Promoting the health of marginalized populations in Ecuador through international collaboration and educational innovations.

This paper examines two innovative educational initiatives for the Ecuadorian public health workforce: a Canadian-funded Masters programme in ecosystem approaches to health that focuses on building capacity to manage environmental health risks sustainably; and the training of Ecuadorians at the Latin American School of Medicine in Cuba (known as Escuela Latinoamericana de Medicina in Spanish). We apply a typology for analysing how training programmes address the needs of marginalized populations and build capacity for addressing health determinants. We highlight some ways we can learn from such training programmes with particular regard to lessons, barriers and opportunities for their sustainability at the local, national and international levels and for pursuing similar initiatives in other countries and contexts. We conclude that educational efforts focused on the challenges of marginalization and the determinants of health require explicit attention not only to the knowledge, attitudes and skills of graduates but also on effectively engaging the health settings and systems that will reinforce the establishment and retention of capacity in low- and middle-income settings where this is most needed.

Descentralización y equidad: una revisión de la literatura latinoarmericana / Decentralization and equity: a review of the Latin America Literature

Se realizó una revisión de los artículos publicados, con el fin de presentar una descripción de losantecedentes históricos de las reformas en salud en América Latina y así establecer una brevepresentación del proceso de descentralización en países como Colombia, Brasil, Chile, Méxicoy Costa Rica. De esta forma se ilustran las diferentes tendencias en las transformaciones de lossistemas de salud de la región.Esta revisión de la literatura reveló la necesidad imperiosa de contar con más estudios sistemáticosen esta área. Aunque en teoría, la descentralización puede considerarse un mecanismopoderoso en la promoción de la equidad en la salud, puede resultar insuficiente o prejudicial enel contexto de políticas inciertas que promueven la equidad por parte del Estado. Igualmente,se debe discutir tanto el papel de otros fenómenos afines, por ejemplo la privatización, como laescasez de fondos estatales en salud. Sin embargo, la evidencia respecto de los resultados de ladescentralización en América Latina y el Caribe es aún contradictoria y ambigua: no es claroque sus logros puedan alcanzar sus intenciones de mejoras en equidad en salud en la región.

A literature review of published articles were done to set a description of the historical background of health reforms in Latin America and to provide a brief description of the process ofdecentralization in countries such as Colombia, Brazil, Chile, Mexico and Costa Rica in order to illustrate different tendencies in the transformations of the health systems in the region. Thisliterature review demonstrated the increasing need of more systematic studies in this area. Althoughdecentralization in theory may be a powerful mechanism to promote equity in health, it may be insufficient or prejudicial in the context of unclear policy intended to promote equity by the state. Moreover, the role of other concomitant phenomena like privatization and shortage of state funding of health must also be discussed. However, the evidence regarding the results of decentralization in LAC is still contradictory and ambiguous. It is not clear that its achievements could reach its intentions of improved equity in health in the region.