Sara Wenger – Tuesday May 8, Learning About how Healthcare is Financed in Costa Rica and Visiting Volcan Irazu and a Coffee Farm

Day two of our trip to Costa Rica started very early with breakfast at 6am. Due to Costa Rica’s new President assuming duties today, we needed to leave early to visit Volcan Irazu in order to avoid road closures. Our first stop of the day was Volcan Irazu which is a volcano about an hour and a half away from San Jose. Volcan Irazu ranges from 2800-3432 meters (9186-11260 feet). On the volcano, there were two separate craters, one dormant crater, and one active crater. The last time that the active crater erupted was in 1962. In my time in the Army, I have visited and lived close to multiple mountain ranges, but this was the first time I was able to see a volcano in person. The view from the volcano looking down over the city was beautiful, and the clear blue water inside the crater was the most beautiful water I have ever seen.

After we visited Volcan Irazu, we traveled about 45 minutes away to a coffee farm that is owned by two Americans that were from Connecticut. Since I have three daughters and am a full time student, I have a mild obsession with coffee, and was very excited to see how coffee is made. Our guide started our tour by showing us how coffee beans are roasted, and the chemical process that coffee beans go through from growth, to milling, and finally to roasting. She said that they are among very few coffee farms that grow, mill, and roast their beans on sight. After the tour was complete, we were able to taste the coffee that is made on sight, and purchase some.

Following the coffee tour, we made our way back into the city and stopped for lunch, and headed back to our hotel to change for a presentation on Costa Rica’s Social Healthcare Plan. Before making this trip, I was able to do a little bit of research on Costa Rica’s healthcare and found it to be very interesting. One of the things that I noticed about their healthcare is that everyone is covered. During our presentation, Dr. Jose Pablo discussed how Costa Rica is able to cover anyone in their country with healthcare, even if they are illegal immigrants. Hospitals in Costa Rica will not turn you away if you are sick or injured as it goes against their constitution of human rights. While this is slightly similar to the some hospitals in The United States, private clinics and free standing emergency rooms in the United States of America can turn you away if you do not have health insurance.

Tomorrow we will be leaving San Jose and Traveling to Las Juntas to visit Calderon Guardia Hospital. I am excited to visit the hospital as it is a smaller hospital than the one we visited in San Jose, as well as view a part of the country that has a lower socioeconomic status.

 

2018 Program Underway in Costa Rica


All students arrived safely in Costa Rica and our 2018 program is underway! I will post an updated itinerary. We had a few schedule changes due to the transfer of power to the new President today. I’m including a few photos from yesterday and today. Thank you to everyone that helped to make this program possible.  -Celeste Newcomb


At the Hospital de las Mujeres the medical records room was interesting for our students. We later talked about electronic medical records and immunization records. In Costa Rica everyone is responsible for keeping their own immunization records. In Costa Rica they spend 9% of their GDP on health care compared to the 17% we spend in the USA.

Students were interested to see the high level of care available to mothers if it was needed.

The nurses were thrilled to learn we had a nurse on our trip this year. Special thanks to Darlene Clark for joining us! 


Visit to the pharmacy in the hospital

We enjoyed a visit to a coffee plantation to learn about how coffee is grown and roasted in Costa Rica. We also enjoyed learning about bananas.  Here is our 2018 group. 

Exploring the Health Care System in Costa Rica

The College of Nursing will host the 2019 program, Exploring the Health Care System in Costa Rica May 5 – 12, 2019. Applications for 2019 are now being accepted.

On the trip, students will learn and see first-hand how health care is delivered in Costa Rica. In addition, students will meet with nurses, physicians, and other providers of care, along with policy makers and administrators, in an effort to learn how Costa Rica is able to achieve impressive health outcomes. The Learning Objective for this embedded program is for students to analyze information obtained on the trip and effectively present what they have learned and experienced to others. In addition to the travel, this course requires class sessions and course work. For 2018, the student price of the trip was $2,135, which included all student lodging, all food, and transportation to and from the base hotel in San Jose. This price did not include airfare or tuition. Most students obtain some type of support funding. The 2019 trip is expected to cost about the same amount. In 2019 we will follow the same model as we did in 2018 with a spring term one credit course and a May term three credit course.  If you have questions about the program, please contact Celeste Newcomb at cgn1@psu.edu.

Fill out the following form to express interest in the 2019 program: – https://goo.gl/forms/OngmuFEYUsg6T0nz1

Learn about the program and what is expected of students by watching this short video created by a student-https://drive.google.com/file/d/0B5LIWNThpDtkdUp5SUNYUURzYWM/view?pref=2…

Reflection Four by Emily Bippus

   The ATAP workers undergo a 6-month training in order to provide services in their communities. Similar to the United States, nurses must attend nursing school and complete the requirements in order to tend to patients. Doctors in Costa Rica study for seven years to receive their medical degree. After they complete their M.D., they study for an additional four to five years to become a specialist in a particular field, such as pediatrics, cardiology, geriatrics, etc.
The amount of training is comparable to the United States, though ATAP workers do not have a direct equivalent. Nurses Aides are the most similar and receive a few months of training as well. Registered Nurses typically have a bachelor’s degrees, however programs such as the Shadyside nursing program in Pittsburgh require two years but those graduates can work as an RN only in the UPMC system. Costa Rican doctors study slightly less time to become an M.D., but there are integrated B.S./M.D. programs that allow students to acquire the degree in a shorter span as well. Because there are no regulations as to the numbers of students who enroll in doctors and nurses programs in Costa Rica, there are many medical professions who have the training but remain unemployed.
Global humanitarian influence seemed limited, although international loans are a source of funding. The largest common influence of the facilities that we visited was the presence of Roman Catholic figures, despite being a public facility. There’s also an emphasis on family, a Costa Rican and Catholic tradition. In the homes, ATAPs ask questions about every family member and focus on the family unit as a whole as well as the individual.
Today we were in the home of an older woman in Tilarán with the ATAPs, Marcela and Sidney. During their questioning, one of the woman’s sons called and she began to cry. The ATAPs revealed that she was lonely and missed her children. They finished the visit and part of her “treatment” was that the ATAPs would contact her children to ask that they call and visit more often.
Clinicians in Costa Rica receive very similar trainings to those in the United States, but the differences lie in the Costa Rican wholesome approach to health care.

Reflection Five by Megan Struck and Photos From The Past Few Days

Reflection 5 by Megan Stuck

After being in Costa Rica for a week at this point, I have learned that the health care is paid for by people paying taxes for the social security, businesses funding private clinics, and patients paying out of pocket for services. Overall the nation spends roughly 9.9% of the GDP on health care. They run on a primary national health insurance system mostly, but some of the wealthier citizens can afford to go to private hospitals and they have to pay out of pocket. Everyone is entitled to healthcare in Costa Rica because it is seen as a basic human right to be able to live a healthy life no matter what the person’s socioeconomic background is. Due to this concept, the government will provide health care to anyone who needs it regardless of their ability to pay, which includes refugees. Obviously this is a good thing for the refugees, however is reduces the resources available for citizens and it makes their wait times longer than they already are.

Today we spent the day hiking through a cloud forest and doing a canopy tour on bridges above the trees. This was very interesting because we got to learn a lot about the different indigenous species of animals and plants. After this we went to visit our last clinic of the trip. This was probably my favorite clinic visit because they did a very good job of explaining the system and showing us a presentation along with pictures on how their clinic operates. After this we went to a hummingbird gallery and we saw different species of hummingbirds as well as one of the most deadly vipers in the country. Then the rest of our day was spent on meals and exploring the local community.

Reflections Two and Three by Katie Smith

Cultural Visit to Coffee Plantation

  Cultural Visit to Poas Volcano

 

 

Reflection Two

Prompt: Discuss how population structure, dependency ratios, birth and death rates, infant mortality rate, age, sex, race/ethnicity, in-migration, out-migration, and net migration influence health and health services in Costa Rica.

Response:

Below is a graph depicting the population structure of Costa Rica in 2016 taken from the Central Intelligence Agency (CIA) World Factbook (2016).

Costa Rica has a population of approximately 4,800,000. As you can see, the ratio of males to females is tilted slightly in favor of there being more males at all ages except for seniors ages 65+. This population structure is common for most developed countries. The dependency ratio is a measure that shows the number of ‘dependents’ (citizens ages 0-14 and 65+) to the total ‘independent’ population (ages 15-64). The assumption is that dependents do not work and therefore rely on the independents to care for them; dependents do not contribute to economic growth of a country whereas those ages 15-64 are assumed to be of working age and therefore, contribute to the economy. Costa Rica has a dependency ratio of 45.4% (CIA, 2016). For purposes of comparison, the U.S. has a dependency ratio of 51%. Generally, a lower dependency ratio is ideal. The population pyramid below provides evidence that the vast majority of dependents in Costa Rica are those 0-14 which is preferable because in the future, there will continue to be a large enough working population to support the aging population. You can see, however, that there is a bulge of increased population ages 15-30 which may pose a problem when this age group reaches retirement age if fertility levels remain constant or decrease.

The current birth rate in Costa Rica is 15.7 births/1,000 population (global ranking: #122). The current death rate is 4.6 deaths/1,000 population (global ranking: #201). The infant mortality rate is 8.3 deaths/100,000 live births (global ranking: #151) The sex ratio is 1.05 males/females and the median age is 30.9 years. 83.6% of the population is white or mestizo, 6.7% is mulato, 2.4% is indigenous, 1.1% is of black or African descent, and the remaining are categorized as “other”.

Costa Rica is a popular choice for regional immigration because it bolsters job opportunities and impressive social programs due to the government’s investment in social spending; almost 20% of their GDP goes to such programs such as education, universal healthcare, and public sanitation efforts. About 9% of the population is foreign-born, and of those, about ¾ came from Nicaragua. To quantify this, the net migration rate for Costa Rica is 0.8 migrants/1,000 population. (CIA, 2016).

All these demographic factors play a visible role in determining health and health services in Costa Rica. This concludes the background research for response #2. See journal for reflection on Day #2 in Costa Rica and for further analysis of how these factors influence the both individual and population health in Costa Rica.

Today we visited Heredia Hospital in Costa Rica. We received a full tour of the hospital and surrounding grounds. I was struck by the drastic difference between this hospital and the one we visited yesterday in San Jose. Today‘s hospital was a regional hospital (level II primary care as compared the the national hospital yesterday) and served a population of approximately 500,000 citizens. On average, 600 beds are designated to the ER and filled daily, and 800-1000 beds are allocated for external consults (non-emergencies).
 Since this hospital was on a lower level than yesterday‘s, I expected the infrastructure to be similar if not worse. However, Heredia was much more modern. In fact, the hospital was built just six years ago. The building itself cost 105 million dollars which is shockingly inexpensive considering the high-tech medical equipment and quality facilities housed in the hospital. Every room was exceptionally clean, the patients were able to enjoy much greater privacy, and the interior design closely mimicked that which one would expect from a typical hospital in the US. I learned that the level of hospital is not indicative of its design or infrastructure. Ideally, because the health care system is run by the government, all hospitals and clinics should receive equal funding and resources to continuously improve facilities. However, many providers acknowledged that politics do play an unfair advantage at times. They stated that often, clinics and hospitals which are located in areas with greater political power receive more funding from politicians who are looking to please constituents. Therefore, these facilities are often much nicer than those in more rural, underserved areas.
Something else that stood out to me during the visit today was that this hospital also had very long lines where patients were waiting to receive their medication from the pharmacy. Since I witnessed this same scenario in San Jose at La Hospital de Caulderon Guardia I wondered if long wait times were a problem for the Costa Rican health care system. The providers answered that yes it is, and often times patients will utilize their public insurance for the visit to the doctor but then purchase their medication or other needed services from a private source to avoid the wait. I have heard this is very popular in many countries where the health care is run publically. It would be interesting to learn if the government is taking any steps to reduce wait times. I plan on asking about this in the coming days.

Visit to Heredia Hospital

Visit to Clinica De Abargandes

Reflection # 3

Prompt: Let’s investigate country-specific data on morbidity and mortality in Costa Rica. What are the main causes of death for different age groups? What are the most prevalent diseases?   What are the policies regarding known health risks such as tobacco, drugs, alcohol, sexual behaviors, guns, violence, automobile accidents and so on?

Response:

Below is an infographic taken from www.infogr.am.com created with Centers for Disease Control and Prevention (CDC) data that illustrates the top causes of death in Costa Rica. As you can see, coronary heart disease is most fatal disease with a 16% mortality rate. Next is stroke at 7%, and third is lung disease at 5%. Grouping all the types of cancers together shows that over 20% of deaths in Costa Rica are attributable to cancer. Hypertension and diabetes are prevalent as well, and some deaths are due to non-disease factors such as road injuries (4%) and interpersonal violence (2%) (GBD Compare, 2010). Costa Rica has an adult obesity rate of 24% which is significantly lower than America’s 35.7% adult obesity rate. However, this is still an increase number and contributes to the fact that over 83% of total deaths in Costa Rica can be attributed to preventable, non-communicable diseases. [See pie chart below]. However, chronic disease primarily affects the older population; the probability of dying from NCD in Costa Rica for those ages 30-70 is only 12%. (WHO, 2016).

The two major risk factors for adults are tobacco smoking and alcohol consumption. It is estimated that 24% of males and 8% of females are current tobacco smokers. Measuring alcohol consumption in liters of pure alcohol, men consume 7.5 annually whereas woman consume 3.2 annually. The Ministry of Health does have an operational policy and strategy plan to reduce tobacco use, however, no such plan is in place to reduce alcohol use.

In 2008, Costa Rica joined the WHO Framework Convention on Tobacco Control which places standardized regulations on tobacco. In Costa Rica nearly all public smoking and promotion/advertisement of tobacco is banned. The minimum age to buy tobacco is 18. On tobacco products, 50% of the label must be covered with health warnings (either text or visual). The MOH uses all fines collected from tobacco violations to fund their anti-smoking campaign. They are hopeful to reduce the rate of tobacco use further as it still accounts for nearly 8% of adult deaths and is a hazard to children with 9% reporting tobacco use (The Tobacco Atlas, 2013).

Costa Rica has different regulations surrounding alcohol consumption than the U.S. has. In Costa Rica, the minimum legal drinking age is 16. At 16 it is legal to consume beer and wine and 18 is the legal age for liquor consumption. Public drinking is illegal in Costa Rica. Drinking and driving is not illegal in Costa Rica, however, while you may drink alcohol while driving you may not be intoxicated while driving.

Costa Rica has strict drug laws. The Costa Rican law states that the “cultivation, production, transport, and trafficking of all drugs, including cannabis, are merged in to a single category and are qualified as criminal offenses punishable to 8 to 12 years of imprisonment” (The Costa Rican News, 2014). However, these strict laws fail to prevent drug trade/violence. Costa Rica’s geography, specifically it’s thinly-patrolled borders and waters, paired with a insufficient security force make the country a major transport and storage location for illegal drug trafficking. From 2014 to 2015 there was a 20% rise in homicide rate alone. The government in Costa Rica is focused on eliminating drug trafficking by allocating more spending on enforcement and focusing on counter-narcotics programs. Improvements in the counter-narcotics programs can be attributed to the help provided by the U.S. government in training, equipment, and infrastructure projects.

According to the U.S. embassy, crime is on the rise in Costa Rica. The majority of criminal action is caused by small groups or individuals and while most is non-violent (theft, robbery), violent acts are increasing. In the U.S. Department of State Crime and Safety report for Costa Rica, the crime rating is listed as high. Theft is the main crime affecting travelers, however, the rising homicide rate is a concern for citizens. Sex tourism is also prevalent, and organized crime groups (gangs) are a threat.

On a more positive note, the terrorism rate is low and Costa Rica has a stable democracy with no civil unrest. Police response is available through 911 when needed, however, limited resources often means that delay occurs. The Fuerza Publica is the uniformed policy agency, the Organismno de Investigacion is in charge of investigating all crimes for prosecution, and the Margracion controls all aspects of immigration with assistance from the Ministry of Governorship and Police (U.S. Department of State, 2016).

Today we started our day by visiting Clinca de Abangares in Los Juntas. I was surprised that the clinic appeared to be even more modern than the first hospital in San Jose as well. I’m learning that the level of the clinic is not correlated with the infrastructure, rather, it is the age of the facility that determines the level of quality and hig-ttech equipment provided within the facility.
Unfortunately, this clinic was undergoing renovations so we were unable to tour the facility. We also did not have a chance to split up into groups to follow all three ATAP workers because one was ill and the other was not working. Instead, we followed just one and split into groups of three. While it was not ideal, I am grateful that we each at least had a chance to accompany the ATAP worker on one house visit. The visit I witnessed was the ATAP worker meeting with a young woman who was about 25 years of age. She had just recently moved in with her husband so this was her first visit with the ATAP worker in this community. The ATAP worker completed a surgery which recorded her personal demographics, her health history and risk factors, her living conditions, and her vaccination records. No vaccines were administered as she was up to date with all medications, however, the ATAP worker did provide her with medication for parasites as a preventive measure since her living conditions put her at risk. The ATAP worker also counseled her on the important of diet, exercise, sanitation, and self-examinations for breast cancer.
The ATAP worker works about 8 hours a day, typically visiting about 5-8 houses per day. He/she is assigned to a geographical region of about 3,000 patients and must visit each house annually, sometimes more than once if needed. The ATAP workers also go into schools and local businesses to provide primary medical care. They then record the health data they collect on their visits into a central registry which the public health workers use to determine the health priorities for that specific community. In order to accomplish these tasks, ATAP workers receive a six-month training as a basic  primary medical techbician. However, most said that the majority of their learning comes from on-the-job experience. While the ATAP worker is not as educated as doctors or nurses, they are sill well-respected in the medical community because they play a vital role in prevention which is a core principle of the health care system in Costa Ricas. They also develop a personal relationship with the community members they serve through the repeated house visits they conduct. It was certainly interesting to see the patients being so welcoming and trusting with the workers, especially when they stop by unannounced. I could not help but think that this same relationship would just not be possible back home in the US where everyone operates on a rushed, very busy schedule centered around work away from the home. This is just one of the many interesting comparisons I have made from my time in Costa Rica.

Cultural visit to Playa Blanca

Not Just Numbers

Students on the 2017 program in front of the Calderon Guardia Hospital in San Jose, Costa Rica with Dr. Chaves.

Reflection 1 – Serena Carlson

We can begin to compare the U.S. and Costa Rica by looking at a few indicators; GDP and HDI within healthcare metrics. The U.S. spends roughly 17% of it’s GDP on healthcare, while Costa Rica only spends 9%. Per capita spending for the U.S falls around $9,400 per person and $1400 for Costa Rica. These are vast differences that mean real dollars and funds diverted.

Another metric to measure between countries is the HDI (Human Development Index). This metric evaluates and measures the quantity of life, overall well-being, and one’s standard of living. Basically, one’s quality of life. There are 188 countries that use this index and the U.S. measures at 8 and Costa Rica measures at 69. Other factors that influence this measurement are: life expectancy at birth, and years of education. Norway comes in at number 1 in this index.

Clearly it appears we have a higher HDI, or a higher standard of life, but do we have a better quality of life or standard of care? There are other factors to consider and measure. Infant mortality rates in the U.S. is 6.1 live births for every 1,000. Costa Rica measures at 8.7 for 1,00 births. Life expectancy for the U.S comes in at 78.8 years and in Costa Rica it comes in at 79.3. Costa Rica has overall longer life expectancy rates than the U.S. Additionally, the U.S. spends the most per patient worldwide and comes in at number 48 overall in outcomes worldwide. This indicates throwing money at a problem doesn’t solve it or provide better outcomes.

These are just numbers and are easy to get lost in translation. Each one of these number listed above equates to a human life. Today I visited The Calderon Guardia Hospital in San Jose, Costa Rica. It was an eye-opening experience. We met with Dr. Eli Chaves who specialized in Geriatrics. He spent 2.5 hours with me and other students. He gave us a detailed explanation of Costa Rica’s universal healthcare system. He also provided us with a tour and detailed explanations on quality and standard of care at his hospital.

On our visit, several things stood out to me of what we can takeaway from Costa Rica: preventive care visits, maternity and post-natal care. In Costa Rica it is common place for elderly patients to have 4 physical checkups: to check in with the patient, monitor their chronic conditions such as dementia, coronary issues and mobility. In the U.S. elderly patients receive one annual visit. Medicare only pays for one each year. Prior to the ACA preventive visits were not covered. Costa Rica sees a patient every 3 months for follow up and to coordinate care. In the U.S. it’s once a year unless an issue arises. Clearly, Costa Rica is aiming for true preventive care. Their model is proactive versus the U.S’s model which seems to be reactive. Dr. Chaves also explained how visits are made to the elderly patient’s homes for follow up if they are not able to make it in to the hospital. We do not have currently have such supports in place.

The maternity and post-natal services in Costa Rica are very different than what we have in the U.S. We spoke with Dr. Barrientos, who specialized in Pediatrics and then went on to gain another specialty in Neonatal medicine delivers healthcare to mothers and babies. Dr. Barrientos cares for the most weak and youngest infants in San Jose. She gave us a comprehensive overview of how her nation delivers healthcare to its women and infants. First off, Costa Rica only has 10% of its births via caesarian. The U.S has about 38%. That means 1 in 10 babies in Costa Rica is delivered via caesarian and in the U.S., almost 4 out of 10. That’s a 30% higher frequency in the U.S., not something to ignore.

While in the hospital I observed how Costa Rica practices maternal and fetal medicine. Two takeaways were infant care and breast milk support. In Costs Rica, the baby stays with mother at all times and shares the same bed to create bonding for both mother and baby. We never see this in the U.S. I never witnessed a brand new baby sharing the same bed with their mother while being moved throughout the hospital. The baby and mother do not have separate beds, they share one. The mother and child are immediately supported in the hospital. Prior to discharge, each mother is sent home with a packet filled with support and services needed foe the infant’s first year of life.

The other large takeaway was breastfeeding. Breastfeeding is highly promoted and only in exceptions formula was provided. A huge progression in what Costa Rica practices is their breast milk bank. This bank keeps breast milk on hand for premature babies, for babies needing extra care or for mothers who have trouble lactating. The hospital asks all mothers to pump extra breast milk and it is sent to the milk bank at a neighboring hospital in San Ramon, Costa Rica.

After the first day it is amazing to see how a poorer nation is striving to provide excellent healthcare to its citizens. The downfall of the U.S. is its outlook on how it views healthcare as an interchangeable commodity and privilege. Costa Rica views healthcare as a right and its mission is to provide equal access to all citizens. The U.S. can learn from Costa Rica and how It delivers healthcare to its citizens.

 

The author of today’s blog, Serena Carlson. Serena is a junior and a HPA major.

They symbol of the health care system in Costa Rica is a mother and child.

 

 

Day Five and Six Reflections by Danika Hoffman, Ama Brown and Caroline Kaschak

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Outside the health clinic in Monte Verde

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Inside the clinic

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

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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 3rd country in the world to develop skin graphs. Even as a 3rd 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 1st level is the personal level as in if you do not want to get lung cancer don’t smoke. The 2nd 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 3rd 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.

Day Four Reflections by Caroline Kaschak, Shannon Wagner and Bridget Wheeler

 

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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!

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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.

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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.

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

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

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Day Three Reflections by Julia Perotta & Olivia Messina

 

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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.

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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.

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

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

Olivia Messina
Costa Rica Reflection—Tool 3
Epidemiology is the study of the frequency, distribution, and determinants of
diseases and health states in human populations. This includes information such as
morbidity, mortality, causes of death, and prevalent diseases in the area. We have learned
about epidemiological factors impacting health in Costa Rica during multiple parts of our
trip. Adriana Salazar, Chief of the Health Affairs Unit in the Ministry of Health, informed us
that some of the main causes of death in Costa Rica include respiratory, digestive, and
circulatory diseases, cancer, and external incidents such as car accidents. She also explained
that the Ministry of Health used World Health Organization (WHO) tobacco protocol in
order to address tobacco use throughout the country. They implemented policies to restrict
smoking in certain areas, leading to a decrease in the prevalence of tobacco use over the
past few decades. The Ministry of Health is also working to address the issue of alcohol
consumption, particularly in young teenagers. Fabian, a Técnico de Atención Primaria
(ATAP), also informed us that Costa Rica is actively working to prevent a disease called
Dengue Fever. In HPA 401, we learned that Dengue Fever is a vector-borne disease that is
spread by mosquitoes and causes fever, rash, and muscle and joint pains. Mosquitoes breed
quickly in water, so it is important to make sure that are no large amounts of water
collecting in people’s homes. The ATAPs check each person’s yard and home for standing
water, and make recommendations if necessary. This method is used to prevent and control
diseases impacting Costa Rica.
Today, we started out by touring a local clinic in Las Juntas, Costa Rica. One thing I
noticed immediately was the skateboarding park located in front of the clinic for the local
children to use. This showed the clinic’s focus on the health and exercise of the youth in Las
Juntas. Next, we were able to speak to a patient who was taking her baby in for his first
round of vaccines. We learned that in Costa Rica, patients are in charge of keeping track of
their own health records; they have hard copies of their medical information and bring it
with them when they visit the clinic. Next, we had the unique experience of going on home
visits with two Costa Rican medical workers known as ATAPs. Each ATAP is in charge of
visiting about 3000 patients at home once every year, and more frequently if the patient is
experiencing health problems. One of their main roles is to serve as the communicator
between patients and doctors. They conduct basic medical tests such as blood pressure and
write down all of the patient information in a folder. Next, they notify doctors about any
health changes patients are experiencing. The ATAP’s other major role is preventative care;
they evaluate the environment of the patients and make recommendations if they believe it
is negatively impacting the patients’ health. One thing I observed was the close relationship
ATAPs have with patients. Although they have about 3000 people to keep track of, they told
us they know each patient personally. I also thought it was interesting that each ATAP visit
has to be random, giving the patient no notice. Many people were in their pajamas or
spending time with their family, but they all welcomed the arrival of the ATAPs. It was clear
that Costa Ricans trust the ATAPs and appreciate their help, and it showed that openness is
an important aspect of their culture.
I also noticed that each Costa Rican family was just as welcoming toward our
student group, even though they knew nothing about us. One family spent time showing us
their handcrafted beehive used to produce fresh honey, and sent us with freshly grown
oregano. We also received a warm welcome when we brought a walker to a local elderly
woman. Immediately after we walked in, one of the woman’s family members started
playing guitar for us. He played two songs about his religion, which is an important part of
Costa Rican culture and also a very personal subject. Even though we had just met, he sang
to us passionately and brazenly, as if we were a part of his family. The hands-on experience
of making house visits with ATAPs was an incredible way to learn about Costa Rican
culture, as well as their health care.
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During our visit to this house, this patient asked if we had ever seen star fruit growing on tree. He insisted on picking us some so that we could try it.
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We all enjoyed the star fruit!
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At the end of the day, we went to the home of a patient that was in need of a walker. The family was so delighted by the donation that one of the relatives asked if he could play a few songs for us. It was a moving experience.