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Background: By the turn of the new millennium 84% of families in rural coastal Ecuador had difficulties to access health services. A health reform some years earlier to improve this situation had not been implemented. In 2001, the non-governmental organization (NGO) Foundation Human Nature together with a rural population established a primary health care center in North-Western Ecuador. A public private partnership with the Ministry of Public Health was formed. Services depended on out-of-pocket payments, restricting the poor's access to care. In order to increase access to primary and emergency care, Foundation Human Nature planned to establish a community-based health insurance. In the meantime, a major health reform was initiated by a new government in 2008. It aimed at universal health coverage, providing qualitative services for all based on primary health care, while ensuring protection from financial hardship. The aims of this thesis were to appraise the feasibility of community- based health insurance in Ecuador; to study how rural stakeholders perceived the 2008 reform and its effects on rural health services; to explore the local population's perception of the NGO in service delivery; and to measure the scope and describe the nature of perceived emergencies, the related health care seeking behavior and health expenditure. Methods: Quantitative and qualitative methods were applied to tackle the research objectives. Data collection for the health insurance study and the study of perceived emergencies was carried out through cross-sectional household surveys. For each of the studies 210 households were sampled with two-stage cluster sampling. Structured questionnaires were used with on the spot household interviews. Focus group discussions with local stakeholders were performed to explore their perceived effects of the 2008 health reform. The population's perception of the NGO was also studied through focus group discussions, which were complemented by key-informant interviews with local stakeholders. Inductive qualitative content analysis, focusing on the manifest content was applied. Results: 69% of interviewees were willing to join the presented community-based health insurance scheme for 30 US$ per household and year. Attitudes towards the scheme were positive and 92% of interviewees stated they would increase their health service utilization with affiliation. The implementation of the 2008 health reform was perceived as top-down, lacking communication. However, the reform's effects were mainly perceived as positive with free medical attendance and drugs. Increased service utilization was described as leading to a relative shortage of drugs and appointments. Access problems for remote dwellers were found, who were described of having to seek private care, also in emergencies. The NGO and its services were perceived positively by the population due to health care improvements in the region. The structure of the public private partnership was unclear, leading to dissatisfaction. Community participation was found to be rather weak. Perceived emergencies occurred to at least 90/1,000 inhabitants in the past year. Fever, traumatic injury and abdominal pain were the most frequent chief complaints. The first contacted providers in 57% of all cases were private for-profit providers, including traditional healers. Public health services treated one third of all cases. Health expenditure was found to be high and catastrophic health expenditure occurred in 24% of all cases. Conclusions: Prior to the 2008 reform community-based health insurance was found to be feasible in the study region. This financing instrument may have a role in the post-reform system, to cover services that the government does not yet sufficiently provide. The effects of the 2008 reform were mainly perceived positively, but an adjustment of the system is needed to improve the relative lack of drugs and appointments, especially for remote dwellers. Free health services may not be sufficient to reach universal health coverage for patients with perceived emergencies. Changes in public emergency departments and improved financial protection for emergency patients may improve the situation. The NGO's role was perceived positively by the population. A lack of communication about the public private partnership and relatively weak community participation restricted the NGO's full potential and should be improved.

Introduction: In many low- and middle-income countries emergency care is provided anywhere in the health system; however, no studies to date have looked at which providers are chosen by patients with perceived emergencies. Ecuador has universal health coverage that includes emergency care. However, earlier research indicates that patients with emergencies tend to seek private care. Our primary research questions were these: What is the scope of perceived emergencies?; What is their nature?; and What is the related healthcare-seeking behavior? Secondary objectives were to study determinants of healthcare-seeking behavior, compare health expenditure with expenditure from the past ordinary illness, and measure the prevalence of catastrophic health expenditure related to perceived emergencies. Methods: We conducted a cross-sectional survey of 210 households in a rural region of northwestern Ecuador. The households were sampled with two-stage cluster sampling and represent an estimated 20% of the households in the region. We used two structured, pretested questionnaires. The first questionnaire collected demographic and economic household data, expenditure data on the past ordinary illness, and presented our definition of perceived emergency. The second recorded the number of emergency events, symptoms, further case description, healthcare-seeking behavior, and health expenditure, which was defined as being catastrophic when it exceeded 40% of a household´s ability to pay. Results: The response rate was 85% with a total of 74 reported emergency events during the past year (90/1,000 inhabitants). We further analyzed the most recent event in each household (n=54). Private, for-profit providers, including traditional healers, were chosen by 57.4% (95% confidence interval [CI] [44-71%]). Public providers treated one third of the cases. The mean health expenditure per event was $305.30 United States dollars (USD), compared to $135.80 USD for the past ordinary illnesses. Catastrophic health expenditure was found in 24.4% of households. Conclusion: Our findings suggest that the provision of free health services may not be sufficient to reach universal health coverage for patients with perceived emergencies. Changes in the organization of public emergency departments and improved financial protection for emergency patients may improve the situation.

Background: Non-governmental organizations (NGOs) have a key role in improving health in low-and middle-income countries. Their work needs to be synergistic, complementary to public services, and rooted in community mobilization and collective action. The study explores how an NGO and its health services are perceived by the population that it serves, and how it can contribute to reducing barriers to care. Design: A qualitative exploratory study was conducted in remote Ecuador, characterized by its widespread poverty and lack of official governance. An international NGO collaborated closely with the public services to deliver preventative and curative health services. Data were collected using focus group discussions and semistructured interviews with purposively sampled community members, healthcare personnel, and community health workers based on their links to the health services. Conventional qualitative content analysis was used, focusing on manifest content. Results: Emerging themes relate to the public private partnership (PPP), the NGO and its services, and community participation. The population perceives the NGO positively, linking it to healthcare improvements. Their priority is to get services, irrespective of the providers structure. The presence of an NGO in the operation may contribute to unrealistic expectations of health services, affecting perceptions of the latter negatively. Conclusions: To avoid unrealistic expectations and dissatisfaction, and to increase and sustain the populations trust in the organization, an NGO should operate in a manner that is as integrated as possible within the existing structure. The NGO should work close to the population it serves, with services anchored in the community. PPP parties should develop a common platform with joint messages to the target population on the providers structure, and regarding partners roles and responsibilities. Interaction between the population and the providers on service content and their expectations is key to positive outcomes of PPP operations. ; Funding Agencies|Karolinska Institutet; Linkoping University; Ecuador

In 2008, Ecuador underwent a major health reform with the aim of universal coverage. Little is known about the implementation of the reform and its perceived effects in rural parts of the country. The aim of this study was to explore the perceived effects of the 2008 health reform implementation, on rural primary health care services and financial access of the rural poor. A qualitative study using focus group discussions was conducted in a rural region in Ecuador, involving health staff, local health committee members, village leaders, and community health workers. Qualitative content analysis focusing on the manifest content was applied. Three categories emerged from the texts: (1) the prereform situation, which was described as difficult in terms of financial access and quality of care; (2) the reform process, which was perceived as top-down and lacking in communication by the involved actors; lack of interest among the population was reported; (3) the effects of the reform, which were mainly perceived as positive. However, testimonies about understaffing, drug shortages, and access problems for those living furthest away from the health units show that the reform has not fully achieved its intended effects. New problems are a challenging health information system and people without genuine care needs overusing the health services. The results indicate that the Ecuadorean reform has improved rural primary health care services. Still, the reform faces challenges that need continued attention to secure its current achievements and advance the health system further. ; Funding Agencies|Centre for General Practice and Primary Health Care, County Council of Ostergotland, Sweden; County Council of Ostergotland, Sweden

"Der Aufstieg der Volksrepublik China (VRC) zur Weltmacht hat schon lange begonnen und sich bei Politikern, Wissenschaftlern und in der Öffentlichkeit als wichtiger Faktor für die Entwicklung der internationalen Beziehungen etabliert. Doch wer weiß heute schon mit Gewissheit, ob und wie lange diese Tendenz anhält? Die eine Antwort auf diese Frage wird es sicher nicht geben. Dieser Artikel stellt im Hauptteil drei alternative Zukunftsbilder gegenüber, unter welchen Bedingungen und wie sich die Außenpolitik der Volksrepublik im Jahr 2020 darstellen könnte. Zu Beginn wird die Szenario-Methode skizziert, mit deren Hilfe die Szenarien entwickelt wurden." (Textauszug)