By Lahra Boitnott and Cara Hrusch

Rural Ecuadorian populations face a menagerie of health care issues rooted in social, economic and political problems.  The established health care system is inadequate to effectively manage these issues.  A major issue for rural populations is inaccessibility of quality secondary (hospital-based) health care; many people live hours away from the nearest facility.  Others with better access do not utilize available facilities due to poor quality of care, limited availability of personnel in an emergency, and maltreatment of patients.  This is compounded by political issues including financial mismanagement, lack of strong governmental leadership, and an inefficient social security system. All these barriers create an inefficient system where only 50% of the population utilizes free services offered by the Ecuadorian Ministry of Health (MOH).  The other half is willing do pay out-of-pocket, despite extremely limited resources, for private providers. 

            These conditions prompted David Gaus, MD, MPH/TM, to begin work in the rural community of Pedro Vicente Maldonado (PVM).  He began by opening a private clinic just 3 blocks away from the MOH facility, with emergency assistance available 24 hours a day, 7 days a week, to gauge public need and interest in that type of facility.  After a single year, staggering statistical differences were noted between his clinic and the MOH facility: 3000 outpatient visits and 60 births in the clinic vs. 900 outpatients and 9 births.  Given that a Dr. Gaus charged a minimal fee for service, these figures show that people are willing to pay for quality, reliable health care rather than the available MOH facilities.  A contract was signed between the Municipality of PVM and SALUDESA (primary financier) to build a 17,000 square foot hospital with 20 beds. 

            One of the primary goals of this project is to create a model self-sufficient rural secondary health care facility that avoids the problems associated with missionary-based or government-based models of care.  The hospital is financed by 3 mechanisms:

            1.  Categorized fee for service,

            2.  Prepaid package (similar to health insurance), and

            3.  Social Security insurance.

For Fiscal Year 2003, the hospital recovered 49% ($155,000) of its operating costs ($310,000) through these mechanisms alone.  Supplemental financing was provided by SALUDESA. 

            The availability of a pre-paid package is a novel approach in this area and acts to reinforce the idea of personal responsibility in health care and preventative medicine.  For only $30/yr for each adult ($15/child), individuals are allotted free doctor visits, preventive treatment, as well as pre- and perinatal care. Discounts on services such as X-rays, surgeries, and medications are also included.  Primary interest in these packages resides with municipal employees, the teacher’s union, commercial farmers, and ecotourism resorts which have a vested interest in health maintenance.

            The Hospital P.V.M.  provides a novel approach to some of the most common health care issues in Ecuador.  It is projected by be financially self sustainable by 2007 and is working to create a service to provide primary health care via satellite centers within outlying communities.  By fundamentally changing the approach to health care delivery, the Hospital P.V.M. has created a model of health care that will be important in the development of a national model of health.