La Revolución Ciudadana and social medicine: Undermining community in the state provision of health care in Ecuador.

Under President Rafael Correa (2007-2017), Ecuador's Ministry of Health established a state-centred health care regime that incorporates elements of Latin American social medicine into post-neoliberalism. These initiatives - which are part of 'The National Plan for Good Living (Buen Vivir)' - include free healthcare, greater attention to social determinants of health, a focus on equity and inclusion, and increased coordination across welfare, health, and development sectors. However, the reforms also use health services to build a sense of inclusive, participatory citizenship, with the Ecuadorean state as the central figure in service provision. In this paper, we demonstrate that state-centred health care reforms have paradoxically weakened community organising for collective health. Drawing on seventeen years of ethnographic research and health solidarity work in rural Northwest Ecuador, we illustrate how Ecuador's health reforms have reconfigured relations among local civil society, transnational NGOs, and the state. Established modes of community participation and international collaboration have been undermined largely because these reforms ignore community sovereignty and self-organisation and overemphasise the threat of neoliberalism. The lessons about balancing the state-based fulfilment of rights with community power are relevant to social medicine advocates, particularly those working in rural communities that are already organising creatively for their own health and well-being.