PUBLIC HEALTH POLICY AND MORTALITY IN LATIN AMERICA:
THE CASE OF ECUADOR
Jorge Eirique Uquillas Rodas
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
TOE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE IREQUIREIETIS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
Jorge Enrique Uquillas Rodas
To my family, whose silent support
is always in my mind, and to the
memory of my brother and father.
I would like to than the Chairman of my dissertation committee,
Dr. Herndn Vera Godoy, for his advice and guidance throughout the period
in which this work was being written. His useful insights often led .ue
to new approaches to the subject matter of this study. I am also in-
debted to the other members of m;y committee, Drs. Anthony La Greca,
John S. Fitch III, Joseph D. Vandiver, and George J. Warheit. To lbe,
they are not only acades'ic counselors but real friends.
Dr. William Carter, Mrs. Vivian Nolan, and many other people at the
Center for Latin American Studies have lent re their support and under-
standing, for which I am very grateful. For financial support, my tian:.s
are directed to the University of Florida and the Tinker Foundation.
Many officials of the Ecuadorian government, particularly from the
Ministerio de Salad Pdblica, the Instituto Nacional de Estadistica, and
the Oficina de los Censos Nacionales either agreed to be interviewed or
provided me with the necessary data for this study and they deserve
special recognition from me.
Finally, I would like to express my sincere appreciation to fellow
graduate students who helped me in the successful co':pletion of this
dissertation just by being friendly and concerned.
TABLE OF CONTENTS
I. Introduction 1
II. The Development of Public Health Policy in Ecuador 12
III. Public Health Policy Programming Since 1960 44
IV. Public Health Policy Implementation: The Differential
Distribution of Health Services 68
V. Mortality Conditions 104
VI. Factors Related to Mortality Decline 129
VII. Conclusions 162
Biographical Sketch 185
Abstract of Dissertation Presented to the Graduate Council
of the University of Florida in Partial Fulfillment of the Require':lents
for the Degree of Doctor of Philosophy
PUBLIC HEALTH POLICY AMD MORTALITY IN LATIN AMERICA:
THE CASE OF ECUADOR
Jorge Earique Uquillas Rodas
Chairman: Hern6n Vera Godoy
Major Department: Sociology
Public health policy in Ecuador has evolved from the traditional
concepts of Christian charity and public beneficence for indigent people
afflicted by disease to its present recognition as a basic human right.
The government is now obliged by law to provide medical and health care
services to the entire population.
After nany years of such rhetoric but practical neglect, there has
been a dramatic increase in the programming and implementation of public
health policy in the country, particularly since the early 1;60's. How-
ever, public health has not been one of the main priorities of the govern-
ment. The percentage of the central government's budget allocated to
public health agencies remains relatively low.
The preventive and curative health services available are concentra-
ted in urban areas, particularly in Quito and Guayaquil, the two largest
cities; very few services are provided for the rural population, which
represents nearly two-thirds of the nation's total. A sLostantial pru-
portion of the presently available health resources serve only a limited
clientele, representing primarily middle and upper class groups, e.g.
the medical care services of the Ecuadorian Social Security Institute,
which are virtually restricted to its mostly urban based, white collar
and skilled blue collar affiliates (about six percent of the total popu-
lation of the country).
The research shows that, although mortality as a whole has declined,
deaths of children under five years of age still account for about half
of all deaths. For the total population, the main causes of death are
infectious and parasitic diseases and diseases of the respiratory sys-
The statistical analysis of the data indicates that most of the
variations in mortality are attributable to unexplained factors. From
1j62 to 1974, variations in mortality rates among Ecaador's provinces
were only slightly correlated with either public health policy Lmplenenta-
tion or socioeconomic development. These findings are probably affected
by the nature of the data and the use of aggregate indices. Further
analysis indicates that lower mortality in 1 62 and 1i'74 is mainly asso-
ciated with increased literacy, greater provision of sewage services, and
more doctors per population. Contrary to expectations, the mortality
decline occurring in the 1962 to 1)74 period is negatively associated
with decreasing agrarianism (i.e., the proportion of the labor force
engaged in agriculture and related activities) and with the provision of
hospital beds, but, on the other hand, as expected, mortality decline is
also positively related with the provision of sewage service and with
increasing number of doctors per population.
Therefore, the prevalent theory that mortality decline in post -130
Latin America is determined mainly by the utilization of modern medical
and health care techniques is only partly supported by the data on Ecua-
dor. Mortality decline is related to the provision of public health ser-
vices nore than to socioeconomic development but, in general, it is still
The Importance of Public Health Policy to Morbidity and Mortality
The reduction of the morbidity and mortality of the population is a
concern of most modern governments. In contrast to the case of fertility
control which has encountered strong opposition in some countries, there
has been almost no opposition to governmental projects designed to con-
trol mortality and to improve health conditions.
Direct government action plays a large role in the reduction of mor-
tality. As Johnson (1965) points out, the accomplishments of nations in
the area of mortality control are related to the execution of development
plans as well as to plans for better provision of health services. The
provision of medical and health services is of particular importance since
their main function is precisely the reduction of morbidity and mortality.
Public health-related decisions determine to a large degree the popula-
tion's level of exposure to disease as well as its differential access
to available health services.
Following Berelson (1971), public health policy -- which can also
be interpreted as mortality policy -- is defined as governmental actions
that are designed to alter the population's mortality or that actually
do alter it. Therefore, this study takes into account not only explicit
health related pronouncements of the government but also what is impli-
cit in other areas such as budget allocations, trends of expenditures and.
programs (executed or in operation) and their achievements. Health policy
outcomes or implementation are thus reflected in the qualitative and quanti-
tative distribution of medical and sanitation services around the country.
The Substantive Context
There is a substantial body of literature dealing with the deter-
minants of mortality decline in both the economically advanced nations
of the world and in the economically less advanced ones (Arriaga and Davis,
1969; Helleiner, 1957; Kusukawa, 1965; McKeown and Brown, 1965; McKeown
and Record, 1962; Matras, 1975; Stolnitz, 1955; Vallin, 1968).
Wnile the literature on public policy relevant to population matters
is becoming abundant (e.g. Berelson, 1971; Ohlin, 1974; Sauvy, 1969;
Vickers, 1974), it tends to focus primarily on the United States and much
less on other areas of the world. In terms of demographic aspects con-
sidered, the available literature leans heavily in favor of public poli-
cies on either fertility control (Berelson, 1973b; Brackett, 1962; Burch,
1974) or its urban growth correlates (Antonini, 1972; Miller and Ga':en-
heimer, 1971). Mortality relevant policies have not received much at-
tention from demographers or public policy analysts. This occurs despite
the fact that population policies to reduce mortality have been found to
be more effective than policies to affect, for instance, fertility (Berel-
There are, however, some authors who deal with the subject of public
policy and health. Kitagawa (1972), for instance, has written about dif-
ferential mortality in the United States and tried, if unsuccessfully, to
analyze its implications for public policy.. A less explicit work but
still relevant to the subject is that of Noonan et al.(1972), in which
the authors indicate, first, that the United States' food distribution
programs, originally conceived to assist farmers, have evolved into pro-
grams strengthening the health of children and the poor, and second, that
all laws promoting health, save those directed to the care of persons
past reproductive age, lead to increased population growth, not only
because they decrease mortality but also because they benefit reproduc-
Important theoretical contributions have also been made by Ugalde
(1972a, 1972b, 1973) and Navarro (1974). Ugalde's work is concerned
mainly with the politico-sociological aspects of public health policy
rather than with its demographic dimensions. Among the author's main
contributions are the concept and model "series of decisions." Series
of decisions is defined as the total number of decisions made in the
attainment of a goal. According to the series of decisions model, there
are four basic types of decisions: 1) input decisions, which mar' the
beginning of series, 2) programming decisions, which are made in the pro-
cess of preparing a program, 3) formal decisions, which accept a program,
and 4) implementation decisions, which are made in the process of imple-
menting a formal decision. In addition, the author provides an inventory
of factors influencing decisions which can be of great value for a de-
tailed study of the decision making process in a nation (see Ugalde, 1973).
Navarro places the matters of both public health policy and distri-
bution of health resources in a wider structural context and states that
"the distribution of human health resources follows and parallels the
distribution of most of the resources in underdeveloped countries" (1974:
6). The author further argues that the maldistribution of health re-
sources in Latin America is determined by the same factors that cause
underdevelopment in the continent, namely its economic and cultural de-
pendency and the fact that certain social classes control the mechanisms
of control and distribution of resources in general, including health
resources. ThIs, he says: "parallel to what occurs in the overall
economy, the same social groups that determine the patterns of production
and consumption in the primary and secondary sectors also shape patterns
of production and consumption in the health sector. And it can be posited
that these are patterns that do not benefit the majority of the popula-
tion" (Navarro, 1974:14).
Using the Republic of Colombia as a case in point, Navarro continues:
"If we look at the type of morbidity prevalent in the surveyed population
(i.e. infectious diseases and malnutrition) and the comparative effective-
ness of the different health activities for combating this morbidity, it
would seem that environmental health services and preventive personal
health services should be given far higher priority than curative servi-
ces, and particularly the hospital services" (1974:17).
The literature dealing with population and health policy in Ecuador
is scarce. While mortality and, to a lesser extent, the health system
in Ecuador have been studied previously (Ecuador, Junta Nantonal de Plani-
ficacidn y Coordinacidn J/PC7, Centro de Analisis Dasogrfico CAs_7, 1974;
Ministerio de Salad PJblica /MSP7, Divisi6n Nacional de Planifica-idn
'DNP7, 1974, 1975, 1976; Favin, 1973; Linden, 1967), the role of public
policy in relation to demographic variables has been practically neglected.
Sanders (1972) points out several cases which illustrate a conscious govern-
mental policy designed to introduce fertility reduction programs in the
country. Vega (1964), on the other hand, indicates some mortality rele-
vant policies when he states that the provision of public services -- in-
cluding, of course, health services -- is one of -the basic functions of
the state. Recent Ecuadorian government publications have also expressed
the intent to improve health and sanitation conditions of the population
and to further reduce general mortality, particularly infant mortality
which is rather high (JNPC, 1972a, 1972b). Public policies affecting
demographic variables, among then mortality also have been discussed
by this author (Uquillas !973).
An Analytical Framework
Existing knowledge indicates that mortality reduction in Latin
America is related to the provision of sanitation and medical services
(see, for instance, Arriaga and Davis, 196Y). In Ecuador, the mortality
rate decline from an estimated 28.9 per thousand in 1920 to 12.4 in 1i65
has been attributed to the improvement of health and sanitation services
through the post-1930 campaigns against cholera, malaria, yellow fever,
smallpox, and other diseases (Sanders, 1972).
After providing the necessary background information on public
health policy making and on mortality change in Ecuador, with particular
emphasis on the 1960-75 period, this study attempts to find whether there
is a relationship between (a) mortality and socioeconomic development and
(b) mortality and what is referred to here as public health policy im-
plementation or, simply, public health. The data analysis involves two
time-related approaches: 1) a synchronic or cross-sectional approach
and 2) a diachronic or longitudinal approach. Using data for two fixed
points in time, circa 1962 and circa 1974, the synchronic approach tests
the main hypothesis that, in Ecuador's provinces, the greater the public
health policy implementation in a given year (lo62 or 1974), the less the
mortality of the population in the same year. In contrast, using data
on the change occurring between circa 1962 and circa 1974, the diachronic
analysis tests the main hypothesis that, in Ecuador's provinces, the
greater the public health policy implementation during the 12-year period,
the greater the mortality decline of the population during the same period.
One basic assumption under which this analysis operates is that, although
the actual data on socioeconomic development and public health policy
implementation say be concurrent to those of mortality, they represent
phenomena prior in time to mortality. This assumption is necessary be-
cause the most reliable and readily available data are either those col-
lected by the national census or those which can be used in conjunction
with the census reports.
The basic sources of data for this work are: 1) the national cen-
suses of 1950, 1962, and 1974; 2) the vital statistics reports published
by the Ecuadorian Civil Register (Anuarios de Estadisticas Vitales); 3)
additional demographic data and health statistics published oy the National
Statistical Institute (AnuarLos de Estadistica) as well as by international
organizations, such as the United Nations (DLemogra-phic Yearbook, Population
and Vital Statistics Report), the InterAmerlcan Statistical Institute
(A-nrica en Cifras), the Pan American Health Organization, etc; 4) official
documents and publications (among them those of the Official Register, the
Ministry of Health and the National Planning Board); and 5) data obtained
from open-ended interviews with selected decision makers and others with
.mowledge in the area of public health.
Ecuador's census data have been reported as being fairly reliable
(Saunders, 1959; Merlo, 1969); however, data on vital events, specifically
on deaths, seem to be incomplete mainly due to underregistration. There-
fore, the author has made a special effort to select those figures of
greater dependability and, when necessary, to identify the shortcomings
of the data.
The data collection phase consisted primarily of the acquisition and
borrowing for consultation of census materials and vital statistics as
well as several other forms of official records and documents (which were
summarized in the previous section). To a lesser extent, data for the
study of public health policy were collected in open-ended interviews
with officials of the Ecuadorian government. These interviews tried to
elicit information on public policy and its implementation, information
which often is not available in written form.
The collection of most of the data was carried out from June to
November, 1975. A great deal of time was invested in locating officials
who were knowledgeable about particular aspects of health and requesting
authorization to review official documents. In some cases, the unique-
ness of a given document or the lack of cooperation of an official re-
quired the researcher to examine and take notes on the document while in
one particular office. Sometimes officials allowed the researcher to take
out documents for xeroxing; and occasionally, some government employees
were kind enough to provide extra copies of them.
Interviewing was a particularly hard task. bhile there were some
officials who were glad to give part of their time to answer questions
and talk about their work, a significan- number of them were hard to find
because their work included frequent travel to provinces. A few high of-
ficials were reluctant to be interviewed personally and designated a
subordinate to do the talking. Frequently, this was beneficial since
career employees, in positions of lesser political significance, had
longer acquaintance and better knowledge of the activities of a given
The officials interviewed were either chiefs of Division ( a sub-
classification of the Ministry of Health), who ranked next to the Minister
and his undersecretary, or their delegated subordinates. The Divisions
they represented were: Planning, Technical Services, Finances, Develop-
ment of Health, Epidemiology, Naurltion, and Odontology.
Some public officials working in other government agencies were also
interviewed, particularly employees of the National Planning Board (Social
Affairs Section) and the Medical Department of the Ecuadorian Social Se-
As the questionnaire was open-ended, the interviews varied in format
and length. In general, officials were asked questions about basic health
policies of the Ministry section in which they worked and were encouraged
to elaborate on their objectives, mode of operation, specific plans or
programs, their financing, methods of implementation, and duration in
time. The need for information on officially adopted programs and their
financing was particularly stressed.
The officials' reaction to being interviewed varied greatly. Some
were disposed to elaborate at length on the subject matter while others
were very incommunicative.*
Public officials do not always think in terms of "public policy,"
"norms," "guidelines," or "implementation." A circuitous manner of ap-
proaching the subject was required in many cases. Therefore, when a
given official was uncertain about the health policies of his subdivi-
An extreme example of the latter is given by a Chief of Division
who basically said "policy is money" and when queried about the meaning of
his statement, he replied that no matter what is stated as policy, its im-
plementation is possible only when money is allocated.
sion, he was requested to answer questions such as: what does your office
do? what are its functions within the Ministry of Health? and what work
does it do at the local or national levels?
For the data analysis phase, the author used suc! procedures as
assembling, summarization, and interpretation of the censuses and other
demographic and statistical data. In the study of mortality there was
an extensive reliance on several basic techniques which are widely used
in the field of demography, among them the crude death rate and the in-
fant mortality rate (see Elizaga, 1969; Barclay, 1970; Saith and Zopf,
1970, UN, 1967). The study of factors related to mortality decline
was performed partly using a social typology constructed according to
Mattelart and Garretdn's (1965) method and partly using statistical mea-
sares appropriate for interval scale variables, primarily simple and par-
Outline of the Study
Following this introductory chapter, some background information
about Ecuador in general and about its public health history in particu-
!ar is provided in chapter II. Some characteristics about the country
and its people are briefly outlined in order to provide a specific frame
of reference and to present some of the terms used in the rest of the
study. Also, an abbreviated history of public health and of the develop-
ment of public health policy is presented beginning with the nineteenth
century. Some specific dates and events are taken as representative of
a period in public health history and as stepping stones leading to an
understanding of present public health policies. For each period con-
sidered, an effort is made to describe prevalent ideas about health, some
problems and solutions, including actions ta' en by the government.
Chapter III deals with public health policy since 1960 to the present.
It is primarily concerned with the series of decisions defined as pro-
gramming, i.e., the elaboration of health plans and programs as well as
the creation of institutions of public health.
Chapter IV covers implementation decisions as reflected in their
outcomes. Tie analysis of public health policy implementation includes
data which range from national budget allocations for public health to
the final regional and provincial distribution of public health services
in the nation. The differential distribution of services, until about
1960 and from 1960 to 1974, is particularly studied in order to find what
sectors of the population are better served than others.
Chapter V looks into the mortality conditions of the country. Re-
gional and provincial differences are analyzed according to various .fac-
tors such as age, sex; and residence. This chapter includes a section on
the main causes of death in relatively recent time periods.
In chapter VI the case of Ecuador is used to test two main hyptheses
of mortality change: 1) that which posits that mortality change is rela-
ted to socioeconomic development and 2) that which affirms that mortality
change is primarily associated with the development of modern techniques
of health care. There is also a brief discussion of the relationship be-
tween mortality and particular aspects within public health policy imple-
Finally, chapter VII presents some concluding commens,. particularly
in regards to the model tested in chapter VI and alternative ways of using
the data available in order to obtain a better explanation of mortality.
It should be pointed out that chapters II to IV, which represent a
large portion of this study, deal mainly with background information.
This relatively large treatment of institutional developments, plans and
programs, and the distribution of health services does not make very
interesting reading. Yet, it is of great importance not only for area
specialists but also for people concerned with the study and improvement
of health conditions in Ecuador This is probably the first comprehen-
sive effort of this type, and is the result of much effort, particularly
that of connecting disjointed pieces of data.
TIHE DEVELOPMENT OF PUBLIC HEALTH POLICY IN ECUADOR
The Country: Selected Characteristics
The Republic of Ecuador at the present time occupies an area of ap-
proximately 271,000 square kilometers. Its territory is located on the
northeastern part of South America, bordering Coio:nbia on the north, Peru
on the south and east, and the Pacific Ocean on the west. The Andes
mountain range crosses the country from north to south creating a con-
tinental area of three contrasting regions: 1) the Sierra (literally
the Highlands) or the territory occupied by the Andes; 2) the Costa
(literally the Coast) or western lowlands, and 3) the Oriente (literal-
ly the Orient) or eastern lowlands. The Galapagos Islands, located over
five hundred miles off the coast, have been traditionally considered a
fourth natural region. The Oriente has about half the country's total
surface, the Sierra and the Costa share the other half.
Ecuador is a country of sharp contrasts. One of them concerns the
way in which the population is distributed. From the data presented in
Table 1 and Figure 1, it can be observed that, in 1974, 97 percent of the
population lived in the highland and coastal regions, where densities
ranged from 13.5 irmabitants per square kilometer in Esmeraldas to 74.6
in Guayas. On the other hand, less than three percent of the population
lived in the eastern region and the Galdpagos Islands; their densities
Table 1. Population of Ecuador, Number and Percent, by Region and Province,
1962 and 1974.
Region Population ('lousands)
Number Percent Nunber Percent
Source: DEC, 1964; Ecuador, Oficina de los
Zones under dispute i0
Censos Nacionales (OCN), n.d.
were below two inhabitants per square kilometer.
Administration and Politics
A unitary State, Ecuador currently divides its territory, for poli-
tico-administrative purposes, into 20 provinces. Each province is ruled
by an appointed governor, who represents the executive branch of govern-
ment. Provinces in turn are subdivided into cantons. There are 114
cantons in the country; each of them is ruled by an alcalde (mayor), who,
by law, is supposed to be elected to the post but when a de facto govern-
ment is in power, is often appointed. Cantons are subdivided into parishes,
which are the smallest politico-administrative units. There are 917 pa-
rishes, 203 urban and 714 rural; each of them is ruled by a political
lieutenant, who is also appointed by the executive branch.
One of the main characteristics of the political system of Ecuador
is the instability of national governments. Tle country's history records
a long succession of constitutions, elections, coups d'dtat, and short-lived
regimes. Since 1830 to the present, there have been 16 different consti-
tutions, an average of one per each nine year period. Only three times --
from 19g18 to 1960 -- have elected presidents finished their terms in of-
fice. All other elected governments have been cut short by coups d'dtst.
In fact coups d'dtat are the usual means of reaching power in the nation.
Regardless of the way in which they acquired power, Ecuadorian presi-
dential regimes have been short-lived. This has been mostly due to the
conflicting interests of the country's olig)rqua (oligarchy) or ruling
elite. The political instability, typical of Ecuador as well as of other
Latin American nations, is vividly illustrated by the events of the last
decade. In 1966, a Military Junta was deposed after three years of de
facto rule. It was soon followed by the interim government of President
Yerovi Indaburu and the election of a Constitational Assembly. This
Assembly selected a new president, Otto Arosemena Gdmez, wrote a new con-
stitution, and called for national elections. In 1968, Jos6 Maria Velasco
boarra was elected president; he declared himself dictator in 1970, doing
away with the latest constitution, the congress, and many other elected
officials. Within two years, in February 1972, Velasco was overthrown
by the Military. The new dictatorship was at first led by Gene-al Guil-
lermo Rodriguez LSar and, since ealy 1976, has been headed by a three-
Also, Ecuador's political system has traditionally been characterized
by decentralization of decision-making. iThus, the power of formulating
public policy often has been relegated to autonomous institutions. Ta a
large extent, decentralization has been due to the existence of regionalism
in the country's politics and to the lack of adequate means of coimmunica-
1ion among the different regions and provinces. The Sierra and the Costa
often have followed different political coarse, as illustrated by the
turn of the century split between the predominantly Conservative high-
lands region and the predominantly Liberal coastal region. In regard
to the lack of communicaation, before the 1920's, the only effective means
of transport between the Sierra and the Costa was the Quito-Guayaquil
railroad and, at.the present time, although the situation has improved
with the opening of several roads across the nation, there are still
large areas isolated from the rest of the country, i.e., the Oriente
In addition to decentralization and instability, some of the factors
affecting policy-making in Latin America -- mentioned by Anderson (1967:
115-137) -- are also applicable to the Ecuadorian case, particularly the
following: 1) the government's limited knowledge of the country's needs,
due to lack of capable personnel and lack of accurate statistical informa-
tion; 2) the low degree of the citizenry's concern and participation in
the political process (usually less than 15 percent of Ecuador's total popu-
lation participates in the electoral process); and 3) the role of special
interest groups in the making of public policy. (For further details on
Ecuadorian politics, see Martz, 1972.)
Social and Economic Aspects
By most social and economic indicators, Ecuador belongs to the so-
called underdeveloped or Third World nations. Traditionally, it has been
one of the poorest nations of Latin America, with no major industries, and
dependent to a large degree on income derived from export of agricultural
products such as bananas, cocoa, and coffee. In the last four years,
thanks to the discovery and subsequent exploitation of oil in the Oriente,
Ecuador has been able to increase its national revenue and has invested
some of it in national social and economic development programs. Its gross
domestic product grew from US $841 million in 1960, to US $1676 in 1970
and US $3475 in 1974; while it took ten years to doable the 1960 figure,
it took only four years to double the 1970 figure. Its mean annual per
capital income has gone from US $195 in 1960 to US $275 in 1970 and US $500
in 1974. The budget expenditures of the Central Government hare also in-
creased from US $69 million in 1960 to US $148 in 1970 and US $447 in
1974 (Ecuador, Banco Central, 1975).
The apparent improvement in socioeconomic conditions, however, does
not mean that social conditions have improved at the same time. The in-
creased benefits the state receives are only partially transmitted to the
masses of people. The degree and speed to which this distribution occurs
depends heavily on whether social welfare is among the priorities of the
national government. At this point in time it is not possible to evalu-
ate properly the effects that recent events such as the exploitation of
oil and the military rule since 1972 will have on the social configura-
tion of the country.
Recent evidence indicates that the'population of Ecuador is still
predominantly rural; in 1974, over 58 percent of all inhabitants lived
in rural areas. The national census (OCN, 1975) defines as arbsn the
population of provincial capitals and canton seats (when the latter are
in concentrated nuclei). The percentage of economically active popula-
tion (aged 12 and over) engaged in agricultural and related activities is
very high, although it has decreased from about 64 percent in 1962 to 56
percent in 1974. Moreover, at a time when many modern states of the world
have practically eliminated illiteracy, over a quarter of the population
(26 percent in 1974) is still unable to read and write a simple paragraph.
Finally, according to sample results of the 1974 national census (OCN, 1975),
over 61 percent of the total number of existing dwellings lacked the mini-
mal services of potable water, electricity, toilet, and sewerage connec-
tion. The majority of dwellings consisted of no more than two rooms and
gave shelter to an average of five persons per dwelling.
A Brief History of Public Health
The history of public health and of medicine in a nation cannot be
segregated from other historical facts and the sequence of events to which
they belong. As a specialized history of Ecuador is beyond the limits of
the present endeavor, the author has opted for the presentation of a brief
sketch of health and health policies taking 189) and 1960 as major turning
points. The year 1895 marks the advent of Liberal governments and a new
conception of the State in relation to Public Health. The year 1960 marks
the beginning of a period of increased awareness of the need for change,
the adoption of planning at the national level, and the creation of im-
portant public health institutions.
The Pre-National Period
Before 15 4, the year in which the Spaniards consolidated their con-
trol of the northern part of the Inca Empire by taking over Quito and
"founding" it with the name of "Villa Real de San Francisco de Quito," the
territory of the present Republic of Ecuador was occupied by innumerable
Indian tribes, some of which formed loose confederations in the hoyos or
intermountain valleys of the Andes. Of these confederations, the "Quitu"
or "Shiry" was the most influential in the period preceding the conquest.
This confederation, also known as the "Kingdom of Quito," was integrated
into the Inca Empire when the Spanish military arrived in America. According
to Phelan (1967:44) the most accurate estimates of the pre-conquest popu-
lation of the Kingdom of Quito are those -hich have placed the figure not
beyond the 780,000 to 1,000,000 mark.
The Spanish conquest radically altered the demographic structure of
the Inca Empire. It provoked a great reduction in the number of inhabi-
tants due to the wars of conquest and the introduction of diseases which,
in the form of sweeping epidemics, decimated the Indian population (who
had not developed any immunity to these new types of virus strains).
During the colonial period, thousands of Indians were killed by succes-
sive epidemics of smallpox and measles, as well as other diseases. In
1589, 30,000 people died in the city of Quito as a consequence of unidenti-
fied epidemics (CAD, 19T5:6); about a century later, in 1680, smallpox
alone caused the deaths of more than 60,000 people in the territory of the
old Kingdom of Quito (Dobyns, 1963).
Regarding the number of innabitants of the Kingdom of Quito during
the sixteenth and seventeenth centuries, there are estimates of about
half a million before 1600 (Fnelan, 1967:14) and 580 thousand in 1650
The illnesses which the Spaniards communicated to the indigenous in-
habitants constituted true bacteriological weapons which facilitated the
conquest and subsequent long-lasting domination of the latter people. To
state that the Indians had no defenses against those diseases does not
mean that they did not have some knowledge of medicine and public health
care. In fact, long before the Spaniards came, the native Americans had
already a vast knowledge of the medical properties of many plants and herbs
and had even performed more complex healing procedures, such as the brsin
surgery the Incas apparently used to extirpate tumors. tireuver, they had
knowledge of preventive hygienic measures, which perhaps were incorpora-
ted in their religion and lore (see Paredes, 1963).
This folk medicine and traditional knowledge, accumulated by trial
and error for many centuries, came to represent the main medical resource
of the people of Ecuador. Even today, it is difficult to say what is the
impact of folk medicine and its contribution to public health. However,
its impotence in the face of epidemics, a commonplace occurrence in Ecuador
until as recently as the 1930's, is beyond doubt. The present historical
sketch does not deal with folk medicine and its contribution to public
health. It is not because it may be considered unimportant. father, it
is suspected to be crucial in the general welfare of the population, and
particularly, in that of the less privileged segments of Ecuadorian peo-
ple. Its neglect is due to the fact that this dissertation is Locused on
public health policy, i.e., governmenLal actions designed to alter the
population's health conditions.
The First Decades of National Life: 1830 to 1895
The population of Ecuador at the time of its separation from the
Gran Colombia in 1830 -- eight years after gaining independence from Spain
-- is estimated at around 800 thousand inhabitants. During that period in
history the population must have increased very slowly because by 1861 a
census of the Sierra and Costa counted approximately 839 thousand inhabi-
tants. About 94 percent of the people enumerated lived in the Sierra.
Quito had about 35 thousand people and Guayaquil over 15 thousand (Paredes,
1963, Vol. II).
According to the limited information available (Pa"edes, 1963; Madero,
1955; CAD, 1975), the population of Quito grew from about 30 thousand in
the 1830's to 45 thousand in the 1890's. The population of Guayaquil grew
from about 10 thousand in the 1830's to somewhere between 30 and 45 thou-
sand in the 1890's.
During the nineteenth century, several diseases periodically ascuned
epidemic proportions and caused great loss of life. Among these were
yellow fever, smallpox, malaria, dysentery, measles, tuaerculosis, syphilis,
leprosy, tetanus, and whooping cough. An 1840 yellow ferer epidemic, for
example, caused the death of 4,550 people in areas which are now the Pro-
vinces of Cuayas and El Oro (Madero, 1955:206).
lTe few preventive services available in the early years of the
Republic were provided by the Juntas de Sanidad (sanitary boards), some
of which predated Independence, while others were created by Sim6n Boli-
var when he was president of Gran Colombia. Quito and Gtayaquil (perhaps
also Cuenca, Loja, and Riobamba) had sanitary boards during most of the
By the 1860's, the main function of the Juntas de Sanidad was to ob-
tain and preserve the smallpox vaccine, and sometimes also the yellow fever
vaccine -- both of which were already available in Europe and North America
-- for use in the frequent epidemic outbreaks. The customary response to
an outbreak of smallpox was mass immunization of the population.
Also considered as a preventive service, and as a forerunner of
sewage services, is the enterprise of the abromicos which was started in
Guayaquil in 1862. People known as abrdmicos obtained their name from the
containers in which they collected hunan refuse for cosequent disposal
outside the city limits. It was a private enterprise and users had to
pay for the service.
Ecuador's first piped water system was installed in Guayaquil in 1891.
Quito at that time was supplied with fresh water by means of open canals
which brought it from a nearby snowcapped volcano, the Pichincha. This
canal system had been in use since before the arrival of the Spaniards
Traditionally, from colonial times through the early republican period,
wealthy people received medical -- mostly curative -- care from the few
persons who had some training in medicine such as the protomAdicos of the
ealy 1800's. The p-otomnidicos were people with at least some theoretical
training in the schools existing at that time. They differed from other
medical practitioners such as the sangradores bleederss) who had almost
exclusively practical training. In later years, wealthy people either
had the services of private physicians or, if needed, were interned in
The majority of the people, primarily Indians and some whites and
mestizos, could not afford the services of private physicians. If they
received any medical care at all, it would have been from the curanderos
(folk medicine people) or from the church in the name of charity.
The cities of Quito, Guayaquil, Cuenca, Riobamba, and Loja had hospi-
tals. Paredes (1963) reports that by the turn of the nineteenth century
there were five hospitals in Ecuador and that the number increased to 17
by 1892. Other hospitals, such as military ones, did not operate perma-
nently because they were created or dismantled according to the needs of
the moment such as the wars of the 1850-60 period or the Liberal insur-
gency of the 1880's and early 1890's. Sometimes military hospitals were
no more than wings of an already existing hospital, reserved for military
The concept of charity predominated in most early nineteenth century
thinking about public health. This type of thinking was a worldwide (or
at least European and American) phenomenon, not limited to Ecuador or
Scuth bAerica. A clear illustration of this is given by the names of the
two oldest hospitals in Ecuador: that of Quito was called ."Hospital de
la Misericordia" (Hospital of Mercy), that of Gusyaquil, "Hospital de la
Caridad" (Hospital of Charity).
The hospitals of the time were mainly built to serve the most import-
ant health needs of the populace, i.e., the Indians and other poor people
that lived in the main cities or fairly close to them. But that majority
of the population that lived in rural areas of the c-ountry had no other
recourse but its folk medicine and whatever hygienic norms it ].earned
through the influcence of the Catholic Church.
Human health resources
In 1854 there were between 50 and 60 physicians in the nation. The
Sierra had 40 (25 in Quito, three each in Cuenca, jfo, and Hiobaimba, two
in Latacunga) and the Costa had only 11 (11 in Guayaquil, two in tanuMb
Province and one in Daule). Besides doctors, the only health personnel
available in hospitals before 1869 were the barchilones who acted as kinds
of nursing assistants. In 1869, the Sisters of Charity arrived in Ecuador
and were the first nurses to work in the country (Paredes, 1963, Vol. II;
Madero, 1955). These nuns came after the National Convention of 186) re-
quested their services on the suggestion of the delegate Gabriel Garcfa
ibreno. Garcia Moreno, who later became President of Ecuador, is one of
the best known political figures of the country, famous for his religious
zeal as well as his ruthless use of power.
From Christian Charity to State Welfare, 18'5 to 196l
In 1895, Liberal forces led by General Eloy Alfaro defeated in the
battlefield the Conservative forces at that time in power and took over
the reins of government. A detailed description of what distinguished
liberals from conservatives in Ecuador is beyond the purposes of this
study. Yet, it is necessary to point out that there were some basic
ideological, political, economic, and regional differences between both
Liberals represented the possibility of radical change at the time.
Their ideological influences could at least partially be traced as far
back as the Enlightenment and the trench Revolution in Europe and, in the
American continent, the principles embodied in the United States Consti-
tution at that time. To a large extent, Liberals in Ecuadoir ere also
influenced by ideological currents operating in Latin America since before
Independence. The writings of Nariio and Espejo alone, in what are now
Colombia and Ecuador, are examples of ideals and principles later espoused
and developed by Liberal thinkers. In more pragmatic terms, Ecuadorian
Liberals found their main support among British commercial interests
(which at that time had a powerful influence in world affairs), among the
increasingly powerful merchant class of the Costa, and among people who
were just fed up with the abuses and corruption of Conservative regimes.
Conservatives represented the maintenance of old political and eco-
nomic structures in the nation. Their ideological influences derived
mainly from the Roman Catholic Church. They had controlled the govern-
ment for many years; for almost 15 years, from about 1860 to 1875, Gabriel
Garcia Moreno was the almost undisputed strongman of Ecuador and, obviously,
the main defender of Conservatism. For additional support, the Conserva-
tives relied heavily on the Church hierarchy and on the common people in-
fluenced by the Church to the point of fanaticism as well as on the tra-
ditional rich families and landowners of the Sierra.
The ascendancy of Liberals over Conservatives, to a large extent,
meant that of merchants over landowners and of coastal interests over
highland interests. Liberalism reduced the influence of the Catholic
Church in most aspects of secular life and, at the same time, gave way
to a greater participation of the state in providing public services.
In contrast to previous years in which health care services for indi-
gents were provided out of Christian piety or charity and on a very limited
scale, with the advent of Liberal governments after 18y5 the idea that it
is the state's obligation to maintain health and to make available services
to the largest number of people possible started to take hold. Tne words
beneficencia (beneficence or welfare) and asistencia (assistance) replaced
misericordia (mercy) and caridad (charity) in the official lingo. A most
insightful comment on the Latin American conception of public health in the
1930's is given by a publication of the Pan American Health Organization.
According to it, the provision of health services was still dominated by
the paternalistic attitude of people in power, and health services to the
very poor were still "regarded as a matter of gracious charity, not as a
human right," and, in addition, "much time -was to pass before it was under-
stood that this 'charity,' in the way it was dispensed through the welfare
organizations, was really financed by the recipients themselves" (Pan
American Health Organization /AHC/, 1973:18).
The antecessors of some of the largest present-day public health
institutions were created in the last years of the nineteenth century.
The Ministerio de Instruccidn Pdblica, Justicia, Estadistica y Beneficen-
cia (Ministry of Public Instruction, Justice, Statistics and Welfare) was
created in 1884. The Junta Nacional de Asistencia Social y Beneficencia
Publica (National Board of Social Assistance and Public Welfare) was crea-
ted around 1896 as a "decentralized" or "autonomous" institution.* Its
main function was to coordinate the work of welfare boards being set up
around the country, especially the Welfare Board of Guayaquil and Social
Assistance Board of Quito, both of which were also autonomous institutions.
At the time, the main responsibility of these welfare boards was to ad-
minister public facilities such as hospitals, asylums (institutions I'o
the mentally ill), and cemeteries.
In 1925, the rinisterio de Provisi6n Piblica, Asistencis Social y
Trabajo (Ministry of Public Welfare, Social Assistance and Labor) -ias
Decentralized institutions in Ecuador have differentt degrees of
autonomy. They respond directly to the executive branch of government
and are sometimes under the nominal control of a ministry. Their budgets
are usually not included in the total national budget and, more often
than not, special legislation has provided them with their own sources
of revenue. The .Tennessee Valley Authority in the United States re-
sembles some Ecuadorian autonomous institutions.
created.* Among the multiple functions of this ministry was that of pub-
lic health care. Only in 1926, after three decades of Liberalism, was
the state's obligation to provide medical and health services to the popu-
lation made into law (Eric!-son et al., 1966:48).
An overview of health conditions
By 1906 the population of Ecuador had grown to an estimated 1.4 mil-
lion inhabitants, almost doubling the 1861 number of 839 thousand. The
city of Guayaquil had approximately 82 thousand inhabitants, having in-
creased about 57 thousand since 1861; in contrast, Quito, the nation's
capital, had only 52 thousand, just about 17 thousand more than in 1861.
Migrations from the Sierra to the Costa were partly responsible for the
faster growth of Guayaquil as compared to Quito. The scarcity of arable
land in the Sierra and both the increment of trade and of agricultural pro-
duction on the Costa were-some of the determinants of such population move-
During the first half of the twentieth century, the population of
Ecuador increased rather slowly. Although reliable data are not available,
it appears that it took the country over 40 years to double its estimated
1906 size. The main determinant of such slow growth was undoubtedly the
extremely high incidence of mortality, which is indicated by the scattered
pieces of information available. For instance, the country's crude death
rate in 1920 is estimated at 28.9 per thousand (Sanders, 1972:2).
Low levels of health were, in turn, a dramatic manifestation of the
low standard of living of the large majority of the people. Scattered
reports show an awareness that factors associated with poverty were re-
lated to numerous illnesses which produced much loss of life, especially
M Its name was changed to Ministerio de Previsidn Social y Trabajo
(Ministry of Social Welfare and Labor) in 1940.
among children. In the early 1940's, for instance, tie greatest health
problems faced by public health institutions in Ecuador were the pLeva-
lence of tuberculosis, malaria, and ankilostomiasis. Tuberculosis was
particularly prevalent among ill fed. individuals, affecting huge segments
of the population (Ecuador, Ministerio de Previsi6n Social y Trabojo
PS/, 1943). Similarly, there were repeated outbreaks of exantihematic
typhus, a disease that thrives in cold weather and in conditions where
poverty and crowding prevail.
Before the 1930's, when systematic campaigns to eradicate various
diseases started, severe epidemics of smallpox, yellow fever, and cholera
were frequent, some of them yearly, throughout all of Ecuador.
The government's limited knowldge of social conditions
One of the foremost limitations of the period was the lac', of accurate
data on the social conditions which a health policy would need to consider
as its base. That disease was everywhere appeared obvious, however, t'iere
was very little accurate information on incidence, causes, fatalities pro-
duced, and so on. In the absence of reliable statitics, the problem, of
health wos usually described in very general terms in governmental reports.
As a consequence, proper planning was mads impossible. Yet, a Growing
awareness of a serious "health problem" is present since the 1 20's.
The systeii of dast collection, some of then relevant to health, in-
proved significantly by mid-century. The first vital statistics reports
covering the whole nation were published in the late 19i10's. Tw.o lo:al
censuses, one in Quito and another in Guayaquil iere conducted in liI
and 1943. The first national population census iwas taken in 1 50. Tihe
census, since then taken every 12 years, yields data whose knowledge is
crucial for the appraisal of health conditions, planning, and the rmak:in!
of policy decisions concerning health.
Preventive care: institutions and activities
Somie important developments occurred in the first decades of the
twentieth century: 1) the creation of sanitation and hygiene institutes
in Quito and Guayaquil, starting in 1903, and the setting up of sanitary
boards in other provincial capitals; 2) the 1908 unification of the Sani-
tary Service with headquarters in Guayaquil, followed by the 1,14 creation
of a subdirectorate in Quito, and 3) the post-1918 work of thie First Yel-
low Fever Commission, sent by the Rockefeller Institute, which had re-
markable effects in reducing the incidence of yellow fever in the country.
These developments indicate a growth of consciousness regarding public
health. They also represent the typical legalistic approach to national
problems by which an institutional administrative apparatus in set up at
the outset, even when adequate financing and human resources are slow to
There is very little documented information on public health activi-
ties before 1940. This could indicate a relative lack of those ascrvities,
but certainly it demonstrates a lack of the need for public accountability
and planning. Notwithstanding, one important health institution, tie
Direccidn Nacional de Sanidad e Higiene (National Sanitation Directorate)
was created around 1930. This large autonomous institution, under the
supervision of the Ministry of Social Welfare, had its headquarters in
Guayaquil and had jurisdiction over the whole country. In 19`4, however,
it was decentralized somewhat by the creation of two Inspectorias Tdcni-
cas (Technical Supervision Offices) one in charge of a cluster of northern
and central provinces and the other of several southern provinces. Also.
the National Sanitation Directorate was expanded through the creation of
Provincial Sanitation Boards.
At first, the National Sanitation Directorate ,.as primarily responsi-
ble for controlling the spread of epidemic diseases either through en-
vironment sanitation or mass immunization campaigns. In later years and
before the creation of the Ministry of Public Health, the National Sani-
tation Directorate served as a Secretariat of Health within the Ministry
of Social Welfare. It theoretically coordinated the work of about 50
agencies of the ministry which worked in the health field.
After 1940, documentation regarding public health activities mounts
dramatically, indicating perhaps a need to respond to domestic and inter-
national pressures for m.ore accountability and, iore important, a gtroewth
in actual number of public health related institutions. Tne crea-ion of
more public institutions and corresponding growth of official barea.s::racy
in Ecuador could be interpreted as reflecting greater permanent concern
for the health needs of' the majority of the people. Yet, it could also
be seen as a political phenomenon with little relevance to puJlic health
care. It is very likely that -- as Jaguaribe (1969) points out in his
study of the Brazilian political process -- the creation of white collar
jobs in Ecuador was a strategy of the national government designed to
benefit its largely wunemployed middle class clientele in exchange for the
latter's political support rather than a measure to improve the administra-
tion and provision of pablich health services.
The main public health institutions created after 193 ore decsribed
The Institato Nacional de Higiene (National Institute of Hygieie)
"Leopoldo Izquieta P6rez" started its operoaions in the early 1 ,O's
(fou-cndLd in l,41). Its main functions were "the sanitary and quality
control of foods, drugs, and cosmetics, the production and storsGe oC
vaccines, and performing many types of laboratory examinaTions" (FaFiin,
The InstitLto Nacional de Nutricidn (National Institute of Nutrition)
was created in 1948 with the principal objective of carrying out research
in the area of nutrition, training specialized personnel, and preparing
nutrition education materials for use in schools around the country One
of the immediate practical objectives of the Institute, according to a
Legislative decree of 1949, was to launch a campaign against endemic goi-
ter. Yet a quarter of a century later, little had been done in this area;
this despite the fact that the National Institute of Nutrition started its
work in 1950 with excellent prospects: it received significant contribu-
tions from the Pan American Health Organization, the Kellogg Foundation,
as well as the public sector in Ecuador.
In keeping with the national tendency to create autonomous organiza-
tions under the National Sanitation Directorate, several other institu-
tions were created for the purpose of combating specific epidemic diseases,
among them: the Ecuadorian Antituberculosis League, the National Service
for the Eradication of Mslaria, and the Yellow Fever Institute.
Outstanding among the above mentioned institutions, particularly
because the incidence of tuberculosis was very high in those years,* was
the Liga Ecuatoriana Antituberculosa (LEA, Ecuadorian Anbituberculosis
League) created in 1942. Tle National Congress provided it with its own
sources of revenue, consisting primarily of taxes on Diports and exports.
Its main functions were curative. The preventive aspect was apparen ly
in the charge of a related institution, te National Antitue'erculosis
Service. In fact, however, the main organization fighting this disease
For instance, by 950a, Ecuador ihd about three thousand deaths
annually attributed to tuberculosis.
was the Antituberculosis League. By 1951, it had under its control three
isolation hospitals, three sanatoriums, 17 dispennarie;, and two sr.'vey
centers, as well as especially assigned rooms in hospitals ran oy the
Public Assistance in some areas, a total of 1200 beds (MPS, 1951).
During the 1950-53 period, the National Directorate of Health started
a campaign to vaccinate people against various infecto-contagious diseases,
especially against typhoid fever, measles, whooping coual, and diphtheria
(MPS, 1953:153). Also in 1952-53, many small scale campaigns to fight
epidemic diseases were carried out mainly in Quito.
Several international organizations became active in the provision
of health services in Ecuador, among them the Pan American Health Organi-
zation, the International Labor Office, the InterAmerican Cooperative
Service of Public Health, and the United Nations International Cildren's
Emergency Fund (UTICEF).
The Andean Mission was created in 195'4 by tiie International Laoior
Office. Its purpose viss the "integration of highland Indians into na-
tional life." Among tie w rorks it performed was minor health care, teaching
better hygienic habits such as latrine construction, trash burning and
burying, DDT spraying, and so on (Favin. 1973:183). The ihe. -'th functions
of the Andean Mission, however, were stripped away in the 1970's after
the creation of the Ministry of Public Health.
The InterAmerican Cooperative Public Health Service, a United States
organization, started operations in Ecuador after th t two governments signed
a 1942 Basic Agreement. According to the agreement, the Service was
responsible for the execution and maintenance of specific public health
projects previously subscribed by it and the Government of Ecuador. T'ie
original agreement lasted only a couple of years but was successfully re-
newed up to the early 1960's. This institution operated with funds from
both the United States and Ecuadorian governments and, to a lesser extent,
from some municipal governments and welfare institutions of Ecuador. For
example, in the 1954-55 operation year, the Services' budget included
8,040,000 sucres from the Ecuadorian Government and about 4 million sucres
(200,000 U.S. dollars) from the United States Government (MPS, 1951:81;
1955:285).. The Service worked in several areas of health, sometimes co-
operating with national agencies, and sometimes independently. Among
them were the following: 1) campaigns to eradicate infectious diseases;
2) provision of drinking water systems and sewerage facilities to several
cities; 3) construction and equipment of various hospitals; 4) otner
health related activities such as contribution. for health education. It
supported the National Nursing School in Quito.
UNICEF's active participation in Ecuador started in 194) when Lt co-
operated with relief efforts for the victims of a severe earthquake e which
hit several central provinces. UNICEF's efforts were aimed primarily at
children affected by the catastrophe. After 1949 the Ministry of Social
Welfare, in collaboration with UNICEF, extended children's health coverage
to most of the nation's provinces. Their work concentrated on four main
aspects of children's health and welfare: 1) improving diets; 2) provi-
sion of medical equipment and supplies to nursing homes and children's
hospitals (six in total); 3) vaccination against tuberculosis;* di) de-
velopment of a tuberculosis laboratory for a Diagnostic Center in Guasa-
As part of a worldwide e campaign against tuberculosis, UNICEF
oegan vaccinating Ecuadorian children in July of 1950. Ecuador's Anti-
tuberculosis League collaborated in the campaign. It was the first aass
immunization in Ecuador using the vaccine B.C.G. (MPS, 195.:1th-116).
Curative core: institutions and activities
A turning point in the participation of the state in providing pre-
doninantly curative health services came in 1 i08 when the extensive prop-
erties of the Catholic Cnur.ch, particularly landholdings, were expropria-
ted and put under control of the National Board of Social Assistance and
Public Welfare. Tius the government directed the revenues of such land-
holdings to programs of public service. Since most expropriations mere
made in the Sierra, the provincial social assistance boards formed in
that region consequently tended to have more income than those provinces
of the Costa.
By 1960, the Board of Social Assistance operated 12 hospitals, four
urban medical dispensaries, and six rural health centers. In addition,
and despite its lack of sufficient funds in later years, it contributed
substantially to the support of other organizations working in the field
of health, among them the Red Cross, the Blood Bank,. and the National
School of Nursing (MPS, 1962:118).
Under the Ministry of Social Welfare, sn aurto ornoeus institution called
the Institute de Previsidn (Institute of Prcvision) lras created in 1:3;.
The Institute of Prevision was in turn subdivided into the C'ijs de Pre-
visidn (white collar social security) and the Caja del Seguro (blue collar
social security.). One of the main responsib citiess; of both social securi-
ty institutions was to p-ovide medical services to their i'ffilioate. Tae
Medical Department of the Ecuadorian Social Security, created in 1'ii0,
started as a subsidiary of the blue collar branch of the Institute of
Revision but, in 1944, its coverage was extended to include also tie
white collar bra'ich, and in 1931, besides covering active members, health
care services were also provided to retired affiliates.
The government, by a law decree of July 16, 1958, made the Medical
Deportment an autonomous institution, with its own legal representauton
and proper status and regulation. At the top of this health organization
were two Directorates, one in Quito and the other in Guayaquil. Each of
these was under the supervision of a Medico-Administrative National Coun-
cil, made up of representatives of the Ministry of Social Welfare, the
Institute of Prevision, and Social Security (Ecuador, Instituto Ecua-
toriano de Segeridad Social. lIESS7, 1975).
Tie Medical Department of Social Security played an important role
in the provision of health services, primarily curative care, to s mall
but influential sector of the population. Its services reached slieost
exclusively urban white collar workers as well as some blue collar workers.
By 1960, for example, only 3.6 percent of the total population ;ece af-
filiated with the national social securi-y syste:n and entitled to its
medical care services.
TIe importance of the Medical Departmrent was therefore not so -uc '
dae to the proportion of people it covered but rotiher to its economic
power since it was financed -y public, private, and individual member
contributions. The Medical Department, unlike other national health
institutions, was usually able to impleiient its programs. uni:indered by
financial problems. It directly operated a large network of iiospitls
and other health care facilities and also provided services throur h
surrogate facilities; to its affiliates.
Evaluation of Pre-l960 Public Health Policy
T:e development of public health policy up to ly60 has, of necessity,
been only briefly sketched and mainly concerned with the organizational
parameters being set up in this work. Besides being concerned twith an
extremely long period of time, it is limited by plain lack of available
The state's concern with public health in Ecuador, for all practical
purposes, started after 1895, with the coming to power of various Liberal
regimes. They adopted the principle that the state is obligated to pro-
vide for the health needs of the population, especially of the large pro-
portion of poor who could not afford the cost of private medical care.
They also provided sources of revenue for institutions such as those under
the National Board of Social Assistance and Public Welfare, which had an
important role in restoring health to those afflicted by illnesses.
After the 1930's, regimes which were not necessarily Liberal but
rather of varied political tendencies, became increasingly concerned with
public health matters and created numerous institutions to deal with par-
ticular problems at the national level.
A rough idea of how the public health institutions under the Ministry
of Social Welfare were related to each other by the late 1950's is, given
in Figure 2. Solid lines suggest various degrees of actual control
while broken ones indicate a mostly nominal relationship.
Despite the progress made, there were a series of deficiencies in
public health policy making in the period under consideration. Some of
the main deficiencies were: 1) lack of planning and coordination, 2) pref-
erence for curative over preventive health care, 3) lack of adequate funds
and personnel, and 4) concentration of services in urban areas.
Lack of planning and coordination
As seen in Figure 2, the health functions of the Ministry of Public
National Board of
Social Assistance & - - -
Boards of Board
Boards of NATIONAL SANITA
Service of Public Health
National Hygiene Institute
League I Institute
Figure 2. Approximate Organogram of the Public Health Institutions
of the Ministry of Social Welfare and Labor, c. 1955.
Welfare were distributed among many institutions, some of their decentral-
ized or autonomous, without effective channels of communication.
Although the National Sanitation Directorate supposedly was intended
to coordinate health (mainly sanitation or preventive) policy, very little
coordination actually occurred. Each health agency constituted a world
in itself. They seldom cooperated with one another and often there was
duplication of effort (i.e., Servicio Nacional Antituberculoso and Liga
Campaigns to eradicate epidemics were sporadic affairs. One year
the campaign was carried out in one area, another year in another area.
It was usually triggered by an outbreak of a particular disease. There
was no systematic follow-up. For example, in 1950 there was an outbreak
of yellow fever in the towns of Santo Domingo, Quinindd, and Esmeraldas,
even though the Yellow Fever Service had declared it eradicated from
The National Board of Social Assistance and Public Welfare was simi-
larly incapable of coordinating the curative efforts of the provincial
welfare boards. And thus, the two strongest institutions, the Social
Assistance Board of Quito and the Welfare Board of Guayaquil, wor :ed in-
dependently in their particular domains.
No general health plan was yet envisaged. Diseases were attacked
individually as if health were the product of unrelated factors. The
approach to some health problems was not holistic but atomistic. Tius,
one witnesses the creation of autonomous agencies to control particular
diseases such as malaria, yellow fever, tuberculosis, etc.
Preference for curative over preventive health care
Among the first health organizations to be created were the boards
of social assistance which were in charge of running welfare centers and
hospitals. These boards had a more secure financial basis than most of
the other health agencies created thereafter, particularly those whose
function was to prevent the appearance of epidemics. Even some institu-
tions such as the LEA which was partly responsible for the prevention of
tuberculosis, at the outset dedicated large portions of its budget to cura-
tive aspects, mainly, building hospitals for treatment and isolation of
tuberculosis patients, equipping laboratories, etc.
Lack of adequate funds and trained personnel
Next, and perhaps one of the most important problems affecting
health action before 1960, was the lack of funds and trained personnel.
The lack of adequate financing for the few health programs in existence
was officially pointed out as far back as 1943 when it was reported that
there were not enough funds for the campaigns to eradicate contagious
diseases (IPS, 1943:27). By 1948, another official report (MPS, 1948)
indicated the many problems affecting the population's health services:
lack of money, low salaries, lack of communication and transport, lack of
specialized personnel, etc. Most of these problems are summarized as
lack of money and lack of personnel. Certain health agencies such as the
boards of social assistance were relatively self-financing; they had
revenues from the exploitation of landholdings. For example, the Central
Board of Social Assistance of Quito received about 6,180 million sucres
(roughly over US $300,000) in 1949 from either direct exploitation or
rent from its landholdings (MPS, 1949). In many cases, however, the in-
come of the social assistance boards did not match their expenses and thus
required special budget allocations.
One of the agencies which did not suffer as much from lack of funds
was the LEA because its income was derived from a congressionally legis-
lated tax on imports and exports. By 1943, the LEA had received about
two million sucres since its creation in 142.
The situation of other health agencies, which depended directly on
annual budget allocations was much worse. The national budget was con-
tinually in deficit, and social services such as health were often the
first ones to suffer cuts. The lack of funds is dramatized in a report
which states that many provincial health (or sanitation) inspection cen-
ters were so broke that they could not even mail their usual report to
the Ministry! (MPS, 1954:159-160).
The lack of skilled personnel is illustrated in the following case.
In 1950, the National Yellow Fever Service was assigned 300,000 sucres
(about US $15,000) for a campaign against yellow fever. The money, at
first, was not used because there were no trained personnel to carry out
the campaign. A Brazilian inspector arrived in Ecuador to help in the
training of personnel, yet no real work was done because he did not speak
Spanish. Part of the money (70,000 sucres) was then used for otner pur-
poses such as paying salaries, for a vehicle, and for supplies (MPS,
Concentration of services in urban areas
Health services were almost exclusively concentrated in the two
largest cities -- Quito and Guayaquil -- and in a few other provincial
capitals. The curative services such as hospitals and immunization cen-
ters were invariably located in urban areas. Also, most of the campaigns
to eradicate contagious diseases were carried out in urban areas, unless
there was an epidemic outbreak. Then the affected area would be the
focus of attention. In 1950, for example, the National Sanitation Direc-
torate, the overall health agency, reported that the fight against yellow
fever in urban areas was progressing very well, that the disease had
completely disappeared in Guayaquil and that by the end of the year its
incidence in the country would be practically nil.
Meanwhile, it also reported cases where sanitary campaigns went to
certain rural areas to control outbreaks which had already occurred but
not to carry on the preventive work (MPS, 1950:38-39).
The Director of the Board of Public Assistance of the Coast reitera-
ted frequent complaints of his institution about the lack of attention
of the central government to the health needs of the peasant and rural
populations of the coastal region. He indicated that the rural popula-
tion lacked both medical attention and medicines, and that with a few
notable exceptions, the canton governments (manicipios) were not con-
cerned with the life conditions of their inhabitants (MPS, .1955:323).
By the end of 1949, there was an important plan to reorganize and
give new impetus to health work in Ecuador, particularly its sanitation
and preventive aspect. This was called the "Plan of Transformation."
Dr. Alfonso Campuzano, one of the health officials who proposed the
plan, in a later report to the nation stated that the then existing Pro-
vincial Sanitary Boards did not meet the hygienic, sanitary, and educa-
tional objectives they were supposed to meet. And then, in a sort of
summary of the health system's drawbacks worth quoting extensively, he
I have seen that the major obstacle to reach those objectives
is the impossibility of finding professionals (physicians)
whose point of view corresponded with that of the social ser-
vices called 'sanitary units,' oriented specifically to give
hygienic education, preventive medicine, health and hygiene.
Almost all physicians working in the provinces have a definite
leaning towards curative medicine, setting aside completely the
hygienic and sanitary social problems that they should face as
Provincial Sanitary chiefs. On the other hand, the lack of
registered nurses and nurses specializing in Public Health make
the situation even more difficult. They are usually recruited
from the group of relatives and friends of the health officials,
not taking into account at least the fact that they could be
trained. The sanitary inspectors with wrong attitudes do not
perform but a police function not being able to intervene other-
wise for lack of programs and practical preparation, despite the
fact that some of them had gone through the courses for sanitary,
inspectors which have taken place in Quito. The physical plants
destined to these services have been chosen among the most in-
adequate ones and this is another reason for their lack of results.
The equipment is the most deficient and is in absolute deteriora-
tion in almost all zones.... (MPS, 1951:144).*
The "Plan of Transformation" had intended to create "sanitary units"
at the provincial seat level, canton seat level, and mobile units to
serve the rural areas. Each unit was to be staffed by skilled medical
personnel, those at the provincial level were to be the better staffed,
with two physicians, two dentists, two sanitary inspectors, two obste-
tricians, two social workers, and two nurses; the rural mobile units, the
least staffed, would have had one representative of the above-named pro-
fessions. In other words, the idea was to have fairly complete teams of
health workers serving areas of the nation. The urban areas were given
preference but the rural ones were also expected to benefit from it. This
plan, while certainly idealistic (for where was Ecuador going to find
enough health personnel to staff all the one hundred or so cantons, let
alone rural units to serve the larger and more dispersed rural population?),
envisioned a radical and much needed organization to face the health needs
of the nation. These ideas could have been set into operation gradually,
starting perhaps at the level of the more populated cantons to then reach
other areas. However, this ambitious plan (partly described in MPS, 1950:
Translated from the Spanish by the author.
120) was scratched because the National Congress eliminated this item
from the national budget: (see MPS, 1951:15).
Tne Ecuadorian Sanitation Directorate was, in the words of a health
official, like a fire station without equipment: "It is called to fight
fires but to its great shame, it goes to fight them without water, without
ladders, without water hoses" (MPS, 1955:246).
Besides plain scarcity, then, public health policy in Ecuador before
1960 suffered from serious misplacement of priorities. This is further
illustrated by another official report which indicates that by the early
1950's, infant mortality in the capital of the country was "shameful,"
being perhaps one of the highest among countries. Yet, instead of openly
facing this problem, the government had been planning to spend millions
of sucres in the creation of an organization to fight cancer. The main
causes of death in Ecuador were diseases of the respiratory system, on
the one hand, and diseases of the digestive tract on the other. Both groups
of diseases took a great toll on children's lives. By 1953, the death
rate due to diseases of the respiratory system (excluding tuberculosis)
was 289.74 per thousand; that due to diseases of the digestive tract was
265.41 per thousand, meanwhile the death rate due to cancer and other
tumors was only 75.52 (MIS, 1953:190-191).
PUBLIC HEALTH POLICY PROGRAMMING SINCE 1960
The present chapter deals primarily with the elaboration of national
health plans as well as the creation of institutions of public health.
Both of these governmental actions are here defined as programming. This
definition follows Ugalde's (19T3) typology in which the series of deci-
sions which are made for the attainment of a goal can be classified into
two types of decisions: (1) programming and (2) implementation.
Programming decisions are those made during the process of converting
policy goals into programs while implementation refers to decisions made
during the implementation of the programs.
A Period of Reforms
At the turn of the 1960's Latin America became involved in talk of
change and reform. The Cuban Revolution sent waves across the continent
with a clear message of basic structural change as a solution to the
great problems affecting that part of the world. The United States'
program for controlled, non-violent reform, the Alliance for Progress,
was officially adopted by the majority of Latin American nations at the
Punta del Este Conference in 1961. This was the continental response to
the questions posed by the Cuban events. Playing up the reform theme,
the Punta del Este Charter tended to raise expectations for a new kind
of life, with less backwardness and higher standards, among the Latin
The principles adopted at Punts del Este had special significance
for public policy. They not only encouraged the utilization of research
(to gather reliable information on each country's conditions) and general
economic planning but, in addition, stated the need to incorporate the
social sectors into development planning. And this latter decision was
of great importance to public health (see PAHO, 1973:22).
Ecuador was no exception to the new feelings of change. In 1960,
President Jose Maria Velasco Ibarra was elected by a large majority of
votes after a campaign in which he stressed a program of territorial
restoration and basic social change. After 15 months in power, Velasco
was replaced by his Vice-President, Carlos Julio Arosemena Monroy. Aro-
semena increased the people's expectation for radical reforms through his
insistence that the archaic structures of the nation should be altered.
But like his predecessor, he only remained in power for less than two
years. In March 1963 he was overthrown by a Military Junta that committed
itself to carry out the reforms contained in the Alliance for Progress
All three governments espoused one or another form of programs of
social and economic change. The emphasis was on economic matters yet
social aspects, such as improving health care, were also considered as
essential for overall development.
As noted in the previous chapter, for many years there had been a
clamor for a reorganization of public health services as well as for giving
them greater national priority. Health officials, legislators, medical
professionals, and, in general, people who realized the low levels of
health in the nation, pressed for change. Lack of sanitation facilities
was perhaps the most serious problem at the time. A 1962 official report,
for instance, indicates that in the previous year Ecuador's population at
large did not have pure drinking water in sufficient quantities. This
lack contributed to the maintenance of enteric diseases and other epi-
demics. In addition, only a few cities had adequate systems of sewage
disposal; some provincial capitals and cities of over 20 thousand innabi-
tants had sewerage systems which did not meet the required minimum stan-
dards. The rest of the nation, from some provincial seats to canton
seats and other localities, had practically no facilities to eliminate
waste. The absence of sewerage services provided fertile ground for the
spread of typhoid fever, intestinal parasites, and enteric diseases in
general (MPS, 1962:ix).
Reforms in the public health sector were slow to come, but some im-
portant steps in that direction were taken in this period. In 1960 the
anti-malarial campaign was entrusted to the InterAmerican Cooperative
Public Health Service. It had been faltering under the direction of the
National Service for the Eradication of Malaria (SNEM), therefore, the
government, on the recommendation of several public health agencies, made
an agreement with the InterAmerican Cooperative Public Health Service by
which the latter absorbed the SNEM and took over its basic functions (MPS,
The fight against epidemic diseases in general was centralized in
1961 under the direction of the National Department of Epidemiology.
This institution absorbed several zonal offices and autonomous agencies
previously in charge of combating contagious and epidemic illnesses. It
was created as part of the National Sanitary Service and had three sub-
divisions, corresponding to the Central, Litoral, and Southern Zones
All the developmental and reformist ideas of the early 1960's began
to materialize into specific plans and programs for public health. Public
health planning received a lift with the 1962 creation of the Junta de
Programaci6n de Salud Piblica (Public Health Programming Board). In addi-
tion, planning was facilitated by the findings of the 1962 national popu-
lation and housing census.
In 1964, the Junta Nacional de Planificacidn y Coordinacidn Econ6mica
(National Planning Board) formulated Ecuador's first National Development
Plan. The general purpose of this plan was to set the country on a route
of social and economic progress through a series of basic structural
changes such as an agrarian reform, tax reform, and educational reform.
The 1964 National Plan of Public Health
Conceived as part of the National Development Plan of 1964, the Pub-
lic Health Plan began with a diagnosis of the prevailing medical and sani-
tary conditions in the nation. Among other things, it pointed out: (a)
the lack of preventive health work, (b) the extremely high rates of in-
fant mortality, (c) the need to control diseases of early infancy and
childhood, (d) the inefficiency and unequal distribution of the sanitary
and assistential medical services, and (e) the scarcity of personnel,
equipment, and funds for the majority of existing services. It also
stated that national problems received little help from the multiplicity
of institutions and public health sponsoring agencies, which added to-
gether, numbered more than 50. The privilege of autonomy that many of
them enjoyed was seen as an obstacle to efficient health service.
Tne Public Health Plan set as major goals several improvements in the
fields of health and sanitation: (1) to reduce morbidity and mortality,
particularly among the infant population; (2) to increase health care
coverage in order to achieve within a decade a ratio of seven physicians
per 10,000 population and 3.6 beds per 1,000 population as well as the
creation of health centers in all cantons, medical dispensaries in all
parishes, and health posts in parishes and other small population centers;
(3) to improve rural health conditions through environmental sanitation
and campaigns against communicable and infectious diseases; (4) to estab-
lish programs favoring the integration of medical services, and (5) to
prepare skilled health personnel.
In addition, the Public Health Plan had several organizational ob-
jectives, among them, (a) the creation of the Ministry of Public Health,
(b) the coordination of all health services until the creation of the
National Health Service, (c) the unification of the Medical Department
of the IESS with the National Sanitation Directorate, and (d) the con-
tinuation of public health planning (JNPC, 1968).
Being the first of its kind in Ecuador, the Public Health Plan had
some shortcomings, perhaps because of the relative lack of experience of
the people involved in its formulation. It established ambitious goals
but lacked details on programs and the means of implementation. For the
most part, it was too general. Nevertheless, it represented an important
step forward and set the basis for future endeavors in the field of
The Institute of Sanitary Works
One of the first achievements of the Public Health Plan was the 1965
creation of the Instituto Ecuatoriano de Obras Sanitarias (IEOS, Insti-
tute of Sanitary Works), attached to the Ministry of Social Welfare. The
IEOS succeeded the InterAmerican Cooperative Service of Public Health which
for over 20 years (1942 to 1964) had operated in Ecuador.
The main functions of the IEOS were, first, to elaborate and execute
programs for the short and long terms in order to solve problems related
to the provision of potable water and sewerage in the cantons and parishes
of the Republic; this was to be done in collaboration with the municipali-
ties* and other entities in charge of the provision of such services, thus
avoiding the scattering of resources; second, to supervise the work being
done by other institutions in order to evaluate the progress of the Na-
tional Plan of Potable Water and Sewerage.
The Water and Sewerage Plan, included in the 1964 National Develop-
ment Plan, set as main objectives the provision of potable water services
to 39 percent of the population and sewerage to 34 percent in a ten year
period. These objectives were rather ambitious in view of the fact that,
according to a 1961 Sanitary Survey, only about 19.5 and 14.3 percent of
the population surveyed (a total of 655 localities between canton and
parish seats) had satisfactory water and sewerage systems. By 1964, it
was estimated that the percentage of population properly served with
potable water and sewage disposal were 20 and 14.7 respectively (Montalvo,
In terms of residential distribution, most work promoted by the IEOS
was to be concentrated in urban areas as this was economically more con-
venient, however, it also tried to meet the needs of the rural inhabitants
that made up more than half the total population (Bahamonde, 1972:7).
The new emphasis on environmental sanitation by sewerage systems
construction and the provision of pure drinking water was bound tc have
a very significant effect on the levels of health of the population.
Ecuadorian legislation states that certain m nicipal revenues
must be used exclusively for the provision of potable water and sewerage
systems. However, those laws were seldom complied with and funds were
spent for other purposes.
According to IEOS estimates, the above-named services alone could reduce
the number of deaths due to transmissible diseases from one to two per
thousand annually (MSP, 1969:115).
Throughout the existence of the IEOS, the central government has
stressed its priority status regarding budget allocations. For example,
in 1972, it decreed that the amount of money designated in the national
budget for the IEOS not only be disbursed in full but also increased both
in 1972 and 19'3 (MSP, 1973:29). Nevertheless, when actual disbursements
had to be made, it was not unusual to find that the amounts given were
below those originally assigned in the budget. Thus, in 1967 and 1968
the IESS was supposed to receive a budget allocation of 20,000,000 sucres
(about US $1,000,000) each year. Tnis amount was agreed under the law
which created the IEOS. However, in 1967 the allocation was reduced to
11,000,000 sucres and at the end it only received 7,450,000 sucres. In
1968, again the allocation was reduced to 11,000,000 sucres. The figures
for the actual amount received are not available (see MPS, 1968:81, 84).
In 1973, it was estimated that satisfactory services of water and
sewerage were provided to 31.4 and 23.6 percent respectively of the
country's population, with the exception of the cities of Quito and
Guayaquil* (MPS, 1973:29-30).
The importance of IEOS functions and its recognition by the public
sector was stressed again in 1973 when an executive decree guaranteed
its economic solvency in the future by establishing adequate revenues
both from utilities derived from oil exploitation as well as from other
Quito, Guayaquil, and a few other cities have their own water
and sewerage systems which operate under municipal boards.
direct fiscal allocations. Toe decree also created a "rotating find" to
be used for credit grants to urban communities in good financial standing
as well as for the execution of programs in rural areas.
The Divisi6n Nacional de Sanidad del Medio Ambiente (Division of
Environmental Sanitation), created in 1972, had functions fairly simi-
lar to those of the IEOS. This agency was directly under the Ministry
and was apparently brought to life in an effort to centralize decision-
making in sanitation matters. Its basic mission was to solve in an over-
all, massive way the sanitary problems of the country in cooperation with
the different institutions working in the field (MSP, 1973:25; 1975:15).
The Division was subdivided into 25 executive offices: one working
on the national level, four on the regional level, and 20 on the provin-
The purpose for the creation of the Division of Environmental Sani-
tation was to have an institution directly under the Ministry in charge
of coordinating overall sanitation policies. Yet, in fact, this dupli-
cated effort and the relative weakness of the Division as compared to
the IEDS did not really bring about the desired centralization. The IEOS
continued operating as an organization with a large degree of autonomy
which had a dynamism of its own, hardly matched by any other institution
in the field of sanitation.
The Ministry of Public Health
A landmark of public health policy-making in Ecuador was the crea-
tion of the Ministry of Public Health by the Assemblea Constituyente
(Constitutional Assembly) on June 6, 1967. This was the first step toward
a much needed reorganization of the health delivery system of the nation.
The law regulating the Ministry of Public Health's structure and
functions gave it numerous responsibilities. Tre Ministry was supposed
to work for the promotion, reparation, and rehabilitation of individual
and collective health; it was charged with dealing with problems of nutri-
tion, housing, alcoholism, and drug addiction. It was also to carry oat
programs of social assistance, sanitation, and hygiene.
Although the Ministry of Public Health was given a wide range of
functions, from the time of its creation to 1972, it did not have the
necessary authority to direct the activities of the many institutions
which, with varied degrees of autonomy, operated in the area of public
health. The central and provincial boards of social assistance, for
instance, acted as sorts of small ministries, capable of setting dif-
ferent policies, independent of any national nor'n. Before the Ministry
could direct or at least coordinate the activities of the autonomous insti-
tutions, there had to be changes in national legislation, as each institu-
tion was backed by specific laws (MSP, 1968, 1973).
In his 1909 Annual Report to the Nation, Francisco Parra Gil, Minister
of Public Health, pointed out the lack of proper structural organization
of the public health sector, its unequal coverage of the population's
health needs, and the insufficient use of the resources available at
the urban level. He insisted that in order to solve these problems it
was necessary to start integrating those agencies previously under the
nominal control of the Ministry and to establish a better coordination
with those autonomous institutions in charge of health. At the same time,
it was necessary to improve the access to health services for the people
who so far had remained marginated from them, namely the inhabitants of
the rural areas and small towns. The above policy, the report continued,
was deemed even more important in light of the deterioration of the popu-
lation's health as indicated by increasing rates of mortality due to
"reducible damage" or diseases which could be controlled by public health
measures. In effect, the rates of general mortality had exhibited an
annual decline of 2.5 percent, but while mortality due to non-reducible
damages had decreased to about 3.32 percent annually, mortality due to
reducible damages had increased about .96 percent. This rather para-
doxical fact was explained by the virtual abandonment of preventive health
services on the one hand and by the technological improvements adopted
for the curative-assistiv e medical services. Mortality rates were
still largely due to infant and maternal mortality. These were good in-
dicators of the poor levels of health of the population at large. T.le
high infant and maternal mortality rates were attributed to the lac: of
professional attention during gestation, pregnancy, and early childhood.
Only about 20 percent of all births occurred with professional attention.
Moreover, in Pichincha and Guayas (provinces with the two largest cities),
the percentage of oirths with medical attention was over 40, but in the
rest of the provinces it did not surpass 12 (MSP, 1969:11,12).
Under the principle that health is a right that should be enjoyed
by all Ecuadorians wherever they live, in 1969, the Minister of Public
Health stated as main objectives of his administration the following:
(1) the study and preparation of the organic law of the Ministry and its
regulations, aiming at the integration of the Sanitation and Social As-
sistance institutions under the Ministry as well as the coordination of
their services with those of the autonomous public health organizations,
and the execution and supervision of programs; (2) the study and prepara-
tion of a health code; (3) the formulation of a law for the obligatory
iodization of salt for human consumption, in order to eradicate endemic
goiter, and (4) the formulation of a national health plan and the approval
of the Rural Medicine Plan (MSP, 1969:12,13).
The Rural Medicine Plan
Throughout national life, the public sector had generally neglected
the health needs of rural inhabitants despite the fact that they repre-
sented the majority of the country's population. In 1962, for example,
according to the national census, the population living in rural areas
represented about 75 percent of the total.
Permanent health services were completely absent in the rural areas
of the country. With the few exceptions of communities reached by the
medical services of the Andean Mission and the scattered activities of
the so-called "Vertical or Central Command Campaigns," whose purpose was
to combat outbreaks of epidemic diseases, modern preventive and/or cura-
tive health services were unknown among rural inhabitants (MSP, 1968:15).
In order to extend public health action to the rural areas and to
promote community development, in 1969, the Ministry formulated the Plan
of Rural Medicine as part of a more general National Health Plan. The
main objectives of the Plan of Rural Medicine were two: a) to provide
complete health services to all 63 canton seats of the Republic (improving
some, creating others); and b) to create a health infrastructure in all
parish seats. The first step was to provide "health subcenters" with a
physician on the staff, to 300 parish seats in the 1969-72 period (MPP,
Since attracting professional medical personnel to work in the rural
areas had always been a problem in Ecuador, as in other nations of the
world, the Government decided to create special legislation requiring
all newly graduated professionals from health related centers of higher
education to serve a year of rural practice before they could obtain an
officially registered degree. The Law, decreed on July 8, 1970, affected
graduates of medical, dental, obstetrics, and nursing schools.
In 1973, three years after the Law was formulated, there were 172
physicians, 82 dentists, 71 nurses, and 16 obstetricians fulfilling their
duties in the rural areas of the country. There were also some 132
nursing assistants and 73 sanitary inspectors.
The Plan of Rural Medicine was carried out mainly by the Ministry
of Public Health, but the Medical Department of the IESS, the Armed Forces,
some municipalities and other institutions also cooperated with it (MSP,
The Health Code
The Health Code, one of the principal objectives of the Ministry from
its creation, was published in June 1971. According to its own definition,
the Health Code constituted a detailed record of the rights, duties, and
norms relative to the protection, development, reparation, and rehabilita-
tion of individual and collective health (Ecuador, Registro Oficial, 1971).
This was a very significant event in the history of policy-making in Ecua-
dor. For the first time there was a body of principles dealing with medi-
cal care, sanitation, and related matters at the national level. Before
the Health Code there had been a sanitary code but it was antiquated and
its subject matter coverage was limited.
The 1972 Reorganization
The National Health Directorate
Several years after its 1967 creation, the Ministry of Health was
still a handicapped structure. It did not have sufficient authority and
power of policy implementation due to its poor degree of organization
and, more importantly, because it controlled a very snall percentage of
the total health resources available to the country. In this context,
it has been pointed out that:
The Ministry of Health itself characterized the Ecuadorian
health organizations as having no planning or organizational
efficiency, as financing simple incremental budgets by defi-
cit spending, and as being staffed by few technically trained
personnel and by many incompetent people (Favin, 1973:178).
The Ministry's power expanded significantly after a number of changes
were introduced by the military government that t-ok control in February
1972. Of foremost importance was the April 1972 Government decree abol-
ishing some autonomous public health bodies, incorporating their services
under the control of a new Direccidn Nacional de Salud (National Direc-
torate of Health) and integrating other health institutions into the
Ministry. This decision gave the Ministry some real coordinating ability
and eliminated what up to that point together constituted the largest
public health organization in the nation -- and thu-s the greatest obsta-
cle to a unified health structure -- the boards of social assistance. In
April 1972, the central and provincial boards of social assistance ceased
to exist. Their bureaucracies, resources, and services were transferred
to the Ministry of Health. Through the same decree, the Ministry obtained
control of previously independent local health-integrating boards (s0ch
as those of CaOar and Santo Domingo de los Colorados).
The newly formed National Directorate of Health was subdivided into
four health regions (Central, Coast, South, and Manabi) and several tech-
nico-administrative divisions. While planning and the setting of techni-
cal standards were centralized, the actual execution of health care pro-
grams were decentralized (Registro OficiaJ, No. 48 of April 25, 1972;
Favin, 1973:179). The organization of the Ministry of Public Healti at
the beginning of the year 1973 is shown in Figure 3.
Further centralization occurred when an executive decree of December
1973 ordered the abolition of the Ecuadorian Antituberculosis League and
incorporated its services and facilities into the Ministry of Public
Health. Only then did the Ministry achieve control of over 50 percent of
all hospital beds in the country. The Ministry's direct control of the
hospital beds available in the country went from three percent before
April 1972, to 48 percent after April 1972 and to 56 percent in Decerber
Institutional Changes in Sanitation
In order to reduce duplication of efforts, to reinforce the existing
technico-administrative mechanisms, and to accelerate programs of hospi-
tal construction and environmental sanitation, in May 1974, it was offi-
cially decreed that both the Ministry's Division of Environment Sanita-
tion and the ITOS be restructured.
The IEOS was given additional functions and, to carry them out, re-
ceived the transfer of human and material resources belonging to the
Ministry's Division of Sanitation. The expanded functions of the IEOS
included constructing water and sewerage systems as well as designing and
building medical and other health care facilities such as hospitals and
medical dispensaries (Registro Oficial, No. 554 of May 16, 1974).
The incorporation of the Division of Sanitation into the IE3S had
the purpose of eliminating alternate structures which were doing basically
the same job. By joining a weak structure to a stronger one, the coordi-
nation and actual execution of sanitary programs was facilitated. However,
it constituted an act of decentralization contrary to the trend begun
with the creation of the Ministry and which essentially aimed at the
unification of all public health services under the control of the Min-
istry of Public Health.
About a year later, in an apparent effort to return its decision-
making functions in sanitary affairs to the Ministry of Health, an execu-
tive decree of April 9, 1975, created the Undersecretary of Environment
Sanitation and Sanitary Works as a dependency of the Ministry (Registro
Official, No. 778 of April 9, 1975).
The National Medico-Social Directorate of the Social Security Institute
From 1958 to 1970, the Medical Department operated as an autonomous
entity under the nominal control of the Social Security and was super-
vised by the Medico-Administrative Council. In 1970, when the social
security system was reorganized, the Medical Department maintained its
autonomy, but was tied to the newly created Instituto Ecuatoriano de
Seguridad Social (Social Security Institute, IESS) and was supervised
instead by the Superior Council of this new organization.
An executive decree of November 1974 stripped the old Medical Depart-
ment of its autonomy and put it directly under the authority of the IESS.
It then became the Direccidn Nacional Medico-Social (Medico-Social Direc-
torate) and was subdivided into national and regional offices with head-
quarters in Quito and Guayaquil respectively (IESS, 1975:3).
By 1974, the Medico-Social Directorate of the IESS had 67 health
care facilities under its direct control (including four hospitals, eight
clinics, and a variety of health dispensaries) and offered medical care
services through 302 other surrogate facilities (ranging from hospitals
to out-patient clinics). The population entitled to its services repre-
sented six percent of the national total (IESS, 1975). In 1976, the health
care services of the Medico-Social Directorate were also expected to bene-
fit, in addition to active and retired members, the immediate relatives
of the members: parents and children.
The National Health Plan, 1973-77
The military gover-nent that came to power in February 1972 defined
itself as "nationalistic" and "revolutionary." In its publication Filoso-
fia y Plan de Acci6n. . (JNPC, 1972a), the government explained its
position, pledging to bring about some substantial structural changes to
the nation. Within a year, through its National Planning Board, the
government published the Integral Plan of Transformation and Development
1973-77, in which it provided a fairly detailed account of the policies
to be followed during a five-year period. The Plan touched almost all
areas of life in Ecuador, from finances to the rural structure, education
and health. In its prologue, it indicated that, considering both the
historical process of internal domination and the external factors which
have conditioned Ecuador's present state of underdevelopment, it became
indispensable to create, first, a decision-making power which considers
structural transformation as a requisite to achieve authentic development,
and, second, a structure of political power in which there is greater
active participation of groups which had been marginal to the political
system (JNPC, 1972b:x).
Tie Plan contained two specific sections pertinent to public health:
the program of potable water and sewerage and the progra- of health.
The Program of Potable Water and Sewerage
The Program of Potable Water and Se-erage, briefly summarized, attempted
to maintain public health by means of 1) the provision of water and sewer-
age services to the majority of the country's population, and 2) to pre-
serve water resources by controlling pollution of rivers and the ocean.
The basic goals for the 1972-77 period were to provide satisfactory water
and sewerage services to 50 and 40 percent of the population respectively.
Disaggregated in terms of residence, the aim was to provide the popila-
tion of urban areas with 80 and 7J percent of water and sewerage services
respectively and the population rural areas with 24 and 14 percent of
water and sewerage services respectively.
As noted above, the goals for rural areas were lower than those for
the urban areas. This, the Program noted, was due to the fact that the
construction of integral sanitary systems is technically and economically
feasible only in concentrated nuclei of population. The IEOS was en-
trusted with the function of coordinating the development of the Water
and Sewerage Program.
The estimated investment necessary for the five year program
amounted to 2,153 million sucres (about US $86,140 million at 1972 values),
65 percent to be used for potable water and 35 percent for sewerage sys-
tems (JNPC, 1972b:337-341).
The Health Program
The Health Program, whose execution was entrusted to the Ministry
of Public Health, aimed primarily at the study and solution of national
health problems. Its main purposes were 1) to create an agile, modern,
and efficient health system, to be achieved after a process of reorganiza-
tion of the technico-administrative structures already in existence; 2) to
organize a health system with a criterion of integrality (wholeness), and
3) to establish a National Health Service by 1977.
The Health Program additionally listed a series of objectives, among
which the most important were: to improve health levels of the popula-
tion (reducing infant and maternal mortality, increasing general life
expectancy), to increase health care coverage at all levels and espe-
cially in the rural areas, to improve the performance of available ser-
vices, and to seek a greater participation of the medical-related pro-
fessions in the public health programs being carried out (JNPC, 1972b:
Besides the programs formulated as part of the Plan of Transforma-
tion and Development, the military government, still in power in 1975,
made some other pronouncements of significance for public health. It
officially recognized the right to health as one of the main rights of
Ecuadorian citizens. It further developed the concept of integral health
and pointed oat that it constituted the basis of a public health policy
designed to provide services to the individual from birth to death,
whether he (or she) is health or ill, and wherever he (or she) resides.
Health was to be given priority as a fundamental factor of development
Short and Medium Term Programs
Since the Health Plan for the 1973-77 period outlines only the main
points of the new public health policy, the Ministry of Public Health
decided to formulate the Plan PATS 1974-77.
The Plan PAIS was made up of a series of specific programs for opera-
tion during both short and medium terms. The several Divisions of the
Ministry were ordered to elaborate programs of action at the provincial
level as well as at the level of operational units (i.e. health centers).
These programs, together with different technical and administrative
norms formulated by the Ministry were expected to contribute directly to
the organization and execution of the National Health Plan.
Among the norms adopted by the Ministry was that of requiring the
use of a Historia Clinica Unica (Clinical History File) in health estab-
lishments having a hundred beds or more. The Clinical History File aimed
at the elimination of confusing practices which up until then tended to
maintain more than one file for the same patient. This practice, along
with other improvements in the collection of data was to lead to far
better health statistics and therefore improved bases for decision, evalu-
ation, and control (MSP, 1975:1, 2).
Many of the general observations made in reference to pre-196 pub-
lic health policy are also pertinent to the post-1960 period. After all,
no radical change occurred at the turn of the decade. The year 1960 has
been used as a dividing line only for purposes of this study. The amount
of information available for the latter period is much greater than for
the earlier years and programming decisions are much more frequent.
Post-1960 public health policy programming indicates that very basic
and significant steps have been taken by the government toward solving
the serious health problems affecting the population and toward creating
a permanent and responsive structure which contributes to the maintenance
of better health conditions in Ecuador.
First, in terms of official public statements, after 1960, there was
increasing talk about basic reforms in the public health structure. The
points most frequently emphasized have been the need for both greater
coordination among institutions working in the field and greater atten-
tion to the health problems affecting the rural population, which makes
up over 50 percent of the nation's total. In the last few years, and
particularly since 1972, the government has reiterated that public health
is a national priority, that it constitutes a basic right for all Ecua-
dorians, and that it is officially seen as an integral process involving
not only curing illness but also its prevention in order to allow people
to live healthier and longer.
Second, regarding public health data, the post-1960 period witnesses
a marked official interest for finding out about the life conditions and
characteristics of the co'nvtry's inhabitants. There have been two national
population and housing censuses, one in i962 and another in 1974, both of
which provide a wealth of information relevant to public health. In addi-
tion, there have been several surveys designed to tap specific health
aspects, among them, the 1961 sanitation survey, a mid-1960's endemic
goiter survey, and several annual health resources and activities surveys.
The improved work of the National Statistics Institute undoubtedly has
also contributed to better knowledge of public health matters.
Third, partly due to a post-1960 trend which stressed the importance
of planning for socio-economic development and partly due also to better
national statistics, official plans and programs multiplied. There were
two national public health plans, the first of this kind ever, one in
1964 and another in 1973. In addition, specific health programs were
elaborated, i.e. of rural medicine, of potable water and sewerage, and
numerous small and medium term programs for the activities of the various
departments of the Ministry of Public Health.
Fourth, in terms of the organization of public health structures, the
most outstanding post-1960 developments are the 1165 creation of the Insti-
tute of Sanitary Works, the 1967 creation of the Ministry of Public Health,
and the abolition of important previously autonomous institutions such as
the Ecuadorian Antituberculosis League and the Boards of Social Assistance,
whose resources and functions came under the Ministry of Health's control.
This period was one in which some degree of coordination in health policy-
making was achieved and, especially after 1972, when the Ministry gained
ascendancy over other public health institutions. A further factor indi-
cating better structural organization after 1972 was the fact that, con-
trary to the five previous years when there were about a half dozen mini-
sters, from 1972 to 1975, only one person held the post, Radl Maldonado
Much needed progress occurred from 1960 to the rnid-1970's, but many
of the problems and shortcomings which characterized the pre-1960 era
were still at work. For one thing, there was a clear lack of coordina-
tion of public health policy in Ecuador. Important medical care and
sanitary institutions such as the Medico-Social Directorate of the Ecua-
dorian Social Security Institute, the Welfare Board of Guayaquil, the
National Hygiene Institute, and the Institute of Sanitary iWrks continued
operating as autonomous agencies, outside the direct control of a central
structure of health decision making. The lac! of cooperation wss so
strong in some cases that even the collection of statistical data wa.,
made difficult by the lack of unified reporting practices.
Reorganization for some public health institutions meant disorganiza-
tion to the point of inactivity. For instance, the National Institute of
Nutrition, after being partially incorporated into the Division of Nutri-
tion and the Ministry of Health, lost control of its budget and lacked
proper direction. WTen queried about the activities of his institution,
one public official declared that the INNE "ha tenido casi dos anos de
receso" (has been inactive for almost two years).*
The programs elaborated since 1960 have been carried out only par-
tially. In only very rare instances have they achieved the goals they
initially set forth. One of the most poignant illustrations is the pro-
grain of iodization of salt. In 1968, the government directed the iodiza-
tion of salt for human consumption as a measure to fight endemic goiter
(and its sequel, cretinism). Yet by the end of 1975 the law was still
not fully implemented. The prevalence of goiter in large areas of the
country continued unabated.
One of the key public health programs of the period, that of rural
medicine, was being carried out only in a very limited way. There was
lack of funds, lack of facilities, lack of personnel, and most of all,
lack of vision. Where a national crusade was needed, there were only
poorly implemented programs. Where full official commitment was essen-
tial, there was only rhetorical interest but practical neglect.
The neglect of rural areas by decision-makers in Ecuador can be ex-
plained at three different levels: 1) Because of its limited available
resources, the country has given priority to investment for social de-
velopment in urban areas, where the populations are concentrated, and
therefore can be easily served, and where usually there already exist
some works of infrastructure which are necessary for the creation of
services such as hospitals and clinics. Rural areas, whose populations
are relatively dispersed and where there are almost no previous infra-
Personal communication of Dr. Ribadeneira, official of IITNE.
structural works, are therefore deprived of public investment. 2) At
the level of political action, rural inhabitants -- made up mainly of
peasant agriculturalists of Indian descent, living in extremely low so-
cial and economic conditions -- have tended to be relatively unable to
articulate their demands and to organize into effective pressure groups.
This inability is partly the consequences of factors such as distance
which makes communication among rural communities very difficult. But
most of all, it is a consequence of centuries of domination of the pre-
dominantly Indian rural people by the predominantly white and mestizo
urban people. Tans, 3) at the level of the structure of society in
Ecuador, rural areas have been neglected because that is the logical
consequence of the prevailing conditions of internal colonialism (for
details on the concept of internal colonialism, see Gonzales-Casanova,
1969; Stavenhagen, 196D). Urban areas represent the dominant metropoles
which exploit their counterparts, the dependent, colonial raral areas.
Urban areas therefore are the main beneficiaries of the social services,
including public health care, provided by the state; ir contrast, rural
areas are either forgotten or given a low second priority.
PUBLIC HEALTH POLICY IMPLEMENTATION: TUE DIFFERENTIAL
DISTRIBUTION OF HEALTH SERVICES
This chapter studies Ecuador's public health policy in terms of its
implementation. After the previous analysis which stressed public health
programming from 1960 to the early 1970's, the present emphasis is on
national budget allocations for public health as well as the regional and
provincial distribution of public health services such as water, sewerage,
hospitals, and clinics.
Expenditures on Public Health
Ecuador's expenditures on public health have traditionally been very
small. This is largely due to the fact that the country is poor. Its
poverty or low level of economic development was particularly acute before
the oil boom, when the gross domestic product ranged from only US $841
million in 1960 to US $1816 million in 1972. As a consequence of the post-
1972 exploitation of newly discovered oil which coincided with the rise
in the world prices of the commodity, Ecuador's economic situation began
to improve. Its gross domestic product increased sharply, reaching US
$2498 million in 1973 and US $3475 million in 1974 (Banco Central, 1975).
Yet, as the figures indicate the country is still economically underde-
Lack of resources is only one of the reasons why Ecuador's exrendi-
tures on public health have been small. Another very important reason is
the low priority which public health has been given by past national gov-
ernments. Public health budget expenditures have usually represented less
than Five percent of tie total expenditures of the central government.
In 1972, for instance (see Figure 4), Ecuador's budget expenditures on
public health represented only 2.4 percent of the total; in contrast,
other Latin American countries selected for comparison had budget expendi-
tures on public health ranging from 3.5 percent of the total in Argentina
to 12.4 percent in Venezuela.
Since most of the study of Ecuador's budget expenditures* is based
on initial budget figures rather than on those revised at the end of each
fiscal year, it is necessary to include a word of caution before proceeding
further: there are no data available on the exact amount of money spent
on public health during a given year. 1) Initial budget allocations to
public health are only an approximation of what actual expenditures would
be; particularly before 1972, they were usually only statements of aspira-
tions because the central government was seldom able to deliver the amounts
indicated in the budget law. 2) The publication of arunal budget alloca-
tions seldom includes those made to the different autonomous and semi-
autonomous institutions operating in the health field.**
:Ependitures of the Central Government
Ecuador's government expenditures on public health (Table 2) increased
The Presupuesto Nscional del Estado...(National Budget of the
State...) is usually published before the beginning of each fiscal year.
** A rare tidbit of information on the matter is given by an offi-
cial report which indicates that the 1962 net expenditures on health were
nearly 319 million sucres, of which 24.7 million corresponded to the cen-
tral government, 55.7 to the municipalities, and 239.2 to other entities
(JNPC, 1964:105). This information is significant also in that it illus-
trates discrepancies between officially reported figures. The 1962 central
government expenditures on public health previously mentioned are only
about 25 million sucres, in contrast with those reported by the Inter-
American Statistical Institute (see Table 2) which are 65 million.
Figure 4. Government Budget 3xpenditilres on Public Health as a Per-
cent of Total Expenditures in Selected Latin American Countries, 1972
a) Includes social welfare.
b) Social services only.
c) Central government expenditures.
Source: Elaborated from data in OEA, I.E, 1975: Table 406-0i.
Table 2. Central Government's Annual Budget Expenditures on Public
Health, Number and Percent, Ecuador, 1960-1975
Expenditures on Public Health
Year Sucres U.S. Dollarsb Percent
1960 55 3.1 3.1
1961 52 2.9 2.5
1962 65 3.6 3.5
1963 85 4.7 4.0
1964 8.3 4.9 3.1
1965 157 8.7 5.0
1966 95 5.3 3.4
1967 96 5.3 3.2
1968 99 5.5 2.4
1969 91 5 1 2.0
1970 149 6.0 2.6
1971 166 6.6 2 8
1972 155 6.2 2.4
1973 785 31.4 8.4
1974 822 32.9 5.1
1975 805 32.2 5.4
Source: Organizaei6n de Estados Americanos (OEA), Instituto Inter-
Americano de Estadistica' (IE), 1968, 1974; InterAmerican Development
Bank (IDB), 1974; El Mundo, Octubre 1975; Banco Central, 1973; Registro
Official, 1962-68; Ecuador, Ministerio de Finanzas (MF), Oficina Nacional
del Presupaesto (ONP), 1970-75.
a) Expenditures correspond to fiscal year (January December) plus
a complementary period of three months.
b) From July 14, 1961 to August 16, 1970, the official rate of ex-
change was 18 sucres per US $1.00; since August 16, 1970, the rate has
been.25 sucres per US $1.00.
from about 50 million sucres (US $7.8 million) in 1960 to over 800 million
sucres (US $32 million) in 1975. The greatest jump occurred from 172 to
1973 when it went from 155 to 785 million sucres or from US $6.2 to 31.4
million. Undoubtedly, the priority given to public health by the mili-
tary government under President Rodriguez Lara (that reorganized the Min-
istry of Public Health in April 1972) and the new oil revenues of 1973 are
the main factors contributing to this drastic increase.
In relative terms, the data in Table 2 indicate that public health
expenditures ranged from 2 0 percent of the total budget in 196; to
;'out 8.4 percent in 1973. Public health's proportional share of the
national budget reached its highest levels in 1965, 1973, 1974 and 1975
(with 5.0, 8.4, 5.1, and 5.4 percent respectively). Apparently, these
increases occurred while military dictatorships ruled the nation and
around the time when national health plans had been elaborated. Military
Juntas took power from civilian governments in 1963 and 1972; the national
health plans of 1964 and 1973 were elaborated shortly after each year.
Contrary to expectations, the creation of the Ministry of Health in 1967
did not bring about any substantial increase in public health expenditures.
Rather, there was a relative decrease from 3.2 percent in 1967 to 2.4 in
1968 and down to 2.0 in 1969.
Expenditures of Autonomous Health Institutions
The health boards (ex-boards of social assistance)
The health boards, now under the direct control of the Ministry of
Health, are analyzed together with other autonomous health institutions
because they succeeded the central and provincial boards of social assis-
tance which operated in an autonomous way for over half a century until
The annual budget expenditures of the provincial health boards in-
creased from about 25 million sucres (US $1.4 million) in 1962 to over
274 million (US $11 million) in 1972 and 721 million sucres (US $28.8
million) in 1975 (see Table 3). Before 1970, the highest figure corres-
ponds to 1966 (48.62 million sucres), representing about 51 percent or
half of the total amount reported that year as the government's expendi-
ture on public health. The budget expenditures for the 1970-72 period
are much higher than those reported for previous years and, when compared
to government expenditures on public health, appear to surpass the latter
by over o0 percent each year.
The IEDS, Institute of Sanitary Works
The IEOS, one of the most important autonomous institutions in the
nation, has had relatively large amounts of annual budget expenditures
since its creation in 1965. From an estimated 92 million sucres (US $5.1
million) in 1966, its expenditures increased to about 1,077 million (US
$43.1 million) in 1975. In two years, 1967 and 1975, they surpassed those
of the central government by 26 and 34 percent respectively.
The National Medico-Social Directorate (ex-Medical Department) of the IESS
Also shown in Table 3 are the annual budgets of the National Medico-
Social Directorate of the IESS. For several years, and particularly from
1965 to 1972, this institution appears to have outspent the central govern-
When they were known as boards of social assistance, these pub-
lic health institutions derived their income from ordinary and special
central government budget accounts as well as from their participation in
specific tax revenues and from profits from their capital holdings (such
as landholdings and shares in LIFE, a pharmaceutical company).
Table 3. Annual Budget Expenditures of Selected Autonomous Institutions
of Public Health, Number and Percent of Total Government Health
Expenditures, Ecuador, 1960-1975
Expenditures Percent of Total
(Million Sacres)b Government Expenditures
Health YMdico-Social Health M6dico-Social
Yeara Boardsc IEOS Department of Boards IEOS Department of
the IESS the IESS
1960 n.a. 43d n.a. 78
1961 n.a. 28d n.a. 38
1962 25 31 38 48
1963 27 31d 32 36
1964 28 89 32 100
1965 29 181 18 115
1966 49 92e 210 51 97 221
1967 39 121 294 40 126 306
1968 35 93 145d 36 94 146
1969 n.a. n.a. 296d n.a. n.a. 325
1970 243 114 383 163 77 257
1971 269 90 431 162 54 260
1972 274 113 513 177 73 331
1973 303 244 508 39 31' 65
1974 539 548 649 66 67 79
1975 721 1077 n.a. 90 134 n.a.
Source: Registro Oficial, 1962-68; ONP, 1970-75; MSP, n.d.; IESS,
n.d.; Instituto Ecuatoriano de Obras Sanitarias (IEOS), 1975.
a) Expenditures correspond to fiscal year (January December) plus
a complementary period of three months.
b) From July 14, 1961 to August 16, 1970, the official rate of ex-
change was 18 sucres per US $1.00; since August 16, 1970, the rate has
been 25 sucres per US $1.00.
c) 1962-68, initial budgets; 1970-72, revised budgets.
d) Author's estimate based on IEOS, 1975: Anexo 3.
e) Partial information; complete figures not available.
ment on health care. The contrast becomes greater when one considers the
fact that the ex-Medical Department was serving only its members -- a popu-
lation representing six percent or less of the national total -- while the
central government was supposed to be serving all the country's inhabitants!
Regional and Provincial Differences
There are very few data available on public health expenditures for
subdivisions of the country. However, some comparisons among provinces
and regions are possible through the use of data on budget expenditures
of the public health boards and investments of the IEOS. As observed in
Table 4, from 1962 to 1974, the budget expenditures of the health boards
increased from 25 million (US $1.4 million) to about 540 million sucres
(US $21.6 million). In terms of per capital expenditures, the health
boards' figure in 1962 was 5.6 sucres per capital (US $.30) and, in l'74,
82.9 sucres per capital (US $3.30).
The 1962 expenditures of the health boards of the highland provinces
reached 16 million sucres (7.4 sucres or US $.40 per capital) in contrast
to those of the coastal provinces, which were seven million (3.5 sucres
or US $.20 per capital) and the eastern provinces, which were two million
(18 sucres or US $.10 per capital Individually, Galdpagos and Zamora
Cninchipe were the provinces with the highest health boards' per capital
expenditures (165 and 43.6 sucres or US $9.20 and 2.40 per capital respec-
tively). Despite the fact that the Province of Guayas had over one fifth
of the country's population in 19o2 (see Table 1), its health boards' ex-
penditures in 1962 were very low (a total of 1.4 million sucres or US $.01
million, corresponding to 1.4 sucres or US $.01 per capital It should
be pointed out, however, that in Guayas there is a very strong autonomous
institution working in the public health field, the welfare Board of Guaya-
Table 4. Total and Per Capita Budget Expenditures of the Public Health
Boards, 1962 and 1974, and Investments of the IEOS by 1974
Public Health Boards' IEOS'
(Million Sucres) (Million Sucres)
Region 1962 1974 by 1974b
Province Total Per Cap. TItal Per Cap. Total Per Cap.
25.10 5.6 539.36 82.9
16.05 7.4 339.85 108.3
7.46 3.5 179.87 56.6
data in Registro
a) Expenditures of the boards of social assistance before 1972.
b) Exact period covered is not available.
Source: Compiled and conmpted by the author from
Official, 1962; MSP, n.d.; IEOS, 1975; and Table 1.
quil, which controls most of the health resources and facilities in the
province. The majority of the other provinces, in contrast, depend pri-
marily on the health boards and their resources.
The 1974 budget expenditures of the health boards of the highland
provinces represented 63 percent of the national total, those of the
coastal provinces 33 percent, and those of the eastern provinces only
about three percent. As shown in Table 4, the provinces with the largest
per capital health boards' expenditures were Galapagos (with an all time
high of 1050 sucres or US $42 per capital Pichincha (with 155.6 sacres
or US $6.29) and Zamora Chinchipe (with 130.3 sucres or US $5.20). Manabi,
the third most populous province in the nation, had a small amount of
health board expenditures, representing only 30.4 sucres or US $1.20 per
The IEOS data (also shown in Table 4) refer only to investments re-
ported until 1974 and not to the total annual budget expenditures of the
institution, which were 538 million sucres (US $21.5 million) in 1974.
Of the total IEOS investment until 1974, the Costa received the largest
amount, 82 million sucres (26.9 sucres or US $1.10 per capital ; most of
this investment went to Manabi, about 54 million (US $2.2 million) (66.6
sucres or US $2.70 per capital The rest of the regions received rela-
tively small investments.
The data available indicate that the per capital expenditures of the
public health boards were the highest in Galipagos, followed in descending
order by the Oriente and Sierra provinces and with the Costa provinces
at the bottom. In contrast, the per capital investment of the IEOS was
higher in the Costa provinces than in either the Sierra or Oriente provin-
ces. Galapagos, which figured very high in public health boards' per
capital expenditures, had no investment reported by 1974. This province
is an exceptional case because it has a very small population (abort
four thousand in 1974) and consequently small expenditures or investments
can be translated into high ratios per capital.
Distribution of Public Health Services
One of the best ways of maintaining high levels of health among the
population of a given area is through prevention of disease and perhaps
the most.important measures of disease prevention are the provision of
piped water supply and sewerage systems as well as spraying and immuniza-
tions. The lack of some of these basic services greatly increases the
population's exposure to illness.
The serious health problems created by deficiencies in water
supply and sewerage systems are evident from analysis of
morbidity and mortality data, particularly of young children.
Tne group, gastritis, enteritis, etc., appears as one of the
principal causes of deaths among yolng children of 1-4 years
of age in every country /of the American continent/ for which
data were available . . . . . . . .. . .
Other diseases which are water borne or spread because of an
insufficient supply of water and lack of cleanliness include
typhoid fever and dysenteries (PAHO, 1970:162).
In Latin America there are wide differences in regards to the pro-
portion of each country's population served by piped water and sewerage
systems. The data for selected countries presented in Figure 5, indi-
cate that Ecuador ranked fairly low in the provision of both public ser-
vices. In 1973, about 32 percent of Ecuador's population had piped water
services, in contrast to about 70 percent in Chile, Colombia and Vene-
zuela, and over 50 percent in Cuba and Argentina. Similarly, 24 percent
Venezuela ::.3 J
"2/////Y/////i//// 3////// 3
Ay/////////////A 2 -
1 Piped water
Figure 5. Percent of Population Served by Piped Water Services and
Sewerage Systems in Selected Latin Anerican Countries, 1973
Source: Elaborated from data in OEA, IIE, 1975: Table 403-01 and
of Ecuador's population had sewerage services, in contrast to over 50 per-
cent in Colombia and about 30 percent in Chile, Peru and Venezuela.
Ecuadorian census data on coverage of piped water and sewerage services
(Table 5) do not refer directly to the population with access to such fa-
cilities but rather to the number of dwellings with house connections or
easy access to them. Nevertheless, the data are useful for comparisons
among regions and provinces and can serve as the basis for inferences
about approximate populations served.
The nation's proportion of dwellings with piped water services in-
creased from 37.5 percent in 1962 to 41.8 in 1974. It can be inferred
therefore that in 12 years the proportion of people exposed to diseases
associated with the consumption of water from other sources (wells, rivers,
lakes, and so on) had a corresponding decrease.
In 1962, the Sierra's proportion of dwellings with piped water (37.7
percent) was greater than those of the Costa (28.8) and the Oriente (12.4).
Pichincha and Guayas were the only provinces having over 60 percent of
their dwellings with piped water services. Of the rest of the provinces,
only El Oro and Galapagos approached 50 percent.
In 1974, both the Sierra and the Costa had roughly similar propor-
tions of their dwellings with piped water (37.5 and 35.1 percent respec-
tively). Pichincha and Galipagos reached 73.7 and 82.6 percent respec-
tively; Guayas, El Oro, Chimborazo, and Imbabura had about 50 percent,
and the rest of the provinces had lower proportions.
At the national level, the proportion of dwellings with sewage dis-
posal systems (also shown in Table 5) increased from 32.5 percent in 1962
Table 5. Water and Sewerage Services, Percent of Dwellings Served, by
Province, Ecuador, 1962 and 1974
Region Piped Watera Sewerage
Province 1962 19'(4 T19- 1974
Source: DEC, 196i; OCN, 1975-
a) Piped Water from Public Systems; 1962 includes private installa-
b) Data for 1962 refer to toilet facilities both for private dwel-
lings and common use connected to public sewerage systems as well as
houses with latrines and septic tanks.
to i40.; in 1974.
In 1)', the Costa had almost twice the proportion of dwellings with
sewerage as did the Sierra (33.4 and 17.4 respectively). Galapagos and
the Oriente followed with 27.3 and 10.8 percent. Only Pichincha and Guayas
had over 50 percent of their dwellings with sewage disposal systems. The
rest of the provinces had proportions which fluctuated widely, from 3.9
percent in Zamora Chinchipe to 26.5 in Tungurahua.
In 1974, the coastal region (with about 40 percent of dwellings with
sewerage) continued surpassing the highlands region (whose proportion was
about 27 percent) but the gap appeared smaller than in 1962. Both the
Oriente and Galapagos increased their proportions to 15.3 and 53 percent
respectively. Pichincha and Guayas had over 60 percent of their dwellings
with such services; of the other provinces, only El Oro and Galipagos had
increased to about 50 percent of dwellings with sewerage.
Traditionally, infectious and communicable diseases have taken a
great toll of life in Ecuador. Tie health history of the country is full
of episodes of dreadful epidemics which caused many fatalities among the
population, young and old. Immunizing the people, particularly children
who tend to be more susceptible to certain communicable diseases such as
smallpox and poliomielitis, is one of the most significant preventive
health activities which can be carried on.
The immunizations or vaccinations given for a selected number of
diseases in two periods about a decade apart are presented in Tables 6a
and 6b. Note that the data refer to vaccinations given, not to number
of persons vaccinated. The number of persons immunized would tend to be
equal to the number of vaccinations when the vaccine is given in only one
Table 6a. Immunizations Given for Selected Diseases, by Province,
1963-65 (Mean Aninal Namber)
Region Smallpox DPT- Polios Typhus Whooping
Source: Ecaador, Ministerio de Salad Pdblica (MSP), Divisidn Ns-
cional de Epidemiologia (DNE), n.d.
a) Complete doses.
b) DPT or "Triple" is a vaccine used against diphtheria, tetanus,
and whooping cough.
Table 6b. Immunizations Given for Selected Diseases, by Province
1972-73 (Mean Annual Number)a
Region Smallpox0 DPT0 Polioc BCGd Typhus Tetanus Yellow Measles
345.3 154.3 492.9 132.5 35.9
179.2 75.6 119.3 49.2 7.6
144.1 63.4 363.0 71.3 23.7
12.0 9.4 11.9 3.7
2.7 2.9 .2 .9
1.6 1.5 7.5 -9
2.0 2.2 4.2 1.4
5.7 3.0 .5
33.2 18.2 34.2
.9 .4 1.3
- .2 .2 .0 .0 .0 .0
1975: Table 25.
Institute Nacional de Estadistica, 1974: Table 23,
a) Vaccinations given in health establishments.
b) Includes revaccinations.
c) Includes either of three doses.
d) BCG is used against tuberculosis.
dose. However, when more than one dose is required, as is the case with
DPT and Polio, the number of persons immunized would tend to be smaller
than the total number of vaccinations given.
As can be observed in Tables 6a and 6b, the number of reported vac-
cinations had increased in most cases from the 1963-65 period to 1972-73.
In the first three year period there are no data available on vaccinations
against tetanus, yellow fever, and measles at the provincial level. Even
in 1972-73 vaccinations against these diseases were relatively few and
restricted to a few provinces of the coastal and eastern lowlands.
In the 1963-65 period the highest mean annual number of vaccinations
(about 920 thousand) was against smallpox.* In contrast, in the 1972-73
period, the highest number of vaccinations (about 493 thousand) was for
poliomielitis, with smallpox vaccinations occupying a second place (about
In general, the data presented in Tables 6a and 6b indicate that in
1963-65 more immunizations were given in the highland region than in any
of the other regions of the country. The coastal lowlands were usually
in second place of priorities, while the Oriente and GalBpagos received
very little attention. The only exceptions to the above statements were
vaccinations against typhus and whooping cough. In the first case, the
Costa had more mean annual vaccinations than the Sierra (32.3 and 10.7
thousand respectively) and in the second case their total numbers were
very similar (9.4 thousand for the Sierra and 8.9 for the Costa). Guayas
Smallpox is a disease with no known cure and the best way to
avoid its fatal affects is by vaccination. Traditionally, countries
immunized as many of their inhabitants as possible; in the 1970's,
several countries around the world started using a different approach
in which vaccinations were given only in the immediate areas where a
case or cases and their possible contacts were found.
and Pichincha appeared to receive the largest share of some vaccinations,
particularly of smallpox, DPT, and polio.
As for the 1972-73 period, the Sierra's predominance in immuniza-
tions administered was restricted to smallpox and .DT. The Costa sur-
passed all other regions in number of polio, BCG, typhus, tetanus, and
measles immunizations and the Oriente had practically all yellow fever
doses given. Although there were some variations by type of vaccine ad-
ministered, the tendency for Pichincha and Guayas to benefit with the
largest amounts of vaccinations continued. Substantial numbers of vac-
cinations of most types were also given to Azuay, Chimborazo, and Mana-
Most of the work of hospitals and clinics is geared to providing
assistive and curative health services to people already afflicted
with disease. Although health establishments such as health centers,
health posts, and medical dispensaries carry on some important preventive
functions such as immunizations and medical checkups, their main work is
on the curative side as they serve ill people and either provide treat-
ment or referrals to hospitals or clinics.
While the degree of a population's exposure to disease can be ascer-
tained by the availability of preventive health services, i.e. sanitary
works, immunizations, etc., the degree of a population's access to medi-
cal technology can be ascertained by the availability of curative health
services, among them hospitals and clinics, health centers, number of
beds, and medical person.ei.
An illustration of the wide differences found in Latin America and
the relative position of Ecuador is given in Figure 6, which presents
0 5 10 15
Argentina .. i .
Colombia '' .r
fl Physicians per 10,000 population
^ Beds per 1,000 population
Figure 6. Physicians per 10,000 Population and Beds per l,0u,
Population in Selected Latin American Countries, 1'68
Source: PAHO, 1970: Figures 72 and 85.
bed/population and physicianpopulation ratios for selected countries in
1968. In both cases, Argentina tops the list with over six beds per
1,000 population and about 19 physicians per 10,000 population. Several
countries have between three and five beds per 1,000 population and be-
tween four and nine physicians per 10,000 population. Ecuador, along
with Bolivia, occupies the bottom of the list with only about 2.2 beds
per 1,000 population and 3.5 physicians per 10,000 population.
Hospitals, clinics, and health establishments
Medical care provided in hospitals and in outpatient services
consnues the greatest part of the health budget of most coun-
tries of the Americas. The demand for medical care varies with
the health problems of the population as weil as with its aware-
ness of the needs and benefits of receiving medical attention.
The level of demand is also influenced by the availability of
resources of institutions and health personnel, their geogra-
phic distribution and the education and cultural characteristics
of the population (PAHO, 1970:148).
The medical care facilities considered in this study are divided
into two classes: first, hospitals and clinics, whose primary function
is to provide medical care to hospitalized patients, and second, health
establishments, i.e. health centers, health posts, medical dispensaries,
ets. whose primary function is to provide medical care to ouQ-patients
with few or no in-patient services
Data referring to number of hospitals and clinics, their bed capa-
city in relation to the population, and a measure of their utilization
are presented in Tables 7a and Tb. As observed, Ecuador increased the
number of hospitals and clinics from 127 in 1965 to 221 in 1973. In the
same approximate period, the number of beds per 1,000 population decreased
from 2.3 to 2.0 while the number of hospital discharges per 1,000 popula-
Table 7a. Indicators of Accessibility to Medical and Health Care, by
Province, Ecuador, c. 1965
Hospitals Health Hospital Beds per Hosp. Disch.
Region and Establish- Beds 1.000 Per 1,000
Province Clinicsa mentsb Population Population
Source: Conpiled and computed
Table 2; JNPC, 1968:24.
by the author from data in IRE, 1972b:
a) Estimated for about 1962; includes 12 hospitals and clinics whose
starting date of operation was not reported.
b) Includes 46 health establishments whose starting date of opera-
tion was not reported.
Table Tb. Indicators of Accessibility to Medical and. health Care, by
Province, Ecuador, c. 1973
Hospitals Health Hospital Beds per Hosp. Disch.
Region and Establish- Beds 1,000 Per 1,000
Province Clinics ments Population Populationa
Source: Compiled and computed by the author from data in INE, 1975b:
a) 1972 data.
tion increased from about 39 to 43.* The decrease in bed/population ratio,
despite a greater number of hospitals and clinics, means basically, that
the country has not even been able to match the increase in number of beds
to population growth during the period considered, much less to improve
the bed/population ratio.
Regarding health establishments, Tables 7a and Tb indicate that Ecua-
dor increased their number almost three-fold, from 222 in 1965 to 602 in
1973. Around 1965, the Sierra had more hospitals and clinics, health
establishments, and hospital beds than either of the other regions of Ecua-
dor. Both the Costa and Oriente, however, surpassed the Sierra in
number of hospital discharges per 1,000 population.
The ratio of beds per 1,000 inhabitants is a very important measure
of the availability of medical care services in an area for it avoids the
problems inherent in simpler measures such as number of hospitals and
clinics or number of hospital beds. In the first case, the fact that one
province has only one hospital or clinic and another has four or seven
does not mean much unless more is known about the bed capacity and, in
general, the quality and quantity of both material and human resources.
Second, the number of hospital beds alone is not aJeouat5e because any
meaningful comparison among provinces must take into consideration their
Across the nation, the number of hospital beds per 1,000 population
in 1965 was very low. Some provinces such as Zamora Chinchipe, and Gald-
pagos did not have hospital beds at all! Most other provinces fluctuated
According to the Pan American Health Organization (PA-HO, 1970:
153) hospital discharges for 1,000 population would probably have to be
at least 100 to meet the need for medical attention in countries of
between one and two beds per 1,000 population. The highest ratios belonged
to Pichincha (4.5), Guayas (3.8), and Pastaza (2.8).
Around 1973, the Sierra still had more hospitals and clinics, health
establishments, and hospital beds than the other regions of the country.
In terms of hospital discharges per 1,000 population, the Sierra had the
lowest ratio (39.9), followed by the Costa (44.5), the Oriente (75.0),
and Galapagos (96.6). The 1973 ratio of beds per 1,000 population (2.0)
was smaller than that of 1965 (2.3). The building of hospitals and clinics
during the period had not been able to keep ap with the growth of Ecuador's
population and, contrary to expectations, the situation worsened. There
were, nevertheless, some positive aspects in 1973. First, some provinces
which had no hospital beds nine years earlier in 1973 had among the high-
eat bed/population ratios of the nation. Galipagos had 10.7, Zamora Chin-
chipe, 3.6, and Napo, 4.7. Second, the greatest reductions in the bed/
population ratio occurred in Pichincha and Guayas and this neant that
during the 1965-73 period there had been a tendency to distribute resources
more evenly among all provinces, instead of the usual preference for these
Human Health Resources
A key element in the provision of medical and health care service to
the population is the availability of well-trained personnel, sufficient
in number and adequately distributed around a nation. Health personnel
consists not only of professional, technical, and administrative staff
but also of auxiliary workers. In addition to the large numoer of doc-
tors, nurses, and dentists required to staff hospitals and other health
units, health work depends on the a-tive participation of auxiliary workers
and paramedical personnel, including sanitary engineers, veterinarians,