The crisis of the national system of health persists

A juridical discussion of the Decree 1024

The Decree 1024 is the result of the pressures that the doctors, the unionists, and certain organizations from the civil society subjected the ARENA administration to during the last couple of months. The decree has a political sense. Many voices interpret the decree as a victory for the unions and the social organizations over a governmental style in which an arrogant attitude can be turned into a law when it comes to deal with the rest of the society. In addition, the fact that President Flores accepted its publication, despite the incendiary declarations against it, is an unmistakable sign of a political force. However, before the decree comes into effect, a series of juridical arguments has emerged, and now it would not be a surprise if the Supreme Court of Justice Annuls it. From this moment on, there are two different versions of the decree: the one of the detractors, and the one of those who defend the decision of the congressmen in order to hinder the privatization of the public health sector.

The detractors of the Decree 1024 (El Diario de Hoy is at the top of the list) enumerate the services that would allegedly have to be suspended if the decree comes into effect. El Diario de Hoy explained that “by forbidding the concession of the services, the institution will have to rescind at least fifty contracts of essential medical services”. In addition, according to the same interpretation, because of the decree “dozens of services of the administrative areas of the Social Security Institute would not be available, such as security, cleaning, potable water, electricity, telephone lines, cellular lines, and the maintenance of the medical and the administrative equipment”. They also spoke about the need to defend the juridical security. According to this perspective, it is completely ridiculous to pretend to end with certain contracts because of the decree.

That is why some people are talking about a storm over the Social Security Institute. Logically, those who accept this interpretation present themselves as those who can act as guarantors of the juridical security and the suffering users of the ISSS, so that the institution does not fall into a technical strike. This apocalyptic vision is essentially based on the fifth article of the decree, which stipulates that “the contracts for the services, the concessions, the subcontracts, among others that might be valid to this date, will not be derogated under any circumstance, and will have to end by December 31st, 2002”.

According to the second perspective, the one of the doctors and the defenders of the decree, there is no such chaos at sight. The president of the Medical Society speaks about a conspiracy inside the right-wing political parties. That conspiracy intends to restrain the aspirations of those who do not agree with the privatization of the public health sector. The offensive of the news media, launched ever since the approval of the aforementioned law, is the response of the right-wing parties to the apparent capitulation of the President before the demands of the doctors and the members of the union.

Before such different perspectives, it would be convenient to take a closer look at the decree in order to clarify the postures in the discussion. In the first place, the text starts with a cliché, which is already contemplated in the Constitution, about the role of the state –to grant the health and the social security rights to the Salvadorans-. It also defines what can be understood as “public health services” and “social security”. This area includes the services rendered by “the general doctors, the laboratory technicians, the assistants, the nurses, the administrative personnel, and the general services’ staff (those who are responsible for assisting the doctors, the hospitalization procedures, the rehabilitation of the patients, and any other service to guarantee the health of the patients at the ISSS, as well as at the chain of hospitals and the health units of the Ministry of Public Health and Social Assistance)”.

Based on the former idea, the third article of the decree “forbids the privatization, the concession, the acquisition of services, the subcontracts, or any other modality intended to transfer the public health services and the social security to a number of private companies”. The ISSS and the hospitals of the Ministry of Health are responsible for providing those services. Some exceptions are considered in reference to the former dispositions, such as the ones mentioned in the literal “d” of the same article “if the institutions of the national public health system and the ISSS are not able to provide the treatment required by certain patients...”. In order to make a decision of such nature, the decree establishes that it is necessary to determine the needs “in a reunion with the doctors who belong to the required medical specialty”.

If the ideas that have been formerly explained here are taken seriously, it is impossible to accept the chaos predicted by some personalities about the alleged confusion of the Decree 1024. In the first place, it is not true that the ISSS and the hospitals of the Ministry of Public Health will not have access to the electricity, the potable water and the telephone services. These are not public health services or Social Security services. The Decree is not intended to deal with these utilities, and those who understand it differently, either do not understand the decree or have something against the struggle of the doctors and the members of the union. If someone said that the definition of “health services” of the second article is ambiguous –since it considers as a public health service the functions of those who assist the medical staff during the appointments, the hospitalization, the rehabilitation process, etcetera-, the literal “d” of the decree could clarify this matter. Something new about that article is that it allows the doctors to participate in the hiring process.

With this we do not only deconstruct the thesis of a chaos, but we can also observe the leading role that the legislator gives to the doctors to determine the future contracts. In this context, it is convenient to ask if the Congress is making a mistake because it is not giving the same leading role to the rest of the public health workers in general. In this sense, if to encourage the participation of the leading actors is their goal, someone would have to consider the other workers who are not doctors and the users in order to determine what are the contracts that will be made with other institutions.

About the issue of the juridical security, those who oppose to the Decree 1024 consider that the rights of the businessmen are not respected when the concessions and the contracts are suspended (by December 31). In this sense, it seems logical to consider the constitutionality of this decision. Those affected are getting ready to bring their complaints before the Supreme Court of Justice and they have the right to do so. It is evident that this is a controversial decree. The congressmen could have waited for the end of the present contracts and they could have established the severance pay criteria for those affected.

However, it is a fact that the congressmen have the authority to decree special laws that can affect certain particular interests without violating the constitution. The “alleged” lawyers who criticize the possible effects of the Decree 1024 have to be reminded that the Article 246 of the Constitution states that the public interest will be more important than the private interests. In this context, it is valid to derogate those rights if the privatization, and the abusive and the mercantilist concession of the health services affect the public interest.

The Central American and the Caribbean XIX Sports Games: Economic Considerations

The Central American and the Caribbean XIX Sports Games were officially inaugurated on November 23rd . This is a historical event for El Salvador. For 68 years, this country was not on the list of the organizers. The last time that this event was celebrated in El Salvador was in 1934. During that time the country was under the severe dictatorship of the most bloodthirsty president that El Salvador has ever had, and the games became a distraction in a scenery affected by an economic crisis an a military dictatorship supported by the Salvadoran oligarchy.

During that time, the celebration of the event demanded the construction of the Flor Blanca Olympic Stadium, and just like in the present, it became a landmark for the development of the facilities for sports infrastructure. In fact, the aforementioned stadium remains as the scenery in which a variety of activities are celebrated.

During the present sporting events, the president has made a considerable investment on the infrastructure of the campus of the National University of El Salvador –and other scenarios-. The facilities of the University had been abandoned for over 30 years (the University has been open, but no major investment on its infrastructure had been made in 30 years). Without a doubt, these are good news, but it is necessary to examine the costs and the economic implications of the event, its benefits and its beneficiaries, and the scale of priorities that the Salvadoran leaders have in their agendas.

About the cost of the Games, it is estimated that it will be approximately $74 million. A total of $40 would have been invested in the renovations of the University of El Salvador. According to an official version, the funds would be acquired through a number of loans, and a series of generous donations. The required investment to promote the Games would come from a $50 million loan obtained at the Central American Bank for the Economic Integration (BCIE, in Spanish), and from a $26 million loan of the Spanish government. Spain would have worked as a channel to obtain a donation of $30 million. In the end, it s-eems as if the Games were over-financed.

The sports conclave has unleashed an important process of investments and economic growth, as well as a promotion of the different branches in sports. However, it has turned into a higher level of indebtedness for the central government. For the Vice-minister of Hacienda (Internal Revenue Service), Mauricio Funes, this is not important. In his opinion, “the perspective of the President was to blend the reconstruction of the country, the needs of the University, and the preparation for the Games... the Games became a sort of a catalyst”.

It is clear that the expenses made by the state to organize the Games have turned into an important dynamo for the construction sector, which has had the chance to execute multi-million dollar projects building and restoring the sports scene. This has also had an important impact on the employment level for the construction workers, a larger demand of all kinds of goods and services, and the activation of other economic sectors because of the multiplying effect of the investment. On the other hand, according to an estimate made by the Vice-minister of Hacienda, approximately 30,000 people will be present at the different sports arenas, and these people “could spend up to $1,000 at all times. We believe that we could receive close to $30 million just from that. In addition, with the sales of the tickets we expect to receive $2.9 million”.

It is not clear who will be the beneficiaries of this new cash flow, because the state will only receive the $2.9 million that will come from the sales of the tickets. On the other hand, the private business companies would have been favored by the public investment on the infrastructure, while the amount of money that the Vice-minister speaks about would circulate mainly through the hotels and the tourist destinations. This could have an undeniable effect over the employment level, but the sector that will receive a larger number of benefits is the elite of hotel owners and the “proudly Salvadoran” airline that monopolizes the aerial transportation in Central America. It should not sound odd then when the president of the National Association of the Private Business Companies (ANEP, in Spanish), Elias Antonio Saca, says that “the growth of the economy will depend on the investment that has been made on the Games”.

In this context, it is necessary to ask how do these Games benefit the poor rural population of El Salvador, those families who live in extreme poverty and whose members are exposed to the slightest climatic change and to a number of drastic alterations because of the conditions they live in. The same question is valid for the informal urban worker, who does not belong to any of the circles that provide the services to organize the Games. Those less fortunate will not even be able to assist to the Games because the prices are too high for them.

The fact that President Flores has decided to go ahead and organize the games does not only reveal a possible interest for the promotion of sports, but it also reflects a scale of values where an image is more important than anything else. This does not sound strange for an administration that for three years has clearly shown an interest to elevate its image through a multi-million dollar campaign in the news media.

While the government has made a multi-million dollar investment on the Games, more than 150,000 families have lost their homes because of the earthquakes in 2001, and many of them still live in temporary homes. Of all the housing projects that were built after the earthquakes, the government has only made a small contribution if we compare it with the donations of the international cooperation. At the same time, there are other needs that have not been fulfilled in the public education and the public health areas. There are hospitals and schools that have not been rebuilt.

The investment on the UES is laudable, and it can contribute to improve the physical and the mental health of the students, but it should not be a secondary goal or the appendix of the games. It should be a priority. The same can be said about the housing issue, and the improvement of the health and the education benefits.

There is no doubt that the Central American and the Caribbean XIX Sports Games will improve the image of the country. However, that does not change the fact that, under the appearances, lies a reality of misery and social deprivation that affects –according to the official figures- half of the country’s population.