Medicines availability in Ecuador's public system (2015–2024): a policy design analysis of financing, public procurement, and governance

Medicines shortages are a major health policy challenge in Ecuador and reflect inconsistencies in the architecture of public-sector medicines access policy. This Health Policy paper, grounded in the policy design framework, synthesises administrative records and policy documents (2015-2024) to show how budget contraction, volatile execution, and weak <i>ex ante</i> needs assessment hinder the translation of allocations into sustained availability. Procurement has shifted from a centralised electronic catalogue towards more fragmented purchasing modalities, while limited transparency in inventory management sustains uncertainty about needs and stock. Governance constraints, including institutional weakness, gaps in timely information, and extensive Constitutional Court oversight, further strain decision-making. Strengthening coherence across financing, procurement, information systems, and governance, alongside more stable leadership, is essential to translate formal commitments into reliable access to essential medicines.