Country Visit to Ecuador, 17-26 September 2019 by the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health Mr. Dainius Pūras

Preliminary observations

Quito, 26 September 2019

Members of the press,

Ladies and gentlemen,

I would like to begin by thanking the Government of Ecuador for inviting me to visit the country to assess, in a spirit of dialogue and cooperation, the realisation of the right to health in the country, including good practices and challenges.

During my visit, I met with high-ranking Government officials, members of the Judicial and Legislative branches, the National Human Rights Institution, as well as with representatives of international organizations, and a wide range of civil society actors. I visited different health facilities in Quito, Lago Agrio, Otavalo and Guayaquil. These facilities included hospitals and primary healthcare centers, a psychiatric hospital and a mental health outpatient center, a maternal hospital, an intercultural center on health and a border attention center for migrants and refugees. I take this opportunity to thank the UN Country Team for their support to my visit. I am an independent expert who reports to, and advises, the UN Human Rights Council and the UN General Assembly on the realisation of the right to physical and mental health.

After almost two weeks in the country, I have gathered a wealth of information and testimony, which will help me assess the realisation of the right to health in Ecuador. Today, I will present some of my preliminary observations, which will be elaborated in more detail in a report that will be considered by the UN Human Rights Council in Geneva in June 2020.

Context and achievements

Ecuador is a founding member of the United Nations and has ratified all the core international human rights treaties. It has played a leading role in the international fora on the right to health.

The 2008 Constitution is remarkably progressive: it recognises health as a human right for all without discrimination. It is based on three pillars: the State as the duty bearer, a system based on primary healthcare and a public network of free services. Such constitutional recognition provides a great opportunity to develop a legal and policy framework in line with a human rights-based approach.

The implementation of the right to health is about availability, accessibility, acceptability and quality of services as much as it is about addressing the underlying and social determinants of physical and mental health.  In other words, the right to health also requires the State to address poverty reduction, food and nutrition, safe and potable water and adequate sanitation, healthy occupational and environmental conditions, and access to health-related education and information.

Respectful and non-violent relationships between individuals and groups, and respectful relationships with nature are crucial to building a healthy and inclusive society. However, the high prevalence of violence -first of all against women and children-, and discrimination of certain groups within and beyond the healthcare system – are the largest threat to the realization of the right to health in Ecuador.

During my visit, I appreciated being able to travel to different regions to witness the diversity of the country and the different realities faced in each region. I have seen that there have been significant investments into the healthcare system.

In the health facilities that I visited, the national health system provides primary and specialized care in well-equipped infrastructures. I also visited facilities that promote intercultural health services, in particular maternal intercultural health. I will elaborate more on these visits in my report.

The Minister of Health assured me during my visit that there is an increased focus on primary care services, as well as health promotion and prevention. I strongly support this and recommend to substantially increase investment in primary healthcare as a highest priority.

National healthcare system

Ecuador has made important efforts in investing in health infrastructure. However, it is not enough to invest in the biomedical elements of healthcare. During my visit, I observed that persistent challenges remain, and some health indicators have worsened.

Regrettably, the country still lacks a public health policy because after almost seven years the Health Code has not been adopted. Without a clear public health policy, the national healthcare system risks being influenced by powerful interest groups that often lobby for investments that may not be in the interest of the public. During my visit, I met with members of the National Assembly and was encouraged to learn that the new Health Code will be adopted shortly. I hope that by the time I present my report, the Health Code will have been adopted and that its contents will be in line with international human rights standards.

The constitutional recognition of free healthcare services has been insufficient to guarantee the right to health for everyone. In practice, out of pocket spending remains over 40% when the universal healthcare system should ensure free access to treatment. To ensure the equal treatment of all persons and improve efficiency, the fragmentation of the current healthcare system should be addressed with a view to integrating all existing elements.

I was concerned to receive widespread reports and testimonies regarding serious problems to access medicines. In some cases, access has required filing legal complaints. This has particularly affected persons diagnosed with cancer and those who need expensive treatment and palliative care.

I have been informed about the austerity measures announced early this year. Such financial constraints can be detrimental for the effectiveness and sustainability of the healthcare system and may add an additional strain to a system that is already overburdened with limited human and financial resources. Although it is not clear yet how the budget cuts will be applied, it seems that much needed medical and technical expertise in the healthcare system risks being suppressed. I strongly recommend increasing investments into the healthcare system and to reach the 4% of GDP provided by the Constitution.

It is important to have a human rights-based national mental health policy guided by modern public health principles and staffed with sufficient qualified mental health specialists. However, despite recent efforts, the mental healthcare system in Ecuador is still underdeveloped. Initial investments in modern mental health policies began in 2014. According to information received the mental health budget only amounts to 1.3% of the general budget for public health.

I believe there is a good opportunity now to develop a rights-based mental health system. Addressing the determinants of mental health -inequalities, poverty, violence, and discrimination- should also be an important part of any mental health policy. Prevention of suicide should be addressed as an issue of societal cohesion and public health: protection and promotion of all human rights is as important to suicide prevention, as is treatment of depression and other mental health conditions.  Mental health services should be integrated into primary and specialized general healthcare and avoid institutionalization and overmedicalization. To achieve this, the network of outpatient community-based services needs to be developed and strengthened throughout the country so that persons with mental health conditions, including persons with psychosocial and intellectual disabilities can receive care and support where they live.

I visited a mental health centre in Quito. It is to be commended that one centre is providing outpatient community services that are not reliant on coercion. The services provided in this centre should be strengthened and replicated throughout the country.

Groups in vulnerable situations

Specific groups who face serious challenges in realizing their right to health, include women and girls; children and adolescents; lesbian, gay, bisexual, transgender and intersex persons; people living with HIV/ AIDS; as well as people on the move. This is aggravated by the limited number of services and human resources for the rural and impoverished population. Indigenous and Afro Ecuadorian peoples show worse health indicators.

Right to health of women and girls: maternal mortality and gender-based violence

In 2017, the maternal mortality rate is reported to be at 42.8 per 100,000 births. Inequalities persist among poorer women, adolescents and youth, as well in rural areas.

I was informed that in Ecuador, 6 out of 10 women have experienced gender-based violence. Accordingly, every day, 7 girls below the age of 14 and 158 girls between 15 and 19 years of age become mothers. It has been reported that 8 out of 10 adolescent pregnancies resulted from sexual violence. Such alarming data as well as the widespread information collected, allow me to conclude that violence against women and girls is endemic, it leads to high numbers of forced pregnancies and motherhoods among girls and affects the communities in the most marginalized situation.

The high rate of early pregnancies reflects a serious protection gap of children's rights including of their right to physical and mental health and integrity, their right to be free from all forms of violence, and their right to receive adequate information and health education. There seems to be a lack of family planning as, according to information gathered, two thirds of pregnancies are unwanted.  

I deeply regret that during my mission, the National Assembly voted not to decriminalize abortion in cases of rape. Such decision disproportionately exposes girls and women to potential time in jail and to extreme mental suffering that may lead to suicide, as shown by the very sad case of Paola Guzman. This decision goes against all modern public health principles and casts doubt as to whether there is political will to improve the health of women and girls. I strongly encourage the competent authorities to veto this decision and promote legislation that complies with the numerous relevant recommendations by the UN human rights mechanisms.

As a matter of priority, Ecuador should enhance its efforts to address gender-based violence and child and adolescent pregnancy. In this regard, I welcome the recently adopted law for the prevention and eradication of violence against women and call for its implementation with the necessary budget and participation of all State agencies involved. But further measures are needed to enhance quality care: access to modern and free contraceptive measures; comprehensive sexual education; and addressing the negative sociocultural patterns of adolescent sexuality and gender-based violence. 

The right to health of children and adolescents

Malnutrition -anaemia, overweight and obesity- remains a very important national challenge. According to official data, 24% of children under 5 suffered from chronic malnutrition by 2016 compared to 25.8% in 2006. As of 2014, among the indigenous peoples, this indicator was 49%. As of 2012, 63.9% of children aged 6 to 11 months suffered from anaemia. 22% of adolescents between 12 and 19 years were overweight and 7% obese. In 2014, 15% of households where children or adolescents live did not have enough food, 26% had problems paying food expenses. This indicator is 33% for Afro Ecuadorian households. Vaccination coverage is below desired levels of 95%.

I would like to recall that children have the right to holistic development, with due importance to their social, cultural, and emotional development, as provided by article 6 of the Convention on the Rights of the Child. It is of utmost importance not only to invest in preventing child mortality, but also to guarantee the healthy holistic development of children and adolescents. This approach requires concerted efforts of the health, education and social inclusion sectors, together with the network of community-based services that protect children from violence and other harmful factors in families, schools, communities and other settings.

The right to health of lesbian, gay, bisexual, transgender and intersex persons

LGBTI persons face important obstacles in the full enjoyment of their right to physical and mental health mostly due to deeply entrenched discriminatory attitudes in society, which generate stigma, violence and abuse.  LGBTI persons have reported discrimination from healthcare personnel and lack of integral health services tailored to their needs. This is particularly relevant for trans people who require hormonal treatment which is not available in public health services.

I was informed that so-called "dehomosexualization clinics" continue to operate despite public knowledge of their existence. I deeply regret such practices, which may amount to ill treatment^[1], and I urge Ecuador to ban them immediately, bring perpetrators to justice and provide redress to victims.

The right to health of people living with HIV/AIDS

The HIV/AIDS epidemic is concentrated with higher prevalence in key populations: men who have sex with men, women sex workers, persons deprived of their liberty and transgender women. According to available data, in 2017, it was estimated that over 36.000 people live with HIV, of which only 61% knew their HIV status.

People with HIV/AIDS face stigma and discrimination in society and, in general, there is little information, dialogue and training on this. It has been reported to me that there is a lack of antiretroviral medicines in the health services of the social security system.

The rights of persons with psycho-social and intellectual disabilities

Ecuador has ratified the Convention on the Rights of Persons with Disabilities (CRPD) and its report was reviewed last week by the CRPD Committee. However, I am concerned that certain services have not shifted from the medical model to the rights-based approach required by the Convention.

For example, during my visit to the Julio Endara Psychiatric Hospital in Quito I was pleased to see investments in providing more dignified care for persons with chronic conditions. However, I am concerned that these persons have remained in this facility for decades as community-based services are lacking throughout the country. Such third level health facility should not provide long term institutional care; this reflects a systemic underdevelopment of the mental health system and calls for urgent development of community-based care, as provided by the Convention.

I heard with concern of cases of women with intellectual disabilities subjected to forced sterilisation and will elaborate on these serious allegations in my report.

According to information received, services for children with mental health conditions, autism, and intellectual disabilities remain insufficient. Ecuador should develop a rights-based national child and adolescent mental health program in line with modern principles. The objective must be to promote networks of community-based services so that families, children and adolescent with mental health needs may have access to preventive ant therapeutic services.

The right to health of people on the move

Since the adoption of the humanitarian visa in July, the number of Venezuelan migrants and refugees crossing the northern border of the country through regular channels has decreased significantly. In practice, this means that those who do enter the country, find themselves in an irregular situation and are thus afraid to demand their constitutional right to medical assistance. For this reason, the requirement of a visa may have a serious effect on the health situation of the overall population including Venezuelans.

The moving stories from Venezuelan migrants crossing Ecuador has made me even more convinced that rights-based responses to health and migration can be a transformative opportunity to rebuild and strengthen a health and a social system that supports and restores dignity, inclusion and rights for everyone in the country.

Discriminatory attitudes and the xenophobic political rhetoric particularly against Venezuelan migrants and refugees on social media, contribute to environments of fear and intolerance. Such environments must be prevented at all costs because they damage the quality of human relationships, bring mistrust, disrespect and intolerance into societal life, affect the health of people on the move and host communities.

The right to a healthy environment

The Constitution guarantees the right to a healthy environment as an integral part of the right to health. However, throughout my visit I received numerous allegations and updated information regarding the impacts of extractive and agricultural industries on the right to health. For example, the use of pesticides in the banana plantations in Esmeraldas, Santo Domingo, Los Ríos, Guayas, El Oro, Santa Elena and Bolivar; the persistent effects of extractive industries in Sucumbíos and risks of similar impacts in other regions as the oil and mining frontier expands; and the concerning situation of numerous Afro Ecuadorian workers and their families who lived and worked inside the premises of the Furukawa abaca plantations.

I will elaborate on these issues in my report and will remain vigilant on the situation of the human rights defenders who have raised their voice about these cases.

Members of the press,

Ladies and gentlemen,

During my visit, the UN High-level meeting on universal health coverage (UHC) took place in New York. Ecuador is in a good position to reach UHC and other health related sustainable development goals. But for this to happen, key elements need to be in place.  Non-discrimination and participation in the healthcare system and beyond must become a reality. Violence, which is detrimental to health, must be addressed with determination and courage by all actors. Investment in primary care, modern mental healthcare services and palliative care, must be substantial and sustainable.

Ecuador has a vibrant and committed civil society and I encourage the public health system to work closely together with them on right to health issues. I also encourage national authorities to make the most of the UN Country Team to increase articulation and build bridges between stakeholders at the national and local governments.

Let me conclude by reiterating that I am very grateful to the Government of Ecuador for inviting me to visit the country. This invitation – and the cooperation provided during my visit – indicates that there is a commitment to ensure and guarantee the enjoyment of the right to health. I hope that my visit and my report will assist the country in moving forward.

Thank you.