A course in care: PSU students get first-hand look at Costa Rica health care system

Patients share a smile with Penn State students Chioma Maduforo, left, and Avni Kothari, right at San Rafael hospital in Alajuela, Costa Rica.
Patients share a smile with Penn State students Chioma Maduforo, left, and Avni Kothari, right at San Rafael hospital in Alajuela, Costa Rica. Photo provided

For the third year, a group of students from Celeste Newcomb’s health policy and administration 401 class traveled throughout Costa Rica earlier this month. The trip gave students an inside look at each component of the country’s health care system.

Fifteen students in majors including health policy and administration, biobehavioral health, nursing and aerospace engineering toured health care facilities, spoke with clinicians and witnessed the country’s renowned health care system in action.

Costa Rican citizens are proud of their health care system and its outcomes. Regardless of income or socioeconomic status, workers and their employers pay 9 percent and 23 percent of the workers’ salaries, respectively, toward La Caja, the collective fund that contributes to the country’s social security system. Even those who do not work receive free health care services.

Costa Rica has had universal health care since the first half of the 20th century, and in 1949 Costa Rica abolished its army in order to help finance the country’s health care system. Now, Costa Rica insures 85.5 percent of its population of 4.71 million people. The majority of the remaining 14.5 percent consists of migrant workers who still receive free basic health care services even though they do not pay into the system. Even tourists are covered by the country’s social security system.

Costa Rica has three levels of health care. First are EBAIS (equipos básicos de atención integral en salud, translating to basic teams of global health care) clinics, which handle basic primary care needs. Also at this level are ATAPs (asistente técnico de atención primaria de salud, translating to technical assistants for primary health care), who visit every house in the country to make sure residents have proper vaccines, live in adequate conditions and receive medical attention. ATAPs also record the prevalence of diseases and health problems and report their findings to the Ministry of Health. The ministry then identifies health care needs, sets goals and makes policies that reflect the ATAPs’ suggestions.

The top priority in the Costa Rican health care system is prevention, which ensures that health care is provided through the most cost-effective means. Focusing on prevention rather than disease treatment is linked to better long-term health outcomes.

Students shadowed Costa Rican ATAPs in their clinics and out in the field while visiting the towns of Las Juntas and Tilarán. Students visited the houses of families that were labeled as low, medium, or high risk based on their living conditions, health and risk potential. The ATAPs also helped to identify residents who were especially in need in Las Juntas, and the students presented mobility-limited individuals with a wheelchair, crutches and a walker.

The second level of care in Costa Rica includes regional hospitals, which patients are directed to if their condition is too severe to treat at a local EBAIS clinic. Students toured the San Rafael de Alajuela regional hospital. Designated as the regional hospital for 571,000 people who live in the surrounding area, the hospital also recently was selected as one of the country’s two medical centers prepared to deal with Ebola due to its close proximity to the San José airport.

The final level of health care consists of national and specialized hospitals, which are dedicated exclusively to fields such as women’s health, pediatrics, orthopedics, gerontology, psychiatry and others. Penn State students started their tour of the health care system at a specialized children’s hospital in the center of San José. The hospital director said that his hospital is considered among the best in Latin America. Although only slightly larger than Mount Nittany Medical Center, it has the potential to treat complex diseases of to as many as 1.3 million children. Like all other health care services in Costa Rica, families can send their children to this hospital at no cost.

The Costa Rican government spends just more than half of what the United States government spends on health care each year. However, the life expectancies in both countries are similar, with the U.S. at 79.6 years and Costa Rica at 78.2 years, according to the CIA World Factbook.

Both countries also face the challenges that come with having an aging population. Although mortality rates are higher in the U.S. than in Costa Rica, the latter country does not have enough growth for its population to replace itself. Much like in the U.S., women in Costa Rica are immersed in the work force and wait until later in life to have children, and family size is decreasing. Now, 20 percent of all Costa Rican births are to teenage mothers. This statistic, along with the high prevalence of babies born with fatal congenital malformations due to the prohibition of abortions, may help to explain the country’s high infant mortality rate of 8.7 deaths per 1,000 live births.

In touring the facilities, it was sometimes hard to believe that Costa Rican health care outcomes are so good, even rivaling those of the United States.

“Even though the appearance of the buildings is not as nice as those in the U.S., the quality of care inside the buildings is the same if not better,” said Kelsey Sims, a Penn State senior studying health policy and administration. “Costa Ricans place more importance on care than aesthetics and only use expensive technology when absolutely necessary.”