The Latino Patient – Health Attitudes, Beliefs, and Practices

¡Abrígate Bien!

One of the many historical attitudes towards health that is held by many Latinos is known as the Hot and Cold Theory. This theory claims that the body has four different fluids of different textures and temperatures:

Blood- hot and wet

Yellow Bile- hot and dry

Phlegm- cold and wet

Black Bile- cold and dry

In this pattern of thinking, a balance in the body among the four types is seen when a person is healthy. A sick person experiences an imbalance among the fluids. According to this theory, temperature plays a big role in the health state of individuals. For example, to lower the temperature of the body, a person may be offered a cool drink. On the other hand, drinking warm liquids and consuming warm foods such as tea or soup is thought to help an individual with a cold.

 I have seen practices similar to this in the belief patterns of nearly every Peruvian person I have met. They all seem to 100% believe the wives' tale that if you are cold, you will catch a cold. It is almost humorous how frequently I am told to “Abrígate Bien,” or “Dress warm.” The temperature here is not exceptionally cold on most days. Usually the temperature ranges somewhere from 55 to 75 degrees, but the people here usually dress as if they were living in the arctic! In the clinic, many of the nurses and ladies wear multiple layers of clothing, including warm jackets and scarves, for the entire day. On multiple different occasions, I have been working in the health center in just my short sleeved shirt and constantly am asked if I am cold. I usually proceed to explain that it is much, much colder where I am from and so I don’t feel so cold here. In addition to this, a few people have sternly told me that I need to dress warm or I am going to get sick and then the whole clinic will be sick. Since then, I have worn at least a long sleeved shirt on most occasions.

The need to dress warm especially applies to the babies who are brought into the health center. When they come in, I always tell the mothers to undress the baby so that we can properly record the weight and height. The undressing process usually is quite lengthy as the babies are typically wrapped in two or three blankets and clothed in several layers of jackets, sweaters, and shirts, complete with socks, gloves, and hats. Sometimes the babies are actually damp with what I presume to be sweat by the time all the layers are removed.

I find it really interesting that even the educated professionals working in the public health center find it so important to dress warm all the time. One time the head nurse working with the babies got mad at a mom for leaving her baby undressed and exposed to the cold for too long. She lectured the mother about how her baby was going to get sick. The same nurse has lectured me about the same thing on a few occasions as well. 

The Latino Patient – Cultural Values

Cultural Values of Latinos

Acculturation increases as individuals remain in a country for a longer period of time and as the generations proceed. The initial immigrants that come to a country will retain many of their core values and traditions from their home country but their children and the children of their children will become more and more representative of the mainstream society. For Latinos in the United States, there are a few basic values that seem to be retained regardless of the amount of time spent in the country or the generation level. While the culture in the United States tends to be very individualistic, the Latino culture is group- and family-oriented. American culture is often focused on personal achievement; Latinos strive for harmonious relationships and cooperation. In the US, respect is often awarded to those who have achieved success, but for Latinos, respect is given due to age, gender, or hierarchy.

In addition to these three values that are constant across generation and acculturation levels, there are several other general values shared by all in the Latino culture that do vary slightly as individuals acclimate to the mainstream culture.

The values listed below are the most relevant to a clinical encounter in a health care setting.

Collectivism

Latinos tend to enjoy spending time with others as opposed to being alone for personal satisfaction and self-assurance. Workplace or social relationships strengthen all and give the individuals a sense of belonging. Situations are viewed from the perspective of the group instead of that of the individual.

Familism

Latinos highly value family relationships and often maintain close relationships with family members, close and distant alike. Due to the fact that many Latinos consider the family to be “sacred,” many health issues can be addressed most effectively by including some or all family members.

I have witnessed this with my host family. We spend time very regularly with various family members, including the brother of my host mom and her father. Much of the distant family, including various distant cousins, aunts, and uncles, has also come to visit on multiple occasions.

Personalismo

Personalismo refers to the ability to relate to other human beings on a personal level, without regard to the social level or economic class.

My host mom is a prime example of this. My host family is well-off compared to much of the population in Peru but when visitors come to our home, she treats everyone the same, always offering food, tea, or anything else we may have to offer. We have had visitors from the “campos” (fields or country, generally people of a lower economic standing) come to our home, and they are always treated with respect and courtesy.

Respect & Power Distance

People in positions of power deserve respect and obedience. In a health care setting, a doctor is rightfully perceived as being more knowledgeable about health and disease than the patient and thus is respected and obeyed. Additionally, respect and admiration are awarded due to valued qualities a person may possess, such as honesty, integrity, and courage.

Simpatía

The ability to develop a harmonious relationship that expresses a warm and caring attitude is known as simpatía. It is important for a health care provider who is working with Latinos to have a “people-oriented” disposition.

Time Orientation

Managing time appropriately is not of high priority for Latinos. In most Latin America countries, the pace of life is a little slower and more relaxed, with less bureaucratic health care systems. Consequently, when Latinos immigrate to a country like the United States, they may often arrive late for appointments, not out of respect for the doctors, but rather because their culture never taught them to value timeliness.

I have fully experienced the lack of concern for time and timeliness during my time here. On more than one occasion I have had to wait at least 30 minutes for a friend to show up to hang out or have coffee. Coming from a culture where time management is crucial, I absolutely hate to be late and hate to have others waiting on me. It is different to experience an entire culture that doesn’t care so much about being on time or not.

Out of the Ordinary Events of the Week

Eat Well. Stay Healthy.

Something a little out of the ordinary happened on Tuesday this week. When I finished working in triage, I made my way back to the CRED ("Crecimiento y Desarrollo del Niño" aka Child Growth and Development) area to help with weighing, measuring, and evaluating the babies. There was an exceptionally large hoard of ladies crowding the tiny space and I wondered why the nurses weren't telling them to wait outside for their turn, like they usually do. It turned out that there was a "charla," or chat/presentation, for the mothers in the clinic and many of them were told specifically to come in on that day to participate in the chat. 

The first segment of the presentation was a very brief talk about how to prevent stomach cancer. One of the doctors in the clinic gave the presentation and talked about various factors that can increase the likelihood of getting cancer, including things like genetics and lifestyle. She stressed that while we have no control over the genes we inherit, we can choose to live in a healthy way and take control of the factors that we can. 

The doctor covered basic healthy habits that can prevent stomach cancer among various other health problems. She recommended that everyone eat five fruits everyday in addition to vegetables like lettuce and broccoli. She also said that exercise is important in preventing cancer and that everyone should get 30 minutes of exercise daily. While it is not likely that many of the ladies in the health center have time to go for a run or hit the gym every morning, the doctor did say that even just walking a total of 30 minutes everyday can be beneficial and they don't have to be 30 consecutive minutes. I don't doubt that many of the mothers walk at least 30 minutes everyday, if not more, just getting around town and such. The doctor also suggested not drinking alcohol in excess or smoking. Most of the advice given seemed pretty basic and nothing was all that novel for me, but it could have been the first time some of the ladies heard some of these things.

The second part of the presentation was much more hands-on and much more interesting. It was about how to properly feed babies and young children and how to eat as a nursing mother. The nurses brought in food and showed examples of various different types of foods in different forms and quantities to give to babies of varying ages. I helped by making a mashed potato puree mixture with other vegetables and meat. It pretty much was homemade baby food made by mashing all the components of a meal into puree. 

There were all sorts of different types of food: rice, quinoa, lentils, potatoes, carrots, squash, chicken, and chicken liver. I found it really interesting that the nurse stressed multiple times how important it is that the babies and nursing mothers eat liver at least 2 or 3 times a week. She said that anemia is a big problem and liver is high in iron. I personally am not a huge fan of the idea but do admit that I have eaten liver a time or two while I've been here. I don't particularly care for it, but it's not horrible either. 

I think the talks were very beneficial and it definitely added some spice to my day. I think that preventative and educational talks are really important as I've mentioned before that I think the majority of the problems experienced by infants and children come from a lack of knowledge. I'll be interested to see if this is a  somewhat regular occurrence or a one time deal. 

Strike!

Today and yesterday in the health center, the doctors were on strike. There still were a few doctors who accepted patients with emergencies or who needed immediate care but there were significantly fewer patients than normal. They only accepted a total of 15 patients yesterday when normally there are double or triple that seen by the medics alone. Today no patients were seen by the medics, but a few patients were still seen by the obstetricians and in the child grow and development area. 

The posters on the door to the health clinic said:

Paro Medico - Por la Reforma de Salud

Más insumos para pacientes

Mejor infraestructura

Más medicamentos por tu SIS

No a la privatización de Salud

 Which translates to:

Medical Strike - For Health Reform

More resources for patients

Better infrastructure

More medicine for your SIS (Integral Health Insurance)

No Privatization of Health

 Today I found out that the strike was not limited to the Santa Rosa health center but was nation wide. I believe unfair pay and salaries were part of the issue that the doctors were protesting, but I am not 100% sure about the exact reasons behind the strike. It made for a slow couple of days in the clinic because of the significant reduction in patients. I hope that Monday of next week isn't too crazy with all the overflow of people who would have been seen today. 

The Latino Patient - Defining the Latino Patient

Who are "Latino Patients" in the United States?

In 2002, when this book was written, there were 35.3 million Latinos living in the United States. In order to provide healthcare appropriately to this population, there are three main challenges that providers must overcome: language, diversity, and culture. Adequately overcoming the barriers in communication involves having some proficiency in the Spanish language in addition to understanding the diversity in the Latino group and its culture. 

Here are a few of the many facts mentioned in The Latino Patient about the Latinos living in the United States:

• The terms Latino and Hispanic can be used interchangeably, both referring to people of Spanish decent (from Spain) and people whose native language is Spanish.
• People from different Spanish-speaking countries in Latin America have distinctive accents and speech patterns. 
• For example, Mexicans use many idioms, Central Americans tend to speak very quickly, and South Americans have melodic intonations and an more educated vocabulary.
• There are 22 different countries to which Latinos can trace their origins.
• The majority of Latinos are Catholics, which can influence their attitude towards health and disease.
• For example, some may believe that an illness or ailment is a consequence of disfavor in the eyes of God.
• U.S. Latinos are a young population, which a median age of 25.9 compared to 35 years as the median age of the general population
• The life expectancy is 79 years for the Latino population while that of the general population is 75 years.
• The major health problems of Latinos in the United States are similar to those of the general population, including diabetes, tuberculosis, and HIV infection, among others.

There are a few interesting theories that may explain the low mortality rates seen in the Latino population. One of these is known as the healthy migrant effect, which suggests that the people who immigrate are those who are physically able to go and healthier than those who remain behind. Additionally, the salmon bias effect states that many Latinos return to their home countries after a temporary stay in the United States, wishing to return home when they grow old or become seriously ill. 

In addition to language differences, which is an obviously barrier, there are many factors that affect the decision of Latinos to seek healthcare and treatment. While nearly two thirds of the Latino population has health insurance coverage, a third still remains uncovered. This increases the difficulty in accessing healthcare for many Latinos. Many resort to seeking care in emergency rooms, which obviously can provide care for temporary problems but lack the ability to offer follow up or preventative services. Acculturation, the changes that must be made to adapt to a new culture, also presents Latinos with unique challenges. This includes learning to live in a culture that is loaded with rules and regulations. Practices such as taking a number, waiting in line, filling out forms, and so on, can be great hassles for Latinos who are unfamiliar with such habits.

The Latino Patient - Introduction

The Latino Patient

The next piece of literature I am working through is The Latino Patient: A Cultural Guide for Health Care Providers by Nilda Chong, MD, DrPH, MPH.

Chong begins her book with a personal vignette about her experience 35 years ago as a doctor in a rural part of a Latin American country. Along with a team of health professionals, she was part of a temporary clinic set up in a very rural area in the tropical rain forest. As the sun sank beneath the dense canopy of the forest and the team packed up their equipment after a long day of work, a woman approached her, barefoot and sweating with a child on her back, and asked if her child could be seen by the doctor. The woman proceeded to explain that she had left her village at 4am that morning to walk to the clinic but was delayed by a flooded river and had to wait 2 hours for the water to subside before she could swim across with the child in tow. The medical team was exhausted after providing medical and dental treatment to over 500 patients that day and Chong thought to her herself that if she said yes to this lady, she would have to say yes to every other person who sought attention at that point. However, the team leader pulled her aside and asked her to imagine what the lady had gone through just to arrive at the clinic. The team agreed to provide treatment to the lady and any other that might come along. The experience greatly impacted Chong as she had never thoroughly contemplated the issues that the people living in such a rural area face on a daily basis and could not relate to the woman's suffering. This experience, among others, inspired Chong to write The Latino Patient so that health professionals who work with patients from a Latin American background might be able to have a more thorough understanding of their culture. She addresses the unique aspects of the Latino culture, including relevant values, health status, beliefs, and practices as well as appropriate ways to interact with and treat Latino patients in order to most effectively and respectfully provide treatment.

The Latin American population in the United States has been growing significantly in the recent past and will continue to grow in the future. In 2002, 13.3% of the population was Latino and it is thought that by the year 2050 that number will have grown to 25%. With this in mind, it has become increasingly important for health care provides to know how to appropriate interact with the Latino population. For non-Latino health professionals, understanding the culture is essential to providing "culturally competent care." This includes establishing sensitive and effective communication with the patients during their time in the clinic and understanding the cultural differences. It is important to understand the critical cultural values and to know a handful of tactics that allow health care providers to interact in a culturally respectful way. As I am reading, I am excited to be able to compare what this book has to say about Latino patients living in the US with the patients I am in contact with in Latin America. I hope to be able to put into practice some of the advice that Chong offers, not only during my time in Peru but also when I become a health professional myself.

Chong, N. (2002). "Latino Patient: A Cultural Guide for Health Care Providers." Yarmouth,  ME: Intercultural Press.

Peru: Improving Health Care for the Poor - Summary Six

Conclusions and Recommendations

The final section of the report offers various recommendations about reforms that need to take place in order to improve health care for the poor. While Peru has seen marked improvements in many areas in the health care sector, a wide gap still remains between the outcomes of health care services for the poor and the non-poor. A continued emphasis must be placed on primary care in addition to caring for poor mothers and infants and controlling communicable diseases. 

There is a great need for expanded coverage and quality of maternal, prenatal, and perinatal services to improve the health status of mothers and infants. While these services need to be strengthened, it is also important to promote their importance to mothers and increase their use by the poor. Additionally, communicable diseases play a much deadlier role in the lives of the poor than in the rest of the population. In order to prevent many diseases and increase the quality of health among the poor, efforts must be put forth towards improving water and sanitation, education, and agriculture. 

It is also imperative that the poor have increased access to hospitals and health care clinics. There should be a certain percentage or amount of expenditures that must be allocated towards the treatment of the poor. This sort of reform would be difficult to achieve, however, because there is no clear way to define or identify the "poor."

The report also states several reforms that need to occur in the realm of Human Resource Policies, including the following, quoted directly from pages 62 and 63 in the report.

"Establish a human resources department in the ministry of health"

Currently (in 1999), MINSA does not have an administrative sector targeted towards addressing human resources issues. The main purpose of this sector would be to set a high and consistent standard for hiring and evaluating existing personnel. It also would be in charge of overseeing continuing education and training of all health professionals. 

"Introduce a public medical service examination"

This exam would be administered to all personnel seeking employment in the health field to clarify the high educational standards that must be met to work in the public sector. It would help raise the bar on the quality of professionals that are allowed to enter the field as well as provide a standard by which the medical universities and institutions can be held responsible. The ministry should be the main enforcer of educational standards and content in order to regulate the quality of education in all institutions.

"Introduce certification of university medical programs"

A certification process would exert direct pressure on universities to continually improve the content of physical training and educational standards.

These are just a few of the many improvements that are listed in Peru: Improving Health Care for the Poor. While I'm sure that much progress has been made in the health care system of Peru in the last 15 years, I am certain that there is still much room for improvement.  A great disparity still remains between the quality of care received by the poor and by the wealth, but that is a problem that even more developed countries face. Overall, I feel like MINSA and the health professionals are putting effort forth towards bettering the health of the entire country and while great progress has been made, there is still much to do.

Peru: Improving Health Care for the Poor - Summary Five

Human Resources for Health Care

According to this report, in Peru in the 1990s (and mostly likely today as well) the quality of health services for the poor was greatly impacted by the availability of trained professionals with an appropriate mix of skills around various parts of the country. In the late 1990s, there was actually an excess of health professionals most likely due to the presences of several new medical schools that allowed for a greater number of students to graduate. MINSA took advantage of the excess of health workers and hired many new workers on short term contracts. 

Geographical Inequality

There is a significant amount of geographical inequality in the health care sector in Peru. The attraction of professional careers and advanced medical equipment pulls many physicians to large metropolitan areas, namely Lima. For this reason, the rural parts of Peru in the Sierra and Amazon areas suffer from an extreme deficit in quality health professionals. "In 1964, the availability of physicians was 5 times higher in Lima than in the rest of the country." While this has been improving, due in part to increased growth of urban areas apart from Lima, there still is a significant shortage.

In an attempt to overcome this problem, in 1982 MINSA created the SERUM program, which mandates that all medical students serve one year in a rural or urban low-income neighborhood health establishment as "a condition for graduation." Although it is technically not a graduation requirement, it is a necessary prerequisite for employment in the public health center and for acceptance to state-sponsored internship programs for increased specialization. In the Centro de Salud Santa Rosa, I met a young dentist named Santi who is serving in the health center this year. I am not sure if the SERUM program itself is still active but if it is not, there is definitely another program that requires similar forms of service. Santi told me that he has to serve for a year if he wants to work for any government health center in the future. He said that some of the positions are paid but most are not. I got the feeling that he wasn't crazy about the time he has to spend in the health center but it is a necessary hoop to jump through before his career can progress. 

Additionally, the Salud Básica Program has offered incentives for health professionals who work in rural and urban low-income areas, often including large salaries and financial bonuses. However, increased salaries often do not overcome the desire of advanced professional careers associated with the city-based specialization and private clinics, especially when combined with the inconvenience of living in extreme rural areas. It is likely that the inequality of the distribution of health professionals will remain a problem that Peru will have to face for many, many years.

Quality of Training

According to MINSA officials and leaders in health professions, the standards in medical education have been falling. There were a handful of new medical schools and universities that opened in the 1990s, many of which lacked the resources to meet the teaching requirements of a modern medical education. Licenses required to operate have been granted liberally, with little regulation or monitoring of the schools prior to their acceptance. 

The quality of training giving to nurses has also changed. The report states that "teaching has become more bookish and less practice-based, while the strong 'warmth and service' orientation of nursing schools - commonly run by religious groups - gave way to a more career (professional quality) orientation." I have heard my host family mention that many nurses nowadays are rather cold and lack the warm mentioned in the quote. They have said that some nurses say things like "don't cry, it doesn't hurt,"and address the patients in an impersonal way instead of with care and compassion. Regardless of this, many people still consider nurses to be better equipped than physicians for primary care, especially in rural and community health clinics.

Many physicians are not equipped to face the challenges presented by providing health care in rural areas. The medical schools have not made appropriate changes to the curricula as the national priorities have shifted towards primary and preventative health or rural health delivery models.

While talking with some of the nurses in the health center, I was surprised to find out that the length of time it takes to become a doctor in Peru in not much different from any other career path. From my understanding, most students spend 5 years studying in college for the majority of the majors. I believe med students are required to attend one additional year and possibly more training for further specialization. The nurses I talked to were surprised that it takes 7 years to become a physical therapist and up to 12 years to become a physician. I feel like the doctors and nurses are able to appropriately equipped to handle the cases they seen in the health center, but I would be interested to know how their training and quality of work compares to the education received by health professionals in the United States. 

The Search for Missing Pregnant Women

Today when I arrived at the health center, I began my day as I usually do by helping pull files for the patients that need to be seen. After working through a few lengthy lists of "historias" (histories or files) the head office lady asked me if I would be interested in shadowing the obstetricians today. Of course I happily replied yes and followed her to the obstetricians' room.

I sat down and waited for a bit while the doctors/nurses (like I have mentioned before, I rarely know if the people I'm working with are doctors or nurses or something else) sorted through a bit of paperwork. One lady, Carmen, was searching through a database on the computer to find addresses of the "gestantes" (pregnant women) who had not been coming in to their regular checkups and control appointments. When the list was completed with a total of about 8 names and addresses, another lady named Milana and I took off to track down the missing pregnant ladies. 

While we were walking in the direction of the first address, Milana told me that the Centro de Salud Santa Rosa is the health care clinic for the region within Cusco called Santa Rosa. Only residents of this region are allowed to come to the clinic and receive the insurance called SIS that is offered there. As far as I have understood, SIS, which stands for Seguro Integral de Salud (Integral Health Insurance), is free or close to free for people who make less than a certain amount of money. I don't fully understand how the whole process works but I know it must be a good deal because Milana told me that some people make up addresses in the Santa Rosa region in order to get the free insurance. 

Milana also talked to me about how many of the pregnant women don't come in for their regular checkups, which is a big problem especially if something goes wrong with the pregnancy. Currently there are 510 pregnant women in the Santa Rosa region and under the care and supervision of the Centro de Salud Santa Rosa. If any of these women experience complications during their pregnancy and do not receive treatment, the Centro de Salud Santa Rosa is responsible. For this reason, the nurses and doctors are very adamant about making sure that the women come in for regular checkups. Often the ladies don't know exactly how to take care of themselves during pregnancy, which can be detrimental for the mother and the child. 

The first lady we met with told us that she had been going to her controls regularly and proved it to us by showing us her control card completed with up to date information. Milana took note and mentioned that the computer system may not have been updated correctly. She gave the lady some advice about different warning signs and various things to watch out for during her pregnancy. She said that if she experiences things like headaches, swelling of the arms or legs, or blood or other fluids coming out of the body that she should go to the hospital for care right away. It was also interesting because at various times while we were walking, we encountered pregnant ladies walking in the street and Milana would always stop to talk to them and ask where they were living, which health center they were going to, and if they were regularly going to their controls. 

While we were actually able to contact a few of the women, others were never found. Milana talked to a couple of ladies on the phone and left a note with the family of another. Every time we talked to someone (whether a family member or the pregnant ladies themselves) Milana filled out a form about the contact that was made. I believe the purpose of this form was to report that the health center made an effort to track down and contact the various pregnant ladies and relieve their responsibility if something were to go wrong during the pregnancy. 

While we only had visit about 8 addresses, this proved to be quite the challenge for various reasons. First of all, the address system in Cusco is far from organized and many of the doors and homes are unmarked. The various sector and blocks are organized by letters and then each of the homes has a number, C-10 for example. There was no clear way to know which direction to walk in to find a certain house number so often we just picked randomly and hoped we were headed in the right direction. More often than not, we walked many circles and up and down incredibly steep hills searching for elusive addresses. The lack of organization was exacerbated by the fact that some of the addresses we were searching for DID NOT EXIST. They were phony addresses that seemed real but were made up by the patients, like I mentioned before. Other times, the address did in fact exist, but the people living in the house did not even know the person who claimed to live there. It proved to be quite an adventure searching for all the missing pregnant women. 

Peru: Improving Health Care for the Poor - Summary Four

Reforms in Health Provision

This section of the report focuses on the reforms put into practice by MINSA in the 1990s in order to increase the availability of health care to the poor. MINSA is divided into a series of programs that are targeted towards different needs. Some of the programs are aimed at helping the poor with a significant portion of their budget while others are not so "pro-poor." MINSA's program for primary health clinics spends more money to provide assistance to the poorest 20% of the population than the richest 20%, unlike outpatient and inpatient hospitals where expenditures to help the poor are very minimal. 

The Dirección General de Salud de las Personas (DGSP) is the primary sector of MINSA targeted towards specific personal health services. This sector is also subdivided into 15 categorical programs and additional targeted programs. The major categorical programs include immunizations, malaria, tuberculosis, maternal-perinatal health, and HIV-AIDS/STD. An additional sector, Dirección General de Salud Ambiental (DIGESA), sponsors national programs directed towards improving environmental conditions of the poor, such as water, food and animal management. The targeted programs of MINSA include Salud Básica, which has been aimed at improving many health centers by offering higher wages for doctors and staff in rural and under-served areas, and Programa de Complementación Alimentaria para Grupos en Mayor Riesgo (PACFO), which supplies food and nutritional supplements to most of the poorest departments in Peru. Additionally, the Proyecto de Salud y Nutrición Básica and Proyecto 2000 focus on improving maternal and child health services in departments and provinces classified as poor.  

A lack of productivity in primary health clinics and under-utilization of hospitals are both big problems that challenge the health care. There are around 1,000 health centers that each employ between three and five doctors or health professionals. Each clinic produces on average 16 consultations per day, with each doctor seeing on average three patients or so per day. In comparison, a busy clinic in Lima might see 40 patients in just one afternoon. One explanation for these low productivity figures lies in the fact that there are weaknesses in the data available. The 1996 Infrastructure Census failed to include various activities performed by the clinics, such as preventive activities and extramural consultations. Hospitals in Peru are also severely under-utilized. The public hospitals play an important role and consume over 50% of the public health budget as well as produce around 50% of ambulatory consultations, most high-cost interventions, and nearly all inpatient services. A main problem with the hospitals lies in the fact that while they are the most available source of secondary and tertiary services, they only budget a small portion of resources to serve the poor. It is also interesting to note that on a national scale, only 52% of the hospital bed-days are utilized. This is a shocking low percentage, given the amount of unmet needs and congestion of some services. For comparison, in the United States, there is cause for concern if bed occupancy falls below 80%. 

While I personally don't have any experience working in a public hospital in Peru, I have seen many MINSA workers in the public health center. There are quite a few workers, including doctors, nurses, and office staff. From my experience, I have seen that they have a TON of paperwork to do for each patient that comes in. As I've mentioned before, I have been working with the child growth and development control unit for babies under one year of age. In this department, there are two ladies that sit and fill out form after form for each baby, in addition to three ladies who constantly enter information into a computer database. I typically weigh and measure the babies and then relay the information to the ladies who are doing the paperwork. I asked one nurse, Maria, about the paperwork, because it seemed like they were doing multiple copies of the same form for each baby. She told me that that specific form has one small box in which they write a four-digit code depending on the service provided or needed. For example, the basic checkup/control might be 0001, malnutrition might be 5554, and the administration of supplementary micro-nutrients might be 6767. For each service and each code, a separate form has to be filled out, which is absurd given that the form is exactly the same except for the one box. In my opinion, part of the problem with the low level of productivity is due to the fact that so many people have to be employed just to fill out the mountains of paperwork. I realize that the paperwork is important but I think it contributes to the low productivity figures.