Libby- Feb 28- A comparison of the Health care systems

Costa Rica, an introduction to the system: Last year, we learned about the nationalized healthcare system in Costa Rica, which came out of a post-war restructurization of the country that included eliminating all armed forces and putting that money into the infrastructure of the country, the education and the healthcare system. According to the WHO, Costa Rica has a better healthcare system than the US. And yet, as we worked in the community, we learned that there are still many gaps in the delivery of healthcare in Costa Rica.

One of the pros of the system is that there are chronic disease registries for everyone in the country who has conditions such as diabetes, hypertension, asthma, etc. Even for the Nicaraguan immigrant children we worked with last year, this chronic disease program is available, to provide medical care and medications related to that specific disease process. In the children's clinic, it meant our asthmatic patients had access to the inhalers and other medications they needed.

The cons were that we still saw our asthmatic patients when they had a cold or parasites because those diseases weren't covered. Even for Costa Rican citizens the healthcare was not accessible if you did not hold a job. There were other people who were excluded from healthcare services. Additionally, even for the people who had access to the healthcare system, there was a shortage of specialists and a long waiting list for certain, non-emergent surgeries, etc.

Overall, the Costa Rican system provides better access to decent healthcare for the majority of the population- a step above what the US has been able to offer its citizens as of now.



Nicaragua, an introduction to the system: When we got to Nicaragua, what we first noticed was the poverty. It was not contained to the "ring of poverty" outside the capital city. It was in the cities and certainly extended out into the rural areas, including the community that we worked in. Our community was a 30 minute drive from the closest town, and the only way there was a dusty dirt road. The healthcare system seemed to parallel the infrastructure of the country. In the biggest cities- Managua and Leon- you could find tertiary care hospitals and just about any specialist you could want. There were private and public hospitals and clinics. As far as the public system was concerned, the medications and medical supplies were distributed first to the tertiary care centers, and then portioned out to the secondary hospitals and clinics in the smaller towns, and then the remaining supplies were packaged and sent to the most distant clinics, including the one in our community. When we arrived at the public clinic, the pharmacy had almost bare shelves, with a few different types of beta blockers, statins, tylenol, antibiotics and antiparasites. One of the supplies that they desperately needed was condoms. One unique feature about the Nicaraguan system are Brigadistas, or health promoters, who are lay people from each rural community who work with the Ministry of Health to help bring clinic and national efforts to their communities (these are the people we taught first aid classes to).

One of the pros of the system is that healthcare is universally available. There are a couple of different levels, depending on what kind of a job you have, but everyone has access to some level of care. The brigadistas are a second pro of the system, as they are the hands and feet of the Ministry of Health, and make a lot of public health campaigns, such as the abate campaign, feasible.

One of the cons of the system is that the healthcare that is universally available is lacking. The doctor was only there a few days a week, which meant that it was mostly the nurse who ran the clinic. Medications were scant, so although medications are free through the nationalized system, there are not many actually available. Also, although there was a clinic in our rural town, a lot of people are unable to access the clinic during the raining season, because the clay-like dirt creates huge rivers across the roads that are impassable at times. When we taught first aid to people from these further communities, it was with the understanding that sometimes their 'first aid' efforts would be the only medical attention that people in their community would be able to access during the raining season. The lack of basic infrastructure such as paved roads and bridges was a huge barrier to access. Another huge aspect of health was the lack of waste management services in all of the country. The streets in the biggest cities and the smallest towns were always lined with garbage, because there was no where else to put it.

Overall, the Nicaraguan healthcare system and overall country structure was severly lacking in terms of population health.



El Salvador, an introduction to the system: Arriving in San Salvador after 2 weeks in Nicaragua was a bit of a shock. The streets were cleaner and many of the store signs contained English words. It looked like a city from the US. From our time here, we have learned that the system sounds a lot like the Nicaraguan system as far as the format. There are lots of specialists and tertiary care centers in the capital city, and smaller hospitals as you go a little further out, ending in rural clinics. At the government clinic closest to our rural site, there are several doctors, a handful of nurses, a dentist and a pharmacy.

The pros: Healthcare is available to everyone, free of charge, including medical and dental visits and medications. There are nurses and health promoters that work for the Ministry of Health, who have specific jobs that they have to complete each month. This includes visiting pregnant women each month for education and health checks, visiting babies every month for the first year for weight and measurements, and every 3 months after that until age 5 for the same. Vaccinating the children and older adults in the community, as needed. Providing PAP smears for women once a year, in the community. Other jobs include tending to wound care, administering TB medications, and providing health education to the community.

The cons: There is a lot of bureaucracy in the health care arena, and I believe throughout the whole government structure. In order to be seen by the next level of care, you need to be referred. In order to be seen at the local clinic, you have to arrive at 7 in the morning (where there are often 50-100 other people), and wait all day in hopes of being seen. If you are not seen that day, you have to go back the next day. Once you see the doctor, you will have a 3-5 minute appointment and, if needed, are granted a referral to see a specialist. You have to pay to get to the city, and may have to make several trips before you get to the right specialist, or get an appointment for the treatment you need. The whole process takes a lot of time and money, and is very difficult for the people in our rural community. Another example of the bureaucracy is that the dentists are only allowed to provide one procedure per person per day. So, if a person needs two fillings, the government will provide it, but the person will need to be seen 2 different days. Similarly, there is a rule that doctors can only see one member of a household per day. So, it can't be a family trip in which everyone is seen in the same day, even if everyone is in need of medical attention. It is one way to ration the limited healthcare resources, but is often very frustrating! Hector, the local El Salvadorean doctor at our clinic tells us that when he was doing his training at the local public hospital, the two imaging tests available were the X-ray and ultrasound. If a patient needed a CT scan, he (the medical student) would escort the patient up the street to the private hospital. As a medical student, he was also the one person in charge of the ER. The 2-3 attending physicians would be taking care of the intensive care patients and the surgeries and he would be the only physician in the ER, as a medical student! He was also dissatisfied with the clinical care he was able to provide during his 'social service' year after medical school. He worked in a public clinic and was forced to see patients in 3 minutes or less.

Overall, the infrastructure of the country is much better than Nicaragua, but the health care resources are very minimal.





It is hard to know what makes a good system until you have seen some systems that have a lot of problems. The experiences this year have certainly helped me to see all the US does have going for it, such as solid infrastructure (roads, electricity, water) and access to life-saving medications and procedures when needed. Although I still think that the US needs to move towards a national health plan, the plethora of problems I have seen on this trip have helped me to realize how carefully such a plan will need to be constructed, so that the end result is an improvement of health for the country.