From the President: Family Medicine in Costa Rica

Photo: Delegates from Nicaragua, with WONCA president, president-elect and CEO, at the 1st WONCA Mesoamericano Congress

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Alejandro Alvarez is a family physician working in the town of Barva in provincial Costa Rica. Alejandro works with his large primary care team, providing community-based health care services to a population of 45,000 people in Barva and the surrounding rural areas. His clinic team includes 10 general practitioners (GPs), primary care nurses, health promotion staff, community dental services and a social worker, dietician, and psychologist.

Photo: Dr Alejandro Alvarez, Family Physician at the Barva Health Clinic in provincial Costa Rica

Alejandro’s clinic also serves a network of ten Basic Primary Health Care Teams, working out of clinics based in rural communities, with each team comprising a GP, a primary care nurse and a primary care technician. The primary care technician is a skilled and well-supported community health worker, who visits every house in the local community, identifying people at risk and referring them to the GP and nurse, gathering data for health planning and resource allocation, and implementing basic health interventions such as vaccination programs. There is a current strong focus on preventing mosquito-borne illnesses due to dengue, zika and chikungunya viruses.

Costa Rica (Spanish for the Rich Coast) is a small country of 4.5 million people in Central America, bordered by Panama to the South, Nicaragua to the north, the Pacific Ocean to the west, and the Caribbean Sea to the east. It is renowned for the remarkable biodiversity of its wildlife, for its coffee and chocolate, and for its national commitment to the use of clean technology and reversal of past environmental degradation. It is also well known for its effective model of primary health care, ensuring universal health coverage, with health care for all delivered by community-based health teams. Each Basic Primary Health Care Team provides care for around 4,000 people and there are now teams covering the entire population, ensuring that all citizens have equitable access to health care services.

Photo: Dr Jose Martin Rojas Castro, general practitioner at the Basic Primary Health Clinic in the rural community of San José de la Montaña

The national social security insurance program of Costa Rica dates back to the 1940s, and the nation ensures free primary care and hospital care for people in rural areas, those on low incomes, and vulnerable populations including mothers and children, indigenous people, the elderly and those with disability. A single health insurance scheme for all people means that Costa Rica avoids some of the health care inequities that occur in some other nations in this part of the world. The nation’s health care budget is also augmented by taxation on soft drinks and alcohol.

I was in Costa Rica to participate in the 6th Iberoamericana Family and Community Medicine Summit (Cumbre in Spanish), hosted in the capital city, San José, by the Association of Family and Community Medicine of Costa Rica, and our WONCA Iberoamericana CIMF Region, which includes the Spanish speaking nations of Central and South America, as well as Brazil, Portugal and Spain. 164 delegates from 23 countries came together to discuss the role of Family Medicine in ensuring universality, equity and quality in health systems across the region. Waynakay, our WONCA Young Doctor Movement in Central and South America, was also well represented, ensuring the voice of the next generation of family doctors in the deliberations.

The outcome report of the Summit is the Letter of San José (La Carta de San José), which I was invited to sign along with Dr Fernando Llorca Castro (Minister of Health of Costa Rica), Professor Inez Padula Anderson (our WONCA Iberoamericana Regional President), Dr Thomas Meoño Martín (President of the Summit) and representatives of the Costa Rica Social Security program, and the Pan American Health Organization (PAHO) of the World Health Organization. The Letter of San José will be published in Spanish and English on the WONCA website.

The Summit was followed by WONCA’s first-ever Central American Family Medicine Conference (Congreso Mesoamericano de Medicine Familiar y Comunitaria) where delegates shared developments in family medicine clinical care, education and research in each of the nations of the region.

Photo: Dr Alexander Paz (in red tie), WONCA’s first direct member from Honduras, with WONCA president and CEO and other delegates from Honduras

I was impressed with the primary health care system in Costa Rica and the potential for family doctors to make further contributions. Costa Rica has the second longest life expectancy in the Americas, following Canada, with current life expectancy at birth of 81.5 years for females and 76.7 years for males. Yet challenges remain, especially with the rise in non-communicable diseases, and the complex co-morbidities that accompany an increasingly elderly population. This is where family medicine offers great hope for the future with an increasing cohort of trained specialist family doctors providing effective leadership of the networks of primary health care services, ensuring the provision of coordinated, comprehensive, integrated care for all people.

The family doctors in Costa Rica ensure that health care costs are kept low through appropriate referral to consultant services only when indicated, that essential health information is made available between health care providers to support quality care, and that there is efficient and effective integration of primary, secondary and tertiary care services.

Michael Kidd
World Organization of Family Doctors (WONCA