Ecuador has made substantial progress in improving child survival rates over the last few decades, and especially in the 1980s. In the light of recent significant erosions in the real level of funding by the ministry of health (MOH), as well as in its service provision record, however, further progress will be difficult to achieve. Given the fundamental role of the MOH in Ecuador's health sector, achieving further improvements in child and infant mortality rates will require improving the performance of the Ministry.

The chief obstacles to additional progress in improving child survival rates are identified as (1) the historically low and currently slipping levels of financial support for public health, which precipitated and, given the Ministry's current structure and operations, now locks it into a recurrent cost crisis; (2) the highly politicized nature of the MOH, which has kept leadership and programmatic initiatives in a resource-squandering, nearly constant state of flux for the past two decades; and (3) a variety of structural, managerial, operational and technical shortcomings of the Ministry, which are most evident in its inadequate support systems. A variety of suggestions are made for addressing each of these sets of problems.

In addition, the Ministry's current major initiative, the Regionalization Programme, is briefly described. The Programme constitutes a timely opportunity for effectively addressing even the most daunting of the Ministry's structural- and managerial-related shortcomings. The crucial elements which must be considered in designing and implementing this initiative's new financial and information systems are highlighted. To effectively combat several of the ills of the present system - particularly those stemming from the Ministry's highly politicized nature, however - will require interventions above the MOH. The MOH must begin working much more closely with the ministry of finance. In addition, various procedures and processes of the National Congress, and specific central government administrative codes, will need to be amended to forestall the continued fragmentation of authority over public health expenditures. Finally, and most obviously, additional national government and/or donor funding must be provided to the Ministry to enable more effective implementation of the Regionalization Programme.