IX. The Impact of Social Movements in Healthcare Reforms: The Case of El Salvador International Journal of Health Services The Role of Social Movements in 2020, Vol. 50(2) 218–233 ! The Author(s) 2020 Strengthening Health Systems: Article reuse guidelines: The Experience of the National Health sagepub.com/journals-permissions DOI: 10.1177/0020731420905262 Forum in El Salvador (2009–2018) journals.sagepub.com/home/joh on1,2, Marta Jim Montserrat Le enez1, Nicole Vidal1 , Keven Bermudez1, and Pol De Vos1 Abstract In 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 deter- minants of health scope. Keywords community participation, health systems strengthening, primary health care, empowerment, social movements, people’s health movement Background Health,4 critically analyzed the important impact of the social, political, and economic contexts on health. It high- Rationale of Social Participation in Health lights the relationship between socioeconomic status and Participation in health is a key concept that involves health outcomes, strongly advocates for adequate com- engagement with communities, or members of communi- munity interventions, and underlines the need for social ties, in strategies for health service development and for and economic change. In addition, there is a growing community interventions. The principle underlying this interest in how socioeconomic conditions contribute to approach is that health interventions will be more respon- sive to participants’ needs – and consequently more effec- tive – if they incorporate stakeholders’ views.1 The primary 1 Institute for Global Health and Development, Queen Margaret University, health care (PHC) paradigm was a key concept of the Edinburgh, UK 2 Alma Ata Declaration.2 Thirty years after the Ottawa Biomedical Research Institute Sant Pau, Iberoamerican Cochrane Centre, Universitat Aut onoma de Barcelona, Spain Charter,3 empowered communities are more than ever Corresponding Author: considered essential for health promotion. Pol De Vos, Institute for Global Health and Development, Queen Margaret In 2008, the report “Closing the Gap in a Generation” University, Edinburgh, UK. of the WHO Commission on Social Determinants of Email: pdvos@itg.be Leon et al. 219 health disparities, including poverty, inadequate educa- relations and power imbalance. In the 1970s, the country tional opportunities, unemployment, limited access to was under a strong military repression and ranked basic services and goods such as nutritional foods, and among the 5 most unhealthy countries.13 The doctor- poorer quality health care.5 One approach to reducing to-patient ratio was the lowest in Latin America. health disparities has been to mobilize community repre- Eighty percent of rural peasants had no potable water, sentatives of target populations to work collaboratively and 60% had no access to health services. When civil with multisector public and private organizations to iden- war broke out in 1980, the health budget had already tify common health issues, develop program or policy been cut by 50%, and the health ministry completely interventions, and attempt to bring about community- pulled out of many regions, so that funds could be allo- level change that supports health-promoting opportuni- cated to military. Life expectancy fell from an already ties and behaviors.6 dismal 56 years to 50.7 years, with 3 out of 4 children Nevertheless, contradictory practices exist, which vary suffering malnutrition, and a mortality rate of 87 per from extremely utilitarian (for example, in relation to the 1,000 for children under 5.14 role of community health workers, where the system takes Later, during the war, the health system was totally advantage of the community-based skills to put health decommissioned, and FMLN guerrilleros forces trained programs in practice) to empowerment approaches that lay health workers in rebel-controlled areas where the enable communities, families, or individuals to make deci- Ministry of Health had closed clinics in the early sions on their own lives. Over time, recognition of these 1980s.12,13 The resistance organizations collected the differences and of the importance of empowering strate- accumulated knowledge of rural social organizations to gies have increased.7,8 In addition, it is recognized that consolidate this “alternative” health system. Self- improved levels of health are achieved through a PHC- managed health structures were created, mainly run by based health policy that includes universal financial cov- health promoters or trained voluntary health workers erage regulated or overseen by the government, equitable from solidarity groups. The communities proposed distribution of resources, integrated services, and zero or these promoters themselves: they chose people who low co-pays for services at the first level of care.9 could read and write, who had leadership abilities, and In September 2003, during the 44th Directing who had a commitment to their community, hence Council, PAHO/WHO approved the resolution CD44. strong organization skills were learned from that.12,15 R6, inviting member states to a series of recommenda- Also, during this war period, there were many forced tions to strengthen PHC in their report “Renewing displacements, terrible massacres and abductions, and Primary Health Care in the Americas.”10 After a long many social groups fled to neighboring countries, period of repression in El Salvador, the newly elected mainly Honduras. These migrations led to the creation leftist government, FMLN, incorporated these guide- of refugee camps. The refugees organized themselves in lines to formulate the Health Reform in 2010, giving different areas of work, including ensuring a clean water special emphasis to the following principles: responding supply, food production, health, education, and security. to the health needs of the population, orientation toward Consequently, different types of organizations and quality, responsibility and accountability of govern- decision-making mechanisms were created, including ments, social justice, sustainability, participation, and general assemblies and meetings between sector and intersectoriality. The reform’s design is based on PHC area coordinators.12 These structures and procedures and its values, since it is made up of a set of essential were maintained and refined after the refugees returned structural and functional elements that guarantee cover- to El Salvador. age and universal access to services, which are acceptable to the population and promote equity; provide compre- The communities generated many organizational mech- anisms during the civil war. These resources were devel- hensive, integrated, and appropriate care over time; oped before and during the conflict. After the peace emphasize prevention and promotion; and take families agreements the organizational mechanisms were activat- and communities as a basis for planning and action.9,11 ed in the struggle for access to medicines, against the Hence, a central strategy of the health reform was to privatization of public entities, all of them were impor- enable participation,11,12 meaning participation turns tant [. . .] individuals into active partners in decision making about the allocation and use of resources, in the defini- – Vice-minister of public health policies tion of priorities, and in the guarantee of accountability. In 1992, after this long period of conflict, the interna- El Salvador and Its National Public Health System tional community endorsed the peace agreements, which The history of El Salvador has been characterized by modified the political appearance of El Salvador, open- abysmal inequalities in the management of social ing the way to the democratization of the nation’s 220 International Journal of Health Services 50(2) political life. Revolutionary organizations joined to form the management model through the creation of compre- a political party, the FMLN, which sought to establish a hensive, integrated service networks (redes integrales e horizontal relationship with the social and popular integradas de servicios de salud – RIIS)21 made it possible movement, based on respect for their autonomy. When to reorganize the services and improve the coordination the peace agreement was signed in January of 1992, the between the first and second level of care. Health preven- civilian deaths had risen to more than 75,000.16 tion and promotion strategies were established through The end of the 1990s saw the growth of a movement intersectoral initiatives coordinated by the Intersectoral for neoliberal reforms in Latin America,17 which in El Health Commission (CISALUD) to ensure a comprehen- Salvador mobilized health personnel, trade unions, and sive approach under a “health in all policies” scope.22 the general population to go on strike and take to the One of the main strategies of the health reform focuses streets in demonstrations and white-coat marches, forcing on the promotion of social and community participation.19 negotiation with the government to halt initiatives toward privatization.9,10,17 In 1999, the social movement led to From the very outset, we knew that in order to achieve the creation of the Council on Health Sector Reform this vision and these objectives,10 we would need to (Consejo de Reforma del Sector Salud – CRSS), which strengthen both community organizations and social par- was entrusted with reforming the sector in consultation ticipation, so that society would be able to both take part with a group of public and private institutions. The coun- in the decision-making process, and identify and success- cil concluded that the Salvadoran health system had fully tackle the determinants of health. adopted a centrist model that excluded much of the pop- ulation and constrained the democratic exercise of deci- – Ma Isabel Rodrıguez, Minister of Health 2009–2014 sion making.18 In parallel, new spaces of social expression were born, such as the Citizen Alliance against the The implementation of a genuine community participa- Privatization of Health advocating for policies aimed at tion strategy evolved from this ideological base as a achieving greater equality and universal access to health strategy of the health reform to guarantee social partic- services. They promoted the idea of conceiving health as a ipation in health decision-making processes. Therefore, public asset, a fundamental human right, and the result of at the same time the health reform was created, the a dynamic interaction between a range of different deter- National Health Forum emerged, a social movement minants (socioeconomic, political, biological, cultural, that grew out of many years of social mobilizations demographic, and environmental).11,19 and that was integrated in the health reform with the In 2009, the FMLN – the former guerrilla movement aim of collaborating, and even co-governing, with the turned into a left-wing political party – won the national Salvadoran Ministry of Health. elections. They immediately launched a national health system reform.11,19 In 2010, the Ministry of Health (MoH) introduced a health system reform, based on The National Health Forum more than a decade of discussions and debates between Background different sectors, focusing on people-centered care and the right to health, and launched the health policy The National Health Forum (NHF) was formally creat- “Building Hope.”19 ed in 2010, with 3 fundamental objectives: The development of a national public health system based on primary health care principles was a central • To build people’s power and strengthen the organiza- priority for the new government. The Ministry of tional fabric Health explicitly committed itself to the right to health • To face the mercantile nature of health of the previ- for all Salvadorans, ensuring free health care in the ous neoliberal governments public system by eliminating co-pays in the health serv- • To stimulate and promote an effective social partici- ices to reduce economic barriers, as out-of-pocket expen- pation in health ditures by Salvadoran households represented 87% of total private spending on health (34% of national expen- As mentioned earlier, the organizational and diture) in 2010.20 The primary health care concept was decision-making structures and the high levels of social not limited to “well organized first line services,” but participation from the years of the war were maintained referred to an integrating approach for the whole nation- and collectively strengthened during the period follow- al health system. Frontline care was dramatically ing the signature of the peace agreements. These existing expanded, improving the health coverage in the poorest social structures and participatory processes have served municipalities, with the introduction of community as the starting point for the creation of the NHF. During family health teams (equipos comunitarios de salud the process of formulating the health reform in 2009, familiar – ECOSFs). In addition, a reconfiguration of many of these organizations, including the Citizen Leon et al. 221 Alliance against the Privatization of Health (ACCPS), APROCSAL – Association of Salvadoran Community were encouraged to take part in “Open Social Dialogue Promoters. APROCSAL is an institution with a critical tables” (discussion panels that were established to and purposeful sense, dedicating its work and effort to include civil society in the design of the health be a health reference based on the promotion, organiza- reform19) to channel proposals and recommendations tion, citizen participation, and alternative use of natural to be included in the new health policy.9,11,19,23 This medicine, which provides and demands a comprehensive commitment is recorded in the policy document health care alternative with a human rights approach “Building Hope”19: “The participatory process already within the reach of the most vulnerable population, begun will have immediate continuity with the creation with an emphasis on women and youth, to contribute of a National Health Forum, which formulates the ele- to the improvement of their living conditions with ments and contribution to the taking of the fundamental gender equity. When the NHF was being established, decisions for the construction of the new health system.” the minister of health at the time, Ma Isabel The National Health Forum was therefore a space for Rodriguez, proposed Margarita Posada, a member of civil society participation in the health decision-making APROCSAL, as coordinator of the organization and process, with a legal basis independent of the Salvadoran creation process of NHF due to her work with the com- Health Ministry, that allows the National Health System munities as well as her expertise in community partici- of El Salvador to advance within the social justice model pation strategies; and her position as NHF’s director proposed by the new health reform. It’s constitution was ratified by the civil society during the NHF’s first is embodied in the strategic consideration that “health assembly.24 Each of the coordinators at the different is a collective task in which everyone takes part.”24 levels are appointed periodically (normally every year) Their legal support is guaranteed through different offi- by membership consultation in the different territories. cial publication documents, including these 2 main ones: At the community level and working with the commu- nity health units, community coordinators are in charge • Legislative Agreement No. 126, published in the of assessing the health needs and follow-up and support Republic Official Gazette No. 33. February 17, of the health policies implemented. 2010, in which the National Health Policy is approved The organizational structure of the NHF is detailed in and indicates the formation of the National Health Figure 1 and follows a parallel organizational structure Forum (NHF) as part of the process of reform. as the MoH (white boxes).22 • Agreement No. 1422 of the Republic Official Gazette, There are 4 levels of decision making: volume 413, number 182, dated October 3, 2016, which recognizes the National Health Policy 2015– 1. Community level: Both the MoH and NHF have 2019 and where the NHF constitutes the fifth axis committees where strategic actions are developed to of the fourth strategy: Deepening and expanding the respond to community needs. At this level and within Strategic Axes of the Health Reform. each community health unit are “right to health offi- ces,” where both institutions engage along with other The NHF has succeeded in developing consensus on a stakeholders such community organizations and civil strategic decision-making process that emphasizes societies. The main function of this offices is to equity, quality, and inclusion, as well as an intersectoral address accountability issues such as shortage of med- approach based on the social determinants of health ication, quality of care, and human rights. At this through a broad process of proactive and vigilant citizen level are also “suggestion boxes” where civilians can participation within the framework of exercising the express their claims. right to health. 2. Municipal level: This level includes hospitals (second and third level) where they meet monthly at the Intersectoral Health Commission (IHC) with other Governance and Decision Making Within the NHF stakeholders, such as the NHF and community organ- During the first months since the health reform was izations. Issues discussed include coordination with the launched and the structure of the NHF was formulated, other levels of decision making, implementation of various community organizations participated in this strategic plans, the comprehensive epidemiological vig- policy formulation. The organizations detailed in the ilance, and compliance with certain statements such as NHF’s website (https://fnssv.com) are those that con- the participatory law. Suggestion boxes have been formed and continue to be part of the NHF; and, the placed at health structures at this level. civil society elected members of these organizations as 3. Regional level: 4 regional health structures are repre- leaders of the NHF for their extensive expertise in com- sented at each of the 4 regions of the country. At the munity participation in health. This is the case of the IHC matters discussed at lower levels of decision making director of the NHF, who was a member of are addressed and used to inform policymaking. 222 International Journal of Health Services 50(2) Ministry of Health NHF- Director IHC CO Regional Committee CO Regional Health Sectoral Panels Network (RIIS) Coordinator Coordinator IHC CO Municipal Municipal Health Committee Network (SIBASI) IHC: Intersectoral Health Commission Coordinator RtHO: Right to health office SB CO: Community Organizations SB: Suggestion boxes Community Community Health Committee Units (ECOS) Coordinator SB RtHO CO Figure 1. Scheme of the organizational structure of the National Health Forum (grey boxes) and the Ministry of Health (white boxes). 4. National level: The Ministry of Health is divided in 2 and addressing the social, environmental, and economic departments: Vice-Ministry of Health Policies and determinants of health. Vice-Ministry of Health Services. The Vice-Ministry This article aims to discuss the social and community of Health Policies ensure that policy formulation with participation approach with the example of the National different stakeholders is being developed and the Health Forum (NHF) in El Salvador since the imple- NHF has a role of “social comptrollership” so that mentation of the health reform up to now; therefore, policies are issued with a human right basis.” the study period covered is from 2009 to 2018. We describe the community empowerment experience result- Within the NHF, different decisions are prioritized ing from the comprehensive PHC reform launched in El and moved to higher levels of decision making, to the Salvador in 2009. We describe the development of a par- municipal and departmental committees, which in turn ticipation initiative that evolves to a long-established collect issues at their level of decision making and formu- social movement. We identify the key elements of the late recommendations to be discussed at the health assem- NHF’s strategy to enable community participation and blies held annually. Within the sectoral organization, the empowerment in health decision making, within the coordinators are selected based on their experience, with health reform context in El Salvador. the panel’s thematic and thorough membership consulta- tion. The coordinator changes every 2 years, and the same person can be elected. Methods Therefore, within the membership of the NHF is a technical workforce composed of members of different The study is a descriptive case study, using qualitative community organizations and associations, which are in methods. We first conducted a document analysis to charge of supporting the training, organizational skills, gather information on the context of El Salvador. and economic sustainability of the NHF, and an opera- We searched PubMed to identify epidemiological data tional workforce composed of leaders of the communi- and community participation strategies. Our search ties or any person from the civil society who participates strategy was (“Community Health Services” [MeSH]) in the NHF, which are the ones responsible for imple- OR “Community Participation” [MeSH]) AND El menting the different activities carried out by the NHF Salvador [tiab]. We retrieved 91 articles, of which (this will be detailed in the following sections). 8 were full-text reviewed. We identified 3 relevant studies The NHF is part of an international global network, from the included reference list. We developed a second People’s Health Movement (PHM, https://phmove search in Google Academy to identify any kind of doc- ment.org), bringing together grassroots health activists, ument which described the functioning of the civil society organizations, and academic institutions Salvadoran health system or community health interven- from around the world, which acknowledge that pop- tions during the civil war, as those reporting during and ular pressure from civil society is essential to ensure the after the health reform: 20 references were included. necessary action by the state on social determinants. Once identified and contacted with key stakeholders, PHM works on various programs and activities and they shared with us other relevant documents to be is committed to comprehensive primary health care able to have a complete understanding of the context Leon et al. 223 in El Salvador. This phase was conducted during that is neither utilitarian nor an object of manipulation. November 2017–February 2018. It is a citizen participation – through its community During 2 field visits in February and June 2018, we organizations and its community leadership – in the for- conducted semi-structured interviews with key stake- mulation of public policies and in the exercise of holders, for which we followed a purposive sampling social control on the performance of the national methodology by selecting participants that had been health system. identified through the document analysis, or referred to by the Ministry of Health and the NHF. The inclu- – Vice-minister of public health policies sion criteria related to participants of the 3 levels of decision making: the political level, the health professio- Community participation is understood as the demo- nals, and the community, which have collaborated with cratic right to participate in decisions affecting commu- the NHF in the design or implementation of health strat- nity development. As citizens are more aware of their egies or are active members of the NHF during the study rights, they organize themselves. The director of the period. Interviews followed a predefined deductive the- NHF explains: matic framework: (1) social understanding of communi- ty participation; (2) description of the NHF, its role The social movement in its struggle. Those were the within the health system, and strategic actions. This people who organize themselves to generate change. was developed through the application of a reflexive When people are aware of their rights, they organize approach and the triangulation of data. and participate in the NHF, in a significant way, and Data collection: 3 interviewers conducted 10 inter- not – as in the past – in a type of instrumentalized par- views during fieldwork: 3 members from the NHF; 2 ticipation by the Ministry of Health. In this way, real cadres of the Vice-Ministry of Public Health Policies; change is generated. one primary health care unit coordinator; one frontline professional; and 3 community leaders. Participants – Director of the NHF were encouraged to speak freely and allowed to lead the interview in the direction they found most interesting Participation in decision making influences the power and important. Interviews lasted from 30 to 60 minutes imbalance. The NHF director considers that, to allow and were recorded with participants’ written informed the population to be part of the decision-making pro- consent. The participants were free to leave at any cess, others must give up part of their power: time of the interview. After transcribing the content of audio-recorded interviews, data was coded using NvivoVR Participation is a power exercise, because those who hold version 10 and then analyzed. the power must give up part of it. If you want everyone Ethical standards were compliant with those set by the to participate in the decisions and democratize the health National Health Ethics Committee of El Salvador facilities, you have to give up power. But also, the pop- (CNEIS/2018/005_A). This study is part of a wider ulation must learn to take advantage of that opening. research on El Salvador’s National Health System (proto- col approved by the NIHR Global Health Research – Director of the NHF Programme 16/136/100, Queen Margaret University, UK). Social determinants of health versus social determination of Results health. The primary health care concept promotes actions to tackle health inequalities. In this sense, the What Is Understood by Community Participation? Salvadoran approach is not based on the (dominant) Community participation is conceived as a mechanism focus on “social determinants of health”4,25 but on the for change, an empowerment process with transforming Latin-American concept of “social determination capacity. The NHF, as a social movement, pursues a of health.”7,25 The vice-minister of public health well-organized and non-instrumentalized, non-utilitari- policies clarifies: an participation that plays a role in decision making and generates ownership. As the vice-minister of public The concept of “social determinants of health” has the health policies details: disadvantage of splitting up the reality in separate parts, while the “social determination of health” integrates The participation that is implemented is linked to the these as a whole, giving importance to the collective concept that was raised in Alma Ata, as one of the determination over free will and individual life styles. basic strategies of primary health care. We understand participation as meaningful participation, participation – Vice-minister of public health policies 224 International Journal of Health Services 50(2) One of the interviewees was a co-developer of the con- an output: the process of creating a culture of cept of “social determination of health,” Ma Isabel participation. Rodrıguez,12,25 who emphasized a shared governance of health issues: The Salvadoran population does not have a culture of participation, due to years of repression and armed con- The change of government and entry of the FMLN facil- flict, where people exercising their right to participate run itated the health reform. I come from social medicine, the risk of losing their lives. People tended not to partic- and I have a commitment to work with the community ipate [. . .] but when communities perceive improvements in the health process. through their participation, they are encouraged to con- tinue [. . .] I think they do it because they are empowered, Ma Isabel Rodrıguez, Minister of Health 2009–2014 they see changes and improvements in their living condi- tions, in their family, and in the community. By incorporating the up-stream determinants of health within a unified analysis, this approach underlines the – Member of the NHF importance of the overall social, political, and economic context on social determinants and on health outcomes. Nowadays, the issue of social violence is limiting partic- This approach ensures that different community organ- ipation because of the violence generated in the territo- izations come together for a national transformation and ries. These youth gangs that control the territories are not for isolated events. Some of the informants explain closing many community spaces, because they see it as a their perceptions on this: threat to them. It is important that the community knows that health is – Territorial development facilitator (member of the NHF) determined socially because that makes links to other struggles; struggles for problems that are generating a There is a difference between living in residential blocks sick society, not only in our country, but also globally. and living in a neighborhood, because of the issue of social violence. For instance, I was threatened because – Director of the NHF of the work I did in the community. A determination-based approach allows us to see that we – Community leader cannot solve problems in isolation: they are related to the country’s production model, to decisions related to the population’s working conditions. Depending on how The National Health Forum people work, that is how they will become ill. If we don’t question that, we will continue operating in the logic of The National Health Forum (NHF) was created in 2010, covering gaps rather than going deeper into the model, within the framework of the health reform. The NHF and we won’t go very far. pursues civil society consensus in strategic decision making, through a broad process of citizen participation – Member of the NHF under a social justice lens. Moreover, it fulfills the role of accountability within the health system, for which it devel- The right to health is not only the access to health care. oped parallel structures with the health system structures. It is a broader concept, including access to drinking water, an agriculture free of pesticides, uncontaminated The FNS, as a community structure, in alliance with many air, etc. other actors, has developed capacities that health profes- sionals do not have. They see beyond the health services, – Territorial development facilitator (member of the looking for more fundamental solutions to health prob- NHF) lems. These are not limited to curative aspects. This stim- ulated a wider organization of society, bringing together The Salvadoran context demonstrates the important other organizations that are not focused on the right to impact that historical and sociopolitical contexts have health. For example, the demand for justice, and people’s on the key issues, approaches, and processes. How com- mobilizations for demands that are much broader than the munity participation is enabled in many fragile countries health sector, such as mobilization against tax evasion and such as El Salvador, where social violence jeopardizes avoidance, in order to be able to finance stronger public community engagement,23,26,27 and therefore the capac- services and funds for education and health. ity to participate in decision making. In this sense, the NHF conceives participation as a process, not (only) as – Vice-minister of public health policies Leon et al. 225 The FNS was born with high participation of different to decide and make changes to the draft developed by the social movements, all united in the same direction. There technical committee. But, people must have the skills to were a series of problems, as they wanted to privatize health participate. The NHF had an important influence on the care [. . .] The NHF was created when the health reform training of people on political issues, such as the function came into being. We, the NHF, are part of the reform, of the state, so they gain skills to be able to participate in we are working in the reform to ensure participation. decision making and are, therefore, able to transfer com- munity knowledge to the political arena. – NHF member All populations have knowledge and are essential in a Only with an active participation in health we will be process of reform. Sometimes the knowledge that com- able to consolidate a comprehensive health reform. munities have about health issues is underestimated. At the territorial level they are discussed through the – Vice-minister of public health policies discussion tables, and territorial trainings are held to open the debate on certain topics [. . .] undoubtedly, people are the ones who know most about their reality, Role of the NHF in the health systems’ policymaking process. so you start to see how they incorporate all the concepts The NHF aims to build the capacity of social movements of the right to health into their reality and that is when to interact with local government in the process of policy- you see changes and improvements. making, thereby promoting a shared local governance (Figure 1), which underscores the move toward participa- – Director of the NHF tory processes of public policy making and devolves influ- ence and power to local communities. The NHF The NHF has worked closed with frontline health pro- facilitates the possibility that all health demands identified fessionals to encourage them to involve the community in through their network of community health centers, planning. Interviewees highlighted that the Ministry of including those of other frontline health professionals, Health is in charge of health services (curative aspects), are addressed in the political agenda. These demands while the NHF takes the responsibility of raising aware- permit the formulation of integrated, settings-based ness and promote strategies focused on health promotion. approaches that best respond to their needs, enabling people to increase control over and improve their In order to get closer to youth, initiatives are set up direct- health, following health promotion strategies. ly with groups of adolescents, in schools or through the radio – many young people listen to the radio – and there The communities that are more organized, or which are they receive radio spots where they are given information. better supported by the NHF, are the ones that partici- Health is specifically promoted. We also reach vulnerable pate most in health campaigns, such as child vaccination, populations through announcements on TV, and in the feline and canine vaccination, and dengue prevention. same way, people who come to the health units also have the opportunity to attend the health assembly we orga- When the NHF is present, the population is well orga- nize. Also, during parent meetings at the schools, there nized, you will notice, and everyone knows what their are opportunities that one takes advantage of. We also get responsibility is. For example, to avoid mosquitoes, they closer during the social mobilizations that are held at the already know that water containers must be covered mayor’s office, or by visiting agricultural cooperatives and that this is the population’s responsibility [. . .]. related to chronic kidney disease. Where the NHF is, The NHF, which is very influential in communities and we have a closer and more effective way of working in health committees, makes the population aware of the with the communities. fact that health is everyone’s responsibility, not only the ministry’s responsibility. And that health is not only – Frontline health professional about coming for a cure but should be more preventive. That’s where the NHF is helping a lot. At first, health professionals showed some resistance to people participating in health decisions, although the – Coordinator of a primary health care unit perception is that this has changed over the years, after seeing that the proposals for improvement from the Related to policy formulation, a process of co-production community have been effective. was reported. There is a technical committee responsible for drafting the policy proposal and an advisory commit- The NHF also has a large and productive interaction tee. The latter is participatory, i.e., through a call to the with the community health teams and the community population during community assemblies, with a mandate health units, which, although they initially rejected the 226 International Journal of Health Services 50(2) NHF, today they recognize its importance. There are Action strategies followed by the NHF clear improvements in the places where the NHF oper- Territorial level. In June 2017, the NHF had 750 com- ates, compared to the places where they are not yet munity committees in 82 municipalities throughout the present. country, within 12 of the 14 departments.22 The territo- rial work is at the center of its activities. This territorial – Vice-minister of public health policies action seeks to generate an organizational fabric that strengthens the analysis of the social determination of Community control over resource allocation is thought health and contributes to generate health policies that to be an effective tool to approach health problems. It reflect the concerns and realities of the communities implies a co-production toward resource allocation, and the population. The objective of this process is to where communities help the health system identify provide or co-create knowledge, skills, tools, and resour- where resources can be more effectively used: ces to monitor the development of the health reform. Community leadership structures have been built up The NHF has developed capacities that health personnel for this purpose. The NHS is organized at the level of do not have, such as looking beyond health services to the community, the municipality, the department, the find more essential solutions to health problems. region, and finally the nation. Accountability mechanisms are one of the most essen- – Vice-minister of public health policies tial elements the NHF is working on, in coordination with the health networks of the Ministry of Health. This government initiative toward participatory policy The objective is to supervise and evaluate the correct formulation, channeled through the NHF, emerged in functioning of the health care system. This happens response to the system’s ineffectiveness in addressing through (1) social control, through the offices of the the population’s health demands; the NHF guarantees right to health that exist in most of the health structures, a place where communities can advocate for the right to (2) assessment of the service delivery, (3) evaluation of health and therefore exercise their right to participate in the quality and warmth of health care, (4) control of the health decisions, as the vice-minister of public health supply of medicines, and (5) an overall evaluation of the policies expressed: health care offered. Finally, suggestion boxes exist in most establish- Due to the National Health System’s inability to respond ments, where people can propose improvements or crit- to population needs, community members began to icize shortcomings in health care. The NHF is the key organize and demand their right to health. When the holder for these boxes (volunteers wielding this task are reform process began, the idea was proposed to stimu- democratically elected within the community), which are late the development of a community organization that opened periodically and discussed with the management mobilizes for the right to health, and this is when the of the establishment. Feedback is given to the health NHF was launched. coordinators of these units and hospitals. In 2018, this social control was functioning in 24 – Vice-minister of public health policies national hospitals and in 5 health regions. Since its open- ing, 6,708 applications have been considered and Political will, therefore, is highlighted as a key element of addressed appropriately.23 success of initiatives that seek to address the social deter- minants of health as governments may support, reject, Before, there was no regulation on how decisions were neglect, or manipulate the demands of the population. made and which decisions were made. We had to decide The NHF director adds that, in her opinion, political if we wanted to collaborate with the public institutions, will was the catalyst for the creation of the NHF: to ensure a participation in decision making and moni- toring of health services. This participation is not for The NHF was created to generate a space for commu- individual interest but for the collective community. It nity participation and took advantage of the political is a meaningful participation that really brings benefits opening given by the FMLN government. The popula- to the community. tion was massively involved against the privatization proposals for health care. That is where many of the – Coordinator of an NHF working group organizations came together. We took the opportunity to create that space, the NHF. These mechanisms have facilitated accountability; how- ever, people are still hesitating to call attention on any – Director of the NHF type of negligence by the health personnel, while health Leon et al. 227 personnel also continue to show resistance to respond to First of all, what keeps me here is the satisfaction of suggestions expressed by the population. helping others, then the amount of knowledge that has been given to us and that we can replicate in the com- Sometimes, health personnel have a technical training munities, where now more and more women know their but do not give adequate treatment to people, (. . .) put- rights and what types of violence exist. ting a mailbox made them very angry, it’s like the nurses do not agree with the mailboxes. (. . .) Nurses know – Community leader already what people think and, therefore, do not agree with the mailboxes. A social movement such as the NHF grows stronger as its members develop a sense of belonging. Communities – Community member must feel motivated to continue participating. This is reinforced when people are aware of their rights and According to the NHF perspective, the idea is to move when they feel they can influence decisions. forward in collaboration with the system, to make the system more transparent and more accountable to the People’s commitment is what ensures continuity, because needs of the population, as stated by one of its members: they don’t get paid, nor do they have a management position. We are teammates who try to guarantee the Our work is complementary, because the MoH does the right to health and that is our struggle. Perhaps, their healing part and they see the patients and all that, but we commitment is what ensures that it works. do the knowledge part, the awareness, the promotion, the supervision. We say we follow the complaints that – Member of the NHF live in this town (. . .) so, for us it is important to know their work, to see how we can support, but also in what way we can do what is right. That is our role. Sectoral level. The NHF has developed a broad struc- ture within society where different institutions, organi- – Facilitator on the territorial development (member of zations, and individuals converge in the movement for the NHF) the right to health. One of the most visible advances of this co-governance The NHF has stimulated a wider organization of society, structure (between the NHF and the Ministry of Health) which brings together other organizations that are not at the territorial level is seen at the municipal level focused on the right to health, but for example in the because a participation law27 was created and has facil- demand for justice, or on the electoral issue. It has stim- itated in a practical way how to implement an intersec- ulated organizations that have made broader demands, toral approach with the participation of both citizens for example, the demand against tax evasion and avoid- and other community actors. ance. To have more public funds for social health pro- The NHF is training community leaders for the com- grams. [. . .] There are factors that cause the population bined purposes of organizing participation and supervis- to get sick and die, but the NHF has gone further, has ing health practices and services. These leaders serve as a gone to the fundamental causes that explain what makes bridge between the community and remove decision the population sick, [. . .] is demanding changes in the makers, channeling bottom-up participation. At the com- environment policies. And it demands greater participa- munity level, differences are reported between territories. tion in the development of health laws, according to its The NHF director points out that this flexible way of rising level of empowerment and fundamental interest to working is necessary for a social movement to grow, participate in health policies. always placing communities’ perspectives at the center: – Vice-minister of public health policies The forum is a process under construction, and any social movement is changing in every way, in terms of agenda, in The NHF actively participates in 4 sectoral panels spe- terms of stakeholders. A social movement cannot have a cializing in sexual and reproductive health, the preven- rigid structure, in any sense. The NHF has community lead- tion of social violence to women and children, ership. People feel proud of belonging to the NHF. That pharmaceutical themes, and environmental management motivates people to participate and to strengthen their net- and climate change. works. For example, for the day of the elderly, several com- At the same time, through the reform, the health munities come together to make a joint celebration. system started an intersectoral line of action that gathers different key actors in a shared space: the NHF as the – Director of the NHF community voice, governmental sectors as education, 228 International Journal of Health Services 50(2) and the nongovernmental sector with community organ- One of the limitations perceived by members of the NHF izations and NGOs. is the lack of following and recording the progress of the reform. That part that I told you about being organized is inter- sectoral, because the mayor’s office participates, the One of our limitations is that we do not measure the church participates, some community leaders partici- impact of our participation, what we have achieved – pate, the health establishment, and on some occasions for example, that the national health reform is widely education, the police, the house of culture, (. . .) So that known. Also, we should assess how we have imple- helps us to solve some situations, for example, if we have mented our work and identify areas for improvement. a pregnant adolescent who went to school, we talk to the We made advances in the culture of participation, also director, and we say “look here we have to do more to in supporting the implementation of health reform, and avoid teen pregnancy,” and then we organize an activity in changing the people’s mentality from a medicalized with the school. culture to a health (approach) that really guarantees a better life. To see it as something positive and something – Coordinator of a health care unit that has to do with all policies, and all those things that affect the communities in the territories. Advocacy. A last pillar, but not the least, is the advo- – Member of the NHF cacy work of the NHF on public policies in defense of the human right to health. Advocacy refers to what is How these 3 strategies are put into practice can be illus- linked to the exercise of power in a society, to the redis- trated through an outstanding example related to access tribution of power. This definition implies that the com- to essential medicines and price regulation. In 2007, the munity should have the power to ensure an equitable University of El Salvador published the study share of health resources: “Availability and Price of Essential Drugs in El Salvador during the Second Semester of 2006.”28 This We are focused on participating in a meaningful way, research, conducted with a methodology developed by bringing benefits to our community, oversight and con- the WHO and Health Action International, explored trol of the resources where they are provided. This availability, price, price of components, ability to pay, doesn’t imply that things are given to us, but that we, and comparison with peer studies, based on the interna- as citizens, also contribute to those institutional resour- tional reference prices of Management Science for ces that are assigned to answer the needs of the popula- tion. A conscious and critical participation, a participa- Health (MSH) sponsored by Harvard University. The tion that has the aim to improve the living conditions of comparative analyses showed that drug prices in El the population and bringing changes to our country. Salvador were among the highest in the world.28 This study was complemented in 2009 by a second study29 – NHF thematic group coordinator to unravel the relationships between different stakehold- ers involved in the marketing chain that allowed such The NHF reported that once people are aware of their high prices and other detected relevant irregularities. rights, they are very willing to mobilize resources and From that moment on, the population mobilized, led engage in advocacy activities, as some of the NHF mem- by the NHF, for the approval of the drug law. In 2012, bers expressed: the drug law was approved thanks to citizen advocacy as expressed by the vice-minister of public health policies: When the NHF calls to a concentration, or something mas- sive in San Salvador, we all come together and, as we say, For the approval of the drug law, the NHF had a much we are many, so that helps to strengthen the processes. greater presence than that of the health personnel, and led the citizen pressure which permitted its approval. – Facilitator on the territorial development (member of the NHF) The drug law comprised 4 main aspects: the establish- ment of a single regulatory authority; the elimination of When people are trained and given the space to debate, conflicts of interest within the regulatory body; the people mobilize and organize for the struggle to guaran- establishment of a price regulation mechanism; and tee fundamental rights. quality control. To this day, many interests are still linked to pharma- – Coordinator of the sexual and reproductive health ceutical companies, which is why the NHF, through its working group (member of the NHF) pharmaceutical sectorial panel, remains vigilant to Leon et al. 229 ensure access to essential medicines. As described by the maximize their crop yield at a minimal cost. Many leader of the NHF pharmaceutical sectorial panel: who work in farmer cooperatives for limited periods tend to overwork, as their income depends on volume The process of regulating the drug culminates with the of daily production, which causes them to neglect rehy- law in 2012, but for everything to happen, a whole pro- dration pauses, if they are even allowed to take them by cess of pressure was necessary. Before there were some their crew captains. Their regular diet is poor in essential health tables and from there, not only the health reform nutrients. Use of unprescribed analgesics and alcohol was born but the issue of medicines was also raised. The abuse to kill pain from strenuous physical labor is wide- NHF prioritized this issue and mobilized its forces, and spread within this population group. With limited finan- we managed to eliminate many of the barriers to access cial resources, many do not invest in necessary protective essential medication. Now, we make a permanent evalu- equipment while exposed to highly toxic pesticides. Nor ation that allows us to identify several things: periodi- do they use health services on a regular basis. All these cally we meet with the general direction of medicines factors combined can weaken the body’s immunological (MoH) so they can tell us what the advances are, and system and, therefore, overexpose them to health risks in we can comment on the problems we have identified in their surrounding environment. Furthermore, study par- the territory; in this way we are able to find common ticipants shared a sense that, while government disin- solutions. But, we are also responsible following their vestment in rural areas is evident, the activities of large accountability, who forms part of the board, if they agrochemical corporations are in continuous expansion. are following the quality protocols the law establishes. These stark differences in economic outcomes between different sectors in society have generated a collective In parallel we work with the community. The main man- sense of injustice within rural communities, due to the date of our working group is that we must work to make perception of an existing collusion between government the community aware of what the right to medicines is, and large corporate interests.26 because the population does not have a clear idea of this, Hence, this disease is an expression of inequities they don’t get taught this elsewhere, so we generate that derived from a highly exclusive and inequitable socio- knowledge in the communities, because knowing that we economic model of development and consumption. It have that right makes us do things so that this right is constitutes very high cost health problems at the individ- fulfilled. ual and family level as well as at the health system level. Recognizing these consequences and with a social deter- – Coordinator of the pharmaceutical working group mination approach to the problem, it is essential that the (member of the NHF) plans for the comprehensive care of CKD include an analysis of the health disease process tending to influence Another example of the activities of the NHF is related the entire process, not only on the final effects at the to their approach to the many cases of chronic kidney individual level. Therefore, the strategies have to tran- disease (CKD) in the country. Chronic kidney disease scend the individual level toward upstream structural has become a serious public health problem in the epi- levels, through strategies based on health promotion to demiological profile of El Salvador. The high rate of guarantee the right to health by acting on the protective deaths in rural communities suggest that traditional factors of health; and the development of strategies causes, such as the presence of comorbidities like diabe- focused on social participation and intersectoriality are tes mellitus and hypertension, are not necessarily part of fundamental. the clinical picture but due to agricultural activity. The RIIS Health Networks of the MoH, in partner- Studies have found that chronic and largely unprotected ship with the grassroots-level NHF, play a vital role to exposure to synthetic pesticides in the course of the agri- enhance prevention by involving at-risk farmers in MeN cultural work, particularly to organochlorides and orga- prevention initiatives. The NHF-linked RIIS has estab- nophosphates, is a common experience among affected lished a coordination mechanism with hospital and farmers. Similar disease manifestations have developed health center–based health promoters to develop multi- in agricultural areas belonging to other Central disciplinary teams, including educators and psycholo- American countries, from Mexico to Panama. Its wide- gists, to provide holistic care to MeN patients. The spread prevalence in the region has led to the epidemic NHF created the sectoral panel Environmental being referred to as Mesoamerican Nephropathy (MeN) Management and Climate Change, which, in its advisory or Chronic Interstitial Nephritis of Agricultural capacity, has visited agricultural cooperatives to raise Communities (CINAC).26 awareness of potential risk factors for chronic kidney In an impoverished state, small farmers cannot ade- disease. During these visits, NHF representatives also quately prevent occupational risk factors. They are identify farmers’ health needs and then include them in driven to use cheap synthetic pesticides, as these the public health policy agenda for discussion during 230 International Journal of Health Services 50(2) meetings with MoH representatives at the national and the contextual limitations and address the underlying regional level. At the community level the NHF has also and structural causes of health inequity, toward a com- organized participatory discussion tables and made mitted government aiming at incorporating people’s health prevention announcements regarding MeN voice.19,22 through television and radio. This awareness led a por- The differences between social determination and the tion of farmers to develop homegrown protective strat- social determinants of health are not only conceptual, egies to counter this threat, which have kept them they are mainly social, economic, and political. They disease-free. Furthermore, strong alliances with other are 2 divergent routes, different explanations on causal- organizations at the community level have been created, ity and health risks, with fundamental implications on such as the “alliance against privatization of water,” power relations, and in the understanding of the health- where the NHF has a strong leadership in the advocacy disease process.25 As reported in this study, 2 things are strategies. This example illustrates how the coordination key in the concept of social determination of health: as between MoH and social movement (led by the NHF) is power relations are involved, mechanisms are imple- on the track for managing such a relevant disease under mented to overcome power hierarchies, such as account- the social determination of health scope, taking into con- ability mechanisms and involvement of the community sideration upstream determinants such as pesticides reg- in the formulation of health policies. The other aspect is ulation; intermediate determinants such as water that, to ensure significant and lasting change, upstream surveillance and access, adequate labor behaviors, and determinants of health4 must be taken into consider- regulation; and downstream determinants through ation: this implies addressing structural aspects such as awareness campaigns and improving access to health housing, agriculture, access to water, and social violence. in remote areas; therefore carrying out a comprehensive Different stakeholders and organizations must unite. A management based on the right to health principles. success factor noted by participants was that strong and long-lasting intersectoral action and local community Discussion alliances are more likely to produce policy change. The context has a strong impact on building a basis This case study gives an overview on how a social move- that permits the social movement to move forward and ment can effectively play a role in ensuring community to empower. Previous studies on El Salvador, as e.g., the participation in decision-making processes. We describe experience of “The Construction of the Community how the National Health Forum (NHF) has been devel- oping its activities since the introduction of the health Health System of Guarjila,”15 describe how a strong reform in El Salvador a decade ago.19 social fabric developed in times of war. The community First, the participants in our study reported that, both created strong resilience mechanisms that later trans- from the health system and community’s perspective, formed into organizational capacity and self- participation must be meaningful. It has to evolve management. Many of these communities acquired from a utilitarian model to a social control model organizational experience during the difficult struggles where the community is continuously empowered of the 1970s and 80s, making it possible for peasants toward making decisions based on their needs.30 The to self-govern their small communities when the govern- term empowerment, as described by participants, is ment withdrew from the area. They had to solve vital closely linked to a rights approach, meaning that com- problems such as health, education, food, and other munities feel empowered to advocate for health care as it daily needs, with few resources. Community organiza- is their human right. A strong social movement is essen- tion made it possible to address problems, i.e., involving tial to be able to challenge the existing power imbalance. the larger community in decision making. Solidarity and In the Salvadoran context, this was possible because of the constant search for equity were ensured through dif- the following reasons: (1) the political will that was cre- ferent community processes.32 ated with the entrance into government of the FMLN, In line with a review of experiences,33 which demon- revoking the neoliberal health policies that had been in strates that comprehensive approaches to address the place for a long time, and (2) the strength of a histori- social determinants of health effectively need to explic- cally organized population. As reported by Espinoza itly tackle issues of participation, equity, governance and and colleagues,31 previous neoliberal governments did the politics of power, decision making, and empower- not promote the right to have access to essential precon- ment, some common elements can be highlighted: ditions for health but only the right to have access to health care services. The health reform moved away • Political will and policy coherence: The NHF was cre- from a biomedical approach focusing mainly on curative ated as one of the main elements of a comprehensive actions, individual responsibility, and lifestyles, with health reform, meaning that political leaders recog- little concern for the state’s responsibility to modify nize the relevance of social participation in the Leon et al. 231 process off public policy making and the setting of a and health system personnel, who accompanied the field local health agenda. research group. • Decentralization strategies: A territorial approach aims at building strong leadership at all levels, in par- allel with the health system. This has helped redirect Conclusion resources to meet actual needs of the communities. A The Salvadoran experience in social mobilization, led by similar experience in neighboring Nicaragua stresses the National Health Forum, and its role in the develop- the importance of local governance.34 ment of the National Public Health System over the • Knowledge of participation generated in fragile socio- period 2009–2018, provides a strong example of commu- political context, throughout the years: Strong trans- nity participation in health. The NHF’s focus on the role fer of organizational and participation knowledge of participation strategies, empowerment, and co- from preexisting organizations and further training governance with health institutions such as the of community leaders and health professionals to Ministry of Health under the social determinants of work together is needed. health scope. The National Health Forum, a nationwide • An intersectoral approach with the creation of the- popular movement belonging to the People’s Health matic working groups, focusing on prioritized areas Movement,36 plays a central role in the strengthening identified by the community: The need for an integrat- of the health system.35 ed approach and comprehensive public health and development plans responds to the need to provide Acknowledgments “windows” for support that integrates people’s own This research was possible thanks to support from members of vision and struggle. the Ministry of Public Health Policies, the National Health • Advocacy work as transversal action: Working with Form (FNS), and the Public Health Policies Observatory, other stakeholders on the right to health leads to an University of El Salvador, which facilitated access to different understanding that health is context-determined, and communities that might otherwise be difficult to reach because therefore other factors such as access to water, farm- of ongoing social violence. We appreciate all the help and sup- ers’ working conditions, and adequate regulatory pol- port given by Queen Margaret University specially Claire Mc icies must be included in the struggle for the right to Lellan, Jone Garcıa, and Alastair Ager. The authors would health. Alliances increase the likelihood of advocacy especially like to thank Eduardo Espinoza, Margarita success, as they are more likely to produce policy Posada, Ma Isabel Rodriguez, Angela Elıas, Rina Abrego, change. Morena Murillo, Henry Palacios, Rene Domınguez, Alex Martınez, Emma Cortez, Moises Garcıa, Juana Rivas, Jorge Social movements are important agents for social Irazola, Luzmila Argueta, Guillermo Argueta, and community change because they raise awareness on people’s health members for their warm welcome. Montserrat Le on Garcıa is a rights and challenge both the process and the outcome of PhD candidate at Universitat Aut onoma de Barcelona, and social and political decision making at local and global this work will be part of her PhD work on shared decision levels.35 The example of the NHF through organized making. communities and strong participation strategies can play an essential role in ensuring the implementation Declaration of Conflicting Interests of adequate government policies to address health The authors declared no potential conflicts of interest with inequities. This is what is required to assert the right respect to the research, authorship, and/or publication of this to health. article. Limitations Funding The limitations of the analytical framework applied in The authors disclosed receipt of the following financial support this study reflect the current lack of evidence-based the- for the research, authorship, and/or publication of this article: oretical frameworks to grasp and generalize the com- This research was funded by the NIHR Global Health plexity of community processes. This study aims to Research Programme 16/136/100, Queen Margaret contribute to the growing body of evidence on commu- University. The views expressed are those of the authors and nity participation and empowerment. Further systemati- not necessarily those of the UK National Health Service, the zation of this experience is recommended for future NHR or the UK Department of Health and Social Care. research. In addition, the high level of community vio- lence in El Salvador at times limited the scope of the ORCID iDs fieldwork carried out. 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Care: from Alma Ata to the era of globalization. Soc Currently, she combines her clinical work in primary Med. 2009;4(2):121–127. 33. Barten F, Mitlin D, Mulholland C, Hardoy A, Stern R. health care with health research and activism for the Integrated approaches to address the social determinants right to health. of health for reducing health inequity. J Urban Heal. 2007;84(1):164–173. Nicole Vidal, BA, MSc, MScRes, PhD, is a social 34. Montiel RP, Barten F. Urban governance and health anthropologist with research expertise in global health, development in Le on, Nicaragua. Environ Urban. public health, and qualitative methods. She has a partic- 2005;11(1):11–26. ular interest in health systems research, primarily focus- 35. De Ceukelaire W, De Vos P. Social movements are ing on health service delivery in low- and middle-income key towards universal health coverage. Lancet. 2009; settings. From 2016 to 2019, she worked first as a 374(9705):1888. research assistant, then research fellow and lecturer at 36. Hurtig A, San Sebastián M. The people’s health move- the Institute for Global Health and Development at ment: what is it and should we care? Scand J Public Health. 2005;33:236–238. Queen Margaret University. Her previous research has focused on increasing health care accessibility for mar- Author Biographies ginalized communities and investigating the role of patient and provider relationships. She has been Montserrat Leon, BPh, MPH, PhD candidate, is a public involved in research projects in numerous countries, health researcher currently developing her PhD dissertation including Peru, El Salvador, Latvia, Uganda, Sierra on shared-decision making in the clinical context at Leone, and Cambodia. She holds a BA in anthropology Universidad Aut onoma de Barcelona, and she holds a from the University of California–Santa Barbara, an grant from Instituto Carlos III. Her field of interest is MSc in social anthropology and an MSc by research in evidence-based research with a special focus on equity global health from the University of Edinburgh, and a and community engagement. Her previous work has been PhD from the Institute for Global Health and developed in addressing social determinants of health under Development at Queen Margaret University. a community perspective. She has participated in several research projects with the Biomedical Research Institute Keven Bermudez is a social scientist and researcher, with Sant Pau (IIBSant Pau), Iberoamerican Cochrane Centre, experience in social care. He also worked with rural com- Health Prevention and Promotion Department (Madrid munities on pesticide intoxication and its prevention. Salud, Spain), and Institute for Global Health and Development at Queen Margaret University. Pol De Vos, MD, MPH, PhD, worked as a public health specialist at the Institute of Tropical Medicine in Marta Jimenez is a specialist in family and community Antwerp until 2017, with a regional focus on Latin medicine. She completed her postgraduate work in inter- America and Cuba. At the time of this research, he national health at the Institute of Tropical Medicine of was deputy director of the Institute of Global Health Antwerp (Belgium) and a master’s degree in human and Development of the Queen Margaret University in rights and governance at the Autonomous University Edinburgh, Scotland. Since January 2020 he works of Madrid (Spain). She conducts research on social again at the Institute of Tropical Medicine in Antwerp, inequalities in health, primary health care, community in the Development Office. participation, and noncommunicable diseases, mostly in low- and middle-income countries. She has collaborated