Renovating the Public Health Care System in El Salvador

Challenge

El Salvador’s population faced development challenges due to inequalities in health care access and quality. Limited access to health care and high out-of-pocket expenditures had a disproportionate impact on the poor and those living in rural areas. The country’s health care system needed enhanced response capacity to effectively address increasing morbidity, mortality, and disability from communicable diseases and chronic noncommunicable diseases within these populations. Maternal mortality had decreased but had not reached the Millennium Development Goal (MDG) of 38 deaths per 100,000 live births; this remains a challenge, with 48 deaths per 100,000 live births in 2015 (decreased from 50.8 in 2011). In 2009, the government launched a health system reform. The National Health Strategy (2009–2014) aimed to reduce inequalities in access, improve health service quality, and strengthen information system management to enhance the Ministry of Health’s monitoring and oversight capacity. The World Bank supported the government in implementing the planned health reforms. 

Approach

The Bank approached these challenges through the Strengthening Public Health Care System project, which provided a flexible response to meeting the country’s evolving needs. Investment innovations included emphasis on maintenance of medical equipment, with more than 51 primary care hospitals and 30 secondary and tertiary hospitals receiving infrastructure and equipment updates. In addition, with project support, the Ministry of Health established the first National Radiotherapy Center to provide complete cycles of care for cancer patients, including training staff in treatment and management of third-generation equipment. 

The project also strengthened the National Institute of Health and National Reference Laboratory, which are responsible for the country’s response and monitoring capacity during outbreaks of infectious diseases; harmonization and collection of data, including the National Health Survey 2016; and the National Survey of Chronic Noncommunicable Diseases in Adults. Results from this survey supported creation of the first National Direction of Noncommunicable Diseases and development of the national strategy for prevention and care of chronic noncommunicable diseases. 

Results

The project had two goals: (i) expand access and improve the quality of health services for El Salvador’s poor and rural citizens; and (ii) strengthen El Salvador’s health ministry stewardship capacity to manage essential public health functions. The project was implemented in 92 municipalities, targeting 2.1 million people. 

Goal 1: Improving health services for poor and rural citizens. 

• The project aimed to increase the percentage of children younger than one year receiving a third pentavalent vaccination. 

• With a baseline of 92 percent The goal was to achieve 92.8 percent of coverage of pentavalent vaccine by 2016. The municipalities surpassed the goal reaching 95 percent in years 2013 - 2014, and reached 92 percent in 2016; and missed narrowly in 2015. 

• In the project’s final year (2017), and in 2015 however, the vaccination rate did not reach the goal. In 2017 it fell to 80.6 percent from the 95 percent achieved in 2016 and even below the 86.6 percent of 2015. The decrease was attributed to gang violence that increased in those years, which may have deterred families from traveling to health facilities. El Salvador’s well-known gang problem was acute in all 92 municipalities, 90 of which are considered highly dangerous. 

• Increasing the percentage of births occurring in health facilities. 

• With a baseline of 81 percent for 2012, the project set a goal of 84 percent of births taking place in health facilities by 2018. That goal was substantially exceeded: 99.8 percent of births occurred in facilities by the end of 2017. 

• The increase in institutional deliveries, combined with improved neonatal equipment, had dramatic results. The rate of maternal mortality in the public system fell to 31 deaths per 100,000 live births in 2017, from 65.4 deaths in 2006, and infant mortality dropped to 12.5 deaths per 100,000 live births in 2017, from 26.9 in 2000.

Goal 2: Strengthening the Ministry of Health’s institutional capacity in essential public health functions.

• The project succeeded in getting hospitals to safely dispose of their biohazardous waste.   

• The number of hospitals targeted increased from 14 to 26 over the course of the project. 

• The new number was surpassed when 30 hospitals are now following environmental regulations for disposal of biohazardous waste.

Bank Group Contribution

The World Bank, through the International Bank for Reconstruction and Development (IBRD), provided US$80 million to fully fund El Salvador’s Strengthening Public Health Care System project. A Japan Social Development Fund (JSDF) trust fund of US$2.8 million was implemented in parallel with this project. It contributed safeguards for pregnant women and children under the age of three against shocks from food price volatility, thus protecting the health, nutritional, cognitive, and social outcomes of very young children in marginalized urban poor families.

Partners

To accelerate progress towards reducing maternal and neonatal mortality, the project included interagency coordination among the Pan American Health Organization, the World Health Organization, the United Nations Children’s Fund, the United Nations Population Fund, the United Nations Development Programme, and the Inter-American Development Bank. The role of partnerships — involving government, civil society, the United Nations, the World Bank, and a preliminary interaction with the private sector — was extremely positive, creating a sense of shared responsibility and efficiency in the investment. The government made an effort to cover many of the activities discussed with and defined along with the partners as key in the effort to reach the MDGs. Agencies found complementary roles in the effort to reduce maternal and child mortality and established coordinating mechanisms integrating the international cooperation in the El Salvador’s National health Strategy. 

Beneficiaries 

The project benefitted 2.1 million people living in 92 municipalities, especially women and children.

Moving Forward 

This project proposed to pilot the line of care for noncommunicable diseases in three regions. A new project — El Salvador Addressing Noncommunicable Diseases — is currently under implementation and is being funded by a grant. Once the model is approved, it will be expanded to the whole country under another project, currently under preparation: Promotion of Human Capital in El Salvador at Different Stages of the Life Course. The new project will include promotion, prevention, and early treatment of disease.

In addition, a new project is now under preparation with the Inter-American Development Bank will fund activities on maintenance of medical equipment as a follow up to this World Bank health project.