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.