Socioeconomic, Political, and Demographic Overview
Peru is located in the central-western part of South America. It has a surface area of 1,285,216 km2 and is divided into three large natural regions: the coast, the mountains, and the jungle. Peru is a multicultural, multilingual, and multiethnic country. The Constitution of 1993 established the department as the main political-administrative unit (the country has 24 departments subdivided into 192 provinces, which, in turn, comprise 1,812 districts, plus one "constitutional province").
State policy is influenced by two main trends: the promotion of economic liberalization and the effort to respond to basic social needs, many of which are unmet. According to the 1993 census, 53.9% of households had at least one unmet basic need. In response, the Government has decided to reform the functions of the State and reorient public spending in order to achieve greater efficiency. This process implies limiting public functions to those areas that cannot be take over by the private sector for reasons relating to national security, social equity, and market regulation. There are two basic objectives of State reform: (1) to free up financial resources by deregulating the market, privatizing State-run companies, and creating an institutional framework that is favorable to free enterprise; and (2) to restructure the general and specific functions of the State. The context of reform is fiscal and monetary austerity and meeting external financial obligations. Alleviation of extreme poverty is a medium-term goal and forms the basis for the Governments social policy; within this policy, the health sector defines its target population through decentralized strategies.
The mid-1970s marked the beginning of a prolonged economic crisis that peaked in 1983 and 1989, with reductions in the gross domestic product (GDP) along the order of 12.6% and 11.7%, respectively. Economic growth collapsed in 1988 and generated a serious recession that was accompanied by hyperinflation, social disorder, and violence. Inflation began to be brought under control only in August 1990, when the new Government introduced stabilization measures. Since the fourth quarter of 1990, however, inflation has declined steadily, dropping to 12.5% in 1994 and to 10.4% in 1996.
Between 1987 and 1992, national output decreased 23.5%, and per capita output dropped 28.9%, which exacerbated the already high levels of poverty. Between 1993 and 1995, the gross national product (GNP) showed an upward trend, thanks to which in 1995 it was possible to recover the real levels of production that had prevailed in the country in 1987. This recovery occurred in a framework of stabilization and restructuring of the economy, as well as actions aimed at quelling internal violence and reintegrating the country into the international economic community
Based on two methods of measuring povertythe poverty line and unmet basic needsit is estimated that around one-half of Peruvian families live in poverty. According to the national surveys of living standards (ENNIV) conducted in 1985, 1991, 1994, and 1996, poverty levels declined from 53.6% to 49.6% between 1991 and 1994, and the latter value was maintained in 1996. According to the definition that has been consistently applied in the ENNIV surveys since 1985, poverty is the inability to cover the cost of a basic market basket of food and other goods and services. In 1994, 20% of the national population was living in extreme poverty. The percentage was even higher in rural areas of the coastal, mountain, and jungle regions (66%, 68%, and 70%, respectively). Extreme poverty is defined as the inability to cover the cost of a market basket consisting only of food that meets minimum nutritional requirements. The Lima metropolitan area has the lowest percentages of poor and extremely poor population: 38% and 5%, respectively. According to the 1993 census, 53.9% of Peruvian households had at least one unmet basic need. In rural areas, the proportion was 88.2%, while in urban areas, it was 39.2%. In 16 of the 25 departments, more than 60% of households had at least one unmet basic need.
In 1995, the Ministry of Labor and Social Promotion redefined the concept of underemployment, which has altered its time-series data. "Openly underemployed" describes workers who work less than 35 hours a week, who want to work more, and who are capable of doing so. "Hidden underemployment" refers to the situation of those who work more than 35 hours a week but earn less than the minimum wage. The minimum wage is based on the cost of a minimum market basket for a family of five with two income earners. According to data from late 1996, 7.1% of the economically active population (people over 15 years of age who are working or are actively seeking employment) was unemployed, 42.4% was underemployed, and only 49.0% had adequate employment. Underemployment based on income (hidden underemployment, 27%) was greater than underemployment based on hours of work (open underemployment, 16%), owing to a shorter work day. Underemployment was higher among females (51%) than males (37%) and among those with only a primary education (50% compared with 29% for those with a university education).
Illiteracy rates decreased from 18.1% to 12.8% in the intercensus period between 1981 and 1993, although notable differences between males and females persist, especially in rural areas. In 1993, the illiteracy rate was 7.1% among males; among females it was 18.3%. In rural areas the rates were very high: 17.0% of males and 42.9% of females.
According to the IX Population Census and the IV Housing Census conducted in 1993, the total population of Peru was 22,639,443 inhabitants. The average annual population growth rate between 1981 and 1993 was 2.0%, maintaining the downward trend of the past 30 years. On the basis of this intercensus growth rate, it is estimated that the total population of Peru as of 30 June 1996 was 23,946,800. In 1993, 70.1% of the national population was urban (15,870,250 inhabitants). In that same year, females made up 50.3% of the total population, more than a third of the population (37.0%) was under 15 years of age and 4.6% was 65 years of age and older.
The crude birth rate declined from 35 births per 1,000 population in 1980 to 26 per 1,000 in 1996. The total fertility rate, which until the 1960s was more than 6.5 children per woman, declined to 4.0 children per woman in 1991. According to the 1996 Demographic and Family Health Survey (ENDES), the total fertility rate was 3.5 children per woman nationwide (2.8 in urban areas, 5.6 in rural areas, and 2.5 in the Lima metropolitan area).
Life expectancy increased from 53.6 to 66.3 years between 1970 and 1993. In the 1993 census, 22.3% of the population (4,921,020 inhabitants) indicated that they had been born in a place different from their place of residence at the time of the census. Most of this internal migration was absorbed by Lima (48.1%) and Callao (7.8%). The departments that lost the most population due to migration were Cajamarca (9.9%) and Ancash (7.5%). Although the precise number has not been determined, a sizable number of people migrated to escape violence. In the past three years, internal migration has intensified as displaced persons have returned to their places of origin, thanks to successful efforts to stem violence and to the development of new agricultural and mining areas in mountain and jungle regions. International emigration has increased in recent decades. The country registered a net population loss of 36,000 in the 19751980 period and 370,000 in the 19901995 period.
In 1992, underreporting of deaths at the national level was estimated at 50.8%. The departments with the highest levels of underreporting were Ayacucho (99.4%), Amazonas (80.5%), and Loreto (79.7%); the departments with lowest rates were Ica (14.3%), Tacna (19.6%), and Lima (22.6%). For the five poverty strata, the underregistration rates are 27.1%, 36.0%, 53.0%, 74.9%, and 75.1%, respectively. Of all reported deaths, the proportion with death certificates was 70.6 % nationwide. The rate at the departmental level ranged from 97.9% in Callao to 24.4% in Apurímac. By poverty stratum, the rates ranged from 90.6% in stratum I to 33.0% in stratum V. The proportion of deaths attributed to ill-defined signs, symptoms, and conditions was 30.6% overall. In poverty stratum I this proportion was 9.9%, and in stratum V it reached 69.8%.
With regard to the structure of mortality by age groups, of all the deaths in stratum I, 13.1% and 2.9%, respectively, occurred among children under 1 and children aged 14 years; in stratum V these percentages were 29.3% and 11.1%, respectively. The risk of dying was five times higher for children under 1 in stratum V than in stratum I (151.1 and 31.0 per 1,000 children under 1) and seven times higher for children aged 14 (13.9 per 1,000 children aged 14 in stratum V compared with 1.8 in stratum I).
The 10 leading causes of death were acute respiratory infections (16.3%), intestinal infectious diseases (7.7%), diseases of pulmonary circulation and other forms of heart disease (5.4%), tuberculosis (5.0%), cerebrovascular disease (4.0%), diseases of the urinary system (3.5%), diseases of other parts of the digestive system (3.2%), nutritional deficiencies and anemias (3.2%), ischemic heart disease (3.2%), and hypoxia, birth asphyxia, and other respiratory conditions of the fetus or newborn (3.1%).
SPECIFIC HEALTH PROBLEMS
Analysis by Population Group
According to the 1993 census, infant mortality was 59.0 per 1,000 live births nationally, and ranged from 22.9 per 1,000 in Callao to 113.9 per 1,000 in Huancavelica. For the period 19952000, this indicator was estimated at 45.0 per 1,000 live births. The 1996 ENDES survey revealed a rate of 42.8 per 1,000. Neonatal mortality, according to the same source, was 25.0 per 1,000 live births. In 1992 the leading cause of death in children under 1 year of age was communicable diseases (39.8%), followed by certain conditions originating in the perinatal period (33.9%). Within the group of communicable diseases, acute respiratory infections (26.6%) and intestinal infectious diseases (11.1%) accounted for the largest proportions of deaths. Among children aged 14, communicable diseases were the leading cause of death (66.7%), followed by external causes (7.3%). Among the communicable diseases, respiratory infections caused 28.5% of all deaths and intestinal infectious diseases caused 25.1%.
According to the first national height census of schoolchildren in the first grade of primary school (1993), 48.0% of children aged 69 suffered from chronic malnutrition. The situation was more serious in males (54%) and in rural areas (67%). According to mortality data from 1992, the principal causes of death in this age group were communicable diseases (46.8%) and external causes (20.2%).
According to the 1993 census, adolescents made up 23.0% of the total population. The leading causes of death in the group aged 1014 years were communicable diseases (40.2%) and external causes (21.7%); these proportions are reversed in the group aged 1519 years (25% and 39.0%, respectively). The same census revealed that 13.6% of children aged 1014 years were not attending school. In the group aged 1014 years, 5.1% worked. Among those between 15 and 17 years of age, 17.9% worked. It was also found that, in urban areas, 69.0% of adolescents aged 1214 had consumed alcohol at least once and 17.0% had used tobacco.
In 1993, 1.2% of girls aged 1214 years and 6.0% of those aged 1517 years had already had a child or were pregnant for the first time. Although 29.0% of adolescent girls aged 1519 years who were in a sexual relationship indicated that they used some method of contraception, only 11.0% used a modern method. In 1993, adolescents accounted for 15.0% of all maternal deaths, and an estimated 20.0% of maternal deaths from abortion occurred in this age group.
In 1996, 64.0% of women living with a male partner were using some method of contraception. The most widely used method continues to be the rhythm method (18%), followed by the intrauterine device (12.0%) and female sterilization (10.0%). In 1996, 66.2% of pregnant women received prenatal care from a health care professional (55.4% in rural areas and 87.4% in the Lima metropolitan area). That same year 55.1% of pregnant women received professional care during childbirth. In rural areas the percentage was lower (19%).
The maternal mortality rate is 265.0 per 100,000 live births. It is estimated that around 1,670 women die annually as a consequence of complications of pregnancy, childbirth, and the puerperium. In urban areas, the rate is 200.0 per 100,000 live births, and in rural areas it is 448.0 per 100,000. The leading direct obstetric causes of maternal mortality are hemorrhage (23.0%), abortion (22.0%), infection (18.0%), and toxemia (17.0%); the leading indirect cause is pulmonary tuberculosis.
In 1992 the leading causes of death in the population aged 1559 years were infectious diseases (21.9%), external causes (20.8%), and malignant neoplasms (17.6%). Among men, the leading causes were tuberculosis (10.0%); homicide and intentional injury, injuries due to legal interventions and operations of war (8.4%); other accidents, including after-effects (6.6%); acute respiratory infections (6.4%); and motor vehicle traffic accidents (5.4%). Among women, the leading causes were tuberculosis (9.6%), malignant neoplasms of the uterine cervix (7.0%), acute respiratory infections (6.1%), cerebrovascular disease (4.5%), and malignant neoplasm of the breast (4.0%).
Among the population aged 60 and over, diseases of the circulatory system are the primary cause of death (30.2%), followed by infectious diseases (20.9%) and malignant neoplasms (19.1%).
The Peruvian Social Security Institute (IPSS) has an Occupational Health Program, but it covers only 28.0% of the countrys economically active population (7,814,809 people). Since 1997, the Ministry of Health also has had an Occupational Health Program. According to IPSS, between 1995 and 1996 the occupational accident rate rose from 12.0 to 20.0 per 1,000 workers and fatal accidents increased from 0.7 to 1.9 per 10,000 workers. These figures have been verified on the basis of information provided by unions and by other ministries. In the mining sector alone, 102 fatal accidents were registered in 1995 (68 in 1992). Data on occupational illnesses are limited. Another major problem is lack of access to occupational health services for workers in the informal sector (53.9%).
Based on the 1991 national census, in 1993 the INEI estimated the total number of children aged 614 who work at 175,022; the estimate of the Ministry of the Presidency for 1995 was 1,100,000 working children under the age of 18. These children work mainly in mining, agriculture, and in gold ore processing.
The indigenous population of Peru can be classified according to language and place of residence. Based on native language (Quechua, Aymara, or another indigenous language), a 1993 census identified 4,035,300 indigenous persons, 52% female and 48% male. Of this number, 75.0% resided in mountain areas, 9.0% in the jungle, and 17% in coastal regions, including the Lima metropolitan area. Of the indigenous population over 6 years of age, 22.0% had no schooling. Forty-two percent of the indigenous population lived in extreme povertydouble the national average. A significant proportion were rural or unskilled workers. Those who resided in rural mountainous areas and in the jungle had limited access to education and health services, owing partly to the geographic characteristics of their place of residence and partly to language and cultural barriers. With respect to basic sanitation services, 54% of Quechua speakers and 70% of Spanish-speaking indigenous persons had water service in their homes; the coverage of wastewater systems was 15% and 40%, respectively. Among the Quechua speakers, only 32% of those who reported that they had been sick or injured in the four weeks before the interview had received medical attention, compared with 46% of the Spanish speakers.
With regard to the indigenous communities living in jungle areas, in 1993 there were 13 linguistic families and 65 ethnic groups. The total population was 299,218 inhabitants (48% female and 52% male). The most populated departments were Loreto, Junín, Amazonas, and Ucayali. Of the total population surveyed, 49.7% were under 14 years of age, 48.8 % were between 15 and 64, and 1.5% were 65 or older. By educational level, 32% had no schooling, 49% had a primary education, 16% had a secondary education, and 2.5% had a higher education. The curricula studied were the standard curricula used in urban areas and did not take into account indigenous languages or sociocultural characteristics. Seventy-four percent of the indigenous population lived in poverty and more than half lived in extreme poverty. In the Campa-Ashaninka group, the fertility rate was 8.1 children per woman and infant mortality was 99 per 1,000 live births.
Analysis by Type of Disease
The number of cases of malaria increased from 30,814 in 1989 to 211,561 in 1996, with an incidence rate of 885.0 per 100,000 population. The annual parasite index (API) increased from 2.4 per 1,000 in 1992 to 8.8 per 1,000 in 1996. The proportion of cases due to Plasmodium falciparum increased alarmingly from 1.6% in 1992 to 28.3% in 1996. Malaria is associated with the tropical and irrigated desert areas of the northern coast and the northeastern mountainous jungle region, the central-southeastern jungle region, and the lowland or Amazon jungle. The seasonal nature of the disease is evident along the northern coast and northwestern region of the country (higher incidence in the first half of the year), but transmission rates remain constant in the Amazon basin. In 1996, the population in high-risk areas numbered 2,382,035 (9.9% of the total population of the country). That same year, 77.9% of the reported cases were concentrated in five regions and health subregions (Loreto, Jaén, Luciano Castillo, Junín, and San Martín), and 88.4% of the P. falciparum cases were concentrated in the first three. Loreto and Jaén reported 55.2% of all cases. The incidence leveled off in 1996, when a significant decline was observed in some high-risk areas located along the northern coast, but epidemic and unstable behavior persisted in lowland jungle areas, especially the Loreto region (where even the city of Iquitos was affected) and the Jaén subregion. In 1996, there were 46 reported malaria deaths, 40 of which occurred in Loreto (87.0%). Of the P. falciparum cases, 20% to 26% were resistant to chloroquine and 9.1% were resistant to sulfadoxine/pyrimethamine. Intense internal migration, the development of new irrigation areas for rice and cotton farming, the spread of the vector Aedes darlingi, and difficulties in management of the control program in hard-to-reach areas contributed to this epidemiological situation.
The first epidemic of dengue fever occurred in 1990, when 9,623 cases were reported. Incidence decreased to 714 cases in 1991 but since then the trend has been upward: 1,905 cases in 1992 and 2,837 in 1996. The serotypes involved in the period 19901995 were dengue 1 and, to a lesser extent, dengue 4. Dengue 2 began to circulate in 1995. The most affected geographic areas have been the northern coast and the northeastern and central jungle region. In 1996 outbreaks were registered in several new localities not considered endemic (Jaén, Bagua, and Juanjui). It was estimated that the population at risk in 1996 totaled 2,750,000 people.
Leishmaniasis is present in 24 health subregionsin particular, the mountain and jungle departments. Between 1985 and 1994 an increase in incidence was observed; the rate increased from 12.7 to 40.0 per 100,000 population. In 1995 a total of 7,343 cases were reported (31.9 per 100,000 population) and in 1996 there were 7,756 (32.4 per 100,000 population). In 1996, 86.7% of the cases were the cutaneous form and 13.3% were the mucocutaneous form.. The Andean cutaneous form affects primarily children under 15 and is associated with the increasing use of child labor for brush clearing and preparation of farmlands on mountain slopes of the Andes, as well as with transmission around the home. The mucocutaneous form occurs most frequently in persons over the age of 15 years and is associated with temporary migration or settlement of highland and lowland jungle areas for agricultural and extractive activities (gold mining, logging, oil drilling), as well as with road-building and hunting.
In 1995, selvatic yellow fever reached epidemic proportions, with 503 reported cases and a case fatality rate of 38.8%. The disease affected predominantly farmers aged 1544 years who were of Andean origin and resided in the departments in the central jungle. The large increases in internal migration beginning in 1994, coupled with the opening up of new agricultural and industrial areas in enzootic areas, were decisive factors in the occurrence of the outbreaks. Intensification of vaccination activities brought about a reduction in the incidence to 86 cases with 34 deaths in 1996. In April 1995, yellow fever vaccination was incorporated into the regular activities of the Expanded Program on Immunization.
In 1996 the total number of cases of Chagas disease in endemic areas was estimated at 24,170 (1,209 were acute or oligosymptomatic forms and 22,961 were chronic forms). Most cases occurred among people between the ages of 20 and 54. The area where Chagas disease is most prevalent is located in the countrys southern portion, where household infestation with Triatoma infestans has been detected in 21 provinces and 90 districts. In this geographic area, which represents 9% of the national territory and contains 160,000 dwellings, 473,918 people (2 % of the total population) are at risk for the disease. Seroprevalence surveys in these areas have revealed infection rates ranging from 0.7% to 12.0% in the population and from 3.0% to 12.0% in blood banks.
The incidence of bartonellosis has been rising steadily since 1974, from 0.25 per 100,000 inhabitants to 3.34 per 100,000 population in 1995.
In 1996, coverage levels were 96.9% for the measles vaccine, 99.6% for BCG, and 100% for polio vaccine and DTP. The last measles epidemic in Peru occurred in 1992, when 22,605 cases and 263 deaths were reported (case fatality rate of 1.8%). The measles elimination program was launched in 1995 with surveillance of eruptive febrile illnesses and door-to-door vaccination activities, as a result of which 96.8% of children aged 9 months to 4 years were vaccinated. A total of 224 cases of measles were confirmed in 1995, and only 2 in 1996. A campaign to eliminate neonatal tetanus as a public health problem was launched in 1991. High-risk districts were identified and all women of childbearing age were vaccinated with tetanus toxoid (TT). In addition, traditional birth attendants and health workers were trained both in how to provide care at delivery and in how to administer vaccines. A total of 128 cases were reported in 1994, 9 in 1995, and 46 in 1996. All cases were in children of mothers who had not received at least two doses of TT, and the mother had given birth in a health institution in only 5% of the cases. The last confirmed case of poliomyelitis in the Americas occurred in Peru in 1991. Diphtheria is under control; 10 or fewer cases of the diseases were reported between 1992 and 1996, with the exception of 1993, when 31 cases were reported, and most of those (24) occurred during an outbreak in a rural area of the department of Cuzco. Peru ranks among the countries with medium endemicity of the hepatitis B virus. In 1996, immunization of children under 1 year with the hepatitis B vaccine was initiated in provinces with high and medium levels of endemicity (25% of the total area of the country).
In 1996, the point prevalence of diarrhea in children under 5, on the 15th day before the survey, was 17.9%. The prevalence was higher in children aged 623 months (29.0%), in rural areas (20.3%), and in jungle areas (25.6%). The seriousness of diarrheal disease, as measured by the proportion of cases with dehydration and serious dehydration, decreased from 34% and 4%, respectively, in 1994 to 25.5% and 1.5%, respectively, in 1996. According to the National Household Survey for the fourth quarter of 1995, 92% of children under 5 with diarrhea received oral rehydration therapy.
The cholera epidemic started in early 1991; since then, the disease has shown a downward trend (322,562 suspected cases in 1991, 71,448 cases in 1993, and 4,369 cases in 1996) and has occurred mainly in persons over 15 years of age. The department with the highest rate of cholera in 1996 was Ucayali, which reported 239 cases per 100,000 population. The average case fatality rate has remained at 0.09% since the beginning of the epidemic.
National monitoring of Vibrio cholerae strains indicates the absence of serotype O139. Cholera is endemic in Peru, and isolated cases of the disease routinely occur between December and March along the coast and between June and October in the jungle.
In 1996, 47,498 cases were diagnosed and treated nationwide; the prevalence rate declined from 256.1 per 100,000 population in 1992 to 227.9 in 1995 and 198.4 in 1996. The rate of incidence of the disease dropped from 243.2 per 100,000 population in 1992 to 162.1 in 1996. The most affected age group consisted of individuals between 15 and 44; the proportion of sputum-positive cases detected in children under 15 was 4.8%. The incidence rate of tuberculous meningoencephalitis in children declined from 2.01 per 100,000 population in 1993 to 1.57 in 1995; mortality was 4.9 per 100,000 population in 1995. A study of tuberculosis drug resistance in Peru in 19951996 found that 15.4% of cases were resistant to one drug and 2.4% were multidrug resistant. In 1990 only 25% of the countrys health services were carrying out diagnosis and treatment activities, but by 1996 96.0% guaranteed free access to such care.
The prevalence of leprosy in endemic areas of the jungle in 1995 was 0.9 per 10,000 population, and the incidence was 0.35 per 10,000 population. Of the 240 cases recorded in 1995, 195 were multibacillary (81.3%) and 45 paucibacillary (18.8%). Of the 90 new cases, 14.4% were detected in children under 15, which indicates recent transmission of the disease.
Acute respiratory infections are the leading cause of mortality in childhood; it is estimated that every year they cause about 12,000 deaths in children under 5 years, of which a high proportion are due to pneumonia. Acute respiratory infections are the leading reason for health service visits, accounting for more than 40% of all such visits and 30% of hospitalizations in this age group. The highest incidence of pneumonia is registered in the mountains and in the jungle.
The cumulative total of AIDS cases as of August 1997 was 6,443; the estimated number of cases is 10,000 for AIDS and 70,000 for HIV infection. The presence of HIV/AIDS has been confirmed throughout the country, although it is more prevalent in the large cities, particularly in Lima and Callao. Sexual transmission predominates and accounts for 95.4% of the cumulative total of cases; transmission by blood accounts for 2.4% of cases and the trend for this route of transmission is downward; perinatal transmission accounts for 2.2% of cases and the trend is upward. Significant changes in transmission patterns include the rise in heterosexual transmission and the increase in the number of women and young people who are affected. The male/female ratio of cases was 20:1 in 1985 and 3:1 in 1997. In the same period, the median age at the time of AIDS diagnosis dropped from 38 to 29 years. Since 1994 the National Program for the Control of Sexually Transmitted Diseases and AIDS has implemented new control strategies, including marketing of condoms, modification of risk behaviors, and syndromic management of other diseases. In addition, the Ministry of Health has instituted a program that administers AZT free of charge to infected pregnant women and newborns, and it is carrying out activities aimed at eliminating congenital syphilis and ensuring mandatory screening in blood banks.
During 19931996, 112 deaths from rabies were reported; in 65 of these cases (58%) the source of infection was dogs and in 47 (42%), vampire bats.
Between 1990 and 1992, Peru had 460 cases of anthrax. The largest number of cases (223) was reported in 1992; in 1993 and 1994 no cases were reported; in 1995, 25 were reported; and in 1996, 12 cases were reported.
Brucellosis is limited to certain regions of the country. A total of 3,606 cases were reported between 1993 and 1995. In 1996.
The endemic area for plague is limited to four departments in the northern part of the country: Piura, Cajamarca, Lambayeque, and La Libertad. An outbreak of bubonic plague began in October 1992 and eventually spread to 122 localities in 31 districts of the four departments. Between 1994 and 1996, 1,288 cases and 54 deaths were reported.
Human hydatidosis occurs in the Andean region. Between 1993 and 1995, 4,829 cases of hydatidosis were diagnosed, mainly the pulmonary and hepatic forms.
Noncommunicable Diseases and Other Health-Related Problems
In 1996, 7.9% of children under 5 had weight-for-age deficits and 1.1% had weight-for-height deficits. Low height-for-age affected 25.9% of children under 5 overall, but in those close to their fifth birthday the proportion was 30.5%. The highest level of chronic malnutrition, 40.6%, is found in rural areas. In the Lima metropolitan area, in contrast, the figure is 10.1%. The prevalence is 17.1% along the coast, 37.9% in the mountains, and 33.3% in the jungle. There are no up-to-date statistics on vitamin A and iron deficiency. By 1995, according to the National Household Survey for the fourth quarter, 93.9% of the population was consuming iodized salt.
The practice of breast-feeding is highly prevalent in Peru, but the period of exclusive breast-feeding usually is very short. In 1996, 38.9% of children under 3 months of age were already receiving food supplements, and among those 46 months old, only 32.3% continued to be exclusively breast-fed. The proportion dropped to 5.6% in children aged 79 months.
Studies conducted in three coastal areas showed the prevalence of diabetes to be between 7% and 8%. The prevalence of hypercholesterolemia was between 14% and 42% in the same areas.
Proportional mortality from diseases of the circulatory system between 1980 and 1992 ranged from 11.8% to 19.4% of all deaths from defined causes. The estimated mortality rates from these diseases for the 19901992 period were 186 and 209 per 100,000 population in men and women, respectively. The prevalence of hypertension in adults was estimated at 17% in coastal regions and at about 5% in mountain and jungle regions, although studies conducted in three areas of the coast showed prevalence rates of 15% to 34%.
Data on the incidence and prevalence of malignant neoplasms at the national level are not available, although information is available from two regional reporting systems, one in the Lima metropolitan area and another in the city of Trujillo. In Lima, the incidence was 88.3 per 100,000 population in 1968 and 112.3 in 19901991. Mortality from cancer in 19901992 was estimated at 113 and 138 per 100,000 population in males and females, respectively. According to the cancer registries of Trujillo (19881989) and Lima (19901991), the most frequent cancer sites in males are the stomach, prostate, and lung; in women, they are the uterus, breast, and stomach.
Homicides (12 per 100,000 population) and traffic accidents constitute a serious public health problem in Peru. In adults, accidents are the most frequent reason for hospitalization and for trips to hospital emergency rooms.
In 1996, 95% of children aged 314 had dental caries, 85% suffered from periodontal disease, and 75% from malocclusion. In children aged 614 years, the average number of permanent teeth affected by caries was six, with premature loss of first permanent molars in 45% to 50%. In the same year, the Ministry of Health launched a program to promote topical fluoride application as a part of comprehensive child health services.
The prevalence of blindness in adults over the age of 60 is estimated at 3.4%. Six of every 10,000 children suffer from blindness due to preventable or curable causes, such as congenital cataracts and glaucoma.
RESPONSE OF THE HEALTH SYSTEM
National Health Plans and Policies
The general objective of the medium-term social policy for the year 2000 is targeting of public spending; the operational goal is reduction of extreme poverty by 50%. In this context, the Basic Social Spending Program is carrying out programs in the areas of education, health, food, and justice. In the area of health, the Basic Health-for-All Program, launched in 1994, seeks to increase the response capacity of primary care health facilities, beginning with those located in the areas of greatest poverty. In 1996, the budget of the Program represented 21% of the total budget of the Ministry of Health. In 1995 the Ministry defined the following policy guidelines for the health sector for the period 19952000: universal access to public and individual health care services, and ensuring that the poorest segments of the population have access to a basic package of health services is a priority; modernization of the sector in terms of technology; restructuring of the functions of financing, service delivery, and control in order to develop competitiveness and improve accessibility and quality; prevention and control of urgent health problems; and promotion of healthy living conditions and lifestyles.
The General Health Law, enacted in June 1997, assigns to the State the inalienable responsibility of providing public health services and of promoting conditions that will guarantee adequate coverage of services for the population. In addition, the State is responsible for monitoring, preventing, and treating problems of malnutrition, mental health, and environmental health, as well as health problems of underprivileged children, adolescents, mothers, and disabled and elderly persons. The law also envisions that State financing is to be oriented toward public health activities and the partial or full subsidy of medical care for low-income populations.
Since 1995 the global restructuring of the State apparatus has been under way. The Ministry of Health has established the following policies for reform of the public health sector: to improve equity in health care by optimizing the allocation, programming, and utilization of resources through the restructuring of health care financing; to develop a user identification system and a basic package of health services as instruments for targeting health spending; to develop governmental capacity in response to the new environment in the public sector at the central and local levels, as well as the function of regulating the health services market; to improve the administration, management, and quality of public health services through organization of public health facilities in networks at the primary and secondary levels; and to implement a program for modernization of the management of national and regional public hospitals as well as specialized institutions.
While the Ministry of Health will concentrate on the formulation of policies, strategic planning, regulation, and control in the area of health, specialized agencies will be created to oversee the administration of financial resources and of the networks of basic public health care establishments, which will have their own decentralized management. The Law on Modernization of the Social Security System, enacted in 1997, relaxes the public monopoly on the delivery of medical services to the beneficiaries of IPSS with a view to improving the quality and coverage of services. It also allows beneficiaries the freedom to affiliate themselves with private health care providers, known as health service delivery companies.
Organization of the Health Sector
The health sector comprises institutions in the public sector (Ministry of Health, IPSS, the armed forces and police health services, and social welfare agencies), private insurance and providers, and nonprofit institutions. According to the second Census of Physical Infrastructure and Resources of the Health Sector, in 1995 the country had 7,304 health facilities, of which 5,931 (81%) were administered by the Ministry of Health; of these, 134 were hospitals, 1,028 were health centers, and 4,762 were health posts.
Nationwide, there was 1 bed per 767 population in 1995. In Lima there is 1 bed per 666 population, and in the rest of the country there is 1 bed per 1,250 population.
Between 1992 and 1996, the availability of physicians increased from 7.6 to 9.8 per 10,000 population, that of nursing personnel from 5.2 to 6.2 per 10,000, and that of dentists from 0.7 to 1.1 per 10,000 population. The departments with the highest poverty levels generally have the fewest health workers. For example, in Huancavelica, Apurímac, and Cajamarca, the rates of physicians per 10,000 population are 2.8, 2.8, and 3.1, respectively, while in Callao, Lima, and Arequipa, the rates are 22.9, 17.3, and 14.5, respectively.
Of the population covered by the Ministry of Health in 1993, 31.9% used health services and each user had 2.3 visits; in IPSS, the corresponding figures were 35.9% and 4.3 visits in 1994. A problem affecting the Ministry of Health is that of "cross subsidies," which occurs when its limited resources are used to care for people who have access to other health care systems. For example, in 1994 the Ministry provided care for 20% of the beneficiaries of the Armed Forces Health Service, 13% of the beneficiaries of the IPSS, and 9.8% of the people covered by private insurance.
Health Services and Resources
The national epidemiological surveillance system comprises 2,690 health facilities (208 hospitals, 924 health centers, 1,504 health posts, and 54 other facilities), 33 epidemiology departments, and a national office of epidemiology, distributed among the three levels of the Ministry of Health: local, subregional, and central. This system monitors and reports weekly on 15 diseases. The countrys public health laboratory network includes a national reference laboratory (in Lima) and 11 regional reference laboratories.
In 1995, not all blood was being screened for the various diseases that can be transmitted through transfusion. The coverage of screening was 60% for HIV, HBsAg, and syphilis and 4% for Chagas disease. The National Hemotherapy and Blood Bank Program was established within the Ministry of Health in 1996.
The country does not have an integrated food safety program. Each sector (agriculture, health, trade, and industry as well as local governments) has food safety standards. There are approximately 60,000 street food vendors in Lima.
Environmental management is divided among several sectors. Law 26410 establishes the National Environmental Board as the national regulatory and policy-making body in this area, designed to plan, coordinate, and monitor activities for safeguarding the environment and the countrys natural resources. The General Environmental Health Directorate (DIGESA), a division of the Ministry of Health, is the technical agency at the national level responsible for setting standards, evaluating, and coordinating activities with local governments and other sectors in the areas of environmental protection, basic sanitation, food safety, control of zoonoses, and occupational health. The National Institute of Environmental Protection for Health formulates standards and policies on environmental protection. The National Water and Sanitation Authority, under the Ministry of the Presidency, is responsible for ensuring the supply of drinking water services, sewerage, storm drainage, and excreta disposal. The Authority is empowered to develop, monitor, and assess the performance of sanitation service providers throughout the country. In addition, the Special National Program on Drinking Water and Sewerage (PRONAP) centralizes most of the investment in water and sanitation. In rural areas, there is no agency within the Ministry of the Presidency that establishes investment policy or investment amounts for sanitation. The main agencies concerned with environmental health in rural areas are the Ministry of Health, the National Compensation and Social Development Fund, the Repopulation Support Program, and PRONAP. Public sanitation services are handled by the municipios themselves, which contract or grant concessions to private companies to provide the services.
Deterioration of water quality is a critical problem in some regions of the country, due basically to pollution by effluents from industrial activities, especially metallurgy, and by domestic and agrochemical waste.
Air quality is poor in some areas of the country. Measurements taken throughout 1996 in the center of Lima indicate that the annual average concentration of particulate matter was 270.48 mg/m3 (allowable limit: 150 mg/m3), and the annual average concentration of nitrogen dioxide was 142.9 mg/m3 (allowable limit: 100 mg/m3). The levels of lead (0.415 mg/m3) and sulfur dioxide (0.0424 ppm) were within allowable limits (0.5 mg/m3 and 0.06 ppm, respectively).
Soil quality also is a problem in several areas of the country. Along the coast, an increase in salinization has occurred as a result of improper use of water and deterioration of forests due to indiscriminate logging and overgrazing by goats. In the mountains, the deterioration in agricultural lands is due to inappropriate farming practices and the consequent destruction of the protective layer of soil on mountain slopes. In the jungle, deforestation is increasing as a result of the clearing for new agricultural lands.
There is no single body charged with monitoring the management of chemical substances in the country.
The countrys drinking water supply systems are severely flawed, and, consequently, water is often supplied under poor conditions and the population is forced to get it from other sources. In urban areas, 66.1% of the population is served by household connections to the public water supply system, 8 % by connections to the public system outside their dwellings but within the building, 7.7% by public water tanks, 3.7% by wells, 12.1% by tank trucks, and 2.4% obtain water from watercourses. The supply is intermittent in most of the country. Only 8% of the population has water supply 24 hours a day, 73% receives water for 16 to 20 hours daily, 18% for 6 to 15 hours, and 1% for 0 to 5 hours. In rural areas, 13.2 % of the population is served by public water tanks, 27.3% by wells, 7.0% by tank trucks, and 52.5% get their water out of watercourses. With regard to sewerage, according to the 1995 fourth-quarter National Household Survey (ENAHO-IV95), 47.4 % of the population has sewerage service and 21.95% has latrines. In urban areas, close to 66% of the population is served by sewerage systems and about 20% has latrines, while in rural areas about 9% of the population is served by sewerage systems and 24% has latrines.
Between 60% and 65% of the population has refuse collection services. Except in the Lima metropolitan area, which has sanitary landfills, and Piura and Trujillo, which also have some kind of landfill, in urban areas solid waste is disposed of in open-air dumps or watercourses. The country does not have adequate systems for the treatment of hospital waste, incineration is very limited and inefficient, and there are no landfills where this hazardous waste can be disposed of safely.
Inputs for Health
The General Department of Drugs and Medicinal Products (DIGEMID), an agency of the Ministry of Health, is responsible for regulation and control of drugs in Peru. In 1994, the value of the pharmaceutical market (factory prices) was estimated at US$ 60 million for the public sector and US$ 422 million for the private sector. The process of opening up the market and deregulating prices that has been under way since late 1990 has made a wide range of drugs available. According to DIGEMID, 43% of the 7,447 generic and trademark drugs on the market in August 1995 were domestic products and 56.7% were foreign products. In 19921993, of 56 laboratories inspected (of 65 registered laboratories), only 25% were complying with good manufacturing practices. Of 312 drugstores and drug importers visited, deficient storage conditions were found in 33%. Street drug sales are a growing problem in the country, and counterfeit and adulterated products sometimes find their way into formal distribution networks.
The Basic Essential Drugs List was revised most recently in 1992 and is applied today to a limited extent. Since 1994, the country has had a program for shared drug management, which provides a set of 63 low-cost essential drugs to some 1,000 health centers and 4,500 health posts at the primary level of care. As of late 1995, the program was operating in all the health subregions, with an approximate coverage of 12 million people and with annual sales amounting to US$ 12.6 million. In addition, IPSS, with an annual budget of US$ 50 million for drugs (1996) and some 6 million beneficiaries, has its own drug supply system based on a list that is differentiated by level of care.
The sector does not have a defined research policy.
Expenditures and Sectoral Financing
In 1995, total spending on health amounted to 3.6% of the GDP. This percentage has remained stable since 1992. The per capita expenditure on health was US$ 89. Spending by the Ministry of Health, the municipios, and the Public Compensation and Social Development Fund is about 1% of GDP (the per capita expenditure was US$ 38), while IPSS spending represented 1.3% of GDP (per capita expenditure of US$ 115). Private expenditure is similar to that of the IPSS: 1.2% of GDP, which is less than in 1992 (1.5%). The health sectors share of public-sector spending rose from 9.9 % to 13.1% between 1992 and 1995.
There are various sources of financing and budgetary resources for the health subregions. Funding is provided by multiple institutions (various programs and institutions of the Ministry of Health, the Ministry of Economy and Finance, and international cooperating organizations). There is no policy concerning the generation of income by health institutions. Several studies have revealed imbalances between the supply and the demand for services, with very low usage rates in many establishments.
External Technical and Financial Cooperation
In 1992, based on data from a UNDP report on development cooperation, Peru received foreign aid totaling US$ 875,871,000. The five recipient areas were economic management (54.9%), international trade in goods and services (10.8%), regional development (7.2%), transportation (4.8%), and health (3.9%). In the period 19921996, bilateral cooperation accounted for 60% of the external resources received, multilateral cooperation accounted for 35%, and nongovernmental organizations accounted for 5%.
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