "Develop guidelines and policies for the development of a personnel management plan and the optimal functioning of the HRM, including the application of performance indicators." Development of operational research Unfortunately, this process has not progressed, despite the existence of a national research agenda for HHR problems for , which was approved on March 18, 2011 by ministerial resolution. 6 Problems encountered during this process are included in the table below. 6 See the national agenda for HHR research in Annex 7.4 Abt Associates Inc. Assessment of HRMS pg. 24

34 Table 10: Constraints in the development of operational research. San Martin, Problem Constraints Consequences Proposal for improvement Neither HRH investigations nor a diagnostic assessment of the HRH situation in the region have been carried out. The lack of research and diagnostics is mainly due to the lack of a responsible party to promote this work. The diagnosis is not taken into account when making decisions. Authorities do not give due importance to this process. HRM directorate has little capacity for HRM: staff must assume multiple roles and cannot specialize in research issues. Due to the lack of research, there is no evidence to support the need for policies and strategies to improve HRM and staff performance. Based on HRMS diagnosis, identify research topics to be co-financed with the central level. SOURCE: SMT technical report HHR information management Progress in this process is 76%, which is deemed moderate development. According to current ROF, the HRM directorate is responsible for maintaining HR information. To accomplish this, the institution employs official reporting systems to record information on HR employment. Key informants report that they use the information from these systems to make decisions. The weaknesses identified in this process are included in the following table. Table 11: Constraints in HHR information management. San Martin, Problem Constraints Consequences Proposal for improvement Current information systems do not register non-remunerative items; staff attendance, tardiness and absences; public tenders; current allocation of each worker; or personnel files. They use MEF reporting applications (payroll system, SIGA), but this data is insufficient for decision making and comprehensive analysis. This is because the RHD does not define the type of information they need for relevant and timely decisions. Insufficient information is recorded to make decisions. By not knowing the allocation of workers, health networks are hiring staff where they are not needed. Operational units do not report to the RHD about public tenders they perform. Define HRM issues to monitor at all levels. Develop reporting systems; flow charts; and collation and analysis of required information. SOURCE: SMT technical report HHR management control No progress has been achieved in this process. According to the current ROF, there is no party responsible for this process although it is noted as an important function of HR offices in the Civil Service Law. Abt Associates Inc. Assessment of HRMS pg. 25

35 "Develop guidelines and policies for the development of people management plan and the optimal HRM functioning, including the application of performance indicators." The weaknesses identified in this process are included in the table below. Table 12: Constraints in HHR management control. San Martin, Problem Constraints Consequences Proposal for improvement A responsible party has not been defined to manage this key function, which is explicitly mentioned in the Civil Service Law. Indicators for HRM have not been defined. RHD does not perceive the need to monitor HRM indicators. Due importance is not given to this process. Insufficient staff to implement HRM processes, and current staff must execute multiple roles and cannot specialize. RHD and operational units do not measure progress in HRMS implementation in order to improve them. Form an ad hoc committee to define indicators and procedures for collecting, recording, measuring and periodically analyzing results. Strengthen capacities of the committee to monitor indicators. SOURCE: SMT technical report The HP project survey tool defines a set of HRM indicators that can be reviewed to establish a HRMS monitoring plan in SMT-RHD. PROPOSED INDICATORS OF HUMAN RESOURCE MANAGEMENT % of micro-networks that have HR needs estimation % of units that have job profiles 7 % of contracts signed after a meritocratic selection process % of vacancies that have been published on the website of the Ministry of Labor % of recruitment and selection processes that have been made based on job profiles % of training conducted on the basis of a performance gap % of workers who have agreed output targets % of workers who have been assessed by competencies % of workers who have been hired in remote areas, based on an attractive pay scale HHR strategic planning Progress in this process is 82%, which is deemed high development. This high level of achievement is based on the following actions: According to the current ROF, the HRM directorate is responsible for this process. Last year, the RHD made calculations of HHR requirements and needs at the first level of care. 7 The standard suggested to be fulfilled is at least 80%. Abt Associates Inc. Assessment of HRMS pg. 26

36 To estimate HHR needs, SMT-RHD considered population growth; an increase in functions; expected increase in production; effective demand projections; and health service use projections. To make accurate calculations, SMT-RHD used a spreadsheet prepared by the project and an application designed by the MoH. The MoH application includes the same criteria as the project spreadsheet. According to key informants, these results are used for hiring purposes to justify the need for an increased budget and request more Civil Health Service in Rural and Marginal Urban Areas (Servicio Rural y Urbano Marginal en Salud - SERUMS) positions. SMT-RHD has a staffing plan for the medium term. Unfortunately, recent staff turnover in the RHD management team has delayed the plan s revision by the new team. Additionally, the HRM directorate has insufficient staff to perform all assigned tasks. The weaknesses identified in this process are included in the table below. Table 13: Constraints in HHR strategic planning. San Martin, Problem Constraints Consequences Proposal for improvement In spite of having a party responsible for estimating HR needs and an application to calculate needs, there is no updated information on current staffing. The MoH has provided an application to facilitate accurate calculations. Micro-networks do not regularly report information on staff allocation and levels because they are not required to do so. Additionally, there is no mechanism to allow this information to flow from the bottom up, at least quarterly. HR gaps cannot be estimated due to unreliable information on current staffing. High risk of overstaffing or misallocation. Develop a staff information mechanism to periodically flow from the bottom up to identify needs; this mechanism could be included in the MOF that is being designed. SOURCE: SMT technical report According to the Civil Service Law, all HRM offices in the public sector must execute the following function: "Study and analyze the quantitative and qualitative staffing of public institutions according to institutional needs." HHR financing Progress in this process is 100%, which is deemed high development. This level of achievement is due to the following actions: There is a body responsible for managing this process. According to key informants, last year the SMT-RHD estimated HHR funding needs and generated calculations based on the number of unfilled positions of contracted staff under CAS mode; HR needs evaluation; implementing units requirements; and the historical budget. The SMT-RHD designed proposals to finance hospitals and SERUMS staff. Abt Associates Inc. Assessment of HRMS pg. 27

37 2.2.2 Results of the assessment in other regions The following table shows the consolidated results from the evaluation prepared by PARSALUD II. Table 14: HHR policy and strategic planning: Performance in four regions at different levels. Institution Ucayali Cusco Huánuco Ayacucho RHD No HRM plan, so HRM is reactive. HRM office activities are focused on a short-term administrative aspects instead of integrated HRM. Personnel files are incomplete. RHD has an HR management plan but has insufficient information. RHD has developed HHR gap analysis based on the MoH s Health Information System (HIS) but did not consider qualitative information. No HRM plan, so HRM is reactive. HRM office activities are focused on shortterm administrative aspects instead of integrated HR management. Personnel files are incomplete. No HRM plan, so HRM is reactive. HRM office activities are focused on short-term administrative aspects instead of integrated HRM. Personnel files are incomplete. HRM office activities are focused on shortterm administrative aspects instead of integrated HRM. Poor allocation of computing resources. No systematic updating of information in personnel files. Network No HRM plan, so HRM is reactive. No HRM plan, so HRM is reactive. No HRM plan, so HRM is reactive. No HRM plan, so HRM is reactive. HRM office activities are focused on short-term administrative aspects instead of integrated HR management. Personnel files are incomplete. Poor allocation of computing resources. No systematic updating of information in personnel files. HRM office activities are focused on shortterm administrative aspects instead of integrated HR management. Personnel files are incomplete. HRM office activities are focused on short-term administrative aspects instead of integrated HR management. Personnel files are incomplete. Micronetwork No HRM plan, so HRM is reactive. No HRM plan, so HRM is reactive. No HRM plan, so HRM is reactive. No HRM plan, so HRM is reactive. HRM office activities are focused on short-term administrative aspects instead of integrated HR management. Personnel files are incomplete. There is a notable shortage of HR in the HRM office. HRM office activities are focused on shortterm administrative aspects instead of integrated HR management. Personnel files are incomplete. HRM office activities are focused on short-term administrative aspects instead of integrated HR management. Personnel files are incomplete. Abt Associates Inc. Assessment of HRMS pg. 28

38 Institution Ucayali Cusco Huánuco Ayacucho Hospital Has an incomplete HRM plan. HRM office activities are focused on short-term administrative aspects instead of integrated HR management. Personnel files are incomplete. SOURCE: PARSALUD II technical report No HRM plan. Poor allocation of computing resources. No systematic updating of information in personnel files. No HRM plan, so HRM is reactive. HRM office activities are focused on shortterm administrative aspects instead of integrated HR management. Personnel files are incomplete. No HRM plan, so HRM is reactive. HRM office activities are focused on short-term administrative aspects instead of integrated HR management. Personnel files are incomplete. PARSALUD II qualitative information shows poor development in the HHR policy and planning subsystem, especially in the capacity to determine HHR requirements and manage HHR information. Regarding Cajamarca RHD, the project will present the results of the assessment using HP project methodology and instruments. Graphic 6: Cajamarca HHR policy and strategic planning: Results by key processes. Cajamarca: HHR Policy and Strategic Planning HHR Financing Policies and Strategies for HHR Management and Development 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Development of operational research HHR Strategic Planning HHR information management HHR Management Control SOURCE: PARSALUD II technical report Abt Associates Inc. Assessment of HRMS pg. 29

39 Table 15: Cajamarca HHR policy and strategic planning: Results by key processes. KEY PROCESSES Expected result Obtained result % Complete Result Policies and strategies for HHR management and development % Little development Development of operational research 4 0 0% Little development HHR information management % High development HHR management control % Moderate development HHR strategic planning % Moderate development HHR financing % High development Average % Moderate development SOURCE: Cajamarca technical report The table below presents the findings for each of the processes in this ssubsystem. Table 16: Constraints in HHR policy and strategic planning. Cajamarca, Key Process Problem Constraint Consequences Policies and strategies for HHR management and development Development of operational research HHR information management HHR management control HHR strategic planning Lack of HRM policies and strategies. Operational research is conducted in an isolated manner with little monitoring of RHD. Cajamarca has a matrix that identifies the allocation of health personnel in each service. Absent or weak HRM control. Lack of HHR strategic planning. Some authorities do not know the scope of HR planning while others show a lack of interest. In addition, the MoH does not provide TA to help regions develop HRM. There is no research unit in the Cajamarca RHD to promote and monitor the development of research. There is a responsible party in each health network to monitor the availability of staff in health facilities. HR offices in health networks have little support from RHD and do not have access to training. These offices do not exercise their authority in HRM. Recently, some HHR plans are being implemented. Cajamarca RHD has Personnel disorganized. Lack of interest and institutional commitment to the objectives. Lack of research hinders progress of health sector development in Cajamarca. The availability of information about the location of HR facilitates the identification of HHR gaps. Staff do not fulfill their duties and are sometimes absent or unavailable. Unavailability of appropriate staff in the right place. Proposal for improvement Formulate a comprehensive proposal for HRM with TA from the MoH. Create a research unit with competent staff. Specify in detail some aspects of the actual and current location of staff, as well as the temporary movement to other facilities. HR offices must exercise greater control, authority and respect for the rules of HHR control. Implementation and strengthening of an adequate HHR strategic plan. Abt Associates Inc. Assessment of HRMS pg. 30

40 Key Process Problem Constraint Consequences HHR financing Cajamarca RHD has sufficient budget to ensure staff salaries, but there are old debts to be paid from the arbitrary and non-technical distribution of staff bonuses and incentives granted by the state. SOURCE: Cajamarca technical report defined HR gaps. There is a plan of action to close HHR gaps, among other issues related to HR planning. No constraints reported. Personnel receive remuneration according to work assignment. Proposal for improvement Continuous monitoring of budget availability, and design of a proper financial plan to include budget needs of both stable and hired staff. 2.3 Work Organization: Progress Results of the assessment in San Martin Regional Health Directorate The following graph shows the results of three processes included in this subsystem. On average, this entire subsystem has only achieved a 32% progress rate, which is deemed little development. In general, all processes have increased but with "little development". According to key informants, processes exhibiting slight improvements are associated with job profiles definitions and competencies design. Graphic 7: San Martin work organization: Results by key processes. San Martin: Work Organization Design of jobs profiles 100% 80% 60% 40% 20% 0% Job rating Identification of labor competencies SOURCE: SMT technical report Abt Associates Inc. Assessment of HRMS pg. 31

41 Table 17: San Martin work organization: Results by key processes. KEY PROCESSES Expected result Obtained result % Complete Result Design of job profiles % Little development Identification of labor competencies % Little development Job rating % Little development Average % Little development SOURCE: SMT technical report More specific findings on each of the processes are listed below. Design of job profiles This process shows a 38% achievement rate due to the following developments, among others: Technical team members have utilized the following documents: Staffing Table 2013 (Cuadro de Asignación de Personal CAP); MOF 2006; and Staff Budget 2012 (Presupuesto Analítico de Personal PAP). According to CAP 2013, the number of stable staff is less than the number authorized in the CAP. However, the total number of workers, both stable and hired, exceeds the quantity allocated in the CAP. Therefore, contracted staff exceeds the authorized number. Job profiles have been created for 60% of the positions in SMT-RHD organizational units. To design the specific functions of each position, the SMT technical team referenced the opinion of experts and general functions established in the ROF. To define the position requirements, the team considered the regional labor market situation, the complexity of the functions and the importance of the position. However, designed job profiles have not yet been officially approved. Despite advances in this process, problems have been encountered and are summarized in the table below. Table 18: Constraints in the design of job profiles. San Martin, Problem Constraints Consequences Proposal for improvement SMT-RHD has not assigned the task of job profile design to a specific group in the institution. The ROF also does not specify a responsible party for this task. The design of job profiles is not based on the Procedures Manual (Manual de procesos MAPRO) because SMT- RHD does have not one. There is an institutional MOF from 2006 that does not correspond to the current organizational structure; Since stripping the National Institute of Public Administration (INAP) of its role as HRMS policy maker, there has been a loss of interest in following HRMS regulations. With the entrance of SERVIR, regulations are being reviewed and important tasks are being identified, including job profile design. Lack of awareness of the importance in managing MAPRO, which identifies all procedures for operational management of the organization. These procedures present the functional tasks for specific The lack of job profiles and unclear technical job requirements negatively affects the recruitment process. Remuneration is linked to the person and not to the specific profile. The disuse of MAPRO results in overlapping functions, shared responsibilities and duplicate subordinated functions. Due to the outdated MOF, workers have no effective responsibility for the tasks performed. Assign this process to an appropriate party. Appoint a committee to develop and institutionalize MAPRO. Appoint a commission to assume development of a MOF aligned to ROF and CAP. Abt Associates Inc. Assessment of HRMS pg. 32

42 Problem Constraints Consequences specific roles are outdated. positions. A new ROF necessitates amending other documents, including MOF, CAP, PAP, MAPRO, and job profiles. Proposal for improvement SOURCE: SMT technical report The Civil Service Law explicitly states the HR office or corresponding body should perform the following function[1]: "Manage Job Profiles." Identification of labor competencies This process has reached a 38% achievement rate, due largely to SMT-RHD progress since January 2013 in designing competency profiles for the first level of care as well as for managerial and administrative positions. In designing the profiles, the technical team is referencing the Competencies Dictionary and MoH-designed competencies and consulting with experts. Despite advances in this process, problems have been encountered and are summarized in the table below. Table 19: Constraints in the identification of labor competencies. San Martin, Problem Constraints Consequences Proposal for improvement There is no party responsible for defining the competency profile since the current ROF does not consider the subject. HRM based on competencies is not well developed in the public sector, which could contribute to implementation failure in the regional governments. Weakly designed job profiles without including competencies would result in hiring people without identifying their skills. Hire an external consultant to apply competency profiles in HRMS processes. SOURCE: SMT technical report Job rating This process has achieved a 10% progress rate due mostly to the development of job profile assessment processes at the micro-network level. Despite advances in this process, problems have been encountered and are summarized in the table below. Abt Associates Inc. Assessment of HRMS pg. 33

43 Table 20: Constraints in job rating. San Martin, Problem Constraints Consequences Proposal for improvement In the current ROF, there is no party responsible for assessing job profiles. Lack of awareness as to the importance of evaluating job positions to design equitable salary scales and career plans. Compensation could not be assigned in a fair and equitable manner. Demotivated staff could weaken institutional achievements. Assign a person or appoint a committee to be responsible for assessing job profiles and rating. SOURCE: SMT technical report Results of the assessment in other regions The following table shows the consolidated results from the evaluation prepared by PARSALUD II. Table 21: Work organization: Performance in four regions at different levels. Institution Ucayali Cusco Huánuco Ayacucho RHD Has updated management records but poorly defined in some cases. Possesses all management records but with incomplete information. Has management documents developed in Has management documents developed in Has designed CAS job profiles. RHD refers to having designed competencies, but they only define knowledge which is part of a competency. Network Networks either do not possess management documents or they are outdated. Functions and responsibilities are not uniform among networks. Possesses all management documents but with incomplete information. Have developed models to design MOF at network level. All networks have management documents, but they are outdated. Functions and responsibilities are not uniform among networks. All networks have management documents, but they are outdated. Functions and responsibilities are not uniform among networks. They use Cusco RHD job profiles to hire network staff. Micronetwork Micro-networks either do not possess management documents or have outdated versions. Micro networks either do not possess management documents or have outdated versions. Micro networks either do not possess management documents or have outdated versions. Micro networks either do not possess management documents or have outdated versions. Functions and responsibilities are not uniform among micro-networks. Functions and responsibilities are not uniform among micro-networks. Functions and responsibilities are not uniform among micro-networks. Functions and responsibilities are not uniform among micro-networks. Abt Associates Inc. Assessment of HRMS pg. 34

44 Institution Ucayali Cusco Huánuco Ayacucho Hospital Hospitals either do not possess management documents or have outdated versions. SOURCE: PARSALUD II technical report Not all hospitals have the entire range of management documents, but if they do, these documents do not contain complete information. The majority uses Cusco RHD hired staff job profiles. All have management documents. All have management documents. PARSALUD II qualitative information shows poor development in the design of job profiles. Additionally, all regions have outdated management documents. Regarding Cajamarca RHD, the results of the project s assessment using HP project methodology and instruments are below. Graphic 8: Cajamarca work organization: Results by key processes. Cajamarca: Work Organization Job rating Design of jobs profiles 100% 80% 60% 40% 20% 0% Identification of labor competencies SOURCE: Cajamarca technical report Table 22: Cajamarca work organization: Results by key processes. KEY PROCESSES Expected result Obtained result % Complete Result Design of job profiles % Little development Identification of labor competencies % Little development Job rating % Little development Average % Little development SOURCE: Cajamarca technical report Abt Associates Inc. Assessment of HRMS pg. 35

45 Findings for each of the processes in this subsystem are presented in the table below. Table 23: Constraints in work organization. Cajamarca, Key Process Problem Constraint Consequences Design of job profiles Identification of labor competencies Job rating There is no responsible party to assume job profile design in the institution, but they have the following management documents: CAP 2013, MOF 2009 and PAP Have not been developed nor implemented. Have not been developed nor implemented. No specialist has been identified who can assume this role within the institution. It is also likely that the institution does not have the budget to hire an external specialist. Lack of competent team. Lack of competent team. Recruitment does not meet job technical requirements. Due to the lack of job profiles, remuneration is often linked to a person and not to the specific job profile. Proposal for improvement Assign a responsible party to develop job profiles for the Cajamarca RHD and decentralized bodies. Assign a responsible party to develop labor competencies for the Cajamarca RHD and decentralized bodies. Assign a responsible party to rate posts for the Cajamarca RHD and decentralized bodies. SOURCE: Cajamarca technical report While this is the most important subsystem, it is also the least developed. Staff has not developed the technical skills needed to perform this function. Management documents are outdated, and functions are not defined in the current HRM framework. 2.4 Employment Management: Progress The following graph presents the results of the five processes that are involved in this subsystem. On average, the subsystem only achieved a 37% progress rate, which is deemed little development. In general, most processes have made some progress. According to information provided by key informants, however, there are processes that have achieved no development, including staff mobility as well as staff termination and retirement. Abt Associates Inc. Assessment of HRMS pg. 36

46 2.4.1 Results of the assessment in San Martin Regional Health Directorate Graphic 9: San Martin employment management: Results by key processes. San Martin: Employment Management Staff termination and retirement Recruitment, Selection, Incorporation and Induction 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Staff mobility Administration of disciplinary process Management of staff files and attendance control SOURCE: SMT Technical Report Table 24: San Martin employment management: Results by key processes. KEY PROCESSES Recruitment, selection, incorporation and induction Expected result Obtained result % Complete Result % Little development Staff mobility 3 0 0% Little development Management of staff files, attendance control Administration of disciplinary process % % Moderate development Moderate development Staff termination and retirement 3 0 0% Little development Average % Little development SOURCE: SMT Technical Report Finding for each process in this subsystem are presented below. Recruitment, selection, incorporation and induction This process shows achieved a 38% progress rate due to the following developments, among others: There is a responsible party for managing staff recruitment, selection, incorporation and induction. However, in some cases there is no one responsible for the development of each process. Key informants said that evaluation instruments in the most recent selection process were only used to fulfill the minimum requirements of current regulations. These evaluation tools Abt Associates Inc. Assessment of HRMS pg. 37

47 included curriculum evaluation; personal interview; and knowledge and psychological test scores. Despite advances in this process, problems have been encountered and are summarized in the following table. Table 25: Constraints in recruitment, selection, incorporation and induction. San Martin, Problem Constraints Consequences Despite having a responsible party for managing recruitment, selection, incorporation and induction of staff, CAS hiring processes conducted last year lack the use of job profiles, terms of reference, functions worksheets, and budgetary certification 8. Affidavits from hired candidates are not verified during the recruitment and selection process. Hired staff does not receive appropriate instruction because there is no responsible party to inform them of policies, rules, roles, goals, vision, mission and institutional values. Lack of administrative procedures in personnel administration. There are no visible leaders to take responsibility for executing these processes. The local labor market is tight, and there is a poor understanding of these processes. Salary scale is not competitive to attract skilled personnel with HRM knowledge. Frequent personnel turnover results in the accumulation of records pending verification and interferes with daily tasks. Lack of awareness regarding the importance of the induction process as a tool for strengthening organizational learning. Absence of qualified personnel and sound knowledge of HRM procedures generate mediocre management results, and an error prone environment that has high civil and criminal liability. The working environment deteriorates as a result of staff who do not fit the job profile, standards or requirements; this can cause a rise in unmet demands. The cost to the state to recruit unqualified personnel is high because turnover is more likely. This creates further costs in time and money to carry out a new recruitment and selection process. Proposal for improvement Design a directive to establish procedures and responsibilities for the different processes of recruitment. This directive must be supported by the correct contract file that includes the standardized job profile of the post to be hired, as well as the budget certification to guarantee remunerative payment without neglecting transparency and information dissemination established by current regulations. Designate a responsible party to develop an induction program with the person responsible for institutional image management. SOURCE: SMT technical report The Civil Service Law explicitly states the following as a function of HR offices or the corresponding body[1]: The selection process is a mechanism to join a group of public managers, career civil servants, and public servants from complementary activities. It selects the best people for the job on the basis of merit, competence and transparency, ensuring equal access to public service." Staff mobility This process has achieved little to no progress. 8 It means "ensure availability of budgetary provision to compromise expenditure for the respective fiscal year". Abt Associates Inc. Assessment of HRMS pg. 38

48 The problems encountered in this process are presented in the table below. Table 26: Constraints in staff mobility. San Martín, Problem Constraints Consequences Proposal for improvement Staff shifting is made according to personal needs rather than institutional SOURCE: SMT technical report Lack of knowledge of rules governing staff mobility. Shifting of staff does not satisfy the needs of the original or destination position. Develop and approve internal job regulation (Reglamento Interno de Trabajo RIT) to clarify and specify all the necessary tasks to implement institutional policies and procedures. Management of staff files and attendance control This process has achieved a 40% progress rate mostly due to SMT-RHD selection of a person responsible for updating information regarding staff files and a person responsible for attendance control records. Despite advances in this process, problems have been encountered and are summarized in the table below. Table 27: Constraints in management of staff files, attendance control. San Martin, Problem Constraints Consequences The filing of staff information is not done through a digital recording system which would facilitate and expedite the organization of information on recruited staff. A digital attendance control system is in use, but physicians do not record attendance in the way agreed to by the medical union. Physicians also disregard the rules requiring a public servant to record attendance in order to maintain payment of their salaries. Failure to implement software for the digital recording system may stem from insufficient budget or poor familiarity with modern devices. In health institutions, it is critical to establish physician attendance controls. Physicians are the only workers exempt from signing attendance control records according to an administrative resolution. Failure to evaluate staff in a timely manner can interfere with efficient decision making. Proposal for improvement Implementation of a comprehensive administrative system of personnel control and records, which includes all personnel administration processes. SOURCE: SMT Technical Report Administration of disciplinary process This process has achieved a 43% progress rate due to SMT-RHD designation of a responsible party to manage disciplinary proceedings. The SMT-RHD has also created a permanent commission to manage administrative processes; the commission s decisions are inherently supported by a resolution. Despite advances in this process, problems have been encountered and are summarized in the table below. Abt Associates Inc. Assessment of HRMS pg. 39

49 Table 28: Constraints in administration of disciplinary process. San Martin, Problem Constraints Consequences SMT-RHD has neither developed nor approved RIT, which identifies the rights and obligations of the public servant. They do not maintain an updated record to report dismissals and dismissal sanctions to the National Registry of Sanctions (RNSDD). Lack of knowledge regarding regulations or insufficient staff to develop regulations and internal policies. Lack of knowledge regarding current regulations administered by SERVIR to develop an updated record of the RNSDD. Disoriented personnel unable to exercise their rights and duties as well as a weak governing body to apply normative standards. Failure to maintain updated records for SERVIR would result in state entities hiring unfit personnel. In the case of health professionals, this [the hiring of unfit personnel] could cause irreparable damage: poor decision making could negatively affect public health. Proposal for improvement Develop internal regulations by hiring a consultant or assigning a manager to lead the development of management regulations. Designate a responsible individual or party to manage registration, dismissals and dismissal sanctions for prompt reporting to SERVIR. SOURCE: SMT technical report Staff termination and retirement This process has achieved little to no progress. The problems encountered are listed in the following table. Table 29: Constraints in staff termination and retirement. San Martin, Problem Constraints Consequences There is no responsible party to manage the process of disengagement in order to effectively manage staff termination in a timely manner. Lack of knowledge regarding HRM processes and lack of verification of data that generates unjustified regular expenses (payments to dead workers). Inappropriate payment of remunerative obligations, which could possibly generate administrative, civil and criminal penalties. Proposal for improvement Implement a comprehensive administrative staff system with detailed information on all types of disengagement according to labor rules and contracts. Alternatively, a responsible party should be assigned for the sole purpose of managing all types of employment termination. SOURCE: SMT technical report Results of the assessment in other regions The following table shows the consolidated results from the evaluation prepared by PARSALUD II. Abt Associates Inc. Assessment of HRMS pg. 40

50 Table 30: Employment Management: Performance in four regions at different levels. Institution Ucayali Cusco Huánuco Ayacucho RHD RHD publicizes CAS vacancies to recruit but does not record information about the recruitment processes. Incomplete use of selection tools. There is no system to register the real destination of HR. Lack of a permanent selection committee. RHD utilizes job profiles in selection process and has a permanent selection committee. RHD does not systematize CAS selection processes. There is no system to register the real destination of HR. RHD publicizes CAS vacancies to recruit but does not record information about the recruitment processes. Incomplete use of selection tools. There is no system to register the real destination of HR. Lack of a permanent selection committee. RHD publicizes CAS vacancies to recruit but does not record information about the recruitment processes. Incomplete use of selection tools. There is no system to register the real destination of HR. Lack of a permanent selection committee. Network Networks publicize CAS vacancies to recruit but do not record information about the recruitment processes. Incomplete use of selection tools. There is no system to register the real destination of HR. Lack of a permanent selection committee. Networks publicize CAS vacancies to recruit. Utilize job profiles in selection process. Have a permanent selection committee. Insufficiently systematized CAS selection processes. There is no system to register the real destination of HR. Networks publicize CAS vacancies to recruit. Use of selection tools as well as recording and storage of examinations do not occur uniformly among networks. All networks lack permanent selection committees. All networks provide induction programs for new staff. Networks publicize CAS vacancies to recruit. Use of selection tools as well as recording and storage of examinations do not occur uniformly among networks. Lack of permanent selection committees. Always conduct induction programs. Micronetwork Micro-networks do not publicize CAS vacancies. Micro-networks do not publicize CAS vacancies. Micro-networks do not publicize CAS vacancies. Micro-networks do not publicize CAS vacancies. Hospital Hospitals do not publicize CAS vacancies. Selection tool usage is not standardized. Formation of permanent selection committees is not uniform. Hospitals use job profiles in selection processes. They have a permanent selection committee. There is no system to register the real destination of HR. All entities publicize CAS vacancies. There are no permanent selection committees. There is no uniformity in the use of criteria and selection instruments. Always provide induction programs. All entities publicize CAS vacancies. There are no permanent selection committees. Always conduct induction programs. SOURCE: PARSALUD II technical report PARSALUD II qualitative information shows incomplete development of recruitment and selection processes. Abt Associates Inc. Assessment of HRMS pg. 41

51 Regarding Cajamarca RHD, the project will present the results of the assessment using HP project methodology and instruments. Graphic 10: Cajamarca employment management: Results by key processes. Cajamarca: Employment Management Staff termination and retirement Recruitment, Selection, Incorporation and Induction 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Staff mobility Administration of disciplinary process Management of staff files and attendance control SOURCE: Cajamarca technical report Table 31: Cajamarca employment management: Results by key processes. KEY PROCESSES Recruitment, selection, incorporation and induction Expected result Obtained result % Complete Level of developme nt % Little Staff mobility 3 0 0% Little Management of staff files and attendance control % Little Administration of disciplinary process % Moderate Staff termination and retirement % Moderate Average % Little SOURCE: Cajamarca technical report The findings for each of the processes in this subsystem are included in the following table. Abt Associates Inc. Assessment of HRMS pg. 42

52 Table 32: Constraints in employment management. Cajamarca, Key Process Problem Constraint Consequences Recruitment, selection, incorporation and induction Staff mobility Management of staff files and attendance control Administration of disciplinary process Staff termination and retirement Cajamarca RHD has a permanent selection committee. Lack of knowledge regarding implementation of the recruitment process required by law. There is an evaluation committee for mobilization (displacement) of staff within the organization, but there is no control or monitoring of other staff, especially health facility staff. Poor management of health personnel files and records. Poor management of attendance records. Disciplinary process commissions unfamiliar with rights and obligations of public servants. Disciplinary process unnecessarily extended. Current processes are incomplete and not based on current regulations. To reduce time in selection process, Cajamarca RHD eliminates some important procedures. Lack of interest among health networks in managing mobility of health facility staff based on current regulations. Poor definition of functions for personnel file control. Lack of staff commitment to register attendance. There is no responsible party to monitor attendance and retention in health facilities and networks. Lack of trained personnel to manage processes and current regulations on disciplinary process. Lack of knowledge regarding the legal basis of personnel administration processes. Contract inadequate staff due to inappropriate recruitment; staff selection does not fit the job profile. There is no real information about personnel allocation. Frequent absence of staff in health facilities. Staff files with incorrect information. Frequent absence of staff in health facilities. Statute of limitations on faults. Staff termination and retirement without technical and legal support. Proposal for improvement Standardize the recruitment and selection processes to include standardized job profiles based on current regulations. Implement a staff attendance and mobility control system. Form a party responsible for managing files and records. Implement an attendance control system in health facilities. Commissions must be properly staffed with qualified personnel who are familiar with labor regulations and administrative procedures. Designate a responsible party to manage all types of employment terminations. SOURCE: Cajamarca technical report Abt Associates Inc. Assessment of HRMS pg. 43

53 2.5 Performance Management: Progress The following graph shows results of the four processes that are involved in this subsystem. On average, this entire subsystem only achieved a 14% progress rate, which is deemed little development. The supervision process as well as the feedback and design of plans for individual performance improvement process achieved little to no development. According to key informants, the performance evaluation process is the most developed within the performance management subsystem despite having a progress rate of 22% Results of the assessment in San Martin Regional Health Directorate Graphic 11: San Martin performance management: Results by key processes. San Martin: Performance Management Performance Planning 100% Feedback and design of plans for individual performance improvement 50% 0% Supervision Performance Evaluation SOURCE: SMT technical report Table 33: San Martin performance management: Results by key processes. KEY PROCESSES Expected result Obtained result % Complete Result Performance planning % Little development Supervision % Little development Performance evaluation % Little development Feedback and design of plans for individual performance improvement % Little development Average % Little development SOURCE: SMT technical report Findings for each of the processes in this subsystem are listed below. Performance planning This process has achieved a 16% progress rate due to the following developments, among others: Abt Associates Inc. Assessment of HRMS pg. 44

54 There is a responsible party for the planning, organization and implementation of a performance evaluation process for the institution. The current ROF indicates that this function is the responsibility of the HRM directorate in the SMT-RHD. The SMT-RHD plans to implement staff performance this year to replace subjective assessment, which does not reflect the true performance and expected results of each worker. Despite advances in this process, problems have been encountered and are summarized in the table below. Table 34: Constraints in performance planning. San Martin, Problem Constraints Consequences Proposal for improvement Although there is a body responsible for planning, organizing, implementing and evaluating staff performance evaluations, there is no methodology or evaluation plan. In spite of this, the SMT-RHD conducted staff performance evaluations. There is no methodology for establishing individual performance goals. SOURCE: SMT technical report Evaluations are conducted only to meet administrative requirements in order to avoid sanctions from the government comptroller. Lack of knowledge in managing staff performance evaluations. Staff is evaluated but without considering the attainment of institutional goals. Retain institutional staff with apparently good performance while in reality staff may not be achieving performance goals. Develop methodologies and management tools to measure job performance in order to contribute to the achievement of institutional goals. Develop a policy that defines the standards of job competence at the individual level within the framework of RHD policies and including identification of performance goals for each unit. The Civil Service Law explicitly states the following as a function of the HR office or corresponding body[1]: Be responsible for assessments to be made by the organization and in the manner established by SERVIR ". "Public managers, career civil servants and related-activity public servants are subject to performance evaluation." Supervision This process has achieved a 0% progress rating, which is deemed poor development. The problems encountered are summarized in the following table. Abt Associates Inc. Assessment of HRMS pg. 45

55 Table 35: Constraints in supervision. San Martin, Problem Constraints Consequences Proposal for improvement There is no responsible party to manage, monitor, coach or mentor. In the current ROF, this process is not defined. There are no methods or instruments to provide TA to staff. RHD does not develop coaching, supervision or mentoring activities. Managers do not realize the importance of standardizing and developing tools and methodologies to accompany staff performance. Errors and wasted time, which affects achievement of individual goals. Confused and demotivated staff feels uncommitted and uninvolved in their jobs and duties, which prevents attainment of institutional goals. Designate a responsible party to develop methodology and management tools to guide staff performance. SOURCE: SMT technical report Performance evaluation This process has achieved a 22% progress rate due to the following developments, among others: There is a responsible party for planning, organizing and implementing staff performance evaluations for SMT-RHD organizational units and its decentralized bodies. The current ROF indicates that this function is the responsibility of the HRM directorate. Last year, the SMT-RHD conducted a performance evaluation but only for staff hired in CAS mode. Results were used to dismiss contract workers with poor scores. Despite advances in this process, problems have been encountered and are summarized in the following table. Table 36: Constraints in performance evaluation. San Martin, Problem Constraints Consequences Proposal for improvement There is a responsible party according to the current ROF, but there is no person in charge of organizing and monitoring the staff performance evaluation process. Methodology and management tools to define the staff performance evaluation process have not been developed or approved. A non-technical staff performance evaluation for CAS staff took place, reflecting only the fulfillment of routine administrative obligations. SOURCE: SMT technical report RHD has not identified a specialist within the current staff who can assume this role. The institution does not have the budget to hire an external specialist. Subjective evaluation that does not reflect the performance achievements of each worker. SMT-RHD will assume administrative responsibility for the failure to implement the mandatory provisions of the Civil Service Law regarding a comprehensive, systematic, continuous, demonstrable and objective assessment process. Designate a party responsible for organizing and monitoring an objective staff performance evaluation process. Develop methodology and management tools to develop a performance evaluation in line with institutional goals. Abt Associates Inc. Assessment of HRMS pg. 46

56 Feedback and design of plans for individual performance improvement This process has achieved a 0% progress rate. The problems encountered are summarized in the following table. Table 37: Constraints in feedback and design of plans for individual performance improvement. San Martin, Problem Constraints Consequences Proposal for improvement There is no party with direct responsibility for processing feedback and designing plans to improve individual staff performance; the current ROF also does not specify a party for these duties. SOURCE: SMT technical report Through performance feedback, heads of organizational units perform appropriate actions to improve staff performance. HHR with poor performance, making the same mistakes indefinitely. Designate a responsible party to manage the feedback process and design plans to improve individual staff performance for all SMT-RHD organizational units and its decentralized bodies Results of the assessment in other regions The following table shows the consolidated results from the evaluation prepared by PARSALUD II. Table 38: Performance management: Results in four regions at different levels. Institution Ucayali Cusco Huánuco Ayacucho RHD RHD conducts performance evaluations using the instrument provided by the MoH but does not put the results to practical use. RHD does not conduct performance evaluations. RHD conducts performance evaluations using the instrument provided by the MoH but does not put the results to practical use. RHD conducts performance evaluations using the instrument provided by the MoH but does not put the results to practical use. Network RHD conducts performance evaluations using the instrument provided by the MoH but does not put the results to practical use. RHD conducts performance evaluations using the instrument provided by the MoH but does not put the results to practical use. All the networks, except Leoncio Prado, conduct performance evaluations using the instrument provided by the MoH but does not put the results to practical use. Only Puquio and Huamaga networks conduct performance evaluations using the instrument provided by the MoH. However, these networks do not put results to practical use. Micronetwork Micro-networks do not conduct performance evaluations. Micro-networks do not conduct performance evaluations. Micro-networks do not conduct performance evaluations. Micro-networks do not conduct performance evaluations. Hospital Hospitals rarely conduct performance Hospitals conduct performance evaluations for staff Hospitals conduct performance evaluations for staff Hospitals do not conduct performance Abt Associates Inc. Assessment of HRMS pg. 47

57 Institution Ucayali Cusco Huánuco Ayacucho evaluations. When they do, they utilize MoH instruments but do not put the results to practical use. SOURCE: PARSALUD II technical report hired on the 276 legal regime and CAS. Administrative and health care staff are evaluated utilizing MoH instruments but do not put the results to practical use. hired on the 276 legal regime and CAS. Administrative and health care staff are evaluated utilizing MOH instruments but do not put the results to practical use. evaluations. PARSALUD II qualitative information shows that RHD, networks and hospitals develop performance evaluation; however, these evaluations are subjective and are not linked to individual goals. Additionally, evaluation results are not used to improve performance, and there is no feedback to employees. Regarding Cajamarca RHD, the project presents the results of the assessment using HP project methodology and instruments below. Graphic 12: Cajamarca performance management: Results by key processes. Cajamarca: Performance Management Feedback and design of plans for individual performance improvement Performance Planning 100% 80% 60% 40% 20% 0% Supervision Performance Evaluation Table 39: Cajamarca performance management: Results by key processes. KEY PROCESSES Expected result Obtained result % Complete Result Performance planning % Little development Supervision % Little development Performance evaluation % Little development Feedback and design of plans for individual performance improvement % Little development Average % Little development SOURCE: Cajamarca Technical Report Findings from each of the processes in this subsystem are presented below. Abt Associates Inc. Assessment of HRMS pg. 48

58 Table 40: Constraints in performance management. Cajamarca, Key Process Problem Constraint Consequences Performance planning Supervision Performance evaluation Feedback and design of plans for individual performance improvement There is no responsible party for objectively managing, planning, organizing, implementing, monitoring and evaluating staff performance using a comprehensive, systematic and continuous assessment. Has not been developed nor implemented. A management tool has not been developed or approved to define the methodology to develop the staff performance evaluation process. Has not been developed nor implemented. Lack of knowledge regarding the importance of design tools and instruments for an objective performance evaluation. Lack of knowledge regarding the importance of guiding staff in the performance of its duties and functions. Lack of knowledge regarding the importance of developing methodologies and management tools to objectively organize and implement staff performance evaluations. Health staff performance evaluation processes have been executed at the health facility level but only to meet an administrative need. Lack of knowledge regarding the importance of providing feedback after a performance evaluation process. Subjective performance assessment. Staff making the same mistakes, repeatedly, without technical assistance to correct them. Health facility staff with apparently good performance ratings but demonstrates minimum achievement in institutional and individual goals. Workers without plans to help them improve performance Proposal for improvement Designate a party responsible for planning performance evaluations at all levels. Train managers in strategies to guide staff to improve performance, through coaching, mentoring and supervision. Designate a party responsible for organizing and monitoring the staff performance evaluation process. Develop a management tool to measure the effectiveness and efficiency of administrative and health care staff for Cajamarca RHD units. Train managers to provide feedback to their workers and design individual plans to improve performance. SOURCE: Cajamarca technical report Abt Associates Inc. Assessment of HRMS pg. 49

59 2.6 Development and Training Management: Progress Results of the assessment in San Martin Regional Health Directorate The following graph shows results of the three processes in this subsystem. On average, this subsystem has achieved a 60% progress rate, deemed medium development. The teaching-service process has progressed the least. According to information provided by participants, the process with the greatest level of progress is labor advancement. Graphic 13: San Martin development and training management: Results by key processes. San Martin: Development and Training Management Labor advancement (Promotion and Career Path) 100% 80% 60% 40% 20% 0% Regulation of the Teaching & Service process Capacity Building SOURCE: SMT technical report Table 41: San Martin development and training management: Results by key processes. KEY PROCESSES Labor advancement (promotion and career path) Expected result Obtained result % Complete Result % Moderate development Capacity building % Moderate development Regulation of the teaching & service process % Little development Average % Moderate development SOURCE: SMT technical report Findings for each of the processes in this subsystem are listed below. Labor advancement (promotion and career path) This process has achieved a 76% progress rate (Development Environment) due to the following reasons: Abt Associates Inc. Assessment of HRMS pg. 50

60 Key informants report that the RHD has designed a promotion policy that has not been approved or disclosed to workers. They have designated a responsible party for this process within the HRM directorate. The promotion policy takes into account personnel file information, including professional background required, years of service, trainings, performance evaluations, and absence of disciplinary offenses; interviews; knowledge test; knowledge required for new position; experience in the public sector; recommendations of previous employers; and opinion of current supervisor. The RHD states that decisions related to promotion are not susceptible to political influence. Despite progress, problems have been encountered and are summarized in the following table. Table 42: Constraints in labor advancement. San Martin, Problem Constraints Consequences Proposal for improvement RHD does not have a standing committee to select staff to be promoted. RHD does not review technical documents produced by the candidate. RHD does not assess whether the applicant has knowledge and skills in public management or conflict management. RHD technical team does not have requisite knowledge or skills to carry out a fair and transparent evaluation of applicants. The promotion process is discredited. Assess the effectiveness of policy implementation, incorporate improvements and manage its approval. Strengthen capacities of responsible party to improve development of the policy. Lack of clear procedures to evaluate candidates. SOURCE: SMT technical report Capacity building This process achieved a 58% progress rate, which is deemed moderate development, due to the following developments: The SMT-RHD has a methodology to lead staff capacity development, which was provided by the MoH. The SMT-RHD has a responsible party for staff training processes. The SMT-RHD has organized the following educational interventions: short courses, workshops, lectures, and internships in regional hospitals and Lima hospitals. To identify training needs, the responsible party takes into account institutional objectives and goals; regional health priorities; MoH training offers; regional educational institution training offers; institutional requests; and direct requests from workers. To select training participants, the RHD takes into account the functions of the position and the request from an immediate supervisor. Salaried and contract staff can participate in trainings. The unit responsible for training mainly deals with logistic details, including: announcing training opportunities; facilitating audiovisual media, managing refreshments, preparing the training room, providing teaching materials, and evaluating acquired knowledge. Abt Associates Inc. Assessment of HRMS pg. 51

61 Despite these advances, problems occurred and are summarized in the following table. Table 43: Constraints in capacity building. San Martin, Problem Constraints Consequences Proposal for improvement SMT-RHD does not have a regional policy for training activities. SMT-RHD does not know how much is invested in training. Each unit develops its own training activities and does not report to the RHD training unit. Training activities do not take place in locations similar to the workplace. First-level-of-care staff does not perform internships at first-level-of-care facilities. RHD does not coordinate the development of training activities with universities. When identifying staff training needs and selecting staff to train, RHD does not take into account the results of knowledge and performance evaluations, or the previous training record of the worker (to avoid duplication). The understaffed HR unit manages multiple activities, which do not allow it to develop a regional training policy and strategies. Each unit manages its training financing. There are no training venues in first-level-ofcare facilities. Logistics absorb time and attention of training unit. No performance evaluations are conducted to identify training needs. Poor ability to manage training activities. Staff performance is not as expected. Trained workers are not always the most in need. RHD training unit is not recognized as a TA unit in training management. RHD does not know the total investment made in training activities, although it considers that the investment made does not significantly improve the quality of care. Strengthen capacities in training management at all levels. Design standards, guidelines and tools to improve training activities. Design training programs and internships in places similar to the working environment of trainees. Develop strategies to create internship opportunities in firstlevel-of-care facilities to train first-level-ofcare workers. Establish a mechanism to centralize information regarding training activities and associated financing. There are no objective criteria to select participants. The responsible party is not developing essential functions, including identifying staff training needs; TA to network regarding training management; controlling training attendance; assessing teacher performance; evaluating skills according to each position; evaluating training impact; and evaluating training funding. SOURCE: SMT technical report Regulation of teaching - service process This process achieved a 35% progress rate, deemed little development, mainly because the RHD has signed agreements with training institutions for undergraduate and graduate students in medicine; undergraduate students in nursing and midwifery; and students in technical institutes. The problems encountered are included in the following table. Abt Associates Inc. Assessment of HRMS pg. 52

62 Table 44: Constraints in regulation of teaching - service process. San Martin, Problem Constraints Consequences Proposal for improvement SMT-RHD does not have criteria to qualify "teaching hospitals". Teaching hospitals are not accredited. SMT-RHD does not have a Pre-degree Regional Committee (Comité Regional de Pregrado en Salud - COREPRES) officially established and running. RHD does not keep records of all students who were trained in health institutions in the region. There is no responsible party to manage agreements with training institutions. No regional rules related to the operation of teaching hospitals. Do not know in detail the national regulations of COREPRES. RHD does not understand the need for or importance of this information. Patients' rights are not respected in teaching hospitals. The quality of training is not satisfactory and not in line with national regulations. Training institutions do not meet the commitments set out in the agreements, which are also outdated. Training institutions use health facilities to train their students, but health institutions receive nothing in return. For example, RHD employees could participate in courses offered by universities but are currently not able to. Revise the existing legislation regarding COREPRES and teaching hospitals. Revise existing agreements and design an advantageous proposal for RHD. Designate a responsible party to manage agreements. Schedule an internship at the MoH to train party responsible for agreements in all related regulations. SOURCE: SMT technical report Results of the assessment in other regions The following table shows the consolidated results from the evaluation prepared by PARSALUD II. Table 45: Development and training management: Performance in four regions at different levels. Institution Ucayali Cusco Huánuco Ayacucho RHD RHD performs promotion processes for stable staff (administrative and care staff). Training activities are guided by the range of courses and not by specific need or demand. Courses are primarily in public health rather than public management. Develop promotion processes for stable staff based on document review. Training activities are arbitrarily oriented rather than guided by needs. Trainings focus on professional staff. Main topic in trainings is public health. There are restrictions in training contract staff. Develop promotion processes for all stable staff. Trainings are conducted based on supply, not demand. RHD prioritizes public health issues and public management. RHD designs and implements its own training courses. No promotion process. Training programs are based on supply. RHD designs and implements its own training courses. Network Some networks do promotion processes for stable staff, mainly care staff. Trainings focus on public health issues. Training activities are Perform promotion processes for stable staff based on document review. Trainings are conducted based on supply rather than Huánuco network is the only one that has performed promotions for stable staff. All networks train both stable and contract staff. Only Huanta network performs promotion process. Trainings are carried out for both stable and contract staff. Trainings only Abt Associates Inc. Assessment of HRMS pg. 53

63 Institution Ucayali Cusco Huánuco Ayacucho Micronetwork Hospital guided by a supply approach. Trainees do not apply what they have learned. One network stated restrictions in training hired staff. Micro-networks do not execute promotion and training processes. Hospitals perform promotion processes for stable staff focused on care staff. Training is led by supply rather than demand. One hospital uses training plan guidelines. Some hospitals restrict trainings to hired staff. SOURCE: PARSALUD II technical report demand. Trainings focus on professional staff and public health issues. There are restrictions to train hired staff. Micro-networks do not execute promotion and training processes. Hospitals perform promotion processes for permanent staff, in some cases through a systematic process but usually based on document review. Training is led by supply rather than demand. Trainings focus on professional staff and on general public health issues instead of institutional governance. No restrictions in training hired personnel. All networks prioritize public health issues in trainings. Only Huánuco and Leoncio Prado networks include governance issues in trainings. Micro-networks do not execute promotion and training processes. All hospitals develop promotion processes, primarily for stable staff who perform clinical work. Hospitals train both stable and hired staff. All hospitals provide training in public health topics but not in governance. Each hospital is responsible for designing and implementing training activities. Contracted staff finances their own training. prioritize public health issues. Each network is responsible for designing and implementing training activities. Micro-networks do not execute promotion and training processes. Hospitals do not conduct promotions or training processes. Each hospital is responsible for designing and implementing training activities. The results of the HRMS performance evaluation conducted by the management team of Cajamarca RHD are shown below. More specifically, the following graph shows results from the three processes in this subsystem. On average, the entire subsystem has achieved a 31% progress rate, which is deemed little development. Abt Associates Inc. Assessment of HRMS pg. 54

64 Graphic 14: Cajamarca development and training management: Results by key processes. SOURCE: Cajamarca technical report Table 46: Cajamarca development and training management: Results by key processes. KEY PROCESSES Labor advancement (promotion and career path) Expected result Obtained result % Complete Result % Little development Capacity building % Little development Regulation of the teaching & service process % Little development Average % Little development SOURCE: Cajamarca technical report Findings for each of the processes in this subsystem are included in the table below. Table 47: Constraints in development and training management. Cajamarca, Key Process Problem Constraint Consequences Labor advancement (promotion and career path) Capacity building RHD does not have regional policies to promote staff. Lack of a single regional plan to RHD managers do not show interest in promoting staff advancement and progression. MoH does not have adequate public policies to promote staff; as a result, regions have not received the proper TA and guidance in this issue. Weak RHD stewardship to lead Health personnel unmotivated with lack of institutional commitment. Health personnel unmotivated, Proposal for improvement Design a proposal for a regional policy to promote HHR. Design a regional training proposal Abt Associates Inc. Assessment of HRMS pg. 55

65 Key Process Problem Constraint Consequences Regulation of the teaching - service process train and build health staff capacity. Poor capacity to manage these activities. Weak regulatory processes for teaching in health services. and manage training activities. RHD units do not coordinate their training activities. Weak institutional commitment to joint work, which would include agreed targets and complementary activities. Lack of a party responsible for managing teachingservice process. without minimum competencies. Poor health care services, both in quantity and quality. Population unsatisfied with health service provision. Graduates of health training institutions do not meet the minimum requirements to work in health services nor do they have the necessary skills to work in rural areas of Cajamarca. Proposal for improvement with appropriate methodologies and institutional training objectives that are mandatory for all units. Generate capacities of the party responsible for managing the teaching - service process. Design a plan to monitor signed agreements between the RHD and universities. SOURCE: Cajamarca technical report 2.7 Compensation Management: Progress Results of the assessment in SMT-RHD The graph below presents results from the five processes in this subsystem. On average, the subsystem achieved a 67% progress rate, which is deemed moderate development. Processes related to the payment of salaries, bonuses and pensions are fully developed with a 100% progress rate. The directorate of operations and the operation offices are responsible for these processes. On the other hand, SMT-RHD has achieved moderate development in the management of incentives and the design of a pay scale; the HRM directorate is responsible for implementing these processes. Abt Associates Inc. Assessment of HRMS pg. 56

66 Graphic 15: San Martin compensation management: Results by key processes. San Martin: Compensation Management Pensions Management Design of Salary Scales 100% 80% 60% 40% 20% 0% Management of Payroll and Salaries Incentive Management Administration of benefits and bonuses SOURCE: SMT technical report Table 48: San Martin compensation management: Results by key processes. KEY PROCESSES Expected result Obtained result % Complete Result Design of salary scales % Moderate development Management of payroll and salaries % High development Administration of benefits and bonuses % High development Incentive management % Moderate development Pension management % High development Average % Moderate development SOURCE: SMT technical report Findings for each of the processes in this subsystem are summarized below. Design of salary scales This process has achieved a 63% progress rate, which is deemed moderate development, due to the following developments, among others: Utilizing HP project TA, SMT-RHD designed and approved a salary scale to hire staff working in first-level-of-care facilities. This approval resolution defines mechanisms for implementation and maintenance. The approved salary scale incorporates the following criteria: level of development (rurality) and poverty in health facility location; distance from Tarapoto to health facility; furthest village still within its jurisdiction. Rioja network used the approved pay scale to hire physicians. This network is also in the process of implementing the new scale for new contract hires. Abt Associates Inc. Assessment of HRMS pg. 57

67 Despite these advances, problems have been encountered and are summarized in the table below. Table 49: Constraints in the design of salary scales. San Martin, Problem Constraints Consequences Absence of a responsible party to lead the design of salary scales for all RHD staff. SMT-RHD does not have pay scales for managers, professionals and technicians from administrative areas. Each budgetary execution unit autonomously defines hired staff salaries without referencing RHD regulation and control. Low wages in remote and underdeveloped areas affect recruitment and retention of health personnel. Technical team members trained in the design of salary scales have been moved to other positions. SMT-RHD has not yet analyzed the budget to approve implementation of the pay scale next year. Salary scale directive includes a variable remunerative component linked to performance but has not yet defined its implementation. The pay scale does not consider position hierarchy or length of service as criteria. SMT-RHD pay scale does not have a corresponding policy to promote hiring staff as part of a career plan framework. SMT-RHD has not identified the importance of monitoring the existing pay scale nor are they exploring the need for other scales. The new technical team does not know how to apply the methodology to estimate other pay scales. Mechanisms to implement the pay scale in all networks have not been defined. SMT-RHD management team has not allocated time to plan implementation of the scale. Hired staff is unsatisfied and perceives that the wage assignment is not fair and equitable. Current wages do not attract and retain health personnel where needed. Health professional positions go permanently unfilled in remote areas because of low wages. Proposal for improvement Designate and train a responsible party to manage all aspects of the pay scale. Design other pay scales where required. SOURCE: SMT technical report Management of payroll and salaries This process has achieved a 100% progress rate, deemed high development, due to the following developments, among others: The SMT-RHD has an exclusive division responsible for managing payroll. Abt Associates Inc. Assessment of HRMS pg. 58

68 Payrolls and pensions are kept up-to-date. This is mainly because there are mandatory national regulations, as well as software which need to be regularly updated so that staff can receive timely payment of their salaries. Administration of benefits and bonuses This process has also achieved a 100% progress rate, which is deemed high development. Like the previous process, the registration of benefits and bonuses is mandatory and is monitored by the Ministry of Economy and Finance (MoF). Operations offices are responsible for this process. Additional bonuses in the form of AETA (Extraordinary Assignment for Health Care Work) are distributed among professionals and technicians working in health care. Each type of professional group and technicians receives 22 AETAs. Bonuses to officers and managers are provided through CAFAE. Technicians in administrative positions receive bonuses through SUB-CAFAE. Incentive management This process has achieved a 44% progress rate, which is deemed moderate development, due to the following developments, among others: While operations offices are responsible for managing monetary incentives, the SMT-RHD has not assigned a responsible party to define non-monetary incentives. Key informants report that the RHD has approved institutional regulations for the implementation of monetary and non-monetary incentives. The SMT-RHD has assigned monetary incentives to work teams and not to individuals. Despite the lack of a responsible party to manage non-monetary incentives, SMT-RHD has granted several, including public recognition of achievement of corporate goals; secretaries receiving training courses; days off; baskets of food; uniforms; and organization of internal sports championships. Despite these advances, problems have been encountered and are included in the following table. Table 50: Constraints in incentive management. San Martin, Problem Constraints Consequences Proposal for improvement SMT-RHD has not designated a responsible party to manage non-monetary incentives. Last year, SMT-RHD did not provide incentives to individuals and did not take into account the results of performance evaluations. Moreover, workers are not all able to receive incentives. HRM directorate is understaffed. SMT-RHD does not have mechanisms to measure and evaluate individual results. SMT-RHD does not know what kind of incentives are desirable to staff. Poor staff motivation and commitment in achieving institutional goals. Designate and train a responsible party to develop incentive programs. Conduct operational research to identify the type of incentives that staff wants, at all levels, whether health care staff or administrative personnel. Implement a performance evaluation system with individual goals. SOURCE: SMT technical report Abt Associates Inc. Assessment of HRMS pg. 59

69 Pension management This process has achieved a 100% progress rate, which is deemed high development. Like previous processes, the registration of pensions is also mandatory and is monitored by the MEF. Operations offices are responsible for administering pensions. There is an approved regulation for handling them, and pensions are awarded according to the current regulation Results of the assessment in other regions The following table shows the consolidated results from the evaluation prepared by PARSALUD II. Table 51: Compensation management: Performance in four regions at different levels. Institution Ucayali Cusco Huánuco Ayacucho RHD Network Micronetwork Hospital RHD does not have a pay scale for hired staff; wages are set on a case-by-case basis. One network has a pay scale for hired staff based on stable staff salaries. Micro-networks do not have pay scale for hired staff; wages are set on a caseby-case basis. Hospitals do not have a pay scale for hired staff; wages are set on a caseby-case basis. SOURCE: PARSALUD II technical report RHD does not have a pay scale for hired staff. Some networks have a pay scale for hired staff. Micro-networks are not involved in remunerative issues. Wages and salaries of micro-networks are defined by network or RHD. Hospitals do not have a pay scale for hired staff; wages are set on a caseby-case basis. RHD does not have a pay scale for hired staff; wages are set on a case-by-case basis. RHD does not have a pay scale for hired staff; wages are set on a case-by-case basis. Micro-networks are not involved in remunerative issues. Wages and salaries of micro-networks are defined by network or RHD. Only Tingo Maria hospital has created pay scales for hired staff based on the remuneration received by permanent staff. RHD does not have a pay scale for hired staff; wages are set on a caseby-case basis. Only the San Miguel network has designed a pay scale for hired staff based on the stable staff remuneration structure. Micro-networks are not involved in remunerative issues. Wages and salaries of micro-networks are defined by network or RHD. Hospitals do not have a pay scale for hired staff; wages are set on a caseby-case basis. In general, PARSALUD regions do not have specific pay scales for hired staff. Every remuneration concept is linked to an official that manages each one of them (pensions, benefits, bonuses and monetary incentives). Every remuneration concept must be updated on a permanent basis because staff payment depends on the timeliness and accuracy of this information. The results from the HRMS performance evaluation conducted by the Cajamarca RHD management team are shown below. More specifically, the following graph shows the results from the five processes in this subsystem. On average, the subsystem achieved a 53% progress rate with some processes achieving a 100% progress rate. Abt Associates Inc. Assessment of HRMS pg. 60

70 Graphic 15: Cajamarca compensation management: Results by key processes. Cajamarca: Compensation Management Pensions Management Design of Salary Scales 100% 80% 60% 40% 20% 0% Management of Payroll and Salaries Incentive Management Administration of benefits and bonuses SOURCE: Cajamarca technical report Table 52: Cajamarca compensation management: Results by key processes. KEY PROCESSES Expected result Obtained result % Complete Result Design of salary scales % Moderate development Management of payroll and salaries % High development Administration of benefits and bonuses % High development Incentive management % Moderate development Pension management % High development Average % Moderate development SOURCE: Cajamarca technical report Findings for each of the processes in this subsystem are summarized in the following table. Table 53: Constraints in compensation management. Cajamarca, Key Process Problem Constraint Consequences Design of salary scales Management of payroll and salaries Regional authorities have not established an appropriate regional salary structure. No significant problems were reported. The decentralization of functions from the MoH to regional authorities has not been accompanied by a transfer of knowledge and skills. Payroll payment is guaranteed for stable staff in Cajamarca RHD has kept the wage structure defined by the MoH for several years. Wages are paid on time in the face of strong administrative Proposal for improvement Set a salary scale according to local conditions and needs. Monitor all procedures. Abt Associates Inc. Assessment of HRMS pg. 61

71 Key Process Problem Constraint Consequences Administration of benefits and bonuses Incentive management Pension management No significant problems were reported. There is no incentive policy. Cajamarca RHD is not authorized to use institutional budget to grant incentives. No significant problems were reported. SOURCE: Cajamarca technical report institutional budgets (the so called ordinary resources.) Benefits are guaranteed for stable staff in institutional budgets (the so called ordinary resources). Decentralization process was not accompanied by adequate budgetary support. Pensions are guaranteed for stable staff in institutional budgets (the so called ordinary resources). sanctions. Benefits are paid on time in the face of strong administrative sanctions. Lack of incentives inhibits staff commitment to achieve institutional goals. Pensions are paid on time in the face of strong administrative sanctions. Proposal for improvement Monitor all procedures. Design an incentive policy for health staff, according to local realities and staff needs. Pursue research to target incentives that can motivate staff to perform well. Monitor all procedures. 2.8 Managing Human and Labor Relations: Progress Results of the assessment in San Martin Regional Health Directorate The following graph shows results from the three processes in this subsystem. On average, this subsystem achieved a 70% progress rate, which is deemed moderate development. The management labor relations process has achieved more progress than other processes. Graphic 15: San Martin managing human and social relations: Results by key processes. San Martin: Managing human and social relations Management of the Organizational Climate and Culture 100% 80% 60% 40% 20% 0% Workplace health, safety and welfare Management of labor relations SOURCE: SMT technical report Abt Associates Inc. Assessment of HRMS pg. 62

72 Table 54: San Martin managing human and social relations: Results by key processes. KEY PROCESSES Management of the organizational climate and culture Expected result Obtained result % Complete % Result Moderate development Management of labor relations % High development Workplace health, safety and welfare % Average % SOURCE: SMT technical report Moderate development Moderate development Findings from each of the processes in this subsystem are summarized below. Management of the organizational climate and culture This process achieved a 63% progress rate, which is deemed moderate development due to the following developments: The SMT-RHD has designated a responsible party to manage organizational climate and culture in the HRM directorate. The SMT-RHD has methodology and tools to assess organizational climate; with these tools, they have assessed the organizational climate this year. The assessment of the organizational climate has received support from the highest levels within the institution and at least 90% of workers. Despite these advances, problems have been encountered and are summarized in the following table. Table 55: Constraints in the management of the organizational climate and culture. San Martin, Problem Constraints Consequences Proposal for improvement The results of organizational climate assessment 9 have not yet been analyzed. No plans have been made to improve the working environment. No immediate action was taken within 30 days of the assessment. SMT-RHD has done only one phase of the organizational climate management, which is the assessment. The team in charge has not yet organized meetings to discuss the results. The delay in analysis could magnify existing problems, and dissatisfaction could grow. Arrange meetings to discuss the results and propose plans to improve the organizational climate. The team responsible has not defined whether the results will 9 The assessment of organizational climate is a snapshot that measures employe perception of organizational factors; rules; procedures; standards of productivity; management style; communication; interpersonal relationships; motivators; and leadership. These factors characterize the organization and influence employee behavior. Abt Associates Inc. Assessment of HRMS pg. 63

73 Problem Constraints Consequences be used to review and improve policies and practices of HRM. Proposal for improvement SOURCE: SMT technical report Management of labor relations This process has achieved a 100% progress rate, which is deemed high development. The project isolated the following positive developments in this process: The HRM directorate is responsible for managing this process. Over 75% of staff is unionized. Doctor, nurse and midwife unions meet monthly to discuss issues related to the health staff on duty and job stability. Administrative and technical staff unions meet at the request of the union leadership to discuss problems about health staff on duty and job stability. Key informants describe the relationship between trade unions and RHD authorities as "good". The latest negotiation between the union and the authorities has left both parties satisfied, and both sides are fulfilling all agreements and commitments. In 2012, the medical strike lasted 72 days. Relations among RHD members, networks and health facilities are generally good. However, relations within operations offices are rated as "poor" due to a lack of communication. The most common causes of labor disputes include salaries, union struggles and internal rivalries. Mechanisms used to solve conflicts include negotiating with unions, direct negotiations with the aggrieved, and negotiations with the immediate boss. Workplace health, safety and welfare This process has achieved a 60% progress rate, which is deemed high development, due to the following advances: The HRM directorate is responsible for managing this process. There are social welfare programs but only in hospitals and mostly for the elderly. Hospitals plan and organize social welfare activities. This year, the RHD is organizing the regional olympics as a social welfare activity. Hospitals have planned social welfare activities including the celebration of national and regional public holidays; staff birthday celebrations; the institution s anniversary celebration; and the organization of sports competitions. The control and regulation directorate is responsible for health and safety at work. There are approved rules, policies and programs to manage health and safety at work. The SMT-RHD plans activities for health and safety at work. Abt Associates Inc. Assessment of HRMS pg. 64

74 The scheduled activities on health and safety at work include fumigation of workplaces; provision of protective equipment for epidemics; occupational disease screening campaigns; vaccination campaigns; and an infrastructure assessment by Civil Defense. Despite these advances, problems have been encountered and are summarized in the following table. Table 56: Constraints in workplace health, safety and welfare. San Martin, Problem Constraints Consequences Proposal for improvement The SMT-RHD has not scheduled other social welfare activities aside from the olympics. Workers do not have a cafeteria or restaurant; cash loan services; financial support for trainings; a nursery; an elderly club; travel arrangements. Workers do not have health insurance in case of accident or illness. The HRM directorate has limited staff to perform these tasks. RHD has not conducted a study to identify employee needs. RHD has not evaluated the institutions ability to provide for these needs. The responsible team is not familiar with the Health and Safety at Work Law. Welfare activities should generate greater companionship to reduce internal conflicts and improve relationships. The institution could be penalized for not applying health and safety measures. Conduct a study to identify workers needs in order to improve work performance. The team responsible should review the Health and Safety at Work Law enacted by the Ministry of Labor and then implement its provision. SOURCE: SMT technical report Results of the assessment in other regions The following table shows the consolidated results from the evaluation prepared by PARSALUD II. Table 57: Managing human and social relations: Performance in four regions at different levels. Institution Ucayali Cusco Huánuco Ayacucho RHD Human relations are good despite the absence of labor climate studies. The most frequent cause of conflict is remuneration. The RHD does not conduct staff welfare programs or health and safety at work activities. Human relations are good despite the absence of labor climate studies. The cause of conflicts is remuneration. The RHD does not conduct occupational safety programs. Human relations are bad due to internal rivalry between health care staff and administrative staff; remunerative differences are also a problem. There have been isolated technical initiatives to assess the work environment, but with little application of the results. There is no information on human relations. The most frequent causes of conflicts are internal rivalries and remuneration. No welfare and safety at work programs. Programs for welfare, health and safety at work focus both on providing protective equipment for diseases and Abt Associates Inc. Assessment of HRMS pg. 65

75 Institution Ucayali Cusco Huánuco Ayacucho Network Micronetwork Hospital Human relations are good despite the absence of labor climate studies. The most frequent cause of conflict is remuneration. Networks do not conduct staff welfare programs or health and safety at work activities. Human relations are good despite the absence of labor climate studies. The most frequent cause of conflict is remuneration. Micro-networks do not keep records of welfare and safety at work programs. Human relations are generally good to very good despite the absence of labor climate studies, The most frequent cause of conflict is remuneration. Only one hospital keeps a record of welfare and safety at work programs. SOURCE: PARSALUD II technical report Human relations in some networks are good and in others bad. The most frequent cause of labor disputes is remuneration. Conflict resolution is managed by the union. No information on the analysis of social and human relations or welfare and safety at work programs. Human relations are in some cases good and in other cases bad. The most frequent cause of labor disputes is remuneration. Conflict resolution is managed by the union. Some hospitals run occupational safety programs. accidents as well as holiday celebrations. Human relations are good except in the Leoncio Prado Network, where they are bad. None of the networks provide welfare and safety at work programs. No information on the analysis of social and human relations or welfare and safety at work programs. Staff at all hospitals believes that human relations are bad. The most frequent causes of conflict are compensation and internal rivalries. Only Hermilio Valdizán hospital provides social welfare programs, as well as sterile and safe equipment for customer service. Human relations are classified as bad. The most frequent causes of labor disputes include salaries, internal rivalries and conflicts generated by unions. No records exist regarding information on welfare and safety at work programs. No information on the analysis of social and human relations or welfare and safety at work programs. Human relations in general are evaluated as good, despite the absence of labor climate studies. Welfare programs are aimed at the supply of sterile and safe equipment for customer service. In general, PARSALUD regions do not have specific activities to assure health and safety at work. Results from the HRMS performance evaluation conducted by the Cajamarca RHD management team are presented below. The following graph shows results from the five processes in this subsystem. On average, the subsystem achieved a 30% progress rate. Abt Associates Inc. Assessment of HRMS pg. 66

76 Graphic 16: Cajamarca managing human and social relations: Results by key processes. Cajamarca: Managing human and social relations Management of the Organizational Climate and Culture 100% 80% 60% 40% 20% 0% Workplace health, safety and welfare Management of labor relations SOURCE: Cajamarca technical report Table 58: Cajamarca managing human and social relations: Results by key processes. KEY PROCESSES Management of the organizational climate and culture Expected result Obtained result % Complete Result % Little development Management of labor relations % Little development Workplace health, safety and welfare % Little development Average % Little development SOURCE: Cajamarca technical report The findings for each of the processes in this subsystem are included in the following table. Table 59: Constraints in managing human and social relations. Cajamarca, Key Process Problem Constraint Consequences Management of the organizational climate and culture Management of labor relations Cajamarca RHD has made little progress in organizational climate management. This is evident on a daily basis: a large number of employees are unhappy and lack commitment to institutional goals. Management of labor relations is Managers show little interest in improving organizational climate among workers. Little interest in strengthening labor Weak health outcomes; poor achievement of institutional goals and objectives; and population dissatisfied with health care services. Staff weakly committed to Proposal for improvement Strengthen HR in the institution. Implement an organizational climate study to establish a baseline and develop mechanisms to solve problems. Design and implement an Abt Associates Inc. Assessment of HRMS pg. 67

77 Key Process Problem Constraint Consequences Workplace health, safety and welfare weak. Processes to ensure staff welfare and safety at work are underdeveloped. relations. Sporadic activities without clear objectives. Authorities show little interest in this subject. achieving institutional goals and objectives. Occupational diseases and frequent absences due to occupational diseases. Proposal for improvement institutional plan for improving labor relations. RHD authorities must be present and monitor this plan. Design and implement an institutional plan for welfare and safety at work with the participation of all appropriate offices and organizational units. SOURCE: Cajamarca technical report Abt Associates Inc. Assessment of HRMS pg. 68

78 3. Activities undertaken to strengthen the HRMS in health institutions 3.1 Activities undertaken to estimate staffing needs To implement universal health insurance (UHI) at the national level, it necessary to assure the availability and proper allocation of HHR with the necessary competencies to provide quality health care services. The first step in this process is estimating the HHR requirements needed to provide the UHI essential package (Plan Esencial de Aseguramiento Universal - PEAS) and cover the HHR gap to assure quality care under UHI. One of the main problems at the national level is the scarcity of health professionals at the first level of care. To rectify this issue, one of the HP project s main activities was designing a proposal to estimate HHR requirements at the micro-network level. The MoH and HP project designed and validated methodology for one region, and this experience was scaled up to the national level. The HP project and MoH supported the following activities: Bibliographic review of methods to identify HHR needs. The project decided to use tools proposed by WISN (Workload Indicators of Staffing Need)[8] as its main reference. Human resources software review which are applying at the regional level. The project specifically reviewed software that manages the centralized registry of payrolls and public sector HR data, which is administered by the Ministry of Finance (MoF); more specifically, the project looked at the level of reliability, data timeliness, and the level of analysis at the point of data entry. HP project regions keep updated information through software that registers HHR data except staff recruited for Health Administration Local Committees (CLAS - Comités Locales de Administración de Salud); CAS hired staff; displacements; and actual HR allocation. All regions must report using MoF software, but they do not analyze the data. Bibliographic review of approaches in estimating HR requirements for the first level of care. The project analyzed three main approaches[9, 10]: - Needs-based: converts projected service needs to personnel requirements using productivity norms and professional judgment. - Utilization-based (or demand-based): estimates future requirements based on current level of service utilization. - Health workforce to population ratio: specifies desired worker-to-population ratio. To meet the health needs and services determined by PEAS and to address population health needs using a mix of HHR, the project selected the needs-based approach. The methodology used within this approach is based on a a bottom-up process: data is collected from each health facility and is consolidated by the micro-network; data from all micro-networks is consolidated at the network level and then further consolidated at the RHD level. Established a formula to calculate HR requirements. This calculation must be done for each type of HHR. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 69

79 Formula: HHR requirement = Total quantity of time (hours) required to produce PEAS procedures Standard of available working time per health worker per year x dispersion index Calculated the numerator. The project reviewed and validated ASEGURA 10 software, which determines the number of hours required to provide each PEAS procedure linked with a specific health staff category and a specific unit time (activity standard or activity time) 11 at the national level 12. In order to validate ASEGURA usefulness in HR calculations at the regional and network level, the HP project and the MoH organized a workshop with Callao RHD and Lima Ciudad RHD. The main conclusion from the workshop was the need to make adjustments in ASEGURA, which was designed to perform financial analysis at the national level. In order to define the total number of procedures necessary to provide PEAS at the regional and local level for a given population, ASEGURA needs to be flexible when considering local incidence of priority diseases; determining the type of procedures actually performed by health staff within networks according to PEAS procedures and the actual operational capacity of health facilities; considering the regional and local population structure which is different from the structure at the national level; and considering current health care norms to calculate activity standards. In order to make calculations and include adjustments in ASEGURA, the project designed a spreadsheet 13. Another option considered was the design of an HR module within ASEGURA, but at that moment ASEGURA was being reviewed and updated. The spreadsheet has the following advantages: o It is based on the probability of occurrence of cases (for healthy and ill conditions) by age group for a given population. o o o o o o For each case, the spreadsheet defines all the procedures involved based on current health care standards. For each procedure, it establishes the HHR types involved and the time spent by each HR type to perform a procedure based on current health care standards. It considers the effective time that will be available to provide health care (that is discounting administrative, training, vacations time, among other issues). Allows adjustment according to current and potential health portfolio in the short and medium term. Allows calculation of the HR requirements adjusted for the conditions of the district in which the health facility is located. It considers the current HR allocation in each health facility to determine the gap that must be covered Software designed by Partherships for Health Reform plus (PHRplus) project to estimate PEAS cost at the national level. How much time on average a case should take each staff category, while working to acceptable professional standards. (WISN, page 5.) See ASEGURA software in Annex 7.5. See procedures to use spreadsheet in Annex 7.6. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 70

80 o Facilitates the design of charts and graphs, which allow for better analysis of HR allocation within the micro-network. Calculated the denominator. The project used the WISN method as a technical reference point: WISN is based on actual work and is useful for calculating both current and future HHR requirements. More specifically, it is based on working time, components of work and activity standards. For our purposes, the project identified indicators related to time spent at work and other components, including time to directly provide services, vacations, sick leave, holidays, training, local travel, and administrative burden. On this basis the project gathered the relevant information in the field. The project provided technical assistance to the MoH team to design and develop the research project using these indicators. The research was executed in Ayacucho RHD to determine the time available to solely perform PEAS procedures. This research project was financed by the MoH. Additionally, the HP project, along with technical teams from Ucayali and San Martin RHD, conducted interviews to determine the available working time to provide PEAS at the first level of care 14. Research results were, in some cases, absolutely unacceptable: in several networks, health workers spend more than 50% of their time doing activities other than providing health care services. One conclusion from this research study is that there is a need to define activity standard : how much time on average a case should take each staff category while working to acceptable professional standards and standards related to distribution of health providers time. It is not acceptable that health workers, who are hired to provide health care services, spend more than 80% of their time doing other activities. If RHDs do not properly organize and control staff time distribution, they will always have HR gaps. Given these results, the SMT-RHD defined standards for the available working time for each type of health facility at the first level of care 15. The MoH analyzed results obtained in Ayacucho, San Martin and Ucayali, and determined a national standard for the available working time needed to provide PEAS. Table 60: Ministry of Health: Percentage distribution of the workload, by occupational group for the first level of care. Occupational group Workload To provide Other Total PEAS activities Physician 82% 18% 100% Dentist 94% 6% 100% Nurse 74% 26% 100% Psychologist 73% 27% 100% Midwife 72% 28% 100% Medical technologist - radiology 94% 6% 100% Medical technologist - laboratory 94% 6% 100% Nutritionist 90% 10% 100% See the survey in Annex 7.7. See a detailed table in Annex 7.8 and a summary table in Annex 7.9. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 71

81 Occupational group Workload To provide Other Total PEAS activities Social worker 90% 10% 100% Technician in radiology 94% 6% 100% Technician in laboratory 94% 6% 100% Technician in laboratory 72% 28% 100% SOURCE: USAID Peru Health Policy Reform project and the Ministry of Health, Calculated the dispersion index. Since expected health worker performance is different in rural and urban settings, it is important to determine a rural index to adjust calculations based on the conditions of the location. Due to the diversity of clusters with different levels of population density and local development in Peru, it was necessary to define an index that adjusts HR requirement calculations. The HP project and the MoH developed a study to determine the rural index for each district nationwide[11]. Based on this study and after many workshops with RHD, the MoH used one of the components from the rural index (population density) and defined a dispersion index for all districts in the country. The dispersion index has only two clusters: dispersed population and no dispersed population. From this, the MoH defined a productivity index to adjust HR requirement calculations. Table 61: Ministry of Health: Productivity index according to dispersion index. Type of district according to dispersion index Productivity index District with dispersed population 0.75 District with no dispersed population 1 SOURCE: Technical Guide No. 001-MINSA/DGRH-V.01 Guide methodology for calculating HR gaps in health care services at the first level of care, page 8[12]. Table 62: Ministry of Health: Productivity index according to rural index. Type of district according to rural index Productivity index Highly rural 0.50 Rural 0.63 Intermediate 0.75 Urban 0.88 Highly urban 1.00 SOURCE: USAID Peru Politicas en Salud project[11]. Determined the formula to calculate HHR gap. Once HR requirements were defined, the next step was to calculate the HR gap by comparing the difference between current and required staff in order to identify understaffed or overstaffed networks. The formula to estimate the HHR gap is: HHR gap = Current staffing HHR requirements Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 72

82 Current staffing. Aside from determining HHR requirements, it is necessary to determine current staffing by network in order to calculate the gap. The main difficulties in estimating the HHR gap were related to staff turnover as well as the lack of reliable information regarding the actual location of health staff. It took more than six months to collect current staff information in Ayacucho, Ucayali and the SMT-RHD; once consolidated, this information proved to be completely outdated. The SMT-RHD decided to organize a workshop with all the micro-networks; each micronetwork prepared the required information, which was consolidated during the course of the workshop. While productive, organizing a workshop whenever RHDs need this type of information is expensive and inefficient. A mechanism is needed to oblige all micronetworks periodically send information about the current staffing at each facility to its respective network; networks would then send this information to the RHD for regional consolidation and analysis. The micro-network is the only source of this kind of information; without this information, any estimation is completely arbitrary. The following table displays an example of the results which could be obtained automatically with the application of the spreadsheet to calculate HR staffing needs. Table 63: Huallaga network: HHR staffing needs, SMT-RHD, Physician Dentist Nurse Psychologist Midwife Biologist Lab Tech Technician Sacanche micro-network (7,782 inhabitants) HHR requirements (A) Current staffing (B) HHR gap (B - A) Workload ratio (B/A) Health workforce to population ratio (B/hab*10000) Saposoa micro-network (19,875 inhabitants) HHR requirements (A) Current staffing (B) HHR gap (B - A) Workload ratio (B/A) Health workforce to population ratio (B/hab*10000) HUALLAGA NETWORK (27,757 inhabitants) HHR requirements (A) Current staffing (B) HHR gap (B - A) Workload ratio (B/A) Health workforce to population ratio (B/hab*10000) Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 73

83 SOURCE: SMT-RHD technical report on HHR gap[13]. Analyzed results. The analysis is based on three calculations using two variables: HHR requirements obtained through ASEGURA plus adjustments for location conditions; and current staffing obtained directly from micro-networks until a comprehensive HHR information system is implemented. o o HHR gap: Comparing the difference between current and required staffing levels to identify which locations are understaffed or overstaffed. In the table above, the negative numbers in red indicate understaffed positions. For example, in Huallaga network there is a severe shortage of nurses, especially in the Saposoa micronetwork. This information could prove useful if Huallaga network has additional funds to hire health workers: the priority would be to hire nurses in Saposoa micronetwork instead of technicians, which is a currently overstaffed position. Workload ratio (the WISN ratio)[8]: Dividing current staffing by HR requirements as a proxy measure to assess the pressure that health workers experience in their daily work. Values over 1 indicate overstaffed; values below 1 indicate understaffed. For example, if a heath facility has four physicians and needs only two, the workload ratio is two; this means that two doctors are working for every one that is needed. Conversely, if a heath facility has two physicians and needs four, the workload ratio is 0.5, which means that one doctor has the workload of two doctors. In Huallaga network, nurses have the lowest workload ratio, which means that they have the highest actual workload and feel the most pressure of all workers. o The availability of HHR measured by the ratio of professionals per 10,000 inhabitants: Dividing the current staffing by the total population. According to the Pan American Health Organization (PAHO), there are usually 10 physicians, 10 nurses, and five midwives per 10,000 inhabitants in developing countries. To compare, Huallaga network has five physicians and five nurses per 10,000 inhabitants; this is 50% less than the average. There are 5.4 midwives per 10,000, which is slightly more than the average. Accordingly, there would be no need to hire additional midwives in this network. The HHR shortage is severe in remote and rural areas mainly due to low wages and poor working conditions, as well as low connectivity in most of the micro-networks which prevents regular professional development. Defined strategies to cover the gap. With these results, the project discussed a set of strategies to gradually bridge the gap: o Improve working conditions, especially in remote and rural areas. o Establish mechanisms to monitor the appropriate use of staff time. o Distribution of tasks or task shifting. o Improve equipment to shorten working time. o Define health facility opening hours according to population needs to increase productivity. The project worked with Ayacucho RHD to implement task shifting at the network level. Preliminary results from task shifting show that at the operational level, where the scarcity of physicians is high, nurses and midwives are performing some medical procedures. In Ayacucho, nurses and midwives are teaming up to share tasks that have traditionally belonged to only one of them. Task shifting resulted in a decrease in the average number of working hours for doctors and nurses, as well as an increase the average number of working hours for midwives. After task shifting, the overall gap of health staff changed. Some networks have a gap in midwives instead of being overstaffed, and fewer networks Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 74

84 are overstaffed in general. This is evidence that the redistribution of tasks as a result of task shifting allows the efficient use of scarce resources such as doctors and nurses. Based on this methodology, the MoH designed an application to perform these calculations, and the project provided TA to support application in Ayacucho. Additionally, the HP project worked with the MoH to design the Methodology Guide to Calculate HHR Gaps for the First-Level-of-Care, which is being approved through a ministerial resolution for nationallevel implementation. 3.2 Activities undertaken to define job profiles The National Civil Service Authority (SERVIR), which directs the HRMS, states that the classification and organization of employment positions is the starting point for the implementation of a HRMS. To promote this idea, SERVIR developed a technical paper entitled "A Methodological Guide for the Development of Job Profiles to facilitate the correct construction of job profiles by human resource managers[14]. Within this framework, job profiles serve as a tool of HR management in providing structured information regarding the location of a position within an organizational structure, the position s purpose and its main functions. A job profile also includes the requirements and demands of the job to clarify expectations and performance standards. Based on the importance of the job profile, SERVIR and the HP project developed two macroregional workshops to disseminate methodology for designing profiles. The methodology, in line with the conceptual framework established by SERVIR, identified a number of procedures to be accomplished before the design of a job profile[15]: Review of institutional policy documents (ROF, MOF, CAP) Define the criterion that determines positions and their functions based on one of the following three approaches: systems approach, process approach, or function focused. Development of a matrix to define functions for each of the positions. Preliminary Job profile design - Determining functions within the matrix of job functions. - Assessing job functions. - Identifying essential job functions. - Identifying position requirements. - Identifying skills and competencies required for the position. The Ayacucho RHD technical team, with technical assistance from the HP project, developed job profiles for the Ayacucho Executive Office of Management and Human Resource Development; these job profiles are listed below and detailed in the HP project technical paper, entitled "Staff Jobs Profiles for the Executive Office of Management and Human Resource Development [16]. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 75

85 Table 64: Job profiles for the Ayacucho RHD. Organizational Unit Executive Office of Management and Human Resource Development Proposed Positions Executive director for HRM and development in health Head of the HR planning unit Head of employment management unit Head of job design and performance management unit Head of pensions and other benefits unit Responsible for social welfare and incentives Responsible for payroll and salary scale Head of occupational health and organizational climate unit Responsible for personnel data and record keeping Responsible for attendance control Responsible for SERUMS SOURCE: USAID Peru Health Policy project and Ayacucho RHD. The HP project continues to support and provide technical assistance to the Ayacucho RHD in designing job profiles for staff who provide primary health care services. More specifically, the project is working to identify and systematize technical information that has been validated by representatives of networks and micro-networks. The methodology developed by the HP project for job profile development dictates that defining "health professional positions is a first step in the process and should be guided by Law N o and its regulations (DS N o PCM). Based on this, health professionals include the following groups: surgeons, dental surgeons, obstetricians, nurses, biologists, psychologists, social workers, and pharmacists. The HP project also considers nursing technicians to be important components of the health team. Having specified professional health groups, the following three points are important in the development of job profiles and are included in the HP project document entitled "First-Level-of-Care Job Profiles"[17]: Point 1: Finding information on the functions of each occupational group by category within each first level of care including I-2, I-3, and I-4. Point 2: Confirmation of job functions through expert judgment (regional workshop). Point 3: Job profile description for first-level-of-care staff. The Ayacucho RHD technical team designed job profiles for the following first-level-of-care personnel: Table 65: First-level-of-care personnel job profiles for the Ayacucho RHD. Health Facility Categories Proposed Positions I-2 Medical care I-2 Nursing care I-2 Obstetrical care I-2 Nursing technician I-2 I-3 Medical care I-3 Nursing care I-3 Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 76

86 Obstetrical care I-3 Nursing technician I-3 Responsible del Pharmacy Services I-3 Responsible for Nutritional Services I-3 Responsible for Social Services I-3 I-4 Medical care I-4 Nursing care I-4 Obstetrical care I-4 Nursing technician I-4 Dental surgeon (primary care) Psychological care (primary care) Laboratory supervisor (primary care) Responsible for Pharmacy Services I-4 Responsible for Nutritional ServicesI-4 Responsible for Social Services I-4 SOURCE: USAID Peru Health Policy project and Ayacucho RHD. In addition, the HP project provided TA to the SMT-RHD in the analysis of a new organizational structure and, more specifically, in the definition of specific functions; job descriptions and analysis; and job profiles. Taking into account SMT-RHD priorities, the following tables summarize organizational units and corresponding job profiles[15]: Table 66: Regional Health Directorate of San Martin. Organizational Unit DIRECTORATE OF HUMAN RESOURCES DEVELOPMENT Proposed Positions Director Institutional organizational development specialist RRHH sector management specialist DIRECTORATE OF OPERATIONS Work management specialist Performance development and evaluation specialist Director Unit chief Budget management specialist OFFICE OF STRATEGIC SECTOR PLANNING Administrative support specialist (decentralized operations) Logistics management and control specialist Internal administrative management specialist Office chief Budget and finance specialist Planning specialist Project investment specialist Organization and quality assurance specialist Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 77

87 Organizational Unit OFFICE OF HEALTH INTELLIGENCE Epidemic Control, Emergency, Disaster Prevention Unit Information Research and Analysis Management Unit OFFICE OF LEGAL COUNSEL DIRECTORATE OF HEALTH SECTOR REGULATION AND AUDIT Health Sector Regulatory Unit Health Sector Audit Unit DIRECTORATE OF COMPREHENSIVE HEALTH Individual and Family Health Unit Public Health and Environment Unit Proposed Positions Office chief Unit chief Epidemiological surveillance specialist Epidemics, emergencies and disaster specialist in charge Unit chief Investigation specialist Information management specialist Communications specialist Documentation specialist Office chief Regulation and supervision specialist Judicial processes and administration specialist Director Unit chief Environmental health specialist Unit chief Public and private services inspector specialist Pharmaceutical establishments inspector specialist Basic sanitation inspector specialist Food hygiene inspector specialist Ecology and environmental protection inspector specialist Director Coordinator of comprehensive health Individual and family health unit chief Youth and adult life stage specialist Senior adult life stage specialist Public health and environment unit chief Health promotion specialist Drug and Health Services Management Unit Technical unit chief Organizational and services management specialist SOURCE: USAID Peru Health Policy project and SMT-RHD. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 78

88 Table 67: Office of Operations - Health (OOH). Organizational Unit OFFICE OF OPERATIONS ADMINISTRATIVE MANAGEMENT UNIT Proposed Positions Office chief Unit chief Personnel manager Accounting manager Treasurer BUDGET MANAGEMENT UNIT Unit chief Budget management unit chief SOURCE: USAID Peru Health Policy project and SMT-RHD. Table 68: Health Network. Organizational Unit Health Network OFFICE OF HEALTH PLANNING AND INTELLIGENCE OFFICE OF SANITARY MANAGEMENT DIRECTORATE OF INDIVIDUAL HEALTH DIRECTORATE OF COLLECTIVE HEALTH MANAGEMENT OFFICE OF ADMINISTRATIVE LIAISON MANAGEMENT Proposed Positions Director Office chief Planning specialist Epidemiology specialist Office chief Organization and health services management specialist Human resource management specialist Director Immunization and child specialist Food and nutrition specialist Director Health promotion and community participation specialist Occupational health specialist Office chief Personnel administration assistant Logistics and control assistant SOURCE: USAID Peru Health Policy project and SMT- RHD. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 79

89 Table 69: Job profiles for the health micro-network: First-level-of-care staff. Organizational Unit Proposed Positions Micro-network Medical care I-2 SOURCE: USAID Peru Health Policy project and SMT-RHD. Nursing care I-2 Obstetrical care I-2 Nursing technician I-2 Medical care I-3 Nursing care I-3 Obstetrical care I-3 Nursing technician I-3 Medical care I-4 Nursing care I-4 Obstetrical care I-4 Nursing technician I-4 Dental surgeon (primary care) Psychological care (primary care) Laboratory supervisor (primary care) The HP project s TA was instrumental in the development of job profiles at the regional health directorate level and has contributed to the improvement of the HRMS in the following ways: - Regarding the recruitment and selection process, job profiles provide information that can help define the types of media and notices necessary to attract the largest number of candidates. - Job profiles facilitate the induction process of orientating a new employee within the organizational structure; clarifying relationships with other positions and organizational units; and outlining objectives and duties. - Training processes are better oriented for the development of Personal Development Plan (PDP). - In the performance evaluation process, updated job profiles are helpful in defining personal skills or competencies to be monitored through performance evaluations. - Job profiles also support decision making regarding displacement decisions, designation, rotation, temporary assignments and staffing redeployment. In recent years, SERVIR has been developing actions within the most urgent aspects identified to initiate civil service reform as a mandatory by the human resources office, or in lieu thereof, as stated in Article 6 of Law N o During the course of the year, there have been a series of regulatory changes regarding HRM in health institutions nationwide. Specifically, it is now mandatory for health care institutions to possess updated job profiles in compliance with administrative regulations and requirements. HP project participation in organizing and structuring Ayacucho HRD and SMT-HRD job profiles has provided both a valuable experience and a considerable advantage for both regions as other regions work towards adapting to current regulations for HRM in health institutions. 3.3 Activities undertaken to define managerial competencies According to the ILO[18], job competencies are divided into general and specific competencies. General competencies can be described as corporative, generic, organizational, core, and Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 80

90 value-based; all members of an organization must possess these competencies. Specific competencies can be described as technical or functional aspects; each worker in an organization performs a set of functions and must demonstrate competency in the proper performance of those functions. The capabilities linked to the employee's functions are "specific competencies". USAID projects provided TA to the MoH in the conceptual and methodological framework to define general competencies. Using this framework, the MoH defined the following general competencies for the health sector 16 : 1. Ethical commitment 2. Respect for life, people and environment 3. Communication based on cultural diversity 4. Teamwork 5. Ability to organize and plan These general competencies must be a part of the job profiles for each posotion in all public health organizations. Accordingly, the HP project provided TA to help design job profiles in the Ayacucho RHD and the SMT-RHD, and these competencies have been included in all job profiles. The Council for the Quality of Professional Education (Consejo de evaluación, acreditación, y certificación de la calidad de la educación superior universitaria CONEAU) is in the process of defining managerial competencies for all health professions. CONEAU is responsible for working with professional associations and training institutions in the definition of professional competencies. There is consensus among health professional associations that all health professionals perform healthcare, training, management and research actions, focusing on their daily activities in one of them. In April 2013, CONEAU officially formed a special committee responsible for designing managerial competencies, which will be used in the mandatory professional certification process. In , CONEAU designed a proposal related to managerial competencies and in 2013 CONEAU submitted the proposal to the special committee for review, but this committee has yet to convene. As part of the decentralization process, a new set of functions was transferred from the MoH to regional health directorates. To support this change, the HP project provided assistance to the SMT-RHD in the definition of specific managerial competencies for each of the new functions through the creation of a competencies dictionary 18. This dictionary has been used in the definition of specific managerial competencies in Ayacucho and SMT. The Ayacucho RHD asked the HP project for TA in the design of HR job profiles. Using the SMT-RHD managerial competencies dictionary, the Ayacucho management team identified specific competencies necessary for HR management 19 and then assigned specific competencies to appropriate job profiles. To define job profiles and develop performance evaluations for managers at the SMT-RHD network level, the HP project supported technical teams at the network level in defining two types of managerial competencies: transversal, which are common to all management positions, and specific, which are related to the specific functions of the position. For specific managerial competencies, the HP project utilized the managerial competencies dictionary, which contains 86 specific competencies. Managers at the network level used this dictionary to prioritize three competencies that are specific to each position and included them in respective 16 See MoH general competencies in Annex See CONEAU managerial competencies in Annex See Managerial competencies dictionary in Annex See HRM competencies in Annex Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 81

91 job profiles. For transversal competencies, the HP project provided a list of 14 competencies 20 determined by a bibliographic search of the most common managerial competencies. Based on this list, network managers defined four competencies to be included in job profiles for all managerial positions and in performance assessments for network managers. The four transversal managerial competencies include: 1. Maintain a satisfactory organizational climate 2. Lead, mobilize and inspire teams 3. Maintain good interpersonal relationships 4. Use resources with a high sense of responsibility 3.4 Activities undertaken to design salary scales One problem in the health sector is the shortage of human resources, especially at first-level-ofcare facilities. One cause of this problem is the inability to attract and retain qualified staff, mainly in health facilities located in remote and excluded areas; unfortunately, these areas also have a greater need for health care services. More broadly, while the level of development and connectivity plays roles in attracting and retaining health care professionals, wages are even more strongly linked to hiring and retention. Given this, RHDs should set fair and equitable salaries for hiring staff, especially since more than 50% of the health workforce is contracted by a variety of regimes. Graph 17: Health professionals by labor condition, MoH and regional governments, SOURCE: MoH HHR Observatory The main problem in setting a regional salary scale for health staff is the lack of governance from RHDs due to the existence of budget spending units (unidades ejecutoras de presupuesto UE). These units have the authority to define the number of staff hired and respective salaries without considering technical criteria. This autonomy generates internal 20 See Transversal managerial competencies in Annex Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 82

92 inequality, dissatisfaction and demotivation among health workers since two or more health professionals doing the same job receive different wages. Additionally, local governments as well as public and private donors can hire health personnel and offer a different salary: this means that professionals working in the same health facility performing the same functions earn different wages. To define a fair and equitable salary scale in hiring health personnel at first-level-of-care facilities, the HP project worked with Ayacucho, Ucayali and SMT RHDs to define methodology and tools to set salary scales according to specific characteristics and regional needs[19]. In February 2012, two directives were approved in Ayacucho: a regional directive approving salaries for first-level-of-care personnel hired by CAS and a second-level-of care personnel hired by CAS 21. In Ayacucho, the wage scale is being implemented in all UE. The RHD team used the methodology to design salary scales for hospitals and RHD workers; they also used the wage scale to establish the 2013 budget. In Ucayali, the HP project provided TA to define criteria and respective weights in order to value job positions and define a salary scale for each micro-network. The salary scale was applied in the recruitment and selection process in some networks, but there was no regional resolution to approve its use in all networks. In SMT, the project presented its experiences from Ucayali and Ayacucho in the design of pay scales for the first level of care. Regional authorities were interested in this methodology because it allows them to consider different contexts and factors. Using this background information, the management team defined four factors to be considered in the SMT pay scale as well as the relative weight and importance of each factor. The team also defined the following characteristics: separate pay scales for medical and non-medical health professionals and technicians; and a pay scale for each health facility. With these guidelines, the project designed SMT-RHD pay scales that were then approved through directorial resolution. Factors and their respective weights are shown in the table below. Table 69: Criteria and weights Level of development Accessibility: Distance from Tarapoto Level of poverty Time spent to get to remote communities A. Most rural 50 A. More than 8 hrs 65 A. Quintile I and II 30 A. More than 6 hrs 36 B. Rural 40 B. 2 to 8 hrs 55 B. Quintile III 25 B. 3 to 6 hrs 30 C. Intermediate 35 C. 15 minutes to 2 hrs 40 C. Quintile IV 20 C. 30 minutes to 3 hrs 25 D. Urban 30 D. Less than 15 minutes 35 D. Quintile V 15 D. Less than 30 minutes Regional Directive N GRA/GG-GRDS-RHD-DEGRRHH and Regional Directive N GRA/GG-GRDS-RHD-DEGRRHH. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 83

93 3.5 Activities undertaken to develop competencies at micronetwork level One of the challenges faced by all RHDs is reducing maternal mortality and child malnutrition. Achieving this depends not only on the availability of equipment but also on the availability of competent health workers to provide quality health care. Accordingly, it is important to identify and confront issues related to HHR management and development, including the following[20]: Limited development of competencies among health workforce. High turnover of trained staff. Reduced or inexistent access to training activities for health personnel in remote areas Poor coordination between RHDs and training institutions resulting in health professionals who are not responsive to regional health needs Training programs conducted in settings which are different from actual work environments Performance evaluations are not competency-based Health personnel are poorly motivated and not committed to the goals and strategies of their respective institutions To manage these issues, USAID provided TA to regional governments to implement regional HHR policies and improve health worker competencies related to the provision of quality health services to mothers and children. As part of this TA, Huanuco, Pasco and Junin RHDs cooperated in the development of a conceptual, methodological and instrumental framework for a "Competencies Development System", which includes the implementation of competencies development centers (CDC). Huanuco RHD was the only institution that implemented all aspects of the system, including the opening of three CDCs in Amarilis, Margos and Acomayo. The objective of a CDC is to generate and strengthen labor competencies among RHD health workers at the network and micro-network level with the involvement of local government, training institutions and professional associations. These centers are part of an in-service training strategy to foster the development of competencies in locations similar to actual workplace settings. Stages of CDC implementation are shown in the graph below. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 84

94 Graphic 18: Stages in CDC implementation Identifying potential internship sites Design and approval of job competencies, performance standards and evaluation tools Continous supervision of certified workers Certification of workers trained Implementation of competencies development center CDC Qualification of micro-networks as CDC Training program design E V A L U A C I O N Supervision of workers trained in their workplace Training program development Source: USAID Health Policy Initiative. Mejorando Las Competencias Laborales en el Ámbito Local. 2009: 31. USAID TA achieved the following results in 2009[21]: CDCs institutionalized in Huanuco, Junin and Pasco regions with the assistance of the regional government s social development management department as well as RHDs and local governments. Labor competencies designed, validated and approved for antenatal care; growth and development monitoring (control de crecimiento y desarrollo CRED); training nutritional sessions; care of women in labor and immediate postpartum; and vertical birth. Non-monetary incentives granted by local governments and civil society to reward competent HHR from San Luis de Shuaro and Pichanaki micro-networks in Junin RHD. Official recognition of competency evaluation committees in Huanuco, Cusco, Junin and Ucayali. Official recognition of CDC qualification committees in Huanuco, Cusco, Junin and Ucayali. Official recognition of CDC tutors. Evaluation of the following competencies: CRED in Huanuco, Junin and Pasco; demonstration sessions for the preparation of food with local products in Junin; and antenatal care in Pasco and Junin. Official recognition of CDCs in Huanuco for CRED; Junin for antenatal care and nutritional demonstration sessions; Ayacucho for antenatal care; Cusco for vertical birth; Pasco for antenatal care; and Ucayali for antenatal care. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 85

95 92 health workers were trained at a CDC through an internship. Six health workers trained at a CDC have received supervisory visits. Achievements in Huanuco in this short time frame were mainly due to USAID TA; strong support from the regional government s social development manager; the involvement of the University of Huanuco s School of Nursing; and most especially the commitment of networks technical team. A year into CDC implementation in Huanuco, regional and RHD authorities changed, and CDCs were left without technical and political support. However, two CDCs in Amarilis and Acomayo are still operating today. The HP project visited these two centers to interview health authorities and tutors to determine how the centers have managed to continue operating. The visit yielded the following findings: All tutors were recognized as certified and competent in CRED through regional resolutions. Many tutors were also employed as teachers in regional universities, and the health facility was incorporated into the university as a teaching center. Mothers attending these health facilities, easily recognized if they are attended by a trained in the CDC, of another who was not involved in the internship at the CDC, and not allowed to be attended by untrained personnel. This causes the staff has not been trained ask to participate in the internship at the CDC. Health workers from other health networks claimed to be trained at the CDC. The local government supports the maintenance of equipment and materials for early stimulation. This program will be implemented in SMT health networks. 3.6 Activities undertaken to assess management performance A performance assessment consists of identifying, measuring and managing human performance in organizations. Identification is based on jobs analyses and intends to determine which work areas should be studied when their performance is being measured. Measurement is the core of an evaluation system and seeks to determine how performance compares with certain objective parameters. Management is the focal point of any assessment system and to realize the full human potential of an organization it should be orientated towards the future rather than focus on examining past activity[22]. The regulatory framework defines performance evaluation as a mandatory, comprehensive, systematic, continuous and demonstrable set of staff activities, skills and performance measures to meeting goals and objectives. Senior management and human resources, or the latter s designees, are responsible for ensuring assessments are carried out in the time and manner established by SERVIR. All evaluation processes are subject to the following minimum requirements: Performance factors measured should be related to job functions, which are clearly defined in the job profiles of the organization. Performance is based on factors related to measurable and verifiable targets. Prior to the evaluation, the worker must be aware of the procedures, factors or goals which are evaluated. Evaluations are conducted on an annual basis. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 86

96 A worker who does not participate in the evaluation process on his own accord, for justified reasons such as illness, receives a disapproving score, since the performance evaluation is mandatory for all employees. All performance evaluations must conform to institutional characteristics, and services provided correspond to the position types in an organization. SERVIR considers the following two types of evaluation as complementary. The first type of evaluation is a measurement of competence that identifies the gap between optimal skills and current skills to identify training needs. The second type of evaluation aims to measure goal achievement and identify staff contribution towards achieving organizational goals as well as areas where adjustments are required to improve performance. Due to the approval in previous months of new regulations for the civil service and the administration of performance evaluation, the HP Project has conducted workshops with the SMT-RHD management team to develop a management tool that allows them to identify training needs. Additionally, the management tool would also verify and qualify achievements according to individual institutional goals programmed into the duties performance required by each position. The objective is to provide the SMT-RHD with a tool to measure the evolution of employee work performance in order to continuously improve institutional management Performance evaluation method The evaluation method developed and proposed by the HP Project ensures that criteria and practices allow distinguishing performance differences that exist between people in the service of SMT-RHD. The performance evaluation consists of two parts: a. Results Evaluation This component measures the performance of position functions and/or processes. These functions, including essential and general functions, as well as position processes, are clearly defined in position profiles for each organizational unit of the SMT-RHD. b. Competency Assessment This component measures general work competencies which have been identified and approved for all health sector staff and are contained within the MoH publication "Work Competencies for Improving the Performance of Health Human Resources". The following graphs demonstrate the two components of a performance evaluation. Graphic 19: Results Evaluation Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 87

97 Graphic 20: Competency Evaluation Performance evaluation implementation The implementation of performance evaluations for SMT-RHD staff contains two components: a) Competency measurements to examine position abilities, skills and attitudes takes place through a 360 evaluation in which the criteria and parameters for each evaluator, including self, supervisor, subordinate, peer and client, are required to measure the competencies established by position type, as shown in the graph below. b) Completion of essential job functions. To achieve strategic and institutional objectives, in which essential functions need to be identified, processed, displayed and valued on levels established by SMT-RHD organizational unit leaders. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 88

98 Graphic 21: 360 Competency Assessment Competencies evaluation definition and criteria The following general competencies were selected by the SMT-RHD technical team while the definitions and evaluation criteria were established by the MoH[23]. ETHICAL COMMITMENT ORGANIZATION AND PLANNING CAPACITY TEAMWORK The health worker demonstrates responsible attitudes and service actions in response to service needs based on principles and values, the common good, human dignity and the right to health. The health worker organizes his/her goals, objectives, resources, roles, activities and tasks to achieve better health and social transformation results working within health guidelines and policies. The health worker cooperates and collaborates; integrating into trans disciplinary teams to achieve organizational objectives and quality care services in community health. Works for the common good, with honesty and confidentiality. Completes his/her work quickly and with quality. Identifies, organizes his/her goals, objectives, functions, activities, tasks and options through an established plan. Works in a planned manner to achieve strategic results, in a set time frame, building towards future progress. Participates in obtaining common goals, respecting different opinions and avoiding competition. Supports team members principally by sharing information, knowledge and resources Analysis of results obtained in the evaluation of goals attained and competencies Once the performance evaluation is completed, the SMT-RHD Directorate of Human Resources processes the information in a format entitled "Analysis of Results Obtained", as shown below, to determine the gap between expected and observed results. The Problem Statement section highlights factors which caused the gap, analyzes the problem and identifies causes. The format also shows proposed corrective actions in the short- and medium-term for each evaluated category. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 89

99 Graphic 22: Analysis of the results obtained 3.7 Activities undertaken to improve recruit and selection processes The recruitment and staff selection sub-processes are defined in the employment management system and framed by the HRM system. These processes are intended to include highly competent persons within varying organization work areas through transparent and efficient processes, where merit, suitability and non-discrimination are central elements of its execution. At present there are irregularities in the implementation of HRM processes (selection, training, evaluation, mobility, separation, compensation and incentives) depending on labor arrangements. For example, in most public sector institutions there is no application of merit and performance principles for either recently hired or long term staff or towards service retention and no monitoring mechanisms both selection and design processes of job profiles. Selection tends to be based on the characteristics of the person to be chosen rather than those required for the position. Following the analysis for estimating health human resource gaps at all SMT-RHD networks and micro-networks, the project performed in January 2013, a baseline evaluation of staff recruitment and selection processes. The analysis took as observation samples the budget execution units at San Martin (U.E. 400) and Alto Mayo (U.E. 401), both of them in San Martin RHD. The purpose of the study was to describe the recruitment process in force, so as to allow the identification of improvement options in the context of the modernization of the human resource management system. Tools used in the baseline evaluation were: questionnaires (items research), interview guides and check lists. Steps from the recruitment and selection process that were evaluated are: preparatory stage, recruitment stage, selection stage, contract signing stage. The organic units which participated in this evaluation are mentioned in table 64: Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 90

100 Table 70: Base Evaluation: Participants U.E 400 U.E 401 SMT-RHD Office of Resource Administration Office of Resource Administration Directorate of the Office of Administration Office of Human Resources Office of Human Resources Executive Office of Institutional Development and Quality Office of Planning Office of Planning Office of Strategic Planning SOURCE: USAID Peru Health Policy project Results of assessment are shown in the table 71 below: Table 71: Results of baseline evaluation of recruitment and selection processes at San Martin RHD. January, 2013 Preparatory Stage Issues assessed U.E. 400 U.E. 401 Comment / recommendation N o workers in the area of human resources 5 3 HRM unit understaffed and under qualified Incumbent officer for recruitment and selection No No Appointment of the incumbent Job profiles availability No No Development and standardization of job profiles Competitive salary scale definition and implementation Scale defined but not implemented Scale defined but not implemented Implementation plan needs to be defined and deployed Estimation of human resources gaps Yes Yes Link recruitment process to gaps identified Triggers to staff recruitment process Recruitment Stage Memo/Micro- Networks Reports/Networks and Micro-networks Define and standardize forms and define formal parties Use of institutional web page Sometimes No Publication is mandatory Ministry of Labor Portal (website) No No Publication is mandatory Other recruitment methods Hospitals murals Hospitals murals Utilize any method that attracts the largest pool of candidates Publication duration 5 days 3 days Use time frame indicated in current regulations Selection Stage Selection committee nomination Yes Yes Recommended composition: at least one representative of HR area and one from the user area N o of committee members 8 5 Standardized criteria Evaluation of CV and personal interview Yes Yes Required by law Other evaluations Publication of evaluation results on institution website SOURCE: USAID Peru Health Policy project Psychological plus knowledge evaluation Psychological Evaluation Structured evaluation instruments should be utilized No No Publication is mandatory Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 91

101 The assessment performed in San Martin RHD revealed that the highest percentage of health workers in health facilities and micro-networks were hired under CAS modality. With that information in mind San Martin RHD requested the project advance a proposal to set policies and procedures for the recruitment and selection of staff. Within this proposal also had to be defined powers, responsibilities, obligations and terms of the organizational units involved in the process, according to regulations and the reality and potential of the region. Particularly, SERVIR regulation for the recruitment procedure were taken into consideration (see graphic 66). Graphic 23: Macro process: administrative services contracting - CAS During 2013, the project conducted workshops with the technical team of San Martin RHD to build the recruitment process proposal. As a consequence San Martin RHD Director and his management team approved the general process flowchart for recruitment. This process is described below (Graphic 24). Preparation Stage: This stage starts the recruitment process, and includes the approval of recruitment requirements to be part of the job announcement. The administrative management unit (UGA) is the body responsible for administrative services contracts within health office operations, hereinafter OOS. Process initialization: a. The user area sends the administrative service requirement to the immediate supervisor in their organization. In San Martin RHD, through the Directorate of Health Management, where an assessment has to be made as related to estimates of human resource requirements. b. All networks forward to their Health Operations Office their approved human resource requirements, within a schedule timetable. OOS budget execution unit evaluates networks requirements based on budget availability. c. Budget execution unit forwards the requirement along with their certified budget proposal to the health network. d. The health network forwards the requirement to San Martin RHD-Directorate of Human Resources Development. This instance assesses the requirement according to stated regional health priorities. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 92

102 e. Directorate of Human Resources Development responds to the health network to authorize and commence the recruitment process through the Directorate of Health Management. The Directorate of Health Management cannot start the recruitment process unless it has the following documents: institutional requirement, terms of reference and budget certification by budget execution unit. It may be necessary to develop or adjust the job profile of the desired personnel to be hired. However, if there is already a job profile, it has to be reviewed and updated according to the functions and competencies required. For facilitating this process, the project defined a methodology for defining job profiles, providing a framework for developing job profiles in health provision and health management positions[15]. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 93

103 Graphic 24: Preparation Stage flowchart Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 94

104 Recruitment Stage. During this stage, dissemination is started in order to inform vacancies available, according to institutional needs. Dissemination must comply with current regulations for recruitment procedures. In the case of San Martin RHD, health networks are entitled to utilize additional dissemination media for attaining recruitment objectives. Minimum media to be used are: a. National Employment Service of the Ministry of Labor b. National Internet Portal c. Institution web portal This process is described below (Graphic 25). The MoH web portal as supplementary dissemination media This tool is currently unavailable for informing on vacancies availability. However, it has been considered by the project as a valuable tool based on the following facts: a. It facilitates of the tracking and monitoring of jobs demands nationwide, since it can concentrate institutional, local and regional offers in each region b. It could serve as a specialized broadcasting tool nationwide within the health sector. Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 95

105 Graphic 25: Recruitment Stage Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 96

106 Selection Stage. This stage comprises the objective assessment of applicants who meet the conditions required by the area user. Assessments required by law are curriculum evaluation and interviews. In San Martin RHD, additional mechanisms are used by health networks, such as psychological evaluations, knowledge assessments, etc. to suit the characteristics of the vacancy service area. a) Curriculum Evaluation: It involves the analysis, review and compliance checking with the minimum position requirements in terms of education, training and/or expertise, experience and skills (mandatory). b) Personal Interview: This technique allows the evaluator to meet and evaluate the applicant during the recruitment process (mandatory). Personal interview includes the following elements: - Presentation and development: Appropriate personal bearing and ease of communication in conveying ideas. - Attitude and qualities: Applicant behavior and expression, both verbal and nonverbal, manifested during the conduct of the interview. - Knowledge and analytical skills: Ability to respond to hypothetical and diverse workplace scenarios related to the job as well as actual work situations. This process is described below (Graphic 26). Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 97

107 Graphic 26: Selection Stage Abt Associates Inc. Activities undertaken to strenghen the HRMS in health institutions pg. 98

108 To create the final technical document proposal for SMT-RHD hiring, the HP project must have all job profiles including competencies of staff to be hired for SMT-RHD. The HP Project s technical paper[24] proposes processes and activities to conduct recruitments is based on existing national and regional norms corresponding to its scope. Abt Associates Inc. Activities undertaken to strengthen HRMS pg. 99

109 4. Conclusions Based on the results of HRMS assessment in six RHDs, the following can be concluded: 1. In general, there is poor development in the implementation of HRMS processes at the regional level; only SMT-RHD shows moderate development at 48% towards goals. 2. The performance management component shows the lowest level of development in all assessed RHDs, including SMT-RHD. The employment management component shows a high level of development in four RHDs. 3. These results are due to a clear lack of delineation of regulatory functions in RHDs regarding HRM, which must be explicitly stated in the manual of operations and functions (MOF). RHDs have not designated responsible parties for many of the HRM processes. HRMS components are not in the same organizational unit which makes it difficult to implement as a whole system with components and processes interrelated and interdependent, under a single person. Additionally, in many RHDs the heads of HR offices are non-professional staff members and have not been trained in HRM. The number of personnel working in HR offices is insufficient to perform all HRM processes well. 4. Processes that have reached more than 50% implementation are mostly related to compliance with the requirements of higher authorities such as the MEF, which requires regular information reporting. 5. Regarding the planning component, there is an absence of operational research to support formulation of HHR policies and strategies as well as monitoring and control of HRM indicators. There have been significant advances in the design of HR policies, which must be reviewed and updated. A national guideline to estimate HHR needs for the first level of care was designed and validated; it is currently being approved by MoH. This guideline incorporates tools and methodologies which were validated and applied by the HP project in Ucayali, Ayacucho and San Martin. 6. For the work organization component, all RHDs show some progress in relation to the design of managerial documents such as ROF, MOF, CAP and PAP. However, there have been few advances in the development of procedure manuals for relevant processes. SERVIR, which is the national authority for HRMS, has defined a methodology for the design of job profiles, and it has been validated and applied by the HP project in Ayacucho and San Martin. 7. In the employment management component, the processes performed to date have not met all the regulatory requirements for conducting a recruitment process. For example, most of the contract files do not include standardized job profiles or the respective budget certification which specifies and guarantees remunerative payment. Additionally, dissemination required by current regulations is not being executed. Staff recruited as a result of this process does not receive the appropriate induction because there is no responsible party to inform them of policy, rules, roles, goals, vision, mission and values of the institution. This situation places new staff in institutional limbo, creating conditions where personnel do not identify with institutional goals. 8. In the performance management component, despite having an organizational unit responsible for the process, there is no designated person to manage this process. Additionally, a management tool has not been developed or approved defining the methodology to evaluate the performance of institution staff. Abt Associates Inc. Activities undertaken to strengthen HRMS pg. 100

110 9. The development management component demonstrates a poor level of implementation. Despite having a promotion policy for stable staff, it is not being implemented. This policy needs to be revised and improved to serve as a reference for more transparent and meritocratic processes. Regarding capacity building, some regions have restrictions in training hired staff; in these regions, training activities focus on professional staff. 10. Regarding the compensation management component, only SMT-RHD and Ayacucho have salary scales for all first-level-of-care facilities. The scales are approved but have not yet been implemented at the regional level in the case of SMT-RHD. 11. For the management of human and social relations component, there have been advances in management of labor relations but slightly less progress in developing processes related to organizational climate and culture as well as workplace health, safety and welfare. Abt Associates Inc. Activities undertaken to strengthen HRMS pg. 101

111 5. Recommendations to implement the HRMS at regional level 1. Diagnose the level of implementation of HRMS at different levels of management. Based on the results, define critical processes to further develop improvement processes. It is important to define whether the deficiency in the implementation of critical processes is due to deficiencies in staff skills or lack of a standard. 2. Establish an organizational structure for HR offices that allows implementing all HRMS processes by assigning each process to a particular party who is responsible for a defined position in the new structure. 3. Define job profiles for the head of the HR office and all units established by the new structure. 4. Build the capacity of the HR office s technical team through a specific program in management of HRM tools and standards, according to the job profile defined, ensuring permanence of trained personnel. 5. Strengthen HR offices at the regional and network level with competent and sufficient staff to implement key HRMS processes and fulfill basic functions of the HR office. 6. Identify indicators for monitoring the implementation of HRMS at the RHD level. 7. Design, adapt or adopt documents or technical tools to improve the management of a given HRM process. The HP project has designed and validated a HRM toolkit which can be used or adapted according to the specific environment. 8. Design, adapt or adopt rules or policies when the proper functioning of a process requires the approval of a regional standard. 9. Establish a workshop among the regional bodies that are involved with HRMS implementation. Employ regional government HR Offices and the RHD HR Office to analyze the results obtained in evaluating HRMS, and define improvement plans for the proper functioning of these processes in accordance with SERVIR provisions. Abt Associates Inc. Recommendations to implemente the HRMS at regional level pg. 102

112 6. References 1. Ley del Servicio Civil, in Ley , Congreso de la República: Perú. 2. SERVIR, El Servicio Civil Peruano; Antecedentes, Marco Normativo Actual y Desafíos Para La Reforma. 2012, Autoridad Nacional del Servicio Civil: Lima. 3. Ipsos, Evaluación de la Reforma del Servicio Civil. 2013: Lima. 4. Villanueva, C., Elaborar un modelo de gestión descentralizado de recursos humanos en salud para las regiones: Ayacucho, Cajamarca, Cusco, Huánuco y Ucayali y los planes de intervención respectivos. 2012, MINSA: Perú. 5. GORESAM, Ordenanza Regional N GRSM/CR, in OR GRSM/CR. 2013: Región San Martín. 6. Nivel de implementación del sistema de gestión de recursos humanos de la DIRES San Martín. 2013, Dirección de Desarrollo de RR.HH. de la DIRESA San Martín. 7. Informe de sistemas de gestión de RR.HH. de la DIRESA Cajamarca. 8. Workload Indicators of Staffing Need (Software Manual). 2010, World Health Organization: Ginebra. 9. Dreesch, N., An approach to estimating human resource requirements to achieve the Millenium Development Goals. 2013, Oxford University England. 10. An overview of human resources for health (HRH) Projection Models. 2008, USAID: North Carolina. 11. Alvarez, C., Cálculo de índice de ruralidad para todos los distritos del Perú. 2012: Lima. 12. Guía de metodología de cálculo de las brechas de recursos humanos en salud para los servicios asistenciales del primer nivel de atención, in Guía Técnica N 001-MINSA/DGRH- V.01, MINSA: Lima. 13. Cálculo de brecha de recursos humanos y propuesta de asignación de dotación del equipo básico para el primer nivel de atención. 2013, Dirección Regional de Salud de San Martín: Lima. 14. SERVIR, Guía metodológica para la elaboración de perfiles de puestos en las entidades públicas. 2012: Lima. 15. Perfiles de puestos de la DIRESA San Martín y sus órganos desconcentrados. 2013, HP: San Martín. 16. Perfiles de puestos para el personal de la dirección ejecutiva de gestión y desarrollo de recursos humanos. 2012, HP: Ayacucho. 17. Perfiles de puestos para el personal asistencial del primer nivel de atención, HP: DIRESA Ayacucho. 18. OIT, Diseñar un modelo integtral y dinámico de gestión de recursos humanos por competencias. 2006, Centro Internacional de Formación de la OIT: Turín. 19. Chiavenato, I., Gestión del Talento Humano. Mc Graw-Hill ed. 2009, México D.F. 20. USAID, Mejorando las competencias laborales en el ámbito local. 2009, USAID Iniciativa de Políticas en Salud Lima. 21. USAID, Desarrollo de recursos humanos en salud; Sistema de Desarrollo de Competencias. 2009, USAID Iniciativa de Políticas en Salud: Lima. 22. WHO, Working together for health - The World Health Report , World Health Organization: Ginebra. 23. MINSA, Competencias laborales para la mejora del desempeño de los recursos humanos en salud. 2011, MINSA - Dirección General de Gestión del Desarrollo de Recursos Humanos: Lima. 24. Directiva que regula el procedimiento de contratación del personal bajo el régimen especial laboral de contrato administrativo de servicios - CAS de la Dirección Regional de Salud de San Martín - Propuesta, HP project. Abt Associates Inc. References pg. 103

113 7. Annex 7.1 Questionnaire to assess the implementation of the HRMS in health institutions SISTEMA DE GESTIÓN DE RECURSOS HUMANOS EN INSTITUCIONES DE SALUD La finalidad de este instrumento es conocer cuál es el nivel de avance en la implementación de los procesos de la gestión de recursos humanos. Para ello, sírvase responder las preguntas que se formulan a continuación. Esperamos que las respuestas se acerquen lo más posible con la realidad de su institución, de tal forma que se puedan identificar las áreas que son necesarias fortalecer. El instrumento consta de preguntas cerradas donde usted puede marcar la o las alternativas que más se acerquen a la realidad de su institución. También hay preguntas abiertas donde se espera que pueda ampliar la información proporcionada en las preguntas cerradas. Se agradece de antemano su colaboración. A continuación, sírvase llenar la siguiente información GESTIÓN Y DESARROLLO DE RECURSOS HUMANOS Nombre de la institución: 1. En su institución Existe una instancia responsable de la gestión y desarrollo de recursos humanos en salud? Cuál es el nombre de la unidad responsable de la gestión de recursos humanos en su institución? 2. Cuál es la ubicación de la unidad de recursos humanos en su institución? ( ) Órgano de Asesoría ( ) Órgano de Línea ( ) Órgano de Apoyo ( ) No existe, se encuentra dentro de otra Unidad 3. Cuántas personas trabajan en esta unidad? Grupo ocupacional Profesionales Técnicos Otros TOTAL TOTAL Régimen 276 Número de personas por régimen laboral Régimen 728 CAS Locador a tiempo completo Otro POLÍTICA Y PLANIFICACION ESTRATÉGICA DE RECURSOS HUMANOS EN SALUD Cuestionario Formulación de Políticas y estrategias de Gestión y Desarrollo de Recursos Humanos Abt Associates Inc. Annex pg. 104

114 1. En su institución Existe una instancia responsable de la formulación y evaluación de políticas de recursos humanos en salud? De acuerdo con su ROF vigente, Cuáles son las instancias que participan en el diseño y evaluación de las políticas de recursos humanos en su institución? Participa? En caso de que participe Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 2. Cuenta con Políticas de Gestión y Desarrollo de Recursos Humanos? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. En caso contrario, pasar a la siguiente Sección. 3. Las Políticas de Gestión y Desarrollo de Recursos Humanos están aprobadas? Cuándo han sido aprobadas? El diseño de las Políticas de Recursos Humanos ha tomado en cuenta los siguientes procesos: (Si es posible, pedir las políticas y revisar) N Pregunta SI NO 4. Planificación de Recursos Humanos 5. Desarrollo de competencias 6. Evaluación del desempeño 7. Motivación e Incentivos 8. Salud y Seguridad en el Trabajo 9. Selección en base al mérito 10. Perfiles de puestos y competencias 11. Agentes comunitarios en salud Otros; Especificar: Otros; Especificar: 12. Las políticas aprobadas han tenido algún nivel de implementación? Si la respuesta a la pegunta anterior ha sido afirmativa, Qué aspectos de la política han sido implementadas? N Pregunta SI NO 13. Planificación de Recursos Humanos 14. Desarrollo de competencias 15. Evaluación del desempeño 16. Motivación e Incentivos 17. Salud y Seguridad en el Trabajo 18. Selección en base al mérito 19. Perfiles de puestos y competencias 20. Políticas de Remuneraciones Otros; Especificar: Otros; Especificar: Abt Associates Inc. Annex pg. 105

115 Desarrollo de investigaciones operativas 21. Han desarrollado algún tipo de investigación relacionada con la gestión de recursos humanos? Si la respuesta a la pegunta anterior ha sido afirmativa, Qué investigaciones han desarrollado? 22. Cuentan con un diagnóstico situacional de los recursos humanos en su Región? Organización y administración de la información en recursos humanos en salud 23. En su institución Existe una instancia responsable de mantener actualizada la información relacionada con los recursos humanos en salud? De acuerdo con su ROF vigente, Cuáles son las instancias que participan en la gestión de la información de recursos humanos en su institución? Participa? En caso de que participe Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 24. Cuenta con algún sistema de información sobre recursos humanos? Si la respuesta a la pegunta anterior ha sido afirmativa, marcar con una X el tipo de información que se registra en cada aplicativo, software o base de datos de recursos humanos que utilizan en su institución. Nombre del aplicativo / software / base de datos Información de RRHH que se registra 25. Nombre completo de todos los trabajadores 26. Número de plazas ocupadas 27. Número de plazas previstas 28. Número de plazas previstas y presupuestadas sin ocupar 29. Conceptos remunerativos 30. Conceptos no remunerativos 31. Gastos en planilla 32. Asistencia/Tardanzas/Faltas 33. Personas por regímenes laborales 34. Personas por unidad orgánica 35. Personas por grupo ocupacional 36. Concursos públicos realizados 37. Ubicación actual del trabajador 38. Legajo de servidores 39. Servidores por especialidad 40. Tipo de desplazamientos Otro: Otro: Otro: Planilla s SIGA Abt Associates Inc. Annex pg. 106

116 41. Los aplicativos que utilizan le ayudan a tomar las decisiones que necesita? Control en la Gestión de recursos humanos en salud 42. En su institución Existe una instancia responsable del monitoreo de indicadores de gestión de recursos humanos en salud? De acuerdo con su ROF vigente, Cuáles son las instancias que participan en el monitoreo de indicadores de gestión de recursos humanos en su institución? Participa? En caso de que participe Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 43. En el último año han definido los indicadores de gestión de recursos humanos en su institución? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. Qué indicadores de gestión de recursos humanos han definido? (puede marcar más de 1) N Pregunta SI NO 44. % de MR que cuentan con la estimación de necesidades de RRHH 45. % de instancias que cuentan con el 80% de perfiles de puestos 46. % de contratos suscritos después de un proceso de selección meritocrático 47. % de convocatorias que han sido publicadas en la web del MINTRA 48. % de procesos de reclutamiento y selección que se han realizado en base a perfiles 49. % de capacitaciones realizadas en base a la brecha en el desempeño 50. % de trabajadores que cuentan con metas de producción concertadas 51. % de trabajadores que han sido evaluados por competencias 52. % de trabajadores que han sido contratados en zonas alejadas, en base a una escala salarial atractiva. Otros; Especificar: Otros; Especificar: 53. Han realizado la medición de los indicadores de monitoreo de la gestión de recursos humanos en su institución. Planificación estratégica de Recursos Humanos 54. En su institución Existe una instancia responsable de la planificación de recursos humanos en salud? De acuerdo con su ROF vigente, Cuáles son las instancias que participan en la estimación de requerimientos de recursos humanos y en el diseño de los planes de dotación en su institución? Participa? En caso de que participe Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red Abt Associates Inc. Annex pg. 107

117 En la MR 55. En el último año han realizado estimaciones de requerimientos y necesidades de recursos humanos en su institución? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. Qué criterio han usado para definir los requerimientos de recursos humanos? (puede marcar más de 1) N Pregunta SI NO 56. Plazas del CAP no cubierto 57. Crecimiento vegetativo de la población 58. Aumento de funciones 59. Aumento de la producción 60. Proyecciones de demanda 61. Proyecciones de uso de servicios 62. Ratio de la OMS Otros; Especificar: Otros; Especificar: 63. Cuentan con algún aplicativo para las estimaciones de requerimientos de recursos humanos? 64. Han podido contar de manera inmediata, con información actualizada acerca de la dotación actual de recursos humanos y su situación laboral? Si la respuesta es NO, indique Por qué? 65. Han utilizado el estudio de brechas o de necesidades de recursos humanos para tomar alguna decisión? Si la respuesta es afirmativa, En qué han utilizado esta información de necesidades de recursos humanos? N Pregunta SI NO 66. Para las nuevas contrataciones 67. Para sustentar más presupuesto 68. Para redistribuir personal 69. Para solicitar mas SERUMS Otros; Especificar: Otros; Especificar: 70. En base a esta información, han elaborado su Plan de dotación para el corto, mediano y largo plazo? Si la respuesta es NO, indique Por qué? Financiamiento de Recursos Humanos 71. En su institución Existe una instancia responsable de estimar las necesidades de financiamiento de recursos humanos en salud para la Región? Abt Associates Inc. Annex pg. 108

118 De acuerdo con su ROF vigente, Cuáles son las instancias que participan en la estimación de las necesidades de financiamiento de recursos humanos en salud para la Región? Participa? En caso de que participe Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 72. En el último año han realizado estimaciones de necesidades de financiamiento para los recursos humanos en salud para la Región? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. Qué criterio han usado para definir los requerimientos de financiamiento de recursos humanos? (puede marcar más de 1) N Pregunta SI NO 73. Plazas del CAP no cubierto 74. Estudio de necesidades de RRHH 75. Requerimientos de las unidades ejecutoras 76. Presupuesto histórico Otros; Especificar: Otros; Especificar: COMENTARIO ACERCA DE LA ORGANIZACIÓN Y FUNCIONAMIENTO DEL SUB SISTEMA DE POLÍTICA Y PLANIFICACIÓN ESTRATÉGICA DE RECURSOS HUMANOS: Cuestionario Diseño de perfiles de puestos de trabajo ORGANIZACIÓN DEL TRABAJO 1. Existe una instancia responsable del diseño de los perfiles de puestos en su institución? De acuerdo con el ROF vigente, Quién o quiénes son las instancias que participan en el diseño de las competencias? Existe En caso de que exista responsable? Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA Abt Associates Inc. Annex pg. 109

119 En la Red En la MR Nivel Existe responsable? SI NO Nombre de la unidad responsable En caso de que exista Función específica Para el diseño de perfiles de puestos, deben tomarse como referencia los documentos de gestión en materia de recursos humanos, al respecto, llene el siguiente cuadro: Existe al menos en el 80% de las En caso de que exista, responda lo que ocurre en la mayoría de los unidades casos N Documento orgánicas? 2. 1 CAP 3. 2 MOF 4. 3 MAPRO 5. 4 PAP SI NO Año de aprobación Año de última modificación # de modificaciones en los últimos 3 años En relación al CAP, marque lo que corresponda para su institución: ( ) El número de personas nombradas trabajando es exactamente igual al número de personas consignadas en el CAP ( ) El número de personas nombradas trabajando es mayor al número de personas consignadas en el CAP ( ) El número de personas nombradas trabajando es menor al número de personas consignadas en el CAP ( ) El número de personas trabajando (nombradas y contratadas) es exactamente igual al número de personas consignadas en el CAP ( ) El número de personas trabajando (nombradas y contratadas) es mayor al número de personas consignadas en el CAP ( ) El número de personas trabajando (nombradas y contratadas) es menor al número de personas consignadas en el CAP Para el documento CAP más avanzado y completo, marque el contenido N Pregunta SI NO 6. Puestos ocupados 7. Puestos previstos 8. Cargos de confianza 9. Puestos por grupo ocupacional 10. Puestos del personal CAS Otros; Especificar: Para el documento MOF más avanzado y completo, marque el contenido N Pregunta SI NO 11. Funciones específicas del puesto 12. Conocimientos requeridos 13. Experiencia previa Otros; Especificar: Para el documento MAPRO más avanzado y completo, marque el contenido N Pregunta SI NO 14. Procesos desarrollados 15. Responsables de cada proceso Abt Associates Inc. Annex pg. 110

120 N Pregunta SI NO 16. Metas por procesos 17. Metas por persona Otros; Especificar: Para el documento PAP más avanzado y completo, marque el contenido N Pregunta SI NO 18. Monto de Ingresos por servidor 19. Clasificación de conceptos remunerativos 20. Clasificación conceptos no remunerativos 21. Frecuencia de otorgamiento de conceptos salariales Otros; Especificar: 22. En el último año han diseñado perfiles de puestos en alguna unidad orgánica? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. En caso contrario, pase a la siguiente sección. Cuentan con al menos el 60% de perfiles para los puesto de los siguientes niveles? N Nivel 60% de perfiles SI NO 23. DIRESA 24. Red 25. Oficina de Operaciones 26. MR Qué han tomado como referencia para definir las funciones específicas de los puestos? N Pregunta SI NO 27. Las funciones vigentes del MOF 28. Las funciones descritas en los TDR 29. Opinión de expertos 30. Perfil de competencias 31. Las funciones generales del ROF 32. Un análisis de procesos Otros; Especificar: Otros; Especificar: Qué han tomado como referencia para definir los requisitos para los puestos? N Pregunta SI NO 33. La situación del mercado laboral regional 34. La situación del mercado laboral nacional 35. La situación laboral de los trabajadores actuales 36. La complejidad de las funciones 37. La importancia del puesto Otros; Especificar: Otros; Especificar: Abt Associates Inc. Annex pg. 111

121 38. Los perfiles de puestos diseñados, tienen algún tipo de aprobación oficial? ( ) SI, Cuál? ( ) NO 39. Han utilizado los perfiles de puestos diseñados para tomar algún tipo de decisión?, Por qué? En qué han utilizado los perfiles de puestos diseñados? N Pregunta SI NO 40. Para los procesos de reclutamiento 41. Para los procesos de selección 42. Para los procesos de capacitación 43. Para definir las compensaciones 44. Para la evaluación del desempeño 45. Para los ascensos Otros; Especificar: Otros; Especificar: Identificación de competencias 46. Existe una instancia responsable de definir el perfil de competencias en su institución? De acuerdo con el ROF vigente, Quién o quiénes son las instancias que participan en el diseño de las competencias? Existe En caso de que exista responsable? Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 47. En el último año han diseñado perfiles de competencias en alguna unidad orgánica? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. Cuentan con al menos el 60% de perfiles para los puesto de los siguientes niveles? N Nivel 60% de perfiles SI NO 48. Asistencial 49. Gerencial o Directivo 50. Administrativo Qué herramientas han usado para definir las competencias? N Pregunta SI NO 51. Diccionario de competencias 52. Las competencias del MINSA 53. Las competencias de los colegios profesionales 54. Las competencias definidas por otras instituciones similares 55. Análisis Funcional 56. Análisis Conductual 57. Consulta a expertos Abt Associates Inc. Annex pg. 112

122 N Pregunta SI NO Otros; Especificar: Otros; Especificar: 58. Las competencias definidas, tienen algún tipo de aprobación oficial? ( ) SI, Cuál? ( ) NO 59. Han utilizado las competencias diseñadas para tomar algún tipo de decisión?, Por qué? En qué han utilizado las competencias definidas? N Pregunta SI NO 60. Como parte de los perfiles de puestos 61. Para la evaluación de candidatos en los procesos de selección 62. Para definir los contenidos de la capacitación 63. Para definir la línea de carrera 64. Para la evaluación del desempeño 65. Para definir las compensaciones Otros; Especificar: Valoración de puestos de trabajo 66. Existe una instancia responsable de valorar los puestos de trabajo en su institución? De acuerdo con el ROF vigente, Quién o quiénes son las instancias que participan en la valoración de los puestos de trabajo? Existe En caso de que exista responsable? Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 67. En el último año han desarrollado algún proceso de valoración de puestos de trabajo? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. La valoración de puestos realizada, han sido para los puestos en los siguientes niveles: N Nivel SI NO 68. DIRESA 69. Red 70. Oficina de Operaciones 71. MR Qué criterios han usado para definir las competencias? N Pregunta SI NO 72. El perfil del puesto: Jerarquía, formación, experiencia 73. Presupuesto bajo responsabilidad Abt Associates Inc. Annex pg. 113

123 N Pregunta SI NO 74. Cantidad de personal bajo responsabilidad 75. Ubicación geográfica del puesto 76. Carga de trabajo del puesto 77. Condiciones de desarrollo del lugar donde se ubica el puesto 78. Nivel de pobreza del lugar donde se ubica el puesto Otros; Especificar: Otros; Especificar: 79. Han utilizado la valoración del puesto para tomar algún tipo de decisión?, Por qué? En qué han utilizado la valoración del puesto realizada? N Pregunta SI NO 80. Para definir la línea de carrera 81. Para definir el salario 82. Para distribuir el personal 83. Para definir los incentivos Otros; Especificar: Otros; Especificar: COMENTARIO ACERCA DE LA ORGANIZACIÓN Y FUNCIONAMIENTO DEL SUB SISTEMA DE ORGANIZACIÓN DEL TRABAJO: Cuestionario Reclutamiento, Selección, Incorporación e Inducción GESTIÓN DEL EMPLEO 1. Cuentan con una instancia responsable de administrar los procesos de reclutamiento, selección, incorporación e inducción de personal? De acuerdo con el ROF vigente Quién es la instancia responsable de administrar los procesos de reclutamiento, selección, incorporación e inducción de personal? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR Abt Associates Inc. Annex pg. 114

124 2. En el último año han realizado procesos de reclutamiento y selección en su institución? En el último proceso de contratación Cómo han SUSTENTADO la necesidad de contratación de personal? N Pregunta SI NO 3. Existencia de plazas del CAP no cubiertas 4. Incremento en el presupuesto 5. Requerimiento del área usuaria 6. En base a un estudio de brechas 7. Este tipo de decisiones no tiene influencia política 8. Por aumento de la producción Otros; Especificar: En la fase preparatoria de los procesos de contratación de CAS realizados el año pasado, han contado con lo siguiente: (puede marcar más de 1) N Pregunta SI NO 9. El requerimiento realizado por el área usuaria. 10. Perfil del puesto 11. Términos de Referencia 12. Hoja de funciones 13. Existencia de la disponibilidad en la Certificación Presupuestaria Otros; Especificar: En relación al Reclutamiento, en el último concurso de plazas, qué medios de difusión han utilizado? N Pregunta SI NO 14. Radio local 15. Televisión local 16. Periódicos locales 17. Mural de la entidad 18. Página web de la institución 19. Servicio Nacional del Empleo del MINTRA Otros; Especificar: En relación a los concursos realizados durante el año pasado, llenar la siguiente información Resultado 2012 # días de difusión del Mes concurso Concurso culminado Concurso desierto Concurso impugnad o Plazas concursadas: # Plazas concursadas Tipo y # de plazas asistenciales concursadas Mes Directiva Asistencia Administrati A B C D E s les vos Abt Associates Inc. Annex pg. 115

125 A= Médico; B=Enfermera; C=Obstetra; D=Técnico; E= Otro En relación a las plazas ocupadas # Plazas contratadas Tipo y # de plazas asistenciales contratadas Mes Directiva Asistencia Administrati A B C D E s les vos A= Médico; B=Enfermera; C=Obstetra; D=Técnico; E= Otro 20. Existe una Comisión permanente de Procesos de Selección? 21. El último proceso de convocatoria realizado, Fue comunicado a la Red CIL PROEMPLEO? Si la respuesta es afirmativo: Con cuántos días de anticipación se cursó dicha información a la Red CIL PROEMPLEO? días. 22. En el último proceso de convocatoria de personal, cualquiera sea la modalidad, han consultado el Registro Nacional de Sanciones de Destitución y Despido (RNSDD), para verificar si alguno de los candidatos se encuentra inhabilitado para ejercer función pública? En el último proceso de selección realizado, utilizaron los siguientes instrumentos de evaluación: (puede marcar más de 1) N Pregunta SI NO 23. Lista de chequeo para evaluar CV 24. Guía de entrevistas 25. Examen de conocimientos 26. Presentación de un caso 27. Examen psicológico 28. Prueba psicotécnica 29. Evaluación de competencias Otros; Especificar: Otros; Especificar: En el último proceso de selección realizado, la puntuación se realizó sobre los siguientes aspectos: (puede marcar más de 1) N Pregunta SI NO 30. Formación 31. Capacitación 32. Experiencia laboral 33. Competencias 34. Entrevista personal 35. Conocimientos Otros; Especificar: Otros; Especificar: 36. Tiene un sistema para archivar y llevar el registro de todos los procesos de selección realizados? Qué tipo de información de los procesos de selección está archivada? (puede marcar más de 1) Abt Associates Inc. Annex pg. 116

126 N Pregunta SI NO 37. Bases del concurso 38. Solicitudes recibidas 39. Resultado de las evaluaciones 40. Impugnaciones 41. Actas del Comité de Concurso Otros; Especificar: Otros; Especificar: 42. En el último proceso de contratación, Han realizado la inducción al nuevo personal incorporado? En el último proceso de contratación, Quién ha sido la unidad responsable de la inducción al nuevo personal? ( ) Director de la DIRESA ( ) Jefe del Área usuaria ( ) Jefe de la Red ( ) Un trabajador del área usuaria ( ) Jefe de la MR ( ) Otros; Especificar: En el último proceso de inducción, Qué temas se han abordado? N Pregunta SI NO 43. Misión, Visión y Valores de la institución 44. Políticas regionales de salud 45. Políticas y estrategias sanitarias institucionales 46. Reglamento Interno de Trabajo (RIT) 47. Funciones Generales de la unidad orgánica 48. Funciones específicas del puesto 49. Procesos claves que se desarrollan 50. Metas de desempeño esperadas Otros; Especificar: 51. El último proceso de inducción duró en promedio de 3 días a 1 semana a tiempo completo Desplazamiento o movilidad del personal 52. Cuentan con un responsable de mantener actualizada la información de los desplazamientos del personal? De acuerdo con el ROF vigente Quién es la instancia responsable de autorizar el desplazamiento del personal? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 53. Cuentan con un sistema que permita mantener actualizada la información de los desplazamientos del personal? En el 2011 y 2012, cuánto personal ha sido destacado fuera de la institución? # total de # total de Año # de destaques por grupo ocupacional personal personal # destaques por plaza Abt Associates Inc. Annex pg. 117

127 movilizado destacado asistencial Directivo Administrativ Asistencial A B C D E o A= Médico; B=Enfermera; C=Obstetra; D=Técnico; E= Otro Administración de legajos y declaraciones juradas; control de asistencia y permanencia 54. Cuentan con un responsable de mantener la actualización de la información del legajo? De acuerdo con el ROF vigente Quién es la instancia responsable del mantenimiento del legajo de personal? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 55. Cuentan con algún sistema para registrar la información del personal, como por ejemplo un legajo de personal? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. Qué información del trabajador contiene el legajo de personal? N Pregunta SI NO 56. Datos personales (nombre, edad, sexo, etc.) 57. Régimen laboral al que pertenece 58. Registro de amonestaciones o sanciones 59. Informes de evaluaciones de desempeño 60. Registro de las faltas o tardanzas 61. Capacitaciones recibidas 62. Incentivos recibidos Otros; Especificar: 63. El año pasado han realizado la actualización de la información del legajo? Cuándo realizaron la última actualización de la información del legajo? ( ) El mes pasado ( ) El año pasado ( ) Hace 6 meses ( ) No se realiza En relación al Control de Asistencia y permanencia: 64. Cuentan con un responsable del Control de Asistencia y permanencia del personal? De acuerdo con el ROF vigente Quién es la instancia responsable del Control de Asistencia y permanencia del personal? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR Abt Associates Inc. Annex pg. 118

128 N Pregunta SI NO Cuentan con un sistema confiable de Si la respuesta es SI, Cuál? 65. control de asistencia del personal, que no sea el Cuaderno de asistencia? 66. Todos marcan su asistencia? Si la respuesta es NO, Quiénes no marcan y por qué? 67. Tienen alguna Resolución donde se señala el personal que no está obligado a registrar su asistencia? Si la respuesta es NO, Por qué? Administración de procesos disciplinarios 68. Cuentan con un responsable de administrar los procesos disciplinarios en su institución? De acuerdo con el ROF vigente Quién es la instancia responsable de administrar los procesos disciplinarios en su institución? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR En relación al Reglamento interno de Trabajo (RIT): N Pregunta SI NO 69. Cuentan con un RIT? Cuándo fue diseñado? 70. El RIT está aprobado? Cuándo fue aprobado? 71. El RIT es conocido por el personal? Cómo se ha difundido El RIT ha sido entregado al nuevo Si la respuesta es NO, Por qué? 72. personal contratado en el último proceso? 73. Tiene ejemplares del RIT Si la respuesta es NO, Por qué? disponibles en este momento? En relación a los Procesos Disciplinarios: N Pregunta SI NO Cuentan con una Comisión de Procesos Administrativos Disciplinarios? Han realizado procesos disciplinarios el 2012? Todos los fallos formales de la Comisión de procesos administrativos del 2012 cuentan con Resolución? Mantienen un registro actualizado de los expedientes de Procesos Administrativo? Mantiene actualizado el Registro Nacional de Sanciones de Destitución y Despido (RNSDD), con el registro oportuno de las sanciones y todos los demás actos relacionados como la modificación, suspensión o anulación, según corresponda Si la respuesta es NO, Por qué? Cuántos procesos disciplinarios han desarrollado en el 2012? Si la respuesta es NO, Por qué? Si la respuesta es NO, Por qué? Si la respuesta es NO, Por qué? Abt Associates Inc. Annex pg. 119

129 Desvinculación del personal 79. Cuentan con un responsable de administrar los procesos de desvinculación del personal? De acuerdo con el ROF vigente Quién es la instancia responsable de administrar los procesos de desvinculación del personal? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 80. Cuentan con un sistema que permita mantener actualizada la información de los procesos de desvinculación del personal por régimen laboral y grupo ocupacional? En el periodo , cuántos casos de desvinculación por régimen laboral han ocurrido? Tipos de desvinculación laboral DL DL DL DL DL DL CAS CAS Fallecimiento Renuncia Despido Destitución por falta grave Invalidez permanente Jubilación Término del contrato CAS COMENTARIO ACERCA DE LA ORGANIZACIÓN Y FUNCIONAMIENTO DEL SUB SISTEMA DE GESTION DEL EMPLEO: Cuestionario Planificación del desempeño GESTIÓN DEL DESEMPEÑO 1. Cuentan con un responsable de planificar, organizar, implementar y evaluar los procesos de evaluación el desempeño del personal de su institución? De acuerdo con el ROF vigente Quién es la instancia responsable de planificar y organizar los procesos de evaluación el desempeño del personal de su institución? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red Abt Associates Inc. Annex pg. 120

130 En la MR En relación a las metas de rendimiento N Pregunta SI NO 2. Cuentan con una metodología definida para establecer las metas de rendimiento individual? 3. Cuentan con una metodología definida para establecer las metas de rendimiento grupal? 4. El año pasado y durante el presente año, Han establecido metas de rendimiento de manera concertada, para algún grupo ocupacional? 5. Tienen planificado realizar la estimación de las metas de rendimiento para este año? En relación a la metodología e instrumentos para evaluar el desempeño del personal N Pregunta SI NO 6. Cuentan con una metodología definida para evaluar el desempeño del personal? 7. Cuentan con una metodología aprobada oficialmente para evaluar el desempeño del personal? 8. Cuentan con instrumentos para evaluar de manera objetiva el desempeño del personal? 9. Tienen planificado realizar la evaluación del desempeño del personal durante el presente año? 10. En el último año han elaborado un plan para la evaluación del desempeño del personal de su institución? Acompañamiento 11. Cuentan con un responsable de planificar, organizar, implementar y evaluar los procesos de supervisión, coaching o mentoring en su institución? De acuerdo con el ROF vigente Quién es la instancia responsable de planificar y organizar los procesos de supervisión, coaching o mentoring de su institución? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR En relación al acompañamiento del personal: N Pregunta SI NO Cuentan con una metodología e instrumentos definidos para que los jefes de unidades puedan realizar el acompañamiento a su personal? La metodología definida para que los jefes de unidades puedan realizar el acompañamiento a su personal, está aprobada? Cuentan con algún mecanismo para registrar los procesos de acompañamiento que realizan los jefes de unidades orgánicas? (Por ejemplo: Informes de supervisión) 15. En el último año los jefes de unidades orgánicas han reportado la ejecución de actividades de acompañamiento al personal para mejorar su desempeño? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. Abt Associates Inc. Annex pg. 121

131 N Pregunta SI NO Los reportes o informes del acompañamiento registran los problemas en el desempeño encontrados Los reportes o informes del acompañamiento registran las medidas correctivas adoptadas Los reportes o informes del acompañamiento registran la fecha de la próxima visita Los reportes o informes del acompañamiento son firmados por el personal visitado Evaluación del desempeño 20. Cuentan con un responsable de organizar y monitorear los procesos de evaluación de desempeño en su institución? De acuerdo con el ROF vigente Quién es la instancia responsable de organizar y monitorear los procesos de evaluación de desempeño en su institución? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR En relación a la evaluación del desempeño: N Pregunta SI NO Las unidades orgánicas de su institución programan evaluaciones de desempeño a su personal Cuentan con algún mecanismo para registrar los procesos de evaluación del desempeño que realizan los jefes de unidades orgánicas? 23. En el último año los jefes de unidades orgánicas han realizado procesos de evaluación de desempeño? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. N Pregunta SI NO 24. Los jefes de unidades orgánicas han usado los perfiles de puestos para diseñar los instrumentos para evaluar el desempeño del personal a su cargo. 25. Los jefes de unidades orgánicas han establecido las metas de rendimiento del personal a su cargo, de manera concertada 26. Los jefes de las unidades orgánicas han definido los estándares de desempeño esperados en el personal a su cargo 27. Los jefes de las unidades orgánicas han definido los indicadores de desempeño en base a las funciones del puesto 28. Los jefes de las unidades orgánicas han definido las preguntas para evaluar conocimientos en base a la información del perfil del puesto 29. Los trabajadores son informados con anticipación sobre la evaluación 30. Los trabajadores son informados sobre los temas a ser evaluados 31. Los trabajadores son informados sobre los instrumentos de evaluación 32. Los trabajadores son informados sobre los mecanismos de impugnación 33. Los trabajadores son informados sobre las consecuencias de la evaluación 34. Han realizado la evaluación de conocimientos específicos para el puesto Abt Associates Inc. Annex pg. 122

132 N Pregunta SI NO 35. Han realizado la evaluación de conocimientos generales para el puesto 36. Han realizado la medición de las metas de producción del personal 37. Han realizado la medición de las competencias específicas del puesto 38. La evaluación del desempeño es realizada por un agente externo a la unidad orgánica (par o superior) 39. La evaluación del desempeño se realiza semestralmente Las evaluaciones de desempeño se realizan preferentemente a personal: N Nivel SI NO 40. Gerencial o Directivo 41. Profesionales asistenciales 42. Técnicos asistenciales 43. Profesionales administrativos 44. Técnicos administrativos 45. Personal nombrado 46. Personal contratado bajo cualquier modalidad 47. Han utilizado los resultados de la evaluación del desempeño para tomar algún tipo de decisión?, Por qué? En qué han utilizado los resultados de la evaluación del desempeño? N Pregunta SI NO 48. Para definir los contenidos de la capacitación 49. Para definir la promoción y los ascensos 50. Para definir las compensaciones (incentivos monetarios o no monetarios) Otros; Especificar: Otros; Especificar: Retroalimentación y Diseño de planes de mejora del desempeño individual 51. Cuentan con un responsable de asegurase que el personal evaluado reciba la retroalimentación y diseñe con su jefe los planes de mejora de su desempeño? De acuerdo con el ROF vigente Quién es la instancia responsable de asegurase que el personal evaluado reciba la retroalimentación y diseñe con su jefe los planes de mejora de su desempeño? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 52. Cuentan con algún mecanismo para registrar los procesos de retroalimentación del desempeño que realizan los jefes de unidades orgánicas? 53. En el último año los jefes de unidades orgánicas han realizado la retroalimentación al personal evaluado? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. Abt Associates Inc. Annex pg. 123

133 N Pregunta SI NO 54. Se entregan los resultados de la evaluación del desempeño al evaluado 55. Se otorga algún tipo de certificación al personal que ha demostrado ser competente en la evaluación del desempeño 56. Como resultado de la medición de las metas de desempeño, se reformulan las metas operativas para la siguiente evaluación. 57. En base a los resultados de la evaluación se formulan planes de mejora con el evaluado Considera que existen problemas para desarrollar los procesos de evaluación de desempeño en su institución? Cuáles son las principales dificultades que existen para desarrollar procesos de evaluación de desempeño basado en metas de rendimiento y en competencias en su institución? Poco apoyo por parte de la alta dirección Poco apoyo por parte de los evaluados Problemas SI NO Uso casi nulo de los resultados de la evaluación por parte de los jefes inmediatos Desconocimiento sobre herramientas de diseño y aplicación referidos a la evaluación de desempeño No se entiende la importancia de la evaluación para mejorar el desempeño El personal asocia la evaluación con despidos Las evaluaciones de desempeño tradicionales son subjetivas y desmotivan al personal El personal no acepta ser evaluado por temor a los resultados Otro COMENTARIO ACERCA DE LA ORGANIZACIÓN Y FUNCIONAMIENTO DE LA GESTIÓN DEL DESEMPEÑO: Cuestionario GESTIÓN DEL DESARROLLO Y LA CAPACITACIÓN Progresión laboral (Promoción y Carrera) En relación a los ascensos del personal N Pregunta SI NO 1. Han diseñado una política de ascensos? 2. Esta política está aprobada? 3. Esta política es conocida por todos? Si la respuesta es SI, Cuándo ha sido aprobada? 4. Cuentan con un responsable de administrar los procesos de promoción y ascenso del personal? Abt Associates Inc. Annex pg. 124

134 De acuerdo con el ROF vigente Quién es la instancia responsable de administrar los procesos de promoción y ascenso del personal? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 5. En el último año han realizado procesos de promoción o ascenso al personal de su institución? Solo si la respuesta es afirmativa conteste las siguientes preguntas; caso contrario, pase directamente a la sección Desarrollo de Capacidades. La promoción y/o ascensos en los últimos 5 años se han realizado tomando en cuenta lo siguiente. N Pregunta SI NO 6. Años de servicio 7. Evaluaciones de desempeño 8. Mediante concurso de mérito 9. Evaluación del legajo 10. Este tipo de decisiones no tienen ninguna influencia política Otros; Especificar: Otros; Especificar: Indicar la cantidad de ascensos ocurridos el 2012, por régimen laboral y grupo ocupacional. Grupo Régimen laboral ocupacional de CAS Total origen Funcionarios Directivos Profesionales Apoyo Total 11. Existe una comisión permanente para los procesos de selección de personal a promover? Marcar los instrumentos que se utilizan para seleccionar al personal a promover. N Pregunta SI NO 12. Entrevistas 13. Exámenes de conocimientos 14. Dinámicas grupales 15. Proyectos/ensayos/documentos de investigación Otros; Especificar: Otros; Especificar: Sobre la difusión del concurso, marcar las que se han utilizado en los últimos 2 años: N Pregunta SI NO 16. Son publicados con anticipación 17. Se estipula el cargo y las funciones Abt Associates Inc. Annex pg. 125

135 N Pregunta SI NO 18. Se definen los requisitos para postular 19. Se define el cronograma del concurso 20. Se difunden los resultados 21. Se difunden los ganadores del concurso 22. Se definen las modalidades de impugnación 23. Este tipo de decisiones no tienen ninguna influencia política Otros; Especificar: Otros; Especificar: Marcar los criterios que se evalúan para promover al personal: N Pregunta SI NO 24. Conocimientos sobre funciones que realizará 25. Conocimientos sobre gestión pública 26. Liderazgo 27. Comunicación 28. Trabajo en equipo 29. No haber cometido faltas disciplinarias 30. Resultados de evaluación de desempeño 31. Experiencia en el sector público 32. Experiencia en las funciones que realizará 33. Recomendaciones 34. Nivel profesional adquirido 35. Manejo de conflictos 36. Participación en capacitaciones 37. Opinión del jefe inmediato superior 38. Este tipo de decisiones no tienen ninguna influencia política Otros; Especificar: Otros; Especificar: Desarrollo de Capacidades En relación a las actividades de capacitación N Pregunta SI NO Han diseñado una política de capacitación? Esta política está aprobada? 41. Esta política es conocida por todos? 42. Cuentan con una guía metodológica para el desarrollo de capacidades? Si la respuesta es SI, Cuándo ha sido aprobada? Si la respuesta es SI, esta Guía es la proporcionada por el MINSA? SI NO 43. Cuentan con un responsable de administrar los procesos de capacitación del personal? De acuerdo con el ROF vigente Quién es la instancia responsable de administrar los procesos de capacitación del personal? Nivel Existe? En caso de que exista Abt Associates Inc. Annex pg. 126

136 En DIRESA En la Red En la MR SI NO Nombre de la unidad responsable Función específica 44. En el último año han realizado procesos de capacitación al personal de su institución? Solo si la respuesta es afirmativa conteste las siguientes preguntas. Qué tipo de intervenciones educativas han desarrollado en su institución, en el último año? N Pregunta SI NO 45. Cursos cortos 46. Charlas 47. Pasantías en sedes del I Nivel 48. Pasantías en Hospitales regionales 49. Pasantías en Hospitales de Lima 50. Diplomados coordinados con una universidad 51. Talleres de capacitación Otros; Especificar: Indicar la cantidad de personas que han sido capacitadas el 2012, por régimen laboral y grupo ocupacional. Grupo Régimen laboral Total ocupacional CAS Funcionarios Directivos Profesionales Apoyo Total Indicar los tres (03) temas que con más frecuencia han sido considerados en la capacitación de cada grupo ocupacional. Grupo Temas más frecuentes en las actividades de capacitación ocupacional Funcionarios a) b) c) Directivos a) b) c) Profesionales a) b) c) Apoyo a) b) c) Marcar los criterios que se han tomado en cuenta para identificar las necesidades de capacitación del personal de su institución: N Pregunta SI NO 52. Los objetivos/metas de la entidad 53. Las prioridades sanitarias regionales 54. Las oferta de capacitación del MINSA 55. Las ofertas de capacitación de instituciones regionales 56. Resultados evaluaciones de conocimientos 57. Resultados de evaluaciones de desempeño Abt Associates Inc. Annex pg. 127

137 N Pregunta SI NO 58. Lineamientos del Plan de Capacitaciones 59. Sugerencia de otras instancias (redes, DIRESA, etc.) 60. Pedidos específicos de las áreas 61. Pedido directo de los trabajadores Otros; Especificar: Marcar los criterios que se utilizan para seleccionar al personal de su institución que participará en una capacitación. N Pregunta SI NO 62. El Perfil del puesto 63. Requerimiento de inmediato superior 64. Resultados de evaluaciones de desempeño (brecha de competencias) 65. Lineamientos del Plan de Capacitación 66. Recomendación otra instancia (microrredes, redes, DIRESA, etc.) 67. Ser personal nombrado de la entidad 68. Que no haya recibido capacitación en el mismo tema 69. Este tipo de decisiones no tienen ninguna influencia política Otros; Especificar: 70. El personal contratado CAS, NO tiene ninguna restricción para recibir capacitaciones? Marcar los roles y funciones que actualmente cumple la oficina de recursos humanos en los procesos de capacitación al personal de su institución. N Pregunta SI NO 71. Identificar las necesidades de capacitación del personal 72. Elaborar el Plan de Capacitación de la DIRES 73. Asesorar a las redes en el diseño de los planes de capacitación 74. Informar sobre oportunidades de capacitación 75. Facilitar los medios audiovisuales 76. Gestionar los refrigerios 77. Facilitar el local o aula de capacitación 78. Entregar materiales de enseñanza 79. Monitorear asistencia a las capacitaciones 80. Monitorear el desempeño de los docentes 81. Evaluar los conocimientos adquiridos 82. Evaluar la aplicación de conocimientos en sus funciones 83. Evaluar el impacto de las capacitaciones 84. Evaluar el financiamiento de las capacitaciones Otros; Especificar: Regulación Docencia - Servicio En relación a las sedes docentes Abt Associates Inc. Annex pg. 128

138 N Pregunta SI NO Cuentan con criterios para calificar a las sedes docentes? Estos criterios están aprobados? Cuentan con convenios con instituciones formadoras? Tienen un Comité Regional de Pregrado (COREPRES) conformado oficialmente? El COREPRES se reúne al menos una vez al año? Cuentan con un sistema de información o de registro de todos los estudiantes que se forman en su institución? Todas las sedes docentes de su ámbito se encuentran acreditadas? Cuentan con un responsable de administrar los convenios docencia servicio? Si la respuesta es NO, Por qué? Si la respuesta es SI, Cuándo ha sido aprobada? Si la respuesta es NO, Por qué? Si la respuesta es NO, Por qué? Si la respuesta es NO, Por qué? Si la respuesta es NO, Por qué? Si la respuesta es NO, Por qué? Si la respuesta es NO, Por qué? De acuerdo con el ROF vigente Quién es la instancia responsable de administrar los convenios con las instituciones formadoras? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 93. En el último año han suscrito convenios con instituciones formadoras? Solo si la respuesta es afirmativa conteste las siguientes preguntas. Para qué tipo de formación tienen actualmente convenios vigentes? N Pregunta SI NO 94. Pre grado en Medicina 95. Post Grado en Medicina 96. Pre Grado en Enfermería 97. Pre grado en Obstetricia 98. Prácticas de institutos tecnológicos Otros; Especificar: COMENTARIO ACERCA DE LA ORGANIZACIÓN Y FUNCIONAMIENTO DEL SUB SISTEMA DE GESTION DEL DESARROLLO Y LA CAPACITACIÓN: Abt Associates Inc. Annex pg. 129

139 GESTIÓN DE LA COMPENSACIÓN Cuestionario Diseño de estructuras salariales 1. Cuentan con un responsable de diseñar, implementar y monitorear las escalas salariales de su institución? De acuerdo con el ROF vigente Quién es la instancia responsable de diseñar, implementar y monitorear las escalas salariales de su institución? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 2. En el último año han elaborado alguna escala salarial? Si la respuesta es afirmativa, responda las siguientes preguntas: 3. La escala salarial está aprobada? Las escalas salariales han sido diseñadas para personal: N Nivel SI NO 4. Gerencial o Directivo 5. Profesionales asistenciales 6. Técnicos asistenciales 7. Profesionales administrativos 8. Técnicos administrativos 9. Personal nombrado 10. Personal contratado bajo cualquier modalidad Las escalas salariales han sido diseñadas para personal que trabaja en: N Nivel SI NO 11. DIRESA 12. Redes 13. Microrredes 14. Cuenta con una metodología para diseñar escalas salariales? 15. Cuenta con normas para el cumplimiento y mantenimiento de la escala salarial aprobada? El diseño de la escala salarial aprobada ha tomado en cuenta lo siguiente: N Pregunta SI NO 16. La valoración previa de los puestos de trabajo 17. Los perfiles de puestos 18. Más de 1 criterio 19. La disponibilidad presupuestal 20. Incorpora un componente variable ligado al desempeño Abt Associates Inc. Annex pg. 130

140 N Pregunta SI NO 21. La escala salarial pública 22. Las funciones que realiza el puesto 23. La jerarquía del puesto que ostenta 24. La antigüedad en el puesto 25. La zona geográfica donde se ubica el puesto 26. El grupo ocupacional al que pertenece Otro 27. Han utilizado la escala salarial aprobada para tomar algún tipo de decisión?, Por qué? En qué han utilizado la escala salarial aprobada? N Pregunta SI NO 28. Para los nuevos contratos 29. Acompaña los ascensos del personal 30. Para definir una línea de carrera Otro Administración de salarios o Gestión de la Planilla 31. Cuentan con un responsable de administrar los salarios y las planillas del personal en su institución? De acuerdo con el ROF vigente Quién es la instancia responsable de administrar los salarios y las planillas del personal en su institución? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 32. La planilla de pagos de remuneraciones y pensiones está actualizada) Administración de beneficios y bonificaciones 33. Cuentan con un responsable de administrar los beneficios y bonificaciones del personal de su institución? De acuerdo con el ROF vigente Quién es la instancia responsable de administrar los beneficios y bonificaciones del personal de su institución? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR Quiénes reciben AETAS en su institución? Gerencial o Directivo Nivel SI NO Si es SI cuántas? Abt Associates Inc. Annex pg. 131

141 Profesionales asistenciales Técnicos asistenciales Profesionales administrativos Técnicos administrativos Personal nombrado Personal contratado bajo cualquier modalidad Nivel SI NO Si es SI cuántas? Administración de Incentivos 34. Cuentan con un responsable de la administración de los incentivos monetarios? De acuerdo con el ROF vigente Quién es la instancia responsable de la administración de los incentivos monetarios? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 35. Cuentan con un responsable de la administración de los incentivos no monetarios? 36. Cuentan con normas o políticas aprobadas para la aplicación de incentivos? 37. En el último año han otorgado incentivos monetarios? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. N Pregunta SI NO 38. Los incentivos que se otorgan se hacen de acuerdo a los resultados de la evaluación del desempeño 39. Todos los trabajadores tienen la oportunidad de recibir incentivos monetarios 40. Los incentivos monetarios son individuales 41. Los incentivos monetarios son grupales 42. En el último año han otorgado incentivos no monetarios? Si la respuesta ha sido afirmativa, favor responder las siguientes preguntas. N Pregunta SI NO 43. Los incentivos que se otorgan se hacen de acuerdo a los resultados de la evaluación del desempeño 44. Otras instituciones participan en el otorgamiento de incentivos no monetarios Qué tipo de incentivos no monetarios aplican en su institución? N Pregunta SI NO 45. Reconocer públicamente los logros que ha conseguido una Red, MR o EESS y cómo ello contribuye a los logros de la DIRES en general. 46. El trabajador del mes 47. Un curso de capacitación Abt Associates Inc. Annex pg. 132

142 N Pregunta SI NO 48. Financiar un paseo con la familia 49. Días libres Otro Administración de Pensiones 50. Cuentan con un responsable de administrar las pensiones del personal? De acuerdo con el ROF vigente Quién es la instancia responsable de administrar las pensiones del personal? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 51. Cuentan con una norma o directiva aprobada para administrar las pensiones del personal? 52. Todas las pensiones se otorgan de acuerdo a la norma vigente? COMENTARIO ACERCA DE LA ORGANIZACIÓN Y FUNCIONAMIENTO DE LA GESTIÓN DE LA COMPENSACIÓN: Cuestionario GESTIÓN DE LAS RELACIONES HUMANAS Y SOCIALES Gestión del Clima Organizacional 1. Cuentan con un responsable de la gestión del clima organizacional de su institución? De acuerdo con el ROF vigente Quién es la instancia responsable de la gestión del clima organizacional de su institución? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR En relación al clima organizacional N Pregunta SI NO 2. Cuentan con una metodología definida para medir el clima organizacional? Abt Associates Inc. Annex pg. 133

143 N Pregunta SI NO 3. Cuentan con los instrumentos para medir el clima organizacional? 4. Tienen planificado realizar la medición del clima organizacional para este año? 5. El año pasado han realizado la medición del clima organizacional? Si la respuesta a la pregunta anterior es afirmativa, responda las siguientes preguntas: N Pregunta SI NO 6. La medición del clima laboral ha contado con el apoyo de la máxima autoridad de la institución 7. La medición del clima laboral ha contado con la participación de al menos el 80% de los trabajadores 8. Los resultados de la medición han sido analizados con los trabajadores 9. Se han elaborado planes para mejorar el clima laboral 10. Se han tomado acciones inmediatas en un lapso no mayor a 30 días de la medición del clima laboral 11. Los resultados se tienen en cuenta para la revisión y mejora de las políticas y prácticas de la gestión de recursos humanos. Gestión de las Relaciones Laborales 12. Cuentan con un responsable de la gestión de las relaciones laborales en su institución? De acuerdo con el ROF vigente Quién es la instancia responsable de la gestión de las relaciones laborales en su institución? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 13. Existen servidores que pertenecen a alguna organización sindical? Cuántos trabajadores están sindicalizados? Menos del 25% del personal Entre el 26 al 50% del personal Entre el 51 al 75% del personal Más del 75% del personal Con cuánta frecuencia se reúnen los sindicatos? Grupo ocupacional Anual Mensual Trimestral Semestral Médicos Enfermeras Obstetras Personal administrativo Personal Técnico General Otros: A pedido del sindicato Ante acontecimientos relevantes Abt Associates Inc. Annex pg. 134

144 Cuáles son los temas que se discuten con más frecuencia con los sindicatos? Bienestar Grupo ocupacional Salarios Movilidad Funciones Ascensos Evaluación social Médicos Enfermeras Obstetras Personal administrativo Personal Técnico General Otros: Otro Cómo califica la relación entre los sindicatos y las autoridades de la institución? Muy Niveles buena Buena Mala Muy mala Médicos Enfermeras Obstetras Personal administrativo Personal Técnico General Otros: 14. En el último año se han realizado negociaciones con los sindicatos que han dejado satisfechas a todas las partes involucradas? Cuántos días de huelga en total han tenido en año pasado? Grupo ocupacional Médicos Enfermeras Obstetras Personal administrativo Personal Técnico General Otros: N total de días Cómo califica en promedio las relaciones laborales en los diferentes niveles? Muy Niveles buena Buena Mala Muy mala DIRESA Redes Establecimientos de salud Cuáles son las causas más frecuentes de conflictos laborales? Grupo ocupacional SI NO Remuneraciones Luchas sindicales Rivalidades internas Otro Abt Associates Inc. Annex pg. 135

145 Otro Grupo ocupacional SI NO Cuáles son los mecanismos de solución de conflictos que mas se han usado en la institución el año pasado? Grupo ocupacional SI NO Negociaciones con el sindicato Negociaciones directas con los agraviados Negociaciones con los jefes inmediatos superiores Otro Otro Bienestar y Seguridad en el Trabajo 15. Cuentan con un responsable de gerenciar los procesos de bienestar de persona? De acuerdo con el ROF vigente Quién es la instancia responsable de gerenciar los procesos de bienestar de personal? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 16. Existen programas de bienestar social en su institución? 17. Planifican actividades de bienestar social en su institución? 18. Se cumplen las actividades programadas de bienestar social en su institución? Si la respuesta a la pregunta anterior es afirmativa, qué tipo de actividades se programan? N Pregunta SI NO 19. Celebraciones de feriados oficiales 20. Celebraciones de feriados regionales 21. Celebraciones de cumpleaños 22. Celebraciones de aniversario de la entidad 23. Organización de campeonatos deportivos 24. Servicio de cafetería o restaurante 25. Servicios de préstamos de dinero 26. Apoyo financiero para capacitaciones 27. Guardería 28. Club de la tercera edad 29. Organización de viajes 30. Organización de hinkanas 31. Organización de paseos con la familia Otro Otro 32. Cuentan con un responsable de gerenciar los procesos de salud y seguridad en el trabajo? Abt Associates Inc. Annex pg. 136

146 De acuerdo con el ROF vigente Quién es la instancia responsable de gerenciar los procesos de salud y seguridad en el trabajo? Existe? En caso de que exista Nivel Nombre de la unidad SI NO Función específica responsable En DIRESA En la Red En la MR 33. Existen normas o políticas aprobadas de salud y seguridad en el trabajo en su institución? 34. Existen programas de salud y seguridad en el trabajo en su institución? 35. Planifican actividades de salud y seguridad en el trabajo en su institución? 36. Se cumplen las actividades programadas de salud y seguridad en el trabajo en su institución? Si la respuesta a la pregunta anterior es afirmativa, qué tipo de actividades se programan? N Pregunta SI NO 37. Fumigación de los lugares de trabajo 38. Provisión de equipamiento protector de enfermedades, epidemias, etc. 39. Otorgamiento de seguros de salud ante accidentes o epidemias 40. Campañas de despistaje de enfermedades ocupacionales 41. Campañas de vacunación 42. Evaluaciones de defensa civil Otros Otros Otros COMENTARIO ACERCA DE LA ORGANIZACIÓN Y FUNCIONAMIENTO DE LA GESTIÓN DE LAS RELACIONES LABORALES: Abt Associates Inc. Annex pg. 137

147 7.2 Qualitative assessment of HRMS conducted by PARSALUD II in 4 Regions PARSALUD: Human Resources Management System in Ucayali RHD SOURCE: PARSALUD II technical report PARSALUD: Human Resources Management System in Cusco RHD SOURCE: PARSALUD II technical report Abt Associates Inc. Annex pg. 138

148 PARSALUD: Human Resources Management System in Huanuco RHD SOURCE: PARSALUD II technical report Human Resources Management System in Ayacucho RHD SOURCE: PARSALUD II technical report Abt Associates Inc. Annex pg. 139

149 PARSALUD: Human Resources Management System in Cajamarca RHD SOURCE: PARSALUD II technical report 7.3 SMT-RHD: HHR regional policies Below are 7 formulated policy guidelines, the same that are aligned to the national policy for HHR management and development. Lineamiento de Política 1.- Formación de los RHUS basado en el Modelo de Atención Integral de Salud, el perfil epidemiológico y sociocultural de la población, acorde a las necesidades regionales, locales bajo el marco de la descentralización. Lineamiento de Política 2.- Gestión de procesos de capacitación articulados a proyectos de desarrollo institucional, utilizando la Educación Permanente de la Salud y el enfoque de competencias para fortalecer el desempeño laboral, caracterizado por el respeto a los derechos, la equidad de género y la pertinencia cultural de la población. Lineamiento de Política 3.- Planificación estratégica de RHUS, sustentada en la información de necesidades reales de distribución y ubicación adecuada de RHUS, acorde al perfil demográfico, sociocultural y epidemiológico de la región, destacando las prioridades sanitarias de la población más excluida. Lineamiento de Política 4.- Gestión de RHUS a nivel regional, que asegure servicios de calidad, generando la participación activa del personal en las innovaciones organizacionales y la toma de decisiones para conciliar las necesidades de la población, los requerimientos básicos de los servicios de salud y las necesidades de los RHUS. Abt Associates Inc. Annex pg. 140

150 Lineamiento de Política 5.- Valoración y reconocimiento del trabajo de los agentes comunitarios de salud como aliados estratégicos en las acciones preventivo-promocionales del sistema de salud. Lineamiento de Política 6.- Aplicación de un nuevo marco normativo laboral consensuado con los RHUS, en base a perfiles ocupacionales por competencias con un sistema de compensación e incentivos; y procesos adecuados de reclutamiento, selección del personal, que aplique la promoción en la carrera pública considerando los derechos y deberes, la equidad de género, y el respeto a la diversidad. Lineamiento de Política 7.- Generar condiciones de trabajo, orientadas por relaciones laborales que promuevan ambientes de trabajo saludables, contribuyan a fortalecer los valores organizacionales, la calidad de las personas, y el aseguramiento de servicios de calidad a la población. 7.4 National agenda for research in HHR Resolución Ministerial MINSA SE RESUELVE: Artículo 1º.- Aprobar la Agenda Nacional de investigación para conocer los problemas de los Recursos Humanos en Salud, para el periodo , que a continuación se señalan: 1. Articulación de la formación en pregrado de los recursos humanos en salud con las necesidades de salud del país. 2. Capacidades del docente y estudiante para el uso y aplicación de las tecnologías de información y comunicación en el proceso de enseñanza aprendizaje en la formación en pregrado de los recursos humanos en Salud 3. Capacidades pedagógicas, metodología y estilos de aprendizaje durante la formación del estudiante de pregrado en escenarios comunitarios. 4. Necesidades de las regiones en la formación de recursos humanos en salud en estudios de postgrado y especialización según niveles de atención. 5. Impacto de las experiencias en la formación y logro de competencias de los recursos humanos en salud en especialización y postgrado. 6. Evaluación de la formación e investigación en postgrado y segunda especialización en salud en respuesta a las necesidades y problemas sanitarios del país. 7. Determinación de brechas de recursos humanos por niveles de atención para el aseguramiento en salud. 8. Análisis de procesos en el marco de la implementación del plan esencial de aseguramiento en salud con énfasis en el estudio de tiempos y movimientos para la dotación de recursos humanos. Abt Associates Inc. Annex pg. 141

151 9. Análisis y formulación de estrategias de financiamiento para la contratación de recursos humanos en el marco del aseguramiento universal en salud. 10. Perfil de competencias asistenciales y gerenciales, para la atención primaria de salud con enfoque de interculturalidad del personal existente en el equipo básico de salud. 11. Motivación e incentivos para desarrollar la atención primaria de salud en el primer nivel de atención. 12. Impacto de los agentes comunitarios en salud y estrategias de integración en atención primaria de salud. 13. Desarrollo de capacidades en base a competencias que respondan a las necesidades y objetivos institucionales y sectoriales. 14. Determinantes que influyen en el desarrollo laboral. 15. Ética y valores personales en la gestión de recursos humanos en salud. 16. Evaluación de experiencias exitosas nacionales e internacionales para la retención de profesionales de salud. 17. Evaluación del impacto económico y sanitario de la migración interna de profesionales de salud. 18. Dinámica y factores asociados a la movilización interna de los profesionales del sector salud. 19. Prevalencia e incidencia de la exposición, enfermedades y accidentes ocupacionales. 20. Estado de la implementación de las normas y organización de los servicios para la gestión de la salud y seguridad del trabajo. 21. Factores de riesgo ergonómicos y psicosociales. 22. Estudio de incentivos laborales. 23. Estudio de ética y funcionamiento. 24. Inequidad entre servidores y funcionarios de la salud. 25. Acceso a cargos públicos, impacto en el clima laboral y prestación de los servicios de salud. 26. Comparación de la jerarquía organizacional en los establecimientos de salud en relación a cargos y puestos. 27. Marco legal en materia laboral. 28. Identificar las competencias gerenciales a nivel regional para la gestión de recursos humanos y la gestión sanitaria regional. 29. Identificar y analizar las políticas/normas nacionales de recursos humanos que deben actualizarse al nuevo contexto regional. 30. Determinar la situación de las unidades orgánicas o sus equivalentes de gestión de recursos humanos en las regiones. Abt Associates Inc. Annex pg. 142

152 7.5 ASEGURA software for HHR requirements calculations Startup screen Screen: Time required for various medical procedures by type of HHR First level of care (hours) This screen displays the total number of medical procedures established by PEAS for the first level of care (132) and respective Current Procedural Terminology (CPT) codes 22. The 22 The Current Procedural Terminology (CPT) is a medical code set maintained by the American Medical Association (AMA) through the CPT editorial panel. The CPT code set (copyright protected by the AMA) Abt Associates Inc. Annex pg. 143

153 "N " column corresponds to the total number of procedures for a given population. The next set of columns represents each type of HR and the total hours they spend on each procedure based on activity standards 23 set by the MoH. The last row displays the sum of all hours for each HR type in delivering the PEAS package. 7.6 Using the spreadsheet to facilitate calculations This annex contains the procedure manual created with the Ayacucho RHD to facilitate calculations at the micro-network level. The manual was not approved due to RHD authority turnover. PROCEDIMIENTO PARA DETERMINAR LA BRECHA DE RECURSOS HUMANOS EN SALUD PARA EL PRIMER NIVEL DE ATENCION I. FINALIDAD. La presente directiva tiene la finalidad de contribuir con mejorar la calidad de atención de los servicios de salud del primer nivel de atención mediante la dotación adecuada de recursos humanos en salud, distribuidos en lugares adecuados. II. OBJETIVOS: a. General. Lograr que los servicios de salud del primer nivel de atención cuenten con recursos humanos adecuados en cantidad y calidad, que permitan satisfacer las necesidades de salud de la población ayacuchana. b. Específicos. La presente directiva permitirá a los jefes de Redes y micro-redes tomar decisiones relacionadas con: Establecer la cantidad requerida del personal de salud para atender a la población que está bajo su responsabilidad y territorio. Mejorar la ubicación del personal con que ya cuenta en los servicios de salud. Distribuir y asignar tareas, que permitan aprovechar de manera óptima el tiempo del personal para producir las atenciones requeridas, Comparar el esfuerzo y presión laboral a los que está sometido el personal de los establecimientos, dado que los desequilibrios se pueden manifestar como sobrecarga o distención laborales. Distribuir mejor el tiempo disponible del personal para la producción de los servicios de salud. describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. 23 The average amount of time a case should take each staff category to complete in compliance with acceptable professional standards (WISN, page 5). Abt Associates Inc. Annex pg. 144

154 III. ÁMBITO DE APLICACIÓN. Lo establecido en la presente Directiva es de aplicación y cumplimiento obligatorio de las Unidades Ejecutoras de Salud del ámbito de competencia de la Dirección Regional de Salud de la Región Ayacucho. IV. BASE LEGAL a. Ley Nº Aprueba reforma constitucional del Capítulo XIV del Título IV, sobre descentralización. b. Ley Nº 27783, Ley de Bases de la Descentralización. c. Ley Nº 26842, Ley General del Salud. d. Ley Nº 27867, Ley Orgánica de Gobiernos Regionales. e. Ley Nº 28411, Ley General del Sistema Nacional de Presupuesto Público, Título III, Normas complementarias para la gestión presupuestaria. f. D.S. Nº PCM, Plan Nacional para la superación de la Pobreza g. Decreto Legislativo Nº 1057 y su Reglamento aprobado por D.S. Nº PCM, modificado por D.S. Nº PCM. h. Ordenanza Regional Nº que aprueba las Políticas Regionales de RRHH. i. Reglamento de Organización y Funciones de la DIRESA j. Lineamientos Generales de Política Regional de Gestión y Desarrollo del Potencial Humano en Salud V. DISPOSICIONES GENERALES. a. Principios y valores: El Personal Administrativo de la Dirección Regional de Salud Ayacucho se rige bajo los Valores y Principios siguientes: i. Calidad. La Calidad es un enfoque que compromete a todo servidor y a todo nivel operacional, entendido como satisfacción del usuario, que puede evidenciarse a través de tres dimensiones: dimensión técnica, dimensión humada y la calidad del entorno. ii. Cumplimiento. Es un valor realizable solo si se cumple tres condiciones: que los objetivos institucionales sean verificables; que las tareas y responsabilidades sean explicitas; y que los niveles de autoridad sean respetadas. iii. Seriedad. Basada en el principio de honestidad en nuestras relaciones con el usuario externo, el usuario interno y los proveedores. iv. Eficiencia. Enfocada al uso optimo de los recursos. b. Objetivos institucionales: El personal Administrativo de la Dirección Regional de Salud Ayacucho desempeña un rol para el logro de los siguientes objetivos institucionales: i. Reducir la Desnutrición Infantil. ii. Evitar la Mortalidad Materna Neonatal. c. Estrategias institucionales: Son estrategias de la Dirección Regional de Salud Ayacucho: i. Estrategia Sanitaria Articulado Nutricional. ii. Estrategia Sanitaria Materno Neonatal iii. Estrategia Sanitaria TBC/HIV Enfermedades Transmisibles. iv. Estrategia Sanitaria Metaxénicas y Zoonóticas. v. Estrategia Sanitaria No Transmisibles. Abt Associates Inc. Annex pg. 145

155 vi. Estrategia Sanitaria Control de Cáncer de Cuello Uterino. d. Políticas. La presente Directiva se implementa en el marco de los Lineamientos Generales de Política Regional de Gestión y Desarrollo del Potencial Humano en Salud. Donde su Política 2 establece: Planificación estratégica de recursos humanos, para su distribución equitativa, de acuerdo al MAIS, el perfil demográfico, socio cultural y epidemiológico de la Región, cautelando las condiciones de trabajo del personal de salud. La Dirección Regional de Salud es responsable de la planificación territorial de los recursos, en coordinación con las unidades desconcentradas. La elaboración de la presente directiva responde al siguiente marco conceptual: e. Marco conceptual: Planificación de recursos humanos en salud: De acuerdo con la OMS la planificación de RRHH en Salud consiste en la Estimación del número de personas y los tipos de conocimientos, habilidades y actitudes que requieren para alcanzar objetivos sanitarios predeterminados y una determinada situación de salud. El Ministerio de Salud ha definido una propuesta de Sistema de Gestión Descentralizada de RRHH en Salud, donde un primer subsistema está relacionado con la Planificación de RRHH. El Objeto del Subsistema de Planificación de Recursos Humanos, involucra la definición de necesidades, cuantitativas y cualitativas de recursos humanos a corto, medio y largo plazo; contrastadas con las capacidades internas; así como las acciones que deben emprenderse para cubrir la brecha identificada. La planificación de recursos humanos comprende programar las necesidades de recursos humanos de la organización y establecer los pasos necesarios para satisfacer esas necesidades. Esta planificación es el primer paso de toda gestión efectiva de los recursos humanos. El desafío de este subsistema es lidiar con la migración interna y externa de los trabajadores de salud, así como la alta rotación del personal fundamentalmente la falta de información. Resulta difícil hacer proyecciones en estos escenarios. La planificación de los recursos humanos en salud debe estar estrechamente vinculada y articulada con las políticas y estrategias institucionales, con el modelo de atención de salud, el modelo de gestión, el modelo de organización de los servicios de salud, entre otros. En este subsistema se plantean las siguientes interrogantes: - Hasta qué punto la capacidad de planificar las necesidades de recursos humanos repercute en el desempeño de los mismos? - Se encuentran las personas adecuadas en los puestos adecuados? - Podemos pronosticar las exigencias actuales y futuras de recursos humanos? - Sabemos cómo y dónde identificar a las personas que poseen las aptitudes necesarias para satisfacer esas necesidades? - Podemos vincular la misión y metas organizacionales con la planificación de recursos humanos? Los procesos principales que se desarrollan en este subsistema son: Gestión de la información de recursos humanos: Un aspecto importante e imprescindible para una adecuada planificación de recursos humanos y para el cálculo de los requerimientos institucionales de recursos humanos es contar con Abt Associates Inc. Annex pg. 146

156 información actualizada y confiable acerca de la cantidad y distribución de recursos humanos en las diferentes unidades de la institución. Diseño de políticas y planes para cubrir la brecha de recursos humanos en salud: Para cubrir la brecha de recursos humanos en salud es necesario realizar un análisis cuantitativo y cualitativo de necesidades de recursos humanos; un análisis de la disponibilidad de recursos humanos; la definición de la brecha de recursos humanos para la definición de estrategias que permitan cubrir la brecha identificada. Las funciones principales del Subsistema de Planificación de RRHH en salud son: Mantener actualizada la información de recursos humanos de la institución. Identificar las necesidades de incorporación de personal en base a los planes y estrategias institucionales. Diseñar estrategias, planes y políticas destinadas a cubrir las necesidades de recursos humanos. f. Enfoques. Se definen varios enfoques para determinar la dotación de RRHH en Salud. Entre los tres principales más utilizados más utilizados son: i. Basado en las necesidades de salud. Permite estimar necesidades futuras de RHUS con base en necesidades de servicios de salud, ajustados por diversos criterios. Satisface las necesidades de salud. Es lógico, consistente e independiente a la utilización actual de servicios de salud, pero requiere de normas o estándares de producción. ii. Basado en la utilización futura de servicios de salud. Este enfoque proyecta requerimientos futuros basados en el uso actual de los servicios de salud. Existen pocos cambios en los ratios de utilización de una población específica. resultan ser alcanzables financieramente sin embargo es una proyección del status quo cuyo supuestos, inexactos, pueden ocasionar errores de cálculo por que no toma en cuenta el nivel de acceso a servicios de salud. iii. Basado en coeficientes de población. Proporción entre trabajadores de salud y población. fácil de aplicar y entender, pero no permite explorar interacciones entre: mezcla, distribución, productividad, resultados. La selección de un enfoque dependerá de la disponibilidad de información confiable, del nivel de decisión y del problema o restricción en la gestión de recursos humanos que se pretende resolver. g. Metodología. La metodología para la estimación de la dotación de recursos humanos en salud desde la Micro red está basado en las necesidades de salud, con las siguientes características: 1. Se basa en la estimación de la probabilidad de ocurrencia de casos, por grupo etáreo, para una población determinada. 2. Para cada caso y sus respectivas variantes, se definen los procedimientos asistenciales involucrados, en base a las normas vigentes. 3. Para cada procedimiento se establecen los tipos de RRHH que intervienen y el tiempo que dedica cada uno de ellos a cada procedimiento, basado en las normas vigentes. 4. Toma en cuenta el tiempo realmente disponible para la prestación 5. Permite ajustes de acuerdo a la capacidad resolutiva actual y potencial en el corto plazo Abt Associates Inc. Annex pg. 147

157 6. Permite calcular los requerimientos de recursos humanos ajustado en función al nivel de ruralidad del distrito donde se ubican los establecimientos de salud. 7. Permite introducir la cantidad actual de recursos humanos en el establecimiento de salud, para determinar la brecha que es necesario cubrir. 8. Permite contar con cuadros finales de análisis que permiten una mejor asignación de los recursos humanos al interior de la microrred. La metodología para el análisis de necesidades de recursos humanos en salud desde la microrred comprende los factores que intervienen entre la disponibilidad de recursos y la producción de servicios. Los cuales están relacionados con: a. La productividad de los recursos humanos y su rendimiento b. El tiempo realmente utilizado en la prestación de servicios de salud c. La distribución de la carga de trabajo d. La accesibilidad geográfica para la asignación territorial. VI. DISPOSICIONES ESPECÍFICAS: Para realizar los cálculos de dotación de recursos humanos en salud para el primer nivel de atención, cada microrred contará con un aplicativo en excell. Las hojas de cálculo destinadas para la estimación tienen tres partes: (i) La parte superior para introducir los datos; (ii) La parte intermedia, para el procesamiento automáticamente de los datos relacionados con: El listado de los procedimientos asistenciales por tipo de establecimiento de salud. Las fórmulas que calculan automáticamente la cantidad de procedimientos en un año, en base a la población asignada. Las fórmulas que calculan automáticamente los tiempos que cada proveedor destina al total de procedimientos. (iii) La parte inferior, para mostrar los resultados. Abt Associates Inc. Annex pg. 148

158 I. PARTE SUPERIOR Para el ingreso de datos II. PARTE INTERMEDIA Para el procesamiento de datos ingresados. III. PARTE INFERIOR Para mostrar los resultados Ingreso de datos: Cada responsable en la microrred deberá introducir los datos relacionados con cada uno de los establecimientos de salud de la MR, para ello deberá llenar los espacios que se encuentran en color rosado. Cada establecimiento de salud tiene una hoja de cálculo donde se ingresarán sus datos. SOLO DEBERÁ LLENARSE LA INFORMACIÓN QUE SE DETALLA A CONTINUACIÓN. A continuación se detalla el tipo de información a llenar. a. Datos Generales: Esta información permitirá identificar la unidad de análisis. Los datos que se ingresen en los campos respectivos, permanecerán a lo largo del análisis. Ejemplo: DIRESA Ayacucho RED MR EESS Cora Cora Cora Cora CS Pacapausa b. Población asignada: En este campo, se deberá colocar la población total de la unidad de análisis. Abt Associates Inc. Annex pg. 149

159 Ejemplo: Población 1,737 c. Datos de los proveedores: Para cada uno de los tipos de proveedores de servicios asistenciales de salud, se deberá consignar la siguiente información: a. Horas disponibles para la prestación del paquete básico de atención.- Se refiere al tiempo que debe destinar el proveedor en el año, para la prestación de los servicios de salud individual. En el caso del ejemplo que coloca líneas abajo, de las 1800 horas que tiene el médico al año, solo destina 1346 horas para los procedimientos establecidos, el resto del tiempo lo dedica a sus vacaciones, capacitación, tareas administrativas, etc.. Estos tiempos serán asignados por la DIRESA, dependiendo del tipo de establecimiento de salud. b. Dotación actual de recursos humanos.- Aquí se consignará la cantidad de personal por tipo de grupo ocupacional que se encuentra laborando en el establecimiento de salud al momento de realizar la estimación de la dotación de recursos humanos. Por ejemplo, no considerar al personal destacado. c. Remuneración anual - Personal contratado (nuevos soles).- Deberán consignar la remuneración anual, según lo establecido en la directiva vigente de la escala salarial para el personal contratado. d. Remuneración anual - Personal nombrado (nuevos soles).- Deberán consignar la remuneración anual, según lo establecido en las planillas del personal nombrado. Ejemplo: Médico Cirujano Enfermera Obstetra Horas disponibles para la prestación del paquete básico de atención Dotación actual de recursos humanos Remuneración anual - Personal contratado (nuevos soles) 38, , , Remuneración anual - Personal nombrado (nuevos soles) 50, , , d. Índice de ajuste de productividad por ruralidad: En este recuadro deberán colocar los índices de ajustes establecidos para cada uno de los establecimientos de salud, los mismos que se encuentran en el Anexo 1 de esta directiva 24. Esta información será permanentemente revisada por la DIRESA y su actualización será distribuida en la directiva correspondiente. Ejemplo: Ïndice de ajuste de productividad por ruralidad Alvarez, Carmela. Calculo de Indice de Ruralidad para todos los distritos del Perú. Para el proyecto USAID/Perú/ Políticas en Salud. Febrero Abt Associates Inc. Annex pg. 150

160 Resultados a nivel del establecimiento de salud: Una vez que se han ingresado los datos, los resultados aparecerán automáticamente al final de la hoja de cálculo respectiva. Los resultados que aparecerán son los siguientes: Ejemplo: TOTAL DE HORAS NECESARIAS , Médico Cirujano Enfermera Obstetra RRHH NECESARIOS SIN AJUSTE RRHH AJUSTADOS POR RURALIDAD DOTACIÓN ACTUAL BRECHA DE RRHH SIN AJUSTE BRECHA DE RRHH CON AJUSTE a. Total de horas necesarias: Lo que aparece es el total de horas al año que se requiere para la prestación de todos los procedimientos, por cada tipo de proveedor. En el ejemplo que se muestra a continuación, se requiere un total de horas del Médico Cirujano para todas las atenciones previstas. b. RRHH necesarios sin ajuste: Se efiere al número de RRHH que se requiere para realizar todos los procedimientos establecidos para la población asignada. Esta cantidad resulta de dividir el Total de horas necesarias entre la cantidad de Horas disponibles para la prestación del paquete básico de atención. En el ejemplo que se muestra, se requieren horas del Médico que divididas entre las 1346 horas disponibles, nos dan 0.60 médicos. c. RRHH ajustados por ruralidad: La cantidad de RRHH necesarios sin ajuste se divide entre el Índice de ajuste de productividad por ruralidad para tener una nueva estimación de requerimientos de RRHH ajustados por el nivel de ruralidad del distrito donde se ubica el establecimiento de salud. En el ejemplo que se muestra, los 0.6 médicos que se necesitan, se dividen entre 0.63 que es su índice de ajuste por ruralidad, y sale una nueva estimación: 0.95 médicos. d. Dotación actual: Es una copia de la información introducida en la parte superior de la hoja de cálculo. e. Brecha de RRHH sin ajuste: Resulta de realizar la resta de RRHH necesarios sin ajuste menos la dotación actual. En el ejemplo, el EESS necesita 0.6 médicos y tiene 2 médicos, lo que significa que tiene una sobredotación de 1.40 médicos (sale en negativo). Si se observa el caso de las enfermeras, se requieren 2.29 enfermeras y se tienen 2, por lo que faltan 0.29 enfermeras. f. Brecha de RRHH con ajuste: Resulta de realizar la resta de RRHH necesarios con ajuste menos la dotación actual. En el ejemplo, el EESS necesita 0.95 médicos ajustados por ruralidad y tiene 2 médicos, lo que significa que tiene una sobredotación de 1.05 médicos (sale en negativo). Si se observa el caso de las enfermeras, se requieren 3.64 enfermeras (con el ajuste)y se tienen 2, por lo que faltan 1.64 enfermeras. g. Información complementaria: Conociendo la brecha por cubrir y la remuneración anual, se puede obtener el costo de cubrir la brecha. Abt Associates Inc. Annex pg. 151

161 Ejemplo: COSTO PARA CUBRIR LA BRECHA SIN AJUSTE Con personal contratado -53, , , Con personal nombrado -53, , , COSTO PARA CUBRIR LA BRECHA CON AJUSTE Con personal contratado -40, , , Con personal nombrado -53, , , h. Resultados a nivel de la microrred: Un visión global de la situación de dotación de recursos humanos a nivel de la MR se observa en la hoja de cálculo Comparativo, donde se puede observar de manera integrada la infomación de todos los EESS de la MR. La matriz que se observará contiene la columna EESS donde están todos los EESS de esa MR, con sus respectivas poblaciones. Para cada grupo ocupacional, se tienen los siguientes indicadores: - RRHH necesarios ajustados por ruralidad (A). - Dotación actual (B) - Brecha de RRHH (A-B) - Ratio de carga laboral (B/A): Es un indicador para la gestión de RRHH que nos mide la magnitud de la carga de trabajo que tiene el prestador. Lo deseado es que el resultado sea 1 ; un número mayor a 1 indica sobredotación, un número menor a 1 indica sobrecarga de trabajo ; mientras mas cerca de 0 mayor sobrecarga. Por ejemplo, los 2 médicos del PS Chaviña realizan el trabajo que debe ser realizado por solo 1 médico (0.95), lo que da un ratio de carga laboral de 2.11, al ser mayor a 1 indica que hay sobredotación de médicos en PS Chaviña. En el caso de las enfermeras, las 2 que están actualmente en el CS Chaviña están cargado el trabajo que deberían realizar las casi 4 enfermeras que se necesitan, lo que da un ratio de carga laboal de 0.55, al ser menor a 1 indica que hay sobrecarga. - Ratio x habitantes (B/pob*10000): Es un indicador que es útil para poblaciones grandes, pero que no ayuda mucho para las poblaciones pequeñas que existen a nivel de EESS. Nota: Se mantiene este indicador, ya que estas matrices pued ser usadas a nivel de Redes y DIRESA. Ejemplo: Abt Associates Inc. Annex pg. 152

162 EESS Población PS Chaviña 2,463 PS Calpamayo 608 PS Sancos 1,461 MR Cora Cora 11,158 Médico Cirujano Enfermera Obstetra RRHH necesarios ajustados por ruralidad (A) Dotación actual (B) BRECHA DE RRHH (A-B) Ratio de carga de trabajo (B/A) Ratio x 10,000 habitantes (B/Pob *10000) RRHH necesarios ajustados por ruralidad (A) Dotación actual (B) BRECHA DE RRHH (A-B) Ratio de carga de trabajo (B/A) Ratio x 10,000 habitantes (B/Pob *10000) RRHH necesarios ajustados por ruralidad (A) Dotación actual (B) BRECHA DE RRHH (A-B) Ratio de carga de trabajo (B/A) Ratio x 10,000 habitantes (B/Pob *10000) RRHH necesarios ajustados por ruralidad (A) Dotación actual (B) BRECHA DE RRHH (A-B) Ratio de carga de trabajo (B/A) Ratio x 10,000 habitantes (B/Pob *10000) Análisis de la información: En la hoja de cálculo Gráficos se encontrarán un conjunto de tablas y gráficos que permitirán analizar la información relacionada con la distribución de los RRHH entre los EESS de la MR. Las últimas tablas resumen todos los cálculos realizados y permiten tomar decisiones. Ejemplo: MR Cora Cora Población Grupo ocupacional EESS RRHH necesarios ajustados por ruralidad (A) Dotación actual (B) BRECHA DE RRHH (A-B) Médico Cirujano Problema en gestión de RRHH Ratio de carga de trabajo (B/A) Presión en la carga Laboral 1,737 CS Pacapausa escasez 0.00 alta 1,087 PS Aycara escasez 0.00 alta 682 PS Ccasaccahua escasez 0.00 alta 655 PS Muchapampa escasez 0.00 alta 682 PS San Marcos escasez 0.00 alta 728 PS San Francisco de Rivacayco escasez 0.00 alta 566 PS Ccochani escasez 0.00 alta 409 PS Upahuacho escasez 0.00 alta 450 PS Sansaycca escasez 0.00 alta 1,699 PS Chaquipampa escasez 0.00 alta 2,463 PS Chaviña sobredotación 2.11 no hay sobrecarga 608 PS Calpamayo sobredotación 3.39 no hay sobrecarga 1,461 PS Sancos sobredotación 1.78 no hay sobrecarga 13,227 Total de la MR escasez 0.77 alta El análisis de esta tabla debe realizarse a nivel de la MR. Por ejemplo, esta MR requiere 5.18 médicos, es decir 6 médicos. La pregunta es Dónde asigno a estos 6 médicos?. Si solo analizo las cantidades puedo decir que requiero colocar médicos en los 6 EESS con cifras mayores, pero debo tomar en cuenta otras variables como: - Ubicación del EESS - Tipo de contrato del personal. - Nivel de producción del EESS. La siguiente tabla muestra cómo se modifican los resultados con la reasignación. Abt Associates Inc. Annex pg. 153

163 Población DECISIÓN Grupo ocupacional EESS RRHH necesarios ajustados por ruralidad (A) Dotación actual (B) BRECHA DE RRHH (A-B) Médico Cirujano Problema en gestión de RRHH Ratio de carga de trabajo (B/A) Presión en la carga Laboral 1,737 CS Pacapausa escasez 0.00 alta 1,087 PS Aycara escasez 0.00 alta 682 PS Ccasaccahua normal # DIV/0! # DIV/0! 655 PS Muchapampa normal # DIV/0! # DIV/0! 682 PS San Marcos normal # DIV/0! # DIV/0! 728 PS San Francisco de Rivacayco escasez 0.00 alta 566 PS Ccochani normal # DIV/0! # DIV/0! 409 PS Upahuacho normal # DIV/0! # DIV/0! 450 PS Sansaycca normal # DIV/0! # DIV/0! 1,699 PS Chaquipampa escasez 0.00 alta 2,463 PS Chaviña sobredotación 2.00 no hay sobrecarga 608 PS Calpamayo sobredotación # DIV/0! # DIV/0! 1,461 PS Sancos normal 1.00 normal 13,227 Total de la MR escasez 0.67 alta Las unidades ejecutoras deberán tomar en cuenta estas matrices para la determinación de las brechas de RRHH a nivel de MR y EESS, así como para determinar la asignación de RRHH a nivel de MR. Es importante que antes de llenar la información, se GRABE el archivo de trabajo con un nombre diferente. Cada vez que deseen hacer un nuevo cálculo, pueden usar la matriz en blanco y grabarla con el nombre que más convenga. VII. RESPONSABILIDADES: DIRESA: a) Como autoridad sanitaria en la Región le corresponde la implementación, el monitoreo, el control y la evaluación del cumplimiento de la presente directiva. b) Brindar asistencia técnica a las unidades ejecutoras para el correcto cumplimiento de la presente directiva. RED/UNIDAD EJECUTORA: a) Aplicar y ejecutar lo dispuesto en la presente directiva de acuerdo a sus competencias. b) Informar a la DIRESA la aplicación de la presente directiva, de manera trimestral. c) Informar a la DIRESA acerca del uso de los resultados de la matriz de cálculo, cada vez que realicen contrataciones de personal para el primer nivel de atención. d) Participar en la reuniones de monitoreo y evaluación de la presente directiva, las mismas que serán convocadas por la DIRESA. VIII. Disposiciones Finales. Disponer que la DIRESA Ayacucho realice una primera evaluación a los tres meses de haberse aplicado el cálculo de la dotación de RRHH en el primer nivel de atención y si el caso amerite, proponer los ajustes que se considere necesarios. Abt Associates Inc. Annex pg. 154

164 7.7 Survey to determine the available working time in the first-level-of-care ENCUESTA N de Encuesta: DISPONIBILIDAD DE TIEMPO EN EL PRIMER NIVEL DE ATENCION La presente encuesta es anónima e individual, su información será muy útil para la dotación de RRHH en la región. Por favor, completar toda la información solicitada con la mayor veracidad posible. SUS RESPUESTAS MÁRQUELAS CON UNA X, ó ESCRÍBALAS EN LOS ESPACIOS SUBRAYADOS SECCION N 1: DATOS GENERALES DE ESTABLECIMIENTO DE SALUD Localidad y Distrito: Nombre del Establecimiento: Categoría del Establecimiento: Microrred a la que pertenece: 1. Qué cargo desempeña? ( ) Médico ( ) Enfermera ( ) Obstetra ( ) Cirujano dentista ( ) Psicólogo ( ) Biólogo ( ) Nutricionista ( ) Tecnólogo Médico: Laboratorio ( ) Tecnólogo Médico: Radiología ( ) Tecnólogo Médico: Terapia Física ( ) Técnico Laboratorio ( ) Técnico Enfermería ( ) Otro: 2. Cuál es su condición laboral? ( ) Nombrado ( ) Contratado Especifique modalidad ( ) SERUMS Abt Associates Inc. Annex pg. 155

165 3. Cuántas horas al mes está usted contratado? (Oficialmente el personal nombrado labora 150 horas al mes) ( ) 150 horas ( ) Otro Cuántas horas? ( ) No sabe SECCION N 2: AUSENCIAS PREVISTAS Y NO PREVISTAS 4. Cuántos días de vacaciones tiene usted en el año? ( ) 15 días ( ) 30 días ( ) Otro días ( ) No tiene vacaciones 5. Durante los meses comprendidos entre octubre del 2011 a marzo del 2012, ha participado usted en capacitaciones dentro de los días laborables? ( ) Si ( ) No (Si la respuesta es No pase a la pregunta 6) Nombre de la Capacitación Cuántas horas duró la capacitación? Cuántas horas empleó en viajar de ida y regreso? Sub total horas Total horas 6. Cuáles son las fiestas o celebraciones regionales y locales cuyos días no son laborables en su establecimiento? (No considerar los feriados nacionales oficiales, semana santa, fiestas patrias, fiestas navideñas, otros) Nombre de la Celebración NO Laborable Nº de días 1. Fiesta patronal 2. Aniversario del Establecimiento Abt Associates Inc. Annex pg. 156

166 Nombre de la Celebración NO Laborable Nº de días 3. Otra: 4. Otra: 5. Otra: Total días 6. Durante los meses comprendidos entre octubre del 2011 a marzo del 2012, sufrió algún imprevisto que lo obligó a ausentarse de su lugar de Establecimiento de Salud? ( ) Si ( ) No (Si la respuesta es No pase a la pregunta 8) 7. Cuál fue el motivo de dicho imprevisto que lo obligó a ausentarse? Motivo Nº de días ( ) Enfermedad ( ) Imprevisto personal o familiar ( ) Fallecimiento de un familiar ( ) Conflicto o huelga ( ) Otros motivos (por favor especifique): SECCION N 3: SALUD AMBIENTAL 8. Durante los meses comprendidos entre enero a marzo del 2012, Usted ha realizado o participado en actividades de salud ambiental, dentro del establecimiento? ( ) Si ( ) No (Si la respuesta es No pase a la pregunta 4) 9. Durante los meses comprendidos entre enero a marzo del 2012, Cuántas salidas y cuántas horas le ha dedicado a las actividades de salud ambiental? Actividades Extramurales Nº de salidas realizas Nº de horas promedio utilizado en cada salida Total horas Charlas a la comunidad Fumigaciones Abt Associates Inc. Annex pg. 157

167 Actividades Extramurales Nº de salidas realizas Nº de horas promedio utilizado en cada salida Total horas Control de la calidad del agua Otras: Otras: Total horas SECCION N 4: LABOR ADMINISTRATIVA O DE GESTION 10. Usted realiza actividades administrati 11. vas o de gestión o participa en actividades o reuniones de relacionadas con la administración o gestión del establecimiento? ( ) Si ( ) No (Si la respuesta es No usted ha culminado la encuesta, muchas gracias) 12. cuántas actividades administrativas o de gestión realiza aproximadamente en un mes? Actividades de Gestión ó Administrativas Nº de veces al mes Nº horas promedio que utiliza en cada actividad Total horas Coordinaciones con actores locales (autoridades, representantes, funcionarios de otras instituciones) Participación en la elaboración de planes estratégicos, operativos, presupuesto, etc. Trámites administrativos (cuadro de necesidades, requerimientos, seguimiento a trámites administrativo, etc.) Elaboración de informes de: gestión, capacitación, evaluaciones, supervisiones, etc.) Codificación, llenado y registro de reportes e información estadística Actividades de monitoreo y/o evaluación del establecimiento Otra: Total horas Muchas gracias! Abt Associates Inc. Annex pg. 158

168 7.8 Detailed table of "available working time" for health facilities This table corresponds to health facilities type I-4 Grupo Ocupacional Condición laboral Hras totales anuales Días de vacaciones al año # total de horas de vacaciones al año Hrs anuales de capacitación N total de días de celebraciones N total de horas de celebraciones N total de días de imprevistos N horas de días de imprevistos N total de horas de actividades administrativ as TOTAL DE HORAS NO DISPONIBLES TOTAL DE HORAS DISPONIBLES PARA LA PRESTACION % de tiempo disponible para NO PEAS Total de horas disponibles para NO PEAS Médico Nombrado ,592 10% ,433 80% Contratado ,652 10% ,487 83% Enfermera Nombrado ,580 15% 237 1,343 75% Contratado ,652 15% ,404 78% Odontólogo Nombrado ,598 1% ,582 88% Contratado ,658 1% ,641 91% Obstetra Nombrado ,592 5% ,512 84% Contratado ,658 5% ,575 88% Tecnólogo Médico Nombrado ,604 1% ,588 88% Radiología Contratado ,670 1% ,653 92% Tecnólogo Médico Nombrado ,598 1% ,582 88% Laboratorio Contratado ,670 1% ,653 92% Tecnólogo Médico Nombrado ,604 1% ,588 88% Rehabilitación Contratado ,670 1% ,653 92% Psicólogo Nombrado ,598 20% ,278 71% Contratado ,658 20% ,326 74% Biologo Nombrado ,604 20% ,283 71% Contratado ,670 20% 334 1,336 74% Nutricionista Nombrado ,598 5% ,518 84% Contratado ,670 5% ,587 88% Trabajadora Social Nombrado ,604 80% % Contratado ,670 80% % Técnico Laborat. Nombrado ,598 1% ,582 88% Contratado ,658 1% ,641 91% Técnico Radiolog. Nombrado ,610 1% ,594 89% Contratado ,664 1% ,647 92% Fisioterapista Nombrado ,610 1% ,594 89% Contratado ,664 1% ,647 92% Técnico Enferm. Nombrado ,604 15% ,363 76% Contratado ,664 15% ,414 79% Total de horas disponibles para PEAS % tiempo disponible PEAS Abt Associates Inc. Annex pg. 159

169 7.9 Available working time to provide PEAS in first-level-of-care health facilities Categoría I-1 I-2 I-3 I-4 Situación laboral Médico Cirujano Cirujano Dentista Enfermera Psicólogo Obstetra TM - Radiología TM - Laboratorio TM - Terapia física Biólogo Nutricionista Trabajador Social Tco. Radiología Tco. Fisioterapis Laboratorio ta Nombrado 1,453 1,610 1,362 1,301 1,533 1,610 1,610 1,610 1,301 1, ,616 1,043 1, Contratado 1,507 1,675 1,423 1,354 1,596 1,675 1,675 1,675 1,354 1, ,675 1,109 1, % hras PEAS contratado 84% 93% 79% 75% 89% 93% 93% 93% 75% 89% 19% 93% 62% 93% 53% Nombrado 1,453 1,327 1,119 1,072 1,262 1,327 1,327 1,327 1,072 1, ,180 1,174 1,616 1,382 Contratado 1,507 1,392 1,180 1,125 1,324 1,392 1,392 1,392 1,125 1, ,675 1,234 1,675 1,059 % hras PEAS contratado 84% 77% 66% 62% 74% 77% 77% 77% 62% 74% 16% 93% 69% 93% 59% Nombrado 1,433 1,451 1,231 1,173 1,387 1,457 1,457 1,457 1,178 1, ,180 1,168 1,180 1,008 Contratado 1,487 1,511 1,292 1,221 1,450 1,523 1,523 1,523 1,230 1, ,239 1,228 1,239 1,059 % hras PEAS contratado 83% 84% 72% 68% 81% 85% 85% 85% 68% 81% 17% 69% 68% 69% 59% Nombrado 1,433 1,582 1,343 1,278 1,512 1,588 1,582 1,588 1,283 1, ,594 1,582 1,594 1,363 Contratado % hras PEAS contratado 83% 91% 78% 74% 88% 92% 92% 92% 74% 88% 19% 92% 91% 92% 79% Servidor Tco./Aux Abt Associates Inc. Annex pg. 160

170 7.10 Ministry of health: General competencies for the health sector FORMULACION DE LAS COMPETENCIAS LABORALES GENERICAS DEL SECTOR SALUD 25 La formulación e identificación de las competencias laborales genéricas tiene como ejes orientadores al propósito clave del sector salud y los objetivos sectoriales (plan concertado de salud), la que permite responder a cuáles son las competencias laborales genéricas que todo trabajador del sector salud debe saber hacer para el cumplimiento de las funciones encomendadas. A continuación se presenta a manera de esquema el propósito clave, los objetivos del sector y las competencias genéricas laborales del sector salud. IDENTIFICACIÓN Y DEFINICIÓN DE LAS COMPETENCIAS GENÉRICAS LABORALES Para el logro del propósito clave y los objetivos del sector, todos los trabajadores del sector salud deberán tener las siguientes competencias genéricas laborales las que se complementaran con las competencias específicas. 25 Extraído de: Competencias Laborales para la mejora del desempeño de los Recursos Humanos en Salud /Ministerio de Salud. Dirección General de Gestión del Desarrollo de Recursos Humanos en Salud. Dirección de Gestión del Trabajo en Salud Lima: Ministerio de Salud; pág.; ilus.; tab. (Serie Documentos Técnicos Normativos de Recursos Humanos en Salud; 2) Abt Associates Inc. Annex pg. 161