Thursday, October 11, 2007

Public Health History and Social Security

Both the public and the private sectors provided health services. Most public health care came under the aegis of the Ministry of Public Health, although the armed forces, the Ecuadorian Social Security Institute (Instituto Ecuatoriano de Seguridad Social--IESS), and a number of other autonomous agencies also contributed. The Ministry of Health covered about 80 percent of the population and IESS another 10 percent.

The Ministry of Public Health organized a four-tiered system of health. (A bit like China's 3-tier system). Auxiliary health-care personnel staffed posts that served small rural settlements of fewer than 1,500 inhabitants. Health centers staffed with health-care professionals serviced communities of 1,500 to 5,000 inhabitants. Urban centers took care of the larger provincial capitals. Provincial and national hospitals were located in the largest cities. In the early 1980s, there were approximately 2,100 health establishments nationwide; the Ministry of Public Health ran more than half. Both the limited numbers of health-care professionals and their lack of training hampered public health care. These deficiencies were most apparent in regard to medical specialists, technicians, and nurses.

Infant mortality-rate estimates in the early 1980s ranged from 70 to 76 per 1,000 live births, with government projections of 63 per 1,000 live births for the period 1985 to 1990. Although these rates were a significant improvement from the death figure of 140 recorded in 1950, they remained a serious concern. Infant mortality (sort of the prime marker for an area's basic health overall) varied significantly by region and socioeconomic status. Surveys in urban areas showed a range of 5 to 108 infant deaths per 1,000 live births, whereas those in rural areas varied from 90 to 200. That's a lot. Intestinal ailments and respiratory diseases (including bronchitis, emphysema, asthma, and pneumonia, which are easily curable and treatable) caused roughly three-fourths of all infant deaths. Crazy.

Childhood mortality (deaths among one- to four-year olds) dropped to 9 per 1,000 in the mid-1980s following immunization campaigns and some attempts to control diarrheal diseases. Acute respiratory infections represented one-third of all deaths in this age group. Further improvement in the childhood mortality rate demanded extending the immunization program, increasing the availability of oral rehydration therapy, improving nutrition, and controlling respiratory ailments.

Precise, detailed evidence about children's nutritional status remained limited and contradictory. The government conducted a national survey in 1959 and followed this with more limited studies in the late 1960s and 1970s. In the late 1960s, 40 percent of preschool children showed some degree of malnutrition. Among children under 12 years of age, 30 percent were malnourished and 15 percent anemic.

The main causes of death among adults in the mid-1980s were motor vehicle accidents, coronary heart disease, cerebrovascular disease, cancer, and tuberculosis. Maternal mortality remained high--1.8 per 100,000 live births in the mid-1980s. As with the case of infant mortality, maternal mortality national averages masked considerable regional variation, with the rate nearly three times higher in some areas. These higher percentages reflected the limited access many rural women had to health care. In the early 1980s, more than 40 percent of all pregnancies were not monitored; the majority of births were unattended by modern medical personnel.

A number of tropical diseases concerned health officials. Onchocerciasis (river blindness) was found in a number of small areas; its range was expanding in the mid-1980s. Although Chagas' disease (a parasitic infection) was not prevalent, environmental factors favored its spread. Leishmaniasis (also a parasitic infection) was expanding in the deforested areas of the coast and coastal tropical forest. Malaria was found in 60 percent of the country and became a major focus of public health efforts in the late 1980s. A drop in mosquito control programs coupled with severe flooding in 1981 and 1982 led to an increase in the prevalence of malaria in the mid-1980s. Between 1980 and 1984, the number of reported cases increased ten times. As of 1988, Ecuador also reported forty-five cases of, and twenty-six deaths from, acquired immune deficiency syndrome (AIDS).

The Ecuadorian Social Security Institute, an autonomous agency operating under the Ministry of Social Welfare, offered its members old-age, survivor, and invalidism benefits, sickness and maternity coverage, and work injury and unemployment benefits. In 1982, however, the system covered only approximately 23 percent of the economically active population (21 percent of men and 33 percent of women). Coverage varied widely according to urban or rural residence as well as sex. Urban women had the highest rates of coverage (42 percent), whereas rural men had the lowest (9 percent). Employees in banking, industry, commerce, and government, and self-employed professionals had coverage for most benefits. Agricultural workers were covered for work injury and unemployment benefits and were gradually being included in pension funds and survivors' and death benefits.

Hope this is helpful.



Ray said...

A few things that might be helpful to think about (especially for the architects as we think about the idea of sustainability):

1. The social security reform proposed by the National Modernization Council during 1992–1996 included the reform of medical services. By eliminating the compulsory inscription of formal workers in the public insurance system (IESS), it was possible to set up competition between public and private providers. The National Health Council, presided over by the Ministry of Health, introduced an alternative national proposal involving the participation of all institutions in the public and private sectors and of civilian society at the central, provincial, and local levels. Taking this in mind, how far is the site from any one of the "four tiers" listed in my post? How far do those in Kallari have to travel? And how does the relationship between public and private services jive with Kallari's commitment to being a "self-governed coalition"?

And has anyone else's research bumped into a project called the Modernization and Development of Integrated Health Services Networks (MODERSA)?

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