Achieving health equity in Ecuador
Authors: M Isabela Troya, M Paz Saavedra
Journal: The Lancet Global Health (2018)

We welcome the Comment by Irene Torres and Daniel López-Cevallos (August, 2018)1Torres I López-Cevallos DF Institutional challenges to achieving health equity in Ecuador.Lancet Glob Health. 2018; 6: e832-e833Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar as an opportunity to expand on the structural challenges associated with seeking health equity in Ecuador. Although we generally agree with the authors, the Comment does not depict the roles of the public and private sectors with regard to health-care delivery.2Giovanella L Feo O Faria M Tobar S Health systems in South America: challenges to universality, integrality and equity.http://isags-unasur.org/wp-content/uploads/2018/03/livro_sistema_saude_2012_eng-2.pdf/Date: 2012Date accessed: October 25, 2018Google Scholar We believe further discussion about reaching health equity without addressing the diversity of actors and contexts at play becomes superficial. By ignoring the heterogeneous locality-specific health dynamics, we fall into simplifying the complexity of the system. We argue that this oversimplification can be detrimental for the consolidation of long-standing processes that have resisted a homogenising model (eg, indigenous movements that have tried to conserve their historical practices) and have shaped more inclusive legislation and practices in past decades.3Fajardo RZY El horizonte del constitucionalismo pluralista: del multiculturalismo a la descolonización.in: César Rodríguez Garavito El derecho en América Latina: un mapa del pensamiento jurídico del siglo XXI. Siglo Veintiuno Editores, Buenos Aires2011: 139-159Google Scholar For instance, in the rural provinces of Imbabura and Chimborazo, initiatives to tackle maternal mortality have brought together public servants and civil society to work in innovative ways.4Pan American Health Organization (PAHO)Concursos buenas practicas y fotografia en maternidad segura.https://www.paho.org/can/index.php?option=com_docman&view=document&slug=concurso-buenas-practicas-y-fotografia-en-maternidad-segura-ecuador-2011&layout=default&alias=6674-concurso-buenas-practicas-y-fotografia-en-maternidad-segura-ecuador-2011&category_slug=ecuador&Itemid=308&lang=esDate: 2011Date accessed: October 25, 2018Google Scholar Although Ecuador's health system remains segmented and fragmented, depending on who is trying to access health care, citizens do not simply bear the consequences of an exclusionary model. In practice, people navigate the system actively in ways that challenge traditional health-care models from inside and outside public health-care institutions. One example is the nationwide incorporation of delivery rooms adapted for vertical birth5Heredia V En 236 centros de Ecuador se realiza parto humanizado.http://www.elcomercio.com/actualidad/ministerio-salud-parto-humanizado-bebe.htmlDate: July 3, 2018Date accessed: July 12, 2018Google Scholar—a result of collaborative work between different groups to expand hospitals' attention to local populations and comply with women's rights to choose their delivery position. Such initiatives were built upon current legislation regarding maternity and intercultural rights. They represent local initiatives that are crucial to advancing the process of achieving health equity in Ecuador, acknowledging local expertise of different actors and networks within which they negotiate and shape these changes. We suggest that structural changes in health systems benefit from legislation and policy changes but also from more stable processes of learning and adaptation among actors and institutions. Efforts to reform the traditionally fragmented, vertical, and centralised health-care model, in both legislation and practice, have been made by third-sector organisations, social movements, and the state (eg, the Comprehensive Health-Care Model [MAIS] with a Family, Community and Intercultural Approach,6Ministerio de Salud Publica EcuadorManual de Modelo de Atencion Integral de Salud-MAIS.http://instituciones.msp.gob.ec/somossalud/images/documentos/guia/Manual_MAIS-MSP12.12.12.pdfDate: 2012Date accessed: October 25, 2018Google Scholar created in 2012 to expand on the traditional biomedical model). However, these efforts must be sustained and improved to better address structural challenges contributing to health inequity. Changing Ecuador's exclusionary model of health necessitates recognition of the agency of the different actors shaping the system inside and outside the public sector. Criticisms addressing a homogeneous system reinforce a centralised, one-size-fits-all model. To successfully deliver the proposed community-based equity system approach suggested by Torres and López-Cevallos,1Torres I López-Cevallos DF Institutional challenges to achieving health equity in Ecuador.Lancet Glob Health. 2018; 6: e832-e833Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar the multiple factors configuring these particular contexts must be taken into account. We declare no competing interests. MIT is funded by a Keele University ACORN studentship. MPS is funded by the Secretaría de Educación Superior, Ciencia, Tecnología e Innovación (Senescyt), Ecuador. Views expressed in this letter are those of the authors and not necessarily those of any of the funding bodies. Institutional challenges to achieving health equity in EcuadorSince at least the 1970s, Latin American public health research has shown the relevance of social, economic, and political power structures in causing health inequities.1 However, regional strategies still struggle to articulate principles of health equity within national policies and programmes.2 The Ecuadorian legislature has been discussing a new health law that builds largely on the same biomedical curative system as previous reforms. To contribute to this debate, we discuss five areas of concern that health reform efforts should consider in moving towards a community-based health-equity system (figure). Full-Text PDF Open Access