Country Report: Ecuador
Ecuador is located in northwestern South America, bordering 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. The political divisions include 24 provinces and 269 cantons, with their respective parishes.
Between 1990 and 2015, the population increased by 56.6%, to 16,278,844 and is highly multi-ethnic and multicultural, including the following groups: mestizo (71.9%), the coastal mestizo group known as montubia (7.4%), Afro-Ecuadorian (7.2%), indigenous (7.0%), white (6.1%), and other (0.4%). Its structure remains expansive, but growth has become more stationary, especially in the under-25 age group.
In 2016, life expectancy was 76.4 years (73.7 in men and 79.1 in women).
The per capita gross national income is US$11,190. The economy has reaped the benefits of high oil prices, international financial flows, and better tax collection.
- According to the 2008 Constitution, the Ministry of Public Health is responsible for formulating the national health policy and regulating, enforcing, and controlling all health-related activities in the country, as well as for the operation of entities in the health sector.
- Furthermore, the Constitution laid the groundwork for a new health system, based on three pillars: the right to health, guaranteed by the State; a primary care-based system; and the establishment of an integrated public network of health services provided free of charge.
- The National Plan for Good Living, as a model for the development of Ecuador, includes a policy for the health sector and several health objectives that Ecuador has committed to achieving. Based on this National Plan, the Ministry of Health has issued national health policies and plans, in addition to a normative agenda that organizes the National Health System.
- The National Health Regulation, Control, and Surveillance Agency and the Health Services and Prepaid Medicine Quality Assurance Agency were created in 2013 and 2015, respectively.
- Both agencies have regulatory power in their scope of action, responding to national policies, plans, and strategies and general regulations issued by the Ministry of Health. The regulatory framework of the agencies includes more than 38 standards issued by the MPH by ministerial agreement (2013-2015).
- In addition to its regulatory structure, Ecuador is among 12 States Parties in the Region that systematically meet the annual reporting requirements of the International Health Regulations.
Figure 1. Distribution of the population by age and sex, Ecuador, 1990 and 2015
Proportional mortality (% of all deaths, all ages, both sexes), 2014
Source: Pan American Health Organization and PAHO Health Information Platform (PHIP).
SELECT BASIC INDICATORS
Note: Population data for 2015 are derived from national estimates prepared by the National Statistics and Census of Ecuador.
Source: UN Population and Statistics Divisions, 1990; PAHO Health Information Platform (PHIP), 2013, 2014, and 2015.
SOCIAL DETERMINANTS OF HEALTH
- Between 2008 and 2014, the country experienced economic growth, with average annual increases of 4.6% in gross domestic product (GDP).
- In 2014, 22.5% of the population lived in poverty, and the Gini coefficient (a measure of income inequality) was 0.47. The national unemployment rate in 2015 was 4.5% (5.7% in women and 3.6% in men).
- The illiteracy rate in the population aged 15-39 was 6.8% in 2010, falling to nearly half of that (324,000 persons) by 2013. In 2015, 96.3% of children and adolescents aged 5-14 attended basic education.
- Between 2006 and 2013, the homicide rate fell from 17.8 to 10.8 per 100,000 population, following implementation of the Comprehensive National Security Plan in 2011.
- In 2013, improved drinking-water source coverage was 87%, and improved sanitation coverage was 85%.
- The country is vulnerable to natural disasters such as volcanic eruptions, earthquakes, and tsunamis. In 2015, a state of emergency was declared due to the eruption of the Cotopaxi and Tungurahua volcanoes, and in April 2016, an earthquake off the coast caused significant damage to the social, educational, and health infrastructure.
HEALTH SITUATION AND THE HEALTH SYSTEM
- In 2014, the maternal mortality rate was 49.2 per 100,000 live births. The leading causes were hypertensive disorders and postpartum hemorrhage. In 2012, 19.4% of births occurred in women under 20.
- Antenatal care coverage is low (24.6%). Between 2000 and 2015, the birth rate declined from 19.5 to 14.3 per 1,000 population.
- Between 2000 and 2014, the infant mortality rate declined from 15.5 to 8.4 deaths per 1,000 live births. The leading causes were respiratory distress of the newborn (6.5%) and disorders related to short gestation and low birth weight (6.2%).
- Mortality in children under 5 changed little between 2010 (14.8 per 1,000 live births) and 2014 (14.2 per 1000 live births).
- Countrywide vaccination coverage reached 80% in 2015. Still, 14% of cantons recorded coverage rates <50%. In 2011, a measles outbreak was reported, with 260 cases.
- Dengue is endemic in the country and affects coastal populations in particular. The overall incidence was 86.5 cases per 100,000 population in 2014. Incidence is higher in 20-49 age group (60%), and the disease is more serious in children under 15.
- Between 2011 and 2015, an average of 589 cases of malaria were reported each year. In 2015, several foci were reactivated in the Amazon and Esmeraldas regions. Leprosy remains an issue, with 92 cases reported between 2011 and 2015, while the figure for Chagas disease is an average of 40 new cases annually.
- In 2014, the TB mortality rate was 2.8 per 100,000 population, and 5,157 new cases were reported. The casefatality rate is 0.08%.
- HIV/AIDS prevalence was relatively stable between 2007 and 2014 at 0.4% of the population. Mortality from HIV/AIDS is 5.2 per 100,000 population, with the most deaths occurring in trans women and in men who have sex with men. The prevalence in pregnant women was 0.18% in 2014.
- It is estimated that 57% of people with HIV know their status, and that 78% of people diagnosed with the infection are receiving treatment through the public health network.
- Chikungunya virus entered the country in 2015, with 33,643 cases and two deaths. Zika virus was introduced that same year, with four imported cases.
- In 2014, the general mortality rate was 6.0 deaths per 1,000 population (7.2 in men and 3.9 in women). Diseases of the circulatory system caused 23% of deaths; neoplasms, 17%; and external causes, 13%.
- That same year, chronic non-communicable diseases (NCDs) were the main cause of premature mortality. Diabetes mellitus, cerebrovascular disease, and hypertension caused 29.3, 23.4, and 23.2 deaths per 100,000 women, respectively.
- In men, ischemic heart disease caused 33.2 deaths per 100,000 population; diabetes 25.5; and cerebrovascular diseases 23.7.
- In 2014, malignant stomach neoplasms (9.87 per 100,000 population) were the tenth leading cause of death in the general population.
- Road traffic accidents were the leading cause of deaths from accidents and violence, and 50% of accidents were related to alcohol consumption.
- The homicide rate in 2015 was 6.4 per 100,000 population.
- In 2014, 2.5% of the population reported some disability; more than half of these cases were considered severe.
- In 2014, 8% of children aged 0-5 and 29.9% of all school-aged children aged 6-11 were overweight or obese.
- It was reported that 2.8% of the population over 15 smoked and 6.6% consumed alcohol, with an average of roughly 12 binge-drinking incidents per year. A full 62.7% of the population reported not engaging in any physical activity, and 62.8% were overweight or obese.
- Regarding NCDs, 17% of the population aged 20-29 years had hypercholesterolemia, and 9.3% of those aged 18-59 had hypertension. Diabetes mellitus was present in 3.4% of the population aged 40-49 years, 10.3% of the population aged 50-59, and 15.2% of older adults.
- The Ministry of Public Health (MPH) is responsible for regulating, enforcing, and controlling all health-related activities in the country, as well as operating all entities in the sector.
- The 2008 Constitution laid the groundwork for a new health system based on three pillars: the right to health, guaranteed by the State; a primary care-based system; and the establishment of an integrated public network of health services provided free of charge.
- To fulfill its regulatory role, the National Health Authority has established two new entities: the National Health Regulation, Control, and Surveillance Agency and the Health Services and Prepaid Medicine Quality Assurance Agency.
- The health system is comprised of the public and private subsystems. The public system is comprised of facilities run by the Ministry of Public Health, the Ecuadorian Social Security Institute (which includes Rural Social Security, the Armed Forces, and the National Police), and the health services of some municipalities.
- The private system is comprised of health insurance companies and prepaid medicine providers.
- The public services are funded through the general federal budget, extra-budgetary funds, emergency and contingency funds, and contributions from national and international projects and agreements. Health expenditure doubled between 2010 and 2015 to 9.2% of GDP.
- In 2012, the MPH instituted reforms in the area of human resources for health, with a view to implementing the new Comprehensive Health Care Model (MAIS).
- Increased availability of the public health services network included 851 new units between 2010 and 2016 and an increase in the number of health professionals, leading to a 10.6% increase in care between 2011 and 2014. Hospital discharge numbers have also steadily increased.
- In 2014, there were 20.4 physicians and 10.1 nurses per 10,000 population. Nevertheless, the number of specialists remains low, and their distribution unequal (urban, 29.0; rural, 5.4).
- Since 2016, the MPH has operated the Epidemiological Surveillance System (SIVE), which collects epidemiological data for certain priority diseases. There is also a Data Recording System for hospital discharges, morbidity, and other indicators. In 2013, underreporting of mortality was estimated at 16.7%; that same year, the proportion of ill-defined causes of death was 8.7% nationwide, but more than 11% in several provinces.
ACHIEVEMENTS, CHALLENGES AND PERSPECTIVES
- The 2008 Constitution provides the legal framework for the health system, guaranteeing the right to health and primary health care, along with an integrated public network of free health services.
- The establishment of two national agencies, one for health regulation, control, surveillance and one to ensure the quality of the health services, has underscored the regulatory role of the national health authority.
- The promotion of healthy habits, control of the health determinants, access to education, and preventive medicine all need improvement. To this end, primary-care services must improve the quality of their management and performance.
- The Organic Law for the Regulation and Control of Tobacco, the Regulations for the Authorization and Control of Processed Food Advertising and Promotion, the Health Regulations for the Labeling of Processed Foods Intended for Human Consumption, and the Support for Continuity of Actions for the Improvement of Living Conditions, defined in the National Plan for Good Living, are examples of how the State’s role in developing and implementing policies for health promotion and protection has evolved.
- A major public health achievement of Ecuador has been the elimination of onchocerciasis and interruption of its transmission. Transmission was halted in 2009, and in 2014, Ecuador was certified free of this disease by the World Health Organization.
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