Costa Rica's health success due to PHC – not because it's a 'crazy, magical place'

In Costa Rica, people live longer than elsewhere – the country has the third highest life expectancy in the Western Hemisphere. They also have a lot less infant mortality – about half of their neighbors in Latin America and the Caribbean.

The key to this success, researchers say, has been the country’s unique primary care system, which combines preventive and curative care for nearly all Costa Ricans.

At the heart of this system are multidisciplinary teams known as Equipos Básicos de Atención Integral en Salud (EBAIS) that consist of a doctor, a medical assistant, a community health worker, and a medical data clerk known as a Registros de Salud Clerk (REDES). These teams care for about 4,000 people and are assisted by nutritionists, psychiatrists, and pharmacists covering larger areas.

Over the past several years, Ariadne Labs, a joint center for health systems innovation at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, has conducted extensive research into the Costa Rican primary health care model.

We spoke with Hannah Ratcliffe, Ariadne Labs' former associate director of research for PHC, and Dr. Madeline Pesec, a PHC research assistant who also works at Brigham and Women's Hospital, about their research on the Costa Rican system and what lessons it could hold for other countries, especially as the world strives to achieve universal health coverage by 2030.

Exemplar News: What was the primary health care situation in Costa Rica prior to the 1990s?

Dr. Pesec: Prior to the 1990s, Costa Rica had excellent primary care principles and values. They had rural health programs and individual hospitals that were doing great work reaching out to communities. The Ministry of Health provided public health and primary care services and they were incredibly patient-centered before that became a buzzword. They would reach out and get to patients by whatever means necessary, by horses, by four-by-fours, by canoes. Separate from that, there was the medical hospital-based system which was owned by the social security system, known as the Caja. They provided some primary care as well, but were a little bit more specialized, a little bit more medicalized.

In the 1990s, they had these two systems (one by the Ministry of Health and one run by the Caja) and there were often overlapping jurisdictions, so who was covering what population wasn't exactly clear. They did have a really strong foundation in primary care principles and have always been really grounded in community-based work. I think it’s really important to understand that the primary care system that emerged in the 90s didn't appear out of thin air. Many individuals did work in the 60s to 70s and the 80s to establish the values and principles that made the primary care system what it is today.

Exemplar News: What prompted Costa Rica’s development of a national primary health care strategy and the EBAIS model?

Dr. Pesec: During the 1980s in Costa Rica, as in much of the world, primary care spending was cut. Everyone was looking for ways to simplify and streamline, and there were a lot of access issues. There was an outbreak of the measles in the early 1990s that seemed to be the tipping point for exposing the cracks in this system, and especially having the duplicative efforts of the ministry of health and the social security administration, both trying to provide primary care, but with slightly different focus. I think all of that was the tipping point for them to say: "Now is the time for us to really think critically about how we provide primary care and come up with one unified approach that is going to encompass everybody's needs and will hopefully help address some of these issues."

Exemplar News: How did the country go about implementing these reforms?

Ratcliffe: I think it’s important to establish first what the reforms were. Our research over the last several years has found there were really four critical elements to these reforms. The first was the merger between the ministry of health and the social security administration and the transfer of responsibility for the provision of primary care over to the Caja, and so that consolidated their efforts and was aimed at reducing those inefficiencies Dr. Pesec mentioned. They also geographically empaneled their entire population, made sure everyone in the country was assigned by where they lived to a care team. They built those multidisciplinary care teams, the EBAIS teams, to care for those empaneled populations. There's also the measurement and monitoring systems that they put in place to track all of this work and support and ensure the quality of the reforms.

We've identified a few tactics that were really critical for actually rolling out this work. First, they did a lot of work to learn. As we said, they'd already had a lot of success internally and so they wanted to understand what had worked about those different models and what hadn't worked. They also conducted international learning tours to see what other countries had done successfully and what was working for others that they could bring back home. They put a lot of emphasis on collaborative problem solving and merging people and cultures across these different organizations, and building lots of technical working groups to tackle specific issues. They also engaged the community a lot when they went about this. When they were trying to understand the best way to geographically empanel people or think about what care teams should look like, they did a lot of community engagement to figure out what the population health needs were and how those could be met.

They also prioritized retraining these clinical teams. This was a new way of providing care for really everyone involved. Some of the cadres were new, but others were being repositioned and redeployed and being asked to do things a little bit differently with this community health lens. They did a lot of retraining, and then ultimately built that training and way of thinking into their medical school curriculum and nursing curriculum. The final thing I'd say is that they prioritized equity throughout. They started in the places with the worst outcomes that were the least well served and made that their first focus, before expanding closer and closer into urban centers.

Exemplar News: Could you tell us more about the creation of EBAIS teams and clinics?

Dr. Pesec: The basic structure of the EBAIS team is a five-person unit, but you could have additional personnel based on the needs of the specific community. It is fundamentally a team model. Each EBAIS has a physician providing general medical care, which in the early 90s was actually a pretty radical idea. That was one of the points that they fought hard for when they were getting funding for the reform. Each EBAIS also has a nurse assistant that assists the doctor in rooming patients and obtaining measurements and other clinical tasks. Costa Rica also created an army of community health workers, called ATAPs, that complete home visits, administer vaccines and provide health education. There is also a unique position in Costa Rica called a REDES, which is a data clerk that helps check in and register patients, but they also keep really detailed records on range of health quality metrics. Finally, most EBAIS' have a pharmacist that dispenses medications and provides patients education around medications and other core health topics. Some of the very small satellite clinics don't all have a pharmacist yet, but ideally they would.

Exemplar News: How has measurement and monitoring contributed to Costa Rica's success?

Ratcliffe: I think a few things which jump out to me are that Costa Rica has taken a parsimonious set of metrics they place a lot of stock and value in, and they measure everyone against those metrics every single year. There's no financing attached to that but there's a culture of valuing that data for what it shows about performance and what it can indicate in terms of where improvement is needed. I think when you combine that with the belief that everyone deserves the best possible care, that's a really powerful force and a tool to have in the tool belt.

Our work has documented how the local teams collect all this data, through the REDES, like Maddy mentioned. All the data gets funneled up to the health area and up to the national level but, crucially, it also gets sent back down. Teams at the local level have data they can work with to assess their own performance. They work with their health area to make an improvement plan if they're not getting the results that they want. We can talk a lot about specific indicators or specific data streams but I think it's really that culture and the bidirectional data flow that have really underpinned a lot of the focus on quality and enabled that focus on quality.

Dr. Pesec: I went to Costa Rica in the summer of 2017 to try to understand these data systems a little bit better. I was trying to figure out what was driving staff to care about data collection because it can be so onerous – especially before computers everything was meticulously tracked by hand. I saw, in clinics all over the country, three-foot-high stacks of books with every patient that had – for example – hypertension in their empaneled population. It's an incredible amount of work to catalog all of this. I had the American perspective of, "Who cares? If your performance numbers are low, so what? What's going to happen? There's no money attached to performance on these metrics, so why bother?" The people I interviewed were dumbfounded. They would say to me, “This is health care! We're dealing with people's lives. Of course, it matters. How could I practice medicine without any accountability to my population?” What I heard from respondent after respondent was that it was distasteful to attach a monetary bonus for doing their job well, especially when people’s health was on the line. It was surprising, coming from an American perspective, that health care workers were motivated to perform well on their metrics without a financial bonus attached. The Costa Rican primary care system has developed a strong culture that data matters not because it's numbers in some book that their boss is going to look at, but rather, data matters because it represents people's lives and people's lived experiences.

Exemplar News: What are some of the challenges that remain for Costa Rica's health care system?

Dr. Pesec: They're at a pivotal moment in how to continue to develop and strengthen their EBAIS teams. Implementation started in late 1990s and really has still yet to be fully completed. There are certain metropolitan clinics in the capital city of San José that never received the full model. By that I mean they're sometimes sharing community health workers (ATAPs) or they have health areas, but the different clinics within each area have not yet been fully defined. I think that is one of the major challenges, just finishing the implementation of the model in the capital.

More broadly, maintaining a strong commitment to primary care is challenging, especially in the era of COVID or when your hospitals are also requiring investment and money. It's hard to maintain the level of excitement around primary care that they had in the 1990s.

Finally, Costa Rica continues to work on the question of how to leverage the private sector without compromising the care provided in the public sector. How to appropriately regulate and integrate the private sector into the public sector is a challenge for every country that has a public provision of health care, and Costa Rica is no exception to that.

Exemplar News: What would you say are the main lessons from CR’s experience for other countries?

Ratcliffe: A few things that really stick out to me are this combination of public health and medical care and the bridging of those functions in a way that doesn't sacrifice one for the other. Also, as we've talked about, measurement and data really matter.

We haven't spent a lot of time talking about their community health workers, but I think it's an amazing piece of the team. That's something that I know more and more countries and places are interested in exploring, that true integration of community health workers into teams in both the way information flows and data flows, the way they're paid and supervised. They're not just this appendage that's tacked on, but they're really the core of teams.

Finally, the piece that has always really resonated with me through all of our years of talking about Costa Rica, is we've gotten a lot of pushback from a lot of different places about why would we even talk about Costa Rica. In many people’s minds, Costa Rica is this crazy, magical place that disbanded its army and is socialist. And yes, they’ve taken a simple, elegant whole system approach to care. But I think there's a lot of very concrete pieces, the measurement, the merger of public health, that even if you can't do everything, those things seem approachable. I think being able to see the underpinnings of the success is not just a cultural aberration, but something that's meaningful and doable elsewhere.