The evolution of socioeconomic health inequalities in Ecuador during a public health system reform (2006–2014)

BACKGROUND: One of the challenges in international health care policy is the reduction of health inequalities. We study the case of a recent health care reform in Ecuador, based on a revised model of public provision and financing of comprehensive care. The policy challenged not only the health care system but also key determinants of health, seeking to grant access and reduce persistent inequalities in utilization of health care services. This study evaluates the progress made on the socioeconomic health inequalities before and after reforms, between 2006 and 2014. METHODS: The Living Standards Measurement Survey 2006 and 2014 are used to examine trends in inequality of two health dimensions: health status and health care utilization in Ecuador. The analysis includes the estimation and decomposition of the concentration index of health care utilization variables to understand which the most important contributors to inequality are, and how they change during the period analyzed. RESULTS: Health inequality reduced after the public health system reform in Ecuador. The utilization of curative visits shows a pro-rich bias, which significantly reduced over the period of analysis. The use of a public facility for a doctor visit also shows a moderate reduction in socioeconomic inequality; although concentrated among the poor, the findings confirm an increase in the utilization of public health facilities by all socioeconomic groups. The decomposition analysis concludes that the most relevant determinants of the inequality in health care utilization variables are income, family size and education. Moreover, the contribution of income decreased dramatically in the utilization of curative visits after the reforms. CONCLUSION: This is the first study that assesses the inequality implications of recent policies targeted at guaranteeing the right to health, equity and social protection of the Ecuadorian population. We provide evidence of a significant reduction of health care inequality, following a well-rounded set of public interventions and investments to attack health and inequality determinants. Yet policies aimed at improving the distribution of education and income are necessary to further reduce health inequalities.