PPEERRÚÚ –– IINNTTRRAA IIII

Inter-daily 3,30 3,50 5,50 6,80 3,60 4,60
31,70
Weekly 21,20 24,20 38,50 44,00 28,20 10,20
45,30
Sometimes 2,60 6,70 14,30 15,30 10,60
7,00
Didn’t practice 65,90 60,00 32,50 23,20 47,70 3,50
21,90
Women ( n = 23521) 6,20
61,40
Daily 4,50 4,20 10,40 9,10 5,20

Inter-daily 2,20 2,10 5,40 4,20 2,60

Weekly 13,10 13,70 30,80 31,70 15,60

Sometimes 2,10 5,30 8,00 8,80 4,90

Didn’t practice 78,10 74,70 45,40 46,20 71,70

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 Total Reference
study 33,00% Seclen, Segundo y col.
Men Women 33,00%
Lima, Ingeniería 32,10% 34,70% 21,80%
Piura, Castilla 35,10% 32,50%
San Martín, Tarapoto 33,30% 17,40%

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% 1998 –2000
Ucayali, Calleria 16,70% 10,70% Non published inform
Arequipa, Yanahuara 14,60% 9,70%
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

Place and population studies Prevalence Total Reference
Men Women 1,60% Zubiate, M y col
Lima 0,40%
Cusco 1,80% 1987
Pucallpa 5,00% Seclen, S
Piura 7,50% 1996
Lima 6,90% Seclen, S y col.
Chiclayo 7,60%
Lima 6,70% 1997
Piura 4,40% Sosa, J y col
Tarapoto 1,30%
Huaraz 2,90% 1996
Tumbes 1,40% Health Ministry, General
Tacna 1,30% Office of Epidemiology
Cusco
Lima, Comas 0,00% 1,90% 1998 –2000
Lima, Magdalena del Mar 8,00% 2,60% Non published inform
Huanuco, Huanuco 33,20% 22,10%
Ica, Parcona 45, 4% 51,00%
Ucayali, Calleria 4,10% 1,50%
Arequipa, Yanahuara 9,90% 4,60%
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

Place and population Prevalence Total Reference
Men Women 22.70% Seclen, Segundo y col.
Lima, Urbanización Ingeniería 47.20%
Piura, Castilla 20.40% 1997
San Martín, Tarapoto 10.60% Health Ministry,
Ancash, Huaraz General Office of
Lima, Comas 14.70% 13.00% Epidemiology

Lima, Magdalena del Mar 27.60% 16.00% 1998 –2000
Huanuco 17.30% 13.00% Non published inform
Ica, Parcona 49.70% 43.00%
Ucyali Calleria 32.50% 28.00%
Arequipa, Yanahuara 17.40% 16.20%
Source: OMS/OPS

Chart 4.33 Peru: Hypertrigliceridemia Studies

Place and Population Prevalence 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

Place and population Prevalence Reference
Men Women Total
Lima,Urbanización Seclen, Segundo y col.
Ingeniería 24.50% 21.70% 22.80%
Piura, Castilla 34.20% 38.00% 36.70% 1997
San Martín, Tarapoto 29.10% 12.50% 17.00% Health Ministry
Ancash, Huaraz 14.80% 20.40% 18.30% General Office of
Lima, Comas 17.50% 28.00% Epidemiology
Lima, Magdalena del Mar 18% 15.30%
Huanuco, Huanuco 10% 23.70% 1998 -2000
Ica, Parcona 24.80% 32.10% Non Published
Ucayali, Calleria 10.40% 25.30%
Arequipa, Yanahuara 16.90% 16.90%
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

Age Proper Over 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%
70% Incontinence
60%
50% Insomnia
40% Falls
30%
20% Acute Confusion
10%
Cognitive Impairment
0% (moderate-severe)*
Inmobilization
Geriatric syn1dromes Mayor depression**
n = 400 n*=312 n**=288
Pressure ulcers

Syncope

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

Cognitive Function 60 to 74 years More than 75 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
74.60% 50.00%
Normal 95.90% 91.80% 85.80% 82.10% 14.90% 14.60%
27.10% 27.10%
Slight Impairment 3.50% 4.80% 7.10% 6.00% 8.30% 8.30%

Moderate Impairment 0.60% 2.70% 7.10% 7.10%

Severe Impairment 0% 0.70% 0% 4.80%

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 Group Population %
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

16% 60 - 69
7% 47% years

30% 70 - 79
years

80 or +
years

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%
100,00%
TOTAL 132 895

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

Gender Social Activity
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 Arce, E
The third age: Retired Retired Pensioners - Workers wish to reach retirement
Worker Integration and
Health within the society Club age as lately as possible
and family
IPSS (now - Health negative state due to lack of

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 San Vicente de areas, but indifference toward the
Condevilla –San Martin Paul Asylum biological area.
de Porres - The lesser the age of the family
member and the closer blood
1987 Relative’s Biosocial Chávez, G relationship, more positive attitudes
1989 are seen
Factors that affect the - There is not association between
marital status and work of the relative
with the attitude toward the EA.

Isolation’s principal factor is the lack of
relatives that look for them

isolation of the elderly

adult

Socio-cultural Factors that Cuellar, M Community The majority of the EA are poorly
integrated to his/her family and
affect the integration of Sáenz, I Centromin community, the most important factors
Workers are age, gender, origin (Lima or
the elderly adult to his/her (Mining company) counties) and instruction level

community and family Outpatient Office The workers had wrong ideas and fear
about the aging process. The lack of
1991 Third age and elderly Huapaya, L knowledge about preventive measures
adult care knowledge for a healthy life determines incorrect
opinions about the elderly adult care. l
1995 Socio-economical and Huillca, D The workers don’t accept the idea of
cultural factors influence Mori, C being elderly adults
in the integration of the Quijada, R
retired military personnel The 62.8% presents a low integration
(more than 60 years old) level with his family and community.
to their family and The most important factors are:
community marital status, origin, previously
Geriatric Navy Center occupation, age, retired years, socio-
economical level. Factors that not
have influence: religion, residence
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

Year % of homes with elderly adults
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
17,70% 21,70%
Total 18,90% 17,20% 19,20%
24,80% 31,80%
Male Boss 17,20%

Female Boss 24,80%

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

Year Elderly adults Only with
Total with other another
members elderly
adults

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 185,801 9.22% Men Women
1’088,800 54.00%
Partner (non married) 501,349 24.87% 10.5% 6.0%
Married 58,883 2.92% 66.7% 40.4%
Widower 157,244 7.80% 14.4% 38.7%
Divorced 24,038 1.19% 5.4% 9.3%
Single 3.0% 5.6%
Don’t tell 100.00% ---- ----

TOTAL 2’016,115 100.0% 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
36
Costa Rica
Venezuela 54
Paraguay 57

Uruguay 65
Ecuador
Bolivia 111
126
Peru 129

00000 00H0e5al0th system po0si0tio1n00 00150

Health system global achievement

Chile 33
Colombia 41
Costa Rica 46
Uruguay 50
Venezuela
Paraguay 65
Ecuador 73

Peru 107
Bolivia 115
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% Health Ministry
3% Social Security
Army and Police
20% Private system

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

80 60 Hos pitalization
65
Outpatient
70 office

60 Rural
50 44 hos pitalization

40 23 18 Rural
12 outpatient
30 5

20 Social Security
US$105 annual
10

0
Health Ministry US$

28 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
4,6 4,9 4,7 4,7
% NGP Health Total Expense 4,4 12,9 13,0 12,7 12,1
Government General Health Expense, % of 11,6
the goverments total expense 43,1 48,3 47,2 51,9
Social Security Health Expenses, % the 43,0
government general health expense
Source: World Health Report 2003, Annex 5.

Graph 6.6 Health Public Expense, Perú 1990-1999

600 1992 1995 1998 1999
500
400
300
200
100

0
1990

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% 70%
80% 54%
60%
40%

20% 13% 30% 0

0% Demand%
Current expences% Primary health care centers

Administrative units Hospitals

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 58
160 2000
140
120
100

80
60
40
20

0
1988

Drug units selled by habitant

7,75 2,26
8 2000
7
6

5
4
3
2
1
0

1988

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

160 68 156 139
140 ESSALUD SANIDADES PRIVADOS
120
100

80
60 30
40
20

0
MINSA

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.

Tasa x 10.000 Hb.• 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
2
0

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
LIM
MACOQAQPL
LMATILADNACADCLCMA

PIU
TLPHAJSHUCPAACUUNUOCUUPAMYMANSMCNTRSAAJUAA

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 Direction Total Hospital Health Health
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
CALLAO 663 480 181 5
CUSCO 287 157 78 2
HUANCAVELICA 79 60 52
HUÁNUCO 186 13 57 6
ICA 312 75 53 54
JAÉN 67 215 30 44
JUNÍN 332 20 106 17
LA LIBERTAD 562 164 115 62
LAMBAYEQUE 204 347 50 100
LIMA II - (LIMA SUR) 768 128 303 26
LIMA III - (LIMA NORTE 1,338 318 305 147
LIMA IV - (LIMA ESTE) 631 811 149 222
LIMA V - (LIMA CIUDAD) 2,764 429 201 53
LORETO 156 2,554 46 9
MADRE DE DIOS 58 99 21 11
MOQUEGUA 91 28 62 9
PASCO 74 19 22 10
PIURA I (PIURA) 190 26 121 26
PIURA II (LUCIANO CASTILLO) 166 10 67 59
PUNO 295 75 105 24
154 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 1 80
80 InInsstittiututotes
70 17
60 PCHeCntcreonster PPueHsCtopsost
50
40
30
20

10 2

0

HoHsopsiptaitlaels

Health Ministry: Physician distribution by
health establishment

70 64

60

50

40
30 25

20 11

10

0 PCHeCntcreontser PPHuCepsotsot s

HosHpoistpailtealss

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

Consult Emergency Medicines X ray Laboratory Hospitalization Surgery Odontology Mobility to Death
other
x x x
x x x institution
x x x
Plan A x x xx x x x x xx
Plan B x x xx x x x x xx
Plan C x x xx x x x x xx
Plan D x xx
Plan E x x xx xx
Plan F x x xx x xx

xx

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 69
11 7 9 19
Ancash 1 11
21 46
Apurímac 1 1 19 26
2 1 8 10
Arequipa 1 2 4 10 16
5
Ayacucho 1 2 14
11 6 3 15
Cajamarca 1 2 58
3 1 1 69
Callao 1 13 1
13 4 9 14
Cusco 1 15 1 9 16
2 4 23 33
Huancavelica 45 4 2 7 16
3 12 42
Huánuco 1 1 46
2
Ica 1 12 34
22 13
Junín 1 14 17
2 2 11 18
La Libertad 1 13 7 15
1 6 11
Lambayeque 1 1 24
1 34
Lima 21 1 45

Loreto 1

Madre de Dios

Moquegua

Pasco

Piura 1

Puno 2

San Martín

Tacna 1

Tumbes

Ucayali

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: