Schreyer Scholar Emily Yanoshak, May 13, Becoming More Worldly


When I heard that there was a course called “Exploring the Healthcare System in Costa Rica,” I knew I had to sign up immediately. As someone who sees themselves working as a physician in Doctors Without Borders, I realized this class would provide me with the opportunity to gain a global perspective on a topic that the US has struggled with for some time and is very important to my future goals- providing quality healthcare to citizens.

This week I’ve had the pleasure to travel Costa Rica’s luscious landscapes with other individuals as invested in the health field as myself. I’ve learned much about the clinical and business aspects that make up a successful healthcare system. During the week, we’ve seen several healthcare facilities and even got to partake in home visits with the local ATAP’s here. From these excursions, I’ve learned that Costa Rica’s healthcare system, the Caja, allows many, if not all, people in need to receive healthcare services.

Additionally, we’ve been able to tour the Costa Rican environment. Throughout the week, we’ve been in the nation’s capital, San Jose, as well as less populated areas, like Las Juntas, and Monteverde. The diversity of these venues has allowed our group to not only see different levels of the healthcare system, but breathtaking rainforests, sunny beaches, and magnificent volcanoes as well. Probably one of the most notable parts from this side of the trip was the Cloud Forest and Zip Lines in Monteverde on Saturday. At the Cloud Forest, our group was able to walk several suspension bridges that overlooked the tops of trees in the area. We also enjoyed hearing from our tourguide, Luis, who taught us about the wildlife living in the rainforest. After that excursion, we tested our bravery on several zip lines. To our pleasure, one of them was over 800m long!

However, on a personal level, I’ve learned more over the course of this week than would have ever been possible to absorb in a classroom setting. As someone who is not very familiar with the policies of healthcare, learning about the Caja in Costa Rica has provided me with a fresh perspective on the importance of having policies that suit a broad range of people. Additionally, I’ve been able to fully immerse myself in Costa Rica’s culture. I’ve been able to step out of the comfort zones of common language, and areas of study I was unfamiliar with prior to this trip. From that stretch of discomfort, I have grown to be more worldly and more knowledgeable about healthcare. Because of this growth, I know I’ll be able to apply what I’ve learned during this week to my profession in the future. When I am able to do that, I know I’ll be able to treat my future patients with proper care they deserve.

Schreyer Scholar Aasma Hossain Reflects on Preventive Care – Friday May 11, 2018

In the previous days here in Costa Rica, we were able to explore many of the healthcare services provided to the people in Costa Rica, alongside the structure of the actual healthcare system including the three levels of healthcare. For example, the first and third days we explored the women’s hospital and the country’s national hospital respectively, which belong to the tertiary level of healthcare where more concentrated services are provided for much more serious cases with specialized surgeries and care available for the patients. On the fourth day, we also were able to explore the primary level care that could be provided to the people of Costa Rica, including the work of the ATAP workers from the local clinic and see how they went from house to house throughout the day in a neighborhood to ensure that all the people were receiving their deserved care and were staying up to date with their vaccines and overall health.

Today we followed similar ATAP workers, Jessica Lopez, Olger Diez, Majorie Carmona Salazar, Marcela Solano and Ana Yanci Ulate, and went from house to house to not only see the types of services they provide, but to also witness the lives of several Costa Rican people and their reliance on the healthcare system. We were able to witness people from different socioeconomic statuses being treated and taken care of by the ATAPs.

In the morning we went to the local clinic at Tilaran and met with nurses who talked and showed us the numerous vaccines they administered. It was fascinating to see that many of their doses of vaccines administered to the people could have up to five vaccines for five diseases called a pentaxim. The pentaxim had vaccines for polio, pertussis, diphtheria, tetanus, and flu. They store the vaccines in a cooler that maintained the temperature between 2 to 8 degree Celsius. After learning about the vaccines, we donated a wheelchair to an old lady who recently lost her leg which was such an overwhelming experience.

Once we visited the clinic, we alongside the ATAP workers, traveled to several families from different socioeconomic statuses including people living under extreme poverty to people living quite comfortably from the United States settled in Costa Rica who were all covered and treated by the Caja, including all their costs for treatment and medication. One of the families that really stood out to me was a small family with a pair of twins, one of which suffered from anencephaly. The family was relocated to a different location after a flash flood. Their house was demolished during the flood which took place in the middle of the night. Their story is truly amazing. During the flood, the whole family was asleep, with no light at all, it was pitch dark. They could not see anything at all, all they could do was hear the roaring water of the stream. During the flash flood one of the brother carried the other brother on his shoulders in only their underwear to safety. Their story was truly inspiring and touching. When I observed their house, even though the house was small and not so luxurious, they had wonderful and new appliances, and all the necessities. Their house as decorated beautifully by cross stitch work done by the mother and we learned that one of the brothers was obsessed with soccer.

After leaving that family, we left with the ATAP workers to a different house whose residents were much higher on the socioeconomic scale. The man, Han, was from the United States and had settled in Costa Rica many years ago and lives with his wife and son. He told us stories about his diseases and injuries. He suffered from cardiac arrest two years ago and continue to suffer from heart issues, but he said the Caja was amazing at taking care of him. We witnessed how the ATAP workers checked their blood pressures and provided them the proper medication, all covered by the Caja as Han pays about eighteen thousand colons per month which is about $33 per month for the complete household. However, when he got in an accident and got injured, the car insurance of the driver was not under the Caja, and so he received attention from completely different hospital and system. He was not tested properly till after two weeks and found that he had fractured his spine and tibia. This shows how efficient the Caja is in Costa Rica and how people of different socioeconomic status really rely on it.

There was so much we learned not only about the actual healthcare system, but also about the diverse socioeconomic statuses and everyone’s dependence on the Caja system. It was truly amazing and awe inspiring. There are truly several things we can learn from Costa Rica’s healthcare system and try to apply them to our own system in the United States, particularly the maternal care and the neonatal health which is part of my research. The emphasis in prevention and pregnant women’s health really makes Costa Rica really different from the Unit

Sravya Valiveti, May 11th – Healthcare Experiences in Costa Rica

Today was the 5th day of Exploring the healthcare of Costa Rica and we were able to engage with the ATAPs who are technical assistants to primary care workers (ATAPs). Our day included some clinic visits and cultural visits near the Las Juntas/Tilaran area. The focus of this post is to introduce the unique public healthcare system of Costa Rica through our multiple visits to patient’s homes with the ATAPs.

We started our day off by getting some breakfast in Pueblo Antiguo and departed for the Tilaran health care clinic early in the morning to continue our work with the ATAPs. The EBAIS is a Level 3 health care system that consists of ATAPs, nurses, pharmacist and a physician and currently, there are 1921 EBAIS systems throughout Costa Rica. The ATAPs, specifically, provide home care for patients in a specific designated region several times throughout the year depending upon their level of risk as recorded on the patient’s medical record. The goal is patient surveillance – to attend to patients more to ensure they are healthy and if patient needs a higher level health care, they can refer them to local physicians and Level 2 health systems. ATAPs are also responsible for prevention, providing resourceful information and detection of potential illnesses. The ATAPs play an integral role in providing health care to vulnerable populations and scan the environment for a variety of socioeconomic factors – quality of water & food, education, electricity (living conditions), occupation along with history of chronic diseases, medication use, immunizations in homes and act as a first point of contact for preventative care. The physician of the EBAIS team, however, focuses on disease management if there is a chronic illness and has more power to prescribe medications to control disease but ATAPs tend to monitor/manage the patient’s illness.

We were able to visit the Tilaran clinic on our way to Monteverde where we interacted with the ATAPs to know more about the services they provide to the patients in that area. ATAPs are very accessible to the patient and have their own bikes to get to a patient’s home with a vaccine cooler that needs to be kept in a sanitary place (needs to cool for 4 hours). They provide a multi-dose vaccine called pentaxim that can be used for tetanus, polio, diphtheria, pertussis and influenza viruses in a patient and they also have Hepatitis (A,B), pneumococcus vaccine (for patients above 60 years of age), meningitis, varicella vaccines and Tuberculosis medication if the patient needs it. The patients typically do not tend to refuse help from ATAPs since it is a simple checkup and patients are receptive to the ATAPs advice. ATAPs tend to provide a flu vaccine and more comprehensive care through multiple visits to at-risk populations such as pregnant women, older people with diabetes/tuberculosis, etc and visit these patients 3-4 times/year while the low risk patients typically only get 1-2 visits/year. Even without insurance, the patients can typically get all required immunizations and basic checkup of vital signs but the patient needs to have health insurance (need to pay into the Caja every month) for referrals to get treatment from other physicians of different levels. It was interesting to know that they typically make unscheduled visits to the patient’s homes and if the patient is not at their house, they go back the following day.

At the Tilaran clinic, we were also able to learn that Costa Rica currently has a pilot HPV vaccine program that is not yet covered by insurance. However, development of this vaccine can prevent warts and bacteria (HPV symptoms) that can spread infection and could potentially lead to cancer. We were also able to donate a wheelchair to an old patient who was admitted at the clinic so that she can navigate better. It was really emotional for all of us when her husband could not hold back his tears because of this gesture. The patient and her husband were extremely moved and they were thankful. We took some pictures with the patient and and she seemed excited to try her new wheelchair. We had 4 ATAPs join us on the coach to visit different patients of different socioeconomic status at their homes and observe the checkup. During our first home visit, we were able to notice that a middle-aged woman was living in very low socioeconomic conditions for the past 2 years– there were not many electric appliances, no potable water, inadequate supply of electricity & water. However, the government was able to provide new housing with 2 bedrooms to the woman, who classified as low income in a 200-house community. The community seemed really welcoming and the woman needs to be able to pay $100 to get access to utilities.

On our next visit, we met with a woman who was living in temporary housing since she lost most of her belongings in the floods a year ago. She has two twin boys but one of them has anencephaly so we provided them with a walker so that her son can walk better. During the floods, one son saved another from a mudslide. Their house was decorated with cross-stitched paintings and it was obvious that she likes to cook as she owns several cooking appliances. I was really moved by what one brother did to rescue another brother from the floods. The last patient visit with the ATAPs was to a low risk patient’s house who has moved to Costa Rica from Switzerland twenty years ago and he said that for what he can afford, the social healthcare system of Costa Rica is very patient-centered and the patient can go to any specialist for treatment as long as he’s paying to the Caja and costs 18,000 colones/month ($30-40), which is not too much considering the comprehensive list of services provided to the patient. He also said that at the end of the year, the government provides donations to high risk families. When the patient had a heart attack 2 years ago, it costed him 0 colones for specialist consultations and follow-ups. The ATAPs were able to check his vitals, medications, immunizations verify data, history of chronic diseases, dietary changes, check their financial status and signed off on blue vaccine card at the end of visit.

On the way to Monteverde, Luis, our very own tour guide told us that 97% of Costa Rica is covered by electricity that’s primarily powered by hydroelectric plants, wind and even volcano. It was also interesting to note that 97% of people have a basic level of education. It can be clearly seen that if the country is well educated, the people know how to care for themselves and know the importance of preventative care & disease management. Costa Rica was primarily formed by volcanoes and we were also able to see the continental divide (Caribbean and Pacific) in the Tilaran mountain range that was extremely windy due to low elevation. We were able to see a Cross in the wind mill park situated in the Tilaran mountains. Through these patient visits and interaction with families in Costa Rica, I was not only able to forge a relationship with these families but also want them to be healthy while living in adequate socioeconomic conditions. In the future, I realized that I would like to have a bigger role in disease surveillance and be involved with patient treatment because at the end of the day, health is wealth and being healthy is what makes people happy.

Friday May 11th- Picture Update

We left Las Juntas this morning and made good time to Tiliran. Louis provided us with a talk on how Costa Rica produces electricity. This small nation is completely self sufficient. Hydro electricity is the main source of electricity for this country but they also create electricity using windmills and geo thermal technology. In this case the geo thermal source is volcanos!

97% of the residents in Costa Rica have electricity. The 3% that do not have electricity is the indigenous population that live in remote areas.

Another interesting fact Louis shared with us – 97% of the residents on Costa Rica can write and read! We are looking forward to learning more about the cultural influences such as education – and how they impact the overall health outcomes in Costa Rica!

Yesterday we enjoyed a stop at this beautiful beach! It was a welcome treat after long hot walks with the ATAPs in Las Juntas.

Yesterday we learned that many vaccinations are done in home.  Sometimes they are done in the clinic. At the Tiliran clinic students enjoyed seeing the room where vaccinations are administered in the clinic. ATAP workers Ana Yanci Ulate, Marcela Solano, Majorie Carmona Salazar, Jessica Lopez and  Olger Diez explain the basics to us.

It is always a treat to see the fresh fruit and vegetables readily available on the street.  This is a large part of everyone’s diet and certainly contributes to overall good health. 

Paula Tabschek – Thursday May 10th – Visits with Technical Assistants to Primary Care (ATAP) – Shadowing Fabian

My name is Paula Tabaschek and my main focus on this trip exploring the different sectors of non-communicable disease prevention. I am a junior studying Biology on a pre-medical track with the intention of focusing on global and public health. Throughout the week we have been learning about the details of the CAJA which is the public health care system in Costa Rica. Our multiple hospital and clinic visits have allowed us to see the system in action, but today we got to explore how the in home aid care Technical Assistants to Primary Care (ATAP) workers function and play their role within the EBAIS.

In each region of Costa Rica there are clinics and hospitals of different levels and specialties. The first level, though, is made up of a team called the EBAIS. In each region there is a designated number of EBAIS that are responsible for different so-called counties or towns. This group is known as the country’s “medical team” because it is made up of a doctor, a pharmacist, an ATAP worker, a nurse, and a medical scribe. When it comes to public health education, disease prevention, and general primary care this is a perfect example of a team that serves as the backbone to a functioning, sustainable, and healthy medical system. Why is that? Well first of all, the ATAP workers are required to go to patients houses for in home visits whether they are insured or uninsured. Each ATAP worker gets assigned certain areas and must perform these visits throughout the year. What makes this system successful is the consistent care from the ATAP workers because they are the first line of contact trained to administer necessary vaccines and detect more serious conditions in patients to refer them to get further treatment.

So where does this process start? First of all the ATAP workers are notified of the different visits they must do the day. They bring certain vaccines and basic medications depending on who they are treating and what may be needed. From there, they go into the homes and assess the safety of the home, check vitals, and proceed with necessary service.

Today we got the opportunity to shadow an ATAP worker named Fabian. He had two in home visits planned for us with two completely different levels of care. The first family we visited was of lower socioeconomic status. This was a unique case because he had not seen this family in three years due to changing circumstances. His main objective with this family was to emphasize the important of vaccines because the youngest child was missing all of his vaccines. He educated the other family members on why it is important to have the vaccines when they are supposed to be administered and what these vaccines will help prevent. In addition, he took each family member’s vital signs and asked basic questions about their lifestyle. The in- home assessments were also recorded on his medical chart. This directly relates to my project and how sustainability with prevention is the key to global health. My focus on chronic diseases is demonstrated with how the ATAP workers delivery primary methods of prevention because they work directly with patients and educate them on how to be healthy. If patients have certain risks or concerns they will get referred by the ATAP workers and that immediately is a closer step towards preventing chronic diseases.

Angie Kelly – May 10th- Shadowing Havier

Today we got to glimpse into the lives of the lower socioeconomic class of Costa Rica. Though this is a fact, it does not mean in any way that the people we met were any lower than us. In fact, we saw how human they were and how capable we are as a species to find happiness with very little material items. The basic principle of sustainability is using resources efficiently, and in such a way that our future generations still have the option of living a comfortable life. Visiting the homes and being given the opportunity to become part of these families lives was incredible, and has been my favorite day of the trip so far. We followed an ATAP, Technical Assistants to Primary Care, named Havier to four houses. At the first we had the pleasure of meeting a four year old named Brenda and her mother. We learned the general process of what an ATAP does, such as names, birthdays, the head of the household and previous vaccines. The ATAP’s make sure to build a personal relationship with their patients, and to ensure those families receive the care that is necessary. In the case of Brenda, only one vaccine was needed. Though she cried quite a bit, a paper airplane and some soothing words is all it took to make it through. The second house was home to a man of 78 years old, who despite having two heart attacks, is still kicking with a blood pressure of 110/70. That is a notable aspect of all the residents within Las Palmas: their blood pressures are impeccable. The third house is where we had the pleasure of meeting Carol, her step-daughter and nephew. Thankfully, no vaccines, nor paper airplanes, were needed today. Carol had just moved into the house, and without her vaccination card that showed which vaccines she had already received. In a case like this, she had to reapply for the vaccines and will get them in the future. Finally, we visited a mother of four boys, named Irma. She and one of her sons received a tetanus shot while we were there. All of these visits relate to sustainability because it was all part of the level one care in the Costa Rican healthcare system. The main goal of level one care, is preventative measures. By preventing diseases and accidents by first providing the care and education that is needed, the country is able to keep their citizens healthy, without requiring them to move on to higher, more expensive levels, unless absolutely needed. This aspect alone helps save costs and resources within the system, while also taking care of the majority of their people. This principle, directly relates to sustainability and shows that a country, and a people, of any status can be sustainable and provide future generations with a healthy life.

Thursday May 10th Picture Update

Today students got the chance to shadow Technical Assistants to Primary Care (ATAP). These are health workers that travel from door to door to ensure that all citizens are receiving the care they need.  ATAPs Fabian Rodriguez and Javier Mojica point out a pair of nesting scarlet macaw’s! What a treat to see these rare birds!

ATAP worker Fabian explains how he collects patient information in the medical record before we go make a home visit. He spends a greats deal of time educating patients.HPA student Serena Carlson asks Fabian how diabetic patients are managed.  

We woke up to monkeys on this morning!


Schreyer Scholar Kristin Sarsfield – May 9th – Caulderon Guardia Hospital and Ministerio de Salud

Today marks Day 3 of Exploring the Healthcare System in Costa Rica, and is primarily dedicated to learning more about the healthcare system with several health-related visits throughout the day. This post will focus on the first two locations: the Caulderon Guardia Hospital near San José and the Ministerio de Salud (Ministry of Health).

After eating our delicious breakfast that included fresh fruit and Costa Rica’s famous rice and beans, we departed in the shuttle to Caulderon Guardia Hospital that was located a few minutes away from the hotel. Upon arrival, we met with a representative of the hospital who gave us a short tour of a few hospital floors. She was very knowledgeable and shared some incredibly interesting facts about Caulderon Guardia such as: it was the first hospital to adopt social healthcare in Latin America, its emergency department serves between 400 and 500 patients per day, and in 2005, the hospital had a tragic fire (which we learned later was started by one of the hospital employees with a mental health disorder) that killed several patients and employees. The hospital is therefore undergoing a 2.5 year long renovation that is adding more hospital beds and upgrading some of the services that are already in place. Calderon Guardia, evidently, is very important to the Costa Rican healthcare system, as it provides many specialized services that are not available in other parts of the country and people must travel there if they need medical help in the fields of neurosurgery and others like it. They also have a service that provides care at the homes of people who are unable to travel to the hospital due to extreme illness or old age, which I think would be very beneficial to the general population. Overall, this hospital provided me with a more thorough understanding of how the Costa Rican healthcare system works in terms of the socialistic aspect compared to the United States and how the citizens pay for and seek medical care. A group photo in front of the hospital can be seen below:


This amazing visit was supplemented by a trip to the Ministerio de Salud, or, in English, the Ministry of Health. Our trip to the Ministerio was well timed because it gave us insight into the administrative side of Costa Rican healthcare right after learning about the application of the healthcare. Instead of a tour, the leader of the information session, Adriana Salazar, gave us a presentation about everything that the Ministerio does and some historical context of how it evolved to exist in its current state. To summarize, the Ministerio de Salud is the sole rector of health in Costa Rica, where it acts to keep order in the healthcare system and establish policies for how the social healthcare system should operate. In addition to overseeing the system, the Ministerio employees also collect numerical statistics on certain aspects of health, and an example is shown in the figure below that describes the percentages of premature deaths due to non-communicable diseases:

Such a high occurrence of cancer was very surprising to me because it is not nearly that high in the United States, and I originally thought that Costa Rican causes of death would mirror ours due to our comparable life expectancies and infant mortality rates. On the other hand, I was not surprised to learn that vehicular accidents are on an exponential rise as a cause of death because people are so reckless while driving, biking, and walking in the Costa Rican streets.

Reflecting on the events of the first half of our day definitely confirms my interest in medicine and wanting to be a physician. Sometimes, especially in the United States, it is easy to take our health care system for granted because it is rare to be exposed to another system that is so different. However the trips to these Costa Rican hospitals and clinics help me to realize the crucial similarities and differences between our system and theirs as well as what I like and do not like. Hearing about the expansion of the NICU in some hospitals and how proud Costa Rican mothers are of their babies makes me very excited to hopefully enter this field in the future and help moms from the United States feel as happy about their pregnancy as these moms do.


Morgan Forr- Wednesday May 8th- Calderon Guardia Hospital, The Ministry of Health, and Puntarenas Hospital

On day three, the group visited Calderon Guardia Hospital, The Ministry of Health, and Puntarenas Hospital. Each was very different in the services they provide, the size, and the populations to which they serve. Despite these differences, all three organizations operate based on Costa Rica’s values of equity, solidarity, and universality.

One of the large national hospitals, Calderon Guardia Hospital, is unique in that they treat large numbers of patients and provide special services. There are 432 beds and 3,200 employees. The hospital is also the only national hospital that provides Extracorporeal Membrane Oxygenation (ECMO). Something extremely unique about the Costa Rican health care system is the medical banks. At Calderon Guardia, there are many transplant operations performed. These operations are both similar and different to transplants performed in the United States. The country uses a national organ bank just as the United States, but there are also national banks for stem cells, breast milk, and bone marrow. From an administrative standpoint, this is extremely beneficial to the access of care aspect of the United States health care system. The goal is to provide access to services patients need in order to promote better health. However, by not allowing banks such as these in the U.S, we are limiting the promotion of health in these areas.

The group also went to a regional hospital in Las Juntas, Puntarenas Hospital. This hospital was extremely unique. There were outdoor spaces which allowed air to flow through the hospital. The connection with the outside made the environment feel more healing and less clinical and isolated. This is an important factor for patient healing and patient mental health, especially during extended stays. The thought in Costa Rican is that if your mental health is good, you will heal faster. Another important point about the facilities were the cracked tiles and worn-down pieces of the hospital. Health care administrators and the Ministry of Health choose to use finances for medical equipment and pharmaceuticals to physically treat patients. The structures do not need to be lavish as quality patient care exists. Although all patients at Puntarenas Hospital are patients as a result of referrals, the hospital will treat emergencies that come in regardless of status. In the US, according to EMTALA, hospitals are only required to stabilize a patient coming into the emergency room, and then can refuse follow up treatment if a patient cannot pay for services. I feel this speaks volumes of both culture and the value Costa Rica places on community, morality, and the human right to health care. Genuinely helping others is important in Costa Rica, and citizens only pay what they can afford based on their income for insurance. For the U.S.A., much can be learned in this area. However, the group did learn that Costa Rica has a sizable social security fund, which supports those covered by La CAJA, the national health insurance, and also is used to pay for those without insurance.

With 95% of the population covered by La CAJA, it is clear to see how much money is being paid into the system. This is the genius of national health insurance systems. There are enough funds to support those who need care although they may not have insurance. One piece of the Costa Rican public health system that needs work is wait times. Looking at the United States golden triangle of health care (cost, quality, and access), wait times greatly effect access and quality. Cost is not so much an issue for Costa Ricans because of La CAJA, however, with more people having the financial capability to receive care, more seek it out and there are only so many doctors to go around. This is an issue that many countries with national health insurances face, and one I am confident I will face as an administrative health care professional. Being tasked with patient flow issues will likely be challenging, but I have gathered a global perspective on that and will be able to pull from my experiences in Costa Rica to make better decisions in the health care industry in the future.