In Costa Rica: How a middle-income country built a world-class primary care system
This episode is the first in a two-part series on the primary care system in Costa Rica. Dr.Tara Kiran sits down with Dr. Madeline Pesec, an internal medicine physician and pediatrician, to explore Costa Rica’s ambitious primary health care system. They talk about how Costa Rica's commitment to health as a human right and its community-oriented primary care have led to significant improvements in health outcomes. From the concept of "Hospital Without Walls" to the role of community health workers, Madeline shares insights from her extensive research and personal experiences in Costa Rica. Then, join us in our next episode where Tara goes on a tour of a Costa Rican clinic and speaks to members of the EBAIS (Equipos Básicos de Atención Integral de Salud) about both how and why they do their work.
Further reading:
Take a look at the research article that first introduced me to Madeline
Explore this brief Commonwealth Fund case study on the Costa Rican primary care system or dive deeper into this more detailed case study from Ariadne Labs
Read the article “Costa Ricans Live Longer Than We Do. What’s the Secret?” in the New Yorker magazine by Dr. Atul Gawande
MAINPRO CREDITS: Family doctors can claim Mainpro Credits by completing a linking learning exercise.
More about Primary Focus:
Subscribe to our Substack newsletter
Have an idea for an episode? Email primary.focus@unityhealth.to
-
In Costa Rica: How a middle-income country built a world-class primary care system
Primary Focus Podcast
Introduction: A Yoga Retreat with a Detour
Dr. Tara Kiran (00:10) This is some sound I recorded about a year ago from the porch of a cabin I stayed in on a trip I took to Costa Rica. I have a busy life — I have three children, I'm a family doctor, I'm a researcher, I work at the university, I give a lot of talks. And at the time, I'd just completed sixteen months of really intense patient and public consultations across Canada for Our Care. I needed a break.
So I decided to go with a friend of mine to a yoga retreat in the jungle. The air was warm, the food was delicious, the people there were so nice, there were birds and monkeys everywhere. We didn't have sunshine — it rained a lot — but the retreat was wonderful in so many ways. Yet even as I was there, supposedly relaxing, I just couldn't resist visiting one of Costa Rica's primary care clinics.
Okay, I know I should be able to turn off the researcher in me. But it was an opportunity I just couldn't pass up. Here I was in Costa Rica, a country I had been reading about for some time — a country I know punches above its weight when it comes to primary care. How do they do it, and what can we learn from their success? I really wanted to find out.
Introduction
Dr. Tara Kiran (01:40) This is Primary Focus, and I'm Dr. Tara Kiran. This episode is the first in a two-part series on Costa Rica's primary care system. In this first episode, we're going to lay the groundwork with Dr. Madeline Pesec, a physician and researcher based at Ariadne Labs and Brigham and Women's Hospital in Boston. Madeline has spent years studying Costa Rica — its history, its values, and the healthcare delivery design that make its primary care system so effective.
In our next episode, Part Two, I'll take you with me to Costa Rica, where I spend a day in a primary care clinic so you can hear directly from one of the teams on the ground.
Background: Why Costa Rica?
Dr. Tara Kiran (02:21) I reached out to Madeline over a year ago. I'd been interested in the Costa Rican primary care system for a while — actually, since I read a paper she co-authored with Dr. Atul Gawande that was published in Health Affairs back in 2017. I remember reading the article and being really struck by their findings. Here was a middle-income country that was consistently outperforming its peers when it came to health outcomes. And the secret really was their primary care system.
That article described four pillars of their primary care system — pillars I felt were really relevant to countries like Canada: integration of primary care and public health, multidisciplinary teams, geographic impanelment, and measurement through reliable data and feedback loops. What was working in Costa Rica were things I thought we could learn from here in Canada to improve our own system.
So I'm excited to share the conversation I had with Madeline. But before I do, I want to share some of the brief history she walked us through so we can understand why Costa Rica looks the way it does today.
A Brief History of Costa Rica's Health System
Dr. Tara Kiran (03:34) Costa Rica is a relatively small country with a population of about 5 million people. It gained independence from Spain back in 1821, and then full independence from Mexico in 1838. Between the 1920s and the 1960s, they underwent a period of really rapid health improvement — developing a Social Security Administration responsible for healthcare delivery, and a Ministry of Health responsible for public health.
In the 1930s, they invested in classic public health interventions like sanitation, clean water, and deworming, but also in epidemiology and a real focus on data. They tracked populations, created nationwide protocols, and made decisions based on real numbers — tracked with good old-fashioned pen and paper.
By the 1940s and 1950s, they were experimenting with new models built on the idea that healthcare shouldn't stop at the clinic door. They launched a transformational system called Hospital Without Walls, where clinicians and public health workers went out to meet and treat people wherever they were — even if that meant taking primary care to remote mountain communities by boat, by horse, or by foot. That was their motto. And their model bridged the gap between community and hospital care.
Over time, community-oriented primary care became deeply embedded in Costa Rica. And then 1978 came along, and the country sent a large delegation to the Alma-Ata Conference, where countries around the world committed to comprehensive primary healthcare — community-oriented, as the foundation of a strong health system. Though there were challenges along the way, Costa Rica took that commitment very seriously and built a strong primary care system rooted in community.
Conversation with Dr. Madeline Pesec
Dr. Tara Kiran (05:34) So that's the reason I reached out to Madeline — and later why I snuck out of my yoga retreat to visit a clinic there. I wanted to understand the magic of the ethos that health is a human right, and how that ethos helps set Costa Rica up to build a system designed for everyone to have access to primary care, no matter where in the country they live. So I hope you enjoy my conversation with Dr. Madeline Pesec.
Dr. Tara Kiran (06:08) Madeline, welcome to Primary Focus. It's so great to have you here.
Dr. Madeline Pesec Thanks so much for having me.
Dr. Tara Kiran Madeline, tell us a little bit about yourself. Who are you? What do you do? Where do you work?
Dr. Madeline Pesec Absolutely. I'm an internal medicine physician and also a pediatrician. I practice here in Boston, Massachusetts, at Brigham and Women's Hospital. And I'm also faculty at Ariadne Labs, which is a joint centre for health system innovation between the Harvard School of Public Health and Brigham and Women's Hospital. I split my time between clinical responsibilities and doing research on incredible primary healthcare systems around the world.
Dr. Tara Kiran Tell me a little bit more about that research and what motivates it.
Dr. Madeline Pesec Yeah, so I actually started researching the healthcare system of Costa Rica about a decade ago. I had just started working for Ariadne Labs, and we were cataloguing all of the different healthcare systems in the world and seeing what we could learn from them. I was an intern at the time and in charge of doing all the literature reviews. And what I read about Costa Rica seemed really interesting, but there really wasn't that much written on the system then. I think I read the abstract of every article on PubMed that had Costa Rica in the title, just trying to find any nugget of information about their primary healthcare system.
Unfortunately, I wasn't able to find a lot in the peer-reviewed literature. So I went to Costa Rica and visited — much like yourself — carved some days out of a family vacation and went to go visit some clinics. And what I found was a system that was outperforming systems that were better funded, outperforming systems that were better staffed, outperforming a lot of other primary healthcare systems around the world. And I said: there has to be something magical and special about what they're doing here.
And I devoted the next seven or eight years of my life to figuring out what the magic was — and really amplifying the incredible work of public health and primary care experts in Costa Rica so that the rest of the world can learn from it.
The Ethos: Health as a Human Right
Dr. Tara Kiran How has Costa Rica developed an ethos where everybody deserves access to primary care? It's pretty clear when you go there that that is the goal of the healthcare system. Where do you think that ethos comes from?
Dr. Madeline Pesec (08:25) I think the ethos is definitely there and it's incredibly strong. And I think it's more than a commitment to primary care — it's really a commitment to health for all and health coverage for all. Costa Rica has incorporated strong government and a socialist bent to the way it thinks about what a government owes its people. A real focus on human rights and health as a human right. And so I think the development of the Costa Rican government, the development of Costa Rica as a country — the Social Security Administration and the Ministry of Health have often played central roles in discussions around presidential candidates and have really been central to Costa Rica's formation and identity as a country. What does it mean to be Costa Rican?
Dr. Tara Kiran I've heard it described — and this is probably a gross oversimplification — that some countries in the same region, when they had independence and resources, decided to invest those in the military to keep the country safe and secure. But Costa Rica decided instead to divert those resources to health and social services. Do I have that right?
Dr. Madeline Pesec Yeah, Costa Rica doesn't have an external military, and that has certainly freed up a lot of room in the budget for other social endeavours. I think sometimes it's described as eschewing a military in favour of other things. I would actually say it was more so a commitment to education and health services that then led them to say: well, maybe a military isn't where we're going to put our money. Not so much that they decided they didn't want a military, as much as they decided what they did want. And when they looked at the numbers, there wasn't a lot of money left for a military.
And so this commitment to the strength of their central national institutions — as a reflection of the strength of the central government and their belief that a strong Social Security Administration was really synonymous with building the country — I think is key. And their immense pride and commitment to the work of the Social Security Administration and the Ministry of Health.
Dr. Tara Kiran (10:46) And I think when you say what's the root cause of that, it's hard to pinpoint what made one country go down one route and another another, a hundred years ago.
Dr. Madeline Pesec We know for sure that there were incredible leaders and visionaries in the world of public health and in the world of health for all, very early in the country's founding. Many presidents throughout Costa Rica's history have emphasized health as a central function of government. And I think there's also a strong positive feedback cycle that happened in the 1940s and 1950s: as they invested in public health and education, they saw incredible, exponential improvements in their infant mortality rate and in their life expectancy.
So they could see very clearly that what they were doing was having a great impact. That led to further investment in those structures and systems. And I mentioned that early on, data was core — being able to see and quantify the impact of those programs really drove a lot of the pride and excitement around what they were building.
Because in this period from 1920 to 1940, Costa Rica was standing up and creating many of its core institutions that last until today — not only the Social Security Administration and the Ministry of Health, but also their ministries of education and nutrition, and lots of their governmental infrastructure were all coming up at once. And so the pride in being able to improve the quality of life for all citizens, and this central belief that health is a core tenant of what it means to be a government, really carried over into the 1950s and 1960s, when a lot of that work and ethos was amplified by visionaries and continued to shape the country's direction.
Dr. Tara Kiran (13:05) Yeah. So what I'm hearing is sort of an ethos of social solidarity, a belief in health as a human right, many visionaries along the way ensuring the country was going in a certain direction, and data that actually helped people see that what was being done was working.
And what's striking is how public health and primary care are very integrated on the ground in the way care is delivered. I know a lot of that comes back to the 1990s and the primary healthcare strategy released at the time. Maybe tell me a little bit more about that.
The 1990s Health Reform
Dr. Madeline Pesec Absolutely. So as Costa Rica came out of the 1980s with increased funding constraints, duplicative work, and then some disease epidemics that catalyzed public outcry for reform, a group of people came up with a health reform. And the fundamental concept of their health reform is pretty revolutionary.
What they decided was that the dichotomy that had developed between the Ministry of Health and the Social Security Administration — where one provides traditional public health services and one provides hospital and clinical care — was a false dichotomy. That those two things actually weren't different. That people needed care, and sometimes that looks like deworming campaigns and nutrition, and sometimes that looks like coronary surgery, but that they're one approach for the same humans.
And so they made the radical decision to really combine all of their public health functions — epidemiology, disease surveillance, nutrition, deworming, malnutrition, all of that we think of as traditional public health — and moved it over as part of the Social Security Administration. What that did was give one entity the responsibility for the health of children, adults, and the elderly, from prevention of disease all the way through treatment of disease.
We talk about kind of one pot of money. And when they combined the public health and the clinical care, the health insurance was being provided in an economically sustainable way for every Costa Rican. So you have one entity in charge of the lives of every Costa Rican. And that one-pot-of-money concept really enables something that is so fundamentally broken in many systems: that the money you invest in prevention, the same entity may not reap the benefits of that disease prevention down the road.
So if you have one entity paying for coronary catheterizations, they have a strong incentive to improve the physical activity of a six-year-old, because they know that they are going to own that life and the health expenditure for that life over the life course. And so by reconceptualizing health and breaking that false dichotomy between public health measures and clinical care, they were able to make primary care that linking, unifying feature — a way they organize the population, organize their primary care efforts, link into networks of hospital care, and continue to carry out epidemiologic surveillance, childhood growth monitoring, antenatal care, and all those other traditionally public health efforts.
Dr. Tara Kiran Yeah, it's so interesting. It's so true that in many high-income countries, the part of the government paying for healthcare services is different from the part responsible for prevention and health promotion. But what's also fascinating is that I actually think ordinary people get the importance of linking the two. We've had conversations with patients and the public across Canada over the last few years, and people would say over and over: we need a wellness-oriented system. Why is it that we're not investing more upstream so that we can prevent downstream?
Geographic Impanelment
Dr. Tara Kiran (17:45) One of the key ways they actually realize the goal of healthcare for all — including primary care for all — seems to be through what I think is often called geographic impanelment. Can you explain what that means on the ground? What does it mean for an average Costa Rican? How does it actually work?
Dr. Madeline Pesec I smile and chuckle because my coworkers say I should get a T-shirt that says "impanelment for all." I really believe in the concept of impanelment as a way to operationalize and execute these concepts we talk about in primary care. So let me try to explain why I think this really nerdy word is the key to primary care success.
In a traditional clinic, healthcare providers sit behind a desk and wait for people to come to them. They call, they make an appointment, they walk in off the street, the doctor does their thing, you get a prescription, and you go home. That's an incredibly outdated way of thinking about health, and it certainly doesn't lend itself to wellness and prevention — because you're waiting for somebody to feel symptoms before they come in.
In order to transition to a proactive system that prevents disease before it starts, that identifies disease before it has symptoms, that finds what risk factors we can modify — you fundamentally have to know who you're responsible for. Who you're taking care of. And somehow we've skipped that step for most primary care systems: who are my patients? Who am I taking care of?
So when you go back to the community-oriented primary care models that developed in the 1940s, 1950s, and 1960s in Costa Rica, they were grounded in geographic space and community. And there's a power in having a group of community come together with a clinic — it gives the clinic the ability to really know the dynamics of that community, the epidemiology of the community, and it provides an opportunity for the community to have a strong voice in what the healthcare system provides and what it sees the needs as being.
Dr. Tara Kiran (20:05) And so in the 1994–1995 health reform —
Dr. Madeline Pesec They decided: all right, we're going to combine the primary care systems and the clinical care system. And we're going to do that around this primary care team. And this primary care team is going to take care of a group of people that live in the same area. Each city or village is going to have one primary care clinic. That's all geographic impanelment is. It's way too long and complicated a word for saying that you're responsible for this group of 3,000 to 5,000 people that all live in the same area.
The second thing they did was say: in order to really take care of people and all of their needs, we're going to need different members of a team. And this can't be a doctor-centric model, and it can't be a community health worker-centric model.
At the time, the pressure from international organizations was actually that primary care should be done only by nurses and community health workers — that Costa Rica was too poor to have a doctor in every clinic. And Costa Rica said: actually, having a doctor at the clinic to address the curative needs of the population alongside the nursing and community health worker needs — that's going back to why we made this system in the first place. It was to link the curative care and the preventative care.
They had a lot of pushback from international organizations. Some walked away and refused to fund the model because they didn't believe there should be doctors at every clinic. And so it was really through visionary and passionate healthcare leaders that they were able to find additional funding and keep a full multidisciplinary team.
The EBAIS Team Composition
Dr. Madeline Pesec So that multidisciplinary team consists of a doctor — which was incredibly important to them. It also has a nurse or nursing assistant. It has a community health worker. It often has a pharmacy technician to dispense medications, and sometimes a pharmacist. And it has this incredible fifth role that speaks to the importance Costa Rica places on data.
Dr. Tara Kiran (22:27) The fifth role is a medical data specialist.
Dr. Madeline Pesec They do some secretarial tasks like checking patients in, but they were also responsible for creating disease registries. If a patient had high blood pressure or diabetes, this person is responsible for identifying all cases and putting them on a list so they could track progress. They were responsible for keeping meticulous records of different disease conditions, identifying epidemiologic disease trends when a new outbreak started to happen. Making them a full member of the team really speaks to the fact that data, measurement, and understanding what was happening on the ground was key from the very beginning. It wasn't added on top — it was baked into the model.
Dr. Tara Kiran Yeah. I mean, I think what I'm hearing from you is that Costa Rica has figured out how to do population-based care. Geographic impanelment is one way to put it, but another way is to say: we're going to look after everyone in this surrounding community. Everyone in this community is going to be connected to this clinic or team, and this team is going to be able to meet their basic care needs. The team proactively thinks about those people — they don't have to necessarily come to the clinic to be considered part of the team's responsibility. And the team is constructed in a way that combines biomedical care with health promotion and community-oriented care. It's really quite beautiful.
So just to step back: you were talking about these EBAIS clinics. Maybe just describe what EBAIS even stands for?
Dr. Madeline Pesec The EBAIS teams stand for the Equipo Básico de Atención Integral de Salud. And what that translates to in English is the basic healthcare teams for the holistic provision of health.
Dr. Tara Kiran (24:49) Wow, that's a big responsibility for a lean team. But I love that name, because it says that these are primary care teams caring for the whole person. They're not a sick-care system — they're a team for health.
Dr. Madeline Pesec Exactly. To promote wellness and health in the community. These are the five-member teams. Sometimes they're located right within the community they serve, which is the ideal; sometimes, in more crowded urban areas, they're centralized in one clinic and share space with each other. Then between five and ten EBAIS teams report to a health area. And at the health area level, that's where a lot of the epidemiologic surveillance gets centralized, and where some of the slightly more specialized services happen — gynecologic nurses, nutritionists, psychologists. So some of that support team that the community might need is at that health area level.
Dr. Tara Kiran And from the reading I've done, it sounds like there are just over 1,300 EBAIS teams — or that was the stat a few years ago — and together there are about 104 of these health areas. So something like ten to fifteen EBAIS teams per health area. And the health area is really thinking about: what are the population needs? What are the demographics? How old are the people in this area? What are the common chronic conditions? How is that changing? And that data informs the services these teams deliver.
Dr. Madeline Pesec (27:09) Absolutely. At the health area level, they have to do a very formalized health needs assessment for their population. You're marrying the objective, hard-number data about what diseases are going up and what the age distribution is, with community input. You ask the community: what do you think the biggest issues for your health are? What do you think are the challenges we should address this year?
So that planning and operationalization happen at the health area level. And different health areas have different challenges they have to meet. In some areas, if you have a higher prevalence of elderly people, you may need to add a palliative care nurse to your team. In some areas with high prevalence of tourists, you may have an increased concentration of sex workers and need additional condom distribution and STI education. You may need to do more street medicine to find people where they're at.
And it's very much linked to the geographic understanding of where people are. In the early days, all of the health areas would have these beautiful hand-drawn maps on the walls that marked every household, the number of people per household, and whether the household was low, medium, or high risk.
And this is one of my favourite elements: when the community health worker is going about their day, they're expected to visit every house once a year and do an assessment. When this first started, they were looking for things like: does the house have a floor? Does the house have a roof? Does it have electricity, running water, a toilet indoors? Now they're looking for things like: does the house have Wi-Fi? Do they have a refrigerator? Is there electricity all the time or some of the time? They're also looking for other facets of social vulnerability — single mothers, households with more than five children, other markers of social vulnerability.
If a home has multiple markers of social vulnerability, it's coded differently. In the old days, they would colour the house red on the map. Now it's all done via GIS-integrated tablets where the community health worker can geotag the location of the house.
Dr. Tara Kiran (29:28) And if the home was high risk —
Dr. Madeline Pesec The community health worker would visit the home upwards of three times a year to check in preventatively: see how everyone is doing, identify any newly pregnant women, identify any new children, make sure they're bringing everyone into the healthcare system when they need it, and do education. Historically, Costa Rica's had very low rates of malaria — and that's not an accident. It's a rainforest; they should have had a lot more mosquitoes than they do. But part of the community health worker's job was to go around the home, identify any areas of stagnant water, do education on standing water, and then treat the standing water to prevent mosquito breeding and malaria transmission.
And so this concept of integrating the social needs assessment — the social vulnerability of a house — with the frequency of contact with the medical system, and really being intentional that if the household is at increased social risk, it's the healthcare system's responsibility to make sure everybody in that house is okay. The community health worker can also connect children in the home to additional nutrition programming, and can bring vaccinations to the home to make sure all children are up to date.
Dr. Tara Kiran Yeah, you're really describing a lot of the roles that the community health worker on the EBAIS team is taking. That's a unique role — or at least unique within the Canadian and American contexts. They call these community health workers ATAPs, and you can let us know what that stands for. You've described some of their roles — home visits, for example — and my understanding is they also do group education. When I met them, in our next episode we're going to go to a clinic and interview some of these ATAPs.
The ATAP: Bridging Community and Clinic
Dr. Madeline Pesec (31:44) The ATAPs are Asistentes Técnicos de Atención Primaria — which means they are the primary healthcare technical assistants. And like you described, they really are the link between the very rich history of public health that Costa Rica has and the rest of the medical team who stay more located in the clinical setting — not a hundred percent, but they are that link between the community and the clinic.
And you can see echoes of this in the Hospital Without Walls model: health doesn't just happen in the clinic. Health is something that should happen in the community. Community members over time should get to know their ATAPs, and the ATAPs should get to know the cultural preferences and needs of their community.
One facet of the system we haven't had a chance to speak about is the Indigenous populations in Costa Rica. Historically, they've been very underserved by the healthcare system. And so the intention behind having the community health workers is to gain the trust of historically marginalized groups. While each country has different groups that have been historically marginalized, in all countries throughout the world we have a need to identify our most vulnerable, most underserved patients, and go to them.
I see the community health worker really as that link to the community — to learn their customs, learn what their needs are, to be able to make notes for each other. For example, I was walking with a community health worker going to visit a patient for a palliative care visit. I was with the palliative care nurse, and we looked in the family file — where they store all of their social needs information. And there was a little note at the top that said: "Make sure you go through the back door, not the front, because there's a really mean dog at the front door and you'll get bitten." And so because of that, we went around to the back door and we had a lovely visit.
Dr. Tara Kiran That's such a great story about how community health workers get to know people over time. You've traveled to Costa Rica many times now and visited many clinics. Are there other stories that bring to life what we've been talking about — this community-centred model?
Dr. Madeline Pesec (35:22) Yeah, absolutely. One experience I'll never forget: I was in the southeastern part of the country working at a clinic — a three-hour drive up a dirt road up into the middle of a mountain — and we met the doctor there. It served a predominantly Indigenous group of Costa Ricans. When they first built the clinic, they had painted it institutional caja blue. The Caja is the Social Security Administration, and they have their signature blue colour — they paint all of their clinics this bright blue, a consistent national language of health and care and wellness. So, of course, at the top of this mountain, painted in Costa Rican blue.
But when they talked to the community members, the community said: "This isn't reflective of our culture." And so on top of the caja blue, they had painted incredible Indigenous murals. And so you can see this visual blending of this Costa Rican national institution and the culture of the people.
From there, we got into a four-by-four and we drove another hour up into the mountains. We came across a stream — unfortunately, it was very full that day, and the four-by-four wasn't going to be able to cross it. So we put all the vaccines on our backs and we walked through the stream, and then we continued to walk until we got to this incredibly remote house on the top of a mountain.
We approached the door. On the door was a yellow, tattered piece of paper nailed to the front — and it had all of this very small, meticulous writing in rows. I asked the community health worker with me what that was. He said: "Well, that's the log of home visits. That's the log of every home visit this family has had." And it showed that every two months or so, someone is taking a van to a four-by-four to cross a stream to hike up to the top of the mountain to make sure this family is okay.
We went inside and met the family. One of the family members has cerebral palsy and is unable to leave bed without a wheelchair — predominantly bound during the day. I asked the family what it was like. Certainly, just imagine doing the trip we just did in reverse to get to the nearest clinic or hospital. Must be incredibly arduous. And they confirmed that when he does have to go to the clinic for a visit, it's a challenge.
And so the community health workers bring everything he needs to him — his vaccinations, they take his vitals. The doctor comes to the house when he needs visits. Once or twice a year they help him get down to one of the larger specialty appointments. But he did not have a single pressure sore, even though he was bedbound. He was up to date on all of his vaccinations. He smiled with recognition when the community health worker approached the home — he knew them. And they knew that on a Wednesday, his aunt usually takes care of him while his mom is out working. So they knew to ask for the aunt. They had all of this information in the file.
We got to visit the family. Everyone was doing okay. The refrigerator was working, so his insulin was staying cold. They checked the power supply, the generator — do they have a plan if the generator goes out? And then we made the trip back down, two or three hours back to the clinic.
And it just struck me: what beautiful, patient-centred, holistic care that is. We make a lot of excuses to say these patients are too far away. It's hard to imagine a more remote area. And Costa Rica has been able to bring high-quality, patient-centred healthcare to every nook and cranny of the country. It was a beautiful thing to see.
Dr. Tara Kiran Yeah, that's a beautiful story — a beautiful example of enacting their ethos of healthcare for all. Health is a human right.
Equity in Action
Dr. Tara Kiran (39:40) As you've been speaking, I've been reflecting a lot on equity. I think a lot of what you've shared shows how we can action health equity. When these EBAIS clinics were first set up, my understanding is that they prioritized high-needs neighbourhoods. An EBAIS team really gets to know a community and maps — on a colour-coded map or a more advanced GIS one — what are the high-risk areas. Then you've got community health workers building trust with communities that have historically been marginalized. And on top of that, you've got very human-centred care delivered to people where they are living — without the expectation that people need to come to a clinic. Even for people who are frail and bedbound, care comes to them. We do a terrible job of that in North America all too often. What are your reflections on that?
Dr. Madeline Pesec I think it goes back to their values and their principles. They do a great job of being a very mission-driven organization — the Social Security Administration. That concept of equity and solidarity across Costa Ricans is plastered on the wall of the main Costa Rican Social Security building when you go in. It is in the mouths of every worker throughout the whole system. And they consistently live those values.
So we talked about areas that might have a higher burden of poverty or social needs. I asked: is there any additional money that goes toward these areas? Typically they're paid per capita — per person. I said, I could imagine they might need more support. Do they get additional funding? And they said — as if incredulous: "You mean, do we pay more for one life than another?"
That completely against our ethos. And so their equity extends even to the edges of how they approach the system. They had to get creative in how they support areas with higher-needs populations, but they are so committed to equity and how that manifests across every household in Costa Rica.
And I reflect on experiences in the United States where we don't have that same assumption — that every life should be worth the same amount, or that every person should have the same amount of money invested in their care. We see incredible funding inequities between the Veterans Health Administration and the Indian Health Service, for example. Those are not equal payments for equal numbers of people. When we look at what we allow private insurance companies to do to distort the market, we're not paying the same amount for every life. And so having equity and solidarity as core values of the system plays out through macro decisions at the presidential level and at the Social Security Administration — but also every day in these micro-moments of every healthcare worker. It's work to sustain that over time and to sustain that culture in the system.
Dr. Tara Kiran It's so interesting because I think when we talk about equity here in Canada, we're often not talking about "the same" — we're drawing a distinction that equity means providing resources based on need in order to achieve similar outcomes. So it's really interesting to hear the Costa Rican perspective on that. At the same time, they've designed this very community-based system that is trying to individually meet people's needs.
The Evidence: What the Research Shows
Dr. Tara Kiran (43:37) We've talked about the strong primary care system that's geographically oriented around community, integrating public health and primary care, with these interprofessional teams and data fed back to teams to constantly drive quality improvement. What's been the impact of these investments? I think you've studied some of that.
Dr. Madeline Pesec Yeah. Because they've had such a strong commitment to data over time, Costa Rica has meticulously tracked every death in the country since the mid-1970s. And so we can very clearly see the impact of different social programs on mortality — which is typically incredibly arduous for researchers to link any intervention to.
And so together with Dr. Claudio García [uncertain: surname] from the Costa Rican business school, we were able to look at what happened when they rolled out the new primary care model. In 1995, they rolled out these EBAIS clinics, and as you said, they started in areas with the highest need — very far away from existing clinics, or with very high rates of poverty. They didn't open every clinic on the same day; they staggered it throughout the country over a seven-year period, which gave us a nice natural experiment to see what happened to mortality rates as different clinics opened with this special wraparound, holistic, population-health-focused model.
And what we found was astounding — keeping in mind that in 1995, Costa Rica already had pretty good stats. Pretty good infant mortality, pretty good overall life expectancy. So they weren't starting from a particularly easy place to see gains. And what we found, across multiple statistical models, was a 13% reduction in all-age, all-cause mortality nine years after opening a primary care centre.
Dr. Tara Kiran (46:04) I want to point out that it takes nine years.
Dr. Madeline Pesec We saw it very linearly — cumulatively. Year one, about 1%. Year three, about 3%. Increasing over time. But when you invest in communities and people, it takes time to see the return on investment. And so when you use traditional funding models — venture capital, investors who want to see a return in three years — it doesn't match up with the biology of humans.
We know it takes time to build trust. We know it takes time: if you treat diabetes today, you may prevent a heart attack in five years. It takes five years to see that effect. And so I think the study shows that primary care works, that looking at populations works, that centring communities, families, and people works. But it also shows that it takes time. We shouldn't judge a primary care model or system based on performance at five years — we should look at performance over ten, twenty, thirty years. And we know that investing in public health and primary care is the right thing to do. This study helped prove, once and for all, that it really impacts people's lives.
Something else we found in the study was that the largest gains were in cardiovascular diseases — like heart attacks and strokes — and among the elderly. People over 65 lived longer with primary care. And those two types of mortality are historically very difficult to move the needle on. When we talk about infant mortality, you can sometimes make large gains relatively quickly because things like handwashing and vaccinating babies can lead to quick wins. But in order to help a 65-year-old live to 85, you really need to be thinking about the whole person — the whole family, their food, their physical activity, their spirituality, their engagement with the community. So those are tougher to change.
So I was very heartened to see that comprehensive, person-based, impaneled primary care is what we're going to need as our population ages and as these chronic conditions — like diabetes, high blood pressure, what we call non-communicable diseases — proliferate. What you need is primary care.
Dr. Tara Kiran I love that research. It clearly shows the value of primary care. You and I both believe it, but not everyone does. But I think it's also worth noting: from a values perspective in Canada, primary care is what people want. We've spent the last few years talking to patients and the public to put forward a vision centred on what they want to see in a better system. And they want to see primary care for all. A wellness-oriented system where primary care connects to community care and addresses social determinants of health. Primary care that's accountable to the communities it serves, with community members involved in the design of services. And services with an equity orientation. So it's really interesting to see so many aspects of what people wanted to see in Canada reflected here in the Costa Rican healthcare system.
Lessons for Canada
Dr. Tara Kiran (49:30) Just as we're closing out, I wonder if you could reflect on what a country like Canada — or more specifically for a lot of our listeners, Canada — can take away from the Costa Rican example?
Dr. Madeline Pesec This is a question I get asked all the time and I don't have a perfect answer. Certainly Canada has more opportunities more readily available than the United States does. But a lot of the Costa Rican system is driven by values, and by commitment to health as a human right. If we want our system to reflect that, we need to collectively agree and call for it.
What can we learn? We can learn that whole-person care is essential. Team-based care matters. We've got to find a way to make sure everyone has a primary care team — not a primary care doctor, but a primary care team. We need to make sure we are recruiting the best and the brightest from medical schools into primary care. Make sure we're taking care of our primary care workforce so they stay and serve, and make primary care an exciting and attractive field.
We need to invest in ways to link our social care services to our healthcare system. There's been a lot of lip service paid to social determinants of health, and a lot of healthcare systems screen for needs and then have no way to fill those needs. We're going to need to get a lot better at linking social care to healthcare. And we're going to need to get better at taking care of one another — really thinking about how to get people what they need, regardless of whether it falls into a traditional health service or not.
If you don't have a refrigerator, you'll have a hard time controlling your diabetes because you can't refrigerate your insulin effectively. If you can't pay for your medicines, it's really hard to take them consistently. And so better integration with our social services, leveraging our schools as places to instill healthy habits — in Costa Rica, every child in elementary school brushes their teeth when they arrive at school, and again after lunch. So they know that every child in Costa Rica is brushing their teeth at least twice a day — and that led to huge improvements in adult dental health. So really going back to disease prevention, a focus on accompanying patients over their life course, and working together.
But these aren't easy, and they're going to require a real, radical change in what we as a healthcare system think our job is — and what patients expect from us.
Dr. Tara Kiran That's so beautiful. Thank you for sharing that. And thank you for joining us, Madeline. This has been a wonderful conversation.
Dr. Madeline Pesec (53:06) Of course. Thank you so much for having me. It's always a pleasure to speak with you.
Closing Reflections
Dr. Tara Kiran (53:19) I was really blown away by Madeline — her expertise, her on-the-ground experiences in Costa Rica, and the passion she has for sharing her knowledge about this incredible system they've built over the decades. A system that integrates primary care with public health, that's really community-oriented, and is designed so that everyone is able to meet their full health potential.
Next up, in Part Two, I take you with me to a clinic in Costa Rica, where I speak to community health workers, a pharmacist, a nurse, and a doctor about how exactly they deliver care — in the clinic and beyond the clinic walls. Stay tuned.
Credits and Closing
Primary Focus was created by Dr. Tara Kiran and is made possible by funding from the MAP Centre for Urban Health Solutions, the St. Michael's Foundation, and the Max Bell Foundation. Maryam Danesh is our research coordinator. Seema Marwaha and Emily Holton are our creative advisors. Our producer is Avery Moore Kloss.
For more information on the Our Care standard and the public's vision for a better primary care system, visit ourcare.ca. And if you'd like to read more content from Dr. Kiran about Canada's primary care system, follow her on LinkedIn.
We'd really appreciate it if you could send this episode along to a friend or colleague. Don't forget to give us a follow on your favourite podcast app. We'd also love to hear ideas from you or comments about what you think of these episodes — email us at primaryfocus@unityhealth.to.
Family doctors listening to this episode can claim Mainpro+ credits by completing a Linking Learning exercise. See the show notes for more information.
The information shared in this podcast is for educational and informational purposes only. It is not intended as medical advice and should not be used as a substitute for professional medical care, diagnosis, or treatment. Always consult with a qualified healthcare professional before making any medical decisions or changes to your health routine. Views expressed in this podcast are those of the speakers and do not necessarily reflect the views of any organizations the speakers may be affiliated with.
Side effects of listening to this podcast may include: a strong impulse to help fix the primary care crisis in Canada; a feeling of anger over how many Canadians do not have access to primary care; increased feelings of empathy toward primary care professionals who are just trying to make it work; and intermittent visions of hope that we can find a better way.