in Public Health
and Education in Peru
Richard Webb and Sofía Valencia
This chapter reports on a study of the causes of poor performance by human resources in public health and education in Peru. The findings are based mostly on unstructured and nonrandom interviews of education and health professionals, government officials, and analysts, carried out between October 2004 and July 2005 in the cities of Cuzco, Lima, and Trujillo, and in rural areas of two provinces in the Sierra, and on available research reports, project evaluations, and official statistics.
The main conclusion is that deficiencies in the delivery of public education and health are the product of a historical and human adjustment process that is not easily reversible. The process was triggered by fiscal collapse, which forced a substantial reduc- tion in real wages for all civil servants. However, the path followed by that crisis, and especially the degradation of the civil service career, was also a consequence of institu- tional weakness. In one case, it was the government’s failure to monitor performance and enforce work rules. In another, it was the incapacity of users to perceive or react against service deficiencies. These institutional weaknesses opened the door to a perverse mode of adjustment: the cutbacks required by fiscal poverty took the form of a reduc- tion in professional effort and service quality rather than in the number of employees or establishments.
Low productivity, low quality, and anti-poor bias in those services have become rooted in institutions, forms of behavior, and life and career arrangements that include parallel business and educational investments and residential decisions. Providers, bureaucrats, politicians, and union leaders have accommodated to a status quo of low wages, lax disci- pline, informal and illegal practices, falling entry standards, and inadequate levels of effort. The main policy implication is that reform requires the emergence of a new, exogenous source of pressure sufficiently strong to overcome the accommodating preferences of the