Impact of Urbanisation on All-Cause Mortality in Ecuador: Evidence from 27 Years of National Data

Introduction

Ecuador became predominantly urban in the 1970s, nearly three decades ahead of the global trend. Since then, continued urban expansion, economic changes, migration, and insecurity have reshaped its social landscape, and influenced health patterns. These changes have contributed to the growing burden of chronic diseases alongside emerging causes of mortality. We explore the relationship between urbanisation and all-cause mortality in Ecuador, accounting for excess mortality during the COVID-19 pandemic. This is the first national-level analysis of urbanisation and mortality in Ecuador, using official data from population censuses (1990–2022) and mortality records (1997–2023).

Methods

A spatiotemporal ecological analysis was conducted. Multilevel regression models were used to evaluate changes in mortality in relation to urbanisation, defined as the proportion of the population living in officially classified urban areas, and disaggregated by age and sex. Spatial techniques were applied to examine geographic variation in both mortality and urbanisation.

Results

Mortality rates declined progressively, though not linearly, until 2019 (352 deaths per 100 000; 95% CI: 335–369), followed by a marked increase during the COVID-19 pandemic (498; 95% CI: 480–516), and a partial reduction thereafter. Excess mortality reached 35.5% in 2020 and 20.7% in 2021. Mortality rates were consistently higher among men than women. By urbanisation level, highly urban populations had the greatest excess in 2020 (49.1%), while highly rural areas showed 25.2% excess mortality.

Discussion

Findings from this long-term, nationwide analysis of urbanisation and mortality in Ecuador suggest that rapid urban growth, particularly during the oil-driven expansion of the 1970s, has had lasting effects on population health. The use of a binary urban–rural classification remains a limitation, and ongoing work aims to develop a more comprehensive multidimensional Urbanicity Index.

Key messages

• The last 27 years of national data, show how rapid urban growth is linked to changing mortality patterns and unequal pandemic impacts across urban and rural areas.

• Long-term declines in all-cause mortality were disrupted by COVID-19, with sharper excess mortality in highly urban areas, men and in 70+ age group.