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DEVELOPING INTEGRATED RESPONSES OF HEALTH CARE SYSTEMS TO RAPID POPULATION AGING INTRA II – PERÚ
General Coordinator
Dr. Luis Varela Pinedo
Coordinator Team
Dr. Helver Chávez Jimeno Dr. Antonio Herrera Morales Dr. Francisco Méndez Silva Dr. Miguel Gálvez Cano
MULTIDISCIPLINARY TEAM
Dr. Luis Varela Pinedo General Coordinator INTRA II-Peru Project Director, Gerontology Institute Universidad Peruana Cayetano Heredia
Dr. Helver Chávez Jimeno Titular member, Gerontology Institute, Universidad Peruana Cayetano Heredia Dr. Antonio Herrera Morales Correspondent member, Gerontology Institute, Universidad Peruana Cayetano Heredia Dr. Fernando Portocarrero Salazar Medical Director, Military Geriatric Hospital Dr. Carlos Sandoval Cáceres Resident Tutor in Geriatrics, Medicine Faculty, Universidad Nacional Mayor de San Marcos Dr. Elizabeth Sánchez Yturrizaga Executive coordinator, Consorcio Perú Envejecimiento y Desarrollo (NGO) Dr. José Francisco Parodi García Geriatric Physician, San Martin de Porres University Dr. Pedro Vera Vílchez Elderly Adult Social Program responsible, Hospital Nacional Cayetano Heredia Dr. Juan del Canto y Dorador Elderly adult program responsible Health Ministry (MINSA) Dr. Carmen del Pilar Estela Benavides Elderly adult general direction Woman and Social development Ministry (MIMDES) Dr. Francisco Méndez Silva Correspondent member, Gerontology Institute, Universidad Peruana Cayetano Heredia Dr. Miguel Gálvez Cano Resident Geriatric Physician, Universidad Peruana Cayetano Heredia Dr. Luis Álvarez Cóndor Physician, Geriatrics Service, Geriatric Institute Peruvian Aerial Force (FAP) Dr. River R., Cersso Bendezú Coordinator SBS, Elderly Adult Pilot Program, DISA II, Cañete-Yauyos, South Lima Dr. Diana Rodríguez Hurtado Scientific investigator office and technological development chief, Arzobispo Loayza Hospital Dr. María del Pilar Gamarra Elderly Adult Attention National Commission President, Social Security (EsSalud) Dra. Isabel Benate Gálvez Elderly Adult Affairs Responsible Primary Health Care, EsSalud Dra. Blanca Deacon Castillo Association Pro-Vida Peru President (NGO) Dr. Felipe Aguirre Salinas Executive Director, Association Pro-Vida Peru (NGO)
INTRODUCTION
During the last 50 years a decrease of the world's population natality and mortality had been leading to the world's population aging. In the Latin American countries (Peru among them) the population's aging is also a demographic characteristic. This has a great importance, because it implies economic and social consequences; as well as changes in work, housing, recreation, and education areas, and mainly in the health necessities that will take place.
According to census and estimates, in 1970 the elderly adult population in Peru constituted 5.54% of the national total. According to 1993 census, it was of 6.34%; that means that in a 23 year period the elder adult population grew in less than 1% of the total population. A real growth took place in the last 11 years, since for the end of 2004, it is calculated that this population will arrive to 7.55% and for the 2025 will represent 13.27%; this means that in next 20 years the proportion of elder adult population will be almost duplicated. We are witness of a process of a quick demographic transition, so is our duty to be prepared to confront these changes and their consequences.
The expectation of the Peruvian population's life has also changed in the last years. In 1970 this was 53 years, for the 2004 is of 70 years, and is considered that it will reach 75 years for the 2025.
1. GENERAL CHARACTERISTICS
1.1 GEOGRAPHY
Peru is in the western and central region of South America, it limits for the west with the Pacific Ocean, for the East with the countries of Brazil and Bolivia, for the North with Ecuador and Colombia; and for the South with Chile. It presents a surface of 1 285 215 km², being the third country in territorial extension of South America after Brazil and Argentina.
Located in a tropical region, the typical climate would be expected. However, due to a great number of geographical peculiarities, as the Peruvian current that affects the temperature of the adjacent sea and the Andes mountains that crosses the country from north to south; Peru presents a wide climatic and ecological variety. Traditionally are considered three geographical regions:
The Coast: to the west, next to the Pacific Ocean, is constituted by a narrow desertic fringe that concentrates most of the Peruvian population (52%).
The Sierra: Central mountainous region that constitutes around 30% of the national territory. It is conformed by mountain ranges and an extensive plateau. This configuration implies that around 30% of the national territory it is located between the 2000 and the 4000 meters over sea level. 34.48% of the Peruvians habit this region.
The Forest: to the east, it constitutes the forest plains of the Amazon basin. This region occupies 60% of the territory, but only 13.52% of the Peruvian population's habits it.
Since the year 2004 the country is conformed by 25 regions (the old 24 departments and the constitutional county of Callao) whose first representatives, were elected in November of the 2003. With this current and recent process of decentralization it is expected that the country overcome the strong centralism that has characterized it for five centuries. These regions are divided in counties (188) and these in turn are formed by districts (1595).
Peru’s capital is the city of Lima, located in the central coast of the country. This city was founded in 1535, beside Rimac River by the Spanish conqueror Francisco Pizarro. From the beginning of the Spanish colonization until today Lima has been the center of the political and economic power; configuration that has been prejudicial for the development of the rest of the country and that has generated deep social and economic inequalities.
According to the 1993 census, Lima city had 5 854 608 inhabitants; the projections of the National Institute of Statistics (INEI) for the year 2004 give it a population of 7 208 794 people that almost represents the fourth part of the national total
The second city of the country is Arequipa located at 2360 meters over the sea level, in the Peruvian Andes. With 851 750 inhabitants, and located in the region of the same name, concentrates 2.95% of the Peruvian population's.
1.2 POLITICAL - ECONOMIC SYSTEM
1.2.1 Historical aspects
Peru was one of the last countries in South America that reached its independence that was proclaimed in 1821. Almost from the beginning of Peru’s republican life, the government’s system was democracy, based on the division of the powers of the state, government's alternation and congress's renovation by means of elections.
Peru has had 13 constitutions, the first one promulgated in 1823, and the last one in 1993.
1.2.2 Political Aspects
The Peruvian State is conformed by three autonomous powers: a) Executive Power: The Peru has a presidential government's system. The executive power resides in the President of the Republic who has chief of state functions. It is him who directs the government politics, supported by a political-electoral majority, determined by popular vote. b) Legislative Power: Resides in the Congress that at the moment consists of an unique Camera. The number of congress members is one hundred twenty. The Congress is chosen by a five-year period. Their main functions are to give the laws and permanent inspection, as well as the eventual reformation of the Constitution. c) Judicial Power: Is integrated by jurisdictional organs that administer justice on behalf of the Nation, and for organs that exercise their government and administration. The jurisdictional organs are: the Supreme Court of Justice, the Superior Court, specialized and mixed Tribunals, and Peace Tribunals. The Full Room of the Supreme Court is the maximum organ of deliberation of the Judicial Power.
Parallel to these three powers, there are autonomous organisms that are:
· Republic General Controllership . National Elections Jury · People Defensory · Public Ministry
1.2.3 Economic process in the last two decades
The Peruvian economy in the 80s decade had one of the highest hyperinflations in the world, the reduction of the per capita income, and the increment the foreign debt. Peru was also excluded of the support of the IMF and of the World Bank (ineligible country), due to the incomplete payment of the foreign debt. In the 90s answering to this situation, were applied programs of macroeconomic adjustment, commercial opening and structural reformations that considered among other measures, the privatization of public companies, and modifications in the administrative structure of the public sector. These measures reduced the inflation drastically and created the conditions to recapture the route of the growth and sustained development as well as a progressive reinsertion in the international economic system. This process entered in crisis at the end of the 90s due to the impact of El Niño phenomenon in the agriculture, the financial crisis of Asia, and the political instability due presidential re-election of Alberto Fuijmori and its subsequent renouncement. All of these factors limited the growth among the years 1998 to 2001. In July 2001 Alejandro Toledo assumed the presidency; from then on the Peruvian economy has presented a slow but stable growth.
The growth of the National Gross Product for the year 2002 were 4.85%, registering an increment of 5.5% regarding the year 1998 that registered negative values. The rate of inflation of the year 2003 was of 2.48%, something superior to that of the 2002 that was of 1.10%. The Chart 1.1 summarize some socioeconomic indicators and their evolution among 1993 - 2003
Chart 1.1 Socioeconomical indicators and their evolution among 1993 - 2003
1993 1995 1997 1999 2001 2003
National Gross Product (NGP) 87375 107025 117214 117507 121132 130817 Millons of NS$ NGP growth, % 4.76% 10.69% 4.67% 0.13% 1.53% 3.92%
Inflation rate, % 39.50% 12.80% 9.15% 4.85% 3,90% 1.79%
NGP per-capita 3842.3 4548.3 4809.6 4657 4642.8 4853.9 Nuevos Soles per hab Source: Análisis estadístico, Perú en números 1993 – 2002, Cuanto 1 dollar = 3.5 Nuevos Soles
The Social situation of the country is also reflected in the PBI structure. The agriculture that contributed with 23.8% of the NGP in 1950, drop to almost the half by the end of the 90’s. While the commerce, that in the 50s represented 4.1% of the PBI grew in important form, reaching 14.4%; being the small and the informal commerce those that contributed in great measure to this increment. Fishing that contributed in 1950 with 0.2% it grew six and half times, reaching to 1.3 %. Graph 1.1
Graph 1.1 Evolution of the structure of the NGP, Peru 1950 - 1996 National Gross Product Structure, 1950 - 1996
100%
80%
60% 1996 40% 1950 20%
0% AgricultureAgricultura Manufactura Industry Minería Mining PescaFishing Comercio Commerce
Peru’s Poverty evolution is summarized in the chart 1.2. Total poverty is defined like a situation in which the home income don't reach to satisfy a group of minimum necessities (food and not food), contained in the Consumption Minimum Basket. The total poverty diminishes from 1993 to 1998, while starting from 1999 increases due to the period of economic crisis mentioned previously.
Chart 1.2: Perú: Total poverty evolution, 1993 – 2001
1993 1995 1997 1998 1999 2001 Total 56,80% 45,30% 42,70% 42,40% 47,50% 49,80% Urban 42,40% 37,40% 29,70% 29,70% 34,70% 35,70% Country side 90,10% 59,40% 66,30% 65,90% 71,80% 75,90% Lima (city) -- 28,30% 25,40% 24,10% 31,40% 35,70% Source: Encuesta Nacional de Hogares 1995 -2001; INEI
Extreme poverty is defined as the situation in which the home doesn't have enough income to acquire a Minimum Consumption Alimentary Basket that satisfies the nutritional minimum requirements in terms of calories and proteins. The evolution of this indicator is in the Chart 1.3
Chart 1.3: Perú: Extreme poverty evolution, 1993 – 2001
1993 1995 1997 1998 1999 2001 Total 28,30% 19,30% 18,20% 17,40% 18,40% 19,50% Urban 16,10% 8,90% 5,30% 5,20% 4,70% 5,70% Countryside 56,90% 38,40% 41,50% 40,00% 44,40% 45,20% Source: Encuesta Nacional de Hogares 1995 -2001; INEI
In chart 1.4 is observed that the unemployment level has stayed almost constant during the last years, while the sub employment has grown almost 10% since 1995.
Chart 1.4 Peru: employment evolution, 1995 - 2001
1995 1996 1997 1988 2000 2001 Employment rate 92,50% 92,90% 92,50% 92,10% 92.60% 92.20% Unemployment rate 7,50% 7,10% 7,50% 7,90% 7.40% 7.80% Sub employment rate -- 42,60% 41,80% 44,10% 52.20% 55.70% Source: Encuesta Nacional de Hogares 1995 -2001; INEI
1.3 HISTORY OF PERU AND THEIR ELDER ADULTS
In Peru, there are human evidences of human life that has more than 15 thousand years of antiquity. Chavin culture is considered the most ancient of Peru, after this culture, diverse cultural groups and towns developed in different regional spaces, among these groups are the Paracas, Nazca, Mochica, Huari, Tiahuanaco, Chimu and the Inca cultures.
The Inca expansion takes place by the middle of the 12th century, reaching a remarkable level of political and administrative unification based on conquest or annexation of other towns or cultures of the Andean area. They extended the use of the Quechua as the common language and built an extensive net of roads and tambos (depots). They also redistributed the resources inside of an organizational system of social economic planning that unified and respected the diversity of towns and cultures, as well as the natural resources and economic areas, also very diverse.
Toward the year 1500, the Inca political organization had incorporated most of the Andean social formations, forming the Tahuantinsuyo whose territories embraced from the south of the current Colombia until the center of what today is Chile, also included Bolivia and the north of Argentina. This vast and complex social economic formation had sustenance in a theocratic government model, in which the Inca elite was located in the peak of the system and were considered divinities.
In the Incan Empire, the base of the social and economic organization was the ayllu that was conformed by groups of families. The Inca economy was based on the collective work, the elderly adults maintained their labour status in a permanent way, carrying out appropriate works to his biological condition. When arriving to very advanced ages the ayllu took charge of their maintenance.
About other pre-inca towns and cultures, we doesn't have information regarding the elderly adult's situation; but is probable that they were in disadvantage just as it was in almost all the civilizations of the past.
In the year 1532, a conflict for the succession and control of the Inca throne started between the brothers Atahualpa and Huáscar. The scale had leaned in favour of Atahualpa when a group of Spaniards, led by Francisco Pizarro and Diego de Almagro arrived to Peru. They went to the encounter of Atahualpa in Cajamarca and seeing the favourable conditions, they captured and later execute him; this action began the process of the conquest of the Inca Empire and of other towns of South America.
Socially a division took place between the colony of Spaniards and that of Indians; arising intermediate sectors - the mestizos - characterized for their struggle to differ from the Indians and resemble to or be assimilated by the Spaniards. The African Americans were introduced in America like slaves. They constituted a category apart from the social structure; their social inclusion has meant a long process. In this way, the Peruvian society became multi-ethnic, multi-cultural and of many languages.
In this new economic structure the only native who was worth, was the one capable of work, giving place to the abandonment of those no capable, among them the elderly adult. The natives had to pay a tribute until they were 50 years old; the epidemics brought by the conquerors and the implanted mining exploitation system raised the mortality (especially the masculine one) at alarming levels. For these reason only a few people were able to reach the age of 50 years.
It was also during this time that took place the establishment of medical institutions; being founded hospitals and hospices under the help of the Catholic Church. After that the teaching of a medieval medicine settled down
Peru’s independence was achieved by Simon Bolivar’s troops in the battle of Ayacucho in 1924. After Bolivar leaved the country, each one of his lieutenants wanted to take control of the new created Republic, this situation faced them in multiple wars for political power. In this way, the first decades of independent life were characterized by a political and social economic chaos. The country would not enjoy order neither peace up to 1845, year in that the general Ramón Castilla, was made president. Castilla was a skilled ruler that began numerous and important reformations in the two periods of its presidency, as the abolition of the slavery, the construction of railroads and of telegraphic facilities, as well as the adoption of a liberal Constitution in the year 1860. Castilla also began the exploitation of the natural resources of the country, as the deposits of guano and the nitrate. In 1864 these deposits would unchain the first Pacific war (1864-1866) between Peru and Spain, country that had taken possession of the rich guano islands of Chincha. Ecuador, Bolivia and Chile helped Peru, defeating the Spanish forces in 1866.
The relationships between Peru and their neighbours were difficult from the beginning of its republican life. The bordering problems mainly with Chile, gave place to the second Pacific War with this country in 1879, in which after five years of war, Peru lost part of its territories in the south. The period of post-war was characterized for a destroyed economy and a conflict for power between the military commanders defeated by the Chilean army; for this reason the next 30 years the Peru was governed by successive dictators. After this period democracy returned but our republican life since then has been characterized by the alternation between elected governments and civil or military dictatorships.
In the initial period of the republic, the elderly adult population's marginalization persisted. They were considered a devaluated work force, with very little acceptance in the labour market.
By the middle of the XIX century, with the development of the national medicine, under the influence of French, English and German medicine, the interest arose to satisfy the necessities of the elderly adult’s attention, especially those of popular sectors.
The Society of Charity of Lima (Sociedad de Beneficencia de Lima) was founded in 1834 during the government of the general Orbegoso with the purpose of offering attention to the helpless. This society established several hospices with limited functions, as the Manrique, Castaño, Ruiz Dávila, and Corazon de Jesus housings among others.
In 1924 the San Vicente de Paul Asylum was built, today Geriatric Home, belonging to the Society of Charity of Lima, for the attention of helpless elderly adults.
The creation of an Obligatory Public Health for the workers in 1936 is important, because for the first time the workers had insured their medical care during their old age, after the jubilation. This type of attention was extended in 1951 in the form of the Social Insurance. The Pensions National System of the Social Security was created in 1973, replacing the Pensions Fund of the Social Security, the Employee's Social Security and the Jubilation Special Fund for Employees of Non-governmental companies.
The Peruvian Armed Forces created services of geriatric attention in the Military Central Hospital, in 1975; in the Police Forces Hospital, in 1982; in the of Aeronautics Central Hospital, in 1983 and in the Navy Central Hospital, in 1985.
In August 27 of 1982, were inaugurated in the district of the Rimac the geriatric asylum that takes their benefactor's name, Ignacia Rodolfo widow of Canevaro.
In 1998 was created the Geriatrics Service in the Social Security Hospital, “Guillermo Almenara Irigoyen”, while in the hospital “Edgardo Rebagliati Martins”, also of the Social Security was created a unit of geriatric evaluation.
Recently, Geriatrics Services have been created in some hospitals of the Health Ministry, such as “Cayetano Heredia”, “Archbishop Loayza”, “2 de Mayo”, “Sergio Bernales” , but they are not implemented to work in a proper way yet.
The Geriatrics began as a discipline in our country by the middle of the XX century by a group of physicians interested in this relatively new specialty; they decided to found the Peruvian Society of Geriatrics in 1953, and their first president was Dr. Eduardo Valdivia Ponce. This society was made member of the International Association of Gerontology in 1957. Later on this group went in crisis because their members didn't know how to come to an agreement in the identity of the institution.
In 1978 another group of physicians believed necessary to form the Peruvian Society of Gerontology and Geriatrics. Their first president was the Dr. Miguel LLadó. This society is recognized by the Peruvian College of Medicine and had been acting through medical education courses of the specialty and through it official organ, the magazine Geronto whose first number appeared in 1982.
In the city of Arequipa, the University Health Center “Pedro P. Díaz” of the National University of San Agustín, created in 1979, has among its activities Elderly Adult Programs and social projection programs as: psychological campaigns of Attention to Children, Adults and Elderly Adults. In the Catholic University of Santa María, the infirmary program includes, among it objectives, to guide their students actions towards the human necessities of the women, newly born, boy, adolescent, young adult and elderly adult in chronic and critical states
Most of geriatric institutions are concentrated in Lima. However, in the last years, the Social Security has been carrying out an active work of forming services of geriatric attention and other similar ones, in the main cities of the country.
In the year 2002 was approved " THE NATIONAL PLAN FOR THE ELDERLY ADULT 2002-2006"with the objective of implementing coordinated actions between the government organizations and the civil society in order to increase the participation and the elderly adult's social integration. The coordination and evaluation of this plan is in charge of the Ministry of Promotion of the Woman and Human Development (MIMDES).
The Health Ministry also had considered the medical attention according to the stages of the vital cycle, developing norms for the elderly adult's attention in an integral model of health attention.
August 26, day of the death of Santa Teresa Jornet Ibars, co-founder of the Order of the Sisters of the Abandoned Elderly Adults, has been instituted as the Peruvian Elderly Adult’s Day.
In the educational and formative field, the geriatrics course has been integrated in some universities. Also, the specialty of geriatrics is integrated in the resident program. Mastery programs in gerontology are dictated in diverse universities. In 1989, the Peruvian University Cayetano Heredia creates a gerontology institute, which has for mission to carry out and to foment the investigation in the geriatrics and gerontology area in Peru.
2. DEMOGRAPHIC TENDENCIES
According to the Pan-American Health Organization report on the "State of the Aging and Health in Latin America and the Caribbean, the socio-economic situation of the elderly adults", presented in January of the 2004, the region has been divided in four sub- regions. Peru is located in the sub-region of Andean Countries together with Bolivia, Colombia, Ecuador and Venezuela where the aging index will be duplicated in next two decades and the rural area will continue being important for elderly adult population.
The components that determine the growth, size and the structure of the populations are the natality, the mortality and the migration rate. In our country the growth is mainly consequence of the interaction of these first two demographic factors. The rate of mortality and natality have diminished in the last 30 years and it is expected they continue diminishing up to the 2015; starting from this year the mortality will began to increase while the natality will continue diminishing. The changes in the fecundity in Peru have been notorious and it is expected that the global rate of fecundity diminishes up to 2.1 children per woman for the 2025. Chart 2.1
Chart 2.1 Peru: Natality, mortality and fecundity rates, 1970 - 2025
Natality Global Mortality Year Rate ( per mil) Fecundity Rate Rate (children per women) ( per mil) 1970 42.35 6.30 14.01 1980 35.64 5.01 9.83 1985 32.49 4.36 8.31 1990 30.42 3.90 7.27 1995 27.7 3.45 6.68 2000 24.52 3.02 6.29 2005 22.18 2.72 6.07 2010 20.38 2.48 5.99 2015 18.84 2.29 6.00 2020 17.29 2.15 6.06 2025 16.48 2.10 6.36 Source: INEI
In the Chart 2.1, can be observed an increase of the longevity; that it is measured by means of life expectancy at birth that has increased from 53.47 years in 1970 to 70.4 years for the present year, 2004. (chart 2.2)
Chart 2.2 Peru: Life expectancy at birth, 1970 – 2025
Life expectancy at birth ( by years) Year Total Men Women 1970 – 1975 55,52 53,88 57,25 1980 – 1985 61,55 59,46 63,75 1985 – 1990 64,37 62,08 66,77 1990 – 1995 66,74 64,40 69,20 1995 – 2000 68,32 65,91 70,85 2000 – 2005 69,82 67,34 72,42 2005 – 2010 71,23 68,68 73,90 2010 – 2015 72,53 69,93 75,27 2015 – 2020 73,75 71,08 76,55 2020 – 2025 74,87 72,14 77,73 Source: INEI
The rate of the population's growth is defined as the relationship between the annual surplus of the births and the deaths of the population, measured in the period of observation and it is expressed in percentage (chart 2.3).
Chart 2.3 Peru: Evolution of the population's growth rate, for five year period, 1980 - 2025.
1980 - 1985 - 1990 - 1995 - 2000 - 2005 - 2010 - 2015 - 2020 - 1985 1990 1995 2000 2005 2010 2015 2020 2025
2,41 2,19 1,85 1,7 1,5 1,4 1,31 1,19 1,04
Source: INEI
Between the years 1970 and 2004, the group with ages of 50 or more years increased their participation. The projections for the year 2025 indicate that the population of elderly women would reach, 13.7% and the elderly men, 11.53% (Chart 2.4)
Chart 2. 4 Peru: Structure of the population according to age and gender (% 1970 - 2025)
1970 1990 2004 2025
Total 13192677 21753328 27546574 35725458 0 - 14 years 5805842 8313015 9013296 8606711 % 44.01 38.21 32.72 24.09 15 - 50 years 5927997 10815052 14531002 19030660 % 44.93 49.72 52.75 53.27 50 - 60 years 727904 1307885 1923141 3659460 % 5.52 6.01 6.98 10.24 60 + 730934 1317376 2079135 4428627 % 5.54 6.06 7.55 12.40 Men Total 6648691 10944495 13852228 17879352 0 - 14 years 2949225 4222387 4585173 4391704 % 44.36 38.58 33.10 24.56 15 - 49 years 2998457 5458566 7330314 9615530 % 45.10 49.88 52.92 53.78 50 - 59 years 358957 647925 955095 1811267 % 5.40 5.92 6.89 10.13 60 + 342052 615617 981646 2060851 % 5.14 5.62 7.09 11.53 Women Total 6543986 10808833 13694346 17846106 0 - 14 years 2856617 4090628 4428123 4215007 % 43.65 37.84 32.34 23.62 15 - 49 years 2929540 5356486 7200688 9415130 % 44.77 49.56 52.58 52.76 50 - 59 years 368947 659960 968046 1848193 % 5.64 6.11 7.07 10.35 60 + 388882 701759 1097489 2367776 % 5.94 6.49 8.01 13.27 Source: INEI
If the changes are analyzed inside the group of elderly adults; it can be observed that among 1970 and 2025 the group of 75 years old or more presented a sustained increase inside the group of elderly adults. (Chart 2.5)
Chart 2.5 Peru: Structures of the population elderly than 50 years by five-year age groups, 1970 – 2025
1970 1990 2000 2010 2025
50 - 54 years 26,79% 27,18% 26,38% 26,68% 24,39% 55 - 59 years 23,11% 22,64% 21,27% 21,66% 20,86% 60 - 64 years 18,78% 17,61% 17,60% 16,78% 17,51% 65 - 69 years 13,71% 13,07% 13,76% 12,78% 13,60% 70 - 74 years 9,64% 9,20% 9,65% 9,66% 10,08% 75 - 79 years 5,32% 6,09% 6,14% 6,61% 6,78% 80 years o + 2,65% 4,21% 5,20% 5,83% 6,78% 100,00% 100,00% 100,00% 100,00% 100,00% Source: INEI
In the graph 2.1 is the population elder than 50 years current percentage distribution.
Graph 2.1. Peru: Structure of the population elder than 50 years by decade age groups, 2004
5,43% 48,05% 16,18% 50-59
60-69
70-79
30,34% 80 or + years
Source: INEI
When analyzing the structure changes of the population elder than 50 years between 1970 and 2025 for each gender; the women elder than 80 years increased their participation in the group from 2.93% in 1970 to 7.68% this year, while the men increased in smaller proportion, from 2.34% to 5.79%. (Chart 2.6)
Chart 2.6 Peru: Structure of the population elder than 50 years for each gender, according to five-year groups of age (%, 1970 - 2025)
1970 1990 2000 2010 2025 Men 50 - 54 years 27.65 28.11 27.38 27.47 25.34 55 - 59 years 23.56 23.18 21.69 22.14 21.45 60 - 64 years 18.83 17.74 17.45 17.00 17.78 65 - 69 years 13.45 12.89 13.58 12.74 13.53 70 - 74 years 9.21 8.83 9.47 9.41 9.77 75 - 79 years 4.96 5.63 5.84 6.18 6.34 80 years o + 2.34 3.62 4.60 5.05 5.79 Total 100.00 100.00 100.00 100.00 100.00 Women 50 - 54 years 25.98 26.32 25.63 25.94 23.52 55 - 59 years 22.70 22.14 20.81 21.22 20.32 60 - 64 years 18.75 17.50 17.40 16.58 17.25 65 - 69 years 13.95 13.23 13.84 12.82 13.67 70 - 74 years 10.03 9.55 9.93 9.89 10.36 75 - 79 years 5.66 6.51 6.51 6.99 7.20 80 years o + 2.93 4.75 5.88 6.56 7.68 Total 100.00 100.00 100.00 100.00 100.00 Source: INEI
During the last five decades, the Peruvian society has been marked by a clear tendency to the urbanization, expressed in the population territory redistribution. The migratory flows are evidenced, through a quick growth of the population of the urban areas, as well as of a slow growth and a relative loss of population of the rural areas. The changes in the Peruvian population's composition between 1940 and 1993 are significant. Of a population for the most part rural in 1940 (65%) it passes to a mainly urban population in 1972 (60%), increasing their participation in 1993 to 70% and according to estimates for the 2004 will arrive to 72.48%.
The urban population has grown much more quickly that the rural one. The rates of growth of the first one in the periods 1940-61 and 1981-93 were respectively of 3.7% and 2.8%. While the rural one in the same periods grew 1.3% and 0.9% respectively. It is appreciated in the last period a relative descent of the speed of the urbanization. From 1940 to 1993, the urban population has grown 6 times, while the national population almost 3 times, and the rural one hardly in 0.6.
The evolution of the population's structure elder than 50 years, in rural environment as in the urban one is in the chart 2.6. In 1970, it is observed that almost 2/5 of the elder than 50 years population lived in the rural environment; in the 90s less than a 1/3 of this group lived in the rural areas. For the 2025, is expected that only a 1/4 of elder than 50 years population will live in rural areas.
Chart 2.6. Peru: Structure of the population elder than 50 years Urban vs. Rural, 1970 – 2025
1970 1990 Urban % Rural % Urban % Rural % Total 7659211 58.06 5533466 41.94 14955100 68.75 6798228 31.25 50 a 59 years 408187 56.08 319717 43.92 896465 68.54 411420 31.46 60 a 69 years 260479 54.95 213584 45.05 540693 67.13 264759 32.87 70 a 79 years 117683 53.92 100589 46.08 269405 67.10 132097 32.90 80 years or + 20440 52.95 18159 47.05 76242 69.04 34190 30.96
2004 2025 Urban % Rural % Urban % Rural % Total 19966180 72.48 7580394 27.52 26838213 75.12 8887245 24.88 50 a 59 years 1486059 77.27 437082 22.73 2939151 80.32 720309 19.68 60 a 69 years 904713 74.50 309680 25.50 2059905 81.86 456399 18.14 70 a 79 years 480071 74.15 167322 25.85 1112086 81.52 252040 18.48 80 years or + 173572 79.86 43777 20.14 449683 82.03 98514 17.97 Source: INEI
In Chart 2.7 is the regional distribution of the Peruvian population and the percentage of elder than 60 years in each one of them.
Chart 2.7 Peru: Elderly Adult’s total population, by regions, 2004
Total pop of Elderly Adult Regions Total 60 years or Population % 60 population Population more years or more distribution Amazonas 436073 24637 5.65% 1.18% Ancash 1139083 93966 8.25% 4.52% Apurímac 478315 31114 6.50% 1.50% Arequipa 1126636 96021 8.52% 4.62% Ayacucho 571563 41017 7.18% 1.97% Cajamarca 1532878 95086 6.20% 4.57% Callao 811874 74207 9.14% 3.57% Cusco 1237802 82620 6.67% 3.97% Huancavelica 459988 27513 5.98% 1.32% Huánuco 833640 48541 5.82% 2.33% lca 709556 57539 8.11% 2.77% Junín 1274781 89590 7.03% 4.31% La Libertad 1550796 123938 7.99% 5.96%
Lambayeque 1141228 86545 7.58% 4.16% Lima 8011820 739089 9.22% 35.55% Loreto 931444 44137 4.74% 2.12% Madre de Dios 104891 3213 3.06% 0.15% Moquegua 163757 12933 7.90% 0.62% Pasco 277475 14780 5.33% 0.71% Piura 1685972 108437 6.43% 5.22% Puno 1297103 93697 7.22% 4.51%
San Martín 777694 39864 5.13% 1.92% Tacna 309765 18495 5.97% 0.89% Tumbes 211089 11112 5.26% 0.53% Ucayali 464399 21045 4.53% 1.01% Total 27546574 2079135 7.55% 100.00% Source: INEI
It is prominent the elderly adult population concentration in certain regions of the country that doesn't always present the highest percentages of elderly adult population's total distribution.
It can also be observed in the previous chart that the regions with more proportion of elderly adult population are located in the coast, where the biggest urban centers in the country are also located. This was expected since these regions offer to the population more labour options as well as an easiest access to education services, culture, health, and recreation. This in turn generates conflicts of coexistence, overalls in Lima. Lastly the unequal regional development drives to political-social and economic conflicts when concentrating financial resources on some few regions.
3. GENERAL CONSIDERATIONS FOR THE POPULATION OF 50 YEARS OLD OR MORE
According to the United Nations Development Program (UNDP) the indicators of life quality in Peru are as the one as the average of Latin America that is to say below the developed countries. According to the index of human development, that is measured in three basic dimensions (hope of life, educational level and income) the Peru is a country of intermediate development, being located in the 13th place in the Latin American context and 82nd at world level.
3.1 WORK
3.1.1 Occupation, unemployment and inactivity rates
According to the National Home Survey (ENAHO 99), only the 37.46% of the elderly adults was economically active (EA) in the urban area; 52.07% of them were males and 24.41% females. This difference are explained in function of the social factors prevalent decades ago, in which the feminine presence was important at home, and at the same time and by this excuse her participation inside the productive activity was restricted.
Chart 3.1 Peru: Elderly adult population, by gender, activity condition, Urban Area at National Level (1999)
Activity Total Men Female Population 1,185,126 559,348 625,778 EA 444,004 37.46% 291,267 52,07% 152,738 24,41% Employed 425,193 95.76% 273,574 93,93% 151,62 99,27% Unemployed 18,811 4.24% 17,693 6,07% 1,118 0,73% NON EA 741,122 62.54% 268,081 47,93% 473,04 75,59% Source INEI- ENAHO 1999-III Trimestre
3.1.2 Underemployment and Unemployment
ENAHO 1999 also find that at Urban Peru level, the 44.7% of the population elder than 55 years was under-employed. Chart 3.2
Chart 3.2 Urban Peru, Underemployment by age groups: 1999
Under- Age employment Rate Total 43.40% 14 - 24 years 52.50% 24 - 44 years 39.50% 45 - 54 years 39.10% 55 or more years 44.70% Source: INEI
In Peru the unemployment had increased in all age groups. Among the elderly adult population this could be due aspects that are related with the labour offer like: health problems, lack of qualification, or with the labour demand: lack of opportunities, age discrimination. The unemployed population of this age could probably be looking for a job due an subsistence objective, mainly if he/she doesn't have access to a social security pension, own rents or family support.
For the year of 1997, 7.6% of the males and 4.3% of the females elder than 55 years were unemployed. The males of this age group present the highest unemployment rate, after the youths between 14 and 24 years. Due the lack of information, to be able to analyze the evolution of the unemployment, it is necessary to restrict the analysis to Lima City. In 1990, while the unemployment only affected 3.1% of the economically active elder than 65 years population; in 1993 reached the maximum level of 9.9% and diminished lightly in 1997 remaining at 8.84%.
Lima City: Unemployment rate evolution, by age group 1986-1998 14-19 20-34 35-49 50-65 20.2 19.42 20.0 65-+
13.1 13.0 11.6 11.1 9.8 9.76 9.2 9.9 9.0 8.84 10.0 7.3 8.1 8.0 6.64 6.1 6.16 2.9 5.1 3.4 3.8 2.5 2.6 3.1 0.0 1986 1990 1993 1995 1997
If the differences are analyzed by gender, it is observed that contrarily to what happens in other age groups, the elder males had the highest unemployment rates. This could be probably because the women elder than 65 years are more dedicated to home tasks or offering family support to their sons or daughters and they are not looking for an employment actively (This means they are part of the non economically active population).
The working men elder than 50 years, had a high increment in the unemployment rate. It rose from 3% for the period 1986-1990 to 7.7% for the period 1994-1997.
In the chart 3.3 can be observed more recent statistics about the characteristics of the economically active population at Lima City.
Chart 3.3 Economically Active Population in Lima City: Employment, Underemployment and Unemployment levels, 2002
Unemployment Underemployment Proper employment EA population 9,72% 41,91% 48,37% Men 14 - 24 years 14,63% 50,58% 34,79% 25 - 44years 5,76% 34,94% 59,30% 45 - 54 years 6,55% 31,91% 61,54% 55 or + years 10,10% 34,43% 55,47% Females 14 - 24 years 18,05% 51,03% 30,92% 25 - 44 years 10,76% 44,61% 44,63% 45 - 54 years 7,03% 46,09% 46,88% 55 or +years 8,01% 59,79% 32,20% Source: INEI - ENAHO 2002
3.1.3 Characteristics of the elderly adult's occupation categories and work place
In the year of 1996, the age group from 25 to 44 years was the most prevalent in most of all the occupational categories. The adults elder than 55 years represented 10.5% of the economically active urban population, having a significant participation among the groups of the independent workers and of employees or bosses. Chart 3.4
Chart 3.4 Peru: The Economically Active Population distribution and by age groups, 1996
Occupational Age groups( by years ) Category 14 - 24 25 - 44 45 - 54 55 or + Total Hard-Worker 34.0 46 12.7 7.3 100 Employed 22.5 59.5 12.8 5.2 100 Independent worker 11 52.1 20.2 16.7 100 Professional 12.8 49.2 21.7 16.3 100 Non professional 11 52.2 20.1 16.7 100 Boss 5.7 54.7 21.7 17.9 100 Family worker non paid 50.3 32.2 9.2 8.3 100 Home 55.8 31.6 7.8 4.8 100 Others 55.3 27.6 12.9 4.2 100 Total 23.4 50.8 15.3 10.5 100 Fuente: ENAHO 1996
However, inside the group of adults elder than 55 years, most of them were independent workers, employees and hard-workers. Chart 3.5
Chart 3.5 Peru: Urban population elder than 55 years distribution by occupational category, 1996
Occupational 55 or + (%) Category Population Hard-Worker 13.7 Employed 14.1 Independent worker 54.3 Professional 1.6 Non professional 52.7 Boss 9.7 Family work non paid 5.6 Home 1.8 Others 0.1 NEP 0.7 Total 100.0 Source: ENAHO 1996
For 1996, the age group that worked more in the agricultural area was the one of 55 years or more, while the youths worked more in commercial locals or shops. Chart 3.6
Chart 3.6 Peru: Population's distribution by age groups and by work place, 1996
Age groups ( by years ) Work place 14 - 24 25 - 44 45 - 54 55 or more Total Commercial local or shop 26.5 53.7 13.6 6.2 100 At home 15.9 47.9 18.4 17.8 100 On the street (a fixed place) 21.3 52.8 15.9 10 100 On the street (a mobile place) 22.9 53 14.1 10.0 100 Transport vehicle 22.1 53 14.9 10.0 100 Clients home 17 54.1 16.2 12.7 100 Marketplace 22.1 48.5 14.7 14.7 100 Agricultural area 18.4 37.9 17.3 26.4 100 Others 30.3 43.3 17.9 8.5 100 Total 22.9 51.4 15.1 10.6 100 Source: ENAHO 1966
Among the group of elder than 55 years, most of them worked in commercial locals and shops, at home and in the agricultural area. Chart 3.7
Chart 3.7 Peru: The 55 year-old urban busy population's percentage distribution and but for age groups, according to work place, 1996
Occupational 55 or + (%) Category Population Commercial locals or shops 26.9 At home 25.6 On the street (fixed place) 6.1 On the street(mobile place) 8.4 Transport vehicule 6.6 Clients home 6.3 Marketplace 4.2 Agricultural area 14.3 Others 1.6 Total 100.0 Source: ENAHO 1996
3.1.4 Characteristics of the none economically active population
It is considered none economically active population the one that is not working or isn’t looking for employment actively. The reasons for this "inactivity" are multiple, but the most important are: waiting the beginning of a work, home tasks, being retired or pensioner, to be sick or disabled.
In Lima City for the year 2002, the main causes of inactivity were home tasks (also the first cause among women) and being retired or pensioner (first cause among men). Although illness or inability were not the most important causes of inactivity, the elderly adult group is the age group that suffers more of these causes in comparison to other groups. Chart 3.8
Chart 3.8 Lima City: None economically active elder than 55 years population distribution, 2002
% Total Total Men Women Waiting for beginning of work 0,76% 4318 77,86% 22,14% Home Tasks 46,33% 263335 8,42% 91,58% Being retired or pensioner 39,57% 224913 57,52% 42,48% Illness or disability 12,14% 68981 42,29% 57,71% Others 1,20% 6826 73,33% 26,67% Source: ENAHO 2002
The elderly adult population's situation in regard to the labour activity, it is limited, due to the scarce possibilities with which they count to stay active inside the labour environment. Also at certain age they are pressed to leave the labour status to augment the lines of the pensioners.
This situation can generate inside this group, anxiety states, frustrations and social area retirement, factors that impact directly in the deterioration of health.
Also, staying subject to a fixed pension that is insufficient in most of the cases, exercises pressure inside this group to attempt their re-insertion in the labour activity, being in some cases, staying active after arriving to the retirement age a viable perspective.
3.2 SOURCES OF INCOME
3.2.1 The contributions according to sources of labor revenues
Given the scarce existent information of this topic at national level, we should restrict the analysis to Lima City. During the 1986-1998 period, the elder than 65 years population's monthly income has been only lower than the one perceived by the population's group between 35 and 64 years. Chart 3.9
Chart 3.9 Lima City: Monthly labour income by age group (In soles of June of 1994)
Age 1986-1989* 1992 1997 1998 14 - 18 years 225.50 211.77 193.05 191.55 19 - 34 years 580.03 406.65 514.02 564.97 35 - 49 years 842.81 573.38 663.41 802.52 50 - 64 years 909.30 568.81 657.38 682.46 65 or + years 621.11 469.28 340.50 300.91 All ages total 686.91 475.07 557.32 640.24 Source: Elaboración propia en base a las Encuestas de Hogares del Ministerio de Trabajo y el INEI.
The group of people elder than 65 years received revenues below the average during this whole period, increasing the difference notably starting from 1997; on the other hand the group of 50 to 65 years, having been the first one in terms of perceived revenues, was seen in second place starting from 1992.
According to the information of the National Home Survey (ENAHO) of the year 2002, the employed population of Lima city elder than 55 years perceived more incomes that the ones of 14 to 24 years and that of 25 to 44 years. This pattern doesn't repeat in other coastal cities; this way for example in Ica, the 55 year-old population is the age group that perceives the highest incomes, while in Tacna this group only had higher incomes than one of 14 to 24 years; similar pattern to the one presented in the cities of the sierra (mountain) and the forest. Chart 3.10
Chart 3.10 Metropolitan Lima and other cities: monthly labour according to age group, 2002 (in soles of the 2002)
Coast Sierra (Mountain) Forest Lima Ica Tacna Ayacucho Huanuco Huaraz Tarapoto 14 to 24 years 495,65 358,71 408,51 338,18 271,09 263,66 341,97 25 to 44 years 985,33 674,27 639,99 681,77 649,36 714,00 717,79 45 to 54 years 1353,91 856,42 608,07 746,87 716,81 743,00 867,79 55 years or more 1157,93 874,70 462,79 497,18 577,00 470,00 512,44 Source: Elaboración propia en base a las Encuestas de Hogares del Ministerio de Trabajo y el INEI.
In Lima City, for all the age groups, the males perceive more income that the females. This difference that is minimum in the group of 14 to 24 years increases progressively with the age, being observed that in the 55 or more years-old group the men almost triplicate the incomes of the women. In other cities the difference of income for this group is similar or smaller than the one registered in Lima, but always favouring the group of the males. Chart 3.11
Chart 3.11 Lima City: Labour monthly income according to age group and gender, 2002 (in Soles of the 2002)
Men Women 14 to 24 years 497,5 493,3 25 to 44 years 1159,8 756,5 45 to 54 years 1716,6 868,6 55 or more years 1482,6 508,5 Source: ENAHO, October 2002
Although a great percentage of the elderly adult’s counts with a family, mainly sons or daughters that can most of times offer their economic support; it is one of the main concerns of people that have passed the first half of their existence, to assure some form of income.
However, the back of a small capital, the own housing, the investment carried out in the education of the sons and daughters that is translated then like family help; don't always attenuate the lacks that elder people can suffer.
3.2.2 Pensions and jubilation
Aging in Peru also means an economic deterioration, since the pensions have not increased together with the economic inflation and is a fact that the pensioner cannot exclusively live only with his/her pension. Most of the elderly adults appeal to the support of their families, but that help cannot be constant in a context where the general population income is low and with so much unemployment and poverty.
Also the labour market, hardly accepts the 60 or more years old population's participation, being more negative for the elderly adult feminine population, many times with the excuse that they are retired people.
The pensions constitute one of the first means to consider, when assuring a source of income. However the establishment of social politics guided to give the benefits of the jubilation without having the necessary sustenance, has determined an imbalance, overloading the national systems of pensions; making the pensions insufficient for the elderly adult’s necessities.
At the present time, Peru is in a transition stage between an allotment system administered by the State and a system of individual capitalization of private property (AFPs). The number of pensioners outside the economically active population has increased from 67,700 in 1972 to 97,599 in 1981 and to 312,000 in 1993. Lima concentrates approximately half of these people.
There is a significant increase of the minimum age of retirement in 1995. The jubilation age in women was increased in ten years, from 55 to 65 years, and in the case of men, increased from 60 to 65 years.
In the year 2002, 41.66% of the adult's elder than 65 years (pension beneficiaries for jubilation) were affiliated to a pensions system. The 97% of this last group were affiliated to the National System of Pensions (SNP) and the rest to Private pensions systems. Chart 3.12
Chart 3.12 Peru: Adults elder than 65 years, according to pension system affiliation condition: 2002
Affiliation condition 2002 Non affiliated 58.33% Affiliated 41.67% National Pensions System 97.72% Private Pensions System 2.28% Source: INEI y ONP
A. National Pensions System
The number of affiliated pensioners to the national pensions system and other entities whose pensioner population is administered by the Office of Previsional Normalization (State System) can be found in chart 3.13.
Chart 3.13 Pensioner population administered by the Office of Previsional Normalization, 2002
Funds Pensioner population Pensions National system - SNP 383737 Education ministry - MINEDU 145044 Workers Work accidents Insurance 11964 Acquired Rights Funds - FODASA 2460 Electricity Enterprise of Lima - ELECTROLIMA 1125 Others 1987 Total 546317 Source: Oficina de Normalización Previsional (ONP)
In Lima, the group of pensioners presents strong differences between men and women. For the year 2002, 30.2% of men elder than 65 years were retired or financiers, while only 19.38% of women of this age group perceived this rent type.
The jubilation income varies according to the legislative ordinance to which the pensioners are under. At the moment the jubilation incomes are determined by the Law Ordinances 19990 and 20530. The last one is no longer valid for new insured and its restructuring is under evaluation.
Chart 3.14 Peru: Jubilation Incomes of the Population 60 or more years old, 2003
Average income in soles according to law Region D.L 19990 D.L 20530 Amazonas 411.9 896.08 Ancash 466.16 78.93 Apurímac 474.5 1006.30 Arequipa 585.76 1191.27 Ayacucho 447.09 385.55 Cajamarca 423.14 904.53 Callao 549.85 527.36 Cusco 419.09 No Dete. Huancavelica 485.19 1014.75 Huánuco 502.29 773.19 lca 556.76 529.10 Junín 565.90 793.7 La Libertad 524.72 649.67 Lambayeque 501.57 859.77 Lima 422.44 345.49 Loreto 394.45 No Dete. Madre de Dios 625.72 141.96 Moquegua 624.01 No Dete. Pasco 423.40 548.33 Piura 534.05 No Dete. Puno 456.29 683.83 San Martín 404.97 521.68 Tacna 548.98 529.70 Tumbes 412.83 1021.79 Ucayali 426.80 843.35 Source: ONP (oficina nacional de pensiones) al año 2003
B. Pensions Private System
Aside to the previous state system, the Peru has also private models of attention and social security, in the form of Pensions Fund Administrators (AFP's). These systems are flexible and are applied in other countries of the world. In our country this system is institutionalized in 1995. At the moment in the Peru four AFP's works: HORIZONTE, PROFUTURO, INTEGRA and UNION VIDA, among all had a total of 2 millions 551 thousand 503 affiliated workers for the 2001. The number of affiliated elder than 50 years can be observed in the Chart 3.15.
Chart 3.15 Affiliation to the Pensions Private System, according to age group at December 31, 2002
Age Groups AFP Affiliated number From 50 to 65 years 253138 More than 65 years 11567 Total 264705 Source: Superintendencia de Administradoras Privadas de Fondos de Pensiones
3.2.3 Levels of Poverty
According to ENAHO 2001, the population in a situation of poverty reached 49.8% of the total population of the country; and 19.5% lived in extreme poverty. The elderly adults that live in a state of poverty were 41.7%, a little less than the national average; however this number is still alarming. Chart 3.16
Chart 3.16 Peru: Population of 60 or more years old according to condition of poverty, 2001
Poverty Poverty Non Extreme Non extreme Poverty National total 49.80% 19.50% 30.30% 50.20% Elderly adults 41.70% 17.50% 24.20% 58.30% 60 to 69 years 41.66% 17.58% 24.08% 58.34% 70 to 79 years 41.50% 16.74% 24.76% 58.50% 80 or more 42.50% 19.30% 23.20% 57.50% Source: Condición de vida en el Perú evolución, ENAHO 1997 - 2001
3.3 GRADE OF INSTRUCTION
3.3.1 Illiteracy for age and for residence area
According to the National Home Survey (ENAHO) of the 2001; the illiteracy at national level was of 12.1%. Adults of 60 or more years old have a rate of illiteracy of 35.4%; this is the highest rate between all the age groups. From this age group 29.3% of illiterates are men and 70.7% are women, being most of them from the rural environment (57.9%).
According to the census of 1993 the regions that present the highest rates of illiteracy are Apurimac (73.9%), Ayacucho (69.2%), Cusco (61.3%), Huancavelica (68.9%), Puno (63.9%), Pasco (52.8), Cajamarca (56.6%) and Huánuco (52.5%). These regions concentrate 46.6% of the total of illiterate elder than 60 years. These regions also maintain an important presence of rural population; this would evidence deficiencies as much in covering as in educational quality in this area.
3.3.2 Average of years of study
The average of years of study reached by the population of 60 and more years, according to data taken from ENAHO 2001, is of 4.0 years, very below the national average that reaches 7.7 years. The year of studies average is superior in the urban area that in the rural one (5.3 vs. 1.3). The masculine population reached an average of 4.9 years of studies while the feminine population only achieved an average of 3.2 years.
3.3.3 Reached instruction level
The instruction level reached according to projections of the 2003 is shown In the Chart 3.17
3.17 Peru: Reached Instruction levels, 2003
3.17 Instruction level reached n % Non Level 705438 34.99% Kindergarten 9073 0.45% Elementary school 861486 42.73% High school 266933 13.24% Superior non University 49193 2.44% University 90322 4.48% Non specified 33669 1.67% Total 2016114 100.00%
Spurce: INEI
For 1999, only 15.9% of the elderly adult men had achieved university education, while only 5.2% of the women of the same age group had achieved the same level. The gender inequity has marked the differentiated access of men and women to a superior education, this fact also determines the different participation from both genders in the labour market and in the decisions making.
3.4 HOUSING AND COMFORT
In 1997, the 87.7% of people elder than 60 years inhabited a house of their own and 10% had additional properties to the housing that they inhabited. In the rural area of the country, 92.2% had their own housing and 76.3% agricultural properties. Although this population's had the security of having housing where to inhabit, there are evidences of situations in which other members of the family make use of the property that belongs to their parents or grandparents.
The housings of the elderly adults are in a precarious situation. According to the ENAHO 1998, 48% of the housings inhabited by this age group only have public net hygienic services. Equally, 25% of these housings don’t have services of water and 33% it doesn't have electricity.
Also, only 18.8% of the elderly adult population have phone service. 10% only has car for its particular use, 67.6% possesses television and only 35.4% have a refrigerator.
4. HEALTH INDICATORS OF THE ELDERLY ADULT POPULATION
4.1 MORTALITY
For the year 1966 the mortality gross rate was 15.6 per thousand habitants; the main causes of death were the transmittable diseases. Almost 60.07% of all the deaths happened to those younger than 15 years of age. (Chart 4.1)
Chart 4.1 Peru: Registered deaths by age groups and causes, 1966
Death causes Cardio Population Transmittable Perinatal death External Tumours vascular Others Total diseases causes causes diseases 0 to 14 years 5062504 61411 689 288 24820 2573 17520 107241 15 to 49 years 5101919 9556 2650 1600 0 492 7507 21865 50 to 59 years 667095 2587 1992 1231 0 4729 2917 13456 60 or more years 635707 9407 6289 8332 0 1181 10732 35941 11467225 82961 11620 11451 24820 8975 38676 178503 Source: OPS/OMS - MINSA
The elder adults represented 5.54% of the peruvian population's for the year 1966, this group had 20.13% of the deaths happened in that year; however their mortality gross rate was of 56.54 per thousand habitants elder than 60 years. The main causes of mortality for this age group were the transmittable diseases with 26.17%, followed by the cardiovascular system diseases with 23.18%.
The mortality gross rate for the year 2000 was 6.15 per thousand habitants for the general population; while for the elder adult population was 39.49 per thousand habitants. This age group had 46.41% of the deaths happened in that year. The main cause of mortality for the elderly adult group were the cardio-vascular diseases with 25.87%, followed by tumours with 23.30% and in third place the transmittable diseases with 18.84% (Chart 4.2).
Chart 4.2 Peru: Registered deaths by age and causes, 2000
Death causes Cardio Population Transmittable Perinatal death External Tumours Vascular Others Total diseases causes Causes diseases 0 to 14 years 8567257 11292 1307 985 10721 5723 11458 41486 15 to 49 years 13572989 6110 5022 2911 0 7288 7301 28632 50 to 59 years 1664975 1969 4067 2541 0 1531 4409 14517 60 or more years 1856469 13811 17078 18967 0 2560 20892 73308 25661690 33182 27474 25404 10721 17102 44060 157943 Source: OPS/OMS - MINSA
There is a major change of the patterns of mortality from year 1966 to 2000; the most significant changes are the reduction of mortality for transmittable diseases in the general population as in the elder adult one. Chart 4.3
Chart 4.3 Peru: Indexes of mortality in elderly adult and general populations, 1966-2000
Cardio Transmittable Perinatal External Tumours Vascular Others Total diseases death causes Causes diseases >= 60 years 14.80 9.89 13.11 0.00 1.86 16.88 56.54 1966 General Pop. 7.23 1.01 1.00 2.16 0.78 3.37 15.57 >= 60 years 7.44 9.20 10.22 0.00 1.38 11.25 39.49 2000 General Pop 1.29 1.07 0.99 0.42 0.67 1.72 6.15 Mortality rate per 1000 habitants Source: OPS/OMS - MINSA
4.2 MAIN DEATH CAUSES
For 1986, the transmittable diseases and certain infections originated in the perinatal period occupied the first places among the mortality causes; also by this year some degenerative chronic illnesses were characteristic as main causes of death, most of all in the aging population. The acute respiratory infections occupied the first place among the causes of death in the general population; they were followed by the intestinal infectious diseases and tuberculosis.
For the year 2000, the acute respiratory infections were still the first cause of mortality for the general population. The other main causes belonged to a constellation of damages corresponding to diverse stages of the life cycle, including the stroke and the ischemic heart diseases on one side, and the intestinal infectious diseases, the perinatal respiratory affections and nutritional deficiencies for another. Chart 4.4
Chart 4.4 General population’s main causes of mortality in Peru, 2000 (List 6/61 OPS -CIE 10)
Mortality causes Mortality rate Acute respiratory infections 70.36 Stroke 26.60 Ischemic heart diseases 24.16 Urinary system diseases (chronic renal insufficiency and others non specified) 23.20 Cirrhosis and others chronic liver diseases 21.36 Perinatal respiratory affections 21.05 Others accidents 19.51 Stomach malignant tumour 18.48 Septicaemia, except neonatal 17.48 Congenital malformations, deformities and cromosomal anomalies 17.01 Tuberculosis 15.83 Nutritional deficiencies y nutritional anaemia 15.74 Terrestrial vehicle accidents 15.01 Cardiac insufficiency 13.72 Diabetes mellitus 13.39 Mortality rate per 100000 habitants Source: OPS/OMS Ministerio de salud
In the group of adults elder than 50 years the acute respiratory infections still are the main cause of mortality, followed by the stroke, ischemic heart disease and the urinary system diseases; however cancer and chronic illnesses as the diabetes mellitus have more importance today than past ages. Chart 4.5
Chart 4.5 Peru: Adults elder than 50 years main causes of mortality, 2000 year (List 6/61 OPS -CIE 10)
Mortality Mortality Causes Rate Acute Respiratory Infections 294.96 Stroke 163.23 Ischemic heart diseases 159.39 Urinary system diseases (chronic renal insufficiency and others non specified) 127.53 Cirrhosis and others chronic liver diseases 120.8 Stomach malignant tumour 115.86 Diabetes mellitus 88.96 Cardiac Insufficiency 85.96 Hypertensive diseases 85.79 Septicaemia 62.62 Thraquea, bronchus and lung malignant tumours 54.84 Tuberculosis 53.25 Malignant Prostate tumour 45.75 Nutritional Deficiencies and Nutritional Anaemia 45.63 Chronic respiratory tract diseases 41.57 Mortality rate per 100000 habitants Source: OPS/OMS Ministerio de salud
In Peru, like in other countries, the tumours have been acquiring more importance as morbidity and mortality causes in the last decades. While the mortality gross rate has decreased in the country, the mortality rate for this group of illnesses has stayed without significant changes; this situation has increased their relative importance as mortality cause. The neoplasic illnesses represented 17.5% of the elderly adults mortality causes in 1966, while for the year 2000 were 23.29%.
The stomach malignant tumour is and has been from the second half of the 20th century the main type of malignant neoplasia among the peruvian population. The bronchus’s and lung tumours have displaced the malignant tumour of other parts of the uterus. Chart 4.6
Chart 4.6 Peru: Mortality Main Causes for Tumours, 2000
Main causes of mortality for tumors Mortality rate Stomach malignant tumour 19.27 Lung and bronchus malignant tumours 8.50 Liver and biliary tract malignant tumours 7.38 Prostate malignant tumour 7.18 Uterus Neck malignant tumour 6.46 Breast malignant tumour 5.33 Non Hodgkin Lymphoma or other non specified type 4.15 Colon malignant tumour 3.85 Uterus malignant tumour; non specified part 3.50 Pancreas malignant tumour 3.32 Brain malignant tumour 3.01 Kidney malignant 1.58 Mortality Rate per 100000 habitants Source: OPS/OMS Ministerio de salud
There is not an important difference between the mortality rate by tumours in men and women, but there are significant differences among the neoplasia types that affect these two population groups. Charts 4.7 and 4.8
Chart 4.7 Peruvian male elder than 50 years mortality rate for tumours, 2000
Mortality main causes Mortality rate Stomach malignant tumour 2174 Prostate malignant tumour 1748 Lung and bronchus malignant tumour 1132 Liver and biliary tract malignant tumour 655 Non Hodgkin Linfoma of non specified type 403 Colon malignant tumour 367 Pancreas malignant tumour 358 Kidney malignant tumour, except from renal pelvis 220 Esophagus malignant tumour 201 Brain malignant tumour 193 Bladder malignant tumour 192 Multiple Myeloma and plasmatic cells tumours 177 Mortality rate per 100000 habitants Source: OPS/OMS Ministerio de salud
Chart 4.8 Peruvian female elder than 50 years mortality rate for tumours, 2000
Mortality main causes Mortality rate Stomach malignant tumour 2010 Uterus Cervix malignant tumour 1020 Breast malignant tumour 921 Liver and biliary tract malignant tumour 817 Lung and bronchus malignant tumours 732 Uterus malignant tumour, non specified parts 648 Colon malignant tumours 468 Pancreas malignant tumours 395 Biliary tract malign tumour of others non specified parts 325 Ovary malignant tumour 319 Non specified Hodgkin Lymphoma and of other parts 303 Gallbladder malignant tumour 292 Mortality rate per 100000 habitantes Source: OPS/OMS Ministerio de salud
Although the mortality profile shows the differences between men and women; there are also differences between the different levels of poverty. In the less poor population (Y- I) the diabetes mellitus and the lung and bronchus malignant tumours acquire higher importance like main cause of death. Of another side, in the poorest stratum (Y-V) acquire higher importance, the nutrition deficiencies, the appendicitis and intestinal obstruction. Chart 4.9
Chart 4.9 Peru: Elder Adults Mortality Main Causes for Socioeconomic level, 1997
Order Mortality causes Estrata I MR Estrata V MR Respiratory acute infections Respiratory acute infections 1 376.8 895.4
Ischemic heart diseases Ischemic Heart disease 2 239.3 546.6
Urinary tract diseases 3 Stroke 218.5 401.1
Circulatory Lung diseases Stomach malignant tumour 4 200.5 311.8
Stroke 5 Urinary tract diseases 165.7 304.9
Digestive tract diseases Nutrition deficiencies 6 150.7 274.2
Stomach malignant tumour Intestinal Obstruction and 7 149.8 257.4 Appendicitis 8 Diabetes Mellitus 114 Cirrhosis 251.6
9 Cirrhosis 106.4 Septicaemia 190.9
Lung malignant tumour 10 100.8 Hypertensive diseases 179.4
Mortality rate per 100000 Source: Cálculos por OPS a partir de los certificados de defunción, 1996 – 1998
The social security health system counts with more recent statistical information of intra-hospital deaths; In the year 2003, the main death causes of EsSalud adults elder than 65 were the low respiratory tract infections (12.68%), followed by the hypertensive diseases with 9.48% and stroke with 5.57%. Chart 4.10
Chart 4.10 Peru: Adults elder than 65 years main causes of intra-hospital mortality, EsSalud 2003
65 or + 75 or Death causes years +years Low respiratory tract infections 1137 12.68% 921 15.78% Hypertensive diseases 850 9.48% 550 9.42% Stroke 500 5.58% 352 6.03% Diabetes mellitus 480 5.35% 283 4.85% Cirrhosis 328 3.66% 153 2.62% Chronic Obstructive Lung Disease 263 2.93% 205 3.51% Nephritis, nephrosis 256 2.85% 125 2.14% Stomach malignant tumour 253 2.82% 131 2.24% Accidents 238 2.65% 165 2.83% Ischemic heart diseases 235 2.62% 151 2.59% Trachea, bronchus’s and lung malignant tumour 229 2.55% 122 2.09% Other causes 4200 46.83% 2679 45.90% Total 8969 100.00% 5837 100.00% Source: Sistemas de Información y vigilancia epidemiológica, Gerencia de prestaciones-EsSalud
Although the main cause of death for those elder than 65 years that assisted to Social Security Services are the low respiratory tract infections, as a group the transmittable diseases occupy the third place (17.2%) in this age group, behind the cardiovascular illnesses (21.34%) and the malignant tumours (20.5%). Chart 4.11
Chart 4.11 Peru: Social Security Adults elder than 65 years old, Mortality Main Causes by groups of diseases, 2003
65 or + years %
Cardiovascular diseases 1914 21.34% Malignant Tumours 1839 20.50% Transmittable diseases 1542 17.20% Digestive System diseases 793 8.84% Respiratory diseases 780 8.70% Genital-urinary diseases 436 4.86% Others 1665 18.56% Total 8969 100.00%
Source: Sistemas de Información y vigilancia epidemiológica, Gerencia de prestaciones-EsSalud
4.3 HEALTHY LIFE EXPECTANCY
A highest life expectancy doesn't necessarily mean that it lapses in a good health state. The high frequency of functional limitations in the elderly adult population deteriorates their quality of life; this makes indispensable to invest the maximum effort in decreasing the morbidity and their disability. It is clear that the life expectancy is not enough as a good health indicator, it is necessary to have an indicator that allows to plan that proportion of life expectancy that corresponds at the time lived with disability.
In the WHO reports about the year 2001 World Health, the calculation of a healthy life expectancy is included as an indicator of health level reached by the populations.
The healthy life expectancy at birth is equivalent to the numbers of years in complete health that a newly born wait to live based on the current levels of bad health and mortality in his/her country. v The measure of the time spent in bad health is based on a combination of the estimates made for different health states by age and sex made by the study of various diseases. The estimates for the peruvian population are in the chart 4.12
Chart 4.12 Peru: Healthy life expectancy, 2001
Healthy life Total Healthy years Men Women expectancy lost population lost at birth (percentage) When born When born At 60 years When born At 60 years Men women men women 61 59.6 12.7 62.4 14.4 7.9 9.6 11.70% 13.30% Source: Informe sobre salud del mundo 2001, OMS
4. 4 SECONDARY AND THIRD CARE
At Health Ministry institutions a defined geriatrics attention is almost not existent; some few hospitals have geriatrics services whose functions are limited to the outpatient practice and the answer of the inter-consults of the specialty. The geriatric patient that requires hospitalization passes to internal medicine services. It is considered that the 30% to 40% of the beds of these services are occupied by this group of patients.
About rehabilitation, most of hospitals of the Health Ministry have this type of service. There are rehabilitation centers that offer attention to the general population, including the elderly adult population; the most important of these centers is the Peruvian National Institute of Rehabilitation. In the year 1999 assisted 1743 elderly adults, the 67.1% were women. Chart 4.13
Chart 4.13 Elderly Adult Population with problems of the locomotive apparatus, consult and attentions in the National Institute of Rehabilitation, 1999
Gender Number ofr Attentions Number of Consults N % N % Total 1743 100% 4493 100% Men 573 32.90% 1385 30.80% Women 1170 67.10% 3108 69.20% Source: INEI
On the other hand, the Social Security (EsSalud) and the health services of the Army Forces have been creating diverse geriatrics assistance levels with the purpose of satisfying the necessities of their users, they have Domiciliary Attention Programs; as well as Geriatrics Attention Units, Outpatient consults, Day Hospital and Acute Cases Attention Units in their hospitals of higher levels.
The Social Security (EsSalud) assistance levels can be seen in the Chart 4.14, some of these levels are exclusive of the Hospital Guillermo Almenara Irigoyen.
Chart 4.14 Assistance Geriatrics Levels, EsSalud
Assistance level Centros de Salud Acute Hospitalization Unit Guillermo Almenara Irigoyen Hospital Hospitalization Unit Assistance Health Center Day Hospital Guillermo Almenara Irigoyen Hospital Medium care hospitalization unit San Isidro Labrador Clinic Long care hospitalization unit Level IV Clinic Geriatrics outpatient office Assistance Health Center Health attention program Assistance Health Center Domiciliary attention program PADOMI Basic attention unit Elderly adult health center Complementary medicine Assistance Health Center Source: EsSalud
EsSalud and the Armed forces also have rehabilitation services in their main assistance centers, their programs of domiciliary visits also offer these services. In the chart 4.15 is a report of the activities and resources of the Visits of EsSalud Domiciliary Program for March, 2004.
Chart 4.15 Social Security (EsSalud), Domiciliary Program Activities and Resources, March 2004
Consults Continued Number of Activities and resources Visits (N+R) attentions professionals Domiciliary program General Domiciliary Medic Visit 22970 881 20604 122 Specialized Domiciliary Medic Visit 4580 2105 1539 31 Domiciliary Nurse Visit 7928 381 1618 48 Domiciliary Rehabilitation Visit 13484 435 3127 69 Domiciliary Psychology Visit 783 267 467 5 Domiciliary Social Service Visit 437 426 9 5 Source: Padomi
4.5 MORBILITY RATES
Health Ministry Morbidity
The highest causes of morbidity registered by the peruvian health ministry system are the respiratory system diseases, followed by the osteum muscular and connective tissue diseases and the nervous and senses system diseases. Chart 4.16
Chart 4.16 Elderly adult population's morbidity diagnosis by programmatic damage, MINSA 1998
Diagnosis TOTAL MEN WOMEN PROGRAMMATIC DAMAGE Respiratory System Diseases 169,904 69,296 100,608 Osteum muscular and connective tissues diseases 136,180 48,236 87,944 Nervous and senses system diseases 83,979 36,072 47,907 Trauma and poisoning 69,923 36,384 33,539 Dysentery and gastroenteritis 66,778 28,072 38,706 Oral cavity diseases 53,838 25,334 28,504 Skin diseases 39,289 17,088 22,201 Mental illnesses 28,133 8,808 19,325 Diabetes mellitus 12,172 3,649 8,523 Cancer 9,805 4,460 5,345
Mycosis 8,557 3,391 5,166 Helmintiasis 8,418 3,345 5,073 Tuberculosis 7,757 4,109 3,648 Ischemic Heart Diseases 4,168 1,676 2,492 Nutrition deficiencies 2,854 1,077 1,777 Typhoid Fever 1,265 495 770 Congenital anomalies 735 300 435 Cholera 628 342 286 Sexual transmittion diseases 461 304 157 Virus Hepatitis 331 174 157 Other diseases of the circulatory system 94,550 35,348 59,202 Other diseases of the gastrointestinal apparatus 88,677 33,727 54,950 Diseases of the genital urinary apparatus 83,624 34,099 49,525 Non defined symptoms and signs 46,265 18,303 27,962 Other parasites 23,933 11,115 12,818 Blood and other haematopoietic organ diseases 17,591 6,055 11,536 Other external causes 10,486 6,109 4,377 Other metabolism and endocrine diseases 9,550 1,744 7,806 Tetanus, Sarampion 11 8 3 TOTAL 1,079,862 439,120 640,742 Source: INEI
The elderly adult outpatient attention causes by illness groups for the year 2002 are in the Chart 4.17, the first cause of consults were the respiratory system diseases, followed by the osteum muscular system diseases.
Chart 4.17 Elderly adult outpatient attention causes of attention, MINSA 2002
Group diseases Total Men Women Respiratory system diseases 15.14% 40.00% 60.00% Osteum muscular diseases 13.50% 37.00% 63.00% Circulatory system diseases 8.79% 36.00% 64.00% Digestive apparatus diseases 7.88% 37.00% 63.00% Genital urinary system diseases 7.70% 42.30% 57.70% Rest of Diseases 46.99% 41.75% 58.25% Source: Oficina de Estadística e Informática - MINSA
Social Security (EsSalud) Morbility
EsSalud registered a total of 4650035 outpatient attentions for the general populations in the year 2003, of these 33.15% belonged to adults elder than 65 years. The first morbidity cause was the primary arterial hypertension, followed by the arthrosis and other dorsopathies. 55,9% of the Primary Hypertension cases belong to this age group. Chart 4.18
Chart 4.18 EsSalud Outpatient Office Attentions Profile, 2003
General %of cases that affect 65 years Population the population elder or more % Total than 65 year old Essential Hypertension (primary) 123387 8,00% 220735 55,90% Arthrosis 82738 5,37% 167514 49,39% Other dorsopathies 53681 3,48% 278668 19,26% Other skin and connective tissues diseases 47977 3,11% 283680 16,91% Acute pharyngitis and amygdalitis 46729 3,03% 596464 7,83% Prostatic Hyperplasia 46085 2,99% 75624 60,94% Diabetes mellitus 44653 2,90% 105083 42,49% Gastritis y duodenitis 41842 2,71% 200202 20,90% Glaucoma 39991 2,59% 62690 63,79% Cataract and other crystalline problems 31915 2,07% 40455 78,89% Soft tissue problems 31484 2,04% 132922 23,69% Others 951201 61,70% 2637813 43,28% Total 1541683 100,00% 4650035 33,15% Source: Sistemas de Información y vigilancia epidemiológica, Gerencia de prestaciones-EsSalud
EsSalud registered a total of 2699672 attentions in the emergency services in the year 2003. Of these, 14.62% belonged to adults elder than 65 years. The Primary Arterial Hypertension was the elderly adult’s first cause of consultation. Chart 4.19
Chart 4.19 EsSalud Emergency Services Attentions Profile, 2003
General %of cases that affect the 65 years Population population elder than 65 or more % Total year old Essential Hypertension (primary) 32694 8,28% 66535 49,14% Other trauma 26766 6,78% 186823 14,33% Abdominal and pelvic pain 22393 5,67% 150884 14,84% Diarrheic and gastroenteritis of infectious origin 18675 4,73% 144351 12,94% Acute Pharyngitis and Amygdalitis 17697 4,48% 274656 6,44% Others dorsopathies 14874 3,77% 85496 17,40% Asthma 12638 3,20% 121466 10,40% Acute Bronchitis 10357 2,62% 82158 12,61% Other urinary system diseases 10017 2,54% 65196 15,36% Fever of unknown origin 9176 2,33% 146605 6,26% Other ear and mastoid apophysis diseases 7463 1,89% 30819 24,22% Other acute respiratory infectious diseases 6880 1,74% 115606 5,95% Other 205004 51,95% 1229077 16,68% Total 394634 100,00% 2699672 14,62% Source:Sistemas de Información y vigilancia epidemiológica,Gerencia de prestaciones-EsSalud
EsSalud Hospitalization Services registered a total of 352332 users in the year 2003; of them 20.49% were adults elder than 65 years. Pneumonia was their first cause of hospitalization, followed by the cholecistitis, cholelitiasis and the prostatic hyperplasia. Chart 4.20
Chart 4.20 EsSalud Hospitalization Services Attentions Profile, 2003
General %of cases that affect the 65 years or Population population elder than 65 more % Total year old Pneumonia 3669 5,08% 9799 37,44% Cholelitiasis and cholecistitis 3291 4,56% 15254 21,57% Prostatic Hyperplasia 3095 4,29% 4385 70,58% Other urinary system diseases 2647 3,67% 7371 35,91% Other respiratory system diseases 2070 2,87% 3808 54,36% Septicaemia 2066 2,86% 3030 68,18% Others symptoms, signs y abnormal clinical findings 1963 2,72% 5255 37,35% Cardiac Failure 1953 2,71% 2883 67,74% Inguinal Hernia 1911 2,65% 5182 36,88% Diabetes mellitus 1836 2,54% 3761 48,82% Others digestive apparatus diseases 1716 2,38% 3370 50,92% Femur Fracture 1570 2,17% 2322 67,61% Others ischemic heart diseases 1542 2,14% 2607 59,15% Others 42869 59,38% 283305 15,13% Total 72198 100,00% 352332 20,49%
Source:Sistemas de Información y vigilancia epidemiológica,Gerencia de prestaciones-EsSalud
EsSalud domiciliary attention program (PADOMI), presents as first morbidity cause essential hypertension (18.97%), followed by osteoarthrosis and urinary tract infections. Chart 4.21
Chart 4.21 PADOMI Morbility Causes, March - 2003
Number. Of Causes % attentions Essential Hypertension (primary) 5249 18,97% Generalized Primary Osteoathrosis 1048 3,79% Urinary tract infections 634 2,29% Parkinson Disease 513 1,85% Chronic Gastritis, non specified 423 1,53% Chronic Bronchitis, non specified 361 1,30% Dementia, non specified 327 1,18% Stroke Sequels 321 1,16% Acute Pharyngitis, non specified 304 1,10% Cardiovascular diseases sequels 275 0,99% Pressure Ulcers 272 0,98% Other general controls 6079 21,97% Others 11867 42,88% Source EsSalud: Padomi, 2003
4.6 CHRONIC DISABILITY
For the year 2003, 1.3% of the total population had some type of disability, while the elderly adult population had almost quadrupled the general population's value. Chart 4.22
Chart 4.22 Peru: Disability type distribution. 2003
%of population Mental Mental Blindness Deafness Mutest Invalid Othes with disability Retard Problems Total population 1,30% 20,90% 14,40% 6,70% 12,40% 9,80% 28,00% 7,90% 60 to 64 years old 5,30% Elder than 65 years 23,10% 17,10% 32,10% 2,00% 3,10% 5,60% 30,60% 9,60%
Source: INEI Censo de población 1993
CONADIS is a public organism of the Woman and Social Development Ministry that has as function to promote the execution of the law of people with disability, as well as the establishing of national multisector politics for the people with disability in order to contribute to their social, economic and cultural integration process. This organism registered for the year 2003, 2263 elderly adults with some type of disability, the distribution by gender and type of disability can be seen in the chart 4.23
Chart 4.23 CONADIS: Registered Elderly Adults distribution according to disability type. 2003
Population Behaviour Communication Self-care Locomotion Body Dexterity Situation Registered l Men 1693 44 186 180 517 248 313 205 Women 570 13 74 53 159 89 96 86 Total 2263 57 260 233 676 337 409 291 Source: Gerencia de Sistemas, Identificación y estadística – CONADIS
4.7 FUNCTIONAL CAPACITY; basic activities of daily life (ADLs)
Few peruvian works evaluate the activities related to the daily life in the community. Recently Varela and collaborators carried out a national hospitalary study that evaluates this indicator as part of a integral geriatric assessment. This study found that 53% of the elderly adults were independent two weeks before their hospitalization ( 0 score in the scale of Katz), 30% were partial dependent (score between 1 at 5) and 17% were dependent total ( 6 score in the scale of Katz). Graph 4.1
Graph 4.1 Functionality in patients two weeks before their hospitalization, 2003
Functionality by KATZ
17% Autonomy
Partial 53% Dependence 30% Total Dependence n = 400
Source: Valoración Geriátrica Integral en Adultos Mayores Hospitalizados a Nivel Nacional, 2003; Diagnostico Vol 43, Num 2, Marzo-Abril 2004
Another important work was the Trujillo county Elderly Adults Profile carried out by Leiton, Villanueva, and collaborators among the years 1999 and 2000; the study had a sample of 681 elderly adults and the instrument for gathering information was a survey elaborated by the PAHO/WHO (1990) adapted to the Peruvian reality. It evaluates economic characteristic, health risks and problems; among them the levels of independence to carry out activities of daily life.
According to the results of this study, the elderly adults present levels of independence in basic activities of the daily life of 82% for men and 76.4% for women. Also found that in this population there is a decrease in independence as the age increase. However, the dependence in the men began at 85 years, while in women started at 75 years. Chart 4.24
Chart 4.24 Trujillo, Basic Activities of the Daily Life by age and gender, 1999 -2000
60 - 74 years 75 - 79 years 80 - 84 years 85 or + years Men 0.00% 0.00% 0.00% 16.70% Women 0.00% 8.00% 3.00% 14.00% Source: Perfil del adulto mayor en la provincia de Trujillo, 1999-2000
Besides the previous studies, there are other smaller studies in hospitalized patients, national health clinics and localized communities; most of these studies used as instrument the Katz Test . Chart 4.25
Chart 4.25 Elderly Adults Functionality Studies, Peru
Year Researcher Place N Age group Origin Results Lima Outpatient with 50% Lima were independent 1990 Chu, M 913 + 65 years Cusco Social Insurance 25% Cusco were independent Sandoval, L Outpatient and 77.3% Outpatient independent 1998 Lima 168 + 60 years Varela, L Hospitalized 59.5% Hospitalizes independent Outpatient and 22.4% ADLs dependent 1999 Hardy,G Lima 168 + 60 years Hospitalized 40.3% ADLs dependent Varela, P Hospitalized 77% functional dependence 2000 Lima 130 + 60 years Sillicani, A Villar, D Outpatient and 13.4% Outpatient dependent 2000 Lima 60 + 60 years Varela, L Hospitalized 50% Hospitalized dependent Higher levels of dependence in the 2001 Ruiz, W Lima 100 + 60 years Elderly adult club asylums patients Asylums Lisigurski,M Health campaign 40% functional dependence 2002 Barranca 90 + 60 years Varela, L
4.8 INSTRUMENTAL ACTIVITIES OF THE DAILY LIFE
In Peru there are only a few studies about the instrumental activities of the daily life. In the elderly adult’s profile of Trujillo county, the levels of independence in instrumental activities of the daily life are also found in a high frequency, although in smaller proportion than the dependence levels in basic activities. Chart 4.26
Chart 4.26 Trujillo, Instrumental Daily Life Activities by age and gender, 1999 - 2000
60 - 64 years 65 - 74 years 75 – 79 years 80 - 84 years 85 or + years Men 0.00% 0.00% 8.00% 3.00% 33.00% Women 0.00% 4.00% 4.00% 23.00% 53.00% Source: Perfil del adulto mayor en la provincia de Trujillo, 1999-2000
4.9 RISK FACTORS FOR NON TRANSMISIBLES CHRONIC ILLNESSES
Although a few national studies about risk factors for chronic illnesses exist for the general population, few make emphasis in the elderly adult population and generally take this age group like part of the one of all the adults.
Noxious habits
Smoking
According to the Pan American Health Organization the smoking prevalence in Peru in the population between 12 and 50 years is 41.5% for males and 15.7% for women. According to the 2002 Lima City Epidemiology Study of the National Institute of Mental Health Hideyo Noguchi, the life prevalence of tobacco use is 69.5% (84.1% males and 56.2% women) and the annual prevalence of tobacco dependence is 1.9% (3.3% males and 0.5% women) for the general population.
According to the national survey of prevention and use of drugs of 1999, the tobacco dependence in the age group between 17 and 40 years was 9.3% to 10.4%, and 3.9% for the adults among 60 to 64 years. This study doesn't make reference to the population elder than 65 years but it is considered that the prevalence should be smaller than the one of the last group. The results can be observed in the Chart 4.27
Chart 4.27 Peru: Tobacco Dependence, Contradrogas, 1999
12 to 13 14 to 16 17 to 19 20 to 40 41 to 59 60 to 64 Total 0.80% 1.60% 9.30% 10.40% 6.20% 3.90% Men 0.30% 2.30% 16.60% 15.90% 9.10% 5.60% Women 1.40% 0.90% 2.80% 5.80% 4.20% 2.90% Source. Contradrogas, 1999
Alcoholism
In Peru, it is considered that the percentage of alcoholism is higher than 10% in the adult population, especially in the males and in the rural area. According to Contradrogas, in Peru the age group with more alcoholic dependence is the one between 20 to 40 years, however the groups among 41 to 64 years present an important prevalence, in males mostly. Chart 4.28
Chart 4.28 Peru: Alcohol Dependence, Contradrogas, 1999
12 to 13 14 to 16 17 to 19 20 to 40 41 to 59 60 to 64 Total 1.00% 3.00% 11.50% 13.50% 7.30% 7.20% Men 1.60% 4.30% 19.00% 21.60% 12.50% 18.80% Women 0.00% 1.60% 4.70% 7.00% 3.50% 0.00% Source. Contradrogas, 1999
Other noxious habits
In the Trujillo County Elderly Adult profile a 56.2% of the elderly adult population consumed coffee, a 44.9% fat and 20.6% salt; it is also appreciated that although this consumption is high in the elderly adults, it becomes smaller as the age increases. Chart 4.27
Chart 4.27 Trujillo, Presence of noxious habits: coffee, fat and salt in the elderly adult by age and gender, 1999 - 2000
60 - 64 years 65 - 69 years 70 - 74 years 75 - 79 years 80- 84 years 85 + years Coffe 53.00% 47.00% 45.00% 39.00% 19.00% 36.00% Fat 50.00% 45.00% 41.00% 48.00% 37.00% 37.00% Salt 23.40% 17.00% 25.00% 21.00% 17.00% 12.00% Source: Perfil del adulto mayor en la provincia de Trujillo, 1999-2000
Physical Activity
According to Seclen-Palacin and Jacobi study, that was based on the information of the National Home Survey of the year 1997. Only 11.6% of the population elder than 18 years old had physical activity in a daily or inter-daily frequency, a higher proportion was found in men that in women; 53.7% of the population didn't practice sports. The age group that practiced more regular sport activities (daily or inter-daily) was the one of men between 50 to 55 years (20%) and for women the group of 40 to 45 years (18%).
The 11.4% of those interviewed was 60 or more years old, of this group only 13.5% of the males had regular sport activity and 47.7% didn't practice any sport, while in the group of women 6.6% had a daily or inter-daily physical activity and a 61.4% didn't practice any sport. Chart 4.28
Chart 4.28 Frequency of Regular Sport Activities in the urban population, by age group and gender. Peru 1997
Age groups (years) Frecuency 15 - 19 20 - 29 30 -44 45-49 >=60 Total % % % % % Men ( n = 21798) Daily 7,00 5,60 9,20 10,70 9,90 8,20 Inter-daily 3,30 3,50 5,50 6,80 3,60 4,60 Weekly 21,20 24,20 38,50 44,00 28,20 31,70 Sometimes 2,60 6,70 14,30 15,30 10,60 10,20 Didn’t practice 65,90 60,00 32,50 23,20 47,70 45,30 Women ( n = 23521) Daily 4,50 4,20 10,40 9,10 5,20 7,00 Inter-daily 2,20 2,10 5,40 4,20 2,60 3,50 Weekly 13,10 13,70 30,80 31,70 15,60 21,90 Sometimes 2,10 5,30 8,00 8,80 4,90 6,20 Didn’t practice 78,10 74,70 45,40 46,20 71,70 61,40 Source: Seclen – Palacin, cuadro elaborado en base a ENAHO –1997
The practice of sport activities was significantly higher in males in all the socio- demographic levels. There was not a relationship between socioeconomic level and sport activity, but it was found that in men a higher educational level had a direct association with a regular sport activity. Is also important to mention that men and women from Lima had less sport activity than the population that lived in other urban areas outside the capital.
Being married, have an employment, access to modern communication technologies (Internet or Cable TV) or to consume sport information are significant factors and are directly associated with the regular practice of sport activities. Finally the practice of regular sport activities by the family boss is associated with the family high levels of sport activities.
Hypertensive Illnesses
The arterial hypertension is recognized as an important risk factor for the presentation of other circulatory system diseases of the brain and the heart.
In Peru, there are two studies that had tried to measure the general population's frequency of this condition: the one of Seclen in 1997 and the one of the Ministry of Health General Office of Epidemiology of the 1998 -2000. These studies found frequencies from 15% to 33% in the Peruvian population. At the moment there is not information about the prevalence of this pathology by age groups, but is considered that the frequency must be higher in the elderly adult population. Chart 4.29
Chart 4.29 Arterial Hypertension Prevalence Studies
Place and population of Prevalence Reference study Men Women Total Lima, Ingeniería 32,10% 34,70% 33,00% Seclen, Segundo y col. Piura, Castilla 35,10% 32,50% 33,00% San Martín, Tarapoto 33,30% 17,40% 21,80% Ancash, Huaraz 22,20% 18,00% 19,55% 1997
Lima, Comas 11,00% 7,10% Health Ministry, General Lima, Magdalena del Mar 24,60% 7,70% Office of Epidemiology Huanuco, Huanuco 16,40% 9,10% Ica, Parcona 18,80% 11,50% Ucayali, Calleria 16,70% 10,70% 1998 –2000 Arequipa, Yanahuara 14,60% 9,70% Non published inform Source: OPS/ OMS
Diabetes mellitus
There are a few studies that had measured the general population frequency of Diabetes Mellitus. These studies are not necessarily comparable due to the different methodologies for the population's selection, as well as for the techniques for the glycaemia measurement; however they offer an idea on the prevalence of this problem in some populations of the country. Chart 4.30
Chart 4.30 Diabetes Mellitus Studies
Prevalence Place and population studies Reference Men Women Total Lima 1,60% Zubiate, M y col Cusco 0,40% Pucallpa 1,80% Piura 5,00% 1987 Lima 7,50% Seclen, S Chiclayo 6,90% 1996 Lima 7,60% Seclen, S y col. Piura 6,70% Tarapoto 4,40% Huaraz 1,30% 1997 Tumbes 2,90% Sosa, J y col Tacna 1,40% Cusco 1,30% 1996 Lima, Comas 0,00% 1,90% Health Ministry, General Lima, Magdalena del Mar 8,00% 2,60% Office of Epidemiology Huanuco, Huanuco 33,20% 22,10% Ica, Parcona 45, 4% 51,00% Ucayali, Calleria 4,10% 1,50% 1998 –2000 Arequipa, Yanahuara 9,90% 4,60% Non published inform Source: OMS/OPS
In a study carried out by the Endocrinology Service of the Hospital Guillermo Almenara Irigoyen in workers of diverse labour centers of the cities of Lima, Cusco, Pucallpa and Piura found that the frequency of Diabetes Mellitus was 8,3% in adults elder than 50 years, while the ones below 40 years didn't reach the 0,5%. Chart 4.31
Chart 4.31 Diabetes Mellitus frequency in workers of some cities of the Peru
Age groups % Till 29 years 0,20% From 30 to 39 years 0,50% From 40 to 49 years 2,40% More than 50 years 8,30% Total 2,20% Source: Calderon, R; Peñaloza, J. Diabetes Mellitus en el Perú. Lima 1996
Hyperlipidemia
For these conditions the series varies from 10% to 47% for the general population; these great differences are probably due the same inconveniences of methodology found in the cases of hypertension and diabetes, for this reason the results cannot be extrapolated for the country. At the moment there are not information about he prevalence for these conditions by age groups, but is considered that the frequency must be higher in the elderly adult population. Chart 4.32 and 4.33
Chart 4.32 Peru: Hypercholesterolemia Studies
Prevalence Place and population Reference Men Women Total Lima, Urbanización Ingeniería 22.70% Seclen, Segundo y col. Piura, Castilla 47.20% San Martín, Tarapoto 20.40% Ancash, Huaraz 10.60% 1997 Lima, Comas 14.70% 13.00% Health Ministry, General Office of Lima, Magdalena del Mar 27.60% 16.00% Epidemiology Huanuco 17.30% 13.00% Ica, Parcona 49.70% 43.00% Ucyali Calleria 32.50% 28.00% 1998 –2000 Arequipa, Yanahuara 17.40% 16.20% Non published inform Source: OMS/OPS
Chart 4.33 Peru: Hypertrigliceridemia Studies
Prevalence Place and Population Reference Men Women
Lima, Comas 15.80% 3.70% Health Ministry Lima, Magdalena del Mar 46.00% 22.80% General Office of
Huanuco 36.70% 26.50% Epidemiology Ica, Parcona 26.50% 23.80% Ucyali Calleria 32.50% 22.70% 1998 –2000 Arequipa, Yanahuara 39.90% 14.80% Non published inform Source: OMS/OPS
Obesity
The frequency of Obesity varies from 10% to 36.7% for the general population. Chart 4.34
Chart 4.34. Peru: Obesity Studies
Prevalence Place and population Reference Men Women Total Lima,Urbanización Ingeniería 24.50% 21.70% 22.80% Seclen, Segundo y col. Piura, Castilla 34.20% 38.00% 36.70% San Martín, Tarapoto 29.10% 12.50% 17.00% Ancash, Huaraz 14.80% 20.40% 18.30% 1997 Lima, Comas 17.50% 28.00% Health Ministry Lima, Magdalena del Mar 18% 15.30% General Office of Huanuco, Huanuco 10% 23.70% Epidemiology Ica, Parcona 24.80% 32.10% Ucayali, Calleria 10.40% 25.30% 1998 -2000 Arequipa, Yanahuara 16.90% 16.90% Non Published Source: OPS/OMS
A recent study carried out by Varela and col. in the elderly adult hospitalizated population found that the overweight frequency was 9.56%, for obesity, 4.13%; and for malnutrition, 54.52%.
A study carried out by Rosas and col.. in workers of a state institution of Lima, found that 25.4% of the adults elder than 50 years presented obesity; becoming the age group with the highest frequency of this problem. Chart 4.35
Chart 4.35 Obesity frequencies in workers of a state institution of Lima - Peru
Proper Over Age Obesity Weight Weight Less than 40 years 42.60% 42.60% 14.80% From 40 to 50 years 36.30% 45.80% 17.90% Elder than 50 years 14.30% 60.30% 25.40% Source: Rosas, A;. Prevalencia de obesidad en trabajadores de una institución estatal en Lima -Perú
4.10 Integral Geriatric Assessment
In Varela and col. study the 82.5% of the hospitalized elderly adults, presented some grade of auditory or visual loss, 54% of faecal or urinary incontinence; 52.75%, of insomnia; 39.75% have had falls; 37.25%, acute confusion; 28.25%, moderate or severe cognitive impairment; 22.11%, immobilization; 15.97%, depression; 14.25% pressure ulcers and 12% syncope. Graph 4.2
Graph 4.2 Integral Geriatric Assessments in Hospitalized Elderly Adults at National Level, 2003
Integral Geriatric Assesment in the Hospitalized Elderly Adults at National Level
90% Sensorial impairment
80% Incontinence 70% Ins omnia 60% Falls 50% Acute Confusion 40% Cognitive Impairment 30% (moderate-severe)* Inmobilization 20% Mayor depression** 10% Pressure ulcers 0% Geriatric syndromes1 Syncope n = 400 n*=312 n**=288
Source: Valoración Geriátrica Integral en Adultos Mayores Hospitalizados a Nivel Nacional, 2003; Diagnostico Vol 43, Num 2, Marzo-Abril 2004
4.11 Mental State
According to the Lima City Mental Health Study carried out in the year 2002 by the National Mental Health Institute Hideyo Noguchi, the 10.5% of the elderly adult population (with more than 8 years of instruction) presents according to the Folstein Mini Mental an abnormal cognitive function. This study also found that the adults elder than 75 years present a frequency of abnormal cognitive states of 30.2%, while those who are between 60 and 74 years present a prevalence of 5.3%. Chart 4.36
Chart 4.36 Lima and Callao: Elderly Adult Cognitive Function Evaluation by Folstein Mini Mental Scale, 2002
More than 75 Cognitive Function 60 to 74 years Total years Normal 34.70% 23.40% 32.10% Doubtful 60.00% 46.40% 57.40% Abnormal 5.30% 30.20% 10.50% Total 100.00% 100.00% 100.00% Source: Estudio epidemiológico metropolitano de Salud Mental, 2002
According to the Trujillo County Elderly Adult Profile a 85.5% of the elderly adults had a normal mental state.
The elderly group (85 or more years) had the highest frequency of mental state severe deterioration (8.3%). Chart 4.38
4.38 Trujillo, Elderly Adult Cognitive Deterioration by Age, 1999 - 2000
60 - 64 65 - 69 70 - 74 75 - 79 80 - 84 85 o mas Normal 95.90% 91.80% 85.80% 82.10% 74.60% 50.00% Slight Impairment 3.50% 4.80% 7.10% 6.00% 14.90% 14.60% Moderate Impairment 0.60% 2.70% 7.10% 7.10% 27.10% 27.10% Severe Impairment 0% 0.70% 0% 4.80% 8.30% 8.30% Source: Perfil del adulto mayor en la provincia de Trujillo, 1999-2000
Depression
Depression and aging have been associated in diverse ways. Formerly, it was considered that the classic depressive symptoms were aging unavoidable consequence. Now, it is believed that they are the result of diverse biological risk factors and psycho socials characteristics of this stage of the life.
In the year 2002, the Mental Health National Institute Hideyo Noguchi, carried out the Lima City Mental Health study; this research found that the current prevalence of depression in the elderly adult population was of 9.8%, becoming the age group with the highest prevalence of depression (young adults, 8.6% and adults, 6.6%). Chart 4.39
Chart 4.39 Lima City: Current Depressive Episode in Elderly Adult population; by gender and age, 2002
Population % Population Group with depression Total 9.80% Men 7.00% Women 12.30% Elderly Adults between 60-74 years 8.00% Elderly Adults more than 75 years 15.90% Source: Estudio epidemiológico metropolitano de Salud Mental, 2002
Suicidal indicators
The frequency of suicidal thoughts according to the 2002, Lima City Mental Health Study was of 12.2%; while 0.3% had at least one suicidal attempt. Chart 4.40 and 4.41
4.40.- Lima City considerations or suicidal thoughts month’s and year’s prevalence, 2002
Year Prevalence Elderly Adult Adults Total 12.20% 3.60% Men 7.10% 1.50% Women 16.70% 5.60% Month Prevalence Total 6.20% 8.50% Men 3.80% 4.90% Women 8.30% 11.90% Source: Estudio epidemiológico metropolitano de Salud Mental, 2002
4.41.- Lima City Suicidal Attempt, Month’s and Year’s Prevalence, 2002
Year Prevalence Elderly Adult Adult Total 0.30% 1.00% Men 0.30% 0.60% Women 0.30% 1.50% Month Prevalence Total 0.00% 0.30% Men 0.00% 0.20% Women 0.00% 0.50% Source: Estudio epidemiológico metropolitano de Salud Mental, 2002 5. SOCIAL LIFE OF THE POPULATION OF 50 OR MORE YEARS
In our country the elderly social group’s organization were most of the times limited to labour aspects (pensions and jubilation). Only recently in the 90’s decade the elderly adults organized for other reasons the access to income security, health, companionship meetings and social interaction.
5.1 Organizations
5.1.1 Woman and Human Development Ministry (MIMDES)
In the social aspect, the Woman and Human Development Ministry is the organism in charge of coordinating the multisectorial commission for the application of the Elderly Adult National Plan. 2002 - 2006.
This public organism promotes some activities in the elderly adult’s population social area, as the Handmade Fair "Micro-Enterprising Elderly Adult Women" that summons the elderly women that come from diverse institutions, as Canevaro Housing, Family Promotion Centres of the Well-Being Family National Institute (INABIF), Santiago de Surco Municipality, the Impaired Persons National Council for Integration (CONADIS), and Santa Anita's and Cercado de Lima market merchants. In this Fair they can offer their products to the public, improving their qualification and insertion in the labour market.
This institution also tries to motivate and commit the representatives of local and regional governments, government and not government organizations and the civil society to develop activities directed to the elderly adult population, by means of realization of forums, shops and conferences at national and regional level. It gives special emphasis to self-esteem and self-care like facilitator’s elements for obtaining a better life quality, health and social participation. It promotes the organization of meetings, showing other sectors, the necessity to carry out actions in the elderly adult populations at all the levels of the society (family, school, community, etc.).
5.1.2 Health Ministry
Except for the creation of elderly adult's clubs in some hospitals of the Health Ministry, like in Archbishop Loayza or Cayetano Heredia Hospitals, this institution doesn't exercise a lot of influence in the social area, concentrating mainly on the health assistance area. These clubs offer promotional preventive chats, programs of exercises; carry out tourist trips and promote companionship meetings.
5.1.3 Public Recreation Programs
In Peru the public programs directed to recreation are insufficient, fickle and don't cover all the populational segments. The elderly adult population only has a few public recreation programs that give marginal benefits.
The Sport Peruvian Institute is a public organism dedicated to the development and promotion of the sport in Peru. It carries out only a few recreational sports programs dedicated to the elderly adult population denominated “Elderly Adult Program”. In the year 1999, around 6000 elderly adult participated in these programs, insufficient number considering that the elderly adult population that year it already had surpassed the 1'800,000 people.
5.1.4 Municipal programs
Lima Municipalities had the most important changes in relation to the elderly adult population. Making programs specifically directed to them that include courses, meetings, aerobics, dance, tai-chi, swimming, theatre; and chats about common elderly population illnesses (arthritis, glaucoma, etc.), with the purpose to improve this population's health and to increase their physical activity.
In Lima, Lince Municipality was the first one to organise an Elderly Adult club and create a date for the elderly adults of the district. In a same way, municipalities like those of Callao, Comas, Independence, Jesus María, Miraflores, Surco, San Borja, Villa El Salvador, among others, have elderly adult's special programs. In some cases, this population is assisted by Local Participation offices as in Cieneguilla and Breña municipalities. It should be emphasized that not all the municipal town councils have developed Programs for the elderly adult because they require constant financing that cannot be covered by the activities because most of the courses and meetings are free or of minimum cost.
The programs are guided to channel the elderly adult’s recreation and many of them have been developed to form third age homes like in the cases of La Molina, San Miguel, Chorrillos, Pachacámac and San Isidro districts.
At national level, the provincial municipalities also have elderly adults support programs, but due to budget restrictions, they are not able to satisfy the demands of this population sector.
5.1.5 Social Security (EsSalud)
Elderly Adults Centers (CAM)
The Elderly Adult's Centers (CAM) were conceived by EsSalud (social security) as spaces of generational encounter, guided to promote an authentic interpersonal relationship, by means of recreational development, productive social-cultural activities and of health attention directed to improve the quality of the elderly adult's life.
In December of 2002, EsSalud had 107 of these centers at national level, 31 in Lima city and 76 in the counties, with a total of 132895 members, 57% of women and 43% of males (Graph 5.1).
Graph 5.1 Elderly Adult Centers Population by gender, December 2002
43%
57%
Male Female
132895 members
This program is directed to retired elderly beneficiaries of the social security. The services that gives are: Social dining room, games room, social-law orientation, medical and preventive care (UBAAM), social tourism, cultural and artistic activities, family encounters, physical culture (Thai Chi) and recreational events. They also give self-esteem, memory, self-care, literacy, and others classes.
EsSalud with theirs CAMs is the organism that had developed more the topic of the elderly adult's social integration, but some limitations still persist. For example, it centers the attention in the young elderly adults (among 60 to 70 years) that conform their 47% of population. Another important limitation is the covering, since most of affiliated (43%) are in Lima City (Graphics 5.2 and 5.3).
Graph 5.2 Elderly Adult centers population's distribution by age group
60 - 69 16% years 7% 47% 70 - 79 years 80 or + years
30% less than 60 years
Graph 5.3 Distribution of Elderly Adults affiliated to Elderly Adults Centers (CAMs) by regions
Nº Region Affiliated % 1 Lima y Callao 57 260 43,09% 2 Lambayeque 11 336 8,53% 3 Arequipa 10 143 7,63% 4 Cusco 10 106 7,60% 5 La Libertad 7 993 6,01% 6 Ica 6 386 4,81% 7 Piura 5 392 4,06% 8 Puno 4 886 3,68% 9 Junín 2 854 2,15% 10 San Martín 1 829 1,38% 11 Amazonas 1 714 1,29% 12 Huánuco 1 686 1,27% 13 Ancash 1 676 1,26% 14 Moquegua 1 670 1,26% 15 Tacna 1 244 0,94% 16 Ayacucho 1 059 0,80% 17 Pasco 1 017 0,77% 18 Ucayali 829 0,62% 19 Apurímac 702 0,53% 20 Cajamarca 691 0,52% 21 Loreto 682 0,51% 22 Tumbes 666 0,50% 23 Madre de Dios 560 0,42% 24 Huancavelica 514 0,39% TOTAL 132 895 100,00%
5.1.6 Pensioners Organizations
The pensioners of our country grouped initially according to the laws that corresponded them, in reason of their labour rights, for pensions raise, reduction of dismissal age, etc.
Some of these institutions have taken a turn in their activities, being guided more toward the community, developing of local and regional work nets, as well as extending their work toward non pensioners elderly adults organized sectors
These organizations are:
· Pensioners National Center of Peru – CEAJUPE, that initially contained the pensioners under the law 1990; later on it incorporated affiliated of different regimens. It is the organization of this type with most strength and affiliation in Peru, it has local, and regional bases at national level. · Pensioners Unified Central of Peru – CUPPER, that contains the pensioners and pensioners under the law 20530.
Special law regimens have their respective groupings:
· National Association of Retired Fishermen of Peru - ANPJ (Box of Benefits and Social security of the Fisherman, Law 27301) · Regional Associations of Mining Pensioners (Law 25009) · Association of Pensioners (Law 19846) · Association of Pensioners of the Education Sector - ANCIJE and their departmental dependences · Association of Pensioners of the Nation Bank, of the Health Ministry, of the San Marcos National University, of the Armed and Police Forces, of the Credit Bank of Peru, of the Transport and Communications, etc.
Finally, we have the Mutual Associations that have been developed mainly by the Armed and Police forces.
5.1.7 Elderly Adults Civil Organizations
The initial characteristic of these organizations was that they were referred to activities of recreational type and of use of free time. However, because of the work of the NGOs, these institutions have begun to develop a new role and they are propitiating the elderly adult population's revaluation in relation with the development of their communities.
Nets Development
The work developed in nets as: The Third Age Distrital Association of Independence - ADITEI, the Elderly Adults National Association of Peru - ANAMPER, the Net Horizons of Villa and the Net Wonderful Age of the Small North have as main achievements the establishment of relationships with the local governments.
5.2 Abuse and violence against the elderly adult
Our country is not free of the violence against elderly; this could be because our society has diverse factors that propitiate this type of behaviours. The poverty and unemployment in that a big part of the population's live contribute to the generation of behaviors and negative attitudes in front of the aging process. However, it is convenient to keep in mind that in the rural area, particularly in the rural indigenous populations, the respect to the elderly adults continues being a central value in the life of the communities.
The data and figures in this respect are scarce, in spite of constituting a relatively daily problem. The Centers of Woman Emergency (CEM) of the National Program against the Family and Sexual Violence (PNCVFS) of the MIMDES that work in the mark of the Law of Protection against the Family and Sexual Violence, registered during the year 2002, 1120 cases of elderly adult victims of family and/or sexual violence. This represents 3.6% of the total of cases assisted in the 38 CEM at national level during the 2002 (29,759 cases). Of the total of cases of elderly adults, family and/or sexual violence registered by the CEM, 76% corresponds to females.
It is also important to mention that the 46% of the elderly adults, victims of aggressions, had an educational elementary level and the 28.6% hadn’t any educational level. Also, 70.4% didn’t make any activity that offered them revenues.
Most of aggressions are given in the family environment. According to the statistics of the PNCVFS, the main elderly adult’s aggressors are their own mature children, with 44.4%; their spouses, 14.6%; their current couple, 9.7% or other relatives (daughter-in-law, son-in-law, etc.), 17%. It is necessary to highlight that the ages of the mature children aggressors fluctuate between 26 and 45 years and that 68% are male.
In the family environment, the type of violence that is exercised most against the elderly adults it is the psychological abuse (95%). The most frequent aggressions are the insults (85%), humiliation and devaluation (66.3%), threats of death (40%) and rejection (48.8%). However, the elderly adults are not exempt of the physical violence that represented 39% of the total of cases registered in the CEM in the 2002.
2% of the total of cases (22) pointed out to be victims of sexual violence, being female elderly adults the mainly affected ones. Of this group, 8 denounced violation and 12 pursuit or sexual blackmail. Both crimes were only referred by women.
We should be kept in mind that the Law of Protection against Family Violence and the Penal Code, aids the people in risk, being able to go to the extrajudicial reconciliation. However, the elderly adult’s abuse don't have a defined space for its legal treatment, neither instances with the qualified human resources for its attention, as well as an explicit legislation that favors the attention and the elderly adult population's protection.
5.3 Studies about socio-gerontological aspects
In our country, the scientific works in the social area are scarce. According to the social evaluation carried out in hospitalized patients (as a part of a Integral Geriatric Assessment) at national level by Varela and collaborators, 23.25% of the hospitalized elderly adults were in a situation of social problem, while 49.5% were in a situation of social risk.
In the Trujillo's county Elderly Adult's Profile, the social activity carried out in the free time was measured, either as singular activities: listening radio, see television, to read newspaper, read magazines, make handiworks, go to the cinema; or activities in group, as attendance to sport events, social and religious meetings, practice of sports, friends/family visits, carry out walks and receive visits. The most of the elderly adults in this county had a low social activity (63.4%) and 32.4%, had a moderate activity. Also, the social activity diminish as the age increases, this is slightly more evident in the case of the women.
Chart 5.1 Trujillo: Elderly Adults Social Activity, 1999 – 2000
Social Activity Gender Low Moderate High Total Male 54.70% 38.80% 6.50% 100.00% Female 69.00% 28.30% 2.70% 100.00% Total 63.40% 32.40% 4.20% 100.00% Source: Perfil del Adulto mayor en la provincia de Trujillo, 1999-2000.
In both genders the groups that still work is the one with a higher social activity, this difference is higher in the case of the women.
Another aspect to consider is the desire to work in connection with the labor activity. A 71.5% of the elderly adults of this county, referred not to be working at that moment. In the group that didn't work, 57% manifested desires to carry out a labor activity.
In the chart 5.2 is a relationship of other scientific works carried out in the elderly adult population's social area (Chart 5.2).
Chart 5.2 Social gerontological studies; Peru
Year Title Author Place Results 1986 The third age: Retired Arce, E Retired Pensioners - Workers wish to reach retirement Worker Integration and Club age as lately as possible Health within the society IPSS (now - Health negative state due to lack of and family EsSalud) income, sometimes explained also by previously life and work conditions. - Marginalization feelings due to lost of economic power and decrease of the home directing role. - Lesser participation in organizations and activities
1986 Family Attitudes Toward Pérez, F Community - There is a positive attitude toward the Elderly Adults (EA) in the EA in the psychological and social two communities of areas, but indifference toward the Condevilla –San Martin biological area. de Porres - The lesser the age of the family member and the closer blood relationship, more positive attitudes are seen - There is not association between marital status and work of the relative with the attitude toward the EA. 1987 Relative’s Biosocial Chávez, G San Vicente de Isolation’s principal factor is the lack of Factors that affect the Paul Asylum relatives that look for them isolation of the elderly adult 1989 Socio-cultural Factors that Cuellar, M Community The majority of the EA are poorly affect the integration of Sáenz, I integrated to his/her family and the elderly adult to his/her community, the most important factors community and family are age, gender, origin (Lima or counties) and instruction level 1991 Third age and elderly Huapaya, L Centromin The workers had wrong ideas and fear adult care knowledge Workers about the aging process. The lack of (Mining company) knowledge about preventive measures for a healthy life determines incorrect opinions about the elderly adult care. l The workers don’t accept the idea of being elderly adults 1995 Socio-economical and Huillca, D Outpatient Office The 62.8% presents a low integration cultural factors influence Mori, C level with his family and community. in the integration of the Quijada, R The most important factors are: retired military personnel marital status, origin, previously (more than 60 years old) occupation, age, retired years, socio- to their family and economical level. Factors that not community have influence: religion, residence Geriatric Navy Center place and military rank
5.4 Family Nets
A significant number of elderly adults lack of a proper economical support and, in consequence, will depend on their families. The family support assumes diverse forms as: direct monetary help, personal cares in the case of a sick relative or partially impaired or by means of the emotional support.
In chart 5.3 is seen that in Peru the elderly adults co-residence with their families continues being an extended practice.
Chart 5.3 Elderly Adults Proportion that live alone, Peru 1993
Year Total Men Women 1993 8,70% 8,70% 8,80% Source: Censo 93, INEI CELADE.
Approximately one of four peruvian homes have at least one elderly adult among their members. The distribution of homes according to residence areas shows that in the rural area the proportion of homes that counts among its members with at least one elderly adult is a little higher than in the urban area.
Chart 5.4 Percentage of family homes with at least one elderly adult, by residence area, Peru 1993
% of homes with elderly adults Year Total Urban Area Rural Area 1993 24,70% 23,90% 26,80% Source: Censo 93, INEI CELADE.
The proportion of homes headed by elderly adults in our country is of 18.9%. The homes leaded by a female elderly adult overcome the ones leaded by male elderly adults as a result of the differential mortality for sexes.
Chart 5.5 Percentage of homes leaded by an elderly adult, by gender and residence area, Peru 1993
Total Urban Area Rural Area Total 18,90% 17,70% 21,70% Male Boss 17,20% 17,20% 19,20% Female Boss 24,80% 24,80% 31,80% Source: Censo 93, INEI CELADE.
Most of homes with elderly adults; also have other younger members (children, grandsons, other kindred ones and non relatives), constituting multi-generational homes where, in general, they live in dependence relationship. The cohabitation is in this way a form very common form of intergenerational solidarity that reduces the expenses for person housing and the purchase and preparation of meals and facilitates the direct support to relatives with special necessities.
Chart 5.6 Distribution of homes that includes Elderly Adults, by residence with other non elderly adults members, Peru 1993
Total Only with Elderly adults Year another with other elderly members adults Total 80,80% 19,20% Urban Area 84,20% 15,80% Rural Area 73,60% 26,40% Source: Censo 93, INEI CELADE.
Regarding the marital status, is observed that there is a higher proportion of divorced, single and widower women than men.
Chart 5.7 Elderly Adults Marital Status, by gender, Urban Peru 2003
Marital Status Men Women Partner (non married) 185,801 9.22% 10.5% 6.0% Married 1’088,800 54.00% 66.7% 40.4% Widower 501,349 24.87% 14.4% 38.7% Divorced 58,883 2.92% 5.4% 9.3% Single 157,244 7.80% 3.0% 5.6% Don’t tell 24,038 1.19% ------TOTAL 2’016,115 100.00% 100.0% 100.0% Source: INEI - MIMDES, 2003.
6. HEALTH SYSTEM DESCRIPTION
6.1 PANORAMIC VISION OF THE PERUVIAN HEALTH SYSTEM
The peruvian health system had have an inadequate global acting for decades. According to the World Health Organization (WHO) evaluation published in the World Health Report of the year 2000, our country is located in the position 129 for health system global acting, among the 191 studied countries. In what concerns to achievement goals, it occupies the penultimate place (Graphics 6.1 and 6.2).
Graphics 6.1 and 6.2: Acting and global achievements of the peruvian health system, 2000
Health system global acting
Colombia 22 Chile 33 Costa Rica 36 Venezuela 54 Paraguay 57 Uruguay 65 Ecuador 111 Bolivia 126 Peru 129
00000 00050Health system position 00100 00150
Health system global achievement
Chile 33 Colombia 41 Costa Rica 46 Uruguay 50 Venezuela 65 Paraguay 73 Ecuador 107 Peru 115 Bolivia 117
0 50 100 150 Health system position
Source: Informe sobre la salud en el mundo 2000, OMS
The most important factors that have contributed to this faulty acting are the administrative disorder and lack of leadership of the Health Ministry.
During last decade the Health Ministry didn't reach enough leadership, taking place an intra-sectorial fragmentation with the presence of programs and projects financed with external co-operation that acted parallel to planning and administration of the central and regional formal health structures. There was also a scarce investment in health promotion and illnesses prevention.
6.1.1 Health sector segmentation
In Peru, several instances take charge of health attention. Approximately 20% of the country population have access to the Social Security Services (EsSalud). 12% are assisted to private services (health lender entities, private clinics, medical clinics and other institutions) and 3% have access as to the Armed Forces (FFAA) and of the Peruvian National Police (PNP) Sanities. The 65% remaining depends on the health public services that offers the Health Ministry; but is considered that inside this sector, 25% doesn't have possibilities to access any type of attention (Graph 5.3).
Graph 6.3 Health Sector Segmentation, Peru 2002
12% 3% Health Ministry Social Security Army and Police Private system
20%
65%
Source: Lineamientos dela politica sectorial para el periodo 2002-2012, MINSA
This segmentation of services prevents the articulation of efficiently health actions. It is also the cause of duplicities and hinders the Health Ministry directing role. Also, it doesn't facilitate the country’s process of decentralisation that requires an efficient co- ordination of the attention and organisation, for an appropriate articulation among the local, regional and national levels.
It is also observed a separation and duplicity of functions between diverse state organs like the Woman's and Social Development Ministry, the Ministry of the Presidency, the Defence Ministry, the Interior Ministry, the Health Ministry and the Work Ministry. EsSalud (Social Security) belongs to this last Ministry, and does not have the co-ordination instances and necessary intersector planning. In this mark, the Health Ministry has not been able to reach a leadership role in the formulation of health inter-sector politics.
There is also a disproportion in the distribution of resources and the responsibilities that have the different subsectors. The Health Ministry has an expense per capita 4 times minor that EsSalud (Social security); however it administers more health establishments and carries out a higher number of attentions (Graph 5.4).
Graph 5.4 Resources and responsibilities proportion by expense per layer
90 81 Hospitalization 80 65 70 60 60 Outpatient 44 office 50 40 Rural 23 hospitalization 30 18 20 12 Rural 5 outpatient 10 0 Health Ministry US$ Social Security 28 annual US$105 annual
Source: Lineamientos de la política sectorial para el periodo 2002-2012, MINSA
The Armed Forced and Police health system assumes 2% of the hospitalizations, 2% of the outpatient attentions at national level and 1% of the total outpatient attentions. They don’t assume hospitalisations in rural areas.
The private sector assumes 9% of the hospitalizations, 36% of the outpatient attentions at national level, 7% of the hospitalizations and 34% of the outpatient attentions in the rural areas. It should be kept in mind that at least 50% of the outpatient attentions of the private subsector corresponds to pharmacies (mainly in urban areas), to faith healers and community agents of health (mainly in rural areas). The participation of the private sector of social and humanitarian projection (NGOs, churches) is not appropriately valued neither systematized.
In 1994, the Health Ministry assisted the13% of the insured population of EsSalud (Social Security) and 10% of the population with private insurance.
Although the expense per layer in health at national level is of US$100, the sub- sector Health Ministry has much lower and very more variable figures of region to region, constituting the subsector that assumes the highest number of attentions in spite of the scarce assigned resources. The access to the services of health is shown in the Graph 6.5.
Graph 6.5 Medical Services Population Access, Perú 2000
18% Population: with access without access
82%
Source: Lineamientos de la política sectorial para el periodo 2002-2012, MINSA
6.1.2 Financing
According to the WHO Report, Peru is one of the countries of the region that invest less in health; only 4.7% of its national gross product (Chart 6.1). The public expense in health in the 90s by millions of dollars is shown in the Graph 6.6.
Chart 6.1 National Expense Health Indicator, Peru 1997 - 2001
1997 1998 1999 2000 2001 % NGP Health Total Expense 4,4 4,6 4,9 4,7 4,7 Government General Health Expense, % of 11,6 12,9 13,0 12,7 12,1 the goverments total expense Social Security Health Expenses, % the 43,0 43,1 48,3 47,2 51,9 government general health expense Source: World Health Report 2003, Annex 5.
Graph 6.6 Health Public Expense, Perú 1990-1999
600
500
400
300
200
100
0 1990 1992 1995 1998 1999
Source: Lineamientos de Política Sectorial para el periodo 2002 – 2012, MINSA.
In 1997, 13% of the average expense was dedicated to the administrative units, 54% to the hospitals (that only assisted 30% of the demand), and 33% to the primary health care centers (that assisted 70% of the daily demand) (Graph 6.7).
Graph 6.7 Average Health Expense Distributions, Peru 1997
100% 33% 80% 70% 60% 54% 40%
20% 30% 13% 0 0% Current expences% Demand% Administrative units Hos pitals Primary health care centers
Source: Lineamientos de Política Sectorial para el periodo 2002 – 2012, MINSA.
6.1.3 COVERING
Barriers of diverse nature limit health service cover, some of which affect the elderly adult population.
Economic barriers
According to the National Home Survey (ENAHO), the lack of economic resources was an important barrier to the health services access. 40% of people that didn't have access to health services in the year 1998 didn't make it purely for economic reasons; in 1999, the percentage ascended to 49.4%.
Geographical barriers
It is still not possible to cover the demand of the whole national territory, in spite of the increment of services. The existence of many areas of the country in those that the pattern of dispersed populational establishment prevails is an important factor in the geographical inaccessibility to the services. This situation is increased with relationship to the health centers and local hospitals of more resolutory capacity that in general are at a considerable distance of some rural towns or communities. The communication difficulties and public transportation are additional factors to the geographical problem, especially in the rural areas.
However, in the big coastal cities as Lima, Arequipa and Trujillo, although public transportation means exist, these are not the appropriate ones for the population's sectors that have great demand for health services, as the elderly adult and impaired people.
In 1999, approximately 8% of the sick people that had not access to the health services didn't make it up due to geographical reasons.
Cultural barriers
Our country is characterized by its great cultural diversity, one that manifests with great vigor in the different perceptions of the health-illness process and the relationship between life and death.
Qualitative studies developed in some of the poorest regions in the country show, that the residents and health personnel of the communities have very different ideas on what normal is and in what cases is required a qualified health personal intervention.
Distrust exists toward the primary health care personnel, as well as toward the diagnosis and treatment techniques employed. To this we must add that the public services of health have little acceptance for traditional medicine; that is very used by the general population, especially by the ones that live in rural areas.
Health care professional’s behaviour barriers
The main causes for service dissatisfaction referred by the users were abuse and/or inadequate treatment (55% of the total complaints).
Medications Access
The most expense that a person makes when using health services to recover of some illness corresponds to medications. According to the ENAHO 1998, the total cost of an average medical consult is composed in 12% by personnel fee (physician, nurse, secretary etc.), 13% by auxiliary exams and the 75% by medications.
The access reduction of the Peruvian population to the medications is appreciated in Graphics 6.8 and 6.9. The main reason of this contraction in medications consumption is the cost, which implies a higher marginalization of the population's poorer sectors.
Graphics 6.8 and 6.9 Peruvian population to medications access, 1988-2000
Drugs units quantity selled (by millions)
160 160 140 120 100 58 80 60 40 20 0 1988 2000
Drug units selled by habitant
7,75 8 7 6 5 4 3 2,26 2 1 0 1988 2000
Source: Lineamientos de Política Sectorial para el periodo 2002 – 2012, MINSA.
6.1.4 HUMAN RESOURCES
Between 1994 and 1997 were incorporated in the “Basic Health Program for All”, 10,806 workers (physicians, professionals non physicians and technicians) to work in the first level establishments (primary health care centers) for renewable contracts of 90 days, without rights for vacations neither for social benefits. This means that approximately the sixth part of the human resources of the Health Ministry is working with extreme labour flexibility that generates labour uncertainty, a precarious work situation and inadequate conditions for the good performance.
The Health Ministry is the main employer of the Health sector; however, the highest growth of labour positions has taken place in the Sanity of the Armed and Police forces (156%) and in the private subsector (139%) (Graph 6.10).
Graph 6.10 Growth of labour positions by subsectors, 1999
156 139 160
140
120
100 68
80
60 30
40
20
0 MINSA ESSALUD SANIDADES PRIVADOS
Source: Ricse 2000, World Bank 1999.
The labour positions are concentrated in the hospitals; however, an increment of positions has been given in the first level attention services (primary health care centers). This way, in 1996 these increased in 200% and in 1999, in 314%.
In the year 2001 the most important problems for the development of the human resources of the administration were:
• The not planned growth of the health personnel formation. The sector lacks an unit specialized in the planning and development of human resources. • A weak regulation and accreditation of the medical professional, observed in an excessive growth of medicine faculties. Also, the sector has not had the proper participation in the qualification of the medical professionals in activity (professional certification). • Exists a tendency to the over-specialization of the medical professionals, but specialties like anaesthesiology and other necessary to assist regional pathologies, are not promoted. Little interest also exists in forming integral general doctors and general nurses that are required in the first and second level of attention. • The Marginal Rural and Urban Service of Health doesn’t have enough resources and doesn't fulfil the appropriately the function of linking the practice of the young professionals with the necessities of the population's health. • A limited formation and training of distance health teams
For the year 2000, Peru had 11.7 medical professionals per each 10000 inhabitants most of them were concentrated in the cities of the coast, being Lima and Callao the cities with more concentration (Graph 6.11).
Graph 6.11 Number of physicians by region, Peru 2000
22 20 18 16 14 12 10 8 6 4 Tasa x 10.000 Hb. 2 0
M L P Q A C D L C M U S N M S A C A R T A N A U J LI Q O IC A D A PI U U M U CA A M T M L AN LA PA JU TU C AY HN H LO S UC P AM AP CA
6.1.5 Health System New Reforms
It is prominent the recent impulse of the primary health care attention as a central function of the Coordinated and Decentralized National System of Health (SNCDS). This new system looks for the construction of health equity and its fundamental strategy is the public and solidary health insurance, with tendency to the universalization, through the invigoration of the Health’s Social Security (EsSalud) and of the Health’s Integral Insurance (SIS) of the Health Ministry, this last one created in the year 2001 and guided fundamentally to insurance of the most vulnerable population in extreme poverty.
6.2 HEALTH MINISTRY
History
In 1568, when Peru was a colony of Spain, was created the Royal Tribunal of the Protomedicato with the purpose to guarantee the correct exercise of the medicine, the operation of drugstores, to combat the empiricism, to classify plants and medicinal herbs, to write the Peru’s natural history and to acquit the government's consultations on the climate, existent illnesses, hygiene and public health in general. The physician who works most in this period was Hipólito Unanue, also an eminent person of the independence process.
In the republic, this institution was conserved along the XIX century, under the name of General Protomedicato of the State. In 1903, the Peruvian government created the Public Health Direction dependant of the Development Ministry, later acquiring autonomy as a ministry thanks to the1920’s Republic Constitution.
In 1935 was promulgated the legislation decree 8124 that creates the Public Health, Work and Social Forecast Ministry. In 1942 it adopted the name of Ministry of Public Health and Social Attendance and from 1968 the name that maintains until the present time: Health Ministry.
Mission and Objectives
The Ministry of Health has the mission of protecting the personal dignity, promoting the health, preventing the illnesses and guaranteeing the integral health attention of all the inhabitants' of the country; proposing and driving the limits of sanitary politics in agreement with all the public and social sectors.
Organization
With the purpose of fulfilling their functions, the Peruvian Health Ministry is composed by seven organs:
1. High Direction • ·Health Minister • ·Health Vice minister • ·General Secretary 2. Advisory organ • ·Health National Council 3. Control Organ • ·General Inspectors Office 4. Judicial Defence Organ • Public Attorney's office of the Health Ministry 5. Consultantship Organs • · General Office of Strategic Planning • · Cabinet of Advisory of the High Direction • · General Office of International Cooperation • · General Office of Epidemiology • · General Office of Artificial Consultantship 6. Support Organs • · General Office of Statistic and Computer Science • · General Office of National Defense • · General Office of Administration of Human resources • · General Office of Administration • · General Office of Communications 7. Line Organs • · General Direction of Environmental Health • · General Direction of People’s Health • · General Direction of Health Promotion • · General Direction of Medications, Inputs and Drugs
Among the Line Organs, it is necessary to mention some of the functions that performs the General Address of People’s Health, as the establishing of the norms, supervision and evaluation of the attention of the people’s health from their conception until their natural death, as well as the categorization, and operation of the health services and the sanitary administration in the health sector. This Direction is composed in turn of the following executive’s directions:
· Executive Direction of Health Integral Attention · Executive Direction of Health Services · Executive Direction of Health Quality · Executive Direction of Sanitary Administration · Direction of Health Basic Services · Direction of Health Specialized Services
The Executive Address of Integral Attention of Health (DEAIS) is in charge of the formulation and diffusion of the attention politics, of the identification of priorities and of the proposition of national sanitary strategies, as well as their pursuit and evaluation. This direction is responsible for the implementation of the Health Integral Attention Model (MAIS), according to the Political Linings of the Sector 2002 - 2012. This model contemplates the integral attention of people's health by Life Stages, including the elderly adult’s stage. It constitutes the reference mark for the health attention in the country, based on the development of health promotion actions of, illness prevention, recovery and rehabilitation.
Decentralized organs 1. Specialized institutes 2. Health Directions (Lima) 3. Regional Health Directions (counties) 4. Lima and Callao Communicators
The Assistance Levels, are determined in function of the users affluence, the installed capacity and the modernization of the infrastructure and equipment, they are the following ones:
1. First level: health posts and centers 2. Second level: Small hospitals 3. Third level: General hospitals 4. Fourth level: Specialized Institutes (for example: Neoplasic Diseases National Institute or Mental Illness National Institute)
HEALTH ESTABLISHMENTS
The Health Ministry has 6874 health establishments in the whole country. 80.48% are health posts; 17.43%, health centers and only 1.99%, hospitals. 97% of the infrastructure of the Health Ministry of Health is dedicated to offer primary health care (Chart 6.2).
Chart 6.2 Health Ministry Establishments by region, 2004
Region TOTAL Hospital Health Center Health Post TOTAL 6,874 137 1,198 5,532 % 100.00% 1.99% 17.43% 80.48% AMAZONAS 289 2 30 257 ANCASH 414 12 50 352 APURÍMAC 237 6 33 198 AREQUIPA 246 4 51 191 AYACUCHO 383 8 45 330 CAJAMARCA 600 8 98 494 CALLAO 57 2 50 4 CUSCO 268 4 47 217 HUANCAVELICA 286 1 44 241 HUÁNUCO 233 4 21 208 ICA 138 6 34 98 JUNÍN 454 7 56 391 LA LIBERTAD 208 8 44 156 LAMBAYEQUE 154 2 43 109 LIMA 677 24 205 442 LORETO 327 3 53 271 MADRE DE DIOS 114 2 13 99 MOQUEGUA 60 1 26 33 PASCO 254 3 15 236 PIURA 385 4 73 308 PUNO 439 11 80 348 SAN MARTÍN 350 11 43 296 TACNA 72 1 17 54 TUMBES 44 1 13 30 UCAYALI 185 2 14 169 Source: Oficina General de Estadística e Informática MINSA. Base de Datos de Infraestructura.
The Chart 6.3 presents the Health Ministry physicians distribution by Regional Health Directions.
Chart 6.3 Health Ministry physicians distribution by Regional Health Directions. , Peru 2002
Health Ministry physicians by Regional Health Directions and type of establishment Health Health Health Direction Total Hospital Center Post TOTAL 11,388 7,244 2,822 1,322 100% 63,61% 36,39% AMAZONAS 89 22 34 33 ANCASH 313 226 48 39 APURÍMAC I (APURÍMAC) 82 30 31 21 APURÍMAC II (ANDAHUAYLAS) 45 19 15 11 AREQUIPA 642 369 170 103 AYACUCHO 217 132 65 20 BAGUA 43 12 25 6 CAJAMARCA I (CAJAMARCA) 120 58 34 28 CAJAMARCA II (CHOTA) 54 16 34 4 CAJAMARCA III (CUTERVO) 27 22 5 CALLAO 663 480 181 2 CUSCO 287 157 78 52 HUANCAVELICA 79 13 60 6 HUÁNUCO 186 75 57 54 ICA 312 215 53 44 JAÉN 67 20 30 17 JUNÍN 332 164 106 62 LA LIBERTAD 562 347 115 100 LAMBAYEQUE 204 128 50 26 LIMA II - (LIMA SUR) 768 318 303 147 LIMA III - (LIMA NORTE 1,338 811 305 222 LIMA IV - (LIMA ESTE) 631 429 149 53 LIMA V - (LIMA CIUDAD) 2,764 2,554 201 9 LORETO 156 99 46 11 MADRE DE DIOS 58 28 21 9 MOQUEGUA 91 19 62 10 PASCO 74 26 22 26 PIURA I (PIURA) 190 10 121 59 PIURA II (LUCIANO CASTILLO) 166 75 67 24 PUNO 295 154 105 36 SAN MARTÍN 180 66 87 27 TACNA 133 60 53 20 TUMBES 74 27 35 12 UCAYALI 146 85 37 24 Source: Ministerio de Salud - Oficina General de Estadística e Informática. Bases de datos de Recursos de Salud.
Most Health Ministry physicians are in the hospitals (64%); only in Lima and Callao were working 6,164 physicians that represent 54% of the total of these professionals in the sector (Graphics 6.12 and 6.13).
Graphics 6.12 and 6.13 Health Ministry physician’s concentration for establishment, MINSA 2002
Health establishment distribution, Perú 2002
90 80 80 70 60 50 40
30 17 20 10 2 1 0 Hospitales Hospital Institutos Institute PHC Centros center Puestos PHC post
Health Ministry: Physician distribution by health establishment
70 64
60
50
40
25 30
20 11
10
0
Hospitales Hospitals PHC Centros center PHC Puestos post
Source: Lineamientos de Política Sectorial para el periodo 2002 – 2012, MINSA.
Access
Chart 6.4 Elderly Adults Health Assisted and Attentions, Ministry of Health, 2003
Region Assisted % Attentions % Total 781,314 100,00 2’010,706 100,00 Lima and Callao 306,641 39,25 845,797 42,06 Rest of the country 474,673 60,75 1,164,909 57,94 Source: Informe de registro Diario HIS Ministerio de Salud – OEI, cifras preliminares.
The Health Ministry offers attention to all people that requires its services, without restriction and at a lower cost than most of private health centers. Also offers the Health Integral Insurance (SIS) guided fundamentally to the vulnerable population in extreme poverty. The ministry also have other free programs, as the Tuberculosis Control Program and of other pathologies, of which the elderly adult benefits, together with the general population.
Health Integral Insurance (SIS)
The Health Integral Insurance-SIS is a free attention system directed to the less economically favoured. This insurance that was directed initially to the children and pregnant mothers, now involves also some people considered in extreme poverty:
Plan A, 0 to 4 years infants Plan B, 5 to 17 years children and adolescents of Plan C, Pregnant mothers Plan D, Adult in Emergency situation Plan E, Focalized Adult Plan F, a monthly payment whose value is not calculated yet
Some health authorities say that the SIS is on the process of constitute the institution that contributes to the universal insurance and guarantee the full exercise of the population's health right in our country. The Benefits Plan is appreciated in the Chart 6.5.
Chart 6.5 Integral Health Insurance Benefits Plan, Peru 2002
Mobility to Consult Emergency Medicines Laboratory Hospitalization Odontology Death X ray Surgery other
institution Plan A x x x x x x x x x x Plan B x x x x x x x x x x Plan C x x x x x x x x x x Plan D x x x x x x x x Plan E x x x x x x x x x x Plan F x x x x x x x x x
The SIS also has incorporated, for political decision and without another approach, the following populational groups:
Popular Dining Rooms Directors Mothers of the milk glass program Administration committee’s integrants and wawa wasi mothers caretakers
Hospitals
The national hospitals of more complexity level are generally in Lima. They have a specialist doctor in Geriatrics or a Internist qualified in the elderly adults attention: Archbishop Loayza Hospital, 2 de Mayo Hospital, National Cayetano Heredia Hospital, María Auxiliadora Hospital, Hipólito Unanue Hospital and Sergio E. Bernales National Hospital. However, some of these hospitals, with Geriatrics Services don't have the enough human resources and lack of infrastructure; therefore, they don't really operate as properly conformed Geriatrics Units, being limited, in most of the cases, to the Outpatient consultation and in giving answer to the specialty inter-consults. In counties this situation is even more dramatic, especially in the rural areas.
6.3 THE SOCIAL SECURITY (ESSALUD)
History
In July of 1980 by Legislative decree #23161 was created the Peruvian Institute of Social Security (IPSS), among its functions were: the cover of the insured and their relatives against the illness, maternity, disability, accidents, age and death risks; also pointed out as objective the insured's and their family social realization.
Until 1994 the Peruvian Institute of Social Security took charge of the Health Services Benefits for the insured population and their family and of the grant of pensions for the population in pension age. At the present time, the Previsional Normalization Office (ONP), as autonomous entity, is the one in charge of administering the resources dedicated to cover the jubilation pensions.
In 1999, on the base of the Peruvian Institute of Social security (IPSS) was created the Health Social Security (EsSalud) as decentralized public organism, attributed to the Sector Work and Social Promotion, with technical, administrative, economic, financial and accountant autonomy.
Mission and objectives
EsSalud has for purpose to give cover to the insured through the grant of prevention, promotion, recovery, rehabilitation, economic and social benefits that correspond to the Health Social Security contributive regime, as well as other human risks insurance.
Organization
EsSalud attention levels present a similar distribution to that of the Health Ministry, although it has a Domiciliary Attention Program (PADOMI) and Elderly Adults Centers (CAM), this last one already described in the previous section.
Program of Domiciliary Attention (PADOMI)
Through this program EsSalud provides home health services to patients elder than 80 years and with physical limitations. This program intends to achieve the patient and family participation in the health attention, fomenting self care and prevention, and contribute to the effective use of the Medical Consultation and of EsSalud Hospital Bed Services, as well as the rational use of the hired clinics.
Access
Social security health service offers attention to the workers, pensioners and their family (spouses and children) that are in the system. The beneficiaries constitute a minority group, in which the elderly adults represent 13% of the total of insureds. These age group use EsSalud health services in an important way because they have the 25% of the outpatient office consults it, 29% of the hospitalizations, and 22% of the emergency attentions. On the average they use 25% of the total of attentions, without counting the special programs for chronic non communicable diseases as hypertension, diabetes, osteoartrosis, asthma and other exclusive services as the Domiciliary Attention Program (PADOMI), the Elderly Adults Centers (CAM) and the Elderly Adult Basic Units of Attention (UBAAM) that elevate the use from the services to 30% in relation to the other populational groups.
The elderly adults represent an increment of 1.6% annual inside this institution. In absolute numbers the population of elderly adults, regular pensioners ascends in EsSalud, to 600123; if we include the spouses we must add another 294,060 people, reaching a total of 894,193 insured. Although all the spouses are not necessarily elderly adults, is assumed that in their majority they are contemporary.
Making an approximate calculation, the elderly adult’s contribution is of 84 million annual suns, while the costs of their attention rise to near 390 millions in the same period, being the expense subsidized in 78.46%.
The new contributors cannot cover the expense breach made by the benefits given to the elderly adults, the problem becomes worse because of others factors resultant from the economic crisis. The qualitative change of being retired elderly adults goes accompanied by a decrease of their contributions.
It is important to mention that 5 EsSalud hospitals spend 60% of this institution general budget; of this it is deduced that in this institution the expense in recuperative medicine is higher than the investment in health prevention and promotion. In the Chart 6.6 is a list of EsSalud establishments and their distribution by regions.
Chart 6.6 EsSalud Establishments by level and regions, Peru
Hosp IV Hosp III Hosp II Hosp I Policlin PHCCenter PHC post TOTAL
Amazonas 3 6 9 Ancash 1 1 1 7 9 19 Apurímac 1 1 4 6 Arequipa 1 2 1 2 1 19 26 Ayacucho 1 1 8 10 Cajamarca 2 4 10 16 Callao 1 2 1 4 Cusco 1 5 6 3 15 Huancavelica 1 2 5 8 Huánuco 1 1 1 6 9 Ica 1 3 1 9 14 Junín 1 1 3 1 1 9 16 La Libertad 1 1 3 1 4 23 33 Lambayeque 1 2 4 2 7 16 Lima 2 1 4 5 15 3 12 42 Loreto 1 1 4 6 Madre de Dios 1 3 4 Moquegua 2 1 3 Pasco 1 2 14 17 Piura 1 2 2 2 11 18 Puno 2 2 4 7 15 San Martín 1 3 1 6 11 Tacna 1 1 2 4 Tumbes 1 3 4 Ucayali 1 4 5 TOTAL 8 8 22 40 30 36 186 330
6.4 THE ARMED FORCES AND POLICE SANITIES
As was mentioned previously, the Armed forces sanity offers health services to the military or police personnel, and their spouses and children, according to the institution to which the person belongs.
4 sanities exist: · Military Sanity · Navy Sanity · Air Force Sanity · Police Forces Sanity
In the Peru, the sanities were the first institutions that created specialized services of attention for the elderly adults and have very differentiated attention levels for the attention of this age group.
6.5 PRIVATE INSURANCE, PRIVATE CLINICS, PARTICULAR CLINICS AND OTHERS
PRIVATE INSURANCE (Health lenders entities (EPS))
In 1997, the Health Social Security Modernization Law N° 26790 was approved, that is based in the constitutional principles that recognize the right to the well-being and that guarantee the free access to benefits in charge of public, private or mixed entities.
The health plans and programs of the Health Lenders Entities properly credited supplement the covering of the Health Social Security, financing the benefits by means of contributions and other payments according to law.
The Health Lenders Entities that function at the moment are two;
· INTERNATIONAL RÍMAC EPS · PEACEFUL HEALTH EPS
Nova Salud EPS has been fused to Pacifico Salud EPS. (Graph 6.14).
Graph 6.14 Insured Population's Distribution by EPS, 2003
46%
54%
Rimac Novasalud/Pacificosalud
Source: Reportes mensures de aplicación de las EPS
EPS DEFINITION
According to the regulation of the Health Social Security Modernization Law, EPS is defined as the companies and public or private institutions different to ESSALUD whose only end is to lend health attention services, with an own infrastructure, held to the controls of the Health Lenders Entities Superintendence (SEPS) that is the decentralized public organism of the Health sector that authorizes, regulates and supervises the operation of the EPS and caution the correct use of the administered funds.
CONTRIBUTIONS
Regarding the contributions, at the moment the Health Lenders Entities affiliated to the system contribute the 6.75% of the remuneration from their workers to EsSalud and 2.25% to an EPS.
BENEFITS
In what refers to the benefits, these include the preventive, promotional, and recovery activities, benefits of well-being and social promotion (Social help projection activities and of rehabilitation for work, guided to the promotion of people and protection of their health) and economic benefits, as subsidies for temporary inability, maternity, nursing or benefits for burial.
ATTENTION PLANS
Simple Plan: Group of health interventions of more frequency and smaller complexity, they can be lent by the EPS or for EsSalud.
Complex Plan: Group of interventions of smaller frequency and higher complexity. They are in charge of EsSalud.
AFFILIATION The affiliations are classified according to the insurance type: Regular, Optional and Risk Work Complementary Insurance (SCTR).
Regular insureds People that work in dependence relationship and their claimants (spouse, children smaller than 18 years and work impaired elder children). Additionally they could be included the principal affiliated children elder than 18 years, the parents and the parents in- laws.
Optional insureds Workers and independent professionals and other people that don't qualify for the regular affiliation.
Assured for Sure Complementary of Work of Risk (SCTR) The SCTR gives cover to the professional diseases and the workers' labor accidents (for those who carry out high risk activities, defined in the Technical Norms of the Risk Work Complementary Insurance, D.S. 003-98-INC).
The total number of affiliations at the end of the year 2003 was of 417,293, the highest since the creation of the system. This number of affiliations doesn't indicate the total number of insureds, because some duplicity is given due to 211 companies that have workers insureds under the regular insurance and the SCTR modalities.
6.15 Population assured to EPS by affiliation type, 2003
3% 37%
60%
SCTR Regulars Potestatives
Source: Resportes mensuales de afiliacion de las EPS
GEOGRAPHICAL ENVIRONMENT
The geographical environment in which the EPS operates is composed by 17 regions of the country. In some regions of the mountain, such as Apurímac, Huánuco, Huancavelica and Pasco this system has not still been implemented.
LINKED ENTITIES TO THE EPS SYSTEM
When concluding the year 2003, were registered 528 entities linked to the EPS system, with a total of 932 establishments or health services in the whole country. This number includes the branches of the linked entities and health establishments that form the net of services of the Health Services Administrators given by third persons. Of the total of establishments, 497 are located in Lima and Callao (53%) and 435 (47%) in other counties of the country (Chart 6.7).
Chart 6.7 Entities linked to EPS Health Plans, 2003
Lima and Callao Countryside Total Entity type Nro % Nro % Nro % Hospitals and clinics 38 37% 65 63% 103 11% Institutes 4 80% 1 20% 5 1% Medical Centers 25 64% 14 36% 39 4% Odontological Centers 0 0% 28 100% 28 3% Medical Poli-Clinics 26 68% 12 32% 38 4% Odontological Poli-Clinics 70 89% 9 11% 79 8% Private Physician Outpatiant office 139 48% 153 52% 292 31% Dentist Outpatient office 101 46% 118 54% 219 23% Psychological Outpatient office 9 100% 0 0% 9 1% Diagnostic and Therapeutic services 59 65% 32 35% 91 10% Medical Support Center 8 100% 0 0% 8 1% Domiciliary attention services 9 75% 3 25% 12 1% Patients movement services 6 100% 0 0% 6 1% Other establishments 3 100% 0 0% 3 1% Total 497 53% 435 47% 932 100%
CLINICAL AND PRIVATE HOSPITALS
The private sector faces diverse problems, among those more important are its non used infrastructure capacity that oscillates between the 40 and 50%. The private health services possess near 7,300 beds and constitute the second subsector, after the Health Ministry in hospital beds capacity of the country. The other great problem in the private sector is that in the last years it has registered a significant descent in the margins of utility, which doesn't allow it to be developed appropriately.
Nursing Homes
For the economic sectors with more income, elderly adult’s private centers of attention are being established.
In the year 2001, in Lima officially existed 20 nursing homes. At the moment the number should be higher and it is very probable that some of them are not properly accredited. The lodgings can vary from 60 to 600 dollars monthly. These nursing homes are generally dedicated to the care, lodging and attention of the elderly adult with health problems that cannot be assisted by their relatives by some reason. Almost all the nursing homes are located in middle class neighborhoods.
6.6 ELDERLY ADULT POPULATION PUBLIC ATTENTION PROGRAMS
In the Peru exist public programs for the attention of the elderly adult of scarce resources, however, these, in most of cases, are inscribed inside integral programs of attention to the poor population that are developed by Woman's Ministry and Human Development (MINDES) and the Health Ministry (MINSA) dependent organisms, as well as for programs developed by provincial municipalities and districts of the country. Maybe the only exceptions constitute those denominated housings or homes that depend on the Charity Societies whose activity almost exclusively is concentrated in the needy elderly adult's attention.
6.6.1 Family Well-being National institute (INABIF)
The Family Well-being National Institute is a decentralized public organism that belongs to the Woman's and Human Development Ministry that carries out promotional preventive actions directed to the population in social risk. The elderly adult population attention is in charge of the Family Promotion Direction that also assists adolescents, women and adults in poverty situation, through family promotion centers. The service offered to the elderly adult population is made through Elderly Adult's Clubs, by means of biohuertos productive courses, labour-therapy courses, literacy promotion, health prevention; motivation and cultural courses, and alimentary support.
The Population in Risk Development Direction is responsible for (asylums, housings) distributed at national level. They assist the population that doesn't have family, or that for diverse reasons (generally economic or of incompatibilities that affect the coexistence) doesn't have a housing or minimum comfort or attention.
The main housings or asylums for the elderly adult of Lima city depend on the Public Charity Society, a decentralized organism of the Woman and Human Development Ministry that have been experiencing an increment in the demand of services. In 1998 the elderly adult population residents ascended at 673; in 1999, to 794 people and in the 2000, 802 elderly adult already resided in the group of housings administered by Lima Public Charity (Canevaro, San Vicente of Paul Geriatric Home and outlying housings).
6.6.2 Feeding programs
The feeding and nutrition programs in our country are in their majority in charge of five institutions that belong to the MIMDES; these programs are not directed specifically to the elderly adult population:
• PRONAA National Alimentary Support Programs • PRO MARN Nutrition and Feeding Program for the Minor • PREDEMI School breakfasts and Micro-nutrients Deficiencies • PANFAR Family in Risk Feeding and Nutrition • PACFO Alimentary Complementation for Groups of more Risk
The MINSA is in charge of the TBC Patient and Family Feeding and Nutrition Program, while the local governments are in charge of the Milk Glass Program. The proliferation of programs seems an administration problem, for the quantity of operators for a similar objective population, creating in this way overlapping in the action of alimentary support.
The Elderly Adult Population of scarce resources benefits from the PRONAA alimentary attendance programs in popular dining rooms. When they suffer tuberculosis, they benefit from the Feeding and Nutrition Program for TBC Patient and Family; when they reside in rural areas of extreme poverty through the program of the Milk Glass, although this last program prioritizes the attention to children from 0 to 6 years and pregnant mothers.
6.6.3 Development Compensation Fund (FONCODES)
The Development Compensation Fund (FONCODES) is a decentralized autonomous organism dependant of the Woman's and Human Development Ministry. The different work areas and projects that FONCODES supports, are those linked to the construction and equipment of health centers and the health campaigns specially those directed to the elderly adult population. These programs must be executed by base organizations, rural or native communities, religious organisms seated in popular areas, non government organisms (ONG), municipalities and public organisms. FONCODES, the same as the PRONAA, carry out its activities generally by channel resources coming from international cooperation organisms.
6.6.4 Health Centers or municipal clinics
Other establishments that offer services of public health nature are the Health Centers or Municipal Clinics. However, due the limited resources of this Centers and Clinics; in most of the cases they only services offered are of ambulatory consultation and of smaller surgery. They don't have implemented departments or programs for the attention for the elderly adult population, except for sporadic campaigns for some special circumstance.
6.7 CIVIL SOCIETY AND INTERNATIONAL COOPERATION
The civil society in our country has been working in regard of the elderly adult population.
6.7.1 NON GOVERNMENT ORGANIZATIONS - ONG
Unofficially it is known that for the year 2001 in Peru existed more than 3,000 non government organizations (NGO), without ends of economical profits, inscribed in the juridical people register. However, the Technical Secretary of International Cooperation, SECTI (now APCI) has registered officially only 2,000 NGOs.
In the VI National Conference on Social Development (CONADES) was incorporated the aging dimension in the formulation of the civic strategies for the democracy, decentralization and development. Also it was developed the First National Forum on Aging.
For the year 2001, the 5 non government organizations considered as the most important operators of the social attendance and of development at national level programs, programmed a social programs investment of 166'470,592 New Soles (US $48 millions 392 thousand American dollars). The available information of these organizations doesn't specify differentiation for age group programs, but it is known that they prioritize the attention to children, women and families in risk situation.
The NGOs universe that works with and in favor of the elderly adults is not very wide yet. These institutions began their work, supporting people of lower resources initially; but with the pass of the time this NGOs had specialized in elderly adults.
Among the main NGOs that work with elderly adults, there are those associated to the Peru Consortium and the NGOs work table of elderly adults integrated by IPEMIN, Center Social Process, ACECO and Auquis of Ollantay, in which other institutions like the Vigencia Group are attributed.
The Aging Rural Net is integrated by CEPROM Huancayo, KAUSAY Huancavelica, CICCA AYLLU, National University of San Cristóbal of Huamanga and Agrarian National University of the Molina.
Institutions like PROVIDA PERU, the Consultant Labor Center of Peru - CEDAL are specialized in labor topics and of gender, urban and rural Services for women of low incomes - SURUMBI of Trujillo and organizations like the Young Christian Association (elderly Adult Programs), the Cantares Voluntary Association, Caritas of Peru (Lima’s elderly adult Program of Attention) and Christ's Home are developing an important work in particular in association to the churches, specially the Catholic Church.
Finally, other NGOs that work with elderly adults are APROUTED, APROMUC, CCCUNSCH, CEDINCO, Forging Identity, the Institute San Bartolomé, the Integral Health Table, SISAY and Voluntary Vicentinas.
The fundamental achievements are: - The development of certain specialization areas, as the jubilation, rights, ecology, environment and health programs. - The influence in the emergence and development of elderly adult’s organizations. - The recognition of this age group in the local organizations, as well as a higher sensitization toward the problem on the part of the members of the community. - The influence in the formation of elderly adults' nets at regional and district level, in Lima as in counties.
6.7.2 International cooperation
The international cooperation agencies are grouped in the International Cooperation Foreign Entities Coordinator - COEECI, constituted as civil association that acts as organized speaker of the foreign international cooperation entities before the Peruvian government.
Of 74 affiliated institutions to the COEECI, only 8 include among their objective population the elderly adult:
1. Cooperations and Sviluppo - CESVI Italy 2. Pharmacists without Frontiers - Spain 3. Health Unlimited - England 4. International Center for the Biological Control of Pest and Pathogens - it USES 5. Physicians of the World - France 6. Counselling Service Project - Denmark 7. Summer Institute of Linguistics - it USES 8. Terra Nuova, Voluntary Center - Italy
It is necessary also, to mention Help Age International that is a global net of organizations without ends of economical profits with presence in more than 70 countries. Their mission is to work with and for the elderly adults in disadvantage in the entire world so that they can achieve a lasting improvement in their life quality. In Latin America this organization works actively in Argentina, Chile, Bolivia, Peru, Colombia, Ecuador, Dominican Republic and Costa Rica. From the work of this net the elderly adult organizations and the NGOs that work in her, have been able to take important steps in the improvement of the life quality of this population sector.