In the last two decades, Peru has made significant progress in improving maternal and child health, although health inequities remain in rural areas and among indigenous populations. The epidemiological transition toward noncommunicable diseases poses challenges, as well. Peru’s health system is segmented, and it is comprised of public facilities administered by the decentralized Ministry of Health (Ministerio de Salud, MOH), the social security system, and the private sector, which accounts for 40 percent of spending. Established 10 years ago in parallel — al though uncoordinated — with the country’s decentralization reforms, the Comprehensive Health Insurance (Seguro Integral de Salud, SIS) has been Peru’s major effort to expand health coverage. The SIS aims to reduce economic barriers through the elimination of user fees for a package of services. Although its budget has been low, the SIS has played an important role in the reduction of maternal and child mortality. However, the improvements expected to the overall health system have not materialized. Meanwhile, when the decentralization process transferred funds and authority to the regions, it did so in a context of weak management capabilities, and it failed to clearly define the relationship between the national and regional governments. What is needed is a substantial and sustained effort to improve coverage with a comprehensive approach — one that integrates national and regional health priorities but that allows for flexibility within networks and health facilities and establishes clear incentives as a means to achieve desired results. The SIS appears to be the best vehicle through which to achieve this approach, and it would be feasible to incorporate into it the “Health Strategies.” Indeed, the SIS has the advantages of a broad package and the use of instruments that provide greater administrative flexibility, and it has the potential to use incentives. The inequity of basic care demands a special effort to improve the coverage and effectiveness of care in rural areas, where one -quarter of Peru’s population lives. In these areas, it is necessary to integrate SIS efforts with adequate human resource policies. In Lima, where 30 percent of the country’s population lives, the challenge is no longer providing basic care, but rather responding to noncommunicable diseases through promotion, prevention, and early detection. To achieve this, the following strategies are necessary: (a) increased non communicable disease awareness; (b) integrated public health programs that are designed to address all stages of prevalent chronic diseases; and (c) a single purchaser, like the SIS, to procure services from multiple providers. A major effort to strengthen the technical capacity of the MOH should accompany the strategies outlined above. This effort should emphasize a review of health priorities, the design of effective interventions within a fiscally sustainable benefits package, and the introduction of incentives and new payment mechanisms
at hospitals and other health facilities.