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.