Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 https://doi.org/10.1186/s12939-020-1140-x RESEARCH Open Access Comprehensive primary health care and non-communicable diseases management: a case study of El Salvador Marta Jimenez Carrillo1* , Montserrat León García1,2, Nicole Vidal1, Keven Bermúdez1 and Pol De Vos1 Abstract Background: One 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. Methods: 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. Results: 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. Conclusions: 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. Keywords: Comprehensive primary health care, Non-communicable diseases, El Salvador, Community participation * Correspondence: majicauam@gmail.com 1 Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 2 of 17 Introduction Comprehensive Primary Health Care (CPHC) principles The growing burden of non-communicable diseases and values: the right to health with equity and solidarity, (NCDs) represents one of today’s greatest challenges in through quality health care that is free at the point of de- public health worldwide and it has been highlighted the key livery [16]. In over 10 years (2009–2019) the public health management from PHC [1]. NCDs are the leading cause of expenditure of El Salvador increased 33.7% [17], 67% of global mortality and disability worldwide (71% of all deaths this amount being spent by the public health sector (com- globally) [2], with a rising burden in low- and middle- pared to 59% in 2007) and 33% by the private sector (of income countries [3] (LMIC). Each year, 15 million people which 27% was out of pocket expenditure, and 6% through die from an NCD between the ages of 30 and 69 years; over private insurers). Between 2008 and 2013, the country’s 85% of these “premature” deaths occur in LMICs [4]. The income-poverty rate decreased from 46.4 to 34.8%, and burden created by NCDs undermines individual and family extreme poverty dropped from 15.4 to 9.1%. Similarly, El well-being and hampers social and economic development Salvador’s Gini coefficient (0 less inequality-1 more in- [5]. The rapid rise in NCDs is predicted to impede poverty equality) improved from 0.47 in 2009 to 0.41 in 2013 [18] reduction initiatives in low-income countries, particularly and the Human Development Index (0–1) moved by increasing household costs associated with health care. from 0,529 in 1990 to 0,666 in 2013 [19]. The multifactorial aetiology of NCDs [6] implies the need The Comprehensive Primary Health Care strategy [20] for the implementation of integral, intersectoral [7] and (CPHC) implies that the ‘Primary Health Care’ concept is political strategies through accountability for health impact not limited to ‘well organized first line services’. It refers to [8]. Health in all policies [9] involve an explicit concern for an integrating approach for the whole national health sys- health in all areas of public policy. This seeks to ensure tem. First line health coverage has expanded by doubling public policies across sectors systematically consider the the number of health units. A special focus was put on in- health implications of decisions, seek synergies, and avoid creasing coverage in the poorest municipalities. The com- harmful health impacts in order to improve population munity level of PHC networks are health units where health and health equity. Moreover, NCD management re- community teams effectively bring healthcare closer to re- quires an opportunistic case finding for assessment of risk mote populations. The budget for PHC increased from 140, factors, an early detection of disease, the identification of 18 USD millions in 2008 to 256,73 USD millions in 2018. high risk status, a combination of pharmacological and psy- Although a large amount of quantitative data has been chosocial interventions and a long-term follow-up with recorded by the Salvadoran Ministry of Health (MoH) and regular monitoring and promotion of adherence to treat- others since the implementation of the Comprehensive ment that requires a comprehensive approach based in Health Reform in El Salvador, to date there has been no PHC [10]. qualitative study of these development providing fan in El Salvador, located in Central America, has a popula- depth understanding of the reform process. tion of around 6.3 million inhabitants (data for 2016) The study was focused on the NCDs management in [11] of which 61.7% of the population live in urban PHC. Therefore, a case study method was applied to areas, while 23,7%, almost one third of the Salvadoran explore the functioning of the network model of the population, live abroad. The median age is 26 years, and Salvadoran PHC, its comprehensive approach in the the life expectancy is 69 years for men and 78 for management of NCDs in PHC settings, as well as the women. El Salvador is considered a country with a fragil- role of social participation to strengthen NCDs services. ity context as it has one of the highest homicide rates in This work relates to other Global Health research from the world [12]. Young people are the most affected by the NIHR Research Unit on Health in Fragility (RUHF), at violence, the war between gangs (“maras”) remains a the Institute for Global Health and Development of the serious social problem, leading to extensive displacement Queen Margaret University in Edinburgh, emphasizing and thousands of deaths every year. The UN has classi- strengthening the provision of quality care for Non- fied El Salvador as one of the deadliest countries in the Communicable Diseases and mental health in fragile set- world outside of a war zone. NCDs are a leading cause tings: Syrian refugees and host communities in Lebanon, of early death among the adult Salvadoran population fragile communities in Sierra Leone, and El Salvador. [13]. During the 2011–2015 period, cardiovascular dis- eases accounted for 12.0% of the total deaths registered Methods nationwide, followed by chronic kidney disease with Data collection & sampling 6.3%, cancer with 5.4%, and diabetes mellitus with 3,0% The case study gathered information through a qualitative [14]. For 2015, the premature mortality rate due to car- assessment consisting of semi structured interviews and diovascular diseases was 59.3 per 100.000 inhabitants. official document reviews (mostly from the Salvadoran In 2009 a Comprehensive Health System reform [15] MoH as well as international health organizations as was started in this Latin-American country based on the PAHO and WHO). Both interviews and document review Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 3 of 17 explored three questions:1. How is the PHC organized in patients and PHC providers’ experiences and assessing El Salvador? 2. What is the current NCDs approach in official documents such as the “National multi- PHC? 3. How is community participation playing a role in sectorial strategic plan for a comprehensive approach PHC for NCDs prevention and care? to NCDs” [23] . The objective of this analysis was to contrast and We conducted 26 interviews using a semi-structured complete the information provided in the interviews interview guide to 14 chronic care patients and 12 PHC and find new data that will contribute to the fulfilment staff members as shown on Table 1. Purposive and snow- of the objectives of the implementation of CPHC and ball sampling methods were used to recruit participants. its approach to the NCDs. A case study is an appropri- Staff members and patients were initially identified by the ate methodology when a holistic, in-depth investiga- coordinators of the health units and interviewed at their tion is needed and is designed to bring out the details place of choice, either in the workplace or domicile. Inter- from the viewpoint of the participants by using mul- views took around an hour and participants were free to tiple sources of data [21]. By drawing upon both quan- stop the interview at any time. titative and qualitative data, case study methodology Patient inclusion criteria was being over 35 years of helps to explain both the process and outcome of a age, living with an NCD, and receiving care from the phenomenon within its real-life context [22]. In this PHC units. The age group was determined based on the empirical inquiry the contemporary phenomenon in- WHO-defined ‘higher risk group’ for NCDs [24]. The 14 vestigated was the development and organization of NCD patients interviewed suffered from Hypertension, CPHC in El Salvador since 2009, particularly regarding Diabetes Mellitus type 2 (DM 2) and/or Chronic Kidney NCD management, considering the voice of chronic Disease (CKD). Table 1 Chronic patients interviewed and Staff member interviewed working at different levels of PHC Chronic Patients NCD suffered Sex Age Marital status Children Level of education Occupation 1. Hypertension F 44 Accompained 6 Primary education (until 8 years old) Homemaker 2. Hypertension F 77 Married 6 (2 died) Primary education Seamstress 3. DM type 2 F 57 Married 12 (5 died) Illiterate Street food vendor 4. Hypertension F 70 Married 6 – Homemaker 5. Hypertension M 77 Widow 6 Primary education Farmer 6. DM type 2 F 62 Widow – Basic (1 year) Domestic worker 7. Hypertension + CKD F 49 Separated 4 Primary education Homemaker 8. Hypertension F 70 Accompained 8 (2 died) Primary education Homemaker 9. DM type 2 F 61 Married 3 Illiterate Homemaker 10. CKD M 58 Married 6 Primary education Farmer 11. Hypertension M 80 Married 4 Illiterate Farmer 12. Hypertension + CKD M 66 Accompained 6 (2 died) Illiterate Farmer 13. Hypertension + CKD F 61 Married 3 Illiterate Homemaker 14. Hypertension F 64 Married 7 Primary education Cook PHC staff Professional profile Sex Coordination level 1.Departamental Coordinator Male (M) 2.&3.Intermunicipal coordinators M 4.Regional coordinator M Interdisciplinary PHC team 5. Health educator Female (F) 6.Sanitary inspector F 7.Medical student completing year of social service M 8.General practitioner M 9.Family doctor F 10.Nurses F 11.Pharmacist F 12.Laboratory technician M Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 4 of 17 Staff member interviews were included to incorporate a A thematic framework [25] method was applied for comprehensive understanding of the PHC system by pre- the analysis. A non-pure deductive approach was used senting the providers’ perspective of NCD care. Health to develop an open coding system around the topics professionals working in different levels within PHC (in- based on the content and context of patient/provider in- ter-municipal, departmental and regional level) were se- teractions, work practices and patient/provider experi- lected to participate. The study included staff of basic, ences of care. After grouping codes into potential intermediate and specialized community health units, themes, a purposive thematic framework was developed seeking to collect a variety of viewpoints and experiences. through the application of a reflexive approach and the Inclusion criteria for staff members interviewed were to triangulation of data [26] through different meetings be actively working at some level of the PHC system at (personal or virtual) of the research team to identify the time of this research and having worked at least for a consistencies or variations across the dataset. year in PHC since the health reform started in 2009. The interviews took place between March and August Ethical considerations 2018 in three different departments of El Salvador: Chala- The study was approved by the Salvadoran Ethical Com- tenango, Morazán and Bajo Lempa. Acknowledging that mittee (CNEIS/2018/005_A) and by the Queen Margaret El Salvador has 14 departments, the aim of this case study University (QMU) Research Ethics Panel. Prior to each was to see some representative pattern in the management interview, an information sheet was given and explained of NCDs in PHC more than trying to generalize the data to each participant, after which they were invited to sign for the whole population or making and in-depth evalu- an informed consent form. Interviews were recorded ation of the PHC system itself. Our interest was to closely using a digital voice recorder. All data involving partici- investigate contemporary real life of people living with pants were made anonymous at the start of data collec- NCDs in El Salvador and how the implementation of PHC tion. Participation in the research project was voluntary has had an impact on its management as well as on the and no incentives were given. care offered by staff members of PHC. The three depart- ments were selected considering socio economic, histor- Results ical and geographical disparities between them (with Findings are presented through quotes from interviews special focus in reaching remote areas), to represent vari- with PHC workers and chronic patients. The thematic ation in size of health infrastructure, population served framework (see Table 2) was structured in 3 main and prevalence of chronic conditions. The selection of de- themes: The Salvadoran PHC system is firstly described partments was also influenced by security factors during based on the perception of the stakeholders and docu- fieldwork and willingness of the PHC care team to partici- ments reviewed emphasizing its main characteristics. pate in the research. Access to data was facilitated by Secondly, the specific management of NCDs in PHC was members of the MoH, social movement members (NHF), assessed in terms of policies implemented, prevention and medical staff from the health facilities where data and health promotion strategies for NCDs and longitu- were collected. dinal care. Finally, the community perspectives and the potential of social participation to strengthen NCD care is presented. The perception of changes since the imple- Data analysis mentation of the health reform in 2009 is a crosscutting All interviews were conducted by the primary re- theme reflected in most of the codes. searchers in their mother tongue (Spanish) and were Regarding the background of the chronic patients inter- digitally recorded. For data analysis qualitative informa- viewed for this case study, their median age was 64 years tion collected was transcribed. After transcribing, audio old. Most of the participants had a low level of education recordings were permanently deleted. Then all qualita- achieving primary education until the age of 8 and were tive data were coded, both manually and then using able to read and write. Regarding their marital status, most Digital coding with NVivo® version 10. of the participants were married or accompanied and Table 2 Coding and thematic framework Themes PHC Organisation in El Salvador NCD Management in PHC Social Participation in PHC CODES Integrated comprehensive health networks Health policies for the management of National Health Forum Community health networks and interdisciplinary NCDs Accountability PHC teams Prevention of NCDs and health Right to Health offices Coordination between levels of care promotion Community-based peer support groups for Intersectoral participation and health in all policies Longitudinal care of NCDs NCDs Accessibility Quality of care Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 5 of 17 those who weren’t were mainly widow women whose hus- of the department. Following this, the coordinator band was either killed during the war or through social shares them in the regional meeting which is helping violence. The participants had an average of 6 children, to organize better health services in PHC” - Regional and some have lost children before the age of one (infant Coordinator. mortality has decreased from 21,52 in 2009 to 16,8 in 2017 (https://www.indexmundi.com/g/g.aspx?c=es&v= Different levels of decision-making exist at municipal, 29&l=es)). Most of the participants had sons or daughters departmental, regional and national level (Fig. 1). The living abroad (mostly in the USA); family remittances departmental level, called the Basic Integrated Health benefit more than 20% of households in El Salvador. The System (SIBASI by its Spanish acronym, Sistema Básico chronic patients interviewed also mentioned their grand- de Salud Integral), is the basic operational structure of children with great concern as some of them have been the NHS where the Primary Health Care system is artic- killed or threatened by the social violence. In terms of oc- ulated with the other levels of care, and with community cupation, men are more likely to work in agriculture, a organizations. These meetings facilitate the sharing and fact that is related with the high prevalence of chronic dissemination of information and the coordination of ac- interstitial nephritis of agricultural communities (CINAC) tivities to ensure a comprehensive care under the equity linked to pesticide intoxication among these workers [27]. scope. Women interviewed worked in relation to care (inside and outside home). Chronic patient interviews covered aspects “As a Basic Integrated Health System we hold meet- of their experience receiving care at the PHC facility and ings every 2 weeks in order to monitor acute and included questions on treatment initiation, care and sup- chronic diseases and we evaluate health indicators port, communication with providers and quality of care as (mortality and morbidity rate within the region, well as their perception of change in the management of etc.). Depending on the number of detected cases, we their NCD after the implementation of the health reform decide which activities should be prioritized” - De- and role of social participation. One of those patients was partmental coordinator attending to community-based peer support groups for NCDs. In relation to the health workers interviewed, those One of the main purposes of these networks is the man- working at the coordinator level were all men whereas in agement and provision of health services to ensure a the interdisciplinary PHC team 5 out of 8 are women. The continuity of care: promotion, prevention, diagnosis and most recent MoH data shows that the staff members treatment, as well as in disease management, rehabilita- working in the NHS are 61.9% women and 38.1% men tion and palliative care. The coordination within the dif- [17]. ferent levels of the integrated and comprehensive health networks helps to optimize resources, for example dur- Primary health care organization in El Salvador ing medicine shortages. Integrated and comprehensive health care networks El Salvador’s PHC system is organized through ‘integrated “We have good coordination between the micro- and comprehensive health networks’. Their objective is to networks. If some medication is missing, we coordin- provide equitable, comprehensive and integrated health ate it in order to avoid drugs shortage.”- Intermuni- services to individuals and communities, for a well- cipal coordinator. defined population, within a specific geographic area. This organization has contributed to have a better follow-up of “If for example there isn’t a specific medication in the the epidemiological situation for each territory region, we put them in contact with other places where there is enough supply and we try to avoid through “Epidemiological surveillance, also of NCDs, is en- our ‘integrated and comprehensive health networks’ sured, and every Community Healthcare Unit has the medicine shortage”- Regional coordinator. identified its chronic patients for follow-up and medication. Data on drug supply are included in this surveillance. In micro-network meetings these Community health networks & interdisciplinarity health data are used to prioritize health services at The Comprehensive Primary Health care in El Salvador municipal level”- Intermunicipal coordinator. is organized in Family Health Community Units (UCSF by its Spanish acronym- Unidades Comunitarias de “We have the ‘Integrated Health Service Delivery Salud Familiar). These are the facilities of the First Level Networks (IHSDNs) health indicators’ which include of Care, where integral health services of different com- NCD data. The departmental level analyses the epi- plexity are provided and they are classified as basic, demiological surveillance data of all micro networks intermediate or specialized Family Health Community Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 6 of 17 Fig. 1 Integrated and comprehensive health networks and management councils (left section), social participation spaces and intersectoral participation (right section) Units. In El Salvador there are two types of PHC teams “We work in a network, that means that each Com- [28]: The aim of having two type of teams is on one munity Family Health teams are connected with the hand to improve access in remote areas including spe- Community health team with specialized within the cialized care, and in the other to provide care at the fam- area as well as with community organizations in ily level rather than individual level. order to properly approach the real needs of the -Community Family Health Teams (Family ECOS, by population”- General practitioner (GP). its Spanish acronym Equipos Comunitarios de Salud): composed of a medical doctor, a nurse, a nursing assist- The Family and specialized ECOS are intended to know ant, three health promoters, and a polyvalent staff mem- the reality of their environment, identify with the com- ber. They work in basic and intermediate Family Health munity and, with the help of community leaders and Community Units. In rural areas of small municipalities where there is presence of the National Health Forum, with dispersed population, the family ECOS has an ap- consider the dynamics of the social determinants of the proximate population of 600 families under its scope of health of the population. This is done by analysing the responsibility. In large urban areas, Family ECOS have health situation of the persons by traditional biological 1800 families within their scope of responsibility. risk factors and identifying vulnerabilities of their fam- -Community health teams with specialities (Special- ilies as well as considering social risks (violence, un- ized ECOS): comprising a family doctor, a paediatrician, employment, etc.). Their purpose is to ensure the an obstetrician/gynaecologist, a psychologist, three den- adequate follow-up of the health of their population of tists, a health educator, a sanitary inspector, a statistical responsibility. assistant, a physiotherapist and two laboratory techni- cians. The specialized ECOS have approximate 6000 “My work includes three types of populations: the families, 30,000 people under its scope in rural areas primary population is the patient with a chronic dis- and in average 9000 families, 42,000 people in urban ease. The secondary population is the family of the area. person, and the tertiary population is the community Each Family ECOS works in coordination with its cor- as a whole.” - Health Educator. responding Specialized ECO, integrating a networking, being responsible for the health of the ascribed popula- Interdisciplinary PHC teams help to address health in a tion, incorporating the needs identified by the popula- comprehensive way, addressing both preventive and cura- tion itself in order to be responsive. tive health care. It also promotes health infrastructure Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 7 of 17 development and community involvement, thereby pro- health staff still do not trust the strengthened primary moting sustainable improvements of community health. care services in their follow-up of health problems. As a result, hospitals remain saturated with patients having to “We work as a team, even if each of us have specific travel long distances for routine follow-up. duties, we try to give a comprehensive care working together with the rest of the PHC team”- Sanitary “From the time I make the referral at the first level, inspector. it takes about 4-6 months for a patient to make an appointment with a nephrologist or another hospital Community health promoters play a key role in the co- specialists” - Family doctor. ordination between patients and PHC staff. They are the actors in contact with patients in the community and “When hospitals diagnose a chronic patient, they who inform the rest of the PHC team about particular sometimes do not inform the first level of care. Some situations considering the fragile context of the country hospitals have not yet understood the health reform due to violence. They discuss an intervention plan or in which PHC is the system’s frontline, where patient organize appointments to make sure that patients can be follow-ups can perfectly be conducted. Instead of re- attended by a specialist and inform health staff when moving the burden of so many patients being treated complications arise. Health promoters also identified pa- at the hospital, they do not make referrals because tients that have never had contact with the health system they think first line personnel has not enough train- before in remote areas and are in charge, together with ing ... Finally, the most vulnerable people are the the rest of the PHC team, of community health preven- most affected as they cannot afford the transport to tion and health promotion. In this sense, an essential reach the hospital” - Regional Coordinator. strategy of the 2009 health reform has been fulfilled: the strengthening of the health promoter as an essential Intersectoral participation and health in all policies element at the first level of care. The strengthening of intersectoral approaches constitutes a strategic axis of the health reform, aimed at focussing on “Our ‘community eyes’ are the health promoters. the social determination of health. At the national level, They identify patients who have some risk factor” - the Intersectoral Commission of Health (CISALUD, by its Regional Director. Spanish acronym Comisión Intersectorial de Salud) brings together more than 40 public, autonomous, private, and “Then the health promoters say, ‘Come doctor, I grassroots institutions to address health issues and consid- want you to accompany me to the house of a dia- ering the social determinants of health. This intersectoral betic patient.’ And we go to the patient’s house, approach responds to the Health in all policies premise, in where they are given counselling, and where we also which participation involves not just health but other sec- see what the patient’s living environment is like” - tors for local development. The strategic role acquired by GP. CISALUD and the departmental councils, covers the iden- tification, analysis and proposal of joint strategic lines and Due to the high burden of Chronic Interstitial Nephritis activities for occupational health and safety, health promo- of Agricultural Communities (CINAC) in El Salvador tion and the prevention of diseases, integrated vector [29], in specific areas where this chronic disease is highly management and pregnancy in childhood and adoles- prevalent a nephrologist is part of the PHC team. cence, besides promoting territorial management spaces. Departmental health councils are established as instru- “The nephrologist is oversaturated with renal pa- ments for the participation of health professionals, trade tients, at the first level of care. Even if he tries to give unions, cooperatives and NGOs working together with an high-quality attention, it is difficult to do so with intersectoral approach. such a heavy workload. He also works at the tertiary level of care in Jiquilisco’s hospital on Mondays and “This intersectoral approach is strategic, as it implies Fridays”- Intermunicipal Coordinator. the coordination with other institutions. At local level this intersectoral committee is formed by: directors of Coordination between levels of care community associations, NGOs, school directors, Some of the participants interviewed pointed out that it teachers, the police, etc… They meet periodically, and can take months before a referred patient is seen at the we inform them of difficulties we face, the epidemio- hospital. Moreover, when patients had an appointment logical surveillance, etc… to work together and im- at the 2nd or 3rd level of care, they rarely return to the proved health outcomes trough coordination of the first line services for follow-up. Probably some hospital different actors”. - Departmental coordinator. Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 8 of 17 Accessibility “Transport is a weakness that we have as a special- Accessibility is defined as the possibility for individuals to ized Community Health Unit, as some people come receive the necessary medical assistance for their health from remote areas and there is no adequate public problems, without geographical, economic or cultural bar- transport for them”. - Intermunicipal Coordinator. riers [30]. Accessibility can be understood as a condition of equity and as a component of the quality of care in gen- The specialized PHC team travels twice per week to eral [31]. Since the health reform began, the dominant dis- basic and intermediate Family Health Community Units course of the patients interviewed refers to improvements in order to facilitate access to specialists for those living related to free access to care - including the abolition of in remotes areas. With programmed community visits of consultation fees and the overall reduction of out-of- the specialized CHT they ensure monthly visits to every pocket payments - better access to health care units, and basic and intermediate Family Health Community Units to medicines and laboratory tests. In this sense, the health belonging to a specific geographic area. Nevertheless, the reform abolished consultation fees, known as ‘voluntary specialized team also express difficulties in reaching re- fees’, within the health system. This substantially reduced mote areas. the out-of-pocket costs (while indirect costs, e.g. for trans- port, and some laboratory tests remain). Patients per- “We conformed a specialized CHT, and we visit each ceived this as facilitating access to care. basic and intermediate unit at least once per month. Chronic patients for the family doctor, children for “The abolition of voluntary consultation fee has the paediatrician...” - Family doctor. helped us to have more access to the health system, be- cause before the reform, we needed money to be able “There are very remote areas that in the rainy sea- to pay the consultation”- Man with hypertension. son are flooded. Despite the geographic difficulties in accessing these sites, we also try to reach these “I no longer have to pay the ‘voluntary fee’ every time places.”- Health educator. I go to the doctor. That has been a great change for me and my family”- Woman with Diabetes Mellitus “Even though the health unit is closer to my house, I type 2. had an emergency once and the nurse came to inject me at home”- Woman with Diabetes mellitus type 2. According to the last accountability report published by the MoH of El Salvador in 2018 [32] there are currently “We organize home visits where the whole interdis- 753 Family Health Community Units, 577 Family ECOs ciplinary team goes to see a patient with special and 39 Specialized ECOS all over the country focusing needs. The doctor, nutritionist, psychologist, physio- to increase access in the poorest municipalities. therapist, health educator and nursing, we all go”- Health educator. “When the health reform started, we started to focus on reaching population groups that never came to Concerning the access to medication and laboratory tests, the health units. This is what I do, apart from work- the main discourse of the chronic patients interviewed ing with the community” - Sanitary inspector. reflected the perception that access to free medicines is provided in PHC Units. But participants also commented “Before 2009 I had to take the bus to reach the on shortages in some Family Health Community Units. health unit, but they opened a new one close to my house and l normally come walking now” - Woman “Access to medicines is much better now than before with hypertension. because we used to pay for all of them and now the government pays all that...” - Woman with “I take a moto-taxi to reach the health unit that is hypertension. close to where I live. Before the health reform every time I was sick due to my illness, I had to go to the “They give us treatment in the health unit pharmacy hospital that it is far away from here and I couldn’t where we get our prescriptions, but sometimes there afford a moto-taxi until there” - Man with Chronic is not enough medication” - Woman with Kidney Disease. hypertension. Nevertheless, some geographical limitations persist, due Although the health reform has facilitated the transport to the lack of public transport and the limited access to of laboratory tests from basic health units to health units an ambulance (with gasoline) in case of emergency. with laboratories, some barriers still exist with transport Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 9 of 17 due to long distances from and to remote areas. Inevit- Health policies for the management of NCDs ably, some laboratory tests cannot be realized at the first Interviews with staff members and the analysis of official level, and the patients have to go to the hospital or to documents from the MoH revealed that the following the private sector. policies were of support in designing an approach to NCDs (Table 4): “In basic health units, there is a specific day of the week when lab samples are taken by the nurse, and Prevention of NCDs and health promotion a polyvalent person from the staff brings the sample In relation to health education and health promotion, to the lab (...) There are specific laboratory tests that the implementation of the CPHC has provoked a shift I have to send for analysis to private laboratories”. from an assistance care model to a preventive model -Laboratory Technician. that fosters a community perspective. However, some PHC staff mentioned that more prevention and promo- Finally, in terms of accessibility to the health profes- tion efforts must be done. sionals, even though the number of staff members work- ing in PHC has increased in 6000 more workplaces since “The NCDs strategy based in PHC is aimed at the 2009 to 2015, the dominant perception of the stake- prevention and health promotion approach that will holders is that more work force is needed in PHC. avoid many deaths emphasizing they quality of life of chronic patients while also preventing others from “It would be nice to have more health personnel in getting sick” – Intermunicipal coordinator. the Family health Community Units, especially health promoters as they are the ones often coming “Children and adolescents are not aware of the for home visits”. Woman with Diabetes Mellitus type NCDs as they see it as something far away, in order 2. to improve awareness, especially among young popu- lation, the use of mass media and health promotion “Even if the number of workforce has increased a lot activities in schools can be very useful” – Health since the beginning of the health reform, it is import- Educator ant to keep investing in human resource in order to assure quality and access” - Regional Coordinator. During the interviews, several preventive actions for NCDs that have been implemented in PHC were men- tioned (see Table 5 below). Quality of care Some interview items regarding the quality of care in Longitudinal care of NCDs in PHC PHC included in the interviews pointed to how patients Longitudinal care allows the continuous evaluation of pro- felt they were treated by health workers or to the quality gress as well as the impact of the disease and disability on of the information received in PHC Units. the chronic patient’s daily life. Attention is better adapted to The results show what participants understand by qual- specific needs and tends to show a greater capacity to re- ity of care [33] and were summarized along the following spond to recommendations [34]. The Salvadorian PHC sys- dimensions (see Table 3 below): quality of care by health tem seeks to improve the quality of care and to have better workers, waiting time, attention time in consultation, health outcomes, therefore improving longitudinal continu- health workers’ communication skills (including, the adap- ity of care. There is evidence of better preventive care, better tation of language to the patients’ educational and socio- use of health services, more appropriate and timely assist- economic backgrounds), information and mechanisms to ance, fewer preventable diseases, fewer hospitalizations, bet- make suggestions and complaints as a PHC user. The ter compliance with prescribed pharmacological treatment dominant discourse of chronic patients interviewed was a and lower total costs among those patients treated by their positive perception regarding the quality of care in PHC. family doctor/general practitioner over time [31]. In the table below (see Table 6), the main pathways of care for an NCD in PHC [diagnosis, follow up and com- NCD management in primary health care plications] are shown, as well as the main conclusions Secondly, interview questions were focused to explore after the analysis of the interviews and an illustrative the management of NCDs in PHC. The different policies quote of each of them. for NCDs were analysed through the participants’ per- spectives as well as the prevention and health promotion Social participation in PHC programmes and the longitudinal continuity of care of The Ministry of Health of El Salvador made a political and chronic patients in PHC. strategic commitment to create comprehensive PHC with a Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 10 of 17 Table 3 Perception of quality of care in PHC Quality of care Conclusions Illustrative stakeholder’s quotes Quality of care Chronic patients mainly expressed having received adequate “In the health unit, I have always felt well treated. The nurses are provided by health care. very kind to me. To be honest I cannot complain; they have all workers in PHC been very nice every time” Woman with diabetes. “Here, in the new health unit, I feel well-treated (...) The nurses and the doctor are nice to me” Man with CKD. Waiting time Waiting time is shorter in PHC than in hospitals. “Before the health reform every time I had a problem because of In PHC, the waiting time for specialist consultants who my blood sugar was too high or down I had to go to the attend patients by appointment was shorter than the GP’s hospital and wait for hours, now I just walk to my nearest health (waking patients)". Unit” Woman with Diabetes. “When you go to see the general practitioner, they give you a number at the entrance of the health unit and then attend in numerical order. When the specialist comes, I have my scheduled appointment from the previous time that I was seen” Man with Diabetes. Attention time in Health workers take the necessary time. “To be honest, in the health unit they have always given me the consultation Family doctors have 15 min per patient. time I needed in the consultation” Woman with hypertension. “The standard is 15 min per patient, 4 patients per hour, but if for example a patient (...) needs more time, we make sure we give them the time they need” Family Doctor. Health workers’ Communication is adequately adapted to the educational “I speak to them with words that are easily understandable, not communication skills level of individual patients, while also engaging with the with technical words. I adapt my language to the educational chronic patients’ families (especially cases where the patient level of each patient” Pharmacist. may be illiterate or advanced in age). “I explain to the patient and their family, especially when I am dealing with older patients, all the details about the treatment and. In cases when patients are illiterate, I draw signs to help them to know when to take the pills. I also ask them to repeat to me what I have just said in order to verify that they have understood” Family doctor. Health information The majority of the discourse of the interviewed chronic “The information I received was good because they explained quality patients responded positively when asked about the quality what my disease was and how to take the medicine. Everything of the information given to them by the health staff in PHC. is fine. They always try to assure us that we understand everything correctly” Man with Diabetes. “The doctor gives us information about why we have to do lab tests, how to take the medication, information about diet and so on” Woman with Diabetes. community orientation. For this reason, the fourth strategic perceived as such within the community. The par- axis of the Health Reform is social and community engage- ticipation of the NHF in the local committees, micro ment through the NHF. This strategy aims to strengthen network and other spaces of decision-making, help community organization and social participation, so that us to improve particular situations or coordinate in society is empowered and can fully exercise its right to order to provide additional support” -Departmental health. The NHF is the autonomous social health move- Coordinator. ment with presence in most of the country and that coordi- nates with the MoH for achieving the right to health The NHF pursues civil society consensus in strategic through community participation [35]. The NHF has estab- decision-making, through a broad process of citizen par- lished citizen participation mechanisms that guarantee so- ticipation. The integrated and comprehensive health net- cial participation in the design, execution and evaluation of works also strengthen community capacity towards health policies that help to create policies based on the real becoming active partners in the governance and per- needs of the population. The NHF opened spaces for mak- formance evaluation of the network. Actions - not only ing health decisions where people from the community can related to the provision of care, but also towards pre- actively participate in addressing those obstacles that hinder ventive activities - are coordinated with community net- better attention to health problems. These health commit- works. Community organizations participate actively, tees of the NHF are composed of PHC staff members, co- mainly through the NHF, thereby serving as a bridge be- ordinators of the Family Health Community Units and civil tween communities and the health system. It fulfils the society actors organized through the NHF. role of social auditing within the health system, for which it developed parallel structures with the health “Community participation makes us see things that systems structures (see Fig. 1). The NHF is organized at we believe we are doing well but that are not being municipal, departmental and national level, and has local Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 11 of 17 Table 4 Health policies for the management of NCDs in PHC Knowledge and capacity building in NCDs “The ministry has been giving us training in noncommunicable diseases. In 2012, they gave us a complete course, -National Training Plan which was specifically about diabetes, high blood pressure ...” Health Educator. Having specific protocols and intervention “The protocols are created by the National Institute of Health. As ECOS we have protocols for both the prevention and plans treatment of NCDs. They existed before the 2017 guidelines, but have been evaluate. They are already on the third validation” Family doctor. Coordination throughout the healthcare “In the integrated and comprehensive health networks, networking has improved communication between the first system level and the hospital”. Departmental coordinator. Intersectoral participation “In the intersectoral participate the mayor’s office, the church, some community leaders, the health unit, the police, civil protection services, the house of culture and, education” Intermunicipal coordinator. Interventions focused on prevention and “Informative workshops are given, community-based, peer support groups for NCDs are formed, and we also use the health promotion mass media to inform the population” GP. More medication and medical supplies “Medication supplies have been improved, glucometers too, now that the Ministry provides them. There are also more lab tests available” Health educator. Better prioritization of resources “We can only evaluate and prioritize certain health programs and resources” Pharmacist. Community engagement “The work of the NHF is complementary, because we do the healing part and they do the awareness part, with social participation, with promotion and accountability” Health educator. Medical specialists at the community level “Community approaches of the specialized team go once a month to each unit and have an annual scheduling”. Intermunicipal coordinator. Epidemiological surveillance of NCDs “The beginning of the epidemiological surveillance of NCDs has been carried out for a year now. Each Eco has -Morbidity and mortality database identified its chronic patients for follow-up and medication. In addition, data on drug supply are also included” (SIMMOW) Intermunicipal coordinator. -Map of health inequalities Table 5 Prevention of NCDs in PHC Primary prevention Biological and environmental Risk Maps. “The health promoters make the identification of medical, environmental and social risk factors for every individual and family within same health unit, establishing a ranking of high, medium and low risk, drawing a risk map (…) home visits of the PHC team are scheduled according to risk” Departmental Coordinator. Comprehensive diet programs. “After detecting that a person has an unhealthy diet, not only the nutritional part is evaluated. We also visit their homes and detect the economic and geographic barriers that may limited them from accessing healthy food and from adapting our recommendations to each context”. Nurse. “Healthy passport, Exercise is medicine” “A strategy called ‘Healthy passport’ has been implemented in PHC leaded by the National institute of program. Sports (INDES), which is specifically for non-communicable diseases. It is a card that targets what we call ‘exercise is medicine’, where patients are given a prescription of exercises, not just medications. The specialist doctor gives them a prescription of exercises, and then the nurse explains how to do those ex- ercises and fill out the healthy passport” Health Educator. Screening programs for Chronic Kidney “One of the proposals that was driven from this health unit was the screening of people with traditional Disease (CKD). and non-traditional risk factors for CKD (mostly farmers working with agrochemicals)” Sanitary inspector. Information talks of the Specialized ECOS “We organized informative talks in every health unit that we visited weekly before the consultation, with special focus in NCDs. which are already organized in a chronogram. We inform about chronic diseases, another day about vaccination, gender violence, etc. We are an interdisciplinary team, and we all attend to this information talks and it takes around 15–20 min. We always give those talks because it is part of the primary care that is provided, of the integral approach” Family doctor Secondary prevention Community-based peer groups for people “The self-help groups are conformed by chronic patients talking about their own experience with dis- living with an NCD eases, how they have overcome, or how they feel, and there is self-development. We firstly give a small information talk, and then they share about their chronic disease” Health Educator. “Regarding the educational part of NCD in PHC, the IHSDNs indicators include how many ECOs have self-help groups for NCDs and which ones still don’t have them in order to encourage them to start conforming them with chronic patients” Regional Director. Terciary prevention Prevention of complication of Diabetes “We also check diabetic patients’ feet and explain what the shoe should be like and the hygienic measures to prevent complications” Nurse. Prevention of complication of CKD. “There are people living with a kidney damage that is maintained, that does not reach dialysis, and that is because they understand the need to be treated by the psychologist and the nutritionist, because nutrition and good hydration is basic, and also the guidance of the psychologist” Sanitary inspector. Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 12 of 17 Table 6 Pathways to care of NCDs in PHC committees in most of the country that work actively management of chronic diseases that is finally con- with the MoH. This strategy ensures a type of ‘co-re- sidered in the departmental network”- Regional sponsibility’ between the Salvadoran civil society and the coordinator. National Health System. Through these spaces of community participation, The NHF also developed an accountability system. “Of- PHC personnel can create mechanisms based on the real fices for the right to health” exist in the main hospitals needs of the population, considering their socio-political across the country, where community members can and cultural context in order to develop a better ap- claim their rights. With the support of the MoH, proach by the co-dynamization of community processes. suggestion boxes are placed in every health unit and hospital. Complaints or suggestions are assessed by “In these participation spaces for health, the commu- the facility management in presence of the NHF nity can request specific initiatives for improving the representatives. Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 13 of 17 In relation to the community-based peer support improves the coordination of the different stakeholders groups for NCDs, the main discourse of interviewed and follows a Health in all policies [38] approach. health staff members and chronic patients showed that At the first level of care, a CPHC approach has shown these groups provide space for sharing and learning to reduce accessibility problems for marginalized and about the reality of living with a chronic disease. Even impoverished populations [39]. Strong advances in terms though the groups are currently coordinated from the of accessibility have been confirmed not just with the primary health care units, the final objective is to have quantitative data reporting improvements in health self-managed groups from the community. These coverage, but also as perceived by stakeholders. community-based peer support groups for NCDs could El Salvador is now closer to achieving Universal Health improve chronic patients’ quality of life while also im- Coverage (UHC) [40] due to the implementation of proving the prevention on NCDs through forms of social CPHC with free access to care (after the abolition of engagement that exist in coordination with PHC. consultation fees and the overall reduction of out-of- pocket payments). As shown in other studies, countries “For the daily support for people with a chronic dis- can achieve greater health benefits when strengthening ease like me, it is nice that we all get together in their first level of care [41]. Moreover, WHO’s recent these groups where we learn more about our disease. universal health coverage (UHC) monitoring report from It allows us to give each other advice and to learn to 2019 frames PHC as the “programmatic engine for UHC survive in the best way with a specific chronic health in most contexts” [42] in a variety of ways including problem...”- Woman with hypertension attending a community empowerment, social accountability and a community-based peer support group for NCDs. multisectoral approach. However, from this case study some difficulties regard- “There are many factors / obstacles in our lives that ing PHC organization have been identified. The challenges interfere with leading a healthy life, but the objective mentioned are similar to the ones assessed in previous of this group is that you know how to accept and studies [43] and some proposals for improvement were recognize your own chronic diseases, how to control formulated by participants. Regarding accessibility, the them and to know better what to do when there is main problems pertain to the supply system (access to some complication” - Health Educator coordinating medications and laboratory tests) and geographical access a community-based peer support group for NCDs. to health services. Participants proposed to simplify the supply system to avoid shortages and to increase public transport services. In relation to coordination between Discussion levels of care, stakeholders proposed to reinforce it by im- This case study has enabled an in depth understanding proving health system referrals and counter referrals. Fi- of how CPHC is organized in El Salvador and how its nally, it was suggested to further increase the PHC implementation is facilitating NCD management with a workforce, with special focus on community health pro- strong social participation and accountability. moters. These were considered by interviewees to be a key Regarding the organization of CPHC, the dominant element in effectively responding to people’s health needs. discourse of the stakeholders interviewed was that the In relation to NCD management in PHC, the different implementation of the Integrated Health Services Deliv- policies implemented follow the recommended interven- ery Networks (IHSDNs) was an improvement in the co- tions for the prevention and control of NCDs according to ordination between different levels of decision making, the WHO Global Action Plan of NCDs 2013–2020 [44] as well as better follow-up of the epidemiological situ- adapted to the Salvadorian context. Concerning the pre- ation. The Pan American Health Organization considers vention measures implemented, the biological and environ- the development of IHSDNs to be essential to provide mental risk maps facilitate the identification and treatment equitable, comprehensive, integrated and continuous of people at high risk of NCDs or with already established health services to the population [36]. The Salvadoran disease [45]. This approach should avert deaths in the short health care system networks follow this logic [37] but term as it has been identified by WHO as one of the best have gone beyond this point: the networks also include buys for NCDs [46]. Moreover, these maps also considered social and community organizations and working groups the social risk affecting health. The high levels of violence linked to the NHF. This strategy aims at strengthening suffered by most of the Salvadoran population imply the the right to health, not only in terms of service need for adapting the counselling given by the PHC staff in provision, but also towards preventive community ac- relation to lifestyles behaviours in communities (e.g. modi- tion. In addition, establishment of the Salvadoran Inter- fying guidance about doing outdoor exercise). sectoral Health Commission (CISALUD) is perceived as The CPHC strategy in El Salvador is focused on redu- a key strategy for improving health outcomes as it cing inequities in the management and provision of Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 14 of 17 health services based on the citizenship taking control of community participation with the pursuit of government “the social determination of health” [47]. This concept accountability. The NHF is part of The People’s Health [48] is a broad theoretical analysis coming from Latin Movement [56], a global movement for the right to American critical epidemiology [49] that emphasizes the health, which argues that achieving health equity will re- social structures and their impact on individual and col- quire a redistribution of power and resources and the lective health. It develops a critique of empirical- adoption of structural reforms. The collaboration of the functionalist paradigm of epidemiology and serves as a Salvadoran MoH with the NHF ensured the strengthen- tool to study the relationship between ways of living, ing of social participation and strong health system ac- getting sick and dying based on solidarity, sustainability, countability towards the community (through the sovereignty and biosecurity [49]. The social determin- Offices of the right to health as an example). Spaces of ation of health could be applied to health promotion in community participation have been created in which NCDs; specific initiatives for managing the risk factors PHC personnel can create mechanisms based on the real need to be supported by measures that tackle the root needs of the population in order to develop a more com- causes of inequities [50]. Health behaviours that increase prehensive approach of NCDs. Community-based peer the risk to develop NCDs are greatly influenced by peo- support groups for NCDs provide spaces for sharing and ples’ environmental, socioeconomic and cultural settings, learning about the reality of living with a chronic and are more prevalent among the socially or economic- disease. ally disadvantaged worldwide [51]. Therefore, NCD As the 2019 elections put an end to the decade long management and prevention should consider the struc- FMLN (Farabundo Marti National Liberation Front) tural causes of poverty and inequity in health, to adopt government with the likelihood of important changes in effective means of promoting health equity. the public health system analysed here; we consider it of Despite all the achievements, stakeholders also called importance to have documented and assessed the results for more prevention and health promotion programmes and limitations of this experience of reform. for NCDs. Some of their suggested recommendations in- More than 40 years have passed since the Alma Ata cluded: to increase the use of mass media to provide in- declaration [57] and numerous experiences in imple- formation about chronic diseases; to reinforce lifestyle menting PHC have taken places all over the world, rais- programmes adapted to the sociocultural and economic ing important achievements and challenges [58]. The contexts, with special focus on children and young pop- implementation of the CPHC and its management of ulations; to promote community-based peer support NCDs in Latin America and worldwide is still a work in groups for NCDs; to implement screening programs to- progress [59]. Nevertheless, the analysis of the imple- wards those populations who cannot access health units. mentation of PHC, amplifies knowledge for addressing This last proposal is especially focused on the prevention inequalities in health and reinforces the importance of and early diagnosis of Chronic Interstitial Nephritis of an intersectoral approach with social participation and Agricultural Communities (CINAC). Regarding the con- accountability within the health system. tinuity of care in chronic patients, the implementation of CPHC has facilitated NCDs diagnosis, follow up and Limitations management of any complications through different pro- Resource limitations meant that fieldwork was limited to grams and strategies such as the repetitive prescription. a period of 3 months, and the full complexity of the The interdisciplinary PHC teams ensure a holistic ap- sociocultural, political and economic context may not proach for chronic patients. However, difficulties in co- have been fully captured. Moreover, the high level of ordination between levels of care were also commonly community violence in El Salvador at times limited the noted. scope of the fieldwork carried out. These challenges Furthermore, our study underlines the importance of a were partially solved thanks to the support of key com- community perspective at its core, based on the princi- munity members and health system personnel, who ac- ples of social participation, equity and participatory companied the field research group. evaluation, which are all essential triggers for high- A more crosscutting general gender perspective is quality community action [52]. Social engagement has lacking from the research and it should be considered been one of the strengths of the Salvadoran CPHC in as a key aspect in studies in health [60]. Regarding the contrast to other PHC implementation experience which limitations of the methodology used, a common criti- sometimes have been more focused on issues of effi- cism of case study method is its dependency on a single ciency and effectiveness in health care delivery [53] while case exploration making it difficult to reach a generalis- showing less concern for equity and community partici- ing conclusion [22]. This study complements two other pation in PHC [54, 55]. The National Health Forum has qualitative methodologies (illness narratives and social developed a strategy that combines empowering connections mapping) that were applied in different Jimenez Carrillo et al. International Journal for Equity in Health (2020) 19:50 Page 15 of 17 departments of El Salvador and have been contrasted Claire McLellan, Institute Officer and Jone Garcia Lurgain, Research Unit and enriched with objective information from official Officer. document review. In this sense, this case study demon- Authors’ contributions strates the value of context specific knowledge. On the Three researchers developed the fieldwork with two interview guidelines (for other hand, even NCDs have specific characteristics in chronic patients and PHC staff members) and transcribed them. The first two authors had a previous contact visit in November 2017 and met Salvadoran each context, although there are common patterns glo- key actors in health attending the 10th anniversary congress of the health bally [61]. Lastly, in regard to the NCDs considered for reform together with the research coordinator. Digital coding was carried this study, cancer and mental health patients were not out with N-Vivo version 10 that was facilitated by the QMU. A thematic framework was worked out through the application of a reflexive approach represented and it would be appropriate to redress this. and the triangulation of data by all the researchers involved in the study. In this context, it is important to reinforce the research The author(s) read and approved the final manuscript. capacity of the Public Health Policies Observatory of the University of El Salvador – in which the NHF ac- Funding This research was funded by NIHR Global Health Research Programme 16/ tively participates – as it could ensure the analysis of 136/100, Queen Margaret University. The views expressed are those of the further developments of the national health system of authors and not necessarily those of the UK National Health Service, the El Salvador, and the impact of government change in NIHR or the UK Department of Health and Social Care. 2019 on its structure and functioning. Availability of data and materials The datasets used and analysed during the current study are available from Conclusion the corresponding author on reasonable request. The Salvadoran Primary Health Care System, as devel- Ethics approval and consent to participate oped between 2009 and 2019, shows strong advance in This study was approved by the National Health Ethics Committee of El terms of accessibility, continuity of care of NCDs and Salvador (CNEIS/2018/005_A) and by the Research Ethics Panel of Queen Margaret University. quality of care and reinforces the importance of an inter- sectoral and comprehensive approach. Community en- Consent for publication gagement plays a key role in PHC and has ensured long- Prior to each interview, an information sheet was given and explained to term commitment to remote communities and social ac- each participant, after which they were invited to sign a consent form. countability. However, challenges in PHC remain such Competing interests as supplies shortages, the need to reinforce PHC work- The authors declare that they have no competing interests. force and the need for better coordination between levels of care in the approach to address NCDs. The Author details 1 Institute for Global Health and Development, Queen Margaret University, process of identification of strengths and weaknesses in Edinburgh, UK. 2Biomedical Research Institute Sant Pau (IIBSant Pau), the management of NCDs in PHC provide keys to con- Iberoamerican Cochrane Centre, Universidad Autónoma de Barcelona, tinue working and researching effective actions to reduce Barcelona, Spain. NCDs inequalities by further strengthening the right to Received: 1 September 2019 Accepted: 7 February 2020 health in PHC with UHC. References 1. Beaglehole R, Bonita R, Alleyne G, Horton R, Li L, Lincoln P, et al. 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