2009年-世界发展银行全球_Extension_of_Health_Services_Coverage_in_El_Salvador___The_RHESSA_Project_Experience_4页_1mb

Summary of the RHESSA Project in El Salvador

Core Content

The RHESSA (Reforzando la Cobertura en Salud para la Población Rural y Vulnerable) Project in El Salvador aimed to extend basic healthcare coverage to rural and impoverished populations, especially mothers and children, in response to poor health indicators and limited access to services. The project was initiated to address the challenges posed by the lack of healthcare personnel in remote areas, rural-urban and rich-poor divides, cultural and language barriers, and insufficient transportation infrastructure. These issues were exacerbated by the 2001 earthquakes, which damaged healthcare facilities and infrastructure, increasing the need for improved access.

Main Objectives

The primary goals of the RHESSA Project were:

• To increase access to basic healthcare services for vulnerable populations.
• To improve health indicators, particularly for children and mothers.
• To achieve equitable access to healthcare services.
• To meet the Millennium Development Goals (MDGs) related to health.
• To ensure the sustainability and institutionalization of the healthcare extension program.

Key Strategies

The Ministry of Health implemented two modalities to extend coverage:

1. NGO Mobile Teams:

   • Services were contracted to private non-governmental organizations.
   • Legal contracts defined service requirements, including geographic coverage, frequency of visits, and service quality.
   • NGOs were incentivized through bonuses and withholdings based on performance.
   • Monthly monitoring and evaluation were conducted by the Ministry and independent auditors.

2. Institutional Mobile Teams:

   • Mobile units were created within the Ministry of Health.
   • These teams operated under performance agreements and were monitored monthly.
   • The Ministry had direct control over the services and infrastructure.
   • Funding was used for medical supplies, transport, and direct hiring of medical staff.

Key Results

• Coverage: Over 635,805 inhabitants, including 75% in extreme poverty, gained access to essential healthcare services in 104 municipalities and 591 cantons.
• Child Health:
  • 100% of children under one year were enrolled in the program.
  • 99.2% received complete vaccination coverage.
  • 95.3% of children were immunized with the six most essential vaccines.
  • 95.5% received a critical check-up before 28 days.
  • Malnutrition rates dropped to 15.2%.
  • Infant mortality rates improved to 16.1 per 1,000 in NGO areas and 13.3 per 1,000 in Institutional areas.
• Women's Health:
  • 86.3% of pregnancies were attended by qualified professionals.
  • 52% of women complied with the five or more prenatal visits requirement.
  • Postnatal visits increased to 89%.
  • No recorded cases of maternal mortality.
  • Pap smear tests increased to 79% in NGO areas and over 90% in Institutional areas.

Sustainability and Institutional Strengthening

• The project was supported by a World Bank loan and international donors.
• The Salvadoran Government allocated US$4.3 million for continued services and US$2.9 million for institutionalization.
• The Ministerial Accord No. 1000 formalized the institutionalization process, ensuring the program's integration into the national health system.
• The project emphasized the need for continued financial and institutional support to maintain improvements and prevent regression.

Beneficiary Satisfaction

• High levels of satisfaction were reported, with 98.4% to 100% of beneficiaries finding the services valuable.
• 98% of beneficiaries reported adequate supply of medicines.
• 95.5% to 97.6% indicated their health needs were met by the extension coverage teams.
• There was a significant reduction in out-of-pocket healthcare spending and travel time to health units.

Conclusion

The RHESSA Project demonstrated that a combination of public-private partnerships and institutional strengthening can effectively improve healthcare access and outcomes in underserved regions. The project's success highlights the importance of financial sustainability, monitoring, and evaluation in ensuring long-term impact. It also underscores the need for continued investment in the health system to address the remaining challenges, particularly in rural and indigenous communities. The strategy has proven to be a sustainable solution in the context of economic crisis and rising health demands.