Medical specialist distributions in Ecuador: a geographical and temporal analysis of data from 2000 to 2017

The number and geographical distribution of physicians have a major impact on health provision [1]. There is extensive evidence showing that regions with a low density and poor distribution of medical professionals have negative health indicators, low coverage and limited accessibility [2, 3]. Although there is evidence that coverage with and distribution of physicians has improved over recent years in some Organization for Economic Co-operation and Development (OECD) countries, [3, 4] most Low and Middle-Income Countries (LMICs) still face workforce inequalities because of a concentration of physicians in urban areas and scarcity of professionals in rural areas [5, 6].

The shortage or surplus of physicians has been a primary concern in health sectors workforce planning and remains a controversial issue in many countries [1]. There is no clear benchmark to decide what is an adecuate number of physicians in any country or region [7]. However, the most common approach to monitoring the Health Workforce (HW) has been the workforce-to-population ratio method [1]. This approach estimates the current HW density or supply per 1,000 or 10,000 population (e.g. physicians per 1,000 population), and it has been widely used for comparative analyses across countries and regions [8]. Over recent years, the benchmarks of 23 physicians, nurses and midwives per 10,000 population has been commonly used as a minimum threshold for comparisons between countries [8]. However, in 2016 the World Health Organization (WHO) recommended a new parameter of human resources for health of 44.5 professionals per 10,000 population (including physicians, nurses, and midwives) [9]. In the context of Latin America (LA), only eight countries met this threshold in 2016: the Bahamas, Barbados, Brazil, Cuba, Grenada, Mexico, Trinidad and Tobago, and Uruguay [9].

In Ecuador, the number of HW has increased steadily in the last two decades [10]. For example, over the period 2000 to 2017, the number of physicians increased from 0.8 to 2.2 per 1,000 population [10]. However, although the rate of physicians in Ecuador has almost tripled since 2000, this rate is lower than the average rate of OECD countries of 3.5 physicians per 1,000 population [4]. In the case of LA, data available for 2015 showed that the average rate for the region was 2.2 physicians per 1,000 population, slightly higher than the 1.8 physicians per 1,000 populations in Ecuador in the same year [11].

In the specific case of medical specialists, there are limited data on the number of specialities and specialists in Ecuador. Currently, the country does not have indicators for these, and there are no studies to permit comparisons with other countries in the region [7]. The number and distribution of specialists is a measure of workforce availability and accessibility and are equity indicators in health systems performance and efficiency [1]. For a LMIC country like Ecuador, these indicators are important in identifying differences in geographical distributions, supply-and-demand projections, and definition of policies in medical education. The present study aimed to examine the temporal and geographical distribution of medical specialists in Ecuador over the period 2000 to 2017 and asses the implications of these findings for medical education.

In the present study, we conducted an ecological time-series analysis between 2000 and 2017 to describe the geographical distribution and temporal trends for medical specialists in Ecuador. Using the population ratio method, we estimated rates of medical specialists by year, geographical area, and groups of specialities. Our results showed that the quantity and density of specialists grew continuous during the analysis period but with clear differences in health care professional allocation. Our study identified the presence of more than 45 medical specialities in the country by 2017, of which the so-called “traditional specialities” accounted for more than 30% of professionals. However, other specialities such as family and community medicine and epidemiology have significantly increased over the last few years.

In Ecuador, the total number of doctors and other health professionals has grown steadily over the last 20 years [11]. Several demographic, socio-economic and political factors may explain this increase. Firstly, population growth directly impacts the demand for health services. In the case of Ecuador, between 2000 and 2017, the population increased from 12,531,210 to 16,776,977 [13]. Likewise, between 2006–2017, the number of medical consultations increased from 14,372,251 to 66,899,675, representing an 365% increase [20]. Secondly, over the last two decades, a series of policies and reforms aimed at increasing the population's social and health security coverage has led to a greater demand for medical specialists in the country [21, 22]. Finally, coupled with social reforms, the country also experienced major investments in health infrastructure [20]. For example, between 2009 and 2015, 47 hospitals and 74 health centres were built or repaired [20].

In LA, several studies have addressed the number and the distribution of medical specialists using different methodologies [7, 23‐28]. In the specific case of medical specialists in Ecuador, our results showed that the country experienced a growth rate of 158% between 2000 and 2017. This increase has caused concerns about a possible surplus of physicians in the country. However, comparing the Ecuadorian rate with rates in high-income countries and other countries in the region, we can see that the number of specialists in the country is relatively moderate. For example, in 2013, the average rate of medical specialists for countries in the European region was 21.3 per 10,000 population [29]. The Ecuadorian rate was 6.7 specialists per 10,000 population in the same year. In 2017, Australia, Denmark, Italy, Spain, and the United Kingdom had equivalent rates of 17.8, 17.9, 31, 25.3 and 20.5, respectively [11]. For the same year, the Ecuadorian rate was 10.3, a lower rate than those mentioned above. In the case of LA, the rate of medical specialists varies widely across countries. For example, the number of specialists in Ecuador in 2017 was higher than El Salvador, Honduras and Costa Rica, whose rates were 6, 1.4 and 6.7 specialists per 10,000 population, respectively [11]. However, countries such as Uruguay, Brazil, Mexico, and Chile (with rates of 25, 14.3, 15.2 and 12 specialists per 10,000 population, respectively) present relatively higher rates than Ecuador [11]. Our results also showed that (over the entire analysis period) medical specialists represented, on average, 46% of the total number of physicians (see Fig. 5). This percentage is lower than the OCED average, where medical specialists represent 65% of the total number of physicians [4]. The lower rate of specialists in Ecuador compared to some middle- and high-income countries, for now, do not suggest a surplus in the number of medical specialists.

In agreement with other studies, that observed an unequal geographical distribution in the number of specialists [2, 30‐32], our study identified geographical differences in the number of specialists by region and province within Ecuador. Our results showed that more than 50% of the specialists were found in three largest cities (Quito, Guayaquil and Cuenca). Several studies have shown a greater concentration of medical professionals in large cities because these localities present more significant economic, social and professional incentives [23, 24, 32, 33]. However, despite an unequal distribution, the proportion of medical specialists in other cities and rural areas increased from 37 to 46% between 2000 and 2017. Part of this increase and redistribution of medical professionals in minor urban centres and rural areas could be related to health cooperation agreements between Ecuador and Cuba, where Cuban physicians were placed in the least densely populated areas of the country [34]. Another factor associated with the concentration of specialists in urban centres, although to a lesser extent, is the use of special equipment and materials generally found in hospitals in large cities. For example, radiologists' work requires expensive medical equipment such as computer tomography, magnetic resonance imaging, and positron emission tomography scanners [3].

Likewise, the geographical analysis by province showed marked inequalities throughout Ecuador (see Fig. 3). The provinces Pichincha, Azuay, Guayas and Loja had a higher concentration of specialists over the entire study period. In contrast, provinces as Esmeraldas, Carchi, Los Ríos and Bolívar showed a relative scarcity of medical specialists. The low number of medical specialists in these areas could be linked to social problems such as poverty and violence, especially in Esmeraldas and Carchi, which face drug trafficking and guerrilla problems due to their proximity to the Colombian border.

Although this study did not evaluate the structure of medical residencies and specialised training in Ecuador, it provides a broad frame of reference to identify specific policies for training specialists through the description of specialities and the number of specialists. According to our data for 2017, there were more than 45 specialities and subspecialties registered in the RAS database. However, the so-called “basic specialities” such as gynaecology, paediatrics and family and community medicine together represented almost 35% of total medical specialists. In contrast, other specialities such as geriatrics, rheumatology, or epidemiology did not exceed 1%. Such imbalances suggest that specialised training have not undergone similar changes in line with population growth and demand [7]. For example, increasing ageing of the population should generated a greater demand for medical care for the elderly, however, the number of specialists in geriatrics did not alter significantly over the analysis period. These disparities between the number of specific specialists and the epidemiologic and demographic characteristics of the population present a challenge for medical schools and health agencies responsible for the policy of HRH.

The amount of specialists in a country depends on the number of graduates from medical schools and the number of physicians practising medicine in the same country. In Ecuador, the number of physicians who graduated from medical schools (physicians doing the rural year) increased from 908 to 4609 between 2000 and 2017, increasing by 121%. The constant growth in medical schools plays a vital role in understanding the steady increase in medical specialists in the country. For example, over the past 30 years, medical schools have increased from 7 to 25 schools (with a national rate of 1.4 schools per 1,000,000 population) [35]. In the country, the training programs for medical specialists are offered by medical schools accredited by the government [36]. In 2014, the government implemented a standardised university accreditation system for the 22 medical schools. Currently, the country has 25 medical schools and 33 accredited medical specialist programs [35]. A standard habilitation test was implemented in 2014 to measure theoretical knowledge for medical graduates wanting to practice medicine in Ecuador. However, the admission system for specialisation programs is based on non-standardised tests. The graduation criteria from medical specialisations are tests or research papers. Most of the specialist training programs are self-financed. The Ministry of Public Health and private hospitals finance specific programs with repayment periods by graduates in the same institution. There is no standard habilitation test for medical specialists.

The present study has several limitations. 1) The study is based on secondary source, so information biases, specifically over-registration, must be considered. We minimised the risk of over-registration by counting the working hours of each professional and not the presence of the professionals by health institutions. Additionally, the data for this analysis comes from a single data source devised to collect information especially for health professionals, contrary to other studies that have used several sources of information to estimate the number of specialists [30]. 2) The RAS database does not provide detailed information at the individual level, such as nationality, age, sex, ethnicity and professional qualifications of health workers. The presence of demographic variables in the analysis would enrich the understanding of the differences in specialists' spatial and temporal distribution. Finally, the workforce-to-population ratio method does not consider variables such as disease burden, health care models, organisational efficiency, health policies, regulations and standards, technological capacity, among others. These variables profoundly modify the performance of medical specialists in health outcomes. Further studies of supply and demand for medical professionals are needed to overcome this limitation.

In conclusion, a country needs to know whether there is a shortage, surplus or inequitable geographical distribution in the medical workforce. However, there is no minimum number recommended by the WHO in the specific case of medical specialists [8]. The number and type of specialists respond to several factors such as the epidemiological profile of the population under study, type of health system, the demographic composition of the population, patient demand, advances in technology, medical knowledge and planning in medical residencies [25‐28, 37]. So, what is the correct number of doctors? This question has several answers. It will fundamentally depend on the health system's vision and service delivery model. It is important to recognise that the health model itself conditions the need for professionals. Conversely, the availability of professionals can condition the provision of health care and its structuring [26]. Studies of supply and demand for medical professionals could provide the answers to the question of how many medical specialists a country needs. However, this methodology requires a detailed and rigorous analysis of numerous factors as the number of new medical students in the faculties, number and distribution of resident places, defined retirement policies, migration of professionals, strategies for territorial distribution of resources or policies on working conditions and professional motivation, among others [23].

This study showed that medical specialists have increased significantly in Ecuador over the past two decades. However, specialists are mainly concentrated in large cities where healthcare facilities are more numerous and better resourced and where living conditions are superior. Rural areas and small urban settlements are underserved areas needing more specialised medical services. Although the present study has generated information to evaluate the distribution of the health workforce in the country, future studies must be conducted to examine the implications of the increase and distribution of specialists in the health system, health care policies, human resources of health, and the behaviour of the labour and education markets.