Cucunubá Zulma M, Manne-Goehler Jennifer M, Díaz Diana, Nouvellet Pierre, Bernal Oscar, Marchiol Andrea, Basáñez María-Gloria, Conteh Lesong
Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine (St Mary's Campus), Imperial College London, London, United Kingdom; London Centre for Neglected Tropical Disease Research (LCNTDR), Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom; Grupo de Parasitología - RED CHAGAS, Instituto Nacional de Salud, Bogotá, Colombia.
Department of Global Health and Population, Harvard School of Public Health, Boston, MA, United States.
Soc Sci Med. 2017 Feb;175:187-198. doi: 10.1016/j.socscimed.2017.01.002. Epub 2017 Jan 4.
Limited access to Chagas disease diagnosis and treatment is a major obstacle to reaching the 2020 World Health Organization milestones of delivering care to all infected and ill patients. Colombia has been identified as a health system in transition, reporting one of the highest levels of health insurance coverage in Latin America. We explore if and how this high level of coverage extends to those with Chagas disease, a traditionally marginalised population. Using a mixed methods approach, we calculate coverage for screening, diagnosis and treatment of Chagas. We then identify supply-side constraints both quantitatively and qualitatively. A review of official registries of tests and treatments for Chagas disease delivered between 2008 and 2014 is compared to estimates of infected people. Using the Flagship Framework, we explore barriers limiting access to care. Screening coverage is estimated at 1.2% of the population at risk. Aetiological treatment with either benznidazol or nifurtimox covered 0.3-0.4% of the infected population. Barriers to accessing screening, diagnosis and treatment are identified for each of the Flagship Framework's five dimensions of interest: financing, payment, regulation, organization and persuasion. The main challenges identified were: a lack of clarity in terms of financial responsibilities in a segmented health system, claims of limited resources for undertaking activities particularly in primary care, non-inclusion of confirmatory test(s) in the basic package of diagnosis and care, poor logistics in the distribution and supply chain of medicines, and lack of awareness of medical personnel. Very low screening coverage emerges as a key obstacle hindering access to care for Chagas disease. Findings suggest serious shortcomings in this health system for Chagas disease, despite the success of universal health insurance scale-up in Colombia. Whether these shortcomings exist in relation to other neglected tropical diseases needs investigating. We identify opportunities for improvement that can inform additional planned health reforms.
获得恰加斯病诊断和治疗的机会有限，这是实现世界卫生组织2020年为所有受感染和患病患者提供护理这一里程碑的主要障碍。哥伦比亚被视为一个处于转型期的卫生系统，其医疗保险覆盖率在拉丁美洲位居前列。我们探讨这种高覆盖率是否以及如何惠及恰加斯病患者，这是一个传统上被边缘化的群体。我们采用混合方法，计算恰加斯病筛查、诊断和治疗的覆盖率。然后，我们从定量和定性两方面确定供应方的制约因素。将2008年至2014年间提供的恰加斯病检测和治疗官方登记记录与感染人数估计数进行比较。我们利用旗舰框架，探讨限制获得护理服务的障碍。筛查覆盖率估计为高危人群的1.2%。使用苯并硝唑或硝呋莫司进行的病原学治疗覆盖了0.3%-0.4%的感染人群。我们针对旗舰框架感兴趣的五个维度（筹资、支付、监管、组织和宣传）中的每一个，确定了获得筛查、诊断和治疗的障碍。确定的主要挑战包括：在分段卫生系统中，财务责任不明确；开展活动（特别是初级保健活动）的资源有限；基本诊断和护理套餐中未包括确诊检测；药品分销和供应链中的物流不佳；以及医务人员认识不足。极低的筛查覆盖率成为阻碍获得恰加斯病护理服务的关键障碍。研究结果表明，尽管哥伦比亚在扩大全民健康保险方面取得了成功，但该国的恰加斯病卫生系统仍存在严重缺陷。这些缺陷是否也存在于其他被忽视的热带病方面，有待进一步调查。我们确定了改进机会，可为其他计划中的卫生改革提供参考。
