Assessing the impact of the 2008 health reform in Ecuador on the performance of primary health care services: an interrupted time series analysis

Abstract

Background In 2008, Ecuador started a national health reform based on the principles of Alma Ata to achieve Universal Health Coverage. While coverage indicators have increased, a systematic assessment of the impact of the reform on the delivery of health services at primary level is lacking. The aim of this study was to assess the impact of the 2008 health reform on the performance of primary health care services in Ecuador. Methods Ambulatory Care Sensitive Conditions (ACSC) are a subset of diseases where hospital admission is potentially avoidable by high quality well-functioning primary care. Thus, observing the behaviour of ACSC hospitalizations can serve as an indicator of how the primary health care level is performing. Crude and adjusted rates, stratified by sex, were calculated from ten selected ACSC hospitalization discharges during 22 years of data representing 11 years before and after the health reform. An interrupted time series analysis was then conducted by applying a negative binomial regression and adjusting for overdispersion and autocorrelation. Results Overall higher crude and adjusted rates for ACSC hospitalizations were observed in women compared to men; both increased gradually since the start of the observation, reaching a peak around 2010, and then started a downwards trend. In men, the incidence rate ratio increased significantly by 3 % per year during the period before the intervention. During the first year after intervention, an increase (13 %) was detected, and then a statistically significant 1 % decrease (IRR = 0.99; 95 % CI: 0.98, 0.99) was observed in the ACSC rate ratio per year in the period after the intervention. Similar trends and effect sizes were found for women. Conclusions The study revealed significant decreasing trends of the ACSC hospitalization rates in both sexes, indicating an improvement of the performance of the primary health care services following the 2008 national health reform. A continuous strengthening of the primary care model as well as a regular monitoring of ACSC hospitalization rates in the country is recommended. A health economic evaluation considering hospitalizations avoided and associated costs is also advisable.

Can primary health care mitigate the effects of economic crises on child health in Latin America? An integrated multicountry evaluation and forecasting analysis

“… 6 Ecuador also had stagnation in its health spending in the past few years and saw a decrease in spending during the COVID-19 pandemic. 10 Our forecast analysis broadens the conclusions of other studies, 8 , 26 showing how in Latin American and Caribbean countries, the implementation of fiscal austerity measures affecting primary health care will have a substantial negative impact on child health outcomes, potentially causing a large number of preventable child deaths in the next decade. In the upcoming years, additional studies will be necessary to assess which specific characteristics of primary health-care strategies contribute to the ability to mitigate and demonstrate resilience in the face of socioeconomic crises.…”

“…These covariates were stratified according to their median value over the period for: the Gini index (0 for ≤46·5% and 1 for >46·5%); the poverty rate index (0 for ≤27·0% and 1 for >27·0%); illiteracy (0 for ≤12·6% and 1 for >12·6%); the percentage of households with adequate sewage (0 for ≤38·5% and 1 for >38·5%) and clean, piped water (0 for ≤71·5% and 1 for >71·5%); the number of physicians per 1000 population (0 for ≤0·6 and 1 for >0·6); and the number of hospital beds per 1000 population (0 for ≤1·7 and 1 for >1·7). Time dummy variables were also included in the models to control for the creation of the SPS in 2004, 19 health reform in Ecuador in 2008, 10 and major economic crises in Latin American and Caribbean countries over the past two decades (ie, the 2007–08 subprime mortgage crisis, the 2015 trade crisis, and the austerity measures introduced in 2018 by the Brazilian Government). 20 Moreover, fixed terms were used to adjust for other time-invariant, unobserved variables with potentially confounding effects.…”

“…More details on each primary health-care strategy are available in appendix 3 (pp 12–14) . 10 As a consequence, primary health care has been strengthened but implemented in different ways in Brazil, Colombia, Ecuador, and Mexico. In this study, we consider the ESF, SPS, RS, and MAIS-FCI nationwide strategies for delivering public primary health care inspired by the main principles of the Declarations of Alma-Ata and Astana: 11 , 12 promoting universal access to health services for everyone; fostering comprehensive care; and including health promotion, health prevention, treatment, rehabilitation, and palliation with a health equity prospective and a particular focus on providing health-care access to the most vulnerable populations.…”

Policies for expanding family planning coverage: lessons from five successful countries

“…The use of modern contraceptives increased progressively, especially from 2008, due to the increase in social spending and health policies introduced at the time of the reform, which improved the performance of primary health care services ( 89 , 90 ). The adolescent fertility rate was reduced from 80 births per 1,000 women in 2007 to 71 in 2017 ( 91 ).…”

“…The policy created a favorable environment to increase national and international partnerships for family planning service provision. It facilitated diverse strategies such as community-based reproductive health services, social marketing, mobile clinics, and social franchising to enhance awareness and accessibility of family planning and reproductive health services ( 89 ).…”