OECD Reviews of Health Systems: Peru 2025

1. Assessment and recommendations

Abstract

This chapter summarises the in-depth assessment conducted as part of Peru’s accession review and presents key recommendations to enhance the performance of the health system across critical dimensions, including access, quality, sustainability, efficiency, and resilience. While significant progress has been made in population health indicators and access to care – particularly following the introduction of the Universal Health Insurance Law in 2009 – substantial inequalities in access to high-quality care persist among different population groups. These disparities stem from the fragmentation and segmentation of Peru’s health system, compounded by inadequate health infrastructure, a low supply of healthcare workers, and significant geographical imbalances in workforce distribution. Addressing these challenges requires strengthening quality governance and health information systems, investing in high-impact healthcare service improvements, and reducing inefficiencies.

Peru has well designed policies and institutions that other countries could learn from and that deserve to be better known internationally. However, given Peru’s limited resources, efforts to enhance value for money will be essential to freeing up the resources needed for further investment in improving the quality and accessibility to care, especially for women, disadvantaged ethnic groups and population groups living in rural areas.

Peru has made good progress in delivering appropriate healthcare over the past decade, yet further efforts can help reduce the large inequalities in access to care

Over the past 40 years, Peru has significantly improved most general population health indicators. Notably, Peru has achieved large gains in average life expectancy of approximately 13 years since 1980, reaching 72.4 years in 2022. Infant mortality has declined sharply in the last decades, from 83 deaths per 1 000 live births in 1980 to 11 deaths in 2021. Maternal mortality also decreased from 101.9 deaths per 100 000 live births in 2002 to 51.9 deaths in 2023. The expansion of healthcare coverage has contributed to these improvements. Peru introduced a Universal Health Insurance Law in 2009 and has made substantial progress towards universal coverage since then. Insurance coverage has continued to increase, from 61% of the population in 2009 to 83% in 2017 and reaching more than 97% in 2023. Affiliation to Seguro Integral de Salud (Integral Health Insurance – the public insurer) has been the key instrument behind the expansion of healthcare coverage. The past reforms were strongly progressive, being specifically designed to reach poor and vulnerable population. Affiliation increased more rapidly in the poorest population and in rural areas (from 2005 to 2022 for example, coverage of Integral Health Insurance for rural populations increased from 25% to 85%), and access to healthcare services became much more equally distributed. In 2019 for example – before the COVD‑19 pandemic – 77% of children aged less than one year were recorded as having received routine vaccination in both urban and rural areas. Likewise, out-of-pocket payments have decreased by more than 22% over the last decade.

However, there are still large inequalities in access to healthcare. In Puno, for example (the Andean region with a high density of indigenous people), the proportion of people reporting unmet medical needs is almost double that of Metropolitan Lima areas (40% compared to 23%). Unmet medical needs are more often reported among women (33%) than men (29%), and women face longer waiting times for a medical consultation than men. Similar ethnic and regional inequalities are observed in OECD Member countries including Colombia, Chile and Mexico. Other populations, such as the lesbian, gay, bisexual, transgender, intersex (LGBTI) community, also faced difficulties in accessing healthcare.

Peru needs to reduce the fragmentation of its health system

The segmentation and fragmentation of Peru’s health system has an adverse impact on the access to care, quality and efficiency. Peru is facing a dual challenge with a health system that is segmented (it is divided into different sub-systems that serve various segments of the population) and fragmented (these sub-systems lack the necessary integration and co‑ordination). The social health insurance (EsSalud) and the Integral Health Insurance (SIS) cover different groups of the population, provide different levels of coverage, and have separate networks of providers with separated governance structures and financing systems. EsSalud operates an exclusive network accessible only to those affiliated to the social health insurance system, which covers around 26% of the population (all salaried formal workers and their families). Meanwhile, services for those affiliated with SIS are provided by public health facilities directly owned by the Ministry of Health in the metropolitan region of Lima and by regional governments elsewhere in the country. SIS covers around 62% of the population as of 2023, mainly poor individuals, vulnerable groups, entrepreneurs and self-employed workers. While SIS is primarily non-contributory and financed by general taxation, EsSalud is a contributory system which is financed almost exclusively through labour-related contributions.

Fragmentation means that in some regions there is duplication of services with hospitals of both networks operating alongside, while in other regions – most often rural areas – there is only access to the SIS public sector. This results in an inefficient allocation of health resources and inequalities in access to quality care. Many patients, especially those covered by EsSalud, are forced to rely on hospitals for primary healthcare. In 2022, only 32% of Peruvians accessed a public primary health centre first when they sought care. To promote equal access across the sub-systems, a further use of benefit exchange agreements (intercambios prestacionales) – which make it possible for affiliates of either SIS or EsSalud to access health services offered by the network to which they are not affiliated – is recommended for a basic set of services such as primary healthcare services. This would improve access to preventive and comprehensive care and lead to a more efficient use of healthcare supply.

In addition, to reduce fragmentation of the health system, Peru would benefit from progressively harmonising the minimum benefit package between SIS and EsSalud. Chile, Colombia and Mexico, OECD Member countries with similarly fragmented health systems, have taken steps to encourage convergence in benefit packages across different health insurance systems. A key challenge will be to define the level of services offered in the common benefits package. If too restricted, then people in the social health insurance would see their breadth of services reduced relative to the current system, which would reduce support for the reform.

A more unified health system can be achieved through stronger quality governance and an interoperable health information infrastructure

In Peru, there are few quality initiatives at the system level. Each health facility has the responsibility to implement quality management processes – such as implementing clinical practice guidelines, developing patient safety protocols and undertaking audits – but these are implemented sporadically, and monitoring depends on regional or local capacity to assume quality assurance mechanisms. Quality and outcome indicators are also irregularly collected and analysed. The Ministry of Health’s evaluation process for health facilities is focused on assessing compliance with regulations, but the system focuses on compliance with minimum service readiness standards (such as registering infrastructure, equipment and stock of pharmaceuticals in the information systems) and entails sanctions rather than rewarding and supporting improvement initiatives. Centralised functions for quality assurance and stronger oversight of local and regional activities would be beneficial. The role of the National Health Superintendence (SUSALUD) could be strengthened by setting national quality standards for all sub-systems, monitoring compliance with these quality standards, and providing incentives for quality improvements. Similar national inspectorates for health are in place in OECD Member countries. These include the Haute Autorité de Santé in France, which provides independent verification that quality standards are being met, identifies good practices and supports weaker facilities to improve their quality standards.

Peru would also benefit from an interoperable health information infrastructure to further improve the effectiveness of its health system in terms of accessibility, quality and efficiency gains. The Peruvian health information is not standardised across sub-systems and linkage of personal health data across healthcare settings is challenging. This means that it is not possible to comprehensively measure activities, care quality or outcomes nationally, to make comparisons across providers, and follow pathways of care particularly for patients with complex care needs. To do so, Peru is working on a unified national health data system (REUNIS) to be able to report a core set of information across all sub-systems. Yet mainly the Ministry of Health and regional governments’ health data are reported to the REUNIS information system. Greater interoperability across all sub-systems, as well as standardised and mandatory reporting of indicators on resources, activities and quality of care would help to achieve a harmonised monitoring system. Additional efforts are also needed to ensure greater reporting and comparability of the data according to OECD standards for national and international benchmarking. For example, Peru relies on survey data and reports life expectancy for five year blocks while most other countries rely on demographic statistics from life tables. Peru is also not able to report on employment, workforce migration, and health spending by type of services and providers. Many OECD LAC countries have started with the same limitations and gradually expanded the scope of their data submission.

The resilience and sustainability of Peru’s health system can be improved

Health spending in Peru is low, indicating that the healthcare system is underfunded compared to other LAC and OECD countries. In 2022, Peru allocated 6.2% of its GDP to health, a lower share than in Costa Rica (7.2% of GDP), Colombia (7.8% of GDP) or Chile (10.0% of GDP). Likewise, the level of overall public spending in Peru is much lower than in other OECD and LAC countries. In 2021, overall public spending was at 23% of GDP, lower than in Chile (26%) or Mexico (27%) and nearly half the average in the OECD (40% of GDP). This leads to high out-of-pocket spending. In 2022, out-of-pocket payments accounted for 27% of the total health expenditure, almost 1.4 times higher than the OECD average of 19%.

While financial resources allocated to the Integral Health Insurance (SIS) increased around fourfold over the last decade (from PEN 517 million in 2010 to PEN 2 483 million in 2022), low level of public spending is an issue which directly relates to low government revenues – due to a relatively low tax burden and a narrow tax-base due to informality. The financial sustainability of the Peruvian health system is further challenged by a complex budgeting process. The Ministry of Economy and Finance has strict control over the Integral Health Insurance’s budget, preventing reallocations across budget lines. This means that the Ministry of Health, regional governments or executing units may have funds for one line item, but need funds for another and are not allowed to reallocate funds across budget lines. Furthermore, government transfers to the Integral Health Insurance are calculated only on the basis of the variable costs of services and do not include recurrent costs such as maintenance and labour costs. This poses a challenge to the ability of regional and local governments to deliver healthcare services, as they may face limitations in their technical and financial capacities to manage these costs. Addressing this by transferring the payment of recurrent costs to the Ministry of Health would help ensuring the long-term financial sustainability of the healthcare system. This would also increase the ability of the Ministry of Health to further implement payment mechanisms that incentivise good care quality and hiring additional workers.

Peru would benefit from prioritising efforts to drive efficiency gains and reduce wasteful spending within the health sector in order to free up resources to improve the health infrastructure. As several other countries, Peru must address the need for further investments in the health system to improve quality and access, with limited public funding and competing priorities for allocating government funding. To increase efficiency, Peru would need to use risk-adjustment formulae to ensure that SIS is adequately resourced for their affiliated population and their health needs. Greater accountability for public health facilities directly owned by the Ministry of Health in the metropolitan region of Lima and by regional governments in improving population health outcomes and quality of care is also needed through better payment mechanisms. Adopting results-based budgeting for key horizontal health objectives and ensuring greater budget flexibility for regional and local governments will further enhance efficiency in public health spending.

Targeting prevention and health promotion is also necessary through the modernisation of the primary healthcare sector, the ongoing development of the Model of Integrated Care by Life Course for the Person, Family and Community and the roll-out of Integrated Health Networks. This is key to make sure primary healthcare can realise its key functions regarding public health, prevention and management of diseases, backed by sufficient laboratory and diagnostic capacity. This is particularly important given the health needs of the population, characterised in recent years by rising obesity rates, persistently high prevalence of anaemia and still predominant infectious diseases, such as dengue.

Given that the majority of public healthcare facilities are evaluated by the Ministry of Health as being precarious or inadequate to provide proper patient care, Peru should also repurpose small, inefficient hospitals into intermediate care facilities (alongside a strengthening of telehealth applications and medical transportation not to compromise access to acute care for patients in remote areas). This would help to improve patient safety and increase allocative efficiency.

Improving the planning and procurement process for non-strategic medicines, ensuring greater availability of generics and integrating economic evaluation in health technology assessments are also key actions to increase efficiency in pharmaceutical spending.

While Peru improved health crises preparedness in recent years, a stronger workforce planning and incentives are needed to improve the resilience of its health system

The impact of COVID‑19 on population health has been dramatic in Peru. The country had the highest yearly excess mortality in 2020 and 2021 among both LAC and OECD countries. Peru had an average of 437 excess deaths per 100 000 population in 2020 and 2021, almost four times as high as the OECD average of 114 excess deaths per 100 000 population and more than twice the LAC average. Poor determinants of health, weak information systems, shortages in key health personnels and limited co‑ordination across sub-systems to provide appropriate care are all factors explaining poor health outcomes.

Peru’s response to the COVID‑19 pandemic led to improved crises preparedness through better established crises management. Between 2020 and 2022, MINSA implemented five national pandemic plans to address the COVID‑19 pandemic, which were all consistent with the International Health Regulations. The development of the National disaster risk policy for the year 2050 and Strategic Action: Prevention and response to international public health emergencies plans have also led to improved crisis preparedness, alongside the strengthening of laboratory capacity to monitor surveillance of infectious diseases. Peru is also advancing towards a One Health approach by developing an integrated Antimicrobial Resistance (AMR) surveillance system that spans the health, agriculture, production, and environment sector, and the development of a “Framework Law for the Containment of Antimicrobial Resistance under the One Health Approach”. However, the effectiveness of initiatives toward pandemic and health crisis preparedness hinges on robust regional implementation. Despite having clear national plans with identified funding sources, the success of these measures largely depends on regional decisions and implementations. Issues with technical and organisational capacity at the regional level could lead to suboptimal implementation of these critical health policies, calling for additional oversight from the central level.

The development of a stronger workforce planning strategy (spanning across sub-systems), taking into account medium and long-term needs, is needed to improve the resilience of Peru’s health system. While Peru has already taken steps to strengthen its healthcare workforce policies – through for example the development of a National Health Personnel Register, the SERUMS and PROFAM programmes to increase the training of doctors in rural areas and in primary healthcare, Peru still faces challenges to increase health workforce and address geographical imbalances. Peru has for example a low density of physicians per capita, with 1.6 per 1 000 habitants in 2022, slightly lower than the average in the LAC region (2 per 1 000), and well below the OECD average of 3.8. Like other countries in the region and across the OECD, Peru faces significant geographical disparities in the supply of physicians, with rural areas being particularly short of doctors. In 2021, only 9.8% of doctors were located in rural areas compared to 14.8% in 2013. Strategies to retain health workforce in the profession should also be strengthened, for example through plans to improve salaries for healthcare workers employed by the public sector and those working in rural areas. Investing in nursing training and integrating community health workers offer another potential development for Peru to improve resilience of its health system while carrying out health prevention and health promotion activities.

Box 1.1. Policy Recommendations to strengthen the performance of Peru’s health System

Peru can consider the following recommendations to improve its health system performance and strengthen its sustainability and resilience, and bring Peru closer to OECD standards, best policies and practices:

Improve access and quality

• Increase the use of exchange of services between SIS and EsSalud for basic primary healthcare services.

• Harmonise progressively the minimum benefit package between SIS and EsSalud and offer affiliates secondary insurance for services that are not included in the basic benefit package.

• Continue to promote the use of telemedicine to better reach remote populations. Improve connectivity to ensure teleconsultation capabilities in less developed and remote regions.

• Strengthen primary healthcare in Peru to fully realise its key functions regarding public health, prevention and management of chronic conditions. Consider evaluation of medical school curriculum, and make sure the PROFAM training programme is offered in all medical schools and made compulsory for practising as primary care physicians. Primary healthcare should be backed by sufficient laboratory and diagnostic capacity.

• Continue to introduce changes in payment systems for both primary healthcare and hospital care to reward care quality (for example by allocating weighted capitation to health facilities rather than regional units, use payments for a package of services and consider introducing add-on payments to encourage care co‑ordination and effective management of chronic diseases).

• Develop a robust national quality assurance framework at system level, unified across sub-systems. Increase oversight of local and regional activities. Enhance the role of SUSALUD to set national quality standards, monitor compliance with quality standards, and provide incentives for quality improvements. Consider a gradual introduction of a voluntary hospital accreditation system.

• Continue to unify the information system and strengthen national data collection, standardisation, linkage, and analysis of health data to improve care quality. Improve co‑ordination between SIS and EsSalud to achieve greater interoperability of EHRs. Ensure the national health data governance strategy is adopted by 2025.

• Adopt OECD standards for national and international benchmarking capacity to improve data quality and coverage, notably for indicators on healthcare quality, health outcomes and healthcare activities. Yearly reporting of key health status indicators, such as life expectancy at birth, is important.

Strengthening efficiency and financial sustainability

• Consider ways to raise public revenue to secure additional funding for the Peruvian health system, notably by leveraging efficiency gains.

• Reduce complexities of the health budgeting mechanisms to ensure more flexibility in budget reallocations for regional and local governments. Transfer payments of recurrent costs (maintenance and salaries) to Ministry of health, backed by additional resources from the MEF.

• Move away from historical spending and allocate SIS resources according to the number of affiliates and their health needs. Increase the use of results-based budgeting towards key horizontal health objectives.

• Modernise primary healthcare by increasing competencies of general practitioners and making family training compulsory.

• Improve allocative efficiency by repurposing small and less productive hospitals into intermediate care facilities to consolidate resources in larger hospital centres. Ensure timely access to urgent care through telehealth applications and medical transportation from rural to better-equipped general hospitals in urban areas. Implement hospital payment systems that incentivise quality.

• Strengthen the planning behind the procurement of medicines through information systems that allow for a better estimation of health demand. Increase stewardship from the Ministry of Health to support regions with insufficient planning or administrative capacity for carrying out purchases directly.

• Ensure greater availability of generics by making mandatory the requirement for private pharmacies to maintain 30% generics in stock for essential medicines. Integrate economic evaluation in health technology assessments.

Improving resilience and preparedness

• Invest in national workforce planning based on population needs and on regional distribution of healthcare workers. Increase INFORHUS reporting requirements for all sub-systems to assess human resource needs. Provide support to regional authorities that lack the sufficient scale, technical and financial capacity to assess their own health workforce needs and formulate policy options.

• Implement adequate incentive structures to improve recruitment and retention of health workers. Provide higher level of financial incentives, combined with non-financial incentives, for physicians and nurses to work in remote and underserved regions.

• Monitor and regulate dual practice. Allow physicians and nurses to have more than one position in the public sector.

• Invest in nurses’ profession through training and education programmes to support advanced practice. Integrate community health workers more formally into the health system, particularly in remote areas serving indigenous populations.

• Continue to strengthen multisectoral co‑operation to tackle AMR. Fill gaps in policy implementation to improve management and surveillance across all relevant stakeholders, notably through a more consistent application of guidelines for antibiotic use, systematic monitoring to inform policy, and comprehensive national campaigns to raise AMR awareness.

• Develop a policy response at national, regional and local level to revert the decreasing trend in childhood vaccination. This includes maintaining strong quality standards, national public communication campaigns, health literacy and outreach programmes.

• Strengthen pandemic risk preparedness through the national disaster risk policy for the year 2050, backed by adequate operational plans at the regional level.