Barriers to Primary Care in Lima, Peru

• Published date: 01 June 2017
• Author: Sean J. Haley,Jennifer P. Wisdom,Maria Sofia Cuba Fuentes,Kim A. Hoffman,Javier Ponce Terashima
• Date: 01 June 2017
• DOI: http://doi.org/10.1002/wmh3.227

Barriers to Primary Care in Lima, Peru

Sean J. Haley, Javier Ponce Terashima, Kim A. Hoffman,

Maria Sof‌ia Cuba Fuentes, and Jennifer P. Wisdom

Given Peru’s epidemiologic transition, this exploratory study sought to understand the role that

primary care holds in Lima’s medical system. Key stakeholders in Peru were administered semi-

structured qualitative interviews to understand the factors that inf‌luence the availability and quality

of primary care. Five areas were targeted for inquiry: f‌inancing, the training of primary care

providers, access to services, patients’ f‌irst contact with the health-care system, and treatment

coordination. Interviewees described primary health-care services as having a lack of treatment

continuity, inconsistent record keeping, and often staffed by recent medical graduates with little

primary care training, which can manifest to reduce the use of primary care services. Despite

identifying numerous barriers to quality primary care services, interviewees remained committed to

the principles of universal access espoused by Peruvian legislation and offered recommendations

related to metrics, f‌inancing, technology, and workforce development to improve both primary care

access and quality.

KEY WORDS: primary care, barriers, access

Introduction

Sustained economic growth after 1992 (Mesones, Peschiera Cassinelli, & Baca

Campod

onico, 2014) reduced the proportion of the Peruvian population living in

poverty, bolstered migration to urban centers, and propelled a shift in mortality

causes from infectious (from 51 percent in 1996 to 15 percent in 2000) to

noncommunicable diseases (from 48 percent in 1996 to 71 percent in 2000) in Peru

(Huicho, Trelles, Gonzales, Mendoza, & Miranda, 2009). Peru’s health-care

infrastructure originally evolved to support specialists to treat high rates of

communicable disease (Pan American Health Organization, 2013); however, rates

of noncommunicable chronic disease have eclipsed communicable disease, fueling

an epidemiological transition typif‌ied by an increased demand for health services

to treat a range of chronic conditions and a need to expand the primary care

system (Antiporta, Smeeth, Gilman, & Miranda, 2015; Avezum, Costa-Filho, Pieri,

Martins, & Marin-Neto, 2015; Omran, 1971).

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doi: 10.1002/wmh3.227

#2017 Policy Studies Organization

The economic growth also supported considerable public health advances,

including a precipitous drop in infant mortality (43 infant deaths per live births

in 2000 to 27 in 2006) (National Institute of Statistics and Informatics, 2014; Pan

American Health Organization, 2013; World Bank, 2011). Although economic

prosperity improved public health and access to curative medical visits across

economic classes, only 16 percent of Peruvians reported a preventive doctors’

visit (13 percent among the poorest 20 percent) between 2004 and 2008 (Petrera,

Valdivia, Jimenez, & Almeida, 2013). Low rates of preventive medical visits could

signal burgeoning future costs as patients wait longer to seek care, treatment

becomes more expensive as conditions worsen, and the risk of disease related

disability climbs (Nugent, 2008). Some research has suggested that were Peru to

realign its health service system to focus on primary care, the country could

address 70–80 percent of the population’s demand for services (Frenk, Lozano, &

Bobadilla, 1996; Maeda et al., 2014). Instead, patients often resort to self-diagnosis

and treatment; a recent study found that more than half of respondents in Lima

self-refer for prescription medications, gaining access to medications through

loosely controlled pharmacies (Hermoza-Moquillaza, 2016). In the 2015 National

Household Survey, 16 percent of the population reported going directly go to a

pharmacy when they had a health problem, rather than a physician (Sanchez-

Aguilar, Garcia-Zanabria, & Hidalgo-Calle, 2015). In light of the growing

recognition that health-care systems must orient toward primary care to address

increases in noncommunicable disease (Maeda et al., 2014; Pan American Health

Organization, 2013; World Health Organization, 2013b), this study sought to

better understand the role of primary care through an analysis of medical

stakeholders’ perceptions of the need for and barriers to the delivery of primary

care services in Lima, Peru.

Primary Health-Care System Defined

Primary health care is the “the basic level of health care provided equally to

everyone”; it addresses the most common ailments through the provision of

“preventive, curative and rehabilitative services to maximize health and well-

being” (Starf‌ield, 1992). It often serves as patients’ f‌irst point of contact with a

health-care provider. The importance of a primary health-care system was f‌irst

espoused at the international Alma Alta conference in 1978 (World Health

Organization, 1978). In the intervening years, primary health-care systems have

expanded across Latin America to address both communicable and non-

communicable disease (Casas & Vargas, 1980; de Bertodano Id, 2003; Macinko,

Starf‌ield, & Erinosho, 2009; World Health Organization, 2014). However, the

expansions have not kept pace with rapidly rising noncommunicable disease

rates and strained infrastructures. In turn, the Pan American Health Organization

called for an expansion of population-based primary health-care systems across

the region (Macinko, Montenegro, Nebot Adell, & Etienne, 2007).

The Pan American Health Organization broadened the def‌inition of primary

care beyond the four attributes originally identif‌ied by Starf‌ield ([i] f‌irst contact

Haley et al.: Barriers to Primary Care in Lima 165