Shared evidence and analysis between communities and local government in Quito, Ecuador to mobilise cross sectoral action in health
The Metropolitan District of Quito (DMQ) is the second most populated city in Ecuador. It has grown rapidly in recent decades, with a 2010 population of 2.2 million in 65 districts called parroquias, half of which are urban. While there are social differentials in Quito residents, they have a strong sense of belonging in their neighbourhoods.
A 2016 health diagnosis (Diagnóstico de Salud) observed a high burden of chronic conditions, including in young people. Rather than using a reactive biomedical model to address these problems, a Healthy Municipalities Program in Ecuador is investing in a proactive community-based and population health approach. This applies participatory analysis and action to improve the social determinants of health (SDH) and involves locally elected Comités Locales de Salud (CLS) with community representatives in health situation diagnosis and planning. This approach reflects Ecuador’s 2008 Constitution and legal framework that sets a holistic rights-based approach to social participation in health, linking health to the exercise of rights to water, food, education, culture, social security, healthy environments and other areas that sustain good living (buen vivir).
The Health Department of the Municipality of Quito has since 2016 led implementation of a Healthy Neighbourhoods - closing the gap in health inequality project. It started in Ponceano, Centro Histórico, and Chimbacalle districts, with a combined total of 130 000 people. These districts had poorer health status than others in Quito, but had capacities to support the work. The project integrates health into urban planning, local investment and local public policy, by promoting community-led initiatives.
The health department set up a technical committee of sectors contributing to create conditions health to support intersectoral action; and community health work teams at city and neighbourhood levels to bring local community voice to the processes.
From the side of the city, information on health and SDH is gathered and organised using the WHO Urban Health Equity Assessment and Response Tool, the Centers for Disease Control Healthy Communities program and the Ecuadorean Ministry of Public Health National Program for Healthy Municipalities. This information is used to engage with residents on their priorities in the different neighbourhoods, displaying health data and health determinants by district to make the information publicly accessible, including for informal neighbourhoods.
Residents carry out their own awareness raising and local ‘priority setting’ workshops held within settings in their neighbourhoods. To date neighbourhoods in parroquias Carcelen, Cotocollao, Comité del Pueblo, Chimbacalle, Tumbaco and Centro Historico are participating in the project. They identify their own priorities using participatory methods in these local workshops, and combine this with the evidence presented by DMQ to develop a road map with activities for the priorities in their own neighbourhood, and across neighbourhoods at city level.
The responses are organised in an intervention proposal that is presented to the mayor for approval and implementation. DMQ supports the capacity of residents to generate these intervention plans, or community health plans. As a pilot scheme, DMQ provides incentives such as specialized technical support, access to municipal communication channels (newspaper, radio, social media), and financing for community events to promote community involvement in the development and implementation of the plans. These incentives support community-led initiatives to improve health that benefit the wider community and aim to target and stimulate participation in those with higher health need.
Another approach is the community-led certification of ‘healthy spaces’. These cover fresh food markets, schools and parks within the municipality that meet certain criteria. The criteria are developed by the health department in collaboration with relevant sectors and with higher level health agencies. Municipal workers and community teams assesses food markets, parks, streets, schools and other public spaces and develop workplans for health improvements to address the gaps identified. The participatory action plans are implemented in co-ordination with relevant actors in these settings, with participatory review of how well they worked. The certification process aims to support the administrators and users of spaces like markets and schools to prioritise how best invest limited municipal resources to address those issues that preserve and promote health. It is expected that the initial effort around receiving a certification will forge a working relationship between the relevant actors in the improvement of these spaces, which will continue even after the space meets the criteria for certification. Over time, responsibility for certification of these healthy spaces will be fully delegated to the community health teams.
These processes build on Quito’s recognition of the role, orientation and competencies of the municipality in population health, the culture of collective work for common goals, and a supporting legal and policy framework. This has been critical for engaging other sectors and for the participatory processes to grow. It is a work in progress. However, there is evidence that the participatory processes for information gathering, analysis and priority setting in the community, combined with that collected by the services, together with the team approaches used can encourage co-operation across sectors and with the community to solve problems and to improve healthy public spaces.
These practices do face challenges in ensuring that the mechanisms adequately represent specific groups like youth, women or children. It has been difficult to encourage the work in areas where the culture of participation is weaker, to ensure that private actors, like companies, play their role and to encourage co-ordination across sectors. The expectations amongst community members may exceed the resources that DMQ has for the work. Co-ordination across sectors faces siloes that need to be broken to generate shared planning and action.
Those involved have found that this needs time and ways of building confidence through step by step progress. The information gathered helps to build participation, but can also build this confidence of the sectors and communities involved through the local evidence gathered.
From case study by R Loewenson, F Obando . Photos: Students explaining perceived health problems in their neighbourhoods. Quito © LJ Cárdenas 2016; Community assessing a market, Quito, © J Arevalo, 2018; Steering Committee LJ Jurado 2017