Addressing social determinants of health and equity in early childhood: a qualitative document analysis of national policies in Ecuador.

BACKGROUND

Early childhood health is a major policy priority in Ecuador, yet systematic analyses of relevant policies are limited. This study analyses how Ecuadorian national-level policies (2000-2024) have addressed social determinants of health (SDH) in early childhood and promoted health equity. We map the development and scope of the past and present national policy documents across sectors to identify gaps, strengths and priorities within the policy landscape.

METHODS

Following a systematic search, we conducted a qualitative analysis of 29 policy documents using the READ approach (ready the materials, extract data, analyse, and distil findings), with thematic analysis. We combined deductive codes related to governance instruments and six SDH living-conditions domains (healthcare, health services, early education, social protection, childcare, and housing) with inductive codes that emerged during analysis. NVivo software supported data management and theme development, paying attention to contradictory evidence. An advisory board reviewed the interpretation of findings.

RESULTS

Early policy documents focused on sector-specific interventions, whereas later policies reflected more holistic approaches. Recent policies strongly promoted intersectoral collaboration but rarely specified clear financing or evaluation mechanisms. All six SDH domains analysed were represented, but attention was unbalanced: healthcare and health services dominated, while housing, early education and childcare were under-represented. Applying a policy typology, most policies were universal or targeted; only one was redistributive, and the use of proportionate universalism was uneven. Commitments to equity became more prominent over time through recognising vulnerable groups and intercultural approaches, yet concrete recommendations on intersectionality, territorial equity and community-based planning remained scarce.

CONCLUSION

Embedding social determinants of health in policy design, underpinned by robust governance, effective intersectoral collaboration, sustainable financing, and locally responsive strategies, is essential, particularly for children facing intersecting disadvantages and those living in underserved territories. Stronger evidence on governance structures, implementation processes, and equity-oriented evaluations using lower-level territorial health indicators is crucial not only for Ecuador but also for other low-and middle-income countries seeking to advance equity in the earliest years and across future generations.