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Amnesty International April 2007

PERU

Denial of the right to maternal and child health

Illegal charges for health services

Elisabet lives in the rural community of Huitoto Murauy, in the Department of Loreto. Pregnant women and young children in this rural community, where most families live in poverty, are eligible for free health services under the Seguro Integral de Salud (SIS), a health scheme that operates a number of plans, including free access to health services for children under four and for pregnant women and new mothers who live in poverty. However, when Elisabet took her baby to a health centre in 2005, she was charged for the gloves used by staff, the transfer to the regional hospital and 665 nuevos soles (US$200) for seven nights in hospital.

Elisabet’s story is far from unusual in today’s Peru, despite measures introduced by the government to provide free maternal and infant health services to the poor. Several women told Amnesty International (AI) they had received similar requests for payment when they tried to get medical treatment for themselves during pregnancy or for their young children. According to a study carried out by the Pan American Health Organization and the Peruvian Ministry of Health, 40 per cent of pregnant women who should have been covered by the SIS had to pay for examinations at Ministry of Health facilities in 2002.

Zoila had to pay 15 nuevos soles (US$4.50) for an ultrasound scan. As her baby was in the transverse position, she had to go to hospital, where they made her pay for drugs and gloves.

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“They wanted to charge me for providing care for my one-year-old, because it was not an emergency.”

Women in Huitoto Murauy, Loreto Department, 2005

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Health insurance scheme for those in poverty

Free maternal and infant health care and help with medical expenses is available for the poor in Peru. This is means tested and is based on the individual’s ability to pay. However, in certain areas levels of poverty are such that the whole community is entitled to free medical care under the SIS. Yet lack of money continues to be one of the main reasons cited for not attending health centres.

In law, people covered by the scheme should have to pay only 1 nuevo sol (US$0.30) to join the scheme. No other payment should be asked of them. However, AI received numerous reports that people living in poverty are asked to pay medical costs.

Unequal access to health services

Ministry of Health statistics for 2002 showed that around 25 per cent of Peru’s population – some 6,500,000 people – did not have access to primary health care. For women and their babies – and especially those living in poor, rural areas – this denial of health services is reflected in infant and maternal mortality rates which are among the highest in the Americas region.

Although there has been a reduction in child and maternal mortality in recent years, the Ministry of Health stated in 2002 that this is because of improvements among higher income groups. Statistics for poorer communities show an increase in maternal and infant mortality rates.

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Legacy of armed conflict

Discrimination was one of the factors that fuelled the 20-year armed conflict in Peru and that today is reflected in the enormous inequalities which characterize Peruvian society. Women, and in particular Indigenous and peasant women in rural areas, suffered greatly during the conflict. Rape was used as a weapon of war and many women were targeted for other forms of torture and forcible recruitment for work or forced marriage. Years later, they continue to complain of mental and physical health problems, including reproductive health problems, caused by the violence to which they were subjected.

The Truth and Reconciliation Commission, set up after the end of the conflict in 2000, concluded in 2003 that persistent discrimination against poor, Indigenous and peasant communities was one of the factors which contributed to the cycle of violence during the armed conflict. The Commission observed that the veiled racism and contemptuous attitudes prevailing in Peruvian society meant that the deaths of thousands of Indigenous people in poor peasant communities went largely unnoticed and unremarked. In 2003 the Commission recommended that the authorities take urgent steps to address economic, social, ethnic and gender discrimination. While successive governments have made some positive steps in improving access to health care, much remains to be done.

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Breaking down the barriers

Most of the health centres visited by AI lacked accessible information about entitlements to health services, among both users and staff. As a result poor women and children are not able to access the services which should be available to them without charge.

People wanting to register for free medical treatment under the SIS have to fill in a complex and detailed questionnaire known as the Socio-Economic Evaluation Sheet (Ficha de Evaluación Socioeconómica, FESE). In urban areas once the form has been completed, social workers visit the applicant’s home to check the information. People living in poor and marginalized communities have experienced lengthy delays while these checks on their circumstances are carried out. During this time they cannot access free health care.

There is an urgent need to simplify the process and indeed some health professionals have taken initiatives such as using simplified forms that are more relevant to the

people they serve. Health professionals who spoke to AI also suggested that if information gathering could be integrated with the delivery of health care, for example with home visits, this would reduce the bureaucratic burden and speed up the process of registration.

Huánuco is one of the poorest departments in Peru; almost 80 per cent of people live in poverty and more than 60 per cent in extreme poverty. An initiative developed in 2005 by the National Health Directorate and the SIS office in Huánuco Department illustrates how political will and real engagement with local communities can break down the barriers to accessing free health services.

These authorities have recruited volunteers who have agreed to visit rural communities to provide inhabitants with information on the health insurance scheme and on the rights of users under this scheme. They also help local people to complete the necessary documentation to register.

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International human rights law

The Peruvian authorities have an obligation under international human rights law to safeguard maternal and child health. This includes ensuring that health services are equally distributed and that all women and children have equal access to them. The right to enjoy human rights without discrimination is a fundamental principle underlying international human rights law.

The right to health set out in the International Covenant on Economic, Social and Cultural Rights includes not only the right to timely and appropriate health care, but also to the underlying determinants of health, such as access to safe drinking water and adequate sanitation, food and housing, and access to information, including on sexual and reproductive health. According to the UN Committee on Economic, Social and Cultural Rights, this right to health also encompasses the right of peoples and communities to participate in making decisions about health provision.

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Key recommendation

• The Peruvian authorities should ensure that clear information about entitlements to free health services is made available in appropriate languages and formats and is distributed to all health facilities which serve low-income families. The procedures for identifying and registering those who are entitled to free health services should be reviewed and simplified to avoid unnecessary delays during the registration process.

For more information, see Peru: Poor and excluded women – denial of the right to maternal and child health (AI Index: AMR 46/004/2006) which was launched at the III National Conference on Health, Lima, Peru, in July 2006.

Amnesty International, International Secretariat,

Peter Benenson House, 1 Easton Street,

London WC1X 0DW, United Kingdom

www.amnesty.org

AI Index: AMR 46/006/2007