Social Reforms of the National Health System of El Salvador - Lessons for Europe? Eduardo Espinoza Viceministro de Políticas de Salud Ministerio de Salud El Salvador Amberes, 22 de Noviembre de 2013
Health Care Reform in El Salvador Agroexport economy: polarizes society Peace agreements 1992 Background Peasant uprising and massacre in 1932 Political-military struggle to take power 1970 Fifty years of military dictatorship since 1932. Popular struggle in all political fronts
Changing Health System Start with charity hospitals. Later the social security system is created in order to mantain a healthy and productive labour force for the incipient industry. In the transition to a services economy in 1980s, the agressive comercial and financing elite identify the Social Security System of El Salvador as a potential mechanism to enhance profit by its privatization. The attempts of privatization lead to an extensive popular protest movement and the development of organizations that struggle against privatization.
A welfare state never has existed in El Salvador. The newly elected president expressed firm political commitment to ensure essential resources to build a National Health System that would: Acknowledge health as a public good and an essential human right and ensure the colective, democratic and participatory construction of health, based upon the following principles and values: Human Rights, Intersectorial approach to address health problems Ongoing search for equity, Solidarity in provision of efficient, integrated and universal health services Financing via general taxes Integrate, complement and develop health policies at subregional and regional level.
Human Resources Development Integral and Integrated netwoek of health services Medicines and Vaccines Inter/intra sectorial action National System for Medical Emergencies National Institute of Health National Health Forum Unified Information System 5
Budget increased: 74.8% for primary care level 46.7% for hospital network. All user-fees abolished (change from client to partner ) Reform process Increased demand for services at national level (25%), (increase 40% in poorest regions) Distribution of Community Health Teams (Ecos) in the poorest municipalities. Integration of previous information systems (40!!) into one unified national platform
Doubling the coverage Before health care reform (372 health units) Currently (692 community health centres)
Opportunities and mechanisms for social participation, stimulating intersectorial action
And beyond this The cost of medicines reduced by 60% and the lack of institutional availability from 50% to 15 %. Prenatal care increased (90%) as well as institutional birth delivery (95%) The reduction of inequitable distribution of human resources at national level and implementation of massive, intensive capacity building. The health system now leads the region with regards to control of : Epidemics of dengue with the lowest mortality rate in the continent, influenza AH1N1, and disasters due to climate change
250 OTHER CHANGING INDICATORS 200 182.3 182.1 180.6 180.8 187.2 198.1 202.5 160.3 150 100 GENERAL MORTALITY AT INSTITUTIONAL LEVEL 50 0 2005 2006 2007 2008 2009 2010 2011 2012 Fuente: Sistema Estadistico del Sistema Nacional de Salud Datos solo contienen defunciones de la red de hospitales del SNS Poblacion utilizada: Proyecciones de DIGESTYC Mortalidad General SNS (tasa por 100 mil habt) MATERNAL MORTALITY
1,3 Post-war: Hospital beds x 1,000 Inhabitants 1,2 1,1 1,09 1,1 1,07 1,14 1 1 0,9 0,9 0,8 0,7 0,6 0,8 0,7 Previous conservative governments Health as a commodity, market oriented Current government Health as a Right 2003 2004 2005 2006 2007 2008 2012 2013p 2013p: provisional data, expected to increase with construction of the new Maternal Hospital
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005(p) 2006(p) 2007(p) 2008(p) 2009 (pr) 2010 (pr) The threat of a good example.. $600.0 $500.0 $459.0 $517.3 Health Budget increase in times of crisis? To health??!! $400.0 $300.0 $200.0 $100.0 $0.0 $399.3 $368.5 $371.5 $326.1 2005 2006 2007 2008 2009 2010 Times of financial Crisis (GNP) 10% 8% 6% 4% -2% 0% 2% -4% -6% PIB real 12 PIB real per cápita
LESSONS LEARNED (1) The economic crisis does not necesarily need to be accompanied by a reduction of inversion in the social sector and in particular in the health sector.
LESSONS LEARNED(2) HEALTH a right or a commodity? There is sufficient evidence that the privatization of the Health System is ineffective and inefficient, worsening access, generating inequity, social exclusion, social conflicts, instability and increase burocracy.
LESSONS LEARNED (3) Regulation of the market is an imperative, essential and impossible to evade. It implies confronting powerful interests of the medicalindustrial complex and other actors with political influence.
LESSONS LEARNED (4) No justification exists - it is a contradiction- for handing over the Health System to the actors responsible for the crisis (Banks, Insurance companies). This will not solve the crisis; on the contrary it will endanger population health and create more disparities.
Lessons Learned (5) Europe should identify and prepare to confront the main actors in opposition to the Welfare State. Without doubt, these will include those who consider privatization of health care as an opportunity for increased financial benefit Undoubtedly, these are the same players who have opposed fiercly the national health care reform in El Salvador:
Opposing Health Care Reform POLICY SOCIAL DETERMINATION OF CHRONIC RENAL FAILURE BREAST FEEDING REGULATION OF MEDICAL DEVICES AND EQUIPMENT MEDICINES INTERFERENCE OF FINANCIAL CAPITAL IN HEALTH SERVICES MANAGEMENT TRANSNATIONAL ACTORS AGROINDUSTRY MARKETERS OF BREAST MILK SUBSTITUTES MEDICAL-INDUSTRIAL COMPLEX AND HIGH TECHNOLOGY MARKETERS PHARMACEUTICAL INDUSTRY BANKS AND INSURANCE COMPANIES