Key Points
- Even as Peru has made impressive strides to reduce mortality among children under the age of five, significant challenges remain. Perhaps most notably, the country’s vast and varied geography contributes to lingering regional inequalities and distribution problems.
- Supply chain and distribution issues have compromised delivery of interventions and could be a barrier to sustaining and improving coverage levels.
- Out-of-pocket health costs remain high, though they are still lower than the average for Latin America and the Caribbean.
- The quality and precision of data remains uneven and fragmented, hindering the evolution of evidence-based interventions to reduce under-five mortality.
Continued Regional Differences in Coverage
While Peru made progress toward reducing mortality among children under the age of five (U5M) across a wide range of demographic categories, some notable regional differences persisted. For example, in 2012 skilled birth attendance ranged from 61 percent in Loreto to 100 percent in Apurimac.
Neonatal mortality rate vs skilled birth attendance in Loreto vs Apurimac
Data Source: Demographic and Health Survey (DHS); Institute for Health Metrics and Evaluation (IHME) GBD 2017
In addition, while almost half (46 percent) of women living in urban areas received adequate postnatal care, only 28 percent in rural areas did. Regional coverage varied greatly, from only 10 percent in Loreto to 76 percent in Tacna.1
Supply Chain and Distribution Variability
Despite extensive preparation of rapid diagnostic testing (RDT) for malaria, implementation was challenged by supply chain issues and by the end of funding from the Global Fund. In 2004 and 2005, the Ministry of Health (MOH) purchased 40,000 RDTs for use in six regions of the country. However, challenges in procurement and subsequent distribution caused delays in the RDTs reaching their target communities.
Since the selected RDT was made to order, Peru’s order was not shipped until three to six months after the order was placed. After entering Peru, being cleared through customs, undergoing quality testing, and being transported from Lima to other areas of the country via air or water, tests typically took anywhere from 6 to 12 months to reach communities. As a result of such delays, RDT procurement and distribution have largely halted since 2007 – a lapse that has impeded the sustainment of this intervention.
Supply chain issues also challenged Peru’s efforts to achieve widespread coverage of artemisinin-based combination therapies (ACTs). Acquisition of drugs was centralized and the drugs were stored in MOH warehouses in Lima before distribution.
As explained by one interviewee,
“The warehouse worker becomes the owner of the medicine and does not let go. He would tell each promoter to bring the prescription or bring the empty blister pack of a completed treatment and he would replenish it.”
High Out-of-Pocket Health Costs
In 2002, Peru established the Comprehensive Health Insurance program in an effort to address high out-of-pocket costs for health care – a persistent problem in Peru.2
The Comprehensive Health Insurance program contributed to improved rates of facility-based births in Peru. However, despite its successes, these costs remained high throughout the study period. (For more information on the Comprehensive Health Insurance program, see the Context article.)
The Institute for Health Metrics and Evaluation (IHME) found that Peru’s out-of-pocket spending as a proportion of total health expenditures decreased slightly from 35 percent in 2000 to 30 percent in 2015. These levels are actually below the regional average for Latin America and the Caribbean (40 percent in 2015), but still high enough to indicate serious health equity gaps.3
Health expenditure profile in Peru
Specifically, Peru’s out-of-pocket levels reflected the fact that many citizens felt compelled to rely upon private health services for timely delivery of services that might have been difficult to obtain in public health facilities.4
Lower-middle income and some groups of low-income individuals faced especially large out-of-pocket health expenses due to gaps in insurance. These are the Peruvians who fall outside the publicly financed Seguro Integral de Salud because they are not classified as poor or they are unable to participate in formal professional insurance plans because they work in informal sectors.
These individuals and households may also often be unable to partake in private insurance due to the cost of premiums; private insurance covered between 3 percent and 5 percent of the Peruvian population in 2008, despite provisions in the Social Security Health Act of 2002 that allowed workers to gain access to private insurance.5,6
Lack of Data Quality and Completeness
Peru’s Demographic and Family Health Survey (called the Encuesta Demográfica y de Salud Familiar [ENDES] in Peru) has provided granular data to inform decision making, helping identify areas of need and thus enabling the country’s public health gains. However, the survey has also suffered from some important limitations, especially in data fidelity at the regional level and insufficient data about services.
“ENDES, for me, has been insufficient,” said one interviewee. “It is an omnibus of a survey, which gives you big indicators, but then when you want to go in and look at the indicators in detail and with higher quality, the details aren’t there, and there we have a big challenge in the information systems at the MOH because in Peru that is very poor quality.”
More broadly, Peru’s efforts to reduce U5M has suffered from overarching data challenges. The fragmentation of the Peruvian health system impedes the collection of standardized data across providers, programs, and regions. This, in turn, hinders both monitoring and quality assessment.7
In addition, research suggests that Peru needs to improve the quality of primary data recording at the provider and facility levels, as well as the interpretation and use of data for policy making.7
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1
Instituto Nacional de Estadistica e Informática (INEI). Encuesta Demográfica y de Salud Familiar (ENDES) 2000 – Peru. Lima, Peru: INEI; 2000. https://dhsprogram.com/publications/publication-FR120-DHS-Final-Reports.cfm. Accessed February 12, 2020.
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2
World Health Organization (WHO). Success Factors in Women’s and Children’s Health: Mapping Pathways to Progress – Peru. Geneva: WHO; 2013. http://www.paho.org/nutricionydesarrollo/wp-content/uploads/2014/03/Success-Factors-in-Womens-and-childrens-Health.-Mapping-Pathways-to-Progress.pdf. Accessed March 18, 2019.
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3
Institute for Health Metrics and Evaluation (IHME). Flows of global health financing - [data set]. Financing Global Health, Viz Hub. Seattle, WA: IHME; 2019. https://vizhub.healthdata.org/fgh/. Accessed January 17, 2020.
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4
Organisation for Economic Co-operation and Development (OECD). OECD Reviews of Health Systems: Peru 2017. Paris: OECD; 2017. https://dx.doi.org/10.1787/9789264282735-en. Accessed October 14, 2019.
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5
United States Social Security Administration. Program Operations Manual System (POMS). PR 03120.288 Peru. PR 81-007 Max W~, Deceased — Social Security No. ~ Ceremonial Marriage—Perm. June 3, 1981. https://secure.ssa.gov/apps10/poms.nsf/lnx/1503120288. Accessed September 13, 2019.
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6
Francke P. Peru’s Comprehensive Health Insurance and New Challenges for Universal Coverage. Universal Health Coverage Studies Series (UNICO). UNICO Studies Series No. 11. Washington, DC: World Bank; 2013. http://documents.worldbank.org/curated/en/371851468086931725/pdf/750090NWP0Box30r0Universal0Coverage.pdf. Accessed March 8, 2019.
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7
Organisation for Economic Co-operation and Development (OECD). Monitoring Health Systems Performance in Peru: Data and Statistics. Paris: OECD; 2017. https://read.oecd-ilibrary.org/social-issues-migration-health/monitoring-health-system-performance-in-peru_9789264282988-en#page13. Accessed March 18, 2019.