Answer:
Family Planning for All
In 1995, after the implementation of the ICPD Programme of Action (under which Peru is a signatory) and with political support from the president, the Ministry of Health instituted a policy to provide free family planning products and services to all who wanted them. Donors provided 100% of Ministry of Health contraceptive commodities, as well as substantial technical assistance and resources for training; supervision; information, education and communication; and other program components. As a result, the Ministry of Health was able to direct its resources to expansion of family planning service delivery. In 1994, the Ministry of Health introduced an ambitious program (Salud Básica) to expand its network of primary health care facilities, whose services included family planning. The number of health posts, health clinics and health centers run by the Ministry increased by more than 50% between 1995 and 2000, and more than 10,000 medical and paramedical staff were added across the country. In addition, the legalization of female sterilization as a contraceptive method for all women in 1995 increased access to the method.8 Annual government spending on health increased from 59 soles (US$18) per capita during the early 1990s to 93 soles (US$29) per capita during the 1996–2000 period.5 As a result of both public-sector investments and donor support, the National Family Planning Program was delivering services through more than 6,000 facilities by the late 1990s.9
The expansion in service delivery and availability of free contraceptives in Ministry of Health facilities no doubt contributed to the increase in contraceptive prevalence from 41% to 44% between 1996 and 2000—Figure 2. Overall, women increased their use of modern methods from 27% to 32%, with the poorest women increasing their modern method use from 18% to 25% (Figure 3, page 178). In addition, the policy was responsible for the dramatic increase in family planning market share for the Ministry of Health, which rose from 59% in 1996 to 68% in 2000.10,11
At the same time, donors were beginning to reduce contraceptive commodity donations to the government of Peru,† potentially threatening the availability of contraceptives. In response, the Peruvian government earmarked funds for family planning in its annual budget in 1997 and agreed to begin purchasing contraceptives in increasing quantities. The government's first purchase, however, was not made until two years later, in 1999, when funding for contraceptives was actually allocated for the first time, enabling the National Family Planning Program to purchase contraceptives through the United Nations Population Fund's procurement mechanism.9
Between 1992 and 2000, a time in which Peru's public sector was assuming an increasingly dominant role in the family planning market, private providers found it difficult to compete with such widespread provision of free or highly subsidized products and services.12 The commercial sector's market share fell from 39% to 17% between 1992 and 2000. Between 1996 and 2000, the decline was driven primarily by a 50% drop in market share for pharmacies (from 16% to 8%).10,11 Total commercial sales of oral contraceptives and injectables decreased from 1.4 million units in 1995 to 1.1 million units in 1996—and continued to decline consistently until 2001.9
According to several studies, public-sector prices for temporary family planning methods are one of the major determinants of the use of commercial outlets for those methods.13–15 Their findings show that if high-quality contraceptive methods are available free of charge in Ministry of Health facilities, private-sector users are likely to switch to these outlets. From 1996 to 2000, the share of Ministry of Health clients made up of women in the three upper socioeconomic quintiles rose from 46% to 53%, while the share accounted for by women in the two lower quintiles decreased from 54% to 47% (Figure 4).‡ Use of pharmacies for contraceptive supplies declined from 17% to 7% among women in the middle quintile and from 23% to 13% among those in the upper middle quintile.10,11 In other words, women with the ability to pay were benefiting from public subsidies.
The 1995 policy expanded access to family planning and initially adopted the focus of the ICPD Programme of Action on individual women's needs, instead of population control. In 1996, however, Peru's family planning program returned to employing the targets it had used when first established.16 By 1999, the government had changed its service delivery strategy and renounced the use of targets and quotas; measures were put in place to improve quality of care, including procedures to ensure informed consent for female sterilization.8
