Healthcare Equity in Ecuador: Operation Walk

Surgeons performing a hip replacement surgery at Hospital del Río in Cuenca, Ecuador
Surgeons performing a hip replacement surgery at Hospital del Río in Cuenca, Ecuador.


By Grace Malheiro, BHSc Candidate, School of Health Studies


Information gathered through interviews conducted with Dr. Daniela Barzallo (Ecuadorian Medical Doctor) and Mira Ratkaj (Canadian Operation Walk Mission Trip Volunteer)


Many people take for granted the ability to walk. It is not something that everyone thinks about, even while walking and having the ability to move play an important part in so many daily lives. A brisk walk can improve your mental health, physical health and even social health. Perhaps an injury or illness has made you value walking in new ways. Maybe you have observed others move with ease, or lose their ability to do so. Maybe you too have suffered an injury or undergone surgery and have regained or improved on your previous mobility.

Receiving surgeries for conditions that cause walking difficulties is not a reality for many people around the globe, but such surgeries can be life-changing. Various social determinants of health influence access to such surgeries and the physiotherapy that must accompany these to improve individuals’ ability to ambulate.

In the highlands of Ecuador, the prevalence of developmental dysplasia of the hip (DDH) is high. The most recent data indicates that the rate of DDH in Latin America is 16x higher than that in North America (Healthing, 2022) (Grand Challenges Canada, 2016). DDH is a condition where the joint of the hip does not form properly in infants due to inadequate fetal mobility, swaddling or genetic factors (Alsaleem et al. 2015). In Ecuador, the majority of DDH cases are caused by traditional Indigenous swaddling customs. The Shuar Indigenous peoples of Ecuador traditionally swaddle their infants in a way that keeps their hips in an extended adducted position, increasing the risk of DDH. Ecuadorian Medical Doctor, Dr. Daniela Barzallo describes the practice, deeply rooted in Shuar culture as, “wrapping babies like tight tacos”. This practice is derived from old cultural traditions. They believe that if they swaddle their children, they will grow taller. Since the majority of the Shuar population is short, they hope to help their children become strong and tall. It is also said that being tightly swaddled resembles being in a mother’s womb which can help the baby calm down and limit their crying.

Many Shuar lack education about the risks, potential signs and symptoms of DDH. DDH is treatable if diagnosed within the first 6 months of life. Babies diagnosed early enough can be fitted with a brace to re-align the infant’s hips. In the absence of early diagnosis and treatment, DDH can lead to limping, pain and osteoarthritis of the hip and back, impacting their overall quality of life (NHS, 2021). While surgery and accompanying physiotherapy can serve to improve mobility in cases of later diagnosis, accessing such care is no simple matter.

Key reasons the Shuar people may not seek treatment and receive surgery for DDH include poverty and geography. Accessing the surgery outside the rural areas where DDH needs arise involve high costs. Ecuador’s healthcare system consists of two subsystems: public and private. Every Ecuadorian has the option to use the public healthcare system; however, this system is limited and restrictive. Public healthcare services have long wait times, and are marred by limited staff, facilities, and pharmaceutical supply shortages (PAHO, 2017). Private healthcare is available, and is significantly superior to the public healthcare system as it is comprised of a greater number of doctors, and higher quality hospitals and resources. However, for most Ecuadorians, receiving care from this system is too costly. Geographical isolation is an additional barrier. The 2021 Ecuador Pharmaceuticals & Healthcare Report reveals that many people that reside great distances from healthcare facilities cannot travel to hospitals or clinics in major cities because of time and financial constraints. Therefore, many people with DDH avoid seeking treatment altogether.

Dr. Cecil Rorabeck, an orthopedic surgeon in London, Ontario saw this issue and wanted to make a difference. He established a non-profit organization called Operation Walk in 2006. Operation Walk provides knee and hip replacement surgeries in Guatemala and Ecuador. Its purpose is to restore pain-free mobility and improve the quality of life of patients living in poverty who have little or no access to medical care and can benefit from orthopedic surgery. In the first year of Operation Walk, Dr. Rorabeck and a mission team travelled to La Antigua, Guatemala and changed the lives of 52 Guatemalans through hip and knee replacements. Later, in 2009, Dr. Bob Bourne formed a second Operation Walk team to perform hip replacement surgeries on patients with DDH in Cuenca, Ecuador. Today, both mission teams continue to travel to these countries annually where they make a difference in the lives of many people.

The Ecuadorians who are selected to receive surgery through Operation Walk express that they feel very fortunate to receive an operation done by an international team. Unfortunately, and based on chronic underfunding of the public healthcare system, many Ecuadorians do not trust the Ecuadorian healthcare system or Ecuadorian surgeons, whom patients assume have less experience with specialty surgeries. In fact, a survey conducted by Dr. Barzallo and her colleague Dr. Bernal showed that after a total hip arthroplasty surgery was completed by the Operation Walk team, 120 patients were very satisfied, 9 were somewhat satisfied and only 1 was somewhat unsatisfied with the entire operation process (130 patients surveyed) (Barzallo et al. 2020).

Approximately 1-2 days after the surgery (and before the patients leave the hospital), they are provided physiotherapy exercises. The Operation Walk team attempts to make the instructions as clear as possible for the patients to avoid any complications after they leave. Patients will watch a video showing how to perform the exercises and receive paper copies of the instructions to take home, which contain pictures for patients who are not literate. The instruction sheet is also explained to several family members of the patient to avoid any confusion on how to perform the exercises. Months after the surgery, Dr. Manuel Ávila, an Ecuadorian doctor in Cuenca will make a home visit to the patients. Dr. Ávila will review the exercises and monitor their recovery process. The patients receive full support from the start to the finish. This strong support system helps patients recover both physically and mentally.

Providing these surgeries is not solely about restoring strength and mobility, but about impacting various areas of patients’ lives. There are countless examples of lives being changed in unimaginable ways. For example, before surgery, one man could not walk or stand, preventing him from working on a farm. After the surgery, he was able to start working on a farm and began gaining income to support his family. Another patient, a kindergarten teacher in her mid-30s, could not work as a full-time teacher because of the pain she experienced in her hip. Having the surgery enabled her to teach and play with the children.  She was eventually promoted in her school and began working full-time after the surgery. Then, there was a young girl who could not go to high school because she was ashamed of her limp. She spent most of her time at home alone and was depressed. After receiving two surgeries, her life completely changed. She now walks free of pain, attends school, has a boyfriend and is able to work. Almost all patients feel more complete after the surgery as they are able to assist their family financially and can contribute greater to society. It is incredible that a two-hour surgery can make such a difference in a person’s physical, mental and social health.

Health promotion can be a solution to change patterns and behaviours to reduce DDH. There have been attempts to provide education about DDH in Ecuador, but change is slow. It is difficult to get this information to the people living in the highlands. Changing traditional practices in a context of low trust in healthcare professionals, and limited health seeking, is a delicate process that requires community-engaged initiatives. There is no doubt that such initiatives will be key to prevention moving forward. At present, Operation Walk provides two brief education presentations, one regarding the pathology of DDH and the other regarding the surgery to be performed. These presentations are only given to a small number of people receiving the surgery. There is a need for health experts to reach a larger number of people and work with communities to gain their respect.

Operation Walk’s mission trip is an extraordinary way to establish greater healthcare equity in Ecuador, but there is still much to do. Trust must be built between the Ecuadorians and healthcare professionals to enable greater dialogue and collaboration on addressing health challenges such as DDH. And, the filling of gaps in the public healthcare system, which systematically disable poorer segments of the population from accessing high quality care when needed must be rectified. Income is perhaps the most important social determinant of health, and its effects are the most prominent. Therefore, it is essential that healthcare systems make it a priority to define themselves as successful based on their ability to serve those living in poverty so that the health inequity gap can be filled in Ecuador and around the globe.



Alsaleem, M., Set, K. K., & Saadeh, L. (2015). Developmental Dysplasia of Hip: A Review. Clinical Pediatrics54(10), 921–928.

Barzallo Alvarez, D. E., & Bernal López, M. F. (2020, December 2). Calidad de Vida Y satisfacción post- artroplastia total de cadera. Brigada Médica "operation walk", Cuenca, 2013-2019. Repositorio Institucional Universidad de Cuenca: Home.

Ecuador. Operation Walk Canada. (n.d.).

Fitch Solutions Group Limited. (2021). Ecuador Pharmaceuticals & Healthcare Report - Q4 2021. In Fitch Solutions Country Industry Reports (p. 1–). London.

Grand Challenges Canada. (2016).

Health in the Americas 2017. (2017). (2022). from

NHS. (2021). NHS choices.,(femur)%20to%20the%20pelvis



Photo by Mira Ratkaj