Education-CLD Article References & Abstracts

Adomah-Afari, Augustine, and Jim A. Chandler. 2018. “The role of government and community in the scaling up and sustainability of mutual health organisations: An exploratory study in Ghana.” Social Science & Medicine 207: 25-37.

Abstract: Governments of many developing countries, including those in Sub-Saharan Africa have embraced the community-based health insurance schemes phenomenon under the health sector reforms with optimism. Ghana has introduced a National Health Insurance Scheme, which is amalgamated with social health insurance and community-based health insurance schemes. The aim of this study was to explore the role of the Ghana government and community in the scaling-up and sustainability of mutual health organisations. Four district mutual health insurance schemes were selected using geographical locations, among other criteria, as case studies. Data were gathered through interviews and documentary/literature review. The findings of the empirical study were analysed and interpreted using social policy and community field theories. The findings of the paper suggest that in order to ensure their effective scaling up and maintain overall sustainability, there is the need for some form of government regulation and subsidy. However, since government regulation cannot work without the acceptance of the community, there is the need to integrate these actors in policy formulation.

Blickem, Christian, Dawson, Shoba, Kirk, Susan, Vassilev, Ivaylo, Mathieson, Amy, Harrison, Rebecca, Bower, Peter, and Jonathan Lamb. 2018. “What is Asset-Based Community Development and How Might It Improve the Health of People With Long-Term Conditions? A Realist Synthesis.” Sage Open (July-September): 1-13.

Abstract: Asset-Based Community Development (ABCD) appears to be a promising way to supporting people with long-term health problems but there is currently a lack of evidence to support this approach. Taking a realist approach, a review and concept-mapping exercise of ABCD approaches to improve health were conducted with a view to providing a better understanding about these approaches, how they work, and who they work for. Totally, 29 papers were deemed relevant and included in the review. The realist synthesis and concept mapping helped to identify concepts most commonly associated with ABCD but found no papers focused on long-term conditions (LTCs) and thus no evidence that this approach improves health outcomes for people with LTCs. While there is a lack of clarity about how to implement ABCD or how to evaluate it, this article offers a clearer theoretical framework about the essential ingredients needed to activate ABCD.

Bredenkamp, Caryn, Evans, Timothy, Lagrada, Leizel, Langenbrunner, John, Nachuk, Stefan, and Toomas Palu. 2015. “Emerging challenges in implementing universal health coverage in Asia.” Social Science & Medicine 145: 243-248.

Abstract: As countries in Asia converge on the goal of universal health coverage (UHC), some common challenges are emerging. One is how to ensure coverage of the informal sector so as to make UHC truly universal; a second is how to design a benefit package that is responsive and appropriate to current health challenges, yet fiscally sustainable; and a third is how to ensure “supply-side readiness”, i.e. the availability and quality of services, which is a necessary condition for translating coverage into improvements in health outcomes. Using examples from the Asia region, this paper discusses these three challenges and how they are being addressed. On the first challenge, two promising approaches emerge: using general revenues to fully cover the informal sector, or employing a combination of tax subsidies, non-financial incentives and contributory requirements. The former can produce fast results, but places pressure on government budgets and may induce informality, while the latter will require a strong administrative mandate and systems to track the ability-to-pay. With respect to benefit packages, we find considerable variation in the nature and rigor of processes underlying the selection and updating of the services included. Also, in general, packages do not yet focus sufficiently on non-communicable diseases (NCDs) and related preventive outpatient care. Finally, there are large variations and inequities in the supply-side readiness, in terms of availability of infrastructure, equipment, essential drugs and staffing, to deliver on the promises of UHC. Health worker competencies are also a constraint. While the UHC challenges are common, experience in overcoming these challenges is varied and many of the successes appear to be highly context-specific. This implies that researchers and policymakers need to rigorously, and regularly, assess different approaches, and share these findings across countries in Asia and across the world.

Benjamin Chemouni. 2018. “The political path to universal health coverage: Power, ideas and community-based health insurance in Rwanda.” World Development 106: 87-98.

Abstract: Rwanda is the country with the highest enrolment in health insurance in Sub-Saharan Africa. Pivotal in setting Rwanda on the path to universal health coverage (UHC) is the community-based health insurance (CBHI), which covers more than three-quarters of the population. The paper seeks to explain how Rwanda, one of the poorest countries in the world, managed to achieve such performance by understanding the political drivers behind the CBHI design and implementation. Using an analytical framework relying on political settlement and ideas, it engages in process-tracing of the critical policy choices of the CBHI development. The study finds that the commitment to expanding health insurance coverage was made possible by a dominant political settlement. CBHI is part of the broader efforts of the regime to foster its legitimacy based on rapid socio-economic development. Yet, CBHI was chosen over other potential solutions to expand access to healthcare because it was also the option the most compatible with the ruling coalition core ideology. The study shows that pursuing UHC is an eminently political process but explanations solely based on objective ‘‘interests” of rulers cannot fully account for the emergence and shape of social protection programme. Ideology matters as well. Programme design compatible with the political economy of a country but incompatible with ideas of the ruling coalition is likely to run into political obstructions. The study also questions the relevance for poor countries to reach UHC relying on pure CBHI models based on voluntary enrollment and community management.

Chomat, Anne Marie, Menchu, Aura Isabel, Andersson, Neil, Ramirez-Zea, Manuel, Pedersen, Duncan, Bleile, Alexandra, Letona, Paola, and Ricardo Araya. 2019. “Women’s circles as a culturally safe psychosocial intervention in Guatemalan indigenous communities: a community-led pilot randomised trial.” BMC Women’s Health 19:53.

Background: Indigenous Maya women in Guatemala show some of the worst maternal health indicators worldwide. Our objective was to test acceptability, feasibility and impact of a co-designed group psychosocial intervention (Women’s Circles) in a population with significant need but no access to mental health services.

Methods: A parallel group pilot randomised study was undertaken in five rural Mam and three peri-urban K’iche’ communities. Participants included 84 women (12 per community, in seven of the communities) randomly allocated to intervention and 71 to control groups; all were pregnant and/or within 2 years postpartum. The intervention consisted of 10 sessions co-designed with and facilitated by 16 circle leaders. Main outcome measures were: maternal psychosocial distress (HSCL-25), wellbeing (MHC-SF), self-efficacy and engagement in early infant stimulation activities. In-depth interviews also assessed acceptability and feasibility.

Results: The intervention proved feasible and well accepted by circle leaders and participating women. 1-month post-intervention, wellbeing scores (p-value 0.008) and self-care self-efficacy (0.049) scores were higher among intervention compared to control women. Those women who attended more sessions had higher wellbeing (0.007), self-care and infant-care self-efficacy (0.014 and 0.043, respectively), and early infant stimulation (0.019) scores.

Conclusions: The pilot demonstrated acceptability, feasibility and potential efficacy to justify a future definitive randomised controlled trial. Co-designed women’s groups provide a safe space where indigenous women can collectively improve their functioning and wellbeing.

Cotlear, Daniel, et al.. 2015. “Going Universal : How Twenty-Four Countries are Implementing Universal Health Coverage from the Bottom Up.World Bank Publications. ProQuest Ebook Central

Abstract/Foreword Extract: UHC is a triple win: It improves people’s health, reduces poverty, and fuels economic growth. That’s why the Health, Nutrition and Population Global Practice is working with governments, the private sector, and civil society, as well as with other development partners, to: establish systems for fair, efficient, and sustainable financing of health; scale up and strengthen front-line and facility-based services; and harness the potential of other sectors that contribute to health, nutrition, and population outcomes. In working in these areas, we are sourcing the best evidence globally to support appropriate choice and effective implementation of solutions, according to context. Going Universal: How 24 Developing Countries are Implementing Universal Health Coverage Reforms from the Bottom Up is an important contribution to this global evidence base. The book is about 24 developing countries that have embarked on the long journey toward UHC and are following a “bottom-up” approach to embrace the least well-off, even at the start of that journey. Each UHC program analyzed is seeking to overcome the legacy of inequality by tackling both a financing gap and a provision gap—because UHC requires not just more money but also a shift in spending. The book will help policy makers understand the options they face and help develop a new operational research agenda. Most of these UHC programs are less than a decade old; together, they cover one third of the world’s population. They are also transformational in their efforts to improve the way health systems operate, offering the potential to achieve greater equity and better results for the money spent. The report identifies key risks that lie ahead and identifies an emerging agenda where more country and global learning is required. The report offers those committed to the achievement of UHC world-wide a valuable new resource to help chart evidence and experience-informed pathways toward accelerated progress.

Evans, David & Hsu, Justine & Ties, Boerma. 2013. “Universal health coverage and universal access.” Bulletin of the World Health Organization. DOI: 91.546-546A.10.2471/BLT.13.125450. 

Abstract: Universal health coverage has been set as a possible umbrella goal for health in the post-2015 development agenda.Whether it is a means to an end or an end in itself and whether it is measurable are subjects of heated debate. In this issue of the Bulletin, Kutzin argues that universal health coverage not only leads to better health and to financial protection for households, but that it is valuable for its own sake. More recently, attention has shifted to just what the goal should be: whether universal coverage or universal access. This editorial focuses on this question.

Conclusion: In essence, universal health coverage is the obtainment of good health services de facto without fear of financial hardship. It cannot be attained unless both health services and financial risk protection systems are accessible, affordable and acceptable. Yet universal access, although necessary, is not sufficient. Coverage builds on access by ensuring actual receipt of services. Thus, universal health coverage and universal access to health services are complementary ideas. Without universal access, universal health coverage becomes an unreachable goal.

Ko, Hansoo, Kim, Hwajun, Yoon, Chang-gyo, and Chang-yup Kim. 2018. “Social capital as a key determinant of willingness to join community-based health insurance: a household survey in Nepal.” Public Health 160: 52-61.

Objectives: Although community-based health insurance (CBHI) schemes have been considered as an intermediate stage to achieve universal health coverage (UHC) in low-resource settings, there is a knowledge gap on ways to make it better.

Study design: More than 4000 Nepalese households were randomly selected and surveyed. Methods: Logistic and multivariate multinomial regressions were estimated. Results: Overall, 88% of included household heads were willing to join CBHI, 61% were willing to pay annual premium less than 600 Nepalese rupees (US$5.6) per household, and more than half (53%) responded that the government should subsidize a significant portion of the premium.

Results: A higher level of social capital was significantly related with an increase in odds of accepting higher premiums, while individuals’ health status and age did not have such associations. Individuals with bonding social capital were more likely to be inclined to join CBHI. Persons who said they can lend money for a living expense (bonding capital) did not want the government to subsidize the scheme, while this negative association would be reversed if persons had both bonding and bridging social capitals.

Conclusion: We found significantly positive relationships between social capital and willingness to join and willingness to pay for CBHI in Nepal. Policymakers, aiming to achieve UHC, should be advised that bonding and bridging social capital have differing relationships with willingness to cooperate the external funding sources.

Moazzem Hossain, S.M., Bhuiya, Abbas, Rahman Khan, Alia, and Iyorlumun Uhaa. 2004. “Community development and its impact on health: South Asian experience.” British Medical Journal 328, no. 7443: 830-833.

Abstract: Despite a remarkable improvement during recent decades in many countries’ overall health and nutrition statistics and macro-economic indicators, some 10.8 million children aged under 5 years still die annually worldwide, of which 34% occur in South Asia alone. It is too simplistic to relate improvements in economic indicators with better health because this does not take account of inequality, change in focus of public health priorities, and, most importantly, the involvement of the community in improving health. This article discusses some of the most prominent examples in South Asia of involvement of the community in planning, managing, and evaluating health projects. However, showing a direct relation between community development and improved health remains a challenge.

Luiz Odorico Monteiro de Andrade et. al.. 2015. “Universal health coverage in Latin America 3: Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries.” The Lancet 385.

Abstract: Many intrinsically related determinants of health and disease exist, including social and economic status, education, employment, housing, and physical and environmental exposures. These factors interact to cumulatively affect health and disease burden of individuals and populations, and to establish health inequities and disparities across and within countries. Biomedical models of health care decrease adverse consequences of disease, but are not enough to effectively improve individual and population health and advance health equity. Social determinants of health are especially important in Latin American countries, which are characterised by adverse colonial legacies, tremendous social injustice, huge socioeconomic disparities, and wide health inequities. Poverty and inequality worsened substantially in the 1980s, 1990s, and early 2000s in these countries. Many Latin American countries have introduced public policies that integrate health, social, and economic actions, and have sought to develop health systems that incorporate multisectoral interventions when introducing universal health coverage to improve health and its upstream determinants. We present case studies from four Latin American countries to show the design and implementation of health programmes underpinned by intersectoral action and social participation that have reached national scale to effectively address social determinants of health, improve health outcomes, and reduce health inequities. Investment in managerial and political capacity, strong political and managerial commitment, and state programmes, not just time-limited government actions, have been crucial in underpinning the success of these policies.

Moreno-Serra, Rodrigo and Peter C. Smith. 2015. “Broader health coverage is good for the nation’s health: evidence from country level panel data.” Journal of the Royal Statistical Society: Series A (Statistics in Society), Vol. 178, No. 1: pp. 101-124.

Abstract: Progress towards universal health coverage involves providing people with access to needed health services without entailing financial hardship and is often advocated on the grounds that it improves population health. The paper offers econometric evidence on the effects of health coverage on mortality outcomes at the national level. We use a large panel data set of countries, examined by using instrumental variable specifications that explicitly allow for potential reverse causality and unobserved country-specific characteristics. We employ various proxies for the coverage level in a health system. Our results indicate that expanded health coverage, particularly through higher levels of publicly funded health spending, results in lower child and adult mortality, with the beneficial effect on child mortality being larger in poorer countries.

Sarah-Anne Munoz et. al.. 2015. “Processes of community-led social enterprise development: Learning from the rural context.” Community Development Journal 50, No. 3: 478-493. doi:10.1093/cdj/bsu055.

Abstract: This article considers whether, and if so how, rural communities can be supported, through a facilitated process, to create social enterprises within the field of health and care. Using results from the thematic analysis of four community case studies involved in a facilitated action-research process, the article identifies community capabilities and entrepreneurial skills needed to create such rural community-based service providers. The identification of similarities and differences in how the development process took place in four communities allows us to present a development model of our facilitated process. The article contributes to understanding about rural community social enterprises for service provision and the processes associated with their creation.

Helena Nygren-Krug. 2019. “The Right(s) Road to Universal Health Coverage.” Health and Human Rights Journal 21, No. 2: 215-228. 

Abstract: The political momentum around universal health coverage (UHC) provides a welcome opportunity to scale up efforts to dismantle barriers to accessing health services and to create enabling environments for people to thrive and be healthy. However, UHC lacks sufficient clarity, both conceptually and operationally, to generate the societal transformation required to ensure its successful implementation in countries. This article argues that both the messaging and the monitoring and implementation guidance around UHC are ambiguous and flawed from a human rights perspective. To leverage the reforms necessary to achieve UHC, human rights norms and principles need to signpost the direction ahead, and human rights mechanisms need to be involved to enhance the accountability of those United Nations member states that choose to “take a wrong turn.” The article argues that a human rights-based approach to programming offers a practical methodological framework for designing and implementing UHC at the national level. It concludes by illustrating five key areas in which it is critical to invoke human rights as the foundation for UHC and for which consistent, authoritative, and practical guidance is needed to support countries in getting onto the right(s) road to UHC.

Odugleh-Kolev, Asiya and John Parrish-Sprowl. 2018. “Universal health coverage and community engagement.” Bull World Health Organisation 96: 660–661. DOI:

Abstract: Achieving universal health coverage (UHC) and the sustainable development goals (SDGs) requires health systems to shift from an almost exclusively vertical, top-down and curative paradigm to one that places people at the centre of health services. Here we reflect on how efforts towards UHC could offer an opportunity to address those aspects within health systems that continue to hinder efforts to meaningfully engage with patients, their families and local communities. The backbone of these efforts should be a health workforce that is skilled in engagement, responsive to local context and to the needs and expectations of those using their services.

Onoka, Chima A., Hanson, Kara, and Anne Mills. 2016. “Growth of health maintenance organisations in Nigeria and the potential for a role in promoting universal coverage efforts.” Social Science & Medicine 162: 11-20.

Abstract: There has been growing interest in the potential for private health insurance (PHI) and private organisations to contribute to universal health coverage (UHC). Yet evidence from low and middle income countries remains very thin. This paper examines the evolution of health maintenance organisations (HMOs) in Nigeria, the nature of the PHI plans and social health insurance (SHI) programmes and their performance, and the implications of their business practices for providing PHI and UHC-related SHI programmes. An embedded case study design was used with multiple subunits of analysis (individual HMOs and the HMO industry) and mixed (qualitative and quantitative) methods, and the study was guided by the structure-conduct-performance paradigm that has its roots in the neo-classical theory of the firm. Quantitative data collection and 35 in-depth interviews were carried out between October 2012 to July 2013. Although HMOs first emerged in Nigeria to supply PHI, their expansion was driven by their role as purchasers in the government’s national health insurance scheme that finances SHI programmes, and facilitated by a weak accreditation system. HMOs’ characteristics distinguish the market they operate in as monopolistically competitive, and HMOs as multiproduct firms operating multiple risk pools through parallel administrative systems. The considerable product differentiation and consequent risk selection by private insurers promote inefficiencies. Where HMOs and similar private organisations play roles in health financing systems, effective regulatory institutions and mandates must be established to guide their behaviours towards attainment of public health goals and to identify and control undesirable business practices. Lessons are drawn for policy makers and programme implementers especially in those low and middle-income countries considering the use of private organisations in their health financing systems.

Patel, Amit R. and Mary P. Nowalk. 2010. “Expanding immunization coverage in rural India: A review of evidence for the role of community health workers.” Vaccine 28: 604-613. doi:10.1016/j.vaccine.2009.10.108.

Abstract: Poor routine immunization coverage in India has led to a large burden of vaccine-preventable diseases borne by children under 5 years of age. Despite efforts to strengthen infrastructure and service delivery in the past decade, immunization coverage rates have reached a plateau. To meet the formidable needs of India’s growing population and address the shortcomings of health services for rural populations, the country is now turning toward a new national community health worker (CHW) plan. This article reviews the effectiveness of CHWs in expanding immunization coverage in developing countries and examines the potential contribution of CHWs toward strengthening immunization services in rural India. While the limited number and quality of available studies make it difficult to directly compare CHW interventions to other strategies for improving immunization coverage, it is clear that CHWs make diverse contributions toward strengthening immunization programs. Incorporation of evidence-based strategies for CHW selection, retention, and training is critical for success of India’s immunization program. In addition, there is growing need to develop efficient mechanisms for monitoring children’s vaccination status to generate actionable feedback and identify cost-effective strategies.

Reeder, John C., Kieny, Marie-Paule, Peeling, Rosanna, and Francois Bonnici. 2019. “What if communities held the solutions for universal health coverage?” Infectious Diseases of Poverty 8: 74.

Abstract: Universal health coverage is one of the most pressing objectives of the World Health Organization (WHO). A billion people worldwide lack access to basic health care services, even when proven treatments exist. To extend health care and services to the most remote regions and marginalized populations, we must actively engage people and communities as the principal actors in their own health.

Kate Tulenko et. al.. 2013. “Community health workers for universal health-care coverage: from fragmentation to synergy.” Bull World Health Organisation 91: 847-852. DOI:

Abstract: To achieve universal health coverage, health systems will have to reach into every community, including the poorest and hardest to access. Since Alma-Ata, inconsistent support of community health workers (CHWs) and failure to integrate them into the health system have impeded full realization of their potential contribution in the context of primary health care. Scaling up and maintaining CHW programmes is fraught with a host of challenges: poor planning; multiple competing actors with little coordination; fragmented, disease-specific training; donor-driven management and funding; tenuous linkage with the health system; poor coordination, supervision and support, and under-recognition of CHWs’ contribution. The current drive towards universal health coverage (UHC) presents an opportunity to enhance people’s access to health services and their trust, demand and use of such services through CHWs. For their potential to be fully realized, however, CHWs will need to be better integrated into national health-care systems in terms of employment, supervision, support and career development. Partners at the global, national and district levels will have to harmonize and synchronize their engagement in CHW support while maintaining enough flexibility for programmes to innovate and respond to local needs. Strong leadership from the public sector will be needed to facilitate alignment with national policy frameworks and country-led coordination and to achieve synergies and accountability, universal coverage and sustainability. In moving towards UHC, much can be gained by investing in building CHWs’ skills and supporting them as valued members of the health team. Stand-alone investments in CHWs are no shortcut to progress.

Van de Venter, Emily and Sabi Redwood. 2016. “Meeting Abstract: Does an asset-based community development project promote health and wellbeing?” The Lancet.

Background: The potential contribution of asset-based approaches to population health is increasingly being recognised. Asset-based community development (ABCD) aims to identify and build on community assets, including the knowledge and skills of residents. In 2015, ABCD was implemented across four housing estates in South West England. Two community builders worked with residents to increase social networks and support new and existing community groups. A community budget of £4500 was available to fund community initiatives. A year into the project, we aimed to assess implementation and impacts on wellbeing.

Methods: 12 residents and 18 professionals participated in semi-structured interviews and focus groups to explore their experiences including the support received from the community builder, the process of accessing the community budget, perceived impacts of the funding, and personal impacts of being on the funding panel or receiving funding. Community builders invited members of the funding panel and individuals receiving funding to participate. Recruitment messages were circulated to the local professional networking forum and sent directly to the community builders, their managers, and the Steering Group. Framework analysis was used.

Findings: Residents developed skills, confidence, enhanced community roles, and increased social contacts. Building on the skills and interests of local residents was crucial to initiating and sustaining a commitment to volunteering. The distribution of the community budget helped volunteers to feel valued and to overcome barriers to involvement. Community groups, including gardening, dance, and craft groups, were supported to become more sustainable or to extend their offer to the community. A photography exhibition promoted a positive image of the area and showcased the skills of residents.

Interpretation: Good progress was made in the first year of implementation, and early outcomes for residents indicate that the project is helping to promote wellbeing through enhanced social activities in the community. Increased skills and confi dence among residents are important findings; these outcomes increase feelings of self-efficacy, a key component in models of health behaviour change. The study is limited by the short period of time the project has been running and the small scale of the intervention. Effects on social networks or longer-term, community-wide impacts on health and wellbeing cannot be identified yet. However, some transferable insights into the potential of ABCD approaches to enhancing wellbeing in disadvantaged areas have been identified.

Huihui Wang et. al.. 2016. “Ethiopia Health Extension Program An Institutionalized Community Approach for Universal Health Coverage.” IBRD WBG. DOI: 10.1596/978-1-4648-0815-9.

Abstract/Foreword Extract: In 2011, Japan celebrated the 50th anniversary of achieving universal health coverage (UHC). To mark the occasion, the government of Japan and the World Bank conceived the idea of undertaking a multicountry study to respond to this growing demand by sharing rich and varied country experiences from countries at different stages of adopting and implementing strategies for UHC, including Japan itself. This led to the formation of a joint Japan–World Bank research team under the Japan–World Bank Partnership Program for Universal Health Coverage. The Program was set up as a two-year multicountry study to help fill the gap in knowledge about the policy decisions and implementation processes that countries undertake when they adopt the UHC goals. The Program was funded through the generous support of the government of Japan. This Country Study on Ethiopia is one of the 11 country studies on UHC that was commissioned under the Japan–World Bank Partnership Program. The other participating countries are Brazil, France, Ghana, Indonesia, Japan, Peru, Thailand, Turkey, and Vietnam.

Wong, Young Soon, Allotey, Pascale, and Daniel D. Reidpath. 2014. “Health Care as Commons: An Indigenous Approach to Universal Health Coverage.” The International Indigenous Policy Journal 5, no. 3.

Abstract/Introduction: The United Nations’ State of the World’s Indigenous Peoples report clearly documents the stark disparities in health between Indigenous peoples and the national population of many countries (United Nations, 2009) including within developed countries where health care services are comparatively of a higher standard. For example, infant mortality among Indigenous people in Australia is 3 times that of the non-Indigenous population, while in New Zealand it is 1.5 times higher. This same pattern is evident between Indigenous and non-Indigenous populations in the Americas, from North America to Latin America. Globally, Indigenous peoples carry a higher burden of diseases such as malaria, tuberculosis, HIV/AIDS, cardiovascular diseases, respiratory diseases, and diabetes compared with non-Indigenous peoples. Modern day diseases like diabetes have become a major health problem for Indigenous populations due to externally induced changes to diet, environment, economy, and lifestyle. Worldwide, Indigenous populations still battle with poor nutrition whether they are in developed, developing, or less developed countries. In Australia, 12.4% of Aboriginal women give birth to low birth weight children compared to 6.2% of non-Aboriginal women (Better Health Channel, 2012); in Malaysia, various studies show that between 50 – 80% of Orang Asli Indigenous children were undernourished (Idrus, 2013); in El Salvador, 40% of Indigenous children under 5 years were malnourished compared with 23% of non-Indigenous children (United Nations, 2009). One of the reasons for this poor state of health among Indigenous peoples is lack of access to adequate health care. Causes include inadequate state financing, geographical distance or isolation, high out-of-pocket expenses, lower quality of services, and culturally inappropriate or insensitive methods (United Nations, 2009).