Peru: Improving Health Care for the Poor - Summary Three

Progress in Health Outcomes

In the 9 years after 1990, many improvements have been seen in the overall health status of the people of Peru. Child and infant mortality indicators increased by over 25% as a result of improved immunization efforts and control of diarrheal disease in children. Various educational campaigns promoted strong hygienic practices as well as Oral Rehydration Therapy. Additionally, there have been efforts concerted towards improving water and sanitation and malnutrition rates have decreased.

Even though progress has been made, the infant mortality rate was still very high in Peru in 1999. Many of the campaigns and efforts were directed towards the health of older infant and children so much less progress was made in the mortality of infants around the time of birth or maternal mortality. Hemorrhages, mishandled abortions, infections, and hypertension, are the primary causes are maternal death, all of which stem from inadequate birthing conditions both in the hospital and at home. In the population as a whole, about 50% of the births are overseen by skilled health professionals, while in rural areas as few as two out of nine mothers receive help and care during birth. In addition to the less-than-adequate conditions, there are other factors that also influence the health of the child and the mother, such as poor maternal medical and nutritional care during the pregnancy, which can result in low birth weight and prematurity.

The majority of infant and childhood deaths in Peru occur in the poorest 40% of the population where education is minimal and the living environment is worse. The biggest problem that I have noticed during my time working with the infants in the health center is a lack of education among the mothers, which is also addressed in this report.

"The extremely low levels of use of health services by mothers are partly a reflection of ethnic and cultural barriers, combined with low levels of female education and cost barriers... The cultural barrier in rural areas in heavily reinforced by staff that remain unprepared to deal with poor indigenous women, who especially object to unaccommodating birthing conditions and fear various other aspects of institutional care... Part of the problem was due to low quality of surgical care and part was due to the lack of capacity to communicate with mothers and especially indigenous mothers."

During the week and a half I've spent in the Santa Rosa Health Care Center, I have spent a lot of time weighing, measuring, and evaluation babies as they come in for their monthly check ups. I have seen a whole range of types of mothers and families come into the clinic. Some parents come in clean, well-dressed, and equipped with the latest toys and gadgets. There are other mothers who come in and look incredibly young, sometimes maybe 15 or 16 years old. More often than not, the young, poor mothers tend to have babies that are very small and malnourished. I often am often surprised that some of the older, "put-together" moms also have underdeveloped babies.

I have weighed countless babies throughout the past week and have taken note of the measurements I recorded. For example, I have weighed (at least) 5 babies who are one month of age. I saw a wide range of sizes from very small and thin to thick and chubby.
Here are the measurements I took:

Baby #1

weight: 3.300 kg

height: 51.9 cm

head circumference: 35.5 cm

Baby #2

weight: 4.100 kg

height: 54.8 cm

head circumference: 38.3 cm

Baby #3

weight: 4.300 kg

height: 55.6 cm

head circumference: 38.0 cm

Baby #4

weight: 5.000 kg

height: 57.3 cm

head circumference: 37.3 cm

Baby #5

weight: 5.200 kg

height: 58.9 cm

head circumference: 36.6 cm

According to the Weight-Age chart, the ideal weight for a baby boy is 4.500 kg, with a healthy weight ranging from 4 to 6 kg. The ideal weight is about 55 centimeters, ranging from 53 to 59 centimeters. Given this information, it is apparent that Baby #3, #4, and #5 all are within the health range of heights and weights. However, Baby #1 and Baby #2 are small in both the height and weight categories.

When Baby #1 came into the clinic for his checkup, I thought he was a new born baby coming in for his first control and was shocked to find out that he was one month old. His legs were very thin, instead of chubby health baby legs. His mother looked very, very young; I would say she was probably around 15 years old. When the doctor saw the measurements I had taken of the baby, she scolded the mother about the importance of adequate nutrition to promote health growth and development. She told her that her baby will sleep all day if she lets him, but she has to wake him up to nurse every two hours or so. The doctor showed the mother how to properly hold the baby while nursing in order allow the baby to nurse most easily. She also prescribed additional supplements and nutrients to give the baby every day to promote health grow and development. The mother was instructed to bring her child back to the clinic every three or four days for a few weeks so that the growth could be monitored more closely. I have seen Baby #1 and his mother twice since the initial one month checkup and am happy to report that he gained weight and grew a little each visit. His mother obviously took the advice of the doctor seriously and made the appropriate changes to her baby's eating habits. She was glowing when I told her that her baby had gained weight and looked much healthier.

I know that no mother would intentionally allow her child to become malnourished. The young mother of Baby #1 had tears in her eyes when the doctor was telling her about the condition of her baby. I honestly feel like the lack of education and knowledge about proper infant care is a huge issue that leads to cases like this. Many uneducated mothers might thing their babies are healthy without knowing about how they should be progressing in height and weight. Fortunately, the life of Baby #1 was probably spared because he mother chose to bring him in to the health clinic for the routine checkups. While a health care center with child control services was available to this young mother and her baby, I am sure that there are tons of other mothers who live in rural areas without access to routine checkups and care. Their babies may be malnourished and underdeveloped but they may have no idea that there is anything wrong, simply for lack of knowledge.

Peru: Improving Health Care for the Poor addresses the fact that the lack of education, especially in rural areas is a significant issue when it comes to infant mortality rates and maternal health. In rural areas, the report states that infant and child mortality rates are twice as high as in urban areas. While the main direct cause of death is infectious diseases, more often than not the effects of the diseases are exacerbated by malnutrition and a weakened immune system. The areas that experience the worse rates have both poor environmental conditions and low levels of education. Overall, in my opinion, improving the availability of education is essential in improving the health of people in both rural and urban areas in Peru. 

Peru: Improving Health Care for the Poor - Summary Two

Overview of Health Sector Financing and Delivery Systems

The health sector of Peru is composed of 5 primary sectors: the Ministry of Health (MINSA), the Peruvian Institute of Social Security (ESSALUD), several smaller public programs, a large private sector, and several NGOs. While all of these play an important role in various aspects of the Peruvian health sector, MINSA and ESSALUD are the largest government programs and supply the majority of the financing for the public in general. From 1988 to 1993, financing for health care services dropped significantly due to the decrease in personal income caused by the hyperinflation of the 1980s.  Even though rapid recovery took place from 1994 to 1997, the amount of money spent on health in Peru is very low compared to other countries in Latin America and around the world.

Taxes are a primary source of revenue for many of the health sectors. MINSA also receives monetary support from external loans as well as user fees. According to this report, "about half of the health financing is provided by households, mainly as out of pocket payments" in Peru.

MINSA has control of the majority of the assets and staff in the health care sector. It is in charge of most of the Primary Health Clinics as well as most of the large hospitals, employing the majority of Peruvian health care professionals. Additionally, the primary sector is exceptionally large, with other 200 small private clinics that employ 33% of the physicians.

Since 1992, there has been a substantial increase in the amount of health services available, especially in primary health clinics. MINSA and ESSALUD also have set into motion various reforms that encourage clinics to expand their hours of operation. Additionally, in the years since 1992, there has been a rapid increase in the amount of health professionals available.

MINSA plays many important primary roles, including supplying nearly all public health interventions. This includes coordinating the entire immunization program and all vector control operations. Vector control refers to the process of working to limit or eradicate vectors such as insects or animals that transmit disease pathogens. MINSA also shares responsibility in controlling food and water quality. MINSA is the primary and most essential provider of services for the poor. Its main role is played in rural areas in the highlands and in the jungle, although it is also crucial as the most important health care provider in urban areas as well.

"Most of the inequality in health care consumption results from the assignments of greater amounts of private expenditure to health care by the rich than by the poor... This is a common pattern as health care is a good whose consumption normal rises with income or faster." 

As a whole, the amount spent by MINSA on health care services somewhat reduces the inequality but it is not substantial enough or well directed towards the poor to completely equalize expenditures. MINSA is most important for people with the lowest income.

Although this report was written 15 years ago, I know that MINSA still is playing a significant role in the Peruvian health care sector today. I have seen many MINSA workers at the clinic at which I am volunteering. The infant development and growth charts that I have been working with (and mentioned in a previous post) are all approved and provided by MINSA. According to MINSA's website the current mission of MINSA is to protect personal dignity, promote health, prevent sickness, and guarantee integral health attention to all the inhabitants of the country... and so on (http://www.minsa.gob.pe, translation mine).

Working with Babies in the Enfermería

I have spent the last three days working in the "enfermería" with the nurses and doctors who perform healthy baby check-ups on all the infants who come into the clinic. The area in which I have been working is for babies under one year of age. There are other areas where the children over one are seen.

Numerous mother-child pairs come into the clinic each day and I have helped by measuring the weight, height/length, and cephalic perimeter (head circumference) of each baby before he or she is seen by the doctor/nurse. It has been slightly difficult to know what to do because very often they tell me to do something without telling me how to do it. I end up just guessing and hoping that I am doing it correctly. Some of the things are quite easy. For example, it is not difficult to know how to work the digital scale because all it involves is placing the child on the balance and recording the number that shows up. However, other tasks require a little bit more concentration. In order to measure the height/length of the baby there is a table with a wooden measuring board upon which the baby lays while I record their height/length. This involves instructing the mom (in Spanish, of course, which just adds to the difficulty!) to hold the child's head at one end while I flatten the legs and press another wood board against the feet to record the height/length from the head to heel. The measuring board looks something like this wonderful visual I found on the internet...

It is an easy process when the baby doesn't cry and the legs are relaxed and easy to manipulate, but when the child is crying loudly and tensing his or her legs, it can be difficult to get an accurate measurement! Fortunately, the more I do it, the easier it gets.

As I became acclimated to the process and started to figure out how things needed to be done, a head doctor/nurse lady named Maria (side note: whenever I meet someone here, they rarely tell me their name or who they are, so I hardly ever have any idea about who anyone is or what their jobs are. I was fortunate enough to hear Maria's name, so at least I know that even though I don't know if she is a doctor or nurse) also instructed me to perform an "Evalución del Desarrollo Psicomotor" (Evaluation of Psychomotor Development). This involves working through a few criteria that the child needs to have met by a certain age in order to ensure that he or she is developing correctly. 
This is what the form looks like...

There are different criteria for the different ages. For example, it says that by one month of age, an infant should have asymmetric movements of the arms and legs and squeeze any object placed in his or her hand. A child of five months should be able to maintain a straight back with the support of the hands in front, recognize his or her name, and play with her hands and feet. 

Peru: Improving Health Care for the Poor - Summary One

Peru: Improving Health Care for the Poor is a report that was put together by The World Bank as a tool to be used by the government to address the ways in which the Peruvian healthcare system can continue to improve and provide increased health care for the poor. It was put together 15 years ago in 1999 when the healthcare reforms were first beginning after the massive collapse of the health sector of Peru in the late 1980s and early 1990s due to hyperinflation and terrorism. In the three years after 1994, total public and private spending on health rose by over 50 percent. While this report has recorded many of the initial steps taken to reconstruct an effective health care system in Peru, it obviously lacks any changes or improvements that have occurred in the last 15 years. I will be reading this report while working at the Santa Rosa Health Center in Cusco and plan on talking with the physicians, nurses, and staff to learn more about how the health care system currently is working in order to compare the present situation with the conditions 15 years ago and see if any of the changes recommended by the World Bank have taken place.

This report addresses three main issues that the Peruvian health sector was facing at the time it was written (and probably still is facing today). First, how to continue to reduce the large gap between the health status of the poor and non-poor. Second, how to increase the resources assigned to provide care for the poor. Third, how to increase the efficiency in the use of these resources. Essentially, at the time this report was written, reforms to the health sector had already begun to take place but the report declares that the issue lies in sustaining, expanding, and deepening the reforms. The report claims that "for that to happen, key outstanding issues in providing, financing, managing, and manning health services have to be resolved" (World Bank, 1999).

While the reform programs were successful in increasing the coverage of health services in remote areas, there were still many problems that were preventing the poor from accessing health care. The Ministerio de Salud, or MINSA (in English, Ministry of Health), covered all of part of the expenses for services, which excludes additional expenses such as pharmaceuticals. Additionally, there was no standard methodology used to recognize the poor, which created an erratic, inconsistent system with local generosity covering much of the additional expenses involved with serving the poor.

There were obviously many good aspects about the reforms started in 1994 by MINSA but good intentions were accompanied by numerous problems. This report makes it clear that the reforms were successful but it was necessary for them to be sustained, deepened, and expanded in order to ensure that the provision of primary health care services would continue to improve in Peru. My interest in the matter has definitely peaked after serving for a few days in the health center here in Cusco. I am excited to learn more about the health care system of today and how effective it is and has been at serving the poor.

World Bank (1999). "Peru: Improving Health Care for the Poor." Washington, DC: World
        Bank Publications.

First Day at the Santa Rosa Public Health Center

Today was my first day volunteering at the Santa Rosa Public Health Center in Cusco, Peru. My day began at 8:00 when Gabriela, the director of Casa Ayni, the volunteer organization, arrived to show my how to get to the health center. We walked from my house to the bus stop and then took the bus to the Santa Rosa bus stop. After getting off the bus, we walked about a block to a small blue building that was crowded by a swarm of people outside. The building itself is by no means impressive; if anything, it is the opposite. Upon entering the health center, my initial impression of the building was confirmed. The walls and floors both consist of chipped concrete and all the rooms are very small. Nothing looks overly clean, although it did have a smell that was somewhat like the scent of sanitizing cleaners. There was quite a bit of dirt covering various parts of the concrete floor in the main area. It definitely would have extensive health code violations if it were in the United States.

In the health center, there is one hallway with a handful of rooms for patients, including medicine, obstetrics, and a small "pharmacy." Another area has various nurses stations as well as a room for dental visits. In the back there is a small laboratory where blood work and urine analyses are done. There also is a small room filled with files lining every wall with a small desk in the middle where a few ladies work on processing the paper work. Outside of the health center is the waiting area. There is a small dirt space lined with a few small benches where people waiting to be seen sit. I asked another volunteer named Mike from the US if they always have to wait outside and he said that they always do, even when it rains. In Cusco, it in the rainy season right now, so it rains very frequently. All of these areas are connected by one main lobby, hallway type space, which is where I spent most of my time today.

In the main "lobby," there is a lady sitting at a small desk who receives the paperwork from the office area and takes the patients' weight, height, and sometimes blood pressure. After I finished helping the ladies in the office pull files from the crazy mess of paperwork, I went to the help take the weights and heights with Mike. We would walk out to the front and call out the name of the person whose file we had. We took the measurements and then relayed them to the lady at the desk (unfortunately, somewhere between the busyness of the clinic and the language barrier, I never got her name... oops). Mike told me that today was an exceptionally busy day as the waiting area was packed with people. We were very busy weighing and measuring people and did that for most of my time there. There were various people who came in to the clinic: small children and pregnant ladies, and elderly people and teenagers.

Although the whole process seemed a little hectic and chaotic, it seemed to work for all the people working at the health center. It was a little difficult at times to try to be helpful without feeling like I was getting in the way. It was especially a challenge because everyone working there only speaks Spanish. While my ability to talk in Spanish is fair, I am not used to listening and responding in a such fast-paced setting. I am excited about learning new health-related vocabulary and improving my ability to understand and speak quickly in an area outside of the classroom. Today I was very thankful that Mike was there because he was able to explain a few things to me in English that I did not understand. He has not been learning Spanish for very long, so I was able to help him in that aspect as well. I think that it is going to be a fun 8 weeks volunteering at the health center. Mike told me that they often place volunteers not on their medical knowledge but on their ability to speak and understand Spanish. I hope that as my language abilities improve I will be able to help in other parts of the health center as well.