In the August 30, 2021 issue of the New Yorker, Atul Gawande takes a close look at the health care system in Costa Rica that, within a few decades, improved so rapidly that now its people have a higher life expectancy than the US and at a much lower cost. The numbers alone tell the story.
In 1950, around ten per cent of children died before their first birthday, most often from diarrheal illnesses, respiratory infections, and birth complications. Many youths and young adults died as well. The country’s average life expectancy was fifty-five years, thirteen years shorter than that in the United States at the time.
Life expectancy tends to track national income closely. Costa Rica has emerged as an exception… Across all age cohorts, the country’s increase in health has far outpaced its increase in wealth. Although Costa Rica’s per-capita income is a sixth that of the United States—and its per-capita health-care costs are a fraction of ours—life expectancy there is approaching eighty-one years. In the United States, life expectancy peaked at just under seventy-nine years, in 2014, and has declined since.
This success has naturally attracted the attention of analysts everywhere and they point to one key feature. Whereas in most countries the medical services and public health services are largely distinct (and in the US public health is the extremely poor relation), in Costa Rica they are thoroughly integrated with public health being the priority, central to the delivery of health care.
So when did Costa Rica’s results diverge from others’? That started in the early nineteen-seventies: the country adopted a national health plan, which broadened the health-care coverage provided by its social-security system, and a rural health program, which brought the kind of medical services that the cities had to the rest of the country.
But what set Costa Rica apart wasn’t simply the amount it spent on health care. It was how the money was spent: targeting the most readily preventable kinds of death and disability.
In the nineteen-seventies, Costa Rica identified maternal and child mortality as its biggest source of lost years of life. The public-health units directed pregnant women to prenatal care and delivery in hospitals, where officials made sure that personnel were prepared to prevent and manage the most frequent dangers, such as maternal hemorrhage, newborn respiratory failure, and sepsis. Nutrition programs helped reduce food shortages and underweight births; sanitation and vaccination campaigns reduced infectious diseases, from cholera to diphtheria; and a network of primary-care clinics delivered better treatment for children who did fall sick. Clinics also provided better access to contraception; by 1990, the average family size had dropped to just over three children.
The strategy demonstrated rapid and dramatic results. In 1970, seven per cent of children died before their first birthday. By 1980, only two per cent did. In the course of the decade, maternal deaths fell by eighty per cent. The nation’s over-all life expectancy became the longest in Latin America, and kept growing. By 1985, Costa Rica’s life expectancy matched that of the United States.
At some point, once basic public health needs are met, countries tend to switch their emphasis from public health measures to hospitals and advanced specialties. But Costa Rica did not go down that road. Instead in 1994 they expanded their existing model by creating small public health units in every community where the workers would visit each and every home, kept careful records of everyone, and thus could identify and respond quickly to any needs that they encountered. The neighborhood doctor and public health official were rolled into one.
[E]very Costa Rican would be assigned to a local primary-health-care team, called an EBAIS (“eh-by-ees”), for Equipo Básico de Atención Integral en Salud, which would include a physician, a nurse, and a trained community-health worker known as an ATAP (Asistente Técnico en Atención Primaria). Each team would cover about four or five thousand people. The ATAPs would visit every household in their assigned population at least once a year, in order to assess health needs and to close the highest-priority gaps.
By 2006, nearly the entire population had been enrolled with an EBAIS. Universal insurance coverage—to pay for hospitalizations and specialized care—would take longer. But universal primary care, delivered by more than a thousand local teams and with an emphasis on prevention and public health, was now a reality.
ATAPs, a category of clinician we don’t have, combine the skills of a medical worker and a public-health aide. They are professionally trained, salaried, and proud. Herrera, whose dark eyes showed a desire to get moving, wore a long-sleeved white shirt, blue pants, and black shoes, with credentials dangling from a lanyard around his neck. He carried with him a backpack of medical supplies, a tablet computer, and a cooler of covid vaccines.
Each ATAP is responsible for visiting all the people assigned to his or her team, which for Herrera represented about fourteen hundred households. The homes are grouped into three categories. Priority 1 homes have an elderly person living alone or an individual with a severe disability, an uncontrolled chronic disease, or a high-risk condition; they average three preventive visits a year. Priority 2 homes have occupants with more moderate risk and get two visits a year. The rest are Priority 3 homes and get one visit a year.
For each of the households, Herrera keeps an electronic ficha familiar, a family file that provides the primary-care team with remarkably detailed information. This includes medical updates—what ailments have been assessed and what treatments have been administered on any given visit—but also notes on living conditions: whether the floors are dirt or finished, whether there is a refrigerator, a phone, or a computer, and even whether any animals are living “en condiciones insalubres.” According to the C.C.S.S., nearly sixty per cent of Costa Rica’s households have a current, geo-referenced file.
There was nothing magical about the care I saw that day. Herrera wasn’t a saint. But he may have been something better than that: he was the point of contact between a national system and a great many individual lives, seeing to every small detail required for the broader demands of community health.
Gawande spoke with a regional director of the program about how they go about their work.
[Director of the Atenas Health Area, Carolina Amado] wants all the members of her teams to understand that their priority is “the relationship with the community, not just between the physician and patient.” This, she said, is the foundation of the EBAIS system. There are critical services that have to reach everyone in the community at every stage of life, she explained. Children have regular pediatric visits, starting from the first days of life. Pregnant women have their prenatal and postnatal checks. All adults have tests and follow-up visits to prevent and treat everything from iron deficiency to H.I.V. It’s all free. If people don’t show up for their appointments, she makes sure their team finds out why and figures out what can be done.
The results are enviable. Since the development of the EBAIS system, deaths from communicable diseases have fallen by ninety-four per cent, and decisive progress has been made against non-communicable diseases as well. It’s not just that Costa Rica has surpassed America’s life expectancy while spending less on health care as a percentage of income; it actually spends less than the world average. The biggest gain these days is in the middle years of life. For people between fifteen and sixty years of age, the mortality rate in Costa Rica is 8.7 per cent, versus 11.2 per cent in the U.S.—a thirty-per-cent difference. But older people do better, too: in Costa Rica, the average sixty-year-old survives another 24.2 years, compared with 23.6 years in the U.S.
The Costa Rica model suggests that directing those expenditures wisely—in ways attentive to the greatest opportunities for impact—can be transformative when it comes to the less connected and the less advantaged.
The examples of better outcomes extend to even dental treatment.
Dental care was not a significant part of the EBAIS structure that Salas helped design. But its systemic approach took root more widely. As Rodríguez explained to me, members of her profession helped lead an effort, starting in the nineteen-eighties, to institute after-lunch toothbrushing in elementary schools. Toothbrushes were provided for every student; rows of sinks were installed at schools, so that groups of children could brush at the same time. The program insured that all schoolchildren brushed their teeth at least once a day. The effort began in and around Palmares, and soon the idea was implemented across the country. Meanwhile, the Ministry of Health required that table salt be fluoridated—an easier way to introduce fluoride on a national scale than fluoridating every town’s water supply.
The results of such measures have been dramatic. In 1980, Costa Ricans averaged more than nine teeth decayed, missing, or filled by the age of twelve. By 2002, the number was below two. Today, it is below one—results as good as America’s or better, at a fraction of our costs.
Costa Ricans, it now struck me, had some of the best teeth I’d seen anywhere in my travels. Rodríguez and her partners were showing how dental care could be improved even further. They were integrating public health and individualized care—creating an actual health system—even in dentistry.
This program is so popular that it would be extremely difficult for any future Costa Rican government to undermine it.
Other countries have taken note of what Costa Rica has achieved and are using it as a model for improving their own system. Not the US, of course. The medical-pharmaceutical-hospital industry in the US will fight tooth and nail to prevent any such system being ever implemented here since it focuses more on people’s health than their own profits And all those in the US who, because of their ignorance of what other countries do, think they have the best health care system in the world, even if it is obviously not and it serves them extremely poorly, will also fight it.