Peru

Context

In the years since the cessation of violence of the 1980s and 1990s, Peru has experienced a period of relative political stability and sustained economic growth. Today, Peru is an upper middle-income country with an average annual growth of 5.6% over the past five years, a stable exchange rate, and low inflation.[1] Despite the high growth, there remain problems with economic disparity, notably 24% of the population lives in poverty.[2] While most health indicators have improved over the past decades (e.g. maternal, infant, and childhood mortality have decreased while life expectancy at birth has increased), striking differences in quality of care and access to care persist between urban and rural populations.

Cervical Cancer

Cervical cancer is the most common form of cancer in women and the second most common cause of cancer death for women in Peru.[3] Cervical cancer prevention services have been available in the country for almost 40 years, yet only 42.9% of Peruvian women receive regular screening.[4]

The TATI project, a collaboration between the Pan American Health Organization, PATH, and the National Cancer Institute in Peru (INEN) between 2000 and 2004, showed that VIA and cryotherapy can be safely, effectively, and economically incorporated into the primary health level.[5] However, cervical cancer prevention services have not been implemented in all regions of Peru. Since the study, INEN has trained trainers and health professionals in VIA and cryotherapy in some rural areas while promoting the continued use of cytology and, where possible, the introduction of HPV screening, in urban and higher resource areas. In 2012, the Federal Ministry of Health (MINSA) instituted Plan Esperanza, a national plan to prevent and treat cancer. The plan engages various government sectors to reduce morbidity and mortality from cancer. Though cervical cancer is a key component of the plan, MINSA has yet to publish its updated norms and guidelines. MINSA provides personnel, direct services, and finances in support of cervical cancer prevention, while clinical trainings and national oversight are implemented by INEN.

Coffee

Peru is the third-largest coffee grower in South America[6] and the eighth-largest producer in the world.⁶ Most coffee is grown on small-scale family farms by indigenous Peruvians.[7] Over the last decade, many of these farmers organized to create cooperatives, and now as many as 15-25% of coffee growers are members of an association or a cooperative.[8] Though not as affected as Central America, Peru has not been immune to roya, and the outbreak has damaged crops in Cusco, Junín, and San Martín. As a result, Peru’s 2013 exports were projected to be 25-30% lower than the previous year.[9]

The Cajamarca Region is an important area for coffee production and the location of many well-organized coffee cooperatives. After an initial visit in June 2012, Grounds for Health decided to collaborate with the coffee cooperatives CAC La Prosperidad de Chirinos and CENFROCAFE in the northern Cajamarca Region. In September 2013, the partnership was expanded to include coffee cooperative Sol y Café, and further expanded in September 2014 to include the coffee cooperative APROVAT.

Grounds for Health’s program activities focus on the rural districts of Chirinos, La Coipa, and Tabaconas in the San Ignacio Province of the Cajamarca Region. The four co-op partners include 4,148 producer households in these three districts. There are approximately 3,500 women in the target age group for screening from cooperative-member communities in Chirinos and La Coipa districts, and approximately 4,067 women in the target age group from all communities in the two districts. We do not have current census data for women in the target age group from Tabaconas District.

[1] CIA World Factbook. https://www.cia.gov/library/publications/the-world-factbook/geos/pe.html. Accessed Oct 21, 2014.
[2] World Bank Country Data: Peru. http://data.worldbank.org/country/peru. Accessed Oct 21, 2014.
[3] Globocan 2012. Peru Fact Sheet. http://globocan.iarc.fr/Pages/fact_sheets_population.aspx. Accessed Oct. 21, 2014.
[4] WHO/ICO Information Centre on HPV and Cervical Cancer. Peru, HPV and related cancers, fact sheet 2013. January 21, 2014. http://www.hpvcentre.net/statistics/reports/PER_FS.pdf. Accessed Oct 21, 2014.
[5] Cervical Cancer Prevention in Peru: Lessons Learned from the TATI Demonstration Project. Silvana Luciani, PAHO, and Jennifer Winkler, PATH, 2006. http://www.paho.org/english/ad/dpc/nc/pcc-cc-tati-rpt.htm#3. Accessed Oct. 8, 2012.
[6] Bloomberg. Peru 2013 Coffee Exports Tumble as Demand Declines, Chamber Says. http://www.bloomberg.com/news/2013-07-02/peru-2013-coffee-exports-tumble-as-demand-declines-chamber-says.html. Accessed October 21, 2014.
[7] Equal Exchange. History of Coffee in Peru. http://equalexchange.coop/history-of-coffee-in-peru. Accessed Oct 21, 2014.
[8] DE Foundation. Country Profile Peru. http://www.defoundation.com/country-profile-peru. Accessed Oct 21, 2014.
[9] Roast Magazine. Peru Coffee Output to Drop at least 25% from Roya Outbreak, Prime Minister Says. http://dailycoffeenews.com/2013/08/13/peru-coffee-output-to-drop-at-least-25-from-roya-outbreak-prime-minister-says/. Accessed Oct 21, 2014.

Since 2012, Grounds for Health has led 5 clinical trainings for local providers throughout the Jaén and San Ignacio Provinces of the Cajamarca Region of Peru. For each provider trained, the clinical education includes an initial training in VIA and cryotherapy paired with a 3 to 4-day campaign for clinical practice, a refresher training paired with a campaign, and a third campaign for further clinical practice and service provision. In addition to these trainings and campaigns, the providers practice VIA and cryotherapy in their own clinical settings (hospitals, health centers, and health posts) on an ongoing basis and are monitored monthly by Grounds for Health program staff.

The campaigns held so far have been located in three districts and recruited women from communities within those districts where our coffee cooperative partners have members: Chirinos (Program Year (PY) 2013), La Coipa (PY2014), and Tabaconas (currently underway in PY2015). Recruitment is coordinated by a network of Community Health Promoters trained by Grounds for Health in advance of each campaign and representing each of the co-op communities in these districts.

For each of the trainings, the local ministry of health authorities play a key role in selecting local providers to be trained by Grounds for Health, granting them permission to participate in the trainings and campaigns, establishing district-level treatment centers, and ensuring access to appropriate services for women requiring follow-up beyond treatment with cryotherapy. For the campaigns, the co-ops coordinate transportation for the women to and from the campaign site and provide overall logistical support. Beginning in PY2015, the co-ops also assumed responsibility for community visits and the selection of community health promoters, in most cases accompanying Grounds for Health staff to the individual communities where their respect and connections among coffee farmers help to engage the community and mobilize women to seek cervical cancer prevention services.

In PY2015, Grounds for Health is focusing its trainings and campaigns on the coffee cooperative communities in the Tabaconas District while simultaneously expanding its coverage within the three program districts. Until now, we have only trained promoters and organized campaigns in communities where our cooperative partners have members. To achieve coverage of prevention services and reduce cervical cancer, it is necessary to screen and treat women from all communities in the districts, not just the ones with co-op members. One approach already underway is to use the network of one of Grounds for Health’s funders, ECOM, to reach these communities. ECOM supports a network of coffee farmers in Peru through a program known as BioAzul and is willing to coordinate community outreach and mobilization in the BioAzul communities of Chirinos and La Coipa that have not been included in Grounds for Health programming thus far. Another strategy is to approach the local municipalities and seek their financial and logistical support in organizing community health promoter trainings and campaigns for the remaining communities in their districts. The Peruvian government has decentralized resources at the regional and local levels that can be accessed for health and social programs, making it a worthwhile avenue for Grounds for Health to explore partnerships and programmatic cost-sharing in order to achieve full coverage at the district level.

Annual Screening and Treatment Performance – Cajamarca, Peru

Since 2012, 4,487 women have been screened through Grounds for Health’s Peru program. A total of 443 women (9.9%) were identified with VIA positive lesions or abnormal Pap results, and 375 (85%) of these women were treated with cryotherapy. All women with positive screening tests who were not eligible for immediate treatment were either referred or advised to return at a later date, as appropriate.

Program Year (PY): October – September

Key Output Indicators – Cajamarca, Peru

Select practicing providers with the highest level of permanence possible at health centers and posts, and be willing to conduct replacement trainings based on provider turnover

During PY2013, Grounds for Health’s first year in Peru, the local ministry of health selected 12 providers to be trained in our first round of trainings. Of these providers, many held administrative posts and thus did not provide cervical cancer prevention services to women outside of the trainings and campaigns. To prevent this situation in future trainings and ensure that prevention services are being delivered on an ongoing basis, Grounds for Health became more involved in the process of selecting providers for training. Grounds for Health staff meet with the cancer control coordinator at the local ministry of health in advance of each training to ensure that selected providers deliver services regularly at health centers and posts in the districts served by our program.

The largest barrier to continuous service provision is the rotation of health personnel, which occurs on an annual basis in Peru based on provider productivity and other factors. Provider turnover is a common challenge in public health settings, and Grounds for Health does not anticipate solving this challenge on a policy level. Instead, we have chosen to address the challenge in two ways: (1) by selecting providers for trainings who are not in their intern year (a one-year placement post-medical school) but rather have more professional experience in their health centers and posts and are more likely to remain from year to year; (2) by using future trainings as an opportunity for replacement trainings in districts where there has been turnover of previously-trained providers.

Pursue local resources as an avenue for cost-sharing and other program and partnership opportunities

Early into the Peru program’s existence, it became clear that our local cooperative partners were enthusiastic about the program and willing to put time and financial resources into the partnership.. As a result, we quickly engaged the cooperatives in our conversations around community mobilization and established an expectation of their role and contributions to ensuring that cervical cancer prevention services are demanded at the community level. Their leadership and willingness to participate in this way has led to a high turnout during campaigns and the highest local coverage that Grounds for Health has achieved thus far in its programs.

In a recent trip to Peru, Grounds for Health learned of the availability of local government funds that can be used for social and health programs. Grounds for Health immediately saw an opportunity to approach local governments at the mayoral and municipal level to propose the use of these funds for Community Health Promoter trainings, transportation for women to and from health centers, and other activities to increase demand for and uptake of cervical cancer prevention services. In particular, a partnership with the municipality may garner funds to achieve coverage in the communities currently not receiving programming as they are not part of the coffee cooperative membership base.

Connect with local, regional, and national health authorities and other government authorities as a necessary component to overcoming bureaucratic barriers

Although the Peruvian Ministry of Health has acknowledged cervical cancer as a key component to Plan Esperanza, the TATI project supported the use of VIA and cryotherapy in rural places, and the National Cancer Insttitute (INEN) conducts trainings in VIA and cryotherapy, many bureaucratic barriers continue to exist in local implementation of comprehensive cervical cancer prevention. In 2014, no productivity indicators existed for the use of VIA as a screening technique, and providers at local health centers and posts were assessed solely on the number of PAPs they achieved over the course of a year. Without a functioning system for communicating results to women and assuring treatment for those who need it, PAPs are ineffective in preventing cervical cancer. Providers also do not have budget codes for which to charge materials and supplies for VIA and thus are unable to purchase these items for their clinics.

Grounds for Health has used its relationships at the local and national levels to identify the source of these bureaucratic barriers, namely that productivity indicators and budget codes are set at the regional level. As a result, Grounds for Health has reached out to the cancer control coordinator at the regional level, shared the details and results of our program, and encouraged him to present the use of VIA and cryotherapy to the regional ministry of health as a necessary approach to reducing cervical cancer. His response was positive and resulted in the regional ministry of health sending two providers to Grounds for Health’s most recent clinical training in order to be trained in VIA and cryotherapy. Nonetheless, the system is difficult to understand and to influence, and Grounds for Health will need to continue to use its relationships and results as leverage to create changes that will support sustained service provision with VIA and cryotherapy.

Printable Version of this Page (PDF)