“ANALYSIS OF EFFICIENCY AND EFFICACY OF THE
SALVADORAN NETWORK OF HUMAN MILK BANKS”
Acknowledgments
Authorities Ministry of Health
Dr. Francisco José Alabí Montoya, Minister of Health (Ad-Honorem).
Dr. Carlos Gabriel Alvarenga Cardoza, Deputy Minister of Health Management and Development. (Ad-Honorem)
Dr. Karla Marina Díaz de Naves, Deputy Minister of Health Operations.
Editorial Committee
MINSAL
Dr. Juan Morales. Coordinator of the Unit of Integral Attention to Children.
Dr. Mirian Alvarado, Coordinator of the Salvadoran Network of Human Milk Banks.
CALMA
Ana Josefa Blanco Noyola, Executive Director.
Kenny Marielos García de López, Coordinator of the Breastfeeding Unit.
Lic. John Cativo, Management and Monitoring Manager.
Flor Artiga de Bolaños, Communications Coordinator.
Consultant
Ernesto Nosthas, Lead Researcher.
To the staff of the Salvadoran Network of Human Milk Banks interviewed for this study: Human Milk Banks of the
National Women's Hospitals "Dra. María Isabel Rodríguez", "San Juan de Dios" of San Miguel, "San Juan de Dios" of
Santa Ana and the HMCC: Hospital Nacional de Zacatecoluca, Hospital Nacional de Usulután, Hospital Nacional de San
Francisco Gotera, UCSF de La Presita - San Miguel, UCSF Puerto de La Libertad, UCSF Los Planes de Renderos, UCSF San
Martín, UCSF Unicentro-Soyapango, San Julián Integral Center for Maternal and Child Care and Nutrition CIAMIN,
Manufacturing Companies Fruit of the Loom Santa Ana & Ciudad Arce, ISSS Santa Ana Regional Hospital, Hospital
Nacional de Chalchuapa and Hospital Nacional de Ahuachapán.
To the donor and recipient mothers of the HMB who provided information.
I
Content
Acknowledgments .............................................................................................................................................................................. i
Index of tables and figures ............................................................................................................................................................. iv
Acronyms and abbreviations ......................................................................................................................................................... vi
1.
Introduction...............................................................................................................................................................................1
2.
Objectives of the Study ..........................................................................................................................................................1
3.
Rationale of the Study .............................................................................................................................................................2
4.
Methodological Approach ......................................................................................................................................................4
5.
Conceptual framework ...........................................................................................................................................................5
Human Milk Banks and Collection Centers ...........................................................................................................................5
Efficiency analysis ..........................................................................................................................................................................8
Analysis of key factors for improvement in the operation of the HMB-HMCC network. ...................................... 11
6.
Findings of the HMB-HMCC Network Efficiency Analysis ........................................................................................ 12
Phase Zero: Donor Mother Recruitment............................................................................................................................ 12
Phase 1: Collection of DBM .................................................................................................................................................... 16
Phase II Processing of DBM to obtain PBM......................................................................................................................... 20
Phase III Dosage of PBM .......................................................................................................................................................... 22
Installed capacity utilization ..................................................................................................................................................... 24
PBM production performance factor .................................................................................................................................... 26
Pasteurized breast milk production line capacity............................................................................................................... 27
Coverage of the demand for pasteurized breastmilk ....................................................................................................... 29
7.
Analysis of improvement factors to optimize the operation...................................................................................... 30
Recruitment of donor mothers.............................................................................................................................................. 30
Human Resources ..................................................................................................................................................................... 31
HMB Human Resources ...................................................................................................................................................... 31
Human resources at HMCC .............................................................................................................................................. 32
Infrastructure .............................................................................................................................................................................. 36
HMB Infrastructure............................................................................................................................................................... 36
HMCC Infrastructure ............................................................................................................................................................... 36
Equipment .................................................................................................................................................................................... 37
HMCC equipment................................................................................................................................................................. 37
HMCC Freezers .................................................................................................................................................................... 37
Transportation at HMB - HMCC ...................................................................................................................................... 38
II
Inventory and Control Systems at HMB - HMCC ........................................................................................................ 39
Cross-cutting aspects of the HMB-HMCC Network ....................................................................................................... 40
The quality of the processes .............................................................................................................................................. 40
Monitoring and evaluation .................................................................................................................................................. 40
Coordination between units .............................................................................................................................................. 40
Overall Weighting of Key Operating Factors ..................................................................................................................... 41
8.
HMB Network Cost Analysis ............................................................................................................................................ 43
9.
Key Findings from the HMB Network Donor Mother Perceptions Survey ........................................................... 44
10.
Conclusions........................................................................................................................................................................ 45
On the recruitment of donor mothers (Phase 0):............................................................................................................. 45
DBM Over-Capture (Phase 1):............................................................................................................................................... 45
On PBM production (Phase 2): .............................................................................................................................................. 46
PBM delivery and dosage (Phase 3) ....................................................................................................................................... 47
On Cross-cutting Processes ................................................................................................................................................... 47
11.
Lessons learned................................................................................................................................................................. 48
Best practices.............................................................................................................................................................................. 48
Strategic opportunities to enhance the HMB-HMCC Network .................................................................................... 49
12.
Recommendations ............................................................................................................................................................ 49
General recommendations ...................................................................................................................................................... 49
On the recruitment of donor mothers (Phase 0):............................................................................................................. 50
Over-capture of DBM (Phase 1): ........................................................................................................................................... 51
On PBM processing (Phase 2): ............................................................................................................................................... 52
PBM Delivery and Dosing (Phase 3)...................................................................................................................................... 52
13.
Bibliography........................................................................................................................................................................ 53
III
Index of tables and figures
Figure 5-1: Chronology of the establishment of the HMB-HMCC network in El Salvador. ...........................................6
Figure 5-2: Territorial network of HMBs and their network of HMCCs. ..........................................................................7
Figure 5-3: PBM production line in the HMB-HMCC Network. ...........................................................................................8
Figure 5-4: Key elements for the HMB-HMCC network efficiency analysis. ......................................................................9
Box 5-1: MINSAL guidelines on home milk collection.......................................................................................................... 10
Table 5-1: Matrix analysis of improvement factors for the operation of the HMB-HMCC network. ..................... 11
Figure 6-1: Structure of raw breast milk inputs to HMBs between June 2020 and July 2021 (liters). ...................... 15
Table 6-1-A: Key aspects that define the operation of the HMCC network attached to HMB San Salvador. ....... 17
Table 6-1-B: Key aspects that define the operation of the HMCC network attached to HMB Santa Ana. ............ 18
Table 6-1-C: Key aspects that define the operation of the HMCC network attached to HMB San Miguel............ 19
Table 6-2: Pasteurized milk production June 2020-July 2021. ............................................................................................. 21
Table 6-3: Abnormal DBM losses in the HMB-HMCC network June 2020 - June 2021. ............................................. 22
Figure 6-2: Historical trends in PBM delivered and babies benefited. ............................................................................... 23
Table 6-4: Statistics on production and delivery of PBM to beneficiary babies at HMB.l año precedente. ............. 24
Table 6-5: Yields by territorial network and type of establishment to which the HMCC is attached. ..................... 25
Table 6-6: Maximum throughput standards at HMBs............................................................................................................ 26
Table 6-7: PBM production yield factor at HMB. ................................................................................................................... 26
Figure 6-3 Pasteurized breastmilk production line capacity ................................................................................................ 28
Table 6-8: Coverage of newborns under 1500 grams at the national level MINSAL. ................................................... 29
Box 7-1 Key operating factor assessment – Recruitment of donor mothers ................................................................. 31
Table 7-1-A: Staff attending the HMCCs visited for the present study in the HMB network of San Salvador:
Experience and training courses. ................................................................................................................................................ 33
Table 7-1-B: Staff attending the HMCCs visited for the present study in the HMB network of Santa Ana: Experience
and training courses. ...................................................................................................................................................................... 33
Table 7-1-C: Staff attending the HMCCs visited for the present study in the HMB network of San Miguel:
Experience and training courses. ................................................................................................................................................ 34
IV
Table 7-2: Summary of experience and training courses by HMB territorial network. ................................................ 35
Box 7-2 Key operating factor assessment – Recursos Humanos en los HMCC ............................................................ 35
Box 7-3 Key operating factor assessment – Infraestructura ............................................................................................... 37
Table 7-3: Average years of operation by type of equipment in HMBs (2021). ............................................................. 38
Box 7-4 Key operating factor assessment – HMB Equipment ............................................................................................ 39
Box 7-5 Key operating factor assessment – Cross-cutting aspects of the HMB-HMCC Network........................... 41
Figure 7-1: Key operating factors global assessment of the HMB-HMCC Network..................................................... 42
Table 8-1: Analysis of Total Costs of the HMB Network - HMCC of San Salvador (data collected for June 2020 June 2021) ........................................................................................................................................................................................ 43
Figure 12-1: Basic Structure of an HMB-HMCC Network Monitoring and Evaluation System .................................. 50
V
Acronyms and abbreviations
ABC Brazilian Cooperation Agency
CALMA Breastfeeding Support Center
DBM Donated Breast Milk
ECN Necrotizing Enterocolitis
FOSALUD Solidarity Fund for Health
HMB Human Milk Bank
HMCC Human Milk Collecting Center
ISSS Salvadoran Social Security Institute
LM Breastfeeding
MDG Millennium Development Goals
SDGs Sustainable Development Goals
MINSAL Ministry of Health
NGO Non-Governmental Organization
NICU Neonatal Intensive Care Unit
PBM Pasteurized Breast Milk
RIIS Comprehensive and Integrated Network of Health Services
SIBASI Basic Integral Health Systems
SRH Sexual and Reproductive Health
UCSF Community Family Health Clinic
UNICEF United Nations Children's Fund
WHO World Health Organization
VI
1. Introduction
MINSAL has developed a series of policies and programs based on scientific evidence that have been implemented
with the purpose of influencing the reduction of neonatal and infant mortality from these causes, addressing risk
factors in women from before conception, among which, one of the most successful and effective has been the
creation of the National Network HMB-HMCC .
This initiative is being promoted since 2011 under the leadership of MINSAL, with the technical and financial
support of the UNICEF and CALMA, a coalition of different institutions such as the Neonatal Alliance of El Salvador
and the Government of the Federative Republic of Brazil in the framework of international South-South
cooperation agreements and the media.
HMB is internationally recognized as a fundamental and decisive strategy to save the lives of children in special
conditions. CALMA has been part of this effort since its beginning and is currently the only Civil Society
Organization to be a member of the Global Network of Human Milk Banks, being a key partner for MINSAL to
strengthen this strategy.
This document corresponds to CALMA's inter-institutional work priorities for the year 2021 and is part of the
technical assistance efforts to strengthen the HMB-HMCC Network, which is a strategic instrument for the
promotion, protection and support of breastfeeding, also establishing (i) a valuable pool of specialized tools for
the vital development of the preterm and/or low birth weight neonatal population and (ii) a set of good practices
that prevent/address diseases such as neonatal sepsis and necrotizing enterocolitis, which contributes concretely
and gradually to the diminution of neonatal mortality (CALMA-UNICEF-MINSAL, 2017).
This study has been organized into four sections, the first consists of the general presentation of the objectives,
justification, methodology and conceptual framework of the study, the second section presents the results
obtained in the analysis of the operation of the HMB-HMCC system in both the analysis of the efficiency with
which the network currently operates, the key operating factors. The third section analyzes the impact of the
Strategy on donor mothers and their babies through the results of a survey.
The final section synthesizes the lessons learned from the study in terms of conclusions, lessons learned, good
practices and recommendations to improve the management of the strategy within the framework of the National
Policy to Support Early Childhood Development "CRECER JUNTOS (Growing Together)”, the National Policy for
the Promotion, Protection and Support of Breastfeeding and the Law for the Promotion, Protection and Support
of Breastfeeding and its Regulations.
2. Objectives of the Study
The general objective of the study is to systematize and analyze the technical evidence on the Salvadoran Network
of Human Milk Banks in El Salvador to establish the efficiency and effectiveness of the operation of HMBs and
HMCCs in the period from June 2020 to June 2021. From this general objective, the study was conducted with
these specific objectives:
i.
Analysis of the infrastructure of the three existing HMBs nationwide and a sample of fourteen HMCCs to
determine strengths and needs. The study includes information on logistical aspects that affect the transfer
of collected human milk from the HMCCs to the HMBs.
1
ii.
Analysis of the human resources of HMBs and HMCCs to determine current capacities and identify needs
for strengthening.
iii.
Analysis of the promotion of human milk donation, counseling provided to mothers, recruitment of donor
mothers by HMB-HMCC , quantity of milk and conditions for extraction and frequency.
iv.
Efficiency and effectiveness analysis of the functioning of the HMB Strategy and the current status on:

Promotion for human milk donation and recruitment of donor mothers.

Collection of human milk at HMCC.

Human milk storage at HMCC.

Transport logistics from HMCC to HMB.

Processes of analysis and discarding of human milk at HMB.

Pasteurization process and final delivery of pasteurized milk to low birth weight or premature
newborns in Human Milk Banks.
3. Rationale of the Study
According to WHO, malnutrition is directly or indirectly responsible for approximately one third of the deaths
of children under 5 years of age in Latin America. Well over two-thirds of these deaths, often related to inadequate
feeding practices, occur in the first year of life.
Nutrition and care during the early years are fundamental to lifelong health and well-being. In infancy, there is no
more valuable asset than breastfeeding, yet only 5 out of 10 infants in El Salvador are exclusively breastfed for the
first six months.
According to Lancet, "Children who are breastfed for longer periods have lower infectious morbidity and
mortality, fewer dental malocclusions and higher intelligence than those who are breastfed for shorter periods or
are not breastfed. This inequality persists throughout life. There is growing evidence that also suggests that
breastfeeding could protect in the future against overweight and diabetes": without exclusive breastfeeding, there
are higher probabilities that children face chronic malnutrition (CALMA-UNICEF-MINSAL, 2017).
Children suffering from chronic malnutrition not only have short physical stature, but also the development of
their brains-their "gray matter infrastructure" is atrophied. Between the third trimester and the third year of life,
one million synapses are formed every second, and these connections form the essential brain architecture on
which all learning, behavior and health depend. Fewer neural connections are formed in the brain of a malnourished
child and these gaps are not recovered (WHO, 2002).
Based on the above considerations, breast milk is indisputably the best food for newborns and infants, since it is a
safe food par excellence that reduces the risk of diseases such as allergies, diarrhea, respiratory infections, asthma,
otitis, meningitis, urinary tract infections, necrotizing enterocolitis in premature infants and sudden infant death. It
2
also favors a quick recovery in case of illness. Scientific studies have shown that it also favors visual and intellectual
development (WHO, 2002).
For the specialized care of premature infants, WHO recommends that "when the mother's own milk is not
available, PBM from selected donor mothers from certified HMBs is the best option for infant feeding,
especially in the case of sick or high-risk infants" (WHO, 2002).
PBM is the second best feeding option for newborns with special conditions, such as low birth weight or premature
infants. This milk needs to be pasteurized to inactivate viruses and bacteria, but at the same time its nutritional
composition diminishes. Despite this, like breast milk, it has proven to be beneficial for the preterm neonate as it
produces a diminution of enterocolitis, sepsis, bronchopulmonary dysplasia, as well as an increase in food tolerance
and better neurodevelopment (Picaud JC, 2017).
HMBs are specialized centers responsible for the promotion and support of breastfeeding and the collection,
processing, quality control and dispensing of donated mother's milk to any child who needs it, under medical
criteria. HMBs are fed by volunteer mothers who donate their surplus breast milk, which are subjected to strict
validation and certification protocols, both for the health of the donor mothers and for the quality and safety of
the breast milk they decide to donate altruistically for the benefit of sick or premature newborns.
In this context, international and national experience has proven that the creation and operation of a National
Network of HMBs is a successful strategy to contribute to achieve a reduction in infant morbidity and mortality,
in addition, they are a very effective reference for the promotion of breastfeeding.
HMBs are specialized establishments, generally dependent on Hospitals with Maternity Services, which offer the
services of collection, processing, storage, distribution and quality control of donated breast milk, which requires
adequate areas, professional trained in handling babies in special situations. The benefits of HMBs are numerous.
The administration of breast milk is particularly effective for feeding newborns who are at risk, either because of
extreme prematurity, low birth weight or other special condition (CALMA-UNICEF-MINSAL, 2017).
Premature and low birth weight babies are characterized by having an immature digestive system and need breast
milk which is more digestive to feed and properly absorb all their nutrients. It has been shown that feeding preterm
infants with breast milk prevents the incidence of necrotizing enterocolitis caused by the ingestion of other milks.
In addition, breast milk improves their immune system, protects them against infections, and contributes to their
growth, maturation and development (WHO, 2002).
In 2017, a study conducted by CALMA evidenced that during the first years of the operation of the HMB of San
Salvador, within the National Women´s Hospital "Dra. María Isabel Rodríguez", as the level of coverage with PBM
increased, a sustained reduction in the incidence rate of ECN was evidenced. This coincided with the increased
coverage of preterm and low birth weight infants fed with pasteurized human milk with the implementation of the
Strategy between 2013 to 2016 (CALMA-UNICEF-MINSAL, 2017).
Some studies such as "Lactation with colostrum in necrotizing enterocolitis of the neonate" have concluded that
early breast milk in treatment improves the clinical and radiological evolution of infants, preterm with ECN. Other
studies published in the journal Lancet , conclude on the importance of pasteurized human milk as a protective
factor against NEC "In infants fed exclusively on formula, confirmed disease was 6 to 10 times more common than
in those fed breast milk alone and 3 times more common than in those who received formula plus breast milk.
Pasteurized donor milk appeared to be as protective as raw breast milk. Among infants born at more than 30
weeks' gestation, confirmed necrotizing enterocolitis was rare in those whose diet included breast milk; it was 20
times more common in those fed formula alone. (CALMA-UNICEF-MINSAL, 2017)"
3
With all this background, the analysis of the operability of the HMB-HMCC network within the framework of the
“Crecer Juntos” National Policy that prioritizes the promotion of breastfeeding as one of the foundations for the
Salvadoran infant population to reach its maximum development potential, consolidating the results that have been
obtained to date as a friendly strategy for children at risk, based on scientific evidence and that also promotes,
protects and supports breastfeeding through the establishment of a culture of human milk donation.
At the same time, it will allow feedback to key cooperating partners that have provided support for this initiative,
such as UNICEF, the Cooperation of the Government of the Federative Republic of Brazil and the efforts of
different institutions, such as the Salvadoran Women's Parliamentary Fund, the Neonatal Alliance and CALMA.
4. Methodological Approach
In order to fulfill the general objective, the specific objectives and scopes previously defined, this study has
combined the review of bibliographic references, official information on the national network of HMB-HMCC
with primary information collected through interviews with the institutional team that manages the three existing
HMB and a sample of fourteen HMCC selected through a purposive sampling of geographic representativeness
and of the public-private actors participating in the initiative.
The type of study developed was characterized by being:

Descriptive, because it allowed detailing the functioning of the three existing HMBs with respect to promotion,
collection, extraction, distribution of human milk and their working relationship with the HMCCs in their
geographic jurisdiction, developing a process with the participation of the team of professionals.

Transversal, because the variables were studied simultaneously at a given moment, making a cut in time.

Deductive, through the exposition of concepts, definitions, regulations to draw conclusions and consequences
in real life.

Participatory and reflexive, since it includes interviews, surveys and feedback and validation consultation
workshops with representatives of key actors for the research.
The primary hypothesis of the study has been the verification that the HMB network is functioning with the
necessary efficiency and effectiveness, taking advantage of the existing installed capacity for the promotion,
collection, storage, transfer, pasteurization, administration and subsequent dosage of breast milk for its target
population.
In the evaluation of this hypothesis, a multidisciplinary team from CALMA, made up of eight professionals
specialized in breastfeeding and breast milk bank management, under the leadership of the main consultant of the
study, actively participated, conducted a particular analysis of each of the currently operating HMBs and a sample
of HMCCs to establish their operating conditions and the key factors that are influencing production (individually
and as part of HMB networks acting for the benefit of the affiliated maternity hospitals) and their current utilization
to maximize pasteurized breast milk production with the available resources.
As a starting point for the analysis, three structured interviews with Senior MINSAL Officials were conducted (i)
Director of Health Policies and Management, (ii) National Coordinator of the HMB-HMCC Network and (ii)
Head of the Integrated Child Health Care Unit.
4
In the next stage, a compilation of historical-operational information and interviews with the technical team
responsible for the visits to the three HMBs and a sample of 14 HMCCs were carried out:

HMB of San Salvador and a sample of 4 HMCC attached to UCSF (Planes de Renderos, San Martín, Puerto de
La Libertad and Unicentro-Soyapango) and HMCC at Zacatecoluca National Hospital.

HMB of Santa Ana and 6 HMCC (ISSS Hospital Regional Santa Ana), 2 in HMCC attached to Manufacturing
Companies, San Julián Integral Center for Maternal and Child Care and Nutrition CIAMIN and 2 HMCC
attached to MINSAL National Hospitals of Ahuachapán and Chalchuapa.

HMB of San Miguel, HMCC at UCSF San Miguel - Colonia La Presita and 2 HMCC attached to MINSAL
National Hospitals of Usulután and Morazán.
To complement the qualitative information, a survey of donor and recipient mothers was conducted through
virtual means on a representative sample of women who have participated in the process at HMB-HMCC . This
survey allowed broadening the horizon of the research and diagnosis to consider data collection among a broad
conglomerate of the population that has been involved in the HMB-HMCC initiative.
The selection of donor mothers was carried out with a probability sampling technique based on the approximate
universe of 2326 donor mothers registered in the HMB-HMCC , as this method allowed all mothers registered
as donors to have the same probability of being chosen and therefore to obtain a greater possible assurance that
the important characteristics of the population under study were represented in the proportion that corresponds
to them.
Finally, during the phase of field visits to the sample of 14 HMCC, selected jointly by MINSAL and CALMA, it was
possible to observe a wide dispersion of operational and institutional conditions in the territorial networks of
HMCC attached to each of the three HMB, so it was agreed with the National Coordinator of the HMB-HMCC
Network to carry out an operational census that would gather the main production variables and a basic
characterization of the operational conditions.
5. Conceptual framework
Human Milk Banks and Collection Centers
HMBs are internationally recognized as a fundamental and decisive strategy to save the lives of infants in special
conditions. The purpose of HMBs is to "provide pasteurized human milk to newborns in special conditions, mainly
those who are premature and of low birth weight when, due to their same condition, they cannot be directly
breastfed" (CALMA-UNICEF-MINSAL, 2017).
In El Salvador, the initiative for the implementation of HMBs began with the participation during the month of
September 2010, in the "I Ibero-American Congress of Human Milk Banks", where representatives from 24
countries met and El Salvador adhered to the signing of the 2010 Brasilia Charter as part of international efforts
to address infant mortality and aim at strategies for the fulfillment of the Millennium Development Goals, in force
at that time.
Within the framework of the First Brazil - El Salvador Cooperation Project called "Technical Support for the
implementation of a Human Milk Bank in El Salvador", the work process begins for the establishment of the first
HMB within the National Women's Hospital "Dr. María Isabel Rodríguez", (see Figure 5-1) with the financial and
technical support of UNICEF and CALMA.
5
Figure 5-1: Chronology of the establishment of the HMB-HMCC network in El Salvador.
Source: (CALMA-UNICEF-MINSAL, 2017).
Subsequently, always with the support of UNICEF, CALMA and now with the Neonatal Alliance of El Salvador and
the Fund of Women Parliamentarians of El Salvador, the process of implementation of two more Milk Banks
begins, within the Regional Reference Hospitals: Hospital San Juan de Dios de Santa Ana and Hospital San Juan de
Dios de San Miguel, a project that would culminate with the opening of the three HBMs in October 2012 and
February 2013.
The regulatory framework that accompanies the development of the HMB-HMCC Network is based on the
provisions of:

The Law for the Promotion, Protection and Support of Breastfeeding approved in 2013, which establishes in
its Article 20 "Human milk banks are responsible for collecting, analyzing, pasteurizing and executing the
processes of conservation, classification, quality control and distribution of breast milk for the infant unable
6
to receive breastfeeding from its mother... the donation of human milk must be free, no public, private
institution or natural person may establish pecuniary cost for obtaining or distributing it. The State and all
public, autonomous and private institutions shall obtain the donation of human milk for girls and boys who
cannot have access to it."

In the regulation approved in 2015, it is established in Article 24 "in the case of premature newborns, breast
milk should be promoted and indicated as a priority for infant feeding or, feeding through human milk banks
and only when all possibilities of feeding with human milk have been exhausted, breast milk substitutes may
be resorted to."

The Salvadoran Network of HMB is officially constituted under Ministerial Agreement No. 686 and has
expanded nationwide, with HMCC within UCSF, maternity waiting homes, and national hospitals with
maternity services.
The Salvadoran Social Security Institute ISSS has been involved in the process and public-private alliances have
been generated with companies committed to this strategy and within the scope of international cooperation, it
has positioned itself among the countries of the Global Network of Milk Banks, advancing from the consolidation
of the national network to the adherence to the quality certification program of the establishments that make up
the national network, as illustrated in Figure 5-2 (CALMA-UNICEF-MINSAL, 2017).
Figure 5-2: Territorial network of HMBs and their network of HMCCs.
HMCC
HMB
Source: MINSAL, November 2021
The HMB Network is made up of two structures (see Figure 5-2 above):

In the first tier are the HMBs, which operate within a maternity or children's hospital, responsible for the
promotion, protection and support of breastfeeding, which also carries out activities of collection, processing
and quality control of expressed human milk, for subsequent distribution to the beneficiary newborns.

At the second tier, the HMBs have attached to their technical and operational jurisdiction a Network of
Human Milk Collection Centers (HMCC). A HMCC is defined as a unit for the promotion, protection and
support of breastfeeding, which is also responsible for collecting and pre-storing human milk from altruistic
female donors, technically linked to an HMB.
7
The HMCCs have been a fundamental piece in the consolidation of the national HMB network, not only because
of their contribution to the volume of milk collected, but also because they represent a true example of integrated
work in networks, where the conviction and desire of the resources to make a difference in favor of the reduction
of neonatal mortality and the promotion of breastfeeding prevails.
A fundamental strategic contribution to the creation and strengthening of the HMB-HMCC Network has been
the Basic Agreement on Technical, Scientific and Technological Cooperation between the Governments of the
Federative Republic of Brazil and the Republic of El Salvador, which has allowed for technical and financial support
to the process of implementing the Network.
Based on the aforementioned Cooperation Agreement, several technical verification missions have been carried
out, the last of which took place in May 2018 and was integrated by a technical team from the Oswaldo Cruz
Foundation - FIOCRUZ, the Ministry of Health of the Federative Republic of Brazil under the sponsorship of the
Brazilian Cooperation Agency (ABC/MRE). As a result of this mission, a series of technical recommendations were
compiled that are guiding the certification process of the HMB-HMCC Network before the Global Network of
Human Milk Banks and provide a valuable reference for the process of improving the operational conditions of
the three Salvadoran HMBs.
Efficiency analysis
The efficiency analysis was carried out based on the use of the system's installed capacity. The installed capacity is
the production potential or maximum production volume that a particular company, unit, department or section,
can achieve during a given period, taking into account all available resources, whether production equipment,
facilities, human resources, technology, experience/knowledge, etc.
The general procedures for the operation of the HMB-HMCC Network were defined in 2017 by MINSAL in the
technical guidelines for the implementation and operationalization of human milk banks and collection centers
document. , which aim to "guarantee the right to health and food and nutritional security, preserving the quality
of pasteurized human milk for the newborns benefited, in order to achieve the best results in the survival and
development of children in special conditions and thus contribute to the reduction of infant morbidity and
mortality and the protection of breastfeeding".
These guidelines also define the Salvadoran Network of Human Milk Banks, which is made up of the HMBs of the
hospital network, the ISSS and other members of the National Health System that have HMBs, as well as the
HMCCs. For the purposes of this study, the HMB Network is defined as the conglomerate of three territorial
networks of HMCC attached to an equal number of HMB attached to them within the hospital network of the
Ministry of Health and the HMCC of the private sector.
The operation of the Strategy is conceptualized as a system of three operational phases, plus a phase prior to the
entire system, phase 0, consisting of the process of incorporating donors into the system (see Figure 5-3).
Figure 5-3: PBM production line in the HMB-HMCC Network.
Phase 0: Recruitment
or enrollment of donor
mothers
Phase 1: DBM
collection
Phase 2: Processing of
DBM to obtain PBM
8
Phase 3: Dosage of
PBM distributed
among the beneficiary
population of the
strategy.

The "zero" phase consists of all processes necessary to recruit donors to the system, which includes the care
and counseling provided by the network's facilities (on-site and at home). The information for this phase was
collected simultaneously with the staff attending the HMB-HMCC network and was complemented with
donor surveys to estimate the average number of breast milk donations per person.

Phase 1 considers the collection of raw DBM. This phase is developed jointly by HMCCs and HMBs. In this
phase the HMCC network attached to each HMB transports the raw DBM according to established
procedures, generally on a weekly basis.

Phase 2 processing is carried out at the HMBs, where the final selection of the DBM takes place (verifying
aspects of quality, cleanliness, safety and expiration dates), to then carry out the batch pasteurization cycle of
the raw DBM, as described below.

Finally, Phase 3 consists of the delivery of pasteurized breast milk (PBM) to the beneficiaries of the strategy,
i.e., preterm and low birth weight newborns who are in the Neonatal Intensive or Intermediate Care Units
and Neonatology Services of the Hospitals with HMB.
The efficiency analysis was carried out based on the use of the system's installed capacity. The installed capacity is
the production potential or maximum production volume that the HMB-HMCC network can achieve during a
given period, taking into account all the resources they have available, be it production equipment, facilities, human
resources, technology, experience/know-how, etc.
Low utilization of installed capacity means underutilization of infrastructure and thus higher PBM cost produced
and consequently a low level of coverage of preterm and low birth weight infants and increased use of breast milk
substitutes to meet the demand for pasteurized milk.
Figure 5-4: Key elements for the HMB-HMCC network efficiency analysis.
9
Box 5-1: MINSAL
guidelines on home milk
collection.
Guidelines for HMBs
Each HMB will identify the
donors that have been served
in the last year and contact
them for home donation of
breast milk if they are within
their area of responsibility...
Those that cannot be visited,
lists should be provided to
each HMCC in their area of
responsibility, so that they can
contact the donors. The
management of each hospital
should facilitate transportation
for home visits.
Guidelines for HMCC
In UCSF where HMCC
operates, no care will be
provided to donor mothers,
however, information will be
provided to be a home donor
and the general data will be
noted down and visited by the
health team, prior scheduling.
The person in charge of the
human milk collection center
is in charge of receiving the list
of donors provided by the
HMB, to coordinate home
visit... Provide counseling
during the home visit to
pregnant
women,
on
breastfeeding
and
home
donation.
Source: (MINSAL, 2020).
The HMB Network has a clear and delimited outline of the processes and
resources required for optimal functioning during phases 1, 2 and 3, which
include: 1) Technical procedures for the collection of human milk 2) Prestorage of collected human milk 3) Transport and cold chain 4) Receipt of
collected human milk 5) Selection and classification 7) Conditioning 8)
Pasteurization 9) Cooling 10) Microbiological analysis of pasteurized human
milk 11) Storage of pasteurized human milk 12) Prescription of pasteurized
human milk 13) Distribution of pasteurized human milk 14) Handling of
pasteurized human milk 15) Receipt and follow-up of recipients (MINSAL,
2017).
Phase "Zero" is mainly oriented with the guidelines issued by MINSAL in 2020
after the beginning of the pandemic (Technical guidelines for the operation of
human milk banks and collection centers during the COVID-19 emergency).
These guidelines emphasize a notable importance on the design and operation
of home collection programs with donor mothers following their medical care,
both for HMB and for the HMCC network, with their respective follow-up
mechanisms (see Box 5-1).
In production systems, it is normal for there to be factors that affect the level
of production, and one of them is shrinkage. In economic terms, shrinkage is
the loss of stock that is reflected in the accounting and the actual accumulated
stock. Applying this concept to the HMB strategy, "shrinkage" can be defined
as the reduction in the volume of human milk collected during the different
stages of processing to the final product, i.e. pasteurized milk. To carry out the
analysis, the maximum volumes of each factor between June 2020 and June
2021 were estimated.
Finally, the analysis included the analysis of the losses or shrinkage that occur
throughout the process. In this regard, two types of losses are considered, the
first of which are the "normal" losses in the pasteurization process, which are
estimated to be equivalent to 2% to 3% of the initial volume of DBM entering
the pasteurization process.
The second type of losses is conceptualized as "abnormal" and is associated
with incidents of a fortuitous nature due to human action (it could also be
defined as all losses that is not of a normal nature). In the case of the present
study, abnormal losses is that which exists for preventable reasons such as
failure to ensure hygiene, the cold chain, broken or damaged bottles, among
other aspects. Therefore, it is important to measure the efficiency of the
system and establish a yield factor for breast milk.
10
Analysis of key factors for improvement in the operation of the HMB-HMCC network.
Once the efficiency of the system has been established, an analysis of key operating points has been developed. In
this sense, a review of the factors that have a direct impact on efficiency has been prepared: 1) Human resources
2) Equipment 3) Infrastructure 4) Human Milk donation.
The structuring of the analysis considers four weighted dimensions of impact evaluation, in which each of the
factors has on the processes executed in the HMB-HMCC network, also considering aspects such as budgetary
impact, the feasibility of implementing corrective measures and the need to make modifications to MINSAL's
regulatory instruments and institutional policies.
Table 5-1 shows the correlation between the criteria and the dimensions of analysis of the key operating points,
which are rated on a scale of three (as the highest value) to one.
Table 5-1: Matrix analysis of improvement factors for the operation of the HMB-HMCC network.
Analysis Criteria
High (3)
Medium (2)
Low (1)
Impact on the process
Key factor in the
development of the
process.
Moderate impact on the
process in the current
condition.
Low impact on the
process, manageable
with current resources.
Budget impact
Significant investments
that require budget
allocations and/or
international
cooperation projects.
Significant investments
within available
resources, may
eventually require
reprogramming.
Investment items
available in manageable
amounts.
Feasibility of
implementation
Requires significant
coordination efforts
within MINSAL and
external actors.
Coordination efforts are
needed among actors
already working with
MINSAL.
Inter-institutional and
internal work in process.
Policy and guideline
reviews
Requires a major
revision of institutional
policy instruments and
regulations, with a
strong component of
dissemination, awareness
raising and internal
training.
Moderate adjustments to
existing instruments
accompanied by a
process of sensitization
and updating of
capacities within
MINSAL.
Working within existing
guidelines, reinforcing
MINSAL team capacities.
Source: Own elaboration
Based on the structure of criteria and weightings illustrated in Table 5-1, the analysis of the most important aspects
of coordination in the HMB-HMCC network is developed in Chapter 7.
Qualified, trained and motivated human resources are a determining factor in production capacity; therefore, it is
important to determine whether there are areas for improvement in human resources and the solutions that
would increase the efficiency of the HMB Network.
11
As regards furniture and equipment, aspects such as quality and quantity, maintenance and replacement, among
others, were identified. Regarding infrastructure, the influence of the dispersion of the HMCCs assigned to each
HMB and the impact this has on the efficiency of the system was analyzed, as well as other aspects related to the
infrastructure of the HMCCs and HMBs that could be susceptible to improvement. Finally, the importance of the
donor and the factors that determine the amount of milk collected by region and at the national level were
analyzed and how to improve them.

Other cross-cutting aspects that were considered in this analysis were:

The quality of the processes: those qualitative aspects related to quality assurance from donor counseling,
labeling, safeguarding the cold chain, among other aspects, were verified.

Monitoring and evaluation of the HMB strategy: This was analyzed as part of the continuous improvement
elements that must exist for the HMB strategy to detect limitations, propose and develop solutions.

Coordination between units of the HMB strategy: The analysis provided information on aspects related to the
frequency and quality of coordination between units at regional and national level that allow for improving
aspects such as communication, resource management, capacity building, among others.
6. Findings of the HMB-HMCC Network Efficiency Analysis
The key results of the implementation of the HMB-HMCC Network have been grouped according to the four
stages illustrated previously in Figure 5-3.
Phase Zero: Donor Mother Recruitment
The updated processes for recruiting donor mothers are set out in general terms in the document "Technical
guidelines for the operation of human milk banks and collection centers during the COVID-19 emergency", in
which, as previously mentioned, importance is given to complementing the procedures for recruiting donor
mothers in health facilities and through home collection programs.
The territorial network of 55 HMCC existing as of October 2021 is mainly located in UCSF (27), Maternal Waiting
Homes (2) and National Hospitals with Maternity services (17). In the Santa Ana HMB network, there are 6
facilities attached to Manufacturing Companies and three facilities attached to ISSS health centers.
In the territorial network of the HMB of San Miguel there is a predominance of HMCCs located in national
hospitals, which is the opposite of the trend observed in the other two territorial networks.
For the recruitment of mothers, each facility establishes its own methodology according to its situation and the
environment in which it works, but in general, the difference in the success of recruitment is the availability of
personnel and the amount of time dedicated to recruitment.
From the field visits carried out for this study, it was found that:

The recruitment of donor mothers in the UCSFs is based on prenatal care services and postpartum followup consultations. The people who attend the HMCCs carry out activities to recruit potential donor mothers
during working hours in other health care areas of the UCSFs and, eventually, activities to promote the
services. In all cases, breastfeeding and feeding counseling services are provided to newborns.
12

In the hospitals (both in the national network and in the two cases of the ISSS), the main source of donor
mothers is also the population that attends the hospital services, with the additional possibility of recruiting
donors among mothers who have their babies admitted for some medical procedure and who are allowed to
stay in the shelters set up for this purpose inside the hospital facilities.

Another advantage that hospitals have over the UCSF is the possibility of recruiting donor mothers outside
normal working hours, although this is not a usual and established practice in most hospitals.

In both types of facilities (HMCC in Hospitals and in UCSF), before
the pandemic, in general, special events were developed to recruit
donor mothers, informative campaigns in favor of breastfeeding and
maintained a closer contact with their communities of care, especially
in the HMCC that depended on UCSF and its network of health
promoters (this practice was discontinued after the pandemic).

In the HMCCs located in Manufacturing Companies, donor mothers
come from factory workers, who take advantage of the benefits
established in the Law for the Promotion, Protection and Support of
Breastfeeding and its Regulations, to take time to express milk for breastfeeding their babies, donating part of
their milk to the HMB of Santa Ana, which organizes regular collection routes. Breastfeeding promotion and
counseling activities are carried out in the companies to encourage the donation process.
The best practices identified at
HMCC are associated with involving
the nursing staff in mother
recruitment rounds, actively visiting
the main areas of care for women
under rotational schemes, as well as
providing counseling and educational
talks on breastfeeding issues.
After the COVID19 pandemic, community activities have been reduced to a minimum, human and physical
resources have been reallocated to COVID19 care (first to emergency care and then to vaccination) and in general,
the number of mothers who voluntarily participate in donation activities has decreased in many facilities, as could
be verified during the visits.
During the visits and interviews, it was established that the guidelines issued in 2020 are not being applied
extensively in the HMCCs visited, mainly in relation to home collection. Only three of the fourteen facilities visited
have a household program, of which only UCSF San Martin operates in a structured manner:

UCSF San Martín has organized periodic collection routes that include breastfeeding counseling activities,
assigning a person responsible for accompanying the routes and visiting donor mothers. For this activity they
have printed guidance material and the administrative support of transportation to develop the routes. This
case can be systematized as an operational example regarding the guidelines issued by MINSAL in 2020. In
operational terms, it works very similarly to the home-based programs of the three HMBs described below.

UCSF Los Planes de Renderos has home collection as its only DBM collection modality, given that it does not
have a space for donor mother care within the UCSF. Because the UCSF changed location and the new facility
does not have physical space to operate. The home collection routes allow them to collect an average of 0.5
to 0.9 liters of DBM.

USCF La Presita has a home program that operates irregularly on the personal initiative of the nurse in charge
of the facility; it is not structured on a permanent basis and does not have logistical support for transportation,
so it frequently relies on the support of altruistic individuals.

In the three cases of UCSF home programs verified, there is no logistical support for transportation from the
HMB to which they are attached.
13
The three HMBs have a structured program in accordance with the MINSAL 2020 Guidelines, of which the best
organized is the BHL of San Salvador.
HMB personnel carry out an active breastfeeding counseling campaign with
mothers who are identified through daily rounds to identify potential donors
in the maternity, neonatology, puerperium, mothers' shelter and outpatient
services.
During the counseling sessions, they are encouraged to donate their surplus
breast milk on a permanent basis as an act of solidarity for the infant
population in need of PBM support.
The home donation program receives administrative support for
transportation with home collection routes, which in the case of HMB Santa
Ana, include visits to private companies and the ISSS Regional Hospital.
An important part of the success
of San Salvador's home milk
collection program is the
establishment of breastfeeding
support groups using social
networks. These initiatives
engage mothers' interest in
donating and facilitate the
coordination of breast milk
deliveries.
In the HMBs of San Salvador and Santa Ana, communication groups have been organized through social networks
and in the particular case of San Salvador, the strategy of forming support groups and sharing communication and
educational material through social networks has been implemented. All these elements contribute to the
establishment of an effective household collection (see Figure 6-2).
According to the figures presented in Figure 6-1, between June 2020 and June 2021, the home-based program
contributes more than half of the milk collected in the HMB of San Salvador (52%) and the lowest contribution is
observed in the HMB of San Miguel (19%); in the latter, the largest contribution comes from the regionally attached
HMCC network, with 72% of the total milk collected (the opposite occurs in San Salvador, where the HMCC
network represents only 25% of the contribution).
It is important to note that in the case of the San Miguel HMB network, HMCCs installed in National Hospitals
predominate and, as will be seen below, the current performance level in DBM collection is higher than the
collection in HMCCs located in the first level of health care (UCSF).
14
Figure 6-1: Structure of raw breast milk inputs to HMBs between June 2020 and July 2021 (liters).
349,96
Total
HMB-San Miguel
54,17
687,72
117,90
HMB-Santa Ana
117,81
HMB-San Salvador
177,98
0%
10%
917,39
440,14
176,80
286,89
393,02
20%
30%
40%
50%
190,36
60%
70%
80%
90%
100%
Breast milk collected at HMB (liters)
Breast milk collected at HMB - Home collection (liters)
Breast milk collected at HMCC (liters)
Source: Own elaboration with data collected in the HMB-HMCC network.
In the same period of time, in terms of yield, for each liter of milk collected at the HMB facilities, 2.2 liters are
collected at home in San Salvador and San Miguel, although in the latter case, HMB personnel frequently have to
use their personal vehicles to complete the routes.
Based on the survey conducted among donor mothers for this study, it was possible to verify the importance of
actively involving the HMB-HMCC network staff in
the promotion of breastfeeding and the services
During the visits to HMB-HMCC it was possible to verify
offered by the network.
that in all cases the processes outlined in the MINSAL
Among the mothers surveyed, it was verified that the
main mechanism of communication through which the
HMB-HMCC
network is made known is the
information provided by MINSAL officials (39% when
asked to users assigned to an HMB, 51% when asked
to a donor mother identified with an HMCC),
secondly, they knew about the network because the
health facility they frequently visit has an HMB-HMCC
(31%).
Guidelines (MINSAL, 2017) for the enrollment and
registration of donor mothers are followed.
It was possible to verify that not in all HMCCs identification
"carnets" are given to mothers. All records are kept in
physical form without digitalized backup.
On average, donor mothers remain 3.7 weeks as active donors in the process, and in 28% of the cases, they are
repeat donors after their first delivery (the longest participation was the case of a mother who has been a donor
for 61 weeks).
15
Among the mothers surveyed, it was verified that the main mechanism of communication through which the HMBHMCC network became known was the information provided by MINSAL officials (39% when asked to users
assigned to an HMB, 51% when asked to a donor mother identified with an HMCC), and secondly, they knew
about the network because the health facility they frequently visit has an HMB-HMCC (31%).
On average, donor mothers remain 3.7 weeks as active donors in the process, and in 28% of the cases, they are
repeat donors after their first delivery (the longest participation was the case of a mother who has been a donor
for 61 weeks).
From the results of the survey conducted, the following trends can be established:

A mother donates on average 2.5 times a day (the maximum reported was 8 times).

On average, the typical extraction ranges from five to seven ounces (0.15 to 0.21 liters) and takes an average
of 22 minutes to perform.

On average, a donor mother delivers 17.3 ounces per HMB transport visit (0.51 liters), making an average of
10.4 DBM deliveries during her active period.

Among the mothers surveyed, 52% of the volume of milk donated was done directly at an HMB, 35% at
HMCCs, and only 13% through home donation.

In the case of the mothers surveyed who made home donations, 93% received the necessary supplies to carry
out their donation.
Phase 1: Collection of DBM
The series of Tables 6-1-A, 6-1-B and 6-1-C show the compilation of the information obtained during the visits
made to the facilities in the sample selected for the present study by each of the three territorial HMB networks:
five HMCCs dependent on UCSF plus one case corresponding to a facility specialized in nutrition and child care
attached a UCSF (San Julián), six HMCCs dependent on National Hospitals with operating Maternities and two
HMCCs installed in private companies that operate within business clinics/breastfeeding rooms as established in
the respective Law.
Based on the series of Tables 6-1, it is possible to establish that the conditions for DBM removal in HMBs are
more favorable in terms of infrastructure and equipment than those of the average HMCC with the exception of
the private company facilities.
When differentiating the cases of HMCCs, we distinguish those cases that were implemented as of the last quarter
of 2019, for which MINSAL defined new operational standards for their implementation and which were supported
by CALMA in key aspects of their equipment (armchairs to accommodate donor mothers, better refrigerators
and even, better infrastructure conditions).
16
Table 6-1-A: Key aspects that define the operation of the HMCC network attached to HMB San
Salvador.
Medium size airconditioned room
with privacy,
separated from the
common areas.
Four comfortable
armchairs with
electric extractors.
Normal refrigerator
with a freezer that
allows 6.0 lt storage.
They are scheduled
on a hospital minibus
with primary route.
Small living room
without dividers for
privacy.
Four chairs (only two
Normal refrigerator
can be
with a freezer allowing
accommodated due
4.5 lt storage.
to room limitations).
Every Thursday at
7am, on a UCSF
minibus with primary
route.
Small room without
dividers for privacy.
8 chairs (hard).
Large freezer (more
than 10 lt storage).
Every Friday at 7am,
in a UCSF minibus
with primary route.
They do not have a
lactation room.
No armchairs
because they do not
have space for
breastfeeding, they
have two extractors.
HMB San Salvador
Transportation
2 staff, one full time
and administrative
support.
SAN MARTIN
Milk storage
Part-time
coordinator, ten
nurses rotate at least
one per month on a
full-time basis
(although she is able
to take other jobs).
UNICENTRO
SOYAPANGO
Donation chairs
Part-time
coordinator, no
other support.
LOS PLANES DE
RENDEROS
Collection rooms
The same two
people, eventually,
there is support from
health promoters in
recruitment (3 to 4
of the 15 available).
PTO. LA
LIBERTAD
Staff dedicated to
recruiting donors
4 resources, but for
each shift there is
one person and the
shifts are 12 hours
long.
Small room without
dividers for privacy.
Two chairs, two
breast pumps.
Wide freezer (more
than 10 lt storage).
Every Friday at 7am,
is the most usual.
Transported in a
hospital ambulance
with primary route.
ZACATECOLUCA
HMCC
2 people, one full
time and the
coordinator part
time.
Small room without
dividers for privacy.
Pleasant ambience.
Two armchairs, three
pumps.
Wide freezer (more
than 10 lt storage).
Additional normal
refrigerator.
Every Friday at 7am,
in a hospital minibus
with primary route.
Source: Own elaboration based on information compiled during the study.
17
Normal refrigerator
In UCSF vehicles with
with one freezer
primary route.
allowing 4.0 lt storage.
Table 6-1-B: Key aspects that define the operation of the HMCC network attached to HMB Santa Ana.
2 people, one full
time and
administrative
support.
One full-time and the
nursing staff supports
this task on a parttime basis.
Chalchuapa
Ahuachapán
San Julián
HMB Santa Ana
Staff dedicated to
recruiting donors
ISSS Santa Ana
HMCC
Part-time
coordinator, a
maternal and child
health graduate and a
part-time
collaborator
(undergraduate
student in nutrition,
although she is able
to take other
assignments).
One full time, the
nursing staff (14)
supports this task on
a part time basis,
additionally there is a
very intense
collaboration of the
Lactation Committee
and its general
coordinator. GOOD
PRACTICE: use of a
dedicated TV for
video projection at
HMCC and at the
Shelter.
One full-time, the
coordinator and the
nursing staff (9)
support this task on
a part-time basis.
Collection rooms
Donation chairs
Milk storage
Transportation
Small air-conditioned
room with privacy,
separated from the
common areas.
Four chairs with
electric extractors.
Normal refrigerator
with a freezer that
allows 5.0 lt storage Two normal
refrigerators with a
freezer that allows 5.0
lt storage
The deliveries are
scheduled in a
hospital minibus with
primary route.
Small room without
dividers for privacy
Seven chairs and
manual extractors,
accommodates two
donors.
Two normal
refrigerators with one
freezer allowing 5.0 lt
storage.
Every Friday at 7am,
the most usual time,
they are transported
in a hospital
ambulance with
primary route.
Small room without
dividers for privacy.
One recliner and
two extractors (only
one can be
accommodated due
to room limitations.
Large freezer (more
than 10 lt storage).
Transfers are
managed
cooperatively with
several health
facilities in the area.
San Julián does not
have its own
transportation.
Small room with
separate space for
donation.
Two recliners (2 at
HMCC) and two
electric extractors.
Normal refrigerator
with one freezer
allowing 5.0 lt storage.
Every Friday at 7am,
the most usual time,
transport is in a
hospital ambulance
with a primary route.
Three recliners (2 at
HMCC) and two
electric extractors.
Two normal
refrigerators with one
freezer allowing 5.0 lt
storage.
Every Friday at 7am,
the most usual time,
transportation is
provided by a
hospital ambulance
with a primary route.
Small room without
dividers for privacy.
18
Private FolLamatepeq
Private Fol-Santa
Ana
HMCC
Staff dedicated to
recruiting donors
Two nurses
attending the
business clinic. They
are in the process of
expanding HMCC to
a new location.
Collection rooms
Donation chairs
Milk storage
Transportation
Small room without
dividers for privacy.
Pleasant ambience.
One chair, one
electric fan, one
manual fan.
Normal refrigerator
with one freezer
allowing 5.0 lt storage.
Weekly, with routes
coordinated with
HMB.
Small room without
dividers for privacy.
Pleasant atmosphere.
One chair and two
electric extractors.
Normal refrigerator
with one freezer
allowing 5.0 lt storage.
Weekly, with routes
coordinated with
HMB.
Source: Own elaboration based on information compiled during the study.
Table 6-1-C: Key aspects that define the operation of the HMCC network attached to HMB San
Miguel.
Staff dedicated to
recruiting donors
Collection rooms
Small air-conditioned
room with privacy,
separated from the
common areas.
Five chairs with
electric extractors.
Normal refrigerator
with a freezer that
allows 5.0 lt storage.
Transportation with
coordination
problems. HMB staff
frequently use their
personal vehicles.
Small room without
dividers for privacy.
Two metal
armchairs, two
extractors.
Normal refrigerator
with one freezer
allowing 6.0 lt storage.
Every Friday at 7am,
in a hospital
ambulance with
primary route.
HMB San
Miguel
Transportation
Two staff, one full
time.
San Francisco
Gotera
Milk storage
Head of nursing,
neonatology.
La Presita
Donation chairs
Two people fulltime, but they
involve all the
nursing staff, such as
the gynecologist and
all the staff of the
facility on a
voluntary basis.
Small room without
dividers for privacy.
There are three
armchairs, but only
one electric
extractor.
Normal refrigerator
with one freezer
allowing 5.0 lt storage.
There is no
dedicated
transportation.
Transfers are
frequently made by
urban transport
(bus).
Usulután
HMCC
Two staff, one fulltime and the
coordinator parttime.
Small room without
dividers for privacy,
very neglected
conditions.
Two hard-backed
chairs.
Two normal
refrigerators with one
freezer allowing 5.0 lt
storage.
They are scheduled
in a hospital minibus
with primary route.
Source: Own elaboration based on information compiled during the study.
19
During visits to HMB and HMCC, it was
verified that DBM identification and
traceability records are in compliance with
technical guidelines. This information is also
supported by physical records and is the
basis for documenting deliveries of raw
DBM to the HMBs.
The success of DBM collection in the establishments visited
depends on the ability to manage donor mothers and the followup provided to them once their stay in the hospitals and the
postpartum check-ups in the UCSF with attached HMCC is over,
with the implementation of home programs as explained in the
previous section.
The current situation of infrastructure and equipment does not
condition the operational performance, however, in several
HMCC the infrastructure and equipment make the donation process neither comfortable nor private for donor
mothers and require improvements in furniture, particularly in the cases of HMCC that have been in operation
since 2015.
Historically, the HMB-HMCC network has maintained annual collection averages on the order of 2,500 to 2,600
liters of DBM. Between 2013 and 2014, the network basically relied on DBM collection efforts at the three HMBs
until HMCCs were gradually incorporated during 2015, the year in which the first 31 HMCCs nationwide became
operational (the first HMCC in operation was the HMCC at UCSF Unicentro, Soyapango, in August 2014).
During the interviews conducted, the HMB-HMCC Network Coordinator, those responsible for HMB-HMCC
highlighted the development of massive recruitment and mother recruitment events during 2016-2017 which were
then followed up with home collection schemes in the UCSFs with attached HMCCs, through their territorial
health promoter structures.
In these schemes, many UCSFs were particularly
successful, such as HMCC UCSF Unicentro-Soyapango,
which reached an all-time high of 39.0 liters in August
2017 and HMCC UCSF Los Planes de Renderos
accumulated 22.0 liters of DBM.
The start of the DBM cold chain in the HMCC network
relies in most cases on normal (household) refrigerators,
which are equipped with freezers that allow storage of
an estimated 4.5 liters to 6.0 liters of DBM.
In the year leading up to the pandemic, DBM uptake
was 2,198.2 liters; in 2020, the amount of DBM
collected dropped to 1,720.7 liters following the onset
of the pandemic. According to MINSAL projections,
production by the end of 2021 is expected to reach
2,500 liters of DBM. With the data collected between
June 2020 and June 2021, totaling 1,955.1 liters of DBM,
this positive upward trend can be verified.
Only 4 of the 14 HMCCs visited have horizontal
freezers.
The use of household refrigerator freezers has the
disadvantage of not guaranteeing the safety of the DBM,
since it was observed in some cases that the lower part
of the refrigerator is used to store food or beverages of
the establishment's personnel.
Phase II Processing of DBM to obtain PBM
After completing the DBM collection process in the HMB-HMCC network, the three HMBs develop an exhaustive
process of integration, storage, processing and distribution of the PBM, following standardized protocols and
performing bacteriological controls, to distribute PBM to the neonatal population (premature, low birth weight
or presenting special health conditions).
As the nutrient and amino acid content of DBM varies, depending on the gestational weeks and postnatal age of
the donor neonate, the customized delivery of PBM, taking into account gestational and postnatal ages, has proven
to be the most beneficial strategy for the nutrition of preterm neonates with specialized feeding needs.
20
The processing or pasteurization of DBM is based on the Holder methodology, which is the reference procedure
used for the processing of DBM in milk banks globally, as it offers a good balance between microbiological safety
and preservation of the nutritional/biological quality of the milk.
The guidelines are developed by MINSAL in the document
"Technical
guidelines
for
the
implementation
and
operationalization of human milk banks and collection centers"
(MINSAL, 2017), specifically in chapters 9, 10 and 11, and basically
consists of rapid heating by immersion in a hot water bath of a
standardized amount of homogeneous vials of milk to 62.5 °C,
A detailed study of processing times and steps
followed by an "intermediate" stage at 62.5 °C for 30 minutes and
is not available to verify an optimal pattern to
a rapid cooling phase to 4 °C (this cooling phase prevents the
maximize process yield at the three HMBs.
proliferation of residual bacteria). This technique has
demonstrated high microbiological safety, eliminating most
bacteria and viruses with the exception of sporulated bacteria and hepatitis B virus (Picaud JC, 2017).
The Holder pasteurization process is carried
out at all three HMBs under the same
performance standards, with minor variations
in processing quantities per batch.
In the three HMBs the processing duties essentially depend on the Laboratorian assigned to each of the HMBs.
Processing is completed on a daily production line, the volume of which depends on the type of milk to be
processed and yield standard, which is basically set at a combination of number of equal volume vials that are
processed in each production batch.
The laboratorians of the three HMBs emphasized that for the process to be considered effective and safe,
temperature changes must be homogeneous regardless of the distribution of the bottles in the pasteurizer and
the volume of milk they contain. The devices used in the HMBs are water-heated pasteurizers and, as will be seen
in the next chapter, the equipment used in the three HMBs has already exceeded its nominal useful life, which is
reflected in the production capacity. According to the interviews conducted with the laboratorians at each HMB,
based on the equipment available at each HMB, currently the maximum throughput among the three HMBs is 4
to 5 liters on average for a complete daily pasteurization cycle (with a normal processing shrinkage of 2% to 3%).
Based on the information collected and interviews conducted during visits to the three HMBs, Table 6-2 has been
constructed, which summarizes the total milk captured for the period June 2020 to June 2021 and the total
volumes of PBM produced.
Table 6-2: Pasteurized milk production June 2020-July 2021.
Element of analysis
HMB-San
Salvador
HMB-Santa Ana
HMB-San Miguel
Total
DBM collected at HMB (liters - year)
571.0
294.6
172.1
1037.7
DBM received at HMB from affiliated
HMCCs (liters - year)
190.4
286.9
440.1
917.4
Total DBM (liters - year)
761.4
581.5
612.2
1955.1
Abnormal loss in PBM production (literyear)
Percentage of abnormal loss vs. uptake
76.6
118.0
38.5
233.0
10.1%
20.3%
6.3%
11.9%
Total PBM (liters - year)
687.6
455.2
563.0
1705.7
Source: Own elaboration based on information compiled during the study.
21
The above table shows the importance of reviewing the collection processes of DBM from the HMCC network
attached to the Santa Ana HMB, given that it has a higher percentage of abnormal losses or depletions than the
other HMBs and this supply source is equivalent to half of the total DBM collected in the territorial network of
the western zone (see previously illustrated in Figure 5-2). Similar attention is required, given the importance of
the San Salvador HMB household program (51.6% of the DBM - see Figure 5-2).
Table 6-3: Abnormal DBM losses in the HMB-HMCC network June 2020 - June 2021.
Element of analysis
Percentage of milk discarded with
respect to breast milk collected
HMB-San Salvador
HMB-Santa Ana
HMB-San Miguel
10.1%
20.3%
6.3%
Household collection
HMCC shipments
HMCC Shipments
Main reason for discards
Consistency/color
38.1%
Dirt
39.7%
Second reason for discards
Acidity
Consistency/color
94.0%
Positive bacterial
cultures
Main source of discarded breast
milk
Third reason for discards
Acidity
32.0%
5.0%
22.2%
Presence of dirt
Thaw
Expiration
15.2%
1.0%
17.0%
Source: Own elaboration based on information compiled during the study.
Phase III Dosage of PBM
Once the PBM has passed the selection and microbiological control processes and ensures compliance with all
applicable standards, the HMB personnel carry out the production inventory by manual means of recording in
physical control books for the custodian and subsequent distribution among the neonatal beneficiary population.
PBM inventory, control, requisition and
prescription procedures are not uniform among
HMBs and need to be evaluated and
modernized. All records are kept manually,
without digital backup.
Follow-up on the evolution of the beneficiary
population is very limited and does not include a
file associated with the medical discharge report
and the impact of the PBM on health, nor is there
follow-up after the hospital stay. This process
would also facilitate a home donation program.
The prescription follows medical and nutritional criteria
established by the NICUs of each HMB and, in this regard, it is
noteworthy that the collection of prescriptions is not
standardized, while in the HMB of San Salvador, the staff visits
the medical areas of the Hospital daily to collect and inventory
PBM requests, in the other HMB, it is the heads of the medical
areas who visit the Bank to periodically distribute their PBM
requirements for the beneficiary population. This difference in
methods and controls existing in the three HMBs does not
support the efficiency and effectiveness of the distributed PBM
dosing process and makes it difficult to track, trace and evaluate
the impact of PBM prescription among the beneficiary
population.
Figure 6-2 shows the historical trend since 2016 of the numbers of babies benefiting from PBM and compared
with the cumulative data between June 2020-June 2021, it can be established that an estimated 1,300 to 1,400
premature babies, very low birth weight (less than 1,500 grams) and special conditions are benefited annually to
22
which an average of slightly more than one liter of PBM is administered, with 2020 being the year of lowest dosage
(0. 92 liters / baby benefited), which can be attributed to the operational difficulties observed for the collection of
DBM associated with the sanitary measures due to the COVID-19 pandemic, in health facilities at the national
level.
Figure 6-2: Historical trends in PBM delivered and babies benefited.
1600
1.45
PBM/baby (liters)
1.60
1.23
0.92
1.05
1800
1600
1400
Number of babies
2000
1400
1200
1200
1000
1000
800
800
600
PBM (liters)
1800
600
400
400
200
200
0
0
2017
2018
2019
Number of babies benefited
2020
June20/june21
Amount of PBM distributed (liters)
Source: Own elaboration based on information compiled during the study.
The accumulated trend during June 2020-June 2021 is similar to that observed in previous years, and the figures
at the end of 2021 are expected to be higher than those of the previous year.
HMB Santa Ana has negotiated and signed a
cooperation agreement with the ISSS Regional
Hospital of Santa Ana. This initiative has been
generated locally and has not been replicated
in the other HMBs. This agreement allows (i)
that hospital to operate an HMCC that
supplies the HMB and in turn (ii) transfers
PBM from the HMB to babies housed in the
NICU of this hospital. This is the only case of
PBM transfers outside the HMB.
Based on the information gathered during the visits to the three
HMBs, Table 6-4 summarizes the results obtained during the
period between June 2020 and June 2021, where it can be seen
that the largest number of babies benefiting from distributed
PBM is located in the HMB of San Salvador, followed by the HMB
of San Miguel and finally, by the HMB of Santa Ana.
In the particular case of the HMB of Santa Ana, the production
of PBM is the lowest of the three banks, partly due to the
significant percentage of discards that exceeds that of the other
two banks and because it also has the lowest number of babies
attended (a figure that includes 19 patients from the ISSS
Regional Hospital, which means that the dosage received by the
beneficiary population is two liters per baby).
23
Table 6-4: Statistics on production and delivery of PBM to beneficiary babies at HMB
Element of analysis
HMB-San Salvador
HMB-Santa Ana
HMB-San Miguel
Total
Volume in liters of PBM
687.6
455.2
563.0
1705.7
Volume in liters of PBM distributed
672.5
626.7
349.9
1649.1
Total number of babies benefited
902
275
394
1571
Number of babies benefited in other
Maternities
0
19
0
19
TOTAL
902
294
394
1590
Average PBM per baby attended
0.75
2.28
0.89
1.05
Number of donor mothers enrolled
882
632
1761
3275
Source: Own elaboration based on information compiled during the study.
Installed capacity utilization
In the case of the HMCCs, the comparison between the average current productions versus the maximum
historical yield was used, accumulating trends by type of establishment to which the HMCC is attached and by
geographic network. Table 6-5 presents the current monthly DBM production versus historical maximums by
HMB territorial network and type of establishment of affiliation, grouping the averages by geographic area and by
type of establishment, with the purpose of establishing orientation trends.
24
Table 6-5: Yields by territorial network and type of establishment to which the HMCC is attached.
Average Current
vs. historical
maximum
Average Yield
Average Current
Average Yield
liters/month
Historical vs.
current yield
differential
liters/month
Element of analysis
HMCC
Average
Maximum Yield
(liters/month)
HMB Santa Ana
17
9.8
35.7%
2.3
7.6
HMB San Miguel
19
5.1
31.4%
2.0
3.1
HMB San Salvador
19
10.4
27.4%
2.3
8.0
Total
55
8.5
31.4%
2.2
6.3
Element of analysis
HMCC
Average
Maximum Yield
(liters/month)
Average Current
vs. historical
maximum
Average Yield
Average Current
Average Yield
liters/month
Historical vs.
current yield
differential
liters/month
Manufacturing
Companies
6
44.1
4.1%
3.3
40.8
National Hospital
17
6.9
47.4%
3.5
3.4
Community Family
Health Clinic
29
7.4
24.0%
1.4
6.0
ISSS Medical Clinic or
Hospital
3
8.2
26.5%
2.4
5.8
Total
55
8.5
31.4%
2.2
6.3
Source: Own elaboration based on information compiled during the study.
Based on the information in Table 6-5, it can be concluded that the HMB-HMCC network is currently operating
on average at 31.4% of the historical maximum DBM collection capacity (comparing the average collection during
the first eight months of 2020 with the historical maximums achieved between 2016-2017, which is very similar
among the territorial networks attached to the three HMBs).
The comparison is justified by the fact that, according to the data provided by MINSAL, the yields in the first eight
months of 2021 are equal to the same period of 2019 (pre-pandemic year).
On a territorial scale it can be observed:

Santa Ana's network is operating at 35.7% of historical maximum throughput, while San Salvador's network
has dropped to 27.4%, which is a rough indicator of how much the available installed capacity is being utilized
for each case.

In the analysis according to the type of health facility, the performance of the HMCCs attached to National
Hospitals with Maternity maintained average yields equivalent to 47.4% of the historical maximum, compared
to 24.0% in facilities located in UCSF/HEM and with a productive capacity equivalent to 2.6 times.
25

This is more accentuated in the San Salvador and Santa Ana networks. When the analysis is done by type of
facility, private company HMCCs have historically captured the largest amounts of DBM and currently present
the most significant drop (more than 95%).
As previously mentioned, the raw breast milk collection processes in the three HMBs have household collection
schemes, apart from having a private room to accommodate donor mothers with comfortable chairs and
mechanized pumps, which provide a suitable environment to facilitate the donation process.
PBM production performance factor
Current utilization of installed capacity at HMBs was calculated from information provided by HMB laboratorians,
which is summarized in Table 6-6.
Table 6-6: Maximum throughput standards at HMBs.
Data - Laboratorian
HMB-San Salvador
HMB-Santa Ana
HMB-San Miguel
Maximum output
Weekly production
16 bottles of 320
ml = 5.12 liters
14 jars of 300 ml
= 4.20 liters
18 bottles of 300
ml = 5.40 liters
One production
cycle per day - 3
production cycles
per week
Daily volume (with
normal loss)
Monthly volume (with
normal loss)
5.0 liters
64.5 liters
4.1 liters
52.9 liters
5.3 liters
68.4 liters
Source: Own elaboration based on information compiled during the study.
In the practice developed at each HMB, the maximum throughput standard is concluded by the maximum capacity
of homogeneous vials per production batch according to the equipment available (information provided by the
three HMB laboratorians), is concluded by the values illustrated in Table 6-7.
Table 6-7: PBM production yield factor at HMB.
Element of analysis
HMB-San
Salvador
HMB-Santa Ana
HMB-San Miguel
Total
Total DBM (liters/year)
761.4
581.5
612.2
1955.1
Discarded DBM (liters-year)
76.6
118.0
38.5
233.0
Total PBM (liters-year)
687.6
455.2
563.0
1705.7
PBM yield factor
Current production capacity
(liters/month)
Maximum production capacity
(liters/month)
Installed capacity utilization
90.3%
78.3%
92.0%
87.2%
56.4
37.3
46.1
46.6
64.5
52.9
68.4
61.9
87.4%
70.5%
67.5%
75.2%
Source: Own elaboration based on information compiled during the study.
26
HMB-Santa Ana and its
network of affiliated HMCCs
require a special capacity
building effort to reduce
"abnormal"
wastage
and
increase the production of the
HMCC network.
According to the interviews conducted with the laboratorians of the three
HMBs: (i) 3 PBM production cycles are developed in a working week, the other
two days are dedicated to preparation, cleaning and revision of cultures; and
(ii) the production capacity can be increased by developing two daily
production cycles or by introducing a fourth process during the week, but this
depends on more human resources, work outside nominal working hours and
physical space (which is limited in each Bank).
In addition, HMB's equipment
requires that its equipment
capacities be made compatible
to increase its pasteurization
capacity.
Based on the information collected and interviews conducted during the visits
to each of the three HMBs: (i) it was calculated as the correlation in percentage
between the annual total of breast milk that has been pasteurized in the HMBs
and the annual total of breast milk collected (in its natural unprocessed state)
in the National Network and, (ii) from the information in Table 6-7, it can be
concluded that the HMB-HMCC network has managed to transform 87. 2%
of the raw milk collected in PBM suitable for distribution to the neonatal
beneficiary population.
The difference is attributed to the normal loss of processes (according to the standards of the pasteurization
equipment available, this value is usually 2% to 3%) and the rest to the abnormal loss of DBM prior to the
pasteurization process.
Based on the information gathered, with the production data and the production standards provided by the
laboratorians of the three HMBs, it is concluded that an average of 75.2% of the operational production capacity
is being used based on "normal" operating parameters (a single production line in three working days of operation
and the conditions of the human resources and equipment available).
The San Salvador HMB has the highest nominal production rate; however, the San Miguel HMB has the best
standards of utilization of the DBM and the lowest percentage of abnormal losses.
The production capacity of pasteurized milk can be improved with short-term measures, increasing human
resources specialized in processing/laboratory and improving equipment, without modifying the infrastructure of
the three HMBs.
Pasteurized breast milk production line capacity.
The production capacity among the four PBM production phases illustrated previously in Figure 5-3 has been
calculated on the basis of (i) the average yields of the HMB-HMCC network in DBM derived from Table 6-2, (ii)
combined with the PBM yields calculated with the combination of the statistics in Tables 6-6 and 6-7, and finally,
(iii) with the PBM delivery data to beneficiary infants in HMB.
The results of this cross-tabulation are presented graphically in Figure 6-3, on which the following details are
highlighted:

Based on the historical average yield of the HMB-HMCC network, equivalent to 2,600 liters of DBM and the
amount of DBM captured between June 2020 to June 2021, the amount of milk that could be captured in
Phase 1 exceeds by 340 liters the amount of DBM that could be processed with the current yields of the three
HMBs in Phase 2.

This means that the current processing capacity of the network would not be able to assimilate an increase in
DBM capture yield that would match the historical average of the network.
27

If the current average processing capacity of the three HMBs were maximized by increasing the amount of
current DBM to the productive maximum with the current pasteurization equipment, an additional 524 liters
of PBM could be produced.

This capacity to increase PBM would serve to feed an additional 533 newborns to those currently served, for
a total of 2,123 newborns.
Figure 6-3 Pasteurized breastmilk production line capacity
Source: Own elaboration based on information compiled during the study.
28
Coverage of the demand for pasteurized breastmilk
The PBM dosage is distributed among newborns weighing less than 1500 grams, premature newborns with special
feeding needs and newborns with high-risk pathologies (e.g. necrotizing enterocolitis, neonatal sepsis and immune
deficiencies). From the situations illustrated above, the cases of infants presenting 1500 grams or less at birth have
been selected to analyze PBM coverage.
This group of newborns constitutes a high-risk group in relation to developmental problems and therefore require
special feeding with mother's breast milk or PBM from an HMB, more rigorous medical follow-up and more
controls than those required for a child born with higher birth weight.
Table 6-8 presents the national totals of newborns weighing less than 1500 grams at birth and the number of cases
that manage to be attended in the three hospitals with maternity wards that have an HMB attached to them.
It is important to highlight two aspects: (i) the HMBs of San Salvador and San Miguel only distribute PBM among
newborns from their headquarters maternity hospital and (ii) the only HMB that makes transfers outside its
facilities is the HMB of Santa Ana that shares it with newborns from the Santa Ana ISSS Regional Hospital through
a special agreement (in that hospital operates a HMCC that collects DBM for that HMB).
In Table 6-8 it can be concluded that the average coverage of newborns under 1500 grams covers approximately
44% of the average number of cases presented between 2017 to 2020, observing a decrease to 41% during the
year of the pandemic, due to the existing conditions for the operability of the network based on health protocols
and access to donor mothers (the amount of DBM captured in the network in that year fell to 1720.7 liters, 66%
of the historical average).
The above figures would support the development of an institutional policy in MINSAL to operationalize the
transfer and storage of PBM with national hospitals, ISSS and private hospitals that have a NICU for the treatment
of cases that require PBM for the treatment and feeding of newborns with low birth weight, prematurity or special
pathologies. This good practice can be systematized/modeled from the HMB of Santa Ana with the Regional
Hospital of the ISSS.
Table 6-8: Coverage of newborns under 1500 grams at the national level MINSAL.
Hospital - HMB
2017
2018
2019
2020
HMB San Salvador
232
191
222
160
HMB San Miguel
60
44
45
48
HMB Santa Ana
28
26
23
20
Total HMB (babies)
320
261
290
228
National Total (babies)
630
654
639
561
National coverage
51%
40%
45%
41%
Source: Own elaboration with information provided by MINSAL.
29
7. Analysis of improvement factors to optimize the operation
The information compiled in the previous chapter has served as a basis for analyzing key operational factors of
the HMB-HMCC network in five categories linked to operational aspects and three associated with crosscutting processes of quality management of the processes carried out in the network, coordination within the
management and operational teams, and finally monitoring and evaluation of all processes.
Recruitment of donor mothers
In the preceding sections, it was concluded that the HMB-HMCC network operates at 31.4% DBM collection
rate compared to the maximum historical collection rate, and it was established that the processes of counseling,
recruitment and loyalty of donor mothers are a key factor for the operation, which especially influences the
collection of DBM in HMCCs.
In order to characterize this area, three key elements are considered: recruitment methods, the use of donor
mothers' sources of origin, and the implementation of a follow-up program for donor mothers in a home donation
program.
As previously highlighted, the mothers who donate their milk come from the health facilities to which they are
attached in the HMB-HMCC network. During the visits, it was found that the full potential of donors is not being
used and there is no systematized follow-up of the enrollment process; in most cases, mothers make their
donations while they or their babies are being cared for at the health facility.
In this context, it is very important to improve and optimize the methods for recruiting donor mothers. In this
issue there is a methodological dispersion and the recent guidelines concluded by MINSAL in 2020 are being
partially applied, which is reflected in a decrease in the number of donor mothers and in the fact that donor
mothers are not permanently enrolled, particularly in the generality of HMCC and the low level of repeat
donations in the HMB of San Miguel.
It is very important to gradually resume, according to the COVID-19 protocols, actions to recruit and retain
donor mothers that proved to be successful in past years and to support this management with printed and virtual
communication material taking advantage of social networks, as is done by the HMB of San Salvador with its
"Support Groups" strategy.
To complement these efforts, it is advisable to create a monitoring and follow-up system for donor mothers, so
that a home donation program can be implemented, with the logic and procedures defined by MINSAL in the
"Technical guidelines for the operation of human milk banks and collection centers during the COVID-19
emergency" (MINSAL, 2020).
30
Box 7-1 Key operating factor
assessment – Recruitment of donor
mothers
Average Process
Impact
Average Budget
Impact
3.0
1.0
Recruitment of donor mothers
Policy and
Average Feasibility
guideline review
of Implementation
average
2.3
2.3
This key performance factor of the network is the most important determinant for increasing PBM production. These strategies have a
low budgetary impact, but require an intense effort in sensitization and capacity building, particularly in the network that depends on the
Santa Ana HMB. The values in the table are calculated based on the weighting of three factors: Source of donors, Recruitment methods
and Household program (see Table 5-1 in the methodology chapter for an explanation of the categories and values).
Source: Own elaboration based on information compiled during the study.
Human Resources
HMB Human Resources
The staffing structure among the three HMBs is similar: a part-time HMB Coordinator, a laboratory technician,
two maternal and/or child care/nutrition technicians, an administrative assistant and a cleaning assistant (BHL San
Salvador has one as part of the general subcontract). In addition, there is administrative support in Transportation
on a rotational basis.
In this structure, the person who concentrates the greatest responsibilities within the production chain is the
laboratorian, whose training is in clinical laboratory, with additional training in breast milk processing,
bacteriological control and breastfeeding. In the three HMBs this person concentrates on running all PBM
production and quality control processes, as well as primary responsibility for production and inventory controls,
which serves as the basis for administering the PBM dosages that are delivered to the hospital's NICU. These
functions are difficult to delegate, so the absence or indisposition of this person greatly affects the productivity of
the HMB.
Secondly, the two people hired as support technicians, generally with a Bachelor's degree in Maternal and Child
Health or Nutrition, are responsible for inventory and quality control of the DBM prior to processing, as well as
the administration of PBM requisitions and their subsequent delivery to the NICU. This function is shared in
parallel with the activities of recruitment, enrollment, registration and counseling of donor mothers, which are
also critical for HMBs, especially in the case of San Salvador and Santa Ana. A third critical function, which derives
from the previous one, is the operation of the household donation program.
The Coordinator and support technicians have an average of five to six years of experience managing the HMB
and have received the following training courses:

HMB information management course.

International tutor course in HMB.

Breastfeeding course.

Breastfeeding Counseling Course.

Course on the International Code of Marketing of Breast Milk Substitutes.
31
Laboratory personnel have received at least three courses associated with Human Milk Processing and Quality
Control, theoretical and practical aspects.
Based on the interviews conducted at the management level in MINSAL and with the staff of the three HMBs, it
can be concluded that the staffing structure does not favor the optimal functioning of the network, because it
limits the productive capacity (on average, the three HMBs operate at 75.2% of their nominal installed capacity see previously Table 6-7 - and they do not take full advantage of the active follow-up to the recruitment and loyalty
of donor mothers, including the household donation program.
It is important to note that the HMBs of San Salvador and Santa Ana have administrative support for operational
support, particularly in the management of transportation for the activities related to the home donation program,
as well as an administrative assistant. In both aspects, the San Miguel HMB is deficient.
For HMB management, it is advisable to conduct a time and motion study to support the operation and process
guidelines to improve the productivity of HMB human resources and evaluate modifications to institutional
guidelines.
The performance and working conditions derived from the DBM pasteurization processes are a key factor for the
overall performance of the HMB-HMCC network, given that, together with the state of operation of the
pasteurization equipment and the limitations of the infrastructure, they condition the production of PBM to a
single daily production cycle.
Under current HMB operating conditions, it is very difficult to conclude whether the optimal yield previously
defined in Table 6-5 (Maximum yield standards in HMBs) can be improved, unless an additional laboratory
technician is delegated to each facility with staggered schedules that allow the incorporation of one additional
production cycle per week. This aspect should be studied very closely at the time the pasteurization and laboratory
equipment at HMBs is renewed.
Human resources at HMCC
The human resources structure in HMCCs is varied and constantly changing. In the sample of HMCCs visited for
the present study, it can be concluded that the majority of facilities operate with a part-time Coordinator, who
shares functions with the facility to which the HMCC is attached. This person assumes the general administrative
coordination of the facility and in many cases is responsible for its technical operation.
In addition to the Coordinator, nursing personnel from the health facility to which the HMCC is attached support
part-time the operational management and, in most of the HMCC attached to a national hospital, they are
supported by nursing personnel from the medical area to which the HMCC is attached (usually the Head of
Neonatology or Maternity).
During the visit, it was found that these structures function adequately, and even with remarkable operational
results (particularly in San Francisco Gotera, Usulután, Zacatecoluca, Ahuachapán and the Regional Hospital ISSS
of Santa Ana).
The series of Tables 7-1-A, 7-1-B and 7-1-C summarizes details on the assignment of personnel in the 14 HMCCs
visited for this study in each of the three territorial networks attached to the HMBs, detailing the specialized
training courses that the personnel currently managing them have received.
32
Table 7-1-A: Staff attending the HMCCs visited for the present study in the HMB network of San
Salvador: Experience and training courses.
HMCC
Staff
CALMA
MINSAL online basic
course
San Martin
Two Nurses
2
Unicentro
Soyapango
Coordinator
Los Planes De
Renderos
Coordinator
(nutritionist)
Puerto La
Libertad
Zacatecoluca
Bachelor in
Maternal and
Child Health
(3)
Coordinator
(nutritionist)
and Nurse
HMB
Internships
2
1
1
3
3
2
2
Local
Breastfeeding
Courses
1
Other training
at CALMA
Other trainings
Years of
experience
HMCC
2
1
6
1
6
1
5
2
0.5
2
0.3
Source: Own elaboration based on information compiled during the study.
Table 7-1-B: Staff attending the HMCCs visited for the present study in the HMB network of Santa Ana:
Experience and training courses.
HMCC
ISSS Santa Ana
San Julián
Ahuachapán
Chalchuapa
Empresa
Privada FOLSanta Ana
Empresa
Privada FOLLamatepeq
Staff
Coordinator
(Doctor in
Neonatology)
and Nurse
Coordinator
(Doctor) and
Bachelor in
Maternal and
Child Health
Two Nurses
CALMA
MINSAL
on-line
basic
course
2
Local
HMB
Breastfeeding
Internships
Courses
2
1
Other
training at
CALMA
Other
trainings
Years of
experience
HMCC
2
1
5
1
0.5
1
1
Two Nurses
2
0.5
1
2
Two Nurses
1
No information provided
Two Nurses
2
Source: Own elaboration based on information compiled during the study.
33
Table 7-1-C: Staff attending the HMCCs visited for the present study in the HMB network of San
Miguel: Experience and training courses.
HMCC
San
Francisco
Gotera
La Presita
Usulután
Staff
CoordinatorChief Nursing
Officer
(Master's
Degree in
Health Services
Administration;
Bachelor's
Degree in
Nursing) 6
Nurses
Two Nurses
Nurse
Coordinator
(B.S. in
Nursing) and 6
Nurses
CALMA
MINSAL
on-line
basic
course
HMB
Internships
Local
Breastfeeding
Courses
2
3
2
3
Other
training at
CALMA
Other
trainings
Years of
experience
HMCC
2
3
6
2
2
2
6
3
3
4
7
Source: Own elaboration based on information compiled during the study.
From the information in Table 7-1, it is possible to conclude that the preparation and experience of the personnel
involved in HMCC management is variable, in general terms (see Table 7-2):

The staff of the HMCC network territorially attached to the HMB Santa Ana have the least experience
managing HMCC (1.8 years) and evidence the least amount of training courses. This lack of experience and
training may be the basis for the considerable percentage of abnormal shrinkage in this network (20.3%)
compared to the other two networks.

The HMCCs attached to San Miguel HMB have an average of 7.0 years of experience managing the facility and
have accumulated the greatest number of training courses, which results in the fact that the HMB San Miguel
network has the lowest percentage of abnormal losses (6.3%).
34

The staff of the HMCC network territorially attached
to the HMB San Salvador has intermediate values in
terms of experience and presents the greatest
diversity of courses and topics. It occupies second
place in the number of personnel who have taken
training courses.
Table 7-2: Summary of experience and
training courses by HMB territorial network.
HMB-HMCC
Network
HMB Santa
Ana
HMB San
Miguel
HMB San
Salvador
Average Years
of HMCC
experience
Quantity of
training courses
1.83
14
When analyzing the condition by type of facility, the
situation is very variable in the HMCCs attached to UCSF,
7.00
31
with cases of notable management using nursing staff
3.56
26
rotation systems similar to those in national hospitals
(UCSF San Martín, CIAMIN San Julián), with extreme Source: Own elaboration based on information compiled
cases in which the entire operational responsibility of the during the study.
HMCC falls on a single person, who performs these tasks
part-time with little administrative support or infrastructure/equipment facilities of the health facility to which they
are attached.
Two cases notably exemplify this situation, HMCC Unicentro, Soyapango, a facility that came to set historical
records for DBM collection within the network (39 liters/month) and HMCC Planes de Renderos, which also had
remarkable performances between 2016 and 2018 (up to a monthly maximum of 22 liters/month), both of which
declined notably, especially HMCC Planes de Renderos when UCSF changed premises.
This variable structure and with constant personnel movements notably hinders the operational coordination
processes and formative trainings for the correct operation of the HMCC, particularly in the HMCCs that depend
on a UCSF. The result of this is the limited compliance with the operational guidelines concluded by MINSAL and
the low performance of the facilities attached to UCSF compared to those operating within National Hospitals.
By applying the criteria and weightings previously defined in Table 5-1, it can be verified that human resource
management in the HMB-HMCC network is the second most important key operational factor with the greatest
impact on the operational functioning of the network, together with the condition of the equipment for
pasteurization processes in HMBs.
Modifying this situation requires a notable budgetary effort to rearrange priorities and give greater importance to
network management within health facilities, particularly considering the COVID-19 pandemic care measures, in
addition to requiring an intensive process of sensitization and updating of knowledge among the structure of
personnel who directly or indirectly work in the HMB-HMCC network.
Box 7-2 Key operating factor
assessment – Human resources
Average Process
Impact
Average Budget
Impact
Human resources HMB
3.0
2.0
3.0
3.0
Human resources HMCC
3.0
2.0
2.5
3.0
Policy and
Average Feasibility
guideline review
of Implementation
average
This key network performance factor has the greatest impact on network performance. These strategies have a significant budgetary
impact and require a broad review of institutional and regulatory policies, which must be accompanied by an intense effort in awareness
and capacity building, particularly in the network that depends on the Santa Ana HMB (see Table 5-1 in the methodology chapter for an
explanation of the categories and ratings).
Source: Own elaboration based on information compiled during the study.
35
Infrastructure
HMB Infrastructure
The three HMBs are attached to National Hospitals with maternity services with NICU. In all three, spaces have
been accommodated for a layout with (i) reception and administration, (ii) DBM extraction room with sanitary
isolation, (iii) production area (pasteurization), (iv) Laboratory and DBM/PBM storage, (v) cleaning and disinfection,
(vi) general storage - staff room.
The distribution of spaces is functional, but still needs to be improved according to the results of the last
ABC/MINSAL verification mission of the Global Network of Human Milk Banks1. The facilities of the three HMBs
were evaluated by a commission of Brazilian experts as part of the certification process for the Global Network
of Human Milk Banks, which resulted in a series of technical recommendations that, according to information
provided by MINSAL, have not been fully complied with. Currently, the technical redesign of spaces in the San
Salvador HMB is in its final stage, which will serve as a basis for modeling modifications in the other two HMBs.
The main limitation of the infrastructure is the concentration of space to accommodate a single production line
for pasteurization of DBM and certain restrictions for the installation of modern equipment for performing
bacteriological tests for quality control of PBM, particularly for the installation of laminar flow chambers for
handling samples in a clean and sterile contamination-free environment (currently such tests are performed with
the aid of burners).
The milk collection area for donor mothers is very functional and comfortable, providing a safe and clean private
space to accommodate the donation process.
HMCC Infrastructure
The HMCCs visited as part of the present study are mostly attached to UCSF and National Hospitals with
Maternity services and are installed in a room of 10 to 12 m2 in area, generally without internal divisions (except
for those in Ahuachapán and Zacatecoluca). The spaces assigned to the HMCC are reallocations of existing areas
with previous uses different from the nature of the operation of this type of facility.
The rooms assigned to the HMCC are reallocations of existing areas with previous uses different from the nature
of the operation of this type of facility and accommodates all the operational tasks of the HMCC, including the
donation process, which in most cases lacks the necessary equipment to ensure the privacy and comfort of the
donor mother.
Of the fourteen HMCCs visited, most do not have access to their own restrooms, and only four of them have
washbasins and toilets. Except for the cases of the private company, the walls have not been decorated to favor
and/or educate the breastfeeding process.
The visits included two HMCCs built and equipped in 2021 in the National Hospitals of Ahuachapán and
Zacatecoluca, in which the improvement of the operating standards established by MINSAL was verified. These
new guidelines conclude HMCC with separation of areas with more comfortable and private spaces to facilitate
the donation process. It should be noted that, in both cases, MINSAL has received support from the Office of the
First Lady of the Republic and CALMA for the equipment, setting and habilitation of these HMCC.
1
The final report of the mission included a series of observations on the infrastructure of the three HMBs, including the reorganization of internal circulation flows,
separation and isolation of areas with sanitary isolation, and information management systems.
36
In general, with the current operational conditions of the HMCC network, this is not a key factor limiting their
operational capacity; however, in the future, it would be highly recommended to make a greater effort to improve
the physical and operational conditions to improve DBM collection and donor care.
Box 7-3 Key operating factor
assessment – Infrastructure
Average Process
Impact
Average Budget
Impact
HMB Infrastructure
3.0
3.0
3.0
2.0
HMCC Infrastructure
1.0
1.0
2.0
2.0
Policy and
Average Feasibility
guideline review
of Implementation
average
This key performance factor is more relevant to the operation of HMBs, because it limits the productive capacity of PBM. In the case of
HMCCs, it would significantly facilitate the recruitment of donor mothers and make the donation process more private, dignified and
comfortable (see previously in the methodology chapter Table 5-1 for explanation of categories and ratings).
Source: Own elaboration based on information compiled during the study.
Equipment
HMCC equipment
Three situations can be clearly distinguished in the HMCC network: (i) in the cases of HMCCs inaugurated before
2019 the furniture is very limited and has not been renovated recently, except for donations of armchairs to
accommodate the donation process, (ii) in the cases of HMCCs attached to private companies, they have new
furniture and rooms set with acrylic decorations that illustrate the process and benefits of breastfeeding, and (iii)
the HMCCs inaugurated recently, have more modern furniture and equipment to accommodate the most efficient
and comfortable way the donation process.
As previously explained, the furniture itself is not a key factor for the operation of the facilities, however, it is
advisable to update it, especially in cases where donor mothers perform their donation process on uncomfortable
and hard chairs. In the three HMBs, the donation room in San Salvador is equipped with modern and comfortable
furniture; those in the Santa Ana and San Miguel HMBs have normal plastic chairs, without cushioning.
HMCC Freezers
As previously mentioned, the start of the cold chain for DBM in the HMCCs is mainly carried out using normal
household refrigerators; only four of the fourteen facilities visited have a horizontal freezer. The refrigerator
freezers installed in the remaining HMCCs are capable of accommodating an average of four to six liters of DBM.
This includes some cases of recently opened HMCCs (Ahuachapán as the most notable example).
In the current situation, with the network operating at an average of 31.4% of its nominal capacity (and in the
most exceptional cases, at 60% of its historical maximum throughput), freezers are not a key operating factor at
this time.
It is important to note that the use of home refrigerators in HMCCs does not fully ensure the safety of DBM
preservation, given that in some cases the lower part of the refrigerator is used to preserve food, beverages, or
other products. For this reason, when reviewing strategies for improving the operational capacity of the HMCC
network, reviewing the HMCC cold chain may be an aspect of technical consideration.
37
To safeguard the cold chain, it is also key to consider in the analysis the availability of standardized glass jars,
coolers and blocks of dry ice (known as "penguins") to transport the DBM to the HMB of assignment. In all the
cases visited, the necessary quantity of the three inputs was available. In all the HMCCs, with the exception of the
HMCC of the ISSS Regional Hospital and the two HMCCs of the private company, a record book is kept of the
cleaning of ice chests and "penguins". Several HMCCs have a good practice of collecting bottles among the staff of
the health facility to which they are attached, which has the collateral benefit of involving the staff in the operation
and dissemination of the HMCC.
Transportation at HMB - HMCC
All facilities in the HMB-HMCC network depend on transportation services provided by the central administration
of the health facility to which they are attached. This situation presents notable cases of coordination and
collaboration, as well as extreme cases in which the heads of some facilities have to resort to their personal
vehicles or public transportation to carry out DBM transport operations.
The HMCC attached to private factories that have an operating agreement with the Santa Ana HMB are provided
with transportation from the Hospital San Juan de Dios de Santa Ana in an efficient and timely manner.
Transportation services are especially significant for the three HMBs, where DBM uptake is also coordinated on
a household basis. San Salvador and Santa Ana have efficient collaboration from the central authorities of both
hospitals. San Miguel frequently has coordination problems.
This is a key factor for the overall performance of the Network, since it is an important detail to consider in order
to conclude household programs in the majority of HMCC nationwide that do not have this modality of DBM
uptake.
HMB Equipment
Table 7-3 shows the equipment inventory of the three HMBs and
the average time of use for each type of equipment. In general
terms, most of the equipment and furnishings are more than seven
years old, which means that most of them have exceeded their
useful life, especially the pasteurization and laboratory equipment.
The previous chapter highlighted the fact that PBM production in
the three HMBs depends basically on a single production line of
pasteurization equipment. It should be noted that only Santa Ana
has replacement equipment, albeit of lower capacity. This
concludes a critical production route that, combined with the
limitations of the room infrastructure dedicated to processing,
explains that currently only one daily production batch of PBM is
worked with a maximum average yield of five liters (see Table 6-6
in the previous chapter)2.
Similarly, the equipment for laboratory tests and microbiological
cultures has been in use for more than seven years, so most of it
has exceeded its nominal useful life.
Table 7-3: Average years of operation
by type of equipment in HMBs
(2021).
Computer Equipment
Average
Years in
Use
10.0
Oven dryer
8.5
Refrigerators
8.5
Laboratory Equipment
7.5
DBM exhaust fan
7.3
General Furniture
Pasteurization
Equipment
Freezers
7.2
Equipment
7.1
6.3
Air Conditioners
5.3
General Average
7.3
Source: Own elaboration based on information
compiled during the study.
2
In the case of the Santa Ana HMB, the performance is lower, since the cooler has a smaller capacity than the heater.
38
An important aspect is that in all HMBs the handling of biological culture samples for acidity tests and
microbiological control is done in the ambient area with the aid of a Bunsen burner, which, although it is a
procedure accepted by the applicable standards, is not the ideal procedure to guarantee the quality of the
microbiological control.
The test manipulation should be performed in a laminar flow chamber, which is an instrument used to have
contamination-free environments, because it provides decontaminated air from particles down to 0.1 microns.
Using a laminar flow chamber ensures a work area that always remains clean and sterile, an environment that
offers better results than the use of lighters. The HMB in San Salvador has this equipment, but it is not used
because the special gas bypass piping necessary for the equipment to function has not been installed.
Finally, the freezers in the HMBs are, in most cases, specialized upright freezers in acceptable operating conditions
and their capacity is adequate for the levels of DBM capture and PBM storage. In all cases, freezers are kept
separate by specialization (pre-pasteurization storage, post-pasteurization quarantine, culture and PBM released
for dosing). At this time they are not a key operating factor, but their capacity will need to be reviewed if strategies
are developed to improve the level of PBM production.
Inventory and Control Systems at HMB - HMCC
None of the facilities in the HMB-HMCC network have digitized inventory and control systems. All facilities have
computers and the reports required from the Network Coordination are prepared manually from physical records
in Excel spreadsheets. This is a key factor for the monitoring and follow-up of the Network and the administration
of the different operational aspects.
Box 7-4 Key operating factor
assessment – HMB Equipment
Average Process
Impact
Average Budget
Impact
Laboratory Equipment
2.0
2.0
3.0
2.0
Pasteurization equipment
3.0
3.0
3.0
3.0
Other equipment
1.9
1.6
1.7
1.4
Policy and
Average Feasibility
guideline review
of Implementation
average
Pasteurization equipment management at HMBs is the key performance factor of greatest impact to the network. At the time this report
is being prepared, a plan to replace most of the equipment in the HMBs and some areas of the HMCCs is under budget and procurement
management. These strategies have a significant budgetary impact and require an extensive review of institutional policies and regulations,
which must be accompanied by an intense effort in sensitization and capacity building, particularly in the network that depends on the
Santa Ana HMB. In addition, before and after completing the renovation of equipment in the HMBs, it is advisable to carry out a study of
times and movements to conclude operational guidelines for the equipment of each HMB (see Table 5-1 in the methodology chapter for
an explanation of the categories and valuations).
Source: Own elaboration based on information compiled during the study.
There are significant challenges to adapt the care processes, infrastructure and equipment in most facilities to the
needs of the donor mother population in order to make the act of donation a comfortable, private and stimulating
procedure. On this issue, the Network Coordination promotes the sending of management reports to the various
internal entities involved in MINSAL and ISSS, but institutional evaluations of the procedures, care resources and
methodologies are not carried out, although a collaborative spirit is fostered and the issue is part of the
institutional follow-up priorities. In this regard, it is very necessary and convenient to expand collaborative efforts
to exchange information with private companies and the ISSS and to create working relationships with academic
institutions and their research programs.
39
Cross-cutting aspects of the HMB-HMCC Network
The quality of the processes
The Coordination of the HMB-HMCC National Network is in charge of developing the processes of periodic
review and evaluation of the quality of the processes and their adequacy to the normative instruments in force.
These evaluations are carried out through an annual program of visits to the HMB-HMCC National Network.
The quality review of the processes as such is not systematized in a normative-programmatic document. A basic
evaluation form is completed for each visit and a manual historical record is maintained. In these process quality
reviews, the recommendations of the Global Network monitoring reports are also reviewed.
The results of the visits and evaluation reports are discussed internally at MINSAL, especially with the Integrated
Child Health Care Unit and with other units linked to the HMB-HMCC National Network in order to maintain
levels of operability and process quality. The results of these evaluations are the basis for the revision and/or
updating of operating procedures and guidelines.
In this cross-cutting issue, it is important to note that there is no structured capacity building plan for HMB-HMCC
personnel in a normative document. An annual mapping of HMB personnel capacities and the agenda of basic
technical preparation courses derived from the recommendations of the Global Network (Brazil) are developed.
With the HMCCs there is a high staff turnover, therefore, the Breastfeeding Course has been created in virtual
format, which includes the main training aspects that allow the operation of the HMCCs, and however, it is not
able to cover all the Network's staff.
Monitoring and evaluation
The National HMB-HMCC Network does not have a monitoring and evaluation plan. It is important to note that
all records in the facilities are managed in physical files, so it is not possible to share information in real time from
the facilities to the HMB coordination, but it is done periodically.
For this purpose, a basic reporting structure has been created in Excel format, which is shared on-line with the
facilities so that, based on the coordination of each HMB and its territorial network of HMCC, they report their
monthly operating statistics, which are compiled and integrated by the Network Coordination. In this process, a
file exchange platform has been created, which is manually updated and compiled by the Network Coordination.
Additionally, the Network Coordination prepares a report in the Global Network system.
The absence of a Monitoring System is one of the most important observations made during the ABC/MINSAL
Technical Missions to the Global Network in the Network Certification process. The report compiled by the
Network Coordination serves to provide monthly feedback to the national authorities on the productive
functioning and the main operational variables of production, which also serves to provide feedback to the
management areas of the Annual Operational Plan of the Network and MINSAL.
Coordination between units
The Coordination of the HMB-HMCC National Network is in charge of developing the necessary processes to
articulate the working relationships within the Network from the Unit of Integrated Health Care for Children. To
this end, a working group has been set up on a cell phone instant messaging platform and information is constantly
shared from the Coordination Office to all those responsible for the facilities.
However, it was observed that this mode of communication has the weakness of being predominantly vertical and
operational, without promoting horizontal communication among peers to exchange good practices and innovative
experiences in the processes of recruitment and care of donor mothers. It is necessary to build an internal process
40
for dialogue, knowledge management and information exchange among the members who manage the Network's
facilities.
There are significant challenges to adapt the care processes, infrastructure and equipment in most facilities to the
care needs of the donor mother population in order to make the act of donation a comfortable, private and
stimulating process.
On this issue, the Network Coordination regularly shares management reports to the various internal entities
involved in the HMB-HMCC Network within MINSAL and ISSS, but institutional evaluations of processes, care
resources and methodologies are not carried out, although a collaborative spirit is fostered and the issue is part
of the institutional follow-up priorities. In these areas, it is very necessary and convenient to expand collaborative
efforts to exchange information with private companies and the ISSS, and to create working relationships with
academic institutions and their research programs.
Box 7-5 Key operating factor
assessment – Cross-cutting aspects of
the HMB-HMCC Network
Policy and
Average Feasibility
guideline review
of Implementation
average
Average Process
Impact
Average Budget
Impact
Process quality
2.5
1.0
2.0
3.0
Monitoring and evaluation
2.7
1.3
2.3
3.0
Coordination between units
2.0
1.0
2.0
2.0
The Network's cross-cutting management processes are an intangible but very important factor for proactive management in the
Network. Currently, positive efforts are being made by the Coordination of the National HMB-HMCC Network; however, these can be
improved by having a formal monitoring and evaluation system with computer resources that allow the processing and analysis of the
Network's operational and institutional variables interactively and in real time. These strategies do not necessarily have a significant
budgetary impact, but require collaborative work in MINSAL with other actors that can support these tasks, especially with academic
institutions (see Table 5-1 in the methodology chapter for an explanation of the categories and evaluations).
Source: Own elaboration based on information compiled during the study.
Overall Weighting of Key Operating Factors
Finally, Figure 7-1 shows the graphical comparison between the weighting results of the four analysis criteria for
a total of 22 key operating factors previously studied and analyzed in detail in the previous chapter.
Based on this analysis, it can be concluded that the five most key factors influencing the operation of the HMBHMCC Network are (i) The management of pasteurization equipment in the HMBs (and its relationship with the
infrastructure and the human team that operates it), (ii) the management of human resources in the HMBs, (iii)
the status of the infrastructure in HMBs, (iv) the integrated management of the control and inventory systems
together with the Network's monitoring and evaluation system, and (v) the management and capacity building of
the human resources that operate the HMCCs, especially considering that it is an environment with many staff
rotations. The above serves to confirm the trends previously illustrated in Figure 6-3.
41
Figure 7-1: Key operating factors global assessment of the HMB-HMCC Network.
Flasks
HMB Freezers
HMCC Freezers
HMCC Infrastructure
Coordination between units
HMB furniture
HMCC furniture
Staff capabilities
HMCC Processes
Transport
Household program
Monitoring processes
HMB Processes
HMB laboratory equipment
Donor source
Recruitment Methods
Human Resources HMCC
Monitoring System
Inventory and control systems
HMB infrastructure
Human resources HMB
Pasteurization equipment
0
2
4
6
8
Average Process Impact
Average Budget Impact
Average Feasibility of Implementation
Policy and guideline review average
Source: Own elaboration based on information compiled during the study.
42
10
12
8. HMB Network Cost Analysis
Based on the analysis of the information gathered from the HMB - HMCC Network establishments, it was very
evident that estimating operating costs is very complicated, given that such information is not part of a formal
monitoring scheme for the monitoring of the network's operations.
For the first time, and as a result of the special request for information for this study, a preliminary estimate of
the unit cost per liter of pasteurized breast milk produced in the national network has been made, for which the
costs presented by the HMB of San Salvador have been selected as the most representative.
Table 8-1: Analysis of Total Costs of the HMB Network - HMCC of San Salvador (data collected for
June 2020 - June 2021)
Element of analysis
HMB-San Salvador
Total annual operating costs HMB of San Salvador
$85,680.91
DBM captured at HMB (liter-year)
571.00
DBM sent by the network of affiliated HMBs (liter-years)
190.36
Total DBM volume (liter-years)
761.36
Cost per liter of DBM collected HMCC
$413.49
Total HMCC Cost
$78,711.76
Total HMB + HMCC Cost
$164,392.67
PBM volume (liters-year)
687.59
Cost per liter of pasteurized milk
$239.09
Total number of babies benefited
902
Total investment per baby benefited
$182.25
Source: Own elaboration based on information compiled during the study.
43
9. Key Findings from the HMB Network Donor Mother Perceptions
Survey
As mentioned above, 113 surveys have been compiled from the population of donor mothers to the HMB network
during October and November 2021. From the results obtained, the following key findings can be concluded:
i.
51% of the women surveyed are not in permanent employment, only 24% are employed with statutory
benefits, 10.6% are self-employed without benefits.
ii.
Among donor mothers, the average age is 28 years old. On average, the mothers surveyed have two
children.
iii.
81% of donor mothers have had their babies in public hospitals (7% in ISSS).
iv.
54% of the mothers surveyed are exclusively breastfeeding their babies (23% are mixed breastfeeding).
v.
44% of the babies of the mothers surveyed have been premature (31 weeks on average, the extreme case
24 weeks). Of the total number of preterm infants, 86% have received milk from an HMB.
vi.
Of the total number of preterm infants who received pasteurized milk from an HMB, 98% considered that
the milk received met the growth needs of their infants and 95% rated it as excellent.
vii.
The main communication mechanism through which the HMB-HMCC network is promoted is the
information given by MINSAL officials (39% when asked to users attached to an HMB, 50% when asked to
a donor mother identified with an HMCC), secondly, they learned about the network because the health
facility they frequently visit has an attached HMB-HMCC (31%).
viii.
The main reason for a mother to donate breast milk is solidarity felt by collaborating with her donation
(53% identify it as their most important motivation), secondly, because they consider that it helps to
strengthen their breast milk production and thirdly, because of the breastfeeding counseling received.
ix.
Regarding the counseling received, 98% of the donor mothers stated that their doubts on the subject had
been resolved and 85% stated that they had learned a great deal and modified their feeding practices for
their babies.
x.
89% percent of the evaluations on the care received in the national HMB-HMCC network are "excellent",
while 73% of the facilities/infrastructure are evaluated as "excellent".
Based on the results obtained, it is very important to highlight that the key factor in motivating donation will
always be the management of human resources and the feeling of empathy and solidarity promoted by MINSAL
personnel assigned to the network with donor mothers.
In this sense, during the interviews it was possible to verify that most of the personnel working in the network
are motivated and empowered to carry out their work, however, there are many limitations to achieve the goals,
the main one being the work overload, the assignment of complementary tasks and the limited availability of
communication material in quality and quantity to motivate and technically orient the act of donation.
44
10.
Conclusions
Based on the collected documentary information, as well as on the interviews conducted, it has been possible to
conclude that the strategic approaches of the HMB-HMCC Network are very relevant and necessary to promote
breastfeeding and provide the best possible feeding to preterm, low birth weight and special health condition
newborns, thus responding to the National Policy to Support Early Childhood Development "Crecer Juntos"
(Growing Together).
The operation of the HMB-HMCC network has been operationally consolidated and has maintained a steady
growth in the number of facilities: currently there are 55 HMCC organized in three territorial networks attached
to the three HMBs and covering 10 of the 14 departments nationwide.
The HMB-HMCC strategy is one of the most relevant contributions to the commitments made by the country
for the fulfillment of Sustainable Development Goals SDGs, specifically with SDG3, Health and Wellbeing, Target
3.2... "By 2030, end preventable newborn and under-five deaths, with all countries aiming to reduce neonatal
mortality to at least 12 per 1,000 live births, and under-five mortality to at least 25 per 1,000 live births".
From the information gathered during the research, the following specific conclusions about the current conditions
in its operation and management are established:
On the recruitment of donor mothers (Phase 0):
i.
ii.
The primary source of donors are the users of the care services of the health facilities to which HMBs
and HMCCs are attached:

According to the visits made to HMCC and HMB, it is concluded that each facility implements
methodologies for recruiting mothers according to their situation and the environment in which
they work.

According to the results of surveys with mothers, the difference in the success of recruitment is
the quality and coverage of the motivational messages provided by the staff in the counseling
sessions, since mother-to-mother solidarity is the main incentive that motivates donors to
participate in the process of breast milk donation.
The new guidelines defined by MINSAL, after the COVID-19 pandemic, for the implementation of new
HMCC are a remarkable leap in quality to improve the functionality of these facilities, providing more
comfortable and private areas and spaces to facilitate the donation process.
DBM Over-Capture (Phase 1):
iii.
The network operates under the operational guidelines defined by MINSAL and maintains annual DBM
collection averages between 2,500 liters to 2,600 liters. In the year preceding the pandemic, the amount
of DBM collected was reduced to 1,720.7 liters.
iv.
The HMB-HMCC network has the capacity to collect more liters of DBM, given that, based on data to
date:

For the time period analyzed (June 2020-June 2021), the Network is operating at 31.4% of the
historical maximum uptake capacity.
45

HMCCs attached to National Hospitals maintain average yields ranging from 45% to 65% of the
historical maximum, while UCSFs and Maternal Waiting Homes currently produce a quarter of
their historical maximum value.

According to MINSAL projections and the data collected for this study between June 2020 and
June 2021, it is expected that the collection at the end of 2021 will reach an estimated 2,200 liters
of DBM.
On PBM production (Phase 2):
v.
Processing is completed on a single daily production line, the volume of which depends on the milk to be
processed and the standards of operation with the available equipment.

The processing of donated breast milk depends essentially on the Laboratorian and a maximum of five
liters of Pasteurized Breast Milk per day is produced on average.

In this context, the human resource (laboratorian) and the processing equipment are the key factors
for the overall performance of the network.
vi.
Based on the statistics collected for the present study, there is a need to evaluate the processes of DBM
collection, PBM processing and information management in each HMB and its attached HMCC network,
with the purpose of improving collection, decreasing discarding and increasing the number of final
beneficiaries.
vii.
The maximum amount of milk that can be collected in Phase 1 is estimated to be between 2,600 to 2,700
liters, which exceeds the maximum capacity of Phase 2 of 2,229.6 liters (see Figure 6-3 in the previous
Chapter 6). In this scenario, 370 to 470 liters would not be processed, suggesting the importance of
upgrading equipment and strengthening personnel for breastmilk milk processing.
viii.
If the current average processing capacity of the three HMBs were maximized by increasing the amount
of current DBM to maximum production with the current pasteurization equipment, an additional 524
liters of PBM could be produced.
ix.
The current processing capacity of the network would not be able to assimilate an increase in DBM
capture yield that would match the historical average of the network. The maximum possible that DBM
collection could be increased so that the HMB system does not collapse is on the order of 370 to 470
incremental liters per year (which equates to approximately 2,600 to 2,700 liters of DBM per year).
x.
The processing and handling of laboratory samples is performed in the laboratory environment with the
aid of a burner to ensure the safety of the samples for bacteriological culture. The procedure could be
improved with the use of laminar chambers (the HMB of San Salvador has new equipment that has not
been installed).
xi.
According to the interviews conducted with the laboratorians of each HMB, based on the equipment
available at each HMB, the normal loss (shrinkage) of processing is 2% to 3%. However, according to the
46
analysis of the present study, the abnormal losses of the network is 11.9% on average, i.e., 8% higher than
recommended.
xii.
The operational condition of the Santa Ana HMB and its territorial HMCC network needs to be evaluated
and its capacities strengthened.

The Santa Ana HMCC network has an exceptionally high percentage of abnormal losses before being
processed in the Bank and this source of supply is equivalent to half of the total DBM captured in the
territorial network of the western zone.

It is important to note that it was concluded that this territorial network is the one with the highest
personnel turnover, as it has the lowest average experience and the lowest number of training courses
received, compared to the other two territorial networks.
PBM delivery and dosage (Phase 3)
xiii.
With the current production and geographic coverage of the HMB-HMCC network, an average of 44%
of the demand for PBM among the population of newborns weighing less than 1500 grams born in MINSAL
has been covered.
xiv.
Procedures for inventory, control, requirement and prescription of PBM are not uniform among HMBs
and need to be evaluated and modernized.
xv.
All records are kept manually, without digital backup.
xvi.
Follow-up on the evolution of the beneficiary population is very limited and does not include a file
associated with the medical discharge report and the impact of the PBM on health, nor is there follow-up
after the hospital stay. This process would also facilitate a household donation program.
On Cross-cutting Processes
xvii.
It is important to note that all records in the facilities are managed in physical records, so it is not possible
to share information in real time from the facilities to the HMB-HMCC Network Coordination, but it is
done periodically through a monthly on-line file exchange system.
xviii.
In this sense, it is important to mention the urgent need for a Monitoring, Evaluation, Accountability and
Learning (MEAL) system for the Network that allows the generation of standard reports, decision making
and continuous improvement.
xix.
The HMB-HMCC National Network Coordination maintains the necessary processes to articulate the
working relationships within the Network based on the Integrated Child Health Care Unit:
xx.
There is a national level coordinator that stimulates communication between HMB-HMCC . It is important
to promote the exchange of experiences among the different members of the Network in order to have
the opportunity to learn about good practices in different regions and the way in which they solve
problems from the territory.
47
xxi.
Very positive collaborative processes of information exchange have been initiated with the private sector,
ISSS, civil society organizations and academic institutions to promote capacity building and the
implementation of collection centers.
11. Lessons learned
Best practices
Based on the systematization of the information obtained, the following Best Practices have been identified:
i.
Promotion, management and operation of cooperation agreements at the local level between:

ISSS and Santa Ana HMB (agreement managed at the local level).

Private companies (factories) and Santa Ana HMB.
ii.
Creation of a support network for donor mothers from the HMB of San Salvador using free tools in social
networks (Instagram and WhatsApp).
iii.
Systematize the experience of HMCC supported by private companies in terms of::

Decoration and ambience (color of walls, furniture, equipment, ventilation, lighting, among other
factors)

Educational material for the donor mother and various incentives that build mom's loyalty to the
strategy.
iv.
Local gardens in health facilities for the cultivation of the plant used to make a beverage that increases the
production of breast milk (Euphorbia lancifolia also known as Ixbut plant), which have been implemented
in the Hospitals of Chalchuapa, Ahuachapán and the ISSS Hospital in Santa Ana..
v.
Rotation of nursing personnel in alternate shifts to promote breastfeeding counseling and recruitment of
donor mothers (National Hospitals of San Francisco Gotera and Usulután).
vi.
Placement of flat screen televisions in the waiting areas and maternal shelters with a circuit of promotional
videos on breastfeeding issues in the Ahuachapán hospital.
vii.
Several HMCC have as a good practice to collect bottles to collect DBM among the staff of the health
facility to which they are attached, which has the collateral benefit of engaging staff in the operation and
dissemination of the HMCC.
viii.
It should be noted that CALMA has made important contributions in equipment for HMCC, strategic
communication for the HMB-HMCC Network, among other actions within its commitment to be part of
the Global HMB Network as a representative of Civil Society.
48
Strategic opportunities to enhance the HMB-HMCC Network
ix.
Collaborate with MINSAL in the design of more efficient communication mechanisms for the recruitment
of donor mothers in the national HMB-HMCC network.
x.
Generate an inter-institutional work network with Universities and Civil Society Organizations to create
spaces for scientific collaboration and research work around the national HMB-HMCC Network.
xi.
Design, with the support of other actors, a Monitoring, Evaluation, Accountability and Learning System
for the national HMB-HMCC network.
xii.
Negotiate cooperation agreements between CALMA and private companies participating in the HMBHMCC Network, including negotiating new participations through trade union initiatives (following the
example of the agreements signed by Santa Ana HMB with textile factories).
12. Recommendations
General recommendations
i.
Share the results of this study with the authorities of MINSAL, the Office of the First Lady of the Republic,
ISSS, CONALAM and other strategic actors to interest them in generating cooperative alliances and
promoting opportunities to work on initiatives to strengthen the Network of HMBs and HMCCs and to
benefit breastfeeding.
ii.
Disseminate the results of this study with the HMB work teams and their territorial networks for
knowledge management, learning, detection of areas for improvement and motivate them to improve the
overall performance of the HMB-HMCC Network at the current moment of COVID-19 facing the
country.
iii.
Design a Monitoring, Evaluation, Accountability and Learning system based on the network's operating
logic according to the conceptual model in Figure 12-1.
iv.
This system can be built with the support of a university academic entity and the collaboration of civil
society entities specialized in breastfeeding and food security promotion.
v.
Develop an administrative costing system for the services of the HMB-HMCC network based on the
methodology developed for this study, in which not only the associated operational and institutional costs
are considered, but also the savings obtained by PBM dosing (savings in the purchase of substitute foods,
medications, and hospitalization time in the NICU).
49
Figure 12-1: Basic Structure of an HMB-HMCC Network Monitoring and Evaluation System
Phase 0 Donor
Mothers
Basic data
DBM (HMBHMCC
Network and
Household
Collection
Traceability
of bottles
Entry
Module
Phase 1: DBM
Collection
Traceability
of bottles
Shipping to
HMB
Losses and
protocols
Phase 2: PBM
Production &
Dosage
Batches
selected for
processing
Efects on
Newborns
Impacts of the
HMB-HMCC
Network
Baby control
in dispensing
Follow-up
surveys
Production
Biological
cultures
Output Control
Medical
Release
Expost
control
Impact
Indicators
and
Assestments
Dosage
Captation
Module
Production
Module
RESULTS-BASED MONITORING SYSTEM
ASSESSMENTS
NATIONAL
IMPACT
EX POST ASSESSMENT
On the recruitment of donor mothers (Phase 0):
vi.
Gradually resume, based on COVID-19 protocols, donor mother recruitment and fidelization initiatives
that proved to be successful in past years and support this management with printed and virtual
communicational material taking advantage of social networks, as is done by the HMB of San Salvador with
its "Support Groups" strategy.
50
vii.
Develop a strategy to strengthen the methods for recruiting donor mothers and collecting DBM in the
territorial networks of the HMCCs, considering the following activities:

Design and implement a characterization and mapping effort of the capacities, experience and
skills that the HMB-HMCC Network staff.

Based on the mapping, design a training/technical capacity building and awareness program on
current operational guidelines.

Take advantage of the resources and initiatives that have been developed with CALMA and
academic entities for this program.

Increase communication actions from the coordination of the three HMBs to improve the
recruitment of donor mothers.
viii.
Characterize and map the capacities, experience and skills of the HMB-HMCC Network staff to identify
a support team for the HMB Network coordination to implement improvement and capacity building
processes throughout the Network.
ix.
Implement annually a capacity building program, internships and experience exchanges with the purpose
of improving the recruitment of donor mothers in the territorial networks under standardized processes.
The competencies of other actors, such as CALMA and academic institutions, can also be used to support
this strengthening process.
x.
Design a communication strategy for the network and specifically to increase the recruitment of donor
mothers. This strategy can be supported with cross-sectoral participation to leverage the competencies
of institutions and implement new communication strategies that support the functioning of the HMBHMCC Network at the national and community level.
Over-capture of DBM (Phase 1):
xi.
Systematize the UCSF San Martin household care model for replication in other HMCCs that currently
lack this modality of DBM collection.
xii.
Revise the procedures defined by MINSAL to adapt them to the current operating circumstances,
concluding a work regulation that minimizes rotations and personnel changes in the HMCCs.
xiii.
When equipment renovations are scheduled for HMCCs consider replacing and standardizing the use of
horizontal freezers for temporary storage of DBM prior to referral to the respective HMB.
51
On PBM processing (Phase 2):
xiv.
Comprehensively replace the PBM processing equipment plant, given that the current ones have already
reached and exceeded their useful life.
xv.
At the time of replacing the PBM processing equipment:

Develop a time, motion and process study when renewing key PBM processing equipment;

This study will be the basis for informing the operation and guidelines to improve HMB human
resource productivity and evaluate modifications to the institutional Guidelines.

Based on the results of the time and motion study, evaluate the convenience of reinforcing the
HMB staff with an additional technician specialized in clinical laboratory.
xvi.
According to the interviews conducted at HMCC and HMB, the amount of losses are lower in facilities
with more highly trained staff and less personnel rotations, such as the San Miguel HMB-HMCC Network.
xvii.
It is important to strengthen staff knowledge and analyze the other factors that condition the discarding
of breast milk before processing.
xviii.
Structuring the protocol for handling laboratory samples for bacteriological cultures using laminar flow
chambers. Such a protocol can be developed based on the installation of the equipment available at the
HMB of San Salvador that is pending installation.
PBM Delivery and Dosing (Phase 3)
xix.
Make a review of the PBM inventory, control, requirement and prescription procedures among the HMBs
so that they are uniform and capable of being digitized as part of the network monitoring and tracking
system.
xx.
Establish in the HMB procedures the follow-up of the evolution of the beneficiary population by creating
a file in the HMB with the medical discharge report, the impact of the PBM on health, follow-up after the
hospital stay and monitoring of feeding practices with the mother.
52
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53
Databank,
Banco
Mundial.
Obtenido
de