title: How universal is coverage and access to diagnosis and treatment for Chagas disease in Colombia? A health systems analysis.
abstract: 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.
authors.affiliation: 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.
authors.forename: Zulma M
authors.initials: ZM
authors.lastname: Cucunubá
authors.affiliation: Department of Global Health and Population, Harvard School of Public Health, Boston, MA, United States.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Manne-Goehler
authors.affiliation: Grupo de Parasitología - RED CHAGAS, Instituto Nacional de Salud, Bogotá, Colombia.
authors.forename: Diana
authors.initials: D
authors.lastname: Díaz
authors.affiliation: Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine (St Mary's Campus), Imperial College London, London, United Kingdom; Medical Research Council Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine (St Mary's Campus), Imperial College London, London, United Kingdom.
authors.forename: Pierre
authors.initials: P
authors.lastname: Nouvellet
authors.affiliation: School of Government, Universidad de los Andes, Bogotá, Colombia.
authors.forename: Oscar
authors.initials: O
authors.lastname: Bernal
authors.affiliation: Drugs for Neglected Diseases Initiative - Latin America, Rio de Janeiro, Brazil.
authors.forename: Andrea
authors.initials: A
authors.lastname: Marchiol
authors.affiliation: 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.
authors.forename: María-Gloria
authors.initials: MG
authors.lastname: Basáñez
authors.affiliation: Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine (St Mary's Campus), Imperial College London, London, United Kingdom; Medical Research Council Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine (St Mary's Campus), Imperial College London, London, United Kingdom. Electronic address: l.conteh@imperial.ac.uk.
authors.forename: Lesong
authors.initials: L
authors.lastname: Conteh
mesh_terms: D014355:Chagas Disease / Q000175:diagnosis* / Q000628:therapy*; D003105:Colombia; D003695:Delivery of Health Care / Q000458:organization & administration*; D006078:Government Programs / Q000458:organization & administration*; D006297:Health Services Accessibility / Q000458:organization & administration*; D006801:Humans; D007348:Insurance, Health / Q000458:organization & administration*; D019472:Universal Health Insurance / Q000458:organization & administration*
keywords: Access; Chagas disease; Colombia; Coverage; Health system; Mixed methods