Month: January 2016

Outside the health clinic in Monte Verde

Inside the clinic

Telemedicine is used in this remote clinic for some services as the clinic is five hours from the closest hospital.

Vaccination against polio and other diseases is encouraged.

Danika Hoffman – Reflection Six

Tool six regards health care financing. In Costa Rica, the percent of GDP spent on healthcare is 9.9% (The World Bank, 2016). The majority of people pay for healthcare through the Caja Costarricense de Seguro Social (CCSS) system. The CCSS was created in 1941, and it functions as a social security system. Employees pay into the system from their salary, and employers also contribute on behalf of each employee. Then, when healthcare is needed, it is covered by the CCSS. If a person has a lot of money, they pay more into the system, and if a person does not have a lot of money, they do not pay as much into the system. However, everyone receives equal access to the system and equal care in the system. A very small percentage of people (3%), usually very wealthy, own private insurance. Private insurance helps people to receive care more conveniently, but often times when a medical problem is complex people with private insurance have to transfer from private hospitals to public hospitals because public hospitals are best equipped to treat complicated conditions. Also, all vaccines are done through the CCSS system, so people with private insurance are still vaccinated through CCSS. For people who struggle to afford to pay into the CCSS system, there is a state system to help them afford care. Children are a special population in Costa Rican healthcare. For pregnant mothers and people under the age of 18, healthcare is free. Furthermore, vaccinations are mandatory for children. A parent cannot refuse the vaccination of a child because that is against the law. This payment system has created a country with very good health outcomes despite its status as a developing nation. The only drawbacks are the fact non-emergency care likely includes wait times. Currently the waiting lists for orthopedic, ear nose and throat, and urology non-emergency treatments are extensive.

Ama Brown – Daily Log Five

During our time here in Costa Rica, we have visited many types of health facilities, all different in quality and ability. Regardless of all the differences, one thing that they all have in common is a mission to provide quality care to their patients. The first hospital that we visited during our stay here, Hospital Clinica Bilica, which is accredited by the Joint Commission International, is a high quality private hospital. In this facility, they have many of the technologies that can be found in the U.S. New in model, the facility possesses the same look that one would expect in a first world country. Though it provides care for people who have private insurance or financial ability to pay for service, the facility still devotes its time to creating a safety net for the underserved population through social action programs. This aim to help the vulnerable population in their communities is the first of many other provisions that Costa Rican hospitals provide for its people, whether private or public. On the lower end of things, the women’s hospital, Hospital De Las Mujers, was not equipped with many of the resources in Hospital Clinica Bilica. Nonetheless, this facility still provided proper care to the women they serve. In Hospital De Las Mujeres, their use of technology lag when it comes to using electronic health records. They have a room where patient files are kept. Regardless, the hospital makes up for it in other areas like social support. One of the departments in the women’s hospital is a social support room for cancer patients. The purpose of this room is to give women who are suffering from cancer a place to feel special by getting their hair, makeup and nails done. Again, regardless of its rank, social support is adequate. A last facility we visited today, Clinica Santa Elena, had equipment used for telehealth. This was very interesting because though considered as a developing country, it manages to succeed in using such a system even the United States have yet to figure out.

We got a special privilege to visit Dr. Rodolfo Hernandez, who is a pediatrician and Kidney doctor. What made this special was because Dr, Hernandez will be running for president. During our conversation with him, he confirmed how valuable the people of Costa Rica are to the authorities and health providers of Costa Rica. He stressed on the importance of good health for infants and adolescents. He stated that, “the baby in the tummy is the future of our country, it is like putting money in the bank”. This idea of investing in healthcare rather than spending seems to be a common theme here in Costa Rica. He further explained that the success of their health system is mainly due to several components. First is good drinking water. According to Dr. Hernandez, 97% of the populations have access to safe drinking water. A second component is their decrease in contamination. Unlike many developing countries, the people of this nation do not urinate or through feces outside. A third reason is due to their free administration of vitamins and vaccination. A last contributor is their screening program. Overall, 94% of their success is due to medicine and 4.6% is due to their environment.

Regardless of the type of hospital, whether a clinic, community hospital, or private hospital, Costa Rican’s health care system devotes special medical attention to people, even refugees. Their facilities are capable of the same care that can be seen in the United States and even better. Whether it is use of medical records, tele health, or just a helping hand, Costa Rica has health care delivery figured out.

Caroline Kaschak

An important key for a country’s health is to have quality health facilities. This may seem like common sense that, clean hospitals, labs with the most up to date equipment, or even a specialty doctor can improve the health of an individual. Though, it is not just having the facilities that is sufficient, it is important that the health centers can meet the demands of the people in the community. This includes aspects such as access, appropriate specialties, enough space, and much more. In Costa Rica there are three different levels of health care: Level 1, 2, and 3. The first level of Clinics are known as Asistente Tenico de Atencin Primaria or ATAPs. This has a basic level of training for the medical professionals that requires about 4-6 months of intense training. The ATAPs normally belong to a certain clinic, but they do not serve at the clinic, instead, they go door to door of the population to handle vaccinations, prevent diseases, monitor blood pressure, provide parasite pills, and much more. ATAPs focus on preventative care. The ATAPs we visited in Las Juntas specifically just went from house to house and assessed potential disease causing factors as well as gave recommendations to the families. This type of intervention seems to be considerably adequate since Dr. Roldolfo Herendez said that 85% of individuals are vaccinated including refugees. This is a crucial part of the health system in Costa Rica because it reaches a wider range of the population health care that desperately needs it, instead of letting them fend for themselves. Also in the first level is general clinics that have very few specialties. There are 1004 of these small clinics throughout Costa Rica. So almost every town has access to health care, though it may not be the best quality because of the lack of specialties, they fulfill the basic needs of the people. The second level of care is larger clinics and basic hospitals. These hospitals/clinics have several specialties including Gynecology, surgery, pediatrics. There are 80 of these throughout Costa Rica to provide a better level of care to all citizens. The third level of care is large hospitals, this include almost all specialties. There are about 29 of these hospitals in Costa Rica. There are 64 pediatric specialties in their pediatric hospital, they also have multi-organ transplants and are the 3^rd country in the world to develop skin graphs. Even as a 3^rd world country almost any procedure can be done in Costa Rica. Many of the facilities we visited had up to date equipment, even the smaller clinics. Private and Public also made a difference in the facilities. Many more private hospitals have more bed space/rooms and better equipment than the public hospitals. Overall the I was very surprised at the quality of the facilities all over Costa Rica.

Today, we visited a small clinic in Montverde called Clinica Santa Elena. Philippe Casada, gave a us tour of the facility along with discussing the three levels of health care. Even though this public clinic was less advanced than some of the others, it still had a lab, dentist, vaccination room, and women’s health room. The most special part of the day was visiting a pediatrician and presidential candidate- Dr. Roldolfo Herendez. He spoke so eloquently about the health care system here and Costa Rica. He was able to highlight the effort of the Tico people who are trying to have a system with three levels of obligation. The 1^st level is the personal level as in if you do not want to get lung cancer don’t smoke. The 2^nd level of care deals with the community level. If you do not want Dengue then the community has to get rid of the growing level of mosquitoes. The 3^rd level in this would simply be the health system itself. He also spoke how important the equal system was in Costa Rica because it can sustain itself and successfully provide care for all. A quote he left us with that stuck in my mind the most, especially with THON coming up- “Kids don’t belong to a country, kids don’t belong to a political party, kids are kids and they deserve the best care.” Such a wonderful experience to talk to a man who really care about the health of his people.

We departed Los Juntas early in the morning to head to the town of Tilarán. As we pulled out of our hotel we heard and then saw howler monkeys! It was a nice reward for getting up early!

In the town of Tilarán we enjoyed an overview session provided by the ATAPs at the health clinic. They explained how the national vaccination program works. Then we split into three groups and headed out to visit patients in the home.

Caroline Kaschak – Reflection 4

Today, we got the amazing experience of shadowing ATAPs throughout the beautiful city of Tilarán. During this visit we got to walk from house to house of patients that belong to the public primary care, Tilarán Clinic. Our main ATAPs name was Patricia. She gave us a much more extensive trip than our ATAPs visits yesterday. In many of the houses they visit once a year to administer needed vaccinations, TB tests if patients show symptoms, parasite pills, condoms, and much more. They aim to prevent illness so they will also assess the living conditions and give recommendations if necessary. There are three risk levels- red: several visits a year/month, yellow: a couple visits a year, or green: one visit a year. Sometimes this is difficult as we experienced because sometimes the man of the house won’t be home in which case the ATAPs may not be able to visit. In our visit today we visited a house where a women had high blood pressure. She was given some pills and recommendations for how to lower it. The ATAPs also said that they would go to her house and monitor her blood pressure everyday for a month till it lowers. Another house we visited apparently didn’t have running water or electricity from the last visit, but by this visit had both. The ATAPs recorded the improvement of the house on their charts. This really intrigued me because you can tell how deeply the government and medical personnel care for not only treatment, but wellness and public health of their patients. I truly think there needs to be more of an emphasis of this in the United States to improve our health system.

A large part of what determines the health care available in an area or within a country is the number of health care providers located there, and their training. If there is only one provider in a large community, care might not be available to everyone who needs it, or at the time they most need it. Similarly, if the provider doesn’t have a good education and clinical training, the care they provide may be substandard. There are many different countries that have medical training programs and each is unique in their own way. In the United States the culture is to go an Undergrad for 4 years. Most students can major in any major but there are a number of prescribed courses that they must take in preparation for the national exam, Medical College Admissions Test, otherwise known as the MCATs. Students are normally in medical school for 4 years and then 2 years of residency (3 or more for specialties also called a fellowship). This is the same for public and private medical schools in our country. Even though both are rigorous, private school is normally regarded as more intense than a public medical school. For nursing in the United States students have to go through 4 years of undergrad at a university and major in nursing. If they wish to become a nurse practitioner it’s another 2 years of schooling.

This is much different in Costa Rica as we learned from Sandy Gonzalez, an Obstetrics and Gynaecology (OB/GYN) nurse from the Hospital de las Mujeres. For Ticos, the custom is to go straight from high school to medical school. There are two medical schools, one is the very large public institution in which they go to school for 7-8 years, the other is a private school which students go to right after high school and go to school for 5-6 years. For specialties the students must stay for another 2 years. The big difference between Costa Rica and the United States is that in Costa Rica the major public school is more well regarded/better prepares students than the private schools do. Sandy said, that pretty much all the students that go to the public school pass the national medical exam administered after medical school. Not as many students from the private school do. After medical school, all doctors and nurses must work in the public sector for three years. For nursing, the school is virtually the same as the United States, where students go to school for 5 years after high school and then another 2 years if the wish to do a specialty. Costa Rican Health care also has another branch of medical personnel called Asistente Tenico de Atencin Primaria or ATAPs. These are medical personal that require 4-6 months of intense training as long as the individual has some kind of experience. These people go door to door to administer vaccinations, give physical exams, check houses for red flags for any diseases and much more. Individual training, the amount of time, and the presence of a national exam to ensure consistency are all extremely important factors in the education of medical personnel throughout the world.

Shannon Wagner – Day Four Reflection

Though quality of care may be relatively uniform among a slew of countries, each country’s own respective medical educational systems can be vastly different in terms of time invested, money spent, and the work environment that greets them once training is completed. As a result, each country faces unique challenges in training up health practitioners. While visiting Hospital de Las Mujeres, obstetric nurse Sandy Gonzalez Fernandez explained the road to becoming a health professional for the typical Tico, and clearly their issues in education contrast with those in the U.S. For one, Costa Rican health professional schools overproduce doctors and nurses and therefore are unable to place all of them. While 6-year programs in private medical schools have recently been created for this increased demand, the 7-8 year public university still offers the single most competitive medical education in the country. Finally—and much unlike the United States—there are virtually no incentives for specialization here. Program spaces are limited, and if a new doctor wants to specialize after their formal training, they are required to work in the public sector for an additional three years—three years of lesser pay. Therefore, while GPs are plenty, specialists are relatively low in number.

Today, we traveled to the little town of Tilarán—a more rural area that lives up to its old indigenous name, Talawa, meaning “windy and rainy”. In Tilarán, the beautifully vast landscapes are decorated with fincas—“little farms”—and windmills. A sunny, windy day is sure to bring sudden periodic mists from the passing clouds, producing seemingly constant beautiful rainbows. We arrived at the clinic early and met our ATAPs (primary care technicians) for the day, and one named Marcela Solano Quesada provided us with a brief orientation describing the basics of a visit. Her introduction echoed that of Javier and Fabián’s yesterday; her emphasis on the importance of prevention above all else was clear as she walked us through each document recording records and risk factors, the traveling briefcase of medical equipment and supplies, and the cooler they also carry for safely transporting vaccinations that will be delivered in the comfort of patients’ homes. Much like Javier and Fabian’s patient cohorts of around 2000, these women make 7-10 home visits each day in rural Tilarán, leading to about one visit per year per family. Though this may sound inefficient by our American standards, this timing is essential to quality. The reality is that these ATAPs are more than GPs, who may spend a couple minutes carefully asking about our home life in a bright, sterile consultation room. Rather, the ATAPs are lifelong friends and caregivers for each Tico family, fully entrusted with their respect, and this respect gives them the ability to facilitate powerful interactions—even emotional family disputes. In reality, they are simultaneously primary caregiver, social worker, and counselor. My group traveled with ATAPs Sydney and Ana, and while we only had time for one visit, in a single house we observed the two administer a tetanus booster to the father, offer advice to the mother regarding her pregnancy, and converse extensively with the family regarding the physical, verbal, and social development of their adorable two-year-old, Maria. Overall, the two women spent nearly an hour in their home—certainly more time than we spend with our own GPs. Ultimately, this basic but consistent level of primary care results in less crowding of the public clinics and hospitals, a constant complaint of critics of public health systems. The Ticos have certainly found a way; if only such a system could be replicated in back home in the US. Only then could we ensure that all our citizens receive attentive care, and only then could we perhaps experience as positive health outcomes across socioeconomic lines.

We ended our time in Tilarán with a visit to a young man that was in need of a wheelchair. While the medical system in Costa Rica provides care for all, it does not provide durable medical equipment. As part of our community outreach, we brought the wheel chair with us from the USA. The patient was very appreciative and was excited to have a photo with us and the ATAPs. A young girl and a cat also joined us for the photo!

Bridget Wheeler

Tool four will be used to compare the United States and Costa Rica at the level of higher education. In the United States in order to become a MD it is required to complete four years in medical school, after graduating from high school. Then depending on if you choose general medicine or a specialty a set amount of years need to be put into a residence, followed by a fellowship. According to Sandy from the Women’s Hospital in Costa Rica students enter medical school straight from the high school, and spend seven to eight years being educated at the highest level. Not only does the amount of years differ but also the value of the public school system. In America establishments such as Harvard, Yale, and Brown are considered more prestigious then the public universities. In Costa Rica the public school is the hardest to get into, and has the highest passing rate for the Costa Rican board test. The private schools were created due to the influx of students entering the medical field. These locations are significantly more expensive, but does not provide the level of education the single public school offers. Upon graduation they must complete a year in the public hospitals and three years if they desire a specialty. Most doctors leave the public hospitals after they meet the hour requirements due to salary. At the public hospitals they receive a monthly salary around $4,000. In private hospitals they are paid per surgery, and a surgeon can make the same amount of money in two surgeries. These two education styles differ vastly in time as well as price.

The medical education is not the only aspect that differs; home health treatment is vastly different in Costa Rica. Today I had the privilege to meet a family that moved from Florida to Costa Rica. This gave me a first hand advantage of comparing the two health systems. In Costa Rica the residents receive treatments at home based on a color system, used by Asistente Tenico de Atencin Primaria (ATAP). This job title is similar to a home-aid in the United States. The color system includes red, yellow, and green. Red is the sign for multiple visits a year, yellow meaning they may have more then one visit a year, and green was a sign for good health; these residents only receives one visit a year. The family I witnessed today was a green level, and consisted of a four year old girl and two parents. Our ATAP Sandra was able to vaccinate the child, father, and check to make sure the women received exams such as a monogram. This vastly differed from the United States not only due to at home convince, but Costa Rica’s ability to provide a mass selection of medical treatments at once. Even in the clinics they would supply dental, emergency, and primary care. In the United States an individual would have to go to multiple locations to receive the care Costa Ricans can in one place. Finally as covered in previous entries the public systems are not necessary bad. This well privileged family chooses to use the public and private system. They explained the only time the public system is not desired is due to the waiting time for non-emergent services. Overall today taught me the convince and accessibility of the health care system in Costa Rica.

On the outskirts of Tilarán, known for its wind and rain.

We enjoyed the beautiful scenery on the way to Monte Verde.

We started our morning at the local health clinic in Los Juntas. This little boy was here for a vaccination. Costa Rica has an impressive vaccination program for the entire population (even refugees). 85% of the population is vaccinated.

Julia Perrotta

In order to understand the morbidity and mortality rate in Nicaragua it is critical to investigate their epidemiology. By personal definition epidemiology is the study of the frequency, distribution, and determinants of diseases in the human population. This analysis will aid the Costa Rica healthcare system to determine what the main causes of death for different age groups are, as well as what is the most prevalent diseases in the borders of this nation.

According to Chief of the Health Affiliations Unit, Adriana Salazar the most prevalent diseases are chronic diseases like diabetes, hypertension, and cancer. The perceptual determination of premature deaths by non communicable diseases illustrates that cancer makes up about 50% of non communicable disease in Costa Rica. Another epidemic that has caught the eye of clinics in rural areas is the reemergence of infectious diseases such as Dengue and Malaria. Both of these infectious diseases are spread through Mosquitos and can be very contagious. Additional diseases that have just been newly discovered to this region is HIV and AIDS. Lastly, other than morbidity being caused by non communicable and communicable diseases are self inflicted deaths. These deaths may be brought by depression, alcoholism, and drug addiction.

Today, the students and I were fortunate enough to first hand see what it means for preventive care in Costa Rica. Day three overall consisted of visiting the clinic and accompanying two A-TAPS (Asistentes-Tecnicos de Atencion Primaria), Javier and Fabian, for home visits in Las Juntas. Our group split up into two groups in order to enter the house since having too big of a group might appear to be very intrusive to the family of the house. Javier explained to us that the reason for visiting these houses is to prevent the cause of diseases. Specifically they were looking for the signs of Dengue; which is a disease spread by Mosquitos. The symptoms of Dengue may include: High fever, burning of the eyes, nausea and vomiting, swollen glands, and joint and muscle pain, according to Javier. Not only were they seeking if any of the members of that community have those symptoms but how their living situation.

In order to search for all signs of dengue, the ATAPS usually observe each home and their back yard to seek for built up moisture or some type of object that may hold in this moisture. For example Javier first walked through the house to see the hygiene. He quickly examined the rooms to see if any trash was built up or if there were many insects or anything else abnormal. The second factor Javier had observed was their back and front yard. He first wanted to see if there was any water built up from poor filtration of water from poor plumbing or the Rain. All of these observations done by the clinic and ATAPS are just the many examples of Costa Rican’s action plan to decrease this reemergent epidemic of dengue.

An important focus right now for the ATAPS is their work on Dengue Fever prevention. This involves examining back yards and looking for standing water where mosquito’s might lay eggs. Community members welcomed us into their homes and back yards. They frequently asked us to take a photo. The Costa Rica people are warm and friendly and they enjoy a visit from ATAP health worker (and a few PSU students). Our ATAPS always ask is it ok if he brings in students.

In this back yard we found chicken coops. This was noted by the ATAP.

The patient is asked to sign a form indicating his or her home has been visited and Dengue Fever prevention efforts are being followed. 

Danika Hoffman

Reflection One/Tool One

The main indicators associated with Tool One are gross domestic product (GDP) and the human development index (HDI), and they can be used to compare countries that may be very different in size, diversity, etc. because they are statistics with common denominators. Costa Rica’s GDP is $49.62 billion (World Bank, 2013), and the country has an HDI of .763 (Geohive, 2013). For comparison, the United States has a GDP of $16.77 trillion (World Bank, 2013) and an HDI of .914 (Geohive, 2013). Gross domestic product and human development index often correlate with each other from country to country. This is true in the current scenario, where Costa Rica has both a lower GDP and a lower HDI score than the United States. This correlation often occurs because countries with higher GDPs tend to have citizens with higher GDPs per capita, and earning more money usually correlates with better health outcomes. This may apply to the two countries above, but it is also important to remember that these statistics may not tell the whole story. The United States has a very high gross domestic product, however it also has very high wealth disparities. Furthermore, when it comes to accessing healthcare, the United States also lacks in this area.

Today we visited the Costa Rican Ministry of Health (Ministeria de Salud), where we learned that Costa Rica spends about 7% of their GDP investing (not spending) in health care and the National Health System. The mission of the National Health System is to provide equity, solidarity, and universality in the healthcare system. All Costa Ricans, and even non-citizens that are in the country, have access to healthcare through the public healthcare system. The United States has nothing that equates to the work of the Ministeria and it also has nothing like the national health system. The US healthcare system is fragmented, run differently in each state, and care is certainly not available to everyone, not even all citizens. So while the United States might have better health outcomes, access to healthcare is not as good as it is in Costa Rica. The United States has enough people that the average health outcomes are still relatively high, but a minority of people in the United States do suffer from total lack of access to quality healthcare, something that Costa Rica is able to provide despite its smaller size and gross domestic product. The healthcare itself in Costa Rica likely rivals or out performs the healthcare in the United States, and it certainly spends less money doing so. Finally, another reason that the United States may have slightly better average health outcomes than Costa Rica is that the public infrastructure in the United States is slightly better than that in Costa Rica. While both countries report chronic diseases as the main causes of mortality, Costa Rica also reports car accidents and external factors as high on the list, something not as common in the United States. Costa Rica also has a lower percentage of the population reporting access to clean drinking water.

The first hospital we visited today was the Hospital Clinica Biblica, a private, not for profit hospital founded in 1929. Today, the Hospital Clinica Biblica has 110 beds and is the first private hospital in the region to achieve Joint Commission Accreditation three years in a row. Our tour guide was Mary Lys, an employee in the marketing department that had been at the hospital for many years doing various jobs from direct patient care to administration. Because this hospital is private, it is also expensive, and therefore serves only patients with public or private insurance. Most of the patients at this hospital have insurance through CCSS – employees pay part of their salaries into the program, the employer contributes to the program, and then healthcare is covered. A small number of patients may have private insurance. If patients are brought to the Hospital Clinica Biblica that do not have insurance or enough money to pay for their care out of pocket, they are stabilized and transferred to the public hospital. The expense of care at this hospital boasts many perks not available in public hospitals, including aspects of care like private rooms, beds for family members, a patient to nurse ration of 3:1, and an MRI machine that uses fifty percent less radiation than normal MRI machines. The Hospital Clinica Biblica also gives back to the community by donating thirty percent of its income to social action programs.

Our second stop today was the aforementioned Ministeria de Salud. We met with Adriana Salazar, the Chief of the International Health Affairs Unit, who gave a presentation on Costa Rica’s population, health outcomes, and healthcare system. The main aspects of this presentation that especially impacted me were the dedication to universal and fair care provision (discussed in the first paragraph) and the focus on nutrition. Costa Ricans suffer from obesity related health complications just as Americans do, yet the United States government does not seem to actively emphasize diet or other preventative measures against these issues.

Our final stop of the day was to visit the Hospital de las Mujeres, a public women’s hospital. Our tour guide was Sandy Gonzalez, an OBGYN nurse manager that has worked for the hospital for 26 years. 6,500 births occur at the Hospital every year, a number that makes up 30% of the general population. This hospital serves the general Costa Rican public, including people of various economic backgrounds. Because it is a public hospital, it does not turn anyone away, and often people that cannot afford to pay for their care have no repercussions. Despite the fact that this hospital serves a very different population than the ones found at private hospitals, it still has the best neonatal intensive care unit in the country. This fact supports the idea that the National Health Service strives for equality across their healthcare system.

However, there were certainly some stark differences between this hospital and the private Hospital Clinica Biblica. The private hospital operated completely electronically, with all patient and nurse records stored on computers and printed for patients at visits. The Hospital de las Mujeres has yet to convert to an electronic medical records system due to various legal barriers. Patients at the Hospital de las Mujeres do not get to choose their physicians, they are assigned physicians depending on which is available. The rooms of the hospital are often overcrowded and 5 or more beds in once room. Finally, the Hospital de las Mujeres also suffers in comparison to private hospitals because often in Costa Rica physicians will complete their mandatory time working in a public hospital after graduation from medical school, and then transfer to private hospitals shortly after, so that they can obtain higher pay on a salary basis as opposed to fee for service, which is how public hospitals operate.

Today we enjoyed a tour of the Women’s Hospital, a public hospital in San Jose.

We also had a fantastic tour of Clinica Biblica Hospital, a nonprofit private hospital in San Jose.

A young patient said hello. (photo taken with permission)

We also visited the Ministry of Health.

Walking in San Jose

Day 1 Reflection

Elizabeth Norton

January 18, 2016

Today, we were able to visit Hospital Clinica Biblica, the Ministry of Health, Hospital de las Mujeres (Women’s Hospital) and see the sights of downtown San José. Much of what we saw and learned during our first full day in Costa Rica was extremely relevant to Tool One. Tool One encompasses components related to sociopolitical and economic analysis of various health systems around the world. This tool explores the importance of countries’ Gross Domestic Product (GDP) and Human Development Index (HDI) as they relate to the delivery of health care, while also explaining the influence of social, political, and cultural factors.

Costa Rica’s Gross Domestic Product is $14,900 per capita. They spend approximately 9.9% of their GDP on health care. This percentage is low compared to the US (who spends 17.1%) yet it is the highest health expenditure in Central America. The HDI is Costa Rica is 0.77, which is relatively high compared to the rest of the world and extremely high compared to surrounding Central American countries.

Throughout our visits today, I noticed a few different political and sociocultural factors that affected healthcare. Costa Rica’s current public health care system resulted from an evolution of programs and decisions implemented by the government in the past few decades. One of the reasons that their healthcare system is so effective is that government fully supports the key principles of equity, solidarity, and universality. Something else that I picked up on at the Women’s Hospital is that abortions are illegal. This is obviously a huge political debate in our country. However, it does not seem like there is much debate here in Costa Rica. Rather, there is more of a cultural attitude of appreciating the gift of life. Some other sociocultural factors that I noticed were the appreciation of family, mental health, and social support. At Clinica Biblica, they had special ER rooms designed to accommodate the patients’ whole family. There were also pullout couches in each patient room for a family member to stay the night. Our nurse guide, Mary Lys emphasized the importance of treating all aspects of the patient. She also mentioned that the staff is given plenty of vacation time for the purpose of preventing human error. At the Women’s Hospital, it was evident that mother and baby were never separated. At the mother’s first appointment, they assess all aspects of her life, not just clinical components. We got to see a special room and support group for women with breast cancer. It was very clear that in both the public and private hospital, the medical staff was focused on treating the whole patient, not just a set of symptoms.

Our first stop of the day was to Clinica Biblica, a private hospital in San José. We met with a nurse named Mary Lys. She has been working at the hospital for 10 years. She had previously worked in admissions but now she works in the marketing department. The hospital serves both local and international patients (15-17%). Although all residents of Costa Rica have access to the public healthcare system, some will chose to go to the private hospital if they have insurance or if they wish to pay out of pocket for expedited service. Clinica Biblica has 110 rooms including the smaller ER rooms. When admitted to the hospital, patients will be placed in a room depending on the level of care they require. Therefore, rooms with more high-tech services are more expensive. Mary Lys estimated that rates are about $500 per day.

Our next stop was to the Ministry of Health, where we met with Adriana Salazar, the Chief of International Health Affairs. She gave us some general information about Costa Rica’s population, health indicators, and more detailed information about the structure of their health system. She talked a lot about Costa Rica’s changing age structure. The country is seeing an increase in the older population (ages 65+) and also an increase in the intermediate working class (ages 15-64). She also spoke about different health indicators, especially nutrition. A nutrition survey conducted in 2008-2009 gave them a lot of valuable information that they could use to make improvements. She described that the National Health System is composed of various public and private entities such as private health services, international government organizations, national government organizations, universities, and local government. The CCSS is the single provider of direct care to the people. It is broken down into 3 levels of care: health areas and EBAIS teams, regional hospitals, and specialty hospitals.

Our final stop of the day was to the Women’s Hospital, a public hospital in San José. We met with an OB/GYN nurse supervisor named Sandy Gonzalez Fernandez. He has been working at the hospital for 26 years (since he was 18!) Sandy was very friendly and knowledgeable. He also greeted almost everyone that walked by and seemed to know them well, which I think speaks to how much he cares about the work that he does. There are approximately 6,500 births at this hospital per year. There are anywhere from 600-1,000 births per month. While there, we had the opportunity to see a whole lot of newborn babies and learn about their system of caring for patients. We were able to see the breast cancer support room and meet the nurse who created it. We saw the labor rooms and the area for women with high-risk pregnancies. We were able to see the neonatal intensive care unit and meet the doctor who supervises it. We saw the ER and met one of the General Practice doctors who work there. I thought it was very interesting that, ideally, the ER would be staffed completely by specialty doctors. This is not possible because there simply aren’t enough specialists in Costa Rica, which is an opposite problem from our country.

After seeing the public and private hospital, I noticed some major differences between the two. The private hospital appeared to be completely renovated and full of the latest technology. All health records were computerized and the nurses were vigilant about keeping them updated. The public hospital was definitely more cramped and much less glamorous. There was also a noticeable lack of technology in the public hospital. Sandy said that there were plans to transition to a computerized system, but legal barriers have held up the process. Compensation for doctors is also drastically different. In the public system, doctors are paid $4,000 per month. In a private hospital, doctors could be paid $4,000 for two surgeries. The patient rooms were also very different. In the private hospital, all patients get a single room with a bathroom, flat screen TV, pull out couch, and lock box. In the public hospital, 8 patients were squeezed into a room that was intended to hold six beds. After seeing the difference today between two prominent hospitals in the major city, I’m looking forward to seeing what smaller community care looks like!

Dear Students,

Before you leave home on Sunday morning double check to make sure you have your passport.

Please be at the airport no later than 9 am. I will be at the check in counter.

It sounds like we may have some last minute hospital tour changes. Sometimes things like this happen. We will be given an updated schedule.

Please review the packing list and make sure you have everything. Let me know if you have any questions. I am looking forward to spending next week with you all in Costa Rica!

Sincerely,

Celeste Newcomb

Packing List

Please use ONE rolling or carry-on bag.

Passport and other photo ID
(1) Suit (no sleeveless tops)
(2) Business casual outfits
Khakis
Dress shirt (+ tie for guys)
Closed-toed, comfortable dress shoes and business casual shoes
Sneakers/hiking shoes
Shorts
Comfortable clothes for around the hotel and to wear zip lining and hiking
Bathing Suit
Jacket/Windbreaker (rain-proof)
Travel Size Items:
-Toiletries
-Shampoo
-Conditioner
-Sunscreen
-Bug Spray
Bag/purse to bring around and hold change of clothes
Water bottle
Warmer clothes (sweater/coat)
Bug net (optional)
Malaria pills (optional)
$29 (exact change in cash) for the exit tax
Spending money (can be converted in the airport)
Camera (+charger, cord, etc.)
Pen/Paper or laptop (needed to write your daily logs)
Pack of Thank-You cards
Ear plugs
Portfolio with paper for taking notes

Celeste Newcomb, MBA
Instructor
Department of Health Policy and Administration
College of Health and Human Development
The Pennsylvania State University
601 M Ford Building
University Park, PA 16802
cgn1@psu.edu