key: cord-0748180-1t9pfju1
authors: Torres, Irene; López-Cevallos, Daniel
title: In the name of COVID-19: legitimizing the exclusion of community participation in Ecuador’s health policy: Special call: Health Promotion Perspectives on the COVID-19 Pandemic
date: 2021-01-20
journal: Health Promot Int
DOI: 10.1093/heapro/daaa139
sha: 7bfce522ba569686950a410a83c47a0deed6b7ea
doc_id: 748180
cord_uid: 1t9pfju1

Global shifts toward a disease-oriented, vertical approach to health has involved limiting the right for communities to participate in decision-making. Ecuador’s authoritarian legacy has forced civil society and social organizations to adopt ‘coping strategies’, while large protests recently derived into violent struggles. The country has been severely hit by the COVID-19 pandemic amid corruption scandals involving hospital and food purchases by government during the response. This study critically examines how Ecuador’s government took into consideration ‘community participation’ as a value and tenet of health promotion. Our systematic textual analysis focuses on 53 consecutive resolutions by the National Emergency Operations Committee (EOC) leading the decision-making processes, which, explicitly requires community participation. Results show that the ‘lifecycle’ of the central government’s evolving policy framing centered on law enforcement and the private sector, followed by the social sector. Further, there is no evidence of stakeholders from civil society or organizations taking part in decision-making. Having legitimized the exclusion of community participation in Ecuador’s response to the COVID-19 pandemic, it is possible that the government will fail to consider the wider social implications of its impact. In particular, the limits to local governments becoming informed and making decisions without mediation by the National EOC will further impede community participation in health decision-making in the future. This implies that local knowledge and experiences will also not inform health policy.

The pandemic due to the novel coronavirus 2019 (SARS-CoV-2), which causes the disease now known around the world as 'COVID-19', has spread throughout the globe infecting almost 17 million people and causing over 660 000 deaths (as of 28 July 2020) (Johns Hopkins Coronavirus Resource Center, 2020) . We are increasingly aware of COVID-19's differential impact on vulnerable populations, including their physical and psychosocial well-being, exacerbating preexisting systemic health and social inequities (Kluge et al., 2020; Zhang et al., 2020) . In Latin America, countries such as Ecuador have been severely hit, with initial reports sharing dramatic images and descriptions of corpses lying at home or left on the streets because funeral services and the local government of a major city (Guayaquil) were not able to adequately respond, in early March (El Universo, 2020a) . By 11 October, there were 691 confirmed deaths per million people, placing Ecuador in ninth place in this category worldwide (Our World in Data, 2020) .

It could be argued that the 'coproduction' of services between government and community-based organizations (Cheng et al., 2020) and the 'cooperation' of citizens in following measures (Moon, 2020) in response to have been privileged over actual participation of civil society in decision-making. In more extreme contexts, lockdown was enforced with the aid of the military (Kalkman, 2020) ; while in countries such as the United States the response effectively became militaristic, exclusionary and anti-democratic (Forester and O'Brien, 2020) . In Lebanon, shortly after protests, calls for military intervention in the COVID-19 response were announced (Al-Ali, 2020).

Ecuador, with a population of 17.5 million people, faces this global pandemic already weakened by a severe economic crisis, due in part to large external debt commitments, government corruption and low oil prices. While adopting the US dollar (in 2000) is credited with stabilizing the economy at the time, over the years it has limited the country's ability to dictate fiscal policy (increasing cost of living, eroding people's purchasing power and making exports more expensive). More recently, the government's attempt to increase fuel prices (as agreed with the International Monetary Fund) prompted large protests that drove much of the country to a halt in October 2019. Public revolts led to violent repression of protesters by police forces with support from the military, reinforcing their traditional role of social control . The legacy of authoritarian governments has meant that civil society and social organizations in Ecuador have been pressed to develop 'coping strategies' to compensate for or counteract their limited participation in decision-making (Appe et al., 2019) .

After almost two weeks of protests, the Ecuadorian president agreed to withdraw its proposal, further weakening an already unpopular administration battling low credibility and people's support. In this context, Ecuador was one of the first Latin American countries to identify a confirmed case of . Three weeks later (on 17 March), the government decided to impose a national lockdown (with 111 confirmed cases). However, COVID-19 spread rapidly in the initial hotspot (Guayaquil, Ecuador's economic hub) and moved on relatively quickly throughout the country . As of 28 July, Ecuador has 82 279 confirmed cases and 5584 deaths associated with COVID-19 (Ecuadorian Ministry of Public Health, 2020). Quito, the country's capital, has surpassed Guayaquil with the largest number of confirmed cases (12 747 vs. 11 849, respectively).

Ecuador has a segmented and fragmented health system guided by a vertical biomedical approach, which has been shown to perpetuate health inequities and limit community participation (Torres and Ló pez-Cevallos, 2018 ). Such an system echoes global health shifts toward a biomedical, disease-focused orientation that does not consider the values of social justice and equity, and therefore limits community participation, even though others argue it is a right that should be protected (Rifkin, 2018) . Concurrently, the scientific community has been all but absent from governmental response efforts, and the country continues to confront the pandemic without the leadership of an expert health committee. In contrast, a group supporting the risky, unproven treatment of COVID-19 with chlorine dioxide had ample time to address the national legislature, in tune with 10 bishops 'demanding' the ousting of the Ministry of Public Health for refusing to authorize this chemical for treatment (El Universo, 2020c) .

During the study period, confirmed COVID-19 cases rose from 28 on 14 March to 35 484 on 10 June, with only 4765 RT-PCR tests (the 'gold standard') per million people (Secretariat of Risk Management, 2020a,b). On 1 July, Ecuador had one of the highest number of excess death rates during the pandemic among countries that report that figure, having reached more than 2000 per million people or 88% above normal (Wu et al., 2020) . According to Imperial College simulations, without intervention, by the beginning of February 2021, there could be a total of 175 000 deaths due to COVID-19, that is, 10 000 per million people (MRC Centre for Global Infectious Disease Analysis. Imperial College London, 2020).

Although Ecuador is classified as an upper-middle country, the current pandemic has exacerbated preexisting, systemic social, economic and political issues, and exposed the state of the country's healthcare delivery system. According to the World Health Organization, Ecuador's preparedness is at level 3 (in a 1 to 5 scale), which means reaching 60% of capacity benchmarks (World Health Organization, 2020). It should not surprise us then that, despite having considerably more resources, Guayaquil was overwhelmed by the onset of the pandemic. And, as the virus moved across the rest of the country, other localities have found themselves facing similar challenges with fewer resources.

The scars left by the pandemic in the health sector include a series of corruption scandals related to the purchasing of emergency supplies at exorbitant prices, which, together with previous contracts, add to more than 20 'fraudulent' business arrangements tracked by the National Anti-Corruption Commission (El Universo, 2020b). To make matters worse, the Ministry of Public Health (in theory, the national health authority) has had two different Ministers during the pandemic, and continues to struggle with provision of personal protective equipment for health personnel, testing and tracing capacity, with limited clinical and public health resources, making the outlook of the pandemic response highly uncertain. Moreover, early on in the government's response to the pandemic, the leadership role of the National Emergencies Committee was vested upon the Secretariat of Risk Management (sidelining the Ministry of Health). But even the Secretary of Risk Management had to step down amid accusations that she authorized the purchasing of food kits at inflated prices, which was subsequently verified by Ecuador's Office of the Comptroller (Primicias, 2020) .

Although on 8 April there was a call for attention to indigenous populations during the pandemic , the Pan American Health Organization waited 2 months to publish related guidelines (PAHO, 2020a), and sent a belated alert on 15 July (PAHO, 2020b), after COVID-19 had begun to ravage Ecuadorian indigenous populations in the Amazon River Basin. Finally, while there were reports of an increase in intimate partner violence during national lockdowns (as response to the pandemic) around the world, Ecuador saw a decrease of related emergency calls, which was implicitly explained by the government as due to a lack of community-based mechanisms of support (Mena and García, 2020) .

In this complex scenario, and given the extended first wave of COVID-19 in Ecuador, the present study critically examines whether decision-making in Ecuador's governmental response to COVID-19 has taken into consideration-or omitted, negated or distorted-community participation, a value and tenet of health promotion. The study begins by identifying the policy documents that defined the approach to decision-making, including the institutional stakeholders involved, the process of decision-making and the focus of decisions that were made. Then, it centers on a systematic textual analysis of the almost daily formal resolutions of Ecuador's Emergency Operations Committee (EOC). Accordingly, recommendations are made toward improving healthfocused or health-related decision-making in Ecuador by creating and supporting conditions for a communitybased health promotion to respond to either random events such as a health emergency or the persistent health-related needs of the population. In particular, our interest lies in the limits and possibilities for building community-based policy making, assuming that its framing evolves and is dynamic (van Hulst and Yanow, 2016), especially during a health emergency of the nature and scale of the COVID-19 pandemic.

Health promotion considers 'community participation' as an integral value and a right leading to an improved public health practice aimed at greater social justice. However, it has been acknowledged that lack of robust data on its impact continues to undermine support for it (Rifkin, 2014; Van den Broucke, 2017) . Among the weaknesses of the concept, is the fact that 'community' and 'participation' have not been defined with clarity or in a standardized manner within health (Rifkin, 2014) . Also, heightened focus on consensus has replicated power relations that minimize the importance of having a plurality of opinions, which lies at the center of democratic, empowered participation toward greater social justice (Rifkin et al., 1988; Cooke and Kothari, 2001) . In addition, since participation should be a choice (Rifkin et al., 1988) , not an obligation, it brings about the possibility of (intentional) non-participation as a form of participation itself (Torres and Simovska, 2017 ).

An interpretive approach to policy analysis assumes that policy is not value free (Browne et al., 2019) , and that 'dominant political values' influencing public health decision-making (Tesh, 1988) are 'hidden' from us. This implies that critically analyzing community participation in the 'live' policy making process involved in responding day by day to a developing pandemic will allow us to understand whether it has been relevant or not, and how, for the government. If participation is the result and aim of an 'iterative learning process' [ (Rifkin, 1996) , p. 79], its consequential inclusion in decisionmaking would involve accepting opinions can be challenged and, therefore, priorities may shift and strategies change, along with power relations.

We downloaded and compiled 53 consecutive resolutions (in Spanish) between 14 March and 10 June 2020 emitted by the National EOC that was convened in response to the COVID-19 pandemic in Ecuador, following the Guidelines for the EOC (Servicio Nacional de Gestió n de Riesgos y Emergencias, 2017). These resolutions (in Spanish) are available in the Secretariat of Risk Management website (https://www.gestionderies gos.gob.ec/resoluciones-coe). Crucial policy documents that were cited in the resolutions, Decrees 1017 and 1019 (President of the Republic of Ecuador, 2020a,b), were also analyzed for context, as well as the guidelines that define the characteristics of the EOC (Servicio Nacional de Gestió n de Riesgos y Emergencias, 2017).

We used thematic analysis (Braun and Clarke, 2006) to, in a first round, identify words and phrases through line-by-line open coding, and, based on these, concepts were grouped into categories and subcategories through axial coding. In a second round of coding, words and phrases were counted by mention per resolution, according to date. Simultaneously, extracts from the quotes were selected and translated into English. In a third, final round, subcategories were regrouped to correlated data according to themes through selective coding.

We tabulated the number of times each major category (private sector, social sector, law enforcement) was mentioned in each resolution. We then added the counts and calculated the average number of mentions per resolution. Finally, we explored the correlation between mentions per category corresponding to each of the dates the resolutions were released. Table 1 shows the total and average number of mentions of key sectors (private, social and law enforcement) among the EOC resolutions we analyzed. Law enforcement had the largest number of mentions of any sector (n ¼ 99; average number of mentions per resolution ¼ 1.87), followed by the private sector (n ¼ 69; average number of mentions per resolution ¼ 1.30). Although COVID-19 is at its core a public health crisis, health (namely the Ministry of Health) was only mentioned 20 times (average number of mentions per resolution ¼ 0.38).

We then explored the correlation between mentions per sector for the corresponding dates of each resolution (Table 2) . We found that the number of private sector and law enforcement mentions were positively correlated (r ¼ 0.41, p < 0.01).

Our thematic analysis identified three major categories (sectors) mentioned across the resolutions analyzed (13 March-10 June 2020); private sector, social sector and law enforcement. The Private Sector included mentions of construction efforts (such as roads, infrastructure and churches), transportation (air, land, international and internal), food and agriculture, and commerce. Of these, commerce and transportation were most frequently mentioned (22 and 21 times out of 69 for the sector, respectively).

The Social Sector encompassed a wide range of subcategories including: (i) social and solidarity economy, which refers to communal and reciprocal economic activities (Ruiz Rivera and Lemaître, 2017); (ii) human rights office; (iii) ministry of education and universities; (iv) ministry of social and economic inclusion; (v) ministry of health; (vi) psychological assistance; (vii) water and wastewater management; (viii) ombudsman's office; (ix) plans for return of Ecuadorians stranded abroad; (x) voluntary isolation support; (xi) emergency care planning and implementation; (xii) cleaning and disinfecting of public spaces and public transit; (xiii) increasing public entities' ability to process paperwork online; (xiv) basic services payment relief; (xv) environmental risks; (xvi) internet coverage in prioritized sectors impacted by COVID-19; (xvii) food kits; (xviii) sports; (xix) pandemic impact evaluation and oversight app. Although the list of subcategories seems large, a majority were mentioned sporadically across resolutions (mostly one to three times). The Ministry of Health was the most common mention (20 out of 58 instances), followed by The Ministry of Education and universities (six times) and plans for return of Ecuadorians stranded abroad (five times).

Law enforcement sector consisted of mentions of presidential emergency decrees (no. 1017 and 1019), police and military forces, control, undisciplined population and/or regional and local authorities, and punishment, fines and calls to action. Policy and military forces were most commonly mentioned (39 out of 99 mentions), followed by presidential decrees (19 times).

Although almost all of the participants in the EOC meetings have been representatives of the national government (namely ministers and police and military chiefs), the private sector was consistently mentioned across resolutions. One of the major concerns of the EOC has been securing the local food supply chain, and charging the public sector to coordinate with private companies to limit disruptions in the provision of food products across the country:

The Ministry of Production, International Commerce, Investments & Fishing will coordinate, with supermarkets and production chains, the mechanism to prioritize the purchasing of Ecuadorian products (15 March 2020).

Another EOC concern has been securing public transportation services, particularly so that essential workers are able to go to and from work: The urban transportation system must remain operational across the country. Its frequency and number of trips will be lower than usual, but must not be suspended. A total suspension of transportation increases population risk, by preventing health care workers, security service workers, or food workers to reach their workplaces, which is inadmissible during this emergency (18 March 2020).

As mentioned earlier, while the social sector encompassed the largest list of subcategories, they were seldom mentioned across the resolutions we analyzed. Expectedly, given the public health nature of this crisis, the Ministry of Health (MOH) was the most commonly mentioned subcategory, including how its senior leadership employees needed to come back to in-person availability:

In reference to the working hours of the MOH staff, it is resolved . . . starting on April 9 . . . that all employees that make up the higher hierarchy of the MOH will be reintegrated in a permanent in-person way, working daily in the activities and tasks within their competencies . . . personnel from priority care groups (people with disabilities, catastrophic diseases, pregnancy, lactation and over 60 years of age) will be excluded from these teams . . . in the family group where there is more than one person who must carry out a face-to-face day, and there is responsibility for children or people who require permanent care, remote work is authorized (4 April 2020).

This measure was revised on 15 April, to authorize remote work regardless if workers have child/elder care responsibilities. A similar measure was latter applied to Social Security Institute workers, but without a provision to work remotely for employees with family/caregiving responsibilities (20 April).

In the Introduction section, we mentioned that the Secretary of Risk Management had to step down due to evidence that she authorized the purchase of food kits at inflated prices. It is interesting to see how 'food kits' are positioned in the resolutions (which are signed by the secretary herself). In the first mention of 'food kits' (27 March 2020), there is language signaling the urgency of fast tracking approval at the national and local levels. Similar text is used again on 31 March, adding that:

. . .the Public Company National Storage Unit (UNA-EP) is empowered so that, within the provisions of the public procurement law, its regulations and SERCOP [national public contracting service] resolutions, it carries out the necessary procedures to guarantee the delivery of food kits for families that require it nationwide.

One of the most visible social sector measures taken throughout the period studied has been the return of Ecuadorians stranded abroad, particularly more vulnerable groups, for which the EOC released a 'Protocol for the entry into the country during the validity of the state of exception, of children and adolescents who are outside the country without their parents or legal guardians, pregnant women, people with disabilities and the elderly' (Secretariat of Risk Management, 2020c). Other social protections mentioned included domestic violence, which was first brought up on 14 March, tasking the Secretary of Human Rights with addressing this issue. However, there didn't seem to be follow-up resolutions that would provide further details regarding its implementation. In turn, deaths related to the pandemic has been a critical item of discussion in EOC resolutions. In fact, this topic was the only one that merited an appendix (3 April 2020) providing a robust legal framework justification for police and military officers in the Guayas province to serve as witnesses and signatories of a death certificate, when the presence of a physician authorized by the Ministry of Health could not be secured.

Our analysis suggests that law enforcement was robustly mentioned across resolutions in the study period. In other words, maintaining social control was a salient priority for the EOC. The response to the coronavirus in Ecuador was legally bound by Decree 1017 (President of the Republic of Ecuador, 2020a), which declared the state of exception on 16 March 2020, and Decree 1019 (President of the Republic of Ecuador, 2020b), which created a 'special security zone' in the city of Guayaquil, the first major epicenter of the pandemic. Both decrees gave law enforcement officials (i.e., police and the military) broad powers to monitor and enforce EOC orders and recommendations.

By 21 April, some power was delegated to the 221 municipal governments in Ecuador by making them decide on the level of restrictive measures according to a 'traffic light' tool (red or high alert, yellow or medium alert, green or low alert), and 'implement adequate mechanisms to comply with and control the different resolutions and dispositions approved by the National EOC for the management and handling of the sanitary emergency due to COVID-19' (21 April 2020). On 23 April, the National EOC 'reminds' mayors 'that problems derived in the fight against the virus COVID-19 will be channeled and resolved through the National Emergency Operations Committee'. Importantly, EOC resolutions paint a picture of an unruly and undisciplined population (and even regional and local authorities) depicting 'manifest civil disobedience' that justifies strong control mechanisms to be ultimately enforced by police and military forces. In a country where the minimum wage is $400 US dollars, 'people who fail to comply with the provision will be penalized, the first time, with a fine of USD100 . . . the second time with a fine equivalent to one month of minimum wage [USD 400] ; and, the third time with prison, according to the procedures established by the competent entities' (24 March 2020). Even regional and local authorities are considered unruly: Isolated, inconsistent decisions, impossible to apply or outside the framework of their respective powers generate confusion and chaos. We are asking the population to act with discipline in compliance with national instructions, this same request is made to the authorities of decentralized governments (17 March 2020).

Several arbitrary measures taken by local governments are confirmed . . . the municipality of Guayaquil was responsible for the violent intrusion of municipal agents on the airport runway . . . this type of action does not contribute to the management of the emergency. Accordingly, we make a call to the local authorities and to all citizens, in order to follow the official channels and act calmly and in coordination (19 March 2020).

In this context, it seems justified to heavily rely on police and military forces to monitor the correct implementation of EOC resolutions:

Due to non-compliance by citizens on the restriction of mobility between provinces . . . the Armed Forces are ordered to tighten the control of the flow of private persons in the provincial limits of the entire national territory (4 April 2020).

And even extending their responsibilities beyond their training:

The police will continue to carry out random controls. . .of people placed in mandatory preventive isolation (17 March 2020).

To order the national service of legal medicine and forensic sciences, the national police and the armed forces to lend their contingent in whatever is necessary for the application of the 'Protocol for the Manipulation and Final Disposal of Cadavers with a Background and Presumption of COVID-19' (24 March 2020).

A salient aspect of control is that most resolutions (48 out of 53) affirmed that decisions of the National EOC had been approved 'unanimously', and participation was for the most part limited to national government representatives. Regional and local government associations representatives were part of many but not all sessions, while civil society organizations did not participate in these meetings (a list of participants by date can be found in the Supplementary file).

Information control was a key priority of the national government, reminding local authorities, time and again, of the preeminence of their decision-making: 'Municipal EOCs must go to or require official information from the Provincial EOC' (23 April 2020), which in turn receive information from the national EOC. The 28 April resolution points out that provincial EOCs will 'permanently provide information to municipal EOCs to define traffic light color signal' and commits the national EOC to 'publish and update all available information such as statistics, protocols for different activities and other relevant data regarding the actual and evolving status of the pandemic, so that municipal EOCs can make informed decisions'.

Local governments then will have access to 'relevant data' for decision-making through the provincial EOC, which will 'report using official data uploaded through technological tools' (19 April).

Control of information went to the extent of denying or masking the trajectory of the pandemic when on 27 May, the resolution affirmed that 'there is no increase in the number of contagions in municipalities that have switched color [in the traffic light system], with a decrease in contagions, and control of cases, as well as the decrease in the number of deaths'.

Our study is the first, to our knowledge, to critically examine whether a country's governmental response to COVID-19 has taken into consideration-or omitted, negated or distorted-community participation, a value and tenet of health promotion. Our systematic textual analysis of the almost daily formal resolutions of Ecuador's EOC show that the 'lifecycle' of the central government's response and its evolving, dynamic policy framing (van Hulst and Yanow, 2016) has been centered around law enforcement, private sector, and social sector priorities, in that order. Although the social sector had the largest number of subcategories, they were exceptionally mentioned across resolutions. Moreover, we found little to no evidence of the participation of civil society or social organizations. A review of participant lists (in Spanish) registered by the EOC (see https:// www.gestionderiesgos.gob.ec/participantes-de-lassesiones-del-coe-nacional) show that ministries and other national governmental entities constitute the largest contingent of representatives at EOC meetings. In addition, representatives from the Red Cross, the Ecuadorian Municipalities Association, the Consortium of Provincial Governments, and the Ecuadorian Conference of Catholic Bishops have participated in these meetings. Hence it seems clear that, following Rifkin et al.' s key elements of community participation-action oriented, involving choice and having a potential effect on health-we find that, at least in Ecuador's case, there were more limits than possibilities of 'live' policy making grounded in a community-based response to COVID-19 (Rifkin et al., 1988) .

According to the Guidelines for the EOC (Servicio Nacional de Gestió n de Riesgos y Emergencias, 2017), 'it is the duty of authorities and institutions of the National Decentralized System of Risk Management to recognize, facilitate and promote the organization and participation of ethnic communities, civil society, community, charity, voluntary and of common good associations' (authors' translation, p. 12). Further, 'risk management processes must be respectful of the cultural nuances of each community' (p. 12).

In theory then, community participation in its broadest sense, i.e. including social protection measures that, presumably, would be in the agenda of the 'ethnic communities, civil society, community, charity, voluntary and common good associations' should be taking part in decision-making of the National EOC, as envisioned by its guidelines (Servicio Nacional de Gestión de Riesgos y Emergencias, 2017). In practice, however, we find no evidence that any social or civil society representatives have been involved in the EOC meetings and the release of EOC resolutions. Hence, the EOC decision-making process relies heavily on the feedback and judgment of national-level authorities with, to say the least, questionable public credibility. It is no surprise then that, in the absence of community engagement, the resolutions present the public as culpable, undisciplined, unruly and consequently, in need of a strong law enforcement response. Such an approach may be due in part of the erosion of public trust of the current administration, with low approval ratings, and still reeling from the October 2019 protests that paralyzed much of the country for almost two weeks.

Although the previous government (which lasted in power for almost a decade) seemed to favor more inclusive mechanisms of development, such as popular and solidarity economy, it also eroded civil society trust by legally suppressing dissenting voices (Appe et al., 2019) . In this context, it is somewhat understandable (although not at all justifiable) that EOC lacks civil society representation. Moving forward, we recommend EOC and other national authorities to rethink their approach to the pandemic by engaging in meaningful dialogue with civil society organizations, representing vulnerable and marginalized groups, to rebuild trust and increase the likelihood that EOC recommendations are more meaningful and actionable to the realities of the Ecuadorian population, and moving away from law-enforcement-centered initiatives.

A number of limitations must be acknowledged. First, our analytic sample of resolutions was limited to a specific timeframe (13 March-10 June 2020), to allow for our thematic analysis to take place. However, given the ongoing nature of the pandemic, the EOC continues to meet and release resolutions almost every other day. After 10 June, sixteen additional resolutions have been released. Future studies should certainly incorporate these resolutions and any other that may be released until the pandemic crisis subsides. Second, due to the primarily qualitative interpretive nature of our inquiry, results may not have taken into account all aspects of such a complex crisis. Hence, generalizability of our findings is not to be implied. Third, our observations rely primarily on written resolutions and related public documents (e.g. emergency decrees, participants' lists), and our expertise regarding the Ecuadorian realities of policy and decision-making. That said, we did not attend any of the EOC meetings or interview any of its participants. Future research should certainly consider adding these and other triangulation methods to incorporate additional vantage points of view.

Similarly to other countries, Ecuador implemented a vertical, militaristic response to the COVID-19 pandemic. The authoritarian legacy in Ecuador (synthesized in an executive decree calling for a 'state of exception') has eclipsed the potential for a participatory approach to health. In this context, mechanisms of community participation in policy making were mostly missing, despite the concept being explicitly guaranteed in guidelines for emergency response. Further, it is evident that governmental decisions to tackle the COVID-19 pandemic were not centered on the social sector, which is supposed to be a priority in a participatory, communitycentered approach. Not even the consideration that both participation and community-based efforts are essential to adequately confront the COVID-19 pandemic and its aftermath has been elevated to discussion. This means that, to the government's credit, the term 'participation' is not used for utilitarian or even symbolical purposes.

Concurrently, in the absence of community participation, a health promotion approach was not embraced by the EOC in charge of the pandemic response. Moreover, the scientific community has been absent from decisionmaking, with information being distorted or interpreted subjectively. Without a culture of participation and open channels of communication, what was left for the government was an emphasis on enforcement, derived from a 'unanimous' perspective in which there was no options for challenging or disagreeing. This means that, for the future, assessing or evaluating the response presupposes that everyone-or nobody-involved in decision-making can be made accountable.

Lack of checks and balances also involves the police conducting epidemiological surveillance and the Catholic Church being an interested stakeholder, lobbying for self-serving risky exceptions such as permission for gatherings in closed buildings, while no other nongovernmental organization that could have contributed toward greater social protection measures was participating in EOC meetings.

Having legitimized the exclusion of community participation in Ecuador's response to the COVID-19 pandemic, the government will continue, unchallenged, to sustain decision-making and resolutions that do not consider their social implications. In particular, the limits to local governments becoming informed and making decisions without mediation by the National EOC will further impede community participation in health decisionmaking in the future. Consequently, local knowledge and experiences will be least likely to inform health policy.

Addressing the gap between the intentions and realities of risk management policy in Ecuador will require that the central government must define more clearly the powers that local authorities should have during emergencies, but also in regular times, with regard to health promotion. There must also be clearly defined procedures and supporting mechanisms for community-based organizations to take part in meetings and decision-making processes, for which all public officials and participants involved should be publicly announced, together with relevant information on the outcomes, in a timely manner. Further, all centralized decision-making bodies, in the case of Ecuador, the national and local EOCs, should guarantee fully accessible information, together with established, transparent mechanisms for providing feedback and improving accountability.

Supplementary material is available at Health Promotion International online.

Covid-19 and feminism in the Global South: challenges, initiatives and dilemmas

Organized civil society under authoritarian populism: cases from Ecuador

Using thematic analysis in psychology

A guide to policy analysis as a research method

Coproducing responses to COVID-19 with community-based organizations: lessons from Zhejiang Province

The New Tyranny. Zed Books

Cadá veres empiezan a aparecer abandonados en varias esquinas de Guayaquil

Comisió n Anticorrupció n denuncia irregularidades como sobornos y favorecimientos en 23 contratos de hospitales entre

Obispos de Ecuador piden la salida del ministro de Salud Juan Carlos Zevallos

Anti-democratic and exclusionary practices: COVID-19 and the continuum of violence

COVID-19 Dashboard

Journal of Contingencies and Crisis Management

Refugee and migrant health in the COVID-19 response

Analysis by the Secretariat of Human Rights of emergencies related to violence against women from calls for help registered by the ECU 911 system during the pandemic due to Covid19 -March [Análisis de intervenció n de la SDH a emergencias por violencia contra las mujeres a partir del registro de llamadas de auxilio del sistema ECU 911 durante la pandemia

2020) Fighting COVID-19 with agility, transparency, and participation: wicked policy problems and new governance challenges

COVID-19 scenario analysis tool

Coronavirus (COVID-19) deaths

Considerations on indigenous peoples, afro-descendants, and other ethnic groups during the COVID-19 pandemic

Epidemiological alert: COVID-19 among indigenous peoples in the Americas

Executive Decree No. 1017. Quito, Ecuador. President of the Republic of Ecuador. (2020b) Executive Decree No. 1019

Cadá veres empiezan a aparecer abandonados en varias esquinas de Guayaquil

Paradigms lost: toward a new understanding of community participation in health programmes

Examining the links between community participation and health outcomes: A review of the literature

Alma Ata after 40 years: primary Health Care and Health for All-from consensus to complexity

Primary health care: on measuring participation

Social enterprise in Ecuador: institutionalization and types of popular and solidarity organizations in the light of political embeddedness. ICSEM Working Papers

Situació n nacional por COVID-19

Situació n nacional por COVID-19

Protocolo para el ingreso al país, durante la vigencia del Estado de Excepció n, de niños, niñas y adolescentes que está n fuera del país sin sus padres o tutores legales, mujeres en estado de gestació n, personas con discapacidades y de la tercera edad

Hidden Arguments: Political Ideology and Disease Prevention Policy/Sylvia Noble Tesh

Institutional challenges to achieving health equity in Ecuador. The Lancet Global Health

Localising an asset-based COVID-19 response in Ecuador

Ecuador's response to the coronavirus pandemic. Health Economics, Policy and Law blog series: Country Responses to the Covid19 Pandemic

Community participation in rural Ecuador's school feeding programme: a health promoting school perspective

Strengthening public health capacity through a health promotion lens

From policy "frames" to "framing": theorizing a more dynamic, political approach. The American Review of Public Administration

COVID-19 strategic preparedness and response plan: country preparedness and response status for COVID-19 as of

000 missing deaths: tracking the true toll of the coronavirus outbreak. The New York Times

The differential psychological distress of populations affected by the COVID-19 pandemic