Beads of sweat dripped down the faces of those waiting in a line that snaked around the public hospital in Quito. It was March, and the humid air made every breath feel heavy. The crowd outside Unidad Metropolitana de Salud Norte was a mosaic of Ecuador's people—young schoolboys coughing, pregnant mothers cradling babies, elderly men and women hunched in wheelchairs. As I walked past, I couldn’t help but wonder: what brought them all here, and what stories lay behind their wait?
I was here as part of a service-based needs assessment project team through the University of Michigan’s Michigan Health Engineered for All Lives (MHEAL). Our aim was to understand the realities of healthcare access in Ecuador, especially for those who need it most. The scene in front of me spoke volumes even before I spoke to a single patient.
In the crowd, I met a 74-year-old woman who had been waiting a year for a follow-up appointment. She had suffered two strokes—after the first, she managed to scrape together money for private in-home care, but the second left her with no choice but to seek help at this overcrowded public hospital. It’s the closest affordable option, yet she commutes an hour each way. Inside, she waits even longer. Her face showed both patience and frustration as she explained that, like many others, she had been forced to pay out-of-pocket for medications that the hospital couldn’t provide.
The financial chief of the clinic, a man with seven years of experience managing the books, painted a stark picture of the clinic’s inner workings. “Only about 2% of our patients have issues paying their bills,” he explained in Spanish, “but in an emergency, patients need to pay 60% upfront. If they can’t, they sign an IOU, a written promise by a patient to pay a portion of their medical bills later, with the medical director.” The clinic can discount bills, but not by much. Despite these measures, the strain on patients and their families is evident. The system prioritizes solvency over access, leaving many to choose between care and cost.
Even with money, time is another hurdle. One man, also in his seventies, had been waiting over three years for spine surgery. “They didn’t have the tools,” he shrugged, resigned. He wasn’t a priority, so his surgery kept getting delayed. For him, the long wait meant daily pain, managed with sporadic access to painkillers from the hospital. Yet he still believed this was “the best public hospital” he’d been to. It’s a bittersweet reality—the expertise is there, but the resources aren’t.
As we moved through the hospital, another issue became clear: mental health care is a luxury many cannot afford. I spoke with a woman in line for a cardiologist appointment, who confided that her husband had been emotionally abusive, leaving her anxious and sleepless. “They have psychologists here, but getting an appointment takes so long,” she said. Like many older Ecuadorians, she was reluctant to speak openly about mental health. “People think you should just be strong.” The younger generation, she noted, is more open to seeking help, but the resources just aren’t there to meet the growing demand.
For many patients, the free services offered at public hospitals come at a steep cost—waiting. Some told us they’d arrived as early as 2 a.m. to secure a spot in line, wrapping themselves in jackets against the cool mountain air. A young mother, carrying her baby while waiting for a pediatric appointment, described the endless waiting as a gamble. “Sometimes, you get lucky and they have an opening. Other times, you wait for hours and leave empty-handed.” Yet despite these frustrations, she praised the doctors, calling them “worth the wait” for their dedication.
Throughout my time in Ecuador, one truth became clear: the system is strained. There aren’t enough supplies or specialists, and the government funding simply doesn’t stretch far enough. Even basic tools like Tylenol can run out. Yet there’s resilience here, in both the staff and the patients who endure long waits and limited resources. The public hospitals do what they can for those who have nowhere else to turn, but the cracks in the system are deep, and without intervention, they’ll only grow wider.
Reilly Hanson, secretary of MHEAL and co-lead of our project team, reflected on our experience, saying “Our trip to understand the inequities of healthcare in Ecuador will continue to impact our everyday lives as we think about ways to help the strong community that we met.” Her words capture a sentiment we all felt– that this trip was more than just an observation of challenges; it was a call to action.
As we packed up our notes and prepared to leave Quito, I thought back to the faces I’d seen that day. Those waiting in line for care were more than statistics—they were people with stories, each hoping for a chance at better health. Their patience and resolve were inspiring, but they deserve more than resilience. They deserve a system that works for them, not against them, and it is advocacy from those in a privileged position like us that can drive change. Until then, the lines will remain long, the wait will continue, and the struggle for equitable healthcare in Ecuador will persist.
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