Data updated for 2001

ECUADOR

GENERAL SITUATION AND TRENDS

Socioeconomic, Political, and Demographic Overview

During 1992–1995 inflation fell from 54.6 % to 22.9%, monetary reserves increased from US$ 1,300 million to $1,600 million, and the fiscal deficit declined from 7% to 3% of gross domestic product (GDP). Seasonal migrations from the countryside to the towns and from the towns to the large cities swelled the ranks of the informal work sector, which represented 60% of the urban economically active population (EAP) in 1994. Net unemployment went from 3.6% in 1990 to 6.9% in 1995. Between 1991 and 1994 underemployment remained at approximately 48.0%. In July 1996 a worker’s total income, as established by the National Wage Council, amounted to US$ 154, including a minimum living wage of $27 and additional compensation mandated by law (in 1990 the corresponding amounts were $130 and $65, but purchasing power was greater).

In 1997, Ecuador’s population was estimated at 11,936,858, of which 55.4% lived in urban areas. The population growth rate was 2.1% in the last intercensal period (1982–1990), and the annual rate for 1995–2000 is estimated at 1.9%. In 1995 the population under 15 years of age represented 36.4% of the total, as opposed to 38.9% in 1990. In the year 2000 this age group will represent 33.8% of the total population. In 1995, 49.8% of the population lived in coastal regions, 44.8% in the mountains, 4.6% in the Amazon region, 0.1% on the islands, and 0.7% in areas without geopolitical boundaries.

The national birth rate, corrected for delayed birth registrations (50% of the total) was 23.7 per 1,000 inhabitants in 1995, representing a decline of 7.8% with respect to 1990 (24.7 per 1,000). According to the Demographic and Maternal and Child Health Survey (ENDEMAIN-94), total fertility decreased from 4.0 children per woman in 1985–1990 to 3.6 in 1989–1994 (4.6 in rural areas and 2.9 in urban areas). The decline is explained in large part by the increased years of schooling for women, their growing participation in the work force, migration from the countryside to the cities, and family planning programs. The indigenous population, on the other hand, continues to have high fertility rates, as observed in mountain provinces such as Bolívar, where the rate is 5.12 children per woman, and on the Pacific coast in districts such as Esmeraldas, with a rate of 4.66 children per woman.

Eight percent of the men and 12% of the women are illiterate; 30% of indigenous-language speakers are illiterate, compared with 10% of Spanish-speaking individuals. Only 53% of the indigenous population attends primary school, 15% is in secondary school, and fewer than 1% is enrolled in institutions of higher learning.

It is estimated that 63% of the total population was affected by some degree of poverty in 1995, compared with 54% in 1990; 40.3% of the total population has at least one unmet basic need, ranging from 60.8% in rural areas to 27.0% in urban areas. Forty percent of the total population is poor and 15 % is indigent. The provinces that are poorest and have the highest percentage of households with unmet basic needs also have the lowest indexes of urbanization and, paradoxically, the lowest registered death rates. This can be explained by underregistration, which has not yet been quantified at the provincial level.

Based on data from the 1990 Population Census, it is estimated the indigenous population at that time stood at 910,146 (9.4% of the total) and was concentrated in the rural areas of the Ecuadorian Amazon region and the mountains. The exact locations of the various ethnic groups have not yet been mapped. Statistical data from 1994 indicate that the most numerous group is the Quichua, who live mainly in the mountains (66,964) and the Amazon area (72,528). Other ethnic groups in the Amazon area are the Shuaras (36,634), the Aschuaras (4,000), the Huaoranis (1,200), the Cofanes (627), and the Siona-Secoya (600). Along the coast there are 5,000 Chachis, 1,000 Tsachelas, and 27,648 Quichuas. No figures are available for the Ecuadorian population of African origin, which is concentrated along the coast and in two mountain provinces.

In the rural mountain and Amazon areas, it is estimated that 76% of the children live in poverty, a figure that reaches 80% for indigenous children and adolescents. In coastal areas, among the rural Ecuadorian population of African origin, 70% of those under 18 years of age are living in poverty. In these areas, as well as along the borders with Colombia and Peru, the situation is aggravated by migration of adult men to the cities or to other countries in search of work. Pichincha and Chimborazo have most of the emigrants from the other provinces (29.5% apiece). It is estimated that a million Ecuadorians are living abroad, mainly in the United States of America.

Life expectancy at birth in 1990–1995 was 68.8 years for the general population (66.4 years for men and 71.4 years for women); for 1995–2000 the estimate is 69.9 years (67.3 for men and 72.5 for women). The increase reflects the work that has been done in health education and health promotion, which has benefited children in particular.

Mortality profile

Between 1990 and 1995 the leading causes of death in the general population remained the same, but their rank changed: cerebrovascular diseases dropped from first to second place as the rate fell from 25.6 to 23.1 per 100,000 inhabitants; pneumonia, on the other hand, rose from third place to first, with a rate of 27.2 per 100,000; intestinal infectious diseases moved from second to ninth place and the rate dropped to half; traffic accidents remained in fourth place, with a decline in the rate from 19.4 to 15.8 per 100,000; and malignant tumors of the stomach remained in seventh place, showing a slight increase from 11.7 to 12.7 per 100,000. Deaths due to homicide and injuries purposely inflicted by other persons went from ninth to sixth place, with a 50 % increase, and were responsible for 55,443 years of potential life lost (YPLL), 50,200 of them in men. A total of 1,191,882 YPLL are estimated to have been caused by deaths occurring before the age of 70—713,785 of these in men.

SPECIFIC HEALTH PROBLEMS

Analysis by Population Group

ENDEMAIN-94 estimated infant mortality for the country as a whole at 44 per 1,000 live births, with large differences among the provinces: in Chimborazo, where the population is predominantly rural and indigenous, the estimated rate was 100 per 1,000 live births, whereas in Pichincha and Guayas, where the two largest cities (Quito and Guayaquil) are located, the estimated rates were 32 and 33 per 1,000, respectively. Acute respiratory infections were responsible for 37% of the deaths in infants from 1 week to 11 months of age and for 32% of deaths in children from 1 to 4 years old; they accounted for 28% and 24% of hospital discharges, respectively. Congenital anomalies went from eighth to sixth place, although in 1995 the mortality rate from this cause had dropped to half.

In the group 5 to 9 years of age the sharpest decline in deaths was under the heading of infectious diseases, especially diarrheal diseases and respiratory infections. In 1995, accidents were the leading cause of death for both sexes. Violent causes, including accidents, were responsible for 285 deaths and affected males disproportionately (male/female ratio, 1.7:1). Of all the deaths in 1995, 4.2 % were among adolescents. In both the 10-to-14 age group and those aged 15 to 19 the leading cause of death for both sexes was accidents and violence, with 971 reported deaths, which represents a rate of 37.6 per 100,000 population. Males were predominant (716 males and 255 females; 2.8:1 ratio).

In adolescent females, the main external causes of death in 1995 were: suicide, 76 deaths (66 in the group aged 15 to 19) and traffic accidents, 48 deaths (30 in the 15-to-19 age group). There were 23 maternal deaths, representing a maternal mortality rate for this group of 76.8 per 100,000 live births—lower than the rate for 1990.

According to a 1995 survey, prevalence of the use of illicit drugs was 3.2% in the group aged 12 to 19, and prevalence of the use of alcohol and tobacco was considerably higher. Partial surveys conducted in the 1990s, which corroborated the national data gathered at the end of the 1980s, showed that tobacco use in adolescents was 14.9%, with no difference by sex. In 1995 it was estimated that, at the national level, 48.5% of all adolescents 11 to 13 years of age had consumed some type of alcoholic beverage; the figure increased to 73.9% in the population aged 14 to 16 and to 87.1% among 17-year-olds, with no significant differences according to sex.

The leading causes of death in adults from 20 to 59 years of age are cardiovascular and cerebrovascular diseases, malignant tumors, and accidents and violence. In 1995 the leading cause for men aged 20 to 44 was accidents and violence, with 3,046 deaths, or 52.3% of the total (5,828) from all causes in this age group. Deaths from violence have homicides (936) and traffic accidents (653) as the most important causes. Other causes, in descending order, were cardiovascular and cerebrovascular diseases (535 deaths, or 9.2% of the total), malignant tumors (257, or 4.4%), and tuberculosis (252, or 4.3%). For women in the 20-to-44 age range the leading cause also was accidents and violence, with 486 deaths, or 18.1% of the total, followed by malignant neoplasms (425, or 15.8%), cardiovascular and cerebrovascular diseases (398, or 14.8%), tuberculosis (154, or 5.7%), and maternal causes (145, or 5.4%).

In 1995 a total of 170 maternal deaths were registered. The national rate adjusted for late registrations was 62.7 per 100,000 registered live births, a number that reflects significant underregistration. The average for the 1991–1995 period was 110.1 per 100,000 live births, with significant regional differences. The leading cause of death in men from 45 to 59 years of age was accidents and violence (849 deaths, or 23.2% of the total), followed by cardiovascular and cerebrovascular diseases (663 deaths, or 18.1%), malignant neoplasms (392, or 10.7%), diabetes mellitus (169, or 4.6%), and tuberculosis (115, or 3.1%). In women of this age group the leading causes, in order, were malignant neoplasms (638 deaths, or 26.2% of the total), cardiovascular and cerebrovascular diseases (551, or 22.7%), diabetes mellitus (158, or 6.5%), and accidents and violence (147, or 6.0%). The most frequent site of malignant neoplasms was the uterine cervix, which accounted for 176 deaths in 1995. Detection programs have been targeted toward this high-risk age group.

In 1995 the two leading causes of death in the group aged 60 and over were cardiovascular and cerebrovascular diseases and malignant neoplasms.

In 1992, of the total EAP, only 1,101,131 (30%) were covered by occupational hazard insurance through their affiliation with the IESS. Since 1994, work-related accidents have been reported to the National Epidemiological Surveillance System. Between 1994 and 1996, approximately 5,000 cases were reported each year.

According to a study conducted by the International Labor Organization (ILO) and UNICEF, in 1990 some 800,000 children and youth between the ages of 8 and 18, or 30% of the total minor population of 2.5 million, were working, and this proportion increased to 38.7% in 1996. More minors (310,000) were working in rural areas than in cities, and under worse conditions. Only 23% of the minors who worked attended school

In Ecuador, 13.2% of the population suffers from some form of disability. Given the link between disability and poor living conditions, low income, and difficult access to health services, the incidence of disabilities is greater in marginal urban areas and in rural areas. There is no systematized national register of disabilities, but prevalence surveys provide at least a basic understanding of the situation.

Chief among the leading causes of death and disease in the indigenous population are those related to poverty: acute respiratory infections, acute diarrheal diseases, and malnutrition. Hypoxia and complications of delivery and the puerperium are the leading causes of infant and maternal death, respectively. Chronic malnutrition in children under 5 years of age reached 69% in some of these areas, compared with the national figure of 49.4%.

Among black children in Esmeraldas, malnutrition is estimated at between 60% and 70%. The health situation of populations living near the borders with Colombia and Peru is critical, especially among those living in the eastern region. Chronic childhood malnutrition is 65%, and infant mortality rates exceed 50 per 1,000 reported live births.

Analysis by Type of Disease or Health Impairment

Communicable Diseases

In 1996, 12,011 cases of malaria were reported, or one-fourth as many as in 1993. The highest rate was in Esmeraldas (1,175.0 per 100,000 inhabitants). In 1996 Plasmodium falciparum infections represented 16% of the cases in the coastal area. The coastal provinces were also the areas most affected by dengue, with 12,796 cases in 1996, a marked increase since 1992. In the 1992–1996 period, Chagas’ disease was diagnosed in 12 provinces located in the mountains, along the coast, and in the Amazon region. In the blood banks, 95% of the donations are screened. The principal vectors are Triatoma dimidiata and Rhodnius ecuadoriensis. It is estimated that some 500,000 persons are infected, mainly in Guayas, El Oro, and Manabí. Cutaneous leishmaniasis is the most prevalent form of the disease. Its incidence increased slightly, to 1,655 cases in 1996, with reports received from 18 of the 21 provinces. Of the 12 provinces that reported 27 cases of onchocerciasis in 1992, only 6 filed reports in 1996, for a total of 10 cases. The main foci were located in Esmeraldas; however, no new cases were reported there in 1995 or 1996.

In 1994 and 1995 no cases of jungle yellow fever were reported in the country, but in 1996 there were eight in Morona-Santiago. Of 24 cases of the hemorrhagic syndrome investigated in Morona-Santiago, 2 were seropositive for the oropuche virus; none of the patients had had a recent infection or prior exposure to the dengue or yellow fever virus.

No cases of poliomyelitis have been reported since 1990. Between 1992 and 1996 the number of confirmed cases of measles dropped from 4,356 to 40, and cases of neonatal tetanus went from 71 to 37. In 1996, vaccination coverage of infants under 1 year of age was higher than in any of the preceding five years (BCG, 100%; OPV3, 89%; DTP, 88%; and measles, 79%). During the same period, cumulative coverage with two doses of tetanus toxoid was 54% in women of reproductive age in 49 areas at risk for neonatal tetanus, compared with 20% in 1992. In 1995–1996 some cases of neonatal tetanus were detected in marginal urban areas of Guayaquil among mothers originally from indigenous areas of the province of Chimborazo who had migrated to the city only a few days before delivery.

There were epidemic outbreaks of diphtheria in 1994 (565 cases) and 1995 (145 cases) in the adult population in the provinces of El Oro and Pichincha. In 1996, however, only 22 cases were reported. In 1966 a total of 136 cases of whooping cough were reported, compared with 320 in 1992.

The earliest year for which information has been available on hepatitis B is 1994, when 443 cases were reported. In 1995 a total of 564 cases were reported, and in 1996 the figure was 569. Cholera has declined sharply since 1991, when the first case was detected and the number reached 46,320. In 1994 the disease was detected in 17 of the country’s 21 provinces. In 1996 a total of 1,060 cases were reported in 12 provinces, with 59% of the cases occurring in Imbabura. During 1992–1996 the case fatality rate from cholera remained lower than 1%.

The incidence of diarrheal diseases has remained stable. There were 193,352 cases in 1996. A total of 14,887 cases of salmonella were reported in 1996, for a rate of 127.3 per 100,000 inhabitants—almost 50% more than in 1992. Food poisoning of all types fell from 8,742 cases in 1995 to 6,992 in 1996. There were 598,558 cases of respiratory infections in 1996, capping a trend that has been rising steeply since 1992, when 138,684 cases were reported. Of the 65 human rabies cases reported in 1996, 20 were in the province of Pichincha and 13 were in Guayas. The remaining 32 cases were scattered among 11 provinces. Dogs are the principal source of human rabies infection.

Human cysticercosis increased from 111 cases in 1992 to 336 in 1996. In 1996 there were 186 new reported cases of AIDS/HIV infection, and the cumulative total since 1984, when the first case was reported, was 1,279 infected persons; 608 were classified as cases of AIDS, of whom 432 had died. Heterosexual transmission accounted for 37.7% of the infections; homosexual transmission for 29.2%; and bisexual transmission for 19.4%. Most of the 1,279 people infected were between 19 and 39 years of age, and more than 80% of them were men. In 1996, 21 persons were accidentally infected by HIV at a dialysis unit in Guayaquil—the one that serves the most people in the country.

Gonorrhea has been on the rise in recent years, with 7,703 cases reported in 1996. That year a total of 1,541 cases of syphilis and 87 cases of congenital syphilis were reported.

Chronic Communicable Diseases. Pulmonary tuberculosis showed a generally rising trend, with 7,938 new cases (67.91 per 100,000 inhabitants) in 1996. Cases were reported in all provinces.

There were 151 cases of leprosy reported in 1996. The average rate for the five-year period was 1.16 per 100,000 inhabitants. The only provinces with cases of leprosy in 1996 were Guayas (with the largest number), El Oro, Los Ríos, and Manabí on the coast, and Pichincha in the mountains. Of the new cases, 71% were multibacillary .

Noncommunicable Diseases and Other Health-Related Problems.

Cardiovascular and cerebrovascular diseases together accounted for 9,262 deaths in 1995 (80.8 per 100,000 inhabitants) and hypertensive disease was responsible for 2,216 deaths (19.3 per 100,000).

In 1996 there were 2,035 reported cases of rheumatic fever—2.4 times as many as in 1992. Surveys of the prevalence of streptococcal throat infections in schoolchildren showed rates ranging from 7% to 19%. In 1995 rheumatic fever caused 66 deaths, 37 of these in females and 29 in males. In 1995 the most frequent site of malignant tumors was the stomach, which accounted for 804 deaths in men (14.0 per 100,000 inhabitants) and 644 in women (11.2 per 100,000). In males, tumors of the prostate were responsible for 333 deaths and lung cancer was responsible for 250. In women, tumors of the uterine cervix (plus unspecified tumors of the uterus) caused 676 deaths, and breast cancer was responsible for 243.

Nutritional Diseases and Diseases of Metabolism. The only data available on protein-energy malnutrition in children under 5 years of age that use the Ministry’s services. They reveal the following rates: in infants under 1 year of age, 10.7% had low weight-for-age—i.e., between –2 and –3 standard deviations (SD)—and 2.5% were below –3 SD; of the children 1 to 4 years old, 21.1% were between –2 and –3 SD and 4.94% were below –3 SD. The mean incidence of low weight-for-age in infants under 1 year of age was 13.26% for the country as a whole and reached a high of 25.60% in the province of Carchi. Eight of the 18 provinces covered by SISVAN were above the median. In very poor provinces such as Chimborazo, the prevalence of low weight-for-age in children 1 to 4 years of age was 40%, compared with a national average of 26%. Six of the 18 provinces covered were above the national average.

In 1993 serum retinol deficiency (lower than 20 µg/dl) was reported in 17.7% of the children between 12 and 59 months of age in populations living in poverty, with prevalences ranging from 9.6% to 25.6%. Several studies have confirmed that vitamin A deficiency is a moderately serious problem and is mainly found in certain extremely poor areas.

The system for the surveillance of iodine deficiency reports that in 1995, 94% of the salt samples collected had iodine levels greater than 20 ppm. According to ENDEMAIN-94, between 1990 and 1994, 95% of all live-born infants were initially breast-fed; 36% of those breast-fed babies began to nurse during the first hour of life and 43.5% began to nurse during the first day. The median duration of exclusive breast-feeding was 2 months in the country as a whole, varying from 3.8 months in the rural mountains to 1 month on the coast.

Accidents and Violence. Accidents and various forms of violence were responsible for 7,465 deaths in 1995 (65.1 per 100,000 inhabitants), predominating in men at a ratio of 4:1. These deaths represent an estimated 192,148 and 44,805 years of potential life lost (YPLL) in men and women, respectively. Traffic accidents and homicides are mainly responsible for these deaths, especially in the male population.

Behavioral Disorders. Mental illness was the reason for 5,291 hospitalizations of men in 1995 (9.2 per 10,000 inhabitants). Alcoholism has a prevalence of 7.7% in the population over 15 years of age. Tobacco use is associated with 6.0% of general mortality.

Prevalence of the use of illegal drugs was 3.2% in youths between the ages of 12 and 19, 6.0% in the population aged 20 to 29, 7.7% among those in the 30-to-39 age group, and 3.3 % among persons aged 40 to 49. There is a striking difference between the sexes in the rates of illegal drug use: 10.3 % among men versus 0.9% among women, or a ratio of 11.4:1.

Oral Health. In 1996 an epidemiological study of oral health in public schoolchildren aged 6, 7, 8, 12, and 15 in urban and rural areas showed that at the age of 6 years 87% of the children had caries and at age 12 the rate was 85%. The DMFT index in the group of 6-year-olds was 0.22, and in the 12-year-olds it was 2.95. A reduction observed compared with the indexes for 1988 (DMFT 0.70 and 5.00, respectively).

Natural Disasters. The drought that has affected the provinces of Loja and El Oro in the southeast since 1995 has become a national emergency. In this area, otherwise ideal for agriculture, the scarcity of rain and the lowering of the river levels has seriously hurt the local economy and forced many residents to emigrate. At the same time, the agricultural areas on the coast are flooded every year, and the 1997 floods affected all the coastal provinces. High surf caused major damage in the province of Esmeraldas in the north of this region. By the end of March 1997 the heaviest rainfall in 10 years was recorded, which in the province of Guayas flooded 80% of the territory, caused two deaths, was responsible for countless missing persons, and left some 12,000 people affected by the damage.

RESPONSE OF THE HEALTH SYSTEM

National Health Plans and Policies

The social security reform proposed by the National Modernization Council during 1992–1996 included the reform of medical services. By eliminating the compulsory inscription of formal workers in the public insurance system (IESS), it was possible to set up competition between public and private providers. The National Health Council, presided over by the Ministry of Health, introduced an alternative national proposal involving the participation of all institutions in the public and private sectors and of civilian society at the central, provincial, and local levels. Basically, it calls for the organization of a national health system in which the Ministry of Health is both leader and regulator, assumes responsibility for public health actions, and implements a health insurance scheme to expand medical care coverage based on the principles of equity and partnership and on decentralized management.

In June 1993 the project Strengthening and Extension of Basic Health Services in Ecuador (FASBASE) was launched in 41 priority areas. This project is based on the primary health care policy that has been promoted by the Ministry of Public Health since 1988. Beginning in 1995 it has included a component for improving emergency services in urban areas. As of mid-1997 work began on developing a new project, Modernization and Development of Integrated Health Services Networks (MODERSA).

Organization of the Health Sector

Institutional Organization

The health sector is composed of various public and private institutions, both nonprofit and for-profit, which are very loosely coordinated by the National Health Council.

The public subsector consists of the Ministry of Public Health, the IESS, the Public Health Service of the Armed Forces and Police, the National Child and Family Institute, and the Ministry of Social Welfare. Private autonomous institutions with a social mandate may also be included—most notably, the Guayaquil Welfare Board, the Guayaquil Child Protection Society, and the Society to Combat Cancer. Altogether, the public subsector attends to the needs of approximately 59% of the population, especially in terms of hospital care. It is estimated that the Ministry of Public Health covers 31% of the population; social security, 18%; the Guayaquil Welfare Board, the Society to Combat Cancer, and other nonprofit private institutions, 10%; the Armed Forces and Police, 1%; and various private for-profit enterprises, 10%; the remaining 30% do not receive any formal medical care.

Private for-profit organizations have hospital establishments of varying levels of complexity, physicians’ offices, and auxiliary diagnostic and treatment services for the population that is able to pay for them. They include both insurers and private prepaid medical enterprises. A considerable portion of the population—mainly those with limited resources and especially people living in rural areas—use traditional medicine.

The principal agencies in the sector—namely, the Ministry of Public Health and the IESS—use different decentralization models. The Ministry’s model is based on health areas that constitute small service networks with set geographic and population catchments and on a scheme of technical decentralization and deconcentration of certain administrative activities and budgetary planning and execution.. The IESS, for its part, is decentralizing its administrative aspects at the level of large regions. This subsector has a complex structure because its primary objective is to manage various types of insurances and benefits—of which health is only one.

Certification and Practice of the Health Professions. Under the Health Code currently in effect, the Ministry of Public Health’s Public Health Control Bureau is the agency responsible for regulating provision of health services in general. An amendment to the Health Code currently under study includes a proposal for the codification of all legal aspects related to medical practice.

Control of Medical Technology, Drugs, and Other Supplies. Three somewhat overlapping mechanisms are used to handle the public drug supply: procurement through the National Drug and Medical Supply Center (2% to 6% of the total value); direct imports (10% to 20%), mainly by the IESS, the Society to Combat Cancer, and the Guayaquil Welfare Board; and local purchases (74% to 88%). Lack of definition of the scope and responsibilities of the various entities involved in setting, reviewing, and controlling prices has hampered regulation of the drug market and the health services. No mechanisms are in place to protect the consumer.

The quality control of drugs has improved noticeably in both the private and the public sectors thanks to the application of Good Manufacturing Practices and also to export and production opportunities being offered to third parties under license.

Environmental Regulation. The Environmental Unit of the National Development Council (CONADE), with support from the Inter-American Development Bank (IDB), executes projects and drafts policies that incorporate environmental strategy in the national development plans. There are two sectoral environmental policies: one on drinking water and basic sanitation, and the other on environmental education for sustainable development. Provisions have been developed that strengthen environmental requirements in connection with the use of hydrocarbons, and these are expressly included in new contracts. The Consultative Committee on Chemical Substances and the National Toxicology Commission have promoted the development of a draft law on chemicals. The private sector, through the Association of Importers and Formulators of Agricultural Chemicals, participates in the National Program on the Rational Use of Agricultural Chemicals. The Industrial Association, for its part, supports activities that promote the appropriate management of industrial chemicals.

Food Safety. The Ministry of Industry, Commerce, Integration, and Fishing, working through the Ecuadorian Institute of Standards, is the agency responsible for sanitary standardization and quality control of food.

Health Services and Resources

Organization of Services for Care of the Population

Of the 205 existing municipios in 1997, 7 were taking part in the Healthy Municipios Movement: Tena, Riobamba, Portoviejo, Ibarra, Cuenca, Loja, and Quito. The movement’s line of action centers around development activities, one of the fundamental axes of which is health.

Disease Prevention and Control Programs. The Ministry of Public Health executes national programs for prevention, control, or eradication of the main public health problems. The initiatives address problems such as tuberculosis, public health dermatology (including leprosy and leishmaniasis), tropical diseases (malaria, Chagas’ disease, dengue, and onchocerciasis), rabies, AIDS and other STDs, chronic noncommunicable diseases (especially cancer), and cholera; the National Vaccination Program is also included among the initiatives. The strategy of Comprehensive Care for Diseases Prevalent in Childhood (AIEPI), initiated in 1996, is mainly designed to improve the treatment of children with acute respiratory infections and diarrhea and to reduce mortality in high-risk areas.

Epidemiological Surveillance and Public Health Laboratory System. Between 1992 and 1995 there was an obvious lack of systematized epidemiological information at the various levels of care under the Ministry of Public Health. In 1997 surveillance was standardized, reports were being duly submitted, and other health institutions (IESS, the Police health services) were incorporated in the surveillance system with a view to improving the existing system and promoting epidemiological research.

Environmental Quality Control. Water resources are increasingly being contaminated by coliforms and sediment produced by the uncontrolled dumping of various effluents into waterways that flow through cities or areas devoted to oil exploration, mining, agroindustry, or agricultural exports. There has been a large increase in air pollution, especially in the major cities such as Quito and Guayaquil; this is due to emissions from automotive vehicles and industries. The housing deficit is estimated at 500,000 dwellings in the urban sector and 700,000 in rural areas.

Drinking Water Supply and Sewerage Services. In 1996 water supply services reached 69.7% of the population, and sewerage services reached only 41.7%. The urban populations had better coverage levels (81.5% and 61.4%, respectively) than people living in rural areas (50.9 % and 10.4%). Between 1992 and 1996 programs were implemented to build latrines for 1,841,000 inhabitants, which benefited 9.1% of the urban and 26.3% of the rural population.

Management of Municipal Solid Waste, Including Hospital Waste. In the country as a whole the collection of solid waste corresponds to an average of 51.6 % (69.6% in the cities and 7.5% in rural areas) of all the waste actually produced. Much of this waste is deposited in dumps, ravines, and estuaries.

Food Safety. The Ministry of Health, through the Bureau of Pharmacy and Sanitation Control, Food Control Division, implements policies on food quality control. In 1996 the National Epidemiology Bureau inaugurated the System for the Epidemiological Surveillance of Foodborne Diseases as part of the hemisphere-wide surveillance system for foodborne diseases.

Health Promotion, Food Aid, and Disaster Preparedness.

In the area of disaster preparedness, moderate progress has been made under a program the Ministry of Public Health has been running for several years. Its activities have consisted mainly of regular drills in hospitals to test contingency plans, coordination among health sector agencies, and introduction of disaster mitigation in public health activities. At the end of 1996, the civil defense promoted new initiatives to improve coordination among the various agencies. Several universities have included the subject of disasters in their curricula. The Ecuadorian Red Cross and other nongovernmental relief organizations have programs on disaster preparedness.

A declining trend in international food aid was seen in 1990–1995: the World Food Program reduced its contribution from US$ 1,671,176 in 1992 to $91,596 in 1994, in part because of the country’s reduced management capacity. The principal donors have been Canada, the United States of America, and the European Union. In recent years the World Food Program has been the only source of food donated for direct distribution; its cooperation represents 36% of total food aid.

The 1980s saw a mushrooming of nongovernmental health organizations. Their activities focus on community development, women’s development, health care, research, and training. In general they perform their work independently and have not yet coordinated it with the Ministry of Health.

Organization and Operation of Personal Health Care Services

Health Services. In 1995 there were 3,462 health establishments, 2,988 (86.3%) without beds and 474 with beds. Of the former, 51.4% came under the Ministry of Public Health, 32.6% under the IESS and Farmers Social Security; and the remaining 16% under other institutions in the health sector. Of the establishments with beds, 26 % belonged to the Ministry of Public Health, 62.7% were in the private sector, and the rest corresponded to other institutions. The total number of health establishments in operation includes general, specialized, and canton hospitals plus private clinics. Those without beds include health centers and subcenters, health posts, and doctors’ clinics. Most of the establishments with beds are located in the cities, whereas 57.1% of those without beds are in the cities and 42.9% are in rural areas.

In terms of hospital beds, as of 1995 the normal number was 18,873. There were 17,804 available beds, distributed as follows: Ministry of Public Health, 7,812 (43.9%); Guayaquil Welfare Board and Child Protection Society, 2,580 (14.5%); IESS, 1,839 (10.3%); Ministry of Defense, 916 (5.1%); Society to Combat Cancer, municipalities, and Police health services, 624 (3.5%); and the private sector, 4,033 (22.6%).

Inputs for Health

Drugs. Of 32 drug-producing factories in Quito and Guayaquil, 28% belong to transnational enterprises that manufacture 60% of the products consumed locally and the rest make adaptations of products for local consumption (65%) and for third parties (35%). Between 25% and 30% of Ecuador’s drug production is exported to Latin American countries. In the 1990s the drug market saw an average annual growth of 4.5% in terms of quantity and 22% in terms of value. Imports, which are favored by the pricing policy, take care of 30% to 40% of the market’s needs and increase each year at a rate of 10%. The value of the drug market averages US$ 220 million a year, or some 70 million units sold, of which 61% are brand-name products and 36% are new items. Almost all the products are imported.

The market for medical supplies is valued at US$ 30 million, and encompasses an indeterminate number of providers. Only 21.5% of the population has access to drugs. In urban areas, monthly household expenditures on health increased from 42 % of household income in 1991 to 54% in 1995, and half of this amount is for drugs.

Immunobiological Products. Local production of BCG, DTP (diphtheria, tetanus, whooping cough), DT, and tetanus toxoid vaccines by the National Institute of Hygiene and Tropical Medicine takes care of 30% to 40% of the annual demand, and the rest of the biologicals have to be imported to meet the needs of the Immunization Program. The measles and poliomyelitis vaccines, which are not produced in the country, are imported through the PAHO/WHO Revolving Fund, as are diphtheria and tetanus antitoxins.

Human Resources.

In 1995 the number of employees in health institutions by occupational category per 10,000 inhabitants was as follows: physicians, 13.3; nurses, 4.6; dentists, 1.6; midwives, 0.7; nursing aides, 11.8. In considering these rates, the unequal distribution of human resources should be kept in mind—larger concentrations are found in the mountain region. Also, the concentration of resources is related to the economic development of the provinces: 63.2 % of all health personnel are found in the country’s most developed provinces—namely, Guayas, Pichincha, and Azuay. There is a gap between the supply and the demand for human resources. In the 1980s, of 1,000 aspiring physicians, only 245 graduated, of which 122 were able to secure a residency in a health institution and only 75 finally obtained a position in the sector’s labor market. Of 1,000 aspiring dentists enrolled in the first year of dental school, 326 graduated and only 50 were able to find a job. In nursing, of 1,000 students enrolled in the first year, 150 graduated and 141 found jobs. Salaries do not keep up with inflation, which leads to a rapid decline in purchasing power and ultimately to labor disputes based on demands by the various professional groups and other workers in the public health institutions. The dispute beginning in mid-April 1997 lasted for more than 11 weeks.

The government budget for research is scarcely 0.1% of the gross national product (GNP) and there is no structured national science and technology system. Many of the research projects are based on the investigators’ personal interests, and most of the studies are carried out in the public sector, mainly in the universities.

Expenditures and Sectoral Financing.

Information on health care spending is not very recent, reliable, or complete, especially as far as the private sector is concerned. The data available indicate that public spending on health as a percentage of total government expenditure fell from 5.5% in 1992 to 4.6% in 1996. In addition to the meager amount, the distribution of these moneys is clearly inequitable and their utilization is inefficient and centralized.

Private spending increased, on the other hand, while government spending was declining, thanks to the fiscal crisis and adjustment programs that greatly reduced allocations to the social sector (from 7.8 % of GDP in 1992 to 5.2% in 1996). In the Ministry of Public Health, spending as a percentage of GDP fell from 1.0% in 1985 to 0.75% in 1995. Within the public sector, there is an immense difference between the per capita expenditure for each general IESS beneficiary (US$ 117 in 1994) and that of the Ministry of Public Health ($15), as well as that of a beneficiary under the Farmers Social Security ($17). In general, the IESS expenditures on medical benefits have remained steady, with a slightly rising trend.

According to recent household surveys conducted by the National Institute of Statistics and Census (INEC), as of 1995, 54% of private or direct spending went for drugs, compared with 42% in 1991. The next highest category was spending on office visits—22% in 1995 compared with 26 % in 1991. Spending on hospitalization in 1995 represented 9%, much lower than it was in 1991 (25%), which may reflect a drop in demand because of the rising costs (both direct and indirect) and the growing trend in self-medication. In addition, 9% went for equipment, including prostheses and other related items, compared with 5% in 1991; the purchase of private insurance represented 6% in 1995 versus 2% in 1991.

External Technical and Financial Cooperation.

During 1992–1997 the World Bank granted loans for development and implementation of the FASBASE project to extend coverage and improve basic services for the most vulnerable urban and rural groups. Of the total amount of US$ 102 million (including 30% in funds from the national Government), the sum of $25 million had been executed as of July 1997. The MODERSA project, for the organization of service networks including hospitals, received $30 million from the World Bank. The Environmental Management Technical Assistance project, in turn, has $15 million from the World Bank ($5 million from the national Government).

IDB has contributed nearly US$ 2 million toward a proposal to restructure the IESS medical care system and modernize the management of its hospital system. The Bank also contributed $1 million to the National Modernization Council for a project to update the drinking water and sanitation sector. The formulation of policies for science and technology has been funded in the amount of $30 million, of which $23 million comes from an IDB loan and $7 million from the national Government.

The National Rural Basic Sanitation Plan (SANEBAR) has received support from the Government of Spain in the amount of US$ 30,000, and the program for cholera prevention, public health education, and latrine-building received $400,000 from the Government of Sweden. The program for the control of cholera and diarrheal diseases, in turn, benefited by a contribution from the European Union to strengthen laboratories that do clinical analysis and epidemiological surveillance.

USAID has provided approximately US$ 2 million for projects to improve management capacity in the Ministry of Public Health, information systems, the cost and quality of services, and maternal and child care programs.

Belgian Cooperation contributed US$ 1 million to support consolidation of the endemic goiter control program with the design and implementation of alternative primary health care models.

The second phase (1997–2000) of the project to assist in formulation of the national drug policy (Ecuador/PAHO/
WHO/Netherlands) has benefited from a donation of US$ 900,000 for the development of drug treatment programs in the southern part of the country. The Netherlands provided $1.6 million toward the subregional project for the control of violence against women, which was in its second year in 1997.

The "Healthy Spaces" project, initiated in 1997 in four depressed cantons in the province of Loja, has received nearly US$ 4 million from the Netherlands Cooperation Agency.

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