Esteban Ortiz-Prado ^1* Isaac Alexander Suárez Sangucho ¹ W. Ricardo Cañizares Fuentes ² Jorge Vasconez-Gonzalez ¹ Juan S. Izquierdo-Condoy ¹

• ¹ University of the Americas, Quito, Ecuador
• ² Catholic University of Santiago de Guayaquil, Guayaquil, Guayas, Ecuador

In the past three decades, Ecuador's health system has faced frequent ministerial turnover, often appointing leaders with limited training in public health policy and management. Although many ministers have strong clinical backgrounds, their lack of public health expertise has hindered a cohesive vision, raising concerns about the leadership's capacity to tackle the nation's complex health challenges effectively. The Ministry of Health is responsible for upholding the right to health, promoting health, preventing diseases, overseeing surveillance, and providing integrated care. It also develops clinical protocols and management guidelines, delivers health services, and conducts studies comparing national and international health management best practices [5,6]. To adequately fulfill these responsibilities, a master's degree in public health should be the minimum requirement for those considered for the position of Minister of Health. While ministers are indeed supported by technical personnel, they must have enough training to understand technical matters and not be overly reliant on staff or influenced by conflicts of interest [7]. Advanced public health training equips leaders with essential knowledge about financing, management, cost-effectiveness, and health communication, enabling them to evaluate and implement comprehensive health policies [8,9].A health minister requires both managerial skills to oversee health services and advocacy skills to ensure that potential effects on population health are integrated into the work of other government departments and ministries [10]. Helath Ministers require strong knowledge of epidemiology and public health preparedness, highlighted by challenges from global health crises like COVID-19. However, the Ministry faces internal issues impacting ministerial effectiveness, including overlapping responsibilities in regulations, unclear accountability, fragmented technical programs, and departments prioritizing specific professions over broader functions [11]. Furthermore, governance within the health sector is heavily influenced by institutional power dynamics. This lack of governance can severely hinder the performance of the Ministry of Health, contributing to systemic failures [12,13].Over the past 30 years in Ecuador, most health ministers have lacked advanced degrees or experience in key areas such as public health, epidemiology, or health systems management (see Table 1). This absence of qualifications hinders effective public health leadership, which demands an integrated, evidence-based approach to address social, environmental, and behavioral health determinants [1][2][3][4]. Although the primary role of a health minister is to manage and oversee the national health system, their responsibility also extends to proposing public policies that can be evaluated through tangible improvements in health indicators, such as infant mortality. We believe that this is a significant issue for health governance.Therefore, we conducted an analysis based on the significant reductions in infant mortality during specific periods, identifying the ministers in charge and the outcomes associated with their tenure, highlighting changes that could reflect the impact of effective leadership and policy implementation (Figure 1). In Ecuador, significant milestones in public health were achieved, particularly before the year 2000. Key figures during their tenure led important vaccination campaigns and successfully managed the 1991 cholera outbreak, reducing infant mortality and advancing the Comprehensive Family and Community Health Program [14]. Between 1990 and 2006, the country saw critical reforms, such as the decentralization of health management to municipalities, the formation of Cantonal Health Councils, and the proposal of Universal Health Insurance in 2005-2006 [15]. However, in 2009, these decentralization efforts were reversed with the re-centralization of the health management system [16], undoing much of the progress that had been made.During 2014, the introduction of new food labeling regulations, which made nutritional information more accessible and positioned Ecuador as a global reference in non-communicable disease prevention was an important contrbution. However, this period was also marked by controversial decisions, including the closure of the National Institute of Hygiene and Tropical Medicine, the elimination of the National Service for the Eradication of Malaria (SNEM), and the shutdown of vaccine production in Ecuador [17]. Despite these public health initiatives, the reduction in infant mortality rates (IMR) during this period was less pronounced compared to other periods. While some improvements were made, the IMR did not decrease as significantly as might have been expected, highlighting a period where public health outcomes did not fully align with the scale of reforms introduced.[Insert Table 2 here ] The COVID-19 pandemic highlighted Ecuador's severe shortage of public health expertise, resulting in one of the world's highest excess death rates. Health ministers, often lacking local experience, communication skills, and disease management knowledge, struggled to provide clear public health messaging. This was worsened by significant mismanagement and corruption, including inflated prices for essential medications and supplies, which deepened the crisis [19,20].Corruption has long plagued the health sector, with some ministers facing serious allegations. For example, several scandals have involved the procurement of ambulances and other essential supplies at inflated prices, breaching public procurement laws [21][22][23].Ecuador's health leadership has historically been marked by high ministerial turnover, driven by political interests. This instability, coupled with instances of corruption and controversial policies, has hindered effective public health initiatives and created fragmented health policies. While some achievements exist, persistent leadership issues have led to high malnutrition rates and ineffective campaigns on issues like traffic accidents and drug abuse, contrasting sharply with the successes of neighboring countries like Peru.Appointing leaders focused solely on clinical medicine without a robust public health background poses several risks:• Fragmented Policies: Lacking public health foundations can lead to ineffective, fragmented policies [4,24,25].• Curative Bias: Overreliance on treatment instead of prevention perpetuates unsustainable healthcare costs [26].• Insufficient Emergency Preparedness: COVID-19 underscored the need for leaders skilled in epidemiology and crisis management [27][28][29].To better manage Ecuador's health system, technical skills and public health experience should be prioritized over political considerations in minister selection. Ideal candidates would possess:• Advanced public health qualifications.• Proven experience in public health policy formulation and evaluation.• Active public health research engagement.• Strong leadership and communication skills to articulate a public health vision and make informed, evidence-based decisions.Recent ministers have lacked communication competencies, resulting in fewer public health campaigns and diminishing the perception of health ministers as public health advocates.Selecting health ministers is a nuanced task influenced by social, political, and contextual variables, particularly in developing nations like Ecuador. However, the logic and some of the evidence underscores that this process must be approached thoughtfully, prioritizing technical expertise over political considerations, to ensure sustainable public health progress. While the public often expects a Minister of Health to be an effective administrator, adept at managing public procurement and addressing operational challenges, what Ecuador urgently requires is a leader with expertise in prevention, health promotion, and ensuring equitable access to healthcare services. These competencies are often lacking in physicians focused on curative, private-sector roles. This commentary highlights systemic issues, not as a complaint but as a reflection on persistent shortcomings.For example, despite a 25-year national malnutrition prevention program, Ecuador still has one of the region's highest malnutrition rates. Even during economic booms, investment favored hospital infrastructure over essential primary healthcare. This manuscript urges Ecuadorian authorities to address these issues and adopt the recommended steps for strengthening national health leadership, shifting towards a comprehensive public health focus for sustainable health improvements.