The following three articles were written by students that participated in the trip over the past six years. All of the articles appeared in the Centre Daily Times. The first article, from 2012, was written by Sara Young. The second article, from 2013, was written by Chris Gilbert. The third article, from 2014, was written by Bethan Latten. The fourth article, from 2016, was written by Elizabeth Norton. The fifth article, from 2017, was written by Michelle Lai. The sixth article, also from 2017 was written by Kokila Shankar.
Links to the articles are provided below. The articles are also copied below.
A Breath of Fresh Air: Health Policy Students Get First-hand Look at Costa Rican System
By Sara Young
State College – Centre Daily Times December 15, 2012
In Costa Rica, coffee is always fresh, passers-by smile and wave to visitors, and the colorful views of the mountains seem to come straight from a storybook. But what was most refreshing was the time that I spent learning about Costa Rican hospitals and care facilities — most of which are built without full exterior walls, allowing fresh air and a calm breeze to reach those inside.
Nine students and two professors toured the country for a week to experience and evaluate its health care system first-hand. It was the first of its kind. The trip was sponsored by Penn State’s health policy and administration undergraduate department as an extension of the current comparative health systems course. The course helps students compare and analyze differences in health systems across varying levels of developed countries.
Penn State instructor and trip coordinator Celeste Newcomb said she was excited to offer the opportunity to her students.
“Shadowing community health workers in rural Costa Rica, seeing public health in action and talking with health administrators and providers in a variety of health care settings allows students the chance to broaden their horizons as well as their understanding of Global Health issues,” she said.
It was easy to see how different it is from our service here in the United States when experiencing the Costa Rican health care system up close. At the public hospitals and clinics that we visited, we saw the stark needs of the facilities — flaking paint on the walls, outdated furniture, lack of strict privacy regulations, and limited use of electronic medical records.
But, despite the outward differences, this developing country has impressive health outcomes that are comparable to those in the United States.
The CIA World Factbook reports the 2012 life expectancy at birth in Costa Rica to be 77.89 years, which isn’t far behind the 2012 rate in the United States of 78.49 years. Furthermore, Costa Rica sustains a very low infant mortality rate for a developing country: 9.2 deaths for every 1,000 babies born. This number is only slightly higher than the current infant mortality rate in the United States of 6 out of 1,000.
Additionally, Costa Rica also spends a much smaller percent of GDP and has fewer physicians per population than the United States.
Looking beyond outward appearances and statistics, the roots of the Costa Rican health care system are much different than our own. The country operates under a universal system where health care funds are handled via a third-party (non-government and non-health delivery) organization called “La Caja,” which translates to “The Cashier.”
All funds are paid through direct taxes on payroll, and taxes are paid out by both the employee and the employer. Under this universal system, no person can be refused health care or forced to pay out of pocket. Citizens may purchase private insurance and use private hospitals if they are able, which is a growing trend within the past five years.
We spoke with patients, providers and administrators who all felt it was essential that everyone in Costa Rica have access to health care.
Although there are many differences between the Costa Rican health care system and ours, one of the most influential differences can be found in Costa Rica’s empowering emphasis on preventative care and promotion. This ideal is embodied in the unique health care workers known as ATAPs, who are trained with basic nursing and social work skills.
Part of our time in Costa Rica was spent accompanying the ATAPs on their “rounds” — people in rural communities are visited at their homes at least once per year by an ATAP. While there, the ATAP provides any routine vaccinations, dietary tips or basic medicationsmembers of the family might need.
In addition to checking on basic health, the ATAPs also check each home for running water, electricity, and good treatment of any pets. If there are any social counseling needs, the ATAP will visit up to six times per year to accommodate these families.
Visiting the ATAPs, hospitals and clinics, and learning about the Costa Rican healthcare system was an amazing experience for myself and all of the students involved. The trip gave us the opportunity to see community care on a whole new level, and opened our eyes to the vast array of approaches to improving overall health.
Health Care in Costa Rica: An Up-close Examination
By Chris Gilbert
State College - Centre Daily Times January 11, 2014
While the Northeast was experiencing its first big snowstorm of the year, a group of students spent a week traveling through the lush, green mountains of Costa Rica.
Although most Americans are drawn to Costa Rica for its diverse rain forests, stunning beaches and world-class coffee, these students traveled to study the various facets of the country’s health system.
The trip was offered as an embedded short-term study abroad opportunity through Penn State’s health policy and administration department, as a supplemental component of its Comparative Health Systems class. For the second year in a row, eight students and their instructor traveled through urban and rural areas of Costa Rica to take a firsthand look at how that nation’s universal health system works.
Under the universal system, every Costa Rican citizen has health care coverage and can use the public system. Funded by a 9 percent employee income tax and a variable employer contribution, the health system provides care to all, regardless of pre-existing conditions or the extent of the treatment needed.
There are no bills sent to patients, and prescription medications are free. With an even greater physician shortage than the U.S., the Costa Rican health system’s main flaw is its lines for elective procedures. However, a citizen may purchase private insurance and use the private clinics and hospitals to avoid the lines altogether.
While meeting with Vice Minister of Health Dr. Sisy Castillo Ramirez, students learned that it has been 64 years since Costa Rica disbanded and eliminated its military. Since then, the entire government budget spent on defense has been reallocated to health and public services.
Costa Rica now has potable water and sanitation facility access in 95 percent of the country. It was surprising to hear how proud Costa Ricans are that they do not have an army or any enemies.
“The only reason Costa Rica would ever bring back its army would be if someone threatened our health system,” Ramirez said.
While touring the various hospitals and clinics, it was not difficult to notice the obvious differences between Costa Rican facilities and those in the U.S. For example, most buildings featured an open-air exterior, in which the walls did not fully enclose the facilities.
This allowed for fresh air to flow through the hallways, providing a calming atmosphere for patients and their families. One regional hospital featured a butterfly garden that was not only attractive, but also designed to promote good mental health.
However, one would also notice the needs of the facilities as well.
The buildings themselves were not necessarily visually appealing.
Walls needed new paint, the furniture was often old and there was an absence of that sterile shine that we see in American hospitals.
Despite the need for some remodeling and upgrading, Costa Rica’s health outcomes are well above their neighboring Central American countries and are right up there with our statistics in the U.S.
Doctors and officials at the Ministry of Health were very proud of their low infant mortality rate of 8.6 deaths per 1,000 live births. Though higher than in the U.S., the rate could be even lower if abortion was legalized in Costa Rica. Instead, even when there is evidence of abnormal pregnancy or congenital diseases and disorders, the law prohibits abortion.
The 2013 data from the World Health Rankings lists Costa Rica’s life expectancy at birth to be 79.1 years, which is longer than the 78.6 years in the U.S. Hospital-acquired infection rates match what we see in the U.S. and continue to follow a downward trend.
Credit for the country’s remarkable health outcomes must partially be given to ATAPs, who are health workers trained in basic primary care and social work. ATAPs essentially do house calls for the people living in remote, rural areas where the nearest clinic is a considerable distance away from their homes. During visits, ATAPs administer vaccines, monitor vitals, discuss chronic disease treatments and survey the homes for safety, utility access, and any possible domestic or child abuse.
Touring Costa Rica and seeing its health system in action was an extremely valuable experience for these students. It provided a new perspective on health care delivery, complemented the comparative health systems class and gave them knowledge to make informed opinions about the future of health care in the U.S.
Chris Gilbert is a Penn State student.
A Course in Care: PSU Students Get First Hand-look at Costa Rica Health Care System
By Bethany Latten
State College - Centre Daily Times January 12, 2015
For the third year, a group of students from Celeste Newcomb’s health policy and administration 401 class traveled throughout Costa Rica earlier this month. The trip gave students an inside look at each component of the country’s health care system.
Fifteen students in majors including health policy and administration, biobehavioral health, nursing and aerospace engineering toured health care facilities, spoke with clinicians and witnessed the country’s renowned health care system in action.
Costa Rican citizens are proud of their health care system and its outcomes. Regardless of income or socioeconomic status, workers and their employers pay 9 percent and 23 percent of the workers’ salaries, respectively, toward La Caja, the collective fund that contributes to the country’s social security system. Even those who do not work receive free health care services.
Costa Rica has had universal health care since the first half of the 20th century, and in 1949 Costa Rica abolished its army in order to help finance the country’s health care system. Now, Costa Rica insures 85.5 percent of its population of 4.71 million people. The majority of the remaining 14.5 percent consists of migrant workers who still receive free basic health care services even though they do not pay into the system. Even tourists are covered by the country’s social security system.
Costa Rica has three levels of health care. First are EBAIS (equipos básicos de atención integral en salud, translating to basic teams of global health care) clinics, which handle basic primary care needs. Also at this level are ATAPs (asistente técnico de atención primaria de salud, translating to technical assistants for primary health care), who visit every house in the country to make sure residents have proper vaccines, live in adequate conditions and receive medical attention. ATAPs also record the prevalence of diseases and health problems and report their findings to the Ministry of Health. The ministry then identifies health care needs, sets goals and makes policies that reflect the ATAPs’ suggestions.
The top priority in the Costa Rican health care system is prevention, which ensures that health care is provided through the most cost-effective means. Focusing on prevention rather than disease treatment is linked to better long-term health outcomes.
Students shadowed Costa Rican ATAPs in their clinics and out in the field while visiting the towns of Las Juntas and Tilarán. Students visited the houses of families that were labeled as low, medium, or high risk based on their living conditions, health and risk potential. The ATAPs also helped to identify residents who were especially in need in Las Juntas, and the students presented mobility-limited individuals with a wheelchair, crutches and a walker.
The second level of care in Costa Rica includes regional hospitals, which patients are directed to if their condition is too severe to treat at a local EBAIS clinic. Students toured the San Rafael de Alajuela regional hospital. Designated as the regional hospital for 571,000 people who live in the surrounding area, the hospital also recently was selected as one of the country’s two medical centers prepared to deal with Ebola due to its close proximity to the San José airport.
The final level of health care consists of national and specialized hospitals, which are dedicated exclusively to fields such as women’s health, pediatrics, orthopedics, gerontology, psychiatry and others. Penn State students started their tour of the health care system at a specialized children’s hospital in the center of San José. The hospital director said that his hospital is considered among the best in Latin America. Although only slightly larger than Mount Nittany Medical Center, it has the potential to treat complex diseases of to as many as 1.3 million children. Like all other health care services in Costa Rica, families can send their children to this hospital at no cost.
The Costa Rican government spends just more than half of what the United States government spends on health care each year. However, the life expectancies in both countries are similar, with the U.S. at 79.6 years and Costa Rica at 78.2 years, according to the CIA World Factbook.
Both countries also face the challenges that come with having an aging population. Although mortality rates are higher in the U.S. than in Costa Rica, the latter country does not have enough growth for its population to replace itself. Much like in the U.S., women in Costa Rica are immersed in the work force and wait until later in life to have children, and family size is decreasing. Now, 20 percent of all Costa Rican births are to teenage mothers. This statistic, along with the high prevalence of babies born with fatal congenital malformations due to the prohibition of abortions, may help to explain the country’s high infant mortality rate of 8.7 deaths per 1,000 live births.
In touring the facilities, it was sometimes hard to believe that Costa Rican health care outcomes are so good, even rivaling those of the United States.
“Even though the appearance of the buildings is not as nice as those in the U.S., the quality of care inside the buildings is the same if not better,” said Kelsey Sims, a Penn State senior studying health policy and administration. “Costa Ricans place more importance on care than aesthetics and only use expensive technology when absolutely necessary.”
Bethany Latten is a junior biobehavioral health major in the Schreyers Honors College with minors in biology and Spanish. She is studying to become a primary care physician.
FEBRUARY 12, 2016 10:12 PM
Penn State students get an up-close look at foreign health care system
In January, while Pennsylvania was hit with the first major snowfall of the season, 11 Penn State students escaped the cold and took their education outside the classroom during a trip to Costa Rica.
The goal of the trip was for students to learn firsthand about a foreign health care system by immersing themselves in the unique Costa Rican culture. The course was developed by Celeste Newcomb and has been running for the past four years, with students from any major encouraged to apply. In between visits to a local coffee plantation, the Poás Volcano and hanging bridges of the cloud forest, students gained an in-depth appreciation of Costa Rican health care by interacting with local doctors, nurses and government officials who were eager to share their knowledge.
Unlike the United States, Costa Rica’s government offers free, public health care through its social security program, known as the Caja (Caja Costarricense de Seguro Social). The program, which is overseen by the Ministry of Health, is financed through taxes. There are three levels of care that work together to serve the needs of the people: local clinics staffed by health care teams known as the EBAIS (Equipo Básico de Atención Integral en Salud), regional general hospitals and specialty hospitals.
Throughout the week, students met with health care professionals at facilities that represented each of these three levels. While in the capital city of San Jose, students visited a privately operated general hospital, as well as a public women’s hospital. Outside the city, nestled in scenic green mountains of the country, students visited local clinics in the communities of Juntas, Tilarán and Monteverde. Here, students met with community health care workers called ATAPs (Técnico de Atención Primaria), who have the job of visiting each home in their designated area once a year for a family checkup. During these visits, the ATAPs assess the physical, emotional and environmental factors that impact the health of each patient.
These visits highlighted a few outstanding differences between Costa Rica’s system and our system in the United States. The first major difference is that Costa Rica’s public system provides every person with access to proper medical care, regardless of how much money they make. While there are still private practices in Costa Rica, those services are mostly utilized by international patients and residents who have enough money to pay extra for the convenience they offer.
Another key difference is that Costa Rica’s system focuses a lot of time and attention on preventative care. More than 95 percent of the population is vaccinated. In fact, part of the ATAP’s job is to go directly to a patient’s home to administer vaccinations. When the students shadowed the ATAPs on house calls, the goal of the visits that day was to look for standing water around the homes because it attracts mosquitoes that could be carrying dengue fever. The reason Costa Rica has such low prevalence of tropical disease compared to surrounding countries is because of the extensive preventative steps they take.
Related to preventative care is the prioritization of emotional health. Every hospital we visited catered to needs of the whole family in order to reduce the anxiety of the patient. When ATAPs visit homes, they act as social workers by analyzing family relationships. Additionally, health care staff is given generous vacation time for the purpose of reducing medical errors.
Though neither country’s health care system can be considered perfect by any means, Costa Rica has figured out how to effectively and efficiently provide all of its people with quality care.
The HPA department will be offering this 3-credit, stand-alone course again in January 2017. In the past, students have received various scholarships to offset the cost of the program. I was able to receive funding from both the Schreyer Honors College and the Pennsylvania Commonwealth Grant, covering half the cost of my trip. This was an unforgettable experience that pushed me out of my comfort zone and challenged me to think about health care in a whole new way.
Elizabeth Norton is a Penn State senior in the Schreyer Honors College studying human development and family studies with a minor in health policy and administration.
February 2, 2017 9:06 PM
Penn State student takes new look at health in Costa Rica
By Michelle Lai
For the CDT
In the United States, we look at health care as a transaction with a high price and for a profit. We visit the doctor for a cure, and we buy insurance to avoid going bankrupt after a trip to the ER.
In Costa Rica, health care is viewed as a basic human right, available for everyone and for free. The doctor provides cures too, but along with those, also a plethora of preventative services. Everyone pays taxes toward the social security fund to share the cost with the government and employers. In turn, they receive all medical care for free.
What’s the catch? How can Costa Rica spend 9.3 percent of its expenditure on health care ($1,389 per capita), provide it for everyone and still be ranked higher in outcomes than the U.S., where we spend 17.4 percent ($9,403 per capita) yet have millions still without access?
I found the answer in my weeklong trip to Costa Rica, through the course HPA 499 led by professor Celeste Newcomb, where we visited national and regional hospitals and local clinics. It’s all about preventative care with a holistic view.
For example, we learned that some local clinics hold health fairs to promote healthy lifestyles and preventative measures to the community. We heard from NICU doctors about their breast milk banks that save premature infants from growth and immune problems resulting from only drinking formula. These are problems that are too common in our country because formula companies and hospitals can make a lot of money by not promoting the importance of breast milk. We noticed bulletin boards in every health care facility promoting solidarity as not only a cultural value and foundation of the social health system but also an idea written in the law.
Most striking was our experience shadowing the ATAPs, or mobile caretakers who visit rural homes. The health surveys they gave did resemble ones from a typical visit to the doctor in the U.S. — checking vitals, answering questions about drug and alcohol use and an overview of health concerns. What made their health exam different, however, was the comprehensiveness and reality of being right in the patients’ homes.
The patients treated them like they would a friend, with hospitality and funny banter. The ATAPs really got the whole picture of who a person was by learning about their lifestyles, families and social lives.
They asked questions like:
“Has your mom gotten a mammogram recently too?”
“Is there any domestic violence in your home?”
“How is the condition of your house? Is it at risk for a landslide?”
This is a stark contrast from the U.S. system, where doctors are paid more for spending less time with patients, and patients are encouraged to be concise in order to keep their doctor’s attention and not delay them.
On top of conducting general health surveys for the entire family, they checked houses for risk factors, such as standing water in flower pots and puddles. Instead of waiting until patients came to the clinic with Zika or malaria, ATAPs ensured future safety of currently healthy people by removing from their yards the sources of breeding grounds for mosquitoes that carry those diseases.
One of the most touching and vulnerable moments was witnessing an elderly woman breaking down and sobbing during the visit. She had just received a phone call from her son who lives far away, and she admitted that she felt extremely lonely spending so much time by herself. The ATAPs comforted her until she felt better, and as we left, they told us that they would be contacting her children to ask them to visit her more often. This demonstrated to us that they recognized that health is not just the absence of disease, but also emotional well-being.
Finally, as we neared the end of the ATAPs’ scheduled route, we saw them encounter a pregnant woman living across the street. Even though she wasn’t their patient, they took the time to vaccinate her and made sure she had no other problems.
As Costa Rica (and many other countries such as Canada, Denmark and Switzerland) proves, preventative and universal health care is the long-term solution. It may cost more now, but it’ll save billions later by promoting a thoroughly healthier population to avoid preventable problems. The U.S. has moved toward this, but we still have far to go.
“If you change the way you look at things, the things you look at change.”
Max Planck, Nobel prize-winning physicist
Through observing their system, I changed the way I look at health care, and what health care means to me has changed in turn. As a future physician, I aim to incorporate this into the way I practice and in my mission to help improve our health care system. Only by learning from each other can we gain different perspectives and take the best step forward.
Michelle Lai is a senior at Penn State studying biology and health policy and administration and is heading to Mount Sinai Icahn School of Medicine in the fall. She can be reached at email@example.com.
Supporting healthcare that works for all
Kokila Shankar | Penn State senior
15 hrs ago
At this very moment, our new government is debating the repeal of the Affordable Care Act (ACA) without a replacement system ready to take care of our nation’s population. If that doesn’t scare you, I don’t know what will.
The clash over government-provided healthcare is one I know my generation has grown up watching: a hotly debated issue in our country, no one can agree on the best system to provide accessible, affordable, secure care for our citizens.
The United States currently ranks first in the world in health care expenditures. That may not surprise you, until you hear that our healthcare outcomes rank us at 37th in the world. Conversely, a less developed country like Costa Rica, ranked 57th globally for their healthcare expenditures, actually is ranked higher in healthcare outcomes than we are.
How does that make sense? To examine these disparities in person, I traveled to Costa Rica with a small group of students and instructor Celeste Newcomb through the course HPA 499, Comparative Health Systems (Costa Rica).
The Costa Rican healthcare system is a socialist system – almost all of the country’s working population pay taxes into the Caja Costarricense de Seguro Social (CCSS), from which the money is divided and given to community clinics (EBAIS), regional hospitals, and national hospitals.
A clinic director in Las Juntas, Costa Rica told us that the ACA was actually based on the CCSS. People can also opt out of paying the CCSS, choosing to be treated privately instead, but they can still receive subsidized or out of pocket care at the public institutions should they need it.
Through HPA 499, I had the opportunity to witness this system firsthand at all levels. What I saw amazed me: on such a low budget, the resources were still available even at the lower levels to provide care for everyone. Primarily, this arose from the country’s focus on preventative health. In more rural communities, primary technicians (ATAPs) go to people’s houses, conducting checkups, risk assessments, and providing services like vaccinations and birth control.
By numbers alone, the country proves its system’s efficacy: its life expectancies are on par with ours, its teen pregnancy and violence rates are lower, and the percentage of people with healthcare coverage is significantly higher. The United States is the only developed country whose healthcare provisions are so disparate.
For a country championed as the place to start with nothing and work your way up the ladder to greatness, our system promotes the rich getting the care they need and the poor simply not. Yes, our capitalist origins fuel the competition generated by private insurance companies, but when did we forget that insurance is a service industry, helping those who need it, and not a market that trades diseases as commodities?
In Costa Rica, I saw a healthcare system which truly focused on treating people.
No matter what level of treatment, doctors cared about patients’ well-being, offering them to the best of their ability whatever treatments could help them, not whatever drugs they were pushing that week to make an extra profit.
There, people were not numbers. People were not bodies. People were simply people.
After such an eye-opening experience, I’ve returned to this country with a more cynical view of our system.
I’m grateful to be able to afford private insurance, putting up with ridiculous and unnecessary price hikes or caveats in coverage.
But my experience is not the norm. I shudder to think of the masses of people who live every day in fear of getting sick or injured because they know they can’t recover, physically or financially.
The Affordable Care Act was able to provide around 20 million more people with health insurance, reducing costs and increasing quality outcomes – so why is it something people want to repeal? If we truly want to make our country great again, we need to remember that a healthy population is a productive population, and change our healthcare system from a profit-based institution to a humanity-based one.
Statistics were taken from the World Health Organization, United Nations Development Programme, and the US Department of Health and Human Services. For more information on HPA 499, please contact Professor Celeste Newcomb in the Health Policy and Administration Department at firstname.lastname@example.org.
Kokila Shankar is a senior majoring in Neurobiology with aspirations to eventually enter science policy and outreach. Email her at email@example.com.