Geographic inequalities in neurosurgical capacity and interprovincial hospitalization in Ecuador: a nationwide observational study

Abstract Background Geographic inequalities in specialized healthcare capacity may influence where patients receive hospital care. We examined the distribution of neurosurgical resources and interprovincial hospitalization in Ecuador, assessing associations between provincial healthcare capacity and hospitalization outside the province of residence. Methods We conducted a nationwide observational study linking Ecuadorian hospital-discharge records from 2024 with provincial workforce, neuroimaging, critical-care, and hospital-bed indicators. The study included 15,604 hospitalizations for non-traumatic intracranial hemorrhage, central nervous system tumors, traumatic brain injury, and hydrocephalus. Out-of-province hospitalization was defined as hospitalization in a province other than the province of residence. Associations were examined using binomial generalized estimating equations clustered by province of residence, with bias-reduced covariance estimation. Results Among 3,545 hospitalizations for non-traumatic intracranial hemorrhage, 593 (16.7%) occurred outside the province of residence. Four destination provinces accounted for 84.3% of these interprovincial hospitalizations. Each 0.5-unit increase in recorded provincial neurosurgical workforce per 100,000 population was associated with lower adjusted odds of out-of-province hospitalization (adjusted odds ratio 0.55, 95% confidence interval 0.42–0.72). The inverse association was maintained across sensitivity analyses and was also observed in traumatic brain injury. Neurosurgical resources were geographically concentrated, with substantial differences across provinces. Conclusions Neurosurgical capacity and interprovincial hospital utilization were unevenly distributed across Ecuador. Higher provincial neurosurgical workforce density was associated with lower out-of-province hospitalization, highlighting geographic differences in reliance on specialized services. Linking healthcare capacity with observed hospitalization flows may inform geographically equitable health-system planning, although cross-provincial hospitalization alone does not establish inequitable access.