Introduction by Croakey: As many countries grapple with growing inequality and the pandemic’s impacts upon population health and healthcare systems, it is instructive to consider the experience of Costa Rica, a country with a long history of investing in public health and comprehensive primary healthcare.
Research suggests the country’s success in sustaining primary healthcare reform over decades can be explained by political commitment, strong leadership with a clear, compelling vision, and deliberate implementation strategies such as bringing together key stakeholders, engaging deeply with communities, and adapting global and regional evidence to the specific cultural, political and economic context.
“These reforms have led to dramatic improvements in health outcomes in the past 25 years,” researchers reported in BMJ Global Health in 2020
A middle-income country, Costa Rica has the third highest life expectancy at birth in the western hemisphere (behind only Canada and Bermuda) at 80 years, while measures such as maternal mortality ratio (25 per 100,000 live births), neonatal mortality rate (6 per 1,000 live births) and under-five mortality rate (9 per 1,000 live births) are some of the lowest among low-income and middle-income countries and have been declining since the reforms were implemented in the 1990s, the researchers said.
Costa Rica was also cited in a recent Oxfam International report arguing that universal healthcare is achievable, and not just for rich countries. It spends one-twelfth per capita of what the United States of America (USA) spends on its healthcare system but guarantees health for all, unlike the USA, and outperforms the USA on indicators such as life expectancy, the report said.
“Costa Rica is an example of how a small country can succeed in tackling great challenges – and become a global model,” said Professor Michelle Williams, Dean of the Harvard T.H. Chan School of Public Health, during a discussion last year with former Costa Rican President Carlos Alvarado Quesada. “We have a lot to learn from Costa Rica when it comes to healthcare policy and management,” Williams said.
An article published last month by the International Monetary Fund noted that Costa Rica has a strong welfare and education system and has prioritised public health for decades. “What sets Costa Rica apart, however, is its primary healthcare model,” said the article.
Implemented in the 1990s, the model brings health to the communities. Every Costa Rican is assigned to an equipo básico de atención integral en salud (EBAIS) – a local primary health care team of physicians, nurses, and community health workers. Health workers visit each household annually in the area to which they’re assigned to assess needs. The data they gather are combined with electronic health records and used to set targets, track progress, and focus resources on higher-risk areas.
When the system was first introduced, EBAIS teams were sent to the country’s most medically underserved rural areas before expanding to urban centres, which allowed the country to build a robust information system on the determinants of health, recognising that investment in health starts with improving the conditions and quality of people’s lives.
Writing in The New Yorker in 2021, Dr Atul Gawande describes how Costa Rica made public health central to the delivery of medical care.
“Even in countries with robust universal health care, public health is usually an add-on; the vast majority of spending goes to treat the ailments of individuals. In Costa Rica, though, public health has been a priority for decades,” he wrote.
“The COVID-19 pandemic has revealed the impoverished state of public health even in affluent countries – and the cost of our neglect. Costa Rica shows what an alternative looks like.”
It is timely therefore to hear from Dr María del Rocío Sáenz Madrigal, who was Minister of Health in Costa Rica from 2002 until 2006, and is a professor of health promotion at the University of Costa Rica, and an international expert in public health, disaster management, and health sector reform in Latin America.
She is interviewed below by Professor Bettina Borisch, Executive Director of the World Federation of Public Health Associations (WFPHA), as part of the #WorldInTurmoil series, a collaboration between Croakey and the WFPHA in the lead up to the 17th World Congress on Public Health, to be held in Rome next month.
A member of the WFPHA Public Health Leadership Coalition, she discusses the importance of addressing the social determinants of health and collaboration with communities, the burden born by women during the pandemic, and the need for strong values in public health, including an intergenerational commitment.
Watch the interview
Going beyond the health system
Bettina Borisch: I have the pleasure to be here today with Rocío Sáenz, an extraordinary person. She is a professor of health promotion. She is from Costa Rica, a country that does interesting things.
She has done so many things in her career, between being Minister of Health from 2002 to 2006, to teaching and promoting. But, I think, foremost of all, Rocío you are an advocate.
You are advocating for health. For health of all people, for equal access. And that is really what I admire….
You are from Middle America, from the Latin American countries. How did you experience the pandemic? What did you learn? And what could governments, in general learn from your point of view?
Rocío Sáenz: I think the most important thing … the pandemic showed our inequalities. The inequality was there before the pandemic, but the pandemic was like a photography about how we were about social inequalities and also, some problems and inequalities in the health system. This is, I think, the most important thing that we learned.
And with this pandemic, it was very interesting how important it’s to strengthen the health system based on primary healthcare. The system that has the base of the health system on primary healthcare has more opportunity to respond opportunely, clearly and efficiently for the population.
And I think this is one of the biggest lessons learned that we had in our region.
Bettina Borisch: If you’re talking about this, could you give some examples of really important health inequalities that you saw during or even reinforced with the pandemic?
Rocío Sáenz: For instance, we have experience in Brazil, in Chile, Colombia, and Central America, Mexico about how the population shows poverty. And the difficulties for women especially to stay away from work and the workforce, around the first days of the pandemic. This did not allow to ensure the income for the family.
This was one of the examples that was very interesting, especially in Brazil for the people in the Amazonas. They took their own decisions to stay protected, because they didn’t receive any support from the government at that moment. It was their own community that had to really support each other, and protect themselves, and receive the information, even from other countries. Because they did not receive special attention, even when we know that they are living in very rural and isolated areas. This is one of the examples.
But the other example is how the women handled the situation at home, but also cared for the children, cared for the elderly, even if they lost their job.
Our Economic Commission from Latin America showed how difficult it is for the women to reintegrate into the workforce. It was more easier for the men than the women. And this is one of the difficulties that we still have today.
And in the other hand, there was the gap that we have in the technology, for the people to really receive all the information. Real and good information to protect themselves. And of course, the corruption and the misinformation was spread all over the region.
And this is one of the aspects, I think, we have to take in mind in the next pandemic or in the next sanitary crisis.
Bettina Borisch: Thank you for mentioning one of the very important inequalities that still reign between men and women. And thank you also for this example how people then themselves started to create self-help. As you mentioned, in the Amazonas.
But let me turn it the other way around: Did you see examples of policies that really helped in this situation? What could have been done? What really works? Did you see examples of good policies that helped alleviate the consequences of the pandemic?
Helping the homeless
Rocío Sáenz: For instance, in Costa Rica, we have the example that the government protected the people who stayed out of homes, the homeless. And they keep the person in a shelter, a special shelter and also brought some economic support during the first months. I think for six months they received support from the governments.
And also, how to bring, of course, the vaccines. That is very important because the vaccine is the way to protect and prevent. Prevent the transmission.
Also, how to protect the health workers. That’s very important because the government has to take the decision that really protects the people who are on the front line of this pandemic.
And we have the case of Costa Rica, for sure, but also Panama, Argentina, and other countries took the decision to really protect the people, starting with the social determinants of health. And I think this is very important, because it’s beyond the health system and this is how the society, as a whole, protects the most vulnerable populations.
Bettina Borisch: Thank you for these different examples from Latin American countries. So, policies that work, and for our audience here.
I don’t know if everyone knows Costa Rica is for me an amazing country, that has no military but puts the money into health and education. So, in fact, it’s interesting to look at Costa Rica as a country; how they manage.
But let’s turn, Rocio, to something that’s coming up in May. Our World Congress of the World Federation of Public Health Associations, in Rome. What do you think? What of the policies could be discussed there? Would you think that that’s a good place for exchange?
And how could the Congress help bring change to more places? Because you have mentioned the countries with a very weak system and others who tried to really implement policies. What would be the enablers for that to change?
Leadership matters
Rocío Sáenz: I think the most important is how to keep the leadership in public health. What does that mean? How to put the well-being of the population in the centre of the decisions of the policymakers. It is not only to talk about the suppliers and so on, or about the workforce.
It’s also how to really put in the centre of the decision the people, the population, the communities, with a collective view.
And how to bring the intersectoral approach to help the health system. Because the health system doesn’t play a role for all the society. But if the health system doesn’t make a goodwill, all the population will suffer.
And for that, it’s very important to keep this leadership in the centre, for the population.
But also try to understand that in this work, with the high technology, with the high communication, with the high internship, with the interdependence that we have between the big countries, the small countries, the rich countries the middle-income countries, the low-middle-income countries, the people who are at the school, with the people who are at university, who are working – all of us, have to be well to really save the world and go beyond to attend the emergency or the crisis.
Bettina Borisch: I feel behind your words the passion for health equity that you have. And let me ask it in a more personal way, how did you become so passionate about health equity? What are the sources of your energy that you put into your work for more health equity?
Rocío Sáenz: I think it’s because I have the values, the values from my own family, my own country. But also, I have the strong experience. And how we can make the difference.
This is related to our own responsibility, in our own generation to really not only survive or live, but also how to go beyond and have this intergenerational commitment.
And for that, I think this is very important, to work together and share ideas and try to learn. And really, keep going, like I would say in Spanish.
Bettina Borisch: So that’s really neat for me, you said the next generation…That leads me to the question: what would be your advice for young public health professionals? What would you tell them? What would you like them to do?
Collaborate with communities
Rocío Sáenz: I think, the most important for the next generation is try to keep public health as a value in the own society.
And what that means is that the collective approach, the working together, to know the communities, to working with the health workers on the front line, to know the reality, be in the context, going to the context, live with the people, sense the feeling of the people.
Recognise that we are a professional, but we don’t have all the knowledge. We have to really try to understand how the people live and how they say it and how they build their own lives. And with that, with the share of these two ways not up and down, not only bottom up. It’s how to be collaborating together and to try to understand.
Because if we don’t understand the reality, how they live, how they resolve the problems.
Do they have social network or not? Maybe we have the idea that everyone has a social network and this is not the reality. For that, we have to understand that and build in that reality.
Build intervention, the knowledge, the analysis of the health situation. And also build, of course, the response or the program. And together evaluate.
It’s not only to receive information from the communities, the person; it’s how to design the intervention. And then we have to look together how they will change the situation. And I think this is one of the biggest issues for the next generation.
And, be very proud to be a public health professional.
Bettina Borisch: Thank you so much, Rocio. What a great message to our next generation. [I] hope a lot of them will be able to meet you and to learn from you. I can only say thank you very much, Rocío, for being with me and for having taken the time to do this interview.
Bookmark this link to follow the World in Turmoil series
