This study makes an important contribution to the existing literature because it is one of few studies addressing factors associated with health insurance coverage in Peru. Prior studies have focused on examining the effects of increasing insurance coverage on access to services (34) and financial protection (15, 16), but they did not examine in detail determinants of insurance coverage. Moreover, with its narrow focus on women, our study expands the very limited literature on health financing and gender, highlighting coverage gaps specifically for women (18).
Our study confirmed almost all the expected associations indicated in Table 1, except for “Age”, where every increasing year of age made it more likely that the individual would have “Standard Insurance” and decreased the likelihood of them having SIS coverage.
Our findings reveal that in spite of the efforts made by government over the last few years, a relatively large proportion of women (about 25%) still has no insurance coverage and as such does not enjoy any financial risk protection in case of illness. This value is aligned with official population-based estimates, suggesting that following the introduction of SIS in the early 2000s, the proportion of uninsured people decreased from 57.7% in 2007 to 24.5% in 2017 (10), and in the case of women to around 22% in 2017 (35) The results from our study are consistent with national estimates, which reported that the proportion of uninsured women was lower (22.1%) compared with men (27.2%)(9). Based on these facts, we can conclude that women did not seem to suffer additional barriers to enrolling in a health insurance scheme, SIS in particular, compared to men.
Our findings are worrisome since they indicate that compared with other LAC countries such as Colombia, Brazil or Chile, where insurance coverage has reached 90% (36, 37), Peru still lags behind when it comes to securing social health protection via public channels. However, we must acknowledge that the information from these countries was not stratified and therefore may hide inequities in terms of gendered health access. Hence, these values might not be fully comparable with our current findings.
At first, this gap in coverage may appear surprising considering that SIS was launched with the specific intention of fostering progress towards UHC by increasing insurance coverage. Looking at the history of the scheme and its development over time, however, we note that SIS was a targeted scheme, specifically launched to ensure coverage of vulnerable populations working in the informal sector (not women per se) (6). Highlighting the existence of a positive association between SIS coverage and lower socio-economic status, lower education, rural settings and no current employment, our findings suggest that SIS was largely successful in reaching a considerable portion of the Peruvian population it intended to reach. However, contrary to our expectations, women living in urban settings were also less likely to belong to the “Standard Insurance” group. This may be due to increasing lower income settlements in cities, however further research is recommended to explain this result.
In our study, surprisingly, the uninsured women were neither necessarily the poorest and less educated, nor the best educated and richest; moreover, they represented the middle class of the population. These women also reported to be unmarried, had Spanish ethnicity, were more likely to reside in urban settings and had fewer or no children compared with insured women.
These findings might directly point at problems derived from fragmentation in health financing structures. As mentioned before, most LAC countries have decided to keep some level of fragmentation in the financing and organization of health systems, having a specific tax-financed insurance for the poor coexisting with a social health insurance for formal workers (2, 38). However, despite the increase of population coverage, the existence of multiple pools, each targeting a specific segment of the population, inevitably leaves some women more exposed to the risk associated with falling ill (39) and leads to inequities and inefficiencies in the region (40, 41).
One of the remaining challenges for the Peruvian Government in the coming years is to target this group of insured people, keep increasing population coverage and overcome inequities in the country (42). Therefore, they have introduced a special SIS insurance package which isn’t exclusively for the poorest, but also allows workers from the informal sector, who don’t necessarily live in extreme poverty, to enroll onto this insurance by paying small monthly fees and accessing the national physician and hospital network of the SIS. However, previous research has reported (2, 43) that in order to reduce inequities the focus should be on increasing quantities of pooled financing rather than having a fragmented health system. Authors have suggested that these are necessary conditions to keep progressing toward UHC in Latin America.
Methodological considerations
The key strengths of this study lie in its large sample size, the exclusive focus on women, and its analytical approach. Nevertheless, we must acknowledge several weaknesses. First, given that we relied on secondary data, our sample is limited to women of reproductive age (15-49 years old), hence not representing all women in the country. We cannot exclude the possibility that different, possibly lower, coverage rates would pertain to younger and older women, possibly due to gaps in their knowledge of their entitlements. Second, also because we worked with secondary data, we were forcibly limited to working with variables included in the original survey. For instance, we could not look at the role that distance to public offices and/or health facilities plays in shaping insurance coverage in Peru. Similarly, we had no information on household heads and hence could not relate women’s insurance status to that of their households.