In this guest post, Steve Lewis, RESULTS UK'S former Head of Policy, reflects on a recent visit to El Salvador and the incredible progress that has been made to expand access to basic primary health care across rural communities.
Let me introduce you to my friend Graciela. Graciela’s story shows us that life is getting better in most developing countries, that foreign aid works, and that most people in most poor countries are healthier now than they used to be. They are taking control of their lives.
From 1991 to 1994 I lived in a village in rural El Salvador with my wife Kath. Avelares was one of the villages we visited often, trying to support a primary health service in a very poor area. It’s a small community high in the hills, and in 1991 was in territory controlled by FMLN guerrillas. Local people were trying to provide a very rudimentary health and education system with young volunteers from each community. In Avelares back then, Graciela was the volunteer providing primary health services. She had just a few weeks of training and some medicines and bandages provided by the Catholic diocese and an excellent NGO called Concern America.
In November 2016 Kath and I visited the villages again and were thrilled to meet with Graciela, who remarkably is still the provider of health care in Avelares and three surrounding villages. Twenty five years on she is looking a little older now – but then again so are we! She still lives in the same house and works in the same one room clinic made from mud bricks. But what has changed significantly are the health statistics. Graciela told us with great pride that no child has died in her community in the last eleven years. We were astonished.
In the 1990’s in El Salvador the under five infant mortality rate was 60 deaths per 1000 live births. Today it has fallen to 16. But in rural areas deaths of children were much more common. Kath and I probably saw one child death every couple of months, when we were living and working there. There was little antenatal care, very poor nutrition, and no access to a hospital, due to the war and the very poor roads to the lowland areas. All babies were born at home, with no electricity, and with only a local midwife to help. At a rough estimate I’d say one child in ten died before the age of five in the area around Avelares. Maternal mortality rates in the 1990’s were also very high.
Last month Graciela explained to us with pride the improvements that had been made by the Ministry of Health. ‘"All children are born in hospital now" she explained. "It is my job to deliver antenatal advice, and take weight and health measurements". But two weeks before the birth date the mother-to-be is taken down to the town in the lowlands, to wait in the ‘Casa Materna’, the maternity home. I learnt to my amazement that in the last dozen years only one child had been born in the village. "That time I couldn’t get transport in time" she explained.
Having once been supported by the Church and NGOs, Graciela is now employed by the Ministry of Health under their Primary Health Care system. This has been a very positive move by the state to retain the rural experience of the community health workers (CHWs). In some provinces ex-CHWs make up the majority of the paid primary health workforce. One of Graciela’s old colleagues, Dagoberto Menjivar, is now a senior doctor and administrator. Yet he started as a CHW with fifteen days training on the ‘Curso basico’. A real success story.
Graciela told us that the Ministry is very demanding. She has to visit every house in her communities on a regular timetable and carry out a series of controls and vaccinations in every house. "Once the mother has returned to the village after giving birth, I have to visit the house every day for the first week, then once a week for a month, then once a fortnight etc. If a child were to die in my area, I would be taken before a tribunal and can be held responsible. If a child dies of a preventable early-years illness I could go to jail…”
It is not only infant and maternal deaths that have diminished rapidly in the last 25 years. In El Salvador and nearly all Latin American countries there has been steady progress in life expectancy and other health statistics. With more certainty over the health of their children, families have been taking more control over their fertility. When we lived in the region most parents had 6, 8 or even more children. We knew one neighbour who told us sadly that she had given birth to 18 children “but only five are alive today”. In 1990 nationally only half of women used family planning and in our rural area the percentage was miniscule. Today in El Salvador nearly 75% of women of a relevant age are using contraception", explained Graciela.
In 1990, in our zone, I estimate local women had on average six births. Nationally in El Salvador women had an average of 3.8 births. Today the figure has fallen to just under two. This bodes well for future health of the family. Child and maternal health services under the state system are free – which encourages take-up, especially from rural areas. Donor countries in the 1990’s and 2000’s which supported El Salvador can feel proud of this progress.
There are still many problems in El Salvador, such as ongoing violence from youth gangs, and these problems get covered in the global media. But the country is a democracy (and the current president is a former guerrilla leader from the FMLN). Countries like the UK, and donors such as the EU and the World Bank supported El Salvador to recover from the civil war and build capacity in the health service. Now, El Salvador has a working and effective primary health care service, staffed by local people like Graciela and Dagoberto, who know their communities. To me that is a pleasure to hear. Behind the headlines, the health of poor people in Latin America is steadily getting better.