Socioeconomic inequalities in women´s access to health care: has Ecuadorian health reform succeeded?

Over the last twelve years, Ecuador has implemented a comprehensive health sector reform to ensure equitable access to health care services according to health needs. 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. This study assessed whether the health care reform implemented in the 2007 - 2017 decade contributed to reducing the socioeconomic inequalities in women´s health care access. This study was based on two waves of the Living Standards Measurement Survey conducted in Ecuador in 2006 and 2014. Data from women of reproductive age (15 to 49 years) was analysed to evaluate health care coverage in 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.

3 Background Universal Health Coverage (UHC), defined as ensuring equitable access to health services to improve a population´s health, is proposed as a global policy by the United Nations [1]. The main components of UHC are (i) the delivery of quality essential health services according to need, and (ii) the financial protection of users from hardship, including possible impoverishment due to out-of-pocket payments [2]. Additionally, UHC means an investment in human capital to promote sustainable economic growth, development and well-being [3].
To achieve UHC, a country is required to implement relevant changes and to delineate strategies based on human rights and equity within its political processes. Interventions including a more effective health system, increased decentralisation, a high and effective social engagement, and the strengthening of regulatory frameworks have been advocated [4]. Additionally, enhanced and expanded social protection coverage must be based on affordable and available health care services, including primary health care. Decision-makers should simultaneously address the social determinants of health to reduce poverty and inequalities [3].
Following these strategies, many countries in the Latin America and the Caribbean region (LAC) have implemented various social policies and programs to achieve UHC in the last decade [5]. In several of these countries, the introduction of welfare reforms targeted to empower the poorest people, and particularly women, via conditional cash transfer schemes to reduce poverty, have resulted in an increase in access and use of maternal and child health care services [6]. Similarly, increases in the level of public health care financing have contributed to expanding coverage in socially disadvantaged groups, and reducing maternal and infant mortality. Experiences from Brazil, Costa Rica and Mexico have shown that providing financial risk protection can reduce catastrophic health expenditure among the poorest populations [4,7]. Overall, while countries in LAC have improved coverage in health care over time, they are still far from achieving full UHC [8]. LAC remains one of the most inequitable regions worldwide, and governments face huge challenges related to fragmentation, delivery and the unsustainable financing of health systems to protect their citizens [9].
Ecuador is an upper-middle income country, with high income inequality (Gini index 44.7 in 2017) and an ethnically diverse population. The majority are mestizos (a mixture between Spanish and indigenous people) but 28% belong to ethnic minorities, including indigenous, Afro-Ecuadorian descendants and Montubios [10]. Between 1993 and 2006, Ecuador had eight different governments and experienced administrative instability, corruption, and social violence. Simultaneously, health care funding was slashed, and the government's role in health care decreased significantly. In 2007, however, a new political proposal to reduce poverty and socioeconomic inequalities resulted in a stable government for the following 10 years, that carried out comprehensive social and health reforms based on equity. These reforms incorporated ambitious changes to guarantee the right to health and UHC for all in Ecuador [11] [12].
During the decade of reform, several relevant social indicators were moving in a positive direction.
Poverty levels dropped, employment and wages went up, the literacy rate increased, and the income inequality gap diminished [13]. The Ministry of Health (MoH) introduced comprehensive health insurance policies to reduce cost sharing and fees; and all MoH health services gradually became free of charge. The share of the public health expenditure in the gross domestic product increased from 2.2% in 2004 to 4.2% in 2015. This striking increase was invested mostly in medicines and supplies, vaccines, ambulances, new facilities and health care equipment. New services were introduced, particularly in rural areas and for vulnerable groups, such as home visits, and more than 4,000 physicians were contracted. A legal framework of governance was also implemented to improve the relationship of the MoH with social insurance and the private sector [14,15]. Critics, however, have also noted that the cost recovery mechanisms established between the public and private sector mainly benefited large private sector hospitals, and the opportunity to establish a single health system was gradually fading [16]. During this period, social movements continued to call for a more egalitarian and participatory society [17].
Monitoring and evaluating progress towards UHC is fundamental to improving health policy decisions and promoting an equitable health system [18]. Moreover, evaluations must incorporate all social subgroups and disaggregate for geographical levels, since national averages can mask inequalities in most disadvantaged groups.
Overall, few studies have assessed the impact of the Ecuadorian health care reform on the population's health. The literature has been mainly descriptive and focused on achievements in terms of coverage [15,19]. A recent study has reported significant reductions in income inequalities in health care utilisation [20], however, no study has paid attention to the potential impact of the reform on different socioeconomic groups or specific health care outcomes.
The aim of this study was therefore to assess whether the health care reform had any impact on progress towards UHC in Ecuador; and specifically, whether the reform contributed to decreasing socioeconomic inequalities in three indicators of health care access among women.

Data Collection
Information was collected using face-to-face interviews by a group of properly trained pollsters from the same area and using a questionnaire designed to compile data from all members of the household. Data was collected during November 2005 to October 2006 (before the reform) and from necessary to obtain information from the selected households.
The surveys contained specific information on housing, ethnicity, education, economic activity, health care usage and coverage.

Dependent Variables
Two indicators that represented promotion and prevention services were selected: cervical cancer screening and modern contraceptive use. A third indicator, skilled birth attendance, was selected to represent treatment coverage [22]. These three outcomes have been previously used to indicate progress towards UHC [23].
, Answers to the question "Who assisted you in your last delivery?" were used to capture skilled birth attendance (SBA). We defined assistance by a skilled professional if the answer was a physician, gynaecologist, nurse or obstetrician.
Coverage of cervical cancer screening (CCS) was captured by the question "Have you ever had a Pap smear test?", with yes or no options.
Modern contraceptive use (MCU), was assessed by asking two questions. "Are you using any contraceptive method?" was assessed via yes or no options. Those who responded positively were then asked "What methods are you using to stop you getting pregnant?"; and answers reporting female sterilisation (tubal ligation), implant, contraceptive injection, birth control pill, any type of intrauterine device, or condom (female or male condom), were considered to be using a modern contraceptive while answering other or a natural method were classified as non-modern methods.

Socioeconomic Variables
Place of residence was defined as living in either an urban or a rural area. Towns with less than 5,000 inhabitants were considered rural. Ethnicity was based on self-identification, however, for data analysis only two groups were used: non-indigenous people, including white, mestizos, Afro-Ecuadorians and Montubios; and indigenous people. This division was chosen due to the small sample of some ethnic groups [24].
Education level was categorised as incomplete primary (includes illiterate; literate but no formal education; and initial education categories), primary, secondary (middle secondary and technical) and higher education (undergraduate and postgraduate). We divided occupational class into five Results Population characteristics Table 1 shows the characteristics of the study population in the two periods. One third lived in rural areas and the proportion who identified as indigenous was the same over time. Nearly     The results for the cervical cancer screening inequalities are presented in Table 3. The SII for cervical cancer screening was also statistically significantly positive for residence, ethnicity, education and wealth in 2006, but not significant for occupational class. No significant differences by residence (SII    practices during pregnancy and childbirth [28,29]. Similarly, several barriers have been observed to indigenous women accessing health services [30], and research has shown that indigenous women tend to be less aware of obstetric warning signs, as well as the use of health services, than mestizas in the country [31].

Socioeconomic Inequalities In Health
Studies from Latin America have demonstrated that the integration of traditional birth attendants within the formal health system increases skilled birth attendance and the use of sexual and reproductive health services [32,33], however, this strategy was abandoned during the period of the reform [34], although public health policies to improve the articulation between traditional birth attendances (TBAs) and the formal health system were recently announced [35].

Cervical Cancer Screening
Cervical cancer is the third cause of death in women in Ecuador [36], however, the proportion of women screened for cervical cancer was low in all socioeconomic groups in both periods. As with skilled birth attendance, high inequalities were observed in relation to place of residence, ethnicity and education; but conversely, little inequality reduction was achieved between periods.
A pap test (cytology) is the basis for cervical cancer screening, and is provided free of charge in all public health care facilities. The promotion of testing is also offered during visits to health care services. Although access to health facilities improved significantly over time, a weak application of health promotion policies and persisting barriers to the access and uptake of the screening could explain both the low coverage and inequalities. Studies from Latin America have identified various obstacles related to the accessibility of these preventive services, such as feelings of shame, negative perceptions of health workers, worry about the test results, fear about the procedure or previous negative experiences [37,38]. In the same way, low education, poverty, lack of access to health insurance, and limited use of health services have been reported as barriers to this screening in countries in the Americas region. [39,40,41,42,43]. Similarly, high ethnic disparities in Ecuador have been observed between indigenous and mestizo women regarding preventive knowledge about breast and cervical cancer and sexual transmitted infections [44].
Comprehensive cancer management has traditionally been one of the weakest public health strategies in the country, with high fragmentation between the preventive and curative components in the health system. In an attempt to strengthen this area, the MoH developed a national strategy for cancer care in 2017 to ensure equitable access along the care continuum [45], which will hopefully contribute to increasing access and decreasing inequalities in the future.

Modern Contraceptive Use
The coverage of modern contraceptive use increased from 40.7-48.4%, which is lower than the average coverage reported in the Americas region (68%) [46]. The increase is modest in relation to the huge investment in the purchase and supply of modern contraceptives in primary care and access to female sterilisation (ligation) at the secondary level of care, especially after childbirth. In 2013 the MoH issued new guidelines to guarantee the availability of family planning methods and the promotion of sexual and reproductive health at primary care level nationally [47], which hopefully will have contributed to increasing the coverage more recently.
The socioeconomic inequalities in coverage were surprisingly concentrated in disadvantaged groups, except among indigenous women for the two periods. A study of rural Ecuadorian women has shown how they moved from biomedical to traditional care to accessing family planning due to the inconsistent availability of contraceptive methods in public health services [48]. Similarly, programs that do not respond to community needs or lack cultural adaptation have impeded access even when contraceptives are widely available [49,50,51].
Studies have also demonstrated how bureaucratic barriers in contexts of the free choice of methods can also limit the use of health services; and that the attitudes and behaviours of maternal health care providers in interactions with clients can also be a barrier to the use of contraceptives [52].
There are, however, positive experiences in the country that have overcome some of these barriers. A recent study among women from low resource communities in Ecuador showed how increasing economic opportunities, preventing gender-based violence and valuing their community role contributed to empowerment in the use of contraceptive methods [53].

Methodological Considerations
The strengths of the present study include a large population-based random sample and the national representation of different socioeconomic groups, precluding the possibility of selection bias. The application of the same questionnaires in the two studied periods and the inclusion of several socioeconomic variables are also strong assets of the study.
Given that this is a population-based study, there could be response and recall bias. Although the institution responsible for conducting the surveys carried out a rigorous training of the interviewers, the extent of these biases is difficult to determine. Finally, although changes in socioeconomic inequalities in health have been attributed to the health reform here, there might have been other factors influencing those changes that could not be considered, meaning that the causal inference of these results should be interpreted with caution.

Conclusions
Overall, the results are positive regarding the direction taken to achieve UHC. The reforms in Ecuador have allowed a successful increase in access to health care services but the decrease in socioeconomic inequalities in the examined health indicators has been limited. Most of the socioeconomic inequalities in skilled birth attendance decreased, but only small decreases were observed in cervical cancer screening and modern contraceptive use. Several interventions would be required to address the persistence of health inequalities for indigenous and rural women, such as cultural competency training for health workers and the implementation of intercultural health policies at the primary health care level, which incorporate the strong involvement of indigenous organisations. Structural efforts are also needed to affect the social determinants of these health inequalities.

Funding
This work was partly supported by a scholarship funded by the Erling-Persson Family Foundation.

Availability of data and materials
Data used in this study are publicly available and can be retrieved from https://www.ecuadorencifras.gob.ec/institucional/home/.

Disclaimer
All authors declare no conflict of interest.

Authors' contributions
EQ and MSS conceived of the study and analysed data. ET and AMP reviewed the results and discussion. All authors collaboratively developed drafted the manuscript, and approved its final version.

Ethics approval and consent to participate
Not applicable.