“Costa Ricans live longer than we do. What’s the secret? ”Wrote Atul Gawande, professor at Harvard University School of Medicine and School of Public Health.
That is the title of the article published in August in The New Yorker , in which the endocrine surgeon highlights that, unlike the United States, the Central American nation has made public health a priority.
The also author of four books tells BBC Mundo that behind this extensive report there were six months of research and “a deep trip” to Costa Rica (in April), in which he “observed a lot.”
“It is extraordinary to see that a country went from having a life expectancy 13 years less than the United States to equal it in the 20 years that followed the launch of their public health programs, with only one sixth of the per capita income of the United States States ”, he points out.
“ And not only did it exceed the life expectancy of the United States, but it also achieved the highest in South America and North America, with the exception of Canada. ”
Costa Rica is on its way to approach the 81 years of life expectancy . The United States peaked at 79 years and has decreased, he points out.
“The very fact of its impact and its results , beyond the size of its economy, it is exceptional and I think it has enormous lessons for everyone, including us (in the United States). ”
Although the Costa Rican system is not without Criticism and “tension points,” the key to success, he and many who have studied the case, including his colleagues at Ariadne Labs, believe, is that he has put public health “at the center of care delivery. medical “.
” A recognition “
” It seemed a huge recognition to a country that it has had clear policies and, most importantly, that they have transcended governments “, says the former Costa Rican Minister of Health María Luisa Ávila about the article.
Also thinks Luis Rosero, an expert in demography from Costa Rica, who stresses that Gawande makes visible to a wider public something that has been known for a long time in public health circles , “for 30 – 40 years “.
And it is that according to the Pan American Health Organization (PAHO), the Costa Rican system” has been a benchmark in the region for its orientation based on the Pr Health system and its good results. ”
This was stated in the report“ Profile of the Costa Rican health system and services ”, by 2019. And the Secretariat of the Organization for Economic Cooperation and Development (OECD) indicated in 2017 that “the Costa Rican health system is widely seen as a success story “.
Pride
The Central American nation has a population of 5. 094. 114 people and Rosero, like many of his compatriots, says he is proud of the Costa Rican Social Security Fund (CCSS), the public institution that guarantees universal access to health.
“Although you can also hear many complaints that when you go to the Caja you have to wait in long lines, they don’t treat you well, etc., when the time comes, when you have a catastrophic illness, a serious problem, you know that He will answer you if you need high-level hospital care. ”
He not only speaks from his knowledge as an academic, but from his personal experience:“ I received a kidney transplant and I am here thanks to the Caja . I owe my life “.
Ávila, pediatrician and infectologist, is also proud of the CCSS, for which she has worked for much of her professional life. But he clarifies that is a part of the Costa Rican health system.
“Public health is a system that not only covers when the person is treated for the disease, but also invests in prevention, in health promotion. ”
“ We here often do not value the fact that if I I’m thirsty, I take my glass, I turn on the tap and I can drink the water that comes out of there. Trying to improve people’s global health conditions is part of what has made Costa Rica successful in health ”.
A matter of decades
According to Gawande, “in Costa Rica public health has been a priority for decades ”.
The Fund was created as a semi-autonomous entity in 1941, during the administration of President Rafael Ángel Calderón Guardia, and two years later it was reformed, becoming a An autonomous institution designed to care for the working population through a tripartite financing system.
But it was in the decade of the 70, says Rosero, when it was established as the current system.
“A new health law is issued and what was called the universalization of Social Security, which in reality was to pass all health centers to Social Security, the care provided by the Ministry and thus a universal system is established “.
In that decade, wrote Gawande, Costa Rica concentrated on combating maternal and infant mortality, reinforcing pre and postnatal care.
In addition, it undertook nutrition programs and sanitation and vaccination campaigns, launched a care network for children and invested in education.
“The strategy showed rapid and dramatic results. On 1970, 7% of children died before their first birthday. On 1980, only 2% did. Over the course of the decade, maternal deaths fell by 80% “.
These advances had an impact on the country’s life expectancy.
In the mid-90, Rosero points out, a new reform of the health sector is being carried out, which was different from those of many countries in Latin America, in which they tended to privatize.
“Not in Costa Rica, what is done is to return to the idea of reaching the most needy, most abandoned population through small clinics that were called the EBAIS (Basic Teams for Comprehensive Health Care) ”.
“ That has an extraordinary success: improves people’s accessibility, inequities are reduced. ”
How does it work?
Public insurance covers approximately 95% of the population. However, health benefits cover the 100% of the inhabitants.
The 5% of uninsured include, for example, informal or temporary employees, undocumented immigrants, certain refugees, some indigenous groups.
The Fund is financed with contributions from members, employers and the State.
Between 2011 and 2016 the country invested in health, on average per year, the 8% of Gross Domestic Product , reported the Ministry of Health in 2019.
On 2016 , public spending on health represented the 19, 5% of total government spending, said the PAHO, while the total per capita expenditure was US $ 909.
The country is divided into health areas that have “an assigned population of between 15. 06 and 40. 000 inhabitants in rural areas and between 30. 000 and 45. 000 inhabitants in urban areas ”, indicates PAHO.
And in these areas 1.0 works 45 EBAIS, considered the basis of the national health care system, which have five members, including a doctor and a primary care technical assistant (ATAP).
The ATAP
The ATAP, explains Rosero, make home visits to provide very basic health services and refer patients to medical consultations.
During his time in Costa Rica, the work of these ATAPs impressed Gawande with their professionalism and commitment.
Remember one in particular who, riding on his motorcycle, took vaccines against covid – 19 to patients who could not travel to their local clinics.
Each EBAIS carries a “ family file ”for each household under his charge and according to the priority with which that family is classified, they are visited one, two or three times per year.
Although in practice not all Costa Ricans receive these visits, where home care is best performed, explains Rosero, is in rural areas and towns remote, and priority is given to older adults and those, of any age, at risk.
In the community
“When the team goes to the houses, it can identify the greatest needs,” Gawande tells BBC Mundo.
And that allows the system and public health are intended to “close the gaps” that are found.
“In many health systems around the world, not only in the United States, the system and its spending are not prioritized in function of those main needs. ”
“ I think the finding that Costa Rica can achieve both , even with modest incomes, it suggests that there are also many opportunities in other countries “.
The doctor praises the Costa Rican professionals who” embraced the belief that individual health and public health they are inseparable ”and who care about the needs of both the“ patient who walks through the door ”and the one who does not arrive.
It highlights the importance of understanding the conditions in which the community lives and connecting that knowledge with medical care, as this will allow detecting problems and preventing them.
“You interweave the reality of the context, the community and individual health.”
The system in the US
Rosero had already addressed what led Gawande to Costa Rican lands.
On 2016, signed together with researcher William H. Dow the article “Exploring why Costa Rica surpasses the United States in life expectancy: a story of two gradients of inequality ”, published in the journal of the United States National Academy of Sciences (PNAS).
“Why is inequality in health less in Costa Rica?” They asked.
“One hypothesis is that it is related to universal health insurance for life, with excellent access to primary care in Costa Rica, which provides a strong safety net for the poor in contrast to the high rates of the uninsured, poor and under 65 years, in the United States ”, they wrote.
And it is that with their 329. 484. 123 inhabitants, the North American nation does not have a universal health care program and there is no consensus on lithic around it.
The government finances health plans aimed at older adults, disabled people, in a situation of poverty , pregnant women, youth and children, and also pays for a program for military veterans.
On 2019, health spending represented 17, 7% of GDP, according to official figures.
Employers pay for health care to many Americans, largely through private insurance .
A study of 2009, conducted by Harvard researchers, found that “ almost 45. 000 annual deaths are associated with the lack of health insurance. ”
In 2019, “8% of people, or 26, 1 million, did not have health insurance at any time during the year ”, according to the Social and Economic Complement Annual Current Population Survey (CPS ASEC).
Universality
Do you think that your country could incorporate some elements of the Costa Rican model in the future?
“The way to advance and improve a health system is by observing what I call positive deviation, the places that obtain extraordinary results and then replicates ndo and scale ndo that kind of results “, he said Gawande to BBC Mundo.
” And learning is both ways. There is learning that often comes from places like the United States and then learning can come from all the countries in the world where people have decided to try and achieve new things. ”
Rosero points to the model of the universalization of the health system as a key.
“If the United States adopted something similar to what it already has with the Medicare — a government-run social security coverage program that provides health care to all people over the age of 65 years or younger considered disabled due to to serious health problems — at younger ages, it would achieve something similar to Costa Rica ”, he says.
“ First, it would reduce inequities, the huge gaps between social groups and, second, it would improve hope of national life in national indicators. ”
The shortcomings s
Ávila says that Gawande made a “good review” of the Costa Rican health system in his article, but acknowledges that there are aspects in which progress must be made .
The doctor talks about complaints from part of the population: the lines to access primary care, the waiting lists of the Fund .
“That has to improve, as well as appointments for some surgeries. That is where, as a health system, we are failing. ”
The report“ OECD Studies on Health Systems: Costa Rica ”by 2017 already picked up this problem.
“Frustrated by waiting times of one year or more for procedures such as child surgeries, people increase their out-of-pocket spending to receive health care services in the private sector , causing the risk of a two-tier system ”, he pointed out.
On the other hand, both Ávila and Rosero consider that the coronavirus crisis has been handled well. And although it will continue to pose a challenge for the health system and the Costa Rican economy, it is not the only one.
Challenges
One of the main challenges of the health system, Rosero points out, has to do with the aging of the population.
“Until recent years , the health service enjoyed a demographic bonus because the number of insurance payers who demanded it grew faster days of service, which allowed him to expand and improve ”, he explains.
But that, he says, no longer happens. And what is expected for the coming years is that, due to the aging of the population, demand will grow much faster than the number of taxpayers.
“You will see serious economic problems that may lead to a reduction in the quality of services or you need to look for other sources of financing,” he predicts.
Therefore, he believes in the need for a profound reform.
“Perhaps the most important thing is that the contributions to Social Security do not depend as much as now on taxes on wages “because that subordinates them to” the age structure of the population. blation ”.
“ Points of tension ”
Ávila is more emphatic and believes that the Caja is on the verge of collapse in terms of financing, because health services are “excessively expensive.”
AND “ Many people have insurance from the State, pay a minimum insurance, and unfortunately, some people, not all, think that what they pay is enough. I have always believed that at the level of the Fund, we should give people an invoice. ”
“It may be that you pay US $ 100 per month for his health insurance and I pay US $ 1. 000, but when you need a coronary unit and I do too, they are going to give us the same attention. ”
“There are systems such as, for example, in the United States, where (the care received) depends on insurance that you have. Here, you may be ‘uninsured’ and you came to Social Security, they realized that you cannot pay and you need a liver transplant, it is done and that comes at the expense of the entire health system of the country ”
The one in Costa Rica “ is a solidarity system and that is very good, but we have to look for different forms of financing “, says Ávila.
And he lists other aspects to improve:” The State has to pay Social Security the debts you have, you have to invest more in prevention and promotion . We have to manage chronic non-communicable diseases that have increased a lot in the country, we have to move towards concepts such as healthy aging ”.
The OECD report points out that “there is much to praise the Costa Rican health system”, but warns that there are “serious points of tension” and makes several recommendations.
One of them is that “spending ceilings, regular spending reviews and early warning systems should be used to control spending and stimulate efficiency”.
Another is that “in the longer term, health system funds should increasingly come from the general government budget.”
What can the United States learn?
Costa Rica and the United States represent two very realities different that go beyond history, the extension of their territories or the size of their populations and their economies.
But, for a health expert like Gawande, it is well worth the world power to focus on the Central American nation.
“In the United States and elsewhere, public health and medical care are largely independent entities. Costa Rica shows the benefits of integrating the two: it spends less than we do on healthcare and gets better results, ”he wrote.
Therefore, although the Costa Rican system has areas with cracks – waiting times to receive specialized attention, for example – it underlines that, if they are solved, it could have even more notable results.
“The idea that you have a system in which there is accountability, universal availability of primary care, intertwined with the commitment of the public health ”, that there are teams that“ will identify gaps in care, in access to services and will work to close them, that is the system that has been an important reason why Costa Rica has done so well ”, he tells BBC World.
“And I think that is the capacity that we should try to create in the United States.”
This article was made with the edition of Leire Ventas and the collaboration of María Fernanda Cruz Chaves.
You can read The New Yorker report here
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