Introduction
Peru is a country exposed to natural events such as earthquakes, heavy rains, frosts, as well as epidemics. In order to respond to emergencies and disasters caused by these events, the Peruvian State has established legal mechanisms to simplify administrative procedures and mobilize resources in a timely manner.
The main mechanism is the State of Emergency, which is included in the National Constitution and is approved by the President with the agreement of the Council of Ministers. This procedure is applied for a certain period of time, in part or a whole territory to face a high-risk or a disaster. 1 Another legal mechanism is the Declaration of Environmental Emergency to respond to a sudden event that causes significant environmental damage resulting in a public threat because of air, water, or soil pollution. 2 , 3 There also exists the Declaration of an Emergency Situation, a legal and administrative mechanism that exempts a public organization from the selection processes established to facilitate the acquisition of goods and services. 4
These legal mechanisms are applicable to all sectors, including the health sector, at national, regional, and local government levels. However, in December 2013, the Peruvian State approved an additional legal mechanism, the Public Health Emergency declaration, to reduce the impact on public health and health services of a potential event or an emergency. 5 , 6
The Public Health Emergency declaration is applicable to: a high-risk of, or the existence of an outbreak, epidemic, or pandemic; the occurrence of cases of a disease classified as eliminated or eradicated; the occurrence of events with epidemic potential; the occurrence of a disease with rapid spread that simultaneously affects more than one department in the country; as well as the existence of an event that affects the continuity of health services resulting in a sudden decrease in their operative capacity. 5 , 6 Public Health Emergencies are declared by Executive Decree, signed by the President of the Republic, the Prime Minister, and the Minister of Health, and are accompanied with an action plan detailing outcomes, activities, resources, and funds. These funds could be extraordinary resources assigned by the Ministry of Finance, or rescheduled from the budgets of each health institution.
This report is a systematic review of the Public Health Emergency declarations published in the Official Gazette “El Peruano” between July 2014 and December 2016. 7
Report
Twenty-three Public Health Emergencies were declared: five in 2014, 11 in 2015, and seven in 2016. Fifty-seven percent were caused by a public health risk or epidemics, 30% by natural or anthropic events that generated a sudden decrease in operative capacity of health services, and 13% by the existence of a disease with rapid spread that could affect more than one department of the country. Figure 1 shows the distribution of these emergencies.
Figure 1 Number of Public Health Emergency Declarations by Reason and Year of Issuance, Peru 2014 - 2016.
There were 16 Public Health Emergency declarations due to epidemiological events, including 13 by high public health risk. The outbreaks of Dengue were the most frequent cause of emergency declaration with 69%, mainly in the departments of the north coast and jungle. The rapid spread of canine rabies was the reason of emergency declaration in three departments in the southern area of the country.
Other epidemiological events that caused emergency declarations were Leptospirosis, the re-emergence of Malaria, entry of Chikungunya virus, wild rabies outbreaks, high risk of entry of Zika Virus, outbreaks of canine rabies, and the potential increase of acute respiratory infections and pneumonia cases during the low temperature season. It is worth mentioning that some departments were declared in emergency at the same time, mainly due to the presence of different types of arbovirosis, such as Dengue Fever, Chikungunya, and Zika Virus.
Seven emergency declarations were due to the decrease of the operational capacity of the health services, twice in the Social Security and five times in the Ministry of Health. The main reasons were health worker strikes and operational limitations to meet patient demand in 57% of cases. Other reasons were the arrival of the El Niño phenomenon in 2015-2016 with potential damages in hospitals and the shortage of medicines and medical devices during the period of impact of floods and heavy rains.
The El Niño phenomenon and low temperature season were the two meteorological events that justified the emergency declarations in 19 and 14 of the country’s departments, respectively. These declarations were justified on the risk of a decrease in the operational capacity of health services and the increase of acute respiratory infections and pneumonia in the highlands and jungle.
In 2014, the whole country was declared in Public Health Emergency, while in the year 2015, the departments of Apurímac, Ayacucho, Huancavelica, Moquegua, Tacna, and the constitutional province of Callao were the only ones that were not in sanitary emergency. In 2016, the whole country except for the department of Ica and the Constitutional Province of Callao were not declared in emergency. The declarations had a validity between 60 and 90 days, with the median of 120 and the mode of 90 days.
One-hundred and forty million American dollars were allocated to face the Public Health Emergencies. As shown in Table 1, the largest amount of resources was allocated in 2015 (40%) and the rest was distributed between 2014 and 2016. The 72% was used to keep the operational capacity of health services and 28% for epidemiological surveillance and vector control.
Table 1 Budget in American Dollars Allotted to Public Health Emergencies Care According to Reason and Year of Declaration, Peru 2014 - 2016
The emergency declarations facilitated fast tracks for procurement of goods and contracting of services. Under these measures, health staff were hired, equipment and supplies were purchased, medical brigades were mobilized, and other actions were carried out to face the emergencies.
Discussion
The legal mechanisms to deal with emergencies are necessary to simplify administrative procedures and to facilitate the processes to meet the main needs derived from the effects of the adverse event. The Public Health Emergency declaration, as an exceptional measure, empowers the national health authority to have a greater intervention at regional and local levels, through a High Commissioner that depends on the national health level and manages the emergency in coordination with local health authorities. 8 Unlike the regulations of other countries, the power of this Commissioner is limited to aspects of coordination, mainly in the public health sector, and it does not have the authority to mobilize goods, the redistribution of health staff, or to restrict the transit of people in the affected areas.Reference Haffajee, Parmet and Mello 9
The Public Health Emergency mechanism in Peru is activated at the request of the departmental health authority or a public health organization, and the signature of the President of the Republic is necessary for its approval, along with the compliance of the Health Minister. This is a different situation from what happens in the United States, where states are responsible for declaring and managing the emergency in the face of a natural disaster, outbreak, bio-terrorist attack, or other adverse event. 10
In general terms, the Peruvian legal mechanism covers part or all of the health sector, but it has no measures associated to mobilize support from other sectors such as housing, transport, water and sanitation, and others; this weakens its capacity to respond to epidemics or other events that require a strong involvement of all sectors. The State of Emergency (the other legal mechanism for emergency) has a greater scope and capacity to mobilize other sectors and was used in previous years to respond to epidemics such as Dengue in Pucallpa – Ucayali. 11
The Public Health Emergency mechanism requires specific provisions for prevention and treatment activities, inter-sector coordination, and strategies to increase human resources in health.Reference Rutkow 12 These measures are part of an action plan that should accompany any Public Health Emergency declaration in the country.
In the last three years, at least five Public Health Emergencies were declared per year, without taking into consideration that some of the departments also had a declaration of State of Emergency. The declarations of emergency on average lasted 120 days, a time much higher than what was found in a study carried out for a period of eight years in the United States. This study collected information about 11 Public Health Emergencies in eight states which lasted between 30 and 60 days, of which included important events such as the A H1N1 pandemic and hurricanes like Katrina (2005), Gustav (2008), and Isaac (2012).Reference Rutkow 12 The Public Health Emergency declaration in Peru can be extended up to 180 days by executive decrees signed by the President.
The events with Public Health Emergency declaration were compared with the records in the EM-DATA, identifying nine events for the years 2014 to 2016, which corresponded to floods, earthquakes, and extreme temperatures. 13 None of these events that were registered corresponded to any of the 23 sanitary emergencies declared in Peru because one of the requirements to comply with declaration is that the event should have a declaration of a State of Emergency, of which none of them fulfilled, or because in the EM-DATA, there were no risk situations, and several of the Public Health Emergency declarations were motivated by risk and not by the impact of events.
The declaration of Public Health Emergency must be an exceptional legal mechanism; however, in the three years of its existence in Peru, it has been used in numerous opportunities, mainly in risk or presence of epidemics by arboviruses as Dengue, Zika, and Chikungunya. It can be observed in Figure 2 that some departments have had at least one emergency declaration in the last three years, and that the number of departments with emergency increased year by year. The entry of Zika Virus urged the Ministry of Health to declare the Public Health Emergency in most of the country in 2016 because of the need to improve the prevention and detection to avoid outbreaks in areas where existed the circulation of Aedes Aegypti.
Figure 2 Distribution According to Risk Departments or Presence of Epidemics in the Country, According to Declaration of Public Health Emergency in Peru: 2014- 2016.
Limitations
The study carried out is only a descriptive research study and was not included as an assessment of the health measures made in the framework of the declarations of emergencies. Therefore, conclusions about the effectiveness of measures to reduce risk are not possible. Considering that some departments had an emergency declaration for the same reason year by year, mainly for Dengue, it could be an indicator that the prevention measures did not work properly, had a limited scope, or the public health interventions were not sustainable.
Conclusion
The Public Health Emergency declarations are exceptional legal mechanisms with a restricted scope to the health sector. It can facilitate the execution of technical and administrative processes as procurement of goods and contracting of staff and services to face the risk or the impact of natural disasters, epidemics, and other events that could be a public health problem or affect the continuity of the provision of health services. This legal mechanism may lose its effectiveness and credibility if it is used without a prior risk assessment to face recurrent and preventable public health problems.
