Missed opportunities for vaccination in Peru 2010-2020: A study of socioeconomic inequalities.

Background: Missed Opportunities for Vaccination (MOV) represent a major risk in the re-emergence of immunopreventable diseases. However, in the region, there are few published studies on MOVs using national databases such as demographic and health surveys (DHS). This study aims to describe the frequency and trends of MOVs for the first dose of vaccines against the leading causes of infant morbidity and mortality, their complete vaccination coverage, and trends in socioeconomic inequalities at the national and departmental levels for an 11-years period. Methods: Using DHS data from an 11-year period (2010-2020), we calculated frequencies and trends in MOVs of vaccines for the leading causes of child morbidity and mortality, estimated inequalities in MOVs using the Slope Inequality Index (SII) and conducted a spatial autocorrelation test to identify clusters of higher or lower inequality in MOVs at the national level. Findings: We found that, at the national level, greater inequality was concentrated in the wealthiest categories of each socioeconomic variable. We identified that departments with higher poverty rates concentrated higher levels of inequality in the MOVs in the lowest strata of the socioeconomic variables. In addition, we found that some departments with similar geographic and socioeconomic characteristics had spatially correlated levels of inequality on MOVs. Interpretation: These findings can help to identify the heterogeneity that exists in the distribution of MOVs among departments and socioeconomic strata, which would help to prioritize specific areas and subpopulations for national immunization strategies. Funding: No additional funding source was required for this study.

Peru - Progress in health and sciences in 200 years of independence.

Peru celebrates 200 years of independence in 2021. Over this period of independent life, and despite the turbulent socio-political scenarios, from internal armed conflict to economic crisis to political instability over the last 40 years, Peru has experienced major changes on its epidemiological and population health profile. Major advancements in maternal and child health as well as in communicable diseases have been achieved in recent decades, and today Peru faces an increasing burden of non-communicable diseases including mental health conditions. In terms of the configuration of the public health system, Peru has also strived to secure country-wide optimal health care, struggling in particular to improve primary health care and intercultural services. The science and technology infrastructure has also evolved, although the need for substantial investments remains if advancing science is to be a national priority. Climate change will also bring significant challenges to population health given Peru's geographical and microclimates diversity. Looking back over the 200-years of independence, we present a summary of key advances in selected health-related fields, thus serving as the basis for reflections on pending agendas and future challenges, in order to look forward to ensuring the future health and wellbeing of the Peruvian population. Resumen translated abstract: El Perú cumple 200 años de independencia en 2021. Durante estos dos siglos de vida independiente, junto con periodos sociales y políticos turbulentos, incluyendo un conflicto armado interno, hiperinflación y la inestabilidad política de los últimos 40 años, el Perú ha experimentado importantes cambios en su perfil epidemiológico con repercusiones directas en la salud de la población. En las últimas décadas, los indicadores de salud materno-infantil y de las enfermedades transmisibles muestran mejoría importante, pero el país se enfrenta de manera simultánea a una carga cada vez mayor de enfermedades no transmisibles y de salud mental. En cuanto a los sistemas de salud pública, se han realizado esfuerzos por aumentar la cobertura y calidad de la atención de salud en todo el país, apostándose en particular por mejorar la atención primaria. La ciencia y tecnología relacionadas con la salud también han mejorado, aunque si se quiere que la ciencia sea una prioridad nacional, son necesarias inversiones sustanciales. El cambio climático traerá importantes desafíos para la salud de la población, dada la diversidad geográfica y de microclimas del país. Para conmemorar los 200 años de vida independiente del Perú, presentamos un resumen de avances clave en diversas áreas y temas relacionados con la salud. Este repaso sirve como base para reflexionar sobre agendas y desafíos pendientes y futuros, con el fin de asegurar la salud y el bienestar de la población peruana en las próximas décadas.

Quality of stroke guidelines in low- and middle-income countries: a systematic review.

OBJECTIVE: To identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries. METHODS: We systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences. FINDINGS: We reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations. CONCLUSION: Guidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.

Vulnerable populations and the right to health: lessons from the Peruvian Amazon around tuberculosis control.

BACKGROUND: In 2014 the World Health Organization (WHO) launched the "End TB Strategy", setting new ambitious goals for elimination of tuberculosis (TB). In contrast with previous efforts to control TB, the new strategy adopted the protection and promotion of human rights in TB prevention and care as a core pillar. This mandated the development of national programmes that are sensitive to the characteristics of populations and responsive to structural factors that put people at increased risk of exposure to TB, limit access to good quality health services and make people more vulnerable to TB infection. Indigenous people living in the Peruvian Amazon have been identified as a TB vulnerable group by Peruvian health authorities. This article examines the barriers faced by indigenous people and rural settlers from the Peruvian Amazon in obtaining a TB diagnosis and appropriate TB treatment, through the principles of the human rights based approach of accessibility, availability, affordability, adaptability and quality, and thus provides evidence of the utility of such approach in Peru. METHODS: This is a qualitative study. We combined information from policy documents and legal regulations and in-depth interviews with health workers and health authorities. We used Atlas-ti to conduct a thematic analysis and identify interviewees responses to pre-defined topics. RESULTS: Despite having a strong legal framework to protect the right to health of indigenous people and people affected by TB, there are underlying structural factors contributing to delays in detection, diagnosis and TB treatment, which are mostly related to having a health system poorly prepared to provide care for people living in dispersed rural communities. This article shows the limited level of integration of the "End TB Strategy" principles in the Peruvian National TB Programme and identifies the weakness of the health system to improve health care provision for indigenous people and rural settlers from the Peruvian Amazon. CONCLUSIONS: Our study shows the need to go beyond developing a strong legal framework to ensure vulnerable populations such as indigenous people are able to realize their right to health. Governments need to allocate funds, improve training and adapt healthcare provision to the cultural, geographical, and social context of indigenous people.

Abortion Rights Legal Mobilization in the Peruvian Media, 1990-2015.

State and non-state actors engaged in disputes to expand and limit abortion rights have engaged in legal mobilization-in other words, strategies using rights and law as a central tool for advancing contested political goals. Peru, like other Latin American countries, has experienced an increase in abortion rights legal mobilization in recent years, including litigation before national and international courts. This paper centers on societal legal mobilization, or the legal mobilization that occurs outside the legislative and judicial branches and that includes strategies promoted by the executive branch, political actors, and non-partisan organizations and individuals. It presents an analysis of op-ed articles published in two national newspapers, El Comercio and La República, between 1990 and 2015. The paper argues that the media is also an arena where legal mobilization takes place and is not just a space influenced by legal mobilization. Rather, the media's agenda operates independently of legal mobilization in the legislature and the courts, and it determines whether certain issues receive coverage and the way these issues are framed.

TB in Vulnerable Populations: The Case of an Indigenous Community in the Peruvian Amazon.

This article analyzes the factors associated with vulnerability of the Ashaninka, the most populous indigenous Peruvian Amazonian people, to tuberculosis (TB). By applying a human rights-based analytical framework that assesses public policy against human rights standards and principles, and by offering a step-by-step framework for a full assessment of compliance, it provides evidence of the relationship between the incidence of TB among the Ashaninka and Peru's poor level of compliance with its human rights obligations. The article argues that one of the main reasons for the historical vulnerability of the Ashaninka to diseases such as TB is a lack of political will on the part of the national government to increase public health spending, ensure that resources reach the most vulnerable population, and adopt and invest in a culturally appropriate health system.

Epidemiology of road traffic incidents in Peru 1973-2008: incidence, mortality, and fatality.

BACKGROUND: The epidemiological profile and trends of road traffic injuries (RTIs) in Peru have not been well-defined, though this is a necessary step to address this significant public health problem in Peru. The objective of this study was to determine trends of incidence, mortality, and fatality of RTIs in Peru during 1973-2008, as well as their relationship to population trends such as economic growth. METHODS AND FINDINGS: Secondary aggregated databases were used to estimate incidence, mortality and fatality rate ratios (IRRs) of RTIs. These estimates were standardized to age groups and sex of the 2008 Peruvian population. Negative binomial regression and cubic spline curves were used for multivariable analysis. During the 35-year period there were 952,668 road traffic victims, injured or killed. The adjusted yearly incidence of RTIs increased by 3.59 (95% CI 2.43-5.31) on average. We did not observe any significant trends in the yearly mortality rate. The total adjusted yearly fatality rate decreased by 0.26 (95% CI 0.15-0.43), while among adults the fatality rate increased by 1.25 (95% CI 1.09-1.43). Models fitted with splines suggest that the incidence follows a bimodal curve and closely followed trends in the gross domestic product (GDP) per capita. CONCLUSIONS: The significant increasing incidence of RTIs in Peru affirms their growing threat to public health. A substantial improvement of information systems for RTIs is needed to create a more accurate epidemiologic profile of RTIs in Peru. This approach can be of use in other similar low and middle-income settings to inform about the local challenges posed by RTIs.

Patient perspectives on the promptness and quality of care of road traffic incident victims in Peru: a cross-sectional, active surveillance study.

BACKGROUND: Road injuries are the second-leading cause of disease and injury in the Andean region of South America. Adequate management of road traffic crash victims is important to prevent and reduce deaths and serious long-term injuries. OBJECTIVE: To evaluate the promptness of health care services provided to those injured in road traffic incidents (RTIs) and the satisfaction with those services during the pre-hospital and hospital periods. METHODS: We conducted a cross-sectional study with active surveillance to recruit participants in emergency departments at eight health care facilities in three Peruvian cities: a large metropolitan city (Lima) and two provincial cities (an urban center in the southern Andes and an urban center in the rainforest region), between August and September 2009. The main outcomes of interest were promptness of care, measured by time between injury and each service offered, as well as patient satisfaction measured by the Service Quality (SERVQUAL) survey. We explored the association between outcomes and city, type of health care facility (HCF), and type of provider. RESULTS: We recruited 644 adults seeking care for RTIs. This active surveillance strategy yielded 34% more events than anticipated, suggesting under-reporting in traditional registries. Median response time between a RTI and any care at a HCF was 33 minutes overall and only 62% of participants received professional care during the initial "golden" hour after the RTI. After adjustment for various factors, there was strong evidence of higher global dissatisfaction levels among those receiving care at public HCFs compared to private ones (odds ratio (OR) 5.05, 95% confidence interval (CI) 1.88-13.54). This difference was not observed when provincial sites were compared to Lima (OR 1.41, 95% CI 0.42-4.70). CONCLUSIONS: Response time to RTIs was adequate overall, though a large proportion of RTI victims could have received more prompt care. Overall, dissatisfaction was high, mainly at public institutions indicating much need for improvements in service provision.

[Coverage of the Emergency Health Care Law and the Compulsory Insurance against Road Traffic Crashes (SOAT)]. / Cobertura real de la ley de atención de emergencia y del Seguro Obligatorio contra Accidentes de Tránsito (SOAT).

OBJECTIVE: The aim of this study was to ascertain, from patients' perspective, the degree of knowledge and the actual coverage of the Emergency Health Care Law and the Compulsory Insurance against Road Traffic Crashes (SOAT). MATERIAL AND METHODS: A cross-sectional, active surveillance of emergency wards of selected health facilities in three Peruvian cities (Lima, Pucallpa y Ayacucho) was conducted. RESULTS: Out of 644 surveyed victims, 77% did not know about the law about provision of emergency health care (81% in Lima, 64% in Pucallpa y 93% in Ayacucho; p<0.001). Following the explanation of what this law entails, 46% reported to have received care according to the law specifications. As for SOAT, the health care related costs of 237 persons (37.2%) were not covered by any insurance scheme (74% in Pucallpa, 34% in Ayacucho and 26% in Lima: p<0.001). CONCLUSIONS: In this study, the lack of knowledge about the provision of emergency health care law was important, and the coverage of care was deficient as nearly half of participants reported not to be treated by one or more of the entitlements stated in such law. Road traffic injuriesrelated health care costs were not covered by any insurance scheme in one of three victims. Improvements on citizens’ information about their rights and of effective law enforcement are badly needed to reach a universal and more equitable coverage in the health care of road traffic-related victims.

Cobertura real de la ley de atención de emergencia y del seguro obligatorio contra accidentes de tránsito (SOAT) / Coverage of the emergency health care law and the compulsory insurance against road traffic crashes (SOAT)

Objetivo. Determinar, desde la perspectiva de los pacientes, el grado de conocimiento y de cobertura real de la Ley de Atención de Emergencia y del Seguro Obligatorio Contra Accidentes de Tránsito (SOAT). Materiales y métodos. Estudio transversal de vigilancia activa en los servicios de emergencia de establecimientos de salud (EESS) de tres ciudades del país con heterogeneidad económica, social y cultural (Lima, Pucallpa y Ayacucho). Resultados. De 644 encuestados, 77% negaron conocer la Ley de Atención de Emergencia (81% en Lima, 64% en Pucallpa y 93% en Ayacucho; p < 0,001). Luego de explicarles dicha ley, 46% del total respondió que fueron atendidos bajo los preceptos de la ley. Con respecto al SOAT; en 237 personas (37,2%) los gastos de atención no fueron cubiertos por un seguro (74% Pucallpa, 34% en Ayacucho y 26% en Lima: p < 0,001). De los que contaban con un seguro (SOAT u otro), pero cuya atención no fue cubierta por éste, la mayoría estuvo en Lima (70%), seguido de Ayacucho (30%) y ninguno en Pucallpa. La mayoría (94%) procedió de establecimientos públicos. Las razones incluyeron problemas administrativos (25%), vencimiento del seguro o morosidad en el pago (21%), invalidez del seguro en el establecimiento (18%), no disponibilidad de la póliza (18%), o no cobertura de las lesiones por el seguro (9%). En estos casos, los gastos fueron asumidos por el mismo paciente, familiares o parientes, el chofer o dueño del vehículo, el servicio social del EESS, u otras personas o instituciones. Conclusiones. En este estudio se observó un gran desconocimiento de la Ley de Atención de Emergencia, y una cobertura de atención muy deficiente, pues casi la mitad de atenciones no fueron brindadas de acuerdo a uno o más puntos establecidos por dicha norma.

Objective. The aim of this study was to ascertain, from patients' perspective, the degree of knowledge and the actual coverage of the Emergency Health Care Law and the Compulsory Insurance against Road Traffic Crashes (SOAT). Material and methods. A cross-sectional, active surveillance of emergency wards of selected health facilities in three Peruvian cities (Lima, Pucallpa y Ayacucho) was conducted. Results. Out of 644 surveyed victims, 77% did not know about the law about provision of emergency health care (81% in Lima, 64% in Pucallpa y 93% in Ayacucho; p < 0,001). Following the explanation of what this law entails, 46% reported to have received care according to the law specifications. As for SOAT, the health care related costs of 237 persons (37.2%) were not covered by any insurance scheme (74% in Pucallpa, 34% in Ayacucho and 26% in Lima: p < 0,001). Conclusions. In this study, the lack of knowledge about the provision of emergency health care law was important, and the coverage of care was deficient as nearly half of participants reported not to be treated by one or more of the entitlements stated in such law. Road traffic injuriesrelated health care costs were not covered by any insurance scheme in one of three victims. Improvements on citizens' information about their rights and of effective law enforcement are badly needed to reach a universal and more equitable coverage in the health care of road traffic-related victims.