Reality of Reform: Assessing El Salvador’s 2009 Health Reforms and the Future of Health Under Bukele

Abstract

In 2009, El Salvador’s government embarked on substantial reforms to its healthcare system, with an emphasis on primary health care. The reforms pushed for increased affordability and access to care, and major policy goals ranged from abolishing voluntary fees that made medical services too expensive for many Salvadorans to creating primary care and specialist teams (ECOS) across the country and increasing the national health budget. Despite the immense potential of this reform period, little research has been conducted on the reform-making process, and even less has been conducted on the results of the reforms. Using key informant interviews and a document content analysis, I argue that the 2009 reforms were unsuccessful despite good intentions. Key barriers to implementation included a lack of financing; a lack of political continuity, commitment, and support; failures of reform leaders and government officials; a failure to compensate for negative consequences of reforms; a limited scope; a failure to fully consider the unique country context and challenges (e.g., gang violence); and problems in the actual execution of the plans. I further argue that identifying the barriers to implementation in 2009 is crucial for future policymaking efforts — circumstances have changed dramatically since the FMLN governments, and the Bukele administration has the power to markedly improve health access among Salvadorans. Policy proposals outlined in this thesis include an increased budget for health (particularly for the first level of care), a thorough “testing and diagnosis” of the country’s health system, a consolidation of public health institutions, and a multisectoral approach to health.