Annex 12. PERU
Background
An estimated 28% of Peru’s population is still living in rural areas,185 where people are not only the most
neglected and disadvantaged in terms of access to quality health and education services, but also suffer
most from the social, political, and economic inequities that still characterize the country. This poses
formidable challenges to the state’s efforts to introduce accessible health and education services.
Politically, Peru continues to experiences political unrest since its decentralization attempts beginning in
2000.186, 187 The rural inhabitants of the Andes have suffered most from this, and after several years of
post-violence efforts, there remains substantial social debt that the state needs to fulfill, including
effective poverty fighting and provision of health and education services. Although Peru has been
classified by the World Bank as an upper-middle income economy, the real challenge will be to make
particularly substantial reductions in poverty in the inner Amazon and Andean areas of the country,
which have had the slowest poverty reduction rates,188, 189 indicating where the major efforts of the
state should be concentrated if the country is going to become prosperous and equitable.
The health system in Peru must be prepared urgently if it is going to successfully face the challenges
posed by the country’s epidemiological transition characterized by an aging population, progressive
reduction of communicable diseases, and sustained increase of chronic non-communicable diseases and
injuries, as well as neonatal deaths and congenital malformations.190 The current country case study is
focused on characterization of mid-level health workers, with the objective of highlighting advantages
and limitations regarding several aspects that contribute to their deployment and performance within
the Peruvian health system, as part of the efforts to achieve the health-related Millennium Development
Goals (MDG) and beyond.
Maldistribution of Human Resources for Health (HRH), which are scarce in these areas, is one of the
equity challenges that the government must rectify to consolidate past and current achievements and
ensure accomplishment of the promise of better health for all citizens. The main characteristics and
drivers of the national health policy were established in the Institutional Strategic Plan 2008-2011 of the
Ministry of Health of Peru.191 This Plan incorporates the state, government, and health sector policies.
The driving principles of the Health Policy Guidelines include: universality, social inclusion, equity,
integral profile, cross-cutting profile, efficiency, quality, solidarity, and sustainability.191
The Peruvian health system is a mixed one, as it includes the public sector, the health social security, the
National Police and Armed Forces, and the private sector.192 The main insurers in the Peruvian health
system are ESSALUD (including EPS); SIS (currently AUS); and private insurance companies. The MOH is a
financing agency, not an insurer. By law it is supposed to cover the entire population, but in reality most
public hospitals are so under-funded or payment procedures by AUS are so lengthy and bureaucratic
that many patients eventually buy their own medicines, facing significant out-of pocket expenditures.193
A study published in 2008 compared healthcare spending aspects among Bolivia, Peru, and Chile, using
2004 World Bank data as the information source, and showed that Peru had the lowest total health care
expenditure as a per cent of GDP. The growing weight of pooled expenditures reflects the increased
public financing of the national health system, revealing the extent of improvements needed in order to
achieve an acceptable level of efficiency of the health system.
208
The new decentralization process that started in 2002 meant that regional and municipal governments
have been distributed growing funds and have had administrative responsibilities transferred to them,
with mixed results so far, which we have highlighted in a previous section of this report.194 Other
challenges that the health decentralization process needs to overcome besides capacity building at
policymaking and managerial levels include the huge improvement needed in the provision of capable
and motivated health workers in the poorest areas; the development of extensive infrastructure,
equipment, and supplies to face the ever-changing epidemiological health profile; the improvement of
accountability and governance standards which are reportedly weakest in the poor inner departments
of the country; development of an effective consultation process that considers all stakeholders’
perspectives and expectations;194-196 and a definitive change to a transparent and efficient culture.196
Situational analysis of MLHW
National HRH strategic plan and policy: MLHW
Under the leadership of the Human Resources for Health Direction of the Peruvian Ministry of Health,
the National Policy Guidelines for Development of Human Resources for Health (Lineamientos de
Política Nacional para el Desarrollo de los Recursos Humanos en Salud), the National HRH Strategic Plan
was unanimously approved in September 2005, after a process of analysis, discussion and consensus
building with the active participation of all stakeholders involved.197 These are the guidelines that should
have served as the general framework for developing and implementing the HRH specific strategies at
country and sub-national levels:
Guideline 1. Training of HRH based on the Integral Health Care Model, country demographic
sociocultural and epidemiological profile, and taking into account the regional and local specificities.
Guideline 2. Equitable strategic planning of HRH, considering the above-indicated profiles, as well as the
population health needs, particularly those of the poorest segments.
Guideline 3. Decentralized management of HRH, as part of management of health services, while
recognizing the central and integral aspects of HRH inherent to organization development.
Guideline 4. Management of effective, efficient and equitable processes for promoting capacity
development of health personnel, so as to contribute to performance and quality of health care
improvement
Guideline 5. Acknowledgement of community health workers as valuable human resources of the
Peruvian health system, as well as acknowledgement of their contribution to health and development,
at local, regional and national levels.
Guideline 6. Promotion of a new labour regulatory framework that considers competency and
occupational profile-based entrance, public career promotion, and implementation of equitable and
merit-based incentives and benefits.
Guideline 7. Improvement of job conditions and promotion of motivated and committed health workers
that ensure delivery of quality health services.
Guideline 8. Impulse of agreement and negotiation processes in the labour relationships, based on
respect to dignity of health workers, aiming at the achievement of the institutional mission.
These general guidelines explicitly mention the role of community health workers, but not that of midlevel health providers such as nurses, midwives, nurse technicians, and other health cadres, although
the review of specific strategies related to HRH reveal that a prominent strategy to be implemented
within the framework of the Universal Health Insurance (AUS) is the development and consolidation of
family health teams composed by doctors, nurses, midwives, community health workers and other
209
health professionals. Prosalud Program is notably the strategy designed by the General Management
Direction for Development of Human Resources for Health as a branch of the Ministry of Health for
implementing this approach that privileges primary health care and consequent promotion and
prevention activities and social determinants of health.198 Prosalud also includes a package of incentives
aimed at improving retention of health workers in remote and rural areas of the country, which are the
main targets of AUS.198 Specific incentives proposed by Prosalud are described later in this report. It is
expected that after the definitive approval of Prosalud by the Parliament and the Executive, its
implementation will start rapidly progressing to an expansion phase that should cover the entire
country, with primary focus on the poorest regions. Although a much-needed monitoring and evaluation
plan that includes results-based budgeting components to be taken into account when implementing
specific strategies of this HRH Strategic Plan has been proposed, a systematic costing procedure has yet
to be formally performed.
Situation analysis
The functionality of the HR information systems at national and sub-national levels is still a pending
issue in the agenda of strengthening the information systems in the country. Although there have been
efforts to improve their resources and capacities, they are still lagging behind in their capability of
providing updated, complete and accurate information about the production, deployment, migration,
job and salary schemes, effects of attraction and retention strategies, among other core data needed for
allowing a better planning of interventions to improve the availability of HRH across the country, as well
as their performance in the provision of quality health services. The National Observatory of Human
Resources for Health was established in Peru in 1999 as part of the wider development of a regional
network launched through the initiative of the Pan American Health Organization-World Health
Organization, the Economic Commission for Latin America and Caribbean (ECLAC) and USAID.199 The
development and consolidation of this network in the region and in Peru was a landmark in the efforts
to provide meaningful information on HRH to policymakers, researchers and to the community alike,
although it is not meant to replace efforts for improving and consolidating the institutional HR
information systems at national and local levels. Based on the inspiration provided by the Observatories
and driven by the need to fit the functionality of the HR information systems to the objectives of the
Health Reform, of the National HRH Strategic Plan, and of specific strategies such as Universal Health
Insurance (AUS) and the Prosalud Program, the General Management Direction for Development of
Human Resources for Health (formerly IDRE) has made commendable efforts to strengthen the HR
information systems, and furthermore, to make them more accessible, all of which can be verified by
visiting their relevant links on publications, statistics, technical reports and other valuable documents.199
However, further impetus is needed to ultimately have a fully integrated and functional information
system that serves as a reliable baseline landscape on which to measure the impact of any intervention
addressed to improve the situation of the HRH, including disaggregated information for the different
health worker cadres.
Types of MLHWs
Mid-level health workers involved in health care provision in Peru include nurses, midwives, nurse
technicians, nutritionists, lab technicians and other technical level health workers. Nurses and midwives
are the MLHW cadres mainly considered as part of the basic health teams at all levels, together with
doctors. The nurse technicians, although they also constitute part of the health teams on any level of
the health system, have seen considerable reduction in their scope of action and responsibilities in Peru,
and currently, their role in health care is basically to provide support to nursing care. They are not
210
allowed to diagnose and treat patients, even at primary health level, although in the most remote areas
they can actually still provide health care. Thus, in the next sections of our study, we will consider nurses
and midwives as the focus of our MLHW discussion, unless we state otherwise.
Total number of each type of MLHWs and their disaggregated density
Although a national census of health workers is overdue to get accurate information on the number of
HRH, their distribution and other essential information, the current estimate is that there are 180,000
health workers, among health professionals and non-professionals, and clinical and non-clinical health
workers.198 Among them, 180,000 work at the Ministry of Health and 36,063 at ESSALUD (Social
Security).198 The EPS employ 7,230 health workers and the National Police and Armed Forces providers
employ 14,587 professionals, technicians and auxiliary cadres.198 This is the result of a gradual increase
in the number of HRH since the 1990s. Thus, in 1992, the estimated number at the national level was
66,000 health workers, which had increased to about 101,000 in 1996, and progressed until reaching
about 132,781 health workers for the period of 2004-2005.198
Even if the number of HRH has increased significantly and the redistribution has seen a renewed
impetus in the last few years, there remains an availability gap that should still persist, even if the
density of health workers would meet the population and the health vulnerability of the different
geographical domains.198 By 2007, this gap was estimated to be between 8,446 to 15,363 for doctors,
between 10,541 to 19,393 for nurses, and between 6,884 to 14,855 for midwives, depending on the
measurement standard used.200, 201 A recent publication estimated that the overall deficit of specialist
doctors with regard to offer is about 45%, with important variations at sub-national level.202
Tables 62 and 63 show health professionals’ density by cadre, by labour scheme, and by poverty
quintile. In brief, in the Peruvian health sector, we can distinguish three types of labour scheme: those
that are hired on a temporary basis (“contratados”), those performing a one-year rural service after
graduation (SERUMS), and those with a permanent appointment (“nombrados”). It is clear that doctors,
nurses and dentists are mainly concentrated in the better off areas, while midwives’ distribution is less
inequitable.201 This picture does not change significantly even after considering SERUMS, which is a
strategy aimed at deploying health professionals in the poorest areas.
The distribution of doctors, nurses, midwives, and dentists with a permanent job and those making the
rural service after graduation (SERUMS) at departmental level similarly shows the inequitable
distribution of the health workforce, which is substantially higher in Lima, the capital city, and in the
other major departments of Peru, which concentrate the urban areas.201 This inequity remains largely
unchanged, even when considering all health doctors, nurses, midwives, and dentists (“contratados”,
“nombrados” and SERUMS), although in the last few years, the deployment of SERUMS health
professionals has substantially increased the number of those providing health care in the poorest
areas.
These figures highlight the need to intensify efforts for developing more thoroughly effective attraction
and retention incentives that may persuade health workers to work and remain in the rural and
underserved areas of the country. These incentives will need to take into account both the current focus
on implementation of health teams and the individual needs and expectations of each health worker
cadre. There is scarce international literature on such individual focus, let alone at national level.
Of note, the density of health workers shown in the three tables below show that there is still a
211
substantial gap of all categories of HRH in terms of the population at national and sub-national level,
illustrating once again that the problem is not only maldistribution, but also that there is a deficit in the
production of health workers. This is an issue needing urgent discussion between the Ministry of Health,
the academic institutions responsible for providing pre-graduate and post-graduate training, and
community members, in order to reach an agreement that reflects all perspectives, but also one that
should be based on a thorough labour market study including all health workers and national and subnational health needs. In addition, further in-depth analyses of the distribution of health workers by
cadre, by geographic domain, by poverty indicators, and by gender are warranted, to identify accurately
the existing inequities beyond the departmental level, by including in the analysis the smallest possible
analysis units, as socio-economic heterogeneity has been documented even within the poor
communities that need to be considered when planning interventions such as deployment of HRH.
Moreover, besides the gap mentioned for health professionals in general, there is also a gap for
specialized health professionals, which is estimated at 6,000 for medical specialists,198 although the
emphasis put, up to now, on doctors, should be extended to other mid-level health providers including
nurses and midwives, among others.
Table 62. Density of health professionals with temporary labour scheme (“contratados”), MOH Peru, 2007.
Poverty quintile
Doctors*
Nurses*
Midwives**
Dentists*
I
0.35
1.86
0.61
0.23
II
0.35
1.82
0.56
0.27
III
0.36
1.63
0.39
0.31
IV
0.36
1.16
0.31
0.24
V
0.47
2.69
0.23
0.25
Standard
10.00
10.00
2.00
2.00
*Per 10,000 population; ** Per 1,000 women in reproductive age.
Source: Ministerio de Salud del Perú. Observatorio Nacional de Recursos Humanos. Experiencias de Planificación
de los Recursos Humanos en Salud, Perú 2007-2010
Recently, the Ministry of Health and the Regional Governments have taken measures to assure that
doctors, nurses, midwives, and other health professionals eligible for performing their rural service
(SERUMS) can actually be deployed in rural underserved areas. This intervention has substantially
increased the presence of health services provided by trained health professionals in Apurímac,
Huancavelica, and other poor departments of the country, and health indicators such as the maternal
mortality ratio have started to show measurable reductions.198
Table 63. Density of health professionals with all labour schemes (“contratados, SERUMS and Permanent or
“nombrados”, MOH Peru, 2007
Poverty quintile
Doctors*
Nurses*
Midwives**
Dentists*
I
1.93
2.99
0.77
0.40
II
3.10
3.86
0.82
0.61
III
3.84
4.33
0.70
0.70
IV
3.76
3.12
0.54
0.58
V
11.15
9.27
0.77
0.90
Standard
10.00
10.00
2.00
2.00
*per 10,000 population; ** per 1,000 women in reproductive age.
Source: Ministerio de Salud del Perú. Observatorio Nacional de Recursos Humanos. Experiencias de Planificación
de los Recursos Humanos en Salud, Perú 2007-2010
212
Table 64. Density of health workers by cadre, by labour scheme (permanent and SERUMS) and by department,
MOH Peru, 2007
Department
Doctors
Nurses*
Midwives**
Dentists*
Overall density***
Amazonas
2.50
1.68
0.14
0.36
4.64
Ancash
3.33
2.19
0.26
0.35
6.36
Apurímac
2.92
3.06
0.37
0.32
7.16
Arequipa
5.39
4.57
0.31
0.47
10.96
Ayacucho
2.93
3.33
0.68
0.42
8.44
Cajamarca
1.71
1.65
0.09
0.17
3.65
Callao
5.67
2.89
0.24
0.44
9.31
Cusco
2.45
2.86
0.24
0.25
6.10
Huancavelica
2.44
1.59
0.21
0.40
4.70
Huánuco
2.30
2.58
0.28
0.27
5.77
Ica
5.47
3.50
0.47
1.14
10.48
Junín
2.74
4.38
0.37
0.39
8.32
La Libertad
3.62
1.96
0.07
0.11
5.78
Lambayeque
2.37
1.49
0.13
0.15
4.26
Lima, Metropolitan
7.26
3.59
0.38
0.46
12.07
Lima Region
5.30
1.84
0.26
0.39
7.97
Loreto
2.09
1.46
0.14
0.19
4.00
Madre de Dios
6.04
5.85
0.65
0.57
13.96
Moquegua
6.00
6.54
1.11
1.90
16.10
Pasco
2.38
1.49
0.16
0.18
4.38
Piura
2.47
1.14
0.15
0.22
4.11
Puno
2.68
3.34
0.35
0.30
7.14
San Martín
2.55
1.28
0.41
0.34
5.14
Tacna
5.33
6.01
0.41
0.81
12.66
Tumbes
3.67
2.22
0.48
0.63
7.43
Ucayali
3.42
3.74
0.32
0.39
8.19
National
4.31
2.84
0.30
0.37
8.10
*per 10,000 population; **per 1,000 women in reproductive age.
***Density per 10,000 considering doctors, nurses, midwives and dentists.
Source: Ministerio de Salud del Perú. Observatorio Nacional de Recursos Humanos. Experiencias de Planificación
de los Recursos Humanos en Salud, Perú 2007-2010
MLHW Typology
Nurses
Demographics/Background
Nurses constitute the second largest health workforce in Peru, being almost as numerous as doctors in
absolute numbers (13,275 vs. 13,288, estimates for 2007), while the 2007 estimate number of midwives
at national level was 6,531, and 1,833 for dentists, figures that included all labour schemes
(“contratados,” SERUMS, and “nombrados”).201
About 29% of nurses were “nombradas,” and therefore stable, 31.29% belonged to SERUMS, and almost
40% were “contratadas” (working on a temporary contract basis).201
213
Regarding the distribution of MOH nurses (“nombradas” and SERUMS) displayed by type of health
services, 1,651 were appointed to health posts and health centers, while 5,386 were working at
hospitals of diverse complexity, and 801 were fulfilling administrative duties.201
Table 65 illustrates the profound inequities existing in the distribution of doctors, nurses, midwives and
dentists working at the MOH as “nombrados” or SERUMS, with better off segments concentrating most
health personnel. This situation did not improve when “contratados” were added, which shows that
newly incorporated health workforce for working on a temporary basis had not been displayed at the
poorest areas of the country.201 However, this situation has started to change recently, with more
rational distribution of SERUMS professionals including nurses in the poorest rural areas.198 Hopefully,
this positive change will be sustained.
Table 65. Distribution of health professionals (“nombrados” and SERUMS) by poverty quintile
Poverty quintile
I
II
III
IV
V
Nurses
883
1,501
1,951
1,927
5,633
Midwives
627
1,115
1,513
1,111
3,472
Dentists
95
183
220
192
341
Source:, MOH, Peru, 2007
Recruitment
The public and private nursing schools in Peru recruit pre-graduate students through an examination
whose specific requirements vary from school to school. Examinations include questions on general and
science fields, which are comparatively less rigorous than those for medical student candidates. Public
health, health policy, and systems are consistently underrepresented or even absent in these
examinations. Since 2010, the last technical level nursing schools that had been operating through
agreements with universities have become full university nursing schools (Facultades de Enfermería).
The university nursing schools themselves determine the entry quotas; there are not formal
consultation processes with the Ministry of Health.
A report about the accreditation of academic institutions found that there were 44 of them by 2003
(Table 66).203
Table 66. Nursing school by geographic region, Peru 2003.
Region
North
Lima
South
South
Total
National
7
4
7
7
25
Private
5
8
3
3
19
Total
12
12
10
10
44
Source: Arroyo J. Análisis y Propuesta de Criterios de Acreditación de Campos de Práctica en la Formación de Pre y Postgrado de los
Profesionales de Salud. 2007
214
Training
Pre-graduate nursing training lasts 5 years for all schools: 1 year called “Estudios Generales” (General
Studies) related to general matters, 1 called “Ciencias Básicas” (Basic Sciences) related to medical basic
sciences such as anatomy, biology, physiology, pharmacology, and biochemistry, and 3 years called
“Formación Professional” (Professional Training), related mainly to clinical topics and health facilitybased clinical training and that includes internship, which is an unpaid 1-year practice stage performed
in health facilities.
We present here a typical pre-graduate training curriculum from the nursing school of the Universidad
Peruana Cayetano Heredia:
First Year:
a. Semester I: Mathematics, Chemistry, Language, Social Sciences, Philosophy, Biology, Study
Methods, Arts, Computing, Sports (elective)
b. Semester II: Physics, Biochemistry, Social Reality, Psychology, Communications and Human
Relationships, Ethics, personal, and Professional Identity
Second Year:
a. Semester I: Anatomy, Nutrition, Health Education, Statistics, Microbiology, Nursing Care,
Community Nursing Care
b. Semester II: Epidemiology, Physiology, Inpatient Nursing Care, Parasitology, Health Planning and
Programming
Third Year:
a. Semester I: Nursing in Women Health Care and Development, Nursing in Human Health, Growth
and Development, Economy, and Health
b. Semester II: Pharmacology, Nursing in Child and Adolescent Health care
Fourth Year:
a. Semester I: Nursing in Mental Health Care and Psychiatry, Nursing Research (Thesis), Nursing in
Health Care of Adult and Elderly People I
b. Semester II: Statistics, Nursing in Health Care of Adult and Elderly People II, Nursing Research
(Thesis)
Fifth year:
a. Semester I and Semester II: Management of Services, Nursing Internship
After satisfactorily finishing their pre-graduate training, nurse students defend a thesis and graduate as
Nurse Bachelors (Licenciadas en Enfermería). Then, they are eligible for performing a paid rural service
for one year (SERUMS). The Regional Governments determine the SERUMS quotas, as part of the health
decentralization process.198
Accreditation/Licensing bodies
Schools of nursing of public and private universities provide a nursing diploma upon graduation (“Título
de Enfermera a nombre de la nación”) that is the legal requirement for practicing.
The Peruvian Nursing College is the professional body representing this health cadre. It is an
autonomous regulating institution that oversees the professional practice of nurses, in accordance with
the Nursing Law, after academic completion of pre-service training. It also sets the post-graduate
periodic accreditation and re-accreditation standards that allow nurses to continue their professional
practice, whether they belong to the public or the private sector. However, the accreditation process
215
enforcement is only partially accomplished, particularly in inner areas of the country, where nurses work
most frequently at primary and secondary level of health care provision. Moreover, the accreditation
standards are not systematically developed, and thus, seniority can often be the only criterion for
recertification and renovation of practicing license. It is unclear whether these standards were
developed while taking into account global standards such as those proposed by the International
Council of Nurses.
Training of trainers
There are basically two sources of training of nursing faculty, either the health facility where they work
or the university. In Lima and main cities of the country, trainers may be affiliated to universities and, at
least in theory, they are supposed to have followed pedagogic courses and they can also have
specialization diplomas or post-graduate degrees. However, in practice, nurse trainers may not even be
active members of the teaching health facilities, and they may not receive refreshment courses on a
regular basis. A uniform, systematically elaborated training program for nursing trainers is still to be
established, and ideally, it should be developed through a consultation process with participation of
academic institutions, the Peruvian Nursing College and the Ministry of Health. This review could not
identify if the existing standards were developed in agreement with international recommendations
such as those from the International Confederation of Midwives.
Workplace
Public sector: Ministry of Health, Social Security (ESSALUD), Army and Police sector
Private sector: health clinics and private independent practice. Complexity levels of both public and
private sector where nurses work vary substantially.
Equipment and supplies
Provision of equipment, drugs, and supplies is basically directed to health facilities. Getting accurate
information on provision, use and stocks proved to be hard, although a nationwide study entailing visits
to key informants for assessing adequacy of provision revealed that in general, equipment, drugs, and
supplies were provided regularly, at least for activities related to child health.204 We did not find
information specifically related to the provision of equipment and supplies for nursing activities.
Responsibilities
According to the law (Ley del Trabajo de la Enfermera (o),205, 206 the nurse is the professional with a
university degree and title, affiliated to the Peruvian Nursing College, who is recognized in the his/her
competence areas that include, in broad terms, defense of life, promotion of integral health care, joint
participation in the multidisciplinary health teams, contribution to the solution of the country sanitary
problems, and to its socio-economic development. It is prohibited that anyone not holding the academic
title of nurse make use of this denomination, and any unauthorized nursing practice is considered an
offense to be prosecuted under the above-mentioned law.
Specific functions of a nurse, legally recognized in Peru, include the following:205, 206
a. To provide integral nursing care based on the Process of Nursing Care that includes assessment,
diagnosis, planning, execution, and evaluation.
216
b. To delegate minor complexity activities to non-professional nursing personnel, under supervision
and responsibility of the nurses.
c. To accomplish nursing functions in all health facilities of the country, both in the public and private
sector.
d. To perform functions of consultancy, audit, advising, and to provide opinion on nursing topics.
e. To take technical and administrative leading of the nursing services in the different organic levels of
the health system, occupying the corresponding structural appointments.
f. To lead the training and continuous education nursing programs.
g. To develop promotional and preventive activities in the areas of his/her competence in all health
system levels.
h. To participate in the nursing health care activities for the elderly people.
i. To perform research activities in the field of health and nursing.
j. To provide technical opinion on human resources for health and other aspects within his/her
competence.
Health Worker Performance
We were not able to find formal evaluations of the performance of nurses within the programs they are
inserted in, at least not in Peru. A comprehensive study comparing the performance of doctors and
other mid-level health providers, found that mid-level health workers trained in the Integrated
Management of Childhood Illnesses (IMCI) performed at least as well, if not better, than doctors in
various aspects of health care provision to sick children.207 These encouraging results provide the most
compelling evidence in favor of task-shifting, particularly in settings where there is scarcity of doctors,
and provided there is an adequate supportive context. In Peru, although the tendency is towards an
increased delimitation of practice scope of doctors and mid-level health workers alike, there is renewed
impetus to implement health teams with doctors, nurses, midwives, and nurse technicians as core
members, and there is place for performing similar studies on clinical performance of those health
teams, but also of their individual health cadres.
Cost Effectiveness
No cost-effectiveness evaluation of programs where nurses or other mid-level providers are inserted in
was available.
Supervision and monitoring
Nurses have been part of several programs addressing diverse health problems and with different
objectives. Supervision and monitoring activities of all of them have been consistently deficient, without
sufficient and regular availability of trained and motivated supervisors, clear objectives, or adequate
feedback planning and implementation. However, there are increasing efforts to improve this situation.
One example is FEMME, a program of emergency obstetrics care that strengthened supportive
supervision for the involved health teams and resulted in an improved management of obstetric
emergencies.208
Remuneration
By law, the labour scheme of nurses includes 36 hours a week or its equivalent of 150 hours a month,
including on duty periods.205, 206 All activities performed beyond the regular labour scheme are
217
considered extraordinary hours, and should be remunerated accordingly.205, 206 All activities performed
during non–working holidays or on leave days should be fully remunerated.205, 206
Figure 28 shows the average total annual salary of different health workers working at the Ministry of
Health or ESSALUD in 2009, according to their labour regime (“MINSA 276”, “RECAS MINSA”, ESSALUD
276-728”, “RECAS ESSALUD”), irrespective of the level they belong to. ESSALUD health workers show
higher annual incomes than MINSA (MOH) employees.209 On the other hand, MINSA health workers
hired on a temporary basis for working at MOH health facilities administered by communities (CLAS
MINSA) show the lowest incomes, followed by those hired on a temporary basis and paid directly by the
MOH (RECAS MINSA). Permanent ESSALUD health workers have higher incomes than temporary ones
(RECAS ESSALUD), but the difference is not that marked. On the other hand, doctors receive on average
higher incomes than any other group, while nurses and midwives get similar incomes. It must be
stressed that these average incomes may hide important disparities between permanent and temporary
health workers. Whereas the former ones have several rights such as paid holidays, paid license for
health reasons, amongst other financial incentives, temporary health workers have no formal paid
holidays or any paid license. These income distortions should be corrected, and furthermore,
competency and merit-based financial salary regimes should be progressively implemented, so as to
contribute to the introduction and consolidation of a competitiveness culture.
There have been recent additional adjustments to salary schemes at the national level, with particular
emphasis on increasing salaries of health professionals deployed in remote and rural communities, most
of them as SERUMS workers. This is mainly happening in the MOH. Hopefully, together with nonfinancial incentives, these salary readjustments will have the desired increase in retention of health
workers. However, we must caution against complacency, because effective incentives have proven to
be context-specific and health cadre-specific, and therefore, careful studies should be performed for
assessing the real impact of any salary policy on retention and performance of health workers.
218
Figure 28. Average annual salary income by health worker category and by labour regime
Source: Ministry of Health and ESSALUD, 2009
Career Progress (professional advancement)
By law, nurses should receive continuous training from his/her labour center, to reach a number of
academic credits per year required for certification and re-certification.205, 206 The training hours may be
counted as part of the labour scheme.
The nurses have the right to pursue specialization training in the different nursing areas approved by the
Peruvian Nursing College.
Whenever the specialization process is paid by the professional himself/herself, the employer may
provide paid or unpaid license for the full specialization period.
Although the professional colleges like the Peruvian Nursing College have managed to include various
labour benefits in the laws that regulate nursing activities, in the overall health sector, the consolidation
of a career progress scheme based on competency and merits is a goal yet to be achieved.
Retention
During the last few years, the Ministry of Health and the Regional Governments have been actively
engaged in the development of mechanisms to allow for a better distribution of SERUMS health
professionals, taking into account that implementation of basic health teams (composed mainly of
doctors, nurses, midwives, and nurse technicians) is focused on the poorest areas of the country, and
that primary health care is the cornerstone of their health services provision, privileging promotional
219
and preventative activities.198 Fortunately, this effort has resulted in a significant increase of SERUMS
health professionals in the poorest departments of the Andes and the Amazon regions. Additional
measures are being taken to deploy HRH preferentially in rural areas of those departments rather than
in urban areas. Currently, it is compulsory to allocate all SERUMS posts to the first level of care.
In addition, the Prosalud Program has been designed by the MOH, previous consultation with all
stakeholders, with the main objective to retain SERUMS professionals for at least 3 years in remote and
rural areas, instead of the current 1 year they remain in place (and rather frequently in urban, better off
areas). Thus Prosalud has been conceived as a retention program that includes financial and nonfinancial incentives and is aimed at doctors, nurses, and midwives. There is already an agreement with
the Ministry of Finance to increase their salaries (up to 4,700 nuevos soles/month for doctors and up to
2,700 nuevos soles/month for nurses and midwives). In addition, they receive bonus points whenever
they apply for a residency training (doctors) or a specialization training leading to a diploma (nurses and
midwives). The bonus points will be awarded if they remain 3 years in the assigned place (a rural
underserved area). Additionally, while they are working as SERUMS professionals, they can follow a 3year course of a specialization in Integral Health Care leading to a specialty diploma in Family Medicine
(doctors) or a diploma in Family Health (nurses and midwives). Formal agreements have already been
signed with 4 main universities (Universidad Nacional Mayor de San Marcos, Universidad Peruana
Cayetano Heredia and Universidad Nacional San Luis Gonzaga de Ica). Prosalud had also been included
in the 2010 fiscal budget. Hopefully, the progress made with the former government will be continued
with the new administration, and it is therefore expected that Prosalud will effectively start full
implementation shortly.
Midwives
Demographics/Background
Midwives are health professionals whose main scope of practice is addressed to provide prenatal health
care to pregnant women and to conduct uncomplicated deliveries, and to take immediate care of the
newborn. As previously stated, it is increasingly being promoted to practice as part of basic health teams
at the primary level of the health system,198 but also in more complex teams at second and third levels
of the health system. As Tables 62 and 63 above show, density of midwives show to be relatively less
inequitable when compared with that of doctors and nurses, although they are also distributed
preferentially in better off areas of the country, irrespective of their labour regime (“contratadas”,
SERUMS, or “nombradas”) (Table 65 above).
Recruitment
There are public and private midwifery schools in Peru that recruit pre-graduate students. The specific
entry requirements may vary somewhat, but they basically include an examination that explores their
knowledge on general and science fields, with a degree of difficulty compared with the entry
requirements of nurses. Unfortunately, these entry examinations largely neglect relevant issues such as
public health, health policy and systems. The universities offer midwifery careers through their
Midwifery Schools (Facultades de Obstetricia). The university schools themselves determine the entry
quotas, without a formal consultation process with the Ministry of Health or other health providers.
By 2003, there were 25 midwifery schools at the national level, 11 public and 14 private (Table 67),203
and this number has increased substantially since then. Private institutions are taking the lead in
220
number, but the quality of training they offer is hardly open to rigorous scrutiny, due to difficulties in
enforcing the results and recommendations of accreditation procedures, or even to ensure that all
universities volunteer to undergone periodic accreditation audits.203
Table 67. Distribution of midwifery schools by geographic region, Peru, 2003
Region
National
Private
Total
North
3
5
8
Lima
2
3
5
Centre
3
3
6
South
3
3
6
Total
11
14
25
Source: Arroyo J. Análisis y Propuesta de Criterios de Acreditación de Campos de Práctica en la Formación de Pre
y Postgrado de los Profesionales de Salud. 2007
Training
Pre-graduate midwifery training lasts 5 years in all schools. The first years are basically devoted to
general matters and basic biomedical sciences, and then students attend health facilities to become
familiar with clinical work, particularly that related to health care of pregnant women, delivery and
immediate care of newborn. Similar to nurses, the last year also includes Internship, an unpaid practice
stage performed in health facilities.
A typical training curriculum is presented below. It belongs to the Universidad de San Martín de Porres:
First Year:
a. Cycle I: Mathematics, Communication, University Working Methodology, Chemistry,
Anthropology, History and Evolution of Obstetrics, Biostatistics
b. Cycle II: Human Leadership and Development, Cellular and Molecular Biology, Biochemistry,
Epidemiology, Public Health, Human Sexuality
Second Year:
a. Cycle III: General Human Anatomy, Specialized Human Anatomy, Community Obstetrics, Histology,
Research I
b. Cycle IV: Microbiology and Parasitology, General Semiology, Developmental Psychology, Human
Physiology, Clinical Technics in Obstetrics, Nutrition and Dietary
Third Year:
a. Cycle V: Physiopathology, Clinical Laboratory, Pharmacology, Obstetric Semiology, Obstetric
Therapeutics, Health Informatics, Physical Rehabilitation
b. Cycle VI: Obstetrics I, Social Marketing, Surgery and Instrumentation in Obstetrics, Health
Administration and Management I, Research II
Fourth Year:
a. Cycle VII: Values Education, Gynecology, Training for Delivery and Life Cycle Stages, Obstetrics II,
Neonatology, Health Administration and Management II
b. Cycle VIII: Health Economy, Obstetrics III, Pediatrics, Integrative Medicine, Health Education, Health
Life Promotion, Imaging Diagnosis
221
Fifth Year:
a. Cycle IX: sexual and Reproductive Health, Research III, Elective, Legal Medicine and Forensic
Obstetrics, Internship I
b. Cycle X: Internship II
An additional cycle includes Internship III, for six more months.
After finishing satisfactorily their pre-graduate training, midwife students defend a thesis and graduate
as Midwife Bachelors (Licenciadas en Obstetricia). Then, they are eligible for performing SERUMS, a paid
rural service for one year. Recently, as part of the health decentralization process, Regional
Governments determine the SERUMS quotas for all health professionals, including midwives.198
Accreditation/Licensing bodies
Public and private universities that offer midwifery training provide a midwife diploma upon graduation
(“Título de Obstetriz a nombre de la nación”) that is the legal requirement for practicing.
The professional body representative of Peruvian midwives is the Peruvian Midwifery College. It is an
autonomous regulating body that oversees the professional practice of midwives, in accordance with
the Midwifery Law,210 after academic completion of pre-service training and graduation. It also sets the
post-graduate periodic accreditation and re-accreditation standards that allow midwives to continue
their professional practice in the public or the private sector. Actually, the accreditation process is only
partially accomplished, particularly in inner areas of the country, where midwives work most frequently
at primary and secondary level of health care provision. Moreover, the accreditation standards are not
systematically developed, and thus, seniority is often the only criterion for re-certification and
renovation of practicing license. In recent years, the Ministry of Health and the Regional Governments
have been coordinating to agree on improved accreditation process with clear and adequate standards,
and on the implementation of mechanisms for enforcement.210 Hopefully, these deliberations will allow
a step forward in this important field that is part of the improvement process of quality of health
services provision.
Training of trainers
The midwifery faculty can be grossly separated into those in charge of providing training in general
topics, and those in charge of providing training in basic biomedical sciences. The first group is usually
part of university faculties other than the midwifery school. The second one comprises of mainly doctors
and midwives. They can or can not belong to the formal teaching staff of universities that have
agreements with the health provider institutions (mainly MOH and ESSALUD). It is more likely that
trainers with university affiliation may benefit from pedagogical courses and refreshment and
continuous education courses related to their field of expertise. However, standards of midwifery
practice and teaching are still lagging behind. For instance, Evidence-Based Obstetrics or Midwifery is
not a course that appears in the pre-graduate or post-graduate training of midwifery schools. Thus,
there is the need to develop and consolidate a comprehensive training program of trainers that
combines the basic components of evidence-based health care (critical appraisal of the best evidence
available, expertise, and patients’ opinions and circumstances), and it also considers public health,
epidemiology and health policy and systems, in line with the renewed emphasis that is being paid to the
primary healthcare spirit.
222
Workplace
Similar to nurses, midwives can practice either in the public sector (Ministry of Health, Social Security
(ESSALUD), Army and Police sector and health facilities run by municipal governments, or in the private
sector (health clinics and private independent practice), and also the complexity levels of both the public
and private sectors, where their work varies substantially.
Equipment and supplies
Although we have not found rigorous evidence on the adequacy and regularity of equipment and
supplies provided to midwives or to health facilities where they work, there are reportedly periods of
scarcity at all levels of the public sector, due to delayed payments by the Universal Health System (AUS)
bodies, or to a significant proportion of payment requests rejected due to procedures not in accordance
with the standards set by AUS. On an encouraging note, there are some experiences illustrating that it is
possible to improve managerial capacity for assuring a regular availability of equipment and supplies to
health workers and facilities, which together with adequate incentives, training and supervision, may
lead to a clear improvement of health workers’ performance and ultimately a measurable impact on
health. As stated above, FEMME, a strategy aimed at improving the diagnosis and management of
emergency obstetrics, was implemented jointly by the MOH and the NGO Care Peru in the poorest areas
of Ayacucho until 2005. It emphasized enforced training and motivation of health workers (including
doctors, nurses, midwives, nurse technicians, and other members of the health teams), referral capacity,
supply of equipment and supply, and a strengthened supervision, as well as respect to cultural beliefs
and perceptions about pregnancy and delivery. The experience has been successful and has shown a
measurable decline in maternal mortality in the intervention areas.208 An evaluation of how adequate
IMCI implementation was in Peru also found that reported quality of equipment, drugs and supplies was
acceptable.204 Although it was not specifically aimed at midwives’ facilities for performing their duties,
IMCI training involved doctors and nurses as well as midwives (in a lower degree), and thus, this finding
may have relevance to them.
Responsibilities
According to Midwifery Law,210 the midwives’ responsibilities include:
 Protect the life and health of individuals, particularly those of pregnant women and fetus.
 Comply with ethical principles established by the Ethics Code of the Peruvian Midwifery College.
 Perform their professional activities within the established health policies.
 Comply with the obligations and prohibitions established by law referred to in the administrative
career and public sector remunerations.
Beyond these general principles, licensed midwives should develop their professional activities at all
levels of the health system, focusing on the preventative and curative care of pregnant women (with
emphasis on prenatal care activities), conduction of low risk deliveries and immediate care of newborns.
They are not allowed to perform surgical operations such as cesarean section. Those that have followed
post-graduate training courses may also perform policymaking and managerial duties. If the renewed
interest in primary healthcare and the development of health teams is scaled up, there is scope for
midwives working together with doctors, nurses, nurse technicians and other health professionals, and
their responsibilities will need to be reassessed accordingly.
223
Health Worker Performance
One of the few evaluations of clinical performance with emphasis on midwives and on care of obstetric
emergencies was FEMME, which found that intensive training followed by refreshment courses and
supportive supervision, together with availability of equipment and regular supply of drugs and supplies,
resulted in an improved clinical performance of midwives and other health professionals when handling
obstetric emergencies.208 We did not find other formal performance evaluations within the scope of
programs based on midwives in Peru.
Cost Effectiveness
We did not find any systematic cost effectiveness evaluation of interventions having midwives as key
participants.
Supervision and monitoring
As part of the recent efforts to deploy more trained and motivated HRH in rural and poor areas of the
country, supervision and monitoring activities are being considered as a key component for assuring
quality health care provision. Other specific programs and strategies such as IMCI and FEMME, to name
a few, are also struggling to reinforce in an effective way their supervision and monitoring activities.204,
208
Hopefully, as a result, supervision and monitoring activities will actually be implemented, having the
necessary human resource capacity and funding, as otherwise, the possibility of assessing performance
and impact, and of introducing improvements in the implementation process of such interventions will
have a low probability of success.
Remuneration
Midwives’ salary schemes are, like those from nurses and other health professionals, determined by
general regulations applicable to all servants of the public sector, and also by additional specific
regulations applicable to health professionals. By law, the labour journey of midwives includes 36 a
week or 150 hours a month that are distributed depending on whether they regularly work 6 hours a
day for 6 days a week, or if they perform activities beyond the regular labour scheme, which are
considered extraordinary hours, and thus, they should be remunerated accordingly.210 Additionally, all
activities performed during non-working holidays or on leave days also should be fully remunerated.210
Figure 28 shows the comparative average salary that health professionals working for MOH or ESSALUD
receive, either as temporary or as permanent health workers. It can be seen that salary incomes of
midwives are almost the same compared with nurses. ESSALUD employees, no matter if they are
temporary or permanent, get higher incomes.209 Just as with nurses and other health professionals,
permanent midwives benefit from rights like paid holidays, paid licenses for illness and bonuses for
children of school age, which are not necessarily offered to temporary midwives. Midwives are also
considered as a target health worker category to receive additional remuneration if they are going to
serve in poor and remote areas, and are also being encouraged to become part of the health teams that
Prosalud is promoting to reduce the scarcity of HRH.
224
Career Progress (professional advancement)
Current regulations establish that midwives, like nurses, have the right to receive continuous training
from her/his labour center, so as to reach a number of academic credits per year required for
certification and re-certification.210 The training hours may be counted as part of the labour scheme.
Unfortunately, an effective career progress pathway has yet to be implemented for midwives, as it was
the case for nurses and other health professionals. Seniority often seems the only requirement for
getting appointments with greater responsibilities, and getting post-graduate diplomas or degrees is not
actually considered as a merit to be acknowledged with promotion to higher ranks. Advancement in the
career pathway as a result of merit is not systematically promoted because there are not clear
regulations allowing it, but perhaps the most important barrier for competency and merit-based career
advancement is the lack of a culture based on merits and accountability.
Retention
There are no retention strategies specifically designed and implemented for midwives to go and remain
in rural, remote, and underserved areas. Recently implemented financial incentives offered to those
going as SERUMS professionals are planned to be combined with non-financial incentives, such as bonus
points for applying to a postgraduate diploma, and facilities for pursuing a 3-year in-service training that
leads to a diploma in Family and Community Health, all key components of Prosalud that should be
implemented at scale if the new administration considers it among its priorities. Maternal mortality has
started to decline in departments such as Apurímac and Huancavelica, and they are associated with
substantial recent increments in the number of midwives and other motivated health professionals, but
these retention efforts need to be sustained if the country is going to make continued progress in this
and other health indicators.
Key challenges
The main challenges related to nurses and midwives, as well as other mid-level health workers in Peru
are related to the current health policy tendencies. The new government has expressed its decision to
provide universal quality health care to all its citizens, on the premise that it is a fundamental human
right that needs to be addressed by the state. The strategies for reaching such a goal include tackling
social determinants of health such as poverty and lack of access to basic sanitary facilities, as well as
deficient education, particularly of women.
Scaling up of Juntos, the conditional cash transfer program that has been implemented for various years
now, scaling up of AUS, the universal health insurance system, improvement of the public sector
efficiency, active promotion of a culture of accountability and governance, and more aggressive
implementation of other social inclusion programs, are all considered key for improving the situation of
social determinants of health.
As for the health sector specifically, continued administrative and financial decentralization,
strengthening of health systems based on promotion of competency, merits and efficiency, reduction of
bureaucracy, and implementation of attraction and retention strategies of all health worker cadres are
strategies that the new government is aiming use as the instruments for achieving access to better
health services and improvement of health indicators.
225
A particular challenge that nurses and midwives are already facing and will face increasingly in the
future is population demand for better health services provided by competent, motivated, and
sympathetic health professionals, who should additionally remain accountable. This symptom of
community empowerment and citizenship strengthening is occurring not only in the major cities but
also in the most remote regions of the country. Maternal and child health are sensitive areas, and thus,
health professionals involved in provision of health services to women and children need to be prepared
to face them successfully. Additionally, as maternal, neonatal, and child mortality continue to decrease,
the relative importance of other problems such as chronic non-communicable diseases will be
increasingly important, and will demand a re-appraisal of the role of nurses and midwives within this
epidemiological transition scenario. A fundamental change in the philosophy of health care will be
needed for facing successfully the above-indicated challenges, and will require a concerted effort
between professional organizations, health workers themselves, academic institutions and civil society
members.
Lessons learned
Although Peru has substantially improved the social determinants of health, substantial inequity
remains particularly in rural and remote areas, which are still waiting for an effective and efficient
presence of the state as reflected in the provision of quality and equitable basic services such as health
and education.
Peru is facing a rapid epidemiological transition and therefore diverse sectors have realized that HRH
strategic plans should be better served if this situation is taken into account when planning,
implementing and evaluating HRH interventions. The expansion of universal health insurance (AUS) and
Juntos was instrumental in reinvigorating the role of HRH as a key factor for reaching universal and
equitable coverage.
The development of the Observatory of HRH was important in providing reliable and useful information
on a continuous basis, but it does not replace the need for developing a fully HRH information system at
national and local levels.
The consolidation of an ad-hoc direction of HRH at the MOH allowed the consolidation of policy plans
for HRH, based on data collection at national and local levels. This decision should be reinforced and
maintained as a means of building a necessary HRM component.
Increasingly empowered communities are asking for more specialized health cadres, which poses the
question as to whether basic health teams comprised of general physicians, nurses, midwives and nurse
technicians will be enough. An active debate is needed to reconsider the role of MLHW in the Peruvian
health system that may yield effective results.
The lack of agreement between different stakeholders (government, universities, and civil society)
resulted in an erratic production and deployment of HRH, including MLHW, ill-prepared for facing
prevalent health problems at local level.
The lack of sound labour market analysis studies contributed to the unplanned proliferation of medical,
nursing, and midwifery training academic institutions, which are poorly regulated.
226
The density of HWs including MLHW has increased in the last few years, most likely due to
implementation of wider interventions including decentralization, conditional cash transfer program
Juntos and AUS. This illustrates the importance of putting the emphasis on attraction and retention of
HWs, which is effective when it is related to wider cross-sectoral interventions.
The lack of evaluation studies addressing the role of MLHW as well as their incentives for practicing in
underserved areas hampered the implementation of evidence-based interventions to improve their
availability. Planning of Prosalud as a HRH retention package is an important step to tackle the scarcity
of HRH in poorest areas and needs to be implemented effectively.
Conclusions and recommendations for policy action
Poverty and related social determinants of health in rural and remote areas remain huge challenges, and
need to be effectively addressed. The rapid epidemiological transition characterizing Peru will need
implementation of effective interventions, and renewed emphasis on health system strengthening is a
critical success condition.
Implementation of wider interventions such as expansion of universal health insurance (AUS) and
conditional cash transfer (Juntos) may boost the efforts for intensifying multi-sectoral efforts to improve
presence of capable and motivated health workers where they are needed. Consolidation of functional
HRH information systems are indispensable for better planning and evaluating HRH interventions, while
acknowledging the importance of HRH Observatories.
Definition of composition of basic health teams at all levels and regulation of roles for individual health
cadres (particularly mid-level providers) need to be accomplished through a wide consultation process,
taking into account community demands and expectations of health workers. Training and deployment
of HRH, including doctors and MLHW, has been a largely unplanned process, and needs to be
reconsidered, taking into account the health needs of the community at national and local levels.
Impact and clinical performance evaluation studies of programs where MLHW play a role is largely
overdue, and it should be promoted by the government and by donors, considering the challenges and
the time needed to demonstrate their effects.
The appropriate mix of cadres that include MLHW along with identification of their roles should be
defined at national and sub-national levels, considering demands from empowered community and
renewed emphasis on promotion and prevention activities.
Pre-service and in-service training, supervisory practices and standards for licensing and certification
and of nurses, midwives and other MLHW must be adapted to the country’s epidemiological transition.
Deployment patterns and retention efforts of nurses, midwives and other MLHW should be planned in
agreement with the population’s needs, and in considering their promotional and preventative role at
the community level as part of health teams, while maintaining their clinical role.
Attraction and retention strategies should be planned and implemented for MLHW on the basis of
sound studies suited to identify relevant incentives for working in underserved areas, going beyond the
current emphasis on medical professionals.
227
Appendix 12.1
Country Context
Demographical information
According to the national census performed in 2007 by the National Institute of Statistics and
Computing (INEI), the total population of Peru reached 28.220 million inhabitants,211 while the current
total population is estimated to reach 29.165 million inhabitants.212 Evolution of demographic structure
by age-group population from 2005 to projections for 2020 indicates a progressive and sustained
reduction in the proportion of younger age groups with a consequent increase in the proportion of elder
age groups, configuring a clear demographic transition pattern,212 as shown in Figure 29. An estimated
72% of the population is still living in urban areas,185 revealing that a substantial proportion of people
are still living in rural areas. These people are not only the most neglected and disadvantaged in terms of
access opportunities to quality health and education services, but also suffer most the social, political,
and economic inequities that still characterize the country.
Figure 29: Projections for Demographic structure by age groups and sex, Peru, 2005-2020
Source: Instituto Nacional de Estadística e Informática. Nuevas Proyecciones Nacionales del Perú por
Departamentos, Urbano y Rural y Sexo, 2005 a 2020.
228
Geographical characteristics
Peru is a Latin American country that borders Ecuador and Colombia to the north, Brazil to the east,
Bolivia to the southeast, Chile to the south, and the Pacific Ocean to the west. The Andes Mountains run
parallel to the Pacific Ocean, dividing the country into three geographic regions. These are: the Coast
(Costa), the Peruvian Andes (Sierra), and the Jungle (Selva). The Coast, to the west, is a narrow plain,
largely arid except for valleys created by seasonal rivers.213 The Peruvian Andes (Sierra) include highland
mountains and lower altitude valleys, while the Jungle is a wide expanse of flat terrain covered by the
Amazon rainforest that extends east, covering about 60% of the country’s area.213 In particular, the
Amazon rainforest and the highland Andes concentrate the most remote, isolated, hard to access and
poorest areas of the country.214 The Costa is comparatively easier to access, with better roads, while
urbanization level is much lower in the Sierra and Selva regions, with less and more precarious roads.
Additional and challenging characteristics of these regions include the existence of marked seasonal
changes in weather conditions, with heavy rainy periods in the Selva and the Sierra, and cold winter
periods in the Sierra. Moreover, the existence of scattered, isolated populations often agglutinated in
small clusters is an important characteristic that poses formidable challenges to the state’s efforts to
introduce accessible health and education services.
Socio-political profile
Peru is a presidential representative democratic republic with a multi-party system that has undergone a
large crisis that has worsened since the 1990s, and still remains unsolved.186 The current constitution
mandates to have the President as the head of state and government. The President is elected through
universal elections for 5 years and can only seek re-election after standing down for at least one full
term.186 The President, in turn, appoints the Prime Minister and, with his/her advice, the rest of the
Council of Ministers. Congress is unicameral with 130 members elected for a 5-year term.186 Bills may be
proposed by either the executive or the legislative branch, and become law after being passed by
Congress and promulgated by the President.186 The execution of projects and the spending capacity are
the responsibility of the central executive level and the regional and local governments only, not of the
Parliament.186 The judiciary is nominally independent, though political intervention into judicial matters
has been common throughout history and arguably continues today.186 The Peruvian government is
directly elected, and voting is compulsory for all citizens aged 18 to 70.186
The last widespread political and social unrest period that Peru faced spanned almost 2 decades from
the 1980s to the 1990s, when the Maoist group, Shining Path, put a substantial proportion of the
country, including Lima, the capital city of Peru, practically under siege. After this group was defeated, a
progressive process of democratic recovery was implemented, which is still currently in a consolidation
stage. The rural inhabitants of the Andes suffered most from the spiral of violence and the violations of
human rights that characterized this period, and after several years of post-violence efforts, there
remains substantial social debt that the state needs to fulfill, including effective poverty fighting and
provision of health and education services.
Peru has also undergone several decentralization experiences since its birth as an independent republic,
with little success. A renewed decentralization process was launched in Peru in the 2000s, with several
laws enacted and implemented to empower regional and local governments.187 This process included
the participation of Congress, different levels of government, political parties, and civil society. Of
course, this process has required significant changes in the ways the public sector operates at national
and sub-national levels.187 Of note, these changes have been implemented while maintaining
macroeconomic stability, but they are not yet supported with adequate infrastructure and sustainable
229
human resources capability to develop, monitor, implement, and evaluate the whole policy process of
decentralization.187 Thus, the country remains one with a high degree of political and economic
centralization.
Several challenges must be overcome to make effective progress in generating and sustaining genuine
development centers in the inner regions of the country. These challenges include, but are not limited
to, infrastructure, capable human resources, managerial capacity, governance and accountability. More
specifically, a recent report on the decentralization process in Peru identified various decentralization
bottlenecks, including a high dependency of sub-national governments on central government transfers
and a low rate of own-revenue generation; weak controls over the accumulation of sub-national debt;
limited capacity to handle newly transferred public service delivery responsibilities; and resource and
capacity imbalances in different regions of the country.187
Dominant and alternative languages, ethnic groups, and minorities
Peru is characteristically a multi-ethnic, multicultural country, with a large proportion of the population
considered indigenous. Indigenous communities are largely excluded and marginalized, and not
surprisingly, persistently lack equal access to basic services such as education, health, and justice.215
Gross domestic Product (GDP) per capita over time
Peru has been classified by the World Bank as an upper-middle income economy. It has a Gross Dometic
Product (GDP) of US$ 153,844,936,637 and a GDP per capita (Atlas method) of US$ 4,710.
According to Trading Economics,216 the GDP in Peru increased by 8.80% in the first quarter of 2011, and
over the same quarter of the previous year. This same source indicates that during the period 1980
through 2011, Peru's average annual GDP growth was 3.35%.
Poverty
A technical document produced by the World Bank in 2007 developed a projection for the effect of
sustained per capita growth on incomes and on the consequent reduction of poverty.217 It predicted that
if the country was able to take the necessary measures to reach a sustained GDP growth of 7-8% on
average, it could lower the number of people living in poverty—estimated to include 52% of the
population that year—by half within 10 years (Table 68). Furthermore, the document boldly stated that
there was “no reason why Peru—a country blessed with immense natural resources and a vibrant,
diverse, and talented populace—cannot achieve high levels of growth and prosperity.”217
The official figures released by the INEI for 2010 show that the actual per cent of the population living in
poverty in 2001 was 54.8%, and that has progressively declined, particularly more pronounced in the
last few years, until it reached 31.3% of the total population in 2010 (Figure 30),188, 189 suggesting that
the country is on track to reach the goal predicted in Table 68, although the real challenge will be to
make particularly substantial reductions in poverty in the inner Amazon and Andean areas of the
country. Table 69 shows the poverty trends by geographical domain from 2001 to 2010, illustrating that
rural areas of the Andean and Amazon regions have had the slowest poverty reduction rates,188, 189
indicating where the major efforts of the state should be concentrated if the country is going to become
prosperous and equitable.
230
Table 68. Projections on how sustained per capita growth can raise incomes and reduce poverty, Peru.
Figure 30: Evolution of total population living in poverty (%) at country level, Peru, 2001-2010
Source: Instituto National de Estadística e Informática (INEI). Encuesta Nacional de Hogares Anual,
2009 - 2010.
231
Table 69: Evolution of poverty by geographic domain, Peru, 2001-2010.
Geographic domain
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Total
54.8
54.3
52.3
48.6
48.7
44.5
39.3
36.2
34.8
31.3
Residence Area
Urban
42.0
42.1
40.0
37.1
36.8
31.2
25.7
23.5
21.1
19.1
Rural
78.4
77.1
75.2
69.8
70.9
69.3
64.6
59.8
60.3
54.2
Natural region
Coast
39.3
40.7
37.9
35.1
34.2
28.7
22.6
21.3
19.1
17.7
Sierra
72.0
69.9
68.8
64.7
65.6
63.4
60.1
56.2
53.4
49.1
Jungle
68.7
65.6
64.1
57.7
60.3
56.6
48.4
40.9
46.0
37.3
Geographic domain
Urban coast
44.6
44.1
39.6
37.1
32.2
29.9
25.1
23.4
21.4
21.1
Rural Coast
62.7
63.3
61.7
51.2
50.0
49.0
38.1
34.8
40.6
34.8
Urban Sierra
51.6
48.6
47.1
44.8
44.4
40.2
36.3
33.5
31.3
27.3
Rural Sierra
83.4
81.8
80.8
75.8
77.3
76.5
73.3
68.8
65.6
61.2
Urban Jungle
62.4
58.1
60.6
50.4
53.9
49.9
40.3
31.3
32.5
27.4
Rural Jungle
74.0
71.9
67.1
63.8
65.6
62.3
55.3
49.1
57.4
45.6
Metropolitan Lima
31.9
34.7
32.6
30.9
32.6
24.2
18.5
17.7
14.1
12.8
Source: Instituto National de Estadística e Informática (INEI). Encuesta Nacional de Hogares Anual, 2009 - 2010.
Health systems overview
Morbidity and mortality burden
Peru has shown significant progress in several development aspects in recent decades. Poverty rates,
which constitute a critical social determinant of health, have decreased significantly at departmental
level, in particular extreme poverty rates (Figure 27).190 Life expectancy at birth has increased from 66.7
years in the 1985-1990 period to 73.12 years in the 2005-2010 period, as depicted in Figure 28.218 As for
health indicators, under-5 and infant mortality and maternal mortality rates have also decreased, but to
a lesser extent. However, chronic non-communicable diseases have been increasing steadily and now
account for 60% of all country deaths.180 Also, unacceptably high poverty rates190 and too many
preventable maternal and child deaths still remain in neglected areas, mainly in departments of the
Andean and Amazon regions, particularly in rural and remote areas, illustrating clearly the role of social
determinants of health (Table 70).190
Take, for instance, the under-5 mortality rate, which is 21 per 1,000 live births in urban areas, but 35 per
1,000 live births in rural settings, or the proportion of unmet family planning needs that is 8.7% for poor
rural populations and 6.5% for better-off urban populations.219 A low coverage of effective interventions
for avoiding unnecessary maternal, neonatal, and maternal deaths is due, in substantial part, to the
weakness of the health system, including an inadequate geographical deployment of human resources
for health, but also to low governance standards and underfunding of the health sector.219
The country’s health gains have been achieved through a combination of improvement in social
determinants of health, such as reduction of poverty with increased provision of basic sanitary
conditions and successful implementation of evidence-based effective health interventions to tackle
health problems, most notably maternal and child health indicators.190 The health system, however,
must be urgently prepared if it is going to successfully face the challenges posed by the country’s
epidemiological transition characterized by an aging population, progressive reduction of communicable
232
diseases, and sustained increase of chronic non-communicable diseases and injuries, as well as neonatal
deaths and congenital malformations.
Addressing health system limitations and improving the deployment of capable and motivated health
workers in disadvantaged areas will be key to successfully face the country’s current and future
epidemiological profile. The current country case study is focused on characterization of mid-level
health workers, with the objective of highlighting advantages and limitations regarding several aspects
that contribute to their deployment and performance within the Peruvian health system, as part of the
efforts to achieve the health-related Millennium Development Goals (MDG) and beyond.
Figure 31: Population in extreme poverty (%) by Department
Source: National Institute of Statistics and Computing (INEI): Demographic and Health Surveys (DHS)
2001 and 2009.
233
Figure 32: Evolution of life expectancy at national level by sex, from 1985 to 2015
Source: National Health Institute of Statistics and Computing (INEI). Estimaciones y Proyecciones de
Población del Perú, 1950 - 2050". Marzo 2009.
234
Table 70. Evolution of under-5 mortality rate (per 1,000 live births) by geographic domain, from 1996
to 2009.
Geographic Domain
National
Residence area
Urban
Rural
Natural region
Metropolitan Lima
Coast, rest
Andes (Sierra)
Rainforest (Selva)
Department
Amazonas
Ancash
Apurimac
Arequipa
Ayacucho
Cajamarca
Cusco
Huancavelica
Huánuco
Ica
Junín
La Libertad
Lambayeque
Lima
Loreto
Madre de Dios
Moquegua
Pasco
Piura
Puno
San Martín
Tacna
Tumbes
Ucayali
1996
68
46
2000
60
39
2007/2008
33
23
2009
31
22
100
85
48
46
27
54
94
83
23
46
81
75
17
24
38
43
15
26
39
42
79
52
100
66
94
86
107
145
85
48
84
57
45
31
82
72
62
100
81
106
65
33
64
92
69
72
93
58
68
69
108
108
93
32
62
60
47
27
79
40
33
78
54
85
70
34
47
80
39
29
42
25
41
37
37
37
36
16
38
29
18
19
64
47
44
44
45
58
45
20
19
34
32
26
31
32
25
37
37
37
33
19
32
41
22
14
64
31
37
37
31
61
37
35
24
38
Source: National Institute of statistics and Computing (INEI): DHS 1996-2009.
Maternal and child health
We present below summary indicators for maternal and child health in Peru. The maternal mortality
ratio per 100,000 live births for the year 2005 was estimated at 240 (uncertainty bounds: 170-310).147
The reported maternal mortality ratio for the 2005-2009 period was 190,220 while the adjusted ratio for
the year 2008 was 98.220
Under-5 mortality rate per 1,000 live births was 78 in 1990 and 21 in 2009. The infant mortality rate per
1,000 live births (under 1) progressed from 62 in 1990 to 19 in 2009, while the neonatal mortality rate
per 1,000 live births for year the 2009 was estimated at 11.220
235
Peru is therefore on track to achieve MDGs 4 and 5, that is, child mortality rate reduction by 2/3
between 1990 and 2015, and maternal mortality ratio reduction by 3/4. According to the Institute for
Health Metrics and Evaluation, along with Peru, 8 additional countries will also achieve both MDGs,
namely China, Egypt, Iran, Libya, Maldives, Mongolia, Syria, and Tunisia.221
Regarding child nutritional status, there are figures available from national demographic and health
surveys (DHS) performed by the INEI. They show the time-trend in the prevalence of child chronic
malnutrition or stunting, defined as the proportion of children under-5 with height for age below -2SD of
the mean for the reference population (World Health Organization, WHO and National Center of Health
Statistics, NCHS), which have decreased from 28% in 2005 to 23.8% in 2009 (WHO standard), or from
22.9% in 2005 to 18.3% in 2009 (NCHS standard), as Figure 33 illustrates.222
Figure 33: Time-trend of prevalence (%) of stunting in children under-5, by NCHS and WHO standards,
period 2005-2009
Source: National Institute of Statistics and Computing (INEI): DHS 2005, 2007-2009.
Communicable diseases
Regarding tuberculosis (TB), recent WHO country profile figures per 100,000 population report a
prevalence rate (incl. HIV) of 118 (uncertainty interval: 27-210), an incidence rate (incl. HIV) of 106
(uncertainty interval: 93-121), and a mortality rate (excl. HIV) of 6.1 (uncertainty interval: 5-7.4). Multidrug resistant strains of Mycobacterium tuberculosis (MDR-TB) represent an important challenge to the
control and eradication efforts, and among notified cases, the proportion of new TB cases with MDR-TB
is estimated in 5.3% (uncertainty interval: 4.3-6.4), while the estimated proportion of re-treatment TB
cases with MDR-TB is 24% (uncertainty interval: 19-28).223
236
As for the HIV/AIDS profile, the estimates for 2007 indicate that 76,000 (57,000-97,000) people were
living with that condition, an adult prevalence of 5 (per 1,000 adults 15-49 years), and a proportion of
HIV-infected people receiving anti-retroviral therapy of 48%.224
According to a WHO report in 2009, the country faced a resurgence of malaria in Peru during the 1990–
1998 period, with a peak of 247,000 cases in 1998, a number which was ten-fold higher than in 1990.225
Since 1999, malaria cases have progressively decreased from an annual average of 83,189 during 2000–
2005 to 36,886 cases in 2009 (which represents a 56% decline).225 The percentage of cases due to P.
falciparum has also fallen from 30% in 2000 to 11% in 2009.225 Currently, 34% of the population lives in
areas at high risk and another 13% of the population is at low risk of contracting malaria. Control efforts
are targeted to local areas where active malaria transmission occurs, but no report was provided on
implementation of indoor residual spraying (IRS) or distribution of insecticide-treated bed nets in
2009.225 Approximately 203,000 people were protected by IRS during 2007–2008. The report also states
that there was not information available on funding for malaria control for 2009.225
Non-communicable diseases (NCD)
Non-communicable diseases (NCD) already account for a substantial burden of the country’s morbidity
and mortality, although they have not been included in the MDG. According to the most recent WHO
report, 2008 mortality estimates for Peru are the following:180 Total NCD deaths (000s) for males 41.4,
for females 41.2; NCD deaths under age 60 (per cent of all NCD deaths) 27.7 for males, 28.3 for females.
The age-standardized death rate per 100 000 population for all NCDs was 407.6 for males and 118.9 for
females, for cancers it was 109.5 for males and 118.9 for females, for chronic respiratory diseases it was
32.7 for males and 20.3 for females, while for cardiovascular diseases and diabetes it was 148.2 for
males and 120.8 for females.180
Behavioral risk factors for NCD are not reported, while metabolic risk factors show a higher estimated
prevalence of raised blood pressure for males (35.3%) than for females (28.3%), similar raised blood
glucose prevalence (5.3% for males and 5.7% for females), higher overweight prevalence (41.8% vs.
50.7%) and higher obesity prevalence (10.5% vs. 20.7%) for females than for males, while prevalence of
raised blood cholesterol is slightly higher in females (37.7%) than in males (36.7%).180
Magnitude of health workforce crisis
Peru was considered by the World Health Report 2006 as one of the few human resources for health
(HRH) crisis level countries in Latin America.226 Concentration of the health workforce in the capital and
in major cities of the country, and a massive migration of doctors, nurses, and midwives explain, in part,
such a crisis. For instance, during the 1994-2008 period, more than 1,400 doctors and nurses migrated
abroad.227 However, this crisis also entails the existence of a significant gap between demand and offer
for various specialist health professionals, with the gap for specialist doctors being estimated in about
45% at country level and even more at departmental level.202 Determination of the gap for health cadres
such as nurses and midwives needs further investigation. Since the World Health Report 2006, there
have been country efforts to improve the situation, and a recent report illustrates how the increase in
density of health workers in rural areas of Ayacucho and Apurimac resulted in a decrease of maternal
mortality, although the situation in other departments such as Huancavelica is still largely unchanged.228
237
Adequate mix of health workers cadres
A detailed description of the mix of health worker cadres, focusing on mid-level providers is offered in
Sections 2 and 3. Basic health teams at primary level include doctors, nurses or midwives, and nurse
technicians. Additional professional health cadres are included in more complex health facilities such as
general or specialized hospitals.
Main health problems according to the burden of disease
A detailed description on health problems in Peru has been provided in section A, showing a mixed
picture of general progress, with stagnating or even worsening health disparities that affect the most
deprived areas in the country, mainly located in the Andean and Amazon regions. Maldistribution of
HRH, which are scarce in these areas, is one of the equity challenges that the government must fix to
consolidate past and current achievements and ensure accomplishment of the promise of better health
for all citizens.
Major drivers of the national health policy
The main characteristics and drivers of the national health policy were established in the Institutional
Strategic Plan 2008-2011 of the Ministry of Health of Peru.191 It is a national management tool for the
medium term, and has been elaborated as a result of a wide consultation process and participation. This
Plan incorporates the state, government and health sector policies: it has been formulated within the
context of formulation of the state strategic planning, which is aimed at adoption of a modern
management, based on measurement of progress and impacts achieved at the target population level.
The Health Policies and the Health Strategic Plan are driven by international widely agreed
commitments including the Millennium Development Goals (MDG), and have been adopted by the
Peruvian government as part of the National Agreement, which has established long-term state policies,
as the result of a wide political consultation. The specific health sector policies that form part of these
general state policies include:191


Universal Access to health services and to social security, aimed to guarantee free, continuous,
timely, and quality Access to health, with particular emphasis on the poorest and most vulnerable
areas, promoting the community participation in the management and evaluation of the public
health services.
Promotion of food and nutrition safety, aimed at assuring availability and access to sufficient and
quality food for the population to guarantee a healthy and active life within the context of integral
human development.
The National Agreement has also established the Health Policy Guidelines for the period 2007 – 2020, as
well as the strategic goals and objectives until 2011. These Policy Guidelines include:191
1.
2.
3.
4.
5.
6.
Integrated women and children healthcare, with emphasis on promotion and prevention.
Surveillance, prevention and control of communicable and non-communicable diseases.
Universal insurance.
Health decentralization with transfer of responsibilities to regional and local governments.
Progressive improvement of access to quality health services.
Development of human resources for health.
238
7.
8.
9.
10.
11.
Provision of quality drugs for all.
Results-based budgeting.
Development of the health system stewardship.
Participation of the community in the health decisions.
Improvement of the determinants of health.
The driving principles of the Health Policy Guidelines have been agreed to include: universality, social
inclusion, equity, integral profile, cross-cutting profile, efficiency, quality, solidarity, and sustainability.
In line with the above-mentioned guidelines built within the context of the National Agreement, the
Universal Health Insurance (Aseguramiento Universal en Salud, AUS) was launched by the former
government, focusing on the poorest segments of the population, privileging the primary healthcare
philosophy of prioritizing promotion and prevention activities, and seeking to reduce drastically out-ofpocket expenditure in health.229 It is basically a subsidized and semi-subsidized health insurance model,
financed totally or partially by the national fiscal budget.229 Both the public and the private sector can
provide the health services, although the specific rules governing such provision are still to be refined.
Also, the AUS is considered an important component of the current decentralization process.
The expansion of AUS implementation has been explicitly stated by the new government as one of the
fundamental strategies to improve the population health status, along with the measures to improve
poverty rates and social inclusion as social determinants of health. The Ministry of Health had also
developed a Human Resources Strategic Plan as a key component for a successful implementation of
AUS, and it is expected that the new government will continue and expand the implementation of this
HRH Strategic Plan.
Financing model for the health system
The Peruvian health system is a mixed one, as it includes the public sector, the health social security, the
National Police and Armed Forces, and the private sector. The first 3 aforementioned groups are
financed by the national fiscal budget. A diagrammatic summary of the general scheme of this health
system along with the financial and health service flows is shown in Figure 34.192
The main financing sources for the health system include the Ministry of Health (MOH); the Health
Social Security (ESSALUD); the Health Providing Institutions (Entidades Prestadoras de Salud, EPS)
system; the Integral Health Insurance (Seguro Integral de Salud, SIS); private health insurance
companies, households, and donors. SIS has recently become the Universal Health Insurance
(Aseguramiento Universal en Salud, AUS). The sector’s main source of financing is the private sector,
while the central government’s tax revenues allocated to the health sector is the second largest
source.192 A third financing source is the premiums individuals and employers pay to private insurance
companies, ESSALUD and EPS. The EPS is a system designed to complement ESSALUD by covering mainly
low complexity care.192
239
Figure 34: General scheme of the health sector and financial and health service flow in Peru
Source: Britán & Asociados. Impact of Health Insurance on Access to Health Services, Health Services
USe, and Health Status in the Developoing World. Case Study from Peru. 2009
The main insurers in the Peruvian health system are ESSALUD (including EPS); SIS (currently AUS); and
private insurance companies. The MOH is a financing agency, not an insurer, and it is supposed to cover,
by law, the entire population. Estimates for 2005 indicate that ESSALUD covered approximately 17% of
the population; SIS covered 15% of the population, of which two-thirds are in the two poorest income
quintiles; while the National Police and Armed Forces covered about 1.6% of the population; and the
private sector covered 1.7%.192
As for health service providers in the system, they include the MOH providers (all levels); ESSALUD (all
levels, but actually focused on curative and rehabilitative levels); private providers (all levels, but also
concentrated in curative and rehabilitative levels); EPS (mainly low complexity providers); and National
Police and Armed Forces providers (also focused on curative and rehabilitative health services). More
than 450 public hospitals, clinics and healthcare centers around the country provide healthcare services
to around 6.5 million Peruvians, of whom 2.5 million are employees on official company payrolls, and
the remainder their spouses and dependents.193 Current estimates indicate that hospitals belonging to
the MOH cover around 60% of the population; ESSALUD covers 25%; and the armed forces hospitals
cover another 5% of the population.193 In principle, the MOH is supposed to cover all health services, but
in practice, the MOH target population faces significant rationing through waiting times and
copayments. On the other hand, the private sector offers different health plans with co-payments,
deductibles and ceilings.192 Some universities, municipalities and professional associations also have
240
hospitals and health centers.193
The role of the private sector in the provision of health services has increased substantially over time.
The number of private clinics in major cities has grown rapidly since 1990 and now is estimated to
provide care for around 15% of the population.193 Empresas Prestadoras de Salud (EPS, private-sector
providers) facilities now include more than 60 clinics and hospitals, and it is estimated that the number
of private clinics will continue to grow in the coming years.193 The industry is regulated by the
Superintendencia de Entidades Prestadoras de Salud (SEPS, the superintendence of healthcare
providers), which reported that there were just over 1 million beneficiaries by July 2009, which
represents an increase of 13% since mid-2008.193 Not surprisingly, due to the concentration of
infrastructure, technological advancement, drugs, supplies and specialized health workforce, the best
healthcare facilities are located in urban centers, configuring a picture with huge regional differences.193
Regarding financing mechanisms, under the social security system, employers pay contributions on
behalf of employees, and contributions are made to either the Oficina de Normalización Previsional (the
state pension fund) or the Administradoras de Fondos de Pensiones (AFPs, private pension funds).193
Those who are not affiliated with the state national insurance scheme or to other insurance providers,
and who have no private health insurance, are entitled to healthcare provided by the Ministry of Health,
mainly through AUS (formerly SIS). Technically, it is supposed that AUS is user-free, but actually most
public hospitals are so under-funded or payment procedures by AUS are so lengthy and bureaucratic,
that many patients eventually buy their own medicines, facing significant out-of-pocket expenditures.193
Private health insurance schemes have proved attractive to the well off, but cover only a small
percentage of the population. Private health insurance programs will continue to take on new members
as private consumption grows, while the new government aims to target spending more effectively and
direct it towards basic healthcare services.193
A study published in 2008 compared health-spending aspects among Bolivia, Peru, and Chile, taking the
2004 World Bank data as the information source, and showed that Peru had the lowest total health
expenditure as a per cent of GDP. It ranked second after Chile in health expenditure per capita, in public
health expenditure as a per cent of total health expenditure, in private health expenditure as a per cent
of total health expenditure, and in out-of-pocket health expenditure as a per cent of private expenditure
on health (Table 71).230
Table 71. Comparative health financing(Latin America, Bolivia, Peru and Chile).
Health financing (2004)
Health expenditure per capita (current US$)
Health expenditure, total (% of GDP)
Health expenditure, public (% of total health expenditure)
Health expenditure, private (% of total health expenditure)
Out-of-pocket- health expenditure (% of private expenditure
on health)
Latin America and the
Caribbean
272
7
52
Bolivia
66
7
61
Peru
125
4
49
Chile
359
6
47
48
39
51
53
74
82
80
46
Source: Comisión Nacional de Seguimiento a la Propuesta de Reforma Integral de Salud. Propuesta Política de Desarrollo de Recursos
Humanos en Salud. 2006.
Regarding the evolution of out-of-pocket expenditures over time, the National Health Accounts (Cuentas
Nacionales de Salud, CNS) show that between 1995 and 2005, Peru significantly reduced out-of-pocket
spending and correspondingly increased pooled, prepaid funding for health.231 In 1995, out-of-pocket
241
expenditures accounted for 46% of the total, and pooled funding was 54%.231 By 2005, the share of
pooling rose to 68%, while out-of-pocket expenditures fell to 32%.231 The growing weight of pooled
expenditures reflects the increased public financing of the national health system (the budgets of
MINSA, SIS, and the health regions), but also the increased activity of ESSALUD and the EPS.231 Of note,
even those covered by ESSALUD face significant out-of-pocket expenditures when they have a health
problem,231 revealing the extent of improvements need to be accomplished for achieving an acceptable
level of efficiency of the health system.
Updated figures for health spending show that healthcare expenditure as per cent of GDP is set to rise
to 4.7% over the next two years, from 4.3% of GDP in 2006-08.193 This may be explained as a
consequence of rapid GDP growth in 2003-08 that slightly decreased healthcare spending as a
percentage of GDP, but it is expected that government efforts to increase spending, together with rising
personal incomes of the population, will help to increase the share back towards 5%.193 From a Latin
American comparative perspective, according to WHO, the government accounted for 57% of Peru's
healthcare spending in 2006, more than in Argentina, Brazil, and Chile, but less than in Colombia.193
According to The Economist Intelligence Unit estimates (forecast closing date was February 21 st 2011),
the total spending in local currency terms will rise by an average of over 8% per year over the forecast
period, to 24 billion nuevos soles (US$9 bn) in 2013.232
Decentralization policy
The new decentralization process that started in 2002 meant that regional and municipal governments
have been distributed growing funds and have been transferred administrative responsibilities, with
mixed results so far, which we have highlighted in a previous section of this report. The education and
health sectors are still to be effectively included in the transfer process. There is a hot debate on the
advantages, disadvantages and risks that decentralization of these key sectors will entail. In general,
people feel that administrations closer to them would be able to provide quicker and more friendly
health services, but they also fear that regional and local managers and politicians may not be
technically prepared for successfully facing key issues related to the ultimate equity and efficiency
aspects of provision of such sensitive services.194
Other challenges that the health decentralization process needs to overcome besides capacity building
at policymaking and managerial level is the huge improvement needed in the provision of capable and
motivated health workers in the poorest areas, the development of extensive infrastructure, equipment
and supplies to face the ever-changing health epidemiological profile, the improvement of
accountability and governance standards, which are reportedly weakest in the poor inner departments
of the country, and an effective consultation process that considers all stakeholders’ perspectives and
expectations,194-196 and a definitive change to a transparent and efficient culture.196
Together with the need of a reinforced policy planning and a carefully designed monitoring system in
place, it is also absolutely necessary to promote, from the early stages of the process, a rigorous and
independent impact evaluation of health care decentralization, including an assessment of context,
outcomes, and underlying mechanisms, as well as wide system effects and intended and unintended
consequences. Only in this way will a clear body of evidence emerge, useful for supporting wellgrounded policy decisions, as so far the experience in developing settings has been mixed in terms of
positive and negative impacts.233
242