Living with COVID-19 in Ecuador: a ‘building blocks’ perspective
By guest contributor Irene Torres, PhD
There are many ways to describe the impact of COVID-19 in a small country like Ecuador.
Similar to high-income countries such as the UK and the US, there is government inaction and mixed scientific messages (including from the WHO), which seemed to have been treated fairly selective. There is also the human desperation derived from having one of the highest excessive death rates in speech amidst general indifference even after being confronted with the images of corpses lying in the streets of Guayaquil, a large Ecuadorian city. At the end of 2020, 41,000 more people had it compared to 2019; and, even though the government estimates that only 23,800 died from COVID-19, that number equates to 21% of all deaths last year.
Since the start of this pandemic, I have tried to figure out where decision-makers in Ecuador may have tended or ignored the basics of human well-being. An increased focus on immunization shows that we have not looked to our own ability to fight the pandemic and continue to misinterpret promises to adopt external technologies and models. While Ecuador could use structural and socio-economic transformations, perhaps a few small changes would facilitate our exit from the pandemic while laying the foundation for a better health system. Using the WHO ‘building blocks’ framework, I analyze here the (limited) evidence available reflecting the potential usefulness of grassroots tactics in the country to support 1) service delivery, 2) health care staff. health, 3) health information systems, 4) access to essential drugs, 5) financing and 6) leadership and governance.
The image of “building blocks” can evoke a health system made up of equally important elements coupled with the help of a policy carefully placed between them like mortar, that is, a preconceived modern construction. for success. It is more difficult to imagine an Inca structure with loose stones, unevenly cut, quite resistant to shocks but defying what could be considered technically designed or effective. Without the unique discernment required to predict how the joined stones fit together as in Sacsayhuaman, I only suggest small stones to fill in the crevices, while waiting for the larger slabs to be readjusted.
Ecuador has a fairly limited diagnostic capability for Sars-CoV-2. By the time the pandemic made international headlines at the end of April 2020, only 8 out of 24 provinces had laboratories capable of processing COVID-19 PCR samples and not all of them did. More than 12% of samples took 10 or more days between healthcare attention and notification of results. The price cap for private testing has been set so high, at US $ 120 for an RT-qPCR test, which few could afford one in a country where less than 40% are formally employed and the minimum wage is US $ 400. The government did so few tests that for months the positivity rate read like a game of chance: 1 in 2 came out positive.
The government did so few tests that for months the positivity rate read like a game of chance: 1 in 2 came out positive.
– Author Irene Torres, on the early days of the COVID-19 crisis in Ecuador
Limited testing has implied that COVID-19 surveillance information is also limited; as a result, the contacts are insufficiently traced, if at all. In a country where less than half of the poorest quintile use social media, the government-created app requiring patients to have smartphones was doomed to fail. While classic community-based surveillance efforts have been successful on a small scale, the idea that businesses and private industries report outbreaks has yet to be embraced. Since employees report if they are sick with COVID-19 and can also take free tests at work, this anonymized data could enable faster and more relevant decision-making. Even though formally employed people represent only about 40% of the economically active population, health authorities would still have a better knowledge of the location of epidemics than at present.
Ecuador’s primary health care system for the uninsured (around 60% of the population) largely depends on the year of compulsory service of doctors after graduation i.e. poorly trained staff, with limited access to up-to-date and up-to-date health documentation in Spanish. When my husband had COVID-19, he was prescribed ivermectin, which is not surprising given that the Deputy Minister of Health announced that hydroxychloroquine would be distributed free to doctors as a measure “prophylactic”. The fictionalized portrayal of compulsory service makes it difficult for the physicians concerned to reconsider a different career path for junior staff. For example, when the newly elected government insisted on immunizing using the pressurized and understaffed primary health level, no one complained. it would distract from prevention, promotion and regular health care.
Due to the lack of individual health records, Ecuador does not have an information system common to the various public and private providers. Without being able to automatically link records, the country continues to wait for a more accurate account of the impact of COVID-19, which further means decisions continue to be rather intuitive. In contrast, neighboring Peru has at least made COVID-19 deaths more transparent by linking different types of records based on improved criteria to categorize cases. Only the excessive mortality factor (EDF) in Ecuador shows the dramatic inequality of the impact until September 2020: 2.2 in the indigenous populations versus 1.36 in the predominant MÃ©tis group. What’s more, the EDF among indigenous women is higher than among men in all age groups between 20 and 50 years. It would be strategic to generate more knowledge about all of the 2020 deaths and their broader social determinants – hopefully with advice from Peruvian experts instead of starting from scratch – to develop plans (not just health).
Access to essential medicines has been bogged down by rampant corruption, making government purchases questionable to say the least. Compared to the previous year, the prices paid by public hospitals for medical supplies increased by up to 1,307% in April 2020, which was the month that saw highest peak of deaths in Ecuador. An obsolete and incomplete regulatory policy hampering scientific production in the country has strengthened its dependence on importing drugs and medical supplies, making Ecuador vulnerable to global shortages and the ensuing price speculation. In a country where direct health expenditure represents more than 40% of the total health budget, limited scientific autonomy can draw the line between life and death more than the coronavirus itself. It would not take much for Ecuador to adapt the regulations developed by agencies such as the FDA in the United States, which contemplate many different scenarios and types of supplies and devices that must be approved.
I can only hope that some change can come out of these lessons.
Although I will be the first to say that research and scientific debate should not covid, there is still a lot to learn from Ecuador’s response to the pandemic, and for Ecuador to learn from its own mistakes. I can only hope that some change can come out of these lessons. One by one the smaller stones can be put in place, as we continue to work to find the best way to arrange the larger stones.
Irene Torres works at Fundacion Octaedro in Ecuador, where she is a member of the board of directors of the Ecuadorian Society of Public Health. His research focuses on school health promotion, migration and health, and more recently COVID-19. Twitter: @lairene