Institutional challenges to achieving health equity in Ecuador
Authors: Irene Torres, Daniel F López-Cevallos
Journal: The Lancet Global Health (2018)

Since at least the 1970s, Latin American public health research has shown the relevance of social, economic, and political power structures in causing health inequities.1Almeida-Filho N Kawachi I Filho AP Dachs JNW Research on health inequalities in Latin America and the Caribbean: bibliometric analysis (1971–2000) and descriptive content analysis (1971–1995).Am J Public Health. 2003; 93: 2037-2043Crossref PubMed Scopus (86) Google Scholar However, regional strategies still struggle to articulate principles of health equity within national policies and programmes.2Donkin A Goldblatt P Allen J Nathanson V Marmot M Global action on the social determinants of health.BMJ Glob Health. 2017; 3: e000603PubMed Google Scholar 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). First, the medical–industrial complex continues to grow at the expense of the Ecuadorian population. Although tertiary care has been strengthened, the overall system is still burdened by predictable public health demands (such as lack of potable water and sanitation, particularly in rural areas, leading to the persistence of vector-borne and other infectious diseases).3Joint Monitoring Programme for water supplyEstimates on the use of water, sanitation and hygiene in Ecuador.https://washdata.org/dataDate: 2017Date accessed: February 28, 2018Google Scholar Stunting is persistently common, with a prevalence of 23·9% in 2014; meanwhile, 65% of the population aged 20 years and older are overweight or obese.4Fernandez A Martínez R The cost of the double burden of malnutrition: social and economic impact. Summary of the pilot study in Chile, Ecuador and Mexico. World Food Programme, Rome2017Google Scholar Malnutrition-related costs account for 4·3% of Ecuador's GDP annually.4Fernandez A Martínez R The cost of the double burden of malnutrition: social and economic impact. Summary of the pilot study in Chile, Ecuador and Mexico. World Food Programme, Rome2017Google Scholar The second area of concern is the growing relevance of the loosely regulated processed foods industry, which is strongly linked to the obesity epidemic.5Stuckler D McKee M Ebrahim S Basu S Manufacturing epidemics: the role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco.PLoS Med. 2012; 9: e1001235Crossref PubMed Scopus (358) Google Scholar We see no evidence that the Ecuadorian Government is considering food industry regulation beyond symbolic efforts such as the traffic-light food labelling of packaged products, which was introduced in 2014 under the auspices of UNICEF, the Pan American Health Organization, and WHO. Recent research findings6Freire WB Waters WF Rivas-Mariño G Nguyen T Rivas P A qualitative study of consumer perceptions and use of traffic light food labelling in Ecuador.Public Health Nutr. 2017; 20: 805-813Crossref PubMed Scopus (31) Google Scholar suggest that people understand the information that traffic-light labelling conveys; however, other factors (eg, taste, brand) are more important in food purchase and consumption. Breastmilk substitutes are another related example. In one study,7Ortiz-Prado E Stewart-Ibarra AM Ramirez D Espin E Morrison A Artificial infant formula consumption and breastfeeding trends in Ecuador, a population-based analysis from 2007 to 2014.Glob J Health Sci. 2016; 8: 184Crossref Google Scholar 76% of Ecuadorian children younger than 1 month and 60% of children younger than 6 months were fed breastmilk substitutes, and one in two mothers were advised (mainly by clinicians) to feed their children a dairy product. The investigators also found that food labelling contained messages or images that idealised the consumption of that food, with at least 68% of outlets promoting breastmilk substitutes through price reduction, delivery of gifts, and other benefits. That sales of breastmilk substitutes between 2007 and 2014 reached $530 million is therefore not suprising.7Ortiz-Prado E Stewart-Ibarra AM Ramirez D Espin E Morrison A Artificial infant formula consumption and breastfeeding trends in Ecuador, a population-based analysis from 2007 to 2014.Glob J Health Sci. 2016; 8: 184Crossref Google Scholar Third, Ecuador's one-size-fits-all, centralised, and vertical governance model in the past decade has diminished the role of civil society and other actors in developing a comprehensive and community-based approach. The Ecuadorian Government systematically endeavoured to hamper criticism, which had a chilling effect on grassroots women, indigenous people, and environmental movements and organisations8de la Torre C In the name of the people: democratization, popular organizations, and populism in Venezuela, Bolivia, and Ecuador.Rev Eur Estud Latinoam Caribe. 2013; 95: 27-48Crossref Scopus (37) Google Scholar who would likely enrich the health-reform debate. In a geographically and culturally complex Ecuador, contextualising health promotion on the basis of local autonomy and cultural traditions is crucial to transformation. However, community-level efforts in schools, for example, have been drastically curtailed. The community school meal programme, which offered children a prepared lunch, was replaced by humanitarian-aid-style provision of beverages and snacks with added sugars, further benefitting the food industry to the detriment of local small farmers, who were better placed to provide fresher and more culturally appropriate foods.9Torres I Policy windows for school-based health education about nutrition in Ecuador.Health Promot Int. 2017; 32: 331-339PubMed Google Scholar Similarly, small and rural (and primarily indigenous) schools, a hub for community activities including health promotion, were closed or abandoned in favour of a more centralised model of public education. Fourth, the Ecuadorian Government seems to neglect the value of data for decision making. Ecuador has not released national health account reports since 2006.10Bui AL Lavado RF Johnson EK et al.National health accounts data from 1996 to 2010: a systematic review.Bull World Health Organ. 2015; 93: 566-576Crossref PubMed Scopus (13) Google Scholar Moreover, other than technical or descriptive reports, the research produced by the Ministry of Health is limited, and no system or agenda is in place for research collaborations with academic institutions. When evidence is produced, it hardly translates into (or is informed by) policy and programming efforts. Consequently, Government officials tend to make decisions based on intuition or, as was the case with food labelling, at the suggestion of international cooperation agencies. Fifth, a narrow focus on health-care delivery prevents public health officials from engaging in more robust multisectoral collaborations. Relevant issues such as pesticide exposure11Brisbois BW Harris L Spiegel JM Political ecologies of global health: pesticide exposure in southwestern Ecuador's banana industry.Antipode. 2018; 50: 61-81Crossref PubMed Scopus (8) Google Scholar and traffic accidents12Algora-Buenafé AF Suasnavas-Bermúdez PR Merino-Salazar P Gómez-García AR Epidemiological study of fatal road traffic accidents in Ecuador.Australas Med J. 2017; 10: 238-245Google Scholar are yet to be addressed across multiple ministries and with the participation of community-based organisations in a collaborative and informed manner. In conclusion, Ecuador's most recent efforts to promote health reform should acknowledge the intersectional and societal dimensions of medical and non-medical determinants of health. Our proposed community-based system for health equity would build bridges of communication towards health promotion and prevention initiatives that address, rather than perpetuate, systemic inequities. Although international partners might provide valuable suggestions, implementation of efforts in health reform must consider local realities, ideas, and assets. In addition to bringing back community voices to decision making, policy and programming efforts need to go hand in hand with independent scientific research and evaluation. We hope that Ecuador's current health reform debate becomes a space for substantive discussions with the active participation of health-sector experts, other branches of Government (at the local, regional, and national levels), and grassroots organisations, and that particular emphasis is given to incorporating the voices of groups (eg, low-income, rural, indigenous) that remain largely underserved, marginalised, and politically disempowered. We declare no competing interests. Achieving health equity in EcuadorWe welcome the Comment by Irene Torres and Daniel López-Cevallos (August, 2018)1 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.2 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. Full-Text PDF Open Access