The development and implementation of Plan Fenix in Ecuador to address the devastating effects of the early stages COVID-19 pandemic: a review

Introduction

The coronavirus disease 2019 (COVID-19) pandemic exposed vulnerabilities in healthcare systems worldwide, with low-income countries (LICs) and lower-middle-income countries (LMICs) facing the greatest challenges due to limited resources, political instability, and fragile infrastructures. Ecuador, a nation with a fragmented healthcare system, experienced one of the highest mortality rates during the early stages of the pandemic, as overwhelmed hospitals and morgues struggled to manage the crisis.

Populations along the Ecuadorian Pacific coast were particularly affected. One notable example is Guayaquil, the country’s main port and most populous city, with over 2.7 million inhabitants. It’s warm, humid climate interacts with limited WASH (Water, Sanitation, and Hygiene) service coverage: only 65.8% of the city has access to sewage or safe sanitation systems, and 84.2% of the population has access to clean water (1). These conditions worsened during the rainy season, as water stagnated on unpaved roads and in uncollected garbage. Such circumstances favor the proliferation of vectors such as Aedes aegypti, the mosquito that transmits dengue. Unfortunately, the first COVID-19 outbreak coincided with one of the worst dengue outbreaks recorded in Ecuador in recent years (2).

The first detected case of COVID-19 in Ecuador arrived from Spain to Guayaquil. Within a few weeks of family gatherings and visits to tourist sites, the virus had spread widely across several coastal provinces (3). One month later, the disease had reached the entire country. By March 26, 2020, a total of 1,382 confirmed cases and 34 deaths had been reported (4). The shortage of qualified public health workers, weak epidemiological surveillance, insufficient critical care capacity, and the lack of a structured vaccination plan further exacerbated the situation. These factors contributed to a case fatality rate (CFR) of 6.3% among confirmed cases and a cumulative mortality rate of 190 per 100,000 population (5,6).

In June 2021, the newly inaugurated Ecuadorian government launched Plan Fenix (7), a comprehensive epidemiological strategy to control the pandemic, structured around five fundamental pillars:

• Coordination, planning, and monitoring of public health emergency management at the national level;
• Risk communication and community engagement;
• Epidemiological surveillance and pandemic control response;
• Control and monitoring at points of entry;
• Enhancement of diagnostic laboratory capacity at the national level.

The most important strategy under Pillar 3 was the 9/100 National Vaccination Plan, which aimed to contain the pandemic through a strategically designed mass vaccination campaign supported by intersectoral collaboration. By leveraging both national and international partnerships, Ecuador rapidly transformed its public health response, achieving one of the most effective vaccination rollouts in the region (8,9).

This case study examines the development and implementation of these strategies, highlighting the challenges faced, the key policy decisions made, and the outcomes achieved. It underscores the importance of political will, scientific expertise, and coordinated efforts in overcoming public health emergencies. While Ecuador’s response led to a significant decline in COVID-19 mortality and a gradual return to normalcy, the experience also revealed persistent weaknesses in the healthcare system, emphasizing the need for long-term investment in health infrastructure and epidemic preparedness.

Plan Fenix: comprehensive response to the COVID-19 pandemic

LICs and LMICs face numerous challenges beyond limited financial and material resources. Many also suffer from political instability, corruption, weak essential services, and environmental vulnerabilities. These determinants increase susceptibility to pandemics, making preparation difficult, bureaucratic, and chronically underfunded (10-12). Ecuador was no exception: political turmoil further weakened its already fragmented health system, which ultimately collapsed during the pandemic (9).

In March 2020, Ecuador made international headlines. In Guayaquil, the nation’s main port, the number of deaths exceeded those reported in entire countries (13-15). Globally, the COVID-19 CFR ranged between 2% and 3%, varying by country and time period. In Guayaquil, however, it reached 4.3%, reflecting the critical public health situation and Ecuador’s limited capacity to respond effectively to such an emergency (16).

Water accumulation during the rainy season, coupled with insufficient vector control measures and limited community health education, triggered one of the largest dengue outbreaks in the past 5 years on the Ecuadorian coast (17). This outbreak coincided with the emergence of the COVID-19 pandemic, resulting in a syndemic scenario characterized by the simultaneous circulation of multiple infectious agents in the same area. People experienced co-infections and overlapping clinical presentations, which significantly increased morbidity and mortality due to the interaction of dengue virus and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections.

Between March 2020 and May 2021, Ecuador experienced an excess mortality rate of 55% (6). By May 2021, the country had suffered a revenue loss of US dollar (USD) 16.392 billion, with total losses accounting for 16.6% of its gross domestic product (GDP). Of this, 78% affected the private sector. Ecuador lost 532,359 jobs, which reduced contributions to the Ecuadorian Institute of Social Security (IESS) and forced more patients to seek care in the Ministry of Public Health system (18,19). This further strained the demand for medicines, supplies, and medical equipment in the public sector.

Despite efforts to improve triage and convert major hospitals into COVID-19 treatment centers, the healthcare system faced severe shortages of supplies and medicines. Limited financial resources, wasted stock, and insufficient equipment hindered patient care. Additionally, global supply chain disruptions exacerbated the crisis: factory closures in India and China, export bans on raw materials, and the war in Ukraine, which restricted air transport and blocked sea routes, further limited access to essential drugs and devices (20,21). Already insufficient to meet national needs, Ecuador’s pharmaceutical industry struggled even more under these conditions (9,15,16).

Physicians from all specialties were reassigned to treat COVID-19 patients, many without sufficient expertise. Mortality among healthcare workers skyrocketed: physicians, nurses, medical assistants, therapists, laboratory technicians, and paramedics experienced a CFR of 1.07% (22). Ecuador also had one of the lowest ratios of intensive care unit (ICU) beds per population in the region, 10.72 per 100,000 people, compared with the Organization for Economic Co-operation and Development (OECD) recommendation of 16.9 per 100,000 (23,24). This shortage further aggravated the health crisis (14,15,25). The overwhelmed system left thousands of patients with diabetes, kidney failure, cardiovascular disease, cancer, and other catastrophic or rare conditions without adequate treatment, worsening their outcomes.

In large cities, infection rates were significantly higher due to population density. However, mortality rates in rural areas were similar, largely due to limited healthcare capacity and the difficulty of transferring critically ill patients to urban hospitals. With hospitals overwhelmed, there were not enough beds to accommodate all who needed care (23).

The Epidemiological Surveillance System was extremely weak, leading to a lack of reliable data for decision-makers (26). The COVID-19 outbreak, combined with the concurrent dengue epidemic on Ecuador’s coast, resulted in high mortality rates, positioning the country as one of the worst-performing health systems in the Americas (9,13,27).

In January 2021, Ecuador received 500,000 vaccine doses, and some healthcare workers were vaccinated. However, a public scandal erupted when a significant portion of these doses went to politically connected individuals rather than high-risk groups. By April 2021, an additional two million doses had arrived, but the absence of a technical vaccination plan meant that distribution was inefficient and failed to reduce transmission effectively (9).

On May 24, 2021, a new government assumed office, appointing a public health leadership team with expertise in epidemiological surveillance, outbreak management, and vaccinology. Under the direction of the newly appointed Minister of Health, the team launched a coordinated pandemic response known as Plan Fenix, alongside a national vaccination strategy, 9/100, which aimed to immunize nine million people, about 70% of the population aged 15 years and older, within the first 100 days of the new administration (28).

The implementation of these strategic epidemiological interventions was not straightforward, as multiple obstacles were encountered. Although Ecuador is geographically small, it comprises four markedly distinct regions: the Galápagos Islands; the Coastal region, which includes mountainous rural zones and numerous small offshore islands; the Sierra, characterized by high-altitude plateaus and paramo ecosystems exceeding 12,000 feet above sea level; and the Oriente, encompassing Amazonian rainforest areas, where reaching local populations often requires extended travel by land, river, and air. This complex and heterogeneous geography contributes to Ecuador’s pronounced ethnic diversity, which includes indigenous communities that speak different languages and maintain distinct cultural practices and traditions.

Plan Fenix and the 9/100 vaccination strategy were tailored to the country’s demographic and geographic diversity, with the objectives of reducing COVID-19 mortality, minimizing severe cases, restoring healthcare system functionality, and supporting social and economic recovery (7,28). A major challenge was the lack of reliable information on cold chain equipment and transportation for vaccine distribution. Furthermore, the country had no structured pandemic control plan or defined vaccination strategy, which initially limited access to COVID-19 vaccines (9).

By the end of May 2021, the government had established strategic alliances to acquire vaccines from Sinovac, AstraZeneca, Pfizer, and CanSino (29). Once other countries observed that Ecuador had a sound and strategically designed vaccination plan, with adequate logistics and cold chain infrastructure, they began donating millions of doses to support national pandemic control efforts.

As the strategic plan was implemented, and given the significant economic and social impact of prolonged lockdowns, the government adopted targeted quarantine measures in specific geographic areas experiencing outbreaks. Simultaneously, vector control programs were strengthened to contain the dengue epidemic that was ravaging coastal provinces (8,9,30,31).

Even before taking office, the new president sought international support to secure vaccine doses. Upon inauguration, he directed the Minister of Finance to provide all necessary resources to the Ministry of Health (MOH) for implementation. By the completion of Plan Fenix and the 9/100 vaccination strategy, government spending had exceeded USD 600 million.

These expenditures had not been included in the initial fiscal planning of the presidential term. Consequently, the Ministry of Finance was required to reprogram and reallocate funds across multiple budgetary lines to finance vaccine procurement, medical supplies, personal protective equipment (PPE), the recruitment of healthcare personnel, and other logistical operations, including transportation, digital infrastructure, and cold chain systems.

The implementation of Plan Fenix and the 9/100 vaccination strategy involved extensive intersectoral collaboration, integrating efforts from both public and private sectors (32). The National Electoral Council (CNE) provided data from recent elections, enabling the geographic identification of registered individuals aged 16 years and older. This information allowed the MOH to track vaccination coverage and identify populations still awaiting immunization. Many electoral facilities were repurposed as vaccination centers, and the CNE also provided computers to record administered doses (33).

The Ministry of Education played a crucial role by facilitating access to public school facilities for vaccination, supporting logistics, and alerting the MOH about COVID-19 outbreaks when in-person classes resumed. The 9/100 strategy leveraged the capabilities of multiple state entities, including the Ecuadorian Police, the Ecuadorian Red Cross, and the private sector (agriculture, floriculture, fishing, and groceries) as well as academic institutions. These groups provided essential logistics for vaccination brigades, including sites, internet access, computers, chairs, tents, syringes, gloves, and face masks. Medical and nursing students were trained to administer vaccines, significantly expanding the workforce necessary to meet vaccination goals (32,34-36).

The Army Forces contributed their expertise in logistics and geographic information systems (GIS), playing a crucial role in planning and coordinating vaccination campaigns across Ecuador’s diverse and challenging terrain (9,37-40).

To reduce mortality, priority vaccination was given to the most vulnerable populations: older adults (over 65 years), patients with catastrophic illnesses, and people with disabilities. Additionally, workers with high exposure risk—healthcare personnel, teachers, police officers, armed forces members, Red Cross personnel, and firefighters—were prioritized to achieve sufficient immunity levels that would allow essential activities to resume. Vaccination later extended to all adults and adolescents, following a descending age-based strategy from 64 to 16 years old. Individuals who had missed earlier vaccination opportunities could attend any center to receive their doses. This strategy also contributed to mitigating the social impact of the pandemic and supporting economic reactivation (28).

Alongside Plan Fenix, the MOH strengthened data collection systems to predict outbreak locations. Collaborations with the Army Polytechnic School and the Joint Armed Forces Command enhanced georeferencing capabilities. The National Directorate of Epidemiological Surveillance was reinforced with experienced outbreak control staff. Coordination with the National Emergency Operations Committee (COE) and universities facilitated nationwide genomic surveillance, while the National Institute of Public Health (INSPI) received new equipment to expand genomic sequencing capacity in the main cities: Quito, Guayaquil, and Cuenca (9,30,38,39).

Once the Epidemiological Surveillance System was strengthened, real-time data-informed decisions to reopen businesses, schools, and public events. Information on infection rates, fatality rates, and hospital capacity guided safe increases in public activities. Ecuador’s constitution guarantees universal and free healthcare for all residents. Vaccination and COVID-19 treatment were provided without discrimination, regardless of migrant status or minority background (9,35,38).

Ecuador is a key transit and destination country for displaced populations, hosting over 76,000 recognized refugees, 95% of them Colombian, making it the primary asylum country for Colombians globally. By 2023, the Colombian migrant population reached 5,244. It also hosts the fourth-largest Venezuelan refugee and migrant population in Latin America, numbering over 474,000 people, approximately 3% of Ecuador’s total population (41,42).

The 9/100 vaccination strategy was designed to include both regular and irregular migrant populations. Efforts were coordinated with the Pan American Health Organization (PAHO) and United Nations (UN) agencies to deploy mobile vaccination brigades for these populations without requiring documentation, ensuring that migrants could be vaccinated without pressure or risk. The MOH was recognized by the United Nations High Commissioner for Refugees (UNHCR) for vaccinating one of the highest numbers of migrants globally (9,42).

Government communication efforts, led by the MOH and other ministries, were well received. Ecuador has widespread internet coverage, and public health messages were disseminated in both Spanish and Kichwa in regions where the latter is spoken (43). The Minister of Health and her team traveled throughout the country, conveying messages in Spanish and translated into Kichwa or other local languages, emphasizing vaccine safety and the importance of community collaboration in controlling the pandemic. Misinformation remained a major challenge, particularly regarding alternative treatments and the stigmatization of healthcare workers and COVID-19 patients (9,39).

The MOH, with PAHO support, launched the “COVID-Ecuador” application and the PAHOflu informatics system. These platforms facilitated epidemiological surveillance and the generation of indicators for COVID-19 and other respiratory viruses, such as influenza and severe acute respiratory infections, across the national territory. These surveillance systems enabled the identification of hotspots and the implementation of targeted epidemiological controls. Severe cases were reported every 24 hours, georeferenced to track continuous transmission areas. Rapid response teams were deployed for community screenings and antigen testing, facilitating early isolation of potential cases and targeted vaccination efforts (9).

By September 2021, 93 days after the start of the 9/100 vaccination plan, Ecuador achieved its goal of vaccinating nine million people with two doses (complete scheme). The country set a world record by administering 414,000 doses in a single day, twice—once in July and again in August 2021. By December 2021, 85.6% of Ecuadorians had received at least one vaccine dose (8,9,44).

Vaccination efforts continued with children under 16 years old. By December 2021, Ecuador was among the first countries worldwide to vaccinate children aged 5 years and older. Booster campaigns began in January 2022, and vaccination for children aged 3 and 4 years took place in February 2022 (45). By July 2022, 78% of the total population had completed the full vaccination schedule (9).

All decisions to control the pandemic were based on scientific evidence, allowing Ecuador to reopen schools and businesses and resume “normal activities”, despite the introduction of new COVID-19 variants such as Delta and Omicron. These efforts also facilitated economic reactivation.

The interventions led to a dramatic reduction in mortality, from 43 COVID-19 deaths per 1,000 confirmed cases in April 2021 to 1.6 deaths per 1,000 confirmed cases in January 2022. By April 2022, the compulsory use of face masks was eliminated. As of 2023, Ecuador reported 1,065,013 laboratory-confirmed cases and 67,527 deaths (confirmed and probable). By May 2023, following the World Health Organization (WHO) declaration, Ecuador announced the end of the COVID-19 pandemic (46).

Ecuador exemplifies the devastating social and economic effects of the COVID-19 pandemic. By May 2023, the country had recovered significantly, demonstrating the effectiveness of coordinated public health interventions (Figure 1).

Figure 1 COVID-19 case mortality^† reported in the SIVE, by epidemiological week, Ecuador. The figure compares weekly COVID-19 deaths during 2020, 2021, 2022, and 2023. The 2021 curve illustrates the impact of the national vaccination plan 9/100, with a sharp decline beginning at week 16, continuing until week 22. A slight increase in week 23 coincides with the first detection of the Delta variant, and another mild increase at week 52 aligns with the arrival of the Omicron variant (6). ^†, confirmed and probable deaths are used (6). AE, epidemiological year; conf., confirmed; COVID-19, coronavirus disease 2019; PAHO, Pan American Health Organization; PCR, polymerase chain reaction; prob., probable; SIVE, Epidemiological Surveillance System.

Conclusions

LICs and LMICs are disproportionately affected by health emergencies due to the interplay of multiple social, economic, and environmental determinants. Factors such as political instability, corruption, and a lack of political will among decision-makers further exacerbate the impact of epidemics and potential pandemics.

A turning point came when political leadership prioritized public health and appointed a technically skilled team to manage the crisis. Financial and material resources were allocated, inter-institutional support was fostered, and an effective “vaccine diplomacy” strategy ensured sufficient doses to vaccinate over 70% of the population in a short period. Combined with a strategic epidemiological control plan, this approach allowed Ecuador to tackle the COVID-19 pandemic effectively.

Intersectoral and interdisciplinary collaboration, working toward a common goal, enabled Ecuador to overcome the health crisis. This experience demonstrates that prioritizing public health improves social well-being and contributes to economic recovery.

Globally, political and economic changes continue to impact public health. LICs and LMICs must recognize that investing in the health of populations is crucial. Prevention is more cost-effective than treatment and benefits a larger portion of society. Strategies for prevention, early detection, and outbreak control not only save millions of lives but also generate substantial economic savings for countries that prioritize them.

Discussion questions

What critical factors enabled Ecuador, despite its limited resources and political instability, to achieve one of the most effective COVID-19 vaccination rollouts in the region, and how can these lessons be adapted to strengthen pandemic responses in LMICs?

How can health systems in LMICs balance immediate pandemic response efforts with long-term investments in surveillance infrastructure, healthcare workforce capacity, and supply chain resilience to prevent future health crises?

In the context of widespread misinformation and political distrust, what role should governments, multilateral organizations, and civil society play in building trust and ensuring equitable access to health interventions, especially for vulnerable and migrant populations?

Acknowledgments

The author thanks the Ministry of Public Health of Ecuador and the Pan American Health Organization for their technical support. The author is grateful to Dr. Pablo Acosta for his epidemiological advice and to the field teams for their support in data collection.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mellissa Withers) for the series “Case Studies in Global Health Leadership and Management” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-17/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-25-17/coif). The series “Case Studies in Global Health Leadership and Management” was commissioned by the editorial office without any funding or sponsorship. X.P.G.V. was the Minister of Health of Ecuador. She led the design and implementation of Plan Fenix and the 9/100 Ecuadorian Vaccination Plan. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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