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OBJECTIVES: Latin American countries have long struggled with socioeconomic inequalities and health equity. In 2007, Ecuador implemented a health reform to address these issues by making public health services free, coordinating finances between subsystems and increasing the state's health budget. This study evaluates whether Ecuador's health system reform (2007-2017) reduced out-of-pocket (OOP) health spending, catastrophic health spending (CHS) and socioeconomic inequalities in CHS.

DESIGN: Cross-sectional study.

SETTING: Secondary data available of households from the 2006 and 2014 National Living Standards Measurement surveys.

METHODS: Descriptive statistics (means and medians) and log-binomial regression were applied to assess prevalence of OOP and socioeconomic inequalities (residence, region, health insurance status and wealth) in catastrophic health expenditure (CHE) for each period and over time.

RESULTS: Overall, there was a significant reduction of 14% points in the proportion of households with OOP healthcare expenditure. The prevalence of CHE decreased from 17% to 10% and within each socioeconomic group over time. Significant reductions in relative risk were observed in all socioeconomic variables. The inequality in CHE decreased significantly in households placed in rural areas (relative difference (RD): 0.88; 95% CI: 0.79 to 0.97) and poorest (RD: 0.82; 95% CI: 0.69 to 0.97); however, it increased within regions (RD: 0.58; 95% CI: 0.44 to 0.76) and for uninsured households (RD: 1.39; 95% CI: 0.95 to 2.04).

CONCLUSIONS: This study suggests that recent health reform effectively reduced OOP healthcare expenditure, CHE and some socioeconomic inequalities. Future reforms should further invest in key areas, expand health insurance for the most disadvantaged and monitor progress towards universal health coverage to address persistent inequalities.

Introduction: In 2007, the Ecuadorian government initiated comprehensive social and political reforms aimed at improving citizens’ well-being and reducing inequalities. The health system underwent structural changes designed to expand coverage and eliminate financial barriers. This qualitative study therefore examined how key health professionals perceived the facilitators and barriers to implementing the health system reform 2007-2017 to achieve universal health coverage (UHC) in Ecuador.

Methods: Eleven stakeholders directly involved in the reform process were interviewed. Data were analyzed using inductive and latent thematic analysis to identify key themes.

Results: Four interrelated themes shaping the implementation of Ecuador’s health system reform were identified: (i) strong political commitment, facilitated the expansion of free services and infrastructure, but was undermined by political interference and financing challenges; (ii) the introduction of a renewed healthcare model rooted in primary care and intercultural principles enhanced access but impeded from inadequate training, weak territorial planning, and limited community engagement; (iii) efforts to reduce system fragmentation through mechanisms like the Comprehensive Public Health Network (CPHN), which improved referral pathways but failed to fully integrate services across public and private subsystems; and (iv) leadership reforms within the Ministry of Public Health sought to strengthen governance; but were hindered by centralised decision-making, high leadership turnover, and weak intersectoral coordination. These findings highlight a dynamic and complex reform process marked by ambitious goals and persistent structural limitations.

Conclusion: Ecuador’s 2007–2017 health reform expanded universal coverage by removing fees, strengthening primary care, and promoting intercultural health. Yet, weak referrals, inconsistent implementation, and poor planning limited impact. Political will advanced reforms but created resource imbalances. CPHN reduced some fragmentation but segmentation and weak public–private integration persisted. Leadership changes improved governance foundations, though high turnover and poor collaboration undermined progress. Future reforms require stable governance, clear local roles, stronger community engagement, and greater system integration.

Background

Universal Health Coverage (UHC) is vital for improving health outcomes through financial protection and responsive health services, as outlined in the Sustainable Development Goals. In 2007, Ecuador initiated significant social and health system reforms aimed at enhancing its citizens’ quality of life. Over a decade, efforts expanded coverage and improved the efficiency and quality of public health services. Reforms included free health services at all care levels, reducing system fragmentation, and significant investments in health facilities, medicines, and medical equipment. While some studies noted improved health coverage; this thesis aims to assess whether Ecuador’s recent health system reform reduced socio-economic inequalities in health care and financial protection and to identify the main facilitators and obstacles to its implementation.

Methods

The study used quantitative and qualitative methods, including three cross-sectional studies with data from the Living Standards Measurement Surveys (2006 and 2014 waves). Descriptive statistics identified key population characteristics, health indicators, and financial protection coverage. Health inequality was measured through socio-economic differences in UHC components. Population coverage was measured by abstention from seeking care during illness, while preventive care and reproductive health services were key health service coverage indicators. Catastrophic Health Expenditure (CHE) was used to gauge financial protection. The second objective was addressed through thematic analysis of interviews with key stakeholders.

Results

The reforms led to increased population and basic health service coverage, with a notable reduction in care abstention. However, persistent socio-economic inequalities remained, particularly among rural, indigenous, and uninsured groups. CHE and health expenditure on medicines decreased, but uninsured households remained vulnerable. Political commitment, innovative coverage mechanisms, and a focus on prevention facilitated reform implementation, while private interests, weak governance, and health care commodification hindered progress.

Conclusions

The reforms improved UHC in Ecuador but did not fully address socio-economic inequalities, particularly among disadvantaged groups. Ongoing political and structural challenges must be tackled to further strengthen Ecuador’s health system.

Background: Limited research is available about the impact of healthcare reforms on healthcare utilization accord‑ing to socioeconomic group. Although most health reforms in Latin America have focused on reducing the gapbetween the most advantaged and disadvantaged groups and improving the quality of health services, the available information has shown limited progress. Therefore, this study assessed whether the recent Ecuadorian healthcare reform (2007–2017) contributed to decreasing the socioeconomic inequalities in healthcare utilization.

Methods: We used data from the National Living Standards Measurement surveys conducted in 2006 and 2014. Unmet healthcare needs (UHCN) were used as the dependent variable and proxy for difculties in accessing health services. Place of residence, ethnicity, education and wealth were selected as indicators of socioeconomic status. The slope and relative inequality indexes were calculated for adult men and women for each period and socioeconomic variable. A multiplicative interaction term between midpoint scores and time was applied to estimate changes ininequalities over time. Sample weights were applied to all analyses, and 95% confdence intervals were calculated to assess statistical signifcance in the regression analysis.

Results: In 2006, the poor, Indigenous, those living in rural areas and with low education had lower access to health services. In 2014, the overall prevalence of UHCN decreased from 27 to 18% and was higher in women than men. Statistically signifcant reductions of refraining were observed in absolute and relative terms in all social groups, both in men and women.

Conclusions: Our results showed remarkable and signifcant decreases in inequalities in all examined socioeconomic groups in absolute and relative terms in this period. Although a new model of healthcare was established to achieve universal health coverage, its performance must be continuously evaluated and monitored with specifc indicators. Further studies are also needed to identify the main barriers that contribute to UHCN among socially disadvantaged groups.

BACKGROUND: Over the last 12 years, Ecuador has implemented comprehensive health sector reform to ensure equitable access to health care services according to need. While there have been important achievements in terms of health care coverage, the effects of these reforms on socioeconomic inequalities in health care have not been analysed. The present study assesses whether the health care reforms implemented in the decade between 2007 and 2017 have contributed to reducing the socioeconomic inequalities in women's health care access.

METHODS: The present study was based on two waves (2006 and 2014) of the Living Standards Measurement Survey conducted in Ecuador. Data from women of reproductive age (15 to 49 years) were analysed to evaluate health care coverage across three indicators: skilled birth attendance, cervical cancer screening, and the use of modern contraceptives. Absolute risk differences were calculated between the heath care indicators and the socioeconomic variables using binomial regression analysis for each time period. The Slope Index of Inequality (SII) was also calculated for each socioeconomic variable and period. A multiplicative interaction term between the socioeconomic variables and period was included to assess the changes in socioeconomic inequalities in health care over time.

RESULTS: Access to health care increased in the three studied outcomes during the health sector reform. Significant reductions in inequality in skilled birth attendance were observed in all socioeconomic variables except in the occupational class. Cervical cancer screening inequalities increased according to education and occupation, but decreased by wealth. Only a poorer education was observed for modern contraceptive use.

CONCLUSIONS: While most socioeconomic inequalities in skilled birth attendance decreased during the reform period, this was not the case for inequalities in cervical cancer screening or the use of modern contraceptives. Further studies are needed to address the social determinants of these health inequalities.