5. Proposal: Peru

Background

After Brazil, Mexico, Colombia, and Argentina, Peru is the fifth most populous country in Latin America. It is a multicultural, multilingual, and multiethnic country, with populations of 100,000 or more in 21 cities. Over the years, rural migration has increased the urban population from 35.4% of the total population in 1940 to an estimated 74.6% as of 2005. Over half of Peruvians live in poverty (all data from US State Dept). 



Current State of Maternal Health

While the Peruvian government has attempted to improve the overall healthcare system in Peru, challenges surround the issue of maternal and child health in the country. In 2008, the Peruvian government announced that improving maternal and infant health would be one of its priorities for social policy. The government also proposed that it would work to reduce maternal mortality to 120 in every 100,000 births by 2015. In comparison to wealthy nations where the maternal morality is only 9 in every 100,000 births, the maternal mortality in Peru is excessive considering the government advocates for the use of public health care.

 Statistics (from the 2010 Human Development Index)

 Life expectancy at birth
 73.7 (*2003-2008)
 Maternal morality ratio
 240 (maternal deaths per 100,000 live births)
 Births attended by skilled health professional
 73 (per 100)

Despite government promises, many pregnant women in Peru still lack quality healthcare. Often, this lack of quality healthcare falls along rich/poor, rural/urban lines. In fact, recent World Health Organization data show a vast difference in the health of rural women versus the health of urban women. Only 42.9% of rural women have a skilled birth attendant, compared to 89.1% of urban women. Furthermore, women in the poorest Peruvian women have 4 times less access to skilled care than the richest Peruvian women, demonstrating a steep wealth divide. These major tensions between rural and urban, rich and poor must be taken into consideration when implementing any health development project in Peru. See the recent WHO data below:


Some addition statistics on the rural/urban, rich/poor divide in Peru (from 2009 Amnesty Report):

  • 59.1 % of the communities covered by the 2007 national census of Indigenous Peoples did not have a health facility
  • In 2007, only 36.1 % of the women in the poorest sectors of society who gave birth between 2002 and 2007 stated that the last time they had given birth was in a health facility. The comparable figure for women in the richest sectors of society was 98.4 % (National Institute of Statistics and Information – INEI). 
  • Although only just over a third of Peru’s population lives in rural areas, the rural population makes up more than 57.7% of those living in poverty (National Institute of Statistics and Information, 2008)
Additionally, language, cultural, and financial barriers hinder efforts to improve the state of the maternal healthcare in Peru. For example, most healthcare workers in Peru speak Spanish, but over 5,000,000 people in Peru (particularly those who live in rural, poor areas) only speak Quechua, a native Andean language indigenous language. This language barrier has proven to be a major challenge, especially in regards to sharing information on services available to pregnant women. Furthermore, the language barrier is a serious issue for women who need to communicate possible implications related to childbirth to a health worker.

Clinics with clean health facilities and doctors have opened around the country, but cost of care still remains an issue. With the high rate of poverty, affordable care is an issue. International organizations, like USAID, have worked to tighten the gaps, by redistributing aid, which make healthcare unaffordable to Peru’s poor. 

 

Current State of Mobile Tech

 

In comparison to other South American countries, Peru has extremely low mobile penetration. In Peru itself, mobile use ranges from 102% in Lima to only 8% in poor areas of the country. Some statistics show that 94% of the population is covered, although these statistics are likely to be flawed.

 

Three companies dominate the mobile market in Peru. Telefonica and America Movil are the leading service providers, covering approximately 65% of the market. The third leader is Nextel who mainly provides service to companies. The telecommunications market in Peru, like those in most other parts of the world, focuses on growth in the country, specifically in Lima and rural area. The Peruvian government made plans to increase competition and expand mobile coverage, however, the aim is intended purely for market purposes and it seems unlikely that the increase will also increase coverage to the poor.

Current Organizations/Projects 


  • Wawanet uses text messaging via mobile telephones to enhance the health of mothers and infants by enabling them to receive customized advice on nutrition and potential problems during pregnancy.

  • Cell Preven: An interactive-computer system that uses cell phones and the Internet in order to lower STD rates in Peru.

  • Nacer: A phone- and web- based information and communication system for maternal and child health that allows health professionals in remote locations to communicate and exchange critical health information between themselves, medical experts, and regional hospitals. All reported data is recorded in a central database, and is available to health officials in real-time for analysis and decision-making. Health workers in locations without Internet connectivity can access the system using any phone (satellite, fixed-line, mobile, or community pay phone).

Recommendations

Given that there are several pilot mobile technology and maternal health projects already in existence in Peru, the potential for implementation and funding is strong. WaWaNet, which works to address maternal morbidity and mortality in the Callao Region, shows the most promise in using mobile technology to improve access to maternal healthcare, the quality of care, and provide it to low-income women. We thus propose that instead of attempting to create a new mobile phone and maternal health platform in Peru, we work with WaWaNet's existing infrastructure, knowledge, and connections. The recommendations below are therefore geared towards WaWaNet and the expansion of their programs. For more information on WaWaNet, check out their great blog.


WaWaNet's Project Goals


In collaboration with the Inter-American Development Bank, Mobile Citizen Program, Universidad Peruana Cayetano Heredia, the Health Region of Callao, Callao Regional Government and AED-Satellife, the WawaNet project aims to:

  • Develop an interactive computer-based system and a common mobile phone-based platform to support maternal and childcare among pregnant women.
  • Improve health services targeted at pregnant women, reaching women with information to prevent unnecessary deaths and complications.
  • Allow pregnant women to have higher levels of accessibility to the health system, and also enable health centers to improve patient monitoring through mobile technology solutions.
  • Seek empirical evidence of social and economic impact that can demonstrate the potential of mobile services

YouTube Video

WaWaNet's Strategic approach

  • Data collection
  • Health provider point of care support
  • Emergency medical response
  • Electronic medical records
  • Health provider tele-guidance (mentoring, training)
  • Client reminders
  • Prevention and health promotion - equipping clients with knowledge

WawaNet launched its pilot project in Callao, which is made up of six districts: Callao (Cercado) Bellavista, La Perla, La Punta, Carmen Reynoso League and the Ventanilla. Callao Region is the second most populated urban city of Peru, with an estimated 876,877 people. Callao has 53 health facilities that are managed by the State. According to the one of the project leaders, Dr. Walter Curioso, WawaNet seeks to develop a solution to the problems of maternal mortality in Peru, emphasizing that an improvement in the health of mothers and infants would also contribute to Peru’s attainment of the Millennium Development Goals.

Gaps in WawaNet and Potential for Expansion

Since WaWaNet just launched in August 2010, the impact has yet to be measured. However, WaWaNet targets a specific and small population of pregnant women in a region that is close to Lima, the capital city, making resources easier to obtain than for rural populations. If the WaWaNet project is successful in the Callao region, it should expand to reach not only rural populations, but the indigenous populations. The indigenous Quechua population has the least access to care and experiences language barriers with health workers. Once the impact and success of WawaNet is measured, WaWaNet should use its relationship with the IDP and Mobile Citizen program to fill the following gaps and obstacles:

Steps in Implementation

Step 1: Access WaWaNet’s impact and lessons learned. Examine areas outside of Callao with low-income pregnant women and nearby indigenous populations. Access mobile penetration in rural areas.

Step 2: Relationship-building

  • Local health professionals
  • Telecommunications companies
  • Peruvian government
  • Aid organizations
  • Local organizations
  • Local population

*Steps 2 and 3 should be simultaneous

Step 3: Obtain Resources and Funding for:

  • Health workers
  • Health facilities
  • Cell phones (mainly for indigenous populations)
  • Mobile Services: Two Possibilities:
    • Since telecommunications companies are profit-driven, work with the Peruvian government to use part of the tax from telecommunications companies to subsidize text messaging services for the poor.
    • Build relationships and partnerships with Telefonica and America Movil and come up with incentives or push for the companies to provide free short code text messaging for healthcare purposes.
  • Quechua language program for health workers
  • Training for health workers

Step 4: Implementation + Community-building, education, advocacy, and policy

Once the funding is secured, it is important to not only implement a solid program, but also to raise awareness about the program and what it can offer to low-income pregnant women. There may be capacity constraints, but the implementation of an advocacy campaign that focuses its attention on maternal healthcare and the resources available would be crucial for the Peruvian government to make better strides in providing access to quality healthcare to pregnant women. With enough funding and capacity, a local organization could implement the campaign.

 



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