Strengthening primary health care resilience through community innovation: a qualitative case study from Quito's response to COVID-19.

Background: This study aimed to analyse and document how Quito, the capital city of Ecuador, transformed its Primary Health Care (PHC) model following the COVID-19 pandemic. The reform involved a shift from a reactive, hospital-centred response to a community-based model focused on prevention, social determinants of health, and local engagement.

Methods: This study used a qualitative case study design with a comparative and deductive approach, featuring 11 semi-structured interviews with health professionals, decision-makers, and administrative staff, alongside a review of secondary sources, including national and municipal legal framework (such as the Organic Code and the municipal Organic Statute), ordinances, the Municipal Code, and governance documents and accountability reports from three mayoral administrations. Thematic analysis identified key enabling factors and compared Quito's experience with other cities in Ecuador and Latin America.

Results: The central innovation was the creation of multidisciplinary Community Health Teams (Equipos de Salud Comunitaria, ESC) assigned to each of Quito's 65 parishes. These teams focused on health promotion, disease prevention, and intersectoral coordination. Their implementation was supported by continuous training, integration of digital tools, community-based communication strategies, and protocols for operating in high-risk environments. A major driver of the reform was the political negotiation to sustain the increased health budget beyond the pandemic, enabling the long-term operation of ESCs. Ensuring the physical safety of health personnel also became a core component of the model, supported by risk mapping, emergency communication systems, and coordination with local security actors. The model was institutionalized through legal frameworks and aligned with national initiatives such as the Healthy Municipalities Programme and Comprehensive Family, Community and Intercultural Health Care Model (MAIS-FCI). The model demonstrated improved territorial access, community trust, and responsiveness amid rising urban violence, but faces limitations in technological infrastructure, monitoring indicators, and long-term sustainability.

Conclusions: Quito's experience highlights the potential of decentralised municipal governance to lead PHC reform through integrated, preventive, and community-based strategies. The findings provide valuable lessons for other cities in low- and middle-income countries seeking to enhance PHC resilience in fragile contexts. Strengthening digital capacity and ensuring institutional protection and funding for ESC will be key to sustaining progress.