Country Report: El Salvador
El Salvador is located in Central America, bordered by Guatemala, Honduras, and the Pacific Ocean. Administratively, the country is divided into 262 municipalities and 14 departments.
In 2015, the population of El Salvador was 6,459,911, 62.4% of whom were concentrated in urban areas. From 1990 to 2015, the population grew by 16.7%, and its structure shifted from expansive to regressive, due to falling fertility and mortality. In 2015, life expectancy at birth was 67.8 for men and 77.0 for women.
The basic health indicators show systematic improvement in socioeconomic and health status from 1990 to 2015, although the country had an intermediate human development index of 0.666 in 2014.
Per capita gross national income was US$3,940 in 2014. In 2013, remittances (transfers sent from abroad) were the main source of revenue, representing 16.3% of gross domestic product (GDP).
- In the context of the 2009 health reform, in 2014, the groundwork was laid for a primary health care-based model aimed at making significant gains in public health, including access to and coverage of comprehensive health care.
- The Roadmap toward Universal Access and Universal Health Coverage, signed by the institutions that make up the national health system, aims to progressively integrate and network the operations of all system services and facilities.
- Service networks will be organized and managed and human resources developed as a strategy for attaining a universal and equitable system.
- To that end, mechanisms have been put in place such as eliminating charges in public healthcare centers and bringing services to the population through community-based family health teams.
- The Five-year Development Plan 2015-2019 was crafted as a joint effort with civil society and incorporates the principles of the previous health reform.
- The National Policy for Development of Health Human Resources also aims to achieve a universal and equitable system by developing the necessary human resources.
Figure 1. Distribution of the population by age and sex, El Salvador, 1990 and 2015
Proportional Mortality (% of all deaths, all ages, both sexes), 2013
Source: Pan American Health Organization. Health Information Platform (PHIP).
SELECT BASIC INDICATORS
Note: La población del 2015 de acuerdo a la estimación nacional de la Dirección General de Estadística y Censos, El Salvador.
Source: División de Población y División de Estadísticas de las Naciones Unidas 1990; Organización Panamericana de la Salud. Plataforma de Información de Salud (PLISA) 2013, 2014 y 2015.
SOCIAL DETERMINANTS OF HEALTH
- Income inequality in El Salvador is high, with a Gini coefficient of 0.37 in 2015. In 2015, 34.9% of households were living in poverty (32.7% in urban areas and 38.8% in rural areas) and 8.1% in extreme poverty (7.0% in urban areas and 10.1% in rural areas).
- Unemployment in 2015 stood at 7.0% (8.4% for men and 5.0% for women).
- 10.8% of the population aged 10 and over was illiterate (12.4% of women and 9.0% of men). The average years of schooling was 6.8.
- 86.6% of households had access to piped water, and 95.4% had electricity.
- The proportion of homes with Internet access rose from 9.0% to 23.3% from 2010 to 2015.
- It is estimated that around 2 million Salvadorians live abroad, especially in the United States. The main drivers of emigration are insecurity and the wage gap.
- El Salvador is highly vulnerable to natural disasters, such as tropical depressions (heavy rains and flooding) and severe droughts, which impact infrastructure and real sectors, such as agriculture, and have significant effects on health and food security.
- The past three decades have also seen high rates of violence, with 103 homicides per 100,000 population in 2015, together with high levels of gender-based violence, with 1,062 violent deaths of women between 2012 and 2015. Homicides, gang proliferation, drug trafficking, the use of firearms and violence are mainly related to conflict between the country's main gangs.
HEALTH SITUATION AND THE HEALTH SYSTEM
- The maternal mortality rate was 42.3 deaths per 100,000 live births in 2015, and 19.0% of maternal deaths occurred among girls and adolescents. In 2015, El Salvador had prenatal care coverage above 77%; hospital deliveries were at 99%; and over 89% of newborns received their first check-up.
- In 2014, the mortality rate in children under 5 was 20 per 1,000 live births, 17 in children under 1 year, and 11 in neonates. Neonatal mortality was due mainly to premature birth and congenital malformation.
- In 2014, the reported overall mortality was 7.3 deaths per 1,000 population. In 2013, 21% of deaths corresponded to unclassified signs and symptoms, 16% to circulatory system diseases, and 13% to external causes.
- In the period 2011-2015, there was an estimated annual average of 60,000 cases of probable dengue, 0.7% of which were severe; case-fatality was 0.01%.
- In May 2014, the first cases of chikungunya were confirmed. Since then, the disease has affected 2.6% of the population. Zika virus appeared in late 2015 and has steadily increased, peaking in the first week of 2016, when 1,142 cases were reported. From March to August 2016, 109 children were born with microcephaly, but only 4 (3.7%) could be laboratory- confirmed cases associated with ZIKV.
- Since 2011 about eight cases of malaria have been reported per year, most of them imported (75.0%).
- People living in poverty are those primarily affected by neglected infectious diseases, including Chagas disease, leishmaniasis, leprosy, leptospirosis, rabies, soil-transmitted helminth infections, toxoplasmosis, and congenital syphilis.
- Tuberculosis affects 37 people per 100,000 population, with an annual average of 2,150 new cases from 2011 to 2015. In 2015, 33,184 cases of people infected with the human immunodeficiency virus (HIV) were reported.
- From 1990 to 2015, chronic noncommunicable diseases steadily increased and now represent a major burden for the health system, with hospitalizations trending upward and a greater number of deaths. Eight of the 10 leading specific causes of death correspond to chronic noncommunicable diseases.
- The prevalence of diabetes mellitus was 12.5% in 2015 (13.9% of women and 10.6% of men). The 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).
- The prevalence of overweight was 37.9% (39.5% of men and 36.6% of women), while that of obesity was 27.3% and affected women (33.2%) more than men (19.5%).
- In 2014, acute malnutrition was 2.1% and chronic malnutrition, 13.6%.
- Violence and road accidents are priority health problems. Suicide is the second leading cause of death among women aged 10-19.
- The Ministry of Health (MINSAL) regulates the health system and is the country's largest health care provider. Its internal organizational structure, services and facilities are technically and administratively divided into one central level, five health regions, and 17 comprehensive basic health systems.
- The Salvadorian Social Security Institute (ISSS) has the second-highest number of facilities and second-greatest population coverage; its health services are organized into four regions.
- The other institutions of the national health system are the Salvadorian Comprehensive Rehabilitation Institute, the Salvadorian Institute for Teacher Welfare (ISBM), the Health Solidarity Fund (FOSALUD), the Military Health Command (COSAM) and the National Drug Directorate.
- In 2013, total health expenditure represented 17.0% of total public expenditure and 6.9% of the gross domestic product (4.6% corresponded to public expenditure and 2.3% to private expenditure).
- Out-of-pocket expenditure accounted for 85% of private expenditure and 28% of total health expenditure, while spending on prepaid insurance plans represented 15% of private expenditure in 2013.
- MINSAL covers 72.0% of the population; the ISSS covers 25.1%, and the ISBM and COSAM serve 1.6% and 1.1%, respectively.
- The health system reform launched in 2009 has established a primary health care-based model aimed at improving the organization and management of network services, as well as developing human resources for a universal and equitable health system.
- Health system segmentation and fragmentation has not yet been eliminated. Since 2014, the reform process has been reoriented and intensified, with a clear focus on universal access and health coverage and on functional integration of the national health system.
- In 2009, health information was fragmented and scattered; the Ministry of Health alone had more than 40 different applications, although it lacked an entity responsible for their development and integration. The web-based Unified Health Information System went online in 2010, using open-source software; it is made up of nine subsystems and has 1,234 reporting units nationwide.
- El Salvador has 11 institutions of higher education that train technical and professional health personnel in 13 disciplines. In 2015, there were 19.5 health professionals per 10,000 population (physicians, nurses, and people with undergraduate degrees in maternal and child health).
ACHIEVEMENTS, CHALLENGES AND PERSPECTIVES
- In implementing health system reform, commitments and advances in the health system have been established, identifying challenges on which to delve deeper. More globally, the economic sustainability of health system reform must be ensured in order to meet its objectives and address the political polarization that hinders progress.
- More effective integration of national health system institutions is imperative, centralizing budgetary and human resources management. Furthermore the overarching legal framework needs to be consolidated in a consistent manner.
- The health system faces the challenge of boosting its response capacity to effectively address the increase in morbidity, mortality, and disability from communicable diseases and chronic noncommunicable diseases.
- Surveillance, prevention, and treatment of chronic noncommunicable diseases are necessary to effectively control and prevent them, as is intersectoral action to address social determinants and risk factors.
- Consolidation of the National Unified Health Information System will make it possible to obtain useful information for decision-making.
- The Five-year Development Plan 2015-2019 aims to reduce maternal mortality to less than 35 deaths per 100,000 live births, keep infant mortality at under 8 deaths per 1,000 live births, keep vaccination coverage over 95%, and reduce direct out-of-pocket household spending by 3%.
- The problem of gang violence remains a challenge in El Salvador, since it is a major obstacle to the implementation of sustainable development initiatives and is a threat to public health.
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