Coverage and inequalities in health interventions in Ecuador 1994- 2012

Several Latin American countries have reported significant reductions in inequalities and increases in coverage of essential health interventions across the continuum of reproductive, maternal, newborn and child health (RMNCH) care. Although Ecuador has had significant political and economic progress, few studies have evaluated the magnitude and trend of inequalities in RMNCH coverage interventions, a critical step in defining priorities for future health policies and strategies. This cross-sectional study used data from four national representative, standardized health surveys (1994, 1999, 2004 and 2012), analyzing coverage of seven interventions, stratifying by wealth quintile, urban-rural residence and geographic location. We used a variance-weighted least squares regression to calculate the average annual absolute change in coverage across interventions and mapped the results. Using the latest round of the survey, simple and complex measures of inequality were computed. Between 1994 and 2012, in almost all analyzed interventions the differences between rich and poor decreased, especially from 2004 to 2012, period in which primary health care policies were strengthened. In 2012, nevertheless, the most unequal intervention was improved sanitary facilities with 2.4-fold difference between rich and poor (ratio quintile 5:1; concentration index 15.4% 95% CI; 15.0-15.9%); and antenatal care, institutional delivery and improved drinking water kept significant inequality by economic status. While interventions related to the provision of health services showed reduction in inequality gaps, basic sanitation and drinking water had high gaps. Several provinces failed to improve coverage interventions over time, gaps which are masked by national averages and need additional intersectoral approaches to be addressed. Further analysis should focus on other dimensions of inequality such as ethnic group to identify gaps and generate strategies adapted to local realities. Key messages In Ecuador from 1994 to 2012 inequality gaps between rich and poor in most RMNCH coverage interventions declined, mainly from 2004 to 2012, but national means mask inequalities at the provincial level. Interventions related to the provision of health services showed reduction in socio-economic inequalities, while inequalities in basic sanitation and drinking water intervention coverage remained high.