This chapter first examines the sustainability and efficiency of Peru’s healthcare system. It highlights that while financial resources allocated to the Integral Health Insurance increased over the past decade, the financial sustainability of the Peruvian health system remains challenged by low public spending on health and a complex budgeting process. Facilitating a more efficient provision of healthcare could help secure additional funding for the Peruvian health system. When it comes to the resilience of health system, the chapter analyses Peru’s preparedness for health crises and provides policy recommendations for implementing a One Health Approach to address antimicrobial resistance, strengthen the workforce planning strategy and revert the decreasing trend in childhood vaccination.
OECD Reviews of Health Systems: Peru 2025
Abstract
The health system in Peru is underfunded, leading to high out-of-pocket spending
Healthcare in Peru is financed by a wide range of actors with the SIS, EsSalud, private health insurance and direct payment by private households being by far the most important payers. In 2022, Peru allocated 6.2% of its GDP to healthcare. This share is the second lowest in the OECD (after Mexico) and also below other Latin American countries such as Costa Rica (7.2% of GDP), Colombia (7.6% of GDP), Chile (10.0% of GDP) or Brazil (10.1% of GDP in 2020) (Figure 4.1). This corresponds to USD 924 per capita when adjusted for differences in purchasing power, 25% lower than across the LAC (at USD PPP 1 155). The share of health spending has been growing since 2010 up from 4.8% of GDP.
Source: OECD Health Statistics 2024 and Peru’s submission to the 2024 OECD System of Health Accounts Questionnaire.
The country relies heavily on financing from the private sector, either via voluntary private health insurance or direct payments by household. In 2022, 64% of all spending was financed publicly (via SIS or EsSalud), 27% by out-of-pocket payments and 9% by private health insurance. While public health expenditures rose to 4.5% of GDP in 2021- slightly higher than in LAC (4% on average), OOP spending are still high (Figure 4.2). OOP spending in healthcare at 27% health spending, are now lower than in other LAC countries (at 32%), but still 42% higher than on average in the OECD. On a positive note, out-of-pocket spending decreased by more than 20% over the past two decades in Peru.
Source: OECD Health Statistics 2024 and Peru’s submission to the 2024 OECD System of Health Accounts Questionnaire.
Peru devotes a similar share of its public budget to health as other OECD countries, but the level of overall public spending in Peru is half the OECD average
The level of public spending in Peru is much lower than in other OECD countries. In 2021, overall public spending is at 23% of GDP, compared to 40% of GDP in the OECD. This is also lower than in other LAC countries, such as Chile (26%) or Mexico (27%). However, comparing health spending from public sources with total government expenditure suggests that Peru devotes a similar share of its public budget to health as other OECD countries (Figure 4.3). According to the Global Health Observatory, Peru devoted 17% of its public budget to health, slightly higher than the OECD average of 16% and well above other LAC countries such as Brazil, Chile and Mexico, and the overall LAC average (14%) (WHO, 2021[1]).
Source: OECD Health Statistics (2024), WHO Global Health Observatory.
Overall, low level of public spending is explained by low government revenues. According to the 2023 OECD Economic Survey, Peru is characterised by a relatively low tax burden and a narrow tax-base. The tax-to-GDP ratio is at 17%, well below the OECD average of 34% and the LAC average of 30% (OECD, 2023[2]). In addition, Peru has a narrow tax-base because of its large informal sectors, which means that Peru is unable to effectively collect payroll or consumption taxes. The low tax compliance lowers government revenues. While these issues have broader structural causes that go beyond the health system, these constrain the possibilities for meeting social needs and encouraging public investment in health infrastructure. Peru should therefore consider ways to raise public revenue to secure additional funding for the Peruvian health system. Leveraging efficiency gains and reducing wasteful spending in the health sector will help mobilise additional health resources to bring improvements in health infrastructure.
The Ministry of Economy and Finance has strict control over SIS’s budget
SIS public budget for health comes from the central government resources (from the Ministry of Economy and Finance) from general taxation. Regional and local governments’ health budgets are financed mainly by transfers from the central government (94%), donation and transfer from SIS. All the financial flows in the health sector cascade to the administrative offices of the public sector that manage resources, called “executing units” (unidad ejecutoras, UEs). At the regional government level, each of the 24 regional governments constitutes an executing unit, and there are 142 additional executing units (some hospitals and service networks mainly). Finally, at the local level, there are 199 provincial and 1 838 district executing units. Each executing unit receives funds from different institutions. Often, these come with different conditionalities, reporting mechanisms, even different performance targets, suggesting complex budgeting process which does not help to achieve transparency.
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 Hospital (INEN), each regional government (GORE) is also a budgetary unit. The resources of each pliego are in turn managed by executing units.
Annually, the Ministry of Economy and Finance, within the framework of Legislative Decree 1 440, submits the Multiannual Budget Allocation to the Council of Ministers for approval. In addition, the executing units evaluate their needs, based on historical spending, which are aggregated by the regional governments to formulate their budgetary requirements to the Ministry of Economy and Finance. Based on these requirements and the three‑year Multiannual Budget Allocation, the MEF allocates an initial opening budget (the PIA) to each executing unit. The funds are allocated to SIS and regional governments. With the decentralisation of key competencies to the regions, regional governments have the autonomy to constitute a Budgetary Plan for their economic and financial administration.
The PIA is then adjusted during the budget execution according to needs and fulfilment of specific criteria such as performance (“Presupuesto Institucional Modificado, PIM). The budget execution starts on the 1 January, and the PIM is updated on a monthly basis. It is important to note that the PIA is a budget floor, which does not reflect how funds are going to be spent, but rather, which institution is responsible for deciding the allocation of resources and managing the funds throughout the fiscal year.
In addition, other transfer can take place during the year. This is mostly happening for the public sector, as SIS transfer resources to the executive units for primary healthcare providers and hospitals, and there are also transfers from MEF linked to good performance evaluations.1 As the result, PIMs are generally higher than their initial budgets because of these transfers made by SIS and MINSA. Overall, the PIA does not show how resources should be prioritised and how annual policy objective should be achieved. It is recognised that budget execution by executing units is difficult due to insufficient planning and management capacity at regional and local government level (OECD, 2017[3]).
A recent analysis done by the Ministry of Economy and Finance for the National Comprehensive Plan for Cancer Control shows that while the Budget Programme 024 has been increasing from PEN 30 239 303 in 2011 to PEN 985 519 326 for the year 2018, the execution rates were only at 62% in 2019 (MINSA, 2021[4]). There are several factors explaining budget under-execution. These include a lack of regional and local capacity to manage and plan the health sector activities, shortages of health personnels and challenges in retention, as well as budget rigidities. Regions are tied to the general budget document, which is very detailed and divided into many budget line items. There is strong control to prevent reallocations across budget lines. This means that MINSA, regional governments or executing units may have funds for one line item, but need funds for another and are not allowed to reallocate the funds (OECD, 2017[3]). Recently to increase budget execution, the MEF has reduced delays in budget transfers. Increasing timeliness of transfers is important to leave sufficient time for receiving institution to spend funds.
Budgeting process should move away from historical budgets to better match its service obligations
The budgeting process, which is based on historical budgets, does not assure that SIS has access to resources that match the number of affiliates and the actual cost of providing health services. While the 2011 Law of Public Financing of the Subsidised and Semi-Contributory Regimes established that SIS would receive funding based on the premium and the number of beneficiaries, this has never been implemented in practice. The last actuarial study was carried out in 2015 using 2012 data. The 2015 study established an average expected cost of PEN 360 per affiliate per year. In 2024, SIS average expenditure per affiliate was PEN 96, which is almost three times lower the expected cost. This amount, however, exclude recurrent costs such as capital and labour which are paid by regional governments.
SIS financial resources increased almost 4‑fold over the past decade, from PEN 517 million in 2010 to PEN 2 483 million in 2022 (Figure 4.4). SIS financial resources increased quicker that EsSalud one (Figure 4.5), but SIS affiliates doubled between 2020 and 2022 while EsSalud affiliates increased by 46% over the same period.
Source: Ministry of Economy and Finance (MEF), Gerencia Central de Gestión Financiera (GCGF).
Source: Ministry of Economy and Finance (MEF), Gerencia Central de Gestión Financiera (GCGF).
Peru should move away from allocating budgets based on historical expenditure for variable costs to better reflect its service obligations. This is even more important given the remarkable expansion of the compulsory health coverage over the past year. The Ministry of Health and the Ministry of Economy and Finance might want to conduct a new actuarial study to ensure that SIS receives a budget that better matches the number of beneficiaries. The social health insurance (EsSalud) is a good practice example in this regard, with actuarial studies conducted on a regular basis to analyse epidemiological data and predict the expected cost of providing care.
There are ways to achieve efficiency gains in Peruvian health system
Increasing the use of results-based financing (PpR) towards key health priorities and the health benefit packages
In addition to historical budgeting, Peru uses budgeting for results as a public management strategy to introduce incentives for public entities towards the achievement of results, improving the quality of public spending. The Budgeting for Results Programmes (Presupuestos por Resultados, PpR) was implemented in 2007 as part of the National Budget System Reform launched by the MEF. This initiative marked a transition from traditional budgeting methods, which allocated resources on historical basis, without a clear evaluation of the needs (like human resources and goods and services) to an approach centred on productivity and performance. The overarching objective was to improve public expenditure effectiveness by aligning resource allocation with government priorities and linking them to specific goals. The programme focuses on identifying the right mix of inputs to achieve the different intermediary products, which is a very good development.
In 2024, PPR programmes represented 40% of the total health budget. The Budgeting Programme can be Results Oriented Budgeting (PPoR), and Institutional Budgeting Programs (PPI). The PPoRs are intended to achieve results on the population and their environment, and are multisectoral and intergovernmental in nature, while the PPIs are intended to achieve sectoral results and institutional strategic objectives. In 2024, there were 12 programmes implying the health sector. Nine were PPIs, for which the Ministry of Health has the strategic and operational leadership, for example in the area of maternal and neonatal health, tuberculosis and HIV, non-communicable diseases, cancer or mental health (Table 4.1). It also participated in the management of products related to the health function through three PPoRs: vulnerability reduction and emergency care due to disasters, early childhood development and reduction of violence against women.
Note: Budget execution was calculated using data from the Integrated Financial Administration System (SIAF).
Source: CGR (2023[5]), Informe sobre presupuesto por resultados (PpR) en el Perú para el Informe de Auditoría a la Cuenta General de la República, Contraloría General de la República, https://cdn.www.gob.pe/uploads/document/file/4922923/Informe%20T%C3%A9cnico%20002-2023-CG-OBANT%20-%20Programas%20Presupuestales.pdf (accessed on 17 April 2024).
The PpR established public spending accountability, mechanisms for data generation related to outcomes or outputs. It introduced evidence‑based policy making and use of performance indicators to target the budget process. However, the budget document is designed at a very detailed level which does not allow for autonomy to MINSA and regional authorities to manage funds and take corrective actions (OECD, 2017[3]).
Evaluations of PpR programme in the health sector suggest positive results in terms of health budget improvement for specific areas and better health outcomes. In the area of maternal and child health, the PpR led to an increase in institutional deliveries performed by skilled workers from 89.2% in 2014 to 93.2% in 2021, increasing at a higher rate among women living in rural areas (68.5% in 2013 to 81.1% in 2021). Other improvements include a decrease in the prevalence of anaemia in the share of children between 6 months and three years of age from 46.4% in 2013 to 38.8% in 2021, as a result of the programme on articulated nutrition (INEI, 2022[6]).
While the implementation of PpR is a very positive development, the programmes are disconnected from other benefits packages such as PEAS and FISSAL, which are still based on historical budgeting methodology. According to a recent WHO analyses, approximately 40% of the services covered by PEAS are not part of the PpR (WHO, 2020[7]). Additionally, the current design of the PpR does not promote people‑centred care, but rather focuses on specific health problems and vertical health interventions. For health benefit packages or other key health priorities, Peru could incorporate the use of PpR financing mechanisms to enhance efficiency, while allowing regional authorities some flexibility in fund management. Furthermore, the PpR could include a greater emphasis on activities related to integrated care, another key priority on the political agenda.
Rethinking hospital service delivery and payment systems
In 2023, 25 349 healthcare facilities, both public and private, were registered at RENIPRESS (the national Registry of Institutions of Health Services Provision), among which 616 were level II (558 small hospitals) and level III (44 large and specialised hospital centres). As evaluated by MINSA, the hospital sector within the SIS network is deemed to be more vulnerable than the primary healthcare sector. All hospital units in 16 out of 25 regions are classified as having infrastructure that is inadequate for ensuring proper patient care. In addition, previous evidence suggests allocative inefficiency in the Peruvian Health system with low productivity of Level III and Level II healthcare facilities (World Bank, 2021[8]). To achieve efficiency gain, Peru could repurpose small hospitals into intermediate care facilities to consolidate resources (such as staffing, equipment and infrastructure) in larger hospital centres. Strengthening of telehealth application (notably the use of tele‑expertise services) and triaging patients according to the level of urgency will be necessary not to compromise access to acute care for patients in remote areas. In a similar vein, expanding medical transportation from rural to better-equipped general hospitals in urban areas will also be critical to ensure timely access to urgent care. Such reforms would help to achieve gains in allocative efficiency. The specialisation and concentration of hospital services is a reform that many OECD countries have undertaken to achieve efficiency gains, while promoting access and care quality (Denmark, Portugal for example).
Peru has also established Public and Private Partnership hospitals within SIS and EsSalud networks respectively. These are public institutions with administrative, financial and asset management autonomy under contracted private management. Hospital services are jointly provided by public and private parties sharing financial, technical and operational risk. The overarching objective is to improve general performance in the health sector and also ensure that private funds will finance a new set of urgent hospital investments. Overall, there are five PPP health projects in Peru, which have contributed to improve access to quality services, as demonstrated by the National Institute of Child Health of San Borja whose PPP contract is for the management of ten non-clinical services.
The payment transfers from SIS to regional authorities consist of two components. The basic payment is a fee‑for-services mechanism, and the additional component is based on a payment for package of surgical services. The latter component has been introduced in 2024, and includes payments for C-section, extracapsular and phacoemulsification type of cataract treatment, conventional inguinal hernia repair in adult patient, conventional and laparoscopic cholecystectomy in adult patients. In 2023, payments started to be made through the pre‑purchase of service, through a prospective payment mechanism. The current changes in hospital’s payments are good steps to better standardised care and limit incentive for over-production.
To improve efficiency, many OECD countries have also introduced prospective case‑based payment system based on Diagnosis-Related Groups (DRGs) to pay for hospital activity. With DRGs, patients are grouped into different patient groups reflecting the resource‑intensity of the treatment. Different weights are associated with the various DRGs reflecting average treatment costs. After discharge, the hospital receives a payment reflecting the weight of the DRG. Peru should consider developing a mixed payment system for hospitals, which combines fee‑for-service and payment for a package of services, and progressively transitions through the use of Diagnosis-Related Groups (DRGs). As demonstrated by previous OECD work on payment systems, this would necessitate a detailed hospital cost accounting system and meticulous monitoring of care quality.
Strengthening procurement planning would help to address medicines shortages
The General Directorate of Medicines, Supplies and Drugs (Dirección General de Medicamentos, Insumos y Drogas, DIGEMID), which is part of the Ministry of Health, regulates pharmaceuticals, medical devices and other health-related products for the various healthcare sub-systems in Peru. This responsibility covers the regulation of the manufacture, import, export, storage, distribution and commercialisation of these products. DIGEMID is also responsible for evaluating products, inspecting pharmaceutical establishments and issuing certificates and relevant documents. DIGEMID also has a key role in pharmacovigilance, access to medication and proper and rational use of medicines.
MINSA, through DIGEMID, and in co‑ordination with the different entities of health public sector (EsSalud, Health of Armed Forces) establishes a single national list of essential medicines (PNUME). The PNUME covers approximately 80% of the burden of disease and as of 2023, it included 796 essential medicines, which should be covered by all public sub-sectors. The PNUME is updated every two years, during which Complementary Lists (cancer, mental health, HIV etc) are introduced on an ad hoc basis and eventually added to the PNUME.
For the public sector, there are two main purchasers: the National Center for the Supply of Strategic Health Resources (Centro Nacional de Abastecimiento de Recursos Estratégicos en Salud, CENARES) on behalf of MINSA and the Strategic Goods Supply Center (Central de Abastecimiento de Bienes Estratégicos, CEABE) on behalf of EsSalud. There is centralised procurement for certain groups of medicines, through two main mechanisms:
Centralised procurement for the purchase of strategic products, which MINSA offers to all citizens of the country as a public health right, regardless of their socio‑economic or insurance status. This is the case of vaccines, treatments against TB or HIV/AIDS, medicines or supplies against metaxenic diseases such as malaria, dengue, zika, chikungunya and others. CENARES directly purchases and distributes these drugs (Ugarte Ubilluz, 2019[9]).
Corporate purchasing (compras corporativas) for the procurement of non-strategic products, which include some of the most frequently used medicines such as antibiotics, anti‑inflammatory drugs, antihypertensives, antidiabetics, anti‑ulcer drugs or sedatives. The budget for these drugs is allocated to each health entity in the national territory (hospitals, executing units, regional health directorates). First, hospitals, clinics, or regional governments interested in this scheme submit their yearly medication requirements to DIGEMID, which compiles a list of potential medications for purchase. Following this, CENARES conducts reverse auctions, setting a maximum price and allowing suppliers to offer lower bids competitively to secure the best prices for specific quantities. The process concludes with each participating entity or regional government formalising purchase agreements with the suppliers who offer the best terms for price and quantity. This mechanism offers the advantage of unifying purchases across the sub-regimes: regional governments, Armed Forces and National Police health systems as well as EsSalud (Ugarte Ubilluz, 2019[9]). In the case of drugs for oncology and rare diseases, which often pertain small quantities and from specific suppliers, these are purchased directly by each health entity and depend on the budget allocated by the MEF (Ugarte Ubilluz, 2019[9]).
Data from SUSALUD show that in 2022, the most frequent category of complaints were related to difficulties in accessing health services (28.6%) and particularly in accessing medicines or health products (22.2%) (SUSALUD, 2022[10]). The lack of available medicines in public facilities often results in patients having to buy the prescribed medicines out-of-pocket in private pharmacies. Not surprisingly, using ENAHO data, the DIGEMID has estimated that the category of medicines made up the highest share of out-of-pocket healthcare expenditures for 2020 and 2021, at 36.5% and 32.2% respectively (DIGEMID, 2022[11]).
The lack of access to medicines as a result of shortages in public health facilities is reflected in the indicator published by the Integrated Supply System for Medicines and Medical and Surgical Supplies (SISMED), which measures the share of essential medicines with a stock greater than or equal to 2 months of available stock of the adjusted monthly average consumption, for the facilities belonging to MINSA and regional governments. As of February 2024, 20% or more of the health facilities in over half of regions were considered to be understocked or out-of-stock according to this indicator (Figure 4.6). Although this indicator is used to inform procurement planning, SISMED calculates this at the end of the month by consolidating the information received from regional governments, meaning procurement planning is often done with outdated information instead of responding to current needs. Progress in this area can be found in EsSalud’s facilities in Lima and Callao, where a system for inventory management makes it possible to see the stocks available in real time. Additionally, interoperability with EHR allows EsSalud to measure the extent to which prescribed medicines were dispensed to the patients (Videnza Consultores, 2020[12]; Videnza Consultores, 2021[13]; Videnza Consultores, 2022[14]; Movimiento Salud 2030, 2021[15]).
Other reasons for shortages include delays from the executing units from MINSA and regional governments in preparing and submitting their requests to CENARES, which results in delays for both budgeting and procurement. According to the MINSA, while the mechanism for corporate purchases has improved the affordability of products (by aggregating demand and lowering prices), it has also contributed to shortages of medicines in public health facilities since these purchases require regional or local governments, who often lack resources and expertise, to formalise their own purchase agreements with suppliers at the final stage. Additionally, for medicines that have to be purchased directly by regional governments, as is the case once stock-out has been reported, complex public procurement regulations and lack of administrative capacity at the regional level also results in delays for the acquisitions (Videnza Consultores, 2020[12]; Videnza Consultores, 2021[13]; Videnza Consultores, 2022[14]; Movimiento Salud 2030, 2021[15]).
Peru would need to strengthen the planning behind the procurement of medicines through information systems that allow for a better estimation of health demand so that the system can respond in a timely manner. Data from electronic health records and SISMED could be used to monitor dispensing and anticipate shortages so that authorities can be notified and engage in procurement. Additionally, MINSA could increase stewardship to support regions with insufficient planning or administrative capacity for carrying out their purchases. Purchase agreements for non-strategic products could be supported or delegated at central level as done with the centralised procurement for the purchase of strategic products (used for public health interventions), which are purchased directly by CENARES.
Source: SISMED (2024[16]), Resultado del indicador ficha No31 por región del marco de los Convenios de Gestión 2024, https://app.powerbi.com/view?r=eyJrIjoiMmNjNTBmOWItZWM3NS00YTgxLTk5M2ItOGNjNWEyOTU3ODczIiwidCI6IjM0ZjMyNDE5LTFjMDUtNDc1Ni04OTZlLTQ1ZDYzMzcyNjU5YiIsImMiOjR9.
There is room for greater availability of generics
The development of generic markets is an opportunity to increase efficiency in pharmaceutical spending and reduce out-of-pocket payments for patients. Underutilisation of generic drugs can be a substantial source of inefficiency as generics have the same therapeutic effects as branded alternatives but are typically much less expensive. In 2019, DIGEMID conducted an evaluation of the availability of generic INN medicines for a set of 79 essential medicines in private pharmacies. For all regions excluding Lima, the average availability of generic medicines in private pharmacies was 42%, ie. on average 42% of the 79 medicines was available as generics in any given private pharmacy, whereas in Lima it was 40.5%. The availability of medicines varied widely across pharmacies, ranging from 1% to 76%. The availability of generic medicines in private pharmacies also varied widely across regions, ranging from an average of 29% in Pasco to 71% in Tumbes. Additionally, of the medicines assessed, 61% were in stock in less than 50% of pharmacies (Congreso de la República, 2019[17]).
In October 2019, emergency decree N°007‑2019 made it mandatory for private pharmacies to maintain generics in stock for 34 essential medicines. In May 2024, Law Nº 32 033 20 made it mandatory for private pharmacies and health facilities to maintain 30% of their stock as generics for 434 essential medicines. This law is a step in the right direction towards bringing down out-of-pocket expenditures and realising efficiency gains in line with those of OECD countries where generics make up on average 53% of the volume sold in community pharmacy markets.
Further consolidating Health Technology Assessments to perform economic evaluations more systematically
Peru has taken important steps in developing its capacity for health technology assessment. In 2015, EsSalud’s Institute for Health Technological Assessment and Research (Instituto de Evaluación de Tecnologías en Salud e Investigación, IETSI) started to carry out systematic reviews related to devices, equipment and medications. Additionally, the Center for Health Technology Evaluation (CETS) which belongs to the National Institute of Health (INS) has conducted several HTAs for the Ministry of Health in the past, although these assessments seem to have been of an informative character, ie. they did not provide a decision on whether the technology was recommended or not (Taype-Rondan et al., 2022[18]).
In 2020, the National Network of Health Technology Assessment (Red Nacional de Evaluación de Tecnologías Sanitarias, RENETSA) was created, with the aim of co‑ordinating and harmonising the HTA activities across different sectors of the Peruvian health system. RENETSA is made up of DIGEMID, IETSI and CETS-INS, and is led by the latter. The establishment of RENETSA represents a significant step towards consolidating HTA practices in Peru, promoting the efficient use of healthcare resources. Moreover, on February 2022, a technical document describing the methodology to be followed by RENETSA when performing an HTA was issued through Ministerial Resolution N° 112 –2022/MINSA.
From 2021, the Cancer Law gave responsibility to RENETSA for the evaluation of high-cost oncological medicines not included in the PNUME, its Complementary Lists, or medical devices that are necessary for the treatment of oncological diseases, subject to multi-criteria evaluation (such as analysis of disease burden, therapeutic impact, safety profile, level of innovation, equity, or unmet need). Various stakeholders are involved in the process (including government agencies, academic institutions, healthcare providers) and the recommendations derived from this multi-criteria HTA is binding for the coverage of these technologies throughout the public sector. In addition, high-cost thresholds have been established to prioritise pharmaceutical products that require the development of health technology assessments. In a similar vein, the modification of the Rare and Orphan Diseases Law establishes that health technologies for the treatment of these diseases will also be evaluated through RENETSA’s multi-criteria HTA. By December 2023, 170 HTA applications had been submitted and 20 recommendations for the coverage and use of high-cost cancer technologies had been issued by RENETSA.
So far, only DIGEMID2 has carried out economic evaluations of oncology drugs as part of their evaluations, while those carried out by IETSI and CETS focus on safety, efficacy, and clinical effectiveness. In 2022, DIGEMID established the first cost-effectiveness (CE) threshold3 for the analysis of interventions, health technologies and pharmaceutical products (Fernandez-Navarro, Gonzales-Saldaña and Araujo-Castillo, 2022[19]; Saldarriaga, 2023[20]), although the extent to which this has been used is not clear. Integrating economic assessments into routine HTA practices could improve decision-making for the reimbursement of medicines, especially in light of the high prices of novel medicines for oncology and rare diseases.
In Peru, the General Directorate of Health Personnel develops human resources for health policies and carries out monitoring and evaluation of existing human resources for health based on the 2017 Supreme Decree 008‑2017‑SA. In addition, Regional Health Directorates have regions dedicated to managing human resources at the local level, though these regions are not explicitly tasked with assessing needs.
Physician density is more than half the OECD average
Between 2013 and 2022, the number of physicians per 1 000 inhabitants increased by 27%. Despite these improvements, the density of physicians remained below the OECD average. In 2022, Peru has 1.6 physicians per 1 000 habitants, slightly lower than the average in the LAC region (2) and more than half the OECD average (3.8). In a similar vein, the density of general medical practitioners in Peru is very low. The number of primary healthcare physicians per 1 000 inhabitants increased from 0.2 to 0.3 inhabitants from 2009 and 2020, compared to an increase from 0.9 to 1.2 per 1 000 inhabitants from 2000 to 2020 in OECD countries (OECD, 2022[21]). 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[22]).
Nursing profession is in expansion, but still lower than the OECD average
Currently, there are 114 000 nurses in the country, which is equivalent to almost 2 nurses per 100 000 population. More than 70% of nurses work in MINSA or regional government health facilities, 17% in EsSalud facilities, and 7% in private facilities.
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). While Peru ranks as one of the lowest in terms of density of nurses per capita in the OECD, the number of nurses per 1 000 habitants increased by 68% between 2013 and 2022. This trend points to large improvements in the availability of nurses in Peru. However, the uneven distribution between rural and urban areas follows a similar trend observed with physicians, with only 14% of nurses working in rural areas in 2021 (MINSA, 2022[22]).
Over the last two decades, the number of primary healthcare teams expanded rapidly in Peru. The number of PHC teams grew by 38% over the past decade, reaching 0.30 PHC teams per 1 000 inhabitants in 2020 (OECD, 2020[23]).
Investment in workforce planning and adequate incentive structures is needed to improve retention of health workers
Human health resources policies have been implemented in Peru to address geographic imbalances in the distribution of healthcare and close the gap between rural and urban areas. These include the creation of the National Health Personnel Register (INFORHUS) in 2013 to adequately monitor workforce level and plan for current and future needs. In addition, the Servicio Rural y Urbano Marginal en Salud (SERUMS) programme requires health professionals seeking employment in the public sector to complete an internship in either rural or marginal urban areas, typically for one year. SERUMS regulate the practice of several healthcare workers including physicians, nurses, dentists, obstetricians or psychologists. In 2024, a total of 8 048 budgeted positions are available for health professionals who perform the SERUMS service in health facilities located in approximately 2 294 of the country’s poorest districts. The SERUMS service is a mandatory requirement to apply for positions in public entities, to follow professional specialisation programmes and to receive public scholarships. Previous evaluation suggests only 25% of these professionals remain in the public sector one year after completing their SERUMS internship (OECD, 2017[24]). Other evidence shows that the lack of medical equipment and supplies, as well as excessive workload (with both clinical and administrative work) are the main problems reported by physicians under the SERUMS programme (Taype-Rondan et al., 2016[25]).
Peru has also sought to increase the competencies of physicians in family and community medicine through the development of the Programa Nacional de Formación en Salud Familiar y Comunitaria (PROFAM). PROFAM is implemented by the Ministry of Health through the National School of Public Health. The diploma in family medicine and community health offers a comprehensive and integrated approach to care. It includes strategic training in areas such as mental health, public health, and public management. Although this training is not mandatory for primary care practice, it is a necessary requirement to receive a financial bonus when practicing in primary healthcare practices. According to information provided by MINSA, there were five training actions executed in the PROFAM self-training modality in 2017, with a total of 23 512 participants. In the second phase in 2018, 21 training actions were executed, with a total of 74 994 participants.
Emigration of healthcare workers is a driving factor explaining the shortage of health workforce in Peru. According to the ENSUSALUD survey, around 7% of healthcare workers intend to emigrate, notably due to burnout syndrome, poor working conditions, and low wages. These factors pose significant barriers in attracting and retaining healthcare workers in the public sector and in remote areas. Notably, there are salary differences across regions, to the detriment of rural healthcare workers. For example, the monthly average salary for nurses in urban areas is PEN 2 981, compared to PEN 2 818 in rural areas. The monthly average salary for doctors in urban areas is PEN 6 208, compared to PEN 5 430 in rural areas. Peru needs to implement adequate incentive structures to improve the recruitment and retention of health workers. One option for consideration is to provide a higher level of financial incentives than the one currently provided (which were PEN 1 850 and PEN 1 350 monthly for physicians and nurses respectively as of 2024) to attract and retain them in underserved areas. Some OECD countries, such as Chile, combine financial and non-financial incentives to attract and retain physicians in underserved communities.
One issue that may explain problems in accessing SIS or EsSalud services is the widespread use of “dual practice”, which means that many physicians split their time between public and private practice. While the regulation prohibits doctors from having more than one job in the public sector, physicians still have opportunities to take on additional tasks in the lucrative private sector. The incentive for physicians is to obtain better incomes, in the face of low public salaries. Peru needs to properly monitor and regulate dual practice. In 2023, SUSALUD launched a National Platform for Care Shifts named TuASUSALUD, where citizens can access the scheduled hours of health personnel in both public and private establishments, thereby improving transparency and avoiding physicians being scheduled in different places at the same time. Across OECD countries that have taken measures to increase physicians’ time to treat patients in the public sector include Ireland and Israel. Part of their strategies include a pay raise for public doctors that forgo the option to work in the private sector. Another option for consideration would be to allow physicians to have more than one job in the public sector. In the context of the dengue emergency, the government has issued the Supreme Decree 004‑2024‑SA that allows specialist doctors and nurses to temporarily have more than one position in the public sector. The authorisation should be maintained over the long term to address shortages of health workers in the Peruvian Health System.
In addition, Peru would need to invest in the nursing professions. Extensive international evidence supports the transfer of roles traditionally performed by doctors to nurses and other allied health professionals. An initial step would be to train more nurses while investing in advanced practice training. In 2022, 80% of OECD Member countries have increased or are planning to increase training capacities in nursing education. This strategy aims at addressing physician shortages, and reducing pressure on doctor. Community health workers offer another potential avenue for Peru to carry out health prevention and health promotion, communicating with communities in their own language and bridging the gap between traditional and modern medicines. The involvement of community health workers is especially important to support healthcare delivery in the Andes and Amazonas regions, which are very remote areas with populations of indigenous origin. To date, the training and participation of community health workers have not been formalised in Peru.
Designing effective human health resources policies most importantly requires high-quality and comprehensive data that can be used for monitoring health labour market dynamics and evaluating the impact of policies. Global experiences underscore the centrality of investments in information systems that provide reliable and up-to-date information on human resources for health. This helps inform further investigations and policy development. In Peru, both the Ministry of Health and regional authorities use INFORHUS to assess human resources for health needs. However, data on health workers employed in sub-systems are often unavailable due to the lack of reporting requirements for EsSalud and private providers. The dearth of data on the availability of health workers in other sub-regimes undermines efforts to assess human resources for health needs. This partly explains why Peru does not regularly publish recent work focusing on human resources for health assessment. The last reports evaluating the supply of and demand for specialists, and making an assessment of regional goals, were published in 2011 and 2013.
MINSA could also provide support to regional authorities that lack the sufficient scale, technical, and financial capacity to assess their own needs and formulate policy options. Following the 2013 assessment of regional human resources for health goals up to 2015, the Ministry of Health published a set of technical guidance notes in 2014. These were published to lay out methodological approaches that can be used to calculate human resources for health gaps at primary, secondary, and tertiary care. This is a good practice that MINSA should replicate.
Although the national policy landscape for AMR has seen significant improvements, there remain gaps in the practical implementation of these policies
While antibiotics have significantly improved population health, the overuse of antibiotics exerts selective pressure on microorganisms leading to antimicrobial resistance (AMR). In the last 20 years, Peru exhibited the highest growth rates in total antibiotic consumption. In Peru, total antibiotic consumption more than double, rising from 4.5 DDD per 1 000 inhabitants per day in 2000 to 10 DDD per 1 000 inhabitants per day in 2015. By comparison, in the OECD, over the same period, total consumption grew on average across countries by 9% from 21.4 to 23.3 DDD per 1 000 inhabitants per day. Overall, resistance proportions, averaged across 12 priority antibiotic-bacterium combinations, are projected to increase in Peru by 1.7 percentage points between 2019 and 2035 (OECD, 2023[26]).This is compared to an average reduction of 1 percentage point across the OECD. By 2035, AMR rates in Peru will average 27%, compared to 20% across the OECD and 30% in LAC countries (Figure 4.7).
Note: For countries on the left of this graph, resistance proportions are higher in 2035, compared to 2019. For countries on the right, rates are lower in 2035. Otherwise, countries are sorted left to right based on ascending resistance proportions in 2019. Averages for different country groups are unweighted.
Source: OECD (2023[26]), Embracing a One Health Framework to Fight Antimicrobial Resistance, https://doi.org/10.1787/ce44c755-en.
Peru has been making progress in implementing policies to strengthen the resilience of its health system to Antimicrobial Resistance (AMR). The Multisectoral Plan to combat antimicrobial resistance for 2019‑21 was approved through Supreme Decree 010‑2019‑SA. Currently, a new plan for 2024‑26 is under development. In addition, Peru has established a permanent Multisectoral Commission against AMR via the Supreme Decree 010‑2019‑SA. This commission aims to improve surveillance systems to monitor progress towards national targets. The National Institute of Health’s portal provides public access to information on antibiotic use and AMR.
Remarkably, Peru is advancing towards a One Health approach by developing an integrated Antimicrobial Resistance (AMR) surveillance system that spans four main sectors: health, agriculture, production, and environment. These sectors cover human health, animal health, food, and the environment. MINSA will be involved, along with the Ministry of Agrarian Development and Irrigation, the Ministry of the Environment, and the Ministry of Production. The integrated surveillance system is bolstered by the development of a new “Framework Law for the Containment of Antimicrobial Resistance under the One Health Approach”. This law aims to establish essential public mechanisms for co‑ordination, management, and budgetary allocations to address antimicrobial resistance comprehensively under the One Health approach.
While the implementation of the national policy against AMR clearly demonstrates Peru’s commitment to addressing this public health issue by adopting a One Health Approach, a recent OECD analysis identifies some gaps in the level of policy implementation (OECD, 2023[26]). Firstly, although a National Action Plan against AMR has identified funding sources, is being implemented, and involves relevant sectors, it lacks an operational plan. Additionally, while Peru has guidelines in place for optimizing antibiotic use in human health for all major syndromes, they are not implemented across all healthcare facilities. Monitoring and surveillance are also not utilised to inform policy action, update treatment guidelines, and essential medicines lists, and data on antibiotic use are not shared with prescribers (OECD, 2023[26]). Regarding AMR awareness, there are no nationwide, government-supported activities to raise AMR awareness and facilitate behaviour change among priority stakeholders, with regular monitoring of these activities. Some awareness activities are carried out at local and regional levels about the risks of AMR and actions to address it, targeting some but not all relevant stakeholders. Peru also provides training and professional education opportunities to raise awareness of AMR among health professionals in the human health sector, though AMR is not systematically incorporated into pre‑service training curricula for all relevant human health cadres (OECD, 2023[26]).
Peru has increased its crisis outbreak preparedness by bolstering its laboratory capacities
Despite Peru’s long history in risk reduction and disaster response, the resilience of its health system was tested during the COVID‑19 pandemic. The pandemic placed significant pressure on the health system, exposing weaknesses in crisis preparedness and management. Since 2019, Peru has aligned its policies with the International Health Regulations (IHR) and submits annual reports to the WHO on its compliance with disaster risk reduction measures. In 2019, Peru’s average score for IHR core capacity was 59. This was lower than the score in both other OECD and LAC countries such as Argentina (64), Brazil (92), Chile (76) and Costa Rica (77) (WHO, 2022[27]). However, the average of 15 IHR core capacity scores has improved by 6% between 2021 and 2022. Still in 2023, the State Party Self-Assessment Annual Report suggests particular vulnerability in the area of co‑ordination of functions, funding, human resources, emergency planification and management, supply chain management, health service delivery, prevention and control of infections and on risk communication and community involvement. For each area, Peru’s score stands at 20%.
Three different institutions are in charge of risk preparedness and management in the health sector: 1. DIGER (which deals with risk reduction in health infrastructure); 2. CDC (which is responsible for epidemiological surveillance) and 3. RENACE network (which makes weekly and monthly reports/notifications of epidemiological outbreaks). Following the COVID‑19 pandemic, several policy reforms have been instituted in Peru to improve outbreak risk management and preparedness. Between 2020 and 2022, MINSA implemented five national pandemic plans to address the COVID‑19 pandemic. These plans for COVID‑19 were consistent with the International Health Regulations (IHR), and in line with the Strategic Action: Prevention and response to international public health emergencies. They have focused on strengthening specific risk management approach and processes toward preparedness and response. The objective is to improve multisectoral organisation and co‑ordination; prevent and control community transmission of COVID‑19, improve timely detection of COVID‑19 cases, strengthen response capacity and infection prevention, implement active vaccination against COVID‑19 and strengthen the availability of strategic supplies. The country also has a National Disaster Risk Policy for the year 2050, with six objectives:
Enhance the comprehension of disaster risks to inform decision-making processes at both the population and state entity levels.
Optimise the conditions for territorial use, taking into account disaster risks.
Refine the co‑ordinated implementation of disaster risk management across the territory.
Bolster the integration of disaster risk management in both public and private investments.
Guarantee the provision of care for the population during emergencies and disasters.
Improve the recovery process for the population and livelihoods affected by emergencies and disasters.
Peru is highly committed to implementing a One Health approach to outbreak preparedness and risk management. The country shows a strong commitment to transparency to improve its response capacity. Peru has officially requested a voluntary external evaluation from PAHO in the context of IHR capacities, which consists of an assessment of the country’s capacity to prevent, detect and respond rapidly to public health threats.
It’s noteworthy that Peru has made significant strides in bolstering its testing capacity. An advanced laboratory infrastructure and enhanced surveillance capacity are crucial for monitoring the virus and are critical for preparation and response to health emergencies. However, during the COVID‑19 pandemic, the limited laboratory capacity posed a challenge to the implementation of adequate and decentralised molecular testing (Herrera‐Añazco et al., 2021[28]). The network of laboratories managed by the INS was strengthened after the pandemics. In 2021‑22, The INS certified 100 laboratories, located in the 25 regions, which have appropriate technologies and infrastructure to carry-out molecular testing for COVID‑19 and other infectious disease. This is an important step to monitor case notification, trace people and make sure they receive appropriate care. Yet there are still some pending challenges to strengthen Peru’s laboratory capacity. These include developing a transportation system that provide primary cold chain services and enables real time tracking of transported specimens, expanding specimen storage capacity and monitoring specimen stability, and developing a standardised packaging system for specimen transfer (USAID, 2023[29]).
The effectiveness of these national initiatives, however, hinges on robust regional implementation. Despite having a clear national plan with identified funding sources, the success of these measures largely depends on regional decisions and implementations. Issues with technical and organisational capacity at the regional level could lead to suboptimal implementation of these critical health policies.
The decrease in vaccination coverage increases the risk of outbreaks due to preventable diseases
With decreasing vaccination rates, the risk of vaccine‑preventable diseases outbreak increases in Peru. While the Peruvian Government has increased spending on the purchase of vaccines and has established comprehensive vaccination programmes (MINSA, 2018[30]), the vaccination coverage in Peru has experienced a persistent decline in the last two decades. In 2000, coverage for measles, DTP‑3, and polio vaccines were all above 90% for their target population, while latest estimates for 2022 indicate 74% coverage for measles and 82% for DTP‑3 (Figure 3.15).
The decline, in spite of greater spending in this area, signals that other factors are critical to guarantee the success of immunisation programmes. These include enough health personnels, strong vaccine quality standards, raising awareness among the population and good communication campaigns to reduce misinformation. Lack of quality and communication issues have been among the main drivers of the drop in Polio vaccination coverage. Polio vaccination coverage sharply declined in Peru in 2013 (from 92% of one‑year-old vaccinated to 71% the following year) due to severe quality issues with the oral vaccine and a global shortage of a safer, injectable version (MCLCP, 2014[31]).
The COVID‑19 pandemic further impacted vaccine uptake due to social distancing measures and public fear of infection, resulting in a nearly 20% drop in coverage for the third dose of the DTP‑3 vaccine in 2020 (at 72%) compared to 2019 (at 88%). To reverse this trend, Peru must enhance its response through strong quality assurance, effective national communication campaigns, improved health literacy and outreach vaccination programmes. These strategies need to be implemented at national, regional and local levels to address public health concerns and vaccine hesitancy effectively.
The threats associated with climate change include the need to respond to air pollution and to vector-borne diseases
Climate change is a key challenge for the Peruvian health system because it is linked to different type of diseases including spread of tropical diseases and their vector, as well as air pollution health risk.
Partly due to the global increase in rising temperatures, Peru faces climate‑related health challenges including El Niño, a meteorological phenomenon spanning the Pacific that affects South America through the El Niño-Southern Oscillation, causing increased temperatures and heavy rainfall (Cai, McPhaden and Grimm, 2020[32]). Increasing temperatures and frequency of floods increase the suitability of vectors, with particular attention to the mosquito Aedes aegypti, which is a vector of dengue, Zika, Chikungunya and yellow fever. Of these, dengue is of particular concern. Peru is currently one of the three most affected countries by the disease in the region, along with Brazil and Bolivia. Peru has experienced a steady rise since 2010 and has peaked in 2023 with 274 227 cases, almost four times higher than the previous year and almost as many as all cases between 2000 and 2021 combined (Figure 4.8). In February 2024, with dengue threatening to overwhelm hospitals, a health emergency was declared in 20 regions (MINSA, 2024[33]).
Source: PLISA (Health Information Platform for the Americas), PAHO.
Peru needs to also address air pollution, which is already a major cause of death and disability in Peru. While the OECD average saw a reduction of 31% in premature deaths attributable to ambient pollution between 2000 and 2019, Peru has experienced a significant rise of 38% (Figure 4.9), reaching 274.3 premature deaths per 1 000 000 inhabitants by 2019. This figure is higher than neighbouring countries such as Colombia (259.6), Ecuador (244.1), and Brazil (206.6), but lower than Chile (307.5) and Bolivia (337.5). Peru faces the highest exposure to fine particulate matter (PM2.5) in the Americas as of 2019, 31.1 micrograms per cubic metre compared 13.9 for the OECD and 15 for the LAC region (OECD, 2024[34]).
Adequate policy actions should be developed to mitigate and prepare the health impact of these environmental and climate risks. Peru has been taking steps towards addressing the issue of climate change for some time, with the National Climate Change Commissions adopted in 2013 and the National Climate Change Strategy in 2003 (Carrillo-Larco et al., 2022[35]). More recently, Peru has adopted the 2018 Framework Law for Climate Change, set up a Climate Change Commissions in 2020 and adopted the 2021 National Environmental Policy with the aim to reduce air, water and soil pollution. Regulatory frameworks include environmental quality standards, and local-level Action Plans for improving air quality ranging from information and environment education, as well as improving urban and transport planning. Critically, there is no nationwide infrastructure for air quality monitoring, which limits monitoring of compliance with Air quality Standards to take corrective measures or implement improvement plans.
Source: OECD Environment Statistics, 2020.
References
[32] Cai, W., M. McPhaden and A. Grimm (2020), “Climate impacts of the El Niño–Southern Oscillation on South America”, Nat Rev Earth Environ, Vol. 1, pp. 215–231, https://doi.org/10.1038/s43017-020-0040-3.
[35] 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.
[5] CGR (2023), Informe sobre presupuesto por resultados (PpR) en el Perú para el Informe de Auditoría a la Cuenta General de la República, Contraloría General de la República, https://cdn.www.gob.pe/uploads/document/file/4922923/Informe%20T%C3%A9cnico%20002-2023-CG-OBANT%20-%20Programas%20Presupuestales.pdf (accessed on 17 April 2024).
[17] Congreso de la República (2019), Ley que declara a los medicamentos, productos biológicos y dispositivos médicos como parte esencial del derecho a la salud y dispone medidas para garantizar su disponibilidad, https://www.leyes.congreso.gob.pe/Documentos/2016_2021/Proyectos_de_Ley_y_de_Resoluciones_Legislativas/PL0449420160620.pdf (accessed on 18 April 2024).
[11] DIGEMID (2022), Gasto de bolsillo en salud y medicamentos. Período 2020 al 2021, Dirección General de Medicamentos, Insumos y Drogas.
[19] Fernandez-Navarro, M., J. Gonzales-Saldaña and R. Araujo-Castillo (2022), “La importancia de la estandarización de la evaluación metodológica en las evaluaciones de tecnologías sanitarias”, Revista del Cuerpo Médico Hospital Nacional Almanzor Aguinaga Asenjo, Vol. 15/Supl. 1.
[28] Herrera‐Añazco, P. et al. (2021), “Some lessons that Peru did not learn before the second wave of COVID‐19”, The International Journal of Health Planning and Management, Vol. 36/3, pp. 995-998, https://doi.org/10.1002/hpm.3135.
[6] 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).
[31] MCLCP (2014), Alerta - Situación de la vacunación a los menores de 3 años, https://www.mesadeconcertacion.org.pe/sites/default/files/8._alerta_vacunas_06-05-14.pdf (accessed on 21 March 2024).
[33] MINSA (2024), Gobierno aprueba declaración de emergencia sanitaria a 20 regiones por un plazo de 90 días debido al incremento del dengue, https://www.gob.pe/institucion/minsa/noticias/911809-gobierno-aprueba-declaracion-de-emergencia-sanitaria-a-20-regiones-por-un-plazo-de-90-dias-debido-al-incremento-del-dengue.
[22] MINSA (2022), Compendio Estadístico: Información de Recursos Humanos del Sector Salud Perú 2013-2021, https://digep.minsa.gob.pe/bibliografica.html.
[4] MINSA (2021), Plan Nacional de cuidados integrales del cáncer (2020 – 2024), http://bvs.minsa.gob.pe/local/MINSA/5341.pdf.
[30] MINSA (2018), Norma Tecnica de Salud que Establece el Esquema Nacional de Vacunacion, https://docs.bvsalud.org/biblioref/2018/11/948769/rm-719-2018-minsa.pdf.
[15] Movimiento Salud 2030 (2021), “Gestión presupuestaria del sector salud en el Perú Desafíos y recomendaciones”, https://bvs.minsa.gob.pe/local/MINSA/5471.pdf (accessed on 8 April 2024).
[34] OECD (2024), Air pollution exposure (indicator), https://doi.org/10.1787/8d9dcc33-en (accessed on 15 April 2024).
[26] OECD (2023), Embracing a One Health Framework to Fight Antimicrobial Resistance, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/ce44c755-en.
[2] OECD (2023), OECD Economic Surveys: Peru 2023, OECD Publishing, Paris, https://doi.org/10.1787/081e0906-en.
[21] OECD (2022), Primary Health Care for Resilient Health Systems in Latin America, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/743e6228-en.
[23] OECD (2020), Realising the Potential of Primary Health Care, OECD Health Policy Studie, OECD Publishing, Paris, https://doi.org/10.1787/a92adee4-en.
[3] OECD (2017), “Financing and budgeting practices for health in Peru”, OECD Journal on Budgeting, Vol. 2, https://doi.org/10.1787/16812336.
[24] OECD (2017), OECD Reviews of Health Systems: Peru 2017, OECD Reviews of Health Systems, OECD Publishing, Paris, https://doi.org/10.1787/9789264282735-en.
[20] Saldarriaga, E. (2023), “Un paso incompleto en la dirección correcta: el Instituto Nacional de Salud del Perú establece el rango de costo-efectividad”, Revista de Saúde Pública, Vol. 56, p. 106.
[16] SISMED (2024), Resultado del indicador ficha No31 por región del marco de los Convenios de Gestión 2024, https://app.powerbi.com/view?r=eyJrIjoiMmNjNTBmOWItZWM3NS00YTgxLTk5M2ItOGNjNWEyOTU3ODczIiwidCI6IjM0ZjMyNDE5LTFjMDUtNDc1Ni04OTZlLTQ1ZDYzMzcyNjU5YiIsImMiOjR9 (accessed on 8 April 2024).
[10] SUSALUD (2022), 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).
[18] Taype-Rondan, A. et al. (2022), “Características metodológicas de las evaluaciones de tecnologías sanitarias elaboradas en Perú, 2019-2021”, Revista del Cuerpo Médico Hospital Nacional Almanzor Aguinaga Asenjo, Vol. 15/Supl. 1.
[25] Taype-Rondan, A. et al. (2016), “Problems perceived and experienced by health professionals rendering social service in Ancash, Peru. 2015”, Revista de la Facultad de Medicina, Vol. 65/3, https://doi.org/10.15446/revfacmed.v65n3.59055.
[9] Ugarte Ubilluz, O. (2019), Estrategias para mejorar el acceso a medicamentos en el Perú, UNMSM. Facultad de Medicina, http://www.scielo.org.pe/scielo.php?script=sci_arttext&pid=S1025-55832019000100019.
[29] USAID (2023), Strengthening Laboratory Capacity to Improve the Availability and Accuracy of COVID-19 Diagnosis in Peru: Recommendations and Training Plan to Improve Specimen Collection, Handling, and Transport, https://www.lhssproject.org/sites/default/files/resource/2023-04/LHSS_Peru_Recommendations%20and%20Training%20Plan%20to%20Improve%20Specimen%20Collection%20Handling%20and%20Transport_FY23_04-03-23%20sxf.pdf.
[14] Videnza Consultores (2022), “Situación actual del mercado de salud peruano”, https://www.comexperu.org.pe/upload/articles/publicaciones/situacion-actual-del-mercado-de-salud-peruano-informe.pdf (accessed on 8 April 2024).
[13] Videnza Consultores (2021), “Abastecimiento de recursos estratégicos en salud”, https://www.redesarrollo.pe/wp-content/uploads/2021/07/Abastecimiento-de-recursos-estrategicos-en-salud.pdf (accessed on 8 April 2024).
[12] Videnza Consultores (2020), “El abastecimiento de medicamentos en el Perú: retos y oportunidades”, https://videnza.org/el-abastecimiento-de-medicamentos-en-el-peru-retos-y-oportunidades/ (accessed on 8 April 2024).
[27] WHO (2022), Compliance with the International Health Regulations, https://apps.who.int/gho/data/node.main.UHCIHR?lang=fr.
[1] WHO (2021), Global Health Observatory.
[7] WHO (2020), Budgeting for results in health: Key features, achievenments and challenges in Peru, World Health Organization, https://www.who.int/publications/i/item/9789240004436.
[8] World Bank (2021), Financiamiento para la cobertura universal de salud en el Perú después de la COVID-19, https://www.bancomundial.org/es/country/peru/publication/financiamiento-para-la-cobertura-universal-de-salud-en-el-per-despu-s-de-la-covid-19.
← 1. Examples include Budgetary Support Agreements (Convenio de Apoyo Presupuestario CAP) and from the Performance and Social Outcomes Stimulus Fund (Fondo de Estímulo de Desempeño y Logro de Resultados Sociales, FED), and transfers made by the Social Development Ministry (MIDIS) for positive results in performance evaluations.
← 3. https://repositorio-digemid.minsa.gob.pe/collections/37f318c9-7711-4d56-a3d0-cfd8b7c973c0. The methodology was developed by DIGEMID and submitted to the Ministerial Office and the entities of the sector; the entities provided their databases and, from the application of the methodology, the threshold was calculated to be subsequently processed by DIGEMID, with the respective technical report for the approval of the Ministerial Resolution.