Dilemmas of health reform em Latin America: the case of Ecuador

El objetivo de este trabajo fue aproximarnos a la coyuntura y actores del Sistema Nacional de Salud en Ecuador para desvendar los dilemas del movimiento de reforma vigente en el sector durante el periodo 2005-2008 bajo la perspectiva de experiencias paradigm??ticas en Am??rica Latina: el modelo de reforma adoptado por Colombia y por Brasil. Para la elaboraci??n de este estudio, se tom?? como referencial te??rico el trabajode Theodoulou y Cahn 10 sobre los procesos pol??ticos y de Ikenberry 11, acerca del proceso de difusi??n de las agendas. Se propuso, adem??s, una complementariedad de t??cnicas que involucraron revisi??n bibliogr??fica de las reformas de salud en Ecuador, de indicadores cualitativos de salud y la realizaci??n de entrevistas semi-estructuradas, lo que posibilit?? la construcci??n de algunas categor??as anal??ticas que permitieron establecer los indicadores a ser utilizados en la descripci??n de los tres sistemas de salud. Encontramos a lo largo del trabajo que en Ecuador una disputa permanente entre las agendas pol??ticas de los dos modelos de organizaci??n de sistema de salud, por un lado la focalizaci??n con creaci??n de paquetes b??sicos y por otra, la universalizaci??n descentralizada. Identificamos, adem??s, que en el pa??s, la baja capacidad de inclusi??n del sistema, as?? como la d??bil estructura institucional, por la fuerte presencia del corporativismo, dificultan el establecimiento de marcos referenciales consistentes y leg??timos para el sector salud. El dilema de la actual agenda se basa en la b??squeda de negociaciones y consensos sobre los l??mites pol??ticos, econ??micos y estructurales del Sistema Nacional de Salud de una forma democr??tica y participativa que considere las verdaderas demandas del sector.The present work???s aim is an approach to the different scenarios and actors involved with the National Health System in Ecuador. The purpose is to figure out the dilemmas of the current reform movement in the healthcare sector during the 2005-2008 period,under the paradigmatic perspective of other experiences in Latin America, bringing special attention to model reforms adopted by Colombia and Brazil. As grounds for this investigation, Theodoulou???s and Cahn???s 10 theoretical work on political processes were taken under consideration. Ikenberry???s 11 work was also taken into account 11. Their proposals addressed the process of agenda dissemination. The present work also proposes complementary techniques involving literature review regarding healthcare reforms in Ecuador, qualitative health indicators and the realization of semi-structured interviews, which enabled the construction of analytical categories, later used as indicators to describe the three systems. As reviewed throughout this work, a dispute between the political agendas of both models of organizing healthcare system came into evidence in Ecuador, focusing on one hand in the creation of basic packages and a decentralized universal health care system. Moreover, we identified low capacity within the system a weak institutional structure, mainly due to the strong presence of corporatism, and the ongoing obstruction of legitimate and consistent reference frames for the healthcare sector. The main issue of the current agenda is based on negotiations and the search for consensus on political, economic and structural aspects of the healthcare system in a democratic and participatory manner that considers the real demand of the public health sector