Author: Marijke Wijnroks, Ministry of Foreign Affairs

The intention

Two years after the end of the bloody civil war in 1992 in El Salvador, started a health program funded by the Netherlands in six municipalities. It was a so-called multi-bi project, conducted by the Pan American Health Organization (PAHO). The program had two goals:

  • rebuilding the health infrastructure severely damaged by the war;
  • improving the health situation through participatory Primary Health Care (PHC) approach.

The program also aimed to contribute to the process of reconstruction and reconciliation. The war had left El Salvador highly polarized. Based on the idea that health was a politically neutral territory, we wanted to promote collaboration between government and social organizations through PHC.

The approach

Our PHC program paid a lot of attention to bottom-up planning, for community organization and participation and for intersectoral cooperation. Moreover, this fitted seamlessly into the formal policy of the Salvadoran Ministry of Health. I was responsible for the monitoring and evaluation, and therefore also for setting up a baseline study about the starting situation in the municipalities. For this we had consciously contracted the contractor with by far the least experience: the University of El Salvador. For example, we wanted to involve the University – which provided training for the majority of Salvadoran health workers – in our program and in the PHC concept., while strengthening its research capacity. My contact person was the – very involved and motivated – dean of the medical faculty.

The result

Until 1996 the program went well. But in the municipal elections, the health minister's right-wing party lost to the left-wing opposition in four of "our" six municipalities.. The minister turned out to be responsible for his party's political campaign in those municipalities and was looking for a scapegoat. That became our project team. We would have carried out communist propaganda. And we would also have pocketed the overhead of the program budget. Unjustly of course, because agreements on overheads are a standard part of contracts with multilateral organizations such as the PAHO. The result: instant dismissal of our team and completion of the project (it stopped in 1997). I myself left in 1998 to start working as a health theme expert for the Ministry of Foreign Affairs in The Hague. ... unexpected ending In 2009 El Salvador's elections were won – for the first time – by the left-wing parties. The result was a political change of guard at the top of the government. And in 2010 I was in . for the first time since my departure 1998 back in El Salvador. As an AIDS ambassador, I led a mission of the UNAIDS board. At my first meeting at the Ministry of Health, I was very surprised to meet the old dean of the medical faculty. He turned out to be appointed deputy minister responsible for sector policy. He told me that 'our' PHC program had been an important source of inspiration for the new sector policy. The new minister (Rector of the university at the time) had even introduced intersectoral cooperation at national level.

The lessons

  1. The choice of the least qualified provider for the baseline study turned out to be unintentionally brilliant. Not only was the university able to gain research experience, but it initiated a crucial process of change in thinking about health.
  2. Real changes take a long time and a solid endogenous foundation is essential
  3. There are actually no 'politically neutral' areas. 'Our' PHC approach was fully in line with the ruling party's policy on paper. But he had other motives and wanted to maintain the status quo.

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