A/HRC/44/48/Add.1 I. Introduction 1. The Special Rapporteur visited Ecuador from 17 to 26 September 2019 at the invitation of the Government. The purpose of the mission was to ascertain, in a spirit of dialogue and cooperation, how the country has endeavoured to implement the right to physical and mental health. 2. During his visit, the Special Rapporteur met with high-ranking government officials from the Ministries of Foreign Affairs, Social Affairs and Inclusion, Education and Public Health. He also met with high-ranking officials from the Social Security Institute, the Police Social Security Institute, and the Army Social Security Institute. He held meetings with members of the Constitutional Court, the Judiciary Council and the National Assembly, as well as representatives of the offices of the Mayors of Quito, Guayaquil and Otavalo. He also met with representatives of the Ombudsman’s Office, civil society and international organizations, as well as academics and health professionals. 3. The Special Rapporteur visited several health facilities in Quito, Lago Agrio, Otavalo and Guayaquil. Those facilities included general hospitals and primary health-care centres, a psychiatric hospital and a mental health outpatient centre, a maternity hospital, an intercultural centre on health and a border centre where migrants and refugees are provided with services. 4. The Special Rapporteur is grateful to the Government of Ecuador for its invitation and full cooperation during his visit. He appreciates the outstanding support provided by the United Nations country team, the National Human Rights Adviser of the Office of the United Nations High Commissioner for Human Rights (OHCHR) and all those who contributed their time and experience. II. Right to health in Ecuador A. Background 5. With a population of over 16 million, Ecuador is a multicultural and multi-ethnic country divided into four regions – coastal, mountain, Amazon and the islands. According to the most recent census, the population includes the following groups: mestizo (71.9 per cent), montubio (7.4 per cent), Afro-Ecuadorian (7.2 per cent), indigenous (7.0 per cent), white (6.1 per cent), and other (0.4 per cent). 1 The country has vast natural resources and is marked by deep inequalities particularly affecting those living in rural areas, indigenous peoples and persons of African descent. 6. Ecuador is prone to natural disasters, such as volcanic eruptions, earthquakes and tsunamis. In 2015, a state of emergency was declared for the eruption of Cotopaxi and Tungurahua, and in April 2016 a coastal earthquake caused significant damage to the social sectors, including education and health. 7. In the recent past, there have been important investments in the health infrastructure. Health expenditure doubled between 2010 and 2015 to 9.2 per cent of gross domestic product (GDP).2 There were 851 new units established in the public health services network between 2010 and 2016 and an increase in the number of health professionals, leading to a 10.6 per cent increase in care between 2011 and 2014.3 In 2014, there were 20.4 physicians and 10.1 nurses per 10,000 of the population. However, the ratio of specialists remains low and their distribution unequal (urban, 29.0 and rural, 5.4 per 10,000 inhabitants). 4 8. Ecuador experienced a period of growth and poverty reduction thanks to the rise in oil prices between 2007 and 2014. However, structural problems, such as an inefficient public sector, large macroeconomic imbalances, a lack of stabilization mechanisms and 1 2 3 4 See www.ecuadorencifras.gob.ec/resultados/. See Pan American Health Organization and World Health Organization, “Country report: Ecuador”, available at www.paho.org/salud-en-las-americas-2017/?page_id=117. Ibid. Ibid. 3