This study explored transforming and institutionalising a new community-based PHC model in the Metropolitan District of Quito during and after the COVID-19 pandemic. The findings revealed how local governments can reposition health systems to better address public health challenges through territorial governance in a LMIC can reorient its health system through territorial governance, intersectoral collaboration, and community participation to strengthen resilience and promote equity.
One of the key achievements in Quito was the role of municipal leadership in institutionalizing the new model through legal frameworks, dedicated budgets, and administrative continuity. The creation of Zonal Intersectoral Committees facilitated cross-sector coordination and enabled health to be integrated into broader social agendas. These structures align with the World Health Organization’s emphasis on governance and leadership as essential pillars of resilient health systems and reflect recent frameworks that highlight institutional legitimacy and political commitment [14, 15]. The ability to sustain increased health budgets after the emergency phase was essential to ensuring the ongoing operation of the CHTs (Equipos de Salud Comunitaria, ESC), setting a precedent for fiscal sustainability in decentralized systems.
The shift from reactive, episodic model to one based on prevention, and community engagement strengthened the city’s capacity for early case detection, epidemiological surveillance, and timely response [16]. Assigning one CHT per parish enabled tailored interventions at the local level [17]. Transparent communication and the involvement of community leaders helped build trust and overcome resistance to the new model. These elements reinforce the importance of proximity, local responsiveness, and participatory approaches as key enablers of system resilience [18].
Community engagement in Quito’s PHC model was operationalized through a structured territorial approach that placed Community Health Teams at the center of local-level interaction. Each team was assigned to a specific parish and was responsible for conducting regular neighborhood visits, establishing relationships with local leaders, and coordinating health promotion and disease prevention activities alongside existing community committees. Far from being passive recipients of care, community members participated in participatory planning processes, including needs assessments, risk mapping, and prioritization of outreach strategies [19]. This engagement was institutionalized through the role of CHTs as intermediaries, who documented community concerns and relayed them to municipal health authorities to inform service planning and decision-making. While formal representation mechanisms were still evolving, this dynamic interface enabled a continuous feedback loop and helped align the municipal health response with community needs [20].
Although COVID-19 vaccination was not the primary focus of this study, available data highlight the responsiveness of the municipal health system. By the end of 2021, over 86% of residents aged three and older in the Metropolitan District of Quito had received the full vaccination schedule, comparable to or even higher than the national average, particularly in Pichincha [21, 22]. These results reflect both strong national-local coordination and the strengthened PHC model’s ability to implement large-scale public health interventions during emergencies [6, 23].
The implementation of the new model also required rapid reorganization of the health workforce. Professionals were trained to take on new roles in prevention, digital service delivery, and intersectoral coordination. This organizational flexibility reflects an adaptive learning capacity essential for navigating uncertainty [20, 24]. However, challenges remain regarding the availability of personnel, particularly in peripheral or underserved parishes.
The successful implementation of the community-based PHC model in Quito was also supported by a series of targeted training activities for health personnel, especially members of the Community Health Teams. These trainings covered key competencies for territorial work, including social determinants of health, risk management, nutrition, mental health, educommunication strategies, prevention of harmful substance use, and the strengthening of community teams themselves. Although there was no single standardized program solely focused on community engagement techniques, key principles of communication and participation were embedded across all modules [25, 26]. Additionally, professionals were trained to coordinate health promotion and disease prevention actions with local leaders and institutions [19]. These capacity-building efforts were essential not only for the rapid adaptation of roles during the pandemic but also for sustaining the long-term institutional transformation of the local health system [5, 27, 28].
In terms of technology, Quito implemented teleconsultation platforms, virtual mental health services, and digital tools such as KoboToolbox for community activity monitoring. These initiatives marked important progress toward digitalizing key components of municipal health services and facilitated continuity of care during mobility restrictions. However, when comparing the case of Quito with other urban health systems, caution must be exercised in overstating the role of advanced technologies such as artificial intelligence or real-time surveillance tools [29]. While such innovations have been implemented in some metropolitan areas to optimize logistics, support early outbreak detection, and inform public health responses, their relevance and effectiveness remain highly context-dependent, particularly in community-oriented PHC settings, where standalone technological solutions have shown limited empirical impact [30, 31]. In fact, recent syntheses indicate that health system resilience in LMIC has been more consistently associated with decentralized governance, sustained community engagement, and strengthened operational capacity than with high-end technological inputs [30]. For example, during the refugee crisis in Lebanon, health system resilience was preserved not through digital sophistication but through networked governance, diversified financing, and inclusive service delivery mechanisms [32].
Consequently, any recommendation to incorporate specific technologies into the municipal health system of Quito should be grounded in contextually relevant evidence of impact from cities with similar institutional, financial, and infrastructural constraints. Without such evidence, there is a risk of adopting interventions whose benefits may be marginal or even misaligned with the needs of the most vulnerable populations. In Quito, digital platforms were primarily used for basic triage, remote consultation, and communication with the population, yet their long-term utility remains limited by digital literacy gaps and inequitable access to connectivity. Therefore, rather than advocating for generalized deployment of artificial intelligence or predictive analytics, future efforts should prioritize the development of interoperable health information systems, networks of community health workers, and simple digital tools that reinforce, but do not replace, territorial and relational engagement [14, 31]. This is consistent with comparative experiences in cities like Bogotá and Lima, where the resilience of PHC was anchored in the expansion of local teams, interinstitutional coordination, and trust-based community mechanisms, rather than technological sophistication [33]. Frameworks for assessing urban health system resilience should therefore emphasize not only infrastructure and data systems but also institutional legitimacy, adaptability, and participatory governance, dimensions that have gained increasing relevance in the literature on resilient health systems. According to the resilience framework proposed by Paschoalotto et al. (2023), several components are considered critical for strengthening health systems, particularly in crisis response contexts. This framework emphasizes governance and leadership as foundational pillars, alongside the integration of communication and social participation as essential elements that connect system performance with broader contextual realities. Moreover, the role of information systems and digital infrastructure is acknowledged for their potential to support coordination and evidence-informed decision-making [14].
A distinctive feature of Quito’s approach was the municipality’s ability to maintain increased health funding beyond the acute phase of the pandemic. While many jurisdictions scaled back post-emergency investments, Quito reframed health spending as a structural necessity, given the city’s high levels of social vulnerability and historical underinvestment. This long-term financial commitment was vital to institutionalizing the CHT model and underscores the importance of local fiscal autonomy in building a resilient health system [25].
Security in urban neighborhoods with high levels of violence also posed significant operational challenges [34]. The municipality responded with emergency protocols, designated safe service points, and coordination with security forces. The protection of health personnel is widely recognized as a key determinant of service continuity, particularly in fragile or conflict-affected contexts. Institutional resilience strategies must therefore include physical and emotional safety measures for healthcare workers [18, 35].
Compared to international experiences, Quito’s model stands out for its institutional innovation, territorial approach, and strong community engagement. However, key gaps remain, particularly in digital infrastructure, results-based monitoring, and technological self-sufficiency. Strengthening evaluation systems, developing interoperable information platforms, and building sustainable strategies for workforce training and protection will be essential for advancing health system resilience [15].
Table 1 offers a comparative overview of Quito’s COVID-19 response in relation to other international cities. While Quito implemented essential digital tools such as teleconsultations and a basic mobile health app, cities like Mexico City, Bogotá, and Lima adopted more advanced technologies, including artificial intelligence for symptom tracking and real-time data dashboards [36, 37]. Regarding service delivery, Quito mobilized community testing brigades and triage tents, and later established permanent Metropolitan Health Units and 65 Community Health Teams, one per parish, to enhance territorial reach [38]. In contrast, other cities deployed large-scale field hospitals [39]. The table also underscores Quito’s effective community participation model, where local leaders and volunteers played key roles in monitoring and outreach, now institutionalized through Zonal Intersectoral Committees. Finally, it highlights how Quito collaborated with national and international partners during the pandemic, partnerships that have since been formalized to support routine services and emergency preparedness [40].
Despite important progress, several limitations persist. First, Quito’s digital infrastructure remains basic compared to other cities using AI and real-time surveillance. Strengthening technological capacity is essential for future preparedness, though recent tools like teleconsultation and KoboToolbox mark initial progress [6].
Second, although a range of administrative and service-level indicators are available, monitoring remains primarily focused on outputs, such as the number of services delivered, rather than on health outcomes, such as improvements in nutritional status or mental health. This output-oriented approach limits the ability to evaluate the true effectiveness and long-term impact of the PHC model, underscoring the need for a more comprehensive, outcome-based evaluation framework [9]. Although this study primarily relied on qualitative data, the municipal health strategy was accompanied by administrative monitoring systems that incorporated both quantitative and qualitative indicators. These tracked components such as the number of Community Health Teams (CHTs) deployed per parish and the volume of services provided. For example, municipal accountability reports indicate that 231,870 individuals received services through CHTs and municipal patronatos; 9,498 adolescents participated in sexual and reproductive health promotion workshops; 13,258 individuals accessed mental health services at the La Ronda Ambulatory Center; 34,602 students were reached through the Healthy Schools Strategy; and over 5,000 children under five received nutrition-related support through Quito Wawas (municipal early childhood care centers) and CEMEIs (Municipal Early Childhood Education Centers). While these figures do not emerge from an integrated monitoring and evaluation system, they offer valuable benchmarks to assess implementation progress and identify priorities for future system strengthening [25].
Third, tensions between curative expectations and the preventive community model highlight the need for continued institutional learning [41]. Fourth, ensuring health worker safety in violent urban areas remains a challenge despite existing protocols [42]. Finally, trust-building through local leadership and coordination with the Ministry of Health was key to sustaining service delivery [43].
One of the main strengths of this study is its in-depth exploration of a real-time institutional transformation process led by a local government in a LMIC context. The use of a qualitative design allowed for a rich understanding of the implementation dynamics, including political, administrative, and community perspectives that are often underrepresented in health systems research.
The triangulation of data sources, semi-structured interviews with diverse stakeholders, policy documents, and municipal planning instruments, enhanced the credibility and contextual depth of the findings. Additionally, the study provides valuable insights on how a decentralised PHC strategy can be institutionalised through legal frameworks, community structures, and intersectoral mechanisms.
By situating Quito’s experience within national and international comparisons, the study also contributes to the broader literature on urban health resilience, offering transferrable lessons for other cities seeking to strengthen their PHC models post-crisis.
This study also has limitations. First, it relied solely on qualitative data and did not include quantitative indicators to assess the health outcomes or service coverage changes resulting from the new PHC model. Although interviews and document review provided insights into the perceived impacts, the absence of routine data limited the ability to evaluate the model’s effectiveness empirically.
Second, the scope of the analysis was limited to the Metropolitan District of Quito, and findings may not be generalisable to other cities or rural settings in Ecuador. However, the analytical framework may be useful for examining similar processes in other decentralised contexts.
Lastly, some perspectives, particularly those of community members and users of health services, were not directly captured in the data collection process. Future research should incorporate these voices to assess the legitimacy, accessibility and perceived quality of services under the community-based model.
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