After more than two weeks of mobilization, people’s movements in Ecuador reached an agreement with the government, bringing the national strike to halt. On Thursday, June 30, representatives of the Confederation of Indigenous Nationalities of Ecuador (CONAIE), the Council of Indigenous Evangelical Peoples and Organizations of Ecuador (FEINE) and the National Confederation of Peasant, Indigenous and Afro-descendant Organizations (FENOCIN) formally recognized a list of measures announced by the government, including a 15-cent reduction of the price of diesel fuel per gallon and a continuation of the discussion on the inclusion of Indigenous communities in debates that impact their livelihoods, like exploitation of land and water sources.
The end of the state of emergency should also mean the end of the numerous violent incidents led by the police and military, but it does not bring closure to all of the strikers’ demands. While the agreement with the government foresees a halt in extractive activities in Indigenous territories and promotion of small-scale peasant agriculture, which are certain to have positive effects on people’s health, other demands which have to do with health have been less clearly addressed. One of these is the original demand to end privatization of public companies and increase public investment in health, which had been raised as one of the necessary points for improving the health status of the population long before the strike.
Health emergency preceding the strike
Only a couple of weeks before mobilizations started on June 13, health workers from the Quito-Pichincha province warned about a hospital crisis caused by the shortage of essential medicines and the absence of sound health policy from health authorities. According to the representatives of the Medical Association of Pichincha, the hospital crisis had the most impact on the poor, Indigenous and Afro-descendant communities. These communities remain most dependent on government hospitals, which are chronically underfunded and under-capacitated. “We are experiencing a medical emergency every day, but we do not have the necessary tools to combat it,” agreed the health workers during a press conference organized by the association.
According to Ecuador’s constitution, at least 4% of the gross domestic product (GDP) should be allocated for health. Yet, according to the Latin American Association of Social Medicine (ALAMES), in practice this percentage struggles to reach even 3%. Even if the budget did reach what is designated in the constitution, it would not be enough to meet everyone’s needs, especially considering the impacts of the COVID-19 pandemic on the health system. Because of this, ALAMES published a call to the government in 2020, demanding that at least 5% of the GDP be designated for strengthening the health system.
Their call was rooted in the observation of how the current structure of the health system makes it essentially impossible for the poorest to access the care they need. For one thing, the high rate of out of pocket payments in Ecuador – over 30% of health expenditure in 2019 according to the World Health Organization (WHO) and the World Bank (WB) – indicates that a large part of the burden is being shifted to the people, meaning that those without money in their pockets are left without care.
This impression is echoed in the fact that the health system in Ecuador effectively works through three tiers. Selected few – approximately 1 million out of 17.6 million total population – relied on receiving care in private health facilities in 2016. Around 4.5 million people seeked care relying on coverage through the local social security system (IESS), while the large majority – over nine million people – did so through government hospitals. At the same time, the private sector had around USD 6.524 million at disposal for its work. The social security system provided care with a USD 4.404 million budget, while government institutions managed with USD 2.492 million. In other words, the largest and poorest group of people got the least in terms of health resources.
Poverty and extractivism erode health
The structure of the health system has disproportionately negative impacts on Indigenous and Afro-descendant communities, since they are the most exposed to poverty and other social determinants of health. Ecuador is one of the five most unequal countries in Latin America when income is concerned, with about a third of the population living on less than USD 2.85 a day according to the Ecuadorian Institute of Statistics (INEC), with most of them being of Indigenous and Afro-descendant origins.
In 2021, almost 60% of Indigenous people were living under the national poverty line of USD 85.60, and more than 40% were experiencing extreme poverty with a monthly income less than USD 50, INEC data shows. In comparison, a little more than 5% of the white population was living under the extreme poverty line in the same year. As poverty is a clear trigger of ill health, it should be a priority of the government to ensure adequate access to quality health care to the poor. Yet, only a little over 18% of the Indigenous population was covered by the social security system, while the same was true for around 35% of the white population.
The health of Indigenous communities has been additionally eroded by profit-driven policies in the fields of food, agriculture, and extractive industries. As private companies were allowed to dictate what happens to the land and natural resources like water, without the government consulting communities in the process, many people have been uprooted and their livelihoods put under serious threat.
Particularly serious consequences have been felt when it comes to food sovereignty and food production. “The health status of the people is extremely dependent on how food is produced and made available. Essentially all children who were treated by health volunteers during the strike were undernourished. If you talked to school children from Cayambe (a region mostly associated with agricultural production), you’d hear them say ‘We do not have lands for growing food’. So their health is inextricably linked to food sovereignty and self-determination,” explains Erika Arteaga Cruz from the People’s Health Movement (PHM) Ecuador.
The drive for extractivism and large-scale, industrial agriculture has often led to state-backed removal of communities from ancestral lands, as well as contamination of natural resources they relied upon. “For example, although mining has led to the pollution of many water sources used by Indigenous communities, it continues without interruption until today,” said Arteaga Cruz.
The extent to which extractivism and other harmful neoliberal practices have eroded people’s health means that increasing the national health budget is necessary, but unlikely to be enough to put things on the right track, opines Cruz. Instead, she says that “A major overhaul of the whole system is necessary, which would ensure respect for the Indigenous communities’ ancestral practices, put an end to harmful extraction practices, and build a society grounded in values of care. That’s why the part of the agreement which foresees a halt of extractivism is so important, it gives us the chance of doing something we were never able to do before.”
The provisions on the participation of Indigenous communities in dialogues on land and natural resource use mean that the agreement between the organizers of the national strike and the government leave room for hope that the social and environmental determinants of health in Ecuador will improve. Still, given the current state of the public health system and existing health inequities, campaigning for the right to health remains equally important.
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