Peru

In March, RMF Country Director – Peru, Steve Henrichon, spent 5 days in Pisco visiting our Policlínico Peruano Americano. Much of his time was spent observing the clinic and determining which processes are most efficient as well as identifying which processes need improvement.

General Observations

The clinic has carved out a great reputation in the community. During my visit, 70 patients per day visited the clinic on average, and it’s not even winter yet! The clinic is receiving referrals from other physicians for specific services such as ultrasound and laboratory services.

Patient Care

This was the first time I have met some of our new staff members and I was eager to shadow them to gauge their work ethic as well as their rapport with the patients. I was very impressed at the level of care offered to the patients. The patients are greeted with smiles at the front desk by the nurses. The doctors are compassionate and attentive. They attempt to spend a sufficient amount of time with each patient so they can develop an accurate picture of the patient and their ailment. The pharmacist takes time to sit down with the patients and explain their medication to them and the proper dosage indication. Compliance has always been a challenge with this patient population so it is essential that our medical staff does its part right from the beginning to ensure that the patient understands exactly what his/her diagnosis is, and why, how, and when the medicine is to be taken. With a supportive and caring staff eager to motivate, the patients stand the best chance of complying with the prescribed treatment plan so they can regain their health as soon as possible.

Consultation

Peru is the only country where RMF has implemented a pilot project using a modest fee-for-service system. The clinic has been collecting fees-for-service for one year now. Depending on the program’s success, RMF will use Peru as a basis for which to model similar fee structures at other RMF clinics around the world as a step toward economic self-sustainability. During my visit, this system was evaluated closely. It appears that the clinic has not lost patients since the induction of the consultation fee (S./1 per family).

The free nature of the clinic is still preserved because all families in financial need are excused from paying. Their fees are subsidized by the families who are willing and able to make this contribution. In addition to this very small consultation fee, the clinic also charges based on the service provided, i.e. nebulizer treatments, ultrasound diagnostics, sutures, etc. These charges however, are a fraction of the charges at the local hospital. For example, at the Hospital San Juan de Dios, an ultrasound costs S./50. At our Policlínico Peruano Americano, we charge S./10. This is a much easier expense for patients to assume and thus the clinic receives many orders for ultrasounds from physicians at the hospital and surrounding clinics. I explained that charging a fee for service has a positive upside with very little downside since patients in financial need are excused from paying. The upside includes a step towards sustainability and also encourages co-responsibility of the patients with respect to their healthcare.

The Policlínico Peruano Americano currently raises about $400/month in fees which helps to offset part of the monthly operating costs of $6,500. In addition to sustainability, it transfers the symbolic ownership to the people of San Clemente. They are contributing to the viability of their clinic and they express that this is something they take pride in.

Pharmacy

The formulary in the pharmacy has been made more efficient. There are currently about 45 medications on the formulary, including the most commonly prescribed medications. This is a smaller number of different medicines than 2 years ago. Over the course of these last 2 years, our staff streamlined the pharmaceutical supplies according to the most used and most needed medications. This process also made it easier and more economic to manage the inventory for a smaller formulary. If the doctor writes a prescription for a medication that is not in the inventory, the patients are able to bring the prescription to another pharmacy

Suggestions

At the clinic, there is a suggestion box on the wall. From time to time, the suggestions are collected and evaluated. The main suggestions are as follows:

• The wait time is too long – This is true. The clinic sees roughly 70 patients per day between two doctors. We are open from 7am to 5pm. Almost all of the patients arrive at 7am in the morning, however. If a patient’s name is placed at the bottom of the sign-in sheet, then they may have to wait for a few hours. However, patients could easily come in the afternoon when there is lower volume and there would be a very short wait. We have entertained the idea of having an appointment system but, other then a few complaints about waiting, the current system seems to be working fine for most people.
• More Doctors – This goes hand in hand with the previous suggestion. Of course, we would like to have more doctors at the clinic. This depends on funding, though. At this point, funds to staff the clinic with additional doctors are not available, and until that time comes, we will be happy with our staff of two doctors who have been doing a terrific job and have seen upwards of 95 patients per day on some days. It is a compliment that the clinic’s reputation is such that the community is requesting that we expand our services. They want more!
• Dentistry – The word “Policlínico” indicates that multiple services are offered at the clinic. The clinic does have primary care services for all ages, women and children’s health care, imaging services, lab services, and a free pharmacy. The clinic does not have dentistry services yet. We are exploring avenues for dental equipment procurement, but it will still be a fairly significant expense to bring a dentist on board. A dentist will cost approximately $600-700/month.