OECD Reviews of Health Systems: Peru 2025

3. Access and quality of care in Peru’s healthcare system

Abstract

This chapter begins by analysing access to healthcare in Peru, highlighting key achievements toward universal health coverage while also addressing the remaining challenges to provide accessible healthcare services of high quality to the whole population. These challenges include the need for stronger healthcare infrastructure, increased workforce density and better distribution across Peru’s diverse geographical regions, and a more robust primary healthcare system. The second section examines the quality of care in Peru and ongoing policy efforts. Quality indicators suggest that significant improvements are needed, particularly through stronger quality governance at the system level, enhanced collection of health system performance data, and the implementation of new payment models to support the standardisation of care.

Ensuring access to care

Peru has nearly achieved UHC, but the benefit packages and levels of access to care vary between insurance funds

The enactment of the Universal Health Insurance Law in 2009 was an important step towards achieving universal health coverage in Peru, with the aim of improving health outcomes and reducing health inequalities. Since then, Peru has continuously sought to expand healthcare coverage, notably with the Urgency Decree 017‑2019 and the Urgency Decree 046‑2021 approved during the COVID‑19 pandemic.

In May 2009, Peru approved the Universal Health Insurance Law, broadening the right of access to healthcare. The Law aimed to extend health coverage to the entire population, with a particular focus on the uninsured and vulnerable groups. It sought to ensure access to comprehensive, continuous and specialised health services throughout the country, improve equity in the provision of health services and promote the right to health for all Peruvians. In addition, the definition of the Essential Health Insurance Plan (PEAS) in 2010 was an integral part of Peru’s efforts to achieve universal health coverage. It established a basic package of health benefits for all citizens. All available insurance schemes in Peru are required to cover the essential services included in the PEAS, which consists of a package of preventive, recuperative and rehabilitation interventions. SUSALUD supervise adequate funding of the PEAS.

At its inception, SIS eligibility was limited to poor children and poor pregnant women but it was progressively extended. SIS expanded its coverage in 2007 (with increased eligibility to all uninsured poor population), and in 2013 (with increased eligibility to all vulnerable population). More recently, with the promulgation of the Urgency Decree 046‑2021, Peru went a step further with the affiliation of all Peruvians with no health insurance in the national territory, regardless of their socio‑economic status, who have theoretical access to the PEAS benefit package. With the new regulation, SIS finances the affiliation, the provision of healthcare to the entire population, both with regards to the PEAS and the complementary plans. In addition, priority is given to joint activities with RENIEC (National Registry of Identification and Civil Status, which is responsible for the identification of persons born in the national territory), in particular for population of Amazonian and the Andean native communities who previously lacked health insurance. RENIEC works with SUSALUD to identify those with and without health insurance, ensure their identification and provide affiliation to SIS.

The share of the population affiliated to an insurance scheme has considerably increased in the last 15 years. Approximately 44% of the population had healthcare coverage in 2002 compared to more than 97% of the Peruvian population in 2023 according to the Registro Nominal de Asegurados. The remaining 3% of the population not covered by SIS mainly include some extremely poor people living in remote Andean and Amazonian areas, or undocumented migrants who are not yet registered in the National Registry of Identification and Civil Status. To reach these vulnerable populations, SIS has been carrying out campaigns with social workers travelling to remote areas, and the Ministry of Health also established a simplification process in 2023 to regularise undocumented migrants.

In addition, according to the National Household Survey (ENAHO, Encuesta Nacional de Hogares), population reporting to have some type of health insurance grew from 36.2% in 2005 to 85.9% in 2022, meaning that 14% of the population report not having any health insurance in 2022. This signals a lack of awareness, which will translate into poor healthcare access for some population groups. In 2021, SUSALUD made available the mobile application “Susalud Contigo” which allows citizens to use their national identity card to see which insurance scheme they are covered by and based on this, what the nearest facility where they can seek care is. This is a very good initiative that should be further communicated to the Peruvian population to increase awareness of health insurance status.

According to the ENAHO survey, the increase in health insurance coverage can mostly be attributed to SIS, which went from 14.1% of Peru’s population insured through the scheme in 2005 to 60.7% in 2022. EsSalud coverage, on the other hand, saw a more discreet increase in coverage, from 17.3% to 21.6% between 2005 and 2022 (see Figure 3.1). There are disparities in coverage between urban and rural areas. While in 2005 the share of Peruvians with no health insurance was higher in rural than in urban areas (69.7% and 61.3%, respectively), current values show that this trend has inverted, with urban regions having a share of uninsured population almost two times higher than in rural areas (15.4% and 8.5%, respectively) in 2022 (Figure 3.2). The increase in coverage in rural areas is mainly due to an expansion of the SIS. From 2005 and 2022, coverage of SIS for rural populations went from 25.1% to 85.3%.

Figure 3.1. Reported health insurance coverage by insurance scheme, 2005‑22

Note: The value for “No insurance” is calculated as the residual value of all the insurance schemes combined. The value for “other” for 2022 is calculated by excluding SIS and EsSalud insurance shares from the total value of insured population.

Source: INEI (2022), Compendio Estadístico Perú 2022 https://cdn.www.gob.pe/uploads/document/file/3839281/Compendio2022‌_Tomo_I.pdf?v=1668543365, for 2015‑21; INEI (2014), Compendio Estadístico Perú 2014 for 2005‑14 www.inei.gob.pe/media/‌MenuRecursivo/publicaciones_digitales/Est/Lib1173/COMPENDIO2014.html; PERU Instituto Nacional de Estadística e Informática INEI for 2022, www.inei.gob.pe/estadisticas/indice-tematico/sociales/.

Figure 3.2. Evolution of uninsured population by geographical area, 2005‑21

Source: INEI (2022), Compendio Estadístico Perú 2022, https://cdn.www.gob.pe/uploads/document/file/3839281/‌Compendio2022‌_Tomo_I.pdf?v=1668543365; INEI (2014), Compendio Estadístico Perú 2014, www.inei.gob.pe/media/MenuRecursivo/‌publicaciones_digitales/Est/Lib1173/COMPENDIO2014.html.

The PEAS package of services has been continuously expanded, such that it now covers 85% of the disease burden in 2024 compared to 65% in 2016. The PEAS was lastly updated through Supreme Decree No. 023‑2021‑SA, following a collaborative review process involving MINSA working group and a Multisectoral Commission established by Supreme Resolution No. 021‑2019‑SA. This updated list covers 153 health conditions, for example in obstetrics and gynaecological care, paediatric care, neoplastic conditions, transmissible conditions, and non-communicable conditions including mental health, chronic conditions and acute care. It emphasises prevention and early detection to prevent complications and includes procedures for the recovery and emergency care of prioritised conditions.

While all insurance plans have the obligation to cover healthcare services in the PEAS, evidence suggest that the benefit package under EsSalud is more generous than under the SIS plan both in terms of scope and depth of coverage (Carrillo-Larco et al., 2022[1]). Under EsSalud for example, not only ambulatory and inpatient care are covered, but also high-cost treatments as well as medicines with no cost-sharing. Under SIS, before the Urgency Decree 046‑2021, there were caps on healthcare spending related to the PEAS for more expensive services included in the supplementary plans. In a previous OECD report, it is reported that overall financial coverage is 100% for less expensive services, but for other services, effective financial coverage drops (OECD, 2017[2]). The Complementary Plans and the Intangible Solidarity Fund for Health (FISSAL) were designed to cover more expensive services (such as cancers or renal failures), but again caps on healthcare spending limit healthcare coverage in practice. In addition, the lack of infrastructure and low supply of health workers has hindered effective implementation of the PEAS under SIS (Neelsen and O’Donnell, 2016[3]).

Ensuring that entitlement set on the PEAS can actually be realised in practice under SIS, and making sure all Peruvian population has access to the same benefit package should be high in the political agenda. To this end, Peru should progressively harmonise the minimum benefit package between SIS and EsSalud, and offer the option of secondary insurance to all SIS and EsSalud affiliates for services that are not included in the basic benefit package. In the OECD, 81% of countries offer supplemental insurance in addition to compulsory and social health insurance. Experience from other countries, which have faced similar issues, suggests that a key consideration will be the level of services offered in the harmonised package. If too restricted, then people in the more generous of the systems become sceptical about the benefits of harmonisation, and progress in aligning the systems becomes difficult. Progressive convergence between SIS and EsSalud can be achieved by explicitly defining the benefit package using economic evaluations to assess the costs and benefits of health services and interventions to update the PEAS. Chile, Colombia and Mexico are OECD Member countries with fragmented health systems that have taken steps to achieve equal benefit packages between insurance systems, specifically for a set of primary and community care services.

In addition, in order to promote equal access across the sub-system, Peru should facilitate the use of benefit exchange agreements between sub-systems through the purchase and sale of a basic set of services. This is highly advisable in order to reduce fragmentation and improve the efficient use of resources, particularly in the area of primary healthcare. As mentioned in Section 1, about 40% of EsSalud members are attributed to a hospital as their first contact with the healthcare system due to a lack of primary healthcare facilities. Allowing EsSalud affiliates to use MINSA and GORE primary healthcare facilities would reduce fragmentation of care, improve access to care and lead to more efficient use of care. A first step would be to standardise payment for primary healthcare services with a weighted capitation model for all SIS and EsSalud primary healthcare facilities (from level I‑1 to I‑4), and to allow EsSalud affiliates to use SIS primary healthcare facilities when needed (with reimbursement to SIS). The use of exchange of services was encouraged during the COVID‑19 pandemic with Legislative Decree No. 1466. This was a very good practice for optimising the use of resources while expanding access to quality care.

The healthcare infrastructure is lower than in current OECD Member countries

Peru reported a density of 1.2 hospital beds per 1 000 population in 2022, which stood as the second lowest rate when compared with OECD countries but on par with other LAC such as Costa Rica and Mexico (with 1.1 and 1.0 respectively) (Figure 3.3). There are large regional disparities in hospital beds capacity. Beds per 1 000 population range from above 2.0 in Ayacucho, Arequipa, Apurimac and Pasco, to half that in remote areas including Puno, Piura, Loreto and Cajamarca (Figure 3.4).

Figure 3.3. Hospital beds per 1 000 population, 2022 (or nearest year)

1. Data from 2017.

Source: Peru’s submission to the 2024 OECD Non-Monetary Healthcare Statistics Questionnaire. Oher countries’ data from 2023 OECD Health Statistics. LAC average comes from the World Bank Development Indicators.

Figure 3.4. Regional disparities in hospital beds density per 1 000 population across regions

Source: Beds from INEI (2022), Compendio Estadístico Perú 2022, https://cdn.www.gob.pe/uploads/document/file/‌3839281/Compendio2022_Tomo_I.pdf?v=1668543365; Population estimates from INEI (2023) www.inei.gob.pe/media/MenuRecursivo/‌publicaciones_digitales/Est/Compendio2023/cap03/ind03.htm

Overall healthcare infrastructure in Peru is generally regarded as deficient. A comprehensive and detailed list of minimal infrastructure requirements for healthcare units in each level of care – including structural, security and telecommunication standards – is set out in Normas Técnicas de Salud de Infraestructura y Equipamiento n^o 113, 110 and 119. These standards support regular evaluations on the compliance of healthcare providers with Ministry of Health regulations. The latest evaluation indicates hospitals’ infrastructure is very precarious, with all units in 16 out of 25 regions classified as having inadequate equipment (a health facility is considered to have inadequate installed capacity if the infrastructure and equipment are not compliant with the Normas Técnicas de Salud de Infraestructura y Equipamiento) (MINSA, 2021[4]). In addition, in 25 out of the 26 regions of Peru, more than 90% of primary healthcare facilities were classified as “inadequate”. All PHC units located in the regions of Callao, Lambayeque, Loreto, Madre de Dios, San Martin and Ucayali received this classification. These are the most vulnerable regions, in terms of both geographical location and economic development.

Over time, the number of health professionals has grown, yet their density remains low and their distribution across different geographical areas is uneven

According to the Observatory of Human Resources for Health (ORHUS), there was a total of 187 170 health professionals in 2022, including 55 190 medical doctors (14%), 69 515 nurses (18%) and 20 900 obstetricians (5%). The supply of medical doctors almost doubled between 2013 and 2022, and the number of nurses also increased by more than 50% over the same period (Figure 3.5). Among medical doctors, 33 543 are working in a MINSA or GOREs health facility, 16 387 are working in the EsSalud network, and 5 584 are working in the private sector. Among nurses, 47 428 are working in a MINSA or GORE health facility, 18 166 are working in the EsSalud network, and 1 564 in the private sector.

Figure 3.5. Evolution of health professionals in Peru across all sub-sectors, 2013‑22

Note: The data present the number of health professionals working in the Peruvian health system, covering all sub-systems.

Source: ORHUS (2022[5]), Información de Recursos Humanos en el Sector Salud, Perú 2022, Observatorio de Recursos Humanos en Salud, https://bvs.minsa.gob.pe/local/MINSA/7050.pdf (accessed on 6 May 2024).

Looking at the number of health professionals per thousand population suggests that Peru has a low density of physicians per capita, with 1.6 per 1 000 habitants in 2022, slightly lower than the average in the Latin America and Caribbean region (2) and less than half the OECD average (3.8) (Figure 3.6). The density has increased by 27% over the past decade, from 1.1 doctors per 1 000 population in 2013. Peru also faces the issue of misdistribution of healthcare workers between geographical areas. In 2021, only 9.8% of doctors were located in rural areas, a share that has progressively decreased since 2013 (at 15%) (MINSA, 2022[6]).

Figure 3.6. The density of physicians and nurses is among the lowest across OECD countries

Source: Peru data from Ministerio de Salud, https://files.minsa.gob.pe/s/EpdZ38cL32w6NmJ; other countries from OECD Health Statistics 2024.

Peru also ranks as one of the lowest in terms of density of nurses per capita when compared with OECD countries, although the density increased by 68% between 2013 and 2021. In 2022, Peru reported 2 nurses per 1 000 population, in sharp contrast with the OECD average of 9.1 and only above Colombia (1.6). As is the case for physicians, only a minority (14%) of nurses work in rural areas in 2021 (MINSA, 2022[6]).

Regional disparities in workforce availability create bottlenecks in access to healthcare in some rural areas. Only six out of the 26 regions had a higher density of doctors per capita than the national average (Prov. Const del Callao, Moquegua, Lima, Arequipa, Tacna and Ica), two of them located in the metropolitan area of Lima. Overall, remote and scarcely populated regions have some of the lowest densities for both doctors and nurses. This is particularly the case for regions located in the Peruvian Amazonia, such as Loreto (0.8 and 1.2), San Martín (1.1 and 1.4) and Ucayali (0.9 and 1.5, respectively) (see Figure 3.7).

Figure 3.7. Rate of doctors and nurses by region, 2022

Note: Data on the number of doctors and nurses refers to 2022. Population data used to calculate the rate of health workforce refers to a projection of 2023.

Source: Ministerio de Salud, https://files.minsa.gob.pe/s/EpdZ38cL32w6NmJ.

Another commonly used measure of healthcare access relates to medical consultations. Figure 3.8 shows that Peru has the lowest doctor consultations per capita among OECD and LAC countries. In 2022, Peru had 1.1 doctor consultations per capita in the public healthcare system, lower than the OECD average of 6.0 and the LAC average of 2.3 consultations. This could signal some deficiencies in care provision.

Figure 3.8. Average number of in-person doctor consultations per person, 2019 and 2022

1. Latest data available from 2021, Peru data from 2022.

Source: OECD Health Statistics 2024, Peru’s submission to the Non-Monetary Healthcare Statistics Questionnaire.

Out-of-pocket payments are still high, constituting a financial barrier to access

Although out-of-pocket payments have decreased by more than 20% over the last decade, their level in 2022 is still much higher than in other OECD countries. In 2022, out-of-pocket payments (OOP) accounted for 27% of the total health expenditure, 1.4 times higher than the OECD average of 19%. This high level of OOP payments suggests that there is room to improve insurance coverage in Peru and that public health financing is limited. Direct payments for services covered by the PEAS but not provided by health facilities partly explain the high level of OOP payments. Using data from the ENAHO survey, it is estimated that historically, EsSalud affiliates faced the largest share of total OOP spending (see Figure 3.9). Over time, OOP spending for SIS affiliates has been increasing and as of 2021 it has slightly surpassed EsSalud OOP expenditures. Medicines made up 32.2% of out-of-pocket healthcare expenditures in 2021, followed by dental services and consultations (DIGEMID, 2021[7]).

Figure 3.9. Out-of-pocket expenditure across type of expenses, 2012‑21

Source: DIGEMID using data from ENAHO surveys.

Unmet healthcare needs are particularly high in less populated areas and for populations of indigenous origin

Limited access to services is evidenced by the percentage of the population reporting unmet healthcare needs. Based on data from the National Household Survey (ENAHO), the proportion of people reporting unmet healthcare needs has remained constant at around 32% for the last decade, with higher rates of unmet need reported in rural areas (37%) than urban areas (30%) (Figure 3.10). There is large variation in the proportion of people reported unmet medical needs by regions. The regions reporting the highest rates of unmet medical needs are Puno, Ayacucho, Pasco and Ancash (regions which have one of the highest poverty rates), with percentages above 40%. On the other hand, the lowest rates of unmet healthcare needs are concentrated in the generally more urban regions of Tumbes, Metropolitan Lima and the Constitutional Province of Callao with 17.7%, 23.3% and 21.6%, respectively. Unmet medical needs are more often reported among women (33.2%), people aged 60 and over (37.7%) and people with disabilities (42.0%). Moreover, populations of indigenous origin (42.9%) or native language (43.5%) also report highest rates of unmet medical needs (INEI, 2023[8]).

Figure 3.10. Share of the population reporting unmet medical needs by area of residence, 2011‑22

Source: INEI (2023[8]), Perú: Medición de la Pobreza Multidimensional, Dimensiones e Indicadores (Revisión 2023), https://cdn.www.gob.pe/uploads/document/file/5402872/4833930-informe-tecnico-medicion-de-la-pobreza-multidimensional-revision-2023%282%29.pdf?v=1712328912 (accessed on 1 March 2024).

Almost half of the population (48%) cited no need for medical consultation as the reasons for not seeking care, with slight differences between urban (50%) and rural areas (46%). This is followed using home remedies or self-medication (about 37% in urban areas and 46% in rural areas). The geographical location (17% in urban areas and 5% in rural areas) and the financial cost were also given as reasons (4.5% in urban areas and 5.1% in rural areas). Interestingly, 44% of people living in rural areas mentioned no insurance, lack of time and mistreatment by health personnels.

Other populations, such as the lesbian, gay, bisexual, transgender and intersex (LGBTI) community, have also faced difficulties in accessing healthcare (Romani et al., 2021[9]). In Peru, an analytical cross-sectional study by INEI suggested that factors associated with non-use of health services by the LGBTI community were low socio‑economic status and lack of trust in health personnel (Romani et al., 2021[9]). Accordingly, survey results suggested that almost half of LGBTI participants reported experiencing anxiety or depression in the past 12 months. International evidence from the United States (United States Census Bureau, 2022[10]; Australian Bureau of Statistics, 2024[11]) and Australia supports this finding, which is linked to the stigma and discrimination they face, making access to mental health services a priority. In an attempt to increase access to services for this population, the Peruvian Government published a presidential decree in May 2024, which classified trans identities as mental health conditions within the Essential Health Insurance Plan (PEAS). While the intention was to increase access to mental health care for the population, the decree was not in line with OECD practices and it received strong criticism from Peruvian human rights organisations and activists (Human Rights Watch, 2024[12]). In June 2024, Peru amended the decree to no longer consider transsexuality and transvestism as mental illnesses (MINSA, 2024[13]) and publicly reaffirmed its willingness to protect the rights of all, including on the basis of sexual orientation and gender identity.

Waiting times differ significantly across insurance schemes and geographical areas

Self-reported data from the 2022 ENAHO survey highlights a significant difference in waiting times both between networks (SIS and EsSalud) and geographical areas (Table 3.1). While Peruvians have to wait on average almost 1.7 days to obtain an appointment, there is a wide gap between urban (2.7 days) and rural areas (9 hours). The difference in waiting times between EsSalud and SIS follows a similar trend. EsSalud affiliates wait on average over 4.8 days to obtain an appointment, while SIS affiliates wait over 17 hours. Women wait longer for an appointment than men (1.8 days compared to 1.6 days), with the difference being more pronounced among those affiliated to the SIS network, with women having to wait 54% longer than men (20 hours compared to 13 hours).

Table 3.1. Average waiting times for medical consultations, by coverage scheme and geographical areas

Geographical area	Average days until appointment is made
National	1.7
SIS	0.7
EsSalud	4.8
Urban	2.7
SIS	1.2
EsSalud	5.2
Rural	0.4
SIS	0.3
EsSalud	2.1

Note: “Rural” includes “área de empadronamiento local” as well as urban areas with 500 and 1999 inhabitants, “urban” includes all urban centres with 2000 or more inhabitants (INEI methodology).

Source: Encuesta Nacional de Hogares (ENAHO), 2022 (authors’ analysis).

Peru has aspirational plans to transform primary healthcare

In Peru, a wide variety of primary healthcare providers exists. The Ministry of Health and EsSalud have both four types of primary healthcare providers, with a total of 8 820 primary healthcare facilities in 2024. Nearly 36% are categorised as level I‑1 (with non-medical health professionals); 23% are categorised as level I‑2 (with technical staff, a nurse or obstetrician and a doctor), 16% as level I‑3 (includes multidisciplinary health teams) and 2% as level I‑4 (includes a multidisciplinary health team able to manage birth delivery). In rural areas, the capacity of primary healthcare is very precarious and limited. For example, as of 2024, in the region of Amazonas and Huancavelica, 68% and 63% of primary healthcare facilities belonged to level I‑1, the most basic primary facilities.

Despite the large number of first level of healthcare facilities, many patients have direct access to hospitals because first level of healthcare facilities lack medicines, equipment and ambulances. This points to a weak referral system, and limited co‑ordination between primary healthcare and the rest of the health system. The ENAHO survey shows that in 2022 only 32% of Peruvians accessed a primary healthcare centre first – either using SIS or EsSalud facilities – when they sought care.

Peru has set out plans to reinvigorate primary healthcare through major reforms including the Comprehensive Healthcare Model (Modelo de Atención Integral de Salud, MAIS), the Comprehensive Healthcare Model based on the Family and Community (MAIS-BFC) and the Model of Integrated Care by Life Course for the Person, Family and Community (MCI). The overarching objective of these plans was to improve the living conditions and health status of the population by strengthening the community and family approach of primary healthcare. Recently, the main features of the MCI include:

• A life course perspective: The model recognises that health and well-being are influenced by factors and events throughout a person’s life. It aims to address health needs at every stage of life, from prenatal care and childhood through adolescence, adulthood and old age.

• Person, family and community-centred: The model places the individual, their family and the community at the centre of healthcare. It emphasises the role of family and community support in the health and well-being of individuals and promotes an enabling environment for health.

• Multisectoral approach: Recognising that health is influenced by a wide range of factors beyond the healthcare system, the MCI advocates collaboration across sectors, including education, housing and social services, to address the broader determinants of health.

• Cultural sensitivity: The model recognises the diverse cultural contexts in Peru and aims to provide culturally appropriate care that respects the traditions and preferences of different communities.

• Technology and innovation: MCI supports the use of technology and innovation to improve healthcare delivery, including electronic health records, telemedicine and mobile health initiatives to increase access to care.

• Integrated care: MCI aims to integrate different levels of care, from primary to specialised services, to ensure continuity and co‑ordination of care. This integration extends to public health interventions, social services and community involvement.

The development of MCI started in 2020 and involves multidisciplinary health teams to deliver integrated packages of health services according to population health needs throughout the life course. The prioritised health interventions include health promotion and risk prevention with a territorial approach, intercultural adaptation, non-communicable diseases, mental health, oral health and cancer prevention among other preventives intervention. The ambition is to have primary healthcare teams in charge of providing care, not only focusing on diseases, but attending all the health needs in the community. This includes sending reminders for preventive visits, addressing risk factors for health and developing a comprehensive health plan (MINSA, 2022[14]). This would help to achieve a more efficient and patient-centred health system in Peru.

To support the development of MCI, MINSA has issued Health Sector Reform Guidelines and Measures, one of them being the Strengthening of Primary Healthcare to develop new model of primary healthcare based on a territorial organisation to provide comprehensive, continuous and high-quality care. The overarching objective is to ensure efficient delivery of services, notably by increasing the capacity of primary healthcare to provide health promotion, prevention and management of chronic diseases. MINSA, in collaboration with the National School of Public Health, also has developed specific training sessions on Integrated Healthcare Model by Life Course for the Person, Family and Community as part of the PROFAM programme.

Yet the regional and Ministry of Health network of primary healthcare centres are still not responsive to the current epidemiological profile of a growing burden of chronic conditions. A recent evaluation of the Infrastructure and Equipment Gap of the Health Sector pointed out that 90% of health centres presents inadequate installed capacity, assessed as precarious, obsolete, inoperative or with insufficient equipment (GOPBM/MINSA, 2021[15]). This means that patients with conditions that could be effectively managed by primary healthcare (such as chronic conditions or mental health disorders) are in most of the case referred to hospitals due to the lack of adequate infrastructure or care network. A recent evaluation in three districts from the Northern Lima Health Region confirmed insufficient capacity to provide comprehensive care for non-communicable disease like diabetes. Results indicated that only 13% of facilities had metformin treatment available. None of them had the capability for measuring glycated hemoglobin or albuminuria, and only 30% had permanent availability of blood glucose metres. This led many avoidable referrals for laboratory tests or treatment to better control type2 diabetes mellitus (Bellido-Zapata et al., 2018[16]). Another study shows that 34.1% of a sample of low income population had never had a blood pressure assessment; 65.2% had never had a serum cholesterol assessment; and 75.6% had never had a diabetes screening (Flores, O., Bell, R., Reynolds, R., and Bernabé, A, 2018[17]). These findings suggest that screening for hypertension and diabetes can be further strengthened at primary healthcare level, with a greater focus on disadvantaged population.

These facts give strong arguments to continue strengthening primary healthcare in Peru to fully realise its key functions regarding public health, prevention and management of chronic conditions. There is a clear need to increase the capacity of primary healthcare to better meet population health needs through compulsory specialty training. While the specialty of family medicines is provided in 21 regions, evidence shows the minimum competencies that professionals should achieve are not guaranteed by the training (Fraser, 2022[18]). This demonstrates the need to evaluate the quality of training and make sure the curriculum responds to the country’s public health challenges (anaemia, obesity, and malnutrition for example) and population health needs. Peru should consider evaluating the quality of medical school curriculums. This will raise standards of care and ensure patient safety, but also improve the public trust and confidence in physicians. Making sure the National Training Programme in Family and Community Health (PROFAM) is offered in all medical schools and made compulsory to practise as primary healthcare physicians is also one option for consideration.

To modernise and increase the capacity of primary healthcare, MCI model should also be backed up with appropriate public network of laboratories, diagnostic services, emergency services and transport. Once this is achieved, Peru could strengthen the referral system so that primary healthcare facilities can better control and direct the patient’s into specialist care. This would help realise the key objectives of the Peruvian health system, which is to ensure more co‑ordinated and integrated delivery of healthcare services (see also the section on Integrated Health Network – RIS).

The COVID‑19 pandemic accelerated the deployment of telemedicine

The COVID‑19 pandemic led to significant changes in national telemedicine legislation. Before the COVID‑19 pandemic, telemedicine was limited to interactions between health professionals to support smaller health facilities (such as rural primary healthcare facilities or small hospitals) to get tele‑expertise from larger hospitals or health institutes. Virtual consultations between doctors and patients were not recognised as medical acts and doctors were not allowed to prescribe remotely. As part of the National Telehealth Plan 2020‑23, a series of regulatory documents1 established the organisation, strengthening and sustainability of telemedicine in Peru in order to allow the implementation and development of tele‑health, bringing specialised health services closer to the Peruvian population. There are also complementary regulations on the protection of personal data, the payment of telemedicine services by SIS (Institución Administradora de Fondos de Aseguramiento en Salud del Estado Peruano) and connectivity, which allow the safe and sustainable development of telemedicine services. MINSA’s Telemedicine Directorate is responsible for updating the current regulations.

MINSA and EsSalud networks of providers have developed a centralised offer of telehealth services. Through SIS, MINSA offers telehealth services through its National Telehealth Network (RNT) to provide four telemedicine services: tele‑orientation, tele‑consultation, tele‑monitoring, and tele‑expertise. These services have been defined in the Supreme Decree No. 005‑2021‑SA, which approved the regulation of the Telemedicine Framework Law. To facilitate access to telemedicine, MINSA has developed in 2020 the “Teleatiendo” health information system which allows to request online consultations. The platform was initially developed to monitor COVID‑19 patients but was later expanded to patients with underlying health conditions including hypertension, diabetes, cardiovascular diseases or cancer. The platform is currently in full development and is used by more than 1 000 health facilities (mostly at the first level of care). The system includes digital signatures, electronic prescriptions or electronic billing, enhancing the efficiency and reach of healthcare services across Peru. Since its deployment, the RNT has provided more than 35 million telemedicine consultations nationwide and more than 480 000 electronic prescriptions have been generated for citizens. As of 2024, 2 993 health facilities use the RNT to provide the four services. While nearly 100% of IPRESS at the second and third levels of care show full participation in the RNT, adherence has been slower at the first level (34%) (Figure 3.11).

Between 2022 and 2024, the Ministry of Health will provide equipment to 678 primary healthcare centres to further deploy telemedicine. This is part of the Optimization, Marginal Expansion, Rehabilitation and Replacement Investment Projects.

Figure 3.11. Participation of IPRESS facilities to the National Telemedicine Network, by level of care

Source: General Directorate of Telehealth, Referral and Emergencies (DIGTEL), and Peru responses to the 2023 Accession Review Health Policy Questionnaire.

Within EsSalud network, the use of tele‑health started in 2014 with the development of the National Centre for Telemedicine (CENATE). As of 2024, 70.3% of EsSalud health providers are part of the National TeleEsSalud Network, with the aim to reach 100% by the same year. As of March 2024, over 200 000 teleconsultations have been carried out nationally within EsSalud network.

Between 2020 and 2023, the Directorate of Telemedicine, in partnership with the National School of Public Health (ENSAP), certified more almost 35 600 health professionals in telemedicine through courses and diplomas. In 2022, 14 975 health professionals participated in telemedicine courses. Despite this achievement, trained telemedicine workers only represent 9% of all health workers, with marked regional disparities (Figure 3.12). Pasco and Ayacucho have the highest proportion of health workers trained in telemedicine (18.4 and 17.2% respectively), while this figure is the lowest in Lima (5%) and in Callao (4.3%). This can be partially attributed to the “Telehealth at the first level of care – SERUMISTAS” course that focuses on professionals serving remote areas and comprised 49.8% of all telemedicine trainings between 2020 and 2023.

These developments have led to a rapid uptake of telemedicine services. Although this took place during the COVID‑19 pandemic, and the reopening of health facilities has almost completely reversed the trend, it lays the groundwork for further initiatives to expand access to care. Peru needs to capitalise on the use of telemedicine and take advantage of its benefits as a new model of healthcare delivery. One of the main challenges for Peru will be to better reach rural and remote areas, where the use of telemedicine has lagged significantly behind large urban centres (Figure 3.13). About 15% of Peru’s population lacks home internet access, with a significant gap between urban (11%) and rural areas (34%). This means that a large part of the population in rural areas lack the necessary basic technological tools and skills for a teleconsultation. Internet connectivity in rural areas should be prioritised in Peru. The WiLD Multihop Network project has been very successful to provide 3G services to eight villages in the Amazon villages (Alvarez-Risco, Del-Aguila-Arcentales and Yanez, 2021[19]). It allowed to connect 15 primary healthcare centres to the regional Hospital of Loreto. Similar project should be undertaken to implement telehealth programmes in remote areas, particularly in the Amazonian forest and Andeans, to allow specialists to reach patients throughout the country. This would be a key step for bridging the digital divide and enhancing telehealth services across Peru, promoting a digital transformation of the healthcare system.

Figure 3.12. Percentage of health workers trained in telemedicine, by region

Note: Human workers certified in telemedicine courses for the period 2020‑23 are considered trained.

Source: National School of Public Health ENSAP database, Información de recursos humanos del sector salud, Perú 2021.

Figure 3.13. Use of telehealth according to geographic location in Peru, 2020‑23

Source: Peru’s responses to Accession Review Health Policy Questionnaire.

Improving quality of care

Quality of care indicators suggest that there is room to improve care quality in the Peruvian health system

Based on 2022 data from the ENAHO survey, 83.3% of individuals who were treated at a MINSA health facility in the last 12 months rated the service they received as “good or very good” (Figure 3.14). The regions that reported the highest percentage of satisfaction were Cajamarca (92.8%), Ancash (92.0%) and Ayacucho (90.6%). On the other hand, Puno (66.7%), Cusco (69.2%) and Lima (71.7%) indicated the lowest percentages of satisfaction with the health service received. For EsSalud the percentage of respondents who rated the care they received as “good or very good” was lower, namely 68.4%, and this was the case for all regions except Puno. Lower user satisfaction among EsSalud most likely relates to longer waiting times (see Table 3.1).

Figure 3.14. Percentage of users who rated care quality as “good or very good” in MINSA and EsSalud health facilities, 2022

Source: Authors’ own elaboration based on National Household Survey on Life Conditions and Poverty (ENAHO), 2022.

Other key metrics, such as declining vaccination rates, are signs that there is room to improve care quality. Childhood vaccination programmes are one of the most effective and cost-effective health policy intervention to control communicable disease. Peru established a comprehensive vaccination programme for its population: 18 vaccine types are included in its national immunisation programme, while other countries in the region usually offer 13 vaccines (PAHO, 2022[20]). However, Peru does not meet the WHO’s recommendation of 90% vaccination coverage to effectively protect its population against diseases such as diphtheria, tetanus, and pertussis (DTP‑3). In 2022, only 82% of children received the DTP‑3 vaccine at 1 year of age (Figure 3.15). This is 11% lower than the average across OECD countries at 93%, but above the LAC average of 81%. Measles vaccination rates in Peru are also below WHO recommendations to prevent the spread of the disease (95%). In Peru, the measles vaccination rate was 74% in 2022, lower than both the LAC average (83%) and the OECD average (93%).

A worrying trend can also be seen in the change in immunisation coverage over the last two decades. Peru has seen a sharp decline in the percentage of children who have been vaccinated against measles, DTP‑3, and polio. For example, measles vaccination coverage among children aged 1 year decreased by 25% between 2000 (97%) and 2022 (72%).

Figure 3.15. Vaccination rates for measles and diphtheria, tetanus and pertussis (DTP‑3) are amongst the lowest in the OECD, 2022

1. WHO/UNICEF estimates.

Note: LAC average comes from WHO/UNICEF.

Source: WHO/UNICEF.

As mentioned in Section 1, Peru also had 23% higher amenable mortality (at 98 per 100 000 population) than the OECD average (at 79 per 100 000 population) in 2021. This suggests that better care quality, including better secondary prevention and treatment, is needed to reduce avoidable mortality. At the same time, Peru reports one of the lowest rates of avoidable admissions for asthma and COPD in the OECD in 2022 (20.7 per 100 000 population compared to 129 in the OECD) (Figure 3.16). While low rates of avoidable admissions for COPD and asthma generally suggest high quality care for people living with these chronic conditions, it can also reflect problems in access to care for the Peruvian population that lead to underutilisation of hospital resources, or alternatively difficulties in data reporting.

Figure 3.16. Asthma and chronic obstructive pulmonary disease hospital admission in adults, 2021

1. Data from 2020. 2. Data from 2019.

Note: Peru data from 2022.

Source: OECD Health Statistics 2023, Peru’s submission to the 2024 OECD Healthcare Quality and Outcomes Questionnaire.

Peru is committed to ensure patient safety and care quality, but there is limited quality governance at the system level

In Peru, the Health Quality Management System (Ministerial Resolution No. 519‑2006/MINSA, “Sistema de Gestión de la Calidad en Salud”) defines standards of care for health service providers at national, regional and local levels. The Functional Unit for Quality Management in Health (UFGHS), under MINSA, was established by Ministerial Resolution N°896‑2017/MINSA to design, organise the quality management system and define indicators and standards of care. Accordingly, each health facility should have organisational units with technical teams to develop health quality management processes regulated by MINSA. The Health Quality Management System is designed to enhance the quality and safety of healthcare services, ensuring that they meet established standards and are responsive to the needs of the population. The evaluation of user satisfaction, implementation of patient safety rounds, adverse event reporting or healthcare hand hygiene monitoring are all processes that health facilities should theoretically implement (Box 3.1).

Box 3.1. Processes defined as part of the Health Quality Management System in Peru

Peru’s commitment to ensure patient safety and care quality is demonstrated by its Health Quality Management System. These align with international health quality standards to improve patient satisfaction, health outcomes, and overall system performance:

• Evaluation of external user satisfaction of Health Facilities and Medical Support Services

• Healthcare quality audits (RM N° 502‑2016/MINSA, NTS 029‑V.2 Norma Técnica de Salud de Auditoría de la Calidad de la Atención en Salud).

• Registration, notification and analysis of adverse health events (RM No. 727‑2009/MINSA Technical Document “National Health Quality Policy”).

• Application of surgery safety checklists (RM Nº 1 021‑2010/MINSA, Technical Guide for the Implementation of the Surgery Safety Checklist”).

• Monitoring and evaluation of the correct technique and 5 moments of hand hygiene in healthcare (RM N° 255‑2016/MINSA, Technical Guide for the Implementation of the Hand Hygiene Process in Health Facilities).

• Patient safety rounds (RM N° 163‑2020‑MINSA, Sanitary Directive N°92‑MINSA/2020/DGAIN “Sanitary Directive on Patient Safety Rounds for risk management in healthcare”).

• Accreditation of facilities (RM N° 456‑2007/MINSA, NTS Nº 050‑MINSA/DGSP-V.02 “Norma Técnica de Salud para la Acreditación de Establecimientos de Salud y Servicios Médicos de Apoyo”).

• Elaboration and implementation of projects for continuous improvement of healthcare quality (RM Nº 095‑2012/MINSA, Technical Guide “Guide for the Elaboration of Improvement Projects and the Application of Techniques and Tools for Quality Management”).

Source: Peru’s responses to Accession Review Health Policy Questionnaire.

While the Health Quality Management System constitutes a key principle to ensure that all citizens have access to high-quality healthcare services, the implementation of these activities remains unknown. For example, information on healthcare quality audits, application of surgical safety checklists or effective use of clinical guidelines and standardised monitoring of these activities is lacking. Quality initiatives are implemented sporadically by health facilities, and monitoring depends on regional or local capacity to assume quality assurance mechanisms. In addition, the implementation of these activities varies by sub-regimes.

At system level, the UFGCS of the Ministry of Health periodically evaluates Institutes, DIRIS, and Regional Managements, Health of the Armed Forces and Police, and ESSALUD, through the compliance with indicators defined as part of the Quality Management System. UFGCS, for example, monitors patient safety indicators including healthcare‑associated infections through the Technical Standard N ° 163 –MINSA/2020/CDC. All IPRESS are mandated to report healthcare associated infections for surveillance and monitoring purposes (MINSA, 2021[21]). The OECD Hospital Survey on Patient Safety Culture collected data from 17 sites in Peru between 2021 and 2022. The results show that, on average, Peru scores close to the other OECD countries, with higher scores in organisational learning, reporting patient safety events, and hospital management support for patient safety, while scoring lower in staffing and workplace, as well as response to error.

In addition, MINSA has an “accreditation” model which is more an evaluation process for health facility to assess compliance with MINSA regulations. The accreditation focuses on compliance with minimum service readiness standards (such as registering infrastructure, equipment or stock of pharmaceuticals in the information system) and entails sanctions rather than rewarding and supporting improvement initiatives. Contrary to national accreditation programme for hospital nationwide, this evaluation model does not foster a quality improvement cycle.

There are some good local examples such as in the National Institute of Child Health of San Borja, a public-private partnership. The Institute is a specialised and highly complex hospital, paediatric and surgical centre. It has a well-developed quality assurance mechanism, which includes surgery safety checklist, hand washing campaigns and training sessions of health professionals (Box 3.2). The National Institute of Child Health also provides support to other regions by training healthcare workers in remote areas when there are specific needs. In 2023 for example, 54 training were organised in remote areas.

Box 3.2. The strategies of the National Institute of Child Health of San Borja promote quality care

The National Institute of Child Health of San Borja (INSNSB) is a high complexity paediatric and surgical and specialised hospital centre. The hospital is in operation for nine years, receiving children and adolescents from other hospitals in the country, and staffed by both administrative and healthcare workers. It also conducts research and teaching at the national level.

In 2019, the INSNSB became the first “accredited” institution of the Ministry of Health, thanks to a concerted effort of healthcare, administration staff, and the institution’s internal evaluation team. As part of the MINSA Health Quality Management System, the Institute has been carried-out the following quality initiatives:

• Implementation of the Surgery Safety Checklist,

• Quality of care audits,

• Mechanisms for the registration, notification, and analysis of the occurrence of health incidents and adverse events,

• Hand hygiene process at the institute,

• Patient safety rounds, and implementation of the WHO Surgical Safety Checklist

• Evaluation of external user satisfaction.

Overall, the National Institute of Child Health San Borja (INSNSB) has achieved the highest percentage of compliance with these criteria in recent years, demonstrating the institution’s commitment to quality and continuous improvement. The National Institute of Child Health San Borja was the first establishment of the Ministry of Health accredited in the year 2019 and is expected to renew their accreditation in 2024.

Source: Interviews with National authorities and Peru’s responses to Accession Review Health Policy Questionnaire.

Peru would need to strengthen its national quality assurance covering all service providers and across all sub-systems by developing a nationwide quality assurance approach. Core centralised functions would be needed around quality assurance mechanisms with a stronger steering role on the local and regional activities. This will help to achieve a more consistent and ambitious approach towards quality assurance. SUSALUD could play a stronger oversight role of the central level by setting a unifying national standards framework of quality that would apply to all sub-regimes, and by monitoring compliance to quality activities (rather than MINSA regulation). In addition, a progressive implementation of a voluntary accreditation for hospitals would be a key strategy to promote quality in hospital care. Ultimately, SUSALUD could play a stronger role toward producing overviews of current practice and current performance at national level, based on national standards on performance and mandatory performance reporting. For now, none of these functions are consistently and regularly performed by the central level.

Peru needs to strengthen its data infrastructure to capture quality and outcomes data comprehensively

Peru has the potential to improve its data infrastructure, particularly in terms of collecting comprehensive information on health system performance, including data on quality and outcomes. As already mentioned, 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 difficult to comprehensively measure care quality or outcomes nationally, to make correct comparisons across providers, and follow pathways of care to evaluate the quality and effectiveness of care. Peru is already working towards the development of a unified national health data framework (REUNIS) to be able to report a core set of information on care quality and outcomes nationally, across all-sub-systems. This is a very good development that will require interoperability across all sub-systems, use of EHR as well as standardised and mandatory reporting of indicators for all sub-systems.

In addition, the health information currently reported to MINSA mainly focus on maternal and child health, public health and infectious diseases, covering activities or inputs. However, there is a growing need to expand the epidemiological data collected to include a wider range of non-communicable diseases, which are becoming increasingly prevalent such as the management of chronic conditions (diabetes, heart failures), care co‑ordination, and patient experience and outcome measures. While Peru seeks to modernise primary healthcare through the development of MCI and integrated care networks, Peru needs ultimately to ensure that the ongoings reforms do not adversely affect outcome of care and exacerbate health inequalities. At hospital levels also, data on quality and outcomes of hospital care should be collected and be made accessible to the population and providers. This would help people to make informed choices, build public confidence in the public system, facilitate peer to peer benchmarking and steer improvement in care quality.

Peru should also align its reporting of health and healthcare quality indicators with those recommended by the OECD as part of the “Health Statistics”, “Healthcare activities” and “Healthcare Quality and Outcomes Indicators” frameworks. While Peru submitted data for these OECD Data Questionnaires, increased effort is necessary to ensure validity and comparability of the data according to OECD standards. For now, many of the reported indicators do not cover the whole healthcare system making international comparison difficult. This is for example the case of many of the reported healthcare activities indicators that only cover facilities under the authority of the Ministry of Health and regional governments. Low rates of avoidable admissions for asthma and COPD can – beyond problem in access to care – also reflect difficulties in recording and monitoring hospital activities across all sub-systems. Another key issue relates to data quality. While most other countries rely on demographic statistics from life tables to report on life expectancy at birth, Peru relies on survey data for 5‑year blocks, which is a less valid and reliable source of information and limits the analysis of shocks to the health system, such as the effects of the COVID‑19 pandemic.

Improving data’s quality and coverage will allow for international benchmarking and provide valuable insights into the variation in performance between different regions and sub-systems. This alignment would not only benefit Peru but also provide valuable data to the international community, especially as Peru progresses toward near achievement of universal health coverage.

New payment systems for MINSA and regional facilities promise to standardise care and improve quality

The MINSA network implemented a unified national remuneration policy for first level of healthcare and hospital providers. The remuneration has two main components: i) basic payment and ii) additional components which include fee‑for-services and payment by package of services. The payment mechanisms vary according to the level of complexity of healthcare facilities.

For first level of healthcare facilities (level I‑1 and I‑2), a weighted capitation component is applied as a basic payment mechanism since 2013 as defined under the Ministerial Resolution N°446‑2021‑MINSA. The capitation formula allocates resources based on needs depending on socio‑economic (poverty level and social vulnerability), demographic (population density), geographical factors (rurality) and health status (disability adjustment). The model helps ensure that regions and local municipalities with higher population and social needs owing to less favourable socio‑economic situations or higher disability levels receive the necessary funding to provide care. This weighted capitation model, which aims to encourage population health management and more proactive care based on population health needs, is well aligned with many OECD countries’ policies in this area, as done for example in Chile or Portugal. However, first level of healthcare facilities at levels I‑3 and I‑4 are still reimbursed on a fee‑for-service system for their basic payments, highlighting a potential area for policy evolution towards capitation across all primary care facilities. In order to better incentivise proactive population health management, it is also recommended to allocate capitation payments to health facilities rather than regional governments (which have the autonomy to decide financial allocation to health facilities). In addition, the basic payment (before making adjustment) is based on a SIS actuarial study published in 2015 using 2012 data. The health needs of the population have evolved over the past 10 years, and it is advisable to undertake a new actuarial study to ensure that resources are based on the current population health needs.

In 2024, SIS has innovated by introducing payments which are part of the additional component. For level I‑1 to level I‑4 facilities, this includes a payment for surgical package for childbirth delivery (including C-Section). The additional component also includes add-on payments for outpatient specialist services including specialist consultations, rehabilitative services for diabetes, hypertension and chronic kidney disease, vaginal delivery and mental health care.

In addition, level I‑3 and I‑4 facilities have to meet some process indicators to get the additional components. These add-on payments, also used in several other OECD countries (OECD, 2020[22]), include:

• 2 medical consultations for the follow-up and control of hypertensive patients.

• 30% of hypertensive patients have reached the therapeutic goal.

• 50% of diabetic patients have received renal function screening.

• 95% of diabetic patients with glycosylated haemoglobin dosage.

Hospitals at levels II and III continue to be reimbursed on a fee‑for-services basis for basic payments, with additional payments for a package of surgical services. The latter include C-section, extracapsular and phacoemulsification type of cataract treatment, conventional inguinal hernia repair in adult patient, conventional and laparoscopic cholecystectomy in adult patients. The payment covers drugs supplies and medical devices, while health personnels are paid by the Ministry of Economy and Finance under regional budget lines.

The current changes in both primary healthcare and hospital care are good steps to move towards rewarding quality of care. International experience provide evidence that capitation payment helps prioritise prevention while payment for a package of services help to standardise care. Add-on payments also encourage desirable behaviours and activities for the management of chronic diseases (OECD, 2020[22]).

The development of integrated healthcare network receives large attention in Peru but is hampered by the fragmentation of the health system

Peru started to implement Integrated Health Networks (Redes Integradas de Salud, RIS) in 2018 as part of its efforts to reform the healthcare system to provide comprehensive, continuous and co‑ordinated care to the population. The creation of Integrated Health Networks aims to improve access to primary healthcare and to promote collaboration between different levels of care and providers (Box 3.3). The organisation model is characterised by the delimitation of the population and the territory, into territorial health units.

The regulation of Law N° 30885 granted both the regional health authority and the Metropolitan Lima health authority the function of monitoring, supervision, and evaluation of the RIS (DS N° 019‑2020‑SA, 2020). With support from the International Development Bank and World Bank project on the roll-out of integrated health network (Videnza, 2021[23]), networks in Peru have the following key attributes:

• It is based on a territorial and population delimitation. This objective is to foster population health management, within a defined geographical area, taking into account local determinants of health and aiming to reduce health inequalities;

• The population is assigned to a multidisciplinary health team which has a co‑ordinating role to provide a portfolio of first contact health services that includes individual health and public health interventions;

• Integration across levels of care, from primary health centres to specialised and tertiary hospitals. This approach is designed to facilitate the referral and counter-referral system, ensuring that patients receive the right level of care at the right time and in the most appropriate setting. Healthcare services are complementary, from 12 to 24‑hour shifts to ensure care continuity;

• Providing a wide range of health services including public health services, promotion, prevention, recovery, rehabilitation and palliative care, and addressing the social determinants of health.

According to MINSA, there are 155 RIS in 2024, among which 26 RIS are in the Metropolitan area of Lima and 129 RIS are in the 25 regions. In addition, 66 management teams have been formed to carry-out supervision and for organising the provision of public health services, as well as the referral and counter-referral flows from multi-disciplinary teams to hospitals and specialised institutes. The management teams have followed a specific training to manage the RIS, which was developed in co‑ordination with the World Bank, the International Bank for Reconstruction and Development, the Fundación San Marcos and the Universidad Santo Thomas (Chile). In addition, since 2020, in co‑ordination with the ENSAP, training programmes related to RIS roll-out were developed for health personnels from all DIRESA, GERESA and DIRIS, from the Central Administration of MINSA and attached agencies, as well as health personnels from all health insurance funds.

Although initially the RIS is organising the provision of services within MINSA and GORES health facility, the overarching objective over the long term is to integrate other public, private and mixed IPRESS into existing RIS. This will allow to have a more unified health system.

However, a number of challenges have been reported as barriers in the implementation of integrated healthcare networks (Videnza, 2021[23]; Parra Moscoso, 2017[24]). These include for example limited health personnels and technological equipment, low interoperability of information systems and lack of organisational guidelines which hamper an adequate system of referrals and counter-referrals. Overall, the fragmentation of the health systems has led to differences in the logistics management of each sub-system, which prevent from achieving the advantages of an integrated system, such as economies of scale in procurement. In addition, the payment system is prospective on a per capita basis and per package of services for C-Section delivery for some facilities. However, there exist other payment mechanisms that incentivise providers from different levels of care to work effectively together. Add-on payments for co‑ordination between level of care, and bundled payments for chronic conditions are additional payments that Peru could consider progressively to foster implementation of integrated care. Evidence across OECD countries shows that bundled payments have been found effective at containing rising costs, increasing the quality of care, enabling higher patient satisfaction and better adherence to medication and treatment protocols (OECD, 2020[22]).

Box 3.3. Organisation of the Integrated Health Network in Villa El Salvador

The RIS Villa El Salvador (RIS VES) in Lima Province, is one of 20 RIS planned to be implemented in Peru over the coming years. With activities beginning in 2023, RIS VES assigns patients with specific conditions (diabetes mellitus, depression, cervical and breast cancer, arterial hypertension and pregnant women) towards primary healthcare centres. The overarching objective is to deliver health promotion and prevention intervention timely, and to organise appropriate referral to specialised care at the Emergency Hospital of Villa El Salvador when medically necessary.

Training programmes have been delivered to the multidisciplinary health teams to support them in providing comprehensive care for these underlying health conditions. Clinical laboratory and pathology services have also been strengthened within the health network, backed by a single information system. It is expected to increase timely access to appropriate care and services, improve care continuity, and availability of medical support services.

Source: General Directorate of Health Insurance and Benefit Exchange (DGAIN).

The National Law on Cancer represents a significant step toward improving cancer care, yet insufficient medical technology and low screening rates remain challenges

Cancer is a growing public health issue in Peru, as it is in many OECD countries. Excluding COVID‑19, it is the second leading cause of mortality, accounting for 12.3% of all deaths in 2021, following cardiovascular disease (which caused 16% of all deaths in the same year). A previous simulation model predicts that by 2030, the annual number of new cancer cases will increase by 72% compared to 2012 (Carrillo-Larco et al., 2022[1]).

In 2013, Peru took steps to improve the quality and accessibility of cancer care through the implementation of the National Plan for Cancer Control, known as Plan Esperanza. This initiative led to the establishment of a National Registry of Cancer and a National Observatory of Cancer, bolstering cancer research and epidemiological studies. At the individual level, Plan Esperanza aimed to enhance counselling on health promotion, cancer prevention, early detection, and diagnostic improvements. Financial support for the strategy came from an objectives-specific budget approved by the Ministry of Economy and Finance (Carrillo-Larco et al., 2022[1]).

As a result of Plan Esperanza, the number of people receiving cancer care increased significantly, rising from 25 359 in 2012 to 78 284 in 2015. Additionally, there was improved coverage of prevention and screening activities for cervical cancer and breast cancer. Screening coverage for women aged 30 to 49 years with cervical cytology increased from 7% in 2012 to 12.5% in 2015. However, available data highlight that enhancing the quality of cancer care within the Peruvian health system remains a critical challenge. Primary healthcare providers and facilities continue to grapple with ensuring broader coverage for cancer screening. For instance, from 2014 to 2018, there was minimal to no improvement in breast cancer screening coverage, despite the country adopting a population-based approach (PAHO/WHO, 2015[25]).

According to ENAHO data, there has been an overall decrease in screening rates for breast and cervical cancer screening rates over the last eight years (Figure 3.17). As of 2021, only 9.3% of women aged 30‑59 reported having a clinical breast exam in the past year, compared to 22.4% in 2014. Similarly, the proportion of women aged 40‑59 who reported having a mammogram in the last two years declined from 18.7% to 6.7% during the same period (INEI, 2022[26]). These declines were accelerated by the pandemic. However, even before the pandemic, the proportion of women undergoing cervical screening (specifically pap smears) had already started to decline. In 2017, the proportion stood at a high of 62.8%, but by 2021, it had fallen to 45.4%.

Figure 3.17. Rates of breast and cervical cancer screening, 2014‑21

Source: Evolución de los Indicadores de Programas Presupuestales, 2013‑21.

The insufficient supply of medical technologies poses a significant challenge to early disease detection and contributes to delayed diagnoses in Peru. According to the Ministry of Health, the number of mammograms has significantly decreased over time, plummeting from 51 906 in 2019 to 13 844 in 2021. Overall, the low participation in breast and cervical screening programmes leads to disease diagnosis at later stages. In Peru, only one out of every seven breast cancers and one out of every six cervical cancers are diagnosed at stage 1 (Figure 3.18).

Figure 3.18. Distribution of clinical stages at diagnosis by type of cancer, 2016

Note: Data from the Fondo Intangible Solidario de Salud (FISSAL).

Source: Plan Nacional de cuidados integrales del cáncer (2020 – 2024), http://bvs.minsa.gob.pe/local/MINSA/5341.pdf.

The Esperanza Plan was updated in 2020 with the National Comprehensive Cancer Care Plan (2020‑24) to broaden its scope. This updated plan incorporates strategies for palliative care, extends cancer treatment to children and teenagers, and enhances the availability of cancer services across Peru, particularly beyond the metropolitan area of Lima (Box 3.4). In 2022, Supreme Decree No. 004‑2022‑SA approved the National Law on Cancer (Law No. 31336), which was subsequently modified in 2023 by Law No. 31870. The primary objective of this legislation is to guarantee universal, free, and priority health coverage for all cancer patients, regardless of the specific cancer type. The law emphasises promoting prevention and early detection, training of health workers, and institutionalising epidemiological surveillance by establishing a national registry of cancer patients.

The Law also creates the National Oncology Network, composed of regional oncology institutes and oncology centres across Peru, which are responsible for implementing – alongside the National Institute of Neoplastic Diseases – the National Policy for Fighting Cancer. The Network will seek to promote the implementation of specialised centres that deliver comprehensive cancer diagnosis, care, and follow-up at the national level.

Finally, additional provisions from Law No. 31870 allow MINSA to use differentiated purchasing mechanisms of products related to cancer care as well as promoting the centralised purchasing of strategic resources for prevention and control of cancer through the National Center for the Supply of Strategic Resources for Health (CENARES). In 2022, the “Oncologic Traffic Light” (Semáforo Oncológico) platform was launched. Developed by ten oncology patient associations, this platform monitors and reports on the implementation of the National Law on Cancer. It categorises tasks using characteristic colors: red (overdue), amber (due), and green (completed).

The National Law on Cancer represents a significant step toward improving cancer care, enhancing access, and promoting better health outcomes for all Peruvians.

Box 3.4. National Comprehensive Cancer Care Plan (2020‑24)

The National Comprehensive Cancer Care Plan aims to Increase access to comprehensive cancer care through strategic actions with intercultural adaptation, health promotion, primary prevention, secondary prevention, early diagnosis, timely treatment, including palliative care delivered at the primary healthcare and community level. The new plan aims to consolidate efforts made to ensure that cancer care and prevention strategies are equitable and accessible to all Peruvians.

Key objectives include:

• Decrease the prevalence of cancer risk factors in the population.

• Increase the operational capacity and quality of health services for comprehensive cancer care.

• Improve the availability of medical supplies and technologies for comprehensive cancer care.

• Develop the model of integrated cancer care with a life course approach among IPRESS.

• Strengthen decentralised cancer services for timely comprehensive cancer care.

• Develop and integrate information systems for comprehensive cancer care.

• Develop clinical and public health research to improve decision making in comprehensive cancer care.

• Increase human resources and strengthen competencies for comprehensive cancer care.

• Increase financial protection for comprehensive cancer care.

Source: MINSA (2021[27]), Plan Nacional de cuidados integrales del cáncer (2020 – 2024), http://bvs.minsa.gob.pe/local/MINSA/5341.pdf.

References

[19] Alvarez-Risco, A., S. Del-Aguila-Arcentales and J. Yanez (2021), “Telemedicine in Peru as a Result of the COVID-19 Pandemic: Perspective from a Country with Limited Internet Access”, Am J Trop Med Hyg, Vol. 105/1, https://doi.org/10.4269/ajtmh.21-0255.

[11] Australian Bureau of Statistics (2024), Mental health findings for LGBTQ+ Australians, https://www.abs.gov.au/articles/mental-health-findings-lgbtq-australians.

[16] Bellido-Zapata, A. et al. (2018), “Implementation and application of the “Clinical practice guideline for diagnosis, treatment and control of type 2 diabetes mellitus at primary care level”, in a network of public healthcare facilities in Lima”, Acta Médica Peruana, Vol. 35/1, http://www.scielo.org.pe/pdf/amp/v35n1/a03v35n1.pdf.

[1] Carrillo-Larco, R. et al. (2022), “Peru − Progress in health and sciences in 200 years of independance”, The Lancet Regional Health - Americas, Vol. 7/100148, https://doi.org/10.1016/j.lana.2021.100148.

[7] DIGEMID (2021), Gasto de bolsillo en salud y medicamentos. Período 2020 al 2021., Dirección General de Medicamentos, Insumos y Drogas, https://repositorio-digemid.minsa.gob.pe/items/ff39a476-eb94-435d-8670-c422cc94be1e.

[17] Flores, O., Bell, R., Reynolds, R., and Bernabé, A (2018), “Older adults with disability in extreme poverty in Peru: How is their access to health care?”, PloS One, Vol. 13/12, https://doi.org/10.1371/journal.pone.0208441.

[18] Fraser, B. (2022), “Efforts to improve medical education in Peru hit obstacles”, The Lancet, Vol. 400, https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(22)02356-X.pdf.

[15] GOPBM/MINSA (2021), Diagnosis of gaps of infrastructure and equipment of the health sector, https://www.minsa.gob.pe/Recursos/OTRANS/08Proyectos/2021/DIAGNOSTICO-DE-BRECHAS.pdf.

[12] Human Rights Watch (2024), Peru Walks Back Anti-Trans Guidance in Health System, https://www.hrw.org/news/2024/06/27/peru-walks-back-anti-trans-guidance-health-system.

[8] INEI (2023), Perú: Medición de la Pobreza Multidimensional, Dimensiones e Indicadores (Revisión 2023), Instituto Nacional de Estadística e Informática, https://cdn.www.gob.pe/uploads/document/file/5402872/4833930-informe-tecnico-medicion-de-la-pobreza-multidimensional-revision-2023%282%29.pdf?v=1712328912 (accessed on 1 March 2024).

[26] INEI (2022), Perú: Evolución de los Indicadores de los Programas Presupuestales, 2013 - 2021, Instituto Nacional de Estadística e Informática, https://cdn.www.gob.pe/uploads/document/file/3407415/Per%C3%BA%3A%20Evoluci%C3%B3n%20de%20los%20Indicadores%20de%20Programas%20Presupuestales%2C%202013-2021.pdf?v=1657735085 (accessed on 17 April 2024).

[13] MINSA (2024), Minsa orders the cessation of the use of the term transsexualism in the chapter on Mental and Behavioral Disorders of the ICD-10, https://www.gob.pe/institucion/minsa/noticias/977793-minsa-dispone-cese-del-uso-del-termino-transexualismo-en-el-capitulo-de-trastornos-mentales-y-del-comportamiento-de-la-cie-10.

[6] MINSA (2022), Compendio Estadístico: Información de Recursos Humanos del Sector Salud Perú 2013-2021, https://digep.minsa.gob.pe/bibliografica.html.

[14] MINSA (2022), Technical Document “Model of Comprehensive Health Care for the Life Course for the Person, Family and Community (MCI), https://cdn.www.gob.pe/uploads/document/file/496394/resolucion-ministerial-030-2020-MINSA.pdf.

[4] MINSA (2021), Diagnóstico de Brechas de Infraestructura y Equipamiento del Sector Salud, https://www.minsa.gob.pe/Recursos/OTRANS/08Proyectos/2021/DIAGNOSTICO-DE-BRECHAS.pdf.

[27] MINSA (2021), Plan Nacional de cuidados integrales del cáncer (2020 – 2024), http://bvs.minsa.gob.pe/local/MINSA/5341.pdf.

[21] MINSA (2021), Situación epidemiológica de las Infecciones Asociadas a la Atención en Salud (IAAS), https://www.dge.gob.pe/portalnuevo/wp-content/uploads/2021/09/SDSS-IAAS_Primer-semestre-2021.pdf.

[3] Neelsen, S. and O. O’Donnell (2016), Progressive Universalism? The Impact of Targeted Coverage on Healthcare Access and Expenditures in Peru, https://papers.tinbergen.nl/16019.pdf.

[22] OECD (2020), Realising the Potential of Primary Health Care, OECD Health Policy Studie, OECD Publishing, Paris, https://doi.org/10.1787/a92adee4-en.

[2] OECD (2017), OECD Reviews of Health Systems: Peru 2017, OECD Reviews of Health Systems, OECD Publishing, Paris, https://doi.org/10.1787/9789264282735-en.

[5] ORHUS (2022), Información de Recursos Humanos en el Sector Salud, Perú 2022, Observatorio de Recursos Humanos en Salud, https://bvs.minsa.gob.pe/local/MINSA/7050.pdf (accessed on 6 May 2024).

[20] PAHO (2022), La pandemia de COVID-19 provoca el mayor retroceso en la vacunación de los últimos 30 años, https://www.unicef.org/peru/comunicados-prensa/pandemia-covid19-provoca-mayor-retroceso-30-anos-vacunacion-situacion-peru (accessed on 19 March 2024).

[25] PAHO/WHO (2015), Country Capacity Survey Results, Pan American Health Organization & World Health Organization, https://ais.paho.org/phip/viz/nmh_ccs_resultstool.asp.

[24] Parra Moscoso, M. (2017), “Propuesta de un modelo de gestión pública de referencia-contrareferencia para optimizar la calidad de servicio al paciente en una microred hospitalaria de Lima ciudad 2017”.

[9] Romani, L. et al. (2021), “Factors associated with the nonuse of health services in LGBTI people from Peru”, Rev Peru Med Exp Salud Publica, Vol. 2, p. 38, https://doi.org/10.17843/rpmesp.2021.382.6149.

[10] United States Census Bureau (2022), LGBT Adults Report Anxiety, Depression at All Ages, https://www.census.gov/library/stories/2022/12/lgbt-adults-report-anxiety-depression-at-all-ages.html.

[23] Videnza (2021), Redes integradas de salud en el Perú, Videnza Consultores, https://www.redesarrollo.pe/wp-content/uploads/2021/07/Redes-integradas-de-salud-en-el-Peru.pdf (accessed on 8 March 2024).

Note

← 1.  These include i.Law No. 30421 and Telehealth Regulations, ii. Telehealth Technical Standard, iii.Administrative Directive on Synchronous and Asynchronous Telemedicine., iv.Administrative Directive on Tele‑guidance and Tele‑monitoring. v.Telemanagement Administrative Directive, vi.National Telehealth Plan 2020 – 2023.