A/HRC/44/48/Add.1 31. The Minister of Health assured the Special Rapporteur during the visit that there was an increased focus on primary care services, as well as health promotion and preventive health care. The Special Rapporteur strongly supports this and recommends that investment in primary health care is substantially increased as a high priority. 32. Regarding intercultural health, article 32 of the Constitution provides that health services shall be governed by, inter alia, the principle of interculturalism. However, as observed by the Special Rapporteur on the rights of indigenous peoples, following her visit to Ecuador in 2018, there is a lack of coordination and integration between ancestral systems and the national health system, as well as persistent inequality in the enjoyment of the right to health for indigenous peoples. The Special Rapporteur on the rights of indigenous peoples also highlighted the lack of culturally appropriate health services of quality in many indigenous communities and the persistence of racism and discrimination, which obstructs access to public services (see A/HRC/42/37/Add.1). 33. The Special Rapporteur received similar first-hand information about indigenous midwives not being paid, feeling inferior to those working in the national health system and not being fully recognized as part of the national health system. On the other hand, he was also pleased to visit the recently established intercultural centre on health and the so-called Establishment Friends of Mother and Child in Otavalo. In particular, the Establishment Friends allows women to give birth in a public hospital but with an indigenous midwife and following traditional practices, including “vertical births”. The Special Rapporteur encourages the National Directorate for Intercultural Health of the Ministry of Public Health to strengthen its programmes in the area of ancestral medicine and supports enhancing the participation of indigenous midwives in the national health system, so that traditional systems of medicine can be fully recognized. Notwithstanding those initiatives, the Special Rapporteur emphasizes that planned births outside hospitals may also be an affordable and accessible option. Women must be able to make informed choices as to their delivery preferences. They should not be deprived of assistance should they choose to give birth at home and health-care personnel and indigenous midwives should be allowed to provide such assistance. III. Mental health 34. The Special Rapporteur has always highlighted the importance of a human rightsbased national mental health policy guided by modern public health principles and staffed with a sufficient number of qualified mental health specialists. During the visit, the Special Rapporteur was concerned to find that despite recent efforts, the mental health-care system in Ecuador remains underdeveloped owing to the insufficient integration of mental health services at the community level and into general health care. Initial investments in modern mental health policies only began in 2014 with the adoption of the national strategic plan on mental health (2015–2017) and its corresponding mental health-care model with a family, community and intercultural focus. Those initiatives seek to strengthen community participation in the development and planning of mental health-care services and provide for, inter alia, the opening of community mental health centres and the deinstitutionalization of persons with mental health conditions so that they may receive dignified and integrated care in society. However, the Special Rapporteur regrets that very few advances have been made in that regard. One commendable example is the establishment of the San Lazaro mental health centre in Quito, which he visited. The centre provides outpatient community services that are not reliant on coercion; such initiatives should be replicated throughout the country. 35. The mental health system has not yet transitioned from a model that is based around hospitals to a community care model. The Special Rapporteur observed that the process of deinstitutionalization had been obstructed by a number of factors, including the lack of community centres without the possibility of family and social reintegration; a weak system of outpatient care at the primary and secondary levels that made it difficult to follow up on patients discharged from hospitals; and insufficient resources for community-based services. For example, during his visit to the Julio Endara psychiatric hospital in Quito, he was pleased to see the investment that had been made in providing more dignified care for persons with chronic conditions. However, he was concerned that those persons had remained in the facility for decades, as community-based services were lacking throughout 8