"Popular" health and the state: Dialectics of the peace process in El Salvador

The poor performance of large-scale "vertical" rural health programs tied to state Ministries of Health in Third World countries has often been attributed to a lack of "political will". But that term tells little about the conditions that favor health reform and may obscure disparate power relations and struggles over development. This work explores such a struggle over community health that emerged as part of the peace process in a former war zone of El Salvador since the 1992 ceasefire. The formalized negotiations (and behind-the-scenes confrontations) over health in Chalatenango province took place between Ministry of Health administrators and proponents of a "popular" health system that has functioned in repopulated villages of rebel-controlled Chalatenango since 1987. The Ministry has set up its own national (U.S. AID-designed) community health worker program, and agreed in theory with the popular system's emphasis on village-based lay health promoters; however, in negotiations and efforts at collaboration in Chalatenango the Ministry has been unwilling to support the promoters in the popular system, to accommodate local participation in health decision-making, or to restructure its own physician-centered practices around the need for more comprehensive approaches to health.