Challenges

Health system fragmentation and care limitations

Despite all the reforms Peru has made to its health system over the past 20 years, it remains fragmented, with many funding sources, a range of insurance schemes (provided by the Ministerio de Salud, EsSalud, the police and armed forces, and the private sector) with different coverage levels, and multiple channels for health service financing (prepayment schemes and budgetary programs) and delivery.¹ This fragmentation constrains Peru’s ability to provide timely, high-quality care for all its citizens.^2,3

Access to health services in Peru also remains fragmented because it depends on individual insurance schemes and, to a lesser extent, on geographic location. (For instance, private insurance often has more human and financial resources per user than Seguro Integral de Salud [SIS] does.)¹ This, too, perpetuates systemic inequalities and reduces the comprehensiveness and coordination of the services the system can provide.

Inequality

Geographic and human resources barriers to health service delivery

Another challenge Peru faces is the persistence of inequalities, especially in the rural Andes and Amazon regions. The accessibility and availability of health services differs markedly between rural and urban areas—hospital services are overwhelmingly concentrated in urban areas—and from one region to the next. In general, there are insufficient health workers to meet the rising demand for services that Peru’s health system reforms have made possible.

It can be especially difficult for people in rural areas to access care, regardless of their insurance status.^4,5 As a result of the SERUMS system, a substantial proportion of health providers nationwide start their careers working in rural areas—though most do not remain in those marginalized communities when their training period ends. Pay in the public sector is persistently low, and health workers in rural areas report limited access to diagnostics and other key tools.⁶ Consequently, almost 96% of the population in urban areas can access health facilities within approximately one hour of travel, compared to 76% of people in rural areas.⁵ The density of health workers is also greater in urban areas. As of 2021, nearly half of Peru’s health workforce worked in Lima, the capital.⁷

Even for maternal and child health, analyses of administrative databases show variability between regions, with Ancash, Madre de Dios, and Ucayali reporting the lowest share of facilities with adequate human resources and equipment. Within each region, health facilities located in the most resource-constrained districts reported the lowest availability of equipment.¹

The Indigenous populations in Peru—roughly 25% of the country’s population⁸ —are most vulnerable to health system inequalities. They experience major disadvantages, such as lack of access to high-quality health services and a lack of population-specific metrics to direct policy and improve their health outcomes.⁹ Only about 30% of Indigenous communities in the Amazon have adequate access to a health post, for instance.⁹ Despite efforts by the government to make services accessible and acceptable – through practices such as “Enfoque Multicultural” that promotes attention to local cultural practices and languages at health facilities¹⁰ – some Indigenous populations report discrimination and exclusion, which further prevents them from receiving key health services.¹¹

Financial barriers to access

Alongside Peru’s efforts to expand financial access to care and protect citizens from catastrophic health spending—for example, by eliminating user fees through SIS for a defined package of services¹² —out-of-pocket (OOP) health spending has fallen.¹³ However, it remains high.^14,15 This is, in part, because some key health services are not included in the SIS benefits package. Also, Peruvians often assume that the quality of care they will receive at private facilities is better than the care they could receive in the public sector, and waiting lists for private care are often shorter.¹⁶ Consequently, many people—especially those with higher incomes—choose to pay out of pocket to access those services.^13,14

In 2022, ENAHO found that seven out of 10 people who needed medical care did not get it—but only 3% of those people said it was because they did not have health insurance.¹⁷ Thirty-five percent cited long wait times.

Political instability

Instability is one constant in Peruvian politics. Peru’s current president, Dina Boluarte, assumed office in 2022 after Pedro Castillo—who was president from July 2021 to December 2022—was impeached and removed from office after he too attempted a self-coup. Boluarte is Peru’s sixth president since 2016 and its 10th since 2000, when Alberto Fujimori stepped down. (In 2009, Fujimori was found guilty of human rights abuses for authorizing death squads during his presidency and sentenced to 25 years in prison; he was pardoned in 2017 and released in December 2023.)¹⁸

Including Fujimori, six presidents of Peru since his time in office have been accused of corruption. Boluarte was accused of genocide after police killed people protesting her government, and her presidency was not universally recognized by countries around the world when she took office.¹⁹

As one result of this historic and ongoing political instability, Peruvians report low rates of trust in and satisfaction with the country’s political system and institutions.²⁰

The impact of COVID-19

The COVID-19 pandemic had a devastating effect on many countries in Latin and South America, in both numbers of deaths and per capita impact. However, it is possible that COVID-19 impacted Peru even more than reported estimates indicate.

For example, through April 1, 2023, there were almost 225,000 cumulative reported deaths (656 per 100,000) in Peru. But this might be an inaccurate picture of COVID-19 in Peru. The Institute for Health Metrics and Evaluation (IHME) estimated “total” COVID-19 deaths to include excess mortality—a term WHO defines as “the difference between the total number of deaths estimated for a specific place and given time period and the number that would have been expected in the absence of a crisis.” ²¹ The estimate shows that through April 1, 2023, more than 330,000 people (971 per 100,000) died of COVID-19 in Peru.²²

Put another way, the total per capita impact of COVID-19 in Peru might have been among the most severe in the world, after countries like Bulgaria (1,293 per 100,000) and Peru’s neighbor Bolivia (1,316 per 100,000).²²

Peru’s economy contracted sharply during the COVID-19 pandemic. Between 2019 and 2020, global GDP declined 2.85%. Meanwhile, Peru's GDP declined 11.55%, and the poverty rate increased to 26% in 2021. According to the World Bank, two in five Peruvians were at risk of falling into poverty that year, the highest rate since 2004.²³

Overall, the COVID-19 pandemic delivered a major shock to Peru’s health system and economy. Additional work is needed to completely assess the full impact of COVID-19 on the health of Peruvians, and specifically on the country’s PHC efforts and outcomes.