title: Assessing the context of health care utilization in Ecuador: a spatial and multilevel analysis.
abstract: BACKGROUND
  There are few studies that have analyzed the context of health care utilization, particularly in Latin America. This study examines the context of utilization of health services in Ecuador; focusing on the relationship between provision of services and use of both preventive and curative services.
  
  
  METHODS
  This study is cross-sectional and analyzes data from the 2004 National Demographic and Maternal & Child Health dataset. Provider variables come from the Ecuadorian System of Social Indicators (SIISE). Global Moran's I statistic is used to assess spatial autocorrelation of the provider variables. Multilevel modeling is used for the simultaneous analysis of provision of services at the province-level with use of services at the individual level.
  
  
  RESULTS
  Spatial analysis indicates no significant differences in the density of health care providers among Ecuadorian provinces. After adjusting for various predisposing, enabling, need factors and interaction terms, density of public practice health personnel was positively associated with use of preventive care, particularly among rural households. On the other hand, density of private practice physicians was positively associated with use of curative care, particularly among urban households.
  
  
  CONCLUSIONS
  There are significant public/private, urban/rural gaps in provision of services in Ecuador; which in turn affect people's use of services. It is necessary to strengthen the public health care delivery system (which includes addressing distribution of health workers) and national health information systems. These efforts could improve access to health care, and inform the civil society and policymakers on the advances of health care reform.
authors.affiliation: Division of Health and Physical Education, Western Oregon University, Monmouth, Oregon, 97361, USA. lopezced@wou.edu
authors.forename: Daniel F
authors.initials: DF
authors.lastname: López-Cevallos
authors.forename: Chunhuei
authors.initials: C
authors.lastname: Chi
mesh_terms: D003430:Cross-Sectional Studies; D004484:Ecuador; D018166:Health Care Reform / Q000331:legislation & jurisprudence; D006296:Health Services / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D006801:Humans; D008430:Maternal-Child Health Centers / Q000706:statistics & numerical data; D055361:Multilevel Analysis; D017149:Private Sector / Q000706:statistics & numerical data; D017150:Public Sector / Q000706:statistics & numerical data; D012044:Regression Analysis; D012424:Rural Population; D014505:Urban Population; D000078329:Workforce