Fulbright Research Proposal

STATEMENT OF PROPOSED RESEARCH
Ecuador, Public Health
“Decentralization of Health Care in Ecuador”

I intend to work with the Ecuador chapter of FLACSO (Latin-American Faculty of Social Sciences) on an empirical research study to investigate the effects of decentralization on distribution of health care throughout Ecuador. (Please see Letter of Affiliation from Dr. Betty Espinosa, investigator and professor of Political Sciences at FLACSO-Ecuador.) The project that I will join is already in its primary stages of planning, and the first phase of inquiry will begin as soon as January 2008. My component of the project will begin in September 2008, when we assess the process of providing health care on a municipal level in the cities of Quito, Guayaquil, Cotacachi, and Cuenca. Starting in January 2009, we will move into a more in-depth analysis in which we will conduct a comparative study of regional public health programs throughout the country.

Concurrent with my research project, I will be enrolled in the Master’s of Public Health program at the Universidad San Francisco de Quito. (Please see Letter of Affiliation from Dr. Benjamin Puertas, Director of the Master’s of Public Health program at USFQ.) During the first semester in Fall 2008, I will take an introductory course on community nutrition, which will help inform my regional comparative study with FLACSO, and during the second semester in Spring 2009, I will take a course on international health to develop a foundation for public health administration. In my spare time, I will use the Simón Bolívar Volunteer Program to arrange a volunteer internship at Hospital Baca Ortiz, a children’s hospital in Quito that is in constant need of help with taking care of the patients, teaching English, and tending to general clinical needs.

According to the 2006 CEPAL Annual Statistics Report for Latin America and the Caribbean, 48.3% of Ecuadorians live in poverty. Thus, it comes as no surprise that malnutrition is one of the leading public health problems in Ecuador, since lack of access to food is a direct result of poverty and an inadequate national infrastructure. In order to fully address Ecuador’s public health needs, projects must therefore consider social and economic factors such as the availability of nutritional supplementation and health care to those without insurance, as well as the specific cultural needs of the diverse Ecuadorian population. However, such reform is difficult to conceive in a country with a lack of national resources and little governmental assistance. One proposed solution to these problems is decentralization, which is intended to redistribute the administration of public policy and resources to local communities that might be better equipped to allot national assets. However, decentralization could fall subject to local problems such as inefficient administration and distribution of supplies. Therefore, finding the right balance between the parallel goals of administrative efficiency and maximum improvement in health care requires a more critical examination of the effects of decentralization on public health.

Building upon the model proposed by Bossert for evaluating the state of decentralized public health systems, we will first determine the amount of administrative authority that has been transferred from centralized to local institutions. Then, we will evaluate changes in the public health policy-making practices of local officials. Lastly, we will measure the effects that these changes have had on the distribution of public health. To gather data about each of these aspects of Ecuador’s health care system, we will employ a variety of research techniques. One of the primary tools that we will employ is interviews conducted with health care leaders and providers about 1) their perceptions of the costs and benefits of changes in the health care system, and 2) how the increase in local autonomy has (or has not) changed their approach to administration of public health. In addition to these qualitative methods, we will use quantitative data from a variety of sources, including past studies of municipal health care, recent surveys of living conditions in Ecuador, and statistics gathered by hospitals and clinics of various sizes. Analysis of this data can expose trends in both the intended distribution of health care and the actual impact of provided care, and they can be specified regionally to detect differences between the Sierra, Costa, and Oriente regions, and between rural and urban settings. This work will culminate in a final written report, to be published by FLACSO.

While in Ecuador, I will be based in Quito, where I will work at FLACSO’s Quito office and commute to classes in Cumbayá. In addition to my time in Quito at the FLACSO office, I will spend time in various regions of the country to get a broad overview of the country’s public health system, which will complement my more in-depth research. The provinces of Pinchincha and Guayas have distinct health care structures due to the presence of the two largest Ecuadorian cities, Quito and Guayaquil, respectively. Therefore, I will also go to provinces throughout the Costa, Sierra, and Oriente regions during the second phase of the study, because the decentralization of public health has affected each of these sections of the country differently based on cultural and environmental factors.

Through my coursework at Pomona College in Biology and Spanish, my semester of study abroad in Ecuador, and various internships with laboratory and clinical research projects, I have dedicated myself to understanding and implementing effective health care systems, especially in Latin America. I am interested in public health in Ecuador in particular because a multicultural and multiethnic population occupying such a small geographical area provides an invaluable model for studying the social, political, and economic effects on public health. Therefore, being a Fulbright grantee in Ecuador will afford me the opportunity to better understand the best practices and common challenges in administering public health programs, particularly in developing countries. This research will lay the groundwork for my future studies in medical school and at public health graduate school, culminating in my career goals to work as a physician and as a medical advisor to public health programs throughout the world.