La Revolución Ciudadana and social medicine: Undermining community in the state provision of health care in Ecuador

ABSTRACT

Under President Rafael Correa (2007–2017), Ecuador’s Ministry of Health established a state-centred health care regime that incorporates elements of Latin American social medicine into post-neoliberalism. These initiatives – which are part of ‘The National Plan for Good Living (Buen Vivir)’ – include free healthcare, greater attention to social determinants of health, a focus on equity and inclusion, and increased coordination across welfare, health, and development sectors. However, the reforms also use health services to build a sense of inclusive, participatory citizenship, with the Ecuadorean state as the central figure in service provision. In this paper, we demonstrate that state-centred health care reforms have paradoxically weakened community organising for collective health. Drawing on seventeen years of ethnographic research and health solidarity work in rural Northwest Ecuador, we illustrate how Ecuador’s health reforms have reconfigured relations among local civil society, transnational NGOs, and the state. Established modes of community participation and international collaboration have been undermined largely because these reforms ignore community sovereignty and self-organisation and overemphasise the threat of neoliberalism. The lessons about balancing the state-based fulfilment of rights with community power are relevant to social medicine advocates, particularly those working in rural communities that are already organising creatively for their own health and well-being.

KEYWORDS:

• Social medicine
• citizenship
• Ecuador
• non-governmental organizations (NGOs)
• community participation

Social medicine and La Revolución Ciudadana

The Latin American social medicine (LASM) movement, which draws on over a century of primarily Marxist social thought in Europe and the Americas (Arango Panesso, 2008; Laurell, 1989; Tajer, 2003), foregrounds the social determination of health and promotes well-being via community-controlled health care and social transformation.¹ The movement is built on a way of understanding illness and health centred on the following referents, some of which have become commonplace in global public health more broadly: (a) analysing disease not as a purely biological phenomenon but also as a result of capitalist development, socio-economic inequality and related working and living conditions, and national policy; (b) considering the subjects of health care to be not only individuals or a national population of homogeneous individuals but rather a stratified population comprised of classes (defined according to economic status, race/ethnicity, gender differences, urban/rural residency, etc.); and (c) responding to disease via preventative measures, policies for universal and equitable health care, the broader elimination of social inequities that lead to unequal health outcomes, the reduction of environmental and workplace hazards, and the promotion of empowered communities able to manage and advance their own health and healing (Arango Panesso, 2008; Granda Ugalde, 2009; Laurell, 1989; Tajer, 2003; Waitzkin, Iriart, Estrada, & Lamadrid, 2001). In some cases, LASM also adopted an anti-colonial attitude toward health economics and technology development (Breilh, 1995).

Under President Rafael Correa’s administration (2007–2017), the Ecuadorean Ministry of Health (MoH) has established a state-centred, populist health care regime that incorporates elements of Latin American social medicine into a post-neoliberal platform (see, for example, Ministerio de Salud Pública, 2013). Correa’s policies thus represent a backlash against nearly two decades of neoliberal policies that aimed to radically marketise society, minimise the welfare and regulatory arms of the state, and convert basic social services into commodities (North, 2013). Neoliberals hoped that commoditising or marketising social services would prompt the more ‘efficient’ provision of services while fuelling growth through capital accumulation among national and global elite (Harvey, 2005). Unfortunately, the flip side of market efficiency is surrendering democratic decision-making to impersonal market logics of supply, effective demand, exclusion, and profitability. Ecuador never implemented a formal package of neoliberal reforms in the health sector – as it had in other sectors – but ‘the health sector in Ecuador suffered a “silent” neoliberal reform’ through piece-meal initiatives to reduce public health budgets, restrict government health insurance, increase private contracting, and decentralise decision-making (De Paepe, Tapia, Santacruz, & Unger, 2012, p. 219). As Navarro (2008) and Rasch and Bywater (2014) point out, a privatised health care system is particularly conducive to narrowly conceived biomedical approaches that ignore the social determination of health, diverse measures of well-being, and community decision-making.

The post-neoliberal reforms initiated by Correa’s administration entailed the reversal of this silent revolution. Launched primarily via ‘The National Plan for Good Living (Buen Vivir)’ (SENPLADES, 2010) as part of Ecuador’s ‘Citizens’ Revolution,’ the reforms included the introduction of free healthcare, greater attention to social determinants of health, and better coordination across welfare, health, and development sectors. Ecuadoreans have seen significantly increased health funding, movements toward a unified national health system, the establishment of primary and preventative health care as a universal right and a responsibility of the state, and an intersectoral approach through which multiple ministries consider health-related aspects of their work. The Citizens’ Revolution seems to have had a positive impact on health and equity. Between 2006 and 2016, the poverty rate decreased by 38%, inequality dropped,² and social spending doubled as a percentage of GDP (Ray & Kozameh, 2012; Weisbrot, Johnston, & Merling, 2017). The Ministry of Health (MoH) saw a 70% increase in its budget during Correa’s first year, a significant increase in consultations, and a doubling of the use of diagnostic tools, such as x-rays and mammography (De Paepe et al., 2012). The Correa administration also improved access to medical services by mandating higher salaries and a (longer) 40-h workweek for doctors, establishing mobile clinics, and partnering with the Cuban government to benefit from Cuban doctors, medications, and expertise (Ministerio de Salud Pública, 2014). While it is difficult to directly attribute improved health outcomes to these policy changes, during the same period Ecuador saw improvements in infant and child mortality (Pan-American Health Organization, 2017; World Health Organization, 2017), which often outpaced ‘similar countries’ (Ray & Kozameh, 2012), and significant declines in the number of reported malaria cases and deaths, tuberculosis cases and deaths, and deaths due to HIV/AIDS (World Health Organization, 2017).

Ecuador’s vision of Buen Vivir includes strong socialist principles consistent with the LASM socio-political vision of health – such as redistribution, democratisation of the means of production, and a guarantee of dignified work – as well as a commitment to ‘citizen power’ and decentralised, democratic participation (SENPLADES, 2010, p. 7). In many ways, however, Buen Vivir remains aspirational. Hartmann (2016, p. e1) convincingly argues that the so-called ‘postneoliberal public health care models’ implemented in Ecuador, Bolivia, and Venezuela ‘neither fully incorporate social medicine nor completely reject neoliberal models.’ They adopt the LASM tenets that health is a right of all citizens and must be seen as a socio-political issue, and they go beyond LASM by emphasising interculturalism or pluriculturalism. However, they depend on neoliberal policies favouring export-oriented primary commodity extraction (especially mining) and the partial privatisation of health care and health insurance. From the perspective of LASM’s structural analysis, these macroeconomic and institutional deficiencies must be seen as serious contradictions, even if Ecuador’s improved health outcomes have been welcome.

In this article, we shift to a more local scale to examine how the Citizens’ Revolution has been experienced by historically marginalised people and communities; how ideals of decentralisation, community participation, and citizen power have been put into practice; and how this has transformed community health activism. Our long-term perspective illustrates that, despite the rhetoric of inclusion and equity, state-centred health care reforms have weakened community organising for collective health and turned rural people into increasingly passive recipients of state services. More specifically, these reforms have replaced community–NGO–state collaborations that were planned and evaluated largely in terms of community goals with state-led medical services based on abstract, quantified, and centralised metrics of ‘production.’ While these paradoxical impacts may not be generalisable across the country, they provide important insights into a state–community tension that must be negotiated effectively for either LASM or postneoliberalism to have genuinely liberatory effects.

Methodologically, this article draws from seventeen years of ethnographic research and health-related solidarity work in rural northwest Ecuador. Since 2001, Friederic has conducted both ethnographic and historical research alongside applied work with a community health centre and microeconomic projects, all established through collaborations between the local village council and a transnational NGO that she helped form (see Friederic, 2011, 2015 for discussion of the author’s positionality as a scholar-activist). From 2001 to 2006, she conducted focus groups, interviews, demographic surveys, and participant observation about gender relations, common household illnesses and treatments, health care services and utilisation, and community health education and promotion. From 2007 to 2008, Friederic conducted long-term ethnographic fieldwork on gender violence and family well-being in the context of broader cultural politics of development in the region. Since then, co-authors Friederic and Burke have returned every year or two to assess the effects of the Correa administration policies on health care delivery, utilisation, and community organising through focus groups, participant-observation, and interviews with health care staff and community members.

Participation, community sovereignty, and the reconsolidation of the Ecuadorean state

Before turning to our case study, it is worth examining what is required for meaningful community participation in health care, as well as how exactly the Correa administration envisions state and community power. As Vázquez, Siqueira, Kruze, Da Silva, and Leite (2002) note, although participation is a nearly universal principle of health reform, it takes extremely varied forms in practice. Achieving deep forms of participation requires basic civil and political rights and access to health information (Backman et al., 2008), traditions of community organising, and institutional mechanisms for soliciting, hearing, and responding to citizen input and ensuring accountability (Cornwall & Coelho, 2007; Hickey & Mohan, 2004; Vázquez et al., 2002).

Correa’s platform appears to value deep participation. The five branches of the Citizens’ Revolution – democratic, ethical, economic, social, and international revolutions – all suggest increased individual and community influence over a state committed to people’s rights and wellbeing. The National Plan for Good Living provides the guiding framework for how these revolutions should be understood and achieved. The Plan was ostensibly built upon the indigenous notion of sumak kawsay, a Kichwa term most often translated as buen vivir in Spanish and living well or good living in English. However, many scholars have critiqued the technocratic appropriation of this dynamic concept that, at root, implies a transformative and alternative vision of development (Acosta, 2008, 2013; Fernández, Pardo, & Salamanca, 2014; Bretón, Cortez, & Garcia, 2014; Macas, 2010; Whitten & Whitten, 2015). Though the meaning of sumak kawsay varies across indigenous groups, Whitten and Whitten (2015) note that in Canelos Quichua of Amazonia, it ‘means something like “beautiful life” or “beautiful life force”’ and it incorporates related concepts such as deep knowledge, community, conviviality, kinship, and integration with nature and the supernatural (193). Thus, in its original sense, sumak kawsay is embedded in an indigenous ontology, ethical paradigm, and way of living that envisions ‘human beings with respect and in harmony with each other, nature, and the spiritual world’ (Sieder & Barrera Vivero, 2017, p. 5). This constellation of meanings contrasts sharply with the interpretations of Buen Vivir that appear in the National Plan, which are ‘based on capitalist wealth accumulation, albeit for a common good’ (Whitten & Whitten, 2015, p. 193), raising questions about the extent to which revolutionary changes and indigenous ontologies can be pursued through state frameworks (Becker, 2011, 2012). So, while Buen Vivir retains echoes of its original meaning (e.g. community participation, the rights of nature, and collective rights), it loses its dynamism when taken up as a project by the state, one that must be planned, implemented, measured, and incorporated into the current socio-economic context. Intellectually, the Ecuadorean state’s vision of Buen Vivir is framed not in terms of indigenous cosmovision but rather in terms of a historical critique of neoliberal policies that marketized public services, neo-colonial foreign relations that increased Ecuadorean dependency, and the exclusion of ethnic minorities within Ecuador. The linchpin to all three problems, according to the Plan, is to reconsolidate state power primarily by increasing public services. Returning social services to the government will reduce foreign influence and increase citizens’ engagement with and esteem for the central state. Doing this within a ‘plurinational’ framework ensures that even ethnic minorities are included. And strengthening government control over key resource sectors (e.g. oil) while decreasing foreign financial influence (via loans) will provide the capital for public services.

Rebuilding the state – and earning popular trust in the state – was extremely important in Ecuador, which had had seven presidents in ten years (1997–2007) and nine health ministers in five years (2001–2005). Neoliberal policies, natural resource dependency, and high levels of corruption had severely weakened social programmes. However, a close examination of the intellectual framing of Buen Vivir raises concerns about how communities would fare in this new political landscape. First, the historical justification for Buen Vivir is a highly simplified story consisting of only two actors: the state and the market. This history ignores the actual dynamics of power and action that Ecuadorean communities have engaged in, including non-state/non-market interventions in health. As a result, the Plan repeatedly portrays communities and individuals as blank slates that need to be formed into citizens in order to have any agency beyond their market demand. Second, the Plan oversimplifies imperialism. It collapses all forms of North–South interaction into neoliberal empire and thus ignores the fact that communities within Ecuador have often gained power in the face of marketisation via transnational links of solidarity (for examples, see Alvarez, Faria, & Nobre, 2004; Cole & Phillips, 2008; Radcliffe, 2001; Sawyer, 2007). Such international alliances could be harnessed to support both citizen power and the state, but only if they were visible. Overall, then, the Citizens’ Revolution appears to be driven by an extreme fixation on the neoliberal enemy and the need for state-building, with paranoia obscuring nuance. The result is that historically marginalised groups are interpellated as participants in Buen Vivir exclusively as citizens of the state and not in terms of other ways that they have pursued wellbeing.

Indigenous experiences negotiating community autonomy illustrate that our concerns with the discourse of Buen Vivir are warranted. Constitutional reforms in 1998 and 2008 declared Ecuador a pluricultural and plurinational state and recognised a broad range of indigenous rights, including the rights to their own judicial systems. However, a ‘lack of clarity around diverse national, regional, and local sovereignties’ over mineral resources and cultural patrimony (Hill & Fernández-Salvador, 2017, pp. 119–120), and the absence of ‘coordinating rules that would define the relationship between customary law and national law’ (Thomas, 2017, p. 46), have left many questions of community self-governance open to executive or judicial interpretation. In a state whose legitimacy depends on development programmes financed by resource exploitation, ‘local sovereignty is overwhelmingly overridden by national forms of sovereignty and control, despite state discourses of decentralisation’ (Hill & Fernández-Salvador, 2017, pp. 132–133). As a result, the Correa administration has repeatedly eroded indigenous autonomy via regulations on mining, water, education, and the meaning of ‘legitimate’ indigeneity, and by increasing systems of resource exploitation that undermine ‘the material conditions for the reproduction of indigenous communities’ (Becker, 2013; Sieder & Barrera Vivero, 2017, p. 16).

The statist worldview of Buen Vivir and the Citizens’ Revolution may work well in places where neoliberal policies, state weakness, and the lack of public services were accepted passively. Prior to the Citizens’ Revolution, however, the people of Las Colinas³ had already self-organized as an active citizenry engaged in substantial self-governance. They had claimed their ‘citizen’s power’ by mobilising to get what they needed from the central government and from other actors via patronage, citizenship demands, and transnational alliances, but according to their own desires rather than the vision from Quito. These efforts can be thought of as ‘vernacular statecraft’ (Colloredo-Mansfeld, 2009) or the construction of ‘state-ness’ (Martínez, 2017). What follows, then, is a description of what happens when the state-led revolution is enacted upon already active communities. How do vernacular states respond to the reconstitution of the national state?

Grassroots health activism in rural northwest Ecuador

Las Colinas – a rural, cloudforest region in the northwestern coastal province of Esmeraldas – has a long history of community self-organisation dating to the first mestizo colonists of the 1960s and 1970s (Friederic, 2014a, 2014b). Accustomed to political instability, the people of Las Colinas have tended to privilege autonomy and self-reliance in their negotiations with outsiders. These negotiations have become prominent in the last twenty years, as community leaders, transnational NGOs, and state agencies have initiated various development programmes in the region. Shifts in community organising for health care in Las Colinas reveal how relations between local civil society, transnational NGOs, and the state have been reconfigured during the Correa administration (2007–2017).

Since the 1960s and 1970s, most of the region’s inhabitants have emigrated from the neighbouring province of Manabí, where agrarian reform, inheritance laws, overpopulation, and climatic conditions made cultivable land scarce. These mestizo colonists used cooperatives and patronage networks to carve homesteads, villages, and road networks into the cloudforest. To some degree, they fit national stereotypes of people from Manabí, which is seen as a lawless frontier where fiercely independent men lead self-reliant families and order is kept through internal justice (DeWalt, 2004; Hidrovo Quiñonez, 2003; Friederic, 2014b; Striffler & de La Torre, 2008). Now as then, Las Colinas’ inhabitants live in a precarious state of poverty. They survive on minimal income and, as squatters without formal land rights, they suffer from an insecure relationship to the land that sustains them. Despite this, they have typically appreciated their distance from ‘la mirada del estado’ (the view of the state).⁴ For many years, visible state presence in Las Colinas consisted of brief police forays into the region in pursuit of fugitives and sporadic visits by the Ministry of the Environment. Even today, government infrastructure is limited to intermittent, short-term road improvements and inconsistent electricity; the government has yet to provide water or sanitation services, which are managed by households and communities themselves (Comité de Gestión, 2007; Friederic, 2014b).

In the 1990s, government agencies and NGOs became interested in the rich biodiversity of this region’s virgin cloudforest which was threatened by colonisation. In 1996, the region was declared a national biological reserve, and most campesinos lost their land rights. Not surprisingly, Las Colinas’ residents grew increasingly distrustful of the state over the next two decades. On the one hand, they criticise the state’s failure to provide basic services – and yet, they often reframe their position by celebrating their own self-reliance. Don Marcelo, one of the first settlers in this area, described these processes in the following way:

The people who first arrived in this region came with very few possessions, just those they carried on their backs. Then from one moment to the next, the state comes in and says ‘this is my property and we are no longer going to give you any land title because this is mine, this is protected area now, it is primary forest.’ So, how do the people feel? They feel cheated, tricked, betrayed. Most of them had sold whatever little property they had in Manabí, or wherever they came from, and they wanted to resettle here and buy land and security for their children; but then they couldn’t. Some just returned to Manabí, but for those of us who have stayed, the lack of trust has only increased. Nobody knows what is going to happen. Most people hope for change, but we have lots of doubt because we have lived through so many government deceptions. (Interview, 2008)

During the early 2000s, local leaders increasingly collaborated with transnational NGOs to access goods and services; however, they also used these collaborations to maintain their own autonomy and leverage attention from the Ecuadorean state (Friederic, 2015). At that time, there were low rates of coverage, especially for rural populations, and the health sector suffered from a severe lack of coordination (De Paepe et al., 2012). Las Colinas’ residents had to travel to the district capital of Quinindé to access health services – a trip that could take up to two or three days depending on which village one came from, the state of the roads, and the season – and they often arrived to find the hospital with insufficient medication and staff.

Las Colinas’ health difficulties came to a head in 2001, when cerebral malaria ravaged many of the region’s villages. Local leaders from all 26 villages assembled to discuss how to fill the health service gap. They agreed to construct a small health post, asking a German doctor volunteering in the region to raise money to complement community contributions of labour and supplies. The doctor returned home to establish a German NGO and, over the next couple of years, Friederic and others formed sister organisations in the U.S., the UK, and Canada. A Quito-based NGO was established to receive donations from the Global North to assist with construction and administrative expenses of the health centre. In the remainder of this paper, we refer to this network of organisations as the NGO.

At a community assembly in April 2002, NGO funds were disbursed to a democratically elected, community health committee. The Campesino Health Committee, consisting of four men and two women, directed construction efforts, managed funds with oversight from the Quito-based NGO, and solicited further assistance from Ecuador’s central and municipal governments. The Campesino Health Committee and the NGOs agreed that the health centre should be fully owned by the community and built on legally recognised land. Propelled by surprisingly strong support from international donors, the municipality, and Las Colinas communities, the plan quickly grew from a basic health post to a full-service health centre. To support this expansion, NGO volunteers conducted research across the region to assess local people’s health status according to conventional metrics and to gather data on how they conceptualised good health. This input led to a broader definition of health in line with LASM’s social determination model; as focus group discussions progressed, definitions of health expanded from ‘no illnesses’ to healthy families, mutually respectful communities, clean environments, and the ability to meet basic needs. The health project therefore developed a new set of objectives focused on primary and preventative health care as well as improving the quality of life through community health education, environmental health, women’s health, microeconomic initiatives, and capacity building.

After several months of feeling each other out, the NGO, health committee, MoH, and the Quinindé municipal hospital formalised a unique four-way partnership. This was the only partnership of its kind in Esmeraldas and one of only a few nationally. According to the Convenio (the formal agreement), the health centre remained under community ownership but was designated an official MoH ‘subcentro de salud’ (or primary care subcentre). This made the MoH responsible for providing a rural doctor (or médico rural, a required post-graduate residency programme in rural areas), nurse, dentist, some equipment, and access to free medicine and nationwide health programmes (such as Maternidad Gratuita, or Free Maternity), though these obligations were rarely fulfilled in the first five years of the project.⁵ The NGO was responsible for coordinating international medical volunteers, providing medical supplies and equipment, and raising funds to support the Campesino Health Committee. The Health Committee worked with the NGO to supervise health centre staff and volunteers, to design community development programming and capacity building, and to plan, manage, and evaluate health centre operations.

During these early years, donations from the global North covered most health centre expenses (including medications and a laboratory technician, administrator, cooking/cleaning person, and nurse, all of whom were from Las Colinas and were supervised by the Campesino Health Committee), as well as two employees and an office in the Quito-based branch of the NGO. In addition, the NGO coordinated dozens of volunteer doctors and nurses for stays ranging from 3 to 12 months to complement MoH staff but with a focus on community outreach. The NGO’s main goal, however, was not to finance the health centre but to enhance the health committee’s management capacity and ability to negotiate with the MoH, so that the Campesino Health Committee could guarantee sustainable access to quality healthcare and support community autonomy moving forward. In fact, we initially expected that the NGO could cease its involvement in the region within five to ten years. However, this was compromised when the MoH implemented free universal health care in 2006, eliminating a one-dollar-per-consultation fee that was central to the health centre’s plans for financial sustainability (Eckhardt, Forsberg, Wolf, & Crespo-Burgos, 2011).

Another significant aspect of the health project was the establishment of a network of community health workers (CHWs) and direct-to-village medical brigades. The CHWs met monthly to discuss local health needs and participate in workshops on skills including first aid, emergency medicine, family planning, nutrition, malaria prevention, community organising, public speaking, leadership, and basic accounting. The curriculum for CHWs was based on a combination of CHW input, medical volunteer and staff expertise, and input from the Health Committee and NGO staff (many of whom were well-versed in the principles of social medicine and primary health care). In their own communities, CHWs represented the health centre by promoting and providing information about health centre services, holding health education workshops, administering first aid, and attending emergencies using supplies from NGO-provided kits. Their most visible role in their communities was as organisers for health centre medical brigades, when doctors, nurses, dentists, and others visited distant communities to provide consultations and health education. In these early years, brigades were also intentionally designed to build trust and share knowledge through community meetings, focus groups, and interviews, as well as team building activities and informal conversations. At least twice a year, the medical team (accompanied by one member of the Campesino Health Committee and a CHW) would visit multiple communities, often taking a week or more for each brigade.

Throughout the 2000s, health services in Las Colinas remained imperfect. The resources gathered by Northern volunteers and the MoH were never adequate to meet all of the region’s health needs (Ordóñez Llanos, 2005). Some volunteers were still medical students, placing us in the ethically tricky position of providing staff who had not finished their training, a practice that was abandoned once MoH staff were provided on a constant basis. And the CHWs’ work was a significant responsibility that only partially compensated for a lack of government resources. As unpaid volunteers whose work was not always recognised by their fellow community members, CHWs’ commitment and participation waxed and waned; yet nearly all communities had a CHW representative who offered their services with pride (Ordóñez Llanos, 2005). One CHW from that period described his experience in the following way,

First of all, we come here to participate in workshops, and then we take that knowledge back to our communities and inform people about the themes, for example, how to prevent certain diseases. But we know that we can’t do everything, we are not doctors who can diagnose, but we can offer what we have learned, orient people, or give them first aid. (Interview, 2005)

Many described this work as empowering both individually and for their communities. As another CHW remarked,

I’ve been very content with my participation over these years, even when people in my community don’t recognize how much I’ve spent of my time and money to participate in this project. But it feels good, good to serve others, good to fulfil this role, almost as if it lifts the soul. (Interview, 2005)

Through the 2000s, the NGO built significant community-owned health assets, including the health centre, an ambulance, and a multi-use building to house volunteers, MoH medical staff, and special events. The Campesino Health Committee took a leadership role with regards to health and other forms of community development, providing substantial direction to volunteer and government medical staff. Also, NGO staff in Quito and the health centre administrator served as representatives from the community to the state and transnational partners. The health administrator, for example, regularly lobbied (and continues to lobby) the municipal hospital for required medications, health centre equipment and supplies, and the best médicos rurales. This built-in intermediation was meant to ensure a key goal of social medicine: the ‘redistribution of power and resources among the distinct groups implicated in healthcare decisions,’ (Vázquez et al., 2002, p. 33).

The health impacts were impressive. Depending on the season and staffing, the health centre treated anywhere from 40 (in 2001–2002) to 300 patients per month (2006). Through extensive distribution of bed nets during health brigades and via CHWs, malaria transmission in the region was eliminated, despite the fact that malaria was one of the most prevalent and deadly illnesses when the project was initiated. Though reliable data are still difficult to access, childhood vaccination rates have increased at least five-fold since 2001.

The Convenio de Integración was important for fostering and sustaining this deep participation. Community members take great pride in the fact of their ownership, in keeping with their ideal of self-reliance and mistrust of both the state and other potential partners. In interviews and meetings, they repeatedly emphasise their ownership and management of the health centre as evidence of their success in community organising and their capacity for self-governance. The NGO has viewed the Convenio as an important indication that they are not merely creating a relationship of dependency but instead they are supporting participatory governance by local institutions (in this case, both the state and the community). And the national and municipal governments saw the Convenio as a convenient way to provide services to a population in need without investing many resources, since most of the work and funding fell to the NGO and management fell to the community. As we will see, though, this perspective changed in the late 2000s. The history of state–community–NGO relations in Las Colinas contradicts assertions that NGOs are unambiguously part of neoliberal projects; while NGOs have sometimes substituted for state service provision, local inhabitants have also used NGO partners to struggle with and against the state and to expand both the state presence and community autonomy (see also Friederic, 2015; Biermann, Eckhardt, Carlfjord, Falk, & Forsberg, 2016).

La Revolución in practice: post-neoliberal health care and changes in grassroots health activism

One measure of the partnership’s success was increased state commitment to fulfilling basic health rights. Though bolstered by national increases in health funding authorised by Correa as minister of economy and then as president, Las Colinas received a particularly large increase in government support due to community activism. By constructing a high-quality health centre, the community and NGO laid the groundwork for significant MoH involvement. By 2008, the MoH was providing full-time staffing for the health centre and all major medications at no cost. However, as MoH capacity grew, and as MoH staff grew tired of hearing demands from the community and NGO, they began to ignore and sometimes actively resist the Convenio, often treating the health centre as if it were their own. One particularly comedic example of this came in 2009, when we returned from a medical brigade to learn that two MoH administrators had visited the health centre and volunteer house in our absence to inventory ‘their’ equipment, including a dental chair, exam beds, coffee pots, and toaster ovens that belonged to the community and even international volunteers. Aside from the question of fictitious ownership, increased government involvement led to professionalisation and ‘seeing like a state’ rather than community input, planning, and evaluation (Scott, 1998). This critique of Correa’s administration extends to other sectors, with Ecuadorean activists remarking that ‘after the Constitution in 2008, people disengaged from politics because that’s when people got incorporated into the bureaucratic system,’ which also ‘weakened social organising’ more broadly (Miranda, 2017). In Las Colinas, in particular, the strengthening of the state deeply affected both community participation and basic health service delivery.

From 2008 on, the role and participation of CHWs declined overall, despite punctuated bursts of activity due to short term programmes that garnered their interest (for example, a NOKIA-funded mobile communications and data collection project and the implementation of malaria rapid tests). The MoH explicitly encouraged the participation of CHWs in its planning, yet workshops with CHWs led by MoH medical staff were often characterised as ‘boring’ or ‘too technical.’ CHWs still valued the learning, but they complained that they did not feel like their input or work was being appreciated. As one long-time CHW characterised the shift:

It’s just not like it was before, when we participated, and we laughed so much. We were welcome to sleep at the health centre when we couldn’t get back to our communities after full day workshops. We were tired but we enjoyed it because we felt it was our home, it was another family … . We were all in the work together. Now we just sit and listen to the experts tell us things. They are nice and they know a lot, but it’s not like it was. (Interview, 2014)

CHWs no longer felt essential to the project, instead seeing their responsibilities reduced to ‘bringing letters’ to their community about health centre services and events, but ‘that’s it.’

The NGO and Campesino Health Committee initially celebrated the fact that the MoH was taking more responsibility for service provision and, as governance of the health project evolved, the NGO shifted its focus to outreach in distant communities. By 2012, however, CHWs were significantly less active and the frequency of brigades had declined to one to two per year. Perhaps most importantly, the Campesino Health Committee had substantially less influence over health centre programming, primarily because bureaucratic demands on medical staff allowed them less flexibility to adapt to community needs.

While outreach is still important on paper to the MoH, staff complain that the need to show ‘high production,’ or a high quantity of patients, disincentivises outreach in distant communities. Amid isolated homesteads, they see fewer patients than they would at the health centre located in the region’s most densely populated village. As doctors tried to compensate for the ‘unproductivity’ of brigades, they increased formal workshops and talks and decreased the amount of time dedicated to building trust and soliciting community input. Furthermore, brigades now required complex and onerous planning, coordination, and paperwork. Medical staff regularly complained about needing to solicit permission to be absent from the clinic, put in requests for extra medication, and wait for those to arrive (which they often did not). After brigades, they then had to produce official reports verifying that they saw enough patients and dispensed enough medications to justify the brigade.

The emphasis on metrics and documentation has changed the way health education is provided, as evidence in the following excerpt from Friederic’s field notes:

Last night, the young rural doctor was up until 11 pm creating a poster for today’s talk on breastfeeding. The perfectionist that he is, he was up for three hours tracing drawings from books of maternal figures with babies. In the morning, he asked me to take pictures of him with his precise, intricate drawings. When I asked why he needed the photographs, he said, ‘The Ministry [MoH] wants to see what we are doing for the community. I have to have documentation of meetings with community members so I need to get a photo of the meeting today and a photo of the attendance sheet. But they always want to see if I am making a good poster. It’s important that we do this. But I tell you, it is a shame that I can’t do a talk on dengue, considering the outbreak we’re in the midst of!’ When I asked why not, he replied, ‘Well, because it’s international breastfeeding week, and it’s part of the planning we were given for the month, so we have to give at least one talk about that theme in the community with at least 20 participants. They have a set calendar and schedule of the important themes throughout the year.’

At the talk later that day, the doctor, who was quite shy when it came to public speaking, explained the important nutrients that mothers passed on to their babies through breastmilk. He was meticulous, but he used difficult medical language and failed to connect with his audience. The crowd was uncomfortable and a bit confused, though certainly appreciative of his efforts. After the talk, I asked a friend what she thought, and she said, ‘it was good, he was very knowledgeable.’ When I urged her to explain to another friend what it was all about, she said, ‘I don’t remember the details, but he told us it is very important to breastfeed.’ (Fieldnotes, 2014)

Outreach, or increased contact with people outside the clinical setting, is certainly valued by the MoH and health centre staff. However, outreach is prioritised (at least in part) because deeper penetration into the communities allows for greater surveillance and coverage, two concepts that are central to the MoH’s national health care plan. Outreach is also planned at national and municipal levels, disallowing the type of flexible and adaptive work that the Campesino Health Committee once promoted. Whereas health education was once community driven, with health promoters choosing the themes, shaping the content of workshops, and often participating in the delivery of workshops, they (like the rest of the population) have become passive beneficiaries. So, while MoH health centre staff characterise recent shifts in national health care as increasingly oriented towards community outreach, there have been major changes in what counts as outreach, which activities are prioritised, and what form of participation they provoke. In order to fulfil the community outreach requirement, it is well-known that most staff prefer giving educational talks in the central village (and counting the number of heads present, or that walk by), or visiting households in the nearest communities, which can be accessed by car and visited in one day so that staff can sleep in their own apartments.

Audit culture and the fetishisation of ‘production’ has transformed the provision of health care in Ecuador, much like it has in the field of global health more broadly (Adams, 2016; Brotherton, 2012). In recent years, teams of vaccinators have been hired and trained by the MOH on a short-term basis. They travel out to remote areas with low rates of vaccination coverage, like Las Colinas. In 2014, we travelled with one of the medical brigades to a community six hours from the health centre. Even before the doctors began to see patients, the vaccinator walked up to every adult present, including those participating in the soccer game beside the school, and began administering vaccines with little to no explanation. He barely mumbled which vaccine he was giving, he did not ask adults if they had received the vaccination before, and he failed to notify people if they needed follow-up booster shots. In most cases, they did. The vaccinator even pressured two of our students into getting yellow fever and tetanus vaccinations, diligently logging them into his notebook, despite the fact that these non-Ecuadorean students had already been immunised. The vaccinator was getting paid and evaluated per dose administered. If he did not administer all of the doses, he would be chastised, as valuable doses would have to be thrown out. Plus, as with medications in the health centre, the quantity used during this brigade would determine how many we would be given for future brigades. As the dentist noted when jumping onto her mule to leave the community, ‘the only thing the Ministry cares about is production, production, production, it’s all about the numbers.’

This was a common sentiment among MoH medical staff and the long-term health centre staff hired by the Campesino Health Committee. In 2014, Friederic asked a community staff member (who had been with the health project since 2002) about the increased role of the MoH in health care in Las Colinas:

Yes, there have been good changes. For example in terms of medications, we’re better stocked … . But it all depends … on ‘production,’ or on all of the work that the doctor does. Because everything begins from there. And also the people who come, the patients. For example we can look at the patients with chronic illnesses, like the diabetics. This is an established program and it’s already in the hospital but [resources] all depend on whether the patient comes from month to month, does their check-up, is taking their medications, is having their exams, and is controlling things. Then the doctor takes his report [about patient compliance] and passes it on. Here we have 20 diabetics and this month all showed up, so this means that for the next month, all of the medicine will come for those patients. But if the patient doesn’t come, the doctor doesn’t have to report [that they exist], and then we don’t get the medications. Sometimes we don’t have medicine for diabetics, or we don’t have the strips to do the exams. [Also], the things that have to do with family planning sometimes don’t come. It all depends on the production, on the [patients] who come, because one isn’t going to ask [for resources] on behalf of patients who aren’t doing their controls. It’s just not possible.

On the other hand, for example, right now we’ve been asking for lab supplies for more than a month. So in this case it’s the hospital’s problem. I was asking for them and they don’t give them … . Sometimes there’s a delay in purchasing or uploading requests … when there are administrative changes in the region. And sometimes this has happened and we don’t have medicine here. Sometimes patients come and there’s no medicine. Then it’s no longer our fault. Maybe it’s the region’s fault. But yes, things have gotten a lot better in this respect.

This focus on numbers, coverage, and statistical surveillance reveals that the ‘revolución ciudadana’ (insofar as it concerns healthcare) is successfully reaching most populations, but it encourages token forms of inclusion while discouraging deeper types of participation. This system is not currently designed to respond to needs but to provide coverage, which is broadly and shallowly construed, and to be highly visible in the performance of providing coverage.

People in the village seem quite content. Like the woman at the breastfeeding workshop and the long-term health centre staff we cited above, they remark on the performance of coverage (informative talks, increased house visits, vaccination campaigns, etc.) and downplay questions about effectiveness. The health centre doctor is enthusiastic about his role ‘serving the pueblo’ with an increased emphasis on prevention, but he acknowledges that the medication is always running out, and the demands of data collection are completely out-of-touch with reality. ‘But,’ he says, ‘if we had money and good infrastructure (like technology, roads, medication), then this would be another story.’ In response, the dentist (who was trained in Cuba) responded, ‘no, this is all a farce. I mean, it looks good on paper, but that’s it,’ later implying that the entire emphasis of the new programmes was on metrics and shallow participation.

Conclusions

The health activism we describe here was only one facet of Las Colinas’ self-organisation. From 2000 to 2008, the community also lobbied the government and NGOs for other initiatives, including clean water, road improvements, police presence, economic cooperatives, and ecotourism. At the time, it seemed that new community organisations were forming at every turn, and both NGO staff and community members would marvel at the unified organising that seemed to be at the heart of community life in Las Colinas. Of course there were factions and most of the workload fell on an ‘elite’ group of leaders, but all would agree that this was a period of growth, excitement, and possibility. The hopeful rhetoric of the Citizens’ Revolution really captured this spirit – and in fact, the majority is still Correísta. However, the last several years have left people struggling to explain the splintering and de-activation of so many local organisations. People in Las Colinas often attribute the current ‘apathy’ or ‘lack of organisation’ to ‘the youth of today who don’t know what it means to really suffer’ or a culture of ‘handouts’ that has made people lazy. Others point out that a generation of community leaders has moved, died, or directed their efforts to improving life for their own families rather than the community. While contributors to the slowdown in organising are diverse, we posit that the state-centred and context-blind approach of the Citizens’ Revolution and Buen Vivir are also a major cause of community de-mobilization. Interestingly, post-neoliberalism promotes state-based decentralisation as an antidote to neoliberalism’s market-based decentralisation, but both approaches ignore a third option of community-based decentralisation.

Our case study makes an important contribution to research on the Latin American Pink Tide by illustrating that the Ecuadorean state’s contradictory approach to decentralisation and participation is governed not only by a desire to appropriate extractivist revenues for reinvestment in social programmes, but also by a broader state-building project. In our case, the state is undermining local sovereignty and communal institutions because they need to accomplish the identity work of the cultural/citizens’ revolution. Instead of autonomy, it offers a new model of citizenship that incorporates rural people as beneficiaries of the Citizens’ Revolution, but in a way that reinscribes their marginality and poverty – ‘receiving’ is key to the performative symbolism of citizenship, just as ‘providing’ is key to the state’s performances. To bring everyone into their roles, the state has to undo competing sovereignties in order to re-incorporate community members as citizens. In short, the Citizens’ Revolution is inclusive not through invitation but through the erosion of alternative sovereignties.

Ultimately, however, to avoid the romanticisation of community we must evaluate the trade-offs between state and community. Advocates of post-neoliberalism and LASM, which hope for strong and generous states, cannot automatically opt for community power. As Atun, et al. argue, decentralised health systems like the one in Las Colinas circa 2004 can democratise health services and empower communities, but they have also ‘generated more complex environments for governance and performance management’ and raise the possibility for new forms of inequality and health system fragmentation (2015, p. 1235). Furthermore, states in the process of re-consolidation may fear that community power and vernacular statecraft will yield counterhegemonic movements that are not only anti-neoliberal but also anti-state. As Martínez (2017) notes, communities succeed in taking control over resources and governance – even in the face of corporate and state opposition – primarily when they have strong organising traditions, are able to use rights discourses effectively in official spheres, and build a strong web of translocal allies. The Ecuadorean state’s position is, most likely, that it is far better to surrender community power to an ostensibly democratic and well-intentioned state than to risk transnational alliances that may support communities but may also be backdoors for neoliberal and neocolonial resurgences.

While we continue to welcome the strengthening of the Ecuadorean state and increased funding and reform in the MoH, we believe there are both normative and pragmatic reasons to be concerned about the erosion of community self-organising. Among the latter, we would like to underscore four. First, as we have shown here, and Rasch and Bywater (2014) have argued regarding urban Ecuador, top-down, state-administered health systems are often insufficiently responsive to local needs and demands. Second, states in countries as diverse as Ecuador rarely represent local interests adequately, but this can be addressed in large part by creating mechanisms for real community influence. Third, democratic and progressive governance is further undermined in Ecuador by the central contradiction of post-neoliberalism – that the anti-neoliberal state and its public services are dependent upon transnational capital and precarious petrodollars. And finally, the erosion of community organising leaves communities vulnerable in the event that the Ecuadorean state is destabilised in the future.

Crucially, the cautionary tale of Las Colinas’ health activism also applies to LASM itself. As critical public health activists promote basic rights to health and combat political and economic determinants of disease, state policy and state services will be among the most valuable levers for change. Engaging the state with oversimplified understandings of local context, however, will often be counter-productive, especially in traditionally marginalised communities that are already organising creatively for their own health and well-being. A more sound approach might include strengthening transnational solidarities, establishing convenios between official and vernacular states, and encouraging empowered communities to create alternatives to standardised metrics so they can establish health priorities and health professionals can be flexible enough to meet local needs. We hope that a more mature Citizens’ Revolution will encourage state- and citizen-building through state–community–NGO partnerships, even when those partnerships magnify contradictions in the national project.

Acknowledgements

This article is dedicated to our dear friend, Guido. Thank you to staff and volunteers at the health clinic in Las Colinas (a pseudonym) and the NGO for your collaboration. At various stages, Karin Friederic’s fieldwork was supported by the National Science Foundation, the Wenner-Gren Foundation, the P.E.O. Foundation, the Harry Frank Guggenheim Foundation, the Feminist Review Trust, the University of Arizona, and Wake Forest University. IRB Approval was attained through the University of Arizona and Wake Forest University, and a research permit attained through the Ministry of the Environment in Ecuador (2007). Brian Burke’s fieldwork in Ecuador was supported by the Goodnight Family Sustainable Development Department at Appalachian State University.

Disclosure statement

In accordance with Taylor & Francis policy and my ethical obligation as a researcher, I, Karin Friederic, am reporting that I have served as a co-founder and volunteer board member of a non-profit organisation that has developed projects in this region of Ecuador, as noted in the article. I have no reason to believe that my organisation will benefit from publication of this article or that any other conflicts of interest may arise from this affiliation.

Additional information

Funding

At various stages, Karin Friederic’s fieldwork was supported by the National Science Foundation, the Wenner-Gren Foundation, the P.E.O. Foundation, the Harry Frank Guggenheim Foundation, the Feminist Review Trust, the University of Arizona, and Wake Forest University. Brian Burke’s fieldwork in Ecuador was supported by the Goodnight Family Sustainable Development Department at Appalachian State University.

Notes

1. In this article, we use the term ‘social determination of health’ when referring to LASM and Marxist approaches to health, and we use ‘social determinants’ as a broader term referring to the more proximate social factors that influence health and illness, as it is used by the World Health Organization. As Morales-Borrero, Borde, Eslava-Castañeda, and Concha-Sánchez (2013) note, these terms are not synonymous; instead, they reflect different conceptual understandings of causation and prevention, as well as distinct ethical-political entry points. Whereas ‘social determination of health’ invokes a critique of capitalist development, ‘social determinant’ approaches identify risk factors and propose improvements ‘within an inherently unjust system’ (Eslava, Borde, Morales, & Torres-Tovar, 2015; Morales-Borrero et al., 2013).

2. Inequality declined as measured by the GINI coefficient and as the ratio between the top and bottom deciles of the income distribution (Ray & Kozameh, 2012; Weisbrot et al., 2017).

3. In keeping with anthropological convention, we use a pseudonym, Las Colinas, to refer to the region discussed in this article.

4. To be clear, we are not arguing that the state is irrelevant even in this ‘out-of-the-way’ place (Tsing, 1993; McCullough, Brunson, & Friederic, 2014; Friederic, 2014b). ‘Vernacular statecraft’ through seemingly autonomous practices (e.g. communal labour organising, self-organized land colonisation, and the use of local judicial councils) is nonetheless shaped by Quito’s selective presence and absence (Colloredo-Mansfeld, 2009).

5. Later, the MoH would provide an OB-GYN, additional staff, and other programmes.