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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.