Costa Rica prioritizes public health
By Analisa Bala
March 9, 2022
Editor’s Note: This article first appearance in the latest issue of Finance & Development.
Pura vida, “pure life”. It’s an expression you’ll hear often in Costa Rica. One that represents the laid-back lifestyle the country is known for and gives an idea of why Costa Ricans are as happy as they are.
“If you are healthy, have a job and can spend time with friends and family, you are pura vida,” says Luis Alberto Vásquez Castro, former congressman from the province of Limón in Costa Ric.
The 2021 world happiness report ranks Costa Rica as the 16th happiest place in the world. Apart from the Czech Republic, it’s the only emerging market economy in the top 20. For a middle-income country, that’s a lot of happiness per dollar of GDP.
Professor Mariano Rojas, a Costa Rican economist, attributes the country’s high well-being to strong social relationships and a sense of community. “People are warm; the pace of life is slower. It’s not a competitive society where everyone is trying to climb the career ladder.
The country also has a strong social protection system. Costa Ricans have access to free education and a guaranteed state pension. It is the only country in Central America where 100% of the population has access to electricity and a source of drinking water.
It is also one of the few countries in the region to offer universal health coverage.
Community-based primary health care
Costa Rica has prioritized public health for decades, investing heavily in targeting the most preventable types of death and disability. In the 1970s, the country spent more on health as a proportion of GDP than even some advanced economies, including the UK.
These investments have paid off. In 1985, the country’s life expectancy was the longest in Latin America and matched that of the United States. Infant mortality rates fell from about 74 deaths per 1,000 in 1970 to 17 in 1989.
However, what sets Costa Rica apart is its primary health care model.
Implemented in the 1990s, the model built on decades of experience in rural and community health programs, changing the culture of care delivery in the country. “It brings health to communities,” says María del Rocío Sáenz Madrigal, former Minister of Health of Costa Rica.
Each Costa Rican is assigned to a basic equipment of integral attention in health (EBAIS) – a local primary health care team made up of doctors, nurses and community health workers. Health workers visit every household in their assigned area each year to assess needs. The data they collect is combined with electronic health records and used to set goals, track progress and focus resources on high-risk areas.
When the system was first introduced, EBAIS teams were sent to the most underserved rural areas of the country before expanding to urban centres. “This has allowed the country to establish a very solid information system on the determinants of health, that is to say the conditions in which people live,” explains Sáenz Madrigal. “It goes beyond disease management. Investing in health starts with improving people’s conditions and quality of life. It is a very complete vision of what health and well-being are.
The evidence shows that the model works. Life expectancy has fallen from 75 in 1990 to 80 (well above the United States). An enviable health result, but the country now spends less on health care as a percentage of GDP than the world average (7.3% compared to 10% in 2017).
Rojas thinks that access to primary care pays off. “Happy people live longer. That’s why you need to spend less. It is not only that health contributes to happiness. Happiness contributes to health.
So, which comes first: happiness or health? Sáenz Madrigal thinks this is the wrong question.
“We have in Costa Rica what we call a social pact,” she says. “Whatever government comes in, the next one has to put in one more brick. The mistake we often make is to say, “Everything the previous government did is useless. It costs more to replace a brick than to build on it. This requires a long-term vision and political will.
Costa Rica has a long democratic history of leaders who have made welfare a government priority. In 1869, the country became one of the first in the world to make primary education both free and compulsory. Cristina Eguizábal, professor of political science, believes that “Costa Rica has always had a very enlightened elite”.
“Costa Rican elites have been wise enough to maintain a certain level of well-being through a very vigorous fight against poverty,” she says. “Even though income inequality widened, the percentage of people living in extreme poverty fell, until the COVID-19 crisis hit. This sense of security, empowerment and equality is very important.
And how did they become so wise? “Enlightenment has a dose of self-interest,” says Eguizábal. “In the 1970s, the country had one of the highest deforestation rates in Latin America. Energy in Costa Rica comes mainly from hydroelectricity and the dams are drying up. The government changed course because if it did not, the country would lose power. Today, Costa Rica is a world pioneer in ecology. “The greener your environment, the more jobs there are,” adds Eguizábal.
There is not just one, but several good reasons to be happy in Costa Rica, it seems.
Castro, the former congressman, confirms this: “Before being born, a Costa Rican is guaranteed life, education, food, social security and the fact that he will only learn about war through a movie… it’s pure vida country!”
Analisa Bala is part of the Finance & Development team.
Read the full December 2021 health issue of Finance & Development.