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fter two decades of social and political upheavals that nearly bankrupted the government on several occasions, Ecuador is now enjoying the most stable period in its history. This new calmer context has enabled the country to break with the priorities of previous governments. Rafael Correa’s government has rehabilitated public services, placing fundamental issues such as education and health, previously the preserve of the technocrats, back at the core of politics and citizenship.
Ecuador’s new constitution, approved by referendum in 2008, gives an important place to public health. It recognises the need for a far-reaching structural reform of the sector, not only the government’s management of it, but more broadly its many social, economic and cultural ramifications through a radical review of the country’s health policy based on a new social contract.
Article 32 of the new constitution states: “Health is a right guaranteed by the state and whose fulfilment is linked to the exercise of other rights, including the right to water, food, education, sport, work, social security, a healthy environment and everything that promotes well-being. The state shall guarantee this right by implementing economic social, cultural, educational and environmental policies. It shall guarantee permanent, timely and non-exclusive access to programmes, actions and services promoting and providing comprehensive healthcare and reproductive health. The provision of healthcare services shall be governed by the principles of equity, universality, solidarity, interculturalism, quality, efficiency, effectiveness, prevention, and bioethics with a fair gender and generational approach.”
Article 32 highlights the government’s multi-disciplinary approach. In addition to direct action, the goal is to combine healthcare policy with various related social issues — such as access to potable water — and lay down some fundamental principles to guide the state in the management of its services.
The true novelty of the constitution is the role allocated to well-being (sumak kawsay in Quechua), of which public health is one of the pillars. It is not just a development tool, a way of ensuring that the economy operates smoothly because a healthy workforce is able to produce more; it is also a prerequisite for the common good, since healthy citizens are better able to exercise their democratic rights.
The constitution also stipulates the requirements for the effective implementation of universal access to healthcare. Article 362 states: “Healthcare as a public service shall be provided through state, private, autonomous and community institutions, as well as those that practice alternative and complementary ancestral medicine. … Public state health services shall be universal and free of charge at all levels of care, and shall include necessary procedures of diagnosis, treatment, medicines and rehabilitation.”
By placing health back in the realm of public service, the constitution has freed it from the market forces that governed it over the past decades. The exercise of human rights is the departure point in this historic process. Now it is up to the state to ensure that universal access to healthcare becomes a reality by setting up an integrated public network of medical services and consolidating the national health system.
Such an ambitious objective clearly requires significant financing. Since Rafael Correa became president six years ago, public investment in healthcare has totalled more than $9bn (the four previous governments only spent a combined total of $2.6bn).
Health coverage has grown proportionately. In 2006, 16m medical treatments were provided. In 2012 the figure was more than 40m. The increase was due to the building of new infrastructure (14 hospitals and 956 health centres by 2017), greater flexibility of consulting hours, and a determination to improve coordination between the central health administration and the many services depending on it at grass roots level, as well as clear rules on complementarity with private health service providers.
Ecuadorians are benefitting from an unprecedented redistribution of wealth. This historic effort has allowed public health to become a key factor in social justice. The increase in the number of hospitals and healthcare centres throughout the country has given millions of patients access to services from which they had been excluded, because of distance, poverty, discrimination or lack of information. Even taking demographic growth and an increasing demand for checkups into account, the increase in consultations suggests that the new public health service has successfully passed its field trials. Public health policy has mobilised all the public sectors, as reflected in the objectives for the National Plan for Good Living for 2013-17.
The remaining questions are how health services and preventative actions will be taken on board by society, and how the people themselves, as the driving force of citizenship, will take charge of their own part in the process. The task now facing the government is to show that real democracy remains the most important social determinant. The right to health in Ecuador today may be perceived both as a victory and a challenge.
Carina Vance is Ecuador’s health minister.
Translated by Krystyna Horko.
This article appears in the excellent Le Monde Diplomatique, whose English language edition can be found at mondediplo.com. This full text appears by agreement with Le Monde Diplomatique. CounterPunch features two or three articles from LMD every month.