USAID CBJ FY 2002: El Salvador

Summary: USAID/El Salvador's health strategic objective is linked to the Agency objective of stabilizing world population and protecting human health. USAID supports the Ministry of Health (MOH) and NGOs to achieve this objective through three key intermediate results: 1) increased use of appropriate child survival practices and services, 2) increased use of appropriate reproductive health practices and services, and 3) enhanced policy environment to support sustainability of child survival and reproductive health programs. Through this strategic objective USAID will improve the health status of the Salvadoran population, especially poor women and children living in rural areas. This assistance should also result in major reforms in the organization, financing and delivery of health services, leading to expanded coverage for the most vulnerable groups, overall improvements in efficiency and quality of care, and sustainability of the health care delivery system.

USAID is reducing child mortality and morbidity through support for expanded coverage of primary health care services, prevention and treatment of respiratory illnesses and diarrhea, improved nutrition, use of the Integrated Management of Childhood Illnesses (IMCI) programs, and increased access to potable water and sanitation services. USAID's activities are also strengthening and expanding reproductive health and family planning information and services, reducing reproductive health problems through improved safe motherhood and birthing practices, and preventing sexually transmitted infections (STIs) and HIV/AIDS. USAID is supporting policy efforts by the Ministry of Health (MOH) and the Social Security Institute (ISSS) to reform the health sector.

Intermediate results indicate positive trends such as increased access to potable water, increased services by rural health promoters, increased family planning, pre-natal and post-partum care, and progress toward health sector modernization. All major activities are being executed as planned without major obstacles or delays, except for the community-based IMCI initiative. The IMCI interagency committee decided that the IMCI clinical training should be condensed from 15 to 6 days so that training of all necessary personnel could be completed in a shorter timeframe. After the committee revised the clinical course, USAID financed the revision of the community-level course materials. These revisions caused a one-year delay in implementation of the initiative.

Key Results: In the area of child survival, five USAID activity sites have achieved at least a 26% reduction in cases of diarrhea among children under five years old. Also, diphtheria, pertussis, and tetanus (DPT3) vaccination coverage increased to 98%, surpassing all targets set through the end of the activity period. The results-level indicator for reproductive health, percent of pregnant women receiving prenatal services, which reported a decrease last year (from 60% in 1998 to 56% in 1999), showed a slight improvement in 2000 with an increase of three percentage points to 59%. There was also a 10% increase in couple-years protection (CYP) and a 7.7% increase in the number of new family planning users. The Salvadoran Demographic Association (SDA) increased the effectiveness of its USAID-supported rural program as demonstrated by a 14% increase in CYPs per promoter.

Policy and reform indicators show a slight increase in the percent of MOH expenditures allocated to primary care and a leveling off in the number of municipalities served by MOH rural health promoters (at 83% for the past two years).

Performance and Prospects: Child Survival (CSD funds): Results achieved in 2000 by the Water Supply, Sanitation, and Health Program (PROSAGUAS) water and sanitation activity exceeded the original life of activity targets in terms of the number of beneficiaries receiving latrines and health education. An external mid-term evaluation of PROSAGUAS concluded that the activity is successfully achieving its expected results. In the area of maternal and child nutrition, USAID supported the training of 90 nutrition counselors in improved management of nutrition deficiencies, and breastfeeding support was supported through the start up of a breastfeeding monitoring system in five departmental level hospitals. In the area of infant health, 200 medical personnel were trained in neonatal resuscitation from 14 different hospitals. Also, the safe motherhood initiative was introduced in 21 rural hospitals and maternity centers. USAID assisted the MOH to implement a revised national strategy for IMCI coverage, and USAID will finance IMCI training for community-level providers early in 2001.

To support MOH efforts to expand rural health services, USAID financed in 1999 the training and deployment of 240 MOH health promoters and the contracting of five NGOs to provide health services to priority areas of the country that have limited access to healthcare. The MOH has now picked up the financing of 160 of these promoters, with plans to cover the financing of all the promoters by the beginning of 2002. In 2000 the MOH experienced a setback in terms of not securing a line item in their budget to finance the five NGOs as planned. However, the World Bank is considering a loan to El Salvador to build upon and expand this model. USAID financing of the five NGOs will end in December 2001.

USAID's tuberculosis control activity with Pan American Health Organization (PAHO) and the MOH continued on track in 2000. USAID supported the Centers for Disease Control and Prevention (CDC) which began work on Post-Hurricane Mitch activities, with a focus on the training of field epidemiologists and support for the MOH's epidemiology division and central laboratory. USAID also assisted the CDC and the MOH during the dengue epidemic by financing the purchase of medical and vector control equipment and an information campaign to help control the epidemic. Beyond these collaborative efforts, USAID also worked with the U.S. Military Group and the U.S. Private Voluntary Organization Food for the Poor through the Excess Property Program to deliver much-needed medical supplies and equipment worth millions of dollars to upgrade health services in rural MOH hospitals and health centers.

USAID financed the MOH's development of guidelines for counseling HIV/AIDS patients and the subsequent training of health professionals using these guidelines. Treatment guidelines for HIV-infected individuals care were also formulated in a combined effort by MOH, the ISSS, and a Salvadoran non government organization working on HIV/AIDS (FUNDASIDA) with technical assistance from the regional USAID AIDS project and the United Nations Organization against AIDS. These guidelines were published in early November. Guidelines for the management of STIs were also developed and published.

Reproductive Health (DA funds). Performance showed great progress, particularly under the SDA agreement. SDA, which serves nearly 20% of all contraceptive users in El Salvador, opened three pharmacies and began to offer a wider range of services in its efforts to generate revenues to subsidize its rural family planning services and adolescent health programs. SDA also provided counseling to 10,000 adolescents and trained 211 new counselors and peer educators. Through USAID support to the MOH, 495 midwives, 200 doctors, and 156 health promoters were trained in reproductive health, family planning, and adolescent-friendly services. The 200 physicians were also trained in the application of the Client Oriented-Efficient Provider (COPE) tool. Three hundred and twenty-five hospital personnel were trained in postpartum care using a training of trainers cascade approach. Also at the MOH, USAID financed the design, installation; training and monitoring associated with implementing a new contraceptive logistics management system.

Policy and Reform (CSD funds). The most significant result in the area of policy and reform is the preparation and presentation to the President of a health reform proposal by the National Health Council, an effort supported by USAID technical assistance. The ISSS received support in the area of developing a new hospital management model for implementation in two new hospitals. The opening of these hospitals under this management model is expected to increase the efficiency and quality of care provided by the ISSS, thus alleviating pressure on the MOH to provide services to people insured under the ISSS.

In FY 2001, $3,991,000 of DA funds will support SDA's and the Ministry of Health's reproductive health/family planning services programs. $6,014,000 in CSD monies also are requested. $5,114,000 will support the Ministry of Health's child health programs, NGO maternal and child health interventions, construction of water and sanitation systems, and the training of health workers in areas of child health, nutrition, and prenatal care; $900,000 will support health policy and reform.

In FY 2002, USAID will allocate a total of $3,307,000 in CSD funds. $2,807,000 in CSD monies will support the MOH's programs to reduce diarrheal and respiratory diseases, improve the nutritional status of children, train rural promoters on IMCI and breastfeeding promotion, train midwives and rural hospital workers on prenatal interventions and support policy and reform activities, as well as CARE's water and sanitation activities. Another $500,000 in CSD funds will be delivered to address HIV/AIDS issues. Also, $4,022,000 in DA funds will be allocated (a) to support the SDA and MOH's reproductive health/family planning services, adolescents reproductive health and clinical services programs, (b) to provide for the training of health personnel in family planning counseling, and (c) to improve the MOH's contraceptives logistic management system.

Possible Adjustments to Plans: MOH implementation problems resulting from multiple epidemics, audit findings, and an imminent reorganization in the year 2000 --all intensified by the recent earthquakes in early 2001--have caused USAID serious concern regarding the MOH's ability to implement planned activities for 2001. USAID will seek measures to shift some of the implementation role to other entities. In addition, one million dollars in FY 2001 funds originally slated for the MOH will be reprogrammed to the Water Supply, Sanitation and Health Activity to expand its scope of work to repair and rehabilitate latrines, wells, and water systems in earthquake-affected areas of the country.

Other Donor Programs: Three other major donors work in the health policy and reform area: Pan Anerican Health Organization (PAHO), the Inter American Development Bank (IDB) and the German Development Agency (GTZ). PAHO and GTZ focus on supporting the MOH's decentralization process in limited geographic regions. PAHO also supports the MOH's implementation of IMCI and other aspects of child health and emerging diseases. After the recent earthquakes, the Legislative Assembly ratified a $21 million, 25-year IDB loan that had been pending since 1998. It was approved with up to seven million dollars refocused to rebuild health units damaged by the quakes. In November, the European Union (EU) completed a $12 million water and sanitation program in the western region of the country; Sweden, Luxembourg and the Japanese International Cooperation Agency(JICA) are also financing improvements in rural water and sanitation services. The United Nations Childrens Fund (UNICEF) supplies essential medicines and is the lead donor on food fortification and micronutrient issues. It also provides adolescents with information on HIV prevention and, with PAHO, educates Salvadorans on domestic violence and women's role in society. The United Nations Fund for Population Activities supported the development and adoption of the National Reproductive Health Plan. JICA, PAHO and the GTZ also support reproductive health programs in El Salvador.

Principal Contractors, Grantees, or Agencies: The two major grantees are CARE International with the Water Supply, Sanitation, and Health Program (PROSAGUAS) activity and the Salvadoran Demographic Association (SDA). Other implementation partners include the Center for Desease Control and Prevention (CDC), Management Sciences for Health, Booz Allen and Hamilton and its subcontractor Cambridge Consulting Corporation, Family Health International, the Population Council, and John Snow, Inc.

FY 2002 Performance Table

El Salvador: 519-003

U.S. Financing

(In thousands of dollars)

	Obligations		Expenditures		Unliquidated
Through September 30, 1999	140,959	DA	136,171	DA	4,788	DA
	16,570	CSD	6,101	CSD	10,469	CSD
	36,610	ESF	36,290	ESF	320	ESF
	0	SEED	0	SEED	0	SEED
	0	FSA	0	FSA	0	FSA
	0	DFA	0	DFA	0	DFA
Fiscal Year 2000	3,972	DA	4,257	DA
	7,060	CSD	7,299	CSD
	0	ESF	9	ESF
	0	SEED	0	SEED
	0	FSA	0	FSA
	0	DFA	0	DFA
Through September 30, 2000	144,931	DA	140,428	DA	4,503	DA
	23,630	CSD	13,400	CSD	10,230	CSD
	36,610	ESF	36,299	ESF	311	ESF
	0	SEED	0	SEED	0	SEED
	0	FSA	0	FSA	0	FSA
	0	DFA	0	DFA	0	DFA
Prior Year Unobligated Funds*	0	DA
	0	CSD
	0	ESF
	0	SEED
	0	FSA
	0	DFA
Planned Fiscal Year 2001 NOA	3,991	DA
	6,014	CSD
	0	ESF
	0	SEED
	0	FSA
	0	DFA
Total Planned Fiscal Year 2001	3,991	DA
	6,014	CSD
	0	ESF
	0	SEED
	0	FSA
	0	DFA
			Future Obligations		Est. Total Cost
Proposed Fiscal Year 2002 NOA	4,022	DA	1,416	DA	154,360	DA
	3,307	CSD	4,178	CSD	37,129	CSD
	0	ESF	0	ESF	36,610	ESF
	0	SEED	0	SEED	0	SEED
	0	FSA	0	FSA	0	FSA
	0	DFA	0	DFA	0	DFA

El Salvador

Activity Data Sheet

FY 2002 Performance Table

El Salvador: 519-003

U.S. Financing