Universal Health Care in El Salvador – A Personal Reflection

Source: CISPES

In August, I went to El Salvador with a group of fellow healthcare professionals from the US to learn firsthand about the health reforms initiated by the current FMLN government to provide free health care to all. We were told what a precious moment this is for the FMLN: the first time in El Salvador’s history that the left has led the country. As Dr. Peñate, one of the Regional Directors of the Ministry of Health told us, “Transformation is not easy but it is possible. We have the opportunity to re-write and construct a new history.”

Under the right-wing ARENA party, which governed from 1989 to 2009 with continued US backing, neoliberalism flourished. Corruption was rampant; hundreds of millions of dollars of public funds would disappear with nothing to show for them. For example, past governments borrowed funds from the International Monetary Fund (IMF) – twice – to rebuild the Maternity Hospital that was damaged in the 2001 earthquake; not a brick was laid. (Former officials, including the ex-Minister of Health, were arrested on corruption charges under the new administration).

When the FMLN came to power, the country was an economic disaster. The previous administrations had deliberately restricted access to health care as part of the attempt to privatize; by 2006, 47% of Salvadorans were outside of any health care system. To go to a public hospital or clinic, a “voluntary” donation was demanded; that was abolished the day that President Funes was inaugurated in 2009.

Now, medicines, clinic visits, specialty services, and hospitalization through the Ministry of Health, which serves between 80-85% of the population, are free. As the Ministry told us, guaranteeing health care for all depends not only on access, but also on political will, economic justice, and a more equal distribution of resources.

The two-year-old reform is based on primary care, prevention, and public health. Hundreds of new clinics, which are staffed by Community Health Teams (ECOS), have been established in the poorest, largely rural, areas of the country, which had the least-available health care services. Each team, composed of a nurse, doctor, nurse’s aide, and several health promoters, is charged with surveying the population in their area (6-9,000 people) through home visits to document health risks of individuals, families and the community. The health care workers we met are extremely committed, working long hours with a lot of love and care. We walked for hours – across rivers, over mountains – with promoters to visit patients who live at the end of muddy paths, in areas with no vehicle access.

The ECOS are the smallest units in local, regional and national networks of integrated health services.

Within a network of 4-6 ECOS, there is also a specialty clinic with a lab, pediatrician, internist, gynecologist, dentist, health educator, nutritionist, and physical therapist as well as psychological and ER services. I was repeatedly told that people who needed emergency specialty evaluations could get seen in 24 hours and that routine consultations were available within 15 days. Compare that to the many months my patients in the US have to wait!

The FMLN’s healthcare reform raises the standards for other countries by providing world-class, universal healthcare. One of the things that most impressed our delegation was how much has been accomplished with so few resources; in just two years, they have made extraordinary progress. Maternal and infant mortality rates have decreased; in fact, El Salvador recently met the UN Millennium Development Goal for reduction of maternal mortality – four years ahead of schedule.

Despite the opposition of the right-wing, the FMLN managed to increase the budget for the Ministry of Health from 1.7% to 2.5% of Gross Domestic Product. However, nearly everyone we met with emphasized the need for more resources – from stethoscopes to medication to MRIs. The dearth of supplies was nowhere more evident than during our meeting with union workers at the Benjamin Bloom Children’s Hospital, who told us that even with “free” health care, parents may have to buy a syringe when the hospital runs out so that their child can receive an injection. For example, the union had to raise funds themselves for a refrigerator to store vaccines.

Though many of these workers and their union are very supportive of the FMLN, they expressed serious concerns about the conditions of their hospital under the new government. These militant workers made it clear that fiscal reform to make the wealthy pay taxes is the solution. We heard this message from workers and administrators alike: requiring corporations and the wealthy to pay their fair share is the only sustainable way to fund this system (Sound familiar?)

We also heard concerns about the fragility of programs like the ECOS, which are based on the political will of the FMLN and the Funes administration, not guaranteed by law; a change in government could end the reform. That’s why the Ministry has been helping to organize Community Health Committees, with a goal of helping the population to internalize and defend their right to health care and a better life. As the Vice-Minister of Health, Dra. Violeta Menjivar, told us, “The people should be the primary actors for their own health. We do good work but it’s the people who must defend the changes.”

The main message I was asked to covey to people in the US was that El Salvador is a small country struggling to make a better world. The FMLN government is young and still learning, making mistakes, and working to improve. I was asked to let people know about the health reform so that we in the US can help prevent the destruction of its gains. As William Hernández of the FMLN told us, “Our big fear is that the US will intervene in the internal affairs of El Salvador. We have the maturity to solve our own problems.”

I believe that health care is a basic human right. We must call upon our own government for universal healthcare with access to quality care for all instead of enriching the insurance companies. We must also oppose any attempt by the US government to intervene in El Salvador in order to privatize their health and other social services. (See article “Salvadoran Social Programs in Peril’).

The pioneering reforms that I saw in action in El Salvador were inspiring. As this effective model continues to be developed, the Salvadoran people will achieve better health and the government will meet its goal of improving people’s quality of life, even with limited resources. I am grateful for the opportunity to have witnessed the gains being made by Salvadoran society and I will fight for their right to continue.