SECCIÓN ESPECIAL Equidad en los sistemas de salud / SPECIAL SECTION Equity in health systems Investigación original / Original research Equity in health and health care in Peru, 2004–2008 Margarita Petrera,1 Martín Valdivia,2 Eduardo Jimenez,1 and Gisele Almeida 3 Suggested citation Petrera M, Valdivia M, Jimenez E, Almeida G. Equity in health and health care in Peru, 2004–2008. Rev Panam Salud Publica. 2013;33(2):131–6. ABSTRACT Objective. This study evaluates whether recent positive economic trends and pro-poor health policies have resulted in more health equity and explores key factors that explain such change. Methods. This study focuses on the evolution of measures of health status (self- reported morbidity) and use of health care services obtained from the 2004 and 2008 rounds of the Peruvian National Household Survey (Encuesta Nacional de Hogares). It concentrates on health inequalities associated with socioeconomic status and uses interquintile differences (gradient), concentration indices with and without needs-based adjustments, and decomposition analysis. Results. Findings show a low level of inequality in measures of health status, with a slightly pro-poor inequality in self-reported health problems and a slightly pro-rich inequality in self- reported chronic illness. Inequity in the use of curative services declined significantly between 2004 and 2008, while inequity in the use of preventive services increased slightly. Use of hospital and dental services remained unchanged during the same period. Conclusions. Limitations of self-reported morbidity measures probably underestimate the results of health inequalities across socioeconomic groups. Improved equity in the use of curative health services can be explained by a number of positive factors that occurred concurrently during the analysis—namely, increased mean household income, reduced economic inequality, the Juntos conditional cash transfer program, and gradual expansion of public health insurance, Seguro Integral de Salud (SIS). Given that SIS expansion is the main public policy for promoting health equity in Peru, it is crucial that future steps in expansion come with a strategy to isolate its contribution to health equity improvements from that of other positive socioeconomic trends. Key words Health inequalities; health insurance; Peru. According to the latest population with 76% of the population already living due to an increase in private investment), census, in 2007 the population of Peru in urban areas. By 2004, the beginning of which strengthened its public finances reached 28.2 million, with a growth rate the period of analysis, Peru’s per capita and attracted foreign investment (2). The that decreased from 2% between 1981 and gross domestic product was US$ 2 559 average gross domestic product growth 1993 to 1.6% between 1993 and 2007 and and was categorized by the World Bank rate reached 6.8% between 2002 and 2008. as a lower-middle-income country (1). Although the growth rate fell to 0.9% in 1 Consorcio de Investigación Económica y Social, Observatorio de la Salud, Lima, Peru. But the beginning of the 21st century rep- 2009 because of the world economic crisis, 2 Grupo de Análisis para el Desarrollo, Lima, Peru. resents one of the greatest periods of eco- it recovered quickly as it grew 8.8% in 3 Pan American Health Organization, Washington, nomic growth in the history of Peru, led 2010, one of the highest growth rates in D.C., United States of America. Send correspon- dence to: Gisele Almeida, [email protected] by exports and domestic demand (mainly Latin America that year. Rev Panam Salud Publica 33(2), 2013 131 SPECIAL SECTION • Original research Petrera et al. • Equity in health and health care in Peru, 2004–2008 This economic growth came with in- are politically and administratively au- tributions to cover informal and small creased employment and reduced pov- tonomous and are responsible for pro- business workers. The latter two are erty. In 2004, 48.6% of the population viding primary, secondary, and tertiary managed by SIS. was living in poverty, with 17.1% in health care services. The main funding Peru has historically had high levels extreme poverty. These rates dropped to source is still the treasury, although of poverty and socioeconomic inequal- 36.2% and 12.6%, respectively, by 2008. contributions of regional budgets have ity, including health inequalities. How- Although socioeconomic inequality, been increasing. MINSA maintains a key ever, recent positive economic trends as measured by the Gini coefficient of regulatory role. have started to show sizable reductions household per capita expenditures, also With SIS, health insurance enrollment in poverty rates and socioeconomic in- decreased during the period (3), rural– increased from 36.8% to 54.1% of the equality. At the same time, health poli- urban differences remain strikingly high, population between 2004 and 2008. SIS cies aimed at universal health insur- as more than 60% of the rural population is comprehensive public health insur- ance have been gradually implemented. remain poor. ance managed and financed by MINSA This study seeks to evaluate whether Health services in Peru are provided to expand health services for the poor. such positive socioeconomic trends have to the population through a network In practice, it provides health services also resulted in more health equity and of facilities from the public and pri- mainly for women and children under explore key factors that explain such vate sectors (4). Public sector services the age of 18, although the intention is change. include those of the Ministry of Health to gradually expand these services to (Ministerio de Salud, MINSA), Social the entire adult population. Formal em- MATERIALS AND METHODS Health Insurance (El Seguro Social de ployees and their families are covered Salud, EsSALUD), and the armed and by EsSalud, which is financed by payroll This descriptive study is based on police forces. Private sector services in- contributions; until 1996, it was known health and socioeconomic status indica- clude those provided by private clinics, as the Peruvian Social Security Insti- tors available in the National Household medical offices, and to a much lesser tute (Instituto Peruano de Seguridad So- Survey (Encuesta Nacional de Hogares, extent nongovernmental organizations cial, IPSS). EsSalud provides most of its ENAHO) in 2004 and 2008. The previ- and providers of traditional and uncon- health services through its own network ous study looking at inequalities in the ventional medicine. of facilities, including primary, second- use of health services in Peru dates back Health expenditures in Peru increased ary, and tertiary care. Formal employees to 1998 (4, 6). However, changes in the slightly between 1995 and 2005, from have the right to complement EsSalud questionnaire, especially in the period 4.5% to 4.9% of gross domestic prod- services by allocating a small fraction of reference for reports of illness events uct (5). However, per capita purchasing of their contributions to accredited pri- and utilization of health care services, power in health services did not im- vate health service providers (EPS). In between that year and 2003 did not al- prove because of a similar increase in the practice, EPS facilities have focused on low for constructing a comparable series health care and health maintenance price primary care, allowing workers and based on the following years of ENAHO. index. The public share of health expen- their families to avoid waiting lines, It is a nationally representative survey ditures increased from 25.2% to 30.7%, while EsSalud facilities remain the main that is applied continuously throughout as it channeled the contribution through source of secondary and tertiary care. the year every year and measures ex- EsSalud, private insurance companies, The Peruvian system allows the public tensive numbers of dimensions of well- and Health Services Entities (Entidades sector to provide special insurance ar- being of families in Peru. Every year, a Prestadoras de Salud, EPS), from 29% rangements to some of its employees, cross-sectional sample is interviewed; to 35.1%. In turn, the contribution of such as teachers and the armed forces. the sample size reached 20 866 dwellings out-of-pocket household expenditures The most important one is the health in 2004 and 22 640 in 2008. The question- decreased from 45.8% to 34.2%. subsystem associated with the Armed naire is answered by each member of the Three important processes related to Forces and the National Police, which household except children under age 5 public health have taken place in the provide health care to their members, and those who are not present at any country since the late 1990s: decentral- direct relatives, and workers through of the visits made by the surveyors. ization of the provision of public health their own health facilities. These fa- Table 1 presents key characteristics for services through regionalization, cre- cilities are financed mainly by public the sample in each year, showing no ma- ation and expansion of public health treasury funds and to a lesser extent by jor differences. insurance (Seguro Integral de Salud, member copayments. This study focuses on self-reported SIS), and recent legislation instituting The Universal Health Insurance Law morbidity and health service utiliza- universal health insurance. of April 2009 aims to eventually provide tion of adults (18 years or older). Self- The public health system, led by universal health insurance coverage to reported morbidity indicators include MINSA, operates at three levels: na- the entire Peruvian population through illness and accidents associated with the tional, regional, and local. The provision three basic mechanisms: contributive use of health services in the previous of health care services has largely been insurance (via payroll-based contribu- four weeks and diagnosis of a chronic transferred to regions as part of the de- tions and private payments), subsidized condition. Health service utilization is centralization process initiated in 2003.