Doctors strike wins national attention for healthcare

El Salvador Update, March 1998

Despite a multi-million colon publicity campaign and legal action by the ISSS (the Social Security Institute/national hospital system) the first national protest movement by Salvadoran doctors has brought the President of El Salvador to the negotiating table and has opened national debate on reforms to El Salvador's healthcare system.

Public healthcare in El Salvador is inadequate for the needs of the population. Hospitals are under-staffed, under-equipped, and doctors and staff under-paid. In the nation's only public hospital for trauma and grave illness, Rosales Hospital, three staff people often work a shift, taking care of 40 patients, (15 of them on stretchers between beds and in the hallways outside of different wards. The 3 x-ray technicians on a shift deal with x-rays for Rosales Hospital, for Chalatenago's Hospital as well as the x-rays for the national health clinics in municipalities around the country. Intensive care has space for a total of 4 patients though staff on the ward assess the need for 8-15 beds daily (more if staffing could be increased as well). In the ISSS, and health clinics doctors are given 15 minutes maximum to spend per consultation. Patients often must wait a month for an appointment. Specialization appointments can sometimes require 3-4 month waiting periods. If patients are late they are often given a new appointment for one month later. Equipment is old and outdated and doctors are ordered to use costly treatments as infrequently as possible. Medication is often poor quality and in insufficient quantity. Even basic medication such as pre-natal vitamins for pregnant woman is rationed out so a woman receives enough for two to 3 weeks every month rather than enough for a daily dosage throughout the course of her pregnancy.

Thus it was viewed as a substantial victory for doctors and the population as a whole when President Calderon Sol yielded to mounting pressure and personally joined his negotiating team to meet with doctors (as they had demanded) of the Social Security Institute. The doctors were in their third strike this year, the first strikes by a union of doctors in El Salvador. Since then an additional work stoppage has been held nationally and the situation remains unresolved.

On January 29, SIMETRISSS, the Union of Doctors, Workers of the ISSS, carried out the strikes. It lasted for 24 hours. The first strike came 8 months after negotiations were halted by the ISSS, to send a message to the ISSS leadership with the aim of re-opening negotiations. Eight hundred doctors participated at 8 hospitals throughout the country. The strike gained the commitment of the President of the ISSS Board of Directors, in the presence of the Director General of the ISSS, Dr. Maria Julia Castillo, to open a dialogue on the doctors demands.

While some of the 22 demands of SIMETRISSS deal with salary and economic issues they also seek to change the very structure of the healthcare system. The doctors are calling for democratization of decision-making in the ISSS through direct participation in planning based on resolving the needs of users; a higher quality and quantity of medications; a longer allotment of time to spend with each patient; improved quality in personnel requirements and equipment; less waiting time between appointments for patients and, a general improvement in services.

After a month of talks with a negotiating team with no real negotiating power, the doctors' union called a second strike, which began March 3. This time the strike was national and included 1,488 doctors, 93% of the physicians in the Social Security system.

The night before the strike began, the ISSS began airing professional quality television commercials as part of million colon propaganda effort denouncing the strike as hurting patients, risking lives and aimed at personal enrichment of the doctors. Hospitals were militarized by riot police at the request of Dr. Castillo.

Despite the show of force through the media and police by ISSS authorities, support for strikers began to grow within the medical profession. On the third day of the strike, 95% of the doctors at Hospital Rosales held a 4 hour work stoppage. The Association of Doctors at Rosales declared their work stoppage symbolic solidarity and explained that for the last four years they have been calling for the same changes in healthcare.

When asked to comment on the work stoppage, Rosales Hospital's Director, Dr. Avila Rosales, told La Prensa Grafica, that "the fundamental thing is to get the public to understand that the doctors of Social Security are not alone and that they have the support of all doctors at the national level."

With support rising for the ISSS doctors, Director Castillo, (known to workers as "la pistolera" during the war due to her style of walking around with a pistol strapped to her waist), took legal action against the strikers based on article 221 of the Constitution which prohibits strikes by public workers, Castillo won a ruling, that the strike was illegal.

The Minister of Health joined the fray charging that the FMLN, particularly Legislative Deputy Miguel Saenz, was behind the strike. Minister Interiano also denounced the work stoppage of Rosales doctors dismissing them as the same "4 or 5 doctors" that provoked so much unrest under the previous hospital administration.

On Friday, March 6, doctors returned to work declaring the effort a success despite the failure to have their demands addressed. The order of arrest however also continued in effect, forcing SIMETRISS leaders underground.

The next move by the ISSS Directorate was to offer a pay raise through televised commercials heralding a thousand colon increase per medical hour.

On March 16, SIMETRISSS rejected the pay offer and reasserted the need for overhaul of the healthcare system. The same day their 11 member leadership board went underground, as arrest orders had been issued for collective abandonment of functions during the 3 day strike.

While Calderon Sol refused to intervene against the orders and reiterated previous statements that he would not negotiate with the doctors, FMLN Deputy Shafick Handal called on the ISSS to be more flexible to seek a solution and insinuated that the Justice System needed to be more impartial. For its part the Legislative Assembly Commission's of Health and Labor announced that they would intervene to work for a rapid solution to the doctors' demands.

On March 17, SIMETRISSS announced the third labor action, a strike at the national level, demanding the rescinding of arrest orders against their leaders before any negotiations would begin. By this point national support across the profession had reached its peak. On this strike's first day, the Colegio Medico, the professional trade association of doctors, convened its General Assembly. The Assembly gave full support to the strike. Furthermore it opened a process to consider the expulsion of both Dr. Castillo and Minister of Health, Dr. Eduardo Interiano, from the body, which would mean their disbarrment as doctors.

By March 19, doctors at Hospital Rosales were joined by doctors at Hospital Zacamil and Santa Ana in a 4 hour work stoppage in support of the strike. Paid ads began filling the papers from private and public medically related associations in support of the strike and its list of demands. By the evening of the 19th the night before a national doctors march had been called by SIMETRISSS, Calderon Sol announced he would participate with a high level negotiating team and the arrest orders were overturned.

"Healthcare is sick but there is a remedy" was the theme of the protest carried out by thousands of doctors on the 20th, marching in their labcoats to the Ministry of Health and the legislature. The march filled 10 city blocks. While doctors were turned away by the Health Ministry, a group of marchers entered the Legislative Assembly to present a draft Plan for National Health. The plan was simultaneously submitted to the President as negotiations opened over the SIMETRISSS strike but with additional representatives of the Colegio Medico to follow up on the demands related to the health profession as a whole.

Dr. Castillo, ISSS Director, was conspicuously absent from the negotiating team after allowing the situation to reach crisis proportions. Instead of health officials, the Minister of Labor, Eduardo Tomasino was named to head the group.

On March 25, the strike was lifted as talks continued with the Commission headed up by El Salvador's Labor Minister. The 18 points agreed upon to date include: revising, improving and updating administrative processes in the ISSS; participation by SIMETRISSS in the purchase of medicines and equipment; providing necessary human and material resources for doctors; providing for specialization studies abroad; creating mechanisms and norms for hiring processes; just salary levels among the different workers at the ISSS and overtime pay. Most of the economic issues remain pending as the negotiating commission has not gone higher on salary offers than the ISSS had previously proposed.

On April 2-3, a 48 hour work stoppage was held to demand the empowerment of the negotiating team in order to go above previous salary offers. The work stoppage was carried out in the ISSS, 6 national hospitals and 2 state health clinics. Doctors of the health clinics are being consulted on their willingness to participate in future actions. According to SIMETRISSS, health clinic doctors as well as some ISSS doctors have been threatened be superiors regarding participation in strike actions in recent days. In mid-May if the government position does not change, growing protest by doctors is inevitable and may be joined by other workers in the healthcare system.

The demands of SIMETRISSS have demonstrated to doctors nation-wide that their demands are the same throughout the national health system. Doctors have taken steps to form a nation-wide doctors union and have also formed a tri-partite commission to parallel to the negotiations to communicate, coordinate and plan strategies for the restructuring of El Salvador's healthcare system. The Commission includes SIMETRISS, the Colegio Medico and National Hospital representatives. The Commission will be presenting their proposals to the political parties to take up in their platforms for the 1999 elections.

Throughout the strike the FMLN has worked in the legislature to bring the issues raised by SIMETRISSS to the Commission's of Labor and Health. More importantly perhaps they have encouraged the doctors to develop a health plan for the nation which has been presented to the Legislative Assembly and to the President. As a result of the protests, the legislature is considering revising El Salvador's Health Code which was last revised in 1988. The future of the ISSS Director is unclear. In late March the Social Christian Unity party called for her resignation and it was rumored that she had resigned and that a Legislative Deputy from the PCN was going to replace her. This unfounded rumor probably came from the PCN, which considers the ISSS their domain. The current director is a member of that small right-wing party.

It is unlikely substantial changes in healthcare will come under Dr. Interiano's leadership and even less likely he will be replaced. Interiano, a member of the Executive Committee of the governing party ARENA, and party coordinator for the Department of San Salvador, is a major player within the governing party. Under Interiano's tutelage massive campaigns of propaganda have been carried out as the main work of the ministry. The national health clinics have been re-painted and re-designed externally and he has praised that the health clinics have seen thousands of more patients in recent years. More sick people however, cannot be evaluated as equal to improved healthcare or advances in prevention of illness. Interiano's recent objections to the environmental impact studies for the new solid waste management plan being built by the Council of Mayors of the Greater Metropolitan Area of San Salvador is just one indication of the politicization of his post.

Another example of political demagoguery is the Ministry's most touted campaign, "las Escuelas Saludables" or Healthy Schools, in which schools are recognized for their sanitary conditions. This program has come under public scrutiny as it has become public knowledge that a good number of these schools have no electricity and water. The actual requisite for recognition is the washing of eating utensils. Last week the Minister remained silent when the Escuelas Saludables of Chalatenango denounced the Education Ministry for donating food to the schools in rusty cans with of expiration as old as 1996. While the Health Ministry remained silent, the Education Ministry explained that the expiration date was just a recommendation.