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Improving Health Care Quality

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What Does Community-Oriented Primary Health Care Look Like? Lessons from Costa Rica

Key feature

Costa Rica’s primary health care (PHC) model is built on five main pillars: integrated public health services and PHC delivery; multidisciplinary PHC teams integrated into communities; citizens assigned to PHC teams through geographic empanelment; ongoing quality assurance and improvement efforts; and integrated digital technology.

Target Population

All Costa Ricans.

Why it's important

Access to high-quality primary health care is the foundation of any equitable health care system. Costa Rica has shown that multidisciplinary PHC teams (including advanced community health workers), remote access to electronic health records, and data-driven improvement interventions can be instrumental in delivering comprehensive care to patients, even in rural settings.

Benefits

Costa Rica has achieved and sustained improvements to its quality of health care and health outcomes while spending less on health care than the world average. It has simultaneously improved equity in access and health outcomes and improved its ability to identify and address population and system issues early.

Challenges

Advanced community health workers can play an important role in supporting PHC. In addition, the pragmatism and incrementalism reflected in Costa Rica’s efforts can inform any complex change process, including improving primary health care in the United States.

Introduction

The health care system in the United States continues to experience skyrocketing costs, high chronic disease burden, and poor population health. It has repeatedly fallen short on delivering timely and accessible health care, and disparities between populations continue to grow — as the COVID-19 crisis has highlighted. In particular, inadequate access to primary health care has diminished the U.S. system’s capacity to prevent chronic disease and manage population health, led to delayed diagnoses and incomplete treatment adherence, and created problems related to patient safety and care coordination.1

With public frustration over the current system mounting, many in the United States believe that significant reforms are warranted. Costa Rica offers an example of an efficient health care system centered around a backbone of robust, community-oriented primary health care, characterized by strong and effective use of community health workers to improve access, quality, and equity. Although circumstances in Costa Rica and the U.S. differ in many ways, the story of this Latin American nation’s success demonstrates what can be achieved with other models of care.

Primary Health Care in Costa Rica: How it Works

Costa Rica’s community-oriented primary health care (PHC) model is built on five main pillars:

  1. Integration of public health with primary health care: Responsibility for the provision of all curative and preventive public health care — from public health functions to primary, secondary, and tertiary care — is consolidated under one agency, the Social Security Agency (Caja Costarricense de Seguro Social, or CCSS). The Ministry of Health sets policy and national direction but is not a direct provider of care. This integration promotes efficiency and reduces redundancy. In the U.S., such consolidation would be equivalent to the Department of Health and Human Services’ provision of oversight and national direction to the Department of Veterans Affairs, except extended to the entire population.
  2. Multidisciplinary teams integrated within the community: Each integrated PHC team, known as an equipo básico de atención integral de salud (or EBAIS), provides comprehensive and coordinated PHC. Teams comprise a doctor, nurse assistant, medical clerk, and asistente técnico en atención primaria (ATAP). ATAPs, similar to advanced community health workers, aim to visit each household annually, using risk stratification to prioritize order and frequency of home visits (see box). Additional support for EBAIS is provided by teams of nutritionists, psychiatrists, and pharmacists within the main PHC organizational unit, called a health area. Each health area provides care to 30,000 to 110,000 residents at five to 15 EBAIS clinics (Exhibit 1).
  3. Geographic empanelment: All citizens are assigned to an EBAIS team through geographic empanelment, which promotes access and continuity of care. Each team has a target panel size of about 4,000 people. To promote greater equity in access and outcomes, empanelment and introduction of EBAIS teams began in the country’s most medically underserved rural areas, and then moved to urban areas, including the capital, San José.
  4. Measurement and quality improvement at all levels: Quality assurance and improvement are a primary focus for PHC and the health system overall and are supported by robust data feedback mechanisms. EBAIS teams collect comprehensive population data, which are compiled by the health area and sent to the national level of the CCSS. The data are used to assess performance against targets and ensure a high quality of care.
  5. Integration of digital technologies at all levels: The country’s electronic health record (EHR) system, the expediente digital único en salud, facilitates the delivery of comprehensive care to patients. Patient charts function as clinical guides, reminding providers of issues to discuss during their visit, such as hypertension, type 2 diabetes, and elder care. EBAIS teams use mobile tablets for data collection across urban and rural settings.
VanderZanden_costa_rica_exhibit_1

ATAPs: Community Health Workers “Plus”

The EBAIS teams are designed to be nimble, providing services in clinics and patients’ homes. To this end, the ATAPs (who have similar roles as community health workers but with additional responsibility and opportunity for growth into other positions) conduct regular home visits at a frequency determined by a risk stratification scheme. Priority 1 homes — inhabited by an elderly person living alone or an individual with an uncontrolled chronic disease, high-risk pregnancy, or other issue that puts them at high risk — receive three visits per year. Priority 2 homes with more moderate risks receive ATAP visits twice a year. Priority 3 homes, considered low risk, receive preventive ATAP visits once per year.

ATAPs use the ficha familiar, or family file, to gather health information for each household, using tablets that geocode the houses. The tablets help ATAPs keep track of patient history, including vaccination records. The system enables post-hospital-discharge visits as well as tracking for community determinants of health. Cell phone chips in each tablet upload information to the cloud as it is gathered. Graphic dashboards allow ATAPs to see patients’ houses on a map. All data are highly secured to ensure privacy of confidential patient information.

The ATAPs are our champions,” says the Jacó health area director. The ATAPs have a lot of pride in the information they collect and recognize that it is vital for the CCSS and for the populations they serve. Calling the ATAPs technicians in primary care gives them gravitas and elevates their work to a technical health professional level. Although they serve as the link to the community, much like community health workers (CHWs), the ATAPs are more technically trained than traditional CHWs. In fact, they are more like “CHWs plus”: they are professional, efficient, salaried, and supervised.

Supporting a Culture of Transformation in Primary Health Care

Costa Rica implemented its PHC model in the 1990s, a process facilitated by a focus on changing the culture of care delivery. Leaders nurtured this cultural shift through negotiations and structural changes between and within the CCSS and the health ministry; through provider trainings; and through development of a 10-year reform timeline that allowed providers to retire if they were not interested in adapting.

Community involvement and leadership were critical in supporting the successful scale-up of the EBAIS model, particularly in rural areas but also in urban settings. EBAIS teams were deployed first in communities eager to welcome them to help build momentum. Community health advisory boards offered feedback and enhanced community participation in the EBAIS model. For example, at EBAIS Lagunillas in the rural Pacifico Central Region, the community advocated for and built the EBAIS clinic building. The CCSS leases the property and provides equipment and human resources, while the community is responsible for the building’s upkeep.

VanderZanden_costa_rica_exhibit_2

Evidence of Impact

By 2019, there were 1,053 EBAIS teams and 106 support teams (providing more advanced behavioral health and social services) operating throughout Costa Rica,2 averaging about one EBAIS team per 4,660 citizens. More than 94 percent of the population had been empaneled.

Today, there is ample evidence of improved health outcomes, access, and quality under Costa Rica’s reformed PHC system. Costa Rica demonstrates effective PHC coverage and better outcomes compared with other low- and middle-income countries.3 For example, deaths from communicable diseases dropped from 65 per 100,000 people in 1990 to 4.2 per 100,000 in 2010, and maternal and child mortality have declined since 1995.4 In the reform’s first decade of implementation, there was an 8 percent reduction in infant mortality and a 2 percent reduction in overall adult mortality.5

Costa Rica has improved its quality of health care and health outcomes while spending less on health care than the world average, measured by share of gross domestic product (7.6% versus the world average of 10.0% in 2016) and by per capita spending ($889 versus the world average of $1,026 in 2016).6 Within a decade, household spending on health care services was dramatically lower than in other Latin American countries: while the average share of private health expenses was approximately 58 percent throughout other countries in the region, in Costa Rica it was only 25 percent.7

Achieving Equity in Outcomes

  • Costa Rica established the first EBAIS teams in areas with poorer access to care, and over time, the geographic distribution of clinics expanded across the country.8
  • To improve equity, the CCSS uses data collected by EBAIS teams to focus resources on higher-risk areas, budgeting nearly one-third of its funds on the poorest 20 percent of the population.9
  • Premature mortality decreased in Costa Rica between 1980 and 2000 but saw larger declines for the poorest quintile of the population (48% reduction) than the richest quintile (39% reduction).10
  • A 2009 analysis of infant mortality indicated high regional equity: there was no association between geographic region and increased mortality.11

Challenges

Maintaining momentum after two decades of reform and attaining an appropriate EBAIS-to-population ratio have been challenges for policymakers in Costa Rica. Despite the introduction of more than 1,000 EBAIS teams since the mid-1990s, as of 2019, nearly 300 additional clinics were still needed to achieve the target ratio of one EBAIS team to 4,000 citizens.12

As in the United States, the growing burden of noncommunicable diseases, such as diabetes, heart disease, and chronic lung disease, are also challenging the health system. CCSS Executive President Dr. Román Macaya explained that “we can’t ‘build our way out’ of the current health care situation. [We] can’t create enough hospital beds realistically to meet the high demand. Therefore . . . the primary and secondary care levels [must] increase their ability to resolve issues before they reach the hospital level.”

Lessons for Health Care Delivery

Empanelment of the entire population makes PHC the first point of contact for most people’s care needs, enabling Costa Rica to maintain a dual focus on both individual and population health so that no one is left behind.

In turn, the provision of comprehensive, coordinated, and continuous care for empaneled populations is facilitated by the multidisciplinary nature of EBAIS teams. This promotes facility-based and community-based care provision and data collection (primarily via ATAPs), as well as the use of robust data systems (including EHRs) even in rural and remote settings. Data are used to drive accountability and quality improvement at the clinic, health area, and national level. All of this is supported by a shared cultural vision to provide equitable access to care and an ethos of health as a human right.

The U.S. policy environment may be becoming more open to significant change. One sign is growing recognition of the value of a health system grounded in strong primary health care that relies in part on community health workers to stay connected both to individuals and to the population as a whole. In fact, by late 2017, all but three states in the U.S. were working to integrate CHWs into their health care systems in some capacity, whether through the enactment of CHW legislation or efforts in areas like financing, education and training, certification, and oversight of active CHW programs.13

Can Costa Rica's Primary Health Care Model Be Adapted to Work in the United States?

Discussing the value of CHW workers to the U.S. system, experts writing in the New England Journal of Medicine noted that the “potential lies in their ability to remedy inequities in health care access and quality by means of culturally congruent interventions and advocacy in their communities.”14

An ATAP conducts a risk assessment of a community member at EBAIS Horquetas de Sarapiquí.

An ATAP conducts a risk assessment of a community member at EBAIS Horquetas de Sarapiquí. Photo: Tim Llewellyn

Enabling Contextual, Cultural, and Historical Factors

Economic crisis: During the 1980s, Costa Rica faced mounting public dissatisfaction with its health care system. The Ministry of Health and the Social Security Agency (Caja Costarricense de Seguro Social, or CCSS) shared responsibility for PHC service delivery, and overlapping charters made responsibilities unclear and efforts duplicative. Budget cuts during the worldwide economic crisis meant PHC funding decreased, contributing to sentiments that public PHC services lacked basic resources. From 1985 to 1990, primary care visits decreased by 17 percent.15

Dissatisfaction hit crisis levels in 1991 with a major measles outbreak. Employers, a main funder of the public health care system, were forced to pay for additional private care when the public system was unable to meet the increased demand for health care created by the outbreak.16 They threatened to stop their mandatory CCSS contributions if the government did not take action to fix the system.17

Health care as a human right: A major enabling factor for reform was a national ethos of health as a human right. The CCSS was founded on the principles of universality, equity, and solidarity — values that have guided Costa Rica’s health system for decades and are embodied throughout the system. The system’s focus on pragmatism and incrementalism has driven sequential, ongoing improvement.

Nationwide training: Dr. Cristina Vásquez, who now runs the Clinica Carlos Duran in the Zapote District of San José, was one of many who played an instrumental role in training doctors in the new EBAIS model and bringing a vision of prevention to the traditionally curative providers who had come up through the CCSS. “There were many intentional activities to cultivate this in providers,” she says. “It wasn’t expected to happen overnight.”

The EBAIS de Palmar Norte care team outside their clinic.

The EBAIS de Palmar Norte care team outside their clinic. Photo: Tim Llewellyn

Ideas for Adaptation

Costa Rica’s well-trained and highly skilled ATAP workforce provides an important lesson on how professionalizing and integrating CHWs can bring huge dividends. CHWs in the U.S., if properly trained and enabled, could address some of the current challenges in the health system, especially among underserved populations. This would require patient and provider willingness to engage with CHWs and a supportive policy environment, including changes to regulations and training requirements. For example, CHWs may ultimately need to be licensed to take vital signs, administer vaccinations or other preventive care, or provide other home-based services to optimize the potential value they could deliver.

Policy Options for Improving PHC

  • Key enablers of the Costa Rica model — including multidisciplinary PHC teams, robust data collection and analysis, and ongoing quality improvement efforts — can likely be replicated in certain states and regions that lack them in the U.S.
  • Mobile technology and risk stratification can support patient access and monitoring, which might be especially useful in rural areas where connectivity and distance are both challenges.
  • Community engagement in PHC models, through connections to community-based CHWs as well as community health advisory boards, can enhance feedback and participation.
  • The United States and Costa Rica share common challenges, even with very different health systems. Many of the solutions Costa Rica has implemented during the past 25 years — especially using CHWs to support PHC service delivery — might have relevance for the U.S. Multidisciplinary PHC teams, empanelment, advanced electronic health records, and data use can be instrumental in facilitating the delivery of comprehensive care to patients, even in rural settings. In addition to specific interventions, the pragmatism and incrementalism reflected in Costa Rica’s efforts support a mindset of sequential, ongoing improvement that is valuable for any complex change process, including improving PHC in the United States.

ACKNOWLEDGMENTS

We are appreciative of all the assistance and support provided by national stakeholders in Costa Rica, especially Román Macaya, Ph.D., M.B.A., executive president of the Costa Rican Social Security Agency (Caja Costarricense de Seguro Social, or CCSS); Andrés Madriz Montero, M.Sc., advisor to the executive president of the CCSS; Oscar Villegas del Carpio, M.D., M.P.H., director of Health Service Delivery Strengthening for the CCSS; Rodrigo Cabezas, M.D., advisor to the executive president of the CCSS; and Daniela Rivera, M.D., advisor to the director of the medical department of the CCSS.

NOTES

1. Eric C. Schneider et al., Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care (Commonwealth Fund, July 2017).

2. Caja Costarricense de Seguro Social, Compendio Estadístico de Áreas de Salud, Sedes, EBAIS y PVP de la CCSS I Sem. (CCSS, 2019). [Spanish]

3. Primary Health Care Performance Initiative, Costa Rica: Universal Health Coverage and Community-Based Health Teams Create Effective Care (PHCPI, 2017).

4.Costa Rica,” World Bank DataBank, 2016.

5. Luis Rosero Bixby, “[Assessing the Impact of Health Sector Reform in Costa Rica Through a Quasi-Experimental Study],” Revista Panamericana de Salud Pública 15, no. 2 (Feb. 2004): 94–103. [Spanish]

6.Current Health Expenditure (% of GDP),” World Bank DataBank, 2017; and “Current Health Expenditure per Capita (Current US$),” World Bank DataBank, 2017.

7. Jean-Pierre Unger et al., “Costa Rica: Achievements of a Heterodox Health Policy,” American Journal of Public Health 98, no. 4 (Apr. 2008): 636–43.

8. Alvaro Salas, in-person interview, 2017. See Madeline Pesec, Hannah Ratcliffe, and Asaf Bitton, Building a Thriving Primary Health Care System: The Story of Costa Rica (Ariadne Labs, Dec. 2017).

9. Unger et al., “Costa Rica,” 2008.

10. Unger et al., “Costa Rica,” 2008.

11. Melvin Morera Salas, “[Geographic Distribution of Human Resources in Primary Care in Costa Rica: Equity and Regional Convergence],” Revista Costarricense de Salud Pública 18, no. 2 (Dec. 2009): 66–71. [Spanish]

12. Maria del Rocío Sáenz, in-person interview, 2017. See Pesec, Ratcliffe, and Bitton, Building a Thriving, 2017.

13.State Community Health Worker Models,” National Academy for State Health Policy, n.d.; and Tina Kartika, “Community Health Workers Resources for States,” National Academy for State Health Policy, Nov. 7, 2017.

14. Adrienne Lapidos, Jeremy Lapedis, and Michele Heisler, “Realizing the Value of Community Health Workers — New Opportunities for Sustainable Financing,” New England Journal of Medicine 380, no. 21 (May 23, 2019): 1990–92.

15. World Bank Group, Costa Rica Health Sector Reform Social Security System Project: Staff Appraisal Report (World Bank Group, 1993).

16. Mary A. Clark, “Health Sector Reform in Costa Rica: Reinforcing a Public System,” prepared for the Woodrow Wilson Center Workshops on the Politics of Education and Health Reforms, Washington D.C., April 18–19, 2002.

17. For more detail on the reform, see Madeline Pesec et al., “Primary Health Care That Works: The Costa Rican Experience,” Health Affairs 36, no. 3 (Mar. 2017): 531–38; and Pesec, Ratcliffe, and Bitton, Building a Thriving, 2017.

Publication Details

Date

Contact

Dan Schwarz, Director, Primary Health Care

[email protected]

Citation

Amelia VanderZanden et al., What Does Community-Oriented Primary Health Care Look Like? Lessons from Costa Rica (Commonwealth Fund, Mar. 2021). https://doi.org/10.26099/ehbv-g283