- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
The 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 ().
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 ().
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
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|
Source: National Institute of Statistics and Censuses (INEC). Statistical compendium 2014. Ecuador: INEC; 2014.
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 ().
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 ().
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 ().
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|
|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|
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.
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%) ().
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 ().
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
|Area/Rate||Total||Specialists||Generalists||Graduates||Residents||Rural||Obstetricians||Dentistsa||Nursing personnel||Other professionalsb|
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.
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%).
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% ().
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
The MMR showed a rising trend between 2010 (59.04 per 100,000 live births) and 2011 (70.44), then declining to 49.16 in 2014. The province of Zamora Chinchipe had the country’s highest MMR (142.20) (), and the MMR was highest in the 20-to-34 age bracket. The leading causes of death were hypertensive disorders and postpartum hemorrhages.
MoH provided care for 149,287 deliveries in 2014, of which 62.8% were normal, 2.9% with complications, and 34.2% via cesarean section, an increase of 5.3 percentage points in caesareans over 2010. The total number of live births in 2014 was 148,401; 8.4% of these infants weighed less than 2,500 g. There were 1,447 stillbirths, with weights less than 2,500 g in 63.4% of cases (). It was estimated that 14.6% of pregnancies were undesired, a situation most frequent among women with no schooling ().
In 2014, 20,812 miscarriages were recorded, a rate 20 percentage points lower than in 2010, when there were 25,930 miscarriages. The Comprehensive Organic Penal Code of Ecuador prohibits abortion, with exceptions when the life or health of the pregnant woman is in danger and the danger cannot be averted by other means, or when pregnancy is the result of the rape of a woman suffering from a mental disability. In 2015, the United Nations Committee on the Elimination of Discrimination against Women asked the government to decriminalize abortion in cases of rape, incest, and severe fetal malformation.
The health survey conducted in 2011 and 2012 showed that there had been a moderate decline in the national prevalence of height retardation or chronic malnutrition (low height for age), with the 2012 figure of 25.3% representing a reduction of 15 percentage from the 1986 level (). The prevalence of chronic malnutrition (low height for age) in the indigenous population was reported to be especially high—42.3%, nearly twice the national average of 25.3%. Analysis by region shows that the rural mountain areas were most affected, with a rate of 38.4%, followed by the urban mountain areas (27.1%) and the rural Amazon (27.2%) ().
The infant mortality rate (under one year of age) declined steadily between 2010 (9.32 per 1,000 live births) and 2014 (8.35 per 1,000 live births). The majority of deaths (55%) occurred during the first month, while 31% occurred during the first three days after birth. The leading causes were breathing difficulties in newborns (6.4%) and disorders related to short gestation and low birthweight (6.2%) ().
The under-5 mortality rate did not vary significantly between 2010 (14.8 per 1,000 live births) and 2014 (14.2 per 1,000 live births). The MDG target figure of 14.4 by 2015 was achieved ().
Health of Adolescents
ENSANUT 2012 estimated that 19.4% of live births were to women under the age of 20 (). However, births among teenage mothers decreased significantly, as the specific figures show. In 2010, the birth rate among women between the ages of 10 and 14 was 2.8 per 1,000 women, while the rate in 2014 was 1.8 (). Pregnancy among adolescents constituted a priority problem, and the National Intersectoral Strategy of Family Planning and Prevention of Teenage Pregnancy was implemented from 2011 to 2014, providing comprehensive services and creating communication strategies to modify cultural patterns. The strategy included a Project for the Ensured Availability of Supplies and Contraceptives.
The fourth survey on drug use, in 2012, reported that 29% of the adolescents interviewed (ages 12 to 17) had seen a student using drugs at school. The figure was higher in urban areas (34%) than in rural areas (18%). Interviewees indicated that it was easy to obtain marijuana (15%), heroin (8%), cocaine (6%), and ecstasy (4%). The average age of first use was 14 years ().
Health of the Disabled
Between 2008 and 2013, major advances were made in registering persons with disabilities through the Manuela Espejo program. From 2013 to 2014, 410,832 persons with disabilities were registered, of whom 55.6% were women and 36.4% were in the 20- to 49-year-old age bracket. This was followed by the 65-and-over segment, with a percentage of 26.5%. In terms of level of disability, 41.8% had moderate disabilities, 35.4% severe disabilities, and 17.9% very severe disabilities (); 1.8% of all outpatient consultations were for persons with disabilities. The labor inclusion programs of the Technical Secretariat of Persons with Disabilities brought employment to 60,758 people with disabilities between 2010 and 2013.
Among the leading causes of death, hypertensive diseases rose from 4.4% in 2000 to 6.6% in 2013, and diabetes mellitus from 4.5% to 7.4%. In 2014, the leading cause of death in men was cardiac ischemia (33.29 per 100,000 men), while diabetes was the leading cause for women (29.32 per 100,000 women) ().
In 2011, the Pan American Health Organization (PAHO) estimated 16.7% underreporting of mortality in Ecuador; INEC records for that year indicate that the proportion of ill-defined causes of death was 9.4% at the national level (versus 4.8% in Latin America as a whole). This figure had declined to 8.7% by 2013 (). Despite this trend toward a reduction in the proportion of ill-defined causes over the last 10 years, the figure for several provinces was more than 11% in 2013.
Dengue is endemic in Ecuador. It most strongly affects populations on the coast, where 90% of cases were reported in 2014. This situation is linked to widespread infestation by Aedes aegypti in this region’s cities, and to poor urban development and lack of access to basic services. The annual incidence of dengue varied between 2010 (118.72 per 100,000 population) and 2014 (86.51 per 100,000), as a function of winter conditions. Between 2010 and 2015, four serotypes circulated, with DEN1 predominating. On average, 19,188 cases were recorded annually for all forms of the disease, with the highest prevalence in the population between ages 20 and 49 (60%), though serious cases were more frequent (50%) in the under-15 population. Deaths from dengue and its complications averaged 18 per year, with 35% occurring in the 20- to 49-year-old population ().
In 2015, the chikungunya virus epidemic affected the coastal population, especially in the provinces of Manabí and Esmeraldas, and 33,643 cases (without differentiation of the clinical forms of the disease) were reported through the epidemiological surveillance system. In two cases, chikungunya was recorded as the primary cause of death ().
Zika virus was introduced in 2015, with four imported cases detected in the provinces of Manabí, Esmeraldas, and Pichincha. As of epidemiological week 44 of 2016, 2,661 cases had been reported ().
The average number of malaria cases between 2011 and 2015 was 589. In 2015, however, a reactivation of transmission was observed in several foci in the Amazon region and in Esmeraldas, following a dramatic 99.8% reduction between 2000 and 2014.
Leprosy persists in the country, with 554 cases between 2011 and 2015 (92 cases annually).
During that same period, there was an annual average of 40 new cases of Chagas disease along he northern coast and in the Amazon regions.
Only 1.2% of cases of tuberculosis with respiratory symptoms were detected in 2014, falling short of the national goal of 4%. That year, Ecuador reported 5,157 confirmed cases, out of 8,600 new cases that the World Health Organization (WHO) estimated for the country (a 60% detection rate). The rate of TB/HIV co-infection was 13%, and there were estimated to be 320 cases of multidrug-resistant (MDR) tuberculosis, of which 179 (56%) were reported. Twelve provinces account for 90% of cases, and Guayas alone reported 62% of the total number of cases nationally.
Between 2006 and 2014, some 2,000 cases of MDR-TB were admitted for treatment. Case fatality from TB was reduced from 0.19 per 100 cases in 2010 to 0.08 in 2014. However, TB continued to be the third leading cause of deaths from infectious diseases in the country.
Between 2013 and 2015, vaccination coverage for the majority of vaccine-preventable diseases in children up to and including 1 year of age dropped to 80% (). Moreover, the number of vaccine doses administered was reduced by 10 percentage points between 2012 and 2015. Although vaccination coverage at the national level was 80%, 51% of the cantons in 2015 had coverage of below 80%, while 14% reported coverage below 50%. The cantons with less than 80% coverage are home to 40% of the children under the age of 1 ().
In 2011, there was a measles outbreak, with 260 cases reported in the country, of which 163 were in the province of Tungurahua, most in the locality of Quisapincha, where a majority of the population was susceptible to the disease. Other provinces with large numbers of cases were Pichincha (49), Guayas (37), Pastaza (), and Morona Santiago (). As of epidemiological week 41 of 2012, there were a total of 329 cases ().
Chronic, Noncommunicable Diseases
In 2014, NCDs were the principal cause of premature deaths (i.e. in the 30- to 69-year old age bracket). The highest specific mortality rates in women were for diabetes mellitus (29.32 per 100,000 women), cerebrovascular disease (23.38), and hypertensive disease (23.17). In men, the highest specific mortality rates were for ischemic heart disease (33.29), diabetes (25.57), and cerebrovascular (23.75) and hypertensive (21.39) disease ().
Diabetes ranked as the second leading cause of death in 2014, affecting 414,514 people. It was estimated that 3.4% of the population between the ages of 40 and 49 suffered from diabetes, 10.3% of the population between 50 and 59, and 15.2% of the older population (). In addition, the prevalence of hyperglycemia in 2012 was 2.7% for the population in the 10-to-59 age bracket, 4.1% for the 30-to-59 population, and 15.2% for the older population ().
The prevalence of hypertension, as measured in the 18- to 59-year-old population by ENSANUT 2012, was 9.3%, with greater prevalence in men (11.2%) than in women (7.5%) (). The 2010 Older Adult Health and Well-being Survey (SABE II) showed 44.4% prevalence of hypertension in the 60-and-over population ().
In terms of malignant neoplasms, in 2014, malignant neoplasms of the stomach (9.87 per 100,000 population) were the tenth leading cause of death in the general population. Malignant neoplasms of the lymphatic tissue (6.73 per 100,000), prostate (5.20), uterus (4.49), trachea (4.47), and colon (4.43) were among the 20 leading causes of mortality ().
Accidents and Violence
In 2014, there was an increase in deaths due to traffic collisions, constituting the sixth leading cause of death in the general population (19.9 per 100,000 population) and second in the male population (30.71 per 100,000 men) (). Some 50% of the deaths were associated with alcohol use. The homicide rate in 2015 was 6.4 cases per 100,000 population (). Nationwide, six out of 10 women had experienced some type of gender violence, with significantly higher figures for indigenous (67.8) and Afro-Ecuadorian (66.7) women; in 87.3% of cases the violence was perpetrated by the woman’s husband or partner. Furthermore, one out of four women had experienced sexual violence, psychological violence being the most frequent form (53.9%) ().
The Ecuadorian mental health system model is hospital-focused, and its budget, representing 0.057% of the total health budget in 2014, is insufficient. Nevertheless, there has been progress, as reflected in the 33% reduction in the number of psychiatric beds since 2006. The country has two psychiatric hospitals, three private facilities, and a semiprivate center, which together have 1,091 beds, or seven available beds per 100,000 population.
In 2014, 2,257 patients were hospitalized for mental disorders, of whom 45% were women and 4% were children under the age of 17. According to discharge diagnoses, the principal problems were schizophrenia, schizoid and delusional disorders (39%), emotional or affective disorders (26%), mental and behavioral disorders due to the use of psychoactive substances (17%), neurotic disorders related to stress and somatoform conditions (2%), personality disorders and adult behavioral disorders (1%), and other disorders (15%), including epilepsy, organic mental disorders, mental retardation, and initial appearances of behavioral and emotional disorders. In 2014, 734 deaths were the result of these disorders, including deaths due to depression and excessive alcohol use.
Risk and Protective Factors
Risk factors related to NCDs have been reported in the over-15 population: 2.8% used tobacco and 6.6% used alcohol to excess at least 12 times per year; 62.7% engaged in no physical activity; and 62.8% suffered from overweight or obesity ().
Risk factors associated with cardiovascular disease in 2014 included a high prevalence of dyslipidemia: the estimated figure for hypercholesterolemia was 17.0% in the 20- to 29-year-old age bracket, and 51.1% in the 49 to 50 age bracket. The latter group also had a high prevalence (20%) of low-density lipoproteins (LDL-C) and of hypertriglyceridemia (28.7%). Another risk factor was hypertension, which affected 9.3% of the population in the 18 to 59 age bracket. The frequency of hypertension in the population between the ages of 20 and 59 was greatest in the poorest quintile (10.3%), and next highest in the fourth quintile (9.9%). Of the population with reported hypertension, only 51.3% indicated that they had received treatment for hypertension ().
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
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.
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/.
13. IESS. Aumenta el número de afiliados a la Seguridad Social. [Internet]. Available from: https://www.iess.gob.ec/es/sala-de-prensa/-/asset_publisher/4DHq/content/aumenta-el-numero-de-afiliados-a-la-seguridad-social/10174?redirect=https%3A%2F%2Fwww.iess.gob.ec%2Fes%2Fsala-de-prensa%3Fp_p_id%3D101_INSTANCE_4DHq%26p_p_lifecycle%3D0%26p_p_state%3Dnormal%26p_p_mode%3Dview%26p_p_col_id%3Dcolumn-1%26p_p_col_pos%3D1%26p_p_col_count%3D2%26_101_INSTANCE_4DHq_advancedSearch%3Dfalse%26_101_INSTANCE_4DHq_keywords%3D%26_101_INSTANCE_4DHq_delta%3D6%26_101_INSTANCE_4DHq_cur%3D66%26_101_INSTANCE_4DHq_andOperator%3Dtrue?mostrarNoticia=1.
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://188.8.131.52/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/.
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.