Peru: Slow, Steady Health Reform in a Weak State

Abstract

Chapter 5 focuses on health sector reform in Peru, which is a prototypical “weak state” in health. It is characterized by weak autonomy—no clear health goals, and weak capacity—little infrastructural, technical, and other ability to carry out health reforms, programs, and goals in the 1980s and beyond. Peru then is the case in which we expect the sharpest neoliberal shift, as it is most vulnerable to international pressures and social program cutbacks. Surprisingly, this case displays the opposite trend: the expansion of public health financing and coverage, though provision is sub-contracted, sometimes to private providers. This case spotlights the complexity of understanding what neoliberalism means for health. The relatively recent Seguro Integral de Salud (SIS) aims to create an overarching publicly regulated health insurance in Peru though many of the functions: provision, financing, and delivery are left to the private sector. Of the three cases, Peru also demonstrates most clearly the ways in which the logic of economic productivity and human capital are used to advance health. The World Bank, via its support of the precursors to the SIS—the maternal insurance and school children insurance instituted under Alberto Fujimori’s dictatorship—has played a key role in these reforms and seemingly supports the expansion of government provision of health insurance. The Peruvian case demonstrates that this extension is grounded in theories of human capital in the service of economic efficiency, and that it advances the government’s coordinating and regulatory role. This calls for a reconceptualization of neoliberal reforms that do not always reduce the role of the state, but rather transform it, together with the expansion of the role and presence of private providers. This chapter demonstrates, however, that even in a weak state movement toward universal care, albeit in a segmented way, is possible. Peru then embodies the paradox of the strength of weak states: the central apparatus cannot be entirely co-opted for neoliberal ends because it is too disorganized and segmented to co-opt, and shows the World Bank’s support of movements toward universal insurance.

“When there is an endogenous process, and from the outside they help, you channel that. I find it interesting, and indeed in Peru , there is a will, there is a need to extend social coverage, coverage of health to the most marginalized sectors… one of the most serious problems is the financing. Because the expansion of services, and the expansion of resources needs to be accompanied by an increase in funding, in a sustained manner.”

— interview with Dr. Manuel Jumpa Santamaría, then Head of the Office of Decentralization in the Peruvian Ministry of Health, formerly an official advisor to two Deputy Ministers of Health and a Minister of Health in 1991, 2001 and 2008 respectively on the problems facing the Peruvian health care system. (Interview #34)