This chapter provides an overview of Peru’s health system, beginning with a summary of the country’s socio‑economic context, followed by an analysis of its health and healthcare needs. The first section shows that while Peru has made significant progress in improving general population health indicators, rising obesity rates, persistently high levels of anaemia, and the continued prevalence of infectious diseases pose increasing public health challenges. The second section examines the structure of the health system, highlighting the key actors within the government-funded healthcare sector. The third section focuses on the health information infrastructure underpinning healthcare delivery. It presents the large amount of digital health data that is collected but also highlights the lack of standardisation across sub-systems and the challenges in linking personal health data across healthcare settings.
OECD Reviews of Health Systems: Peru 2025
Abstract
The socio‑economic context in Peru today
Peru is the third largest country in Latin America and is extremely diverse, both geographically and socio‑economically. The country is divided into 26 regions, bordered by Ecuador and Colombia to the north, Brazil to the east, Bolivia and Chile to the south and the Pacific Ocean to the west. Peru is crossed by the Andes Mountain chain which, together with the Amazon jungle in the north-east, creates a geographically complex environment. In 2022, Peru had approximately 34.1 million inhabitants (World Bank, 2024[1]), with most people living on the Pacific coast, and fewer in the mountain ranges and rainforests. Mestizos are the largest ethnic group in Peru, comprising about 60% of the population, including people of mixed indigenous and European descent. According to the 2017 Census, the Quechua population is the largest indigenous group, comprising about 20% of the population, while the Aymara population is estimated at 5% of the total population, the Afro-Peruvians at 4% of the population and the white population (from European descent) at 6% of the population (OECD, 2023[2]).
Between 2000 and 2019, Peru enjoyed sustained economic growth with an average annual growth rate of 5.1%, driving progress towards higher living standards, and emerging as one of the fastest growing and most stable economies in Latin America (OECD, 2023[2]). Macroeconomic stability, trade openness, and a favourable international environment allowed the country to become an upper middle‑income economy, with per capita income rising from USD 2040 in 2002 to USD 7 126 in 2022 and poverty dropping from 60% to 33% over the same period (World Bank, 2024[3]). There has also been a significant reduction in inequality, with the Gini coefficient decreasing from 0.49 in 2000 to 0.40 in 2021 (Figure 2.1). However, Peru still faces considerable economic and social challenges, with marked disparities across regions. For example, the region Moquegua has a GDP per capita almost 8 times as high as that of San Martín.
Source: World Bank (2024).
In addition, convergence to higher living of standards slowed after the commodity price boom ended in 2015 and in 2020, the COVID‑19 pandemic had a severe impact on both lives and livelihoods, resulting in higher excess mortality and a sharper economic contraction than in most countries in the world, and reversing some of the gains in poverty reduction (OECD, 2023[2]). The pandemic also revealed pre‑existing structural weaknesses, such as one of the highest levels of informality in the Latin America region (Figure 2.2), with around 75% of workers without any access to social protection mechanisms, savings or credit, including state‑guaranteed, to fall back on. Informality, which is associated with high levels of poverty, income inequality and social exclusion, is high among women, rural populations and indigenous and Afro-Peruvians.
In addition, the COVID‑19 pandemic brought stress to the Peruvian health system which already experienced important structural challenges. 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). While Peru made substantial progress towards universal coverage since the introduction of Universal Health Insurance Law in 2009, there is broad recognition that there is room for ensuring that high-quality services are accessible to all Peruvians. The fragmentation of the Peruvian health system, the gaps in human resources and the limited health information infrastructure hamper the delivery of efficient, sustainable and good quality care.
Source: ILO, System of Labour Information and Analysis of Latin America and the Caribbean (SIALC).
Peru has achieved considerable gains in life expectancy
Peru’s life expectancy increased by 13 years over the past four decades. In 2022, life expectancy at birth stands at 72.4 years (Figure 2.3), 6.1 years below the OECD average and also relatively low when compared to other Latin American and Caribbean (LAC) countries, including Mexico (75), Colombia (77), Costa Rica (81) and Chile (81).
1. Data for 2021.
Note: Latest available data for the United Kingdom is from 2020. No 1980 data for Latvia and Croatia, data for Slovenia from 1982. Data from the World Bank Development Indicators was used to calculate the LAC average.
Source: OECD Health Statistics 2023, World Bank 2024.
Peru is marked by a slightly lower gender gap in life expectancy than OECD countries. On average, Peruvian women live nearly 5 years longer than men, whose life expectancy is 70.1 years. This is lower than the average OECD gender gap of 5.2 years in 2022.
Infant mortality in Peru has declined sharply in the last decades, from 83 deaths per 1 000 live births in 1980 to 11 deaths in 2021. This trend has occurred in parallel to a sharp decrease of infant mortality in other countries of the LAC region, such as Mexico, Brazil, Argentina and Colombia. Despite all selected countries drastically reducing infant mortality rates in the last decades, they remain above the OECD average of 3.9 deaths per 1 000 live births in 2021 (see Figure 2.4). Data from the 2017 National Census also revealed disparities by ethnic groups in Peru. Among women in reproductive age self-identifying as indigenous or originating from the Andes, 2.9% of children born alive died, compared to 2% among women from other ethnicities (INEI, 2018[4]).
Although maternal mortality also decreased from 101.9 deaths per 100 000 live births in 2002 to 51.9 deaths in 2023, there was an increase to 80.9 deaths in 2020 and 87.4 in 2021, which could be explained by the reduced supply of health services and increased barriers to access during the COVID‑19 pandemic (CDC, 2021[5]). Moreover, when looking at maternal mortality as a share of women in reproductive age, there are wide inequalities across geographical regions in Peru, with Madre de Dios region having 8.3 times the maternal mortality rate of Moquegua as of 2021 (Figure 2.5) (CDC, 2021[5]).
Note: Brazil data is based on estimates.
Source: OECD Health Statistics 2023, and Peru’s submission to the 2024 OECD Health Statistics Questionnaire.
Source: CDC (2021[5]), Análisis de Situación de Salud (ASIS) 2021.
The high prevalence of anaemia remains a major public health concern in Peru
Anaemia remains one of the largest and longest standing public health concerns in the country, primarily stemming from malnutrition, due to either an insufficient or imbalanced diet lacking iron. As of 2023, on average, 43% of children aged between 6 and 35 months suffered from anaemia (Figure 2.6). There are significant differences in prevalence between urban (at 40%) and rural areas (at 50%), as well as between regions. In 2022, Puno had the highest prevalence of anaemia (at 67% of children aged 6‑35 months), well above the prevalence in Moquegua (at 28%) (Figure 2.7). Peru has pursued several strategies to address this issue including the Multisectoral Plan to Fight Anaemia, the National Plan for the Reduction and Control of Maternal and Child Malnutrition 2017‑21 and more recent strategies such as “Niños de hierro” and “Cuna Más con punche contra la anemia” from the Ministry of Health (MINSA) and the Ministry of Social Development (MIDIS), respectively.
In 2021, chronic malnutrition affected 11.5% of children under the age of five, decreasing from 13.1% in 2016. By area of residence, chronic malnutrition affected girls and boys residing in rural areas significantly more (24.4%) than those in urban areas (6.8%) (INEI, 2021[6]).
Note: Data for 2023 is from a press release as ENDES 2023 dataset was not yet publicly available at the time.
Source: Elaboration using data from the Demography and Family Health Survey (ENDES) 2022 and 2023.
Source: ENDES, 2022.
The impact of COVID‑19 on population health has been dramatically high
In 2021 the leading causes of death were COVID‑19 (35.7%), followed by cardiovascular diseases (16%), cancers (12.3%), and infectious and parasitic diseases other than COVID‑19 (10.1%) (Figure 2.8).
Source: MINSA (2021[7]), Repositorio Único Nacional de Información en Salud, www.minsa.gob.pe/reunis/data/tasas_mortalidad.asp and CDC (2021[5]), Análisis de Situación de Salud (ASIS) 2021, Centro Nacional de Epidemiología, Prevención y Control de Enfermedades (CDC) del Ministerio de Salud, www.gob.pe/institucion/ensap/informes-publicaciones/4509305-analisis-de-situacion-de-salud-asis-2021 (accessed on 21 February 2024).
Excess mortality provides a more complete understanding of the impact of COVID‑19 across countries, as it is unaffected by country-specific variations in the recording of COVID‑19‑specific deaths, and accounts for both deaths directly attributable to COVID‑19 and deaths indirectly linked to the virus. Peru had the highest yearly excess mortality in 2020 and 2021 among comparable Latin American countries, with an average of 437 excess deaths per 100 000 population, almost four times as high as the OECD average of 114 excess deaths per 100 000 population (Figure 2.9). Other key metrics, such as life expectancy, maternal mortality and access to preventive services also worsened during the pandemic. For example, life expectancy in Peru decreased by 3.8 years (compared to 0.7 years on average across the OECD) between 2019 and 2021, while maternal mortality increased by 55% over the same period.
Source: WHO (2022[8]), Global excess deaths associated with COVID‑19 (modelled estimates).
The share of population aged over 65 is increasing
Although Peru has a relatively young population compared to OECD countries, the share of the population aged 65 and over is expected to increase from 8.4% in 2022 to 17.4% in 2050, while the share of those aged 80 and over is expected to increase from 1.6 in 2022 to 4.8 in 2050. These rates are very much on par with the demographic projections for other LAC countries (Figure 2.10).
Source: OECD Health Statistics 2021 and UN World Population Prospects 2022.
A large number of premature deaths could be avoided, notably through more effective public health policies
Peru has high levels of preventable and treatable mortality. Figure 2.11 presents two different indicators of avoidable mortality, the left panel presents preventable mortality and shows that after Mexico, Peru has the second highest rate of preventable mortality, more than two times the OECD average. This indicates that in Peru, much more people are dying from diseases that could have been prevented through effective public health and prevention interventions to control the wider determinants of health, such as lifestyle or environmental factors. The right panel presents amenable mortality, which are the proportion of deaths that could have been avoided through better quality care, including better secondary prevention and treatment. Peru has 24% higher amenable mortality (at 98 per 100 000 population) than the OECD average (at 80 per 100 000 population).
1. Most recent data point corresponds to 2016‑19.
Note: LAC average is calculated from the seven countries present in the graph.
Source: OECD Health Statistics 2023, based on WHO Mortality Database.
Some risk factors for chronic conditions are increasing in Peru. While the prevalence of smoking is amongst the eight lowest among OECD countries and has decreased from 16.5% in 2010 to 9.5% in 2022, alcohol consumption increased slightly from 5.2 in 2010 to 5.7 in 2019, as opposed to most OECD countries where it fell during the same period. However, consumption levels of alcohol in Peru are still low compared to the average among OECD countries (8.6 Litres per person).
Obesity levels in Peru are well above the OECD average, and the share of the Peruvian adult population with obesity has more than doubled over the past two decades, from 12.0% in 2000 to 25.6% in 2022 (29.8% among women and 21.2% among men) (Figure 2.12). For the younger population, UNICEF has reported that obesity affects 16% and 5.5% of children aged 6‑13 and adolescents aged 12‑17, respectively. Additionally, it is predicted that by 2030, 16.1% of children between the ages of 5‑9 will suffer from obesity (UNICEF, 2023[9]). Targeted public health policies require further strengthening to promote healthier lifestyles and reduce obesity and overweight population rates, especially in Metropolitan Lima and other urban areas which show much higher prevalence than rural areas (Figure 2.13) (CDC, 2021[5]).
Source: Peru’s submission to the 2024 OECD Health Statistics Questionnaire.
Source: CDC (2021[5]), Análisis de Situación de Salud (ASIS) 2021, Centro Nacional de Epidemiología, Prevención y Control de Enfermedades (CDC) del Ministerio de Salud, www.gob.pe/institucion/ensap/informes-publicaciones/4509305-analisis-de-situacion-de-salud-asis-2021 (accessed on 21 February 2024).
In 2017, it was evaluated that most of the risk factors that generate the greatest burden of disease are modifiable, such as malnutrition, high body mass index, dietary risks, high fasting glucose and high systolic pressure, alcohol consumption, air pollution, tobacco, among others. The main challenge is to implement multisectoral policies to control the social determinants of health, so that all sectors (from housing to education) have an active participation in the reduction of communicable and non-communicable diseases.
The share of the population aged 15 and over with a diabetes mellitus diagnosis has increased from 3.3% in 2017 to 5.1% in 2022. Moreover, from 2020 to 2022 there was a slight increase from 39.9% to 40.6% in the share of Peruvians aged 15 and over with at least one chronic condition (obesity, diabetes mellitus or hypertension).The prevalence of people living with chronic conditions was significantly higher in urban areas (42.9%) than in rural (30.5%), and affected women (42.7%) more than men (38.3%) (INEI, 2022[10]).
Mental health disorders are the second leading cause of disability in Peru, but there has been remarkable progress in the provision of community mental health services
According to the 2019 Burden of Disease study conducted by the Centro Nacional de Epidemiología, Prevención y Control de Enfermedades, mental and behavioural disorders are the second leading cause of disease. Peru had 17.7 disability adjusted life years (DALYs) for mental health disorders per 1 000 population in 2019 (MINSA, 2019[11]). For young and adult population, anxiety, depression, self-harm and somatic symptoms are the most common mental health disorders (accounting for 38% of mental health disorders), followed by headaches (23%), substance use disorders (16%, with alcohol use disorders accounting for 10%), and schizophrenia and bipolar disorder (10%) (PAHO, 2023[12]). However, in 2021, the number of deaths by suicide (2.73 deaths per 100 000 population) was well below the OECD average of 9.9 deaths per 100 000 population.
Peru initiated a mental health reform in 2012 with the approval of Law N° 29 889, to implement a new mental health care model at community level, shifting away from the historical, more hospital-centric, model that was marked by large inequalities in access to treatment (Toyama et al., 2017[13]). This led to the inclusion of mental health care within the public universal health insurance plan and the creation of a results-based budget programme in 2014 (“Budget Programme 0 131. Control and Prevention of Mental Health”) which through a set of interventions made it possible to sustain and channel funding to install new services, expanding community mental health provision across the country (Toyama et al., 2017[13]; PAHO, 2023[12]). More recently, the adoption of the Mental Health Law in 2019 (Law N° 30947) established a comprehensive legal framework to ensure the right to health and well-being through access to promotion, prevention, treatment and rehabilitation services for mental health. The law emphasises the importance of integrating mental health services into the general healthcare system, promoting community-based care, and ensuring that the rights and dignity of those with mental health issues are respected (see Box 2.1). Overall, annual funding for mental health grew by 223% (in nominal terms) in the years 2015 to 2022 (decreasing by 0.8% in 2021 due to the prioritisation of other interventions during the COVID‑19 pandemic). The share of public health sector budget allocated to mental health increased from 1.4% in 2015 to 2.6% in 2023. This has resulted in an expansion of community-based mental health services between 2015 to 2022 (Table 2.1). This is the result of co‑ordinated efforts between MINSA, regional governments and hospitals, together with local governments, community and local organisations (PAHO, 2023[12]), leading to the creation of new mental health services, such as community mental health centres, inpatient mental health and addiction units in general hospitals, sheltered homes, and residences. Figure 2.14 shows the increasing role that community mental health centres (CSMC) have had in the provision of mental health services, treating around 24% of mental health disorders in health facilities belonging to MINSA and regional governments (GOREs) in 2021.
Additional achievements from the mental health reform include an increase in mental health care coverage, with the number of mental health cases treated more than doubling from around 719 000 in 2014 to 1.6 million in 2022; an expansion in the list of publicly covered medicines suitable for treating mental health conditions (from 1 to 20), and improved training for health workers in mental health promotion, prevention, and recovery (Carrillo-Larco et al., 2022[14]; PAHO, 2023[12]). The number of psychologists in MINSA and GOREs facilities increased from 5.5 per 100 000 inhabitants in 2015 to 17.4 in 2022, a figure that is above the rate for the region of the Americas (5.4 per 100 000) (PAHO, 2023[12]). By the end of 2022, of the 1 270 psychiatrists registered with the Peruvian Medical Association, 669 were working in a health facility belonging to MINSA, Regional Health Directorates (Dirección Regional de Salud – DIRESA) or Regional Health Management (Gerencia Regional de Salud – GERESA), an increase of 60.5% compared to 2019.
Source: PAHO (2023[12]), Avances y desafíos de la reforma de salud mental en el Perú en el último decenio, https://iris.paho.org/handle/10665.2/58312 (accessed on 15 April 2024).
The mental health reform also led to updating the system for coding and recording interventions, implementing a platform for monitoring activities and indicators, and developing the mental health module of the electronic medical record with the support of MINSA’s General Office of Information Technology (OGTI). Additionally, the Centro Nacional de Epidemiología, Prevención y Control de Enfermedades has launched sentinel epidemiological surveillance of prioritised mental health problems, while the first National Specialised Mental Health Survey (ENESM) is being carried out by the Honorio Delgado-Hideyo Noguchi National Institute of Mental Health (INSM HD-HN) (PAHO, 2023[12]).
Despite these major achievements, there are still significant gaps that need to be addressed in the availability of mental health services across regions. As shown in Figure 2.15, the share of the population with mental health disorders that received care varies from 9.8% in Loreto (in the Amazonia) to 80.9% in the region of Callao (in the Lima metropolitan area), with an average of 27.6% for the country as a whole. In addition, professional training is still based on a biomedical and hospital-centric model, with difficulties to incorporate community-based approaches in the deployment of clinical, psychosocial and management interventions (PAHO, 2023[12]).
Note: Covers MINSA and GOREs health facilities.
Source: PAHO (2023[12]), Avances y desafíos de la reforma de salud mental en el Perú en el último decenio, https://iris.paho.org/handle/10665.2/58312 (accessed on 15 April 2024).
Source: PAHO (2023[12]), Avances y desafíos de la reforma de salud mental en el Perú en el último decenio, https://iris.paho.org/handle/10665.2/58312 (accessed on 15 April 2024).
The implementation of the Mental Health Law in 2019 emphasised five key priority areas:
1. Access: The law aimed to improve access to mental health services by integrating them into the general healthcare system, making it easier for individuals to receive care within their community rather than through specialised hospitals. The overarching objective is to reduce stigma and barriers to access.
2. Community-based Care: The law aimed at developing mental health services that are closer to where people live, work and study to better provide early intervention, prevention, and continuous support for individuals with mental health conditions and their families.
3. Rights and Dignity of Patients: A strong emphasis is placed on respecting the rights and dignity of individuals with mental health conditions, ensuring they are treated with respect and without discrimination. This includes the right to informed consent, the right to be involved in treatment decisions, and the protection of their privacy and autonomy.
4. Prevention and Promotion: Mental health promotion and the prevention of mental health disorders is at the core of the Mental Health Law. It called for public policies and programmes to tackle the social determinants of mental health, such as education, employment, housing, and social inclusion.
5. Intersectoral Approach: Given the wide range of determinants affecting mental health, the law promotes an intersectoral approach involving various sectors such as health, education, labour, and social welfare, to address the comprehensive needs of individuals and encourage integration into society.
Source: Carrillo-Larco, R. et al. (2022[14]), “Peru − Progress in health and sciences in 200 years of independance”, The Lancet Regional Health – Americas, Vol. 7/100 148, https://doi.org/10.1016/j.lana.2021.100148.
The National Multisectoral Health Policy 2030 aims at improving healthcare and addressing social determinants of health
The National Multisectoral Health Policy 2030 (PNMS) called “Peru, Healthy Country” is a comprehensive policy led by the Ministry of Health, and developed in consensus with various sectors, regional and local governments, focusing on social determinants of health and strategic interventions across the lifespan. It combines a territorial and a Health in All Policies approach. The Plan has three priority objectives:
1. Improve the population’s healthy habits, behaviours and lifestyles.
2. Ensure that the population has access to quality, timely and comprehensive health services.
3. Improve the living conditions of the population that create vulnerability.
By the year 2030, the PNMS seeks to reduce disability adjusted life years by 5% and reducing years of life lost due to premature mortality and disability. The multi-sectorial plan focuses on 15 national health priorities, including the progressive implementation of Integrated Health Networks; the promotion of telemedicine services to support Integrated Health Networks and facilitate access to care. Other health priorities include addressing public health challenges such as anaemia, chronic child malnutrition, maternal and neonatal mortality, metaxenic diseases (malaria, dengue, chikungunya), cancer, overweight and obesity and mental health disorders, among others.
The PNMS 2030 Multisectoral Strategic Plan defines multisectoral actions undertaken by 16 participating sectors that are relevant actors for health interventions and for addressing the social determinants of health. Progress in the implementation of the PNMS 2030 is monitored through the national monitoring system administered by the National Strategic Planning System (SINAPLAN). This entails the production of monitoring and compliance reports on the implementation of the PNMS 2030 and implementation plans.
The health system in Peru is decentralised and segmented
There are various stakeholders within the Peruvian healthcare system. The Ministry of Health (MINSA) is the governing body of the health system, having the mandate to formulate, define, co‑ordinate, execute, supervise, and evaluate the set of policies and services linked to the health sector. The implementation of national policies and programmes and the execution of activities are carried out by eight health sub-systems (MINSA, Regional Governments, the social health insurance EsSalud, Armed Forces Health, National Police of Peru, Local Governments, the National Penitentiary Institute from the Ministry of Justice and the nonprofit and for-profit private sector). Some functions are also transferred to the regional government of the special regime of the metropolitan area of Lima.
The health sector has a territorial approach to manage the organisation of health promotion, prevention, recovery and rehabilitation through the Integrated Health Network Directorates (DIRIS) in the metropolitan area of Lima, and the Regional Health Directorates (DIRESA) and Regional Health Managers (GERESA) at the regional level, whose functions are to direct, execute, control and manage resources to implement health sector policies in their region in accordance with national policies and sectoral plans.
MINSA, as the directing and co‑ordinating authority in the public health sector, is also responsible for enforcing compliance with the regulatory framework and monitoring performance and achievements at national, regional and local levels, being allowed to directly intervene and take corrective actions while also providing technical support for the proper execution of decentralised functions. MINSA is also responsible for the co‑ordination between regional and local governments in the implementation of national and sectoral policies and evaluating their compliance. MINSA elects the head of the regional health directorates (Dirección Regional de Salud – DIRESA) and local hospitals.
Furthermore, the National Superintendence of Health (SUSALUD), a governing body part of the Ministry of Health, is responsible for authorising, controlling, and supervising the good performance of the health system. SUSALUD was created with the mission of promoting, protecting and defending the health rights of the Peruvian population, and ensuring that healthcare services are timely, equitable, safe, and of good quality. It oversees and registers provider institutions (Institutiones Prestadoras de Servicios de Salud, IPRESS), as well as the different insurance funds (Instituciones administradoras de fondos de aseguramiento en salud, IAFAS). SUSALUD regulates the collection, transfer, dissemination and exchange of information generated or achieved by the IAFAS, IPRESS and IPRESS Management Units; as well as promotes conciliation mechanisms for the resolution of conflicts between the different stakeholders of the health system.
The regional governments are competent to promote and regulate activities and/or services in agriculture, fisheries, industry, agribusiness, commerce, tourism, energy, mining, roads, communications, education, health and the environment, in accordance with the law; but they also have shared competencies in public health. Regional governments as governing bodies have political and economic autonomy, being responsible for implementing regional health policies in accordance with national health policies. They are in charge of health service provision (with the exception of facilities located in the metropolitan region of Lima, which include those managed by the Ministry of Health and all national specialised hospitals in the country), and for organising the delivery of public health services in co‑ordination with the local governments. Regional governments also manage the regional hospitals, most of the health centres and health posts. Local governments are responsible for executing health promotion and prevention campaigns in their communities. It is recognised that still many regional governments have insufficient capacity to implement national health policies and achieve targets.
In addition to its decentralised nature, the health system in Peru is highly segmented, with multiple health insurances. Compared to many other OECD countries, health insurance is composed of several sub-systems:
The public insurer called the Integral Health Insurance (Seguro Integral de Salud, SIS) covers around 62% of the population as of 2023, mainly poor individuals, vulnerable groups, entrepreneurs and self-employed workers. It provides free healthcare services for certain health conditions established in the Essential Health Insurance Plan (PEAS) and is primarily financed by general taxation. There are two insurance schemes within SIS: the subsidised regime which provides fully subsidised healthcare (SIS Gratuito, SIS Para Todos) and the semi-contributory regime who are required to pay an enrolment fee (SIS Emprendedor, SIS Micro‑empresas, SIS Independiente). SIS is an independent public institution under MINSA governance.
The social health insurance, which is a contributory system, called Seguro Social de Salud (EsSalud), provides healthcare, but also pension and welfare coverage. It is an independent public institution managed by the Ministry of Labour and Employment Promotion. It covers around 26% of the population, all salaried formal workers and their family. It is financed exclusively by labour charges (9% payroll tax contribution).
Healthcare provider entities (EPS) which are private health insurers that complement EsSalud. They are private companies that offer coverage to EsSalud affiliates to opt out of EsSalud’s network and use private health providers. They are financed by EsSalud contribution from formal workers who decide to opt-out of EsSalud’s network, and charge premiums, co-payments, deductibles and financial caps. It is held by around 8% of the population.
Other private supplementary healthcare providers, which are contributory systems targeting higher-income groups, with voluntary private health insurance based on ability to pay. They charge premiums, co-payments, deductibles and financial caps.
The armed forces and national police have also their own closed sub-systems, which are financed through budgets derived from the Ministry of Defence and the Ministry of Home Affairs (Police) respectively.
Each regime replicates fundamental health care system activities with separated governance structures, and with separated financing, service delivery mechanisms and working with their own healthcare providers. Not only does each regime have their own funds, resulting in no risk pooling between them, but they are also managed by different ministries: the SIS budget is managed by the Ministry of Economy and Finance (MEF), the EsSalud budget by the Ministry of Labour and Employment Promotion (financed by contributions from public and private employers, with budgetary autonomy under the National Fund for the Financing of State Entrepreneurial Activity – FONAFE)1, and the budgets of the army and police sub-systems are financed by the Ministries of Defence and Home Affairs, respectively.
In Peru, the budgeting process is rather complex and mainly based on historical spending. Budgeting is divided into budgetary units (pliegos). Though there are five budgetary units at the national level in the health sector, which include the Ministry of Health, the National Superintendence of Health (SUSALUD), the Integral Health Insurance (SIS), the National Institute of Health and the National Cancer Institute (INEN), each regional government (GORE) is also a budgetary unit. The resources of each pliego are in turn managed by executing units (unidades ejecutoras, UE), which may include entire networks of health facilities as well as individual hospitals.
At the primary care level (also called first level of care), SIS agrees with regional governments on capitation-based transfers to the executing units, while for secondary and tertiary levels (second and third levels of care), transfers are based on a combination of fee‑for-service, add-on payments and payments for packages of services. SIS pays its network of providers for variable costs only (such as procedures, medicines, and supplies), while capital (infrastructure and equipment) and human resources are covered by regional authorities through other budget lines. Budget execution by regional executing units is difficult, due to both the complexity of budgetary regulations and insufficient planning and management capacity at that level of government.
Other organisational and financial arrangements undermine effective governance from the part of the Ministry of Health. For example, there is a strong focus on highly vertical programme budgeting, a legacy of a disease‑focused financing system which may not be suitable for a long-term integrated strategy. In fact, such a fragmentary approach has led to challenges in tracking spending towards the minimum benefit package (PEAS), which is split into different programmes or budgetary allocations (WHO, 2020[15]). In addition, it is reported that there is unequal allocation of resources across budget programmes which do not reflect evolving healthcare needs in Peru.
As each sub-system has and operates its own provider network, the regimes provide services that differ significantly, resulting in inequities. The Ministry of Health and the GORES have an extensive network of primary healthcare centres (first level of care), which is the main network from SIS health services but infrastructure and equipment are found inadequate. For example, 42% of primary healthcare facilities in the country belong to the SIS network, while only 1.5% belong to the EsSalud network (Figure 2.16). However, the latest evaluation from the MINSA indicates that in virtually all Peruvian regions (25 regions out of 26), more than 90% of SIS primary care facilities are precarious, obsolete, inoperative or with insufficient equipment. EsSalud has a better provision of more complex healthcare interventions.
In 2006, to strengthen the provision of services, SIS insurance fund and EsSalud signed an Interinstitutional Co‑operation Framework Agreement, establishing guidelines for the use of benefit exchange agreements (intercambio de prestaciones, IP) and constituting a step towards addressing institutional fragmentation between the two largest national health networks (MINSA, 2006[16]). Through IPs – signed between the relevant IAFAS and regional governments and setting out the payment mechanisms (regulated by Supreme Decree No. 006‑2020‑SA), benefits, and obligations regarding service provision – it is possible for affiliates of either SIS or EsSalud to access health services offered by the network to which they are not affiliated. The overarching objective is to expand coverage and efficiently allocate resources at the national level. In 2012, complementary provisions were made for IPs between SIS and EsSalud through the Supreme Decree No. 005‑2012‑TR, with the subsequent signing of 27 IPs on the same year. In 2019, Legislative Degree No. 1302 was passed with the aim of regularising the IP process and, during the COVID‑19 pandemic, the Legislative Decree No. 1466 was issued to facilitate the exchange of services and allow adequate provision of preventive and curative services to all COVID‑19 patients. As of 2024, a total of 74 IPs have been signed between regional governments and the different IAFAS.
However, the extent to which these mechanisms are being used is still very limited, mainly due to lengthy negotiations about the definition of a common tariffs and standards of service for a large set of procedures, which stifles implementation of service exchanges. An exception to this being the Legislative Decrees No. 1302 and 1466 which facilitated the exchange of services and allowed adequate provision of preventive and curative services to all COVID‑19 patients regardless of affiliation. Although these were successful initiatives to further promote exchanges of services across sub-systems, they are no longer in force.
Note: Most of the IPRESS under “No category” correspond to active Level I facilities, clinics and private medical support centres, which for various reasons have not yet been assigned a category.
Source: RENIPRESS – SUSALUD as of 23 February 2024, www.minsa.gob.pe/reunis/data/Monitoreo_Sistema_HISMINSA.asp.
Note: MINSA (Ministry of Health); SUSALUD (National Superintendence of Health); SBS (Banking and Insurance Superintendence); MINDEF (Ministry of Defense); MINTERIOR (Ministry of the Interior) FISSAL (Intangible Health Solidarity Fund); IAFAS (Administrative institution of Health Insurance Fund); FFAA (Armed Forces); EPS (Healthcare Provider Entities), SIS (Comprehensive Health Insurance scheme), EsSalud (Social Health Insurance of Peru).
Source: Videnza Consultores (2021[17]), The Peruvian health system, https://doi.org/10.6084/m9.figshare.14977839.v1.
Source: OECD Secretariat based on Peru’s responses to Accession Review Health Policy Questionnaire.
The limited co‑ordination between sub-regimes leads to inefficient allocation of the country’s health resources
Healthcare services are provided through Institutions of Health Services Provision (IPRESS). There are public, private and mixed IPRESS, and they are under the supervision of SUSALUD. IPRESS are organised into three levels of care: the first level ranges from basic service posts (I‑1) to maternal and child health centres offering 24‑hour care and regular deliveries (I‑4). The second level of care includes hospitals with specialties and basic services (delivery, surgery, diagnostic imaging, pathology, blood banks, rehabilitation and hospitalisation). At the third level are hospitals with a higher concentration of technology, services in all medical specialties and some sub-specialties. In addition, the third level includes the treatment of cancer and other complex diseases (radiotherapy, haemodialysis).
There is an inefficient allocation of the country’s health resources, with some duplication of healthcare supply in some areas, while other areas face the challenge of no supply of healthcare services. As mentioned in the previous section, SIS has the largest network of primary healthcare facilities, with 42% of primary healthcare facilities providing services to SIS affiliates (compared to 1.5% belonging to EsSalud network). There is also unequal distribution of resources across regions, with primary healthcare services concentrated in rural areas and hospital services concentrated in urban areas. In Lima and Callao regions (metropolitan areas of Lima), there is less than one primary healthcare facility per 10 000 population, compared to over nearly 12 in Amazonas and Huancavelica region (Figure 2.19). The uneven allocation of health facilities across sub-regimes and regions translates into limited referral systems and weak co‑ordination across service levels. Within EsSalud network, for example, evidence shows that 40% of users are ascribed to a hospital as their first point of contact with the health system because of a lack of primary healthcare facilities. This is also confirmed by the 2022 ENAHO survey, which shows that while there are 8 820 public primary care centres in the country, only 30% went to a MINSA primary health centre when they perceived a health need, and 2% sought care in an EsSalud primary healthcare centre (Figure 2.18).
Note: Respondents were allowed to choose multiple options.
Source: National Household Survey (ENAHO) 2022.
Source: INEI (2023[18]), Situación de la Población Peruana: Una mirada hacia los jóvenes 2023, as of 26 February 2024.
A recent analysis of health facilities productivity also suggests that when taking into account the resources allocated to each level of care, there are large gap in productivity level between level I, II and III facilities. Accordingly, level I is more productive than level II, and level II is more productive than level III. On average, level I produces 8.1 visits per assigned medical or dental staff, while level II produces 3.5 visits, and level III produces 1.7 visits (World Bank, 2021[19]). While 80% of level I facilities have medical staff producing more than 5 visits per day, 30% of level III facilities produce less than 1 visit per day. The productivity gap between levels of care suggests that there is room for improving the allocation of resources within the Peruvian Health System.
Patient engagement is supported by the National Health Council and the National Health Superintendence
Patient participation is effective in decision-making and policy formulation through the National Health Council (CNS), a consultative body of the Ministry of Health and of the National Co‑ordinated and Decentralised Health System (SNCDS). The CNS is the national space for dialogue and co‑ordination to achieve national health priorities.
In addition, SUSALUD aims to protect and guarantee people’s right to high-quality, timely, and readily available healthcare. It is the main agency responsible for patient engagement and handling complaints. SUSALUD carries out regular surveys, including the ENSUSALUD, and undertake several patient engagement initiatives through in-hospital representatives and health literacy initiatives. ENSUSALUD, for example, evaluates the degree of satisfaction of users receiving healthcare services in 24 regions from all healthcare providers (SIS, EsSalud, military/police forces and private providers). The survey is a very good tool to make comparison of performance indicators of healthcare services in different regions and different sub-systems; on key indicators including accessibility of hospitals, quality of consultations, waiting time data by type of insurance scheme or type of provider.
SUSALUD has also developed user groups (called Juntas de Usuarios, JUS) to promote patient’s empowerment to drive improvement in healthcare quality and ensure patient’s rights and duties are respected in the Peruvian health system. JUS are embedded in hospitals to encourage patients to share their views, concerns and reflections on healthcare services, and work with other patient interest groups. They promote citizen participation in health, promoting accountability and safeguarding the exercise of health rights at all levels of care. To date, 22 JUS have been created in Amazonas, Arequipa, Ayacucho, Apurímac, Cajamarca, Callao, Cusco, Huánuco, Junín, Lambayeque, La Libertad, Loreto, San Martín, Piura, Puno, Ucayali, Tumbes and Lima.
Patients’ complaints and denunciations of inadequate medical practice are also collected by SUSALUD as a way to promote patient empowerment. Table 2.3 shows that the number of enquiries and complaints submitted to SUSALUD has grown by 71% in the period between 2018 and 2022, increasing from 83 768 to 143 125. In 2022, the most frequent categories of complaints related to difficulties in accessing health services (28.6%) and access to information (27.2%). Around 22% of these complaints were related to difficulties in accessing medicines and health products, and 22.7% were related to not receiving necessary or sufficient information (SUSALUD, 2022[20]).
Source: SUSALUD (2022[20]), Anuario Estadístico 2022, Superintendencia Nacional de Salud, https://cdn.www.gob.pe/uploads/document/file/4873728/ANUARIO%20ESTADISTICO%20SUSALUD%202022.pdf?v=1689889186 (accessed on 29 March 2024).
Patient engagement is also made possible through various civil society organisations (NGOs, professional associations, academics, popular and grassroots organisations, etc.) which are effective in encouraging expression of patients’ views on health services with a focus on social justice, equity and equality.
Peru has a large amount of digital health data, but the health information infrastructure is siloed
MINSA has overall responsibility for the management and organisation of the national health information system. It is responsible for the strategic planning, administrative support, development, integration and operation of health information. MINSA is responsible for a number of information systems, including System for vital facts (Sistema de hechos vitales), System for disability (Sistema de discapacidad), Integrated system for emergency services (Sistema integrado de egresos de emergencia), Geographic information system (Sistema de información geográfica), and HIS-MINSA (Sistema de Información de Salud).
By Ministerial Resolution (No. 780‑2015‑MINSA), The HIS-MINSA (Sistema de Información de Salud) is the main information system for collecting and reporting health and healthcare activities. It is a mandatory reporting system used in all first, second and third levels of care for facilities under the authority of the Ministry of Health and regional governments. It records healthcare activities around health promotion, prevention, vaccination services, prenatal and childcare, and allows to perform epidemiological surveillance. It can be processed and consulted by health professionals. In addition, for second and tertiary levels of care (hospitals and specialised hospitals), specific systems are used for hospital management, such as SIS-GALENPLUS, the Hospital Management System, or other developed locally or acquired systems by hospitals themselves. These hospital systems record information on resources, processes and activities such as bed management, scheduling surgeries, outpatient appointments and prescribing. SIS-GALENPLUS currently operates in 62 hospitals under MINSA and Regional Governments.
The Integral Health Insurance (SIS) also generates a significant volume of health data because each IPRESS facility completes a standard digital form (Formato Único de Atención, FUA) to report on administrative information, diagnostics, consultation or surgery on a dedicated software called “ARFSISWEB”. The FUA is completed on a monthly basis, and the digital files are sent to the regional levels in the Health Directorates which, after quality control, are transmitted to MINSA’s General Office of Statistics and Informatics (OGEI) to ensure that public health facilities send the necessary information. MINSA used it for validation of services during audits or for payment purposes. The SIS and HIS MINSA data are made accessible to the public through the National Platform of Open Data (Plataforma Nacional de Datos Abiertos), which is an open data platform. In 2024, 96 datasets were published on the national Open Data Platform, including for the health sector, education, social development among other sectors. For the health sector, the data focused on the number of SIS affiliation, care provided to SIS affiliates, health coverage for cancer care, chronic kidney diseases, and rare diseases.
However, HIS MINSA or the Plataforma Nacional de Datos Abiertos provide only a partial view of the national picture as the various sub-systems (EsSalud, the health systems of the military and police force, as well as the private health sector) also have their own information systems and collect their own indicators with different timeliness coding practices and coverage. Health information systems were developed in siloes, hindering integration of information and patient tracking through the health system. The lack of interoperability hinders resource management and decision-making.
Apart from MINSA, other national institutions, such as the National Statistics and Informatics Institute (Instituto Nacional de Estadística e Informática, INEI) and the National Health Institute (Instituto Nacional de Salud, INS) play an important role in the collection and dissemination of national health information in Peru. INEI is a crucial institution for the Peruvian health information system, responsible for producing statistical information on demographic and vital health statistics and household’s questionnaire. Among the most important sources are the National Household Survey on Life Conditions and Poverty (ENAHO), the Demography and Family Health Survey (ENDES) and the National Healthcare User Satisfaction Survey carried-out in conjunction with SUSALUD (ENSUSALUD). INS which is responsible for the regulation, promotion, and diffusion of public health research, collects data around food, nutrition and diseases surveillance. SUSALUD also manages a wide range of health information from health providers and insurance funds. These include health resources, ambulatory care, emergencies, surgeries, and births from both public and private institutions through SETI-IPRESS administrative system. The information is made accessible to the wider public in a user-friendly way.
Overall, the health information system has been widely developed over the past decades and Peru generates a large amount of digital health data. However, mirroring its health system, the health information infrastructure is siloed and suffers from limited co‑ordination between the different sub-systems. This makes it inherently difficult to undertake comprehensive analysis of system performance, to provide sound comparisons of performance across providers, and to compare different population segments. As mentioned in the following section, Peru is working on a unified national health data system (called REUNIS) to be able to report a core set of information across all sub-systems. This is an excellent initiative.
Data reporting in Peru is more limited than in current OECD Member countries
Peru’s capacity to share internationally comparable data on health is still more limited compared to current OECD Member countries. There are several gaps in data availability and reporting between Peru and OECD Member countries. In April 2024, Peru submitted data on health spending, health status, healthcare activities and healthcare quality indicators in line with the OECD frameworks. However, some increased effort would still be needed to ensure greater reporting and comparability of the data according to OECD standards. For example, Peru relies on survey data and reports life expectancy for 5‑year blocks while most other countries rely on demographic statistics from life tables. Peru was however able to report on maternal and infant mortality, and on risk factors for health. For the Joint Non-Monetary Healthcare Activities Questionnaire and the Joint Health Accounts Questionnaire, Peru submitted data on hospital resources and activities as well as health spending by financing schemes and source of revenue respectively, even though key information is still missing on health employment, workforce migration, and health spending by type of services and providers. Many OECD LAC countries have started with the same limitations and have gradually expanded the scope of their data submission. There are also issues related to the Healthcare Quality and Outcomes questionnaires. Peru submitted data on avoidable admissions, acute care, patient experience and long-term care, but for now many of the reported indicators do not cover the whole healthcare system, making international comparison difficult. In addition, there is no data available on five‑year cancer survival rates, prescribing in primary care and mental health care.
In addition, the focus of the health information infrastructure has been on resources, service coverage and activities. Current data collection on care quality is mainly based on population surveys to assess the perceived quality of healthcare, notably through the ENAHO, ENDES and ENSUSALUD surveys. While these are insightful instruments, Peru also needs to rely on administrative data to measure care quality. Quality aspects need to be incorporated into national monitoring of the health system to support clinical improvements of medical effectiveness and patient safety. If Peru wants to achieve more uniformity in its health system, and mitigate its fragmentation, efforts should be made to ensure that services are delivered with a high and equally distributed degree of quality across all insurance sub-systems. Consistent with the OECD framework for healthcare quality indicators, Peru should collect and report regularly on overall volume of antibiotics prescribed in primary healthcare or patient safety indicators for example.
Due to the fragmentation of health information system, data reporting is still incomplete. Administrative data used to construct some quality indicators is only collected from public institutions which lead to both underestimations and inaccuracies of performance level. To report valid quality indicators, Peru needs to collect data from all sub-systems in a standardised way to get a comprehensive picture of system performance at the national level and improve international comparability.
To collect and report on quality indicators, Peru will have to address issues with coding practices for principal and secondary diagnoses, and with linking data across information systems. The OGTI reported that coding of secondary diagnoses is recorded mainly by public health facilities, while only the principal diagnosis is recorded by other health facilities. Coding practices also vary according to the geographic region, mainly due to heterogeneity in training of health workers performing the coding. On linking databases, good examples exist with linking census data with outpatient database to monitor anaemia in children. However, other attempts to link hospital databases to monitor healthcare utilisation and care quality failed due to invalid unique patient identifiers.
The use of Electronic Health Records (EHR) has been promoted since 2017 through several regulations and ministerial resolutions (Ministerial Resolution N° 1344‑2018/MINSA; N°214‑2018/MINSA; N° 618‑2019‑MINSA, N° 816‑2020/MINSA; N°356‑2022/MINSA and No. 080‑2022‑MINSA). The SIHCE (Electronic Health Record Information System) developed by MINSA is being deployed in primary care facilities thanks to the successful implementation of a unique patient identifier in the first level of care. So far, 4 354 IPRESS of MINSA and GOREs have been using the SIHCE. In hospitals and specialised hospitals, different information systems are used. EsSalud also uses its own medical record in its general hospitals, polyclinics, and specialised facilities. The Health Services Management System is called EsSI (Servicio de Salud Inteligente) which includes comprehensive information ranging from auxiliary tests, diagnoses, prescriptions, and treatments. Accordingly, around 400 EsSalud health facilities are using EsSI since 2019. Peru needs to continue efforts in nationally implementing Electronic Health Records (EHR), that facilitates interoperability across SIS, EsSalud and other sub-systems. A close co‑ordination will be required to facilitate linkages of information.
The Digital Agenda for the Health Sector 2020‑25 aims to further develop the National Health Information System
Peru has launched an ambitious digital health strategy to leverage the potential of digital health data, EHR and telemedicine. The Digital Agenda for Health 2020‑25 is a strategic framework to guide the digital transformation of the health sector over a five‑year period. This agenda is part of a broader effort to modernise the country’s health system, improve the quality of health services and make them more accessible to the population, especially in remote and underserved areas. The 2021 Budget Law (Law No. 31084) granted an amount of PEN 150 million to finance the strengthening of electronic medical history, electronic prescription telemedicine and telemedicine at the national level. In addition, the 2022 Budget Law granted PEN 90 million to finance the integration of Health Information Systems and the implementation of Electronic Medical Records, Electronic Prescription and Telehealth at the national level.
The Digital Agenda focuses on six strategic areas:
1. Introduction of EHRs: Establish a unified and interoperable system of EHR that can be accessed across different levels of healthcare facilities.
2. Telemedicine and digital health services: Promote the expansion of telemedicine services to improve access to healthcare for people living in remote areas. This includes the use of digital platforms for medical consultations, follow-up and remote diagnostics, minimising the need for physical travel to healthcare facilities.
3. Health information systems: Strengthen health information systems to support decision-making at all levels of the health sector. This includes integrating and analysing health data to monitor health trends, manage resources more efficiently, and respond effectively to public health emergencies.
4. Digital literacy and capacity building: Improve the digital skills of health workers and administrators to ensure they can effectively use digital health technologies. This includes training programmes and workshops on the use of EHRs, telemedicine platforms, and data management systems.
5. Infrastructure and connectivity: Improve digital infrastructure and ensuring reliable internet connectivity in health facilities across the country, particularly in rural and underserved areas.
6. Cybersecurity and privacy: Establish robust cybersecurity measures and data protection protocols to protect patient information and ensure privacy and confidentiality in the digital health environment.
The Digital Agenda gives further impetus to the development of the unified National Health Information System that was launched in 2016 through the Repositorio Único Nacional de Información en Salud (REUNIS) under the Strategic Sectorial Plan for the period 2016‑21 (Plan Estratégico Sectorial Multianual 2016‑21). REUNIS aims at generating quality, timely and complete information through the exchange of health data to achieve interoperability between all sub-systems to define better health policies. The OGTI is responsible for REUNIS administration.
During the COVID‑19 pandemic, REUNIS was used as the national health information system, linking data between COVID‑19 infections, hospitalisation and mortality databases. The REUNIS portal presents more than 50 dashboards with health statistics and indicators to track the performance towards national health strategies. As of 2024, REUNIS contains information on health data and healthcare activities from health facilities belonging to the Ministry of Health and regional governments, and only immunisation activities registered within the EsSalud network. It currently does not have comprehensive, system-wide comparable data at the national level.
Peru’s Digital Agenda for the Health Sector 2020‑25 represents a significant step towards leveraging technology to improve healthcare delivery and outcomes. In total, there are 119 targeted actions to be achieved in the digital Agenda. Ongoing efforts to digitalise the Peruvian health system should accelerate given that as of March 2024, only 25 of these actions have been completed (representing a 21% compliance rate).
References
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← 1. Transfers made by the Peruvian Ministry of Labor and Employment Promotion to ESSALUD during the years 2020, 2021 and 2022 were exceptional in response to the health emergency caused by the pandemic.