Equity and coverage in RMNCH health interventions by ethnicity, 2004- 2018: lessons learned from integral policies in Ecuador

IntroductionIn Latin America, ethnic disparities rooted in the colonial legacy have persisted. There is limited scientific evidence critically analyzing the temporal changes in ethnic inequalities in reproductive, maternal, neonatal, and child health (RMNCH), and the potential impact of policies on the progress of reducing these gaps for Indigenous peoples. After the 2000 crisis, Ecuador had the regions largest ethnic disparities in intervention coverage and social determinants due to structural racism. Inclusion policies improved starting in 2008. The main study aim was to analyze the coverage and ethnic inequalities of six RMNCH health interventions, the evolution of social determinants, and the potential impact of policies and strategies over 14 years. Methodsusing a mixed method design, we analyze three nationally representative surveys (2004, 2012, and 2018) to compare the evolution of social determinants; and the coverage and inequalities of six RMNCH health interventions, stratified by ethnicity (women and child Indigenous, Afro-Ecuadorians, and reference group); and we estimated absolute inequality measures and adjusted coverage ratios using Poisson regression models. Through a literature review and temporal graphs, we analyzed plans, policies, and strategies in health, education, and ethnic inclusion during the same period to estimate their potential impact. ResultsBy 2018, the population self-identifying as Indigenous had doubled the percentage of people in the 4th and 5th wealth quintiles (from 10% to 20%) and increased secondary education attainment from 25% to 45% compared to 2004, though these changes were less evident in rural areas. Between 2004 and 2018, prenatal care coverage, institutional delivery care, and births attended by professionals increased from 27% to 75% among the Indigenous population. Although the coverage ratios show that ethnic gaps persist, inequalities progressively reduced during this period. These reductions coincided with efforts of social participation and organization that led to the constitutional recognition of pluractionality, combined with increased social investment in education and health in rural areas, and the development and implementation of policies and strategies that promoted intercultural practices in health. However, there is a noted lack of monitoring processes and impact assessment of these strategies. ConclusionsThe reduction of ethnic inequalities in RMNCH in Ecuador could be explained by inclusive policies and programs implemented in recent years, social organization and participation, and the involvement of actors and leaders in the implementation of these. Temporal studies based on routine surveys allow for the observation of changes and analysis of the potential impact of policies and strategies. Ecuador exemplifies actions that may have contributed to the reduction of inequalities, which could serve as a reference for other countries seeking to improve the health of Indigenous peoples. These observations also provide a pre-pandemic image, offering insights prior to the potential effects of COVID-19 and five years before assessing the outcomes of the 2030 Agenda for Sustainable Development.