Photo: Socios en Salud, Sucursal Perú ©SES 2014.
Worldwide, 80% of patients with diabetes reside in low- and middle-income countries (LMICs). These patients are at higher risk of having inadequate glycaemic control and developing serious complications from their diabetes when compared with patients from high-income countries.1 There are multiple causes explaining poor outcomes, one being the failure of healthcare systems to adapt to the necessary challenges of managing patients with chronic diseases.
In Peru’s highly fragmented health system, most patients use free or low-cost public health services. In comparison with private healthcare services, those using the public healthcare system report lower satisfaction rates and longer waiting times. Nevertheless, it seems that neither public nor private health systems provide adequate diabetes prevention and management services.2 To illustrate this situation, we created the story of a fictional Peruvian patient (Lucho), who has diabetes, basing him on typical experiences collected from patients with chronic diseases using the Peruvian public health system.
Lucho lives in a peri-urban area, and uses his local community health centre (CHC). Lucky to have been diagnosed at an early stage of his illness, he still goes through many difficulties receiving adequate diabetic care. After receiving the diabetic diagnosis a nurse at the CHC informed him that neither the glucose-lowering medications nor the equipment needed to screen for diabetic complications were in stock in that CHC. Lucho was therefore referred to the outpatient clinic of a public hospital 2 hours away from his house by public transport. Once in the hospital, Lucho requested an appointment, which was scheduled for 10 days later. On the appointment date, he waited 2 hours before seeing a physician with the consultation lasting 15 minutes.3 The physician spent much of this time filling in long clinical forms, and little time talking directly with Lucho. With such limited physician–patient interaction, Lucho wasn’t able to ask any of the many questions he considered important. At the end of the appointment, the physician gave him a prescription for metformin and captopril, and a list of required laboratory tests, with a return visit scheduled for 3 months later. Once out of the doctor’s office, Lucho went to the hospital’s laboratory, where he was told to return in 2 days to conduct the laboratory tests.
Once home, Lucho felt stressed and had many unanswered questions about his illness, so he sought help at the nearest CHC. However, he received contradictory recommendations from the staff, not trained in diabetes management. Eventually, he stopped taking his prescribed medications, and resumed inadequate lifestyle behaviours, such as eating a high-carbohydrate diet and taking little physical activity.
Lucho also became an easy target for charlatans promising him a quick cure for cash (a common scenario). Not surprisingly, his diabetes condition only worsened.
The Peruvian public health system is characterised by serious weaknesses in its infrastructure. For example, sometimes only a limited supply of drugs are available, there is a lack of basic laboratory tests such as glucose tests and a lack of trained health professionals. In addition, the fact there are few proper patient education programmes for chronic diseases plays its part.
One possible explanation for these deficiencies is that the healthcare system in Peru, as many healthcare systems in other LMIC, remains largely focused on the management of communicable diseases and prenatal care.4
In the context of ongoing demographic and epidemiologic transitions, many countries are facing growth in their elderly populations and an increase of chronic diseases burden. LMIC like Peru thus have to make radical changes to their public health systems. They must recognise chronic disease as a health priority and adopt a patient-centred approach ensuring that patients like Lucho receive the proper diabetic control, education, and social support required to meet their specific health needs.5
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