Advancing towards universal health requires resilient and functional health systems based on equitable and sustainable financing and capable of delivering quality, timely and people-centered health services while eliminating direct payments at the point of service (¹1. World Health Organization. 64th World Health Assembly. Resolution WHA64.9 Sustainable health financing structures and universal coverage. WHO: Geneva; 2011., ²2. Pan American Health Organization. 53rd Directing Council. Resolution CD53.R14 Strategy for universal access to health and universal health coverage. PAHO: Washington, DC; 2014.). Building such systems is therefore a centerpiece in the quest for universal health.

However, this is not an easy undertaking. Strong health systems need appropriate infrastructure, affordable and safe medicines; well-trained professionals, adequate in numbers and distribution; integrated health-care networks; sufficient financial resources; and sound and evidence-based decisions about what services to provide (²2. Pan American Health Organization. 53rd Directing Council. Resolution CD53.R14 Strategy for universal access to health and universal health coverage. PAHO: Washington, DC; 2014.). All this in turn requires sustained political will, strong leadership with clear objectives and goals, regulatory frameworks to ensure the quality and safety of health interventions, and a legal foundation to promote and protect people's right to health (³3. Pan American Health Organization. 53rd Directing Council. Agenda item 4.3 CD53.5, Rev2 Strategy for universal access to health and universal health coverage. PAHO: Washington, DC; 2014.).

In a setting of new and reemerging epidemiological challenges brought about by aging populations, unhealthy lifestyles, climate change, emerging infectious pathogens, and social and political strife, health systems must find innovative ways to organize and finance health services to be able to progressively expand coverage, increase equitable access to care, and provide financial protection, especially for the most vulnerable population groups.

Health reform processes must address all these challenges if countries are to successfully advance the universal health agenda. In the late 1980s, many Latin American countries instituted social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide financial risk protection. In the 1990s, health reforms started to focus on strengthening health systems to reduce inequalities in access to care, improve health outcomes, and expand health coverage, especially for the disadvantaged (⁴4. Atun R, de Andrade LO, Almeida G, Cotlear D, Dmytraczenko T, Frenz P, et al. Lancet. 2015; 385(9974):1230-47.). However, only a few countries in the Americas have engaged in comprehensive health reform that involves all health system functions and revisits the health sector's legal framework to adapt it to the universal health agenda. Ecuador is one of these countries.

This special issue of the Pan American Journal of Public Health examines Ecuador's recent experience in health system reform through a series of articles on specific areas that have undergone major transformations as part of the health reform process.

It is our hope that this special issue will help Ecuador's health authorities take stock of their accomplishments and remaining challenges while encouraging health leaders in other countries to implement the changes their health systems need to advance further toward universal health.

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