—from Epidemiological
Bulletin , Vol. 25 No. 2, June 2004—
Country Profiles: Ecuador
General situation and trends
In the year 2000 the estimated population was 12,645,495, with average density
of 49.3 pop./km2. The country is formed by 22 provinces, 215 cantons, and
1,149 parishes (361 urban and 788 rural) and indigenous and Afro-Ecuadorian
districts established by law. Urban areas include 63% of the population;
of this, 46% is concentrated in Quito and Guayaquil. The deepening of the
political, economic and social crisis between 1997 and 2000, the economic
impact of El Niño 1997-1998, and the sharp fall of the price of oil
in 1999 negatively affected the scope of the goals toward modernization of
the State, decentralization of the public management, political democratization,
and social equity.
The annual population growth rate 1995-2000 was 1.9%. In 2000, 34% of the
population was under 15 years (39% in 1990) and 4.7% over 64 years of age (4.1%
in 1990) (Figure 1). The total fertility rate declined from 4.0 children per
woman in 1985-1990 to 3.3 in 1994-1999 (2.6 urban; 4.4 rural; 5.5 in women
without formal education.) Since 1997 intense migration has been observed toward
urban areas and to the exterior.
Figure 1: Population structure, by age and sex, Ecuador, 2000.
Growth of GDP fell 3.4% in 1997 to -7.3% in 1999, rising to
2.0% in 2000 (Figure 2). In 1999 hyperinflation (63%) led to serious economic
recession and a drop in real income. Between 1997 and January 2000 the currency
was devalued more than 800% in relation to the American dollar, in the process
of "dollarizing" the monetary system. In December 2000, inflation
reached 96%. Urban unemployment increased from 9% in 1998 to 17% in 1999; in
December 2000 it lowered to 9%, attributed in part to the massive emigration
of unemployed population. In 1999 the living conditions of 69% of the population
were poor (urban 55% and rural 88%). Between 1995 and 1999 the Gini coefficient
increased from 0.54 to 0.59. In 1998, the richest decile of population comprised
41% of the national income, 68 times that of the poorest decile (0.6%). In
1999, illiteracy was 8% in males and 12% in women; 30% in the indigenous population.
Figure 2: Gross domestic product, annual growth (%), Ecuador, 1990-2000.
In 1999 the crude death rate was 5.9 per 1,000 pop. (6.8 in
males; 4.9 in women). Underregistration is estimated at 25%; 13% of deaths
do not have medical certification and 14% have signs/symptoms and ill-defined
as an underlying cause of death. In 1999 mortality (per 100,000) from circulatory
diseases was 155; cancer (85); external causes (82); communicable diseases
(79); diseases originating from the perinatal period (28). The Figure 3 shows
the estimated mortality by groups of causes and sex . Life expectancy at birth
was estimated at 69.9 years (67.3 in males; 73.5 in women), 1995-2000.
Specific health problems
Analysis by population group
Health of the children (0-4 years) and schoolchildren (5-9 years): The estimated
infant mortality rate was 30 per 1,000 live births (22 urban; 40 rural); 63%
in its neonatal component; 26% due to communicable diseases, 1994-1999. The
prevalence of low birthweight was 16% (rural 19%). In 1999, mortality in children
from 1-4 years was 354 per 100,000; comprising 47% of deaths from communicable
causes, respiratory infections (21%) and acute diarrheal diseases (16%). The
prevalence of chronic malnutrition in children under 5 was 26% in 1998. In
the group 5-9 years, mortality was 92 per 100,000 (31% external causes and
24% communicable diseases), 1999.
Health of the adolescents (10-14 and 15-19 years): Among those 10-14 years
of age, external causes were the leading cause of death, 340 per 100,000 pop.
and 634 among those 15-19 years of age. Sexual activity was reported by 25%
of women 15-19 years of age (average inception age: 16.6 years) and 11% described
use of contraceptives, 1994-1999. The age specific fertility rate was 91 per
1,000. The prevalence of illegal drug use was 6% at the national level in 2000.
Adults (20-59 years): Of the population 20-59 years, 63% reported using some
contraceptive method. In 1999, 81% of pregnant women had at least one prenatal
check-up, 43% made 5 visits; the institutional coverage of deliveries was 69%
(86% urban; 49% rural); maternal mortality was estimated at 91.7 per 100,000
live births.
Health of the adults (20-59) and elderly (60 years and
older): External causes
are a leading cause of death, 107 per 100,000 pop. Violence and motor vehicle
accidents were especially important in this category. Among older adults neoplasms
are the first leading cause of death, 685 per 100,000 pop. The prevalence of
disability was 13%, 1994-96.
Figure 3: Estimated mortality, by broad groups of causes and sex, Ecuador, 1999.
Analysis by type of health problem
Diseases preventable by vaccination: The country has been declared free from
measles since 1997. Monitoring of acute flaccid paralysis remains active.
Neonatal tetanus declined from 24 cases in 1998 to 6 in 2000. Since the diphtheria
epidemic in 1994-95, there have been no confirmed new outbreaks. Between
1999 and 2000 outbreaks were reported of whooping cough in children less
than 5 years from indigenous communities, including more than 80 cases in
less than 6 months. The national immunization coverage in 2000 was 100% for
BCG, 83% for OPV3 and 89% for DPT3 in children under 1 year and 89% for anti-measles
in population from 12 to 23 months (Figure 4).
Figure 4: Vaccination coverage among the population under 1 year of age, by vaccine,
and tetanus toxoid coverage for women of childbearing age, Ecuador, 2000.
HIV/AIDS and sexually transmitted infections: As of 2000,
Ecuador had accumulated 1,561 cases of AIDS and 1,559 cases of HIV; in 2000
there were 315 cases of AIDS reported and 348 cases of HIV. The incidence by
sex is shown in Figure 5. In 95% of cases, sexual transmission was reported
as heterosexual, 62%; those 20-39 years of age accounted for 64% and women
accounted for 20%.
Figure 5: AIDS incidence, by sex, with male-female ratio, Ecuador, 1990-2000.
Vector-borne diseases: Malaria went from 11,991 to 104,598
cases, including 50,000 cases of P. falciparum in 1999 (case-fatality 3.2 per
10,000), being associated with El Niño. The malaria risk area included
133 cantons and 6.6 million pop. In 2000 there were 22,958 cases of dengue
reported, in contrast to 6 thousand annual cases between 1997 and 1999, including
suggestive cases of hemorrhagic fever. The 4 serotypes of dengue virus were
in circulation. Yellow fever declined from 31 cases in 1997 to 4 in 1998 and
2 in 2000, associated with yellow fever vaccination in endemic areas.
Zoonoses: Three cases of human rabies and 82 of canine rabies were reported
in 2000, in contrast to 65 and 1,175, respectively, in 1996. After 12 years
without plague, 13 cases were reported in 1998 and 8 in 1999 in Chimborazo.
In January 1998 an outbreak of leptospirosis occurred with 160 cases in Guayas
(case-fatality 10%).
Chronic communicable diseases: The number of cases of tuberculosis recorded
and treated declined from 7,214 in 1997 to 5,064 in 2000. There were 194 new
cases of leprosy reported in 2000, in contrast to 129 in 1997.
Nutritional and metabolic diseases: In 1999 mortality from diabetes mellitus
was 27 per 100,000 (30 in women); 19% of schoolchildren of Quito were obese
and 22% presented dyslipidemias. Cardiovascular diseases: Mortality (per 100,000)
from cerebrovascular diseases was 36, ischemic of heart (31) and hypertensive
disease (23), higher in males.
Accidents and violence: Motor vehicle accidents produced a mortality rate
of 19 per 100,000 pop., homicide (20) and suicide (6.5).
Oral Health: In 1996, the prevalence of caries in children by age 12 years
was 85%; the DMF index-D was 3.0 in contrast to 5.0 in 1988.
Natural disasters: Damages associated with El Niño were estimated at
US$ 2,869 million (17% of the GDP of 1997). The volcanic activity of the Pichincha
induced the fall of 1,131,000 tons of ash on Quito in 1999 and that of the
Tungurahua the evacuation of 25,000 people between 1999 and 2000. The rupture
of the pipeline in Emeralds (1998) and in Sucumbíos (2000) caused human
losses and considerable material and ecological damage.
Response of the health system
National health policies and plans
The national consultation of 1997 established four roles of the State in health:
steering role, health promotion, guarantee of equitable access to care and
decentralized delivery of services; and three levels of political action: intersectoral
(health promotion and social participation); sectoral (system and health insurance,
sectoral regulation, allocation and use of resources, medical practice, science
and technology and legal reform); and institutional (essential public health
functions and coordination of international cooperation). In the legal field,
decentralization comes under the special State Decentralization and Social
Participation Act, which has been in effect since October 1997 and sets guidelines
for transferring social and economic competencies and resources to the provincial
councils and municipalities.
Health sector reform
Since 1994 sectoral reform focused on the development of a model for provision,
financing, and management of decentralized health services that combine equity
with efficiency and a common plan of action among providers.
Institutional organization
The functions of the health sector include management, regulation, planning,
insurance, human resources development, and services provision; the latter
is undertaken through the MPH, the Ecuadorian Social Security Institute (IESS),
the Armed Forces, municipalities, and private institutions, whether for social
or commercially profitable purposes. Lack of coordination is more accentuated
among the institutions that provide services, which are governed by different
type of policies, health care models, and financing schemes, with the resulting
duplication of investments.
Organization of regulatory actions
The Ministry of Public Health regulates the provision of health services, especially
as regards the development of infrastructure and the endowment of outpatient
and hospital services. These regulatory activities are based on health laws.
The Ministry of Industry and Trade regulates the price of drugs and the MPH
maintains the health registry, quality control, marketing and sales. The
Ministry of Foreign Trade regulates food quality control; the MPH performs
the sanitary control of food production and consumption.
Organization of public health care services
Activities of the Expanded Program on Immunization have existed and have a
high priority in the plan of action 2001-2005. Since 1997 the strategy of
the Integrated Management of Childhood Illness is carried out nationally
and has been used to coordinate efforts and integrate actions of intergovernmental
agencies providing child health care. Since 1995 the MPH has carried out
a program of micronutrient deficiency control. In 1999 malaria control was
strengthened with financing of the World Bank; in 2000 the DOTS strategy
for tuberculosis control was implemented. In 1999 the law that creates the
National AIDS Institute was promulgated. The national laboratory network
of public health was expanded for surveillance of rubella, measles, hepatitis
B, influenza, meningitis, bacterial pneumonia, rabies, plague, congenital
syphilis, yellow fever, diseases of food transmission and quality of water
for human consumption. An integrated national health information system did
not exist and there was a lack of human resources trained in statistical
and epidemiological analysis. The delivery of water and sanitation services
is a municipal responsibility. In 1988 there were 214 systems of urban potable
water supply and 3,500 rural; the population without access to services of
water was 30% and without disposal of excreta services, 42%.
Organization of individual health care services
In 1999 there were 2,825 establishments in existence providing outpatient care
and 541 providing hospital care. The country had 19,083 hospital beds in
1999 (1.5 per 1,000 pop.) and there were 635,766 hospital discharges; the
average length of stay was 5.2 days. There were 38 blood banks that collected
82,237 units of blood in 2000. The national system of civil defense operates
throughout the country. The National Council on Disability created a register
in 1996 which includes the whole country and in 2000 the National Committee
for the Elderly.
Health Supplies
In 1998 there were 6,903 registered drugs; 28% generic drugs; 80% imported.
The pharmaceutical market value was US$ 344 million.
Human resources
In 1999 there were 13.8 physicians per 10,000 population, 1.6 dentists, 5.0
nurses, 0.8 midwives, and 10.7 nursing auxiliaries. In 1999, 2,800 physicians
migrated from the country (10% of the total membership of the Ecuadorian
Medical Federation). Lower wages, labor instability, and unemployment are
persistent problems among health workers.
Health expenditure and financing
Between 1997 and 2000 the per capita health expenditure declined from US$ 52
to 26. The public spending in health fell from 1.1% of the GDP in 1995 to
0.5% in 1999. The poorer quintile had 7.6% of the health expenditure; the
richest (38%). For the private sector, 88% of expenditure is out of pocket.
Sectoral financing
Sources of financing include: households (49%); State (24%); employers (13%);
international cooperation (9%) and National Lottery and municipal income
(5%). The contribution of international cooperation amounted to US$ 60.5
million in 1997. Contributions went to the MPH (26%), health of armed forces
(25%); for-profit private sector (21%); IESS (11%); private pharmacies of
the Welfare Board of Guayaquil (4%) and other health providers (13%). The
greatest amount is provided through credits from the World Bank: Project
Fasbase 1993-2000 (US$ 70 million), Project Modersa 1999-2003 (US$ 45 million),
Project Health and Development 1998-2001 (US$ 20,2 million) and Project Roll
Back Malaria (US$ 3 million).
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Epidemiological
Bulletin , Vol. 25 No. 2, June 2004
