------------------------------
PAHO Basic Health Indicator Data Base This is a multidimensional query tool that offers a collection of 108 indicators from 1995 to 2005. The system presents data and indicators on:
- demography
- socioeconomic
- mortality by cause indicators
- morbidity and risk factors
- access, resources and health services coverage.
Selected indicators are disaggregated into age groups, sex and/or urban/rural region. Generated tables can be exported and printed.
The data presented is updated annually with the latest country information.
GENERAL SITUATION AND TRENDS Demographic and socioeconomic context: According to the results of the National Census (November 2004) the Republic of Ecuador had 12,090,804 inhabitants (49.6%, male and 50.4%, female). Sixty-one percent of population lived in urban areas and 39% in rural ones. Ecuador is composed of 22 provinces and the most populated were Guayas (27.2% of the total population), Pichincha (19.7%) and Manabi (9.8%). In 2004, the Statistics and Census National Institute estimated a 13,026,891 population. The country is divided in three regions: Costa (Coast), Sierra (Mountain) and Oriente (East) due to its situation in relation with the Andes; it also includes an insular region, the Galapagos Islands. Ecuador area is 256,370 sq km.
According to the 2001 census, 830,418 people declared themselves as Amerindian. However, indigenous organizations estimate that 25-30% of the entire population is Amerindian. This population is mainly concentrated in the Amazon and rural Andes regions. According to the 2000 Household Survey (EMEDINHO), 72% of the population above 15 years of age, considered appropriate the “Mestizo” (mixed Amerindian and white) designation: 15% defined themselves as“White”; 6% as Amerindian, 4% as “Black” and, 2% as “Mulatto” (half Black, half White).
Population growth rate in 1990 was 2.0%: urban growth was 2.92% and rural was 0.73%. National growth rate was lower than predicted, which has made necessary to re-estimate vital statistics for the past decade. Global fertility rate during 1994-1999 was 3.3 children per woman; by 2003 it was estimated in 2.7 children per woman.
During the 1990-2001 intra-census period, life expectancy at birth rose from 71.4 to 76.8 years in women and, from 67.6 to 70.9 years in men. The population between 15 to 64 years of age increased from 56.9% to 60.1%; population above 65 also increased from 4.3% to 6.7%. That ageing trend is confirmed by the mean age that increased from 24.1 years to 27.4.
Urbanization has been an important social change; in 1950 more than 70% of Ecuadorian population lived in rural areas, by the end of 2001 that proportion dropped to 39%. Since 1960, the number of cities with more than 30,000 inhabitants grew five-fold. During the 1990’s urban population increased 3.1% yearly, and rural 0.8%.
Poverty level: In 2004, the last measurement done by INEC (ENIGHU, February 2003 to February 2004) revealed that 41.5% of population was classified as poor and 8.5% as extremely poor. The survey detected that the top 20% of households had access to 43.6% of the entire consumption. In comparison, consumption of the bottom 20% of population was 6.5 times smaller (6.7%). Four out of ten urban-living people and, eight out of ten rural–living people are poor.
Data of 2001 census suggested that between 1996 and 2001, 378,000 Ecuadorian people went abroad looking for job opportunities. That figure represented 8.3% of the economically active population and, 3.1% of the total population registered in that census. The emigration volume influenced the monetary transference from abroad to Ecuador, that transference is the second source of “hard” foreign currency after oil exportation. Between 2000 and 2002, monetary transfer to Ecuador amounted $1,400 billion USD (7% of the GNP). Those revenues helped raise consumption level of Ecuadorian households, which was a crucial factor to diminish poverty levels after 2001.
In 2001, the national poverty level was estimated in 61.3%. The correlation between poverty and ethnic groups (Amerindians and Blacks) was obvious, since nine out of ten households, and 73.8% respectively, were classified as poor. Average illiteracy rate was 9%, but among Amerindians and Black people was 28.2% and 11.6%, respectively. Illiteracy rate in women was 10.3%. If both exclusion factors (being Amerindian and woman) are combined, differences are even more deepened: 28% of Amerindian women are illiterate. On the other side, the average educational level is 7.3 years; while in the Amerindian population it is 3.3 years. Moreover, illiterate mothers have an average fertility rate of 3.3 children per woman, while those having higher education have 1.9 children per woman. That effect is key considering that prolific families have more chances of being poor, as in 2001 72% of households having more than six members were poor.
Depending on the person that acts as head of family, poverty affects households in a different way: 58.3% of female-managed households, and 62.5% of those having a male head of family are poor. It is important to take this into account in the social investment programs among women. The minimum wage was raised from $146.00 USD (2001) to $163.8 (in 2002), while the value of the basic poverty basket was $248.20 USD in the same year.
Social Investment: The debt coefficient over social investment reached 1.4 in 2003; which means that debt service was greater than social investment. For each dollar deposited in the National Treasury, fifty cents were directed to the debt payment, while 33 cents were assigned to social expenditure. In that year, 7.3% of GNP was directed to social investment (Latin American average for 2003: 13.1%). Health expenditure of the Central Government, which had fallen 0.5% of GNP in 2001, was increased to 1.38% in 2003. In 2001, Health expenditure represented 2.7% of the State General Budget, while in 2003 constituted 5.7%.
Mortality: Even though, general mortality diminished from 4.8 per 1,000 inhabitants (1994) to 4.1 (2003). Mortality due to non communicable diseases and conditions increased and has displaced infectious diseases as the main causes of death. In 2003, cardiovascular diseases presented highest death rates in the country; 9.% of all deaths were due to “other forms of heart diseases”. The next causes of death in importance were cardiovascular diseases and diabetes.
In 2003, death certificates showed that deaths due to motor vehicle accidents, accidental falls and violence, were three, five and eight times more frequent in men than in women of same age group. However, deaths caused by malnutrition and anemia were more frequent in women than in men (351 vs. 336; 262 vs. 226, respectively). Acute respiratory diseases occupy the first place, and are followed by food-borne illnesses (diarrheic diseases) and vector-borne diseases (mainly malaria and dengue fever) among mandatory notification diseases.
SPECIFIC HEALTH PROBLEMS Priority population groups (Millennium Development Objectives-ODM) Infant population (children under 1 year of age): The national infant mortality rate fell from 30.3 per 1,000 newborns (in 1990) to 18.5 in 200; in 2003, this rate increased to 22.3. It is important to mention, that the estimated rates for Carchi and Cotopaxi provinces were two times the national rate, and Guayas, Pichincha and Azuay provinces have rates 30% lower to the national indicator. This means that under–registration remained high, as the estimated national infant mortality rate (ENDEMAIN 99) was 30 per 1,000 newborns. In absolute numbers, 3,895 deaths of children under 1 year of age were registered in 2003; in comparison, about 6,000 deaths in that age group were registered around 1995. Children born of illiterate mothers (the poorest population) have a mortality rate 4.6 times higher than children born of mothers having a higher education level. Fifty-three percent of all deaths were attributed to neonatal component. The main causes of infant death, in 2003, were diseases related with gestational and fetal growth (11.5%), and pneumonia (9.1%).
Reproductive age women (15–44 years of age): Maternal mortality rate fell from 117.2 per 100,000 live newborns (1990) to 77.8 in 2003. Differences among provinces range from 135.6 per 100,000 (Loja province) to 39.3 (Los Ríos Province). One hundred and thirty nine maternal deaths were registered in 2003; during the first four years of the 1990’s that figure was above 300. It is estimated that the actual number of deaths could double the registered figures. Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and puerperium caused 41.7% of all maternal deaths registered in 2003.
Analysis by type of Health problem Acute respiratory infections and diarrheic diseases: These are still the first causes of ambulatory care, and their trend is rising. According to available data for the 1990-2003 period, cases notified as acute diarrheic diseases and acute respiratory infections increased 40% and 80% respectively.
Dengue Fever: The Dengue vector has been spread through ways (domestic commercial flights and fluvial trips) different from the traditional ones. These have also contributed to the transportation of infected or sick people; that can be appreciated through the recent detection of Aedes aegypti in the Galapagos Islands and the presence of Dengue Fever cases in Santa Cruz Island.
Malaria: It is an important Public Health problem in 197 Ecuadorian townships, particularly in the most poor areas, rural and periurban communities comprising a 7,965,565 risk–population. Malaria is concentrated in 32 high–risk, very active–transmission, well–defined townships where 2,249,283 people live, most of them in precarious housing without the most basic hygienic–sanitary infrastructure. Besides, there is also the chloroquine resistance developed by Plasmodium falciparum.
Malaria went epidemic in 1996, when 11,991 cases were registered. Since that year the malaria morbidity, confirmed in laboratory, has increased up to 106,641 cases in 2001, which was considered the acme of the epidemic that began three years ago. During the following years, malaria cases diminished to 87,649 (2001) and about 52,065 cases in 2002. In 1999, the annual parasite incidence was 13.74, in 2000; it was 15.73 and then diminished progressively to 14.22 in 2001 and to 6.54 in 2003.
Tuberculosis: The notified trend incidence in the last decade has been irregular; the average incidence is 50/100,000. In 2003, 5,789 new TB cases (all forms) were notified (incidence: 44.95/100,000). Seventy-eight percent of all cases (4,488, incidence rate: 34.85/100,000) were pulmonary TB BK+. Due to the significant under-registration, the real scope of TB epidemic in Ecuador is unknown. Its control has great variability according to regions and provinces. Cure rate in DOTS provinces (Pichincha, Guayas and Azuay) is 85%, while the other 19 provinces (non DOTS) have great inconsistencies in the information system.
HIV/AIDS: The course of the HIV epidemic in Ecuador has shown from 1984 to 2003, an annual average increase of 265 cases. The total cumulated number of cases is 5,291; 81% (4,285) is concentrated in the Ecuadorian coastal provinces. Seventy–one percent is focalized in Guayaquil. Three hundred and thirty seven cases were registered during the first semester of 2004; 279 of them were concentrated in Guayas province and within that province 233 cases were focalized in Guayaquil canton. Seventy–five percent of all pediatric cases (children under 10 years of age), and 83% of all deaths due to HIV/AIDS are concentrated in Guayas province, where the epidemic advance speed seems to be the fastest of the country. Currently, heterosexual transmission is the main mode of transmission; 20–29 year age group with HIV/AIDS reaches 45% with an accelerated increasing rate.
Blood Banks Surveillance: In 2003, according to information provided by the Blood National Secretariat (Secretaría Nacional de Sangre, in Spanish), there are five institutions whose blood banks are authorized to collect, process and distribute blood and other hemoderivates. Those institutions are the Ecuadorian Red Cross (it collects about 80% of the entire blood donation), the Health Ministry, the Social Security, the Junta de Beneficencia (Charity Board) and the Armed Forces, that have collected 78,886 blood units. All blood units have been screened for HIV, Hepatitis B and C, syphilis and Chagas Disease and 37% of them for malaria in high endemic areas. In that year, the prevalence of serological markers for HIV infection was 0.28%, 0.15% for Hepatitis B, 0.35% for Hepatitis C, 3.9% for syphilis, 0.36% for Chagas Disease and 0.14% for malaria. Blood collected in 2003 from voluntary blood donation was 29.9% of the total.
Vaccine preventable diseases: Between 1985 and 2003, there was a significant reduction in vaccine preventable diseases morbidity and mortality. The last case of poliomyelitis occurred in 1990, since 1998 none measles outbreak has been confirmed and since 2001 there has been no cases of Yellow Fever; the whooping cough outbreaks have been reduced in frequency and magnitude. In 19 provinces (86%), and in 130 health districts (78%) neonatal tetanus is no longer a public health problem; it has been calculated that in the last 15 years 4,800 cases and 3,300 deaths due to that disease have been prevented. Rubella incidence fell in all age groups, but in children under 1 year of age, after the 2002 campaign with the SR vaccine. Surveillance of acute flaccid paralysis, measles and rubella maintains indicators according to the standards. The country expanded and modernized the cold chain of the great vaccine banks and operative units.
Zoonoses: The epidemiological situation of rabies improved during 2003, the highest risk persists in five provinces (Cañar, Tungurahua, Guayas, Cotopaxi, Azuaya, Pichincha and Manabí), where intensive control actions were carried out. After two years, the canine anti–rabies vaccine campaign was done with great success in October, 2003. The national control program was subjected to an external evaluation with the help of PAHO Central Office and PANAFTOSA. External quality control of the INH laboratory net for rabies diagnosis has been regularized and he National Committee for Zoonoses was reactivated.
Food and Nutritional Safety: From 1998 to 2000 prevalence of short height for age (chronic malnutrition) diminished slightly from 27.0% to 25.8% (ECVEEMDINHO/INEC, 2004). However, the situation worsened in rural areas where that indicator grew up to 36%. Likewise and for the same period, the low weight for age indicator (global malnutrition) ranged from 11.6% to 15.0% among population under 5 years of age.
A national study, led by the Food and Nutrition School of the Central University of Ecuador, showed that among urban school-age children (under 8 years of age) overweight and obesity prevalence was 14% (5% for obesity and 9% for overweight). The study also detected that school children watched television an average of 24 hours/week; this is contributing as a strong risk factor along with the consumption of unhealthy diets and junk food to the early presence of overweight and obesity.
Smoking: According to the Second National Household Survey on Drug Consumption, carried out by CONSEP, smoking life prevalence (people that have at least smoked once in their lives) affected 51.6% of the 12-49 years population; the smoking monthly prevalence in general population was 28.3%. Among people that have smoked sometime, in the last month 44.6% did not smoke, 33.8% smoke at least once, 17.0% smoked 1-5 cigarettes/day, 2.5% smoked 6-10 cigarettes/day, 1.% smoked 11-20 cigarettes/day, 0.5% smoked more than 20 cigarettes/day.
In 1998, the First National Survey of Drug Consumption in school–age Children, carried out by SEVIP-CONSEP, showed that life prevalence (having smoked sometime) was 44.3% and that 5.5% of interviewed children smoked on a regular basis. A recent survey done in school-age children (CONSEP-OPS/OMS-CDC, 2001) revealed that smoking at an early age was rising.
Health and Environment: Households having piped water in the house in 2001 amounted 52.1%, households having piped water near the house represented 26.0%, while 21.9% of all households did not have access to drinking water. The actual country drinking water coverage is even lower and it requires and in-depth study, as 95% of water systems run intermittently, 60% has some chlorine level and 70% of rural systems are working.
In 2001, 48% of the population had sewer systems, and only 5% of wastewater was treated. Nationally, population having latrine is just 15.6%. Considering that 70% of Ecuador’s water resources are used for agriculture, this represents a strong risk to human health, especially to vegetable crops and other staples that are consumed raw.
Environmental conditions: Between June, 2003 and May, 2004, air pollution in Quito was above desirable levels during 123 days; Carbon monoxide (CO) was the most important pollutant, its level (8 hour-period) was above 9 mg/m3 and was above 10ug/m3 (hourly average). The frequency of ozone level above maximum allowable value was 26.2% and CO level exceeded the maximum value in 9.3%•, especially during the September-March period. Particulate Matter reached a 3365.53 ug/m3 concentration in the most critical areas of Quito.
Pesticide intoxication cases have increased from the early 1990’s to 2002: 363 cases were registered in 1990 by the Surveillance System of MSP; 1,559 cases were registered in 1997, and 2,163 in 2002. This increase reflects two facts: the growth of the border and Agro-industries, especially the banana and flower crops, and the actions of the Ministry of Health and other agencies to strengthen the surveillance and safe agrochemicals usage and handling programs.
In the last years, the Ministry of Health has developed pilot projects in specific agricultural sectors like the flower, banana and rice producers. This has developed actions directed to improve the surveillance systems, as well as actions directed to the good use of agrochemical products, including information about risks directed to farmers, people in general and changes in agricultural practices sustained in Agro-ecology (pest integrated handling).
Natural and man-made hazards: The most frequent natural phenomena that can produce disasters, are in order of importance: floods, fire, accidents and landslides; those four represent 66% of all events registered in Ecuador from 1970 to 2003. Events that produce most damages are floods, volcanic eruptions, earthquakes, landslides, epidemics and heavy rain. At a national level, floods generate an average of 6,816 affected people in 19 events. Epidemics affected 2,365 people in five events; heavy rains affected 1,860 people in seven events and landslides produced 1,715 affected people in 12 events.
Floods occur mainly in Manabí, Los Ríos, El Oro and Esmeraldas provinces. Landslides take place in the interior cantons of Manabí province, especially in the cantons of Ecuadorian Sierra. Ecuador has 13 active volcanoes; eight with historical activity and five with potential activity. In the last five years volcanic eruptions of Tungurahua, Pichincha and Reventador volcanoes have mobilized national and international resources to mitigate the impact of those eruptions on health, agriculture, economy, and national development. According to the Geophysical Institute of the National Politechnical (IGEPN), the volcanic activity of the Cotopaxi is one of the most dangerous, it would affect densely populated areas like the Chillos Valley, Rafael and the north flank of Quito. Southwards, it would affect Latacunga and Salcedo cities with mud floods and lahars which speed, depending on the steep, could range from 20 to 60 km/h.
Priority geographical area: Ecuador North Border: The Colombian armed conflict worsens every day and causes forced immigration of Colombian families to Ecuador, especially to the border provinces of Sucumbios, Esmeralda, Carchi, Imbambura, Santo Domingo de los Colorados City in Pichincha and to a lesser extent to Napo and Orellana. From January, 2000 to July, 2004 and according to the Refugee Office of the Foreign Ministry, 27,190 asylum applications including 7,329 refugees have been applied. The annual behaviour has increased, in 2000 the number of applications were 475 (comprising 354 refugees), in 2001 there were 3,017 applications (1,319 refugees), in 2002 there were 6,766 applications (1,567 refugees); one year later, 11,463 application were filled (3,112 refugees). From January to July 2004, 5,469 applications have been applied and 1,019 have been accepted.
The government has executed a Contingency Plan to provide care to that population. The UNO and especially, the United Nations High Commissioner for Refugees (ACNUR, in Spanish) develop actions around the Plan. Since 2002, PAHO/WHO are supporting the Public Health Ministry (MSP, in Spanish) through the Health Sector Strengthening Project to provide care to the refugees. The project has allowed to develop the operative capabilities of the border provinces confronted with emergencies and the necessity to supply medical attention to the refugee population. It also has made easier the national and local inter-institutional coordination with the inter-agency help of the United Nations System and local governments to integrate in a single plan of the health sector all actions directed to provide care for the refugee population. Besides, the MSP has modified its registry system, including information about the displaced Colombian populati
on.RESPONSE OF HEALTH SYSTEM
The Health System: According to the Life Conditions Surveys (INEC-BM, 1995 and 1998), the MSP provides health services to 30% of Ecuadorian population. The Social Security Institute (IESS, in Spanish) through the General Insurance and the Peasant Social Insurance covers 18% of the population, 2% is covered by the services of the Armed Forces and the Police; the Guayaquil Charity Board, the Association Against Cancer (Sociedad de Lucha contra el Cáncer, in Spanish), and other NGO’s provide care to an estimated 5%; private services cover 20%. Twenty-five percent of the population is not protected by none of the formal systems; it is basically constituted by poor communities, most of them Amerindians, of rural areas located in the central provinces, the Amazon area and in urban shantytowns.
Summing-up, population having regular access to public and private assistance services is 52% of the total, while the one having some kind of health insurance, public or private is just 23%. As a result of this, proposals directed to expand coverage to guarantee access to health services for people living in the two most poor quintiles, issued by the MSP a the end of 2004 and others designed to provide universal insurance for the population, are the first signs of improvement in the Health Social Protection.
The staff of twelve hospitals has been trained to cope with disasters; contingency plans. Besides, drills have been developed in most of them, more than 250 health officers, including some of provincial response organisms have taken part in them. The Marcos Vinicio Iza Hospital of Sucumbios and the San Vicente de Paul Hospital in Ibarra have implemented those plans in about 70%.
Human Resources for Health:
The National Commission on Health Human Resources (CONARUS, in Spanish): The CONARUS has been working for five years within the National Health Council (CONASA, in Spanish). In CONARUS participate different institutions involved with training, management and regulation of human resources in health as well as deputies of professional associations and health union workers.
Since CONARUS began its activities, data related to health workers have improved in quantity and quality. Access to those data has also been improved, through printed papers and the Health Human Resources Observatory website, (Observatorio de Recursos Humanos en Salud, in Spanish), http://www.opsecu.org/orhs.ecuador.
Availability, distribution and trends: According to INEC, in 2001 there were 70,381 health workers (professionals, technical and auxiliaries), that worked in public and private health facilities. 69.9% worked for the public health sector (Table 1).
Table 1.- Health human resources (absolute numbers and percentage) , Ecuador 2002
Kind of Personnel
Total Number Personnel working for Public Sector % of Total Numbers
% OF Total Public Sector
Physicians 20,592 10,279 29.1 20.7
Auxiliary Nurses 13,434 10,916 19.0 22.0
Services 10,058 7,699 14.2 15.5
Nurses 6,875 5,742 9.7 11.6
Administrative staff 4,834 3,349 6.8 6.8
Auxiliary Technique Services 3,918 3,024 5.5 6.1
Technologists 3,236 2,221 4.6 4.5
Dentists 2,230 2,039 3.1 4.1
Intern medical students 1,837 1,301 2.6 2.6
State and regional physicians 1,150 958 1.6 1.9
Midwives 1,090 920 1.5 1.9
Other professionals 678 471 1.0 1.0
Pharmacists. 494 260 0.7 0.5
Social workers 415 366 0.6 0.07
TOTAL 70,831 41,932 100 100
Source: Merino Cristina. Use of Human Resources in Public Sector Institutions, Quito, CONARHUS – MODERSA, 2004.
In 2002, MSP employed 59.2% of human resources working for public sector. The Ecuadorian Social Security Institute medical services employed 16.9%; the Defense Ministry, 6.2%; Association Against Cancer, 3.0%; Government Ministry, 2.1%; Townships 1.8%, and other institutions 10.8%. Between 85% to 92% of health human resources are located in urban areas. In general terms and related to the training of health human resources, the enrollment of health resources to Ecuadorian universities tends to diminish.
