percent; the Armed Forces and Police, 1 percent; and various private for-profit enterprises, 10 percent. The remaining 30 percent of the population do not have access to formal medical care. Private for-profit organizations have built hospitals of varying levels of complexity, as well as physicians’ offices, and auxiliary diagnostic and treatment services for the population that is able to pay for them. These organizations include both insurers and private prepaid medical enterprises. A considerable portion of the population—mainly those with limited resources and especially people living in rural areas—use traditional medicine. Under the Health Code currently in effect, the Ministry of Public Health’s Public Health Control Bureau is responsible for regulating the provision of health services in general. In 1995, there were 3,462 health establishments, 2,988 (86.3 percent) without beds and 474 with beds. Of the former, 51.4 percent came under the jurisdiction of the Ministry of Public Health, 32.6 percent under the Instituto Ecuatoriano de Seguridad Social (IESS) and Farmers Social Security; and the remaining 16 percent under the jurisdiction of other health sector institutions. Twenty-six percent of the establishments with beds belonged to the Ministry of Public Health, 62.7 percent were in the private sector, and the rest corresponded to other institutions. The total number of health institutions in operation includes general, specialized, and canton hospitals plus private clinics. Those without beds include health centers and subcenters, health posts, and doctors’ clinics. Most of the establishments with beds are located in the cities, whereas 57.1 percent of those without beds are in the cities and 42.9 percent are in rural areas. Information on health care spending is not very recent, reliable, or complete, especially as far as the private sector is concerned. The data available indicate that public spending on health as a percentage of total government expenditures fell from 5.5 percent in 1992 to 4.6 percent in 1996. Government spending on health declined due to the fiscal crisis and adjustment programs that greatly reduced allocations to the social sector (from 7.8 percent of GDP in 1992 to 5.2 percent in 1996). Spending by the Ministry of Public
Health as a percentage of GDP fell from 1 percent in 1985 to 0.75 percent in 1995. Not only is the share of public spending allocated to health small but also, in addition, its distribution is clearly inequitable and its use is inefficient and centralized. Fortunately, private spending on health increased between 1992 and 1996. Epidemiological Context Ecuador’s estimated life expectancy at birth in 2004 was 76 years for the general population (73.2 years for men and 79 years for women). Between 1990 and 1995 the leading causes of death in the general population were the following: pneumonia (27.2 per 100,000); cardiovascular diseases (23.1 per 100,000); traffic accidents (15.8 per 100,000); and malignant tumors of the stomach (12.7 per 100,000). Deaths due to homicide were the sixth cause of death, responsible for 55,443 years of potential life lost (YPLL), 50,200 of them in men. In 2004, the estimated infant mortality for the country as a whole was 24.5 deaths per 1,000 live births, with large differences among the provinces. In Chimborazo, for example, where the population is predominantly rural and indigenous, the estimated rate was almost double. Acute respiratory infections were responsible for 37 percent of the deaths of infants from 1 week to 11 months of age and for 32 percent of deaths in children from 1 to 4 years old; and they accounted for 28 percent and 24 percent of hospital discharges, respectively. Chief among the leading causes of death and disease in the indigenous population are those related to poverty: acute respiratory infections, acute diarrheal diseases, and malnutrition. Hypoxia and complications of delivery and the puerperium are the leading causes of infant and maternal death, respectively. Chronic malnutrition in children under 5 years of age reached 69 percent in some of these areas, compared with the national average of 49.4 percent. It is estimated that between 60 and 70 percent of black children in Esmeraldas suffer from malnutrition. The health situation of populations living near the borders with Colombia and Peru is critical, especially among those living in the eastern region. Chronic childhood malnutrition
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