El Salvador

Overall Context

El Salvador, officially the Republic of El Salvador, is a country in Central America, bordered by Guatemala, Honduras, and the Pacific Ocean. The country is composed of 262 municipalities grouped into 14 departments. Each department has economic, technical, and administrative autonomy.

Demographics

El Salvador spans 21,041 km² and has the highest population density in the continental Americas. Its 2014 estimated population was 6,459,911: 55% were aged < 30 years and 12% were aged > 60 years; 52.7% were female, and 62.4% lived in urban areas (1, 2). Figure 1 shows El Salvador’s population structure in 1990 and 2015.

Figure 1. Population structure, by age and sex, El Salvador, 1990 and 2015

From 1990 to 2015, the population increased 16.7%. In 1990, the population showed a marked expansion among groups younger than 25 years old. By 2015, the population younger than 20 years old manifested a contractive structure, related to a reduction in fertility and mortality in the last two decades.

Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Population Division. 2015 Revision. New York 2015.

The Economy

The economic growth rate in 2015 was 2.4% (3). GDP increased from US$ 23.814 billion to US$ 25.850 billion from 2012 to 2015, and during this same period, per capita income rose from US$ 3,730 to US$ 3,940 (4). The national public debt to GDP ratio increased from 40.0% in 2008 to 58.0% in 2013 (4). National average monthly household income in 2015 was US$ 538.70 (1.1% greater than in 2011), with a marked rural–urban disparity: US$ 630.10 in urban areas and US$ 373.90 in rural areas (2).

Social Determinants of Health

In 2015, the illiteracy rate was estimated at 10.8% in the population = 10 years (women, 12.4%; men, 9.0%), with an annual reduction of 2.0% since 2011. Average schooling nationwide was 6.8 grades (7.9 in urban areas and 5.0 in rural); the sex distribution for schooling was 6.9 grades for men and 6.7 for women (2). The dependency ratio[1] reported for 2013 was 58.9%, which dropped to 53.9% in 2015 (2, 5); unemployment remained at 7.0% (6.5% urban and 7.9% rural); 8.4% of men and 5.0% of women were unemployed (2).

The principal source of income is personal transfers (family remittances), which fund around one sixth of private consumption. This income accounted for 16.3% of the gross domestic product (GDP) in 2013. Family spending increased due to remittances, of which 83.2% was spent on consumption (6).

The Human Development Index (HDI) of El Salvador was 0.664 in 2013 and 0.666 in 2014, making it a medium-HDI country, ranked 116th in the world (7). The Gini coefficient in 2010 was 0.46 and by 2015 it had declined to 0.37 (8). In 2015, of 1.8 million households, 44.4% were overcrowded[2] (61.4% rural and 34.9% urban). With regard to poverty, 34.9% of households were poor (38.8% rural and 32.7% urban), while 8.1% were extremely poor (10.1% rural and 7.0% urban); this indicator increased 3.8% from 2011 to 2015 (2). Historically, rural areas have the greatest percentage of people living in poverty, compared to national and urban percentages (Figure 2).

Figure 2. Changes in rural and urban poverty, El Salvador, 2010-2015

Source: General Directorate of Statistics and Census of El Salvador. Household and multiple use survey 2015 (2016). Available at: “http://www.digestyc.gob.sv/index.php/temas/des/ehpm/publicaciones-ehpm.html

Violence and Security

El Salvador was considered the most violent country in the Western Hemisphere in 2015 (9), a year that was the country’s most violent since the 12-year civil war ended on 16 January 1992. The national homicide rate was estimated at 103 per 100,000 population.[3] According to data produced jointly by the National Civilian Police, the Forensic Medicine Institute, and the Office of the Attorney General of the Republic, there were 1,062 violent deaths of women from January 2012 to June 2015 (10).

In El Salvador, the benefits of peace and development have been slow to reach vulnerable and marginalized communities in several regions of the country. Lack of law enforcement has enabled the proliferation of youth gangs, drug trafficking, firearms use, and gender-based violence.

Leading Environmental Problems

El Salvador ranks among the world’s top 10 countries at greatest risk from high exposure to hazards from natural events (11). Two serious hydrometeorological events have occurred in the past five years: Tropical Depression 12E in 2011, which caused US$ 44.9 million in health-related damages and losses (12), followed by four consecutive years of drought that culminated in 2015 and affected 712,200 people who depended directly on agriculture for their livelihoods, impacting food security (13, 14).

Vulnerable Populations

According to the Multipurpose Household Survey, in 2015, 140,700 children and adolescents, aged 5 to 17 years, were found to be working, equivalent to an incidence rate of 8.9%. This represented a 13.5% reduction from 2013. This working child population was largely male (73.4%), was aged 14 to 17 years (66.6%), and resided in rural areas (60.7%). Furthermore, nearly 4 out of 10 children and adolescents who worked did not attend school (2).

In 2015, according to the aforementioned Multipurpose Household Survey, 36.3% of the population aged 0 to 17 years lived without one or both parents; 15.8% of these cases was due to parental abandonment (76.1% by the father, 8.1% by the mother, and 15.8% by both) (2).

The Health System

The Ministry of Health is El Salvador’s health regulatory entity and its largest health service provider. Its internal organization, services, and facilities are technically and administratively organized in a central level, five health regions, and 17 comprehensive basic health systems. The Salvadorian Social Security Institute (ISSS, for its Spanish acronym) is the institution with the second-greatest number of facilities and population coverage; its health services are organized into four regions. The other institutions that form the National Health System (SNS) are the Salvadorian Comprehensive Rehabilitation Institute, the Salvadorian Institute for Teacher Welfare, the Health Solidarity Fund, the Military Health Command, and the National Drug Directorate.

As part of the health sector, the National Drug Directorate regulates drugs throughout the country through the National Drug Policy, which gave rise to the Medicines Act, adopted by the Legislative Assembly in 2012. The Higher Council for Public Health is the sector institution that regulates and oversees the exercise of health professions and the operation of private-sector health institutions and establishments.

The Ministry of Health—with Health System Reform since 2009—has a health services system, organized according to levels of care and complexity into 68 municipal and intermunicipal micronetworks, 13 departmental networks, and 5 regional networks, which form the national network of health system services One of the greatest achievements of the reform with regard to health services is the creation and equipping of community health teams that are the basic operational unit of the National Health System. At the time of this writing, there are a total of 575 of these teams (536 family teams and 39 specialized teams) that work in 184 (70.0%) municipalities and cover 377,483 families (22.0%).

The Road Map Toward Universal Access and Universal Health Coverage, ratified by the institutions that make up the National Health System, aims to progressively integrate and network operations of all the system’s services and facilities. There are 956 outpatient, 104 specialized outpatient, and 43 hospital facilities in the country.

In 2013, total health expenditure accounted for 6.9% of GDP (4.6% public spending and 2.3% private spending), and 17.0% of total public expenditure. Out-of-pocket expenditure made up 85.0% of private expenditure and 28.0% of total health expenditure, while spending on prepaid insurance plans represented 15.0% of private expenditure in 2013.

In 2015, 1,735,875 people (26.9% of the population) were covered by public insurance. The ISSS covered 1,636,265 beneficiaries in 2015, including 796,626 subscribers (84.3% active and 15.7% pensioners) and 693,076 dependents. In 2015, the Salvadorian Institute for Teacher Welfare covered 98,296 beneficiaries; 42,046 subscribers; and 56,250 dependents (23% spouses and 77% children) (15).

• This entry is also available in Español

Leading Health Challenges

Critical Health Problems

Neglected Diseases and Other Infections Related to Poverty

In El Salvador, neglected infectious diseases primarily affect those who live where poverty is widespread, where resources and access to opportunities to improve quality of life are limited. The National Plan for the Prevention, Control and Elimination of Neglected Infectious Diseases (16) targets the following diseases for prevention, control, and elimination: Chagas disease, with 446 chronic cases treated per year; leishmaniasis, with 18 new cases per year; leprosy, with 3 new cases; leptospirosis, with 2 new cases; rabies (no cases of human rabies since 2009); soil-transmitted helminth infection, with a prevalence of 7.9% among children 8-10 years old; toxoplasmosis, with 2 new cases per year in pregnant women; and congenital syphilis, which affects 7 newborns per year. Neglected infectious diseases are primarily found in central and western El Salvador.

Regarding the human immunodeficiency virus and AIDS (HIV/AIDS), in 2015, the Ministry of Health’s network reported a total of 33,184 cases of HIV infection, of which 28.0% were classified as having advanced HIV or AIDS and 72.0% as having HIV infection without manifestations of the infection (17). The epidemic continued to primarily affect men (63.0% of those infected) with a male-to-female ratio of 7:1. Unprotected sexual relations (> 90.0% of cases) continue to be the main transmission mechanism. All 14 departments of the country reported HIV cases: 7 (50.0%) had rates of more than 150 cases per 100,000 population, among them, San Salvador with 262, Sonsonate with 241, La Paz with 188, Santa Ana with 190, Ahuachapán with 169, San Miguel with 169, and La Libertad with 165.

Maternal Mortality

The maternal mortality ratio in 2015 was 42.3 deaths per 100,000 live births, 10.3 points less than the previous year. However, in this same year, 19% of maternal deaths occurred among girls and adolescents (18).

Adolescent Pregnancy

Of all deliveries attended in the National Health System facilities, 23.6% and 22.9% were to adolescents in 2014 and 2015, respectively (18). The incidence of adolescent pregnancy in 2015 rose as formal education declined, which underlines the greater burden of adolescent pregnancy among the most socially disadvantaged. Hence, among those with least education, there were 1,683 pregnancies more per every 100,000 adolescents than among those who had at least 10 years of formal instruction(18). This also influenced the probability of pregnancy occurring, since it was greater (60.0%) if the young woman belonged to the quintile with the least formal instruction (5th quintile), compared to the group with the greatest access to education (1st quintile).

Malnutrition

In 2014-2015, the estimated prevalence of malnutrition in the general population was 12.4%, or approximately 800,000 individuals (18). Despite the efforts of the National Health System, the country still faces problems of acute (2.1%) and chronic (13.6%) malnutrition at a national scale (2014 data). Meanwhile, overweight remained at 6.0% from 2008 to 2014 (19).

Chronic Conditions

According to the Ministry of Health’s Directorate of Health Surveillance, noncommunicable diseases (NCDs), together with injuries, were the leading causes of death in the last five years, which means that they will pose a great burden for the entire health care system. This makes them a priority to be targeted through intersectoral interventions aimed at their determinants, especially those linked to lifestyle (alcohol and tobacco use, poor diet, and a sedentary lifestyle).

The increase in morbidity, mortality, and disability caused by NCDs, mental disorders, and injuries is a major health challenge. It will require surveillance, prevention, and treatment to control NCDs and intersectoral actions to have an effect on their social determinants and risk factors.

Hospitalizations and deaths from NCDs in 2015 increased 1.6% and 1.9%, respectively, in comparison to 2014. Hypertension, diabetes, and chronic lower respiratory diseases accounted for 91.6% of consultations for NCDs. Diabetes, chronic renal disease, and cancer constituted 62% of hospitalizations and 57% of NCD deaths (18).

Human Resources

Density of health professionals in 2015 was 19.5 per 10,000 population (physicians, nurses, and maternal and child health graduates). Despite not achieving the goal of 25 professionals per 10,000 population, distribution of personnel has become more equitable, compared to 2010, especially in the most vulnerable departments (Figure 3). Density of professionals in rural areas was 1.6 per 10,000 population in 2010, and increased to 4.4 per 10,000 in 2015. Nevertheless, gaps still persist in the rural–urban distribution by percentage of health personnel. Nationally, only 13.9% were located in rural areas; the department of San Salvador had the greatest deficit, with only 1.9% of its health personnel located in rural areas, which contrasted with 47.0% in the department of Sonsonate.

Figure 3. Health professionals per 10,000 population, by department, El Salvador, 2010 and 2015

Source: General Direcorate of Statistics and Census of El Salvador. Household and multiple use survey 2015 (2016). Available at: “http://www.digestyc.gob.sv/index.php/temas/des/ehpm/publicaciones-ehpm.html

Six National Health System institutions employed the health labor force. In 2015, a 46,983 workers were distributed as follows: 17.7% general practitioners and specialists, 2.1% dentists, 10.5% graduate nurses, 13.1% nursing auxiliaries, 19.6% technical personnel, 8.1% community health workers, 27.8% administrative personnel, and 0.9% interns. Of all human resources working in the National Health System, 62.4% worked at the Ministry of Health (20).

The country has 11 higher education institutions that train technical and professional health personnel in 13 disciplines; on average, 670 physicians, 722 nursing professionals, and 1,276 nursing technicians graduate annually. Specialist physicians are trained in 14 National Health System teaching hospitals in coordination with four of these universities.[4]

The administration of work in regional service networks involves the development of effective managerial and communication skills and abilities, including use of information and communication technology in the health sector (21).

From 2013 to 2015, through the Virtual Campus for Public Health and the implementation of the El Salvador node, 504 health workers were trained in the following areas: 360 in primary health care, 9 in information systems, 45 in educational program design, 18 in family therapy, 36 in occupational health and safety, and 10 in applied research methods for blood banks; 26 received online tutoring. National professionals also participated in regional processes such as policy making in health, with 11 participants, and in issues dealing with human rights (22).

El Salvador’s Human Resources for Health Observatory[5] provides information on and understanding about the dynamics of human resources, which is used as a foundation for implementing health policies. As part of the Health System Reform that began in 2009, the Ministry of Health regulates the National Policy on the Development of Human Resources in Health (21). This policy’s objectives include attaining a universal and equitable health system, which means that some of its work consists of the organization and management of service networks and human resources development (23).

Health Knowledge, Technology, and Information

Between 2010 and 2015 there was an increase in the proportion of homes with Internet, from 9.0% to 23.3% (24).

In 2009, health information was fragmented and scattered; the Ministry of Health alone had more than 40 different applications, but with no entity responsible for their management and integration. Through Inter-American Development Bank (IDB) funds, the web-based Unified Health Information System went online in 2010, using open-source software; the system has nine subsystems and 1,234 reporting units nationwide (18). As the system has been rolled out, the flow of information has gradually changed and the National Health System has been able to avail itself of new online technologies and timely information and analysis for strategic decision-making.

The Environment and Human Security

According to the publication The Economics of Climate Change in Central America by the Economic Commission for Latin America and the Caribbean (ECLAC) (25), loss of biodiversity will be one of the most harmful effects of climate change. Is estimated that by 2050, El Salvador will have 70% to 75% reductions in its Potential Biodiversity Index, due partly to temperature increases and to the occurrence of extreme weather events such as torrential rains and droughts (25, 26). The 1.3 °C temperature increase in the last six decades portends the future effects of climate change in El Salvador. In addition to harming wetlands and other ecosystems, the effects of climate change aggravate already existing problems such as limited access to drinking water.

The amount of open-air waste declined from 1,611 tons in 2007 to 800 in 2012; however, this decline has stagnated due to a lack of policies that can ensure economic sustainability by covering transportation costs and final waste disposal. As a consequence, illegal waste dumps have proliferated in in recent years (26). In 2015, 51.1% of the country’s 1.8 million households disposed of the refuse they did not recycle through public household collection, 37.4% burned it, and 5.7% dumped it anywhere they chose.

Nationwide, 84.4% of households used propane gas to cook and 11.1% used firewood. In 2015, propane gas (90.9%) was the primary cooking fuel in cities, while only 4.0% used firewood; on the other hand, gas and firewood use in rural areas was 72.7% and 24.0%, respectively (2).

Aging

The aging index increased from 34.3% to 38.8% from 2012 to 2015 (1). According to projections, the index is expected to continue to increase as a result of health policy, socioeconomic, and health improvements, so that by 2020 it is projected to reach 46.5% and continue to rise (1).

From 2012 to 2015, life expectancy at birth increased from 72.1 to 72.7 years, rising from 76.6 to 77.0 for women and from 67.2 to 67.8 for men.

According to the 2007 census, it was estimated that at least 23% of households in the country were led by an older person, and of these, 10% were led by women, who also cared for their family group. With regard to health, the elderly care program does not offer home-based services nor does it have databases that make it possible to identify persons with disabilities. The most frequent illnesses among the elderly are diabetes, heart disorders, hypertension, and mobility problems.

Migration

An estimated two million Salvadorians live abroad, mainly in the United States of America (4). The conjunction of low economic growth and violence impels citizens to migrate in search of a better life. The determinants of migration are insecurity and a wage gap five times greater between migrant families and their counterparts that remain in El Salvador (4). During 2015, 20.2% of Salvadorian households received remittances (17.9% of urban and 24.0% of rural households). Remittances were calculated at US$ 63,375,611 for 2015, with a monthly average per household of US$ 180.08 (US$ 193.1 in urban and US$ 164.7 in rural households).

Monitoring the Health System’s Organization and Performance

The Government of El Salvador presented its Five-year Development Plan 2015–2019, with input from the public and multiple sectors, which provides continuity to the Health System Reform policy that the government promulgated for the five years this report encompasses. The Plan, through 2019, contains four objectives: reduce maternal mortality to < 35 per 100,000 live births, maintain infant mortality (in children aged < 1 year) at < 8 per 1,000 live births, maintain vaccination coverage at > 95%, and reduce direct out-of-pocket household spending by three percentage points (27).

Strengthening of the National Health System’s Leadership and Integration

In 2010-2014, the Health System Reform that began in 2009 laid the groundwork for a health care model based on primary care; it made advances in public health, access, and coverage by comprehensive health care by eliminating charges at public health care locations and bringing services to the population through community-based family health teams. Furthermore, service networks were organized and managed and human resources developed to attain a universal and equitable health system (23).

Nevertheless, the National Health System continues to be segmented and fragmented. Since 2014, the reform process has been reoriented and intensified, with a clear focus on access and universal health coverage and on the system’s functional integration. All institutions and agencies that are part of the National Health System came on board with this effort by signing (in September 2015) a Road Map designed to advance toward these objectives.

The Ministry of Health covers of 72.0% of Salvadorians, the Salvadorian Social Security Institute (ISSS) covers 25.1%, and the Salvadorian Institute for Teacher Welfare and the Military Health Command serve 1.6% and 1.1%, respectively. Fragmentation becomes evident in the inequitable distribution of per capita public health expenditure: per capita expenditure in the Ministry of Health is US$ 137 (23); in the ISSS, US$ 236; in the Military Health Command, US$ 349; and in the Salvadorian Institute for Teacher Welfare, US$ 509. The composition of the national health expenditure[6] from 2009 to 2015 indicated that public institutions financed more than 60.0% of the national health expenditure; one-third came from household out-of-pocket spending and less than 7.0% came from private insurance companies (Table 1).

Table 1. Public and private national health expenditure, El Salvador, 2009-2015

In order to ensure the expansion of universal health, National Health System’s leadership functions must be strengthened and the country’s legal framework must be reformed; this will ensure viability and legal support for the integration of the National Health System and the reforms that began in 2009.

Eliminating Barriers and Expanding Coverage

Acute upper respiratory infections, diarrheal diseases, parasitism, genitourinary diseases—in particular chronic kidney disease—and skin disorders are among the 10 leading causes of morbidity for which Salvadorians sought health care during 2014 (18). Despite efforts to control the HIV/AIDS epidemic in the country, from 2011 to 2015, 1,312 new cases per year were confirmed, with little variation from one year to year; AIDS affected 63% of men in the group aged 20 to 24 years. In terms of HIV/AIDS, the country must identify the target population and, in particular, detect coinfection with tuberculosis (17, 28).

Tuberculosis affects 37 people per 100,000 population, with an annual average of 2,150 new cases in 2011-2015; the infection is particularly concentrated in persons deprived of liberty, who are six times more likely to be infected than the general population (17).

The health system must strengthen its response capacity for coping with the increase in morbidity, mortality, and disability caused by communicable diseases and, especially, by chronic NCDs. Surveillance, prevention, and treatment are needed to control them, as well as intersectoral actions to impact social determinants and risk factors.

Consolidating Intersectoral Coordination and Social Participation

In 2015, more than half of families owned their homes (51.1%). Most dwellings were poorly built: 76.4% of houses had concrete walls, 16.5% had a dirt floor, and 41.3% were roofed with sheet metal. Of all homes, 95.4% had access to electricity and 86.6% to running water, although service is irregular; in rural areas, 76.3% of homes had access to water (2).

Independent studies show that drinking-water quality was poor and that around 40.0% of systems analyzed had microbiological contamination, in addition to a degree of irregular chlorination, in both rural and urban areas (29). Low coverage and poor service are factors that contribute to poverty in the most vulnerable groups. In addition, limited access to drinking water increases the burden of disease from vector-borne diseases, due to improper water storage, which is a risk factor for diseases such as arboviral diseases (dengue, chikungunya, Zika, and yellow fever, among others) (18).

Other development indicators show that the poorest and unsubsidized populations pay 30 times more for each barrel of water (42 gallons) than do those with greater resources. In rural areas, 27.7% of the population cooks with firewood. Furthermore, some 4.1 million people (64% of the population) live in the country’s 50 most violent municipalities (30).

• This entry is also available in Español

Health Situation and Trends

Health of Population Groups

Maternal and Reproductive Health

In 2014, the total fertility rate of women of childbearing age (15 to 49 years) was two children per woman (3). The fertility rate of women 15-19 years old was estimated at 74 per 1,000 women. The percentage of women aged 20 to 24 years who had at least one live birth before the age of 18 years was 18.0%. Research into the use of any contraceptive method (modern or traditional) showed that 72.0% of women aged 15 to 49 years who were either married or in a consensual union used some form of contraception, or their partners did (19).

Between 2014 and 2015, a 2.0% increase was observed in the number of maternal care contacts; 610,379 women were seen in the latter year. A slight increase also was observed in institutional delivery coverage, in those two years, from 99.0% to 99.6%. Only 0.4% of deliveries were attended in nonhospital facilities in 2015 (161 fewer deliveries than in 2014) (18).

In 2015, El Salvador’s prenatal care coverage stood above 77.0%, hospital deliveries at 99.0%, and early childhood registration (the newborn’s first checkup) at higher than 89.0% (18). This high coverage notwithstanding, there are issues that should be addressed, such as improving the quality of care in preventive services through interventions that strengthen the technical capabilities of specialized and nonspecialized human resources, enhancing infrastructure, and increasing access to health care technology in the health services.

The Ministry of Health reported that in 2014 there were 1,053 deliveries in girls 10-14 years old (4.0% of total deliveries in adolescents) and 22,659 in adolescents 15-19 years old (31.0% of total deliveries)(31).

The Forensic Medicine Institute reported a total of seven forensic inspections of suicide among pregnant adolescents between 2011 and June 2014 (31). Furthermore, in 2012 the percentage of nuclear families headed by adolescents 14-17 years old increased 15.7% and the percentage of single-parent households headed by 14-17 year olds increased 15.1% (32).

Child Health

In 2015, the Ministry of Health’s hospital network recorded 1,343 deaths of children under 5. Of these, 86.1% occurred in children under 1 year and 56.1% occurred during the neonatal period. According to data from the 2014 National Health Survey, the mortality rate in children under 5 was 20 per 1,000 live births, 17 in children under 1 year, and 11 in neonates (19). Among the causes of neonatal mortality, premature birth accounted for 28.3% of deaths and congenital malformations accounted for 25.0%, with a predominance of central nervous system and cardiovascular system anomalies. The neonatal mortality rate in mothers with a high school education was 3.0 per 1,000 live births, compared to a rate of 10.0 among illiterate mothers (18), revealing stark social inequities. Infant mortality was four times greater among teenage mothers who were not enrolled in school (37.0 per 1,000 live births) than among college-educated mothers (8.4) (18).

To address nutritional disorders, prevent growth retardation, and improve health and nutrition in the first 1,000 days of life, the Complementary Feeding Project was implemented in 218 municipalities. The program targets children 6 months old to 2 years old, pregnant women, and breastfeeding mothers; it benefited 108,872 persons (18). The Nutritional Recovery Project—an initiative targeting children aged 6 months to 9 years who are suffering from acute, moderate, and severe malnutrition¾is being implemented in 14 priority municipalities in the departments of Usulután, San Miguel, and Morazán; it has helped 14,000 boys and girls. Food fortification helped to reduce anemia, congenital malformations, and child morbidity and mortality. Monitoring such foods confirmed that more than 90.0% have adequate levels of fortification. All sugar is fortified with vitamin A and more than 70.0% of salt contains iodine (18). The 2014 National Health Survey concluded that 9.0% of children born in the two years prior to the survey had low birthweight (19).

El Salvador conducted its first World Breastfeeding Trends Initiative (WBTi) assessment in 2011, obtaining a score of 85.5/150. The results revealed several gaps, among them the need to develop a national breastfeeding plan with interinstitutional commitments. In 2013, the Law for the Promotion, Protection, and Support for Breastfeeding was passed, and in 2015, maternity leave was extended from 12 to 16 weeks, which facilitates helps encourage breastfeeding (33). In 2014, 96.0% of women with a live birth in the last two years breast-fed their children (no matter for how long) and 42.0% breast-fed their newborns within an hour of delivery. The National Health Survey confirmed that 58.0% of children aged < 6 months received breast milk as their main source of food during the day prior to the survey (19).

As a way to continue to improve comprehensive care for children, the National Network of Human Milk Banks has been strengthened; this effort that has received recognition from the Global Network of Human Milk Banks because of its overall performance and because of plans to expand the strategy to the first level of care through the operation of collection centers (18, 33).

The National Vaccination Schedule, updated in 2015, includes 15 vaccines, 8 of which are administered to children under 5 (18, 34). Despite attempts to vaccinate some 110,000 children under 1 year old, the country’s coverage record for 2011-2015, according to the Ministry of Health, was 93.0%, short of the set goal of covering 95% of that age group.

In 2014, it was reported that 25.0% of children aged 36 to 59 months attended an early childhood education program. It was also reported that in the three days prior to the survey, 59.0% of children in this age group had carried out four or more activities to stimulate learning and increase school readiness(19).

Health of Schoolchildren

In 2013, 2.0% of students 13-15 years old who attended 7th to 9th grades were low weight or underweight. In contrast, 38.4% were overweight or obese (28.8% overweight and 9.6% obese), with no differences between the sexes. Among students, 20.8% stated that they engaged in physical activity at least one hour a day for five days a week or more. In this group, boys were more active than girls (26.6% and 14.8%, respectively) (35).

Regarding alcohol consumption, 37.3% had consumed alcohol at some point in life, and 17.1% drank one or more times in the month prior to the survey; 68.5% of those who had consumed alcohol obtained their first alcoholic beverage before the age of 14 years, even though the country has a Tobacco Control Law and a Law to Regulate the Production and Marketing of Alcohol that restricts access to alcoholic beverages for those under age 18 years (35).

Of the students surveyed, 22.7% had had sex, mainly boys; the trend increased with age up to 30.1% among those in 9th grade. Of students who had had sex, 49.9% had initiated sexual activity before 14 years old (50.1% in boys); 9.5% said they had had sex with one or more partners in their lifetime (14.6% of boys and 3.7% of girls). When cross referencing those students who had been inebriated at least once with those who had had sex, 53.9% of respondents met both conditions; in disaggregating the indicator by sex, 65.2% of boys claimed to have had sex while inebriated (35).

Health of Adolescents and Young Adults

Nationwide, 358,627 (26.6%) young people aged 15-24 years “not in education, employment, or training” (NEET).[7] NEETs accounted for 32.3% of rural and 22.3% of urban residents, and by sex they accounted for 38.5% of women and 14.7% of men. Furthermore, this issue mainly affected young people who come from lower income households, since NEETs made up 46.9% of the lowest income quintile, and only 14.7% of the highest income quintile (2).

Health of Adults and the Elderly

The highest prevalence rates in the population 20 years old and older were for hypertension (37.1%), obesity (26.8%), chronic kidney disease (13.3%), and diabetes mellitus (12.5%) (18). It is important to point out that hypertension, obesity, and diabetes mellitus mainly affected women, while chronic kidney disease was more common among men (18).

Mortality

According to regional core health data from the Pan American Health Organization/World Health Organization (PAHO/WHO), a total death rate of 7.3 per 100,000 population was reported for El Salvador for 2013; the age-adjusted rates by major groups was 507.4 for NCDs, followed by 112.3 for external causes, and 110.6 for communicable diseases (36). Disaggregated by sex, the three leading causes of death for men were homicide (115.2), ischemic heart disease (64.4), and diabetes mellitus (44.5). For women, the three leading causes were diabetes mellitus (56.3), ischemic heart disease (48.9), and cerebrovascular disease (24.8) (36). In the population aged 10 to 34 years, homicide was the leading cause of mortality for both sexes; in men, homicide was the leading cause until age 44 years. In men aged 10 to 44 years, land transport accidents were the second or third leading causes of death in each age subgroup (36).

Morbidity

Communicable Diseases

An inequity analysis demonstrated that the incidence of dengue increased in parallel lower access to household water and fewer years of formal schooling (18). This analysis found that of all cases of dengue in 2015 (50,169), it would have been possible to prevent at least 16,300 (32.5%) suspected cases attributable to a lack of access to water (absolute population attributable fraction) and 27,700 (55.2%) if the entire Salvadorian population had at least 10 years of formal instruction. From 2011 to 2015, an annual average of 60,000 probable cases of dengue, 446 case of severe dengue (0.7%), and 6 deaths were reported, for a case-fatality rate of 0.01%.

In May 2014, the first cases of chikungunya were confirmed. Since then, the disease affected 2,662 people per 100,000 population and the year closed with 168,462 suspected cases, 166 laboratory confirmed, 54 hospitalized, and 6 deaths. The departments of San Salvador, Usulután, San Vicente, La Unión, La Paz, and Sonsonate had the highest incidence rates and the group aged 20 to 29 years was the most affected, with 4,444 cases per 100,000 population (37).

In El Salvador, the first cases of Zika were confirmed in late November 2015; cases steadily increased through December, peaking in the first week of 2016, when 1,142 cases were reported (37). As of 6 August, 10,959 clinically suspicious cases of Zika virus infection had been reported (54 were laboratory-confirmed). These represented 24.2% of the cases in Central American countries reported to PAHO/WHO (38). El Salvador was the third country in the Americas to report an unusual increase in cases of Guillain-Barré syndrome, which coincided with the increase in the number of Zika patients: 224 cases were reported, of which 36 (16.1%) occurred in December 2015 and 188 (83.9%) during 2016. None were laboratory-confirmed.

Once the risk of vertical Zika transmission was confirmed, monitoring of pregnant women began: in the same period, 333 pregnant women were recorded, samples were collected from 67 women, and 7 (10.4%) were positive by RT-PCR.[8] Between March and August 2016, there were 109 births of children with microcephaly, but only 4 (3.7%) could be laboratory-confirmed, while 18 (16.5%) were positive for toxoplasmosis infection, and 15 (13.8%) for cytomegalovirus (38).

The country reported an average of eight cases of malaria each year in 2011-2015, of which 75.0% were imported. In 2013, El Salvador pledged to eliminate indigenous malaria transmission by 2020. The few reported cases, compared to neighboring countries that report greater incidence, is the result of having a nationwide human resources network (331 people) devoted to surveillance and control, and a network of 211 laboratories that diagnosis malaria. This has led to the number of municipalities with an at-risk population to drop from 11 (4.2% of the total 262 municipalities) in 2011 to 2 (less than 1.0%) in 2014.

In terms of vaccine-preventable diseases, the country’s vaccination coverage for children under 5 years old exceeded 90.0% in 2011-2015. El Salvador has initiated the process of certification for measles and rubella elimination, and eradication of poliovirus (18). In 2015, TDaP (tetanus, diphtheria, and acellular pertussis) coverage of pregnant women was 75.0%.

Regarding zoonoses, El Salvador has not reported any cases of human rabies since 2009 (16). Strengthening of this area included: 1) increases in the production of 38 lots of SMB (suckling mouse brain) vaccine with 30,000 doses each, for a total of 1,140,000 doses, by the Ministry of Health’s Biologicals Laboratory, and 2) the success of the National Canine and Feline Vaccination Campaign, which vaccinated 1,017,835 animals, for a coverage of 79.0% and a total investment of US$ 2,035,670 (16, 18).

Chronic, Noncommunicable Diseases

Half of all consultations for NCDs in public hospitals in 2015 were among those aged 60 years old and older, followed those 20-59 years old (44.3%). The discharge ratio by sex in these hospitals is 1.9 women per 1 man (18).

According to the 2015 National Survey on Chronic Non-communicable Diseases in the Adult Population (ENECA-ELS) 2015, 37% of the adult population older than 20 years suffered from hypertension in 2015 (38% of women and 35.8% of men). Prevalence of diabetes mellitus was 12.5% (13.9% of women and 10.6% of men). Prevalence of chronic kidney disease was 12.6%, affecting men (17.8%) more than women (8.5%), primarily in rural areas (14.4%, compared with 11.3% in urban areas). Overweight prevalence was 37.9% (39.5% of men and 36.6% of women), while obesity was 27.3% and affected women (33.2%) more than men (19.5%). Dyslipidemia (defined in the study as cholesterol > 239 mg/dL or triglycerides > 199 mg/dL) had a prevalence of 26.9% (28.5% of men and 25.6% of women) (39).

Among behavioral risk factors, 93.8% of Salvadorians aged older than 20 years old consumed fewer that five servings of fruits and vegetables a day, 92.8% of men and 90.9% of women. The prevalence of a sedentary lifestyle (no moderate or vigorous physical activity in the week prior to the survey) was 39.9%, higher in women (44.6%) that in men (33.8%). Daily smokers (daily consumption of smoked tobacco) were 4.7% of those aged older than 20 years; tobacco use was more prevalent in men (9.5%) than in women (1%) (39).

Nutritional Diseases

Based on anthropometric indices, chronic malnutrition declined from 19.0% in 2008 (40) to 13.6% in 2014, while acute malnutrition increased from 1.0% to 2.1% in the country (2.2% in urban areas and 2.0% in rural areas) (19). The highest levels of chronic malnutrition were reported in the Paracentral and Western regions (16.4% and 1.3%, respectively); differences were also observed among chronic malnutrition levels in the country’s departments, with the highest prevalence rates, higher than the national average, concentrated in Cuscatlán (18.5%) and Cabañas (17.7%).

Accidents and Violence

Homicides and road accidents are leading causes of death. Suicide was the second cause of death among women aged 10 to 19 years. Road accidents were the third cause for men, but the second cause of death for young men aged 20 to 24 years, and the third for women of this same age. This health problem calls for the adoption of coordinated measures to serve these at-risk groups in the immediate future.

According to InSight Crime’s 2015 report on homicides in Latin America, El Salvador has surpassed neighboring Honduras as the most violent country in the Western Hemisphere (41). From 2012 to 2015, there was a record-breaking increase in the homicide rate per 100,000 population. The homicide rate was 41.5 in 2012; 39.9 in 2013; 61.1 in 2014; and in 2015, it reached a high of 103.0.[9] The national government’s Safe El Salvador Plan (30) is a response aimed at decreasing levels of violence in the 50 most violent municipalities, which are home to an estimated 4.1 million people and where homicide rates have varied from 43.5 per 100,000 in 2013 to 110.6 in 2015. Such escalation is the result of the conflict between the two leading gangs in the country (Mara Salvatrucha and Barrio 18). The gang problem poses a challenge for Salvadorians, since it is the fundamental obstacle to implementation of sustainable development initiatives and threatens the health of the population.

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Prospects

The transition from Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs), starting in 2016, is generating commitments for the Post-2015 Development Agenda.

Global urban growth is a factor that affects the necessary sustainable development for attaining the SDGs. El Salvador is not immune to this situation, in that 62% of its population lives in cities and urban sprawl is increasing. Such a high degree of urbanization sparks all manner of violence, urban pollution from particulate matter, and peri-urban or marginal areas at high risk for disasters; it demands urban planning and infrastructure for motor vehicle traffic.

These conditions require basic services, health care networks, gathering places, and green spaces, among others. Responding to these needs entails pursuing economic and social investment that will promote inclusion of local governmental and nongovernmental actors from society as a whole, as well as a strategically and politically positioned health sector.

In the seven years of since the Health System Reform has been in effect, commitments and progress have been made, but challenges to expanding the reforms have also been identified along two broad categories:

• External factors—the economic sustainability of the Health System Reform to fulfill the proposed Road Map, within the framework of political polarization that hinders progress.
• Internal factors—the true integration of National Health System institutions, centralization of budget management and human resources, coupled with the existence of several outdated legal frameworks, are endangering progress toward universal health.

The implementation of the Road Map for health system integration and adoption of a legal framework and its complementary standards constitute the cornerstone of the system’s sustainability, which is based, among other aspects, on reorienting the first level of care with an urban health approach.

Other pending tasks for El Salvador’s health system are to:

• strengthen response capacity through new modalities of care
• establish comprehensive, integrated, guaranteed, and universal National Health System benefits
• improve the quality of care and patient safety along the continuum of care
• consolidate the Unified National Health Information System that enables obtaining information for decision-making
• incorporate technologies and a workforce with the skills and abilities to act at the three levels of management: an intersectoral approach, leadership, and networking and
• provide quality health services that are human-centered.

Although El Salvador has made great progress with prenatal coverage, institutional delivery care, and early childhood registration by eliminating geographical access barriers, there is still room to further improve these indicators in coming years. This will involve improving the quality of maternal and child care, preventive services emphasizing clinical practice, strengthening the technical capabilities of specialized and nonspecialized human resources, and developing the infrastructure and technologies necessary for health care delivery, as well as robust information systems that ensure national statistics.

Adolescents and young adults inhabit an adverse environment, characterized by social violence and a high proportion of NEETs. Such an environment fosters the emergence of public health issues such as teen pregnancy and homicides (the leading cause of death for men and women aged between 10 and 34 years old). Further, among those aged 10-19 years old, the second cause of death for women was suicide and the third cause for men was road accidents. For the population aged 20 to 24 years, road accidents were the second cause of death for men and the third for women. These causes call for coordinated interventions in the immediate future designed to serve this age group.

The leading causes of death in the adult and elderly populations include the following: in men aged 45 to 74 years, diseases of the genitourinary system, with the greatest burden from chronic kidney disease; in women aged 35 to 44 years and 45 to 54 years, cancer of the uterus was the second and third causes of death, respectively; the leading cause of death among women aged 55 to 74 years was diabetes mellitus; and for both sexes aged = 75 years, ischemic heart disease was the leading cause of death. In addition to the predominance of NCDs in this population group, the aging index increased from 34.3% to 38.8% from 2012 to 2015.

NCDs will represent a great burden for the entire health care system; as a result, the health system should recognize them as priorities and influence risk factors, especially those linked to lifestyle.

The Ministry of Health’s leadership of the health sector will guide the reform process with commitments to attain universal health, reduce NCDs, and finalize the elimination of those communicable diseases that are in process of being eliminated. This will requires leadership in developing and implementing health policy and sectoral planning, and in putting in place regulatory frameworks for a new health code. It also requires compliance with International Health Regulations (IHR) and the WHO Framework Convention on Tobacco Control, as well as the capacity to respond to emergencies and crises in an environment of new global structures, in a world that is interconnected and very resilient.

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References

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39. Ministerio de Salud (El Salvador). Boletines Epidemiológicos 2016 [Internet]. San Salvador: MINSAL; 2016. Available from: http://www.salud.gob.sv/boletines-epidemiologicos-2016/.

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41. Asociación Demográfica Salvadoreña (El Salvador); Centers for Disease Control and Prevention, Division of Reproductive Health (United States). El Salvador Encuesta Nacional de Salud Familiar (FESAL) 2008: informe final. San Salvador: ADS; 2009. Available from: http://pdf.usaid.gov/pdf_docs/Pnadr208.pdf.

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