"We feel like orphans": listening to users' expectations to ensure more responsive healthcare services in rural Peru.

The goal of health systems is to meet the health needs of the population in order to improve and/or maintain their health. To do so, it is necessary to understand the expectations regarding local health services. Meeting users' expectations is key to responsive health systems. However, there is little understanding about the expectations of rural populations in low- and middle-income countries regarding Primary Health Care. Through interviews with rural people affected by a chronic condition (n = 15), local leaders (n = 7), and focus groups with users of health services in Northern Peru (n = 109), this paper explores the perceptions they have of local Primary Health Care services and their expectations of how services ought to be. We used Atlas-ti to conduct a thematic analysis, and found that peoples' concerns about the health system go beyond commonplace elements such as lack of medications or healthcare workers. Rather, participants' concerns revolve around not feeling respected and that their health needs were less important than the ones of those with money or who live in the city. This was captured in their feeling of abandonment by the State who sends young and inexperienced doctors to work in rural communities and ineffective medications. Interventions to improve the responsiveness of health systems cannot be based on blanket approaches but rather should be specific to each context and take into consideration the expectations and experiences of those it seeks to serve. For instance, re-consider the policy of sending young doctors to work in rural areas and/or providing a sustained mentorship from more experienced doctors, during their year of service.