Pan American Health Organization

Peru

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Outlook
  • References
  • Full Article
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Overall Context

Flag of PeruPeru is located in western South America. The Pacific Ocean lies along its coastline, and it is bordered by Ecuador and Colombia to the north, Brazil to the east, and Bolivia and Chile to the southeast. The country has a land area of 1,285,215 km2. The Andes mountain range divides it into three regions: the coastal region, the mountain region, and the Amazon jungle region, where 56.3%, 29.7%, and 14.0%, respectively, of its population live. Politically and administratively, the country is divided into 26 regions, 196 provinces, and 1,854 districts.

Demographics

According to data for 2015, the total population was 31,151,643. Of that number, 27.9% were children under 15 years of age and 9.7% were persons over 60 (). Between 1990 and 2015, the population grew 43.8%. In 1990, Peru’s overall population structure was an expansive pyramid, with a preponderance of population under 30 years of age. By 2015, the base of the expansive pyramid had shifted to persons aged 25 and over, while the population under that age had become relatively stationary, reflecting declines in fertility and mortality rates, especially in the last three decades (Figure 1).

Figure 1. Population structure, by age and sex, Peru, 1990 and 2015

Source: Pan American Health Organization, based on data from the UN Department of Economic and Social Affairs. Population Division. 2015 Revision. New York; 2015.

In 2005, 71.1% of the population lived in urban areas; the proportion had risen to 74.0% by 2010 and to 76.7% by 2015 (). In 2015, 73.8% of the urban population (17,640,896 inhabitants) lived in 32 large cities with more than 50,000 inhabitants apiece, including Metropolitan Lima (provinces of Lima and Callao), which had 9,886,647 inhabitants (31.7% of the national population).

The Economy

The Bicentennial Plan, adopted in 2011, is a strategic plan for national development with six strategic lines of action: i) fundamental rights and dignity of people; ii) opportunities and access to services; iii) State and governance; iv) economy, competitiveness, and employment; v) regional development and infrastructure; and vi) natural resources and the environment. During the five-year period 2010-2015, gross domestic product (GDP) growth averaged 4.8%, with inflation of under 4%. Peru is an upper-middle-income country, with a per capita GDP adjusted for purchasing power parity of US$ 11,960.

Violence and Security

In 2015, 30.8% of the urban population 15 years of age and older reported having been the victim of a crime in the 12 months preceding the survey, with theft or attempted theft of money, handbag/wallet, or cellular telephone and swindling cited as the most frequent crimes. Between 2014 and 2015, the perception of insecurity grew from 85.8% to 88.4% (), while between 2011 and 2014 homicides increased from 1,617 (5.4 per 100,000 population) to 2,076 (6.7 per 100,000 population). In 2014, the rate was higher in the coastal region (7.7 per 100,000 population) and the jungle region (7.6) than in the mountain region (4.5), and the rate was also higher among men than women (11.1 versus 0.2) and in the group aged 15 to 49 years (9.2 per 100,000 population). As of December 2015, the Office of the Ombudsman had registered 211 public disputes, 143 of them active and 68 latent. Of that total, 69% were socio-environmental disputes related to mining, the majority occurring in Apurímac (11%), Ancash (10%), and Puno (9%). That same year, 19 deaths and 872 injuries resulting from this type of violence were reported.

Violence against women, sometimes at the hands of their husbands or partners, declined between 2011 and 2015 from 74.2% to 70.8%. Psychological and verbal violence declined from 70.0% to 67.4%, physical violence from 38% to 32%, and sexual violence from 9.3% to 7.9% (). Between 2010 and 2014, the number of cases of domestic and sexual violence handled by women’s emergency centers rose from 43,159 to 50,485, with women making up 96.8% of the victims in the latter year (). The number of femicide victims dropped from 139 to 83 () during the same period (2010-2014).

The number of victims of human trafficking increased from 308 to 782 between 2010 and 2014. In the latter year, 80.6% of the victims were women, the majority between 13 and 34 years of age (78.8%), and the principal motives were sexual exploitation (61.8%) and labor exploitation (13.8%) ().

Leading Environmental Problems

Peru is located in a highly seismically active area and major earthquakes occur frequently. The Pisco earthquake of 2007 was the last significant one. In addition, the country experiences heavy rainfall, flooding, droughts, forest fires, frosts and snowfalls, and the periodic occurrence of the El Niño climatic phenomenon. Many parts of Peru are vulnerable to natural disasters, in general associated with rapid growth of human settlements in risk areas with insufficient planning and services.

Globalization

Since the 1990s, Peru has participated in the Asia-Pacific Economic Cooperation (APEC) and in the Pacific Alliance, and has entered into free-trade agreements with Canada, the European Union, South Korea, and the United States, among others. With the resulting economic and commercial benefits, there have been increases in some drug prices as a result of intellectual property right protections.

Health Policies, Plans, and Programs

The most significant achievements arising from health reforms undertaken between 1990 to 2016 were the adoption of Act No. 29,344 (Framework for Universal Health Insurance) in 2009 and the issuance of 23 legislative decrees in 2013, whose objectives include expanding insurance coverage for vulnerable populations; reducing fragmentation and segmentation of the health system; expanding investment, especially in infrastructure, with new financing mechanisms through public–private partnerships; formulating a new remuneration policy, with incentives based on geographic location and performance, among other criteria; and functionally reorganizing the Ministry of Health.

Social Determinants of Health

JUNTOS (TOGETHER). The National Program of Direct Support for the Poorest, JUNTOS, is a program of conditional economic assistance, the aim of which is to provide monetary incentives directly to poor and extremely poor households in exchange for a commitment that children in the household will attend schools and health care facilities in the areas where they live.

Pension 65. The National Assistance and Solidarity Program, Pension 65, provides protection, in the form of a periodic cash payment, for people over 65 years of age living in extreme poverty.

Scholarship 18. This program provides scholarships to young people with strong academic performance and low levels of economic resources (poor, extremely poor, and vulnerable populations) who have entered an institution of higher education.

The Coordinated Nutritional Program is aimed at reducing chronic malnutrition among children under 5. It includes a set of coordinated interventions involving the Ministry of Health, the Comprehensive Health Insurance system, the Ministry for Women and Social Development, the Office of the President of the Council of Ministers, and the regional and local governments.

The Qali Warma National School Feeding Program offers food services, together with an educational component, to boys and girls registered in public educational institutions at the initial primary level throughout the country and at the secondary level in indigenous communities in the Peruvian Amazon region. The aim is to enhance students’ school attendance and attentiveness in the classroom and improve their eating habits, encouraging participation and shared responsibility among the local community.

The Techo Propio (My Home) program offers financing to families with monthly incomes of up to 2,427 Peruvian soles (approximately US$ 740) for the purchase, construction, or improvement of housing.

The National Water Resources Plan and the Multi-year Sectoral Strategic Plan 2016-2021 for the housing, construction, and sanitation sector, approved in 2015, are aimed at improving access to drinking water and sanitation and promoting wastewater treatment and reuse, sea water desalination, and knowledge management and a culture of responsible water use.

The Building Peru Program assists unemployed Peruvians through the provision of financing for community-proposed projects and services employing unskilled laborers.

The National Gender Equality Plan was adopted in 2012 with a view to closing gender gaps. The Multisectoral Plan for the Prevention of Teenage Pregnancy was launched in 2013, and Act No. 30,364, on prevention, punishment, and eradication of violence against women and other family members, was adopted in 2015.

Within the framework of International Labor Organization Convention No. 169, Act No. 29,785, adopted in 2011, recognizes the rights of indigenous or native peoples to prior consultation and provides that the State should come to an agreement with indigenous or native populations on legislative or administrative measures that will affect them directly. A sectoral policy on intercultural health was approved in 2016.

Vulnerable Populations

Between 2011 and 2015, poverty declined from 27.8% to 21.8% and extreme poverty from 6.3% to 4.1%. The biggest reduction has occurred in the mountain region, where poverty fell from 41.5% to 32.5% and extreme poverty from 13.8% to 8.8% ().

The rate of unemployment among the economically active population rose by a scant 0.2% (from 4.0 to 4.2%) from 2011 to 2015. In 2014, 72.8% of workers held informal-sector jobs. In the same year, a worker in the formal sector earned an average of 11.9 Peruvian soles (US$ 4.00) per hour, more than double what a worker in the informal sector earned (5.3 soles/US$ 1.80).

Between 2011 and 2015, the percentage of illiterate people over 15 years of age decreased from 7.1% to 5.7%. The proportion was higher in rural areas (15.5% in 2015) than in urban areas (2.8%) and was also higher among women (8.6% in 2015) than among men (2.8%).

Although there are no official data that accurately reflect the size and number of ethnic groups in the country, a 2007 census found that 13% of the population reported that the language in which they had learned to communicate was Quechua and 1.7%, Aymara. In 2015, the incidence of poverty was greater in this population (33.4%) than in the total population of the country (21.8%).

There are estimated to be 51 indigenous groups in Peru, which include 1,786 native communities in the Amazon region. In 2007, a total population of 332,975 was reported, including 173,758 males and 159,217 females. The total fertility rate for 2011 was 7.7 children per woman, and the mortality rate was 10.6 per 1,000, double the national rate. The leading causes of death were infectious diseases, tuberculosis, pneumonia, malaria, diarrheal diseases, and yellow fever, while the chief causes of morbidity were parasitic diseases, diarrheal diseases, anemia, malnutrition, malaria, pneumonia, yellow fever, and sexually transmitted diseases ().

A 2006 survey on ethnic self-perception found that 1.6% of the Peruvian population considered themselves black, mulatto or zambo (of mixed indigenous and African ancestry). The Afro-Peruvian population is concentrated in the coastal region. In 2014, the most prevalent conditions in this population were hypertension (25.3%), high cholesterol (14.1%), diabetes (6.3%), and cardiac problems (6%); 40.7% of heads of household had a chronic disease; and 24.1% of Afro-Peruvian women reported having been the victim of psychological violence, 23.7% of physical violence, and 4.7% of sexual violence.

The Health System

The health system is structured according to a pluralistic model, with both public and private service providers, and is organized by specialized functions. The Coordinated Decentralized National Health System, created in 2002, aims to coordinate the application of the national health policy, promoting its concerted and decentralized implementation and coordinating the plans and programs of all institutions in the sector in order to ensure comprehensive health care for all Peruvians and advance towards universal social security in health. The health system comprises the Ministry of Health as the regulatory body in the health sector, the Social Health Insurance (EsSalud) system, the municipal health services, the Armed Forces and National Police health services, private-sector health services, universities, and organized civil society (nongovernmental organizations and associations of older persons, women, indigenous persons, and lesbian, gay, bisexual, and transsexual (LGBT) persons, among others).

The public subsector includes: i) the Ministry and the regional health directorates, which operate the largest network of public health care facilities in the country and provide services to poor populations through the Comprehensive Health Insurance (SIS) system; ii) the social security system, which has the second largest network in the country and exclusively serves wage-earners and their family members; and iii) the Armed Forces and National Police health services. The private subsector mainly serves higher-income populations.

The SIS provides health care to the poor and extremely poor population through the Ministry’s network of services. Members receive the services covered under the Essential Health Insurance Plan, together with some additional benefits covered through a special solidarity fund for the treatment of cancer (Plan Hope) and other high-cost diseases. The various providers operate independently of one another, and as the coexistence of different institutions that administer health care financing is permitted, with benefit plans based on ability to pay and/or affiliation with a particular type of health insurance, the segmentation of the population has become increasingly marked.

Leading Health Challenges

Critical Health Problems

Emerging Diseases

The first case of Zika in Peru was identified in April 2016 and was found to have been sexually transmitted. As of 13 May 2017, a total of 6,447 cases had been reported from Ica, Loreto, Tumbes, San Martín, Cajamarca, Ucayali, and Lima. By the end of 2016, 4,477 cases had been reported, 72.1% of them from Ica and 23.8% from Loreto. Since the onset of the epidemic, 349 cases have been detected in pregnant women.

The first autochthonous cases of chikungunya occurred between May and June 2015 in Tumbes (northern coast), the majority (64.5%) among women. The average age of those affected was 34 years. From June 2015 to 13 May 2017, a total of 2,433 cases were reported, of which 76.2% were concentrated in Tumbes and 20.2% in Piura, reflecting geographic spread of the virus.

Between 2010 and 2016, 170,454 cases of dengue were reported, with an average of 24,351 cases per year. A total of 227 deaths were reported for the period, with an average of 32 deaths per year (average case-fatality of 13 deaths per 10,000 cases). During the period 2004-2009, an average of one death per year was reported. The increase in the severity of the disease has been associated with the emergence of the DENV-2 Asian/American genotype in 2010. The low coverage of household drinking water, coupled with large migration flows and weak intersectoral coordination, among other factors, has complicated the control of Aedes aegypti, which in 2016 was found in 20 regions that are home to 60% of the country’s population. By 13 May 2017, the intensity of dengue transmission had increased owing to the coastal El Niño phenomenon, mainly in Piura, which accounted for 52.2% of all cases nationwide and 66.6% (26/39) of deaths from the disease. As of 22 April 2017, the groups that showed the highest risk of contracting dengue were young adults and adolescents ().

The first four confirmed cases of hantavirus were reported in 2011 in Loreto; 2 additional cases were reported in 2012 and 2013.

Between 2010 and 2015, the country still showed epidemic activity of influenza A (H1N1), with three virus circulation peaks (in 2010, 2012, and 2013). Transmission was low in 2014 and 2015.

Neglected Diseases and Other Infections Related to Poverty

Between 2011 and 2015, five cases of dog-transmitted human rabies were reported in Puno. In 2014, after a hiatus of 20 years, canine rabies reappeared in Arequipa, jeopardizing the process of elimination of dog-transmitted human rabies. In the Amazon jungle region, outbreaks of human rabies transmitted by vampire bats continue to be reported periodically. A total of 60 cases were reported between 2011 and the first half of 2016, most among children under 15 belonging to indigenous communities. In 2011, the Ministry introduced pre-exposure vaccination in communities in the endemic area.

Between 2010 and 2015, 147 new cases of leprosy were reported, with an annual average of 25 cases (less than 1 per 10,000 population). The highest numbers of cases (32) were reported in 2012 and 2015, with a predominance of the multibacillary form of the disease (96.8% of the total).

No official information on soil-transmitted helminth infections is available, although some publications show high prevalence among schoolchildren in Loreto. One study found the prevalence of soil-transmitted helminths to be 37.0% (95% confidence interval: 24.3–51.3), while a subsequent study found a prevalence of Ascaris lumbricoides and Trichuris trichiura of 82.4% ().

Tuberculosis

Between 2010 and 2015, the reported incidence of all forms of tuberculosis fell from 95.7 to 88 per 100,000 population. A total of 27,418 new cases were reported in the latter year, of which 65.2% occurred among people aged 15 to 44 years and 62.2% among males. The incidence rate among people aged 65 and older was 150 per 100,000 population, and in the group aged 15 to 24, the rate was 139 per 100,000 population. The regions with highest incidence were Callao (214.0), Madre de Dios (149.3), Lima (147.5), Ucayali (129.6), and Loreto (123.8). Lima and Callao accounted for 60% of the cases of drug-susceptible tuberculosis, 70% of multidrug-resistant (MDR) cases, and 73% of extensively drug-resistant (XDR) cases (). Between 2011 and 2015, suspected tuberculosis cases declined from 3.1% to 2.6%. During the period 2010-2014, the treatment success rate for new cases declined from 89.7% to 86%, treatment dropout increased from 5.8% to 7.0%, and deaths rose from 2.7% to 4.4%. The number of tuberculosis cases among the health workers declined from 215 in 2011 to 126 in 2015. Between 2010 and 2014, the number of cases of tuberculosis-HIV coinfection increased from 861 (2.7%) to 1,385 (4.4%). HIV testing coverage among tuberculosis patients increased from 18.4% in 2013 to 74% in 2014. At the same time, tuberculosis screening among persons with HIV increased from 65.2% in 2011 to 84.1% in 2014.

HIV/AIDS and Other Sexually-transmitted Infections

The HIV epidemic in Peru is concentrated in the highest-risk groups, with a prevalence of 20.8% among trans women, 12.4% among men who have sex with other men, and 0.23% among the general population. Between 2010 and 2015, the annual number of reported cases of AIDS remained stable at an average of 1,240 cases per year, while the number of HIV infections increased, rising from 3,058 cases in 2010 to 5,247 cases in 2015. In the latter year, there were an estimated 2,300 new infections, and 72,000 people were living with HIV, of whom 64% knew that were infected, 46% were receiving antiretroviral therapy, and 37% showed viral suppression. Lima and Callao accounted for 68% of the cases nationwide, followed by Loreto and Ica, with 4% each.

Among the population living with HIV/AIDS, the male:female ratio declined from 3:1 in 2010 to 2.3:1 in 2015. Between 1983 and 2015, the group aged 20 to 44 years accounted for 71.9% of AIDS cases. During the period 2009-2015, AIDS cases among HIV-infected individuals fell from 25% to 19%. Between 1983 and 2015, 97% of HIV infections were acquired through sexual transmission and 2% through mother-to-child transmission. Cases acquired through blood transfusion have fallen to less than 1% since 2011 (). Between 2010 and 2015, the number of people receiving antiretroviral therapy rose from 16,542 to 36,753.

HIV screening coverage among pregnant women reached 85% in 2014. The prevalence of HIV infection in this group has remained at 0.2% since 2005. Between 2012 and 2014, the percentage of HIV-infected pregnant women who were receiving antiretroviral therapy rose from 56% to 74%, as a result of which mother-to-child transmission dropped from 6.1% to 4.0% during the period. In 2015, the rate of loss to follow-up among HIV-exposed newborns was 15% in urban areas but up to 80% in rural areas (). Between 2012 and 2014, the incidence of congenital syphilis ranged from 0.48 to 0.57 per 1,000 live births. In the latter year, 67.7% of pregnant women were screened for syphilis, 79.9% of those who had syphilis received treatment, and 270 cases of congenital syphilis were confirmed.

Maternal Mortality

The maternal mortality ratio was 93 deaths per 100,000 live births in 2011 () and 68 per 100,000 live births in 2015. An increase in the coverage of prenatal care and skilled attendance at birth were among the factors contributing to this reduction. In 2015, 97% of pregnant women received prenatal care from skilled personnel and 95.6% had four or more prenatal checkups, while 92.9% of deliveries were attended by skilled personnel and 90.7% occurred in a health facility (). In the same year, the leading cause of maternal mortality was hemorrhage (33%), followed by pregnancy-induced hypertension (31%), infection (13.3%), and abortion (9%). In the period 2007-2011, the regions with highest maternal mortality ratios were Loreto (149.4 per 100,000 live births), Cajamarca (144.7), Piura (126.8), and Puno (109.6) ().

Adolescent Pregnancy

Between 2011 and 2015, the percentage of pregnancies among adolescents aged 15 to 19 rose from 12.5% to 13.6%. In the latter year, the percentage reached 22.5% in rural areas and 24.9% in the jungle region. Teenage pregnancy rates were higher among young women with only a primary education than among those with secondary or higher education (37.9%). Rates were also higher among adolescents in the lowest income quintile (24.9%) ().

Malnutrition

Between 2011 and 2015, chronic malnutrition among children under 5 years of age declined from 18.5% to 14.4%. Nevertheless, in the latter year the rate was 27.7% in rural areas and 31.6% among children in the lowest income quintile. Moreover, 10 regions registered percentages of over 20%, with the level rising to 34.0% in Huancavelica ().

Anemia among children aged 6 to 59 months rose from 30.7% in 2011 to 32.6% in 2015. In the latter year, the prevalence of anemia was higher in rural areas (39.7%) than in urban areas (29.8%); overall, 41.3% of children in the lowest income quintile were affected, although the level varied widely between regions (from 23.7% in Lambayeque to 61.8% in Puno). Only 19.8% of affected children had received iron supplements in the seven days preceding the survey, with higher percentages in the rural areas (24.3%) than in urban ones (18.1%) ().

Chronic Conditions

In 2012, the burden of disease (years of healthy life lost, or disability-adjusted life years (DALYs)) due to noncommunicable diseases (NCDs) was 3,508,431 years (60.5% of the total of the burden of disease) (). The categories of disease that accounted for the largest number of DALYs were the neuropsychiatric diseases (33.5 DALYs per 1,000 population), cardiovascular diseases (15.2), malignant neoplasms (13.9), and diseases of the musculoskeletal system and connective tissue (12.0) (Table 1).

Table 1. Noncommunicable diseases accounting for the largest number of DALYs*, Peru, 2012

Disease DALYs*
Harmful alcohol consumption 254,527
Depression 224,535
Diabetes mellitus 199,495
Arthrosis 193,774
Cerebrovascular disease 139,394
Hypertensive disease 113,852
Cerebral degeneration, dementia 108,354
Schizophrenia 104,941
Dental caries 91,856
Cirrhosis 87,854

*DALYs: Disability-adjusted life years, or years of healthy life lost. Source: Valdez W, Miranda J. Carga de enfermedad en el Perú. Estimación de los años de vida saludable perdidos, 2012. Lima: Ministry of Health; 2013.

Heart Disease

In 2012, 69,087 years of healthy life were lost due to ischemic heart disease (2.3 DALYs per 1,000 population), with a higher number lost among men than among women (47,071 versus 22,017 years) (). Mortality from ischemic heart disease rose from 22.8 per 100,000 population in 2011 to 29.1 in 2014. In the latter year, it was higher among men than among women (38.2 and 21.1 per 100,000 population, respectively).

Cerebrovascular Diseases

In 2012, this cause accounted for 139,394 years of healthy life lost (2.4 DALYs per 1,000 population); the number was slightly higher among men than among women (75,332 versus 64,062 years) (). In 2014, mortality from cerebrovascular diseases was 26.8 per 100,000 population (30.2 among men and 23.8 among women).

Hypertension

In 2015, 9.5% of the population (11.9% of women and 7.9% of men) had hypertension (10.5% in the coastal region, 9.3% in the jungle region, and 7.4% in the mountain region). Of the total of number of persons with high blood pressure, 62.1% had received treatment in the 12 months preceding the study ().

Chronic Obstructive Pulmonary Disease

In 2012, a total of 33,383 years of healthy life were lost due to chronic obstructive pulmonary disease (1.1 DALYs per 1,000 population). There was no significant difference between men and women ().

Malignant Neoplasms

Between 2006 and 2011, the Cancer Surveillance System () recorded 109,914 cases. The most frequent cancers among men were those of the stomach (15.1%); prostate (15.1%); skin (7.8%); hematopoietic system (7.3%); and lung (6.3%). Among women, cancers of the cervix (24.1%); breast (16.6%); stomach (8.6%); skin (5.8%); and hematopoietic system (3.7%) were most frequent, while among children under 15, cancers of the hematopoietic and reticuloendothelial systems (44.2%); brain (8.0%); eye and adnexa (7.8%); lymph nodes (6.9%); and bone, cartilage, and joints (5.2%) were most common.

Mental Health

In 2012, neuropsychiatric diseases were one of the leading causes Disability Adjusted Life Years (DALYs) lost (1,010,594 years, 17.4% of life years lost, 33.5 DALYs per 1,000 population) (). According to 2015 estimates, 20% of the adult population suffered from mental disorders, including depression, anxiety disorders, and alcoholism, while behavior and developmental disorders affected 20% of the child population. Depression is the clinical diagnosis most frequently associated with suicidal behavior. In 2013, the national suicide rate was 3.5 per 100,000 population; suicide was more common among men than among women (ratio of 2:1).

Peru is reforming its mental health services and is developing a system focused on community-based mental health care, strengthening of mental health promotion and protection, and continuity of family care for people with mental disorders.

Human Resources

In 2015, the ratio of human resources for health (physicians, nurses, and obstetricians) to population was 29.6 professionals per 10,000 population, with the number ranging from 16.9 in Loreto to 46.5 in Callao. In urban areas, the ratio was 33.1 professionals per 10,000 population, compared to 17.6 in rural areas. At the national level, the availability of health professionals was 12.2 physicians, 12.8 nurses, and 4.6 obstetricians per 10,000 population. There were 18,567 specialized physicians, distributed mainly between the Ministry of Health (45%) and EsSalud (33%). The Rural and Urban Fringe Service provides coverage in poor and underserved areas. In 2015, a total of 7,811 new professionals joined the health workforce, of whom 30% were physicians, 30% nurses, 25% obstetricians, and 15% professionals with other specialties. Act No. 30,453 (National Medical Residency System), promulgated in June 2016, is intended to increase the number of specialists. In 2011, the shortage of medical specialists in the country was estimated at 11,738 ().

Health Knowledge, Technology, and Information

Online registration of certificates of live birth, which commenced in 2012, has helped to ensure newborns’ access to public services. A national registry of electronic medical records was created in 2013, and a single national repository of health information was launched in 2016, with a Web platform that has facilitated access to health information. Act No. 30,421 (Framework for Telehealth), adopted in 2016, provides for development in the areas of health services delivery, management of information services, public education and communication on health services, and personnel capacity-building.

According to CS Imago Research Group, Cayetano Heredia University, San Marcos National University, and the Catholic University of Peru were the institutions producing the most scientific articles between 2009 and 2013, publishing 1,228, 892, and 644 articles, respectively, in academic journals. In mid-2016, the Virtual Health Library showed 33,856 scientific health publications and documents registered in the national database, 20,767 of which were available online.

Each entity within the health system has its own information system. The absence of a unified system that would tie them all together hinders information-sharing and health situation analysis in the country. The health system requires an online platform to organize and manage the information generated by its various agencies and health care facilities.

The Environment and Human Security

Deforestation and Land Degradation

Between 2001 and 2014, a total of 1,613,844 hectares of rain forests were lost, of which 329,938 hectares were reforested (20.4% of the deforested area). In the latter year, 144,117 hectares of forestland were lost, mainly in Loreto (29,846 hectares), Ucayali (28,055 hectares), Huánuco (23,697 hectares), and San Martín (20,564 hectares) ().

According to the Ministry of Environment, 3,862,786 hectares (3% of the country’s land area) had succumbed to desertification in 2012 and another 30,522,010 were undergoing desertification (24% of the land area). The annual land degradation rate reached 4.5%, affecting almost 11% of the population.

Air Pollution

Between 2002 and 2012, carbon dioxide emissions rose from 20,000 kilotons to 31,000 kilotons. In the latter year, concentrations of various other air pollutants were recorded, including nitrous oxides (114.6 kilotons), sulfur oxides (45.7 kilotons), and methane gas (35.2 kilotons). In 2014, the concentration of particulates less than 2.5 µm in diameter was 40.2 µg/m3, a level exceeding the national standard (20 µg/m3).

Persistent Organic Pollutants

Although Peru has signed the Stockholm Convention on Persistent Organic Pollutants, there is no published information on such pollutants.

Pesticides

Between 2007 and 2013, there was a sustained increase in imports of pesticides for agricultural use, which rose from 10,552.9 to 18,530.9 metric tons over the period (). According to the General Epidemiology Directorate, there were 15,711 cases of pesticide poisoning between 2008 and 2012. In 2012, the highest percentages of cases were recorded in Lima (17.8%), Arequipa (9.7%), and La Libertad (9.2%).

Natural and Anthropogenic Disasters

A total of 4,322 emergencies occurred in in 2015, as a result of which 171 people died, 474 were injured, and 18 went missing; in addition, 5,878 dwellings were destroyed and 148,870 were damaged. Between 2003 and 2015, the most frequent types of disasters were urban and industrial fires (31.6% of the total), heavy rainfall (20.8%), strong winds (13.6%), low temperatures (12.5%), and flooding (7.9%).

The most recent El Niño phenomenon occurred in 2017, causing major damage between February and March. Its impact was severe, with heavy rainfall, flooding of rivers and streams, and landslides, affecting mainly the northern coastal region. As of 19 May 2017, the National Civil Defense Institute had reported a total of 1,138,619 persons affected, 235,806 severely affected , and 145 deaths; 260,522 dwellings damaged and 25,817 collapsed; 840 health facilities damaged, 25 collapsed, and 38 rendered unusable; 426 bridges and 3,963 km of roads destroyed; 34,916 km irrigation canals destroyed; and 80,853 hectares of farmland affected. The most heavily hit region was Piura, with 80,434 affected persons, 360,904 severely affected persons, 5,732 collapsed dwellings, and 81,506 damaged dwellings.

Although there are no official statistics or reports on the number of oil spills in the Amazon region or on their impact on the environment and the population, news reports indicate that between 2000 and mid-2016 there were at least 60 spills associated with the Northern Peruvian Pipeline, with damage to native communities in the affected areas.

In terms of mercury pollution, between 2000 and 2014, mercury imports increased from 34.04 to 113.65 tons, with most of the mercury destined for use in artisanal and small-scale mining. According to the Ministry of Environment, more than 3,000 tons of mercury have been released into rivers in the Amazon region in the last 20 years, contaminating the water and poisoning aquatic organisms and human populations, with the worst damage occurring in the Madre de Dios region. A 2010 study found urine levels of up to 508 µg Hg/L among inhabitants of the district of Huepetuhe in Madre de Dios (the recommended level is < 5 µg Hg/L for persons not exposed occupationally).

Food Safety

Peru has made progress in adapting its national technical standards on the basis of the Codex Alimentarius standards. The country has a Permanent Multisectoral Commission on Food Safety (COMPIAL), created pursuant to the Food Safety Act (Legislative Decree No. 1,062), which sets national policy on the issue.

Waterborne Diseases

In 2015, the prevalence of diarrhea among children under 5 years of age was 2.0% in the two weeks preceding the survey, slightly less than in 2011 (13.9%). There were no major differences by sex (12.9% among boys, 11.1% among girls) or area of residence (11.4% urban, 13.6% rural), although higher prevalence rates were reported among children in the Amazon region (16.9%) and those in the lowest income quintile (14.1%) ().

Between 2010 and 2015, access to sources of safe water and improved sanitation increased from 84.6% to 86.7% and 72.0% to 76.2%, respectively. During the same period, the proportion of people defecating in the open declined from 10% to 5% (). In 2015, 81.3% of the population had access to the public water system (85.4% in urban areas and 69.6% in rural areas) and 66.8% to the public sewerage system (84.9% in urban areas and 15.6% in rural areas); 7.7% of homes did not have any excreta disposal system.

In 2014, a total of 2,217,946 m3 of wastewater was generated per day and was discharged into the sewerage system of the public sanitation corporations, although only 32% of that water received treatment.

Solid Waste

Data from the Ministry of Environment indicate that a total of 7,047,000 tons of municipal solid waste was generated in 2012. Between 2012 and 2014, the percentage of municipalities that used open dumps to eliminate solid waste was reduced from 71.5% to 70.8%, and the use of sanitary landfills rose from 29.9% to 31.7%. In 2014, 95.3% of urban households had household waste collection services ().

Aging

Between 2000 and 2015, the population over 64 years of age grew from 1,235,855 to 2,043,348 (from 4.8% to 6.6% of the total population), the aging index increased from 14 to 23 older persons per 100 children under 15, and life expectancy at birth rose from 70.5 to 74.1 years (Table 2).

Table 2. Demographic indicators, by five-year period, Peru, 2010-2025

  5-year period
Indicator 2010-2015 2015-2020 2020-2025
Total fertility rate (children/woman) 2.4 2.2 2.1
Birth rate (per 1,000 population) 19.4 17.9 16.6
Mortality (per 1,000 population) 5.5 5.6 5.9
Life expectancy at birth (years)      
Both sexes 74.1 75.1 75.9
Males 71.5 72.5 73.4
Females 76.8 77.8 78.6
Net migration rate (per 1,000 population) -2.7 -1.7 -1.2
Total growth rate (per 1,000 population) 11.2 10.5 9.5

Source: National Institute of Statistics and Information Technology (INEI). Population Estimates and Projections 1950-2050. Demographic Analysis Bulletin No. 36. Peru: INEI; 2009.

In the latter year, 80.8% of older women and 68.0% of older men had some type of chronic health condition, and 45.8% had some type of disability (57.2% of women and 35.8% of men). Difficulties in the use of arms and legs (33.3%) and impairments of vision (13.4%) and hearing (13.4%) were the leading forms of disability. Between 2011 and 2015, the percentage of older persons with some form of health insurance grew from 68.0% to 79.2%. Of that total, 41.6% had access to the SIS system and 30.9% to EsSalud ().

Peru has two retirement pension systems, one public and the other private, between which employed and self-employed workers can choose. Under the National Pension System, workers are required to contribute 13% of their monthly salary or income over a period of not less than 20 years in order to receive, starting at the age of 65, a pension in an amount ranging from 857.36 soles to 415.00 soles (approximately US$ 260 to US$ 125). Under the Private Pension System, workers can begin receiving a retirement pension at the age of 65 years, without any required minimum contribution period. The pension amount is calculated on the basis of the contributions made and the interest earned.

In 2012, a total of 1,088,846 years of healthy life were lost in the group aged over 60 (400.3 DALYs per 1,000 population over 60 years of age), the majority as a result of neuropsychiatric diseases (61.8 DALYs per 1,000 population over 60 years of age), cardiovascular diseases (60.9), malignant neoplasms (50.1), unintentional injuries (41.5), and diseases of the musculoskeletal system and connective tissue (37.3) ().

Migration

In Peru, internal migrants tend to move from rural to urban areas, particularly the large cities. The economic dynamic that has prevailed in the country during the last two decades has produced several new development centers (in addition to Metropolitan Lima): La Libertad, Lambayeque, and Piura in the northern part of the country; Ica, Arequipa, Moquegua, and Tacna in the southern part of the country; and San Martín, Loreto, and Ucayali in the east. During the periods 2000-2005 and 2010-2015, net annual migration decreased from –105,000 to –83,000 (and the net migration rate fell from –3.9 to –2.7 per 1,000 population). In 2013, the top destinations for Peruvian emigrants were the United States (31.4%), Spain (15.4%), Argentina (14.3%), Italy (10.2%), and Chile (9.5%).

Monitoring the Health System’s Organization, Provision of care, and Performance

The public subsector, which comprises the Ministry of Health and the regional governments, accounts for 57% of the country’s health care facilities, most of which (98%) are located at the first level of care, while the hospitals and specialized institutions of the public sector are located mainly in Lima and the other large cities. The public system serves the poor and vulnerable populations covered by the SIS. The social security subsector, which includes EsSalud and the military and police health services, is limited to wage-earners and entitled beneficiaries. It accounts for 3% of the country’s health care facilities and provides mainly relatively complex services. The private sector accounts for 40% of all health facilities and has an extensive first level of care (accounting for 95% of the private facilities), with numerous clinics located mainly in the large cities. In 2015, 72.3% of the population had some form of health insurance; 40.5% were covered by the SIS, 25.8% by EsSalud, and 6% by private insurers and/or the military or police health services. Of the population living in poverty, 71.7% were covered by the SIS, 7.4% by EsSalud, and 0.3% by both; 20.6% did not have any type of insurance.

In 2014, there were three main sources of health care financing: resources from the public treasury (34.2%), contributions to the social security system (31.3%), and out-of-pocket spending by households (31.1%). In the period 2010-2014, total health spending rose from 19,857,000,000 soles to 23,628,400,000 soles (US$ 6.62 billion to US$ 7.876 billion). Per capita spending increased from 674 soles to 864.20 soles (US$ 224.70 to US$ 288.10), and the percentage of health financing covered by a health fund or insurance increased from 37.1% to 40.4%. In 2014, of the total covered by funds, EsSalud accounted for 64.5%, private insurance for 13.1%, health care provider entities (EPS) for 12.3%, and the SIS for 10.1% (). In 2015, health spending represented 5.3% of GDP (3.1% for public spending and 2.2% for private spending); 84.7% of private expenditure was out-of-pocket spending or direct payments. Funds for the provision of public health services and interventions are transferred to the regions. Between 2011 and 2015, there was a 22.1% increase in the budgets of the regional and local governments, which rose from 45.982 billion soles to 56.15 billion soles (from US$ 15.327 billion to US$ 18.717 billion); however, the level of budget execution was low (82.0% of what was transferred in 2015), owing to management problems at the regional and local levels.

In 2013, an “inclusive pharmacy” mechanism was established with a view to improving access to essential medicines for individuals covered by the SIS. Two years later, the Ministry approved a technical standard for administering clinical practice guidelines and implemented a methodology for developing such guidelines. A set of policy guidelines for access to biotechnology products and regulations for registering such products were published in 2016.

Prospects

In 2021, Peru will celebrate the bicentennial of its independence, a landmark occasion that represents a good opportunity to take stock of the results of the country’s collective efforts to achieve the national development objectives set out in the Bicentennial Plan: Peru 2021 (Plan Bicentenario: El Perú hacia el 2021), which calls for the country to work towards meeting the Sustainable Development Goals and joining the Organisation for Economic Co-operation and Development (OECD). The Plan’s second strategic line of action (opportunities and access to services) establishes the following objective: ensure Peruvian citizens the opportunity to access quality services in an increasing, sustained, and equitable manner, with due attention to the cultural diversity of the population and emphasis on rural and urban fringe areas. Access to quality health and education services and to water, sanitation, and electricity services are identified as priorities under this line of action.

In 2015, 17.7% of the population continued to lack health insurance, and those covered by the SIS, those with limited economic resources, and other population groups living in conditions of vulnerability, only had access to services provided under the Essential Health Insurance Plan, except for some complementary benefits, such as treatment for cancer.

It is clear that in order to achieve its health-related objectives, Peru will need to: i) increase public spending on health while also reducing out-of-pocket expenditure by individuals and direct charges at the point of service; ii) improve the infrastructure of the Ministry’s health services, particularly at the first level of care, and ensure the continuous availability of skilled health workers; iii) develop policies and strategies for increasing the number of health professionals over the next five years and ensuring that they are distributed in an equitable manner throughout the country, prioritizing the poorest areas and rural and remote locations; iv) put in place a system for assessing the quality of care provided by health services at all levels; v) develop a system for referring patients from rural and remote areas to regional hospitals and specialized institutions—including communication systems and vehicles and personnel for patient transfer; vi) formulate a strategy for delivering specific services in remote areas of the Amazon region; vii) increase the benefits included in the Essential Health Insurance Plan and continue to move forward in building a health system that eliminates the current fragmentation in service delivery; and viii) develop strategies for reaching the almost 20% of the population that continues to lack health insurance and reduce the 20% of the population currently covered by the SIS that is neither poor nor vulnerable.

Despite progress in tuberculosis control, the rise in cases of MDR tuberculosis and the emergence of cases of XDR tuberculosis represent a significant challenge; this increase, which raises the morbidity and mortality from this cause, also adds to treatment costs. At the same time, the spread of Aedes aegypti has increased the number of people at risk of dengue, chikungunya, and Zika virus disease. Against this backdrop, it is necessary to rethink current control strategies and to involve local and regional authorities and the population of infected areas in their implementation. The increase in malaria cases, particularly in Loreto, warrants an assessment of the factors that have led to this situation with a view to redefining the strategies for control of the disease, thus reducing its impact on the health and the economy of the poorest populations in the Amazon region.

Although great strides have been made in reducing maternal and neonatal mortality at the national level, major differences persist within the country and rates remain very high in the mountain and Amazon regions. Interventions are therefore needed to help improve the coverage and quality of care provided by culturally appropriate health services. Since the decline in immunization coverage could reverse the gains made in the control of vaccine-preventable diseases, it is necessary to improve strategic vaccination interventions and intensify vaccination campaigns in low-coverage areas. To that end, a monitoring and evaluation system is needed that will identify low-coverage areas quickly and easily, as well as targeted policies and interventions to address the causes of low coverage.

Chronic malnutrition among under-5 children has declined significantly, but the same cannot be said of anemia in this age group. It is necessary to identify the social, economic, and programmatic factors that are impeding adequate food and micronutrient intake in this population in order to revise the current intervention strategies.

Mental health disorders are one of the largest contributors to the overall burden of disease. Given this reality, it is essential for the Ministry of Health to step up its efforts to implement a community-based mental health care model in order to close the enormous care gap and protect the human rights of persons with mental health problems.

As land transport accidents are among the leading causes of mortality among young people and adults, a comprehensive road safety policy is needed, along with results-oriented budgetary programming, and intersectoral and intergovernmental commitment for its implementation.

The design and implementation of a policy on alcohol use, which Peru does not currently have, is a priority. The policy should include a cost-effective strategy for further restricting access to alcohol, regulating marketing of alcoholic beverages, and raising alcohol consumption taxes.

Another of the priorities to which the national government is committed under the Bicentennial Plan is the provision of drinking water and sanitation to the entire population of the country. The major challenge in this area is to develop and implement appropriate, cost-effective technologies and necessary infrastructure to ensure access to safe drinking water and improved sanitation in the most remote areas, particularly in the Amazon region. To that end, it is important to identify and evaluate successful experiences at both the national and international levels that can be replicated or improved upon in keeping with prevailing conditions in the areas of intervention.

Box 1. The National Agreement to Achieve Health System Reform by 2021

In October 2015, following a process of dialogue and consensus-building among government authorities, political parties, civil society organizations, and other stakeholders involved in the National Agreement, health system reform objectives were approved with the aim of ensuring the political viability and continuity of policies that will put Peru on track to achieve universal health by 2021. The Agreement underscores the need to achieve individual and collective access to comprehensive health care as a universal right, regardless of socioeconomic status or geographic location, and also highlights the importance of gender-sensitive approaches, health rights, and interculturalism. The National Agreement will serve as the main basis for building consensus on the national policies of Peru.

References

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8. Instituto Nacional de Estadística e Informática (Peru). Características sociodemográficas de los grupos étnicos de la Amazonía Peruana y del espacio geográfico en el que residen. Lima: INEI; 2011. Available from: ftp://www.unfpa.org.pe/POBLACION_DESARROLLO/INEI/INEI-Estudios-Amazonia/Tomo5-Caracteristicas-Sociodemograficas/Contenido.pdf.

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11. Ministerio de Salud, Dirección General de Epidemiología (Peru). Análisis de la situación epidemiológica de la tuberculosis en el Perú 2015. Lima: MINSA-DGE; 2016. Available from: http://www.dge.gob.pe/portal/index.php?option=com_content&view=article&id=599&Itemid=204.

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Reference/Note:

1. Disputes arising from public grievances, whether formally submitted or not (Office of the Omudsman).

2. Hidden or seemingly inactive public disputes with a concurrence of factors on a collision course, or else disputes that have occurred, but have been dormant for a considerable time (Office of the Ombudsman).

3. According to the National Institute of Statistics and Information Technology (INEI), these are workers who do not enjoy the benefits stipulated by law, such as employer-provided social security, paid vacations, sick leave, and others.

4. In other words, the health system is no longer organized by social groups (population segments), but by functions. The modulation, financing, service delivery, and coordination functions are a key feature of this model. The specialization of health system personnel by function is therefore encouraged.

5. Act No. 27,813 (Coordinated Decentralized National Health System Act), article 1.

6. These institutions include the SIS, EsSalud, the military and police health services, health care provider entities (EPS), private health insurance companies, health care entities that offer prepaid health services, self-insurance plans and health funds, and other public, private, or mixed insurance schemes.

7. Safe sources of water include public water systems, tube wells or boreholes, protected dug wells, protected springs, and rainwater collection systems.

8. Improved sanitation includes siphon systems with discharge into a sewerage system, septic tanks, pit latrines, ventilated improved pit latrines, pit latrines with slab, and composting latrines.

9. A negative net migration rate indicates population loss due to migration. In the five-year period 2010-2015, 2.7 people per 1,000 population were lost.

10. Created in 1997 under Act 26,790, health care provider entities are private insurers that offer coverage for “first-layer” health care services (health care and interventions included in the basic plan selected) as a complement to EsSalud, for which they receive between 4% and 9% of the contributions paid by the employer.

11. Available from: http://acuerdonacional.pe/2015/10/los-objetivos-de-la-reforma-de-salud/.

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