HEALTH SPENDING IN EL SALVADOR - euroresources.org
HEALTH SPENDING IN EL SALVADOR - euroresources.org
HEALTH SPENDING IN EL SALVADOR - euroresources.org
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
EU <strong>HEALTH</strong> ODA AND AID EFFECTIVENESS / COUNTRY BRIEF<strong>IN</strong>G 3 / FEBRUARY 2011<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong><br />
<strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
THE IMPACT OF CURRENT AID STRUCTURES<br />
AND AID EFFECTIVENESS
2<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> TANZANIA<br />
ACKNOWLEDGEMENTS<br />
This report was produced by DSW for Action<br />
for Global Health and written by Sibylle<br />
Koenig and Liliana Marcos. Action for Global<br />
Health would like to thank the representatives<br />
from the Ministry of Health, the Ministry of<br />
Foreign Affairs, the Ministry of Economy and<br />
the Ministry of Finance in El Salvador, as well<br />
as Members of the Salvadoran Parliament,<br />
the representatives of the donor agencies and<br />
Civil Society <strong>org</strong>anisations interviewed during<br />
the fact-finding visit for taking the time to<br />
share their views with us, in order to make this<br />
policy briefing more relevant. In particular, we<br />
would like to thank Vice Health Minister Dr.<br />
Eduardo Espinoza, Diputada Mirtala Lopez,<br />
Dr. Juan Ruales (OMS/PAHO), Tito Lopez<br />
(Ayuda en Accion) and Johannes Conrads<br />
(DSW Brussels) for their invaluable support<br />
and contributions to the preparation and<br />
successful implementation of this mission.<br />
Action for Global Health is supported by a<br />
grant from the Bill & Melinda Gates<br />
Foundation.<br />
Design and layout: James Kontargyris<br />
www.jameskontargyris.co.uk<br />
Front Cover Photograph: Joe Philipson<br />
Inside Cover Photograph: DSW
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
CONTENTS<br />
<strong>IN</strong>TRODUCTION AND METHODOLOGY 4<br />
SUMMARY OF KEY F<strong>IN</strong>D<strong>IN</strong>GS 6<br />
AND RECOMMENDATIONS<br />
OWNERSHIP AND THE 8<br />
PARTICIPATION OF CIVIL SOCIETY<br />
AND THE PARLIAMENT<br />
THE IMPACT OF DONOR 16<br />
COORD<strong>IN</strong>ATION ON <strong>HEALTH</strong><br />
<strong>SPEND<strong>IN</strong>G</strong><br />
THE ROLE OF AID FOR PROGRESS 25<br />
TOWARDS THE MDGS AND FOR<br />
UNIVERSAL ACCESS TO PRIMARY<br />
<strong>HEALTH</strong>CARE<br />
RECOMMENDATIONS TO 28<br />
STAKEHOLDERS <strong>IN</strong> THE EU AND<br />
<strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
BIBLIOGRAPHY 31<br />
LIST OF ACRONYMS 31<br />
3
4<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
<strong>IN</strong>TRODUCTION AND<br />
METHODOLOGY<br />
In recent years, the EU has been committed to<br />
reforming its external aid instruments according to<br />
aid effectiveness principles established by the Paris<br />
Declaration on Aid Effectiveness (2005), as well as<br />
the Accra Agenda for Action (2008). In particular,<br />
attention has been paid to increasing the<br />
“ownership” of developing countries’ development<br />
assistance 1 .<br />
Despite such positive efforts, key social sectors<br />
such as health have suffered significant decreases<br />
and gaps in EU funding in recent times. Official<br />
Development Assistance (ODA) spending in health<br />
worldwide decreased by USD 124 million between<br />
2006 and 2007, mainly due to a decrease in<br />
European health ODA. Compared to total ODA<br />
disbursements, European donors contribute<br />
relatively less to health than other international<br />
donors. In 2007, the EU-15 and other European<br />
donors represented only 50% of health<br />
disbursements, while accounting for some 67% of<br />
global ODA 2 .<br />
In the light of such trends, there is a perceived<br />
need to reassess aid effectiveness principles<br />
against sector-specific funding for health. Action for<br />
Global Health (AfGH), a network of European<br />
health and development <strong>org</strong>anisations 3 ,<br />
consequently decided to commission DSW - the<br />
German Foundation for World Population, an NGO<br />
supporting family planning and sexual and<br />
reproductive health projects in Africa and Asia, to<br />
undertake six combined fact-finding and advocacy<br />
visits to developing countries in 2010/11 in order to<br />
assess the impact of current aid structures and aid<br />
effectiveness principles on health-spending in<br />
those countries.<br />
The overall objective of these fact-finding visits is to<br />
bring evidence and experience from developing<br />
countries to support European advocacy for global<br />
health, by producing country-specific policy<br />
briefings and disseminating them to key decisionmakers<br />
and <strong>org</strong>anisations in Europe and in<br />
developing countries.<br />
The target countries were jointly selected by the<br />
AfGH Network on the basis of a number of criteria,<br />
including:<br />
■ Countries from different continents, including<br />
Latin America<br />
■ If possible, countries which are or were until<br />
recently major recipients of EU health ODA<br />
(except for Latin America)<br />
■ Some IHP+ 4 countries, if possible<br />
■ Countries where AfGH has some kind of<br />
support, either from country offices or strong<br />
partnerships<br />
■ If possible, avoid countries where missions on<br />
health / aid effectiveness had recently been<br />
carried out<br />
■ At least some non-English speaking countries<br />
■ In the light of the missions’ objective to assess<br />
development aid channelled to existing health<br />
systems, conflict or immediate post-conflict<br />
countries were not to be considered<br />
The AfGH Network finally selected the following<br />
countries for the fact-finding visits: Uganda,<br />
Tanzania, El Salvador, Mozambique, India and<br />
Vietnam. Three fact-finding visits have been<br />
undertaken so far: Uganda (February 2010);<br />
Tanzania (April 2010) and El Salvador (July 2010).<br />
This country briefing aims to compile the main<br />
findings gathered during AfGH’s visit to El Salvador<br />
in July 2010 and provide recommendations to<br />
policy-makers and civil society. During the factfinding<br />
visit to El Salvador, AfGH was represented<br />
by the DSW EU Liaison Office and FPFE Spain.<br />
AfGH partners met with key stakeholders in the<br />
country, in particular, the Ministry of Health (MoH),<br />
Ministry of Foreign Affairs (MoFA), the Ministry of<br />
Economy and the Ministry of Finance (MoF). The<br />
1 For more information on Aid Effectiveness Principles, see: www.oecd.<strong>org</strong>/dataoecd/11/41/34428351.pdf<br />
2 DSW, EPF, EuroNGO. “Euromapping 2009: Mapping European Development Aid & Population Assistance”. 2009, Brussels, Belgium.<br />
3 Established in 2006 by 15 <strong>org</strong>anisations under the leadership of ActionAid, Action for Global Health (AfGH) is today active in France, Germany, Italy, Spain,<br />
the UK and Brussels and includes membership of almost 30 NGOs. AfGH advocates for Europe to play a more proactive role in enabling developing<br />
countries to meet the Health Millennium Development Goals by 2015. For more information on AfGH, please visit: www.actionf<strong>org</strong>lobalhealth.eu<br />
4 The international Health Partnership (IHP+) is a group of partners who share a common interest in improving health services and health outcomes by<br />
putting Paris and Accra principles on aid effectiveness into practice. http://www.internationalhealthpartnership.net/<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
<strong>IN</strong>TRODUCTION AND METHODOLOGY<br />
5<br />
fact-finding team also interviewed key donors,<br />
Members of Parliament and civil society in the<br />
country, in particular:<br />
DONORS<br />
EU Delegation<br />
WHO/PAHO<br />
Global Fund CCM Coordinator (UNDP)<br />
USAID<br />
AECID<br />
German Embassy<br />
MEMBERS OF PARLIAMENT<br />
Dip. Mirtala Lopez<br />
Dip. Zoila Quijada<br />
CSOs<br />
Centro de Apoyo a la Lactancia Materna CALMA<br />
Asociación Salvadoreña Pro Salud Rural.<br />
ASAPROSAR<br />
Alianza por la Salud Sexual Reproductiva de El<br />
Salvador<br />
Plan Internacional.<br />
Asociacion Vida Nueva<br />
Asociacion Demografica Salvadoreña<br />
FUNDASIDA<br />
Asociación para la auto determinación y<br />
desarrollo de mujeres salvadoreňas.<br />
Medicos por el derecho a la salud.<br />
All interviews held focused in particular on the<br />
following three thematic axes related to health aid<br />
effectiveness:<br />
■ Country Ownership and the participation of civil<br />
society and the national parliament in the<br />
health sector<br />
■ The impact of donor coordination on healthspending<br />
in developing countries<br />
■ Managing for Results: The role of aid in<br />
progress towards the MDGs and in universal<br />
access to primary healthcare<br />
AfGH had chosen these themes on the basis of the<br />
findings of its first mission in Uganda, which had<br />
focused on all the Paris Principles in order to test<br />
which of them were still topics of major concern to<br />
developing countries: the interviews conducted<br />
revealed that the three above-mentioned topics<br />
were seen as particular challenges by a variety of<br />
stakeholders in developing countries, and that they<br />
had often been neglected by other evaluations on<br />
Aid Effectiveness. Moreover, AfGH could see its<br />
own extensive expertise in carrying out research<br />
and advocacy for increased health funding,<br />
progress towards the Health Millenium<br />
Development Goals (MDGs) and universal access<br />
to primary healthcare, as well as Civil Society<br />
Organisation (CSO) and community participation,<br />
as being an added value when addressing the<br />
above-mentioned issues.<br />
The results of these interviews have been<br />
complemented with previous and subsequent desk<br />
work in order to provide a comprehensive<br />
perspective on the effectiveness of health aid in El<br />
Salvador, based on the principles of the Paris<br />
Declaration and Accra Action Plan on aid<br />
effectiveness. However, as the primary objective of<br />
this policy briefing is to reflect the views of the<br />
stakeholders interviewed, some of the statements<br />
made in this paper do not necessarily reflect the<br />
views of Action for Global Health.<br />
<strong>EL</strong> <strong>SALVADOR</strong> COUNTRY CHOICE<br />
Despite being classified as a middle-income<br />
country, El Salvador still faces high poverty rates<br />
and a major problem of inequity: The UNDP<br />
human development reports have identified<br />
Guatemala, Brazil and El Salvador as the most<br />
inequitable countries within the planet’s most<br />
inequitable subcontinent (Latin America).<br />
Although significant progress has been made in<br />
terms of reducing poverty over the period 1991-<br />
2002 – with the share of the population living in<br />
poverty decreasing from 58% to 35% and the share<br />
in extreme poverty from 33% to 14.4% 5 – extreme<br />
poverty rates have remained relatively stagnant<br />
since 2001, in part due to the impact of increased<br />
food and fuel prices in 2007/08: According to the<br />
World Food Programme (WFP), more than 100,000<br />
people in this country of 5.8 million slipped below<br />
the poverty line between September 2007 and<br />
June 2008 6 . The country is also marked by a strong<br />
urban-rural divide: In urban areas the extreme<br />
poverty rate is around 7.9% while in rural areas it is<br />
around 16.3%. According to the World Health<br />
Organisation (WHO) in El Salvador “Middle income<br />
countries such as El Salvador still need substantial<br />
start-off assistance from donors in order to<br />
overcome such inequalities”.<br />
According to the European Commission’s Country<br />
Strategy Paper 2007-2013, “the health sector is a<br />
cause for concern: [...] access to health services is<br />
limited; only around half of the population suffering<br />
5 El Salvador / EC Country Strategy Paper 2007-2013.<br />
6 World Food Programme study "Alza de precios, mercados e inseguridad alimentaria y nutricional en Centroamérica" (Price Rises, Markets and Food and<br />
Nutritional Security in Central America).<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
6<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
<strong>IN</strong>TRODUCTION AND METHODOLOGY<br />
from an illness or accident receive medical<br />
assistance; there is inappropriate allocation of<br />
resources among public health institutions; health<br />
spending is low and fragmented; the quality of care<br />
provided to citizens is poor”. According to the<br />
WHO, a research study conducted in 2005-2007<br />
showed that 41.7% of the population of El Salvador<br />
were still excluded from the health system 7 .<br />
However, the country is in the process of<br />
implementing a major health reform, which is seen<br />
by AfGH as being a crucial moment and<br />
opportunity for all stakeholders, specifically<br />
European donors, to contribute to improving the<br />
country’s health sector situation.<br />
SUMMARY OF KEY<br />
F<strong>IN</strong>D<strong>IN</strong>GS AND<br />
RECOMMENDATIONS<br />
COUNTRY OWNERSHIP, CIVIL SOCIETY<br />
PARTICIPATION AND THE PARLIAMENT<br />
■ With regard to the newly established health<br />
sector social participation mechanisms, a<br />
code of conduct for civil society<br />
participation procedures should be<br />
established in order to jointly tackle what<br />
could still be considered as one of El<br />
Salvador’s major obstacles to good<br />
governance: The high degree of party<br />
polarisation affecting every sphere of<br />
society.<br />
■ Increased efforts of coordination need to<br />
be made by civil society <strong>org</strong>anizations in<br />
order to strengthen their advocacy work. To<br />
that end, they need to generate spaces<br />
where everyone is welcome and listened to,<br />
independently of their relations with one or<br />
other political party.<br />
■ In the light of the government’s intention to<br />
significantly expand public health services<br />
coverage, it would be recommendable to<br />
involve a representative diversity of CSOs<br />
with the required sector-expertise in<br />
continuous quality control of public<br />
health services. In general, the relationship<br />
between public and private entities should<br />
be pushed towards collaboration and<br />
complementarities – existing competition<br />
and rivalries need to be overcome.<br />
■ To the same end, more efforts need to be<br />
made in order to improve and strengthen<br />
the relationship between International<br />
Nongovernmental Organizations (<strong>IN</strong>GOs),<br />
local NGOs, Community-based<br />
Organisations (CBOs), local authorities and<br />
Members of Parliament in El Salvador in<br />
order to ensure that these alliances<br />
contribute to true country ownership of<br />
development policies. Donors should<br />
therefore actively seek to support<br />
partnership-building among all actors.<br />
■ Increased efforts need to be made by CSOs<br />
themselves in order to put advocacy<br />
capacity-building on the donors’ agenda,<br />
for instance by submitting advocacy project<br />
proposals.<br />
DONOR COORD<strong>IN</strong>ATION<br />
■ In the light of the new health sector<br />
reform’s financing needs and the<br />
upcoming end-of-term review of the<br />
European Commission’s Country Strategy<br />
Paper, a strategic change towards healthfinancing<br />
should be considered by the EU.<br />
The government of El Salvador needs to<br />
seize this opportunity and assert its strive<br />
for a stronger and more equitable health<br />
system by explicitly asking important<br />
European donors, such as the European<br />
Commission, whose multi-annual country<br />
strategies are about to undergo their end-ofterm<br />
revision, for sector budget support.<br />
■ Potential health sector budget support<br />
needs to be accompanied by specific<br />
capacity-building measures for MoH<br />
officials. While technical assistance to the<br />
Ministry shall be continued, as it can be<br />
seen as a key condition for sector budget<br />
support, donors should increasingly<br />
consider employing local (rather than<br />
international) consultants to that end. The<br />
WHO/PAHO should support National<br />
Sanitary Authorities to continue the<br />
development of their leadership and sectorsteering<br />
role.<br />
■ Potential support from European donors to<br />
the health sector reform should be provided<br />
in a harmonised and aligned manner, in<br />
order to collectively contribute to health<br />
systems strengthening. To that end, donors<br />
should accept the leadership of the newly<br />
reinforced External Cooperation Unit<br />
within the MoH with regard to sector<br />
coordination. For the Department, on the<br />
other hand, there is still a need to fully<br />
assume its role as an autonomous<br />
coordination entity by effectively uniting<br />
donors under its leadership, instead of<br />
continuing bilateral negotiations with each of<br />
them.<br />
7 This data is based on the information given during the interview with the WHO in El Salvador.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
<strong>IN</strong>TRODUCTION AND METHODOLOGY<br />
7<br />
■ Adherence to IHP+ would unite donors in<br />
their sector harmonisation efforts, no matter<br />
how large their health aid contributions, and<br />
contribute to increasing the technical<br />
assistance needed to implement the sector<br />
reform. Donors should therefore promote El<br />
Salvador’s adherence to IHP+.<br />
■ European budget support for the<br />
“Comunidades Solidarias” programme<br />
should be reformed and capacity-building<br />
provided in order to effectively link its water<br />
and sanitation component to health systems<br />
strengthening, especially by allocating<br />
adequate financial resources to this<br />
integrated approach.<br />
■ Vertical health funding mechanisms such<br />
as the Global Fund should adopt a more<br />
integral approach in order to contribute to<br />
health systems strengthening. Recent<br />
efforts made by the Global Fund in that<br />
direction, through the Health System<br />
Strengthening funding window, involvement<br />
in the Joint Health Systems Funding<br />
platform as well as in the JANS 8 , can be<br />
seen as positive developments in that<br />
respect, but their effective impact on health<br />
systems strengthening at country level still<br />
needs to become more apparent.<br />
■ In the light of El Salvador’s scarce external<br />
funding for health, there is a particular need<br />
for European donor agencies to seek a<br />
strong collaboration with their non-<br />
European counterparts in order to<br />
canalize funding and jointly improve aid<br />
effectiveness in the health sector. In the<br />
context of increased funding needs related<br />
to the health sector Reform, European<br />
donors will need to step up their support to<br />
health in order to prevent the deepening of<br />
the current funding gap affecting the sector.<br />
■ As each donor agency currently still has its<br />
individual information management<br />
systems, one of the first priorities of the<br />
newly created Vice-Ministry for<br />
Development Cooperation is to establish a<br />
unified online development cooperation<br />
database, which could be going in the<br />
direction of the IATI 9 initiative. For such a<br />
system to be effective the government and<br />
donors need to ensure that it is linked to the<br />
national budget planning exercise.<br />
MANAG<strong>IN</strong>G FOR RESULTS: THE ROLE OF<br />
AID FOR PROGRESS TOWARDS THE<br />
<strong>HEALTH</strong> MDGs AND UNIVERSAL ACCESS<br />
TO PRIMARY <strong>HEALTH</strong>CARE<br />
■ In order to monitor whether health services<br />
reach the most vulnerable in El Salvador,<br />
donors should support the country’s first<br />
steps made towards social auditing at<br />
community level.<br />
■ International cooperation needs to become<br />
more needs-based, specifically in the<br />
health sector, where European and other<br />
donors are still concentrating a<br />
disproportionately high amount of financial<br />
resources towards the fight against specific<br />
diseases and health infrastructure financing.<br />
Programmes should also be based on data<br />
and indicators that are adequately<br />
disaggregated according to vulnerable<br />
groups.<br />
■ The government of El Salvador will need to<br />
overcome inequities in terms of per capita<br />
distribution of financial resources to health<br />
by reforming the health sector’s currently<br />
fragmented structure. Donors could<br />
support the government in this aim, for<br />
instance by providing technical assistance<br />
and advice.<br />
■ With regard to CSOs’ own responsibility<br />
for results-based management, external<br />
evaluations of development programmes in<br />
El Salvador show that it is worth working<br />
with CSOs and CBOs in order to achieve<br />
tangible results at local level.<br />
■ New aid modalities and initiatives, such<br />
as results-based financing and the<br />
“Iniciativa Mesoamericana”, need to be reassessed<br />
with regard to their impact on<br />
health equity and their degree of alignment<br />
with existing national policies and priorities<br />
in the health sector. This assessment<br />
should be undertaken by the governments<br />
of the beneficiary countries, by involving<br />
CSOs, CBOs, women’s <strong>org</strong>anisations and<br />
the most marginalised communities.<br />
8 Joint Assessment of National Strategies: www.internationalhealthpartnership.net<br />
9 International Aid Transparency initiative (IATI): www.aidtransparency.net<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
8<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
OWNERSHIP AND<br />
PARTICIPATION OF CIVIL<br />
SOCIETY AND THE<br />
PARLIAMENT<br />
The following section analyses El Salvador’s<br />
development and health sector structure,<br />
challenges and opportunities in order to evaluate<br />
the existence of some of the fundamental preconditions<br />
for true country ownership.<br />
DEV<strong>EL</strong>OPMENT STRATEGIES AND <strong>HEALTH</strong><br />
POLICIES <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
Classified as being a middle-income country, El<br />
Salvador has seen its development cooperation<br />
resources decrease year on year since its return to<br />
democracy two decades ago. Official Development<br />
Assistance is now of relatively limited relevance to<br />
the country (ca. 1.7% of GDP) compared with<br />
neighbouring Central American countries (e.g. ca.<br />
16% of GDP in Nicaragua) and is gradually<br />
declining (from an average of more than USD 300<br />
million/year in the early 1990s to USD 211 million in<br />
2004) 10 .<br />
In this context, the government recognises the<br />
importance of increasing the effectiveness of aid in<br />
order to make the best use of the scarce resources<br />
available 11 . El Salvador has only very recently<br />
become a signatory of the Paris Declaration on Aid<br />
Effectiveness, namely in May 2009, shortly before<br />
a historic change in government: For the first time<br />
since its return to democracy in 1992, the country<br />
saw the left-wing party Farabundo Martí National<br />
Liberation Front (FMLN) win the presidential<br />
elections in March 2009, thus putting an end to a<br />
17-year rule of the Nationalist Republican Alliance<br />
(ARENA).<br />
One of the first challenges which needed to be<br />
tackled in order to achieve true country ownership<br />
is the fact that El Salvador has, since its return to<br />
democracy in 1992, not had an overall<br />
development framework or long-term social and<br />
economic development goals. El Salvador, as a<br />
middle income country, does not have a poverty<br />
reduction strategy similar to the PRSP in Heavily<br />
Indebted Poor Countries (HIPC).<br />
However, the previous government had launched<br />
the “Plan de Oportunidades” (Opportunities Plan)<br />
which includes an innovative sub-programme –<br />
“Redes Solidarias” – aimed at improving the quality<br />
and coverage of social services in the country’s<br />
hundred poorest municipalities. This subprogramme<br />
was seen as a first step towards a<br />
more integral strategy on poverty alleviation and<br />
local development. The programme is going to be<br />
continued by the current government despite<br />
renaming it “Comunidades Solidarias”<br />
(Communities in solidarity) and integrating it into<br />
the programme targeting the poorest urban areas.<br />
The country’s new five-year development plan<br />
(Plan Quinquenal 2010-2014) 12 was launched in<br />
June 2010. Through this plan, the government<br />
established ten priority areas for the five-year<br />
period, including poverty reduction and the<br />
promotion of social participation in policy-making<br />
processes. It equally establishes a ten-priority longterm<br />
vision for 2024, including the objective to<br />
facilitate a “healthy, educated and productive<br />
population”.<br />
<strong>HEALTH</strong> SECTOR POLICIES AND REFORM –<br />
CHALLENGES AND OPPORTUNITIES<br />
CHALLENGES<br />
El Salvador’s health sector has been characterised<br />
by severe fragmentation: Until recently, the<br />
country has not had one unique, long-term<br />
strategic framework, but instead a variety of health<br />
programmes with little or no coherence between<br />
them. Until recently, the Ministry of Health’s<br />
<strong>org</strong>anigram reflected this fragmentation: The<br />
institution had separate departments for adult<br />
women, adult men, adolescents, children, and<br />
disease-related themes with little or no connection<br />
between the departments and de facto links<br />
between certain health issues and certain age/sex<br />
groups were consequently ignored. For example:<br />
Prenatal and Post-partem care addresses both<br />
women’s and children’s needs, but related<br />
10 European Union Country Strategy Paper 2007-13 - El Salvador.<br />
11 Ministry of External Affairs: Aid Effectiveness Agenda.<br />
12 The plan (in Spanish) can be found at: http://www.presidencia.gob.sv/tecnica/<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
OWNERSHIP AND PARTICIPATION OF CIVIL SOCIETY AND THE PARLIAMENT<br />
9<br />
programmes usually fell under the responsibility of<br />
just one department.<br />
The structure of the health sector as a whole is<br />
marked by a lack of coordination and coherence:<br />
Health services have, until recently, been provided<br />
by both private (16%) and public (84%) entities.<br />
Among the public providers, the Social Security<br />
Institute (ISSS), the Military Health and the<br />
Teachers Welfare Institute (BM) attend their own<br />
closed population (18%) whereas the Ministry of<br />
Public Health and Social Assistance (MPSAS) and<br />
the Social Solidarity Health Fund (FOSALUD) are<br />
responsible for the rest of the population (66%),<br />
although in practice they do not have complete<br />
coverage 13 .<br />
This fragmentation is making it difficult to manage<br />
and overcome some of the major challenges the<br />
health sector is currently facing, such as, for<br />
example:<br />
■ A lack of health services coverage: About one<br />
third of the population have limited or no access<br />
to primary healthcare. 14<br />
■ Inequities in per capita health spending (for<br />
further explanations on these points, see part 3:<br />
“Managing for Results”), as well as in terms of<br />
regional distribution of resources: 60% of the<br />
health sector resources are allocated to San<br />
Salvador, Santa Ana and San Miguel.<br />
■ There is little if any coordination between the<br />
public service providers, resulting in a<br />
fragmented and malfunctioning information and<br />
medical supplies management and monitoring<br />
system.<br />
■ A shortage of ca. 40% in human resources for<br />
health 15 .<br />
■ A chronic stock out of essential medicines.<br />
■ Exorbitant prices for medicines (among the<br />
highest worldwide), due to national pharmaindustry-friendly<br />
import restrictions. Medicines<br />
are more than ten times more expensive than in<br />
the rest of the Latin American region 16 .<br />
■ Hospital infrastructure which is outdated and<br />
was affected by recent natural disasters.<br />
■ A lack of transparency in the award procedures<br />
and pricing of health infrastructure contracts<br />
during previous administrations: A scandalous<br />
example in that respect was the diversion of<br />
World Bank funds aimed at financing the<br />
establishment of a new Maternity Hospital,<br />
which were used to cover disproportionately<br />
high construction costs of other newly<br />
established hospitals.<br />
■ Corruption and lack of transparency in general:<br />
Hospitals had, in the past, been able to claim<br />
about USD 1 million per year in total for their<br />
contingency reserves which were not subject to<br />
audits.<br />
■ Party polarisation affecting health resources<br />
distribution to municipalities ruled by the<br />
opposition.<br />
■ Low coverage of family planning 17 and a lack of<br />
skilled health personnel in pre-natal, childbirth<br />
and postnatal care.<br />
■ Deficiencies in the quantity and quality of<br />
training of health workers and the quality of<br />
health service delivery.<br />
HUMAN RESOURCES FOR <strong>HEALTH</strong><br />
It is worth paying special attention to one of the<br />
major challenges of the health sector in El<br />
Salvador: According to the MoH, the country has a<br />
shortage of ca. 40% in human resources for health.<br />
This is related to a number of factors, including low<br />
wage levels for health personnel working in the<br />
public sector: Although the Human Resources<br />
budget line accounts for more than half of the<br />
national health budget, health workers are not<br />
adequately paid due to financial constraints related<br />
to the fact that the health budget has over the last<br />
years only accounted for around 2% of GNI.<br />
Consequently, a common practice in El Salvador is<br />
that medical professionals choose not be hired on<br />
a full-time basis by public facilities, but also work<br />
13 USAID “El Salvador Health Sector Needs Assessment”. July 2009.<br />
14 Extension of Health Services Coverage in El Salvador: The RHESSA Project Experience:<br />
http://www-wds.worldbank.<strong>org</strong>/external/default/WDSContentServer/WDSP/IB/2009/12/08/000333037_20091208011619/<br />
Rendered/PDF/520490BRI0EnBr10Box345549B01PUBLIC1.pdf<br />
15 This figure was given by one of the stakeholders interviewed.<br />
16 These statements are taken from the interview with the Ministry of Health representative.<br />
17 For more information, see, for example: http://www.unfpa.<strong>org</strong>.sv/documentos/plan_pais.pdf<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
10<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
OWNERSHIP AND PARTICIPATION OF CIVIL SOCIETY AND THE PARLIAMENT<br />
part-time for private facilities in order to<br />
compensate for the low pay in the public sector.<br />
According to the Ministry of Health, only 18% of<br />
doctors are full-time employees (8 hours/day),<br />
whereas about 40% of health specialists are<br />
currently only working two hours a day in the same<br />
institution, which represents a significant challenge<br />
for any health facility in terms of recruitment and<br />
service delivery continuity 18 .<br />
A visit to a health centre in El Salvador confirmed<br />
this picture, with over half of the 21 employees<br />
having 2-hour contracts and only one person<br />
having an 8-hour arrangement. In short, for its<br />
district coverage population of ca. 28,000<br />
inhabitants (ca. 700 patients per week), the health<br />
centre only has the equivalent of ca. 7 full-time<br />
employees, when totalling the number of hours<br />
worked by all staff members. This figure appears all<br />
the more drastic when compared to the situation in<br />
Cuba, where there is one full-time doctor per 170<br />
patients. The director of the health centre<br />
confirmed that this situation led to human<br />
resources management problems, long waiting<br />
times for patients, and demotivated health<br />
personnel.<br />
The government recently introduced a new Human<br />
Resources Policy, which establishes four main<br />
areas of work: Employment of sufficient personnel<br />
and adequate distribution health staff as needed<br />
under geographic, demographic, and equity<br />
criteria; institutionalisation of health public servant<br />
careers; establishment of adequate labour<br />
conditions and systematic training programmes.<br />
The policy prioritises full-time work contracts.<br />
However, a wages reform has so far not been<br />
envisaged. Particular incentives will also need to<br />
be created in order to retain health personnel in<br />
rural areas.<br />
OPPORTUNITIES<br />
The newly elected government has made it one of<br />
its priorities to launch a major health sector reform<br />
in order to overcome these challenges. The reform<br />
has been piloted in the country’s 63 poorest<br />
municipalities. In the next three years, all 262<br />
municipalities will be covered.<br />
The new Minister of Health, Dr. Maria Isabel<br />
Rodriquez, a woman of 87 years of age, is widely<br />
respected, even across parties, for her clearsighted<br />
and pragmatic approach with regard to the<br />
steps to be taken to reform the health sector.<br />
During her first months in office, she published a<br />
programme 19 outlining the following first ten actions<br />
to be taken by the government during its first 100<br />
days in order to overcome the current challenges of<br />
her country’s health sector:<br />
TEN PRIORITY ACTIONS FOR THE FIRST ONE<br />
HUNDRED DAYS <strong>IN</strong> OFFICE<br />
1. Elimination of charges (“voluntary fees”) or any<br />
other form of payment in the public system,<br />
offset by corresponding budget allocations that<br />
prevent deterioration of service quality.<br />
2. Stocking of essential medicines and basic<br />
medical supplies in all Public Health System<br />
facilities, gradually and according to priorities,<br />
taking into account the assessment of the<br />
conditions in each facility.<br />
3. Reduce waiting times for surgery and specialist<br />
care, which will require the hiring of additional<br />
personnel but which urgently needs to be done,<br />
since at present an individual must wait up to<br />
two years or more for cataract or hernia<br />
surgery.<br />
4. Allocation of medical specialists to regional<br />
hospitals, which will decongest the national<br />
hospitals and resolve the needs of the public<br />
more quickly, increasing public satisfaction.<br />
5. Expand coverage of health services in rural<br />
areas and in more socially vulnerable urban<br />
areas across the country, which can be done<br />
through well-trained community health workers<br />
from the communities themselves.<br />
6. The President shall lay the cornerstone for the<br />
new Maternity Hospital during his first one<br />
hundred days in office.<br />
7. Institutionalise social participation through the<br />
formation of intersectoral committees at the<br />
local, municipal, provincial, and national levels,<br />
which shall identify the basic needs most<br />
affecting people’s living conditions and prioritise<br />
their resolution, through communities working<br />
together with government institutions, where<br />
true community participation is crucial in<br />
decision-making and in resolving these<br />
problems.<br />
8. Conduct a National Environmental Sanitation<br />
Campaign for the prevention of epidemics with<br />
the participation of all social leaders in the<br />
country, including government structures.<br />
9. Initiate, as soon as possible, a process to<br />
re<strong>org</strong>anise the entire public sector (MSPAS,<br />
ISSS, FOSALUD), aimed at making services<br />
more efficient and at laying the groundwork to<br />
increase coverage.<br />
10. Convene the National Health Forum.<br />
18 Ministry of Health: “Rendicion de Cuentas 2010”.<br />
19 Isabel Rodriguez, "Construyendo la Esperanza: Estrategias y Recomendaciones en salud. 2009-2014".<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
OWNERSHIP AND PARTICIPATION OF CIVIL SOCIETY AND THE PARLIAMENT<br />
11<br />
The Ministry of Health’s most recent annual report<br />
2009-2010 evaluates progress made in the health<br />
sector against these ten targets. This past year, the<br />
government not only achieved to abolish user fees<br />
for health services, but also made the first steps<br />
towards the establishment of a unified information<br />
system, as well as the extension of access of the<br />
most impoverished communities to basic medical<br />
care, while enhancing the participation of civil<br />
society.<br />
Moreover, a new National Health Policy 2009-<br />
2014 20 came into force in February 2010,<br />
establishing eight preliminary priority areas for the<br />
health sector reform process:<br />
1. Construction of an integrated Network of health<br />
services;<br />
2. Human Resource in Health as a cornerstone for<br />
the system;<br />
3. Response to demand for medicines and<br />
vaccines;<br />
4. Instalment of the National Health Forum;<br />
5. Establishment of a single information<br />
management system;<br />
6. Strengthening the Medical Emergencies<br />
system;<br />
7. Progressive coordination among all national<br />
service providers; and<br />
8. Creation of the National Health Institute and<br />
strengthening of the National Association of<br />
Laboratories.<br />
For a country previously lacking any long-term plan<br />
for its health sector, the establishment of this new<br />
National Health Strategy can be seen as an<br />
important step.<br />
This policy also groups all public health providers<br />
into a National Health Service. However, the fact<br />
that the different entities will keep their institutional<br />
identities with separate budgets and lines of<br />
authority in the medium term complicates<br />
interagency coordination.<br />
On the basis of this document, the structure of the<br />
Ministry of Health has also been reformed in order<br />
to become more operational and interlinked across<br />
issues – the new <strong>org</strong>anigram can be viewed in the<br />
annual report 2009-2010 soon to be published on<br />
the Ministry’s website 21 .<br />
CIVIL SOCIETY, THE PARLIAMENT AND<br />
OWNERSHIP <strong>IN</strong> THE <strong>HEALTH</strong> SECTOR<br />
The purpose of this sub-section is to highlight that<br />
ownership should be exercised by all stakeholders<br />
in a society, not only by certain government<br />
ministries. Hereafter, the authors will analyse<br />
whether one can speak of true democratic<br />
ownership when it comes to El Salvador’s health<br />
sector, by focusing in particular on the opportunities<br />
and challenges faced by CSOs when trying to carry<br />
out their watchdog function and their role as health<br />
service providers, before analysing the powers and<br />
the weaknesses of the parliament in El Salvador.<br />
CSOs’ MEAN<strong>IN</strong>GFUL ENGAGEMENT <strong>IN</strong> POLICY<br />
PROCESSES<br />
The newly elected government has committed itself<br />
to establishing strong non-state actor participation<br />
mechanisms. The health sector in El Salvador can<br />
be seen as a tracer sector in that respect: A<br />
“National Policy for Social Participation in the<br />
health sector” was elaborated in April 2009.<br />
However, it has neither been linked to any concrete<br />
financial commitment nor has it come into force yet.<br />
Nevertheless, a number of participatory<br />
mechanisms were strengthened or created during<br />
the last few years:<br />
Fact-finding team meets<br />
Vice Health Minister<br />
Eduardo Espinoza.<br />
Photograph: DSW<br />
20 http://www.salud.gob.sv/index.php/servicios/descargas/documentos/Documentación-Institucional/Política-Nacional-de-Salud/Diario-Oficial-No.33-Tomo-<br />
No.386-del-17-02-2010.-Acuerdo-No.126.-Política-Nacional-de-Salud-2009-2014/<br />
21 www.salud.gob.sv<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
12<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
OWNERSHIP AND PARTICIPATION OF CIVIL SOCIETY AND THE PARLIAMENT<br />
The Intersectoral Committee (CISALUD), formed<br />
by government representatives, civil society and<br />
other main stakeholders, was established as a<br />
consultative entity for the elaboration of policies,<br />
with the participation of civil society and private<br />
actors. CISALUD played a key role in the early and<br />
successful control of A H1N1 (2009) and the<br />
dengue emergency (2010), among other<br />
achievements.<br />
Moreover, as mentioned above, one of the key<br />
priorities of the Ministry of Health during its first 100<br />
days in office has also been the establishment of a<br />
national health forum, aimed at uniting the existing<br />
diversity of non-state actors around the issue of<br />
health. It seeks to overcome two of the major<br />
challenges characterizing civil society and<br />
community movements until recently, namely a<br />
high degree of fragmentation and polarization<br />
around party affiliation: While many CSOs under<br />
the previous government were associated with the<br />
opposition and often excluded, on that basis, from<br />
decision-making processes, the right-wing ARENA<br />
is now in the process of establishing its own<br />
counter-movement, which is equally experiencing<br />
some degree of stigmatization under the new<br />
government 22 :<br />
The National Health Forum, which was launched<br />
on 28 May 2010, will seek to unify and strengthen<br />
the civil society movement by acting as an open<br />
platform for all non-state actors working on health.<br />
In that sense, it is to be distinguished from the<br />
existing CISALUD which involves government<br />
officials. In order to achieve it its objectives, the<br />
Forum, headed by the so-called “Organising<br />
Committee”, will be in charge of <strong>org</strong>anising regional<br />
conferences, thematic roundtables as well as<br />
establishing joint planning and monitoring systems<br />
for health sector policies, by prioritising community<br />
leadership. To name just some of the topics<br />
selected for the thematic roundtables in 2010:<br />
■ Sexual and reproductive health<br />
■ Social violence and violence against women<br />
■ Prevention and Mitigation of natural disasters.<br />
■ Medicines and health<br />
■ Water and sanitation.<br />
The representative of the Ministry of Health<br />
interviewed during the fact-finding visit stated that<br />
he would like to see the consultation of this entity<br />
become a mandatory precondition for establishing<br />
new policies in the health sector, thus ensuring that<br />
non-state actors can effectively carry out their<br />
policy watchdog role. However, clear Terms of<br />
Reference, membership adherence rules, as well<br />
as working procedures and consultation rules need<br />
to be established in order for the forum to function<br />
properly.<br />
Some civil society <strong>org</strong>anisations interviewed during<br />
the mission claimed they had neither been invited<br />
to contribute to the process of establishing the<br />
Forum nor to any events <strong>org</strong>anised by the Forum.<br />
They suspect that a certain favouritism based on<br />
party affiliation is still common practice in their<br />
country. This picture was confirmed by some of the<br />
donors interviewed, claiming that social<br />
participation is still very polarized and faith-based<br />
as well as the feeling that opposition party CSOs<br />
are still being excluded from the process.<br />
In general, those CSOs interviewed claim that<br />
there is still a lack of recognition on the<br />
government’s side of the added value that CSOs<br />
and CBOs can bring to policy-making processes:<br />
With regard to those few consultation processes in<br />
which the interviewed CSOs participated, there<br />
was also hardly any follow-up to the<br />
recommendations given by CSOs.<br />
Only two of the six interviewed CSOs had so far<br />
been involved in the government’s health services<br />
coverage expansion programme and in the<br />
consultation process about the new health reform.<br />
There is also a perceived lack of transparency on<br />
the government side about their consultation<br />
processes and the possibilities for Civil Society to<br />
get involved in budgetary scrutiny of public<br />
expenditures.<br />
On the other hand, those CSOs interviewed which<br />
were affiliated with the governing party were able to<br />
name a number of occasions in which they had<br />
been invited to participate in policy-making<br />
processes. This divergence in opinions about Civil<br />
Society participation reflects the impact that party<br />
polisarisation has in every sphere in El Salvador.<br />
One positive example of CSO participation<br />
mentioned by some of the interviewed was the socalled<br />
DAIA (Disponibilidad Asegurada de Insumos<br />
Anticonceptivos) initiative, launched in several<br />
Latin American countries by Civil society in<br />
conjunction with government officials and the<br />
support of USAID, in order to jointly advocate for<br />
the allocation of public resources to the purchase<br />
of Family Planning supplies.<br />
22 These statements are based on the opinions expressed by Civil Society representatives interviewed during the mission. They do not necessarily reflect<br />
AfGH positions.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
OWNERSHIP AND PARTICIPATION OF CIVIL SOCIETY AND THE PARLIAMENT<br />
13<br />
When asked to name the major health networks<br />
in their country, the interviewed CSOs mentioned<br />
the following platforms:<br />
■ REDSALUD El Salvador<br />
■ ASSR Alianza por la Salud Sexual y<br />
Reproductiva de El Salvador (Alliance for<br />
Sexual and Reproductive Health)<br />
■ ACCP Alianza Ciudadana Contra la<br />
Privatización (Civil Alliance against<br />
privatisation)<br />
■ FOROSAN Foro Para La Seguridad Alimentaria<br />
y Nutricional del Oriente (Eastern Forum for<br />
food and nutritional security)<br />
■ Acción Ciudadana de Lucha contra el VIH (Civil<br />
Action to flight HIV/AIDS).<br />
In the case of REDSALUD, the network has had<br />
successful experiences with advocacy towards<br />
decision-makers with regard to the health budget.<br />
ASSR successfully advocated for a national policy<br />
on Sexual and Reproductive Health (SRH) and<br />
became a platform of national reference for SRH.<br />
To mention another positive example, FOROSAN<br />
initiated a coordination process among CSOs,<br />
private companies, academics and government<br />
institutions in order to jointly advocate for an<br />
increase in the budget for food security.<br />
With regard to Civil Society participation in<br />
European donor decision-making processes, none<br />
of the interviewed CSOs stated having known or<br />
participated in any consultations. However, the EU<br />
Delegation, for instance, claims that society has<br />
been regularly consulted regarding thematic<br />
projects, and on actions of the current CSP 23 . The<br />
discrepancy between these views can probably<br />
again be linked to a lack of diversity in the choice of<br />
actors invited to such consultation processes, with<br />
the EU Delegations having the tendency to invite<br />
CSOs that they have already supported in the past.<br />
The Delegation also indicates that it had been<br />
advocating for a “Quadrilogue model” involving<br />
the government and its institutions (including<br />
autonomous and local authorities), civil society (in<br />
particular Non-State Actors) and interested<br />
Members of the Legislative Assembly 24 . The first<br />
such forum took place in November 2008, with a<br />
second one taking place in November 2009. The<br />
initiative was considered innovative by participants<br />
and by October 2009 led to efforts by Development<br />
NGOs to establish a national platform (MODES –<br />
Movimiento de ONGs de Desarrollo Solidario)<br />
supported by the Vice-Ministry of Development<br />
Cooperation. This example can be seen as highly<br />
positive, but continuous efforts should be made by<br />
European donors to support the integration of a<br />
greater diversity of NGOs, including health and<br />
women’ <strong>org</strong>anisations, in these processes.<br />
Moreover, these entities need to be continuously<br />
supported and strengthened in order to ensure<br />
their sustainability. On the other hand, there is also<br />
a responsibility on the CSOs’ side to increase their<br />
visibility and advocacy work.<br />
With regard to advocacy capacity-building, most<br />
of the interviewed CSOs had participated in some<br />
kind of advocacy or leadership training financed by<br />
certain donors, related to their area of expertise,<br />
such as, for instance, SRHR. In general, these<br />
trainings received positive evaluations. However,<br />
some of the CSOs would like to see an increased<br />
focus being put on ensuring that CSOs have the<br />
technical capacities and knowledge necessary for<br />
undertaking advocacy activities at policy-making<br />
level.<br />
However, EC officials indicate that no proposals for<br />
advocacy capacity-building projects had been<br />
submitted to the EC in the framework of its last<br />
non-state actor calls for proposals. Therefore,<br />
increased efforts need to be made by CSOs<br />
themselves in order to put advocacy capacitybuilding<br />
on the donors’ agenda.<br />
With regard to the relationship between<br />
International NGOs (<strong>IN</strong>GOs), local NGOs and<br />
Community-based <strong>org</strong>anisations (CBOs) in El<br />
Salvador, three of the interviewed <strong>org</strong>anisations<br />
stated having had extensive experience with<br />
service delivery in rural areas, where they<br />
simultaneously contributed to strengthening<br />
community-participation processes.<br />
However, these CSOs see a clear difference in the<br />
way the government and donors are treating<br />
<strong>IN</strong>GOs, local NGOs and CBOs, in terms of<br />
outreach, resource allocation, information flows<br />
and involvement in consultation processes. CBOs<br />
are still often excluded from these processes.<br />
23 EC Mid Term Review of the Country Strategy of 2007-2013 and National Indicative Programme 2011-2013 – El Savador.<br />
http://www.eeas.europa.eu/el_salvador/docs/2010_midterm_el_salvador_annex_en.pdf<br />
24 idem.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
14<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
OWNERSHIP AND PARTICIPATION OF CIVIL SOCIETY AND THE PARLIAMENT<br />
With regard to their relationship with local<br />
authorities, the interviewed CSOs mentioned a<br />
number of successful, joint initiatives which had<br />
been implemented during the last few years, such<br />
as:<br />
■ The conformation of multi-sector committees for<br />
health-monitoring and the prevention of sexual<br />
and gender-based violence.<br />
■ The conformation of Youth Networks for the<br />
promotion of SRHR.<br />
■ The Joint Initiative for the elaboration of<br />
municipal policies for the rights of girls, children,<br />
adolescents and young adults.<br />
■ Municipal Regulation for maternal<br />
breastfeeding.<br />
However, more efforts need to made in order to<br />
improve and strengthen the relationship between<br />
<strong>IN</strong>GOs, local NGOs, CBOs, local authorities and<br />
Members of Parliament in El Salvador in order to<br />
ensure that these alliances contribute to true<br />
country ownership of development policies. Donors<br />
should therefore actively seek to support<br />
partnership-building among all actors.<br />
Making policy and funding processes in a more<br />
participatory manner is ultimately not only a shared<br />
responsibility between all actors, including donors,<br />
the government and CSOs, but also a necessary<br />
step towards true country ownership.<br />
CSOs AS SERVICE D<strong>EL</strong>IVERY PROVIDERS<br />
While the new government’s policy with regard to<br />
CSO participation in policy processes can in<br />
general be qualified as positive, its relationship with<br />
health service delivery CSOs is still marked by<br />
rivalry: The MoH representative interviewed, for<br />
example, stated that CSOs have gained a<br />
disproportionately high role in service delivery<br />
during the last few years, as a consequence of<br />
conditionality imposed by certain donors (namely<br />
the World Bank) wanting to push for a more<br />
prominent role for CSOs in the health sector. The<br />
MoH also highlighted that the cost of their services<br />
were three times more expensive than the services<br />
provided directly by the public sector and that they<br />
used to give a basic package of services which<br />
was not fully integrated with the system.<br />
While it can be seen as positive that the<br />
government is trying to take a lead role in service<br />
delivery in order to increase coherence within the<br />
health system and avoid user fees, there is also a<br />
risk that those services taken over by the public<br />
sector will not be as effective in terms of their<br />
outreach to the most vulnerable and most remote<br />
segments of the population in the country.<br />
Continuous quality control will be necessary –<br />
preferably by involving CSOs with the required<br />
sector-expertise in order to assess whether the<br />
new primary healthcare reform with a health<br />
promotion approach achieves to improve access to<br />
services in the communities. In general, the<br />
relationship between public and private entities<br />
should be pushed towards collaboration and<br />
complementarities, rather than competition and<br />
rivalry. Nevertheless, donors should not push for<br />
NGO or CSO services to be paid by public funding<br />
if their costs could become a burden to the health<br />
system.<br />
In their policy dialogue with the government,<br />
donors should therefore not only advocate for a<br />
greater diversity of non-state actors to be invited to<br />
consultation processes, as well as for the<br />
systematic follow-up of recommendations given by<br />
CSOs during these processes, but also for the<br />
recognition of CSOs as service providers.<br />
It can be seen as a step forward that the Ministry of<br />
Health recently established a mechanism on its<br />
website 25 , where citizens who feel that their right to<br />
health has been violated can post their complaints.<br />
However, it remains to be seen if effective follow-up<br />
will be given to such complaints.<br />
AfGH Civil Society<br />
meeting in San Salvador.<br />
Photograph: DSW<br />
25 see www.salud.gob.sv<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
OWNERSHIP AND PARTICIPATION OF CIVIL SOCIETY AND THE PARLIAMENT<br />
15<br />
OWNERSHIP AND THE PARLIAMENT<br />
The “Asamblea Nacional” or the Parliament in El<br />
Salvador has, as in most other countries in the<br />
world, the legislative power and the right of<br />
budgetary scrutiny. However, MPs confirm that, due<br />
to the high polarisation marking their country’s<br />
party system, no party has the majority in the<br />
parliament. This makes it exceptionally difficult for<br />
Salvadoran MPs to advocate, within the parliament,<br />
for the consensual adoption of significant<br />
amendments to the sector ceilings set by the<br />
Ministry of Finance at the beginning of the budget<br />
cycle. For the health sector this means that the true<br />
entity to refer to for health advocates should be the<br />
Ministry of Finance.<br />
With regard to health sector performance, the<br />
parliament has three months to analyse the<br />
Ministry of Health’s annual report, which includes a<br />
section on external sources of funding for the<br />
health sector. However, this section merely shows<br />
how many on-budget funds have been disbursed<br />
that year and by which donors 26 – it does not<br />
indicate whether the funds have been adequately<br />
used by the government.<br />
As for budget transparency in general, a request<br />
for an independent audit of government spending<br />
can be made by the parliament, but it needs to be<br />
based on one of the following grounds:<br />
Recently, the government established the<br />
“Secretariat for Transparency” which should take<br />
responsibility for these issues, but its<br />
independence with regard to the government is<br />
already being questioned. At the time of the<br />
mission, the country was also in the process of<br />
elaborating a legal framework on transparency and<br />
accountability.<br />
Again, supporting the establishment of new<br />
partnerships between MPs and Civil Society<br />
should be seen as the way forward by donors in<br />
order contribute to increased transparency and<br />
accountability at country level. Some of the CSOs<br />
interviewed during the mission stated having<br />
contacts within Parliament in order to promote their<br />
cause, but they see a need for these relationships<br />
to be strengthened.<br />
As a result of such partnerships, MPs would benefit<br />
from CSOs’ knowledge of the needs of local<br />
communities and the most vulnerable, whereas the<br />
latter would thus get an entry point to the<br />
parliament in order to influence budgetary<br />
procedures and the elaboration of new legal<br />
frameworks. In a country as polarized as El<br />
Salvador, there is a need for innovative<br />
programmes promoting cross-party associations,<br />
whose advocacy work is not guided by party<br />
interests but rather by the true needs and rights of<br />
El Salvador’s citizens.<br />
■ Irregularities uncovered in one ministry’s annual<br />
report;<br />
■ The filing of a complaint by an individual or the<br />
Court of Auditors;<br />
■ An issue of national interest presented by a<br />
special commission established to that end.<br />
Even though corruption and misuse of funding<br />
remains a problem in El Salvador 27 , it can be seen<br />
as a very positive sign that the so-called “Partida<br />
Secreta” – the “secret budget line” – a contingency<br />
fund, to which an undefined and unlimited part of<br />
the budget used to be channelled every year and<br />
the use of which was entirely at the discretion of<br />
the President, has been declared unconstitutional<br />
in 2010 by the Supreme Court of Justice.<br />
As for international agreements and contracts,<br />
they should also undergo a scrutiny by Parliament,<br />
which is not always the case – as an example, one<br />
MP mentioned the IMF agreements, which can<br />
deeply affect a country’s social and economic<br />
situation and should therefore be pre-approved by<br />
the parliament.<br />
26 See table below in section entitled “The impact of donor coordination on health spending”.<br />
27 As confirmed by a number of the interviewees.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
16<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
THE IMPACT OF DONOR<br />
COORD<strong>IN</strong>ATION ON <strong>HEALTH</strong><br />
<strong>SPEND<strong>IN</strong>G</strong><br />
In order to assess the impact of donor coordination,<br />
an analysis needs to be made about current<br />
financing for health structure in El Salvador. The<br />
purpose of the following sub-section is also to<br />
uncover whether there is a country need and<br />
demand for donors to invest in health.<br />
F<strong>IN</strong>ANCIAL RESOURCES FOR <strong>HEALTH</strong><br />
A health sector reform process of the magnitude as<br />
the one currently being launched in El Salvador<br />
requires a significant amount of additional financial<br />
resources. The government itself recognises this –<br />
for instance by declaring, in its new National Health<br />
Policy, that public expenditure on health should<br />
progressively be increased in order to reach 5% of<br />
GDP by 2014. This figure is based on recent<br />
studies made by the PAHO suggesting that in the<br />
Americas no country that may be classified as<br />
having a universal healthcare system (Aruba,<br />
Canada, Cuba and Netherlands Antilles) was able<br />
to achieve a universal coverage with a level of<br />
public expenditure of less than 6% of GDP –<br />
Panama and Costa Rica, covering around 80% of<br />
their population, are currently investing 5% of GDP.<br />
Due to the impact of the crisis on the country, the<br />
Ministry of Health of El Salvador itself sees it as<br />
unlikely that these targets will be reached in the<br />
indicated period of time and will look into the<br />
possibility of a downward revision of the target to<br />
4%. Despite the government’s official commitment<br />
to health as a basic condition for social<br />
development, the national health budget in El<br />
Salvador is still only about half as high as its<br />
budget for education. Even though there has been<br />
an increase in the absolute numbers of the budget<br />
of the Ministry of Health during the last two years,<br />
from USD 459 million in 2009 to USD 517.3 million<br />
in 2010, the share of the Ministry of Health’s own<br />
budget within the public expenditure currently only<br />
represents 2.4% of GDP 28 . If increases continue to<br />
be made at the same pace as between 2008 and<br />
2010 (i.e. by 0.3% per year) then the share could<br />
eventually reach 3.6 % by 2014.<br />
However, whereas in other developing countries,<br />
such as Tanzania and Uganda, for instance, the<br />
Ministry of Finance and Economic affairs have a<br />
tendency towards macro-economic priority-setting<br />
and limiting social sector expenditures, the<br />
representatives of both ministries interviewed<br />
during the fact-finding visit seemed to be aware<br />
and conscious about the immense needs of their<br />
country’s health sector. Despite the budget for<br />
health still being low, there is potential for advocacy<br />
towards an increase of health funding in order to<br />
bridge the financing gap uncovered by the health<br />
reform: For example, The Ministry of Health<br />
received an extraordinary extra-budgetary funding<br />
from the National Government in 2010, increasing<br />
its budget from USD 390.65 million to USD 436.13<br />
million (excluding other sources such as donations,<br />
ministry-owned sources etc). 29<br />
NATIONAL PUBLIC <strong>HEALTH</strong> BUDGET, ALL FUND<strong>IN</strong>G SOURCES<br />
<strong>IN</strong>CLUDED, PERIOD 2005-2010 (<strong>IN</strong> USD MILLION)<br />
$600.0<br />
$500.0<br />
$459.0<br />
$517.3<br />
$400.0<br />
$300.0<br />
$326.1<br />
$368.5 $371.5<br />
$399.3<br />
$200.0<br />
$100.0<br />
$0.0<br />
2005 2006 2007 2008 2009 2010<br />
28 Estimates for 2010 – Ministry of Health Annual Report 2009-10.<br />
29 Ministry of Health Annual ”Rendicion de Cuentas” 2010.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
THE IMPACT OF DONOR COORD<strong>IN</strong>ATION ON <strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong><br />
17<br />
GNI SHARE OF THE M<strong>IN</strong>ISTRY OF <strong>HEALTH</strong>’ BUDGET (2005 – 2010)<br />
2.5%<br />
2.0%<br />
1.9%<br />
2.0%<br />
1.8% 1.8%<br />
2.2%<br />
2.4%<br />
1.5%<br />
1.0%<br />
0.5%<br />
0%<br />
2005 2006 2007 2008 2009 2010<br />
Source: Ministry of Health: Rendicion de Cuentas 2010<br />
Moreover, the new National Development Plan<br />
prioritises health financing for the next five years,<br />
thus opening the door for new loans from the Inter-<br />
American Development Bank (IDB) (USD 60<br />
million) and the World Bank (USD 80 million).<br />
Despite these essential external sources of<br />
funding, the government estimates that there is<br />
already for the first year of the reform an additional<br />
funding gap of ca. USD 100 million 24 in order to<br />
implement the health reform. At the time of the factfinding<br />
visit, no commitment had been made by<br />
European donors to co-finance the health reform.<br />
New opportunities for health financing should be<br />
ceased by those European donors whose multiannual<br />
country strategies are about to undergo<br />
their end-of-term revision.<br />
In order to better channel exisiting financial<br />
resources, the National Health Policy stipulates<br />
that financing coming from international<br />
cooperation agencies should be streamlined with<br />
National Health Plan priorities and incorporated<br />
into the country’s financial system.<br />
The share of foreign resources in the MoH<br />
budget saw a temporary peak in 2009 due to the<br />
financial crisis, with external loans accounting for<br />
23% of the national budget. In 2010, external<br />
resources accounted for about 17% of the national<br />
health budget, 13% of which are reimbursable<br />
loans. The remaining 4% are classified as onbudget<br />
“non-reimbursable Cooperation”, including<br />
in-kind contributions such as medical brigades or<br />
equipment donations. Purely financial external<br />
donations represent merely ca. 1% of the total<br />
national health budget 30 . However, as only part of<br />
the external funding is captured on-budget, it can<br />
be assumed that the actual share of external<br />
resources to the health sector is much higher.<br />
AID TO THE <strong>HEALTH</strong> SECTOR <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong> 2006-2008<br />
Top Ten Donors<br />
USD Million<br />
as a share of total aid to health<br />
for the selected recipient, %<br />
All Donors 28.0 100.0 7.3<br />
United States 9.6 34.2 4.1<br />
Global Fund 6.6 23.4 100.0<br />
Spain 4.7 16.7 8.3<br />
Luxembourg 1.6 5.7 15.5<br />
Japan 1.5 5.5 10.4<br />
UNFPA 1.0 3.5 100.0<br />
Canada 0.8 2.8 50.9<br />
Italy 0.4 1.4 24.5<br />
Sweden 0.2 0.8 7.6<br />
Germany 0.2 0.6 0.7<br />
Source: OECD Health Charts 2006-2008.<br />
as a share of total aid for the<br />
selected recipient, %<br />
30 Ministry of Health Annual Report 2009-2010.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
18<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
THE IMPACT OF DONOR COORD<strong>IN</strong>ATION ON <strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong><br />
ON-BUDGET DONOR CONTRIBUTIONS TO THE <strong>HEALTH</strong> SECTOR FOR<br />
THE F<strong>IN</strong>ANCIAL YEAR 2009-2010<br />
Country / International Entity<br />
Disbursements USD<br />
Bilateral Cooperation<br />
USAID 3,279,610.00<br />
Luxembourg 3,239,240.00<br />
Spain (incl. decentralised coop.) 2,533,450.00<br />
Korea 2,000,000.00<br />
Japan 1,091,000.00<br />
Multilateral Cooperation<br />
Global Fund* 964,356.00<br />
OPS* 964,356.00<br />
UNFPA* 260,000.00<br />
BID 100,000.00<br />
UNICEF* 11,000.00<br />
Total 13,662,313.00<br />
Medical Brigades – Cuba, USA and Italy 2,632,000.00<br />
In-kind donations – Germany and USA<br />
(Medicine, equipment, other material)<br />
2,026,375.00<br />
Grand Total 18,320,688.00<br />
Source: Ministry of Health Annual Report 2009-2010.<br />
* A high percentage of these funds are managed directly by the international agencies or the coordinating project offices. These figures<br />
do not include funds allocated to technical assistance provided by these entities.<br />
These figures show that – compared to other lowincome<br />
countries – the share of foreign donations<br />
to the national health budget is relatively low – too<br />
low if they are to contribute to covering existing<br />
needs, especially in the light of the health reform<br />
being implemented. Consequently, one of the aims<br />
of the Ministry of Health is the elaboration of a socalled<br />
“National Strategy for the Retention of<br />
International Cooperation” in order to reverse the<br />
recent tendency of specifically bilateral cooperation<br />
agencies to withdraw from the country due to its<br />
status of middle-income country.<br />
■ The establishment of a unified information<br />
management system for the health sector, for<br />
which an additional USD 20 Million is needed to<br />
complement the government’s initial investment<br />
of USD 12 million.<br />
■ Policies aimed at ensuring universal access to<br />
primary healthcare.<br />
In the light of the above-mentioned funding gap 31<br />
affecting the implementation of the health reform,<br />
the government’s claim for increased funding to the<br />
sector does indeed appear to be justified. More<br />
specifically, stakeholders interviewed mentioned<br />
the following areas still in need for external<br />
financial injections:<br />
Paper Archives in District Health Centre in San<br />
Salvador illustrating the need for a unified, electronic<br />
information management system.<br />
Photograph: DSW<br />
31 Estimates established by the Ministry of Health.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
THE IMPACT OF DONOR COORD<strong>IN</strong>ATION ON <strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong><br />
19<br />
<strong>EL</strong> <strong>SALVADOR</strong>’S AID EFFECTIVENESS AND<br />
DONOR COORD<strong>IN</strong>ATION AGENDA<br />
Until now, International Assistance to El Salvador<br />
has been characterised by some degree of<br />
fragmentation and a lack of leadership from the<br />
government with regard to donor coordination.<br />
The Mid-Term Review of the EC’s Country Strategy<br />
Paper (CSP) 2008-2013 gives a vivid and accurate<br />
summary of the challenges the country is still<br />
facing in terms of its donor coordination agenda:<br />
“Although UNDP was mandated by the previous<br />
government to initiate donor coordination in form<br />
of MDG sector round tables (mesas de<br />
donantes), the previous Salvadorian government<br />
preferred bilateral negotiations with individual<br />
donors and the meetings of the sector roundtables<br />
held every six months did not substantially help to<br />
improve coordination. Meetings between donors<br />
and the government remained mostly informative<br />
and did not develop into a proper forum for<br />
debating policies. In addition, donors have been<br />
rather unwilling to have joint programming, even<br />
if most donors have tried to align their aid to the<br />
few policies of the government of El Salvador such<br />
as Solidarity Network and the National Education<br />
Plan 2021. Most of them focused their efforts on<br />
the same sectors while certain sector lack funds.<br />
Therefore, the impact of their actions has been less<br />
strong”.<br />
In this context, the paper also highlights that<br />
coordination between the EC and EU Member<br />
States agencies did not go beyond the <strong>org</strong>anisation<br />
of information sessions about the CSP2007-2013.<br />
However, the EC also mentions an important and<br />
positive example of donor coordination, namely the<br />
El Salvador Budget Support Group. Its<br />
members, the World Bank, IDB, AECID and the<br />
Commission, jointly conducted the Public<br />
Expenditure and Financial Accountability (PEFA)<br />
assessment, financed by the European<br />
Commission in the first quarter of 2009.<br />
At local and community level, donors and<br />
international <strong>org</strong>anisations have, since 1998,<br />
coordinated their initiatives through RECOD<strong>EL</strong><br />
(Red de Cooperantes para el DEsarrollo Local –<br />
Donor Network for Local Development). In 2003,<br />
members reviewed the role of this forum and<br />
attempted to reinforce its impact through enhanced<br />
dialogue with state and non state actors.<br />
All stakeholders interviewed indicated that the<br />
change in government in June 2009 created new<br />
windows of opportunities in terms of aid<br />
effectiveness. The new government has already<br />
demonstrated a new openness towards<br />
international cooperation and a strong willingness<br />
to assume more ownership and to discuss and<br />
align donor programmes: For instance, in July<br />
2009, the government established a Donor<br />
Roundtable in order to coordinate the support of<br />
the international community for the implementation<br />
of a Universal Social Protection System.<br />
The new government sees it as particularly<br />
necessary to ensure that the scarce external<br />
resources available to El Salvador are used in an<br />
effective manner. Consequently, in June 2010, El<br />
Salvador presented its new “National Aid<br />
Effectiveness Agenda” (“Agenda Nacional de<br />
Eficacia de la Ayuda”) which defines key actions to<br />
be taken by all stakeholders (government, donors<br />
and non-state actors) in order to achieve each of<br />
the Paris Declaration principles.<br />
However, some development partners, such as the<br />
European Union, have until now not been able to<br />
sign the document as it would compel them to take<br />
certain decisions which can only be made in<br />
consultation with their headquarters – such as, for<br />
instance, the decentralisation of institutional<br />
decision-making. One development partner also<br />
mentioned that the wording of the paper is geared<br />
towards unconditional General Budget Support as<br />
the only possible aid modality – which would<br />
undermine the current mixed funding practice, as<br />
well as the conditionality of funding.<br />
In order to make more operative the committments<br />
acquired in the Aid Effectiveness Agenda, the<br />
government has also worked on a Code of<br />
Conduct for the Rural and Urban Solidarity<br />
Communities Programme, that seeks to define<br />
best practices and committments adopted by the<br />
governmental institutions and development<br />
partners in order to obtain better levels of<br />
coordination, harmonization and alignment of the<br />
actions and interventions to be developed in the<br />
framework of the Programme. It is expected to be<br />
signed shortly.<br />
In that context, it is worth mentioning that aid<br />
provided by the European Union, including EU<br />
Member States, has accounted for ca. 51% of all<br />
ODA disbursements to El Salvador between 2001<br />
and 2007. El Salvador is receiving EUR 121 million<br />
for cooperation from the EC in the current CSP<br />
period. An evaluation of EU cooperation in El<br />
Salvador between 1998 and 2008 has shown that<br />
there has so far been little coordination between<br />
the EU and other donors, with the Delegation of the<br />
European Commission following its own agenda<br />
and priorities 32 .<br />
32 “Evaluation of the Development Cooperation between the European Commission and El Salvador”. ADE, on behalf of the European Commission, March 2010<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
20<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
THE IMPACT OF DONOR COORD<strong>IN</strong>ATION ON <strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong><br />
The government is expected to continue pushing<br />
the aid effectiveness agenda during the coming<br />
years. To that end, a new entity has recently been<br />
created within the Ministry of External affairs: The<br />
Vice-Ministry for Development Cooperation is<br />
responsible for the relations with development<br />
partners and for elaborating and implementing a<br />
National Cooperation Strategy. A first step made in<br />
that direction was the decision to participate in the<br />
2011 OECD survey on Aid Effectiveness to<br />
evaluate the aid instruments in El Salvador. The<br />
results of this survey will be made available at the<br />
High Level Forum in Busan.<br />
An interview with the Vice-Ministry confirmed that<br />
coordination between all donors in El Salvador is<br />
still in its infancy. In line with the principles of the<br />
Accra Agenda for Action, however, a definite<br />
change has taken place from past UNDP<br />
leadership of donor roundtables to government<br />
leadership of alignment and harmonization.<br />
As each donor agency currently still has its<br />
individual information management systems, one of<br />
the first priorities of the Ministry is to establish a<br />
unified online development cooperation<br />
database, which could be going in the direction of<br />
the IATI initiative. For such a system to be effective<br />
the government and donors need to ensure that it<br />
is linked to the national budget planning exercise.<br />
The mid-term review of the EC’s CSP 2007-13,<br />
undertaken in 2009, revealed that additional efforts<br />
needed to be made to improve joint programming<br />
and coordination. According to the outcome<br />
document, donors “should show more willingness<br />
to align their programmes instead of seeking out<br />
individual advantages with the government. Also, it<br />
remains to be confirmed if the government will be<br />
able to avoid frictions in its own team and whether<br />
donor coordination could be structured by the<br />
government without overlapping of responsibilities<br />
between several competent authorities such as the<br />
Ministry of Foreign Affairs, the Technical Secretariat<br />
of the Presidency and a new Secretariat on<br />
Strategic Affairs” 33 . The overlapping of<br />
responsibilities is a result, in part, of the new<br />
government architecture and the need for a new<br />
institutionalism which has re-allocated functions<br />
accordingly.<br />
Spain is currently developing a code of conduct for<br />
budget support to which all donors will be invited to<br />
adhere. However, following the principle of “mutual”<br />
accountability, the government should respectively<br />
increase its own transparency, especially with<br />
regard to the traceability of funding channelled to<br />
its own treasury.<br />
The first memorandum of joint coordination<br />
between the Delegation of the European Union in<br />
El Salvador and the Technical Office of<br />
Cooperation of AECID to support the social<br />
protection and poverty reduction poverty in El<br />
Salvador was signed on 24th October 2010.<br />
However, these actions that are seen as positive<br />
initiatives, need to advance to align and harmonize<br />
with the partner government and not limit<br />
themselves to development partners, otherwise,<br />
harmonization could be taken as an end in of itself<br />
when it should instead be a tool for alignment<br />
under governmental leadership.<br />
Aid effectiveness and donor coordination are also<br />
two key issues highlighted in the National Health<br />
Policy, which refers to the need of establishing a<br />
donor roundtable on health. According to some<br />
European donors this is an important step forward<br />
as the country has until present lacked an effective<br />
sector-specific approach with regard to donor<br />
coordination. Leadership of the Ministry of Health<br />
with regard to sector-aid has historically been<br />
weak. Consequently, the new government has<br />
decided to establish an External Cooperation<br />
Department within the Ministry of Health,<br />
specifically in charge of coordinating the country’s<br />
aid to the sector. Ministry officials have been<br />
trained accordingly and a donor roundtable is in the<br />
process of being launched. However, according to<br />
some of those interviewed, further strengthening is<br />
needed if the Ministry is to manage budget support<br />
channelled to the sector.<br />
Moreover, as stated above, CSO involvement in<br />
these coordination processes will need to be<br />
closely monitored in order to ensure that a<br />
representative sample of CSOs is invited to<br />
participate and that there is a follow-up to the<br />
recommendations expressed by CSO<br />
representatives.<br />
In that context, it is worth analyzing the current aid<br />
architecture in El Salvador, which is characterized<br />
by two predominant aid modalities: Programme<br />
Support and Project Support, including vertical<br />
funding and technical assistance.<br />
PROGRAMME AND SECTOR BUDGET<br />
SUPPORT <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
Due to the absence of a long-term poverty<br />
reduction strategy, El Salvador has, until now, only<br />
been eligible for Programme and Sector – rather<br />
than General Budget – Support from the EC and<br />
other donors. In other words, funds channelled to<br />
the national treasury were earmarked for one<br />
national policy programme (for instance, the<br />
programme “Comunidades Solidarias”) or sector<br />
33 Source: Mid-Term Review of El Salvador’s Country Strategy Paper 2007-2013<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
THE IMPACT OF DONOR COORD<strong>IN</strong>ATION ON <strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong><br />
21<br />
District Health Centre<br />
Facilities in San Salvador:<br />
Linking health, water and<br />
sanitation is crucial.<br />
Photograph: DSW<br />
(namely education). Until now, European funding<br />
for health policies had been relatively modest.<br />
Two of the EU’s biggest bilateral donors to El<br />
Salvador – Spain and Germany – concentrate<br />
cooperation on poverty reduction, social services,<br />
good governance (including security), and business<br />
development. Spain’s programme includes funding<br />
of Spanish NGOs (over 40% of the total assigned<br />
to El Salvador), as well as national citizens’<br />
contributions to post-earthquake assistance.<br />
Even though the EC’s Country Strategy Paper<br />
(CSP) 2007-2013, which foresees a total allocation<br />
of EUR 121 million to El Salvador, aims at<br />
fostering social cohesion through social<br />
investments in health, water and sanitation, and<br />
human capital development, health has been deprioritized<br />
in favour of the education sector. The EC<br />
argues that support to health was not possible in El<br />
Salvador due to the absence of a strategic policy<br />
framework guiding the sector.<br />
However, it is worth noting that the EU and AECID<br />
have been among the biggest donors co-financing<br />
the Water and Sanitation component of the<br />
national Programme “Redes Solidarias” –<br />
“Solidarity Networks” (now renamed:<br />
“Comunidades Solidarias” – Communities in<br />
solidarity). This programme, which aims at reducing<br />
poverty through targeted interventions in the<br />
country’s 100 poorest municipalities, will<br />
progressively be expanded to cover another 14<br />
localities. The EU has already invested EUR 37<br />
million in this programme and has committed to<br />
continue co-financing the second phase.<br />
The programme has been evaluated on a yearly<br />
basis according to seven outcome indicators;<br />
including some health-related indicators. For<br />
example, disbursements were linked to the usage<br />
rates of the health (and education) facilities<br />
created, as well as TB control for pregnant woman.<br />
The programme has received very positive<br />
evaluations and has earned a good reputation even<br />
at regional level. The aid modality used by the EU<br />
to co-finance the programme has also been<br />
positively criticised in that it combines certain<br />
advantages of general budget support (institutional<br />
strengthening; use of government public financial<br />
systems, etc.) with some favourable characteristics<br />
of programme support (the achievement of clearly<br />
definable results, for example) 34 .<br />
However, the stakeholders interviewed all<br />
emphasised that government spending needs to<br />
become more transparent and accountable and<br />
that there should be a quality control mechanism<br />
for the services or products (for example<br />
medicines) provided by the government. The<br />
country is currently in the process of establishing a<br />
new unified information management system for<br />
the health sector, as well as elaborating new legal<br />
frameworks on transparency and accountability, as<br />
well as quality control: For example, the so-called<br />
“Pro-Calidad” programme, which will be cofinanced<br />
by European donors through a<br />
contribution of EUR 12.1 million, will address crosscutting<br />
issues and concerns among all sectors<br />
including health, as it aims to establish and<br />
strengthen the national quality control system. The<br />
programme has long been delayed, though, as the<br />
draft National Quality Law, which should be the<br />
basis for implementation of the programme, had,<br />
until recently not been presented to the Legislative<br />
Assembly. At the time of the fact-finding visit the<br />
government stated that the programme was to be<br />
launched during the coming months.<br />
Moreover, CSOs see a necessity to have<br />
integrated health and education programmes, as<br />
donors should acknowledge important linkages<br />
between the two sectors. However, caution should<br />
be exercised in monitoring that neither of the two<br />
sectors is neglected within an integrated<br />
programme.<br />
34 “Evaluation of the Development Cooperation between the European Commission and El Salvador”. ADE, on behalf of the European Commission, March 2010<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
22<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
THE IMPACT OF DONOR COORD<strong>IN</strong>ATION ON <strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong><br />
NEW OPPORTUNITIES FOR <strong>HEALTH</strong> SECTOR<br />
BUDGET SUPPORT<br />
Contrary to other government ministries in El<br />
Salvador, the Ministry of Health has, to date, not<br />
received any Sector Budget Support from<br />
European donors. The latter argue that the sector<br />
has so far been lacking a budgeted strategic plan<br />
on the basis of which funds could have been<br />
channelled to the national treasury. As mentioned<br />
above, the recently launched health sector reform<br />
could open new doors in that respect.<br />
One year after its initiation, the health sector<br />
reform process has already led to some notable<br />
results, such as the abolition of user fees, the<br />
recruitment of new health personnel to cover the<br />
resulting shortages and the assignment of<br />
important additional resources for the procurement<br />
of essential medicines 35 .<br />
However, according to the Ministry of Health, the<br />
financial gap to be overcome in order to<br />
successfully implement this new health reform is<br />
estimated to be ca. USD 100 million. At present,<br />
the implementation of the reform depends on loans<br />
from the World Bank and the IDB.<br />
During the meetings at country level, all of the<br />
Ministry representatives interviewed emphasised<br />
the need for additional international support for<br />
implementing their health sector reform process.<br />
Ministry representatives and MPs generally also<br />
expressed their discontent with the fact that a big<br />
part of the funds supposed to be channelled to El<br />
Salvador’s health sector ended up being used for<br />
contracting international experts and consultants<br />
for technical assistance to the Ministry of Health.<br />
While technical assistance to the Ministry will be<br />
continued, as it can be seen as a key condition for<br />
sector budget support, donors should increasingly<br />
consider employing local (rather than international)<br />
consultants to that end.<br />
The EC, one of El Salvador’s biggest donors, has<br />
so far only financed health infrastructure<br />
programmes. In addition to the above-mentioned<br />
arguments used to justify the EC’s limited presence<br />
in the health sector during recent years, the EU<br />
Delegation in El Salvador upholds division of labour<br />
considerations and the EU Member States’<br />
preference for health – versus the EU Delegation’s<br />
expertise with infrastructure – programmes.<br />
However, it is notable that in El Salvador, a<br />
significant amount of funding has already been<br />
channelled to the health infrastructure sector by<br />
other donors, such as the World Bank, for example.<br />
Moreover, the use of such funding by the<br />
government has been marked by corruption<br />
scandals which involve the infrastructure<br />
procurement industries.<br />
Another argument frequently used by EC officials to<br />
explain their decision to opt out of health is that the<br />
government had explicitly asked the EC for support<br />
to the infrastructure sector. However, the EC’s main<br />
counterpart within the government is the Technical<br />
Secretariat of the Presidency. When asked about<br />
their efforts to collaborate with line ministries as<br />
required by new decentralisation processes, EC<br />
officials comment that they have, so far, not been<br />
able to bypass the Secretariat and negotiate<br />
directly with the Ministries. However, this had<br />
clearly been the case for the Ministry of Education,<br />
since the EC co-financed an education programme<br />
implemented by the Ministry.<br />
In the light of the new health sector reform’s<br />
financing needs and the upcoming end-of-term<br />
review of the EC’s Country Strategy Paper, a<br />
strategic change towards health-financing<br />
should be considered by the EC. The EU<br />
Delegation in El Salvador does not exclude this<br />
possibility, but also points to the government’s own<br />
responsibility in demanding such a change. Other<br />
European donors, such as AECID, also expressed<br />
their interest in participating in a joint budget<br />
support initiative, if based on the government’s<br />
request and agreed upon by several donors.<br />
VERTICAL FUND<strong>IN</strong>G <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
According to the Ministry of Health, “vertical<br />
funding has been detrimental to health-system<br />
strengthening [...] Disease-specific programmes<br />
obviously led to rapid results for the particular<br />
Health issues they are targeting, but once external<br />
funding for these programmes comes to an end,<br />
the system will be too weak to ensure their<br />
continuity”.<br />
As further pointed out by some donors interviewed,<br />
vertical funding specifically used for HIV/AIDS and<br />
some maternal health programmes, also<br />
contributed to aid fragmentation, due to the high<br />
number of parallel implementation units established<br />
in that context.<br />
Currently, El Salvador faces the challenge of<br />
having to comply with the diverging procedures of<br />
22 vertical programmes and about 60 different<br />
disbursement systems. Some donors highlight that<br />
GAVI, for example, has shown some progress in its<br />
approach towards health-system strengthening,<br />
while alignment of the Global fund remains a<br />
challenge.<br />
35 For more information, see: “Results-based management” in this paper and: Ministry of Health Annual Report 2009-2010.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
THE IMPACT OF DONOR COORD<strong>IN</strong>ATION ON <strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong><br />
23<br />
PROjECT SUPPORT FOR CSO PROjECTS<br />
Regarding the use of the project approach for CSO<br />
projects, some European donors highlight several<br />
difficulties experienced with this aid modality, such<br />
as the compliance with procedures as well as the<br />
lack of capacities of the beneficiaries, frequent<br />
delays with the regard to implementation resulting<br />
from and leading to disbursement problems, which<br />
affect the results. Consequently, certain European<br />
donors, such as the EC, have considerably<br />
reduced the number of classic projects financed.<br />
Nevertheless, the EC still values direct support for<br />
CSOs and invests EUR 2 million annually for<br />
projects of non-state actors in development, as well<br />
as EUR 600,000 for the EIDHR projects in El<br />
Salvador. Funding for health – specifically sexual<br />
and reproductive health – projects is available<br />
under the Investing in People Programme.<br />
The Ministry of Health sees it as problematic that<br />
donors have, in the past, channelled part of their<br />
funding available to the country’s health sector<br />
directly to CSOs. The Ministry claims that this has<br />
not only contributed to some degree of<br />
fragmentation of health aid, but also to a lack of<br />
transparency of spending, as CSOs do not report<br />
back to the government on their funding. However,<br />
as the latter often have to follow strict reporting<br />
mechanisms established by donors, it should also<br />
be the responsibility of donors to share information<br />
about direct project support for CSOs with the<br />
government in order to ensure greater alignment<br />
and transparency of this aid modality. The online<br />
development database soon to be launched by the<br />
government should provide the adequate basis for<br />
this.<br />
On the other hand, those CSOs interviewed during<br />
the fact-finding visit noted a drastic reduction of<br />
support channelled directly to CSOs during the last<br />
few years. They also state that funding provided by<br />
non-European donors, and among European<br />
donors, by EU Member States was generally easier<br />
to access than EC funding. Moreover, national<br />
CSOs deplore the fact that there is still little support<br />
for institutional strengthening or “core” funding<br />
available to them.<br />
In the light of the new health sector reform, as well<br />
as the government’s new policies on social<br />
participation in the health sector, it will become all<br />
the more crucial for donors to ensure that CSOs<br />
are able to participate in the new coordination<br />
mechanisms – direct support should therefore<br />
increasingly be channelled to partnershipbuilding<br />
initiatives between MPs, Civil Society<br />
and local authorities, as well as advocacy<br />
capacity-building and institutional strengthening for<br />
non-state actors.<br />
ALIGNMENT AND HARMONISATION: CAN EU<br />
DONORS LEAD BY ExAMPLE<br />
Donor Coordination and alignment efforts made by<br />
European donors need to be mirrored against<br />
practices of other donors to the health sector. To<br />
that end, it is interesting to look at the example of<br />
one of El Salvador’s biggest donors to the health<br />
sector:<br />
Every year, the United States Agency for<br />
International Development (USAID) and the<br />
Government of El Salvador (GOES), sign<br />
Assistance Agreements (AOs) that describe the<br />
type of activities USAID and the GOES will<br />
financially support. These activities are agreed<br />
upon by each sector Ministry, such as the MoH.<br />
Before developing new AOs, USAID must<br />
undertake a sector needs assessments which<br />
include interviews with MoH, NGOs, CSOs, etc.<br />
Due to reforms in US foreign assistance, USAID is<br />
currently in the process of developing new<br />
strategies across sectors. The reform is in its very<br />
early stages and consultations are ongoing. At the<br />
same time, the US Congress earmarks/designates<br />
funding for a specific sector. Currently, USAID is<br />
supporting maternal and child health, family<br />
planning and reproductive, and HIV/AIDS<br />
prevention; health systems strengthening is<br />
included across these interventions. USAID will<br />
decrease its funding because family planning<br />
assistance is ending in El Salvador in September<br />
2011. This decision was reached and agreed upon<br />
under the previous Salvadoran Administration.<br />
USAID will continue to provide financial support in<br />
health systems strengthening, maternal and child<br />
health, and HIV/AIDS prevention.<br />
In addition to USAID, the Centers for Disease<br />
Control and Prevention (CDC), Peace Corps, and<br />
the Department of Defense (DOD) also provide<br />
funding for healthcare services and information<br />
including direct technical assistance to the MoH.<br />
DOD has refurbished/renovated clinics due to the<br />
effects of Hurricane Ida and brings medical<br />
providers to give free medical care to underserved<br />
communities. It is worth noting that the private<br />
sector such as American Foundations and<br />
Corporations financially support local NGOs/CSOs<br />
to provide health services in El Salvador.<br />
However, a major part of the funding provided by<br />
important health donors in El Salvador will still be<br />
allocated to the fight against HIV/AIDS, The<br />
HIV/AIDS adult prevalence rate in El Salvador is<br />
currently only at about 0.7% 36 , placing it at the<br />
36 WHO World Health Statistics 2010.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
24<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
THE IMPACT OF DONOR COORD<strong>IN</strong>ATION ON <strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong><br />
same level as certain European countries, such as<br />
Spain. USAID’s and the Global Fund’s diseaserelated<br />
approaches have consequently been<br />
fiercely criticized by the government as they are<br />
“concentrating all resources on one problem<br />
instead of strengthening the system as a whole” 37 .<br />
The table below shows that a major part of El<br />
Salvador’s external funding for health is still<br />
allocated to STD control including HIV/AIDS.<br />
<strong>HEALTH</strong> FUND<strong>IN</strong>G FOR <strong>EL</strong> <strong>SALVADOR</strong> BY SUBGROUPS – 2006-2008<br />
Subgroups<br />
2006-2008 USD million average<br />
Population policy & admin. Management 0.7<br />
Basic health infrastructure 2.6<br />
Medical services, training & research 0.4<br />
Family planning 1.5<br />
Reproductive healthcare 4.4<br />
Infectious disease control 1.7<br />
Basic healthcare 3.3<br />
Health policy & admin. management 5.4<br />
STD control including HIV/AIDS 8.0<br />
Grand Total 28.0<br />
Source: OECD Health Charts 2006-2010<br />
USAID officials themselves expressed wishes for a<br />
closer cooperation and coordination between<br />
European and non-European donors in order to<br />
jointly elaborate mechanisms for health-systems<br />
strengthening.<br />
Especially in countries such as El Salvador, where<br />
financial resources for health are scarce, there is<br />
hence a need for European donor agencies to seek<br />
a strong collaboration with their non-European<br />
counterparts in order to canalize funding and jointly<br />
improve aid effectiveness in the health sector.<br />
Moreover, in order to be able to “lead by example”,<br />
European donors need to continue fighting their<br />
own deficiencies in terms of alignment and<br />
harmonization.<br />
Finally, in the light of the drastic reductions in<br />
funding undertaken by what has so far been El<br />
Salvador’s biggest donor to the health sector,<br />
European donors will also need to step in order to<br />
prevent the deepening of the current funding gap<br />
affecting the sector.<br />
IHP+ <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
Despite their comparatively straightforward aid<br />
architecture, adherence to the International Health<br />
Partnership (IHP+) in Latin America could result in<br />
a more effective deployment of available resources.<br />
To date no Latin American government has signed<br />
up for the IHP+, an initiative primarily designed for<br />
countries with a high share of development aid in<br />
their health budgets. However, the latter often<br />
already display very elaborate donor coordination<br />
mechanisms introduced by the aid community,<br />
while these mechanisms have often been<br />
neglected in low-priority countries, such as El<br />
Salvador.<br />
Accordingly, when asked about his view on IHP+<br />
during the fact-finding visit, El Salvador’s Vice<br />
Minister of Health’s answer was: “Where do I<br />
sign”. Other stakeholders interviewed during the<br />
mission also expressed great interest for the<br />
initiative even though most of them, including the<br />
CSOs, had never heard about it before.<br />
On the one hand the adherence to IHP+ in this<br />
country could contribute to increasing the technical<br />
assistance needed for strengthening the health<br />
system. On the other hand, IHP+ could also unite<br />
donors in their efforts, no matter how large their<br />
health aid contributions. In doing so, results<br />
attained could be maximised, granting political<br />
support to a determined effort to achieve universal<br />
access to primary healthcare. Donors should<br />
therefore promote El Salvador’s adherence to<br />
IHP+.<br />
37 This quote has been taken from one of the interviews held during the fact-finding visit.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
25<br />
MANAG<strong>IN</strong>G FOR RESULTS:<br />
THE ROLE OF AID FOR<br />
PROGRESS TOWARDS THE<br />
MDGs AND FOR UNIVERSAL<br />
ACCESS TO PRIMARY<br />
<strong>HEALTH</strong>CARE<br />
As stated in the EC’s 2010 Mid-Term review of El<br />
Salvador’s CSP 2007-2013 38 , “unless welldesigned<br />
social policies integrated with the<br />
economic development strategy of the country are<br />
implemented El Salvador is unlikely to reach the<br />
MDGs by 2015”.<br />
Only equality and empowerment of women seems<br />
to be on track, while achieving universal primary<br />
education, reducing child mortality and improving<br />
maternal health requires changes of the policy<br />
implementation of targets to be achieved by 2015.<br />
Access to health services is limited: only around<br />
half of the population suffering from an illness or<br />
accident receive medical assistance 39 . According to<br />
the Ministry of Health 40 , “important groups of the<br />
population, especially young women, the poor and<br />
the children, lack access to primary healthcare, and<br />
even when they do have access, they so far<br />
needed to pay the treatment expenses out of their<br />
own pocket. As a consequence of the chronic<br />
stockout of supplies in public health facilities,<br />
patients are coerced into buying from private<br />
pharmacies, where the prices for medicines among<br />
the highest in the world. This has severely<br />
aggravated the economic situation of many<br />
households in the past to the point of leading them<br />
into poverty”.<br />
There is also a remarkable inequity in terms of per<br />
capita distribution of financial resources to health:<br />
While the Ministry of Health should be responsible<br />
for 75% of the population 41 , it only had USD 87 per<br />
capita at its disposal in 2008, whereas the per<br />
capita figures of the ISSS and the BM, jointly<br />
responsible for ca. 25% of the population, were<br />
between 2.5 (ISSS – USD 221) to four times (BM –<br />
USD 340) higher than the Ministry ones 42 .<br />
Each system is paid through separate ways, but<br />
the MoH is responsible of covering the financial<br />
gap for each of the other systems. In addition, the<br />
MoH pays for all primary care (also for formal<br />
employees, soldiers and teachers Primary<br />
Healthcare consultations) and no clear<br />
compensation mechanism is established to return<br />
this money to the MoH budget. The result is that<br />
the MoH, responsible for providing care to almost<br />
80% of the population, lost funds and the attention<br />
is inequitative.<br />
The Ministry itself admits 43 that there is a critical<br />
need for reforming this system. The health reform<br />
launched by the new government is expected to<br />
bring about fundamental changes in that respect,<br />
but still faces enormous challenges, especially in<br />
terms of financial resources needed: One of the<br />
first actions undertaken by the government was to<br />
eliminate user fees, which immediately led to a<br />
radical increase of up to 40% in the demand for<br />
services in certain regions of the country.<br />
The additional budget of USD 11 Million that the<br />
Ministry of Health had received from the Ministry of<br />
Finance for the reform was consumed immediately<br />
by this increase in demand. Another challenge the<br />
system had to face as a consequence of this new<br />
policy is the lack of capacities of health centres to<br />
accommodate the new demand for services. Due<br />
to the over-emersion of primary health facilities,<br />
more and more patients are referred to secondand<br />
third level health centres and hospitals, leading<br />
to the rapid saturation of all these facilities.<br />
38 http://www.eeas.europa.eu/el_salvador/docs/2010_midterm_el_salvador_annex_en.pdf<br />
39 WHO data and EC Mid Term Review CSP 2007=2013.<br />
40 “Construyendo la Esperanza: Estrategias y recomendaciones en salud 2009-14”.<br />
41 See table “Distribution of population responsibility by Institution” – Ministry of Health Annual Report 2009-2010, p. 131.<br />
42 Ministry of Health Annual Report 2009-2010.<br />
43 See Mnistry of Health Annual Report 2009-2010.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
26<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
MANAG<strong>IN</strong>G FOR RESULTS<br />
A gradual reform of the Primary Healthcare<br />
system undertaken by the government aims,<br />
among other things, at breaking the biggest barrier<br />
of healthcare access of El Salvador, which are<br />
rural-urban inequities. To do this, they will opt for a<br />
family medicine and health promotion model,<br />
carrying doctors and nurses to all communities to<br />
reach out this half of the population that today<br />
doesn’t have regular access to healthcare. The aim<br />
is to have a family doctor for every 3,000 people<br />
and a community health worker for every 200<br />
families.<br />
However, what that this means is that in 2010 and<br />
2011 there is a need for recruitment of 2,272 new<br />
workers with an additional charge of USD 14<br />
million. As previously mentioned, a substantial<br />
increase in both domestic and external funding for<br />
health will need to occur if such reforms are to be<br />
successful.<br />
With regard to the access to medicines, the<br />
government purchased additional medicines to a<br />
value of USD 18.5 million in 2009. It also started a<br />
pilot programme of purchasing medicines through<br />
the United Nations System, of an initial value of<br />
USD 3 million. The sustainability of such a system<br />
will however need to be tested in the long-run.<br />
Another fundamental change brought about by the<br />
reform is the Health system’s substantially<br />
increased emphasis on prevention, as opposed to<br />
the formerly curative approach. By raising<br />
awareness among patients on how to conduct a<br />
more healthy life, this new approach is ultimately<br />
also expected to lead to immense savings in terms<br />
of treatment and medicines costs.<br />
According to the EC’s Mid Term Review of El<br />
Salvador’s CSP 2007-2013, the two key<br />
programmes launched by the previous government<br />
to accelerate country progress towards the MDGs<br />
(Solidarity Network and the National Education<br />
Plan 2021) have only brought limited results and<br />
certain issues, such as health, water and<br />
sanitation, “were not adequately addressed”.<br />
When asked about what they consider to be the<br />
most neglected health issues in their country,<br />
CSOs interviewed during the fact-finding visit came<br />
up with the following list:<br />
■ Family Planning, reproductive health and<br />
abortion<br />
■ Gender equality and women’s empowerment –<br />
specifically the issue of gender-based violence<br />
as a public health issue<br />
■ People living with disabilities<br />
■ Adolescents’ health<br />
■ Infants’ Primary Healthcare<br />
Moreover, CSOs indicated that aid often did not<br />
achieve to reach all vulnerable groups, such as, for<br />
instance, women and adolescents, especially since<br />
these groups are often also excluded from<br />
decision-making processes at community level.<br />
As previously discussed, various different<br />
stakeholders interviewed also pointed at the<br />
disproportionately high funding allocated to certain<br />
diseases: “There are those who live with HIV/AIDS<br />
and those who live OFF it”, was a comment made<br />
by one donor interviewed. In an interview, the<br />
director of a health centre visited in El Salvador<br />
confirmed that funding for HIV/AIDS is<br />
disproportionately high compared to funding for<br />
other very common diseases in El Salvador, such<br />
as Dengue.<br />
When looking at recent data about the most<br />
prevalent diseases in El Salvador, nontransmissible<br />
chronic diseases represented 74.2%<br />
of all deceases occurred in 2007. Other common<br />
causes of death were injuries caused by violence,<br />
followed by cardiac illnesses, cancer, renal<br />
insufficiency and diabetes 44 . As none of the socalled<br />
“killer”-diseases (Malaria, HIV-AIDS and TB),<br />
Disease prevalence map<br />
of a district health centre<br />
in San Salvador. Green<br />
spots: registered<br />
dengue cases. White<br />
spots: TB cases. Black<br />
spots: H1N1 Influenza. no<br />
HIV/AIDS case had been<br />
registered.<br />
Photograph: DSW<br />
44 Ministry of Health Annual Report 2009<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
MANAG<strong>IN</strong>G FOR RESULTS<br />
27<br />
Posters in district health centre in San<br />
Salvador raising awareness about how to<br />
prevent two of El Salvador’s major health<br />
threats: dengue and malnutrition.<br />
Photograph: DSW<br />
usually affecting developing countries, figures on<br />
this list, certain donors to the health should<br />
consider whether to revise their funding priorities<br />
accordingly.<br />
The Ministry of Foreign affairs would also wish to<br />
see international cooperation become more<br />
sensitive to the country’s needs. The Ministry sees<br />
a disproportionately high focus being put by<br />
European and other donors on infrastructure<br />
financing as opposed to capacity building.<br />
In addition to that, civil society in El Salvador points<br />
out that there can only be effective, results-based<br />
management if local control and monitoring<br />
mechanisms are in place and functioning at<br />
community level, for instance through the<br />
institutionalisation of social auditing (contadores)<br />
of public spending at community level. Such<br />
mechanisms would allow the government and<br />
donors to measure the concrete impact of their<br />
funding to health at the most local levels of society.<br />
Programmes should also be based on data and<br />
indicators that adequately disaggregated according<br />
to vulnerable groups. CSOs are making efforts to<br />
undertake such a disaggregation within their own<br />
projects, even though there is no apparent interest<br />
or support from the donor side for this kind of<br />
activity 45 .<br />
With regard to CSOs’ own responsibility for resultsbased<br />
management, some CSOs highlighted that<br />
they had been involved in the Hospital<br />
Reconstruction and Health Service Extension<br />
Project (RHESSA) programme’s external<br />
evaluations. The programme components which<br />
had been run by CSOs apparently scored a lot<br />
better in terms of results than the Ministry of<br />
Health’s ones. Such evaluations show that it is<br />
worth working with CSOs and community-based<br />
<strong>org</strong>anisations in order to achieve tangible results<br />
at local level.<br />
RESULTS-BASED F<strong>IN</strong>ANC<strong>IN</strong>G FOR <strong>EL</strong><br />
<strong>SALVADOR</strong>’S <strong>HEALTH</strong> SECTOR – THE NEW WAY<br />
FORWARD<br />
A new, health-specific public-private initiative has<br />
been launched in mid 2009 at regional level by<br />
several donors, i.e. the Bill and Melinda Gates<br />
Foundation, the IDB, AECID, and the Health<br />
Institute Carlos Slim, in cooperation with the Health<br />
Ministries in eight countries including El Salvador:<br />
The “Iniciativa Salud Mesoamericana 2015” 41 aims<br />
at reducing the health equity gaps affecting<br />
populations in extreme poverty in the region,<br />
according to country-specific priorities. Three of the<br />
donors will contribute with USD 50 million each –<br />
i.e. USD 150 million in total to the initiative,<br />
whereas the IDB will be in charge of designing and<br />
implementing the projects in cooperation with the<br />
partner country health ministries. However, the<br />
overall priority areas have already been predefined<br />
by the donors, namely: Nutrition,<br />
Vaccination, SRH and the fight against both<br />
Dengue and Malaria.<br />
An innovative aspect of the initiative is the use of<br />
results-based financing as a new aid modality: the<br />
country-specific funds allocated by the initiative will<br />
need to be complemented by domestic resources.<br />
If partner countries achieve the jointly agreed<br />
targets for policy reform, coverage and quality of<br />
Health services, the initiative will reimburse the<br />
partner country 50% of its contribution. To that end,<br />
rigid and independent evaluations will accompany<br />
the project cycle.<br />
Despite its innovative character, the initiative has<br />
been fiercely criticised by a number of actors in El<br />
Salvador, highlighting that it is far from being<br />
aligned with the country governments’ policies, and<br />
is lacking a country- and needs-based approach:<br />
The Ministry of Health, for instance, does not see<br />
any opportunity for capacity-building in this<br />
programme, as it is managed by its headquarters in<br />
Mexico. One European donor added that a regional<br />
integration process for the health sector had been<br />
started before this initiative, but in more respectful<br />
and sustainable manner. A regional health sector<br />
assessment had been undertaken and a Central-<br />
American agenda for health had been established.<br />
There is a risk that the new Mesoamerican<br />
initiative, seen as being imposed by certain donors<br />
on the participating countries, will undermine the<br />
original integration process as funding provided by<br />
the biggest health donors in the region will be<br />
concentrated towards the new initiative.<br />
45 These statements are taken directly from the interviews held and do not necessarily reflect AfGH views.<br />
46 http://www.saludmesoamerica2015.<strong>org</strong><br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
28<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
RECOMMENDATIONS TO<br />
STAKEHOLDERS <strong>IN</strong> THE EU<br />
AND <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
COUNTRY OWNERSHIP,<br />
CIVIL SOCIETY<br />
PARTICIPATION AND THE<br />
PARLIAMENT<br />
■<br />
■<br />
■<br />
■<br />
There is a need for donors and the<br />
government to further take advantage,<br />
during their decision-making processes, of<br />
CSOs’ expertise with service delivery,<br />
specifically with regard to working with<br />
communities and reaching the most<br />
vulnerable.<br />
Continuous quality control of public<br />
health services delivery will be necessary –<br />
preferably by involving CSOs with the<br />
required sector-expertise. In general, the<br />
relationship between public and private<br />
entities should be pushed towards<br />
collaboration and complementarities, rather<br />
than competition and rivalry.<br />
CSOs should be engaged at every stage of<br />
the programme cycle, including the design,<br />
implementation and monitoring of national<br />
programmes.<br />
Continuous efforts need to be made by the<br />
government and European donors to<br />
support the involvement of a greater<br />
diversity of CSOs, including health and<br />
women’s <strong>org</strong>anisations, vulnerable groups,<br />
as well as CBOs in these processes. To that<br />
end, the latter will need to receive<br />
specifically targeted support in order for<br />
them to be able to attend, understand and<br />
value these processes.<br />
■<br />
■<br />
■<br />
■<br />
To the same end, more efforts need to made<br />
in order to improve and strengthen the<br />
relationship between <strong>IN</strong>GOs, local NGOs,<br />
CBOs, local authorities and Members of<br />
Parliament in El Salvador in order to ensure<br />
that these alliances contribute to true<br />
country ownership of development policies.<br />
Donors should therefore actively seek to<br />
support partnership-building among all<br />
actors.<br />
Some CSOs in El Salvador recommend<br />
undertaking a cost-benefit analysis of<br />
programmes implemented in the health<br />
sector, by including an impact evaluation of<br />
CSOs’ contribution to the sector.<br />
In the newly established social participation<br />
mechanisms, any favouritism based on<br />
party affiliation needs to be strongly<br />
condemned by the government, for instance<br />
by establishing a code of conduct for<br />
government officials, CSOs and donors, in<br />
order to jointly tackle what could be<br />
considered as one of El Salvador’s biggest<br />
obstacles to good governance: The high<br />
degree of party polarisation affecting every<br />
sphere of society.<br />
Mutual accountability and trust between the<br />
government, donors and Civil Society could<br />
be enhanced through the establishment of a<br />
publicly accessible online development<br />
database where all actors are asked to<br />
indicate and regularly update the<br />
programmes they are implementing in El<br />
Salvador. For this tool to be truly effective, it<br />
needs to be linked to the budget cycle and<br />
planning. The IATI initiative could provide<br />
guidance in that respect.<br />
■<br />
CSOs in El Salvador would welcome<br />
increased funding made available for<br />
advocacy-capacity building, but some<br />
would like to see an increased focus being<br />
put on ensuring that CSOs have the<br />
technical capacities and knowledge<br />
necessary for undertaking advocacy<br />
activities at policy-making level. Increased<br />
efforts also need to be made by civil society<br />
<strong>org</strong>anisations themselves in order to put<br />
advocacy capacity-building on the donors’<br />
agenda, for instance by submitting<br />
advocacy project proposals.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
RECOMMENDATIONS TO STAKEHOLDERS <strong>IN</strong> THE EU AND <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
29<br />
DONOR COORD<strong>IN</strong>ATION<br />
■ In the light of the new health sector<br />
reform’s financing needs and the<br />
upcoming end-of-term review of the EC’s<br />
Country Strategy Paper, a strategic change<br />
towards health-financing should be<br />
considered by the EC. The EU Delegation in<br />
El Salvador does not exclude this possibility,<br />
but also points to the government’s own<br />
responsibility in demanding such a change.<br />
The government of El Salvador therefore<br />
needs to seize the opportunity and assert its<br />
strive for a stronger and more equitable<br />
health system, which adequately addresses<br />
neglected issues such as SRHR and<br />
Gender-based violence, by explicitly asking<br />
important donors, such as the EC, for<br />
sector budget support.<br />
■ A potential support from European donors to<br />
the health sector reform should be provided<br />
in a harmonised and aligned manner, in<br />
order to collectively contribute to health<br />
systems strengthening, gender equality and<br />
women’s empowerment. To that end, donors<br />
should accept the leadership of the newly<br />
reinforced External Cooperation Unit within<br />
the Ministry of Health with regard to sector<br />
coordination.<br />
■ Adherence to IHP+ in this country could<br />
contribute to increasing the technical<br />
assistance needed for strengthening the<br />
health system. Additionally, IHP+ could also<br />
unite donors in their efforts, no matter how<br />
large their health aid contributions. In doing<br />
so, results attained could be maximised,<br />
granting political support to a determined<br />
effort to achieve universal access to primary<br />
healthcare. Donors should therefore<br />
promote El Salvador’s adherence to IHP+.<br />
■ Potential health sector budget support<br />
needs to be accompanied by specific<br />
capacity-building measures for Ministry of<br />
Health officials and integrate gender<br />
sensitive policies. While technical<br />
assistance to the Ministry shall be<br />
continued, as it can be seen as a key<br />
condition for sector budget support, donors<br />
should increasingly consider employing<br />
local (rather than international) consultants<br />
to that end.<br />
■ The aid modality used by the EU to cofinance<br />
the “Comunidades Solidarias”<br />
programme has been positively evaluated in<br />
that it combines certain advantages of<br />
general budget support (institutional<br />
strengthening; use of government public<br />
financial systems, etc.) with some<br />
favourable characteristics of programme<br />
support (the achievement of clearly<br />
definable results. If this programme is to be<br />
continued under the EC’s new financial<br />
framework, a truly integrated approach<br />
should be adopted in order to ensure that<br />
the water and sanitation component is<br />
effectively linked to health systems<br />
strengthening, especially by allocating<br />
adequate financial resources to this subcomponent.<br />
■ As each donor agency currently still has its<br />
individual information management<br />
systems, one of the first priorities of the<br />
Ministry is to establish a unified online<br />
development cooperation database,<br />
which could be going in the direction of the<br />
IATI initiative. For such a system to be<br />
effective the government and donors need<br />
to ensure that it is linked to the national<br />
budget planning exercise.<br />
■ Vertical health funding mechanisms such<br />
as the Global Fund should adopt a more<br />
integral approach in order to contribute to<br />
health systems strengthening. Recent<br />
efforts made by the Global Fund in that<br />
direction, through the Health System<br />
Strengthening funding window, the Joint<br />
Health Systems Funding platform and<br />
support for the JANS, can be seen as<br />
positive developments in that respect, but<br />
their effective impact on health systems<br />
strengthening at country level still needs to<br />
be assessed.<br />
■ With regard to project support, CSOs<br />
interviewed during the fact-finding visit<br />
noted a drastic reduction of support<br />
channelled directly to CSOs during the last<br />
few years. In the light of the new health<br />
sector reform, as well as the government’s<br />
new policies on social participation in the<br />
health sector, it will become all the more<br />
crucial for donors to ensure that CSOs are<br />
able to participate in the new coordination<br />
mechanisms – direct support should<br />
therefore increasingly be channelled to<br />
partnership-building initiatives between<br />
MPs, Civil Society and local authorities, as<br />
well as advocacy capacity-building and<br />
institutional strengthening for non-state<br />
actors.<br />
■ Donors should also consider flexibilising<br />
and simplifying funding procedures for<br />
local CSOs, in order to allow for increased<br />
access by smaller CSOs and CBOs, whose<br />
projects are often very effective in terms of<br />
reaching the most vulnerable, but which lack<br />
the capacities to both absorb higher<br />
amounts of funding and to follow the<br />
complex procedures established by certain<br />
European donors.<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
30<br />
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
RECOMMENDATIONS TO STAKEHOLDERS <strong>IN</strong> THE EU AND <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
■ As CSOs are first and foremost accountable<br />
to their donors, there is a shared<br />
responsibility of CSOs and donors to<br />
inform the government about direct<br />
project support for CSOs in order to<br />
ensure greater transparency and alignment<br />
of this aid modality. The online development<br />
database soon to be launched by the<br />
government should provide the adequate<br />
basis for this.<br />
■ In the light of El Salvador’s scarce external<br />
funding for health, there is a particular need<br />
for European donor agencies to seek a<br />
strong collaboration with their non-<br />
European counterparts in order to<br />
canalize funding and jointly improve aid<br />
effectiveness in the health sector. In the light<br />
of the current health sector reform,<br />
European donors will also need to step up<br />
their support to health in order to prevent<br />
the deepening of the current funding gap<br />
affecting the sector.<br />
■ Finally, the MoH needs to assume increased<br />
leadership with regard to donor coordination<br />
in the health sector and institutionalise joint<br />
and regular meetings instead of continuing<br />
with bilateral negotiations with each<br />
individual donor.<br />
MANAG<strong>IN</strong>G FOR RESULTS:<br />
THE ROLE OF AID FOR<br />
PROGRESS TOWARDS<br />
THE <strong>HEALTH</strong> MDGs AND<br />
UNIVERSAL ACCESS TO<br />
PRIMARY <strong>HEALTH</strong>CARE<br />
European and other donors on infrastructure<br />
financing as opposed to capacity-building.<br />
While there was undoubtedly a need for<br />
infrastructure programmes in the immediate<br />
aftermath of the recent natural disasters<br />
which affected the country, assistance<br />
should progressively start turning towards<br />
institutional strengthening.<br />
■ Programmes should also be based on data<br />
and gender sensitive indicators that are<br />
adequately disaggregated according to<br />
sex, age and vulnerable groups.<br />
■ With regard to CSOs’ own responsibility<br />
for results-based management, some<br />
national programme evaluations (RHESSA)<br />
have shown that those components which<br />
had been run by CSOs apparently scored a<br />
significantly better in terms of results than<br />
the Ministry of Health’s ones. Such<br />
evaluations show that it is worth working<br />
with CSOs and community-based<br />
<strong>org</strong>anisations in order to achieve tangible<br />
results at local level.<br />
■ New aid modalities and initiatives, such<br />
as results-based financing and the<br />
“Iniciativa Mesoamericana”, need to be reassessed<br />
with regard to their impact on<br />
health equity and their degree of alignment<br />
with existing national policies and priorities<br />
in the health sector. This assessment<br />
should be undertaken by the government of<br />
the beneficiary countries, by involving<br />
CSOs, CBOs, women’s <strong>org</strong>anisations and<br />
the most marginalised communities.<br />
■ One of the major challenges affecting health<br />
aid to El Salvador is the fact that it currently<br />
does not reach all vulnerable groups, such<br />
as, for instance, women and adolescents.<br />
These groups are often also excluded from<br />
decision-making processes at communitylevel.<br />
Donors should support the country’s<br />
first steps made towards social auditing at<br />
community level.<br />
■ A disproportinately high amount of health<br />
funding is still allocated to the fight against<br />
HIV/AIDS, compared to funding for other<br />
more common causes of morbidity in El<br />
Salvador, especially non-communicable,<br />
chronic diseases and Dengue. In general,<br />
the Ministry of Foreign affairs would also<br />
wish to see international cooperation<br />
become more sensitive to the country’s<br />
needs. The Ministry sees a<br />
disproportionately high focus being put by<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
<strong>HEALTH</strong> <strong>SPEND<strong>IN</strong>G</strong> <strong>IN</strong> <strong>EL</strong> <strong>SALVADOR</strong><br />
31<br />
BIBLIOGRAPHY<br />
ADE, on behalf of the European Commission: Evaluation of the Development Cooperation between the<br />
European Commission and El Salvador”, March 2010.<br />
DSW, EPF, EuroNGO. Euromapping 2009: Mapping European Development Aid & Population Assistance.<br />
2009, Brussels, Belgium. http://www.<strong>euroresources</strong>.<strong>org</strong>/euromapping.html<br />
European Commission Mid Term Review of the Country Strategy of 2007-2013 and National Indicative<br />
Programme 2011-2013 – El Salvador.<br />
http://www.eeas.europa.eu/el_salvador/docs/2010_midterm_el_salvador_annex_en.pdf<br />
European Commission. Country Strategy Paper El Salvador – 2007-2013.<br />
Ministry of Health Annual Report 2009-10 (hard copy).<br />
Ministry of Health Website and National Health Plan<br />
http://www.salud.gob.sv/index.php/servicios/descargas/documentos/Documentación-Institucional/Política-<br />
Nacional-de-Salud/Diario-Oficial-No.33-Tomo-No.386-del-17-02-2010.-Acuerdo-No.126.-Política-Nacional-de-<br />
Salud-2009-2014/<br />
Ministry of Health: “Construyendo la Esperanza: Estrategias y recomendaciones en salud 2009-14”.<br />
Ministry of Health: “Rendicion de Cuentas 2010” (hard copy).<br />
Ministry of External Affairs: National Aid Effectiveness Agenda” (“Agenda Nacional de Eficacia de la<br />
Ayuda”) (hard copy)<br />
OECD. Health Focus Charts – Disbursements average 2006-2008. Paris, 2008.<br />
www.oecd.<strong>org</strong>/dac/stats/health<br />
USAID “El Salvador Health Sector Needs Assessment”. July 2009.<br />
Website of the “Iniciative Mesoamericana”: http://www.saludmesoamerica2015.<strong>org</strong><br />
WHO World Health Statistics 2010.<br />
World Food Programme study "Alza de precios, mercados e inseguridad alimentaria y nutricional en<br />
Centroamérica" (Price Rises, Markets and Food and Nutritional Security in Central America).<br />
LIST OF ACRONYMS<br />
AfGH<br />
AECID<br />
ARENA<br />
BM<br />
CBO<br />
CISALUD<br />
CSO<br />
DP<br />
DSW<br />
EDF<br />
EC<br />
EU Delegation<br />
EU-15<br />
FMLN<br />
FBO<br />
FOSALUD<br />
FY<br />
GAVI<br />
Action for Global Health European NGO<br />
Network<br />
Spanish Agency for International Development<br />
Cooperation<br />
Nationalist Republican Alliance (Opposition<br />
Party at the time of the AfGH visit)<br />
Military Health and the Teachers Welfare<br />
Institute<br />
Community-based Organisation<br />
Intersectoral Committee<br />
Civil Society Organisation<br />
Development Partner<br />
Deutsche Stiftung Weltbevoelkerung (German<br />
Foundation for World Population)<br />
European Development Fund<br />
European Commission<br />
Delegation of the European Union to El Salvador<br />
15 EU Member States prior to the accession of<br />
12 new members (2004 and 2007). EU-15:<br />
Austria, Belgium, Denmark, Finland, France,<br />
Germany, Greece, Ireland, Italy, Luxembourg,<br />
the Netherlands, Portugal, Spain, Sweden and<br />
the United Kingdom<br />
Farabundo Martí National Liberation Front<br />
(Ruling Party at the time of the AfGH visit)<br />
Faith based <strong>org</strong>anisations<br />
Social Solidarity Health Fund<br />
Financial Year<br />
The Global Alliance for Vaccines and<br />
Immunisation<br />
GBS<br />
GDP<br />
GoES or<br />
Government<br />
GNI<br />
HIPC<br />
HSSP<br />
IDB<br />
IHP+<br />
IMF<br />
<strong>IN</strong>GO<br />
ISSS<br />
JANS<br />
MDG<br />
MoF<br />
MoFA<br />
MPSAS or MoH<br />
MTEF<br />
NGO<br />
ODA<br />
PAHO<br />
PRSP<br />
RHESSA<br />
SRHR<br />
STD<br />
SWAp<br />
WB<br />
WHO<br />
General Budget Support<br />
Gross Domestic Product<br />
Government of El Salvador<br />
Gross National Income<br />
Heavily Indebted Poor Countries<br />
Health Sector Strategic Plan<br />
Inter-American Bank<br />
International Health Partnership<br />
International Monetary Fund<br />
International Non-Governmental Organisation<br />
Social Security Institute<br />
Joint Assessment of National Strategies<br />
Millennium Development Goals<br />
Ministry of Finance<br />
Ministry of Foreign Affairs<br />
Ministry of Health<br />
Mid-term Expenditure Framework<br />
Non-Governmental Organisation<br />
Official Development Assistance<br />
Pan American Health Organisation<br />
Poverty Reduction Strategy Paper<br />
Hospital Reconstruction and Health Service<br />
Extension Project<br />
Sexual and Reproductive Health Rights<br />
Sexually Transmitted Diseases<br />
Sector-wide Approach<br />
World Bank<br />
World Health Organisation<br />
DSW – German Foundation for World Population<br />
www.dsw-brussels.<strong>org</strong>
Action for Global Health is a network of European<br />
health and development <strong>org</strong>anisations advocating for<br />
the European Union and its Member States to play a<br />
stronger role to improve health in development<br />
countries. AfGH takes an integrated approach to<br />
health and advocates for the fulfilment of the right to<br />
health for all. One billion people around the world do<br />
not have access to any kind of healthcare and we<br />
passionately believe that Europe can do more to help<br />
change this. Europe is the world leader in terms of<br />
overall foreign aid spending, but it lags behind in the<br />
proportion that goes to health.<br />
Our member <strong>org</strong>anisations are a mix of development<br />
and health <strong>org</strong>anisations, including experts on HIV, TB<br />
or sexual and reproductive health and rights, but<br />
together our work is <strong>org</strong>anised around a broad<br />
approach to health. AfGH works to recognise the<br />
interlinkages of global health issues and targets with a<br />
focus on three specific needs: getting more money for<br />
health, making healthcare accessible to those that<br />
need it most and strengthening health systems to<br />
make them better equipped to cope with challenges<br />
and respond to peoples’ needs.<br />
In the light of the upcoming Fourth High Level Forum on<br />
Aid Effectiveness in South Korea in November 2011,<br />
Action for Global Health commissioned DSW Brussels to<br />
undertake six combined fact-finding and advocacy visits<br />
to developing countries in 2010 in order to assess the<br />
impact of current aid structures and aid effectiveness<br />
principles on health-spending in those countries. The<br />
overall objective of these fact-finding visits is to bring<br />
evidence and experience from developing countries to<br />
support European advocacy for global health, by<br />
producing country-specific policy briefings and<br />
disseminating them to key decision makers and<br />
<strong>org</strong>anisations in Europe and in developing countries.<br />
Contact: coordination@actionf<strong>org</strong>lobalhealth.eu<br />
Visit our website to learn more about our work and<br />
how to engage in our advocacy and campaign actions.<br />
www.actionf<strong>org</strong>lobalhealth.eu