Resumen de Territorios y la COVID-19 en Ecuador: regiones funcionales como respuesta a la crisis sanitaria

Fernando Barragán Ochoa, Esthela Salazar, César Benavidez Silva, Galo Andrés Bastidas, Santiago Jaramillo, Jordan Ordóñez, Carolina García

• español

  La propagación de la COVID-19 ha enfrentado a los sistemas sanitarios del mundo a diversos desafíos. El incremento exponencial de casos que requieren atención hospitalaria ha generado escenarios de sobresaturación de los hospitales. En estos contextos la población y las instituciones han planteado diversas estrategias, entre las que se incluye la movilización de pacientes desde los lugares de vivienda a otros donde podrían ser atendidos. Estos desplazamientos se inscriben en una lógica de regiones funcionales construidas a partir de las prácticas espaciales de la población en un contexto de crisis sanitaria. El objetivo de esta investigación es observar el manejo de la crisis sanitaria desde una perspectiva regional para determinar áreas de influencia de infraestructura hospitalaria, flujos hospitalarios y vínculos entre territorios de vivienda y lugares de atención médica. Como resultado se obtuvo que la atención médica en el contexto de la crisis sanitaria devela una configuración regional subyacente. Esta organización espacial tiene un gran interés para la construcción de eficaces y eficientes sistemas territoriales de atención a pacientes en contextos de crisis y para la construcción de una resiliencia territorial.

• English

  The spread of COVID-19 has altered the structure and functioning of spatial systems, giving rise to multiple dynamics. The spatial and temporal concentration of cases requiring medical care has led to the collapse of healthcare systems around the world, particularly in territories with already limited resilience potential and provision of medical services, as was the case of Ecuador. In this South American country, a reform of the healthcare system was launched as part of the 2008 Constitution that involved a strengthened investment in healthcare services; however, when the pandemic started, the implementation of the Comprehensive Healthcare Model (MAIS, in Spanish) had not been consolidated, and a number of constraints limiting its functioning in a scenario of changing public management priorities were expressed. In this context, the present study addressed access to public healthcare from two different perspectives. From a structural perspective, the distribution of hospital infrastructure was studied; from a more contextual perspective, the strategies generated in the context of the pandemic for COVID-19 patients to access healthcare services were analyzed. The structural and contextual perspectives were addressed considering a spatial approach, which led to the configuration of “functional regions”. The hospital infrastructure was analyzed applying gravitational spatial models (Reilly’s and Huff’s models) in the PhilCarto free software to evaluate the hypothetical influence of the existing infrastructure on access to healthcare services in a territory characterized by a duopoly (Quito and Guayaquil) and a great diversity regarding the occupation of space. For the contextual analysis of health care in the COVID-19 pandemic scenario, the Gephi free software was used to perform spatial network analysis from the healthcare database of the Instituto Ecuatoriano de Seguridad Social (Ecuadorian Institute of Social Security; IESS, in Spanish) - one of the main providers of healthcare services in Ecuador. The study of this network was based on the examination of the links between housing areas and healthcare sites for COVID-19 patients, which allowed evaluating both the weight of the territories and the centralities regarding access to healthcare services, leading to the formation of functional regions from spatial links. The application of the modularity algorithm allows the identification of spaces that, beyond a local perspective, form a functional network according to the spatial dynamics of the healthcare provided to COVID-19 patients. The results obtained are discussed from the perspective of spatial inequities in the provision of healthcare services and the analysis of the role of functional regions under crisis scenarios. The first perspective highlights the patterns of inequity in the provision of healthcare services, within the framework of spatial injustice theories. Land-use planning at the national level and the territorial management of public policy are proposed as strategies to achieve higher efficiency and effectiveness levels in the provision of a service that operates in a hierarchical way and where real and potential access to infrastructure are among the driving variables. The functionality of space from this perspective is seen from a multi-scale standpoint, in which the regional scale constructed from functional links is highlighted. Indeed, from the second perspective of the analysis of results, the identification of spatial links and the formation of functional networks reveal spatial structures underlying territorial dynamics. Besides, these results represent strategic and valuable knowledge for the territorial management of the pandemic and, from a broader perspective, of healthcare and the provision of public services. Certainly, functional regions show historically constructed linkages and their use within a crisis scenario. Institutions would benefit by considering these inputs for management more closely linked with historically constructed socio-spatial dynamics that provide clear functionality to space from a regional perspective. The study concludes by highlighting the need for continuous processes to strengthen public services and, even more so, pivotal sectors such as healthcare services, for these efforts to consolidate their effects in the mid- and long term. These efforts have the potential to strengthen contextual management in crisis scenarios such as the pandemic. Both structural and contextual management should incorporate the spatial component as a social construction where citizens and institutions interact. In this sense, pandemic management requires to be founded on the diversity, dynamics, and interaction of spaces.