Limitations of self-reported morbidity measures probably underestimate the results of health inequalities across socioeconomic groups. Improved equity in the use of curative health services can be explained by a number of positive factors that occurred concurrently during the analysis-namely, increased mean household income, reduced economic inequality, the Juntos conditional cash transfer program, and gradual expansion of public health insurance, Seguro Integral de Salud (SIS). Given that SIS expansion is the main public policy for promoting health equity in Peru, it is crucial that future steps in expansion come with a strategy to isolate its contribution to health equity improvements from that of other positive socioeconomic trends.

BackgroundEquity in access to health care among people living with HIV (PLHA) has not been extensively studied in Peru despite the fact there is significant social diversity within this group. We aimed to assess the extent to which health care provision to PLHA, including ARVT, was equitable and, if appropriate, identify factors associated with lower access.MethodsWe conducted a survey among adult PLHA in four cities in Peru, recruited through respondent-driven sampling (RDS), to collect information on socio-demographic characteristics, social network size, household welfare, economic activity, use of HIV-related services including ARV treatment, and health-related out-of-pocket expenses.ResultsBetween September 2008 and January 2009, 863 individuals from PLHA organizations in four cities of Peru were enrolled. Median age was 35 (IQR = 29–41), and mostly male (62%). Overall, 25% reported to be gay, 11% bisexual and 3% transgender. Most PLHA (96%) reported access to some kind of HIV-related health service, and 84% were receiving those services at a public facility. Approximately 85% of those reporting access to care were receiving antiretroviral treatment (ARV), and 17% of those not in treatment already had indication to start treatment. Among those currently on ARV, 36% percent reported out-of-pocket expenses within the last month. Transgender identity and age younger than 35 years old, were associated with lower access to health care.ConclusionsOur findings contribute to a better social and demographic characterization of the situation of PLHAs, their access to HIV care and their source of care, and provide an assessment of equity in access. In the long term, it is expected that HIV care access, as well as its social determinants, will impact on the morbidity and mortality rates among those affected by the HIV/AIDS epidemic. HIV care providers and program managers should further characterize the barriers to healthcare access and develop strategies to resolve them by means of policy change, for the benefit of the health service users and as part of the national response to the HIV/AIDS epidemic within a human rights framework.

RESUMENEl artículo tiene como objetivo ofrecer a los responsables de la rectoría en salud las reflexiones de política sectorial que se derivan del estudio de las Cuentas Nacionales de Salud (1995Salud ( -2014 del país. Si bien el país ha incrementado el gasto en salud del 4,4 al 5,2% del PIB, el «gasto de bolsillo de los hogares» constituye el 33% del total del financiamiento, lo que requiere modificar su composición. Se advierten problemas en la capacidad de respuesta del sistema de salud al mayor financiamiento y gasto público, que se vinculan a temas de rectoría y organización de la prestación. Si bien el aseguramiento se ha incrementado, las restricciones en la oferta impiden que las personas afiliadas a algún tipo de seguro puedan, en su gran mayoría, acceder a los servicios de salud. El cambio más importante en la gestión pública del gasto es la descentralización, mientras que en la gestión privada lo es la integración vertical de prestadores y aseguradoras, dando surgimiento a un agente nuevo: el inversionista en salud. Se concluye que el país se encuentra, todavía lejos de poder financiar la meta de universalización del acceso en salud. Las recomendaciones para mejorar el financiamiento, mancomunación y el gasto apuntan, casi simultáneamente, a generar un mayor financiamiento público y de la seguridad social dentro de una activa política de mejora de la eficiencia global e institucional del sistema, la que debe redundar tanto en mejores resultados sanitarios, como en la disminución drástica del gasto de bolsillo. Por tanto, el buen éxito de la función financiera está íntimamente relacionado con el buen desempeño de las funciones de rectoría y prestación. Palabras clave: Cuentas Nacionales de Salud, seguridad social.