Global Policy Forum

By Gloria Pereira-Papenburg

If you need to see a doctor at the public hospital in the town of Jiquilisco, El Salvador, you'll find that paying a "voluntary contribution" is part of the normal procedure. For example, four months ago 34-year-old Rosa Penado brought her daughter to the local hospital emergency room. The girl needed a hernia operation, and her mother was charged 500 Colons (about 100 Canadian dollars). She could only pay half the cost, and so has not returned to the hospital because she is afraid that she will be asked for the rest, which she does not have.

The case of Rosa Penado and her daughter is just one of hundreds documented by the Human Rights Ombudsman of El Salvador. After investigating the situation of the right to health care in rural communities of the north coast of El Salvador, the Ombudsman's preliminary report concluded that the fear of not being able to pay for the necessary health care services prevents people from seeing a doctor.

In Uzulutan a simple visit to a doctor in a public hospital costs half-day's worth of salary. Others who can get the money to pay for hospital services often can't afford to pay for prescribed medications. Half the people of El Salvador live below the poverty level. The proportion of poor people is higher in the rural areas, such as Jiquilisco, and therefore user fees put health care services out of the reach of most.

More than one in ten people in El Salvador will not live beyond age forty. A quarter of the people do not have access to health services, and 34% do not have clean drinking water at home. (UN Human Development Report 2002) This is the context in which health care professionals, with the support of many Salvadorans, have been fighting for months against privatization of health services and for real access to these services. The doctors went on illegal strike as the only way to make the government to review its position. Hundreds of doctors faced losing their positions; several received death threats.

In the Journal of the Human Rights Commission of El Salvador, the Physicians Union described how the government of El Salvador reduced its financial support for public health care, and undertook a campaign of disinformation to convince the people that the workers are responsible for the health care crisis, that the system is beyond repair, and that the only solution is privatization.

The Inter-American Development Bank (IDB) and the World Bank claim to be supporting projects that improve health care systems in Latin America, but they seem to be particularly inefficient, since public services are declining and corruption is increasing. In the specific case of El Salvador, the IDB approved a loan in 1998 to support the modernization of the Ministry of Health and Social Assistance (a process begun five years earlier with a World Bank loan). The health care sector reform proposal that emerged would transfer direct service provisions to the private sector. The health care unions are concerned that the proposal gives priority to profit-seeking concerns and put health needs in a secondary position.

The unions believe that public health care in El Salvador could achieve its goal of universal high-quality coverage. There have been important improvements in health in the last decade, even with under-paid workers, understaffing and poor working conditions. The public system can take credit for the improvements since they have occurred without corresponding progress in other sectors, sanitation, housing and employment that are important factors in the health of the population.

The Salvadoran group "Journalists Against Corruption" denounced a bill that had been sent to the Salvadorian Congress, saying that it would restrict access to information on the proposed new health care system. They are concerned that this would mean the new health system would be managed without monitoring from media or from the public in general (Transparency International considers El Salvador to be a country with a high degree of corruption). The journalists point out that the Salvadorian Institute for Social Services is one of the institutions most affected by corruption, and that the government has never shown interest in bringing these practices to an end. Many people believe that a cleansing of the Institute's management will allow better health care without need for private funding.

Disregarding opposition from all sectors, the President of El Salvador sent a proposal to the National Assembly to privatize health care services on October 16. The opposition parties rejected it in an unexpected move by a political party that usually votes with the government. The following day, the National Assembly approved a decree blocking the privatization of health care; they called it a "health guarantee". The President stated that the legislative decree was unconstitutional and he had no other option but to veto it.

Thousands of Salvadorans took to the streets of San Salvador on October 23 in support of the strike by health care workers and to protest against privatization. It was a huge show of solidarity with the strikers, with up to 80 thousand people according to international journalists. The people said that they would not accept any changes to their "guarantee of health". This was the second massive public demonstration against health care privatization within a month.

In view of this public outcry, the President softened his position; he would not veto the decree but he would make amendments. It was not clear how much these amendments would dilute the "health guarantee" so this was not acceptable to the doctors on strike.

At the end of the month, the mayor of San Salvador, a physician and a member of the leftist opposition party Farabundo Marti National Liberation Front, offered to serve as a mediator. He proposed that a commission be formed to formulate new proposals to reform the health care sector starting from scratch. The same evening (October 31) the President publicly announced that he accepted the mayor's proposal and would not veto the "health guarantee". This opens the door to negotiate a settlement with the health care workers but there is still the matter of the reinstatement of workers fired at the beginning of the strike, and other sanctions that had been imposed on the strikers.

The 350 doctors on illegal strike have been without salaries for three months, although they have provided emergency services. They say that they will not go back to their regular schedule until any economic, administrative or judicial sanctions are lifted. Despite the fact that the physicians have tremendous popular support, they find themselves now under a media campaign against them, to make an example for other workers who might dare to confront privatization in other areas.

It is possible that the government of El Salvador will try again to introduce private participation in health care but, for now it will have to wait. This may have an impact on other privatization projects in El Salvador, such as the electricity services, and also in other Latin American countries, in projects that are being strongly opposed by the people.

The strong opposition by the people might not be enough to stop these privatization projects. As we saw earlier, the governments are being pushed by the Inter-American Development Bank (IDB) and the World Bank (WB) in the gradual transfer of health care and other social services, previously covered by the government, to the private sector. Privatization is part of the conditions attached to loans by international financial institutions to third world countries.

These institutions have kept this pos ition despite repeated expressions of concern from the UN Committee on Economic, Social and Cultural Rights, the monitoring body of the International Covenant on Economic, Social and Cultural Rights. This Committee has said, since 1990, that the international financial institutions should pay greater attention to the protection of human rights when implementing their policies.

Over the years, the Committee has produced several General Comments to different articles of the Covenant. Comment No. 14 on the right to the highest attainable standard of health (from 2000) says that "States parties have an obligation to ensure that their actions as members of international organizations take due account of the right to health. Accordingly, States parties which are members of international financial institutions, notably the International Monetary Fund, the World Bank, and regional development banks, should pay greater attention to the protection of the right to health in influencing the lending policies, credit agreements and international measures of these institutions."

This means that we must keep vigilant about the defense of human rights in El Salvador and, here in Canada, make our government accountable for its participation in the financial institutions that have such a strong influence on the realization of these rights.

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