La reforma en salud del Ecuador

Para comprender el proceso de reforma del sector salud en el Ecuador, es necesario partir del marco normativo e ideológico sobre el cual se basa la transformación sanitaria de la última década. A partir del año 2008 Ecuador reconoce en su Constitución el derecho a la salud con una visión sistémica, vinculándolo con el ejercicio de otros derechos. La Carta Magna del 2008 establece al Estado como garante del derecho a la salud a través de la formulación de políticas, planes y programas orientados a brindar acceso a servicios de promoción y atención integral bajo los principios de equidad, universalidad, solidaridad, interculturalidad, calidad, eficiencia, eficacia, precaución y bioética, con enfoque de género y generacional (1). De este modo, el mandato constitucional determina la necesidad de iniciar el proceso de reforma y define el ámbito en el cual se conduciría dicho proceso para lograr que el Estado cumpla con las nuevas obligaciones establecidas en la Constitución [...] El sistema de salud ecuatoriano sin duda se ha fortalecido con el profundo y ambicioso proceso de reforma, el cual ha sido posible gracias a un apoyo político explícito y sostenido, expresado en la priorización de la salud como un derecho de todos y de todas. No obstante, existen grandes retos aún pendientes, entre los cuales se destacan la implementación de un modelo de financiamiento sostenible con un fondo mancomunado para el sistema público, que permita una mayor eficiencia en el gasto en salud y garantice la sostenibilidad del sistema en el mediano plazo; el fortalecimiento de la vigilancia epidemiológica y del sistema de información en salud, a fin de detectar de manera temprana y oportuna los brotes epidémicos y las enfermedades crónicas no transmisibles evitando que éstas se transformen en enfermedades catastróficas; la consolidación de las estrategias de prevención y control –las cuales requieren fortalecerse en el marco del proceso de reforma–; la implementación del MAIS y su materialización en rutinas de atención para los enfermos agudos pero sobre todo para los portadores de enfermedades crónicas no transmisibles, a fin de asegurar la continuidad de los cuidados; y la construcción efectiva de redes integradas de provisión de servicios de salud con mecanismos estables y eficientes de referencia y contrarreferencia. Estas son las tareas a abordar en el futuro inmediato como parte de la consolidación de la reforma sanitaria, y como parte de la ruta del sistema de salud ecuatoriano hacia la salud universal.

Systematic documentation of new vaccine introduction in selected countries of the Latin American Region.

BACKGROUND: Countries in Latin America were among the first developing countries to introduce new vaccines, particularly rotavirus (RV) and pneumococcal conjugate vaccines (PCVs), into their national immunization schedules. Experiences and lessons learned from these countries are valuable to donors, immunization partners, and policy makers in other countries wishing to make informed decisions on vaccine introduction. OBJECTIVES: In order to enhance knowledge and promote understanding of the process of new vaccine introduction in the Latin American Region, with particular focus on RV and PCV, we conducted a systematic qualitative assessment. We evaluated the decision-making process, documented the structure in place, and reviewed key factors pertaining to new vaccine introduction. These include country morbidity and mortality data available prior to vaccine introduction, funding sources and mechanisms for vaccine introduction, challenges of implementation, and assessment of vaccine impact. METHODS: From March 2010 to April 2011, we evaluated a subset of countries that had introduced RV and/or PCV in the past five years through interviews with key informants at the country level and through a systematic review of published data, gray literature, official technical documents, and country-specific health indicators. Countries evaluated were Bolivia, Brazil, Nicaragua, Peru, and Venezuela. RESULTS: In all countries, the potential of new vaccines to reduce mortality, as established by Millennium Development Goal 4, was an important consideration leading to vaccine introduction. Several factors-the availability of funds, the existence of sufficient evidence for vaccine introduction, and the feasibility of sustainable financing-were identified as crucial components of the decision-making process in the countries evaluated. CONCLUSIONS: The decision making process regarding new vaccine introduction in the countries evaluated does not follow a systematic approach. Nonetheless, existing evidence on efficacy, potential impact, and cost-effectiveness of vaccine introduction, even if not local data, was important in the decision making process for vaccine introduction.

Progress in the introduction of the rotavirus vaccine in Latin America and the Caribbean: four years of accumulated experience.

BACKGROUND: Two effective and safe rotavirus vaccines became available in 2006 and have been recommended for use in all countries by the World Health Organization. This article provides an update on the use of rotavirus vaccine in Latin American and Caribbean (LAC) countries. METHODS: Data reported by LAC countries to the Pan American Health Organization (PAHO) were reviewed. RESULTS: As of May 2010, 14 LAC countries and 1 territory have introduced the rotavirus vaccine into their national expanded program on immunization (EPI). Reported coverage levels for rotavirus vaccine are lower than those for other EPI vaccines recommended at the same age. A total of 15 LAC countries are part of the PAHO's LAC rotavirus surveillance network; 12 of them are using the vaccine. LAC countries are conducting several studies on rotavirus vaccine effectiveness, cost-effectiveness, and monitoring safety. Also, LAC countries are generating lessons learned on the public health implications of introducing a new vaccine into the EPI. Nine countries and the Cayman Islands pay for the entire cost of the vaccine using government funds. All but 2 countries purchase their rotavirus vaccine through PAHO's Revolving Fund. CONCLUSIONS: Rotavirus vaccine introduction in LAC has been faster than for other new vaccines, but coverage levels need to increase to maximize the effect of the intervention. Rotavirus surveillance needs to expand and be strengthened to better assess the effect of vaccine use. LAC countries will continue to provide useful data to monitor rotavirus trends and vaccine effect.

Cost-effectiveness of measles elimination in Latin America and the Caribbean: a prospective analysis.

BACKGROUND: In 1994, the Americas set a goal of interrupting indigenous measles transmission from the Western Hemisphere by 2000. To accomplish this goal, the Pan American Health Organization (PAHO) developed an enhanced measles vaccination strategy. METHODS: Cost data was collected at PAHO for Latin American and Caribbean (LAC) countries covering 96% of the region's population on components of the routine programs, and the 'follow-up' activities from member countries. In order to interpret our findings we have compared the present scenario regarding measles with one that would have ensued if past trends continued. RESULTS: For the entire LAC population, estimated cost of elimination program will be US$ 571 million in present value terms. INTERPRETATION: The vaccination strategy toward achieving elimination of measles costs USD 244 million, incremental from the cost of vaccination before the elimination program. Within 2000-2020, the current program will have prevented the occurrence of 3.2 million cases of measles and 16,000 deaths. Thus, vaccination strategy prevents a single case of measles at the cost of USD 71.75 and prevents a death due to measles at the cost of USD 15,000. The case fatality rate depends on a well functioning treatment program for measles cases. The vaccination strategy saves a total of USD 208 million in treatments costs due to reduced incidence of measles.