The right to health in Ecuador: a lost case?

by Mauricio Villamar

Even though the World Health Organisation affirms that “essential medicines save lives and improve health when they are available, affordable, of assured quality and properly used”1, they also acknowledge that about one-third of the world’s population1 (the poorest third, of course) are without the access to medicines they need. Unsurprisingly but sadly, the situation in Ecuador does not differ much from that of other developing countries. Ecuador is worldwide-known for its biodiversity and for being one of the most picturesque countries on the face of Earth. However, few are aware of the social inequity in a nation where the top 20% of the population own 64% of the wealth, whereas the poorest 20% own just 2%2; where 1.3% of the GDP is used in health issues, as compared to 9% in debt service; where up to 75% of the population do not have health insurance or proper access to health services3; and where the monthly expenses for a family of four are estimated to be 455 US Dollars4, but the cost of antiretroviral therapy for the same period can be thrice as much. By looking at this information, it would be logical to ask: “Why are Ecuadorians unable to accomplish such an important human right, and provide their people with a proper healthcare system?”

The Political Constitution of the Republic recognizes the role of the State in guaranteeing all the basic rights of its people5, and our governments have ratified several treaties that enforce them, so the reason does not lie on legal aspects. Since the war in Iraq began, we face a relative abundance due to the high revenues from our oil exports, so the rationale is not entirely economic either. The analysis is complex but, in my opinion, it can be best explained by the lack of common sense and solidarity which characterize our people.

Having had 11 presidents since 1997 -and up to 6 health ministers per president-, some of the responsibility definitely lies on the common citizen, who has no criterion for electing his/her leaders properly and keeps voting for the same parties who have been looting the country for the past two decades; the common citizen who ignores the responsibilities of his government towards the people, and thinks of healthcare as charity instead of as a right; the common citizen who remains quiet and apathetic about the social crisis that surrounds him as long as the soccer national team qualify to the World Cup. If the inhabitants of a nation show no interest in making their rights prevail, who will enforce them?

Politicians are probably the ones to blame for the inefficiency of our health system. Numerous illogical and inconsiderate decisions on hospital building, equipment purchases, consulting and licitation plans and vaccination campaigns fall inevitably into what is promoted as “the right to health” during election times; as a consequence, hospitals are built right across the street from each other, but neither of them has enough equipment nor personnel. Every once in a while, we hear of corruption scandals where tons of non-essential drugs are purchased by hospitals -or even the Ministry of Health-, just to be stored in a basement until they expire. Isn’t this a violation of our human rights?

In the same way, economic interests prevent the State from establishing a more rigorous control on the production, distribution, advertising and commercialization of medicines in the country, and unscrupulous pharmaceutics are allowed to profit at the expense of people’s health. In Ecuador, if the production or the importation of a certain drug costs $1, it will be sold to the final consumer for $4.50, after adding up the profit margin of the pharmaceutics, the distributor and the drugstores6. Wouldn’t it be logical to lower the cost of medicines and make them more accessible, instead of using those earnings in bribing physicians to make sure they prescribe your product?

Ecuador does not have a national pharmacovigilance system to verify the security and effectiveness of drugs, and despite the fact that a National Table of Essential Medicines was designed in 20006, neither public nor private hospitals purchase their drugs according to it. Little effort has been made by the Ministry of Health in order to solve both of these national priorities. How can such a State guarantee, defend and promote the rights of its people? If democracy is based upon the citizens’ well-being, how can the government secure it, if due to incorrect political management, becomes directly responsible of the inefficiency of those institutions intended to provide people with welfare?

But what can be done to face crisis of the Ecuadorian healthcare system? The answer is quite obvious but extremely hard to perform: by acting with common sense. Now that we are aware of some of our major problems, it becomes imperative to have the citizens actively participate in the country’s decisionmaking process and supervise the public expenditures; to increase public funding for health and medicines; to enforce the observance of the National Table of Essential Medicines; to allow price competition through tendering of generic products; to introduce and expand the use of generic drugs and reduce their taxes; to control the profit margin on essential medicines; to promote equitable pricing for newer essential medicines that are still protected by patents; and to promote the creation of a national pharmacovigilance system. However, none of these goals will ever be achieved if we do not act honestly and responsibly, understanding our role as active members in our society.

According to Nelson Mandela, “massive poverty and obscene inequality are such terrible scourges of our times - times in which the world boasts breathtaking advances in science, technology, industry and wealth accumulation - that they have to rank alongside slavery and apartheid as social evils.”7 Huge efforts have been made over decades to fight the last two. Now it is our turn to guarantee our people proper medical attention, and help demolish the barriers between those who have and those who do not.