HEALTH SPENDING IN EL SALVADOR - euroresources.org

EU HEALTH ODA AND AID EFFECTIVENESS / COUNTRY BRIEFING 3 / FEBRUARY 2011 

HEALTH SPENDING 

IN EL SALVADOR 

THE IMPACT OF CURRENT AID STRUCTURES 

AND AID EFFECTIVENESS

2 

HEALTH SPENDING IN TANZANIA 

ACKNOWLEDGEMENTS 

This report was produced by DSW for Action 

for Global Health and written by Sibylle 

Koenig and Liliana Marcos. Action for Global 

Health would like to thank the representatives 

from the Ministry of Health, the Ministry of 

Foreign Affairs, the Ministry of Economy and 

the Ministry of Finance in El Salvador, as well 

as Members of the Salvadoran Parliament, 

the representatives of the donor agencies and 

Civil Society organisations interviewed during 

the fact-finding visit for taking the time to 

share their views with us, in order to make this 

policy briefing more relevant. In particular, we 

would like to thank Vice Health Minister Dr. 

Eduardo Espinoza, Diputada Mirtala Lopez, 

Dr. Juan Ruales (OMS/PAHO), Tito Lopez 

(Ayuda en Accion) and Johannes Conrads 

(DSW Brussels) for their invaluable support 

and contributions to the preparation and 

successful implementation of this mission. 

Action for Global Health is supported by a 

grant from the Bill & Melinda Gates 

Foundation. 

Design and layout: James Kontargyris 

www.jameskontargyris.co.uk 

Front Cover Photograph: Joe Philipson 

Inside Cover Photograph: DSW

HEALTH SPENDING IN EL SALVADOR 

CONTENTS 

INTRODUCTION AND METHODOLOGY 4 

SUMMARY OF KEY FINDINGS 6 

AND RECOMMENDATIONS 

OWNERSHIP AND THE 8 

PARTICIPATION OF CIVIL SOCIETY 

AND THE PARLIAMENT 

THE IMPACT OF DONOR 16 

COORDINATION ON HEALTH 

SPENDING 

THE ROLE OF AID FOR PROGRESS 25 

TOWARDS THE MDGS AND FOR 

UNIVERSAL ACCESS TO PRIMARY 

HEALTHCARE 

RECOMMENDATIONS TO 28 

STAKEHOLDERS IN THE EU AND 

IN EL SALVADOR 

BIBLIOGRAPHY 31 

LIST OF ACRONYMS 31 

3

4 


INTRODUCTION AND 

METHODOLOGY 

In recent years, the EU has been committed to 

reforming its external aid instruments according to 

aid effectiveness principles established by the Paris 

Declaration on Aid Effectiveness (2005), as well as 

the Accra Agenda for Action (2008). In particular, 

attention has been paid to increasing the 

“ownership” of developing countries’ development 

assistance 1 . 

Despite such positive efforts, key social sectors 

such as health have suffered significant decreases 

and gaps in EU funding in recent times. Official 

Development Assistance (ODA) spending in health 

worldwide decreased by USD 124 million between 

2006 and 2007, mainly due to a decrease in 

European health ODA. Compared to total ODA 

disbursements, European donors contribute 

relatively less to health than other international 

donors. In 2007, the EU-15 and other European 

donors represented only 50% of health 

disbursements, while accounting for some 67% of 

global ODA 2 . 

In the light of such trends, there is a perceived 

need to reassess aid effectiveness principles 

against sector-specific funding for health. Action for 

Global Health (AfGH), a network of European 

health and development organisations 3 , 

consequently decided to commission DSW - the 

German Foundation for World Population, an NGO 

supporting family planning and sexual and 

reproductive health projects in Africa and Asia, to 

undertake six combined fact-finding and advocacy 

visits to developing countries in 2010/11 in order to 

assess the impact of current aid structures and aid 

effectiveness principles on health-spending in 

those countries. 

The overall objective of these fact-finding visits is to 

bring evidence and experience from developing 

countries to support European advocacy for global 

health, by producing country-specific policy 

briefings and disseminating them to key decisionmakers 

and organisations in Europe and in 

developing countries. 

The target countries were jointly selected by the 

AfGH Network on the basis of a number of criteria, 

including: 

■ Countries from different continents, including 

Latin America 

■ If possible, countries which are or were until 

recently major recipients of EU health ODA 

(except for Latin America) 

■ Some IHP+ 4 countries, if possible 

■ Countries where AfGH has some kind of 

support, either from country offices or strong 

partnerships 

■ If possible, avoid countries where missions on 

health / aid effectiveness had recently been 

carried out 

■ At least some non-English speaking countries 

■ In the light of the missions’ objective to assess 

development aid channelled to existing health 

systems, conflict or immediate post-conflict 

countries were not to be considered 

The AfGH Network finally selected the following 

countries for the fact-finding visits: Uganda, 

Tanzania, El Salvador, Mozambique, India and 

Vietnam. Three fact-finding visits have been 

undertaken so far: Uganda (February 2010); 

Tanzania (April 2010) and El Salvador (July 2010). 

This country briefing aims to compile the main 

findings gathered during AfGH’s visit to El Salvador 

in July 2010 and provide recommendations to 

policy-makers and civil society. During the factfinding 

visit to El Salvador, AfGH was represented 

by the DSW EU Liaison Office and FPFE Spain. 

AfGH partners met with key stakeholders in the 

country, in particular, the Ministry of Health (MoH), 

Ministry of Foreign Affairs (MoFA), the Ministry of 

Economy and the Ministry of Finance (MoF). The 

1 For more information on Aid Effectiveness Principles, see: www.oecd.org/dataoecd/11/41/34428351.pdf 

2 DSW, EPF, EuroNGO. “Euromapping 2009: Mapping European Development Aid & Population Assistance”. 2009, Brussels, Belgium. 

3 Established in 2006 by 15 organisations under the leadership of ActionAid, Action for Global Health (AfGH) is today active in France, Germany, Italy, Spain, 

the UK and Brussels and includes membership of almost 30 NGOs. AfGH advocates for Europe to play a more proactive role in enabling developing 

countries to meet the Health Millennium Development Goals by 2015. For more information on AfGH, please visit: www.actionforglobalhealth.eu 

4 The international Health Partnership (IHP+) is a group of partners who share a common interest in improving health services and health outcomes by 

putting Paris and Accra principles on aid effectiveness into practice. http://www.internationalhealthpartnership.net/ 

DSW – German Foundation for World Population 

www.dsw-brussels.org


INTRODUCTION AND METHODOLOGY 

5 

fact-finding team also interviewed key donors, 

Members of Parliament and civil society in the 

country, in particular: 

DONORS 

EU Delegation 

WHO/PAHO 

Global Fund CCM Coordinator (UNDP) 

USAID 

AECID 

German Embassy 

MEMBERS OF PARLIAMENT 

Dip. Mirtala Lopez 

Dip. Zoila Quijada 

CSOs 

Centro de Apoyo a la Lactancia Materna CALMA 

Asociación Salvadoreña Pro Salud Rural. 

ASAPROSAR 

Alianza por la Salud Sexual Reproductiva de El 

Salvador 

Plan Internacional. 

Asociacion Vida Nueva 

Asociacion Demografica Salvadoreña 

FUNDASIDA 

Asociación para la auto determinación y 

desarrollo de mujeres salvadoreňas. 

Medicos por el derecho a la salud. 

All interviews held focused in particular on the 

following three thematic axes related to health aid 

effectiveness: 

■ Country Ownership and the participation of civil 

society and the national parliament in the 

health sector 

■ The impact of donor coordination on healthspending 

in developing countries 

■ Managing for Results: The role of aid in 

progress towards the MDGs and in universal 

access to primary healthcare 

AfGH had chosen these themes on the basis of the 

findings of its first mission in Uganda, which had 

focused on all the Paris Principles in order to test 

which of them were still topics of major concern to 

developing countries: the interviews conducted 

revealed that the three above-mentioned topics 

were seen as particular challenges by a variety of 

stakeholders in developing countries, and that they 

had often been neglected by other evaluations on 

Aid Effectiveness. Moreover, AfGH could see its 

own extensive expertise in carrying out research 

and advocacy for increased health funding, 

progress towards the Health Millenium 

Development Goals (MDGs) and universal access 

to primary healthcare, as well as Civil Society 

Organisation (CSO) and community participation, 

as being an added value when addressing the 

above-mentioned issues. 

The results of these interviews have been 

complemented with previous and subsequent desk 

work in order to provide a comprehensive 

perspective on the effectiveness of health aid in El 

Salvador, based on the principles of the Paris 

Declaration and Accra Action Plan on aid 

effectiveness. However, as the primary objective of 

this policy briefing is to reflect the views of the 

stakeholders interviewed, some of the statements 

made in this paper do not necessarily reflect the 

views of Action for Global Health. 

EL SALVADOR COUNTRY CHOICE 

Despite being classified as a middle-income 

country, El Salvador still faces high poverty rates 

and a major problem of inequity: The UNDP 

human development reports have identified 

Guatemala, Brazil and El Salvador as the most 

inequitable countries within the planet’s most 

inequitable subcontinent (Latin America). 

Although significant progress has been made in 

terms of reducing poverty over the period 1991- 

2002 – with the share of the population living in 

poverty decreasing from 58% to 35% and the share 

in extreme poverty from 33% to 14.4% 5 – extreme 

poverty rates have remained relatively stagnant 

since 2001, in part due to the impact of increased 

food and fuel prices in 2007/08: According to the 

World Food Programme (WFP), more than 100,000 

people in this country of 5.8 million slipped below 

the poverty line between September 2007 and 

June 2008 6 . The country is also marked by a strong 

urban-rural divide: In urban areas the extreme 

poverty rate is around 7.9% while in rural areas it is 

around 16.3%. According to the World Health 

Organisation (WHO) in El Salvador “Middle income 

countries such as El Salvador still need substantial 

start-off assistance from donors in order to 

overcome such inequalities”. 

According to the European Commission’s Country 

Strategy Paper 2007-2013, “the health sector is a 

cause for concern: [...] access to health services is 

limited; only around half of the population suffering 

5 El Salvador / EC Country Strategy Paper 2007-2013. 

6 World Food Programme study "Alza de precios, mercados e inseguridad alimentaria y nutricional en Centroamérica" (Price Rises, Markets and Food and 

Nutritional Security in Central America). 



6 



from an illness or accident receive medical 

assistance; there is inappropriate allocation of 

resources among public health institutions; health 

spending is low and fragmented; the quality of care 

provided to citizens is poor”. According to the 

WHO, a research study conducted in 2005-2007 

showed that 41.7% of the population of El Salvador 

were still excluded from the health system 7 . 

However, the country is in the process of 

implementing a major health reform, which is seen 

by AfGH as being a crucial moment and 

opportunity for all stakeholders, specifically 

European donors, to contribute to improving the 

country’s health sector situation. 

SUMMARY OF KEY 

FINDINGS AND 

RECOMMENDATIONS 

COUNTRY OWNERSHIP, CIVIL SOCIETY 

PARTICIPATION AND THE PARLIAMENT 

■ With regard to the newly established health 

sector social participation mechanisms, a 

code of conduct for civil society 

participation procedures should be 

established in order to jointly tackle what 

could still be considered as one of El 

Salvador’s major obstacles to good 

governance: The high degree of party 

polarisation affecting every sphere of 

society. 

■ Increased efforts of coordination need to 

be made by civil society organizations in 

order to strengthen their advocacy work. To 

that end, they need to generate spaces 

where everyone is welcome and listened to, 

independently of their relations with one or 

other political party. 

■ In the light of the government’s intention to 

significantly expand public health services 

coverage, it would be recommendable to 

involve a representative diversity of CSOs 

with the required sector-expertise in 

continuous quality control of public 

health services. In general, the relationship 

between public and private entities should 

be pushed towards collaboration and 

complementarities – existing competition 

and rivalries need to be overcome. 

■ To the same end, more efforts need to be 

made in order to improve and strengthen 

the relationship between International 

Nongovernmental Organizations (INGOs), 

local NGOs, Community-based 

Organisations (CBOs), local authorities and 

Members of Parliament in El Salvador in 

order to ensure that these alliances 

contribute to true country ownership of 

development policies. Donors should 

therefore actively seek to support 

partnership-building among all actors. 

■ Increased efforts need to be made by CSOs 

themselves in order to put advocacy 

capacity-building on the donors’ agenda, 

for instance by submitting advocacy project 

proposals. 

DONOR COORDINATION 

■ In the light of the new health sector 

reform’s financing needs and the 

upcoming end-of-term review of the 

European Commission’s Country Strategy 

Paper, a strategic change towards healthfinancing 

should be considered by the EU. 

The government of El Salvador needs to 

seize this opportunity and assert its strive 

for a stronger and more equitable health 

system by explicitly asking important 

European donors, such as the European 

Commission, whose multi-annual country 

strategies are about to undergo their end-ofterm 

revision, for sector budget support. 

■ Potential health sector budget support 

needs to be accompanied by specific 

capacity-building measures for MoH 

officials. While technical assistance to the 

Ministry shall be continued, as it can be 

seen as a key condition for sector budget 

support, donors should increasingly 

consider employing local (rather than 

international) consultants to that end. The 

WHO/PAHO should support National 

Sanitary Authorities to continue the 

development of their leadership and sectorsteering 

role. 

■ Potential support from European donors to 

the health sector reform should be provided 

in a harmonised and aligned manner, in 

order to collectively contribute to health 

systems strengthening. To that end, donors 

should accept the leadership of the newly 

reinforced External Cooperation Unit 

within the MoH with regard to sector 

coordination. For the Department, on the 

other hand, there is still a need to fully 

assume its role as an autonomous 

coordination entity by effectively uniting 

donors under its leadership, instead of 

continuing bilateral negotiations with each of 

them. 

7 This data is based on the information given during the interview with the WHO in El Salvador. 





7 

■ Adherence to IHP+ would unite donors in 

their sector harmonisation efforts, no matter 

how large their health aid contributions, and 

contribute to increasing the technical 

assistance needed to implement the sector 

reform. Donors should therefore promote El 

Salvador’s adherence to IHP+. 

■ European budget support for the 

“Comunidades Solidarias” programme 

should be reformed and capacity-building 

provided in order to effectively link its water 

and sanitation component to health systems 

strengthening, especially by allocating 

adequate financial resources to this 

integrated approach. 

■ Vertical health funding mechanisms such 

as the Global Fund should adopt a more 

integral approach in order to contribute to 

health systems strengthening. Recent 

efforts made by the Global Fund in that 

direction, through the Health System 

Strengthening funding window, involvement 

in the Joint Health Systems Funding 

platform as well as in the JANS 8 , can be 

seen as positive developments in that 

respect, but their effective impact on health 

systems strengthening at country level still 

needs to become more apparent. 

■ In the light of El Salvador’s scarce external 

funding for health, there is a particular need 

for European donor agencies to seek a 

strong collaboration with their non- 

European counterparts in order to 

canalize funding and jointly improve aid 

effectiveness in the health sector. In the 

context of increased funding needs related 

to the health sector Reform, European 

donors will need to step up their support to 

health in order to prevent the deepening of 

the current funding gap affecting the sector. 

■ As each donor agency currently still has its 

individual information management 

systems, one of the first priorities of the 

newly created Vice-Ministry for 

Development Cooperation is to establish a 

unified online development cooperation 

database, which could be going in the 

direction of the IATI 9 initiative. For such a 

system to be effective the government and 

donors need to ensure that it is linked to the 

national budget planning exercise. 

MANAGING FOR RESULTS: THE ROLE OF 

AID FOR PROGRESS TOWARDS THE 

HEALTH MDGs AND UNIVERSAL ACCESS 

TO PRIMARY HEALTHCARE 

■ In order to monitor whether health services 

reach the most vulnerable in El Salvador, 

donors should support the country’s first 

steps made towards social auditing at 

community level. 

■ International cooperation needs to become 

more needs-based, specifically in the 

health sector, where European and other 

donors are still concentrating a 

disproportionately high amount of financial 

resources towards the fight against specific 

diseases and health infrastructure financing. 

Programmes should also be based on data 

and indicators that are adequately 

disaggregated according to vulnerable 

groups. 

■ The government of El Salvador will need to 

overcome inequities in terms of per capita 

distribution of financial resources to health 

by reforming the health sector’s currently 

fragmented structure. Donors could 

support the government in this aim, for 

instance by providing technical assistance 

and advice. 

■ With regard to CSOs’ own responsibility 

for results-based management, external 

evaluations of development programmes in 

El Salvador show that it is worth working 

with CSOs and CBOs in order to achieve 

tangible results at local level. 

■ New aid modalities and initiatives, such 

as results-based financing and the 

“Iniciativa Mesoamericana”, need to be reassessed 

with regard to their impact on 

health equity and their degree of alignment 

with existing national policies and priorities 

in the health sector. This assessment 

should be undertaken by the governments 

of the beneficiary countries, by involving 

CSOs, CBOs, women’s organisations and 

the most marginalised communities. 

8 Joint Assessment of National Strategies: www.internationalhealthpartnership.net 

9 International Aid Transparency initiative (IATI): www.aidtransparency.net 



8 


OWNERSHIP AND 

PARTICIPATION OF CIVIL 

SOCIETY AND THE 

PARLIAMENT 

The following section analyses El Salvador’s 

development and health sector structure, 

challenges and opportunities in order to evaluate 

the existence of some of the fundamental preconditions 

for true country ownership. 

DEVELOPMENT STRATEGIES AND HEALTH 

POLICIES IN EL SALVADOR 

Classified as being a middle-income country, El 

Salvador has seen its development cooperation 

resources decrease year on year since its return to 

democracy two decades ago. Official Development 

Assistance is now of relatively limited relevance to 

the country (ca. 1.7% of GDP) compared with 

neighbouring Central American countries (e.g. ca. 

16% of GDP in Nicaragua) and is gradually 

declining (from an average of more than USD 300 

million/year in the early 1990s to USD 211 million in 

2004) 10 . 

In this context, the government recognises the 

importance of increasing the effectiveness of aid in 

order to make the best use of the scarce resources 

available 11 . El Salvador has only very recently 

become a signatory of the Paris Declaration on Aid 

Effectiveness, namely in May 2009, shortly before 

a historic change in government: For the first time 

since its return to democracy in 1992, the country 

saw the left-wing party Farabundo Martí National 

Liberation Front (FMLN) win the presidential 

elections in March 2009, thus putting an end to a 

17-year rule of the Nationalist Republican Alliance 

(ARENA). 

One of the first challenges which needed to be 

tackled in order to achieve true country ownership 

is the fact that El Salvador has, since its return to 

democracy in 1992, not had an overall 

development framework or long-term social and 

economic development goals. El Salvador, as a 

middle income country, does not have a poverty 

reduction strategy similar to the PRSP in Heavily 

Indebted Poor Countries (HIPC). 

However, the previous government had launched 

the “Plan de Oportunidades” (Opportunities Plan) 

which includes an innovative sub-programme – 

“Redes Solidarias” – aimed at improving the quality 

and coverage of social services in the country’s 

hundred poorest municipalities. This subprogramme 

was seen as a first step towards a 

more integral strategy on poverty alleviation and 

local development. The programme is going to be 

continued by the current government despite 

renaming it “Comunidades Solidarias” 

(Communities in solidarity) and integrating it into 

the programme targeting the poorest urban areas. 

The country’s new five-year development plan 

(Plan Quinquenal 2010-2014) 12 was launched in 

June 2010. Through this plan, the government 

established ten priority areas for the five-year 

period, including poverty reduction and the 

promotion of social participation in policy-making 

processes. It equally establishes a ten-priority longterm 

vision for 2024, including the objective to 

facilitate a “healthy, educated and productive 

population”. 

HEALTH SECTOR POLICIES AND REFORM – 

CHALLENGES AND OPPORTUNITIES 

CHALLENGES 

El Salvador’s health sector has been characterised 

by severe fragmentation: Until recently, the 

country has not had one unique, long-term 

strategic framework, but instead a variety of health 

programmes with little or no coherence between 

them. Until recently, the Ministry of Health’s 

organigram reflected this fragmentation: The 

institution had separate departments for adult 

women, adult men, adolescents, children, and 

disease-related themes with little or no connection 

between the departments and de facto links 

between certain health issues and certain age/sex 

groups were consequently ignored. For example: 

Prenatal and Post-partem care addresses both 

women’s and children’s needs, but related 

10 European Union Country Strategy Paper 2007-13 - El Salvador. 

11 Ministry of External Affairs: Aid Effectiveness Agenda. 

12 The plan (in Spanish) can be found at: http://www.presidencia.gob.sv/tecnica/ 




OWNERSHIP AND PARTICIPATION OF CIVIL SOCIETY AND THE PARLIAMENT 

9 

programmes usually fell under the responsibility of 

just one department. 

The structure of the health sector as a whole is 

marked by a lack of coordination and coherence: 

Health services have, until recently, been provided 

by both private (16%) and public (84%) entities. 

Among the public providers, the Social Security 

Institute (ISSS), the Military Health and the 

Teachers Welfare Institute (BM) attend their own 

closed population (18%) whereas the Ministry of 

Public Health and Social Assistance (MPSAS) and 

the Social Solidarity Health Fund (FOSALUD) are 

responsible for the rest of the population (66%), 

although in practice they do not have complete 

coverage 13 . 

This fragmentation is making it difficult to manage 

and overcome some of the major challenges the 

health sector is currently facing, such as, for 

example: 

■ A lack of health services coverage: About one 

third of the population have limited or no access 

to primary healthcare. 14 

■ Inequities in per capita health spending (for 

further explanations on these points, see part 3: 

“Managing for Results”), as well as in terms of 

regional distribution of resources: 60% of the 

health sector resources are allocated to San 

Salvador, Santa Ana and San Miguel. 

■ There is little if any coordination between the 

public service providers, resulting in a 

fragmented and malfunctioning information and 

medical supplies management and monitoring 

system. 

■ A shortage of ca. 40% in human resources for 

health 15 . 

■ A chronic stock out of essential medicines. 

■ Exorbitant prices for medicines (among the 

highest worldwide), due to national pharmaindustry-friendly 

import restrictions. Medicines 

are more than ten times more expensive than in 

the rest of the Latin American region 16 . 

■ Hospital infrastructure which is outdated and 

was affected by recent natural disasters. 

■ A lack of transparency in the award procedures 

and pricing of health infrastructure contracts 

during previous administrations: A scandalous 

example in that respect was the diversion of 

World Bank funds aimed at financing the 

establishment of a new Maternity Hospital, 

which were used to cover disproportionately 

high construction costs of other newly 

established hospitals. 

■ Corruption and lack of transparency in general: 

Hospitals had, in the past, been able to claim 

about USD 1 million per year in total for their 

contingency reserves which were not subject to 

audits. 

■ Party polarisation affecting health resources 

distribution to municipalities ruled by the 

opposition. 

■ Low coverage of family planning 17 and a lack of 

skilled health personnel in pre-natal, childbirth 

and postnatal care. 

■ Deficiencies in the quantity and quality of 

training of health workers and the quality of 

health service delivery. 

HUMAN RESOURCES FOR HEALTH 

It is worth paying special attention to one of the 

major challenges of the health sector in El 

Salvador: According to the MoH, the country has a 

shortage of ca. 40% in human resources for health. 

This is related to a number of factors, including low 

wage levels for health personnel working in the 

public sector: Although the Human Resources 

budget line accounts for more than half of the 

national health budget, health workers are not 

adequately paid due to financial constraints related 

to the fact that the health budget has over the last 

years only accounted for around 2% of GNI. 

Consequently, a common practice in El Salvador is 

that medical professionals choose not be hired on 

a full-time basis by public facilities, but also work 

13 USAID “El Salvador Health Sector Needs Assessment”. July 2009. 

14 Extension of Health Services Coverage in El Salvador: The RHESSA Project Experience: 

http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2009/12/08/000333037_20091208011619/ 

Rendered/PDF/520490BRI0EnBr10Box345549B01PUBLIC1.pdf 

15 This figure was given by one of the stakeholders interviewed. 

16 These statements are taken from the interview with the Ministry of Health representative. 

17 For more information, see, for example: http://www.unfpa.org.sv/documentos/plan_pais.pdf 



10 



part-time for private facilities in order to 

compensate for the low pay in the public sector. 

According to the Ministry of Health, only 18% of 

doctors are full-time employees (8 hours/day), 

whereas about 40% of health specialists are 

currently only working two hours a day in the same 

institution, which represents a significant challenge 

for any health facility in terms of recruitment and 

service delivery continuity 18 . 

A visit to a health centre in El Salvador confirmed 

this picture, with over half of the 21 employees 

having 2-hour contracts and only one person 

having an 8-hour arrangement. In short, for its 

district coverage population of ca. 28,000 

inhabitants (ca. 700 patients per week), the health 

centre only has the equivalent of ca. 7 full-time 

employees, when totalling the number of hours 

worked by all staff members. This figure appears all 

the more drastic when compared to the situation in 

Cuba, where there is one full-time doctor per 170 

patients. The director of the health centre 

confirmed that this situation led to human 

resources management problems, long waiting 

times for patients, and demotivated health 

personnel. 

The government recently introduced a new Human 

Resources Policy, which establishes four main 

areas of work: Employment of sufficient personnel 

and adequate distribution health staff as needed 

under geographic, demographic, and equity 

criteria; institutionalisation of health public servant 

careers; establishment of adequate labour 

conditions and systematic training programmes. 

The policy prioritises full-time work contracts. 

However, a wages reform has so far not been 

envisaged. Particular incentives will also need to 

be created in order to retain health personnel in 

rural areas. 

OPPORTUNITIES 

The newly elected government has made it one of 

its priorities to launch a major health sector reform 

in order to overcome these challenges. The reform 

has been piloted in the country’s 63 poorest 

municipalities. In the next three years, all 262 

municipalities will be covered. 

The new Minister of Health, Dr. Maria Isabel 

Rodriquez, a woman of 87 years of age, is widely 

respected, even across parties, for her clearsighted 

and pragmatic approach with regard to the 

steps to be taken to reform the health sector. 

During her first months in office, she published a 

programme 19 outlining the following first ten actions 

to be taken by the government during its first 100 

days in order to overcome the current challenges of 

her country’s health sector: 

TEN PRIORITY ACTIONS FOR THE FIRST ONE 

HUNDRED DAYS IN OFFICE 

1. Elimination of charges (“voluntary fees”) or any 

other form of payment in the public system, 

offset by corresponding budget allocations that 

prevent deterioration of service quality. 

2. Stocking of essential medicines and basic 

medical supplies in all Public Health System 

facilities, gradually and according to priorities, 

taking into account the assessment of the 

conditions in each facility. 

3. Reduce waiting times for surgery and specialist 

care, which will require the hiring of additional 

personnel but which urgently needs to be done, 

since at present an individual must wait up to 

two years or more for cataract or hernia 

surgery. 

4. Allocation of medical specialists to regional 

hospitals, which will decongest the national 

hospitals and resolve the needs of the public 

more quickly, increasing public satisfaction. 

5. Expand coverage of health services in rural 

areas and in more socially vulnerable urban 

areas across the country, which can be done 

through well-trained community health workers 

from the communities themselves. 

6. The President shall lay the cornerstone for the 

new Maternity Hospital during his first one 

hundred days in office. 

7. Institutionalise social participation through the 

formation of intersectoral committees at the 

local, municipal, provincial, and national levels, 

which shall identify the basic needs most 

affecting people’s living conditions and prioritise 

their resolution, through communities working 

together with government institutions, where 

true community participation is crucial in 

decision-making and in resolving these 

problems. 

8. Conduct a National Environmental Sanitation 

Campaign for the prevention of epidemics with 

the participation of all social leaders in the 

country, including government structures. 

9. Initiate, as soon as possible, a process to 

reorganise the entire public sector (MSPAS, 

ISSS, FOSALUD), aimed at making services 

more efficient and at laying the groundwork to 

increase coverage. 

10. Convene the National Health Forum. 

18 Ministry of Health: “Rendicion de Cuentas 2010”. 

19 Isabel Rodriguez, "Construyendo la Esperanza: Estrategias y Recomendaciones en salud. 2009-2014". 





11 

The Ministry of Health’s most recent annual report 

2009-2010 evaluates progress made in the health 

sector against these ten targets. This past year, the 

government not only achieved to abolish user fees 

for health services, but also made the first steps 

towards the establishment of a unified information 

system, as well as the extension of access of the 

most impoverished communities to basic medical 

care, while enhancing the participation of civil 

society. 

Moreover, a new National Health Policy 2009- 

2014 20 came into force in February 2010, 

establishing eight preliminary priority areas for the 

health sector reform process: 

1. Construction of an integrated Network of health 

services; 

2. Human Resource in Health as a cornerstone for 

the system; 

3. Response to demand for medicines and 

vaccines; 

4. Instalment of the National Health Forum; 

5. Establishment of a single information 

management system; 

6. Strengthening the Medical Emergencies 

system; 

7. Progressive coordination among all national 

service providers; and 

8. Creation of the National Health Institute and 

strengthening of the National Association of 

Laboratories. 

For a country previously lacking any long-term plan 

for its health sector, the establishment of this new 

National Health Strategy can be seen as an 

important step. 

This policy also groups all public health providers 

into a National Health Service. However, the fact 

that the different entities will keep their institutional 

identities with separate budgets and lines of 

authority in the medium term complicates 

interagency coordination. 

On the basis of this document, the structure of the 

Ministry of Health has also been reformed in order 

to become more operational and interlinked across 

issues – the new organigram can be viewed in the 

annual report 2009-2010 soon to be published on 

the Ministry’s website 21 . 

CIVIL SOCIETY, THE PARLIAMENT AND 

OWNERSHIP IN THE HEALTH SECTOR 

The purpose of this sub-section is to highlight that 

ownership should be exercised by all stakeholders 

in a society, not only by certain government 

ministries. Hereafter, the authors will analyse 

whether one can speak of true democratic 

ownership when it comes to El Salvador’s health 

sector, by focusing in particular on the opportunities 

and challenges faced by CSOs when trying to carry 

out their watchdog function and their role as health 

service providers, before analysing the powers and 

the weaknesses of the parliament in El Salvador. 

CSOs’ MEANINGFUL ENGAGEMENT IN POLICY 

PROCESSES 

The newly elected government has committed itself 

to establishing strong non-state actor participation 

mechanisms. The health sector in El Salvador can 

be seen as a tracer sector in that respect: A 

“National Policy for Social Participation in the 

health sector” was elaborated in April 2009. 

However, it has neither been linked to any concrete 

financial commitment nor has it come into force yet. 

Nevertheless, a number of participatory 

mechanisms were strengthened or created during 

the last few years: 

Fact-finding team meets 

Vice Health Minister 

Eduardo Espinoza. 

Photograph: DSW 

20 http://www.salud.gob.sv/index.php/servicios/descargas/documentos/Documentación-Institucional/Política-Nacional-de-Salud/Diario-Oficial-No.33-Tomo- 

No.386-del-17-02-2010.-Acuerdo-No.126.-Política-Nacional-de-Salud-2009-2014/ 

21 www.salud.gob.sv 



12 



The Intersectoral Committee (CISALUD), formed 

by government representatives, civil society and 

other main stakeholders, was established as a 

consultative entity for the elaboration of policies, 

with the participation of civil society and private 

actors. CISALUD played a key role in the early and 

successful control of A H1N1 (2009) and the 

dengue emergency (2010), among other 

achievements. 

Moreover, as mentioned above, one of the key 

priorities of the Ministry of Health during its first 100 

days in office has also been the establishment of a 

national health forum, aimed at uniting the existing 

diversity of non-state actors around the issue of 

health. It seeks to overcome two of the major 

challenges characterizing civil society and 

community movements until recently, namely a 

high degree of fragmentation and polarization 

around party affiliation: While many CSOs under 

the previous government were associated with the 

opposition and often excluded, on that basis, from 

decision-making processes, the right-wing ARENA 

is now in the process of establishing its own 

counter-movement, which is equally experiencing 

some degree of stigmatization under the new 

government 22 : 

The National Health Forum, which was launched 

on 28 May 2010, will seek to unify and strengthen 

the civil society movement by acting as an open 

platform for all non-state actors working on health. 

In that sense, it is to be distinguished from the 

existing CISALUD which involves government 

officials. In order to achieve it its objectives, the 

Forum, headed by the so-called “Organising 

Committee”, will be in charge of organising regional 

conferences, thematic roundtables as well as 

establishing joint planning and monitoring systems 

for health sector policies, by prioritising community 

leadership. To name just some of the topics 

selected for the thematic roundtables in 2010: 

■ Sexual and reproductive health 

■ Social violence and violence against women 

■ Prevention and Mitigation of natural disasters. 

■ Medicines and health 

■ Water and sanitation. 

The representative of the Ministry of Health 

interviewed during the fact-finding visit stated that 

he would like to see the consultation of this entity 

become a mandatory precondition for establishing 

new policies in the health sector, thus ensuring that 

non-state actors can effectively carry out their 

policy watchdog role. However, clear Terms of 

Reference, membership adherence rules, as well 

as working procedures and consultation rules need 

to be established in order for the forum to function 

properly. 

Some civil society organisations interviewed during 

the mission claimed they had neither been invited 

to contribute to the process of establishing the 

Forum nor to any events organised by the Forum. 

They suspect that a certain favouritism based on 

party affiliation is still common practice in their 

country. This picture was confirmed by some of the 

donors interviewed, claiming that social 

participation is still very polarized and faith-based 

as well as the feeling that opposition party CSOs 

are still being excluded from the process. 

In general, those CSOs interviewed claim that 

there is still a lack of recognition on the 

government’s side of the added value that CSOs 

and CBOs can bring to policy-making processes: 

With regard to those few consultation processes in 

which the interviewed CSOs participated, there 

was also hardly any follow-up to the 

recommendations given by CSOs. 

Only two of the six interviewed CSOs had so far 

been involved in the government’s health services 

coverage expansion programme and in the 

consultation process about the new health reform. 

There is also a perceived lack of transparency on 

the government side about their consultation 

processes and the possibilities for Civil Society to 

get involved in budgetary scrutiny of public 

expenditures. 

On the other hand, those CSOs interviewed which 

were affiliated with the governing party were able to 

name a number of occasions in which they had 

been invited to participate in policy-making 

processes. This divergence in opinions about Civil 

Society participation reflects the impact that party 

polisarisation has in every sphere in El Salvador. 

One positive example of CSO participation 

mentioned by some of the interviewed was the socalled 

DAIA (Disponibilidad Asegurada de Insumos 

Anticonceptivos) initiative, launched in several 

Latin American countries by Civil society in 

conjunction with government officials and the 

support of USAID, in order to jointly advocate for 

the allocation of public resources to the purchase 

of Family Planning supplies. 

22 These statements are based on the opinions expressed by Civil Society representatives interviewed during the mission. They do not necessarily reflect 

AfGH positions. 





13 

When asked to name the major health networks 

in their country, the interviewed CSOs mentioned 

the following platforms: 

■ REDSALUD El Salvador 

■ ASSR Alianza por la Salud Sexual y 

Reproductiva de El Salvador (Alliance for 

Sexual and Reproductive Health) 

■ ACCP Alianza Ciudadana Contra la 

Privatización (Civil Alliance against 

privatisation) 

■ FOROSAN Foro Para La Seguridad Alimentaria 

y Nutricional del Oriente (Eastern Forum for 

food and nutritional security) 

■ Acción Ciudadana de Lucha contra el VIH (Civil 

Action to flight HIV/AIDS). 

In the case of REDSALUD, the network has had 

successful experiences with advocacy towards 

decision-makers with regard to the health budget. 

ASSR successfully advocated for a national policy 

on Sexual and Reproductive Health (SRH) and 

became a platform of national reference for SRH. 

To mention another positive example, FOROSAN 

initiated a coordination process among CSOs, 

private companies, academics and government 

institutions in order to jointly advocate for an 

increase in the budget for food security. 

With regard to Civil Society participation in 

European donor decision-making processes, none 

of the interviewed CSOs stated having known or 

participated in any consultations. However, the EU 

Delegation, for instance, claims that society has 

been regularly consulted regarding thematic 

projects, and on actions of the current CSP 23 . The 

discrepancy between these views can probably 

again be linked to a lack of diversity in the choice of 

actors invited to such consultation processes, with 

the EU Delegations having the tendency to invite 

CSOs that they have already supported in the past. 

The Delegation also indicates that it had been 

advocating for a “Quadrilogue model” involving 

the government and its institutions (including 

autonomous and local authorities), civil society (in 

particular Non-State Actors) and interested 

Members of the Legislative Assembly 24 . The first 

such forum took place in November 2008, with a 

second one taking place in November 2009. The 

initiative was considered innovative by participants 

and by October 2009 led to efforts by Development 

NGOs to establish a national platform (MODES – 

Movimiento de ONGs de Desarrollo Solidario) 

supported by the Vice-Ministry of Development 

Cooperation. This example can be seen as highly 

positive, but continuous efforts should be made by 

European donors to support the integration of a 

greater diversity of NGOs, including health and 

women’ organisations, in these processes. 

Moreover, these entities need to be continuously 

supported and strengthened in order to ensure 

their sustainability. On the other hand, there is also 

a responsibility on the CSOs’ side to increase their 

visibility and advocacy work. 

With regard to advocacy capacity-building, most 

of the interviewed CSOs had participated in some 

kind of advocacy or leadership training financed by 

certain donors, related to their area of expertise, 

such as, for instance, SRHR. In general, these 

trainings received positive evaluations. However, 

some of the CSOs would like to see an increased 

focus being put on ensuring that CSOs have the 

technical capacities and knowledge necessary for 

undertaking advocacy activities at policy-making 

level. 

However, EC officials indicate that no proposals for 

advocacy capacity-building projects had been 

submitted to the EC in the framework of its last 

non-state actor calls for proposals. Therefore, 

increased efforts need to be made by CSOs 

themselves in order to put advocacy capacitybuilding 

on the donors’ agenda. 

With regard to the relationship between 

International NGOs (INGOs), local NGOs and 

Community-based organisations (CBOs) in El 

Salvador, three of the interviewed organisations 

stated having had extensive experience with 

service delivery in rural areas, where they 

simultaneously contributed to strengthening 

community-participation processes. 

However, these CSOs see a clear difference in the 

way the government and donors are treating 

INGOs, local NGOs and CBOs, in terms of 

outreach, resource allocation, information flows 

and involvement in consultation processes. CBOs 

are still often excluded from these processes. 

23 EC Mid Term Review of the Country Strategy of 2007-2013 and National Indicative Programme 2011-2013 – El Savador. 

http://www.eeas.europa.eu/el_salvador/docs/2010_midterm_el_salvador_annex_en.pdf 

24 idem. 



14 



With regard to their relationship with local 

authorities, the interviewed CSOs mentioned a 

number of successful, joint initiatives which had 

been implemented during the last few years, such 

as: 

■ The conformation of multi-sector committees for 

health-monitoring and the prevention of sexual 

and gender-based violence. 

■ The conformation of Youth Networks for the 

promotion of SRHR. 

■ The Joint Initiative for the elaboration of 

municipal policies for the rights of girls, children, 

adolescents and young adults. 

■ Municipal Regulation for maternal 

breastfeeding. 

However, more efforts need to made in order to 

improve and strengthen the relationship between 

INGOs, local NGOs, CBOs, local authorities and 

Members of Parliament in El Salvador in order to 

ensure that these alliances contribute to true 

country ownership of development policies. Donors 

should therefore actively seek to support 

partnership-building among all actors. 

Making policy and funding processes in a more 

participatory manner is ultimately not only a shared 

responsibility between all actors, including donors, 

the government and CSOs, but also a necessary 

step towards true country ownership. 

CSOs AS SERVICE DELIVERY PROVIDERS 

While the new government’s policy with regard to 

CSO participation in policy processes can in 

general be qualified as positive, its relationship with 

health service delivery CSOs is still marked by 

rivalry: The MoH representative interviewed, for 

example, stated that CSOs have gained a 

disproportionately high role in service delivery 

during the last few years, as a consequence of 

conditionality imposed by certain donors (namely 

the World Bank) wanting to push for a more 

prominent role for CSOs in the health sector. The 

MoH also highlighted that the cost of their services 

were three times more expensive than the services 

provided directly by the public sector and that they 

used to give a basic package of services which 

was not fully integrated with the system. 

While it can be seen as positive that the 

government is trying to take a lead role in service 

delivery in order to increase coherence within the 

health system and avoid user fees, there is also a 

risk that those services taken over by the public 

sector will not be as effective in terms of their 

outreach to the most vulnerable and most remote 

segments of the population in the country. 

Continuous quality control will be necessary – 

preferably by involving CSOs with the required 

sector-expertise in order to assess whether the 

new primary healthcare reform with a health 

promotion approach achieves to improve access to 

services in the communities. In general, the 

relationship between public and private entities 

should be pushed towards collaboration and 

complementarities, rather than competition and 

rivalry. Nevertheless, donors should not push for 

NGO or CSO services to be paid by public funding 

if their costs could become a burden to the health 

system. 

In their policy dialogue with the government, 

donors should therefore not only advocate for a 

greater diversity of non-state actors to be invited to 

consultation processes, as well as for the 

systematic follow-up of recommendations given by 

CSOs during these processes, but also for the 

recognition of CSOs as service providers. 

It can be seen as a step forward that the Ministry of 

Health recently established a mechanism on its 

website 25 , where citizens who feel that their right to 

health has been violated can post their complaints. 

However, it remains to be seen if effective follow-up 

will be given to such complaints. 

AfGH Civil Society 

meeting in San Salvador. 


25 see www.salud.gob.sv 





15 

OWNERSHIP AND THE PARLIAMENT 

The “Asamblea Nacional” or the Parliament in El 

Salvador has, as in most other countries in the 

world, the legislative power and the right of 

budgetary scrutiny. However, MPs confirm that, due 

to the high polarisation marking their country’s 

party system, no party has the majority in the 

parliament. This makes it exceptionally difficult for 

Salvadoran MPs to advocate, within the parliament, 

for the consensual adoption of significant 

amendments to the sector ceilings set by the 

Ministry of Finance at the beginning of the budget 

cycle. For the health sector this means that the true 

entity to refer to for health advocates should be the 

Ministry of Finance. 

With regard to health sector performance, the 

parliament has three months to analyse the 

Ministry of Health’s annual report, which includes a 

section on external sources of funding for the 

health sector. However, this section merely shows 

how many on-budget funds have been disbursed 

that year and by which donors 26 – it does not 

indicate whether the funds have been adequately 

used by the government. 

As for budget transparency in general, a request 

for an independent audit of government spending 

can be made by the parliament, but it needs to be 

based on one of the following grounds: 

Recently, the government established the 

“Secretariat for Transparency” which should take 

responsibility for these issues, but its 

independence with regard to the government is 

already being questioned. At the time of the 

mission, the country was also in the process of 

elaborating a legal framework on transparency and 

accountability. 

Again, supporting the establishment of new 

partnerships between MPs and Civil Society 

should be seen as the way forward by donors in 

order contribute to increased transparency and 

accountability at country level. Some of the CSOs 

interviewed during the mission stated having 

contacts within Parliament in order to promote their 

cause, but they see a need for these relationships 

to be strengthened. 

As a result of such partnerships, MPs would benefit 

from CSOs’ knowledge of the needs of local 

communities and the most vulnerable, whereas the 

latter would thus get an entry point to the 

parliament in order to influence budgetary 

procedures and the elaboration of new legal 

frameworks. In a country as polarized as El 

Salvador, there is a need for innovative 

programmes promoting cross-party associations, 

whose advocacy work is not guided by party 

interests but rather by the true needs and rights of 

El Salvador’s citizens. 

■ Irregularities uncovered in one ministry’s annual 

report; 

■ The filing of a complaint by an individual or the 

Court of Auditors; 

■ An issue of national interest presented by a 

special commission established to that end. 

Even though corruption and misuse of funding 

remains a problem in El Salvador 27 , it can be seen 

as a very positive sign that the so-called “Partida 

Secreta” – the “secret budget line” – a contingency 

fund, to which an undefined and unlimited part of 

the budget used to be channelled every year and 

the use of which was entirely at the discretion of 

the President, has been declared unconstitutional 

in 2010 by the Supreme Court of Justice. 

As for international agreements and contracts, 

they should also undergo a scrutiny by Parliament, 

which is not always the case – as an example, one 

MP mentioned the IMF agreements, which can 

deeply affect a country’s social and economic 

situation and should therefore be pre-approved by 

the parliament. 

26 See table below in section entitled “The impact of donor coordination on health spending”. 

27 As confirmed by a number of the interviewees. 



16 


THE IMPACT OF DONOR 

COORDINATION ON HEALTH 

SPENDING 

In order to assess the impact of donor coordination, 

an analysis needs to be made about current 

financing for health structure in El Salvador. The 

purpose of the following sub-section is also to 

uncover whether there is a country need and 

demand for donors to invest in health. 

FINANCIAL RESOURCES FOR HEALTH 

A health sector reform process of the magnitude as 

the one currently being launched in El Salvador 

requires a significant amount of additional financial 

resources. The government itself recognises this – 

for instance by declaring, in its new National Health 

Policy, that public expenditure on health should 

progressively be increased in order to reach 5% of 

GDP by 2014. This figure is based on recent 

studies made by the PAHO suggesting that in the 

Americas no country that may be classified as 

having a universal healthcare system (Aruba, 

Canada, Cuba and Netherlands Antilles) was able 

to achieve a universal coverage with a level of 

public expenditure of less than 6% of GDP – 

Panama and Costa Rica, covering around 80% of 

their population, are currently investing 5% of GDP. 

Due to the impact of the crisis on the country, the 

Ministry of Health of El Salvador itself sees it as 

unlikely that these targets will be reached in the 

indicated period of time and will look into the 

possibility of a downward revision of the target to 

4%. Despite the government’s official commitment 

to health as a basic condition for social 

development, the national health budget in El 

Salvador is still only about half as high as its 

budget for education. Even though there has been 

an increase in the absolute numbers of the budget 

of the Ministry of Health during the last two years, 

from USD 459 million in 2009 to USD 517.3 million 

in 2010, the share of the Ministry of Health’s own 

budget within the public expenditure currently only 

represents 2.4% of GDP 28 . If increases continue to 

be made at the same pace as between 2008 and 

2010 (i.e. by 0.3% per year) then the share could 

eventually reach 3.6 % by 2014. 

However, whereas in other developing countries, 

such as Tanzania and Uganda, for instance, the 

Ministry of Finance and Economic affairs have a 

tendency towards macro-economic priority-setting 

and limiting social sector expenditures, the 

representatives of both ministries interviewed 

during the fact-finding visit seemed to be aware 

and conscious about the immense needs of their 

country’s health sector. Despite the budget for 

health still being low, there is potential for advocacy 

towards an increase of health funding in order to 

bridge the financing gap uncovered by the health 

reform: For example, The Ministry of Health 

received an extraordinary extra-budgetary funding 

from the National Government in 2010, increasing 

its budget from USD 390.65 million to USD 436.13 

million (excluding other sources such as donations, 

ministry-owned sources etc). 29 

NATIONAL PUBLIC HEALTH BUDGET, ALL FUNDING SOURCES 

INCLUDED, PERIOD 2005-2010 (IN USD MILLION) 

$600.0 

$500.0 

$459.0 

$517.3 

$400.0 

$300.0 

$326.1 

$368.5 $371.5 

$399.3 

$200.0 

$100.0 

$0.0 

2005 2006 2007 2008 2009 2010 

28 Estimates for 2010 – Ministry of Health Annual Report 2009-10. 

29 Ministry of Health Annual ”Rendicion de Cuentas” 2010. 




THE IMPACT OF DONOR COORDINATION ON HEALTH SPENDING 

17 

GNI SHARE OF THE MINISTRY OF HEALTH’ BUDGET (2005 – 2010) 

2.5% 

2.0% 

1.9% 

2.0% 

1.8% 1.8% 

2.2% 

2.4% 

1.5% 

1.0% 

0.5% 

0% 

2005 2006 2007 2008 2009 2010 

Source: Ministry of Health: Rendicion de Cuentas 2010 

Moreover, the new National Development Plan 

prioritises health financing for the next five years, 

thus opening the door for new loans from the Inter- 

American Development Bank (IDB) (USD 60 

million) and the World Bank (USD 80 million). 

Despite these essential external sources of 

funding, the government estimates that there is 

already for the first year of the reform an additional 

funding gap of ca. USD 100 million 24 in order to 

implement the health reform. At the time of the factfinding 

visit, no commitment had been made by 

European donors to co-finance the health reform. 

New opportunities for health financing should be 

ceased by those European donors whose multiannual 

country strategies are about to undergo 

their end-of-term revision. 

In order to better channel exisiting financial 

resources, the National Health Policy stipulates 

that financing coming from international 

cooperation agencies should be streamlined with 

National Health Plan priorities and incorporated 

into the country’s financial system. 

The share of foreign resources in the MoH 

budget saw a temporary peak in 2009 due to the 

financial crisis, with external loans accounting for 

23% of the national budget. In 2010, external 

resources accounted for about 17% of the national 

health budget, 13% of which are reimbursable 

loans. The remaining 4% are classified as onbudget 

“non-reimbursable Cooperation”, including 

in-kind contributions such as medical brigades or 

equipment donations. Purely financial external 

donations represent merely ca. 1% of the total 

national health budget 30 . However, as only part of 

the external funding is captured on-budget, it can 

be assumed that the actual share of external 

resources to the health sector is much higher. 

AID TO THE HEALTH SECTOR IN EL SALVADOR 2006-2008 

Top Ten Donors 

USD Million 

as a share of total aid to health 

for the selected recipient, % 

All Donors 28.0 100.0 7.3 

United States 9.6 34.2 4.1 

Global Fund 6.6 23.4 100.0 

Spain 4.7 16.7 8.3 

Luxembourg 1.6 5.7 15.5 

Japan 1.5 5.5 10.4 

UNFPA 1.0 3.5 100.0 

Canada 0.8 2.8 50.9 

Italy 0.4 1.4 24.5 

Sweden 0.2 0.8 7.6 

Germany 0.2 0.6 0.7 

Source: OECD Health Charts 2006-2008. 

as a share of total aid for the 

selected recipient, % 

30 Ministry of Health Annual Report 2009-2010. 



18 



ON-BUDGET DONOR CONTRIBUTIONS TO THE HEALTH SECTOR FOR 

THE FINANCIAL YEAR 2009-2010 

Country / International Entity 

Disbursements USD 

Bilateral Cooperation 

USAID 3,279,610.00 

Luxembourg 3,239,240.00 

Spain (incl. decentralised coop.) 2,533,450.00 

Korea 2,000,000.00 

Japan 1,091,000.00 

Multilateral Cooperation 

Global Fund* 964,356.00 

OPS* 964,356.00 

UNFPA* 260,000.00 

BID 100,000.00 

UNICEF* 11,000.00 

Total 13,662,313.00 

Medical Brigades – Cuba, USA and Italy 2,632,000.00 

In-kind donations – Germany and USA 

(Medicine, equipment, other material) 

2,026,375.00 

Grand Total 18,320,688.00 

Source: Ministry of Health Annual Report 2009-2010. 

* A high percentage of these funds are managed directly by the international agencies or the coordinating project offices. These figures 

do not include funds allocated to technical assistance provided by these entities. 

These figures show that – compared to other lowincome 

countries – the share of foreign donations 

to the national health budget is relatively low – too 

low if they are to contribute to covering existing 

needs, especially in the light of the health reform 

being implemented. Consequently, one of the aims 

of the Ministry of Health is the elaboration of a socalled 

“National Strategy for the Retention of 

International Cooperation” in order to reverse the 

recent tendency of specifically bilateral cooperation 

agencies to withdraw from the country due to its 

status of middle-income country. 

■ The establishment of a unified information 

management system for the health sector, for 

which an additional USD 20 Million is needed to 

complement the government’s initial investment 

of USD 12 million. 

■ Policies aimed at ensuring universal access to 

primary healthcare. 

In the light of the above-mentioned funding gap 31 

affecting the implementation of the health reform, 

the government’s claim for increased funding to the 

sector does indeed appear to be justified. More 

specifically, stakeholders interviewed mentioned 

the following areas still in need for external 

financial injections: 

Paper Archives in District Health Centre in San 

Salvador illustrating the need for a unified, electronic 

information management system. 


31 Estimates established by the Ministry of Health. 





19 

EL SALVADOR’S AID EFFECTIVENESS AND 

DONOR COORDINATION AGENDA 

Until now, International Assistance to El Salvador 

has been characterised by some degree of 

fragmentation and a lack of leadership from the 

government with regard to donor coordination. 

The Mid-Term Review of the EC’s Country Strategy 

Paper (CSP) 2008-2013 gives a vivid and accurate 

summary of the challenges the country is still 

facing in terms of its donor coordination agenda: 

“Although UNDP was mandated by the previous 

government to initiate donor coordination in form 

of MDG sector round tables (mesas de 

donantes), the previous Salvadorian government 

preferred bilateral negotiations with individual 

donors and the meetings of the sector roundtables 

held every six months did not substantially help to 

improve coordination. Meetings between donors 

and the government remained mostly informative 

and did not develop into a proper forum for 

debating policies. In addition, donors have been 

rather unwilling to have joint programming, even 

if most donors have tried to align their aid to the 

few policies of the government of El Salvador such 

as Solidarity Network and the National Education 

Plan 2021. Most of them focused their efforts on 

the same sectors while certain sector lack funds. 

Therefore, the impact of their actions has been less 

strong”. 

In this context, the paper also highlights that 

coordination between the EC and EU Member 

States agencies did not go beyond the organisation 

of information sessions about the CSP2007-2013. 

However, the EC also mentions an important and 

positive example of donor coordination, namely the 

El Salvador Budget Support Group. Its 

members, the World Bank, IDB, AECID and the 

Commission, jointly conducted the Public 

Expenditure and Financial Accountability (PEFA) 

assessment, financed by the European 

Commission in the first quarter of 2009. 

At local and community level, donors and 

international organisations have, since 1998, 

coordinated their initiatives through RECODEL 

(Red de Cooperantes para el DEsarrollo Local – 

Donor Network for Local Development). In 2003, 

members reviewed the role of this forum and 

attempted to reinforce its impact through enhanced 

dialogue with state and non state actors. 

All stakeholders interviewed indicated that the 

change in government in June 2009 created new 

windows of opportunities in terms of aid 

effectiveness. The new government has already 

demonstrated a new openness towards 

international cooperation and a strong willingness 

to assume more ownership and to discuss and 

align donor programmes: For instance, in July 

2009, the government established a Donor 

Roundtable in order to coordinate the support of 

the international community for the implementation 

of a Universal Social Protection System. 

The new government sees it as particularly 

necessary to ensure that the scarce external 

resources available to El Salvador are used in an 

effective manner. Consequently, in June 2010, El 

Salvador presented its new “National Aid 

Effectiveness Agenda” (“Agenda Nacional de 

Eficacia de la Ayuda”) which defines key actions to 

be taken by all stakeholders (government, donors 

and non-state actors) in order to achieve each of 

the Paris Declaration principles. 

However, some development partners, such as the 

European Union, have until now not been able to 

sign the document as it would compel them to take 

certain decisions which can only be made in 

consultation with their headquarters – such as, for 

instance, the decentralisation of institutional 

decision-making. One development partner also 

mentioned that the wording of the paper is geared 

towards unconditional General Budget Support as 

the only possible aid modality – which would 

undermine the current mixed funding practice, as 

well as the conditionality of funding. 

In order to make more operative the committments 

acquired in the Aid Effectiveness Agenda, the 

government has also worked on a Code of 

Conduct for the Rural and Urban Solidarity 

Communities Programme, that seeks to define 

best practices and committments adopted by the 

governmental institutions and development 

partners in order to obtain better levels of 

coordination, harmonization and alignment of the 

actions and interventions to be developed in the 

framework of the Programme. It is expected to be 

signed shortly. 

In that context, it is worth mentioning that aid 

provided by the European Union, including EU 

Member States, has accounted for ca. 51% of all 

ODA disbursements to El Salvador between 2001 

and 2007. El Salvador is receiving EUR 121 million 

for cooperation from the EC in the current CSP 

period. An evaluation of EU cooperation in El 

Salvador between 1998 and 2008 has shown that 

there has so far been little coordination between 

the EU and other donors, with the Delegation of the 

European Commission following its own agenda 

and priorities 32 . 

32 “Evaluation of the Development Cooperation between the European Commission and El Salvador”. ADE, on behalf of the European Commission, March 2010 



20 



The government is expected to continue pushing 

the aid effectiveness agenda during the coming 

years. To that end, a new entity has recently been 

created within the Ministry of External affairs: The 

Vice-Ministry for Development Cooperation is 

responsible for the relations with development 

partners and for elaborating and implementing a 

National Cooperation Strategy. A first step made in 

that direction was the decision to participate in the 

2011 OECD survey on Aid Effectiveness to 

evaluate the aid instruments in El Salvador. The 

results of this survey will be made available at the 

High Level Forum in Busan. 

An interview with the Vice-Ministry confirmed that 

coordination between all donors in El Salvador is 

still in its infancy. In line with the principles of the 

Accra Agenda for Action, however, a definite 

change has taken place from past UNDP 

leadership of donor roundtables to government 

leadership of alignment and harmonization. 

As each donor agency currently still has its 

individual information management systems, one of 

the first priorities of the Ministry is to establish a 

unified online development cooperation 

database, which could be going in the direction of 

the IATI initiative. For such a system to be effective 

the government and donors need to ensure that it 

is linked to the national budget planning exercise. 

The mid-term review of the EC’s CSP 2007-13, 

undertaken in 2009, revealed that additional efforts 

needed to be made to improve joint programming 

and coordination. According to the outcome 

document, donors “should show more willingness 

to align their programmes instead of seeking out 

individual advantages with the government. Also, it 

remains to be confirmed if the government will be 

able to avoid frictions in its own team and whether 

donor coordination could be structured by the 

government without overlapping of responsibilities 

between several competent authorities such as the 

Ministry of Foreign Affairs, the Technical Secretariat 

of the Presidency and a new Secretariat on 

Strategic Affairs” 33 . The overlapping of 

responsibilities is a result, in part, of the new 

government architecture and the need for a new 

institutionalism which has re-allocated functions 

accordingly. 

Spain is currently developing a code of conduct for 

budget support to which all donors will be invited to 

adhere. However, following the principle of “mutual” 

accountability, the government should respectively 

increase its own transparency, especially with 

regard to the traceability of funding channelled to 

its own treasury. 

The first memorandum of joint coordination 

between the Delegation of the European Union in 

El Salvador and the Technical Office of 

Cooperation of AECID to support the social 

protection and poverty reduction poverty in El 

Salvador was signed on 24th October 2010. 

However, these actions that are seen as positive 

initiatives, need to advance to align and harmonize 

with the partner government and not limit 

themselves to development partners, otherwise, 

harmonization could be taken as an end in of itself 

when it should instead be a tool for alignment 

under governmental leadership. 

Aid effectiveness and donor coordination are also 

two key issues highlighted in the National Health 

Policy, which refers to the need of establishing a 

donor roundtable on health. According to some 

European donors this is an important step forward 

as the country has until present lacked an effective 

sector-specific approach with regard to donor 

coordination. Leadership of the Ministry of Health 

with regard to sector-aid has historically been 

weak. Consequently, the new government has 

decided to establish an External Cooperation 

Department within the Ministry of Health, 

specifically in charge of coordinating the country’s 

aid to the sector. Ministry officials have been 

trained accordingly and a donor roundtable is in the 

process of being launched. However, according to 

some of those interviewed, further strengthening is 

needed if the Ministry is to manage budget support 

channelled to the sector. 

Moreover, as stated above, CSO involvement in 

these coordination processes will need to be 

closely monitored in order to ensure that a 

representative sample of CSOs is invited to 

participate and that there is a follow-up to the 

recommendations expressed by CSO 

representatives. 

In that context, it is worth analyzing the current aid 

architecture in El Salvador, which is characterized 

by two predominant aid modalities: Programme 

Support and Project Support, including vertical 

funding and technical assistance. 

PROGRAMME AND SECTOR BUDGET 

SUPPORT IN EL SALVADOR 

Due to the absence of a long-term poverty 

reduction strategy, El Salvador has, until now, only 

been eligible for Programme and Sector – rather 

than General Budget – Support from the EC and 

other donors. In other words, funds channelled to 

the national treasury were earmarked for one 

national policy programme (for instance, the 

programme “Comunidades Solidarias”) or sector 

33 Source: Mid-Term Review of El Salvador’s Country Strategy Paper 2007-2013 





21 

District Health Centre 

Facilities in San Salvador: 

Linking health, water and 

sanitation is crucial. 


(namely education). Until now, European funding 

for health policies had been relatively modest. 

Two of the EU’s biggest bilateral donors to El 

Salvador – Spain and Germany – concentrate 

cooperation on poverty reduction, social services, 

good governance (including security), and business 

development. Spain’s programme includes funding 

of Spanish NGOs (over 40% of the total assigned 

to El Salvador), as well as national citizens’ 

contributions to post-earthquake assistance. 

Even though the EC’s Country Strategy Paper 

(CSP) 2007-2013, which foresees a total allocation 

of EUR 121 million to El Salvador, aims at 

fostering social cohesion through social 

investments in health, water and sanitation, and 

human capital development, health has been deprioritized 

in favour of the education sector. The EC 

argues that support to health was not possible in El 

Salvador due to the absence of a strategic policy 

framework guiding the sector. 

However, it is worth noting that the EU and AECID 

have been among the biggest donors co-financing 

the Water and Sanitation component of the 

national Programme “Redes Solidarias” – 

“Solidarity Networks” (now renamed: 

“Comunidades Solidarias” – Communities in 

solidarity). This programme, which aims at reducing 

poverty through targeted interventions in the 

country’s 100 poorest municipalities, will 

progressively be expanded to cover another 14 

localities. The EU has already invested EUR 37 

million in this programme and has committed to 

continue co-financing the second phase. 

The programme has been evaluated on a yearly 

basis according to seven outcome indicators; 

including some health-related indicators. For 

example, disbursements were linked to the usage 

rates of the health (and education) facilities 

created, as well as TB control for pregnant woman. 

The programme has received very positive 

evaluations and has earned a good reputation even 

at regional level. The aid modality used by the EU 

to co-finance the programme has also been 

positively criticised in that it combines certain 

advantages of general budget support (institutional 

strengthening; use of government public financial 

systems, etc.) with some favourable characteristics 

of programme support (the achievement of clearly 

definable results, for example) 34 . 

However, the stakeholders interviewed all 

emphasised that government spending needs to 

become more transparent and accountable and 

that there should be a quality control mechanism 

for the services or products (for example 

medicines) provided by the government. The 

country is currently in the process of establishing a 

new unified information management system for 

the health sector, as well as elaborating new legal 

frameworks on transparency and accountability, as 

well as quality control: For example, the so-called 

“Pro-Calidad” programme, which will be cofinanced 

by European donors through a 

contribution of EUR 12.1 million, will address crosscutting 

issues and concerns among all sectors 

including health, as it aims to establish and 

strengthen the national quality control system. The 

programme has long been delayed, though, as the 

draft National Quality Law, which should be the 

basis for implementation of the programme, had, 

until recently not been presented to the Legislative 

Assembly. At the time of the fact-finding visit the 

government stated that the programme was to be 

launched during the coming months. 

Moreover, CSOs see a necessity to have 

integrated health and education programmes, as 

donors should acknowledge important linkages 

between the two sectors. However, caution should 

be exercised in monitoring that neither of the two 

sectors is neglected within an integrated 

programme. 

34 “Evaluation of the Development Cooperation between the European Commission and El Salvador”. ADE, on behalf of the European Commission, March 2010 



22 



NEW OPPORTUNITIES FOR HEALTH SECTOR 

BUDGET SUPPORT 

Contrary to other government ministries in El 

Salvador, the Ministry of Health has, to date, not 

received any Sector Budget Support from 

European donors. The latter argue that the sector 

has so far been lacking a budgeted strategic plan 

on the basis of which funds could have been 

channelled to the national treasury. As mentioned 

above, the recently launched health sector reform 

could open new doors in that respect. 

One year after its initiation, the health sector 

reform process has already led to some notable 

results, such as the abolition of user fees, the 

recruitment of new health personnel to cover the 

resulting shortages and the assignment of 

important additional resources for the procurement 

of essential medicines 35 . 

However, according to the Ministry of Health, the 

financial gap to be overcome in order to 

successfully implement this new health reform is 

estimated to be ca. USD 100 million. At present, 

the implementation of the reform depends on loans 

from the World Bank and the IDB. 

During the meetings at country level, all of the 

Ministry representatives interviewed emphasised 

the need for additional international support for 

implementing their health sector reform process. 

Ministry representatives and MPs generally also 

expressed their discontent with the fact that a big 

part of the funds supposed to be channelled to El 

Salvador’s health sector ended up being used for 

contracting international experts and consultants 

for technical assistance to the Ministry of Health. 

While technical assistance to the Ministry will be 

continued, as it can be seen as a key condition for 

sector budget support, donors should increasingly 

consider employing local (rather than international) 

consultants to that end. 

The EC, one of El Salvador’s biggest donors, has 

so far only financed health infrastructure 

programmes. In addition to the above-mentioned 

arguments used to justify the EC’s limited presence 

in the health sector during recent years, the EU 

Delegation in El Salvador upholds division of labour 

considerations and the EU Member States’ 

preference for health – versus the EU Delegation’s 

expertise with infrastructure – programmes. 

However, it is notable that in El Salvador, a 

significant amount of funding has already been 

channelled to the health infrastructure sector by 

other donors, such as the World Bank, for example. 

Moreover, the use of such funding by the 

government has been marked by corruption 

scandals which involve the infrastructure 

procurement industries. 

Another argument frequently used by EC officials to 

explain their decision to opt out of health is that the 

government had explicitly asked the EC for support 

to the infrastructure sector. However, the EC’s main 

counterpart within the government is the Technical 

Secretariat of the Presidency. When asked about 

their efforts to collaborate with line ministries as 

required by new decentralisation processes, EC 

officials comment that they have, so far, not been 

able to bypass the Secretariat and negotiate 

directly with the Ministries. However, this had 

clearly been the case for the Ministry of Education, 

since the EC co-financed an education programme 

implemented by the Ministry. 

In the light of the new health sector reform’s 

financing needs and the upcoming end-of-term 

review of the EC’s Country Strategy Paper, a 

strategic change towards health-financing 

should be considered by the EC. The EU 

Delegation in El Salvador does not exclude this 

possibility, but also points to the government’s own 

responsibility in demanding such a change. Other 

European donors, such as AECID, also expressed 

their interest in participating in a joint budget 

support initiative, if based on the government’s 

request and agreed upon by several donors. 

VERTICAL FUNDING IN EL SALVADOR 

According to the Ministry of Health, “vertical 

funding has been detrimental to health-system 

strengthening [...] Disease-specific programmes 

obviously led to rapid results for the particular 

Health issues they are targeting, but once external 

funding for these programmes comes to an end, 

the system will be too weak to ensure their 

continuity”. 

As further pointed out by some donors interviewed, 

vertical funding specifically used for HIV/AIDS and 

some maternal health programmes, also 

contributed to aid fragmentation, due to the high 

number of parallel implementation units established 

in that context. 

Currently, El Salvador faces the challenge of 

having to comply with the diverging procedures of 

22 vertical programmes and about 60 different 

disbursement systems. Some donors highlight that 

GAVI, for example, has shown some progress in its 

approach towards health-system strengthening, 

while alignment of the Global fund remains a 

challenge. 

35 For more information, see: “Results-based management” in this paper and: Ministry of Health Annual Report 2009-2010. 





23 

PROjECT SUPPORT FOR CSO PROjECTS 

Regarding the use of the project approach for CSO 

projects, some European donors highlight several 

difficulties experienced with this aid modality, such 

as the compliance with procedures as well as the 

lack of capacities of the beneficiaries, frequent 

delays with the regard to implementation resulting 

from and leading to disbursement problems, which 

affect the results. Consequently, certain European 

donors, such as the EC, have considerably 

reduced the number of classic projects financed. 

Nevertheless, the EC still values direct support for 

CSOs and invests EUR 2 million annually for 

projects of non-state actors in development, as well 

as EUR 600,000 for the EIDHR projects in El 

Salvador. Funding for health – specifically sexual 

and reproductive health – projects is available 

under the Investing in People Programme. 

The Ministry of Health sees it as problematic that 

donors have, in the past, channelled part of their 

funding available to the country’s health sector 

directly to CSOs. The Ministry claims that this has 

not only contributed to some degree of 

fragmentation of health aid, but also to a lack of 

transparency of spending, as CSOs do not report 

back to the government on their funding. However, 

as the latter often have to follow strict reporting 

mechanisms established by donors, it should also 

be the responsibility of donors to share information 

about direct project support for CSOs with the 

government in order to ensure greater alignment 

and transparency of this aid modality. The online 

development database soon to be launched by the 

government should provide the adequate basis for 

this. 

On the other hand, those CSOs interviewed during 

the fact-finding visit noted a drastic reduction of 

support channelled directly to CSOs during the last 

few years. They also state that funding provided by 

non-European donors, and among European 

donors, by EU Member States was generally easier 

to access than EC funding. Moreover, national 

CSOs deplore the fact that there is still little support 

for institutional strengthening or “core” funding 

available to them. 

In the light of the new health sector reform, as well 

as the government’s new policies on social 

participation in the health sector, it will become all 

the more crucial for donors to ensure that CSOs 

are able to participate in the new coordination 

mechanisms – direct support should therefore 

increasingly be channelled to partnershipbuilding 

initiatives between MPs, Civil Society 

and local authorities, as well as advocacy 

capacity-building and institutional strengthening for 

non-state actors. 

ALIGNMENT AND HARMONISATION: CAN EU 

DONORS LEAD BY ExAMPLE 

Donor Coordination and alignment efforts made by 

European donors need to be mirrored against 

practices of other donors to the health sector. To 

that end, it is interesting to look at the example of 

one of El Salvador’s biggest donors to the health 

sector: 

Every year, the United States Agency for 

International Development (USAID) and the 

Government of El Salvador (GOES), sign 

Assistance Agreements (AOs) that describe the 

type of activities USAID and the GOES will 

financially support. These activities are agreed 

upon by each sector Ministry, such as the MoH. 

Before developing new AOs, USAID must 

undertake a sector needs assessments which 

include interviews with MoH, NGOs, CSOs, etc. 

Due to reforms in US foreign assistance, USAID is 

currently in the process of developing new 

strategies across sectors. The reform is in its very 

early stages and consultations are ongoing. At the 

same time, the US Congress earmarks/designates 

funding for a specific sector. Currently, USAID is 

supporting maternal and child health, family 

planning and reproductive, and HIV/AIDS 

prevention; health systems strengthening is 

included across these interventions. USAID will 

decrease its funding because family planning 

assistance is ending in El Salvador in September 

2011. This decision was reached and agreed upon 

under the previous Salvadoran Administration. 

USAID will continue to provide financial support in 

health systems strengthening, maternal and child 

health, and HIV/AIDS prevention. 

In addition to USAID, the Centers for Disease 

Control and Prevention (CDC), Peace Corps, and 

the Department of Defense (DOD) also provide 

funding for healthcare services and information 

including direct technical assistance to the MoH. 

DOD has refurbished/renovated clinics due to the 

effects of Hurricane Ida and brings medical 

providers to give free medical care to underserved 

communities. It is worth noting that the private 

sector such as American Foundations and 

Corporations financially support local NGOs/CSOs 

to provide health services in El Salvador. 

However, a major part of the funding provided by 

important health donors in El Salvador will still be 

allocated to the fight against HIV/AIDS, The 

HIV/AIDS adult prevalence rate in El Salvador is 

currently only at about 0.7% 36 , placing it at the 

36 WHO World Health Statistics 2010. 



24 



same level as certain European countries, such as 

Spain. USAID’s and the Global Fund’s diseaserelated 

approaches have consequently been 

fiercely criticized by the government as they are 

“concentrating all resources on one problem 

instead of strengthening the system as a whole” 37 . 

The table below shows that a major part of El 

Salvador’s external funding for health is still 

allocated to STD control including HIV/AIDS. 

HEALTH FUNDING FOR EL SALVADOR BY SUBGROUPS – 2006-2008 

Subgroups 

2006-2008 USD million average 

Population policy & admin. Management 0.7 

Basic health infrastructure 2.6 

Medical services, training & research 0.4 

Family planning 1.5 

Reproductive healthcare 4.4 

Infectious disease control 1.7 

Basic healthcare 3.3 

Health policy & admin. management 5.4 

STD control including HIV/AIDS 8.0 

Grand Total 28.0 

Source: OECD Health Charts 2006-2010 

USAID officials themselves expressed wishes for a 

closer cooperation and coordination between 

European and non-European donors in order to 

jointly elaborate mechanisms for health-systems 

strengthening. 

Especially in countries such as El Salvador, where 

financial resources for health are scarce, there is 

hence a need for European donor agencies to seek 

a strong collaboration with their non-European 

counterparts in order to canalize funding and jointly 

improve aid effectiveness in the health sector. 

Moreover, in order to be able to “lead by example”, 

European donors need to continue fighting their 

own deficiencies in terms of alignment and 

harmonization. 

Finally, in the light of the drastic reductions in 

funding undertaken by what has so far been El 

Salvador’s biggest donor to the health sector, 

European donors will also need to step in order to 

prevent the deepening of the current funding gap 

affecting the sector. 

IHP+ IN EL SALVADOR 

Despite their comparatively straightforward aid 

architecture, adherence to the International Health 

Partnership (IHP+) in Latin America could result in 

a more effective deployment of available resources. 

To date no Latin American government has signed 

up for the IHP+, an initiative primarily designed for 

countries with a high share of development aid in 

their health budgets. However, the latter often 

already display very elaborate donor coordination 

mechanisms introduced by the aid community, 

while these mechanisms have often been 

neglected in low-priority countries, such as El 

Salvador. 

Accordingly, when asked about his view on IHP+ 

during the fact-finding visit, El Salvador’s Vice 

Minister of Health’s answer was: “Where do I 

sign”. Other stakeholders interviewed during the 

mission also expressed great interest for the 

initiative even though most of them, including the 

CSOs, had never heard about it before. 

On the one hand the adherence to IHP+ in this 

country could contribute to increasing the technical 

assistance needed for strengthening the health 

system. On the other hand, IHP+ could also unite 

donors in their efforts, no matter how large their 

health aid contributions. In doing so, results 

attained could be maximised, granting political 

support to a determined effort to achieve universal 

access to primary healthcare. Donors should 

therefore promote El Salvador’s adherence to 

IHP+. 

37 This quote has been taken from one of the interviews held during the fact-finding visit. 




25 

MANAGING FOR RESULTS: 

THE ROLE OF AID FOR 

PROGRESS TOWARDS THE 

MDGs AND FOR UNIVERSAL 

ACCESS TO PRIMARY 

HEALTHCARE 

As stated in the EC’s 2010 Mid-Term review of El 

Salvador’s CSP 2007-2013 38 , “unless welldesigned 

social policies integrated with the 

economic development strategy of the country are 

implemented El Salvador is unlikely to reach the 

MDGs by 2015”. 

Only equality and empowerment of women seems 

to be on track, while achieving universal primary 

education, reducing child mortality and improving 

maternal health requires changes of the policy 

implementation of targets to be achieved by 2015. 

Access to health services is limited: only around 

half of the population suffering from an illness or 

accident receive medical assistance 39 . According to 

the Ministry of Health 40 , “important groups of the 

population, especially young women, the poor and 

the children, lack access to primary healthcare, and 

even when they do have access, they so far 

needed to pay the treatment expenses out of their 

own pocket. As a consequence of the chronic 

stockout of supplies in public health facilities, 

patients are coerced into buying from private 

pharmacies, where the prices for medicines among 

the highest in the world. This has severely 

aggravated the economic situation of many 

households in the past to the point of leading them 

into poverty”. 

There is also a remarkable inequity in terms of per 

capita distribution of financial resources to health: 

While the Ministry of Health should be responsible 

for 75% of the population 41 , it only had USD 87 per 

capita at its disposal in 2008, whereas the per 

capita figures of the ISSS and the BM, jointly 

responsible for ca. 25% of the population, were 

between 2.5 (ISSS – USD 221) to four times (BM – 

USD 340) higher than the Ministry ones 42 . 

Each system is paid through separate ways, but 

the MoH is responsible of covering the financial 

gap for each of the other systems. In addition, the 

MoH pays for all primary care (also for formal 

employees, soldiers and teachers Primary 

Healthcare consultations) and no clear 

compensation mechanism is established to return 

this money to the MoH budget. The result is that 

the MoH, responsible for providing care to almost 

80% of the population, lost funds and the attention 

is inequitative. 

The Ministry itself admits 43 that there is a critical 

need for reforming this system. The health reform 

launched by the new government is expected to 

bring about fundamental changes in that respect, 

but still faces enormous challenges, especially in 

terms of financial resources needed: One of the 

first actions undertaken by the government was to 

eliminate user fees, which immediately led to a 

radical increase of up to 40% in the demand for 

services in certain regions of the country. 

The additional budget of USD 11 Million that the 

Ministry of Health had received from the Ministry of 

Finance for the reform was consumed immediately 

by this increase in demand. Another challenge the 

system had to face as a consequence of this new 

policy is the lack of capacities of health centres to 

accommodate the new demand for services. Due 

to the over-emersion of primary health facilities, 

more and more patients are referred to secondand 

third level health centres and hospitals, leading 

to the rapid saturation of all these facilities. 

38 http://www.eeas.europa.eu/el_salvador/docs/2010_midterm_el_salvador_annex_en.pdf 

39 WHO data and EC Mid Term Review CSP 2007=2013. 

40 “Construyendo la Esperanza: Estrategias y recomendaciones en salud 2009-14”. 

41 See table “Distribution of population responsibility by Institution” – Ministry of Health Annual Report 2009-2010, p. 131. 

42 Ministry of Health Annual Report 2009-2010. 

43 See Mnistry of Health Annual Report 2009-2010. 



26 


MANAGING FOR RESULTS 

A gradual reform of the Primary Healthcare 

system undertaken by the government aims, 

among other things, at breaking the biggest barrier 

of healthcare access of El Salvador, which are 

rural-urban inequities. To do this, they will opt for a 

family medicine and health promotion model, 

carrying doctors and nurses to all communities to 

reach out this half of the population that today 

doesn’t have regular access to healthcare. The aim 

is to have a family doctor for every 3,000 people 

and a community health worker for every 200 

families. 

However, what that this means is that in 2010 and 

2011 there is a need for recruitment of 2,272 new 

workers with an additional charge of USD 14 

million. As previously mentioned, a substantial 

increase in both domestic and external funding for 

health will need to occur if such reforms are to be 

successful. 

With regard to the access to medicines, the 

government purchased additional medicines to a 

value of USD 18.5 million in 2009. It also started a 

pilot programme of purchasing medicines through 

the United Nations System, of an initial value of 

USD 3 million. The sustainability of such a system 

will however need to be tested in the long-run. 

Another fundamental change brought about by the 

reform is the Health system’s substantially 

increased emphasis on prevention, as opposed to 

the formerly curative approach. By raising 

awareness among patients on how to conduct a 

more healthy life, this new approach is ultimately 

also expected to lead to immense savings in terms 

of treatment and medicines costs. 

According to the EC’s Mid Term Review of El 

Salvador’s CSP 2007-2013, the two key 

programmes launched by the previous government 

to accelerate country progress towards the MDGs 

(Solidarity Network and the National Education 

Plan 2021) have only brought limited results and 

certain issues, such as health, water and 

sanitation, “were not adequately addressed”. 

When asked about what they consider to be the 

most neglected health issues in their country, 

CSOs interviewed during the fact-finding visit came 

up with the following list: 

■ Family Planning, reproductive health and 

abortion 

■ Gender equality and women’s empowerment – 

specifically the issue of gender-based violence 

as a public health issue 

■ People living with disabilities 

■ Adolescents’ health 

■ Infants’ Primary Healthcare 

Moreover, CSOs indicated that aid often did not 

achieve to reach all vulnerable groups, such as, for 

instance, women and adolescents, especially since 

these groups are often also excluded from 

decision-making processes at community level. 

As previously discussed, various different 

stakeholders interviewed also pointed at the 

disproportionately high funding allocated to certain 

diseases: “There are those who live with HIV/AIDS 

and those who live OFF it”, was a comment made 

by one donor interviewed. In an interview, the 

director of a health centre visited in El Salvador 

confirmed that funding for HIV/AIDS is 

disproportionately high compared to funding for 

other very common diseases in El Salvador, such 

as Dengue. 

When looking at recent data about the most 

prevalent diseases in El Salvador, nontransmissible 

chronic diseases represented 74.2% 

of all deceases occurred in 2007. Other common 

causes of death were injuries caused by violence, 

followed by cardiac illnesses, cancer, renal 

insufficiency and diabetes 44 . As none of the socalled 

“killer”-diseases (Malaria, HIV-AIDS and TB), 

Disease prevalence map 

of a district health centre 

in San Salvador. Green 

spots: registered 

dengue cases. White 

spots: TB cases. Black 

spots: H1N1 Influenza. no 

HIV/AIDS case had been 

registered. 


44 Ministry of Health Annual Report 2009 




MANAGING FOR RESULTS 

27 

Posters in district health centre in San 

Salvador raising awareness about how to 

prevent two of El Salvador’s major health 

threats: dengue and malnutrition. 


usually affecting developing countries, figures on 

this list, certain donors to the health should 

consider whether to revise their funding priorities 

accordingly. 

The Ministry of Foreign affairs would also wish to 

see international cooperation become more 

sensitive to the country’s needs. The Ministry sees 

a disproportionately high focus being put by 

European and other donors on infrastructure 

financing as opposed to capacity building. 

In addition to that, civil society in El Salvador points 

out that there can only be effective, results-based 

management if local control and monitoring 

mechanisms are in place and functioning at 

community level, for instance through the 

institutionalisation of social auditing (contadores) 

of public spending at community level. Such 

mechanisms would allow the government and 

donors to measure the concrete impact of their 

funding to health at the most local levels of society. 

Programmes should also be based on data and 

indicators that adequately disaggregated according 

to vulnerable groups. CSOs are making efforts to 

undertake such a disaggregation within their own 

projects, even though there is no apparent interest 

or support from the donor side for this kind of 

activity 45 . 

With regard to CSOs’ own responsibility for resultsbased 

management, some CSOs highlighted that 

they had been involved in the Hospital 

Reconstruction and Health Service Extension 

Project (RHESSA) programme’s external 

evaluations. The programme components which 

had been run by CSOs apparently scored a lot 

better in terms of results than the Ministry of 

Health’s ones. Such evaluations show that it is 

worth working with CSOs and community-based 

organisations in order to achieve tangible results 

at local level. 

RESULTS-BASED FINANCING FOR EL 

SALVADOR’S HEALTH SECTOR – THE NEW WAY 

FORWARD 

A new, health-specific public-private initiative has 

been launched in mid 2009 at regional level by 

several donors, i.e. the Bill and Melinda Gates 

Foundation, the IDB, AECID, and the Health 

Institute Carlos Slim, in cooperation with the Health 

Ministries in eight countries including El Salvador: 

The “Iniciativa Salud Mesoamericana 2015” 41 aims 

at reducing the health equity gaps affecting 

populations in extreme poverty in the region, 

according to country-specific priorities. Three of the 

donors will contribute with USD 50 million each – 

i.e. USD 150 million in total to the initiative, 

whereas the IDB will be in charge of designing and 

implementing the projects in cooperation with the 

partner country health ministries. However, the 

overall priority areas have already been predefined 

by the donors, namely: Nutrition, 

Vaccination, SRH and the fight against both 

Dengue and Malaria. 

An innovative aspect of the initiative is the use of 

results-based financing as a new aid modality: the 

country-specific funds allocated by the initiative will 

need to be complemented by domestic resources. 

If partner countries achieve the jointly agreed 

targets for policy reform, coverage and quality of 

Health services, the initiative will reimburse the 

partner country 50% of its contribution. To that end, 

rigid and independent evaluations will accompany 

the project cycle. 

Despite its innovative character, the initiative has 

been fiercely criticised by a number of actors in El 

Salvador, highlighting that it is far from being 

aligned with the country governments’ policies, and 

is lacking a country- and needs-based approach: 

The Ministry of Health, for instance, does not see 

any opportunity for capacity-building in this 

programme, as it is managed by its headquarters in 

Mexico. One European donor added that a regional 

integration process for the health sector had been 

started before this initiative, but in more respectful 

and sustainable manner. A regional health sector 

assessment had been undertaken and a Central- 

American agenda for health had been established. 

There is a risk that the new Mesoamerican 

initiative, seen as being imposed by certain donors 

on the participating countries, will undermine the 

original integration process as funding provided by 

the biggest health donors in the region will be 

concentrated towards the new initiative. 

45 These statements are taken directly from the interviews held and do not necessarily reflect AfGH views. 

46 http://www.saludmesoamerica2015.org 



28 


RECOMMENDATIONS TO 

STAKEHOLDERS IN THE EU 

AND IN EL SALVADOR 

COUNTRY OWNERSHIP, 

CIVIL SOCIETY 

PARTICIPATION AND THE 

PARLIAMENT 

■ 

■ 

■ 

■ 

There is a need for donors and the 

government to further take advantage, 

during their decision-making processes, of 

CSOs’ expertise with service delivery, 

specifically with regard to working with 

communities and reaching the most 

vulnerable. 

Continuous quality control of public 

health services delivery will be necessary – 

preferably by involving CSOs with the 

required sector-expertise. In general, the 

relationship between public and private 

entities should be pushed towards 

collaboration and complementarities, rather 

than competition and rivalry. 

CSOs should be engaged at every stage of 

the programme cycle, including the design, 

implementation and monitoring of national 

programmes. 

Continuous efforts need to be made by the 

government and European donors to 

support the involvement of a greater 

diversity of CSOs, including health and 

women’s organisations, vulnerable groups, 

as well as CBOs in these processes. To that 

end, the latter will need to receive 

specifically targeted support in order for 

them to be able to attend, understand and 

value these processes. 

■ 

■ 

■ 

■ 

To the same end, more efforts need to made 

in order to improve and strengthen the 

relationship between INGOs, local NGOs, 

CBOs, local authorities and Members of 

Parliament in El Salvador in order to ensure 

that these alliances contribute to true 

country ownership of development policies. 

Donors should therefore actively seek to 

support partnership-building among all 

actors. 

Some CSOs in El Salvador recommend 

undertaking a cost-benefit analysis of 

programmes implemented in the health 

sector, by including an impact evaluation of 

CSOs’ contribution to the sector. 

In the newly established social participation 

mechanisms, any favouritism based on 

party affiliation needs to be strongly 

condemned by the government, for instance 

by establishing a code of conduct for 

government officials, CSOs and donors, in 

order to jointly tackle what could be 

considered as one of El Salvador’s biggest 

obstacles to good governance: The high 

degree of party polarisation affecting every 

sphere of society. 

Mutual accountability and trust between the 

government, donors and Civil Society could 

be enhanced through the establishment of a 

publicly accessible online development 

database where all actors are asked to 

indicate and regularly update the 

programmes they are implementing in El 

Salvador. For this tool to be truly effective, it 

needs to be linked to the budget cycle and 

planning. The IATI initiative could provide 

guidance in that respect. 

■ 

CSOs in El Salvador would welcome 

increased funding made available for 

advocacy-capacity building, but some 

would like to see an increased focus being 

put on ensuring that CSOs have the 

technical capacities and knowledge 

necessary for undertaking advocacy 

activities at policy-making level. Increased 

efforts also need to be made by civil society 

organisations themselves in order to put 

advocacy capacity-building on the donors’ 

agenda, for instance by submitting 

advocacy project proposals. 




RECOMMENDATIONS TO STAKEHOLDERS IN THE EU AND IN EL SALVADOR 

29 

DONOR COORDINATION 

■ In the light of the new health sector 

reform’s financing needs and the 

upcoming end-of-term review of the EC’s 

Country Strategy Paper, a strategic change 

towards health-financing should be 

considered by the EC. The EU Delegation in 

El Salvador does not exclude this possibility, 

but also points to the government’s own 

responsibility in demanding such a change. 

The government of El Salvador therefore 

needs to seize the opportunity and assert its 

strive for a stronger and more equitable 

health system, which adequately addresses 

neglected issues such as SRHR and 

Gender-based violence, by explicitly asking 

important donors, such as the EC, for 

sector budget support. 

■ A potential support from European donors to 

the health sector reform should be provided 

in a harmonised and aligned manner, in 

order to collectively contribute to health 

systems strengthening, gender equality and 

women’s empowerment. To that end, donors 

should accept the leadership of the newly 

reinforced External Cooperation Unit within 

the Ministry of Health with regard to sector 

coordination. 

■ Adherence to IHP+ in this country could 

contribute to increasing the technical 

assistance needed for strengthening the 

health system. Additionally, IHP+ could also 

unite donors in their efforts, no matter how 

large their health aid contributions. In doing 

so, results attained could be maximised, 

granting political support to a determined 

effort to achieve universal access to primary 

healthcare. Donors should therefore 

promote El Salvador’s adherence to IHP+. 

■ Potential health sector budget support 

needs to be accompanied by specific 

capacity-building measures for Ministry of 

Health officials and integrate gender 

sensitive policies. While technical 

assistance to the Ministry shall be 

continued, as it can be seen as a key 

condition for sector budget support, donors 

should increasingly consider employing 

local (rather than international) consultants 

to that end. 

■ The aid modality used by the EU to cofinance 

the “Comunidades Solidarias” 

programme has been positively evaluated in 

that it combines certain advantages of 

general budget support (institutional 

strengthening; use of government public 

financial systems, etc.) with some 

favourable characteristics of programme 

support (the achievement of clearly 

definable results. If this programme is to be 

continued under the EC’s new financial 

framework, a truly integrated approach 

should be adopted in order to ensure that 

the water and sanitation component is 

effectively linked to health systems 

strengthening, especially by allocating 

adequate financial resources to this subcomponent. 

■ As each donor agency currently still has its 

individual information management 

systems, one of the first priorities of the 

Ministry is to establish a unified online 

development cooperation database, 

which could be going in the direction of the 

IATI initiative. For such a system to be 

effective the government and donors need 

to ensure that it is linked to the national 

budget planning exercise. 

■ Vertical health funding mechanisms such 

as the Global Fund should adopt a more 

integral approach in order to contribute to 

health systems strengthening. Recent 

efforts made by the Global Fund in that 

direction, through the Health System 

Strengthening funding window, the Joint 

Health Systems Funding platform and 

support for the JANS, can be seen as 

positive developments in that respect, but 

their effective impact on health systems 

strengthening at country level still needs to 

be assessed. 

■ With regard to project support, CSOs 

interviewed during the fact-finding visit 

noted a drastic reduction of support 

channelled directly to CSOs during the last 

few years. In the light of the new health 

sector reform, as well as the government’s 

new policies on social participation in the 

health sector, it will become all the more 

crucial for donors to ensure that CSOs are 

able to participate in the new coordination 

mechanisms – direct support should 

therefore increasingly be channelled to 

partnership-building initiatives between 

MPs, Civil Society and local authorities, as 

well as advocacy capacity-building and 

institutional strengthening for non-state 

actors. 

■ Donors should also consider flexibilising 

and simplifying funding procedures for 

local CSOs, in order to allow for increased 

access by smaller CSOs and CBOs, whose 

projects are often very effective in terms of 

reaching the most vulnerable, but which lack 

the capacities to both absorb higher 

amounts of funding and to follow the 

complex procedures established by certain 

European donors. 



30 


RECOMMENDATIONS TO STAKEHOLDERS IN THE EU AND IN EL SALVADOR 

■ As CSOs are first and foremost accountable 

to their donors, there is a shared 

responsibility of CSOs and donors to 

inform the government about direct 

project support for CSOs in order to 

ensure greater transparency and alignment 

of this aid modality. The online development 

database soon to be launched by the 

government should provide the adequate 

basis for this. 

■ In the light of El Salvador’s scarce external 

funding for health, there is a particular need 

for European donor agencies to seek a 

strong collaboration with their non- 

European counterparts in order to 

canalize funding and jointly improve aid 

effectiveness in the health sector. In the light 

of the current health sector reform, 

European donors will also need to step up 

their support to health in order to prevent 

the deepening of the current funding gap 

affecting the sector. 

■ Finally, the MoH needs to assume increased 

leadership with regard to donor coordination 

in the health sector and institutionalise joint 

and regular meetings instead of continuing 

with bilateral negotiations with each 

individual donor. 

MANAGING FOR RESULTS: 

THE ROLE OF AID FOR 

PROGRESS TOWARDS 

THE HEALTH MDGs AND 

UNIVERSAL ACCESS TO 

PRIMARY HEALTHCARE 

European and other donors on infrastructure 

financing as opposed to capacity-building. 

While there was undoubtedly a need for 

infrastructure programmes in the immediate 

aftermath of the recent natural disasters 

which affected the country, assistance 

should progressively start turning towards 

institutional strengthening. 

■ Programmes should also be based on data 

and gender sensitive indicators that are 

adequately disaggregated according to 

sex, age and vulnerable groups. 

■ With regard to CSOs’ own responsibility 

for results-based management, some 

national programme evaluations (RHESSA) 

have shown that those components which 

had been run by CSOs apparently scored a 

significantly better in terms of results than 

the Ministry of Health’s ones. Such 

evaluations show that it is worth working 

with CSOs and community-based 

organisations in order to achieve tangible 

results at local level. 

■ New aid modalities and initiatives, such 

as results-based financing and the 

“Iniciativa Mesoamericana”, need to be reassessed 

with regard to their impact on 

health equity and their degree of alignment 

with existing national policies and priorities 

in the health sector. This assessment 

should be undertaken by the government of 

the beneficiary countries, by involving 

CSOs, CBOs, women’s organisations and 

the most marginalised communities. 

■ One of the major challenges affecting health 

aid to El Salvador is the fact that it currently 

does not reach all vulnerable groups, such 

as, for instance, women and adolescents. 

These groups are often also excluded from 

decision-making processes at communitylevel. 

Donors should support the country’s 

first steps made towards social auditing at 

community level. 

■ A disproportinately high amount of health 

funding is still allocated to the fight against 

HIV/AIDS, compared to funding for other 

more common causes of morbidity in El 

Salvador, especially non-communicable, 

chronic diseases and Dengue. In general, 

the Ministry of Foreign affairs would also 

wish to see international cooperation 

become more sensitive to the country’s 

needs. The Ministry sees a 

disproportionately high focus being put by 




31 

BIBLIOGRAPHY 

ADE, on behalf of the European Commission: Evaluation of the Development Cooperation between the 

European Commission and El Salvador”, March 2010. 

DSW, EPF, EuroNGO. Euromapping 2009: Mapping European Development Aid & Population Assistance. 

2009, Brussels, Belgium. http://www.euroresources.org/euromapping.html 

European Commission Mid Term Review of the Country Strategy of 2007-2013 and National Indicative 

Programme 2011-2013 – El Salvador. 

http://www.eeas.europa.eu/el_salvador/docs/2010_midterm_el_salvador_annex_en.pdf 

European Commission. Country Strategy Paper El Salvador – 2007-2013. 

Ministry of Health Annual Report 2009-10 (hard copy). 

Ministry of Health Website and National Health Plan 

http://www.salud.gob.sv/index.php/servicios/descargas/documentos/Documentación-Institucional/Política- 

Nacional-de-Salud/Diario-Oficial-No.33-Tomo-No.386-del-17-02-2010.-Acuerdo-No.126.-Política-Nacional-de- 

Salud-2009-2014/ 

Ministry of Health: “Construyendo la Esperanza: Estrategias y recomendaciones en salud 2009-14”. 

Ministry of Health: “Rendicion de Cuentas 2010” (hard copy). 

Ministry of External Affairs: National Aid Effectiveness Agenda” (“Agenda Nacional de Eficacia de la 

Ayuda”) (hard copy) 

OECD. Health Focus Charts – Disbursements average 2006-2008. Paris, 2008. 

www.oecd.org/dac/stats/health 

USAID “El Salvador Health Sector Needs Assessment”. July 2009. 

Website of the “Iniciative Mesoamericana”: http://www.saludmesoamerica2015.org 

WHO World Health Statistics 2010. 

World Food Programme study "Alza de precios, mercados e inseguridad alimentaria y nutricional en 

Centroamérica" (Price Rises, Markets and Food and Nutritional Security in Central America). 

LIST OF ACRONYMS 

AfGH 

AECID 

ARENA 

BM 

CBO 

CISALUD 

CSO 

DP 

DSW 

EDF 

EC 

EU Delegation 

EU-15 

FMLN 

FBO 

FOSALUD 

FY 

GAVI 

Action for Global Health European NGO 

Network 

Spanish Agency for International Development 

Cooperation 

Nationalist Republican Alliance (Opposition 

Party at the time of the AfGH visit) 

Military Health and the Teachers Welfare 

Institute 

Community-based Organisation 

Intersectoral Committee 

Civil Society Organisation 

Development Partner 

Deutsche Stiftung Weltbevoelkerung (German 

Foundation for World Population) 

European Development Fund 

European Commission 

Delegation of the European Union to El Salvador 

15 EU Member States prior to the accession of 

12 new members (2004 and 2007). EU-15: 

Austria, Belgium, Denmark, Finland, France, 

Germany, Greece, Ireland, Italy, Luxembourg, 

the Netherlands, Portugal, Spain, Sweden and 

the United Kingdom 

Farabundo Martí National Liberation Front 

(Ruling Party at the time of the AfGH visit) 

Faith based organisations 

Social Solidarity Health Fund 

Financial Year 

The Global Alliance for Vaccines and 

Immunisation 

GBS 

GDP 

GoES or 

Government 

GNI 

HIPC 

HSSP 

IDB 

IHP+ 

IMF 

INGO 

ISSS 

JANS 

MDG 

MoF 

MoFA 

MPSAS or MoH 

MTEF 

NGO 

ODA 

PAHO 

PRSP 

RHESSA 

SRHR 

STD 

SWAp 

WB 

WHO 

General Budget Support 

Gross Domestic Product 

Government of El Salvador 

Gross National Income 

Heavily Indebted Poor Countries 

Health Sector Strategic Plan 

Inter-American Bank 

International Health Partnership 

International Monetary Fund 

International Non-Governmental Organisation 

Social Security Institute 

Joint Assessment of National Strategies 

Millennium Development Goals 

Ministry of Finance 

Ministry of Foreign Affairs 

Ministry of Health 

Mid-term Expenditure Framework 

Non-Governmental Organisation 

Official Development Assistance 

Pan American Health Organisation 

Poverty Reduction Strategy Paper 

Hospital Reconstruction and Health Service 

Extension Project 

Sexual and Reproductive Health Rights 

Sexually Transmitted Diseases 

Sector-wide Approach 

World Bank 

World Health Organisation 



Action for Global Health is a network of European 

health and development organisations advocating for 

the European Union and its Member States to play a 

stronger role to improve health in development 

countries. AfGH takes an integrated approach to 

health and advocates for the fulfilment of the right to 

health for all. One billion people around the world do 

not have access to any kind of healthcare and we 

passionately believe that Europe can do more to help 

change this. Europe is the world leader in terms of 

overall foreign aid spending, but it lags behind in the 

proportion that goes to health. 

Our member organisations are a mix of development 

and health organisations, including experts on HIV, TB 

or sexual and reproductive health and rights, but 

together our work is organised around a broad 

approach to health. AfGH works to recognise the 

interlinkages of global health issues and targets with a 

focus on three specific needs: getting more money for 

health, making healthcare accessible to those that 

need it most and strengthening health systems to 

make them better equipped to cope with challenges 

and respond to peoples’ needs. 

In the light of the upcoming Fourth High Level Forum on 

Aid Effectiveness in South Korea in November 2011, 

Action for Global Health commissioned DSW Brussels to 

undertake six combined fact-finding and advocacy visits 

to developing countries in 2010 in order to assess the 

impact of current aid structures and aid effectiveness 

principles on health-spending in those countries. The 

overall objective of these fact-finding visits is to bring 

evidence and experience from developing countries to 

support European advocacy for global health, by 

producing country-specific policy briefings and 

disseminating them to key decision makers and 

organisations in Europe and in developing countries. 

Contact: coordination@actionforglobalhealth.eu 

Visit our website to learn more about our work and 

how to engage in our advocacy and campaign actions. 

www.actionforglobalhealth.eu

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