The United Nations (UN) and some of its specialized agencies, such as the World Health Organization (WHO), has recognized the performance of the health sector of Costa Rica, as the first line of action and defense against the COVID-19 pandemic. As of June, Johns Hopkins University reported Costa Rica with a 0.20 Deaths/100K pop (case fatality of 0.9%). Both statistics successfully decreased after 14 weeks into the pandemic. One of the lowest in the world- taking into account that Costa Rica is not an island- it has a system for registering and reporting cases recognized by the Pan American Health Organization (PAHO) and the Organization for Cooperation and Economic Development (OECD). How has Costa Rica achieved this?
The National Emergency Commission (CNE), led by the President of the Republic, Carlos Alvarado Quesada, declared a Green Alert on January 6, 2020, a month before WHO declared the new coronavirus (2019-nCOV) a public health emergency. This step was also taken two months before the first case in Costa Rican territory on March 6. The alert allowed for all public institutions to prepare and take advantage of the limited resources available in a developing country facing a fiscal crisis.
Due to the nature of the emergency, President Alvarado Quesada relied on the health sector to combat the first attack of coronavirus type 2 of severe acute respiratory syndrome or SARS-CoV-2. Alongside the Minister of Health and the CNE, a National Emergency was declared on March 16, 2020. But what does this mean for the health sector? Who are its principal actors? What experience does it have in facing epidemics or pandemics? What resources are available? And how are health authorities utilizing these resources?
A centennial Health Sector
As we approach our Bicentennial Anniversary, our country has been privileged for over 100 years with a health sector. This demonstrates our belief that health is an undeniable human right and not a type of philanthropy or a discourse of good intentions to be publicized in international forums and organizations.
The development of health in Costa Rica is a very clear example of the continuity of state policies in the social field. Social security, as part of the social guarantees of the 1940s, was born as a result of the unusual agreement between the President of the Republic and the charismatic leaders of Catholicism and communism of the time. Work, which maintained and reinforced a revolutionary leader who seized power from the President and a short time later in 1948, abolished the army and reinstated democracy in record time.
Facts that when shared with foreigners who do not know our history, still awaken a look of mistrust and confusion, as if we were telling tales of science fiction or another world. A product of the imagination of true geniuses ahead of their time. What was not spent on soldiers, was invested in an authentic militia of health professionals and teachers nearly 72 years ago.
The investment that Costa Rica has made in health has been internationally recognized. Using the methodology designed by the OECD and applied by the WHO, the first Report of the System of Health Accounts of Costa Rica 2011-2016 documents that in 2016, general spending on health was 7.8% of GDP, with a sustained average of a minimum of 8% in the previous 5 years. On the other hand, the London School of Economics and Political Sciences (LSE), in its 2019 Latin America Health System Overview Report, recognizes that Costa Rica is one of only two countries in the subcontinent, which complies with the recommendation of WHO, that public spending on health remains around 6% of GDP.
This state policy of investing substantially in health has produced a robust and centennial sector that is made up of solid institutions such as the National Insurance Institute (INS), founded in 1924, which administers Solidarity Insurance that protects workers and transporters. Another example is the Costa Rican Social Security Fund or CCSS, established in 1941 and is the most beloved institution by Costa Ricans. Additionally, in 1961 the Costa Rican Institute of Aqueducts and Sewers (AyA) guaranteed access to drinking water. Another notable achievement is the National Directorate of Education and Nutrition Centers and Children's Comprehensive Care Centers (CEN-CINAI). Founded in 1951, they fight against poor nutrition and promote hygiene, comprehensive development and education in early childhood among others.
All of these are led by the Ministry of Health, which has protected us with an "iron hand and silk glove" for the last 93 years. Since 1923, the Ministry was formalized as an independent Secretariat and before existed as a Department of the Police Secretariat. Like the Foreign Service, the health system maintains a hierarchical military organization in its origin. Hence, the respect for the figure of the Minister Stewardship of the Sector and the order it maintains.
Our country has health indicators that show high performance. According to the WHO Global Health Observatory, we are ranked second in the Americas and 28th in the world for life expectancy. PAHO documented in its Profile Report on the Health System and Services of Costa Rica 2019 a life expectancy at birth that exceeds 80 years. According to the Bloomberg 2019 Healthy Nations Indicator, Costa Rica ranks 33rd and in the 2018 Bloomberg Efficient Health System Indicator ranks 25th.
Not by chance, Costa Rica chose the health sector as “the spearhead” in the journey for approval of the 22 Technical Committees of the OECD. On May 15, 2020, our country was officially and unanimously invited to be a part of the OECD by its 37 member countries. OECD Reviews of Health Systems: Costa Rica Assessment and Recommendations, February 2017, shows our Health Policies were endorsed since November 8, 2016 by the respective Technical Committee. Costa Rica’s debut before the OECD was one of a kind.
The Health Sector vs COVID-19
In honor of a long history of giving continuity to state health policies, three administrations decidedly invested in large projects of national urgency: the Strengthening of the CCSS, the role of Stewardship of the Minister of Health, and the digitization of the sector. The Solís Rivera administration (2014-18) largely defined what the Chinchilla Miranda administration (2010-14) had promoted, and the Alvarado Quesada administration has been able to masterfully apply these actions against the COVID-19 pandemic.
In Costa Rica, the figure of the Ministry of Health is the Stewardship of Health, Nutrition and Sports Sector. Costa Rican society expects this position to be fulfilled by highly technical professionals in the field. They are always medical doctors and in the last decade, have had solid training in public health or one of its 5 specialties: health policy, planning, management, economy, and/or epidemiology.
In 2014, investment was made in the training of epidemiologists that multiplied their amount by 7 in 2018 and surveillance technicians in 2017. A product of that generation trained at the National University (UNA) and includes the current Minister of Health, Dr. Daniel Salas Peraza, and his closest advisers. They, together with an army of health professionals, have given an exceptional response to the crisis. Human talent is the strength of the health sector.
But we have previously faced novel epidemics or pandemics. For example, Dengue (1993), Chikungunya (2014) and Zika (2016), all of them transmitted by Aedes. Or pandemics such as HIV/AIDS, treated in a dignified way, or H1N1 influenza that hit us in 2009 and returned with a peak in 2015. In Costa Rica we know about second curves.
Against old acquaintances, in 2016 we were recognized by PAHO/WHO for our elimination of Measles and Rubella and were given certified the Malaria Champion of the Americas. Thanks in part to the intense control of vendors and the solid National Vaccination Scheme (with 96% coverage in 2018), maintaining BCG and increasing influenza vaccinations in 2016 by adding two new vaccines (Rotavirus and HPV) in 2017-18.
In times of epidemic, the understanding process is accelerated. What we learned in 10 years against AIDS, we assimilated in 2 years against Zika and against COVID-19, we are discovering it in a few months. Today, we know that we face more than just a respiratory syndrome against COVID-19. Complex immune processes and intravascular coagulation are also involved. With a long natural disease cycle, SARS-CoV-2 is an efficient propagation machine. Therefore, strategies have focused on reducing the rate of contagion. Avoiding it, in the long term, is impossible and our authorities know it.
Experience has shown us that it is essential to protect the most vulnerable. When we faced Zika, we especially protected pregnant women with innovative strategies. Likewise, against COVID-19 we have protected older adults and young people with risk factors. During Zika, it was possible to offer a “safe country” to our visitors through coordination with a responsible private sector. For example, special hours of attention for vulnerable people were established and donations for supplies or communication services were carried out. A strategy we hope will be similar with COVID-19 and a priority for Costa Rica when the reopening arrives.
The National Liquor Factory (FANAL) increased its alcohol production to manufacture disinfectant, thanks to investments that in 2018 aimed to increase production to supply the CCSS nationwide. It is being sold and distributed in coordination with the national postal service, with priority for older adults. During COVID-19, "greetings from afar" were implemented as a strategy of social distancing, but hand washing and coughing and sneezing protocol have been well known among the population for several years.
Since 1870, education has been free and compulsory for boys and girls. As a result of 150 years of firm policies we have a 97% literacy rate. During COVID-19, the Ministry of Public Education (MEP) has continued to deliver food to more than 850,000 students in more than 4,500 educational centers. A great support for the MEP has been the CEN-CINAI network, which is made up of 627 centers and has a national scope that lets it deliver food to 38,667 socially vulnerable people. Its methods teach infants all forms of personal hygiene, from bathing to valuable dental hygiene. Additionally, AyA has made this possible by guaranteeing that 97% of households have access to drinking water. In Costa Rica, the disposal of open-air excretion is practically null. An educated people are the ideal fertile ground for strong civic education and well-established hygiene.
It is too early to determine which model of confinement and application of social distance has been more successful in the long run. If very aggressive confinement was applied, mortality from COVID-19 and other infectious-contagious diseases, homicides or accidents at work or traffic, would probably decrease, but deaths from domestic violence or suicide, from poor nutrition or simply from not accessing health services in a timely manner would probably increase. The exact accounts will be known with a Cost Utility Analysis (CUA), calculating the Quality Adjusted Life Years (QALYs) net in the different scenarios. But it is just as important to calculate the economic impact for the welfare state, with a generalized Cost Benefit Analysis (gCBA), which will come. The social cost of dying in isolation from loved ones also matters.
In Costa Rica we applied "moderate confinement". We closed borders, bars and clubs. Tourism and massive events were banned. But, we maintained restaurants at 50% capacity, industrial production, basic and international trade. We applied social distancing "without turning off the country", based societal discipline and civic obedience.
Cost-effective epidemiological surveillance
The WHO has always recommended effective epidemiological surveillance by applying tests in two ways. First is the expansive or massive application of tests, usually recommended for countries with a divided or disjointed health system, which forces them to maintain a low positivity rate. This is between 3 and 12% (or less than 5% for more than 14 days). Another strategy is sentinel surveillance. This is only feasible in countries with a solid, disciplined and hierarchical health system, such as Costa Rica and it applies good epidemiological surveillance practices such as "case monitoring".
The collapse of the international market limited the timely provision of quality PCR tests to many countries around the world. This inclined the health sector of Costa Rica to establish an aggressive strategy to "seek and isolate" positive cases, like the one that has been applied against Dengue or Zika, more recently. Before confirming the first case in the country, several suspects from abroad had already been ruled out. High-quality PCR tests applied in a targeted manner are used to rule out suspicious cases, with a better cost-effectiveness ratio, than applying them massively. There are 14 sentinel sites distributed throughout the country. In addition, PCR tests are used by the AyA to monitor entire communities, neighborhoods or even buildings, by detecting the presence of the virus SARS-CoV-2 on residual waters.
The quality of the tests is guaranteed by the registration process of the Ministry of Health, the quality controls of the CCSS supported by the CNT44 Health Committee of INTECO, active since 2016 and the Costa Rican Institute of Research and Teaching in Nutrition and Health (INCIENSA), which has been certified by the Costa Rican Accreditation Body (ECA), under the international standard INTE-ISO/IEC 17025 in 2017 and with the strengthening of the National Centers of Reference (CNR) of INCIENSA, thanks to the investment that allowed the inauguration in 2018 of the Laboratory of Microbiological Food Safety.
Without the use of "rapid tests", that has shown many sensitivity and specificity problems, to date there is a PCR test rate of 600 per 100,000 persons. The Costa Rican Ministry of Health has documented that 25% of the positive cases are from foreigners and it is prohibited for positive carriers of other nationalities to enter the country.
The health care system
The INS recognized the labor risk of COVID-19 on March 14 (1 week after the first case). Therefore, it expanded its coverage, protected the tourism sector of travelers in quarantine, supported the accident rate, and financed the productive sector of micro-enterprises to reduce the impacts of the pandemic. However, the vast majority of the costs of care have been assumed by the CCSS, for reasons of public health.
With decades of recognized Universal Coverage and a strong network of primary care or basic health care teams (EBAIS), the provider of health services par excellence is La Caja (CCSS). It is the largest company in the region and its annual budget exceeds $6.5 billion, 70% of the sector's budget.
Its predecessor was the successful 1955 "Hospital Without Walls", which contributed to developing the declaration of the International Conference on Primary Health Care, Alma-Ata, USSR, 1978. La Caja maintains a community prevention program, based on the home visits of nursing assistants and Primary Care Technical Assistants (ATAP), who have kept the “Family File” up to date and digital since 2017. It is the true secret of universal primary care in Costa Rica.
Between 2016 and 2017, almost 20% of the CCSS annual budget was invested in renovating infrastructure, programs for the control of chronic diseases, and the Single Digital Health File (EDUS). In addition, it financed the first Emergency Medical Team (EMT) to be accredited by PAHO/WHO in the Americas. It also renewed the infrastructure and medical equipment for much of its health services network, which is made up of 29 hospitals, 17 clinics, laboratories or national centers, 7 regional areas, 106 health areas and 1,053 EBAIS, employing 58,000 people.
The Type 1 EMT allows for the separation of suspected COVID-19 patients from the rest, and exclusively provides them access to some hospital ER services by installing campaign modules. Just 14 weeks after the first case, 1.4% of cases had been hospitalized and less than 0.4%, required intensive care units’ beds (ICU). The ICU bed rate is 4.5 per 100,000 inhabitants. In Costa Rica, with a recovery rate of 53% of cases, infected patients were isolated without stopping health services for the rest of the population.
In 2018, the EDUS became the first in the Americas with universal coverage in the 3 levels of care and received the United Nations Public Service Award 2019. Its App has more than 2 million free downloads and is currently used to identify the level of risk of contagion by COVID-19. The digitization of the health sector (2014-18) and telemedicine has been fundamental. Since April 2020, 60% of specialized consultation was by videoconference and medications for at risk patients are distributed in paper bags to their home.
In 2016, it also invested in medical equipment that guaranteed a rate of 8 ventilators or mechanical respirators per 100,000 inhabitants and during this pandemic, orders were made to increase it by 80%. The CCSS, pushed by its medical chief officer, Dr. Mario Ruíz Cubillo, transformed one of the specialized centers into a COVID-19 Patient Care Center (CEACO) in 11 days. The new coronavirus is here to stay.
Under the leadership of its executive president, Dr. Román Macaya Hayes, the CCSS implemented protocol for the use of hydroxychloroquine on March 20th (2 weeks after the first case). Utilizing the experience accumulated by the 50 years of the Clodomiro Picado Institute it is producing an antivirus serum designed to work on various types of SARS-CoV-2. Costa Rica already has a genetic map of the virus strains prepared by INCIENSA and the Technical Council for Clinical Bioinformatics (CTBC), who are responsible for the country's Genomic Project since 2018. And thanks to the National Council for Health Research (CONIS), the activity was reactivated in 2015. We will be able to draw definitive conclusions even under the most demanding methodology with bioethical guarantee.
This virus does not discriminate. Assuming that it is a disease only of the rich or the poor is a mistake. A powerful hospital system is not enough to defeat COVID-19, with appropriate measures we must avoid depending on it. In Costa Rica, health is a human right and, as I have insisted, epidemiological surveillance is a matter of National Security. In Costa Rica we managed to “flatten the curve.”