Because I am working and studying medicine here, I decided to try and describe the Peruvian medical system. I use the word try because language and opinion are big obstacles. Even when you know the language and work within a system, it can still be difficult to compose a concise, understandable and accurate description. I know because I found it to be similarly difficult when I worked in Canada and the UK. Forget the US. Please don’t view this as a whitepaper report. These are my observations from watching, listening and asking some questions. It focuses on my encounters which are mostly in hospital. I have little doubt that there are nuances that I have missed along the way.
For hospital care, there are essentially 3 tracks. As in the US, you are responsible for your bill, less that part covered by any insurance you might have. The private option is just that. I don’t know if people who utilize this system have insurance or if this is all out of pocket. The appearance of the hospitals and clinics suggest that at least the quality of the facilities if not the medical care is superior to that found elsewhere. I have never visited one of these. There is also what some people refer to as social security. This is a system available to everyone (?) who has a job. These people have public insurance that is subsidized by employers and employees. Who pays what toward the insurance depends in part on the work that one does. The actual opperation has evolved over the past 15 – 20 years so it is a work in progress. Not unlike the US, your coverage has limitations. The third group includes those who are poor and have no insurance. These patients find themselves in large wards holding 6 or more people. And many of these people put off seeking care until they are really quite ill. Ironically, often they turn out to have conditions that are covered by government programs (see below). I have no idea about the insurance status of most of the patients that we see at UPCH and the other facilities but I do know that at least part of our tuition here helps to subsidize care for some of our patients.
It is not clear to me that there are COBRA-type regulations in Peru, where everyone is entitled to a screening evaluation and medical stabilization regardless of one’s ability to pay. In the US the definition of this level of evaluation and treatment is very broad and can be quite intense and comprehensive in part because of medical legal concerns. Although US hospitals ask about insurance coverage in the emergency department (ED) no one can be denied an evaluation, care or admission for stabilization of a serious medical problem. Most of the time, decisions about testing and treatment are not consciously weighed based on a patient’s ability to pay. Our system seems to do what is necessary and then hand over the bill. Things are different in Peru. It is clear that testing and medical treatment are predicated on the cost and therefore a person’s ability to pay for it. Tests and treatment can and are withheld for financial reasons. I have seen more than one person await necessary and important surgery, because as I understood it, a surgeon willing to do what amounted to charity work could not be found. The financial consequences are more in the forefront here while in the US we act first, sometimes bankrupting our patients afterwards.
There are some caveats. A hospital bed is much less expensive in the public hospitals. There are also physicians who see patients without apparent regard for a person’s ability to pay. Some work in more than one venue, earning their income one place and doing work pro bono in another. Those who I have met are compassionate and dedicated to do their best with limited resources. It is remarkable how creative they can be when diagnostics and medications are limited because of money concerns.
Before you allow your indignation to get the better of you, there are some other wrinkles here that, quite frankly, embarrass me about our own system, such as it is. Certain people and diseases are covered by the government. These include HIV/AIDS, tuberculosis (Tbc), sexually transmitted infections (STI), pregnant women and children up to at least 2 years of age. Peru is not a wealthy country but some forward thinking people within healthcare have made some hardball decisions about where to focus limited resources for the biggest bang for the buck. There have been conscious, medically sound decisions about which to include. For example, all children receive vaccinations for free. Although kids receive most of those given in the US, decisions have been made based on epidemiologic factors such as infant mortality data. They do not administer varicella (chickenpox) but do give BCG, against tuberculosis. It is possible to point to monitoring data and demonstrate the validity of these decisions based on concrete results. The other really interesting feature is the community clinic system that is an integral and important part of sound, affordable health care policy. I will say more about this later.