The Institute for Global Health and Development
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Item Community and health staff perceptions on non-communicable disease management in El Salvador’s health system: A qualitative study(BioMed Central, 2020-05-27) Vidal, Nicole L.; León García, Montserrat; Jiménez, Marta; Bermúdez, Keven; De Vos, PolBackground: Non-communicable Diseases (NCDs) are the leading cause of global mortality and disability with a rising burden in low- and middle-income countries. Their multifactorial aetiology, and their requirement of long-term care, implies the need for comprehensive approaches. From 2009, the Ministry of Health (MoH) in El Salvador has developed a national public health system based on comprehensive primary health care. This study aims to describe the different stakeholders’ perceptions about the management of NCDs along the pathways of care in this health system. Methods: During three fieldwork periods in 2018, three complementary qualitative data collection methods were deployed and conducted in settings with high prevalence of NCDs within El Salvador. First, illness narrative methodology was used to document the life histories of people living with a chronic disease and being treated in second and third level health facilities. Second, through social mapping, support resources that NCD patients used throughout the process of their illness within the same settings were analysed. Third, semi-structured interviews were conducted in the same locations, with both chronic patients and health personnel working at different levels of the primary health care setting. Participants were recruited through purposive and snowball sampling, and a deductive approach was implemented for coding during the analysis phase. After grouping codes into potential themes, a thematic framework was developed using a reflexive approach and following triangulation of the data. Results: This innovative approach of combining three well-defined qualitative methods identified key implications for the implementation of a comprehensive approach to NCD management in resource-poor settings. The following elements are identified: 1) social risk factors and barriers to care; 2) patient pathways to NCD care; 3) available resources identified through social connections mapping; 4) trust in social connections; and 5) community health promotion and NCD prevention management. Conclusions: The Salvadoran public health system has been able to strengthen its comprehensive approach to NCDs, combining a clinical approach – including long-term follow-up – with a preventive community-based strategy. The structural collaboration between the health system and the (self-) organised community has been essential for identifying failings, discuss tensions and work out adapted solutions.Item Comprehensive primary health care and non-communicable diseases management: A case study of El Salvador(BMC, 2020-04-06) Jimenez Carrillo, Marta; León García, Montserrat; Vidal, Nicole L.; Bermúdez, Keven; De Vos, PolOne of today's greatest challenges in public health worldwide - and especially its key management from Primary Health Care (PHC) - is the growing burden of non-communicable diseases (NCDs). In El Salvador, since 2009 the Minister of Health (MoH) has scaled up a national public health system based on a comprehensive PHC approach. A national multi-sectorial strategic plan for a comprehensive approach to NCDs has also been developed. This analysis explores stakeholders' perceptions related to the management of NCDs in PHC and, in particular, the role of social participation. A case-study was developed consisting of semi structured interviews and official document reviews. Semi-structured interviews were developed with chronic patients (14) and PHC professionals working in different levels within PHC (12). Purposive sampling was used to recruit participants. A non-pure, deductive approach was implemented for coding. After grouping codes into potential themes, a thematic framework was elaborated through a reflexive approach and the triangulation of the data. The research was conducted between March and August of 2018 in three different departments of El Salvador. The structure and the functioning of the Salvadoran PHC system and its intersectoral approach is firstly described. The interdisciplinary PHC-team brings holistic health care closer to the communities in which health promoters play a key role. The findings reflect the generally positive perception of the PHC system in terms of accessibility, quality and continuity of care by chronic patients. Community engagement and the National Health Forum are ensuring accountability through social controllership mechanisms. However, certain challenges were also noted during the interviews related to the shortage of medication and workforce; coordination between the levels of care and the importance of prevention and health promotion programmes for NCDs. The Salvadoran PHC and its comprehensive approach to NCDs with an emphasis on intersectoral participation has been positively perceived by the range of stakeholders interviewed. Social engagement and the NHF works as a driving force to ensure accountability as well as in the promotion of a preventive culture. The challenges identified provide keys to amplify knowledge for addressing inequalities in health by strengthening PHC and its NCDs management.Item The role of social movements in strengthening health systems: The experience of the National Health Forum in El Salvador (2009–2018)(SAGE Publications, 2020-02-19) León, Montserrat; Jiménez, Marta; Vidal, Nicole L.; Bermúdez, Keven; De Vos, PolIn 2009, the newly elected FMLN government of El Salvador launched a comprehensive health reform, which gave the National Health Forum (NHF) a key role in developing community participation. This study aims to examine and analyze the content and impact of this social movement during the study period 2009–2018. The context was analyzed through relevant documents, which helped identify key stakeholders. Semi-structured interviews took place at 3 levels of decision making: the political level, the health professionals, and the community. Data were analyzed using a qualitative methodology. Participation is carried by a structure created by the Ministry of Health, the National Health Forum. The NHF developed 3 strategies: (1) leadership building in the communities through the strengthening of social, political, and economic skills, where they developed social accountability mechanisms at all decision-making levels of the health system; (2) the strategy carried by the sectoral working groups, where they responded to prioritized needs identified by the community; and (3) advocacy for human rights-based policies. The NHF, and its role in the strengthening of the National Public Health System, provides strong evidence of community participation strategies and co-governance with the health system within the social determinants of health scope.Item Utilización de los servicios médicos en un área de salud(Editorial Ciencias Médicas, 2013-01) Díaz Piñera, Addys; Rodríguez Salvá, Armando; García Roche, René; Balcindes, Susana; Jova Morel, Rodolfo; De Vos, Pol; Van der Stuyft, PatrickIntroducción: en la utilización de los servicios de salud convergen no solo la necesidad de atención de la población en términos de enfermedad, sino sus creencias y aspectos culturales; pero, sobre todo, el complejo contexto en que se da la prestación de servicios. Objetivo: exponer las características sociodemográficas y las enfermedades o sintomatologías más frecuentes en la población del área de salud "Marcio Manduley", del municipio Centro Habana, y los que hicieron uso de los servicios de salud durante el período abril - junio de 2010. Métodos: estudio descriptivo transversal. Se seleccionó una muestra poblacional representativa del área; se tomó en consideración el total de viviendas. Como se desconoce la prevalencia del factor bajo estudio, se maximizó la muestra tomando como prevalencia el 50 %, la precisión en 10 % y una posible caída muestral del 10 %. El tamaño muestral fue de 408 familias. Se aplicaron cuestionarios a todos los integrantes de las familias seleccionadas y en particular a aquellos individuos que durante los últimos 30 días enfermaron e hicieron uso de algún servicio de salud. Resultados: se obtuvieron datos de 1 244 personas; de ellas enfermaron 25,1 % en los últimos 30 días y el 17,7 % hizo uso de servicios formales de salud. Las enfermedades más frecuentes fueron respiratorias, cardiovasculares y osteomioarticular. La puerta de entrada al sistema de salud más utilizada fue el consultorio médico (54,1 %). Conclusiones: en nuestro estudio los factores del individuo que influyen en la utilización de los servicios de salud son el nivel de enfermedad percibida o necesidad de salud y el sexo.Item Determinantes sociopolíticos de las políticas internacionales de salud(Instituto Nacional de Salud, 2013-04) De Vos, Pol; Van der Stuyft, PatrickDesde hace décadas, dos lógicas opuestas dominan el debate político de la salud: el enfoque de atención integral de salud, con la Declaración de Alma Ata de 1978 como piedra angular, y la lógica de la competencia privada, haciendo hincapié en el papel del sector privado. Presentamos este debate y su influencia en las políticas internacionales de salud en el contexto de las relaciones de poder económicas y sociopolíticas globales. Se ilustra el enfoque neoliberal de la reforma del sector salud de Chile en la década de 1980 y de la reforma colombiana desde 1993. La lógica pública integral se ilustra a través de los modelos de seguridad social en Costa Rica y en Brasil, y a través de los sistemas nacionales de salud pública en Cuba vigentes desde 1959, y en Nicaragua, durante la década de 1980. Estas experiencias ponen de relieve que los sistemas de salud no gravitan naturalmente hacia una mayor equidad y eficiencia, sino que requieren de decisiones políticas explícitas.Item Evidencias actuales en las propuestas de intervención local para el estudio y manejo de los determinantes sociales de la salud en la población cubana(Editorial Ciencias Médicas, 2014-05) Álvarez Pérez, Adolfo G.; Luis Gonzalvez, Isabel P.; Maldonado Cantillo, Geominia; Romero Placeres, Manuel; Bonet‐Gorbea, Mariano; Lage Davila, Carlos; De Vos, Pol; Van der Stuyft, PatrickLos determinantes sociales de la salud son las condiciones sociales en las cuales las personas que conforman una población determinada nacen, viven y trabajan. El presente artículo tiene el objetivo de documentar las evidencias actuales sobre las propuestas de intervención local para el estudio y manejo de los determinantes sociales de la salud de la población cubana. Desde una perspectiva estructural las variables de servicios de salud muestran diferencias entre territorios, asociadas básicamente a la existencia de un sistema de salud único con cobertura y acceso universal para toda la población. Se observan mayores diferenciales en el comportamiento de los llamados “determinantes no médicos”, como densidad poblacional, producción y circulación económica, mostrando estas diferencias un patrón geográfico. También se observan diferenciales en el comportamiento de la mortalidad materna y la hipertensión arterial entre territorios y en el tiempo. La productividad económica y las condiciones de vida están poco relacionadas con otros indicadores de resultados. Ante lo anteriormente expuesto se presenta una propuesta metodológica para el estudio y manejo de los determinantes sociales de la salud. Se requieren espacios de estudio de los determinantes sociales a nivel local, mediante técnicas multivariadas cuyos resultados aporten insumos para el diseño de intervenciones integrales basadas en los enfoques de planificación estratégica, acción intersectorial y participación social. Se impone insertar en la práctica del sistema de salud cubano un enfoque dirigido a trabajar más con los determinantes sociales de la salud, para lo cual se propone un modelo para el estudio e intervención local.Item The functioning of the Cuban home hospitalization programme: A descriptive analysis(BMC, 2007-05-31) De Vos, Pol; Barroso, Isabel; Rodríguez, Armando; Bonet, Mariano; Van der Stuyft, PatrickBackground Over the last decades hospital at home (HaH) programmes have been set up in many, mainly European, countries. The Cuban HaH programme is not hospital driven, but the responsibility of the first line health services, and family doctors play a pivotal role.Item The direct costs of home care in Cuba(Organización Panamericana de la Salud, 2007) Barroso Utra, Isabel M.; García Fariñas, Anai; Rodríguez Salvá, Armando; De Vos, Pol; Bonet‐Gorbea, Mariano; Van der Stuyft, PatrickOBJECTIVE: To analyze home care services in Cuba and determine how length of stay, per-day cost, and per-patient cost vary by diagnosis and by the area of the country in which the services are rendered.Item Health through people’s empowerment: A rights-based approach to participation(Harvard University Press, 2009-06) De Vos, Pol; De Ceukelaire, Wim; Malaise, Geraldine; Pérez, Dennis; Lefèvre, Pierre; Van der Stuyft, PatrickAnalysis of the academic discourse on participation, empowerment, and the right to health since the 1978 Alma-Ata International Conference on Primary Health Care and the subsequent Alma-Ata Declaration shows that each phase of the evolution of these concepts added important new aspects to the discussion. This article focuses on three crucial issues that relate to these additions: the importance of social class when analyzing the essentials of community participation, the pivotal role of power highlighted in the discussion on empowerment, and the role of the state, which refers to the concepts of claim holders and duty bearers included in a rights-based approach to health. The authors compare these literature findings with their own experiences over the past 20 years in the Philippines, Palestine, and Cuba, and they offer some lessons learned. The concept of “health through people’s empowerment” is proposed to identify and describe the core aspects of participation and empowerment from a human rights perspective and to put forward common strategies. If marginalized groups and classes organize, they can influence power relations and pressure the state into action. Such popular pressure through organized communities and people’s organizations can play an essential role in ensuring adequate government policies to address health inequities and in asserting the right to health.Item Assessment of hypertension management and control: A registry-based observational study in two municipalities in Cuba(BioMed Central, 2019-01-30) Londoño Agudelo, Esteban; Rodríguez Salvá, Armando; Díaz Piñera, Addys; García Roche, René; De Vos, Pol; Battaglioli, Tullia; Van der Stuyft, PatrickBackground - To determine the prevalence of hypertension treatment and control among hypertensive patients in the Cuban municipalities of Cardenas and Santiago and to explore the main associated predictors. Methods - Cross-sectional study, with multistage cluster sampling, conducted between February 2012 and January 2013 in two Cuban municipalities. We interviewed and measured blood pressure in 1333 hypertensive patients aged 18 years or older. Hypertension control was defined as blood pressure lower than 140/90 mmHg. Results - The mean age ± standard deviation (SD) of participants was 59.8 ± 14 years, the mean systolic and diastolic blood pressure ± SD was 130.0 ± 14.4 and 83.1 ± 9.0 mmHg respectively. The majority of patients (91, 95%CI 90–93) were on pharmacological treatment, 49% with a combination of 2 or more classes of drugs. Among diagnosed hypertensive patients 58% (95%CI 55–61) had controlled hypertension. There was no association between hypertension control and gender, age and socio-economic condition. Levels of hypertension control depended on health area and control furthermore was positively associated with post-primary education, not being obese and white ethnicity: adjusted Odds Ratio (95% CI) 1.71 (1.26–2.34), 1.43 (1.09–1.88) and 1.41 (1.09–1.81) respectively. Conclusions - The observed figures are outstanding at the international level and illustrate that hypertension treatment and control are achievable in a resource-constrained setting such as Cuba. The country’s primary health care approach and social equity in access to health care can be seen as key determinants of this success. Nevertheless, there is still room for improvement, as over a third of patients did not have controlled hypertension.