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

Source: The Institute for Health Metrics and Evaluation; GBD 2019

Peru Intervention Details

 

 
Intervention
What was implemented?
What was the result?
 Current status?

 1. 1950s: Grassroots self-help groups

  • Peru's government backed early grassroots, social groups that promoted nutritional supplementation with self-help models
  • This began in 1957 with the Club de Madres (Mothers Club) for local women and their Vaso de Leche (cup of milk) program and extended to the 1970s with the operation of Comedores Populares (communal kitchens)
  • Women’s groups (originating from “Mothers Clubs”) supported PHC by promoting community participation through two programs: Vaso de Leche and Comodores Populares.
  • The model was later institutionalized and is still active today
  • Currently in practice, some are self managed while others are integrated into central and local government structures.
 2. 1970: Rural clinician incentive schemes
  • Peru introduced the Servicio Civil de Graduandos (SECIGRA) program, a compulsory unpaid PHC rotation in underserved communities for all medical students
  • In 1980, SECIGRA became Servicio Rural Urbano y Marginal de Salud (SERUMS) --  a paid professional service that dispatches recent medical science graduates across cadres to rural and underserved areas to cover PHC – was later institutionalized
  • Required for all medical school graduates who wish to work in the public sector and/or access specialization
  • SERUMS improved equitable HR distribution by ensuring a variety of skills are available in underserved rural areas
  • SERUMS staff account for 58% of doctors, 30% of nurses, and 18% of midwives in rural areas 
  • Currently in practice
 3. 1994: Comités Locales de Administración de Salud (CLAS)
  • Local Health Administration Committees (CLAS) were created to  supervise the delivery of key health services using MINSA funds. They also promoted community participation in PHC decision making.
  • Non-profit organizations were contracted by MINSA to administer and manage up to 5-6 health facilities, carry out local needs assessments and identify unmet needs through regular household surveys. Allowed for joint decision-making with the communities receiving the funds. 
  • CLAS succeeded in reaching the most deprived members of the community and was successful in reducing user charges; 25,1% of services were free at point of contact compared to 17.4% in MINSA run establishments
  • PHC budget accounted for 20% of the total MINSA budget by 1996
  • By 2000, such groups accounted for approximately 25% of all public PHC establishments and were numbered 2000 at their peak.
  • Higher women’s participation and user satisfaction, lower user charges, and success at reaching the most deprived
  •  Currently in practice
 4. 1994: Regionally independent procurement autonomy
  • Established PACFARM, a syste for the provision, supply, and distribution of 63 essential medicines, self-supported by revolving fund, and applies to all health centers and posts in the public network. 
  • The program improved supply management efficiency and removed financial barriers to access essential medicines. The reform also brought about administrative modernization 
  • Currently in practice, credited with advancing administrative modernization
 5. 1999: Formal sector health insurance (EsSalud) 
  • Established by the Ley del Seguro Social de Salud - EsSalud is a public, contributory (via payroll tax) health insurance scheme for formal sector wage earners
  • By 2017, EsSalud insurance covered 27% of Peru's population
  • Currently in practice
 6. 2001: National stakeholder roundtable against poverty
  • Strong civil society advocacy process results in signing of documents such as Roundtable Against Poverty
  • National Agreement (Acuerdo Nacional) signed in 2002 by leaders from all sectors decreeing the need to invest in the poorest states
  • Consistent prioritization of health and poverty reduction initiatives
  • Acts as a governance mechanism to keep the central / regional governments accountable to PHC priorities through civil society monitoring and participation
  • Currently in practice and remains a legitimate accountability and prioritization mechanism.. 
7. 2001: Financial incentives to attract and retain skilled managers
  • SERVIR program established to improve the management of human resources. It improved recruitment, developed leadership skills, professionalized managers, and supported pay raises. It equalized pay of public sector managers to private-sector rates.
  •  Attracted and retained skilled managerial staff
  • It equally improved efficiency through improved staff motivation, more equitable HR distribution, and improved service quality and coverage
  • Currently in practice in at least one study department. 
8. 2002: Tax-funded national health insurance (SIS)
  • National social health insurance  started with the poor, and eventually expanded as resources grew
  • Automatic enrollment included at time of birth for access to all preventative, curative, and highly specialized care
  • High enrollment, reflecting the commitment to equity and financial protection. 47% of the population covered (2017), other coverage from armed forces and civil servant programs
  • Gave 6 million Peruvian adults – 21% of the population – entitlement to basic health care at public MINSA facilities without charge. 
  • Currently in practice and all newborns automatically enrolled.  
9. 2002: Digital procurement systems
  • Established SISMED, the government’s digital platform for tracking and ordering stock 
  • High usage of information systems contributed to reduction of stockouts
  • Currently in practice. 
10. 2003: Community outreach and networks of care
  • The Modelo de Atención Integral de Salud (MAIS) was introduced to ensure continuity of care
  • Under MAIS, outreach services were introduced with basic health teams and mobile provision for dispersed populations
  • Networks and micro-networks were formed to provide health services on behalf of the Ministry of Health 
  • Impact was limited during first decade of implementation due to fragmentation of health system, which undermined comprehensive care policy.
  • Reform was revitalized from 2011 onwards 
  • Currently in practice nationwide. 
11. 2004: Annual DHS surveys
  • Peru conducts Demographic and Health Surveys (DHS) every year, including at subnational (departmental) level. Initiated to ensure data was available more frequently than every 5 years.
  • This is facilitated by a decision to permanently maintain DHS unit and field staff within the National Statistics Agency
  • Facilitates routine monitoring of essential health and population programs
  • Lowered turnover among enumerators and improved efficiency of data collection and analysis
  • Allowed for survey customization to local needs (e.g., new modules)
  • Currently in practice, regional reporting started in 2009.
12. 2005: Conditional cash transfers
  • Developed a conditional cash transfer program (JUNTOS) to increase use of health services in rural areas and to reduce poverty
  • Provided direct cash payments to meet certain health/education criteria to eligible families
  • JUNTOS participants experienced reduced underweight and overweight prevalence among women and reduced anemia and acute malnutrition in children
  • Currently in practice. JUNTOs was expanded in 2007 and again in 2010, eventually reaching 1142 out of 1800 districts. 
13. 2005: Re-organized administrative functions
  • Initiation of transfer of administrative functions to local authorities through lawmaking.
  • Regional MOH directorates became responsible for service delivery in 2005 through public providers
  • A strong national commitment to UHC and equitable coverage of health services.
  • High managerial autonomy, low political pressure in staffing decisions, and a high degree of budget autonomy 
  • Currently in practice. MINSA’s regulatory capacity and steering role during emergencies was strengthened in 2015/16 through additional bylaws.  
14. 2007: Results based budgeting
  • Presupesto por Resultados (PpR), a results-based budgeting (RBB) program was introduced as part of broad PFM reforms to enhance efficiency, quality, and accountability of public programs. Moved away from input-based logic towards more transparent resource allocation process.
  • Performance indicators for RBB budgetary programs are regularly collected and published in RESULTA, a MOF web app open to the public 
  • Enhanced accountability for programmatic results across key programs (incl. nutrition, MNCH, TB/HIV, NCDs, cancer, etc.)
  • Currently in practice, used by both the Ministry of Health and Ministry of Development.
 15. 2007: Cross sectoral programming
  • Launched a national strategy aimed at poverty reduction (CRECER) via cross-sectoral social programs 
  • Includes programs in health, education, cash transfers, WASH, housing, and agriculture 
  • RMNCH remained high priority over time, regardless of changes in political leadership
  • Results based indicators leveraged to assess efficiency and impact of all CRECER programs
  • Currently in practice, now absorbed within Ministry of Development and Social Inclusion, created in 2011.
 16. 2013: Independent MOH auditing body
  • Established the Superintendencia Nacional de Salud (SUSALUD) - administratively independent from the MOH with the mandate to audit its operations.
  • Regularly monitors and publishes information on the operating conditions of health establishments through the public register, RENIPRESS
  • Established a body that  promotes and protects the rights of Peruvians to access health services
  • Ensures benefits are granted with quality, timeliness and acceptability 
  •  Currently in practice. 
17. 2013: Comprehensive care networks
  • Plan Esperanza launched as a population-based cancer prevention program in combination with the cancer prevention and control RBB budgetary program
  • Mental Health Care Reform established mental health centers to replace hospital stay wherever possible
  • Promoted health lifestyles, early detection and comprehensive cancer care
  • High satisfaction and acceptability by users and providers
  • Currently in practice and covered by SIS.
18. 2013: Expansion of SIS benefits
  • Expanded range of services covered under SIS insurance program alongside significant budget increases to include more populations and additional (more expensive) services like mental health and oncology
  • Population-wide health insurance coverage increased from 64% to 73%.
  • 72% fewer users faced financial barriers to access
  • Currently in practice, covered by SIS and incorporated in RBB.
19. 2013: Mixed methods provider payments
  • The SIS reform established agreements with regional governments using a mixed provider payment mechanism with fixed payments per patient and variable payments based on defined performance indicators agreed with regional governments
  • It transfers funds directly to implementation units
  • Capitation incentivized improved service delivery, where all Exemplar study districts reported a positive influence of performance related targets on both staff motivation and overall service quality and coverage 
  •  Currently in practice. 

 

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.

Pathway 1: How did Peru change its approach to health system governance?