Socioeconomic inequalities in women’s access to health care: has Ecuadorian health reform been successful?

Abstract

Background Over the last 12 years, Ecuador has implemented comprehensive health sector reform to ensure equitable access to health care services according to need. While there have been important achievements in terms of health care coverage, the effects of these reforms on socioeconomic inequalities in health care have not been analysed. The present study assesses whether the health care reforms implemented in the decade between 2007 and 2017 have contributed to reducing the socioeconomic inequalities in women’s health care access. Methods The present study was based on two waves (2006 and 2014) of the Living Standards Measurement Survey conducted in Ecuador. Data from women of reproductive age (15 to 49 years) were analysed to evaluate health care coverage across three indicators: skilled birth attendance, cervical cancer screening, and the use of modern contraceptives. Absolute risk differences were calculated between the heath care indicators and the socioeconomic variables using binomial regression analysis for each time period. The Slope Index of Inequality (SII) was also calculated for each socioeconomic variable and period. A multiplicative interaction term between the socioeconomic variables and period was included to assess the changes in socioeconomic inequalities in health care over time. Results Access to health care increased in the three studied outcomes during the health sector reform. Significant reductions in inequality in skilled birth attendance were observed in all socioeconomic variables except in the occupational class. Cervical cancer screening inequalities increased according to education and occupation, but decreased by wealth. Only a poorer education was observed for modern contraceptive use. Conclusions While most socioeconomic inequalities in skilled birth attendance decreased during the reform period, this was not the case for inequalities in cervical cancer screening or the use of modern contraceptives. Further studies are needed to address the social determinants of these health inequalities.

National and subnational coverage and inequalities in reproductive, maternal, newborn, child, and sanitary health interventions in Ecuador: a comparative study between 1994 and 2012

“…Our results show that Ecuador remarkably reduced RMNCH intervention inequalities between 2004 and 2012, which is consistent with other studies and indicators that showed a reduction in inequalities in the use of health services after 2006 [ 22 – 24 ]. That could be related with the process of transformation of the health sector that started in 2007, reinforced by the Constitution of 2008 bolstering the protection of health as a human right [ 55 ].…”

“…Existing studies have compared health inequalities in shorter periods of time [22][23][24], and there remains a lack of scientific evidence about inequalities in intervention coverage that reflects the changing macroeconomic and political contexts, particularly through analyses that examine subnational level. Using data from four national health surveys in Ecuador, we describe inequalities in coverage of RMNCH and sanitary interventions during and after periods of marked political, economic, and social crisis, between 1994 to 2012.…”

Ethnic inequalities in reproductive, maternal, newborn and child health interventions in Ecuador: A study of the 2004 and 2012 national surveys

“… 37 Recent studies carried out in similar periods of time show an increase in health service coverage, including of RMNCH health interventions 16 , 17 , 36 and reduction of inequality gaps by wealth and place of residence. 18 Similar to another study, 21 the present study also found increasing coverage of health interventions between the years 2004 to 2012 across ethnic groups. Although a reduction in absolute inequality gaps was identified, the pattern of inequality – which continues to disadvantage indigenous population – remained in 2012.…”

“…19 Finally, in the same period, the infant mortality rate decreased from 11.3 (2004) to 8.8 per 1000 live births (2012). 20 Despite this overall progress, very few studies 21 have analyzed health reproductive interventions, particularly with attention to ethnicity as a stratifier. We were not able to identify studies that examined whether these inequality reductions have been observed for all ethnic groups, in the spirit of the intercultural approach promulgated by the regional policy in 2017.…”

Assessing the impact of the 2008 health reform in Ecuador on the performance of primary health care services: an interrupted time series analysis

“…Two studies have assessed the role of the Ecuadorian health reform on decreasing socioeconomic inequalities in health care utilization and health outcomes, respectively [10,11]. In the first one, a decrease in income inequalities in curative visits was observed after the reform.…”