Impact of frailty status on the cost of drugs and dietary supplements prescribed to nursing home residents: the SENIOR cohort.

BACKGROUND: The financial impact associated with drug consumption has been poorly investigated among frail subjects and, specifically, in nursing home settings. AIMS: To determine the association of the average monthly cost of the drugs and dietary supplements consumed by nursing home residents with their frailty status. METHODS: This is an analysis of the first follow-up year of the SENIOR cohort. All participants were classified into "frail" or "non-frail" categories according to Fried's criteria at baseline. Monthly bills from the pharmacy were analysed to determine the association between the average monthly cost of the drugs and dietary supplements consumed and frailty status. RESULTS: A sample of 87 residents (83.8 ± 9.33 years and 75.9% women) from the SENIOR cohort was included. The prevalence of frailty was 28%. The median number of medications consumed each day was 9 (6-12) (no difference between frail and non-frail subjects; p = 0.15). The overall median monthly cost was € 109.6, of which 49% was covered by Belgian social security and the remaining balance was paid by the patient. When comparing the drug expenses of the frail subjects and the non-frail subjects, the overall average monthly cost did not differ between the 2 groups (p = 0.057). Nevertheless, the expenditure remaining to be paid by the residents, after the Belgian social security intervention, was significantly higher among the frail residents (€ 65.7) than among the non-frail residents (€ 47.6; p = 0.017). CONCLUSIONS: Frailty status has an impact on the expenditures related to the consumption of drugs.

Cardiac rehabilitation availability and delivery in Europe: How does it differ by region and compare with other high-income countries?: Endorsed by the European Association of Preventive Cardiology.

AIMS: The aims of this study were to establish cardiac rehabilitation availability and density, as well as the nature of programmes, and to compare these by European region (geoscheme) and with other high-income countries. METHODS: A survey was administered to cardiac rehabilitation programmes globally. Cardiac associations were engaged to facilitate programme identification. Density was computed using global burden of disease study ischaemic heart disease incidence estimates. Four high-income countries were selected for comparison (N = 790 programmes) to European data, and multilevel analyses were performed. RESULTS: Cardiac rehabilitation was available in 40/44 (90.9%) European countries. Data were collected in 37 (94.8% country response rate). A total of 455/1538 (29.6% response rate) programme respondents initiated the survey. Programme volumes (median 300) were greatest in western European countries, but overall were higher than in other high-income countries (P < 0.001). Across all Europe, there was on average only 1 CR spot per 7 IHD patients, with an unmet regional need of 3,449,460 spots annually. Most programmes were funded by social security (n = 25, 59.5%; with significant regional variation, P < 0.001), but in 72 (16.0%) patients paid some or all of the programme costs (or ∼18.5% of the ∼€150.0/programme) out of pocket. Guideline-indicated conditions were accepted in 70% or more of programmes (lower for stable coronary disease), with no regional variation. Programmes had a multidisciplinary team of 6.5 ± 3.0 staff (number and type varied regionally; and European programmes had more staff than other high-income countries), offering 8.5 ± 1.5/10 core components (consistent with other high-income countries) over 24.8 ± 26.0 hours (regional differences, P < 0.05). CONCLUSION: European cardiac rehabilitation capacity must be augmented. Where available, services were consistent with guidelines, but varied regionally.

An Investigation of Factors Influencing High Usage of Medical and Long-Term Care Services in an Aging Society in Japan.

Medical and long-term care costs are increasing all over the world. In this study, we investigated the characteristics of groups with high cost of medical and long-term care to define targets for curbing social security costs. As a result, for the population covered by the National Health Insurance, a large portion of medical costs were incurred for mental disorders, malignant neoplasms, and lifestyle-related diseases. For those covered by the Late Elderly Health Insurance System, most medical costs were incurred for lifestyle-related diseases, femoral fractures, neurological diseases, mental disorders, pneumonia, malignant neoplasms, and Alzheimer's disease. From multiple regression analysis, the hospitalization days, use of advanced medical treatment, outpatient days, and high long-term care level influenced the increased costs. On the other hand, disease characteristics had only a very low effect. These findings suggest that the target population has complex medical and long-term care needs because they have multiple diseases.

Do beneficiaries' views matter in healthcare purchasing decisions? Experiences from the Nigerian tax-funded health system and the formal sector social health insurance program of the National Health Insurance Scheme.

BACKGROUND: Purchasing is a health financing function that involves the transfer of pooled resources to providers on behalf of a covered population. Little attention has been paid to the extent to which the views of that population  are reflected in purchasing decisions. This article explores how purchasers in two financing mechanisms: the Formal Sector Social Health Insurance Programme (FSSHIP) operating under the Nigerian National Health Insurance Scheme (NHIS), and the tax-funded health system perform their roles in light of their responsibilities to the populations. METHODS: A case study approach was adopted in which each financing mechanism is a case. Sixteen (16) in-depth interviews with purchasers and eight (8) focus group discussions with beneficiaries were held. Agency and organizational behavioural theories were used to characterise the purchaser-citizen relationships. A deductive framework approach was used to assess whether actions identified in a model of 'ideal' strategic purchasing actions were undertaken in each case. RESULTS: For both cases, mechanisms exist to reflect people's health needs in purchasing decisions, including quantitative and qualitative needs assessment, mechanisms to raise awareness of benefit entitlements and allow choice. However, purchasers do not use the mechanisms to effectively engage with and hold themselves accountable to the people. In the tax-funded system, weak information systems and unclear communication channels between the purchaser and citizens constrain assessment of needs; while timeliness of health information and poor engagement practices of Health Maintenance Organisations (HMOs) are the main constraints in FSSHIP. Inadequate information sharing in both mechanisms limits beneficiaries' awareness of entitlements. Although beneficiaries of FSSHIP can choose providers, lack of information on the quality of services offered by providers constrains rational decision-making and the inability to change HMOs reduces HMO responsiveness to beneficiary needs. CONCLUSIONS: Responsiveness and accountability to beneficiaries are undervalued by purchasers in both financing mechanisms. In the tax-funded system, civil society organisations can facilitate engagement and accountability of purchasers and the people. In FSSHIP, NHIS needs to provide stronger stewardship of HMOs to promote effective engagement with members. Furthermore, the NHIS should introduce mechanisms that allow FSSHIP members to choose their own HMO, which could encourage HMOs to be more responsive to members.

Israel's Long-Term Care Social Insurance Scheme After a Quarter of a Century.

Long-term care social insurance schemes exist in a number of countries, while the introduction of such schemes enjoys some support in others. Israel's long-term care social insurance scheme has been operating since 1988. This article examines the emergence, goals, design, and impacts of this scheme and draws out some of the lessons that can be learned from Israel's quarter century experience of long-term care social insurance.

[Medical Rehabilitation in Gastrointestinal Oncology]. / Onkologische Rehabilitation bei gastrointestinalen Tumorerkrankungen.

BACKGROUND: The demographic change of the human population comes along with an increasing aging, a rise of chronic diseases, particular carcinosis, as well as the need for prolonged working life times. This causes big challenges for the public health systems, primarily in the field of surgery. In this respect, oncological rehabilitation has an important supporting function. Its mission is to reintegrate the patient after surgery back into domestic, social and professional life. This article covers the most significant questions for rehabilitation of gastrointestinal oncology. PURPOSE: The aim of this study is to illustrate the legal foundations and routes to access oncological rehabilitation as well as to provide a survey of the contents of oncological rehabilitation with a special emphasis on gastrointestinal tumours. METHOD: We surveyed experience in clinical rehabilitation by means of an appropriate literature search. Key Findings and Conclusions: Oncological rehabilitation is anchored in social legislation. The terms of reference are different from those of an acute hospital. Apart from the treatment of numerous specific somatic problems, both psycho-oncological care and social-medical consultation and evaluation are centrally important tasks.

Estimating medical costs of work-related diseases in the Basque Country (2008).

OBJECTIVES: To estimate the medical costs of work-attributable diseases (WAD) treated by the public health care system for one of the Spanish Autonomous Communities, the Basque Country, in 2008. METHODS: We calculated the burden of disease attributable to work for each category of diseases according to ICD-9-CM by using estimates of attributable fractions. Hospital and specialized outpatient care cost data were derived from the Spanish National Health System analytical accountability system. Secondary sources of information were used to estimate primary health care and drug prescriptions. RESULTS: Direct costs of work-attributable diseases borne by the Basque Regional Health Service totalled 106 million Euros in 2008, representing 3.3% of Basque public expenditures on health and 0.16% of Basque GDP in 2008. Specialized care, including hospitalizations, absorbed the highest proportion of costs (52%), followed by drug prescriptions and primary health care (27% and 21%, respectively). Diseases of the musculoskeletal system and connective tissues accounted for 47.3% of total costs, followed by cardiovascular diseases (19.6%) and cancer (15%). CONCLUSIONS: Occupational diseases and accidents are costly in the Basque Region of Spain, generating a severe deviation of public expenditures and overburdening of the Public Health System because they should really be the responsibility of the Social Security System. Proper identification and assignment of costs of work-related diseases would result in significant savings for the National Health System (Spanish and European), would provide an incentive for the prevention of these avoidable causes of illness and thus contribute to the sustainability of social systems.

[Integrated headache care network. Kiel Migraine and Headache Center and German National Headache Treatment Network]. / Sektorenübergreifende schmerzmedizinische Versorgung. Schmerzklinik Kiel und bundesweites Kopfschmerzbehandlungsnetz.

Migraine and other headaches affect 54 million people in Germany. They rank among the ten most severely disabling complaints and the three most expensive neurological disorders. Nevertheless, they are not adequately recognized in the healthcare system with sketchy diagnoses and inadequate treatment. This inadequate care is not primarily due to a lack of medical and scientific knowledge on the development and treatment of headaches but is predominantly due to organizational deficits in the healthcare system and in the implementation of current knowledge. To overcome the organizational barriers the national headache treatment network was initiated in Germany. For the first time it allows national cross-sectoral and multidisciplinary links between inpatient and outpatient care. A hand in hand treatment programme, better education, better information exchange between all partners and combined efforts using clearly defined treatment pathways and goals are the basis for state of the art and efficient treatment results. The treatment network is geared towards the specialized treatment of severely affected patients with chronic headache disorders. A national network of outpatient and inpatient pain therapists in both practices and hospitals works hand in hand to optimally alleviate pain in a comprehensive cross-sectoral and multidisciplinary manner. For therapy refractive disorders, a high-intensive supraregional fully inpatient treatment can be arranged. This concept offers for the first time a nationwide coordinated treatment without limitation by specialization and bureaucratic remuneration sectors.

Mindfulness therapy for somatization disorder and functional somatic syndromes: analysis of economic consequences alongside a randomized trial.

OBJECTIVE: The objective of the present study is to estimate the economic consequences of somatization disorder and functional somatic syndromes such as fibromyalgia and chronic fatigue syndrome, defined as bodily distress syndrome (BDS), when mindfulness therapy is compared with enhanced treatment as usual. METHODS: A total of 119 BDS patients were randomized to mindfulness therapy or enhanced treatment as usual and compared with 5950 matched controls. Register data were analyzed from 10years before their inclusion to 15-month follow-up. The main outcome measures were disability pension at the 15-month follow-up and a reduction in total health care costs. Unemployment and sickness benefit prior to inclusion were tested as possible risk factors. RESULTS: At 15-month follow-up, 25% from the mindfulness therapy group received disability pension compared with 45% from the specialized treatment group (p=.025). The total health care utilization was reduced over time in both groups from the year before inclusion (mean $5325, median $2971) to the year after inclusion (mean $3644, median $1593) (p=.0001). This overall decline was seen in spite of elevated costs due to assessment and mindfulness therapy or enhanced treatment as usual. The BDS patients accumulated significantly more weeks of unemployment and sickness benefit 5 and 10years before inclusion (p<.0001) than the population controls. CONCLUSIONS: Mindfulness therapy may prevent disability pension and it may have a potential to significantly reduce societal costs and increase the effectiveness of care. Accumulated weeks of unemployment and sickness benefit are possible risk factors for BDS.

[Psychiatric polypharmacy: hazard through drug-drug-interaction and possibilities for prevention]. / Psychiatrische Polypharmazie: Risiken durch Arzneimittel-wechselwirkungen und mögliche Vermeidungsstrategien.

Psychiatric diseases and comorbidity have increased over the past years. Commonly used psychotropic drugs contain a high risk of drug interactions and adverse drug events (ADE). With a frequency of 10-12% psychotropic drugs are, among all pharmaceuticals, the most common cause of hospitalisation due to ADE. During a hospital stay the application of psychotropic drugs can also lead to adverse drug events--sometimes due to drug interactions. Currently, ADEs and drug interactions are the most frequent cause of death for in-patients (18% of all causes of death) with an overall mortality of 0.95%. As studies have shown, hospitals as well as insurers could save a considerable amount of resources by implementing a system with on-ward pharmacists, hereby reducing ADE and re-hospitalisation rates. In recent studies a large amount of current ADEs were rated as preventable. Patient impairment due to ADE is leading to an increase in liability cases with an expected 5% increase of compensation payments in 2011. To evaluate these ADE-related cases, a pharmaceutical assessment should be included in the expert trials, especially since a lack of awareness of medication errors is prevalent. When aiming towards a successful drug therapy, physicians must also consider that cheaper substances may often have an unfavourable drug interaction profile.

La última reforma del sistema general de seguridad social en salud Colombiano / The latest reform of the Colombian healthcare-related social security system

Objetivo El propósito de este ensayo es explorar y analizar los cambios y oportunidades generados con la reforma del sistema de salud colombiano, a partir de la ley 1438 del 2011. Métodos Para lograrlo se revisan documentalmente algunos temas pendientes desde la reforma introducida por la ley 100 de 1993 y los compara con la norma del 2011; también se contrastan con algunas estrategias de la salud pública inoperantes en la etapa de la reforma, bajo condiciones del modelo de mercado. Resultados Se discute esta segunda fase de la reforma en relación con el alcance del derecho a la salud, el acceso y la equidad global. Se reconoce el avance en temas importantes, como la igualación de los paquetes de beneficios, la atención primaria en salud, las redes integradas de servicios de salud, pero se discute su inoperancia para modificar aspectos medulares del sistema, como la sostenibilidad financiera y la lógica económica que se imponen sobre las estrategias mencionadas las cuales ven cercenada su capacidad de respuesta, en aras de mantener incólume el modelo de la ley 100 de 1993. Conclusión Finalmente, se esbozan los puntos cruciales necesarios a una gran reforma estructural del sistema de salud colombiano que se base en el derecho a la salud y en la equidad.

Objective This essay was aimed at exploring and analysing the challenges and opportunities arising from reforming Colombian law 1438/2011 dealing with the healthcare-related social security system. Methods Some outstanding issues from the reform introduced by Law 100/1993 were reviewed and then compared to the 2011 regulations; they were also contrasted (in market model conditions) with some public health strategies which were inoperative during the reform stage. Results This second reform phase was discussed in relation to the scope of the right to health, access and overall equity. Progress regarding important issues such as benefit package equalisation, primary healthcare attention, integrated healthcare service networks was recognised; however, its failure to change core aspects of the system was discussed, i.e. financial sustainability and the economic rationale imposed on the aforementioned strategies which curtailed its responsiveness to keep the model introduced by law 100/1993 intact. Conclusion The crucial points necessary for major structural reform of the Colombian healthcare system based on the right to health and equity were then outlined.

Catastrophic health expenses and impoverishment of households of patients with rheumatoid arthritis.

BACKGROUND: The cost of certain diseases may lead to catastrophic expenses and impoverishment of households without full financial support by the state and other organizations. OBJECTIVE: To determine the socioeconomic impact of the rheumatoid arthritis (RA) cost in the context of catastrophic expenses and impoverishment. PATIENTS AND METHODS: This is a cohort-nested cross-sectional multicenter study on the cost of RA in Mexican households with partial, full, or private health care coverage. Catastrophic expenses referred to health expenses totaling >30% of the total household income. Impoverishment defined those households that could not afford the Mexican basic food basket (BFB). RESULTS: We included 262 patients with a mean monthly household income (US dollars) of $376 (0­18,890.63). In all, 50.8%, 35.5%, and 13.7% of the patients had partial, full, or private health care coverage, respectively. RA annual cost was $ 5534.8 per patient (65% direct cost, 35% indirect). RA cost caused catastrophic expenses in 46.9% of households, which in the logistic regression analysis were significantly associated with the type of health care coverage (OR 2.7, 95%CI 1.6­4.7) and disease duration (OR 1.024, 95%CI 1.002­1.046). Impoverishment occurred in 66.8% of households and was associated with catastrophic expenses (OR 3.6, 95%CI 1.04­14.1), high health assessment questionnaire scores (OR 4.84 95%CI 1.01­23.3), and low socioeconomic level (OR 4.66, 95%CI 1.37­15.87). CONCLUSION: The cost of RA in Mexican households, particularly those lacking full health coverage leads to catastrophic expenses and impoverishment. These findings could be the same in countries with fragmented health care systems.

[The latest reform of the Colombian healthcare-related social security system]. / La última reforma del sistema general de seguridad social en salud Colombiano.

OBJECTIVE: This essay was aimed at exploring and analysing the challenges and opportunities arising from reforming Colombian law 1438/2011 dealing with the healthcare-related social security system. METHODS: Some outstanding issues from the reform introduced by Law 100/1993 were reviewed and then compared to the 2011 regulations; they were also contrasted (in market model conditions) with some public health strategies which were inoperative during the reform stage. RESULTS: This second reform phase was discussed in relation to the scope of the right to health, access and overall equity. Progress regarding important issues such as benefit package equalisation, primary healthcare attention, integrated healthcare service networks was recognised; however, its failure to change core aspects of the system was discussed, i.e. financial sustainability and the economic rationale imposed on the aforementioned strategies which curtailed its responsiveness to keep the model introduced by law 100/1993 intact. CONCLUSION: The crucial points necessary for major structural reform of the Colombian healthcare system based on the right to health and equity were then outlined.

Costs and added value of haemodialysis and peritoneal dialysis outsourcing agreements.

BACKGROUND: Despite the discrepancy in results from Spanish studies on the costs of dialysis, it is assumed that peritoneal dialysis (PD) is more efficient than haemodialysis (HD). OBJECTIVES: To analyse the costs and added value of HD and PD outsourcing agreements in Galicia, the medical transport for HD and the relationship between the cost of the agreement and the cost of consumables used in continuous ambulatory peritoneal dialysis (CAPD) with bicarbonate. METHODS: The cost of the outsourcing agreements and the staff was obtained from official publications. The cost of PD and medical transport were calculated using health service data for one month and extrapolating it to one year. The cost of CAPD consumables was provided by the suppliers. The added value was calculated from the investments generated for each agreement treating 40 patients. RESULTS: Expressed as patient/year, the mean costs for treatment were €21595 and €25664 in HD and PD, respectively. Medical transport varied between €3323 and €6338, while those of the CAPD agreement and consumables were €19268 and €12057, respectively. The added value was greater with the HD agreement, especially considering the jobs created. CONCLUSIONS: One cannot generalise that the cost of PD, which is significantly influenced by prescriptions, is lower than that of HD. It would be appropriate to review the additional cost to consumables in the CAPD agreement. The added value generated by dialysis agreements should be considered in future studies and in health planning. More controlled studies are needed to better understand this issue.

[Cost effectiveness of implantable cardioverter-defibrillators for patients who are at risk for sudden death in Argentina]. / Costo-efectividad del cardiodesfibrilador implantable en pacientes con factores de riesgo de muerte súbita en Argentina.

OBJECTIVE: To evaluate the cost-effectiveness and cost-utility of the cardioverter-defibrillator (ICD) among patients who are at risk for sudden death in Argentina, from three scenarios: public health, social security and private sector. METHODS: We developed a Markov model to evaluate the survival, quality of life and cost of the prophylactic implantation of an ICD, as compared with pharmacological therapy, among three different target populations according to clinical trials selected using a systematic review, and choosing epidemiological, effectiveness, resource use and cost parameters. A healthcare system perspective was adopted. A 3% discount rate was used. RESULTS: The use of the ICD was more costly and more effective than control therapy. The cohort with greater benefits was represented by MADIT I study, showing an incremental cost effectiveness rate (ICER) of $8,539 (dollar 2009) for public, $9,371 for social security and $10,083 for private sector. ICERs for secondary prevention population were $21,016, $22,520 and $24,012, and for MADIT II population were $17,379, $18,574 and $19,799. The analysis was robust to different deterministic and probabilistic sensitivity analyses, except for the cost of ICD and for battery life. CONCLUSIONS: The results varied considerably depending on the cohort and discretely according to the health system. ICD could be cost-effective in Argentina, mainly in the MADIT I patients.

[The cost of treatment of multiple sclerosis in Colombia]. / Costos de la esclerosis múltiple en Colombia.

OBJECTIVE: To estimate, according to the states of disease (remission or relapse) and her level of progression (EDSS), the cost of treatment of Multiple Sclerosis (MS) in Colombia. METHODS: From the perspective of the third payer, a cost study of MS was performed using two-way estimation techniques: a) "Top down" to estimate the costs during relapses from clinical registers of 304 patients; b) "bottom-up" to estimate the cost in remission from a questionnaire (Kobelt 2006) applied to 137 patients, located in different regions of Colombia. RESULTS: The mean of patient's age was 43,7 years and 73% of those were women. The mean annual cost per patient varied according to the disease phase, finding the highest value in Phase II (EDSS 3 - 5,5) with $ 50.581.216 COP (US$ 25.713) and the lowest one in Phase IV (EDSS 8 - 9,5) with $20.738.845 COP (US$ 10.543). The cost of Disease Modifier Drugs (DMD) represented 91.5% from the medial total annual cost of 1,2 and 3 phases. The participation of DMD was 58%.in the 4 phase. Indirect costs are minimal participation in all phases, except for 4 where increases at the expense of reduced consumption of DMD. Costs associated with the period of relapses of MS are low against the total cost, with an average cost of $ 2,433,182 COP ($ 1.237 USD). DISCUSSION: MS in Colombia is a disease with a behavioral pathology "high cost " to the social security system (SGSSS), generated mainly at the expense of their direct costs, which, even without including relapses, an aggregate amount of more than 75 times the annual premium cost of health insurance for Colombia ($ 430,488 COP) in the year under review (2008).

[The cost of diabetes in Latin America: evidence from Mexico]. / Costos de la diabetes en Amerrica Latina: evidencias del caso Mexicano.

UNLABELLED: The main objective was to identify economic burden from epidemiological changes and expected demand for health care services for diabetes in México. The cost evaluation method to estimate direct and indirect costs was based on instrumentation and consensus techniques. To estimate the epidemiological changes for 2009-2011, three probabilistic models were constructed according to the Box-Jenkins technique. Comparing the economic impact in 2009 versus 2011 (p< 0.05), there is a 33% increase in financial requirements. The total amount for diabetes in 2010 (US dollars) will be $778,427,475. It includes $343,226,541 in direct costs and $435,200,934 in indirect costs. The total direct costs expected are: $40,787,547 for the Ministry of Health (SSA), serving to uninsured population; $113,664,454 for insured population (Mexican Institute for Social Security-IMSS-, and Institute for Social Security and Services for State Workers-ISSSTE-); $178,477,754 to users; and $10,296,786 to Private Health Insurance (PHI). CONCLUSIONS: If the risk factors and the different health care models remain as they are currently in the institutions analyzed, the financial consequences would be of major impact for the pockets of the users, following in order of importance, social security institutions and finally Ministry of Health. Allocate more resources to promotion and prevention of diabetes will decrease the cost increase by decreasing the demand for treatment of complications.

[The health system of Nicaragua]. / Sistema de salud de Nicaragua.

This paper describes the health conditions in Nicaragua and discusses the characteristics of its national health system including its structure and coverage, its financial sources its physical, material and human resources the stewardship functions developed by the Ministry of Health the participation of citizens in the operation and evaluation of the system and the level of satisfaction of health care users. It also discusses the most recent policy innovations, including the new General Health Law, the decentralization of the regulation of health facilities and the design and implementation of a new health care model known as Family and Community Health Model.

[The health system of Honduras]. / Sistema de salud de Honduras.

This paper describes the health system of Honduras, including its challenges, structure coverage, sources of financing, resources and stewardship activities. This system counts with a public and a private sector. The public sector includes the Ministry of Health (MH) and the Honduran Social Security Institute (HSSI). The private sector is dominated by a set of providers offering services payed mostly out-of-pocket. The National Health Plan 2010-2014 includes a set of reforms oriented towards the creation of an integrated and plural system headed by the MH in its stewardship role. It also anticipates the creation of a public health insurance for the poor population and the transformation of the HSSI into a public insurance agency which contracts services for its affiliates with public and private providers under a family medicine model.

[The health system of Peru]. / Sistema de salud de Perú

This paper describes the health conditions in Peru and, with greater detail, the Peruvian health system, including its structure and coverage, its financial sources, its physical, material and human resources, and its stewardship functions. It also discusses the activities developed in the information and research areas, as well as the participation of citizens in the operation and evaluation of the health system. The article concludes with a discussion of the most recent innovations, including the Comprehensive Health Insurance, the Health Care Enterprises system, the decentralization process and the Local Committees for Health Administration. The main challenge confronted by the Peruvian health system is the extension of coverage to more than I0% of the population presently lacking access to basic health care.