Peru - Counting What Counts: Tracking Access to Emergency Contraception
Publication date: 2013
April 2013 ABOUT PERU Peru is the third largest and fifth most populated country in Latin America.1 It has a total population of 29,849,303, of which 14,975,195 are women. 77% percent of the total population lives in an urban setting compared to 23% in rural areas.2 Among women of reproductive age, the urban-rural divide is 74.6% by 25.4%.3 HEALTH IN PERU Peru has a universal health insurance program, Seguro Integral de Salud (SIS), which was rolled out in 2001 and designed to provide free maternal and child health, family planning, and preventative health care services to low-income citizens.4 In addition, the government-administered heath plan EsSALUD provides health coverage for workers and individuals who buy into it.5 As of 2009, 37% of the population was covered by SIS, 21% by EsSALUD, a very small percentage by private insurance, and approximately 40% of the population had no coverage.6 93% of individuals in urban areas had health insurance, compared to 59% in rural areas.2 CONTRACEPTIVE KNOWLEDGE AND USE POLICIES • Total fertility rate: 2.6 children per woman • Unmet need for contraception (among married women): 6.1% (5.5% Urban, 7.5% Rural) • Current contraceptive modern method use (among all women): 35.3% Source: Demographic and Health Surveys, Peru 2011. Country-wide restriction: Despite once being touted as a country in which emergency contraception (EC) was readily available,7 in the last several years the right to access EC in Peru has become extremely restricted in the public sector, while the commercial sector has grown tremendously. In 2009, Peru’s Constitutional Court issued a ruling that restricted EC access in several ways. First, it declared free (public sector) distribution of EC to be unconstitutional because it violated right-to-life protections.8 Second, local distributors were required to include a warning about the potential of EC to cause an abortion.9 In response, Peru’s Ministry of Health (MINSA) issued Resolution N° 167-2010/MINSA stating that EC was not an abortifacient, and cited supporting medical and scientific evidence. The courts once again interfered and ruled that No. 167 was PERU KNOWLEDGE AND EVER USE OF MODERN CONTRACEPTION AND EC 0 20 40 60 80 100 ECAny Modern Method Knowledge Ever Use % o f A ll W om en Type of Contraception 99.4 68.5 72.7 10.1 Source: Demographic and Health Surveys, Peru 2011. Peru has a wide array of EC products that are available in the private sector, mainly in pharmacies. However, recent government regulations prohibit the distribution of EC in public sector facilities. Despite these restrictions, knowledge and use of EC are among the highest in the world according to demographic surveys. Peru exemplifies the importance of a robust commercial sector in the face of policy barriers, but poor women still need better access to EC through public health systems. Pe ru COUNTING WHAT COUNTS: TRACKING ACCESS TO EMERGENCY CONTRACEPTION Pe ru 2 unconstitutional, forcing MINSA to issue Resolution N° 652-2010/MINSA in August 2010 prohibiting free distribution of EC in the public health care system. Resolution N° 652-2010/MINSA was officially published in May 2011 detailing the implementation and new rules necessitated by the restriction. Essential Drug List: The 2010 EDL includes levonorgestrel at the proper dose for EC.10 National norms and guidelines: The current status of EC distribution in the public family planning guidelines is unclear. As of the late 1990s and early 2000s, EC was in the guidelines and being distributed.11 In 2009 Population Council reported that EC was readily available in Peru.7 However, changes to the guidelines have most likely occurred in the wake of the 2010 decision to restrict EC access in the public health system. Prescription status: While a prescription is officially required, it is unclear how stringently this requirement is implemented by private sector pharmacies. Post-rape care: Ministerial Resolution N° 652-2010 prohibits EC from being distributed through public sector clinics. However, there is a stipulation that victims of sexual violence should be offered EC8 – how this is conducted and whether it means EC is stocked at public sector clinics is unknown. PRODUCT AVAILABILITY Registered products: There are over 40 brands of EC registered currently, many of which are generic brands. Due to Peru’s drug regulation policies, which help facilitate the development of generic drugs, brands enter and leave the market frequently. Locally manufactured products: Multiple EC products manufactured locally and regionally are on the market. Poor quality or counterfeit EC products: Though not specific to EC, Peru has been cited as a country lacking in strong enforcement mechanisms for intellectual property rights and as a site for the manufacturing of counterfeit pharmaceuticals.12 Since 2010, Peru has created a National Strategic Plan to combat counterfeiting and piracy.13 Many of the EC products on the market in Peru are of unknown quality and have not received approval from a Stringent Regulatory Authority (SRA). WHERE WOMEN CAN ACCESS EC EC in the commercial sector: Multiple products are available in the vibrant commercial sector. As demonstrated by the rates of ever use of EC of around 12% of all women, sales are robust. EC in the public sector: Due to Ministerial Resolution N° 652-2010 EC is not available in public health facilities. Before the restrictions were put in place, there was an active distribution system, with 27,731 EC doses being distributed between January and September of 2009.8 EC in the NGO, social marketing and social franchising sectors: The organization APPRENDE was founded to promote and sell EC in Peru and began operations in July 2002 with the marketing and sales of Postinor-2.14 DKT’s 2011 Contraceptive Social Marketing Statistics Report cites that APPRENDE sold 292,036 units of EC in 2011, an increase from their 2010 numbers.15 Additionally, Instituto Peruano de Paternidad Responsable (INPPARES), the Peruvian national Member Association of the International Planned Parenthood Federation (IPPF), includes provision of EC in its affiliated clinics (1,657 clinics in 2010).16 Community-based distribution of EC: There is no community based distribution of EC. PROVIDERS There is support for EC in the Peruvian medical community. In 2006 the Pan-American Health Organization, the Peruvian Health College, and the Peruvian Health Academy issued medical opinions in support of EC, stating that EC was a contraceptive, not an abortifacient.8 The dean of the National College of Obstetricians was quoted in 2011 as being worried about the implications of the new ruling prohibiting distribution of EC in the public health system. MEDIA COVERAGE OF EC When Ministerial Resolution N° 652-2010 prohibiting distribution of EC in the public sector was officially published in May 2011, it was covered by La Republica17 and the online news site Spacio Libre.18 Spacio Libre reported on the implications of restricting contraceptive access and quoted the director of DEMUS (Estudio para la Defensa y los Derechos de la Mujer) expressing concern about the current and future governments’ violation of Peruvian women’s human rights. Additionally, La Republica Peru 3 This fact sheet has been prepared by the International Consortium for Emergency Contraception and represents the best information we have been able to gather. We welcome your input for future revisions. Please contact us at firstname.lastname@example.org. Visit our website at www.emergencycontraception.org for more information on EC. REFERENCES 1 US Department of State, http://www.state.gov/r/pa/ei/ bgn/35762.htm, accessed January 30, 2012 2 CIA World Factbook: Peru, https://www.cia.gov/ library/publications/the-world-factbook/geos/pe.html, accessed March 28, 2013 3 Demographic and Health Surveys, Peru 2011, http:// www.measuredhs.com/publications/publication- FR269-DHS-Final-Reports.cfm, accessed March 28, 2013 4 Charlotte Kristiansson, et al. Access to health care in relation to socioeconomic status in the Amazonian area of Peru. International Journal for Equity in Health, 2009 Apr 15; 8:11. 5 Ewing, Christina. Second-Wave Neoliberalism: Gender, Race, and Health Sector Reform in Peru. Penn State Press, 2010. 6 Peru: Country Program Evaluation for the World Bank Group, 2003-2009, http://books.google.com/books?id =RixYzMgJdL0C&pg=PA44&lpg=PA44&dq=peru+hea lth+insurance+system+world+bank&source=bl&ots=g Sv1dQv31z&sig=CLkuUaIqPP0AZfkDWMweVS7W0f4 &hl=en&sa=X&ei=-qNUUf_LCe_K4AO2pID4Aw&ved=0 CE8Q6AEwBTgK#v=onepage&q=peru%20health%20 insurance%20system%20world%20bank&f=false, accessed March 28, 2013 7 ECP Handbook: Introducing and Mainstreaming the Provision of Emergency Contraceptive Pills in Developing Countries. The Population Council, 2009. (http://www.popcouncil.org/pdfs/frontiers/Manuals/ FR_ECPHandbook.pdf) 8 Supplementary information on reproductive rights in Peru, scheduled for review by the pre-sessional working group during the 46th session of the Committee on Economic, Social, and Cultural Rights on May 23-27, 2011. (http://reproductiverights. org/sites/crr.civicactions.net/files/documents/ Supplementary-Info-Peru-CESCR-46th.pdf) 9 Below the Waist: Peru’s Highest Court Rules Against EC, http://belowthewaist.org/2009/10/ peru%E2%80%99s-highest-court-rules-against-ec/, accessed February 2, 2012 10 WHO National Medicines List, http://www.who.int/ selection_medicines/country_lists/PER_2010.pdf, accessed January 27, 2012 11 http://www.globalhealth.org/reports/text.php3?id=58, accessed January 27, 2012 12 The Difficult Fight Against Counterfeit Drugs, March 10, 2011. CBS News: http://www.cbsnews.com/2100- 18560_162-20040693.html, accessed January 30, 2012 13 http://infojustice.org/archives/2445, accessed January 30, 2012 14 Coe, Anna-Britt. Informing Choices: Expanding Access to Emergency Contraception in Peru. Center for Health and Gender Equity. (http://www.planetwire. org/files.fcgi/3269_Expanding_Access_to_Emergency_ Contraception_in_Peru.pdf) 15 DKT’s 2011 Contraceptive Social Marketing Statistics Report. DKT International, Washington DC, 2012. 16 Clinical Social Franchising: An Annual Compendium of Programs, 2011. The Global Health Group, UCSF. 17 La Republica – http://www.larepublica.pe/18-05-2011/ minsa-publica-rm-que-prohibe-se-distribuya-la-aoe, accessed February 3, 2012 18 http://www.spaciolibre.net/index.php/demus-rechaza- que-el-sector-salud-limite-entrega-de-una-de-las- variantes-de-la-aoe/ 19 RHInterchange – Peru Summary of Shipments. http:// rhi.rhsupplies.org/rhi/shipmentsummary.do, accessed March 28, 2013 covered the concerns of obstetricians regarding the future of EC in Peru, and cited the director of PROMSEX noting that the Yuzpe method could still be utilized despite the restrictions on dedicated EC. DONOR SUPPORT RHInterchange indicates that UNFPA purchased EC for Peru twice between 2000 and 2012.19 Given Peru’s relatively mature economy and robust commercial sector, donor support is probably less important than in other settings.