Your experience has largely been that basic services that can be found in Tempe, Arizona you can find in Charleston, Carolina or Vancouver, B.C. As a rule, you don’t have to look too far, or hard, to find the product or service you need at an acceptable level of quality wherever you go.
Let’s just call it “The McDonald’s Syndrome.”
Healthcare in Ecuador
Examining Your Norm
As a teenager in the 1960’s I could go from one end of the U.S. to the other and find communities and even whole states noticeably “behind” my area of the country. Today, standards of living, products and services are pretty much comparable from community to community, state to state. In fact, I’ll go so far as to say that so much of America has become homogenized in my lifetime it has almost successfully eliminated the element of chance!
If you are in the middle class you have access to acceptable levels of healthcare, no matter where you live. Inadequate emergency services are rare. Most towns are similar in their demographics, so there are adequately trained and practiced professionals for each age range, no matter where you go, and what goes wrong. Even “exotic” ailments can be dealt with through networking within reasonable distances.
Additionally, in almost any emergency, you are literally no more than a few hours away from a facility able to handle all but the most critical complications, and there are numerous reliable and timely transportation options to get you where you need to go. If insured, not once must you fumble for cash.
This is the way the world is for most expats. Ease of access is ingrained in day-to-day life. Unfortunately, you cannot afford to continue to think like this about your healthcare in Ecuador.
I get a little annoyed when I read articles geared towards expats and soon-to-be-expats that perhaps inadvertently, perhaps not, play into the North American’s inbred weakness of perception; a few good examples means there must be consistency in hospital care wherever you go and whenever you need it in Ecuador. This is the ‘McDonald’s Syndrome’ trap in action.
This is not meant to discourage anyone. Rather it is a tough-love, heads-up notification, that if you move or live here, your well-being demands that you take maximum responsibility for the management of your hospital care in ways you never thought of in North America (or whatever developed nation you’re from).
If you take time to gather the information you need, to pre-plan for the actions you’ll take in the event of a critical emergency in your household, you will be in a better position to move smoothly through a less serious incident that involves hospitalization.
Hospital care in Ecuador has greatly improved in the last eight or so years. I know of many first-hand accounts of superb, cost-effective service and exceptional practitioners. You can find services today that were unknown not too long ago, especially for the aging expat population. The Public Health system is free for all. Social security through IESS provides comprehensive coverage. Private Health Insurance carriers are much more abundant.
It’s a fantastic system…when it works like you’re used to.
It really doesn’t matter if you believe you’re fully covered when you find out that if your spouse is to get a blood transfusion, YOU still have to get the blood and pay for it! Be prepared to roll with the punches to get what you need and don’t expect to get all that you want. Learn to make your best choice based on what is. Using that caution will actually help you to have many pleasant surprises.
The key piece that is missing here, and is so different than in North America, is that very few of the systems for hospital care are standardized. They are not linked with each other in networks capable of providing uniform service and a well-coordinated “chain of care” from onset of incident through discharge and follow-up. Generally – especially when faced with an emergency – you have to make that up as you go if you desire North American standards. It’s doable, but the path can be quite harrowing.
What and who is available today, may not be available tomorrow. If where you are at is threatening your well-being, the time it will take you to get to another facility, with properly trained personnel, could significantly affect your recovery time. No matter where you end up, you may have to both obtain and pay for life-saving materials. You may need to provide your own translator, personal attendant, and “runner” during a hospital stay. If an emergency places you in a nearby hospital, you may even have to obtain your own food until you can be transferred elsewhere.
Time and place have everything to do with the level of health care you can expect in Ecuador. My point is, the more involved or complicated your medical needs, the more care you must take to prepare, in advance, to manage your progress through the system.
The more money you have makes it more likely you’ll be able to be taken care of at a private facility. In Ecuador, however, you often encounter a whole lot of variables on the way to getting to the right one. Having health insurance does not mean that you don’t have to pay a hospital up front; it could boil down to the mood of the administrator on that day.
The reality is, once reassured that healthcare is available here, and there’s plenty of insurance to cover it, most expats don’t give a second thought about medical difficulties until they’re flat on their faces.
Medical Training Perspectives
All too often I hear expats, new to the area, remark that since they know treatment at the Public Health facilities are free, if they get into trouble, that’s where they’ll go.
Let’s add some perspective by learning about the training that Ecuadorian physicians go through:
In the first two years, basic sciences. In the third and fourth year, the clinical phase, a combination of theoretical and practical classes. The fifth year is called Externado, because you have classes outside and inside the hospital and work there. The sixth year is called Internado Rotativo, and you are called an intern, that is because you are practically living in the hospital. You are hired by the hospital, receive a salary and are considered hospital staff. (paraphrased from http://globalmedicine.nl/issues/issue-7/studying-medicine-in-quito-ecuador/ )
From there you are assigned to a Rural Hospital or other facility in the Public Health Sector. There are no “permanent” assignments which mean the Ecuadorian system has a moveable cast of characters manning the fort. At some hospitals it cannot be guaranteed that a physician will be on duty 24/7.
According to Andean Health Development, an educational center seeking to raise the standards of care in Ecuador, (http://www.andeanhealth.org/about-2/page-3/residency-nurse-training-program/ ) “Physicians and nurses working in the public sector are generally hired straight from medical school with little or no hands-on training.”
During their last year (in some cases more) training the medical student’s exposure to emergencies is typically limited to a short-term rotation through the emergency room. The new doctor is assigned to the hospital as a whole and will not pursue a specialty in emergency medicine until after their Public Health service.
Non-city areas do have experienced doctors on staff. Their hours actually AT the hospital, however, are varied and limited and they are not always in town. And don’t forget, Holidays are really taken here!
Sometimes, the Public Health doctor will have more experience than their recent graduation from medical school, and there are usually experienced nurses on duty at the hospital.
The important thing to consider, however, is that you cannot count on a consistent level of trained personnel available to you when you have a critical need.
You now have a basic understanding of the system the doctors come through that leads them into other services like IESS and Private facilities. Keep this in mind when you assume the Public Health sector is standing ready to serve all your medical needs.
An earlier article I wrote for Gringo Tree “Understanding Ecuador’s Emergency Medical Services” helps explain in more detail why the needs of the expat population are out of step with the medical needs of the country as a whole.
Backup Plans Are A Smart Move
Regarding IESS, as full disclosure, I myself am covered by it, and will continue to pay into the system, even though I private pay for most of my medical needs. In the three 1/2 years I have been part of the system, I have found it bureaucratically daunting but manageable. The overall care has been good to excellent. Yes, I have been to a few appointments that never happened, and I’ve learned it’s foolish to go without a translator unless fluent in Spanish. However, most important of all, I have a backup plan in place and am prepared to get everything handled out of the system.
Overall, I’d say for non-exotic/non-emergent healthcare concerns, if you’re patient, you’ll get well-taken care of. I even know a couple of people who have undergone successful surgeries including open-heart and have had nothing but praise. I also know people whose lifestyle and medication-complicated emergencies sealed their fate, however, because they didn’t have instant access to equipment or procedures or expertise that they took for granted up north.
Public Health Realities
In 2016 IESS has been under a lot of financial strain. The monthly premium was reduced, apparently to encourage more people to pay in to the system. This is not a rebate due to abundance; it’s about raising the money to meet its subscribers’ most basic healthcare needs. The most recent earthquake has increased financial pressure significantly. My point is, don’t assume you’ll be covered for everything you need when the going gets tough; the going is already tough for Ecuador.
Theoretically, you can have an emergency and go to any hospital in Ecuador and IESS will foot the bill, however, I have recently heard of people who have been refused service in other than IESS hospitals unless payment in cash was made because IESS was in arrears for earlier admissions.
Private Health Care
Private hospitals and clinics are often subject to many of the same challenges that I described above. You honestly do not know from hospital to hospital unless you investigate. The onus is on you to do the research you need and ask the questions you must ask to figure out where you’re going, especially before you are in the middle of an emergency. If you’re moving here and have unusual illnesses or vulnerabilities, make sure you move into the neighborhood of a hospital that can handle you.
As example, one person I knew had an apparent heart attack. Four hours, thirty miles and two hospitals later he went into cardiac arrest in the emergency room of a private hospital. They could not find a defibrillator in the hospital that worked. He died. Another with chest pain had to go to four hospital emergency rooms before she could find someone versed in cardiology, this in a town of about 150,000.
Health In Your Own Hands
Among the top five major reasons that expats leave Ecuador are challenges with the health care system. I would hazard to guess that “inconsistency” is a major factor leading to that decision. Ecuador, the land of “You never know” is on an economic roller-coaster once again. It hasn’t had a period of stability long enough to get all of the parts of its healthcare system coordinated as can be found in developed nations.
Please don’t get me wrong. I believe there are many aspects of healthcare in Ecuador that are SUPERIOR to what I’ve experienced in North America.
A major reason things are so homogenous in healthcare “up there” has been litigation. Although it appears to be a safety net, in reality it has taken self-determined, community-based healthcare out of the hands of the individual and placed it into the hands of a costly machine.
Once you accept that you’re on your own down here, and subject to a system with many human foibles as opposed to a well-oiled machine, you just have to take the time and responsibility to prepare to work around the inconsistencies within the system.