Bitter medicine

In his  June 1 speech on inauguration to his unconstitutional second consecutive term in office, Nayib Bukele told the Salvadoran public to expect the need for "bitter medicine" if the country was going to achieve economic growth and prosperity.  It was a speech with a prolonged metaphor about following the advice of the wise doctor (Bukele).  Today, the Salvadoran healthcare system might be one example of the bitter medicine the Bukele regime is prescribing.

Ask Salvadorans who rely on the public health system or the social security system, and they will describe problems with long wait times, the unavailability of specialists, and drugs which are never in stock.  These are problems of long standing.

At least 150 specialists and sub-specialist physicians in the social security hospital system have quit since the beginning of the year for reasons of low pay and working conditions.   The result is a shortage of specialists in the social security hospital system, which serves some 900,000 Salvadorans.

The government has also been advertising for doctors in other Latin American countries to come work in El Salvador.  According to Carlos Ramos Hinds, vice president of the Colegio Medico de El Salvador, under the standards of the World Health Organization there should be 23 physicians for every ten thousand inhabitants, but El Salvador only has 17; nurses should have a patient load of 10-12, but Salvadoran nurses are charged with 40-50 patients, and in an intensive care unit there should be one nurse for every 1-2 patients, but ICU nurses in the country are stretched to cover 5-6 patients.

The result is that Salvadorans regularly face long wait times to make appointments for many types of care, and shortages of staff to care for them.

A nurse in a public hospital described to me the supply shortages they face and spoke of nurses purchasing medical supplies out of their own funds so they could care for their patients.  

In a poll from February 2024, some 53% of Salvadorans who utilize the public health or social security systems indicated that those systems lacked supplies of the medicines which were prescribed for them.

To be sure, the systemic problems of scarcity of medicines and long waiting lists go back well before the Bukele administration.  But this is a government which publishes glowing statements and highly-produced media pieces proclaiming that it has made great strides in improving the healthcare system in the country.  Meanwhile, the Bukele regime refuses to disclose its national health plan.  (If it has one).

Given the challenges to healthcare delivery in El Salvador, there was great concern that the government's draft budget for 2025 shows budget cuts.   There will be less investment in providing healthcare for Salvadorans, not more. 

The budget proposed by the Bukele government for 2025 includes a $91 million reduction in funding for healthcare.  The proposed budget puts in place salary freezes, not permitting health system workers to advance on the salary ladder known as the "escalafón."  The budget includes a hiring freeze and actually cuts 3727 positions within government healthcare institutions.  According to an analysis of the budget by La Prensa Grafica, the greatest number of cuts involve doctors and nurses. 

In addition the healthcare budget pares the funding for the public hospitals in the country.  The 31 public hospitals in the country will see a budget cut of $54 million, with the country's tertiary care public hospital, Hospital Rosales in San Salvador, seeing a cut of 10% in its funding.

Ramos Hinds stated:

There is a lack of medicines, a shortage of supplies, there is no adequate equipment. All of this is occurring with the budget funds made available this year. What will happen if $91 million are cut? Nothing good can happen.

Analysts see in the cutbacks a need to satisfy the International Monetary Fund (IMF).  For more than three years the country has been trying to negotiate a $1.3 billion loan from the IMF.  The IMF, however, has reportedly told the Salvadoran government to get its financial house in order and stop funding so much of its budget with debt.  

On October 19, workers in the health system marched in a "white march" to protest the cutbacks and salary freeze by the government.   They were joined by teachers and professors from the education system where similar cuts and freezes are being made. 

#MarchaBlanca| En estos momentos la marcha ha iniciado. Una de las exigencias de los sindicatos es que en el presupuesto de la nación de 2025 se respete la Ley del Escalafón. pic.twitter.com/OwqjnzMN22

— Red Informativa de Arpas (@arpassv) October 19, 2024

      

The white march harkened back to the massive protests in 2003-2004 against proposals to privatize the health system. Those marches, including one in October 2003 which purportedly drew as many as 200,000 people to the streets, effectively forced the ARENA government at the time to pull back from ideas to make healthcare a marketplace good.

The improvements to the healthcare system needed in El Salvador require funding, and they do not lend themselves to publicity videos.   Stocking adequate supplies of medicines in hospital storerooms, or training and equipping sufficient medical personnel is not something you can turn into a TikTok video.  A new hospital can be built and photographed, but if it lacks doctors, nurses, medical supplies and prescription medications, it will not accomplish its purpose.

And while healthcare was on the budget chopping block, the military is actually seeing a $53 million increase in its budget for 2025.  To see a government's priorities, follow the money.