Key Points
- Before and during the Exemplar study period, Peru implemented policies aimed at increasing primary health care (PHC) service coverage alongside social policies aimed at reducing poverty nationwide. Together, these interventions enabled the country to make substantial progress in improving health outcomes.
- Peru’s efforts to build a health system that spends more and better on PHC fall into two main pathways:
- The first pathway enabled good health system governance at the national and regional levels by establishing efficient, data-driven planning processes and by empowering civil society groups for improved accountability and oversight.
- The second pathway enabled better access to health services nationwide by expanding health insurance programs and implementing human resource incentives to attract and retain health workers.
- Primary health care is a comprehensive, multisectoral approach to care that has many components and addresses a large and diverse set of health needs. In Peru, as in every Exemplar country, officials used a combination of interactive, complementary policy levers across the health system’s building blocks—governance, financing, facilities, workforce, supplies, service delivery, and data and information systems—to effect whole-system change. Peru also implemented reforms in other sectors that targeted low-income Peruvians and aimed to improve equity inside and outside the health system.
Two pathways for health system reform in Peru
In Peru, Exemplars research identified two ways (or pathways) through which reforms have over time improved PHC outcomes. Reforms are often complex, with multiple components, and thus they can often operate using multiple pathways. Indeed, efforts to reform PHC in all the Exemplar countries were interactive and complementary, and they evolved and built on one another over time.
- The first pathway strengthened national and local health system governance. Investments in data production and transparency enabled policymakers and others to monitor and audit health system performance and to establish more robust processes for priority setting and planning. Empowering civil society groups enabled local representation in—and oversight of—those processes.
- The second pathway focused on improving access to health care. Increased access to health insurance (and cross-sectoral antipoverty programs) made health services more affordable to more people. Performance incentives increased provider motivation and enabled more equitable human resource distribution nationwide.
Figure 7 below shows the sequence of key PHC system reforms in Peru since 1990.
Figure 7: Peru intervention timeline
Peru Intervention Details
Intervention |
What was implemented? |
What was the result? |
Current status? |
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1. 1950s: Grassroots self-help groups |
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2. 1970: Rural clinician incentive schemes |
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3. 1994: Comités Locales de Administración de Salud (CLAS) |
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4. 1994: Regionally independent procurement autonomy |
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5. 1999: Formal sector health insurance (EsSalud) |
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6. 2001: National stakeholder roundtable against poverty |
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7. 2001: Financial incentives to attract and retain skilled managers |
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8. 2002: Tax-funded national health insurance (SIS) |
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9. 2002: Digital procurement systems |
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10. 2003: Community outreach and networks of care |
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11. 2004: Annual DHS surveys |
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12. 2005: Conditional cash transfers |
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13. 2005: Re-organized administrative functions |
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14. 2007: Results based budgeting |
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15. 2007: Cross sectoral programming |
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16. 2013: Independent MOH auditing body |
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17. 2013: Comprehensive care networks |
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18. 2013: Expansion of SIS benefits |
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19. 2013: Mixed methods provider payments |
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Health system improvement does not happen overnight. Over the Exemplar study period, Peru invested in its PHC system in three phases:
- At first, Peru’s PHC reforms focused on improving nutrition, expanding access to care by implementing early versions of national health insurance schemes, and building foundations for community participation in health administration and delivery.
- In the early 2000s, Peru began to replace those early vertical programs with cross-sectoral interventions focused on reducing poverty and care networks to maintain continuity of patient care. At the same time, the country reformed its overall administrative structuring, as well as its financing and budgeting practices. Likewise, starting with the establishment of comprehensive health insurance, policymakers made health services more accessible and affordable to the country’s poorest people.
- In the past fifteen years, Peru has focused on expanding service provision for conditions requiring chronic care as well increasing the populations and range of services covered under the national health insurance schemes. In recent years, Peru has turned greater attention to fine-tuning and optimizing provider incentives and ensuring greater mechanisms and tools for accountability of the health system.