1 Introduction

The Region of the Americas is characterized by extensive cultural diversity, with an estimated 45 million people belonging to Indigenous populations across 24 countries and more than 600 distinct groups. Despite this diversity, Indigenous populations across the region share a common pattern of structural disadvantage, reflected in lower levels of income, education, and access to basic services such as water, sanitation, and housing, compared to non-Indigenous populations [1,2].

These structural inequalities have direct consequences for health outcomes. Indigenous populations experience higher levels of morbidity and mortality, with Indigenous women facing compounded vulnerabilities associated with gender, ethnicity, and socioeconomic status [3,4]. Maternal and child health indicators, in particular, remain significantly worse in Indigenous communities, where barriers to access, discrimination, and cultural mismatches between health services and community practices persist [5,6].

In response, health systems in low- and middle-income countries have expanded service coverage and infrastructure. However, growing evidence suggests that improving access alone is insufficient to reduce health inequalities. The quality of care, understood as timely, effective, and culturally appropriate services, plays a critical role in shaping health outcomes [7,8]. Inequalities in quality of care may arise from geographic barriers, differences in service availability, or unequal treatment of patients based on socioeconomic or ethnic characteristics [9]. In this context, accessibility must be understood as a multidimensional concept, encompassing not only physical proximity but also economic, administrative, and cultural factors.

Within this framework, intercultural health approaches have emerged as a strategy to improve the responsiveness of health systems to Indigenous populations. These approaches seek to integrate biomedical services with Indigenous knowledge systems, promote culturally appropriate care, and strengthen community participation in health decision-making [10-13]. However, evidence from Latin America suggests that the implementation of intercultural health policies often remains partial, with persistent gaps between formal policy frameworks and actual practice [14,15].

Experiences from different countries illustrate both the potential and the challenges of these approaches. For example, Ecuador’s “Mother- and Child-Friendly Health Facilities” (ESAMyN), Brazil’s Indigenous Health Care Subsystem (Subsistema de Atenção à Saúde Indígena) and Mexico’s intercultural maternal health model (Modelo de Atención Intercultural en Salud Materna) are among several initiatives that have sought to improve maternal and neonatal care by incorporating culturally appropriate practices and strengthening community engagement. Similarly, international experiences in countries such as Australia, Canada, and New Zealand highlight the importance of community participation and self-management in achieving improvements in Indigenous health outcomes. Together, these experiences suggest that effective interventions require not only service adaptation but also the active involvement of Indigenous communities in the design and governance of health systems [16-25].

In Argentina, health services are organized under a decentralized system in which provinces are responsible for the provision and management of care [26]. The province of Salta, located in the northwest of the country, has one of the highest proportions of Indigenous population and is characterized by diverse geographic regions where Indigenous and non-Indigenous populations coexist. These conditions pose significant challenges for the delivery of equitable health services, particularly in maternal and perinatal care. Previous studies have identified limitations in the functioning of health service networks in Argentina, including weak coordination between levels of care and insufficient referral mechanisms, which disproportionately affect Indigenous populations facing additional geographic and cultural barriers [27].

Despite growing attention to intercultural health, there is still limited empirical evidence on how these policies are experienced by users and key stakeholders at the local level. In particular, there is a need to better understand how Indigenous women perceive access to and quality of care, and how these perceptions relate to the perspectives of policymakers and health system actors.

This article contributes to addressing this gap by analyzing the quality of healthcare as perceived by Indigenous and non-Indigenous women, as well as by Indigenous leaders and key public sector actors, in the province of Salta, Argentina. Specifically, the study addresses the following research questions: (i) What are the perceptions of Indigenous communities and their leaders regarding the functioning and quality of health services? (ii) How do public officials perceive maternal and perinatal healthcare for Indigenous women? and (iii) To what extent has an intercultural health model been implemented, and what barriers persist in achieving effective access to care?

Finally, this article is part of a broader research agenda focused on Indigenous health in the Americas and Argentina, including previous work that reviews health interventions aimed at reducing inequalities and improving the well-being of Indigenous populations in the region.

2 Methods

We conducted a mixed-methods study combining survey data from women users of public health services with semi-structured interviews with key stakeholders. This design allowed us to analyze perceived access, coverage, and quality of care, while also incorporating the perspectives of decision-makers and Indigenous authorities.

The quantitative component was based on designing and administering a structured questionnaire to assess perceptions of access, coverage, and quality of care among users of the public health system of Salta Province. The target population included pregnant women and women of childbearing age attending public healthcare facilities.

We selected health facilities in three departments of the province of Salta (Tartagal, Orán, and Iruya) based on their high proportion of Indigenous population, their epidemiological relevance in maternal and perinatal health, and their representation of diverse territorial contexts (urban, peri-urban, and rural). In addition, we included the most important high-complexity referral hospital in the city of Salta, as this facility receives the majority of complex cases referred from the three selected departments, and allows for capturing the continuum of care across levels of the health system. The sample included 34 Primary Health Care Centers (CAPS) and 4 referral hospitals across the selected departments and the provincial capital. Within each facility, we implemented a systematic random approach to participant selection in waiting rooms. Field researchers approached eligible women at different times of the day and week to reduce selection biases and invited them to participate in the study. We collected a total of 609 valid questionnaires.

We established quotas to ensure the representation of Indigenous and non-Indigenous women, according to their relative presence in each facility. Questionnaires were administered in person by trained interviewers, who read the questions aloud and recorded responses. The survey was conducted primarily in Spanish; when necessary, participants received assistance to ensure comprehension. Each questionnaire took approximately 15–20 minutes to complete and was administered in waiting room settings prior to medical consultation.

We analyzed the data using descriptive statistics and inferential methods. We assessed differences between Indigenous and non-Indigenous women, as well as across different Indigenous peoples, using statistical significance tests at the 1%, 5%, and 10% levels. This approach enabled us to identify disparities in perceived access, coverage, and quality of care beyond those typically associated with socioeconomic or geographic factors.

To assess inequalities in geographic access to healthcare services, we constructed an equity index (EI) of access based on survey responses. The index is defined as the ratio of the average travel time reported by Indigenous women to that reported by non-Indigenous women for each type of provider. A value equal to one indicates equality in access, values greater than one reflect relatively worse access for Indigenous populations, and values below one indicates worse access for non-Indigenous populations. This measure follows a ratio-based approach commonly used in the analysis of health inequalities to capture relative disparities between population groups, particularly in relation to geographic accessibility and service utilization [28-30]. In this study, the index provides a simple and context-appropriate metric to summarize differences in access between Indigenous and non-Indigenous populations.

The qualitative component was based on stakeholder mapping conducted to identify key actors involved in the design, implementation, and governance of health policies affecting Indigenous populations. This process included identifying relevant institutional and community-level actors to ensure coverage of all sectors involved in the study topic. Based on this mapping, we selected participants using purposive sampling to capture diverse and relevant perspectives. We contacted participants directly through institutional channels and community networks. The final sample included twenty interviewees.

Twelve interviews were conducted with current and former public officials responsible for primary healthcare policies and programs, including the Sumar Program (formerly Plan Nacer), Essential Public Health Functions (FESP), and Health and Interculturality. Eight interviews were conducted with Indigenous territorial authorities representing the Chorote, Guaraní, Kolla, Iogys, Tastil, Weenhayek, and Wichi peoples.

We conducted all interviews in person using a semi-structured interview guide composed of core questions and follow-up prompts. With prior consent, we audio-recorded all interviews using mobile phone recording applications.

3 Results

3.3 Healthcare utilization patterns

The results reveal important differences in healthcare-seeking behaviors across Indigenous populations. Figure 1 shows that, across all Indigenous groups, family and friends constitute the primary source of care, followed by public hospitals, with limited use of primary care centers. However, reliance on family-based care varied significantly between them, reaching its highest levels among Wichí women and lower levels among Guaraní women (70% and 54.3%, respectively), with Kolla women occupying an intermediate position (57.3%).

The use of public hospitals was relatively homogeneous across Indigenous groups, while the use of CAPS was more limited and uneven. In particular, Kolla and Wichí women reported lower utilization of CAPS (15.7% and 5.6%, respectively), whereas Guaraní women showed a more balanced pattern of health care utilization, with hospitals and primary healthcare centers each accounting for approximately 20% of responses.

Consultation with community health referents remained marginal across all groups, as did the use of private providers, although the latter appeared slightly more frequent among populations located closer to urban centers.

Figure 1: First source of care among Indigenous women, by ethnic group (Source: Own elaboration based on user surveys).

3.5 Perceptions of key actors

This section presents the main findings from the interviews conducted with key stakeholders, organized around areas of alignment and divergence between actors.

3.5.1 Areas of alignment between stakeholders

Despite differences in perspectives, both institutional actors and Indigenous representatives identified several shared priorities regarding the functioning of the health system.

First, there was broad agreement on the central role of primary health care (PHC) as the main strategy for expanding coverage, particularly in geographically dispersed territories. In this context, health agents and community health workers were recognized by both groups as key actors linking Indigenous communities with the formal health system, especially in remote areas.

Second, both groups emphasized the importance of strengthening referral and counter-referral systems within the healthcare network. Government officials described the organization of the system into operational areas that integrate hospitals, health centers, and outreach posts. Indigenous authorities also showed awareness of these structures and stress that they often represent the only available pathway for accessing higher levels of medical care.

Finally, stakeholders agreed on the need to improve infrastructure and service organization to better respond to maternal and perinatal health needs, particularly among Indigenous groups. Institutional actors highlighted ongoing efforts such as the development of regionalized perinatal networks and the adoption of the Family-Centered Safe Motherhood model, which incorporates elements of an intercultural approach and promotes the involvement of families and communities. They also acknowledged the need to re-adapt delivery rooms to better accommodate cultural practices and facilitate family involvement, noting that alternative models allowing family presence during childbirth are currently being evaluated.

Figure 2 presents the main areas of alignment identified in the interviews, organized around two key themes: the PHC strategy and the referral and counter-referral system. For each theme, quotes from government officials are presented on the left and quotes from Indigenous representatives on the right, reflecting the shared recognition of these strategies as central to healthcare delivery in the province.

Figure 2: Areas of alignment in the priorities of government officials and Indigenous communities (Source: Own elaboration based on the interviews carried out).

3.5.2 Areas of divergence between stakeholders

Significant divergences emerged between institutional actors and Indigenous representatives, particularly regarding perceptions of quality of care and the extent to which an intercultural health approach has been effectively implemented.

While government officials generally described the quality of healthcare services as satisfactory and improving over time, Indigenous authorities expressed predominantly negative perceptions. They emphasized the persistence of economic, geographic, and cultural barriers that limit effective access to healthcare services. Cultural barriers, in particular, were pointed as a central issue. Indigenous interviewees reported that the lack of an intercultural approach affected communication with health professionals and undermines trust in the system. Experiences of discrimination and mistreatment were frequently mentioned. As one participant explained, “women who do not speak Spanish are mistreated and treated with contempt”. In addition, the limited recognition of traditional medicine and ancestral practices was perceived as a form of disrespect toward Indigenous knowledge systems.

Differences were also observed in perceptions of institutional initiatives aimed at promoting intercultural health. While government officials highlighted the role of bilingual facilitators and training programs for healthcare personnel, Indigenous representatives reported that these measures had produced limited impact and that major communication barriers persisted. Notably, most Indigenous interviewees were unaware of the existence of specific institutions or programs intended to address their healthcare needs.

Another area of divergence concerned the organization of care during pregnancy and childbirth. Institutional actors emphasized the importance of referring high-risk pregnancies to higher-complexity centers, whereas Indigenous authorities expressed a preference for receiving care within their communities, in settings that respected their cultural practices and social support networks.

Figure 3 presents the main areas of divergence identified in the interviews, organized around two themes: the quality of healthcare and the intercultural health model. For each theme, quotes from government officials are presented on the left and quotes from Indigenous representatives on the right, illustrating contrasting experiences and assessments of the current state of healthcare services in Indigenous communities.

Figure 3: Areas of divergence in the priorities of government officials and Indigenous communities (Source: Own elaboration based on the interviews carried out).

4 Discussion

This study examined perceived access, coverage, and quality of healthcare among Indigenous and non-Indigenous women in the province of Salta, Argentina, and explored the perspectives of key stakeholders regarding the functioning of the health system. The findings reveal three main results. First, significant disparities persist in geographic access and quality of care, particularly affecting Indigenous women. Second, patterns of healthcare utilization show a tendency to bypass primary care services in favor of hospitals and family-based care. Third, important divergences and some areas of agreement were found between institutional actors and Indigenous communities regarding the implementation of an intercultural health model,

These findings are consistent with broader evidence on Indigenous health inequities in Latin America, where structural disadvantages, including geographic isolation, language barriers, discrimination, and limited culturally appropriate care, continue to shape differential access to health services [31-33]. The disparities documented in this study suggest that, despite normative advances such as Law No. 7,856 and the adoption of the Family-Centered Safe Motherhood model, these structural conditions remain largely unaddressed in the province of Salta.

A notable pattern identified in this study is the tendency of Indigenous women to bypass primary care services and seek care directly at hospitals or through family and community networks. This behavior has been widely documented in contexts where primary care is perceived as low quality, culturally unresponsive, or simply inaccessible [34]. In segmented health systems such as that of Salta province, where public, social security, and private networks coexist with limited coordination, this bypass pattern contributes to the saturation of higher-complexity facilities and breaks the continuity of maternal and perinatal care [35].

The qualitative findings highlight a critical tension between biomedical and intercultural models of care. While government officials described improvements in service organization and maternal health indicators, Indigenous communities consistently reported experiences of discrimination, cultural insensitivity, and the limited recognition of traditional practices. This divergence is consistent with evidence from other Latin American contexts showing that intercultural health policies frequently remain symbolic in their implementation, particularly when Indigenous communities are excluded from their design and governance [15,36].

In particular, the concept of “spaces for consensus on priorities,” illustrated in Figure 4, provides a useful interpretive framework for organizing the findings. As shown in the diagram, both institutional actors and Indigenous representatives converge on the importance of strengthening integrated health service networks and the primary health care strategy. However, they diverge significantly in their understanding of what quality healthcare means, the role of traditional medicine, and the degree of intercultural adaptation required within the system. This distinction between formal alignment and substantive divergence reflects a broader pattern in the literature: intercultural frameworks are frequently adopted at the normative level without corresponding changes in institutional culture, resource allocation, or governance structures [37,38].

Figure 4: Spaces for consensus on the priorities of government officials and indigenous communities (Source: Own elaboration based on the interviews carried out).

On the question of primary health care, both groups recognized the central role of health agents and community outreach in reaching geographically dispersed populations. However, Indigenous representatives emphasized that these figures are currently fulfilling a translation function rather than acting as genuine cultural mediators with full understanding of communities’ worldviews and needs. The effective functioning of bilingual facilitators thus requires not only linguistic competence but also institutional recognition and an expanded scope of action.

The incorporation of traditional medicine and the flexibilization of biomedical practices remain key areas of tension in this study, as in comparable contexts across the region. Intercultural health initiatives that have shown the greatest success share a common feature: they were built on genuine community self-management and the equal recognition of Indigenous knowledge systems [39]. In the case of Salta, the evidence from user surveys suggests that the coexistence between traditional and biomedical medicine is already occurring -although with limitations- in certain departments, particularly in Orán, Iruya, and Tartagal. This points to a practical opportunity: these localities could serve as experiences -identifying challenges and improvements- for the development of more structured intercultural care models that formally incorporate ancestral practices and community governance, rather than relying on informal coexistence.

Several policy implications emerge from these findings. First, sthe role of bilingual facilitators should be expanded and redefined: rather than functioning as translators, they should be trained and institutionally recognized as cultural mediators capable of bridging the gap between biomedical logic and indigenous health conceptions. Second, improving the availability and continuity of care in maternal and perinatal health requires simultaneously addressing supply-side constraints—human resources, infrastructure, referral protocols—and demand-side barriers, including institutional distrust and cultural distance. Lastly, and most critically, achieving meaningful progress in intercultural health requires the active and binding participation of Indigenous communities in the design, implementation, and evaluation of health policies.

Declarations

ORCIDs

Abstract in spanish

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