The growing oversupply of physicians in Ecuador: challenges and implications for the healthcare system

As part of the United Nations' Sustainable Development Goals, Goal 3 prompts subscribed countries around the globe to ensure healthy lives and promote well-being for all throughout all ages (1). In order to achieve this, countries must strive to develop a strong and functioning health system that can not only cover the demands of their population, but that can work efficiently to ensure their own sustainability. In this context, policies surrounding the training, development and geographical distribution of a country's health workforce represent an important axis in their ability to achieve this goal. Critical among these is the proportion of healthcare workers for a given population, which varies depending on region, demographic composition and median income.Although the World Health Organization (WHO) widely promotes the benchmark of at least 23 health workers per 10,000 population as the minimum threshold necessary to deliver essential health services (2)(3)(4), this figure does not specifically refer to physicians. In fact, the recommendation encompasses a broader category that includes doctors, nurses, and midwives. Despite this, the figure is often interpreted as a target for physician density, although no globally accepted reference exists for the ideal number of physicians per population. According to World Bank data, countries vary significantly in how they meet this threshold depending on their income level. High-income countries report approximately 3.3 physicians per 1,000 population, while upper-and lower-middle-income countries report 2.2 and 0.7, respectively (2). This excess or deficit of healthcare professionals can be one of the main problems faced by health systems since estimating the real needs of the system (and by consequence, the proportion of physicians needed for each region) is a complicated process for which there is no single accepted method (4,5).In Ecuador, data from the National Institute of Statistics and Censuses (INEC) for 2023 indicate that non-communicable diseases were the leading causes of mortality, with ischemic heart diseases (n=13,318), cerebrovascular diseases (n=4,632), and diabetes mellitus (n=4,460) topping the list. Among infectious diseases, influenza and pneumonia (n=3,781) were major contributors to mortality. Other significant causes of death included assaults (n=7,308) and traffic accidents (n=3,965) (6). The Ecuadorian healthcare system manages these health burdens through its public and private sectors. The public sector comprises the Ministry of Public Health, the Ministry of Economic and Social Inclusion, municipal health services, and social security institutions such as the Ecuadorian Social Security Institute (IESS), the Armed Forces Social Security Institute, and the National Police Social Security Institute. The private sector includes both for-profit and non-profit organizations (7).Nationwide, there are 4,148 healthcare establishments, of which 631 are inpatient (hospital) facilities and 3,517 are outpatient centers (8). Approximately 80% of these facilities belong to the public sector: the Ministry of Public Health operates 47%, and the IESS manages 24%. The remaining public facilities are operated by municipalities, other ministries, and various social security institutions. The private sector accounts for roughly 20% of healthcare establishments, divided between 14% for-profit institutions and 6% non-profit organizations (7).Regarding health coverage, only 32.9% of the Ecuadorian population has access to some form of health insurance, with coverage rates of 30.7% among women and 35.2% among men. Among the insured, 4,279,738 individuals are covered by the IESS general insurance, 69,971 hold private insurance with a policy, and 10,958 have private insurance without a formal policy. Nevertheless, approximately 12,030,720 Ecuadorians remain uninsured (9) Physician density in Ecuador has shown notable growth over recent decades. Between 2000 and 2017, the physician-to-population ratio increased from 0.8 to 2.2 per 1,000 inhabitants (4). In 2016, the national physician proportion per 10,000 inhabitants was 20.52 and in 2017 it climbed up to 22.2 (Figure 1A). In his work, Hidrobo mentions that currently, the physician rates stand at around 38.47 per 10000 inhabitants. If this trend would continue, it would lead to an important risk of physician overpopulation by 2030, as the national medical population grows from 33,925 physicians (or 20.5 per 10,000 inhabitants) in 2016 to 140,734 by the year 2030 (59.1 per 10,000 inhabitants) (10,11).According to data from the Secretariat of Higher Education, Science, Technology, and Innovation (SENESCYT), the largest volume of new physicians that have graduated from 2013 to 2024 have come from public universities. However, the data also shows a clear trend towards the closing of this gap, with a slow decrease in the relative number of graduates from public universities and an increase of those hailing from private institutions (Figure 1B).When comparing the number of medical doctors since 2000 with other health professionals such as nurses or dentists, we can see that the number of physicians has increased the most over the last two decades (Figure 1C). This trend coincides with periods of time in which the country increased its number of medical schools in a disproportionate manner to its population growth. Before the year 2000, Ecuador had 9 functioning medical schools, most of which were located in large capital cities. In the following ten years, this number increased by ten and then by eight more by 2023. As of 2023, state reports show 28 functioning medical schools registered throughout the country, some of which have reported student populations up to 6379 students in the last 10 years (12)(13)(14). This increase in the number of schools is believed to be the result of an increased interest in medical education and rising entry requirements for public schools' admissions programs. This generalized interest is reflected in the number of applications for medical schools throughout the country. For example, data from 2022 showed 22,449 registered applications for that year alone (13,15).In parallel, the inflow of foreign-trained physicians and foreign nationals seeking to practice in Ecuador must also be considered. According to data from the SENESCYT, between 2013 and 2024, a total of 8,555 foreign academic degrees were registered. Of these, 1,952 (22.8%) corresponded to Ecuadorian citizens who pursued studies abroad and subsequently validated their degrees nationally, while 6,603 (77.2%) were registered by foreign nationals. Early in this period (2013-2015), Ecuadorian registrations predominated, but beginning in 2015, foreign registrations surged, largely driven by migration waves from Cuba and Venezuela. For instance, by 2015, foreign nationals represented over 91% of all degree registrations. Cuban nationals predominated early registrations (2014-2015), whereas Venezuelans became the majority from 2016 onwards, mirroring regional political and economic crises. In more recent years, although overall registration numbers have declined, the diversity of countries represented has broadened, with significant contributions from Haiti, Nicaragua, Mexico, and Russia. Notably, most registered degrees were postgraduate qualifications (44 fourth-level degrees), compared to only one technical degree, indicating a trend toward higher academic specialization among both returning Ecuadorians and foreign professionals (14) (Figure 2).Regarding the emigration of Ecuadorian healthcare workers, official national statistics remain unavailable. However, a study by Ayora et al. reported that, as of 2007, Ecuadorian health professionals constituted 59.1% of all foreign-trained medical personnel in Chile (16).Naturally, the increase in the number of faculties does not necessarily correlate with an increase in the quality of education. In Ecuador, medical licensing examinations formally began in 2014, under the Higher Education Quality Assurance Council (then CEAACES, now CACES) providing, for the first time, a benchmark by which to assess end-career results for each medical school. National results from the last decade show a relatively high percentage of physicians who fail to achieve a passing grade in this exam, despite having graduated successfully from their respective Universities (17). To date, an estimated 50 to 70% of physicians who take this exam for the first time are successfully licensed, but these results vary greatly from institution to institution and between regions. Sadly, this has resulted in an approximate of 20 to 30% of graduated physicians not being able to obtain their license, with some cases reportedly failing to do so up to 16 times (18,19). This fact is worsened by the influx of foreign physicians that have immigrated as part of government programs and as the result of humanitarian crises in the region. These professionals often enter a saturated job market and most fail to pass their licensing examination, causing the unlicensed physician problem to bloat (20). For instance, medical licensing results for physicians attempting to legalize their foreign medical degrees had the lowest approval rate for the 2024 examinations, achieving only a 29% approval rate (21). This would imply that the problem may not wholly lie on medical education in the country, but on how the medical system is operating with its related sectors.It is important to acknowledge that licensing examination scores are not absolute indicators of clinical competence. Although evidence suggests that scores like USMLE Step 2 CK moderately predict residency performance, multiple demographic, psychosocial, and administrative factors can influence outcomes (22,23). Nevertheless, Ecuador lacks a comprehensive national strategy to assess and guarantee physician competency, resulting in notable heterogeneity across graduates.Beyond concerns about patient care quality, physician oversupply has led to deteriorating working conditions for both newly graduated and practicing physicians. The mismatch between the number of new medical graduates and the availability of job opportunities forces many to accept precarious employment, adversely impacting healthcare delivery (24)(25)(26). Data from the Ecuadorian College of Physicians indicate that approximately 1,500 doctors graduate each year, yet only 100 to 150 new job positions are created annually (12). In Guayas province, home to an estimated 12,000 medical professionals, only about 50% report holding stable employment. This challenge is not unique to Ecuador; other countries in the region similarly struggle to establish appropriate quotas for training new healthcare professionals (27).This trend predominantly affects general practitioners, who complete a six-year medical baccalaureate program, while the opposite is observed in most medical specialties (25). However, existing residency training programs are insufficient to accommodate the growing demand, leaving many recent graduates to spend years awaiting entry into specialty training or, alternatively, seeking opportunities abroad (10). This situation is exacerbated by limited funding for residency scholarships and an inadequate number of training positions proportional to national healthcare needs. Additionally, these constraints have extended to undergraduate education, as budgetary and infrastructure limitations increasingly hinder access to rotating internship placements during the final year of medical school (11).In Ecuador, as in most other countries, geographic distribution of professionals makes the planning of healthcare workforce supply a complicated manner. There is an international trend of physicians migrating towards urban zones in search of better economic conditions and accommodation. This has motivated governments to implement incentives programs to supply healthcare workers to rural populations. However, evidence from rural programs in the United States suggests that low-income counties outside of the first poverty quartile receive less attention from physicians who seek for better benefits coming from working in more impoverished areas (28), leaving low to middle-income counties undersupplied. In Ecuador, one such program is the community medicine program, colloquially known as "rural medicine". Sadly, while mandatory, this only includes recent graduates who, as discussed, are inexperienced and ever more often prefer to skip the program overall for safety concerns, adding to the population of physicians without a legal license to practice (29). Trends like these negatively affect rural population health and life expectancy as proper, specialized healthcare becomes harder to access (30).The distribution problem of the Ecuadorian healthcare workforce is highlighted when analyzing the data over the years. By analyzing physician supply by province, it becomes evident that rates per 10,000 inhabitants have increased globally. However, this increase is not homogeneous and may not represent the necessities of a particular population. The provinces with the highest increase in physician supply were Pastaza, Zamora-Chinchipe, and Galápagos, which went from rates of 11.3, 9.6 and 7.1 in 2006 to 40.4, 33.2, and 31.0 in 2020, respectively. This increase is not, however, due to a high brute physician output, but to the province's demographic characteristics and local population not increasing in par with the influx of new medical personnel. In provinces with larger populations, such as Pichincha, Guayas, and Manabí, rates have increased more slowly, with rates of 26.9, 22.9, and 23.5, respectively (Figure 3 Supplementary material). Inversely, rural provinces like Santa Elena, Esmeraldas and Los Ríos still suffer from lack of medical personnel for their populations' needs. This makes it clear that coverage is not met despite the increase in medical trainees, and that policies from the last two decades have led to a polarization of professionals, with surplus in urban areas and understaffing in rural ones.To address this issue, emerging technologies such as artificial intelligence (AI) offer promising solutions. Telemedicine platforms equipped with AI-powered chatbots and virtual assistants can facilitate remote consultations, provide health information, and assist in the interpretation of diagnostic imaging such as X-rays and CT scans. By enhancing diagnostic accuracy and supporting early disease detection, these tools have the potential to significantly expand access to healthcare services in underserved regions (31).There is no clear solution to this problem, since estimations of healthcare worker's needs are not definitive or agreed on. As has been seen, increasing the supply of physicians can cause a surplus in already packed populations, with little impact on those with less income. However, limiting quotas for new students poses a risk of worsening the situation for understaffed rural centers. This is particularly important in a country like Ecuador, where most health personnel working in rural areas are the product of the government's community medicine program. There is also the problem of establishing the proper quota for any health system. For instance, necessities in OECD countries vary greatly and predictions for 2030 show an important surplus from countries like Mexico and Germany, but important shortages in the United States and France (32). However, even these estimates have a hard time when accommodating migration and sudden public health crises like the COVID-19 pandemic. Finally, algorhythms should be careful to account for public spending and working days for physicians, since these factors can significantly alter long-term goals for a health system (33).Naturally, there is also the "quality of education problem", since mass education poses a risk of graduating underperforming professionals. A historical view on policies that have led to the closure of underfunded medical schools or unified curricula shows they have been successful in homogenizing medical graduates but have also led to further centralization and diminishing support for vulnerable populations and minorities. This is clear from the effects of Dr. Abraham Flexner's report on medical education in the United States and Canada, published in 1910, and at the time one of the major drivers of the country's pursuit of a highly controlled and centralized medical education system (34). While the positive effects of this were clear in the quality of new medical graduates in the new American system, negative effects included a bias towards a biomedical model, loss of focus on medical humanities and the loss of opportunities for rural populations, minorities and women to formally train in medicine (35,36). This poses a significant challenge for health and education officials who must now seek a balance between laxity and severity in their policies.In the face of this complex problem, the authors consider it necessary that public officials formulate policies to properly regulate the academic offer of both undergraduate and postgraduate medical programs in line with the needs established by the national health authority. Additionally, evaluation and accreditation policies should ensure periodic evaluation of the training process, education laboratories, simulation centers and teaching staff of existing medical schools (11,24). Quality assurance processes should be based on international standards, such as the World Federation of Medical Education (WFME) accreditation policy, for which Ecuador's CACES is not yet a subscriber. Identification of medical schools that fail to provide adequate education environments or lack proper accreditation should be considered for closure (37). Additionally, both the Ecuadorian higher education authorities and the Ministry of Health must collaborate with existing medical associations to rethink the professional profile of the general physician and determine proper funding policies for medical residency programs in needed areas Finally, requirements must be throughout the country, as as periodic that institutions to properly the of the goals to based on the country's real healthcare needs physician it is for the Council for Higher Education and the Ministry of Public Health to take medical training the of to underserved and low physicians from practicing in rural leading to an in major Additionally, an trend has some prefer to the of medical on general to training availability is The limited number of residency positions many physicians to seek training opportunities who remain in Ecuador often face working conditions under the of and by the Council for Higher Education and the Ministry of Public students are to work per without and due to are not but must be through This situation is and of medical the country. and requirements should be to medical schools in Ecuador is Public schools take the exam, which is a and while private schools develop their own admissions While admissions processes should be properly and by national authority. quotas should be in with the Health Ministry and requirements should be In the last the minimum number of training for Ecuadorian medical students has leading to in teaching quality and less a growing oversupply of physicians due to the of medical schools and which are not with market needs. This surplus is exacerbated by in geographic with urban areas while rural regions remain Additionally, high rates in licensing indicate significant in medical education The mismatch between general and training opportunities further leading to and physician workforce accreditation and residency Ecuador healthcare quality, increasing physician and its health study has Although it and the heterogeneity in the outcomes of the which all health professionals must take and the of medical schools with of quality, it does not a of quality or provide data across universities. The of such the ability to more the factors the observed in medical this study on and and does not from such as health medical professional health or physicians The of or focus to these have the by the of those most by physician particularly working and of despite these this a comprehensive and of the of Ecuador's medical workforce and in the national should these with and to achieve a more of the of physician

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.