1. “Let the world change you.” Family Medicine at the Center of Healthcare System Reform in Latin America: The Ecuadorian Experience Susana Alvear MD Medical Coordinator Quito, Child Family Health International Medical Director Family Medicine Residency Program PUCE Edgar León MD Medical Preceptor Quito, Child Family Health International Clinical Faculty, PUCE Department of Family Medicine

2. TOPICS Social and political background for Family Medicine training in Ecuador A short history of Family Medicine in Ecuador New health system model New challenges in Family Medicine training

3. Ecuador covers 280,000 km 2, and is about the size of Colorado or Nevada. It is located on the western side of South America between Peru and Colombia. Ecuador is divided into 24 provinces and has four main regions: coastal, highland, Amazon and Galapagos. Geography of Ecuador www.uweb.ucsb.edu Learning Objective 1: Basic Demographics

4. History Ecuador is a democratic, multicultural and multiethnic country Natural disasters each year from “EL NIÑO” Volcanic eruptions since 2000 Oil is the primary income source Health expenditures are from 2.4% (2000) to 4.9% (2010)

5. Socioeconomic indicators Literacy rate - 91.9% The annual Gross National Product per capita - $2820 Population below the international poverty line - 30.4% Poverty in the rural sector - 80% Poverty in the urban sector - 40% Unemployment - 16% Human development index - 72

6. Basic Health Indicators 2010 Total Population14,204,900 Life expectancy75 General mortality rate (2008)4.35 Infant mortality rate (2009)11.4 Maternal mortality ratio (2008)80 Hypertensive diseases prevalence28.7 Deliveries with medical team rate80 Inmunization rates: Tuberculosis vaccine coverage rate (BCG)99% Measles97.6% Population with insurance4,036,300 Population without insurance10,168,600

7. Principal Causes of Mortality In order of higher incidenceCause of DeathRate 1Hypertension29.8 2Diabetes Mellitus27.7 3Influenza and Pneumonia23.2 4Car Accidents22.8 5Cerebrovascular Diseases22.6

8. Population pyramid – 2010 Total: 14,483,499 inhabitants

9. Ecuadorian Health System Focus on curative and “medicalized” care Privatized without universal coverage Fragmented medical care Inequality Ministry of Health without sufficient power to enforce guidelines

10. Medical Care - Ecuador 2006 Medical Care - Ecuador 2006 (Henríquez y Sánchez) 1000 adults 750 with symptoms or diseases 375 self-treated 100 consult physician per month 11 hospital admissions per month 1 treated in a specialty hospital per month INEC. Anuario Estadístico de Recursos y Actividades de Salud 2006. Disponible en www.inec.gov.ec

11. This is the population that is typically NOT seen by a medical student in Ecuador Medical Care - Ecuador 2006 Medical Care - Ecuador 2006 (Henríquez y Sánchez)

12. Number of physicians per province 2010

13. Budget graph for the Department of Public Health as a proportion of the national budget 2000-2010

14. Public Health facility availability 2006-2010

15. Primary Care Physicians International Labor Organization (ILO) recomends 25 to 50 physicians per10,000 inhabitants ECUADOR - 2006 (INEC) 17 physicians per 10,000 inhabitants.

16. Primary Care Physicians Recommended availability of Primary Care physicians Wonca: The organization of family physicians, establishes a relationship of one family physician per 1500 inhabitants Ecuador 2006 (INEC) In Ecuador for every 5 specialists there is only 1 primary care physician, very few of whom have attended a residency program

17. MD in each province in Ecuador

18. New Health System Model

19. Principles: Universal access Equitable Adapted to the social, economic and epidemiological context Continuity and quality of Care Based in Primary Health Care

20. Care Levels

21. FAMILY MEDICINE The principles of Family Medicine are universal while the implementation will vary according to the local context and needs Jack H. Medalie

22. History of Family Medicine in Ecuador

25. Cambio hacia el Modelo de Medicina Familiar

26. Cambio hacia Medicina Familiar

27. New challenges 2011. 2011. The Ministry of Health decides to train 1000 family doctors in the next 3 years 2012 2012 Development of the new curriculum with 7 univesities and with cuban support Core requirements Core requirements Minimum 3 years of residency training Outpatient training Development and accreditation of teaching units (clinic, hospital and university faculty)

28. Example of a Teaching Unit

29. Caracteristics of the standard Training in F.M. Admission exam 3 years of training Outpatient training Hospital Rotations University faculty travel to the student to supervise their training Classroom sessions with PBL, workshops, etc. National standarized testing

30. Clinical activities during the first and second year PGY1IMOB Ped 8 months1 m Urg Outpatient clinic Population pyramid PGY 2 IMIM OB 1 m Outpatient clinic P Research Project 8 months

31. Desafíos. Challenges Sustainability – Policy – Economic issues Quality – Teaching – Learning – Medical care Evaluation – Process – Impact

32. Conclusions We need to create new relationships between Family Doctors globally who can help us to accomplish this enormous government project. Political fluctuations … Narrow window of opportunity to revamp primary care. In effect we are “mass producing” family physicians for the entire country over 3 to 6 years.

33. This new model of training Family Doctors is an important step in Latin America To create collaborative links among entities as universities, residency programs, who are focusing in Primary Care

34. Avoid using family practice as a “stepping stone” to pursue specialty training. Emphasize prestige and satisfaction of well prepared primary care

35. Edgar Leon MD evls135@hotmail.comevls135@hotmail.com Susana Alvear MD susialvear@gmail.comsusialvear@gmail.com