Recently, IHI President and CEO Derek Feeley described health equity as the “forgotten” aim among the six quality aims set by the Institute of Medicine in 2001. To improve our pursuit and understanding of this aim, IHI Latin America Project Assistant Gonzalo Garrido-Lecca reached out to Raul Cordero, MD, Medical Director of the Clinica Anglo Americana and former Deputy Director of the National Institute for Neoplastic Diseases (INEN) in Peru. During the conversation, Dr. Cordero noted the differences in access, quality of care, and outcomes between the private and public sector in Peru for cancer patients.
How would you describe the ability of the Peruvian public sector to provide care for patients with cancer?
In recent years, Peru has made considerable improvement in broadening access to cancer care thanks to Plan Esperanza (Hope Plan). This was an initiative that allowed people with fewer financial resources to receive treatment without having to worry about the costs.
Initially, this meant a lot more people were going to receive treatment, but due to limited available infrastructure, hospitals were overwhelmed and unable to meet the demand. We see this problem not only found at the INEN, but throughout the entire public sector. For example, EsSalud, a public health insurance organization, had to begin referring patients to private hospitals in order to manage the high demand. We are now treating more patients and providing them with better care, but there is still a big gap that we need to address.
How does this affect patients’ ability to access care?
In order to compare both sectors, let’s use a hypothetical patient diagnosed with the same condition and walk through the steps they need to take to receive necessary care.
Imagine this patient is suffering from abdominal pain and calls a private hospital and asks for an appointment with a gastroenterologist. This patient would probably get this appointment within the next two to three days. Once the doctor sees the patient, he decides that the patient needs to have an endoscopy to find the cause of his pain. The procedure would be scheduled a week after the appointment and, if the results say the patient has stomach cancer, the patient would be referred to a surgeon within 24-48 hours, and would have surgery within a week. This example shows that on average, a patient with access to care in the private sector would start his treatment within two to three weeks of his first appointment.
On the other hand, if this patient needed to use the public sector, he would probably get an appointment in two to three weeks rather than just a couple of days. This patient would then need to wait about a month to get the endoscopy, and another month to see the surgeon who would schedule the surgery during the next couple of weeks. This means that the same patient would start his treatment three to four months after he approached the health system for the first time.
The difference is huge.
What is the impact of this delay?
As you can imagine, the earlier you detect and start treating a cancer patient, the higher the chances are for this person to recover and have a positive outcome. Those three or more months in which the patient in the public sector is waiting can have devastating effects.
In these three months, the cancer can evolve and move from a treatable condition to one with minimal chances of survival. Not only does this allow for the illness to progress, but it also means that there will likely be higher costs associated with the treatment and medications needed due to its higher complexity.
Most importantly, this will also affect the emotional well-being of the patient as he now knows about his condition and is left to wait for months before even starting to fight the illness.
Would you say there is a difference in terms of quality of care?
Many doctors in Peru work in both the private and public sector, meaning that most of the time medical knowledge is equally available. The differences are due to other factors, like the lack of infrastructure.
In many cases, patients receiving treatment from the public sector have to share rooms with five or six others. This brings me back to the emotional well-being of the patient. Not only do they have to wait for a number of months, but the treatment they receive is often less patient-centered.
If you could choose three priorities for the Peruvian health care system in the next 10 years, what would they be?
The first thing we have to do is improve access to care. Comprehensive and inclusive policies — such as Plan Esperanza — have allowed many people to receive treatment without worrying about the financial implications.
But we need infrastructure improvements to support these kinds of policies. Thankfully, many of these are already happening. In the last couple of years, the INEN has created two new facilities and the Ministry of Health is adding oncology departments to state hospitals to reduce the burden hospitals are currently experiencing.
My second priority would be to increase the number of physicians. Luckily, this too is already happening. More young people are becoming medical professionals, thanks to a growing middle class and a rising salary for medical staff in the public sector.
Finally, I think we have to start humanizing care. We need to start teaching all these young professionals that we are not doing the patient a favor by caring for them. People diagnosed with cancer have to carry a huge burden, and our job as doctors and nurses is to help them and hopefully relieve some of that burden.
An easy way to do this is by making the patient feel as informed and comfortable as we possibly can. Again, this all comes back to the limited capacity we currently have to treat patients since it is very hard to give personalized and patient-centered care when you have five patients in a room and a very limited time to spend with each one of them. Sometimes we forget about this, but in recent years I have seen tremendous improvement and I am optimistic about where we are heading.
