Doctors for the people? The problematic distribution of rural service doctors in Ecuador

Primary health care is at the core of health systems that aim to ensure equitable health outcomes. With an estimated 36% of rural population, Ecuador has a service year programme (created in 1970) for recently graduated doctors to provide primary care services in rural and remote communities. However, little has been done to monitor or evaluate the programme since its inception. The aim of this study was to assess Ecuador's rural medical service implementation with a focus on equitable distribution of doctors across the country. For this purpose, we analysed the distribution of all doctors, including rural service doctors, in health-care facilities across rural and remote areas of Ecuador in the public sector at the canton level for 2015 and 2019, by level of care (primary, secondary and tertiary). We used publicly available data from the Ministry of Public Health, the Ecuadorian Institute of Social Security and the Peasant Social Security. Our analyses show that two of every three rural service doctors are concentrated at the secondary level, while almost one in five rural service doctors, at the tertiary level. Moreover, cantons concentrating most rural service doctors were in the country's major urban centres (Quito, Guayaquil, Cuenca). To our knowledge, this is the first quantitative assessment of the mandatory rural service year in Ecuador in its five-decade existence. We provide evidence of gaps and inequities impacting rural communities and present decision makers with a methodology for placement, monitoring and support of the rural service doctors programme, provided that legal and programmatic reforms come into place. Changing the programme's approach would be more likely to fulfill the intended goals of rural service and contribute to strengthening primary health care.