Pan American Health Organization

Ecuador

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of EcuadorThe Republic of Ecuador, located in northwestern South America, borders on Colombia, Peru, and the Pacific Ocean. It covers an area of 256,370 km2 and is divided into four regions—coastal, mountain, Amazon, and island. Political divisions include 24 provinces and 269 cantons, with their respective parishes. In 2008, a constitutional mandate (Articles 279 and 280 of the Constitution) () created the National Decentralized Participatory Planning System. This system has a broad sphere of action for national planning, focused on guaranteeing rights, coordinating public administration, integrating and coordinating the deconcentrated and decentralized areas of government, connecting sectoral and territorial authorities, and integrating the State’s actions at the national level. The system has facilitated territorial reorganization, and governs all sectors, including health, at various administrative levels: 9 administrative regions, 140 districts with some 90,000 inhabitants, and 1,134 circuits with approximately 11,000 inhabitants ().

Demographics

The 2010 Population Census put Ecuador’s total population at 14,483,499. In 2015, the population figure given by the National Institute of Statistics and Censuses (INEC) was 16,278,844. The multi-ethnic and multicultural population includes the following segments: mestizo (71.9%), montubio (7.4%), Afro-Ecuadorian (7.2%), indigenous (7.0%), white (6.1%), and other (0.4%) (). Population growth has declined steadily, with an average annual rate of 1.37%; there were 15,012,228 inhabitants in 2010 and 16,528,730 in 2016. (). Figure 1 shows the evolution of Ecuador’s population structure between 1990 and 2015.

Figure 1. Population structure, by age and sex, Ecuador, 1990 y 2015

Between 1990 and 2015, the population grew 56.6%. In 1990, the population structure presented an overall expansive pyramidal structure, with age groups under 25 years old predominating. By 2015, that structure had shifted to the age groups older than 25 years, with groups under that age presenting an intermediate structure (between expansive and stationary), as a result of declining fertility and mortality rates and an older population; both trends accelerated in the last two decades.

Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Population Division. New York; 2015.

According to the 2010 census, life expectancy at birth was 75 years; by 2016 this had increased to 76.4 years (73.7 for men and 79.1 for women) (). The overall (corrected) death rate was 6.0 per 1,000 population in 2014 (). Infant mortality fell from 15.4 per 1,000 live births in 2000 to 8.4 in 2014 (). The overall fertility rate dropped from 3.26 children per woman of childbearing age in 2000 to 2.29 in 2015 (). According to the National Health and Nutrition Survey (ENSANUT 2012), the fertility rate was highest in women with no schooling (4.4), followed by women in the poorest economic quintile (4.1), indigenous women (4.4), and Afro-Ecuadorian women (4.0). Indigenous and Afro-Ecuadorian women also had the highest rates of non-use of contraceptives (30.7% and 34.0%, respectively) (). In 2010-2015, the birth rate fell from 19.4 to 14.3 per 1,000 inhabitants ().

The Economy

Between 2008 and 2014, the country experienced economic growth, with average annual increases of 4.6% in gross domestic product (GDP). High oil prices, external financing flows, and improved tax collection contributed to this growth (). However, there was an economic slowdown in late 2014, caused principally by a steep decline in the price of oil, difficulty in accessing new sources of financing, and appreciation of the US dollar. GDP grew by 3.8% in 2014, with per capita PPP at US$11,190.

Ecuador has signed several bilateral or multilateral trade agreements that make it a member of different economic blocs, giving the country total or partial tariff preference for marketing its products abroad. The most important of these agreements is with China. The economic blocs of which Ecuador is a member are the Latin American Integration Association (LAIA), the Andean Community (CAN), and the Global System of Trade Preferences among Developing Countries (GSTP).

Violence and Security

In 2011, the National Comprehensive Security Plan was implemented, making the citizenry the leading actor in bringing about individual and collective security. The ECU-911 Integrated Security System was also established to respond to citizen emergencies through video surveillance and alarm monitoring. When an event occurs, specialized resources are immediately sent from public and private agencies that form part of the security system. As a result of these measures, the homicide rate dropped from 17.8 per 100,000 population in 2006 to 10.8 in 2013 ().

Social Determinants of Health

In 2016, Ecuador devoted 2% of GDP to education. In 2010, there were 676,945 individuals over 15 years of age who were illiterate (6.8% of the population between the ages of 15 and 39); between 2011 and 2013, this figure dropped to 324,500 individuals. The primary school attendance rate in the 5- to 14-year-old population increased steadily, from 94.6% in 2010 to 96.3% in December 2015, while the net high school attendance rate was 65.1%. In 2015, the gap between school attendance in the poorest quintile (95.5%) and attendance in the wealthiest quintile (98.1%) was 2.6 percentage points ().

Poverty rates declined between 2008 and 2014, from 37.6% to 22.5%, while the Gini coefficient fell from 0.54 to 0.47 (). In 2015, the government proposed a multidimensional poverty index, according to which poverty in Ecuador decreased by 16.5 percentage points between 2009 (51.5%) and 2015 (35.0%), a reduction of 1.9 million in Ecuador’s poor population. In 2014, with the start of the economic slowdown, poverty increased slightly—from 22.5% in 2014 to 23.3% in 2015—due to a rise in rural poverty, which increased from 35.3% to 39.3% ().

With regard to employment, the INEC report put the economically active population (EAP) at 46% for 2015, 1.8 percentage points lower than the 2014 figure of 47.8%, while the unemployment rate rose from 3.9% in 2014 to 4.3% in 2015. The percentage of adequate employment was 45.9% of the EAP in 2015; the national unemployment rate was 4.5%, higher among women (5.7%) than among men (3.6%) ().

The Health System

The health system in Ecuador consists of two subsystems: public and private. The public subsystem includes the Social Security system and the institutions of the MoH: the Ecuadorian Social Security Institute (IESS), which includes Rural Social Security; the Armed Forces; the National Police; and the health services of some municipalities. Private entities operating within the public sector include the Welfare Board of Guayaquil, the Child Protection Association of Guayaquil, the Cancer Society, and the Ecuadorian Red Cross. The MoH spearheads the processes defined in the government’s health policies. It follows the lines set forth by the National Secretariat of Planning and Development (SENPLADES) and implements the system’s Integrated Health Care Model (MAIS) ().

Public services are funded by the State’s general budget, extrabudgetary funds, emergency and contingency funds, and funds from national and international projects and agreements. The institutional management model and budgetary structure are linked via the internet, through the Integrated Financial Management System of the Ministry of Finance and through the new SENPLADES planning model. Overall health spending rose from US$1.153 billion in 2010 to US$ 2.570 billion in 2015, representing 9.2% of GDP (). Social security services for workers are funded by contributions from affiliated workers, insured under the Social Security Law as an Ecuadorian workers’ protection right, and are guaranteed by the IESS under various regimes: Compulsory General Insurance, Rural Social Security, and Voluntary Insurance. In 2007, the system had 1,518,164 members, a number that grew to 2,951,639 by 2013 and to 3,123,467 by 2014 (). Social security services for the military and for police officers are financed by member contributions, while access to health services is guaranteed by the Social Security Institutes of the Armed Forces and of the Police, and applies to any establishment of the RPIS or, if necessary, to the auxiliary network. An additional funding source is the Public Traffic Accident System, which levies vehicle registration fees and specifically covers expenditures related to traffic accidents by both the RPIS and the auxiliary network.

Private services are financed by selling care services to the public sector, by private health insurers, and by prepaid medical insurance. Private health insurers and companies offering prepaid medical insurance cover 3% of the medium- and high-income population.

Leading Health Challenges

Critical Health Problems

Emerging Diseases

In 2014, deaths from tuberculosis (TB) were 2.79 per 100,000 population, with 5,157 new cases detected. A number of factors contribute to the difficulty in controlling this disease. These include medically-focused health care and insufficient analysis of health determinants. The number of undetected cases of TB is significant, with 3,443 cases estimated in 2014 (). Large cities such as Guayaquil and other coastal cities account for 70% of cases in vulnerable peri-urban populations with insufficient access to health services.

The prevalence of HIV/AIDS remained stable between 2007 and 2014, and was estimated at 0.4% in the latter year. The epidemic primarily affects female transsexuals (31.9% in Quito) and men who have sex with men (11.0% in Quito and Guayaquil). Prevalence among pregnant women was 0.18% in 2014 (). That year, there were 5.2 deaths from HIV per 100,000 population at the national level; however, the real figure could be greater, given the underreporting of deaths associated with HIV. In addition to these realities, access to treatment and treatment compliance were problematic, since only 57% of the total estimated population with HIV (33,569 people) were aware of their condition; of the 19,134 people with confirmed HIV, 14,844 (78%) were living with the disease and receiving treatment in the public health system, but only 7,300 (49%) had undetectable viral loads. This situation was the result of low compliance with treatment (less than 50% of those diagnosed) and with interruptions in the supply of antiretroviral drugs ().

By 2013, at the national level, the number of households with access to drinking water was 90%, with 80% of households having access to sanitation. However, the incidence of diseases associated with environmental and living conditions remained high (Table 1) (). Intestinal parasitoses were the second most frequent reason for visits to public health services, accounting for 17.5% of all consultations (n = 423,483) in the 5-to-9-year-old age group, while the third most frequent diagnosis registered upon hospital discharge consisted of diarrheal diseases and gastroenteritis of presumed infectious origin (30,269 discharges, constituting 2.5% of the total), problems particularly affecting children under the age of 5 (). In 2014, pneumonia was the third-leading cause of infant mortality (under age 1): 171.09 per 100,000 live births. This disease was associated with malnutrition (36.3%), family poverty (35.1%), and overcrowding (22.5%) ().

Table 1. Proportion of households with access to basic services, Ecuador, 2010-2014

  Percentage of households (%)
Year Sanitation Water supply Solid waste collection
2010 82.3 81.2 75.8
2011 82.1 81.1 74.9
2012 85.0 82.7 76.1
2013 85.3 84.0 81.1
2014 88.5 93.3 83.9

Source: National Institute of Statistics and Censuses (INEC). Statistical compendium 2014. Ecuador: INEC; 2014.

Maternal mortality

The maternal mortality ratio (MMR) was 49.16 per 100,000 live births in 2014––meeting neither the 75% reduction target set in the Millennium Development Goals (MDGs) nor the target proposed by the MoH in the National Plan for Good Living, which called for reducing the figure by 72% between 2011 and 2015. In 2014, the MoH identified difficulty in the early detection of obstetric risk, due primarily to the low concentration of prenatal check-ups and the low coverage rate (24.6%) ().

The principal risk factors for maternal mortality were lack of prenatal check-ups and inadequate postpartum care. According to ENSANUT 2012, 23.4% of indigenous mothers reported not having had prenatal check-ups, while only 8.4% had postpartum checkups during the first seven days, while 37.6% had checkups between eight and 40 days after delivery ().

Teenage pregnancy

In 2014, the age-specific birth rate among adolescents ages 15 to 19 was 55.5 per 1,000 women. In that year, the pregnancy rate among adolescents between the ages of 10 and 14 was 1.8 per 1,000 women, while the rate among adolescents ages 15 to 17 was 39.1 per 1,000 (). Pregnancy is frequently the result of sexual abuse; six out of 10 rape victims are girls, boys, and adolescents ().

Malnutrition

Nutritional deficits and excess nutrition remained problems in 2016, despite the country’s success in reducing poverty related to unmet basic needs, controlling the food served in school lunchrooms, and raising taxes on sugary beverages. In 2014, the rate of chronic malnutrition (height/age) was 24.8%; approximately 8% of children between 0 and 60 months of age were overweight or obese; 21.6% were at risk of becoming overweight; and 29.9% of the total primary school-age population (ages 6 to 11) suffered from overweight or obesity ().

Chronic Conditions

Noncommunicable chronic diseases (NCD) contributed more than any other category of illness to mortality in 2014. The 10 leading causes of death include cardiovascular disease, diabetes mellitus, and neoplasms (Table 2) (), all of which were most prevalent in the 30-to-64-year-old age group and were associated with unhealthy lifestyles and behaviors that fostered metabolic and physiological changes.

Table 2. Leading causes of death, Ecuador, 2014

Codea Cause of death No. % Rateb
I20-I25 Ischemic heart disease 4,430 7.0 27.64
E10-E14 Diabetes mellitus 4,401 6.9 27.46
I60-I69 Cerebrovascular diseases 3,777 6.0 23.57
I10-I15 Hypertensive diseases 3,572 5.6 22.29
J10-J18 Flu and pneumonia 3,418 5.4 21.33
V00-V89 Land transport accidents 3,059 4.8 19.09
K70-K76 Cirrhosis and other diseases of the liver 2,038 3.2 12.72
N00-N39 Diseases of the genitourinary system 1,712 2.7 10.68
J40-J47 Chronic diseases of the respiratory system 1,656 2.6 10.33
C16 Malignant neoplasms 1,585 2.5 9.89

a International Statistical Classification of Diseases and Related Health Problems, tenth revision.
b Rate per 100,000 population.
Source: National Institute of Statistics and Censuses (INEC). Statistical compendium 2014. Ecuador: INEC; 2014.

Diabetes Mellitus

In 2014, this was the second leading cause of death in the general population, with 4,401 cases (6.9%), a figure twice the 2000 level (2,533 cases) (). Adjusted mortality in 2013 was 48.3 per 1,000 population, much higher than the regional rate for the Americas (1.9) and higher than the estimated rate for the Andean subregion (31.8) for the same year. According to ENSANUT 2012, 65% of cases of chronic renal failure are attributable to diabetes and hypertension (), which also contributed to the death rate from urinary-system diseases (2.7%). Chronic renal failure affected 9,635 patients, representing a cost of US$168,342,720.

Cirrhosis and other Diseases of the Liver

These diseases were the seventh leading cause of mortality in 2014, with 12.72 deaths per 100,000 inhabitants. Incidence was greater in men (15.50) than in women (9.98). Cirrhosis associated with excessive alcohol ingestion was four times greater among men (33%) than among women (9.5%) ().

Malignant Neoplasms

In 2014, these were a major cause of mortality in the population. Among women, neoplasms of the breast (6.43 per 100,000 women) and cervix (8.90 per 100,000 women) were the most common. Screening to detect these preventable diseases was limited: only 36.4% of women between the ages of 15 and 49 had received breast exams, with 14.5% having been given mammograms (). Moreover, 30.5% of these women had never had a cervical cytology, this figure being highest among women with no schooling (34.6%) and those in the poorest quintile (43.2%). Among men, the most frequent malignant neoplasm was of the prostate, with an incidence of 37.8 cases per 100,000 population; specific mortality was 10.49 per 100,000 men ().

Human Resources

Beginning in 2012, the MoH carried out reforms involving human resources in health, as a part of implementing the new MAIS. As a first step, major human resources gaps in health were identified, particularly the number of health professionals working at the primary care level (family doctors and technical personnel).

The large budget allocated to health between 2008 until 2015, and the program to encourage the return of professionals living abroad (1,948 returned in 2014), contributed to a greater availability of health professionals. In 2014, available physicians numbered 20.35 per 10,000 population, and nursing personnel 10.14 per 10,000. The sum of the two groups exceeded the regional goal for total density of human resources in health for 2007-2015 (25 per 10,000 population). Nevertheless, the availability of specialist physicians and dentists is low, and the allocation of resources remains inequitable in different parts of the country: in urban areas there were 29.01 physicians per 100,000 inhabitants, while the rural rate was 5.42 per 100,000, with uneven distribution between provinces (e.g. 13.04 in Esmeraldas and 26.03 in Pichincha). In 2014, the majority of health professionals (71.5%) worked in the public sector; 60.7% of them for the MoH (Table 3).

Table 3. Personnel working in health facilities, by specialty and type of area (urban/rural), Ecuador, 2014

  Physicians  
Area/Rate Total Specialists Generalists Graduates Residents Rural Obstetricians Dentistsa Nursing personnel Other professionalsb
Urban area 107,461 15,939 6,256 1,203 4,593 1,442 1,703 3,081 14,397 3,703
Rural area 11,833 532 1,022 69 136 1,427 504 1,396 1,853 334
Urban rates 105.9 15.7 6.2 1.2 4.5 1.4 1.7 3 14.2 3.6
Rural rates 20.1 0.9 1.7 0.1 0.2 2.4 0.9 2.4 3.2 0.6
Differential 85.8 14.8 4.4 1.1 4.3 -1 0.8 0.7 11 3.1
Total 119,294 16,471 7,278 1,272 4,729 2,869 2,207 4,477 16,250 4,037

a Includes general dentists, specialists, and rural dentists.
b Includes biochemists, pharmaceutical chemists, nutritionists, psychologists, health educators, sanitary engineers, social workers, environmental engineers, and others (industrial psychologists, public relations specialists, etc.).
Source: National Institute of Statistics and Censuses (INEC). Yearbook of Health Statistics: resources and activities; 2014. Available at: http:/www.ecuadorencifras.gob.ec/documentos/web-inec/Estadisticas_Sociales/Rec ursos_Actividades_de_Salud/Publicaciones/&Anuario_Rec_Act_Salud_20 &14.pdf. Accessed 30 May 2017.

With regard to human resource policy, the MoH, in coordination with the Ministry of Labor, made progress on proposed educational requirements for health degrees, and on reviewing the Technical Standard for Continuing Education, which is expected to soon be approved. Eight universities are providing training for family and community medicine professionals, with 454 people having graduated in 2016.

Health Knowledge, Technology, and Information

Health information technology

In 2016, health-related research was financed by the Secretariat of Higher Education, Science, Technology, and Innovation (SENESCYT), and by universities and international organizations. In 2012, the MoH, in coordination with SENECYT, created the National Public Health Research Institute as a specialized entity carrying out research in science, technology, and innovation in the health sector. In Ecuador, 11 universities offered graduate-level degrees in health research, and 15 produced major scientific output in this field.

The Environment and human security

In 2010, 71.8 million tons of CO2 were released in the country, constituting 0.1% of world emissions of this greenhouse gas. These emissions were attributable primarily to the energy sector, which accounted for 50%, with agriculture, forestry, and other land uses accounting for 43%. The lack of scientists and research programs focused on climate change and climate variability make it difficult to address this problem.

Emergencies and natural disasters, caused mainly by eruptions and severe winter conditions, caused US$237.9 million in losses in 2012. This is equivalent to 4.6% of the annual investment plan, or 1.3% of the State’s general budget. In 2013, 113 tsunami flood maps for 97 coastal localities were completed, along with maps of flood and mass displacement threats for 98% of the country’s cantons.

Ecuador is prone to natural disasters, due to the presence of volcanic eruptions, earthquakes, and tsunamis, and its fragile and diverse ecosystems are highly susceptible to climate change and climate variability. To address this situation, the National Decentralized Risk Management System was established in the 2008 Constitution, and the National Secretariat of Risk Management was created in 2009 to oversee natural risk and disaster monitoring and response ().

In 2015, the government declared a national state of emergency due to the eruption of the Cotopaxi and Tungurahua volcanoes, and allocated US$500 million for emergency response. Income from tourism was affected by these events, and the agricultural sector suffered millions of dollars of losses resulting from the ash expelled by the volcanoes. In April 2016, an earthquake struck the Ecuadorian coast, and US$3.344 billion was required to rebuild the affected areas (). Damage primarily affected the social sectors: in the education sector, 166 schools (52% of the schools in Manabí and Esmeraldas) were declared unsafe, limiting access to education for 141,000 children and adolescents; in the health sector, 39 facilities were damaged and 20 rendered inoperative, leaving 1.2 million people with limited access to health services.

Aging

Older persons constituted 7% of the population of Ecuador in 2010, and will account for 18% in 2050. Of this population, 23.4% were living in conditions of extreme poverty; 53.2% of the elderly population were members of indigenous minorities (). The limitations on access to health services created by this situation are partially overcome by the Human Development Bond provided to families living in extreme poverty. Of these families, 69% needed medical care, and the most common morbidities involved osteoporosis (19%), diabetes (13%), cardiovascular problems (13%), and pulmonary disease (8%).

Migration

Demographic change due to migration in Ecuador occurred mostly as a result of the financial crisis, which forced 1,600,000 people (11% of the population) to leave the country between 2001 and 2007. Between 2008 and 2013, as the economy improved, fewer people left the country and some returned (). Between 2014 and 2015, there was a 20% increase in the number of Ecuadorians leaving the country, possibly as the result of the economic slowdown during that period. Immigration in 2013 included 56,471 refugees from 70 countries, of whom 98% were from Colombia.

Monitoring of Health System’s Organization, Provision of Care, and performance

Under the 2008 Constitution, the Ministry of Public Health (MoH) is responsible for formulating the National Health Policy, governing, regulating, and monitoring all health-related activities in the country, and overseeing the functioning of entities within the health sector (). The Constitution also laid the groundwork for a new health system, based on three pillars: the State as guarantor of the right to health; a system based on primary health care (PHC); and creation of an integrated public network of free health services (Red Pública Integrada de Servicios de Salud, or RPIS). The current Organic Health Law dates from 2006. The National Plan for Good Living (Plan Nacional del Buen Vivir, PNBV), which serves as Ecuador’s development model, includes the national health sector policy, as well as the specific health objectives that the country is committed to achieving. Based on the PNBV and the sectoral agenda, the MoH has issued national health policies and plans, as well as a regulatory framework governing the National Health System ().

In terms of regulatory authority, the health authority oversees the National Health Regulation, Control, and Surveillance Agency, and the Agency to Ensure the Quality of Health and Prepaid Medical Services, created in 2013 and 2015, respectively. These two agencies have regulatory power in their areas of authority and follow the policies, national plans, strategies, and general rules issued by the MoH. Their regulatory framework contains more than 38 regulations established through ministerial agreement on the part of the MoH in 2013-2015.

In addition to this regulatory structure, Ecuador is among the 12 States Parties of the Region which, between 2011 and 2016, systematically presented annual reports associated with the International Health Regulations. The National Directorate of Epidemiological Surveillance is the entity within the MoH responsible for compliance with International Health Regulations. The country’s 2016 self-evaluation regarding the development of basic skills cites 90% performance on eight of the 13 variables evaluated: 80% to 90% on response, risk communication, human resources, and laboratories; and 62% on chemical emergency preparedness.

Improved availability of services in the public health services network (851 new units between 2010 and 2016) and greater availability of health professionals have led to increased access to health services. In 2014, health services at the various care levels accounted for a total of 39,208,319 instances of medical care, an increase of 10.6% over 2011. Some 74.6% of these consultations were at the primary care level. Categorized by type of care, 14.6% were emergency consultations, 45.8% were for illness, 16.5% for dental care, and 22.9% for preventive care ().

Hospital discharges have increased steadily since 2008, both in the public network’s MoH hospitals and in private hospitals. In 2014, there were 1,193,346 hospital discharges, of which 42.7% were from MoH hospitals, 38.2% from private hospitals, and 19.0% from other facilities within the public network ().

In 2014, there were 32,807,630 outpatient consultations. A large percentage of consultations took place in the 20-to-49 age bracket (38% of the total), with a marked difference between women (82.1%) and men (17.1%). Adolescents between the ages of 15 and 19 constituted the group with the fewest consultations, representing 8.5% of all consultations, with a 13% lower rate for men than for women. Physicians conducted 64.3% of consultations, dentists 19.6%, obstetricians 12.9%, and psychologists 1.6% ().

Prospects

One of the government’s principal achievements is its recognition of the constitutional guarantee of health as a fundamental human right, a principle that is expressed in government policies in forms such as the Sumak Kausay National Plan for Good Living, and in specific health sector policies such as the Integrated Health Care Model, with the guiding principles of equity, universality, solidarity, interculturalism, quality, efficiency, effectiveness, precaution, and bioethics, as well as a gender and generational approach.

While Ecuador has met the majority of the MDG targets for 2015, challenges remain, including reduction of the MMR, child malnutrition, and tuberculosis. Some targets that have been met are in danger of dropping back to earlier levels. These include immunization coverage, reduction of vertical transmission of HIV, and preventing the reactivation of epidemic outbreaks of vector-borne diseases such as malaria. The progressive aging of the population also remains a challenge, with the prevalence of chronic degenerative diseases and a high frequency of deaths that could be prevented through improved control of these diseases.

This situation points to the need to encourage patients to share responsibility for monitoring their clinical disorders, as well as the need for the health system to provide quality care to mothers, children, and all patients suffering from chronic diseases, in order to prevent the advance of these disorders and their complications. It is imperative to strengthen the promotion of healthy habits, monitoring of health determinants, access to education, and preventive medical care; without these measures, it will be impossible to provide proper care to all those who need it, even with increases in health services and human resources for health.

Primary care services play a key role in addressing the situation; this requires improving the quality of management, implementing the Integrated Care Model, ensuring that these services truly function as a “smart” entryway to the system, and establishing an integrated network of services that ensures continuity of care, rather than serving merely a means of referring patients to other types of consultations. The MoH-PAHO framework for technical cooperation keeps various perspectives in place, such as: support for the legal framework, specifically in implementing the Organic Health Law; strengthening decentralized management at the district level and of integrated care teams; consolidation of health services networks and implementation of MAIS; strengthening the State’s role in developing and implementing health promotion and disease prevention policies; and maintaining the continuity of actions to improve living conditions as defined in the National Plan for Good Living.

Box 1. Major achievements and challenges

The elimination of morbidity due to onchocerciasis and the interruption of transmission of the disease constitute important public health achievements in Ecuador. In 2009, transmission was interrupted, and in 2014 WHO—having confirmed that there were no cases of onchocerciasis in Ecuador untreated by ivermectin—certified the elimination of onchocerciasis in the country. This is due to effective and coordinated work involving the government, the private sector, the Church, academia, the community, and international cooperation, as well as the result of social strengthening and the creation of opportunities for active community participation ().

Actions were carried out in the 119 communities of the Río Santiago watershed of Eloy Alfaro canton, in the province of Esmeraldas, based on the prevalence of microfilariae. Residents organized and developed capacities to support process of social change, participating in the implementation of essential actions such as rapid evaluations, supervised ivermectin treatment cycles, vector control, and the capture of blackflies. As health volunteers, they facilitated interventions in their communities of origin. This ensured active social participation with a community-based focus on epidemiology, promoted by the Center for Community Epidemiology and Tropical Medicine.

Community epidemiology was implemented in partnership with health promoters and nursing auxiliaries of the Borbón health area, using a multipurpose approach. This involved teams of health professionals visiting communities to reduce harm, detect emergencies and risk situations, and make timely referrals to health services.

These progressive developments attracted the attention of public and private organizations and cooperation agencies, which contributed economic, human, technical, and logistical resources that continue to support this management model.

References

1. Asamblea Nacional: Constitución de la república del Ecuador. Registro Oficial, 20 de octubre de 2008.

2. SENPLADES: Proceso de desconcentración del Ejecutivo en niveles administrativos de planificación. 1ra edición, Quito 2012.

3. Instituto Nacional de Estadísticas y Censos (INEC): http://www.ecuadorencifras.gob.ec/.

4. PAHO/WHO: Situación de la Salud en las Américas. Indicadores Básicos 2016.

5. ENSANUT. Encuesta Nacional de Salud y Nutrición Ecuador 2012.

6. Banco Mundial. Ecuador: panorama. [Internet]. Available from: http://www.bancomundial.org/es/country/ecuador/overview.

7. Ministerio de Coordinación de la Seguridad. Plan integral de seguridad. Ecuador, 2015. Available from: http://www.seguridad.gob.ec/wp-content/uploads/downloads/2012/07/01_Plan_Seguridad_Integral_baja.pdf.

8. Plan Nacional del Buen Vivir. Objetivo 3. Available from: http://www.buenvivir.gob.ec/objetivo-3.-mejorar-la-calidad-de-vida-de-la-poblacion.

9. Ministry of Education. Avances realizados para educación para todos; 2015. Available from: http://www.acaoeducativa.org.br/desenvolvimento/wp-content/uploads/2014/11/Informe_Equador.pdf.

10. World Bank: Ecuador panorama general. WDC, USA 2015. [Internet]. Available from: http://www.bancomundial.org/es/country/ecuador/overview.

11. Ministry of Pubic Health. Modelo de Atención Integral del Sistema de Salud. Ecuador 2012.

12. Ministry of Public Health. Rendición de Cuentas 2015. [Internet]. Available from: http://www.salud.gob.ec/rendicion-de-cuentas-2015/.

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14. Ministry of Public Health. Informe de la Estrategia Nacional de Control de Tuberculosis. December 2014.

15. Data from the GARPR 2014 report, in the conceptual note presented to the Global Fund in February 2016.

16. Ministry of Public Health. Estrategias de VIH: informe 2014. February 20015.

17. Ministry of Public Health. MoH, 2015. Registro Diario de Atenciones y consultas Ambulatorias Automatizadas; RDACAA; dirección nacional de estadística y análisis de información de salud: Available from: https://public.tableau.com/profile/andres.hualca8739#!/vizhome/CONSULTAS_RDACAA_2014_V2/Presentacin.

18. Ministry of the Interior. Seguridad y solidaridad ciudadana. Ecuador, February 2015. Available from: http://www.ministeriointerior.gob.ec/wp-content/uploads/2015/04/SEGURIDAD-CIUDADANA-SOLIDARIDAD-CIUDADANA.pdf.

19. World Health Organization. Observatory Data Repository (Region of the Americas. Global Information System on Alcohol and Health, Levels of Consumption. Available from: http://www.who.int/substance_abuse/publications/global_alcohol_report/msb_gsr_2014_1.pdf?ua=1.

20. SALUD: El Cáncer en el Ecuador. [Internet]. Available from: http://190.216.203.219/vivesaludtotal/index.php/cancer/el-cancer-en-el-ecuador/423-el-cancer-en-el-ecuador.

21. Secretaria Nacional de Planificación y desarrollo. [Internet]. Available from: http://www.planificacion.gob.ec/el-gobierno-nacional-presento-los-costos-de-la-reconstruccion-de-las-zonas-afectadas-por-el-sismo/.

22. W.Waters y Gallegos: Salud y bienestar del adulto mayor indígena. ISBN:978-9978-68-040-7. USFQ.OPS. Ecuador-2012.

23. CONSEP. Cuarta encuesta nacional sobre consumo de drogas. Available from: http://www.prevenciondrogas.gob.ec/wp-content/uploads/2015/08/Cuarta-Encuesta-Nacional-sobre-uso-de-drogas-en-estudiantes-de-12-a-17-a%C3%B1os.pdf.

24. Ministry of Public Health: Clasificación de la discapacidad 2013-2014, Ecuador, 2015.

25. Ministry of Public Health. Dirección de Vigilancia Epidemiológica. Available from: http://www.salud.gob.ec/direccion-nacional-de-vigilancia-epidemiologica/9.

26. Ministry of Public Health. Dirección de Epidemiología. Enfermedades transmitidas por vectores: Fiebre chikungunya. October 12, 2016.

27. Ministry of Public Health. Dirección de Epidemiología. Enfermedades transmitidas por vectores: Zika virus. October 9, 2016.

28. Gaceta epidemiológica semanal. SIVE-alerta Gaceta nº 2, Semana epidemiológica n°.1-4. 2014.

29. MoH/UNICEF/OPS: Reporte sobre el desempeño en Inmunización o (JRF), 2015.

30. PAHO/WHO. Boletín informativo; Brote de Sarampión. Available from: https://www.paho.org/ecu/index.php?option=com_docman&view=download&category_slug=documentos-2013&alias=416-boletin-informativo-n0-31-agosto-2012-marzo-2013&Itemid=599&lang=en.

31. Ministry of the Interior. [Internet]. Available from: http://www.ministeriointerior.gob.ec/ecuador-redujo-drasticamente-la-tasa-de-homicidios-y-asesinatos-a-escala-internacional/.

32. UNICEF. La violencia de genero contra las mujeres en el Ecuador. Análisis de la Encuesta de violencia de género. Ecuador, 2014. Available from: http://www.unicef.org/ecuador/Violencia_de_Gnero.pdf.

33. World Health Organization (WHO). Onchocerciasis Fact sheet. Available from: http://www.who.int/mediacentre/factsheets/fs374/en/, and Ministry of Public Health: Estudios confirman que está eliminada la oncocercosis en Ecuador. Available from: http://www.salud.gob.ec/estudios-confirman-que-esta-eliminada-la-oncocercosis-en-ecuador/.

34. Ministry of Public Health. La Organización Mundial de la Salud (OMS) declara a Ecuador libre de oncocercosis. Available from: http://www.salud.gob.ec/la-organizacion-mundial-de-la-salud-oms-declara-a-ecuador-libre-de-oncocercosis/.

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Reference/Note:

1. Montubio or montuvio refers to the typical mestizo peasant of the Ecuadorian coast. This is the country’s largest ethnic minority, larger than the Afro-Ecuadorian and indigenous populations. The land is the basis of the group’s culture, economy, and society. A montubio is a person who lives in the coastal area and is dedicated to livestock and agriculture (cacao, banana, rice, among other crops), enjoying a rich popular culture.

2. The multidimensional poverty rate defined by the Ecuadorian government has four dimensions: (a) education; (b) work and social security; (c) health, water, and food; and (d) habitat, housing, and healthy environment. Each dimension has 12 indicators that reflect situational and structural conditions.

3. Adequate employment refers to employment that is not deficient in terms of either work hours or income. It replaces the old “full-time” category and includes the “dissatisfied” group, which was previously classified as underemployed merely because these people wanted, and were available for, more work, though they did not lack work hours or income. Cf.: http://www.ecuadorencifras.gob.ec/inec-y-senplades-presentan-nueva-clasificacion-para-la-poblacion-con-empleo/.

4. In the specific case of tsunamis, the set of standards and actions to mitigate damage includes the flood maps created by the Digital Humanitarian Network (DHN). These were given to the relevant authorities in the coastal areas, and will help in designing and planning evacuation routes and shelter areas, as well as in the evacuation plans that local authorities in coastal areas must have in place.

5. The Misión Solidaria Manuela Espejo (Manuela Espejo Solidarity Mission) is part of a social and clinical research effort to study and georeference all person with disabilities. This makes it possible to know exactly who and how many they are, where they are, how they are, and what each disabled person living in Ecuadorian territory needs. This led to the creation of the Joaquín Gallegos Lara program, which consists of providing an allowance to people responsible for caring for a person with a serious physical or intellectual disability in an environment of extreme poverty.

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