Free and Public

Universal Health Care in El Salvador – A Personal Reflection

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 Farabundo Martí National Liberation Front (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 National Republican Alliance party (ARENA), 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, paediatrician, internist, gynaecologist, 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, Dr. 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.

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.

Amanda Bloom is a medical doctor from Oakland, California.  This blog is posted with permission from CISPES.


Misdiagnosing malaria: experiences of the AMFm scheme in Ghana

A few months ago Oxfam published a critical report on the Affordable medicines facility for malaria (AMFm), calling it a ‘dangerous distraction’ from more effective ways of providing treatment. Our problem with the scheme is that it relies on unqualified shopkeepers to diagnose and distribute drugs, rather than trained health workers. This means there’s a huge danger of people being misdiagnosed, given there are many other causes of fever, not just malaria.

Oxfam spoke to people in Ghana, to see what their experiences were. Christiana’s story highlights how harmful selling someone the wrong medicines can be. 

Christiana Donyinaa is 43 and makes a living selling cosmetics. A few months ago her youngest daughter, Gloria (age 12), became ill with a fever. Christiana went to a shopkeeper and described Gloria’s symptoms and was told her daughter had malaria. The shopkeeper sold her malaria drugs.  

“I gave Gloria the medicine and she felt better after a few days. The following week, schools were on vacation so she decided to visit her older sister, who lives in Accra. As soon as she got to Accra she felt sick again. Her sister took her to the hospital and she was diagnosed with typhoid fever.  She was admitted to hospital for several weeks.   

I got very worried because school had resumed and she was still in the hospital.  The doctor said Gloria had been suffering from typhoid for a very long time, but because we didn’t take her to the hospital, we didn’t realise it early enough.   
When I was told that she was sick, I was very concerned and quickly jumped on a bus to Accra.  When I got there her condition was serious and I stayed with her in the hospital for more than two weeks.”   

Gloria’s condition became quite serious, she found it difficult to breathe and couldn’t eat anything without being sick. Because Christiana was at her daughter’s bedside, she was unable to earn any money over those few weeks. She also spent all the money she needed to run her business on medical expenses. In the end Gloria spent several months off school recovering and has now fallen behind with her studies.

“Gloria’s sickness has affected her a lot. She wants to be a Nurse in future but her illness has set her back a bit.”
Christiana believes that malaria medication should only be prescribed and distributed by trained health workers and not through shopkeepers.

“The advice I have for the government and NGOs is that the malaria drug is very good, if you have malaria.  But they should not give it to the drug peddlers; they should give it only to clinics. Some of the drug peddlers have these medicines in their pockets. They sell it to you when you tell them you have a headache, they will just give you the medicines without any diagnosis.  This is very dangerous the drug peddlers don’t know what illness people have.

I will advise every parent that when their child is sick they should take them to a doctor. Because if I had taken Gloria to the hospital from the onset when she was sick I don’t think both of us would have suffered as we have done.”

Oxfam is warning against any further funding for the AMFm scheme and for money to be used to invest in the training and salaries of community health workers instead, who are proven to save lives.

Sarah Dransfield is the Essential Services Press Officer at Oxfam GB


It’s been 100 days since the elections in Georgia: what does the government need to do to fulfil its promises?

Patient having blood pressure taken by local nurse, Georgia. Credit: Caroline Berger/OxfamIn the run up to the Georgian parliamentary elections in October 2012, two of the key policies put forward by Mr Bidzina Ivanishvili and his party Georgian Dream, were that his government would provide a basic universal health insurance and make major reforms to the health care system. There is no doubt that health care reforms that enhance access to services for the poor and improve quality are urgently needed. Years of low levels of government investment have pushed the Georgian health system to its limits – hospitals are poorly managed and health workers do not know when to expect their next pay check. However, scaling up the existing state supported insurance scheme is likely to lead to huge costs for the Georgian Government while not managing to provide health care for the poorest and most vulnerable people.

The previous Georgian government launched the Public Insurance Scheme (PIS) in 2007 to provide insurance for vulnerable groups, such as the extreme poor, through the allocation of vouchers for health services and products. This scheme was expanded in September 2012, just before the parliamentary elections, and it will eventually cover 2.1 million people (46% of the population and three times as many people as previously covered) including all under 5s and over 65s .

Government allocation to the PIS amounted to 58% of public health care expenditure in 2007 (over 88 million US dollars)  but there is little transparency when it comes to how the money is spent. Meanwhile, private insurance companies have been making huge profits from the PIS – in 2010 the State Audit Service reported that some companies were making profits of up to 50% from the PIS. The previous government attempted to tackle the high profit margin of insurance companies by pressuring them to take ownership of some of the 80% of hospitals in Georgia that have been privatised. The insurance companies that now own many of Georgia’s private hospitals are often subsidiaries of the three pharmaceutical companies that dominate the market in Georgia. The near monopoly of much of the Georgian health system has led to a conflict of interest limiting a patient’s ability to choose an insurance provider, hospital or medicine.

In many cases, hospitals owned by insurance companies have been found to be poorly managed and staff have reported erratic and decreasing salaries. In October, there were protests across Georgia by health workers over salaries and the lack of clarity of the future of their hospitals. The low salaries of health professionals has contributed to the entrenchment of a culture of practitioners demanding informal payment for better quality services, leading to out-of-pocket (OOP) payments for those covered by the PIS.

The issue of high OOP payments is a major flaw in the current scheme which excludes the poorest from accessing health care. The PIS covers a select number of secondary and tertiary health services and medicines, with patients paying out-of-pocket for any treatments and services not covered. Additionally, a report by Transparency International Georgia found that low levels of awareness among beneficiaries of the PIS scheme, meant that patients were paying for health care services that should be provided for free.

As 100 days have passed since the parliamentary elections, it is time that Mr Ivanishvili makes some headway in making the needed reforms to the Georgian health system. If Georgia’s universal insurance scheme is to be effective in providing universal health care, the problems with the current health care system must be addressed to ensure that OOP payments are reduced and that services can be maintained. This must include improved monitoring and regulation of private hospitals and insurance companies to ensure that funds are spent effectively and vulnerable populations are able to access health care.

Irakli Katsitadze is the Health Policy Programme Manager for Oxfam in Georgia


Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni