Despite steady economic growth during recent years, health investment in Peru remains among the lowest in Latin America. According to the ECLAC, Peru had a per capita GDP of US$5,378.50 in 2010, but spent just 5.1 per cent of that on health. This lack of investment is especially felt in the poorer areas, where indigenous and Afro-Peruvian populations are predominant. These include the marginalized urban colonias around Lima and the rural communities along the Pacific coast, in the Andes mountains and in the Amazon rainforest. In these rural zones the ECLAC indicates that 56 per cent of the population is classified as poor, versus 18 per cent in urban areas.

Biases in services

According to MRG partner CEDET (Centro de Desarrollo Étnico), a study carried out by Peruvian human rights organizations in 2005 revealed that the government spends more than twice as much per person in service delivery to the more prosperous regions than in the poorer departments. The ECLAC data indicates that, in 2010, some 84.6 per cent of urban households had sewerage services versus 44 per cent in rural areas. Also in urban areas, 88.8 per cent had piped water compared to 38.4 per cent of rural homes, and electricity reached 92.1 per cent of urban homes but just 28.2 per cent in rural zones.

Inequality in health service access is reflected in the contrast between the maternal and infant mortality rates of the richer urban areas, compared to those with majority indigenous and Afro-Peruvian populations. According to the ECLAC, the maternal mortality rate in Peru during 2010 was 67 per 100,000 live births with infant mortality being 18 per 1,000 live births. Although these represent a considerable improvement compared to previous years, the positive change has mostly been limited to urban groups with higher incomes. According to CEDET, the rates of infant and child mortality continue to be especially high in indigenous and Afro-Peruvian communities where CEDET research indicates that 92 per cent of African descendants live below the poverty threshold.

Critics argue that in general there is a lack of a clear policy, appropriate financing and adequate service delivery to these populations, especially given their culturally specific health needs. The official focus is curative more than preventive, with an emphasis on reproductive health that ignores the non-reproductive and preventable illnesses that also affect women, including hypertension and diabetes.

CEDET further argues that adding to the economic challenges that impede access to proper health services for indigenous and Afro-Peruvian communities are the racism and discrimination connected to their cultural and ethnic identity. The perception of many indigenous women is that they are treated with contempt bordering on abuse in some health centres because they are poor and also come from indigenous communities. They complain that among the factors affecting treatment quality are that both rural and urban health staff do not bear in mind their beliefs and cultural practices.

For example, indigenous women in Andean communities have traditionally held that the best orientation for delivering babies is in the vertical position, or kneeling down, which they feel aids the functioning of abdominal muscles.

Nonetheless, CEDET points out that the vertical childbirthing of indigenous Andean women is routinely viewed with scepticism – and even ridiculed – by local health professionals, all of whom have been trained to follow western medical modalities.

As in other countries in the Americas, the situation is complicated by language. In Peru health professionals very rarely speak the languages of the indigenous communities they serve. Therefore, it is often impossible to explain the prescribed treatment or to obtain informed consent. This in turn promotes more anxiety and mistrust.

Traditional cures

For these reasons indigenous women prefer to use traditional medicine and to give birth at home. According to the PAHO almost 50 per cent of deliveries in Peru are conducted at home, mostly by traditional midwives or by family members. Of these some 83 per cent occur in rural areas. The PAHO studies also indicate indigenous women particularly prefer traditional midwives because they feel understood and respected by them.

According to CEDET, this indigenous cultural preference can produce added bureaucratic challenges. Some health centre personnel refuse to provide live-birth verification to indigenous babies born at home or whose parents have not been able to pay a punitive fine for not submitting to official prenatal control. Without this document, the child cannot receive the official birth certificate, which is needed to obtain national identity documents.

Peruvians without identity documents are deprived of a range of rights, among them – ironically – the right to join the national health insurance programme (introduced in 2002), which is mandated to provide free attention to all Peruvians who cannot afford to pay.

In recent years according to the PAHO, progressive medical trainers in Peru have been stressing the importance of cultural awareness, and paying more attention to the positive aspects of traditional medicine such as the extensive accumulated knowledge of herbal treatments.

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