Determinants of access to health services, out-of-Pocket expenditures, and therapeutic adherence in patients with diabetes mellitus

A single-center observational study.

Abstract

Introduction: Type 2 diabetes mellitus (T2DM) is a global epidemic that unevenly affects low- and middle-income countries, where structural factors and financial barriers greatly limit access to effective medical care. In Ecuador, this condition is the fourth leading cause of death, and service coverage is limited. The goal of this research was to identify the factors influencing access to health services, the effect of out-of-pocket costs, and levels of treatment adherence among diabetic patients treated in the metropolitan district of Quito in 2024.

Materials and methods: An observational, prospective, cross-sectional study was conducted at the "Fray Bartolomé de Las Casas" health center. The sample was probabilistic, consisting of adults diagnosed with diabetes. A survey validated by experts (Aiken's V 0.81) and with acceptable internal consistency (Cronbach's alpha 0.782) was used for data collection. The instrument assessed sociodemographic, economic (including consultation, drug, and transportation expenses), and operational access variables. Statistical analysis included inferential tests such as the chi-square test and the calculation of the Odds Ratio (OR).

Results: a total of 95 patients were analyzed. Perceived worsening of health is significantly linked to social security affiliation (OR 2.77; P=0.0258) and the unavailability of institutional medicines (OR 2.86; P=0.0347). The average monthly expenditure on drugs was $82.19 USD, indicating that spending more than $50 USD per month is a critical risk factor for loss of adherence (OR 2.81; P=0.0211). An accessibility paradox was evident: patients who report clinical stability tend to navigate the system by compensating for public shortages with their own resources, while social security users associate saturation and bureaucracy with a decline in their condition.

Conclusion: The stability of the diabetic patient in this context relies less on biological factors and more on the individual's financial ability to compensate for the shortcomings of the public system. The inefficiency of the social security system and the high out-of-pocket medication costs are the primary factors behind perceived health decline and low adherence.