Budget reforms: a strategic model to enhance transplant initiatives at a national institute in Ecuador

This study develops and empirically validates a budget reform model aimed at enhancing the national transplant system in Ecuador. Employing an applied, cross-sectional quantitative design, data were collected from 109 employees of the National Institute of Donation and Transplantation of Organs, Tissues, and Cells (INDOT) through validated instruments assessing budgetary reform dimensions and transplant activity. Ordinal logistic regression and model-fit tests confirmed a statistically significant relationship (χ², Wald; p<0.05), with a pseudo-R² (Nagelkerke ≈0.997). Results reveal that public underfunding, limited earmarked revenues, and rigid execution rules critically restrict the efficiency and sustainability of transplant programs. Descriptive findings also identified advisory, substantive, and decentralized management processes as institutional bottlenecks. Building on these results, the paper proposes a legislative framework to establish a public trust fund, fed by service fees and fiscal transfers, ensuring transparent, predictable, and decentralized financing for transplantation. The proposed model provides a replicable policy instrument for countries facing fiscal constraints, offering practical strategies to strengthen governance, financial sustainability, and access to organ transplantation services.