The rural and tranquil Valle de los Chillos is one hour south of the capital city of Quito, Ecuador. The majority of its inhabitants continue to earn their living much as their ancestors for generations before them, relying on the rich soil and abundant rains of the valley to produce subsistence crops and livestock.

Escalating economic pressures beginning in the 1990’s led to a sharp increase in numbers of commuters from El Valle de los Chillos attracted to service and manufacturing jobs in neighboring cities such as San Golquil and Quito. Runaway inflation and adoption of the U.S. dollar as the official national currency in the late 1990’s also initiated a wave of immigration abroad. Citizens of the parroquia can now be found living and working abroad in countries including the United States, Norway, Italy and Spain.

Despite the natural blessings of climate and location favoring agriculture, the rural character and economy of Cotogchoa contribute to many problems affecting the health of its citizens. These problems are closely related to a historical lack of infrastructure, organization, and the political influence necessary to command sufficient government resources.

Such problems are common in Ecuador and can be found throughout the world. However, people in developing countries tend to be affected disproportionately by deteriorating economic conditions and an ineffective government response to them. Of people in these countries, certain groups, such as the rural poor, in places like Cotogchoa, frequently are among the most underserved of populations when it comes to all services, including healthcare.

These problems have been well identified, and illustrated, in the Parroquia of Cotogchoa’s official 10 year development plan for the years 2002 – 2012. Specific issues identified in this well-documented study affecting the health of the community fall into several categories:

• Education: One third of adults are functionally illiterate. Nursery school space is 70% under capacity. There are no screening programs in the schools to detect hearing or vision loss, orthopedic deformities, or developmental problems. There is no secondary school in the community. The parroquial library is closed.
• Water, Sewage, Basic Services: 20% of residences lack running water. 40% of residences lack any type of septic, or sewage system. 40% of households and businesses have no type of garbage removal. None of the water is treated, resulting in widespread parasitic disease. 30% of houses lack electricity, 40% are without a working telephone.
• Security: Police staffing and equipment are inadequate. Alcohol abuse is widespread, leading to domestic violence and neglect in many families.
• Public Health: Currently a government sponsored Subcentro de salud exists in Cotogchoa Central, but its ability to serve patients is limited. Current issues with the Subcentro de salud include:
  • Limited and irregular staffing hours of the Subcentro de salud.
  • Limited ability to see patients during first come, first serve, morning hours that the Subcentro de salud is open.
  • No medicines are available through the Subcentro de salud, and there is no local pharmacy. With average household income of less that 100 dollars per month (according to a recently conducted HealtheClinc survey), the majority of people cannot afford to have their prescriptions filled.
  • The Subcentro de salud is staffed by newly graduated physicians, fulfilling their government required "Rural Year" of public service. The result of this annual rotation policy is to deprive the Subcentro of an experienced physician, and continuity of care.
  • No dental service, no access to specialty services.
  • No outreach programs in preventative healthcare, such as prenatal care, prevention of water born illnesses, domestic violence, etc.
  • Insufficient access to the Subcentro de salud by many of the members of outlying communities. People in many parts of the parroquia need to take three buses to get to the Centro, and then another 1 or 2 buses to reach a pharmacy if they are trying to fill a prescription.

With on ongoing economic stagnation, continued government instability, and little hope of an infusion of money, equipment or personnel to the existing Subcentro de salud, the community decided to take action.

1. They adopted a new version of the official Vision Statement for the Parroquia of Cotogchoa to prioritize concrete healthcare needs: “Healthcare services shall be permanent, preventative and curative; offering specialist services, rehabilitation, modern equipment and a pharmacy.”
2. They began to talk. Among neighbors, among community leaders, were there other options that to address the gap in healthcare? If they organized and enlisted broad support in the community, could they find technical help and alternative sources of support for healthcare in Cotogchoa?
3. After officially organizing, they decided to enlist the support of HealtheChildren.org to provide assistance in planning, funding and managing Cotogchoa’s own, self-sustaining, community-based healthcare project.

The Valle de los Chillos already contains a government sponsored healthcare clinic. To understand why it’s not serving at least 60% of patients in the parroquia, and those who it is serving, incompletely; it is helpful to review the history of the healthcare system, and the national government, over the past twenty-five years.

When vast oil reserves were first discovered beneath Ecuador’s Amazon basin in the 1980’s it was thought that the future healthcare of all Ecuadorians was assured. A substantial amount of the revenues from the sale of oil were to be directed by law to the national health system which was charged with the care of over 97% of patients (less than 3% have any type of private health insurance.)

Indeed, to the politician’s credit, the (latest) 1998 version of the Ecuadorian National Constitution includes very strong language addressing the government’s responsibility to care for every aspect of its citizens health from birth to grave, including, “that all public health programs are to be free for all persons.”

Further laudable commitment to healthcare by the national government includes specific legislation outlining patient’s rights to receive free prenatal, obstetric, pediatric, dental and other types of care.

Financially, the Ecuadorian government’s total expenditure on health as a percentage of the gross domestic product is 5.1%, or $220 U.S. dollars per person, per year. This ranks far behind the U.S. at 15.1%, ($5,711)but is ahead of such neighboring countries in the World Health Organization’s Region of the Americas, including Venezuela at 4.5% and Peru with 4.4%.

Ecuador’s national health system also benefits from some direct, government-to-government foreign aid, 0.9% for the last published year of 2003. The largest donor to this sector is the United States Agency for International Development, or USAID, with 22 million dollars earmarked for a variety of credible healthcare programs for the calendar year 2006, a reduction of roughly 50 percent from the previous calendar year.

Despite such forward-thinking healthcare legislation, and the commitment of real resources at the national budgetary level, Ecuador has been less than successful at meeting its healthcare goals. Indeed, the national health service has been in a chronic state of under-funding with widespread shortages of even the most basic medicines, equipment, and personnel in state hospital and clinics for the past decade. Health workers receiving under the table payments above the normal service cost to provide better, or more timely care, is widespread. Subcentros de salud all over the country sit closed for lack of funding. The Ministry of Health is short 200 physicians and the funding to pay them for its hospitals in Quito.

The shortage of health professionals is much more severe in outlying, rural areas. Ironically, many well-qualified Ecuadorian physicians, and other healthcare professionals, seek better payment employment outside of the field of medicine to support their families, or are attracted to much better paying healthcare positions in other Spanish speaking countries such as Chile, Mexico, and Spain.

To understand some of the national health service’s shortcomings, why so many people simply are unable to get even the most basic medical care, it is necessary to understand how Ecuador, like many developing countries in the world, has been hampered by a history of instability and corruption.

After the discovery of large oil reserves in the Amazon rainforests of eastern Ecuador in the 1980’s, successive national governments began to spend heavily on all sectors of the economy, including such social programs such as healthcare. It seemed a sure thing, the reserves of oil were large, and the price of oil seemed only to rise. Governments borrowed heavily to pay for development projects, in many cases questionable ones that benefited primarily members of the government and their associates.

An outbreak of war with neighboring Peru over ownership of some of the now valuable Amazon territories initiated a further budgetary strain. Governments borrowed further large sums to finance illegal shipments of often defective weapons from neighboring countries Argentina and Chile, in what turned into a protracted and unwinable war with Peru.

Servicing a huge debt to foreign governments and banks, the country was ill-prepared in terms of financial reserves to meet the collapse of the Asian, and then most Latin American, financial markets, in 1998. This was closely followed by a drop in world oil prices, sinking an economy that had been taking on water. The country’s currency, the Sucre, lost so much value that many large national and private banks refused to accept it as payment for debt. In order to stave off complete economic collapse, the country abolished its own currency in favor of using only the U.S. dollar for all transactions. Millions of people who had their money in banks lost most their savings overnight through devaluation.

This period of economic instability heralded political volatility, as different political parties, and national institutions including the military, began to struggle over who was to blame for the state of the country; and who would control its rich resources. Seven presidents in eight years followed, emblematic of the instability of the political process in Ecuador. The effect of this on government run programs, including healthcare, has been direct and destabilizing. One especially insidious effect has been that with each change of Presidents, through presidential patronage, all appointed health ministry positions are filled with the new president’s supporters. This has included changing thousands of officials from every level of the healthcare system, from top to bottom, seven times in eight years! Most officials have hardly had a chance to learn their jobs, before being replaced.

Instability in Ecuador’s government sector has also affected healthcare delivery by promoting corruption. Transparency International, the Berlin based non profit, compiles an annual Corruptions Perceptions Index devoted to ranking countries by their level of corruption from 10 to zero. The cleanest countries get the highest score and place first on the list. Ecuador scored a 2.5, ranking it 117th in the world, tied with Afghanistan. Both were edged out by the Palestinian Authority which scored a 2.6. That means, that despite whatever money is budgeted for national healthcare, and however favorably that may compare with some of Ecuador’s neighbors, that without effective management and oversight of that money, a huge percentage of it “disappears” before it reaches those it was intended to help.

“Corruption is a major cause of poverty as well as a barrier to overcoming it. The two scourges feed off each other, locking their populations in a cycle of misery. Corruption must be vigorously addressed if aid is to make a real difference in freeing people from poverty.”   Transparency International

Unfortunately, the very nature of healthcare systems makes them especially vulnerable to corruption in all countries. Specifically, healthcare involves uncertainty, as people cannot predict when they will need it. Information is asymmetric meaning not all information is shared between patients, providers, and healthcare systems. Finally, there are a large number of players involved in the healthcare system, including providers, administrators, pharmaceutical companies, equipment suppliers, regulators, payers, et. al.; opening up the system for corruption on many different levels by many different parties, each with differing agendas.

Transparency International reports in its special report on healthcare corruption “that three factors, uncertainty, asymmetric sharing of information, and a large number of players, all create systematic opportunities for corruption. These three factors combine to divide information among different actors – regulators, payers, providers, patients and suppliers – in ways that make the system vulnerable to corruption and that hinder transparency and accountability.”

Specifically, “in the case of direct public provision of health care services [such as Ecuador] the most common forms of abuse involve kickbacks and graft in procurement, theft, illegally charging patients, diverting patients to private practice, reducing or compromising the quality of care, and absenteeism.” Read about the Causes of Corruption in Health Sector here.

Read the Parroquia of Cotogchoa’s official 10 year development plan for the years 2002 – 2012.

Learn more about our project, about current healthcare in Ecuador, the community of Cotogchoa, the project leadership, project planning and local resources. Please contact us here to post your questions and commentary on this page, and others throughout our website.