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Introduction: In 2007, the Ecuadorian government initiated comprehensive social and political reforms aimed at improving citizens’ well-being and reducing inequalities. The health system underwent structural changes designed to expand coverage and eliminate financial barriers. This qualitative study therefore examined how key health professionals perceived the facilitators and barriers to implementing the health system reform 2007-2017 to achieve universal health coverage (UHC) in Ecuador.

Methods: Eleven stakeholders directly involved in the reform process were interviewed. Data were analyzed using inductive and latent thematic analysis to identify key themes.

Results: Four interrelated themes shaping the implementation of Ecuador’s health system reform were identified: (i) strong political commitment, facilitated the expansion of free services and infrastructure, but was undermined by political interference and financing challenges; (ii) the introduction of a renewed healthcare model rooted in primary care and intercultural principles enhanced access but impeded from inadequate training, weak territorial planning, and limited community engagement; (iii) efforts to reduce system fragmentation through mechanisms like the Comprehensive Public Health Network (CPHN), which improved referral pathways but failed to fully integrate services across public and private subsystems; and (iv) leadership reforms within the Ministry of Public Health sought to strengthen governance; but were hindered by centralised decision-making, high leadership turnover, and weak intersectoral coordination. These findings highlight a dynamic and complex reform process marked by ambitious goals and persistent structural limitations.

Conclusion: Ecuador’s 2007–2017 health reform expanded universal coverage by removing fees, strengthening primary care, and promoting intercultural health. Yet, weak referrals, inconsistent implementation, and poor planning limited impact. Political will advanced reforms but created resource imbalances. CPHN reduced some fragmentation but segmentation and weak public–private integration persisted. Leadership changes improved governance foundations, though high turnover and poor collaboration undermined progress. Future reforms require stable governance, clear local roles, stronger community engagement, and greater system integration.