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Editorial

Health reform in El Salvador: a guarantee sustainable health and human


development. To sum up, this system
should have to contribute to healthy
lost opportunity for reducing public policies.

health inequity and social THE PROPOSAL MAINTAINS THE

exclusion? FRAGMENTED STRUCTURE OF THE


PUBLIC SECTOR
Bienestar Magisterial (Teachers’ welfare),
1 2 Sanidad Militar (Military Health
Eduardo Espinoza, Françoise Barten Services), Instituto Salvadoreño del
Seguro Social (Salvadorian Social
Since the 1993 World Bank Report, health of a proposal for health reform (proposal Security Institute) (ISSS) and the
reforms based on market criteria and cost by the Comisión Nacional de Seguimiento FOSALUD (a fund created from the taxes
effectiveness studies have become popu- a la Reforma Integral de Salud. collected on tobacco and alcoholic drinks),
lar.1 The models from Chile and (CNSPRIS), Ministry of Public Health are autonomous public structures which,
Colombia, with their respective varia- and Social Welfare, November 2006). alongside the Ministry of Health
tions, were introduced as social experi- This has been received with scepticism (MSPAS), manage public funds, fragment
ments. Both failed and did not contribute and the feeling is that it will simply assistance and services, hinder a unified
to improved health or health equity.2 On reinforce the status quo defined by social negotiation of items such as medicines,
the contrary, these neoliberal innovations exclusion and conflict. create sub-registers in strategic data and
appear to have widened existing health are a source of health inequities. For
inequity according to critical reviews by example:
ITS GREATEST WEAKNESS IS THE LACK
institutions such as the Pan American
OF A SOCIAL AND ENVIRONMENTAL
Health Organization (PAHO).3
DETERMINANT-BASED APPROACH a. ISSS has an annual budget similar to
The human development reports the MSPAS budget. However, ISSS
This proposal considers health to be the
(UNDP) have identified Guatemala, covers only 17% of the population
absence of disease. It does not promote
Brazil and El Salvador as the most while MSPAS covers 81% (73%
the right to have access to essential
inequitable countries within the planet’s preconditions for health but only the belong to the three lowest deciles).
most inequitable subcontinent (Latin right to have access to healthcare services. b. Financing of health insurance has
America). In El Salvador, the post-conflict This approach reinforces the current recently been fostered for certain
context is causing a high incidence of biomedical tendency to focus mainly on segments of the population, such as
violence and homicides that mainly curative actions, individual responsibility public school teachers and the armed
affects young people. A national health and lifestyles, without taking into forces. This situation, as well as
system (SNS) is one of the few mechan- account the state’s responsibility to mod- opening the door to privatisation,
isms to be established in a state that has ify the life-context and to address the goes against the principle of solidarity
been greatly weakened by structural underlying and structural causes of health and sets a dangerous precedent for
adjustment programmes.4 5 However, similar initiatives that will lead to a
inequity. It limits its vision, its potential
more than 10 reform proposals from stratification of health care depending
role, its scope for action and the involve-
different sectors have classified it as: on the ability of each population
ment of other agents. It does not facilitate group to meet payments or make
a process that would release existing contributions. In the long run, the
‘‘…segmented, inadequately financed in
spite of the existing resources, with
community capacity in order to enhance public sector will be drained of its
scarce coverage, emphasis on curative a social determinants approach. resources and will only be able to
actions and with large groups of the The reformed system should clearly and assist the poor, elderly, unemployed
population unable to access health care’’ firmly promote access to health (not only and chronically ill patients.
to health services), the creation of a
Clearly, a healthcare system with such national health and human development Accordingly, the solution to this frag-
characteristics has been a constant source plan and a radically different financing mentation can be achieved by creating a
of conflict.6 In November 2006, a pres- policy, increased public investment and public sub-system based on a universal
surised national steering committee for protection of families from the health public service network.
the integral health reform proposal impact of adverse economic and social Official statements indicating that pri-
(CNSPRIS), presented the latest version policy and harm. vate sector services must, under no
This new system should promote food circumstances, be substitutes for the state
1
Observatorio de Polı́ticas Públicas y Salud- OPPS/ security, nutritional safety, outline regu- are contradicted in practice. Non-govern-
CENSALUD, Universidad de El Salvador, San Salvador, El lations and activities which avoid envir- mental organisations are currently being
Salvador; 2 Radboud University Nijmegen, UMCN, onmentally harmful practices and hired to provide services in rural areas
Institute for International Health, Nijmegen, The safeguard workers’ health. The public with funds from external financing
Netherlands
sector should be prioritised over the (loans), and the government is obliged to
Correspondence to: Dr Eduardo Espinoza, Final 25 Av
Norte y Boulevard de Los Héroes, Ciudad Universitaria,
private arena, and the signing of binding continue hiring these same NGOs and
Universidad de El Salvador, San Salvador, El Salvador; agreements on a regional and interna- paying them with public funds once the
eduardo@espinoza.ca tional scale should first and foremost loan has expired.

380 J Epidemiol Community Health May 2008 Vol 62 No 5


Editorial

THE PROPOSED FINANCING MODEL WILL THE CONCEPTS OF INTERSECTORAL as El Salvador, the national healthcare
NOT PROVIDE AN ANSWER TO THE COLLABORATION AND SOCIAL system reform is ethically bound not to
INEQUITIES, THE SYSTEM’S PARTICIPATION ARE WEAK perpetuate the status quo generated by
WEAKNESSES OR ENHANCE THE RIGHT In order to reinforce these ideas, it would social experiments. In an increasingly
TO HEALTH be necessary to introduce health and interconnected world, it is no longer
The national health accounts reveal that human development into the state’s possible to delay the revival of the
poor people in El Salvador invest more agenda and achieve a social contract comprehensive primary healthcare
money on their health each year than the between the government and the popula- (CPHC) principles stated in the Alma
state invests. Public health expenditure as a tion. However, the proposal in question Ata Declaration, which was aborted or
percentage of the national health expendi- barely enables other actors/sectors who sidestepped because of the crisis of the
ture has varied in the last few years from perform activities that are relevant and 1980s, rise of neoliberalism and the
42% to 45%, which means that most of it decisive for health to ‘‘collaborate’’ with perceived threat to lost political control
comes out of the household expenditure the health services system even less so to because of reinforced social organisation
(55–58%). The impact this has on house- ensure integrated multilevel approaches, and community participation.8
hold economies and on the increase in organisation, empowerment and social
poverty is unquestionable, and the SNS can mobilisation for health.7 Acknowledgements: We thank Dr Maria Teresa Ruiz
and should avoid it. To do so, the public Social participation is nothing more Cantero from the Public Health Department of the
University of Alicante for her valuable comments and
sub-system should create a public manage- than a fashion accessory when key issues contributions to this editorial and to the Cooperation and
ment and financing model to optimise the such as mechanisms, opportunities, insti- International Relations Office of the University of Alicante
scant resources. This would involve pro- tutional skills development and the orga- for its support in the translation of the final document.
posing and establishing priorities for invest- nisation of the community have not been Competing interests: None declared.
ment in health care while reducing the specified. Consequently, decision-making, J Epidemiol Community Health 2008;62:380–381.
overwhelming household expenditure, so accountability and evaluation processes doi:10.1136/jech.2007.067066
that gradually, and in the short term (five are limited and will continue to be the
years), at least 70% of this expenditure is prerogative of high-level civil servants
covered by state funds. REFERENCES
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