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Barriers for Care and Medicines in Diabetes and Hypertension: A pilot study in Lima-Peru.

Author(s) MARIA KATHIA CARDENAS1, Dulce Morán2, Jaime Miranda3, David Beran4
Affiliation(s) 1CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, 2CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, 3CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, 4Division of International and Humanitarian Medicine at the Faculty of Medicine, University of Geneva, Geneva, Switzerland.
Country - ies of focus Peru
Relevant to the conference tracks Health Systems
Summary The aim of this study is to pilot test the implementation, for the first time in Peru, of World Health Organization manual to identify barriers to access to medicines and care in patients with non-communicable diseases (NCD). As part of an active stakeholder engagement in the process, this study aims to promote a policy response. Tools were prepared to collect quantitative and qualitative data. In total, 141 interviews and meetings were conducted in four levels . This study identifies existing bottlenecks in the access to care and management of patients with diabetes and hypertension. This system-level analysis elicits current challenges and opportunities to improve care for NCDs in Peru.
What challenges does your project address and why is it of importance? Non-communicable diseases (NCDs) have been recognized by the global community as a major public health challenge. World Health Organization's (WHO) response includes the development of a Global Action Plan for the Prevention and Control of NCDs for years 2013-2020 and a Research Agenda with focus on the prevention and control of NCDs in low- and middle-income countries (LMICs) such as Peru. The importance of the challenge posed by NCDs in the context of Peruvian health system was also highlighted by the Peruvian Ambassador during the 43rd Session of the Commission on Population and Development. For Peru, WHO estimates a NCD burden that represents 60% of mortality in Peru, which highlights the relevance of chronic diseases for our health system. According to Nolte and McKee the management of chronic NCDs is one of the largest challenges that health systems throughout the world currently face and each system needs to find locally-adapted solutions. These solutions require a clear understanding of the barriers within the health system to access to NCDs care and medicines, from higher policy-level to the individual patient-care experience. Our projects precisely address this challenge.
How have you addressed these challenges? Do you see a solution? We have addressed this challenge by contributing to the limited available body of evidence concerning NCDs and health systems in Peru. Specifically, our study determined barriers for the access to medicines and health care for diabetes and hypertension using a novel tool for health system assessment that was adapted for the Peruvian health sector context. The tool applied was based on the Rapid Assessment Protocol for Insulin Access (RAPIA), a tool that has previously been implemented in six countries (representing four WHO Regions) with the support of the International Insulin Federation: Kyrgyzstan, Mali, Mozambique, Zambia, Nicaragua and Vietnam. Previous implementations of the RAPIA have resulted in improvements in access to medicines like insulin (Mali, Mozambique and Zambia), development of NCD policies (Mozambique and Zambia), inclusion of recommendations in government policies and programmes (Kyrgyzstan, Mali, Mozambique, Nicaragua and Viet Nam), improvement and increase in the visibility of Diabetes Associations (Mali, Mozambique, Nicaragua and Zambia), inclusion of recommendations in projects and programmes of national NGOs (Mali and Nicaragua), external funding and support for diabetes programmes (Mozambique, Zambia and Vietnam) and the use of RAPIA for monitoring and evaluation (Mozambique).At the health system level, the introduction of this tool for the assessment of NCDs will also be helpful for developing future research agendas in the field. This tool can also serve as a field guide to assist researchers in collection, analysis and presentation of data to evaluate and inform the development of health-care services and policies for specific NCDs or groups of diseases.Policy makers can also benefit from these assessments as it can inform them about ongoing challenges or bottlenecks in NCDs-related health care provision. It is expected that the engagement in the planning phases of the study will provide windows of opportunity and knowledge translation that will likely directly translate in policy changes aimed to improve NCD care.
How do you know whether you have made a difference? The results from this study will contribute to a better understanding of the current situation of the management of diabetes and hypertension in the context of the Peruvian health system, in order to formulate appropriate recommendations for the policy decision makers. However, we know that it is premature to attribute any change to this study. In the context of almost non-existing systematic assessments of health systems in the Peruvian health sector, in particular around NCDs, we expect this research to set the grounds for future policy recommendations. Our results show that NCDs are not yet a priority for policy-makers in Peru, at least not in the practice. There are some initiatives that have not yet reached the expected results such as the basic regulation to protect patients with diabetes and a policy to promote reduction of anti-diabetic drug prices. Presently there is only a national guideline for hypertension attention at the primary health level but no guideline approved for diabetes as well as a National Strategy for NCDs without a current Strategic Plan. The universal health coverage in Peru includes a list of essential treatments for each disease covered by any insurance, but it is partially implemented due to the lack of clinical guidelines and the lack of awareness on this topic by the health professionals. At an intermediate and local level we found problems facilitating the demand for medication and laboratory consumables.General practitioners in the lower-level of management provide care mostly to those patients with no complications. Patients with complicated disease are referred to Hospitals, where patients must wait long periods to obtain an appointment. Even those patients with public health insurance often buy their medication at private pharmacies, due to the lack of stock in pharmacy facilities of public sectors. The high price of medicine in private pharmacies is one of the main reasons for treatment cessation by the patient.In order to strive towards achieving a difference we will perform a follow-up on the following activities. As part of the implementation study, a list of recommendations will be shared with the stakeholders before the end of year 2013 and a follow-up of activities will be performed starting the year 2014. During year 2014, every 4-6 months, a member of the research team will contact the stakeholders by e-mail, telephone or by person in order to monitor the implementation of the recommendations.
Have you or the project mobilized others and if so, who, why and how? Since the beginning of the project we participated in different meeting with stakeholders from different sectors in order to establish initial contacts. The purpose of the meetings was to provide information about the project, to listen to different perspectives, and finally, a last activity will be developed before the end of the year to jointly discuss potential recommendations and to define an action plan towards policy changes that are pragmatic and feasible in the current local context. We have developed a presentation of the study to stakeholders, in which we invited them to a workshop session in order to receive feedback of the study. At this workshop we explained the past experience with RAPIA as well as the background and methodology of the present study. The stakeholders gave suggestions and confirmed their support and interest. Among the participants was a high officer of Ministry of Health (MoH), as well as members of different areas of Peruvian MoH, social Security, public health insurance, health organizations, acadaemia, among others.Members of our CRONICAS research team also participated in meetings with the Experts Committee in NCDs, a coordination unit of the MoH. We participated in one of the activities of this Committee which was the discussion of the National Strategic Plan for Prevention and Control of NCD 2014-2021, as well as the meeting for discussing the National Guidelines for Diabetes Management, which has not yet been approved. Additionally, regarding to the Social Security, we also contributed to the Health Services Portfolio, which is a technical guideline for the effective interventions for specific chronic diseases during the patient's lifespan. CRONICAS contribution was cited in the technical document.
When your donor funding runs out how will your idea continue to live? CRONICAS Center of Excellence in Chronic Diseases has as part of its goals "to contribute to research development on NCD in Peru (Goal 1)" and "to participate actively with public health policy-makers and study population (Goal 2)". Therefore, when funding runs out we will still remain in communication with stakeholders. Most of policy makers and stakeholders find our evidence-generation group an ally for policy-related interactions and a source of technical expertise in the generation of future health policies. Whilst being a research-based institution, our group strives towards contributing to the transition from research to action for the improvement of health care in patients with diabetes and hypertension. We also plan to obtain funding in order to develop the study in other regions in Peru which are less-urban and poorer, and have different epidemiological profiles and, obviously, different health-system needs.

One thought on “Barriers for Care and Medicines in Diabetes and Hypertension: A pilot study in Lima-Peru.

  1. We highly appreciate the support of The Alliance for Health Policy and Systems Research and special thanks to Maryam Bigdeli.

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