Table 1 presents information on the participants’ organization and government level. At the national level, 25 participants worked at the Ministry of Health, affiliating with various national institutes such as the Peruvian Center for Diseases Control and Prevention, the National Institute of Health and the Directorate of Medicine and Supplies. Eight people worked with the Ministry of Agriculture, four reported affiliations with the Agriculture Health Service Unit and four with the Forest and Wildlife Management Unit. Two participants worked at the Ministry of Environment. At the subnational level, interviews took place in two regions, Piura and Tumbes, with 19 participants affiliated with the Regional Directorate of Health and five affiliated with the Regional Directorate of Agriculture.
Table 1 Description of organization and government level of participants
Table 2 lists the main themes that characterize participants’ perspectives regarding the priority-making process, the organizational process for selecting strategies and the rules regarding the organization’s role in developing and implementing policy for the prevention and control of zoonoses among participants from the Ministries of Health, Agriculture and Environment and the Regional Directorates of Health and Agriculture of Peru. In the following sections, we summarize and compare participants’ perspectives. A more detailed description of each theme by organization and level of government can be found in Additional File 2.
Table 2 Main themes of policy process and rules among participants from the Ministries of Health, Agriculture and EnvironmentObjective 1: the priority-making process and the driving and limiting factorsPriority-making process
The Ministries of Health, Agriculture and Environment participants described the priority-making process as reactive, with no institutional strategy to address emergent events preventively. Moreover, they reported that priorities are decided, and strategies are developed, at the national level. National guidelines inform the regional list of priorities, and programs’ annual goals are established for each region. The Ministry of Health’s national and subnational-level participants reported evaluating the disease burden utilizing data captured by the health information systems. Factors such as economic impact, morbidity, mortality and lethality were considered. Directives at the national level include a formal list of zoonotic diseases subject to national surveillance, which also informs program funding assignments.
The Ministry of Agriculture’s participants informed that a passive surveillance system of notifiable diseases from decentralized offices was used to capture or receive reports from various sources, including producers. The Ministry of Agriculture listed the impact of zoonoses on livestock production, international trade and the country’s economy as the main factors influencing their organization’s priority-making process. Proposed activities to be implemented in regions are based on goals from established zoonosis programs such as influenza, rabies and tuberculosis, which have a standard procedure regulated at the national level. Participants also reported that the needs of small- and medium-sized producers influenced the priority-making process. Activities are focused on prevention, such as vaccination campaigns and informational workshops about high-risk diseases in the region. Participants from the Ministry of Environment report that their organization does not have active surveillance systems to look for specific cases or strategic planning regarding wildlife zoonosis control and prevention. There are no guidelines or rules about what must be monitored or captured.
Multisectoral approaches are utilized in priority-making, with the participation of representatives from various ministries at the national and subnational levels. Interviewees also reported taking part in a multisectoral prioritization of zoonoses that applies the OH approach. It was also reported that feedback from regional partners and the community was integrated by organizing regional meetings to discuss problems and confirm cases reported in the system. Civil society, such as scientists, professional organizations, university leaders and community-organized groups, also participate. At the subnational level, multisectoral regional meetings are held to prioritize diseases, applying the perspective of social determinants of health. Almost all regional directorates participate in classifying and prioritizing diseases.
Driving and limiting factors
The Ministry of Health’s participants reported that the unstable political environment and conflict of interest limited work to address zoonoses. High turnover among policy-makers and leaders was a barrier to sustaining communication or building bridges. They also reported that self-interest was prioritized over technical or evidence-based information. One said, “There is an imbalance between economic power and the country’s needs; everything is about profit”. At the subnational level, participants reported feeling apathy among local authorities. Also, high turnover among professionals was reported as a barrier to the continuity of work and coordination with people from the municipalities. Changes in authorities or political conflict are a distraction and a barrier since it is “like starting from scratch”.
Participants from the Regional Directorate of Health reported that national priorities precede regional priorities. Regional activities focused on addressing national program goals that have assigned funding. One participant said, “Everything is formulated in the national operational plans, leaving no room to include more problems [at the regional level]”. They felt local leaders feared doing something new and that policy-makers focus on the diseases with the most political impact and significance. Some participants also reported that decision-makers were interested in solutions that help address various factors. They said, “The [authorities] think that finding a ‘synergy in two policies’ is a good strategy. Activities that addressed sanitation resolved leptospirosis and dengue; they have been successful”.
At the national and subnational levels, participants from the Ministries of Health and Agriculture considered international organizations such as the World Bank as promoters for translating programs into policy. They also described the Pan-American Health Organization as an essential advisor for developing or updating national norms and supporters of projects to address zoonoses, such as hydatidosis, resulting in the creation of a multisectoral commission.
Participants from all three ministries reported that outbreaks that became emergencies incentivized new regulations and guidelines. Owing to the avian influenza emergency, international, national and regional meetings took place, and guidelines were created to manage infected wildlife in the national territory. Also, the COVID-19 pandemic and the avian influenza outbreak generated the need to monitor and systematize information and apply an ecosystem approach to health. This shift in priorities resulted in the creation of a protocol with a multisectoral collaboration that includes mechanisms and methodologies to detect and treat infected animals and guided activities to control the influenza emergency.
Objective 2: the process for selecting policy solutions
The Ministries of Health and Agriculture’s participants described a standard process for selecting and defining interventions or strategies in a policy that includes various review cycles to obtain feedback from all interested parties. However, participants from the national level reported that “it is not a systematic process or method aligned to international standards”. Participants also stated that experts’ opinions influence the selection of solutions and the development of policy documents. Some participants recognize that this practice can be harmful and a serious problem. They said that, even though the process includes a review of the literature of scientific evidence, experts could influence and may make the last decision on what is included in the policy document on the basis of their “judgment, opinion, or experience”. Participants think the process should be based “solely on evidence from systematic reviews or meta-analyses”.
Participants from all three ministries described that a robust accumulation of evidence about an intervention’s effectiveness was needed to include it in a policy. International organizations help update policy documents and provide recommendations for pilots to evaluate and select the strategy that obtains the best results. Multisectoral collaboration meetings, such as the National Commission for the Prevention of Zoonoses, have generated guidelines backed by scientific research. Some participants reported that the OH approach has been applied to develop the latest policies. However, participants believe that it is a lengthy policy-making process. Work to establish specific protocols or technical documents is organized by disease. Owing to the required process, some regulations have taken more than 10 years to develop and have not yet been approved.
There are intergovernmental meetings, including national and regional leaders, to identify solutions and implementation adaptations in the regions. The meetings include technical experts and representatives from sectors that may be relevant to the implementation phase. The national level provides guidelines and coordinates actions with regions to address outbreaks. National regulations and operational procedures are adapted to the context, and when updates are needed, new guidelines are shared with regional experts for feedback. Participants at the subnational level reported there are macro multisectoral regional meetings to propose strategies to address various diseases, including zoonotic diseases. Research and pilot studies inform local regulations. Participants reported that researchers had disseminated studies with them and had influenced changes in local guidelines. Participants believe that the main barrier to testing new solutions is the requirement for scientific evidence to support their effectiveness, which may work in a different context. Pilot studies have been proposed to address that barrier.
Lastly, Ministry of Health participants believe there is a “curative bias” in health policy-making, which aims to treat people instead of taking a preventive approach. They said policy-makers recognize this issue, but it is not reflected in practice. The Ministry of Agriculture participants reported that, in their organization, solutions are focused on prevention rather than control, mainly focused on capacity building and education. Policy solutions include training, health education, vaccinations and surveillance based on reports of infected cases.
Objective 3: organizations’ role in preventing and controlling zoonosesPerceptions of organization’s role in control and prevention of zoonoses
Ministry of Health participants believed the responsibility to control and prevent zoonoses is shared. Still, the Ministry of Health should convene and coordinate collaborations as zoonoses require a social determinant of health approach, which relies on other organizations’ responsibilities. At the subnational level, participants expanded on a similar idea of shared responsibilities: “It is shared, agriculture should be included, there is an issue with breeding grounds, in rice fields, banana fields, so, we have mosquitoes. The issue of basic sanitation, water, and sewage is quite scarce”.
Participants from all three ministries reported there are unclear roles regarding animal management. They stated that the law does not specify who is responsible for the animal reservoir, and some roles are still undefined, such as managing infected pets or wildlife. Participants from the Ministry of Agriculture believed that their organization has an educational role rather than a therapeutic role in zoonosis control and prevention. They said their institution is responsible for providing educational guidance for preventing and managing infected livestock and advising producers and farmers about correctly managing infected animals or culling but do not provide treatments. The Ministry of Environment participants also reported unclear rules on their organization’s role in preventing and controlling zoonosis, especially in managing wildlife zoonoses. However, they said they support other ministries creating policies to address zoonosis.
Participants described that the Ministry of Agriculture’s focus on activities related to the use and transformation of resources may be a problem when applying OH approaches. Farmers are reported to exert some influence on the policy agenda, prioritizing funding for diseases mainly affecting animals. However, participants recognize the value of the OH application in expanding perspectives. One participant from the Ministry of Agriculture said, “We as health authorities have our responsibilities regarding animal health. But now, with this new approach, ‘One World, One Health,’ I believe this is a new way to reengineer and see that we all have to participate […] to work together to see that health is the priority in every sense of the word”.
Lastly, participants at the subnational level through local organizations such as regional governments, municipalities, and prosecutors are essential for addressing public health problems. Engaging with farmers or producers is challenging if the city or the justice department is not involved in enforcing rules or incentivizing preventive behaviour, such as addressing an infectious disease outbreak that requires animal culling.
Authority to develop policy
Participants from the Ministries of Agriculture and Health reported that there are hierarchical rules to propose policies. They said that policies are developed at the national level, and some adaptations can be made at the regional level. Participants explained how this structure hinders addressing regional priorities, “Unfortunately, the diseases that are reported at a regional level or that are worked on are mostly decided in Lima where they make the decisions, so we cannot take action on a new policy or action that should be done”. Also, participants reported that hierarchical norms within an organization could be a barrier to policy-making, for instance, the sub-unit of Zoonotic Diseases Prevention and Control that needs to coordinate with other units of higher rank and that some may consider “not a pair”. One participant explained, “You need to be very technically empowered so that you can [call for collaboration], which is a limitation.”
Participants from the Ministry of Agriculture also reported that there is a need for a clear definition of responsibilities for joined work in policy documents, which could help define obligations without overstepping on functions, as they are not allowed to require the participation of other sectors. They thought clear roles for collaborations would incentivize more involvement from different sectors and local governments and assign funding directly for coordination activities.
Participants at the subnational level also believed that the policy development process needed to involve local authorities and community leaders. One interviewee said, “The process should involve regional leaders, including the community leaders or ‘apus,’ to help make the connections for later implementation work; local leaders’ words are like a law”. Public policies should flow “through the veins of the local governments”. Participants at the subnational level also thought that the regional context was less complicated than the national one for policy-making that involved other sectors. Participants reported working closely with regional directors, especially when developing regional policies that transcend sector boundaries. Regional policy-making related to zoonoses and vector-borne diseases mainly aims to incentivize the participation of external agents such as schools and police. One participant expanded on this: “The ordinance on Dengue had health theory and economics components, and involvement of institutions such as UGELES [school unions], police stations, parishes, fire stations, banks, all to contribute to prevention”.
However, there is conflicting information about what the subnational level can do in policy-making. Some participants reported that their primary role at the regional level was to solely implement operational plans following national guidelines. They said, “Plans, surveillance schedules, program implementation, regional prioritizations are made, but always within the framework of the national regulations; we cannot deviate from it”. In contrast, other participants described some space for regional policy-making: “We do not approve our policies here, but they can be proposed. […] We could issue the evidence in a document endorsed by the general management and send it to the [national level]”. Thus, regional health leaders’ empowerment and technical capacity building were recommended to propose policies.