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This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 IGO License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited. No modifications or commercial use of this article are permitted. In any reproduction of this article there should not be any suggestion that PAHO or this article endorse any specific organization or products. The use of the PAHO logo is not permitted. This notice should be preserved along with the article’s original URL. * Official English translation from the original Spanish manuscript made by the Pan American Health Organization. In case of discrepancy, the original version (Spanish) shall prevail. 1 Universidad Peruana de Ciencias Aplicadas, Facultad de Posgrado, Pontificia Universidad Peruana Católica del Perú, Lima, Perú. * Margarita Petrera Pavon: mpetrerap@gmail.com 2 Universidad Nacional Mayor de San Marcos, Lima, Perú. ABSTRACT Objective. To ascertain which factors affect out-of-pocket spending on health services provided by the Ministry of Health of Peru and regional governments to the population living in relative poverty between 2010 and 2014. Materials and methods. Cross-sectional, descriptive, nationwide, econometric, year-on-year (2010-2014) study using information from household surveys. The dependent variable was out-of-pocket spending by people in relative poverty to pay for medical care at public services in health. The independent variables were affiliation with the Comprehensive Health Insurance (SIS) scheme, level of family expenditure per capita, age group 0-5 years, being a woman of childbearing age (15-49 years), being an older adult (over age 60 years), family burden (using the number of members of the household as a proxy indicator), and the level of complexity of the service provider. Results. Only 5% of the rural population in the study were treated at higher-complexity facilities (hospitals), compared to 16% of the population in urban centers. Drugs accounted for the majority of household expenditures: 44% among those insured via SIS and 62% among the uninsured (2014). Out-of-pocket spending on health was positively associated with not being insured via SIS, higher level of provider complexity, level of family spending per capita, and being an older adult. Conclusions. Comprehensive Health Insurance coverage is a relevant policy variable to reduce out-of-pocket spending in poor households. The lower out-of-pocket spending among the rural poor––an especially vulnerable group––was strongly associated with near-exclusive use of services delivered by primary health care providers. Specific policies are needed to protect older adults living in poverty. To achieve universal health coverage, Peru needs to implement more intensive financial protection policies and restructure its public service offering.

Determinants of out-of-pocket spending on health among the poor population served by public services of health in Peru, 2010–2014