Introduction
Methods
Data collection & sampling
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 |
Data analysis
Ethical considerations
Results
Themes | PHC Organisation in El Salvador | NCD Management in PHC | Social Participation in PHC |
---|---|---|---|
CODES | Integrated comprehensive health networks Community health networks and interdisciplinary PHC teams Coordination between levels of care Intersectoral participation and health in all policies Accessibility Quality of care | Health policies for the management of NCDs Prevention of NCDs and health promotion Longitudinal care of NCDs | National Health Forum Accountability Right to Health offices Community-based peer support groups for NCDs |
Primary health care organization in El Salvador
Integrated and comprehensive health care networks
“Epidemiological surveillance, also of NCDs, is ensured, and every Community Healthcare Unit has identified its chronic patients for follow-up and medication. Data on drug supply are included in this surveillance. In micro-network meetings these health data are used to prioritize health services at municipal level”- Intermunicipal coordinator.
Different levels of decision-making exist at municipal, departmental, regional and national level (Fig. 1). The departmental level, called the Basic Integrated Health System (SIBASI by its Spanish acronym, Sistema Básico de Salud Integral), is the basic operational structure of the NHS where the Primary Health Care system is articulated with the other levels of care, and with community organizations. These meetings facilitate the sharing and dissemination of information and the coordination of activities to ensure a comprehensive care under the equity scope.“We have the ‘Integrated Health Service Delivery Networks (IHSDNs) health indicators’ which include NCD data. The departmental level analyses the epidemiological surveillance data of all micro networks of the department. Following this, the coordinator shares them in the regional meeting which is helping to organize better health services in PHC” - Regional Coordinator.
One of the main purposes of these networks is the management and provision of health services to ensure a continuity of care: promotion, prevention, diagnosis and treatment, as well as in disease management, rehabilitation and palliative care. The coordination within the different levels of the integrated and comprehensive health networks helps to optimize resources, for example during medicine shortages.“As a Basic Integrated Health System we hold meetings every 2 weeks in order to monitor acute and chronic diseases and we evaluate health indicators (mortality and morbidity rate within the region, etc.). Depending on the number of detected cases, we decide which activities should be prioritized” - Departmental coordinator
“We have good coordination between the micro-networks. If some medication is missing, we coordinate it in order to avoid drugs shortage.”- Intermunicipal coordinator.
“If for example there isn’t a specific medication in the region, we put them in contact with other places where there is enough supply and we try to avoid through our ‘integrated and comprehensive health networks’ the medicine shortage”- Regional coordinator.
Community health networks & interdisciplinarity
The Family and specialized ECOS are intended to know the reality of their environment, identify with the community and, with the help of community leaders and where there is presence of the National Health Forum, consider the dynamics of the social determinants of the health of the population. This is done by analysing the health situation of the persons by traditional biological risk factors and identifying vulnerabilities of their families as well as considering social risks (violence, unemployment, etc.). Their purpose is to ensure the adequate follow-up of the health of their population of responsibility.“We work in a network, that means that each Community Family Health teams are connected with the Community health team with specialized within the area as well as with community organizations in order to properly approach the real needs of the population”- General practitioner (GP).
Interdisciplinary PHC teams help to address health in a comprehensive way, addressing both preventive and curative health care. It also promotes health infrastructure development and community involvement, thereby promoting sustainable improvements of community health.“My work includes three types of populations: the primary population is the patient with a chronic disease. The secondary population is the family of the person, and the tertiary population is the community as a whole.” - Health Educator.
Community health promoters play a key role in the coordination between patients and PHC staff. They are the actors in contact with patients in the community and who inform the rest of the PHC team about particular situations considering the fragile context of the country due to violence. They discuss an intervention plan or organize appointments to make sure that patients can be attended by a specialist and inform health staff when complications arise. Health promoters also identified patients that have never had contact with the health system before in remote areas and are in charge, together with the rest of the PHC team, of community health prevention and health promotion. In this sense, an essential strategy of the 2009 health reform has been fulfilled: the strengthening of the health promoter as an essential element at the first level of care.“We work as a team, even if each of us have specific duties, we try to give a comprehensive care working together with the rest of the PHC team”- Sanitary inspector.
“Our ‘community eyes’ are the health promoters. They identify patients who have some risk factor” - Regional Director.
Due to the high burden of Chronic Interstitial Nephritis of Agricultural Communities (CINAC) in El Salvador [29], in specific areas where this chronic disease is highly prevalent a nephrologist is part of the PHC team.“Then the health promoters say, ‘Come doctor, I want you to accompany me to the house of a diabetic patient.’ And we go to the patient’s house, where they are given counselling, and where we also see what the patient’s living environment is like” - GP.
“The nephrologist is oversaturated with renal patients, at the first level of care. Even if he tries to give high-quality attention, it is difficult to do so with such a heavy workload. He also works at the tertiary level of care in Jiquilisco’s hospital on Mondays and Fridays”- Intermunicipal Coordinator.
Coordination between levels of care
“From the time I make the referral at the first level, it takes about 4-6 months for a patient to make an appointment with a nephrologist or another hospital specialists” - Family doctor.
“When hospitals diagnose a chronic patient, they sometimes do not inform the first level of care. Some hospitals have not yet understood the health reform in which PHC is the system’s frontline, where patient follow-ups can perfectly be conducted. Instead of removing the burden of so many patients being treated at the hospital, they do not make referrals because they think first line personnel has not enough training ... Finally, the most vulnerable people are the most affected as they cannot afford the transport to reach the hospital” - Regional Coordinator.
Intersectoral participation and health in all policies
“This intersectoral approach is strategic, as it implies the coordination with other institutions. At local level this intersectoral committee is formed by: directors of community associations, NGOs, school directors, teachers, the police, etc… They meet periodically, and we inform them of difficulties we face, the epidemiological surveillance, etc… to work together and improved health outcomes trough coordination of the different actors”. - Departmental coordinator.
Accessibility
“The abolition of voluntary consultation fee has helped us to have more access to the health system, because before the reform, we needed money to be able to pay the consultation”- Man with hypertension.
According to the last accountability report published by the MoH of El Salvador in 2018 [32] there are currently 753 Family Health Community Units, 577 Family ECOs and 39 Specialized ECOS all over the country focusing to increase access in the poorest municipalities.“I no longer have to pay the ‘voluntary fee’ every time I go to the doctor. That has been a great change for me and my family”- Woman with Diabetes Mellitus type 2.
“When the health reform started, we started to focus on reaching population groups that never came to the health units. This is what I do, apart from working with the community” - Sanitary inspector.
“Before 2009 I had to take the bus to reach the health unit, but they opened a new one close to my house and l normally come walking now” - Woman with hypertension.
Nevertheless, some geographical limitations persist, due to the lack of public transport and the limited access to an ambulance (with gasoline) in case of emergency.“I take a moto-taxi to reach the health unit that is close to where I live. Before the health reform every time I was sick due to my illness, I had to go to the hospital that it is far away from here and I couldn’t afford a moto-taxi until there” - Man with Chronic Kidney Disease.
The specialized PHC team travels twice per week to basic and intermediate Family Health Community Units in order to facilitate access to specialists for those living in remotes areas. With programmed community visits of the specialized CHT they ensure monthly visits to every basic and intermediate Family Health Community Units belonging to a specific geographic area. Nevertheless, the specialized team also express difficulties in reaching remote areas.“Transport is a weakness that we have as a specialized Community Health Unit, as some people come from remote areas and there is no adequate public transport for them”. - Intermunicipal Coordinator.
“We conformed a specialized CHT, and we visit each basic and intermediate unit at least once per month. Chronic patients for the family doctor, children for the paediatrician...” - Family doctor.
“There are very remote areas that in the rainy season are flooded. Despite the geographic difficulties in accessing these sites, we also try to reach these places.”- Health educator.
“Even though the health unit is closer to my house, I had an emergency once and the nurse came to inject me at home”- Woman with Diabetes mellitus type 2.
Concerning the access to medication and laboratory tests, the main discourse of the chronic patients interviewed reflected the perception that access to free medicines is provided in PHC Units. But participants also commented on shortages in some Family Health Community Units.“We organize home visits where the whole interdisciplinary team goes to see a patient with special needs. The doctor, nutritionist, psychologist, physiotherapist, health educator and nursing, we all go”- Health educator.
“Access to medicines is much better now than before because we used to pay for all of them and now the government pays all that...” - Woman with hypertension.
Although the health reform has facilitated the transport of laboratory tests from basic health units to health units with laboratories, some barriers still exist with transport due to long distances from and to remote areas. Inevitably, some laboratory tests cannot be realized at the first level, and the patients have to go to the hospital or to the private sector.“They give us treatment in the health unit pharmacy where we get our prescriptions, but sometimes there is not enough medication” - Woman with hypertension.
Finally, in terms of accessibility to the health professionals, even though the number of staff members working in PHC has increased in 6000 more workplaces since 2009 to 2015, the dominant perception of the stakeholders is that more work force is needed in PHC.“In basic health units, there is a specific day of the week when lab samples are taken by the nurse, and a polyvalent person from the staff brings the sample to the lab (...) There are specific laboratory tests that I have to send for analysis to private laboratories”. -Laboratory Technician.
“It would be nice to have more health personnel in the Family health Community Units, especially health promoters as they are the ones often coming for home visits”. Woman with Diabetes Mellitus type 2.
“Even if the number of workforce has increased a lot since the beginning of the health reform, it is important to keep investing in human resource in order to assure quality and access” - Regional Coordinator.
Quality of care
Quality of care | Conclusions | Illustrative stakeholder’s quotes |
---|---|---|
Quality of care provided by health workers in PHC | Chronic patients mainly expressed having received adequate care. | “In the health unit, I have always felt well treated. The nurses are very kind to me. To be honest I cannot complain; they have all 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. In PHC, the waiting time for specialist consultants who attend patients by appointment was shorter than the GP’s (waking patients)". | “Before the health reform every time I had a problem because of my blood sugar was too high or down I had to go to the hospital and wait for hours, now I just walk to my nearest health 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 consultation | Health workers take the necessary time. Family doctors have 15 min per patient. | “To be honest, in the health unit they have always given me the 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 skills | Communication is adequately adapted to the educational level of individual patients, while also engaging with the chronic patients’ families (especially cases where the patient may be illiterate or advanced in age). | “I speak to them with words that are easily understandable, not with technical words. I adapt my language to the educational level of each patient” Pharmacist. “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 quality | The majority of the discourse of the interviewed chronic patients responded positively when asked about the quality of the information given to them by the health staff in PHC. | “The information I received was good because they explained what my disease was and how to take the medicine. Everything 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. |
NCD management in primary health care
Health policies for the management of NCDs
Knowledge and capacity building in NCDs -National Training Plan | “The ministry has been giving us training in noncommunicable diseases. In 2012, they gave us a complete course, which was specifically about diabetes, high blood pressure ...” Health Educator. |
Having specific protocols and intervention plans | “The protocols are created by the National Institute of Health. As ECOS we have protocols for both the prevention and 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 system | “In the integrated and comprehensive health networks, networking has improved communication between the first 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 health promotion | “Informative workshops are given, community-based, peer support groups for NCDs are formed, and we also use the 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 -Morbidity and mortality database (SIMMOW) -Map of health inequalities | “The beginning of the epidemiological surveillance of NCDs has been carried out for a year now. Each Eco has identified its chronic patients for follow-up and medication. In addition, data on drug supply are also included” Intermunicipal coordinator. |
Prevention of NCDs and health promotion
“The NCDs strategy based in PHC is aimed at the prevention and health promotion approach that will avoid many deaths emphasizing they quality of life of chronic patients while also preventing others from getting sick” – Intermunicipal coordinator.
During the interviews, several preventive actions for NCDs that have been implemented in PHC were mentioned (see Table 5 below).“Children and adolescents are not aware of the NCDs as they see it as something far away, in order to improve awareness, especially among young population, the use of mass media and health promotion activities in schools can be very useful” – Health Educator
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” program. | “A strategy called ‘Healthy passport’ has been implemented in PHC leaded by the National institute of 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 exercises and fill out the healthy passport” Health Educator. |
Screening programs for Chronic Kidney Disease (CKD). | “One of the proposals that was driven from this health unit was the screening of people with traditional and non-traditional risk factors for CKD (mostly farmers working with agrochemicals)” Sanitary inspector. |
Information talks of the Specialized ECOS with special focus in NCDs. | “We organized informative talks in every health unit that we visited weekly before the consultation, 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 living with an NCD | “The self-help groups are conformed by chronic patients talking about their own experience with diseases, 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. |
Longitudinal care of NCDs in PHC
Social participation in PHC
The NHF pursues civil society consensus in strategic decision-making, through a broad process of citizen participation. The integrated and comprehensive health networks also strengthen community capacity towards becoming active partners in the governance and performance evaluation of the network. Actions - not only related to the provision of care, but also towards preventive activities - are coordinated with community networks. Community organizations participate actively, mainly through the NHF, thereby serving as a bridge between communities and the health system. It fulfils the role of social auditing within the health system, for which it developed parallel structures with the health systems structures (see Fig. 1). The NHF is organized at municipal, departmental and national level, and has local committees in most of the country that work actively with the MoH. This strategy ensures a type of ‘co-responsibility’ between the Salvadoran civil society and the National Health System.“Community participation makes us see things that we believe we are doing well but that are not being perceived as such within the community. The participation of the NHF in the local committees, micro network and other spaces of decision-making, help us to improve particular situations or coordinate in order to provide additional support” -Departmental Coordinator.
The NHF also developed an accountability system. “Offices for the right to health” exist in the main hospitals across the country, where community members can claim their rights. With the support of the MoH, suggestion boxes are placed in every health unit and hospital. Complaints or suggestions are assessed by the facility management in presence of the NHF representatives.“In these participation spaces for health, the community can request specific initiatives for improving the management of chronic diseases that is finally considered in the departmental network”- Regional coordinator.
“For the daily support for people with a chronic disease like me, it is nice that we all get together in these groups where we learn more about our disease. It allows us to give each other advice and to learn to survive in the best way with a specific chronic health problem...”- Woman with hypertension attending a community-based peer support group for NCDs.
“There are many factors / obstacles in our lives that interfere with leading a healthy life, but the objective of this group is that you know how to accept and recognize your own chronic diseases, how to control them and to know better what to do when there is some complication” - Health Educator coordinating a community-based peer support group for NCDs.