The Politics of Health Sector Reform in Peru

Health sector reforms in Peru, despite nearly a decade of reform efforts, are best described as piecemeal. The reform project itself lacked a comprehensive vision, and the resulting policies often either conflicted with each other, or with the stated overall goals of health sector reform: “a reform with equity, efficiency and quality”. Major health indicators, moreover, show improvement in health status, but these improvements are not substantially different from improvements in non-reform, and even crisis periods of the health sector. The less than robust outcomes of health sector reform in Peru are the result of multiple political factors and processes. These factors fall in two primary levels: the level of national politics and that of the macro-political context. In the first level, one can trace competing interests and tactics among different political actors, including presidents, finance ministers, ministry bureaucrats, and leaders in civil society such as heads of health workers and labor unions. The behavior of these national players however, was influenced by a macro political context of regional trends toward economic and political reform, the related growing influence of International Financial Institutions (IFIs) on social sector reforms, and national and regional democratization. Yet, in spite of competing national interests and macro political factors, the politics of Peru’s health reform policy process was largely insulated within the bureaucracy. This insulated mode of policy-making led to conflict between policies in the implementation stage, and ultimately, the piecemeal character of Peru’s health reforms.

This paper provides an overview and analysis of the politics of Peru’s health sector reform process of the 1990s, thus tracing the variables and processes that led to the weak reform policies in place today. The paper begins with a general overview of the sector, including reform context, spending patterns, structure of the sector and basic health indicators. This is followed by an examination of the macro-political factors that influenced the reform process. I then shift to the national level politics involved, tracing the formulation of four major reforms. The last section of the paper comments on the politics of implementation, and how conflicts among policies at the implementation phase has affected the overall reform content and emphasis.