El Salvador

The Health in the Americas+¹ country profiles are based on the interagency indicators available as of the dates referenced. The sources are referenced in this table. In some cases, the values of the indicators may differ from the most recent data available in the country.

Environmental and social determinants of health

In 2000 the total population of El Salvador was 5 958 482 inhabitants; by 2023 this figure had risen to 6 364 943, representing a 6.8% increase. Regarding the country’s demographic profile, in 2023 people over 65 years of age accounted for 8.4% of the total population, an increase of 3.5 percentage points compared to the year 2000. In 2023, there were 110.1 women per 100 men and 33.4 older people (65 years or older) per 100 children under 15 years of age, as can be seen in the country’s population pyramids, distributed by age group and sex (Figure 1). Considering the population between 15 and 64 years of age to be potentially active (i.e., potential participants in the labor force), this group represented 66.6% of the total population of the country in 2023 (4 239 597 people). When we add these figures to the potentially passive population (1 593 109 under 15 years of age and 532 237 over 65 years of age), the result is a dependency ratio of 50.1 potentially passive people per 100 potentially active people. This ratio was 72.5 in 2000.

Life expectancy at birth in 2023 was 73.4 years, lower than the average for the Region of the Americas and 3.5 years higher that in 2000.

Figure 1. Population pyramids of El Salvador, years 2000 and 2023

Between 2006 and 2020, the average number of years of schooling in El Salvador increased by 24.9%, reaching an average of 7.2 years in the latest year for which information is available. The unemployment rate in 2022 was 3.8%. Disaggregated by sex, the rate was 4.2% for women and 3.5% for men. The literacy rate was 98.5% in 2020. In men, this figure was 98.7%; in women, 98.3%. In 2019, 1.3% of the population was living in poverty, defined as the percentage of the population with an income of less than US$ 1.90 per day; this is below the regional average of 3%.

During the period 2000-2021, the country improved its score on the Human Development Index, with an increase of 9.4% (from a score of 0.617 to a score of 0.675); during the same period, the index rose 13.5% internationally and 9.4% in Latin America (Figure 2).

Figure 2. Human Development Index in the Region of the Americas, 2021

In 2020, public expenditure on health accounted for 5.83% of gross domestic product (GDP) (Figure 3) and 17.83% of total public expenditure, while out-of-pocket spending on health accounted for 32.88% of total health expenditure.

Figure 3. Domestic general government health expenditure as percentage of gross domestic product, 2020

Digital coverage

In 2021, 62.9% of the population had an internet connection, representing a considerable increase from 2000, when 1.2% of the population had an internet connection.

Health situation

Maternal and child health

Between 2007 and 2021, infant mortality in El Salvador decreased from 21.5 to 9.3 deaths per 1000 live births, a decrease of 56.7% (Figure 4). The percentage of low-weight births (less than 2500 g) increased from 8.0% to 9.1% between 2004 and 2020, while exclusive breastfeeding in the child population up to 6 months of age was 24% in 2003 and 31.4% in 2008 (latest available data).

Regarding the immunization strategy, measles vaccination coverage was 65.0% in 2022, a decrease of 32 percentage points from 2000.

The maternal mortality ratio for 2020 was estimated at 42.8 deaths per 100 000 live births, a reduction of 12.3% from the estimated value for 2000 (Figure 5). In relation to fertility, it is estimated that in 2023 women had an average of 1.8 children throughout their reproductive lives. In the specific case of adolescent fertility, there was a 50.4% decrease, from 107.9 live births per 1000 women aged 15 to 19 years in 2000 to 53.5 in 2023. In 2021, 99.5% of births were attended by skilled birth personnel. Between 2011 and 2018 the percentage of pregnant people who had four or more consultations for antenatal care increased from 75.3% to 82%.

Figure 4. Infant mortality per 1000 live births, 1995–2020

Figure 5. Maternal mortality per 100 000 live births, 2000–2020

Communicable diseases

In 2021, there were 31 new cases of tuberculosis per 100 000 population in El Salvador. In 2019, the overall tuberculosis mortality rate (age-adjusted and per 100 000 population) was 0.9 (0.6 in women and 1.3 in men).

In 2021, the estimated human immunodeficiency virus (HIV) infection incidence rate (new diagnoses) was 18.8 per 100 000 population. The age-adjusted mortality rate for HIV was 14.6 per 100 000 population in 2019. It should be noted that during the 2000-2019 period this indicator decreased by 3%.

 In 2020, there was one reported case of human rabies in the country.

Noncommunicable diseases and risk factors

In El Salvador in 2023, the prevalence of tobacco use among people aged 15 and older was 7.2%. In the same age group, the prevalence of overweight and obesity was 59.9% in 2016. 

In 2015, the reported prevalence of arterial hypertension (high blood pressure) among people aged 18 years or older was 18.7%, a decrease of 3.1 percentage points compared to 2000 (21.8%). The prevalence of diabetes mellitus, which stood at 8.3% in 2000, increased to 10.1% in 2014.

Mortality

In 2019, the adjusted rate of potentially preventable premature mortality in El Salvador was 312.4 deaths per 100 000 population, a decrease of 10% compared to the rate of 347.2 in 2000. This meant that, in 2019, the rate in the country was 37.8% higher than the average rate reported for the Region of the Americas as a whole. Among potentially preventable premature deaths, the rate for preventable causes was 200 per 100 000 population in 2019, which is 45.9% higher than the regional average rate; and the rate for treatable causes was 112.5 per 100 000 population, above the regional average of 89.6.

The overall age-adjusted mortality rate was 6.1 per 1000 population in 2019, a decrease of 13.6% compared to 2000 (7.1 deaths per 1000 population).

When deaths are categorized into three main groups, it is observed that, in 2019, the age-adjusted mortality rate from communicable diseases was 93.9 per 100 000 population (122.9 per 100 000 in men and 72.5 per 100 000 in women), while the age-adjusted mortality rate from noncommunicable diseases was 393.4 per 100 000 population (504.5 per 100 000 in men and 312.4 per 100 000 in women). The rate of age-adjusted mortality from external causes was 122.5 per 100 000 population (188.1 per 100 000 in men and 67.4 per 100 000 in women), including road traffic accidents (21.4 per 100 000 population), homicides (86.7 per 100 000 population), and suicides (6.1 per 100 000 population). In 2000, the percentage distribution of causes was 55.5% for noncommunicable diseases, 21.6% for communicable diseases, and 22.8% for external causes; in 2019, the percentages were 65.1%, 15.8%, and 19.1%, respectively (Figure 6).

Figure 6. Proportional mortality in El Salvador, 2000 and 2019

Cancer mortality

Regarding cancer mortality from tumors, in 2019, the adjusted mortality rate from prostate cancer was 11 per 100 000 men; lung cancer, 5.4 per 100 000; and colorectal cancer, 5 per 100 000. In women, these values were 8 deaths per 100 000 for breast cancer, 4.2 per 100 000 for lung cancer, and 4.8 per 100 000 for colorectal cancer.

The health situation and the COVID-19 pandemic

In El Salvador in 2020, there were a total of 45 960 cases of COVID-19, representing 7 278.6 per million population. In 2021, there were 75 985 identified cases, equivalent to 12 033.6 per million population. In 2020, there were 1 336 deaths directly caused by COVID-19 in people diagnosed with the disease, or 2116 per million population; in 2021, 2 488 deaths were reported, or 394 per million. In 2020, El Salvador ranked 27 in the Region of the Americas in terms of the number of deaths from COVID-19, 44 in 2021, with a cumulative 605.6 deaths per million population over the three years (Figure 7).

According to estimates by the World Health Organization, there were a total of 7506 excess deaths in 2020, or 116 per 100 000 population. A total of 9529 deaths were estimated in 2021, for an excess mortality rate of 146 per 100 000.

As of 31 December 2021, at least one dose of COVID-19 vaccine had been given to 70.6% of the country's population. As of 2 July 2022 (latest available data), 66% of the population had completed the vaccination schedule. The vaccination campaign began on 20 February 2021, and six types of COVID-19 vaccine have been used to date.

Figure 7. Cumulative COVID-19 deaths in the Region of the Americas, to July 29th, 2023

Prospects

Measures to achieve universal health coverage

The Institutional Strategic Plan 2021-2025 (Plan Estratégico Institucional), formulated in alignment with the Cuscatlán Plan 2019-2024, projects that by 2025 the goal is to expand access to health services to 60% of the population without previous access and increase to 60% of the population's affiliation with a health service provider of the first level of care of the Integrated and Comprehensive Health Networks through the synergy and articulation of service providers. This Institutional Plan also seeks that by 2025, 100% of the health institutions that are members of the National Integrated Health System (Sistema Nacional Integrado de Salud, SNIS) implement the intersectoral action plan to address the social determination of health.

Government authorities have established a series of measures to achieve universal health coverage, including the Cuscatlán Plan, which sets out the following health-related objectives:

• Guarantee the progressive increase of coverage and universal access to health, with complete equity for all the inhabitants of the country.
• Strengthen strategies leading to health promotion and education, disease prevention, and the treatment and rehabilitation of people who have suffered damage to their health.
• Fully implement the comprehensive primary health care strategy.
• Guarantee the progressive increase of coverage and universal access to health, with complete equity for all the inhabitants of the country.
• Strengthen strategies leading to health promotion and education, disease prevention, and the treatment and rehabilitation of people who have suffered damage to their health.

Similarly, the Plan proposes, in the strategic line referring to the organization of health services, the need to "Advance in the development towards an integrated National Health System based on Comprehensive Primary Health Care, addressing social determinants to guarantee the human right to health end route to Universal Access and Coverage, the identification and combat of health inequities, as well as the achievement of the Sustainable Development Goals and the 2030 Agenda". 

Challenges related to population health

Among the pending challenges of El Salvador's public policy agenda, the sustainability of the actions undertaken in the Cuscatlán Plan occupies a prominent place, given that it implies a significant public investment in health. Government authorities have indicated that a gradual and sustained increase in health spending is expected to reach values of no less than 5% of GDP.

COVID-19 pandemic response

The response plan for health care during the pandemic included the creation of a fully specialized unit, the El Salvador Hospital, whose installed physical capacity has about 850 beds, of which 250 are prepared and equipped for the care of severe and critical cases. This hospital, which is equipped with the latest and best technology, will soon be converted into a high-specialty hospital. 
El Salvador’ public policy response to this emergency also included the preparation of documents and technical guidelines that were extremely useful, among other aspects, for the correct articulation of the measures implemented, such as the "Technical guidelines for the follow-up of home isolation and outpatient care of suspected and confirmed cases of COVID-19"  and the "Strategy for immunization against SARS-CoV-2 in pregnant and puerperal women"  and other equally relevant documents.

Finally, it is also worth highlighting the COVID-19 vaccination strategy through the creation of a mega-center, with the capacity to apply more than ten thousand doses per day, and the implementation of more than 160 vaccination units distributed throughout the country.

Measures to reduce inequalities in health

The national government has implemented the Crecer Juntos (Growing Together) program, a comprehensive public policy aimed at early childhood, that is, the stage from the time children are born until they reach 8 years of age. This policy has been designed with a rights-based approach to guarantee Salvadoran children access to quality services in the provision of care, stimulation, education, health, nutrition, protective environments for their rights and special protection, with the goal of preventing poverty, violence, inequality, and lack of opportunities.

In accordance with the National Integrated Health System Law and through the coordination of the Health Cabinet and the Expanded Health Cabinet, intersectoral work is addressed to address the social determinants of health, with intersectionality as one of the instruments of integration and periodic monitoring and evaluation of the system.

National strategy to address inequalities in health

The Institutional Strategic Plan 2021-2025 reflects the programmatic and operational vision of the government authorities for the five-year period and explicitly recognizes the importance of the social determinants of health, as it includes them as part of its mission: “Somos el ente rector del Sistema Nacional Integrado de Salud en El Salvador, que […] promueve la intersectorialidad para el abordaje de las determinantes sociales de la salud […]”. 

On the other hand, the National Integrated Health System Law, reformed in 2020, constitutes the legal framework where several regulations that promote the search for equity in health are included. Within that set of regulations, those referring to medicines (2012), vaccines (2012), mental health (2017) and breastfeeding (2013), among others, occupy a prominent place.

Finally, national legislation focused on disease prevention and people's wellbeing is also relevant, such as the Tobacco Control Law, enacted in 2011. 

The sources of the interagency indicators used in this profile can be found in this table.

For the latest data on health indicators for the Region of the Americas, be sure to visit the PAHO Core Indicators portal.