Op-ed for Healthy Debate by Dr. Tara Kiran
I first read about Costa Rica’s primary care system nearly a decade ago. In 2016, I came across a paper by physician-researchers at Ariadne labs, including Madeline Pesec, describing how this small, middle-income country was achieving health outcomes that exceeded what its resources would predict – including lower infant mortality and longer life expectancy than the United States, and outcomes comparable to much richer countries.
What was at the heart of their success? A strong primary care system that’s integrated with public health. And an underlying ethos that health is a human right.
Through the 20th century, Costa Rica invested heavily in public health, including sanitation, clean water, nutrition – but also epidemiology and data collection. Clinicians and public health workers were expected to go to people rather than wait for patients to come to them.
Then in the 1990s Costa Rica made a key structural decision: it placed public health and health-care delivery under a single national social security agency. Prevention, primary care and hospital care are part of one system, accountable for health across the life course. When the agency invests in increasing physical activity in childhood, the same agency reaps the rewards of lower rates of cardiovascular disease in adulthood.
I remember reading Pesec’s article on Costa Rica and thinking how Canada could learn a lot from that approach, particularly the four pillars of their primary care system:
- Strong interprofessional teams. In Costa Rica, care is delivered through more than 1,300 EBAIS clinics (Equipos Básicos de Atención Integral de Salud), each serving roughly 3,000-5,000 people. Teams include a physician, a nurse or nursing assistant, a pharmacist or pharmacy technician, a data specialist and a community health worker (ATAP). Community health workers play a central role in building relationships and identifying populations at risk.
- Geographic empanelment. Costa Rica’s primary care teams are responsible for everyone living within a defined geography. Community health workers maintain a census of every household, mapped and stratified by risk. Every household is visited at least once a year, with more frequent visits for those with higher needs. Teams know exactly who they are accountable for.
- Integrating public health and primary care. Community health workers (or ATAP) act as a bridge between primary care clinics and the surrounding community. ATAPs lead health promotion efforts – delivering vaccines, monitoring health parameters, providing education on disease prevention – and connect people to clinical care when needed.
- Robust data and feedback loops. Data are embedded in daily work. Teams have chronic condition registries, for example, noting who in the community has diabetes or high blood pressure and whether they have received recommended testing. They also track vaccines, pregnancies, social risk and other data that can help them understand population health needs over time.
I should acknowledge that things aren’t perfect in Costa Rica. The country struggles with some of the same challenges we face in Canada, including fiscal and workforce pressures. But even under strain, it continues to achieve better outcomes than its level of spending would predict. Notably, research has shown that the introduction of EBAIS teams in Costa Rica was associated with substantial reductions in mortality over time, particularly among older adults and from cardiovascular disease.
In November 2024, I had the chance to visit Costa Rica. In recent episodes of my podcast, Primary Focus, I take listeners behind the scenes to see an EBAIS team in action and hear directly from the community health workers at the heart of their model.
One of my key takeaways: Costa Rica is a country with far fewer resources than we have in Canada – but much more ambition. It’s designed a system that takes care of everyone – regardless of their geography or background.
And although our countries are very different, there’s a lot we can learn from Costa Rica. I think each of Costa Rica’s four primary care pillars is applicable to the Canadian context.
Can we imagine a future where every person in Canada is “geographically empanelled” to a local interprofessional team that treats illness but is also connected to social services to support wellness and where data feedback loops drive continuous quality improvement? These are all critical elements of what people in Canada told us they wanted to see in a better primary care system.
Compared to Costa Rica, Canada has roughly twice the economic resources per person adjusted for cost of living. In other words, we have enough money. What we need is more ambition – to build a system where every person is accounted for and the responsibility of a healthcare team.
Editor’s note: A version of this article first appeared in The Medical Post.
