San José, Costa Rica, since 1956

The Path to Better Health

With the weight of the pressures bearing down on Costa Rica’s public health system, it’s a wonder Rosa Climent gets to sleep at night.

At five o’clock every morning, lines of sick people form outside local medical clinics to solicit appointments that might be scheduled two or three weeks later. The public hospitals are full, with wait times for surgeries extending to five or six weeks.

And the costs of extending care are creeping up at the same time the government is increasingly tight-fisted in the face of the economic slowdown.

Yet, with Costa Rica’s Social Security (Caja) health care system boasting nearly seven decades of experience and impressive health statistics – including one of the highest life expectancy rates on the continent – Climent, who heads Costa Rica’s public health care system, is confident that this small country with a population of 4.5 million can remain a leader in the field.

“Being able to sustain the system will be a challenge,” she admitted. “How do we continue to maintain (the Caja) after 65 years, with the amount of demand and the need for more technology? I have faith that if we remain unified as a country – committed to solidarity – we can sustain it.”

But many argue that the system is already falling apart.

Roulan Jiménez, president of the Costa Rican Doctors and Surgeons Association, pointed to the loss of hospital beds as just one indicator of the system’s shortfalls. When the public health care system was born, there were 2,000 hospital beds, he said, adding that there are many more people but only 1,500 beds today.

“Our health system is very good,” said Jiménez. “But we aren’t using our resources very well. We need to restore these beds, and that requires an investment.”

For Dr. Pablo Guzmán, rector of the University of Medical Sciences in San José, it is the dearth of specialists that is handicapping the system.

“There is a national emergency (in the deficit of) specialized physicians,” he said. “When people go to the hospital – especially in rural areas – for a specialized service, appointments are given one or two years later.”

And then there’s the aging population, an economic crisis and an increasing population of illegal immigrants who don’t pay into the system. All of these factors put pressure on the public health care system.

Dr. Henry Wasserman, who works within the Health Ministry, said these combined pressures might push Costa Rica to a more privatized approach to health care.

“I hate to be the pessimist,” he said. “But I think we will go in the direction of the United States. Why? Well, in part because we are limited by funding in the public system, which could push us to investigate other options … such as a more developed private wing.”

In the Private Direction

One look at the private health system with its ritzily-furnished offices, Lexus-like equipment and McDonalds-paced services and it’s clear that, compared to the cramped workspaces and crowded hallways of the public hospitals, the private option has a lot to offer. But even the private system faces challenges.

With regular accreditation inspections and corporate reviews, private hospitals in Costa Rica constantly have to update equipment and pitch their services to remain competitive in the growing medical tourism market.

“We are working to increase our technology and skill level to handle more complex cases,” said Arden Bennett, chief executive officer at Hospital CIMA in San José. “At the same time, we need to maintain quality … and keep costs low, which can be a challenge.”

Though Bennett is hoping to guide CIMA to the pinnacle of private health care in Central America, he said he doesn’t want state-of-the-art equipment and the latest technology to price out the local clientele.

“Volume is very important to us,” Bennett said, adding that while pricing is based on a number of factors – including operating costs, infrastructure investments and physicians’ prices – “cost containment (for the patient) is one of my top priorities.”

The Pressure of Greater Volume

It’s that volume that holds prices relatively low at CIMA, which is alternatively threatening the future of the Caja.

Costa Rica has a rapidly growing immigrant population, with an untold number of undocumented residents who don’t pay into the Social Security System.

“The (illegal) immigrant population raises many questions,” Wasserman said. “How far should we go in covering them? What services should they have access to? Should we continue to pay for them, even when they don’t contribute?”

Jiménez said he’s aware of Costa Rican citizens living outside the country who return to their home country for major surgeries. They don’t pay taxes, he said, but they take advantage of the services.

Legislators recently introduced a new immigration law to require foreigners employed in Costa Rica to contribute to the Caja before they can renew or request residency. The law is expected to generate significant funding for the Caja to help meet the costs of the use of the service by immigrants.

Preventing a Decline

Health officials acknowledge the long waiting lists and shortages of specialists, and they say they have tried to solve the problem through further funding.

Between 2000 and 2003, $17 million was invested to address the wait time, but, according to a March 2006 article in the daily La Nación, services for Costa Ricans continued to be delayed for up to nine months for orthopedic surgery, eight months for an appointment with a skin specialist and an average of nine months for the more than 17,700 hoping to see an ophthalmologist.

According to the article, the Caja said it was impossible to eliminate the waiting lists, but seriously ill patients could receive services more quickly. They’ve since created a commission specifically tasked with reducing the wait time and built more hospital space in Heredia.

The Caja also is in the process of rebuilding a section of the CalderónGuardiaHospital, in San José, that was destroyed in a fire in 2005. Climent said the Caja also has launched a campaign to increase the number of specialists in the system.

“We are working on expanding the resumes of our current medics by training them in certain fields,” she said, “but we are also looking to add more specialists to the system.”

Climent said much of the challenge in improving public health care rests in limiting the demand for services. Because care is offered free, many people (especially those with more time on their hands) will take advantage of it for every small ailment.

She acknowledged there are no simple solutions, but she pointed to countries such as Canada and the United Kingdom that are faced with similar situations.

Surviving on Solidarity

The weight of non-contributors and the over-users has not been enough to spark a reorganization of the the system, mainly, many health administrators say, because Costa Ricans have long believed in solidarismo. The idea that those who can pay should support those who can’t is a belief that is embedded in the culture.

Jiménez said, “I think it’s the best system in the world, even with all its defects, for a very simple reason: solidarity. I pay so that I have health services. And the people who can’t pay – they, too, have access to service …”

The system works in his favor, he said, because – by paying for those who can’t pay – viruses and other medical complications are held at bay.

And, while absorbing undocumented residents or informal workers in the Caja threatens the system’s overall health, Costa Rica is so far making it work, which is evidenced in its population.

The Central American country outranks the U.S. in general health, placing 36 in a World Health Organization (WHO) survey compared to the U.S. ranking of 37. Costa Rica also has the second highest life expectancy in the Western Hemisphere, after Canada.

“Our system has been accused of being unsustainable for many years,” Jiménez said. “Many systems like ours have gone bankrupt. But ours has not. In one manner or another, with all the problems that exist now, we have been efficient.

“Many people said it was impossible. But, here we are, doing the impossible.”


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