Community and health staff perceptions on non-communicable disease management in El Salvador Health System: a qualitative study

Non-communicable Diseases (NCDs) are the leading cause of global mortality and disability, with a rising burden in low- and middle-income countries. Their multifactorial aetiology, and their requirement of long-term care, imply the need for comprehensive approaches. From 2009, the Ministry of Health (MoH) in El Salvador has developed a national public health system based on comprehensive primary health care. This study aims to describe the different stakeholders’ perceptions about the management of NCDs along the pathways of care in this health system. During three fieldwork periods in 2018, three complementary qualitative data collection methods were deployed and conducted in high prevalence of NCDs settings within El Salvador. First, we used illness narrative methodology to document the life histories of people living with a chronic disease and being treated in second and third level health facilities. Second, through social mapping, we analysed support-resources that NCD patients used throughout the process of their illness within the same settings. Third, semi-structured interviews were conducted in the same locations, with both chronic patients and health personnel working at different levels of the primary health care setting. Participants were recruited through purposive and snowball sampling, and a deductive approach was implemented for coding during the analysis phase. After grouping codes into potential themes, a thematic framework was elaborated through a reflexive approach and triangulation of the data. This innovative approach of combining three well-defined qualitative analysis frameworks identified key implications for the implementation of a comprehensive approach to NCDs management in resource-poor settings. The following dimensions are identified: 1) social risk factors and barriers to care; 2) patient pathways to NCDs care; 3) resources available identified through social connections mapping; 4) trust in social connections; 5) community health promotion and prevention of NCDs management. The Salvadoran public health system has been able to strengthen its comprehensive approach to NCDs, combining a clinical approach – including long term follow-up – with a preventive community-based strategy. The structural collaboration between the health system and the (self)organized community has been key to identify failings, discuss tensions and work out adapted solutions.