The Council on Foreign Relations recently hosted a roundtable discussion on primary health care with health leaders from Costa Rica and Thailand. Tom Frieden, senior fellow for global health at CFR, moderated the event. An introduction by Dr. Frieden is followed by excerpts from the roundtable.
As we've examined health-care provision throughout the world, one overarching theme has emerged: we need to make primary care the center of our health systems. Accountable, high-quality primary care is essential to improve the health of individuals and populations.
Care should be patient-centered, with clinical encounters at times and places most convenient to patients, and out-of-pocket costs should be minimized or eliminated. The United States is an outlier in that most people receive health care through privatized systems, with public options available only to specific populations. However, even under the government-financed health systems that exist in most of the world, there are few examples of strong, popular, effective primary care systems.
Strong and reliable primary health-care systems are also central to effective epidemic detection and response
In much of the world, there is a shortage of physicians, nurses, and other trained health professionals. Moving to team-based, task-sharing care models, in which integrated, multi-disciplinary teams—including ones where lay community health workers are trained and supervised to provide basic health-care services—will allow physicians to manage larger numbers of patients and use their skills where needed most. People who have a primary care provider coordinating all of their health-care needs have better health outcomes. Over-emphasis on specialty care draws needed focus away from primary care practices, and it results in unnecessary hospitalizations and inadequate treatments.
Provider compensation should be substantially dependent on improved health outcomes versus based on the number of procedures performed. The focus should be on results, not process.
Strong and reliable primary health-care systems are also central to effective epidemic detection and response—including diagnosis, treatment, and vaccination. Healthier populations are less vulnerable to health threats. Strengthening our primary health-care systems can also strengthen population and community resilience and in doing so, reduce the risk and harm from infectious diseases, including COVID and future health threats. By improving prevention and care of conditions such as hypertension, diabetes, and cancer, we raise the population health baseline. Building up individual and population resilience will also necessitate restructuring our environments to support healthy behaviors, making the default choice the healthy choice.
Above all, we need to prioritize and focus our actions on what we can do to save the most lives. Improving access to high-quality primary health care is one of the most efficient and cost-effective ways to accomplish this goal.
From CFR's recent roundtable discussion...
Primary care is both the most important and the most neglected aspect of our health-care system, yet there are few success stories anywhere in the world. For middle- and low-income countries, you can virtually count on one hand the number of primary health-care systems that are effective and responsive. The two in this conversation—Thailand and Costa Rica—are among them.
Román Macaya, executive president of the Costa Rican Social Security Fund, and Costa Rica's ambassador to the United States from 2014 to 2018:
It's underappreciated how much primary health care contributes to our health successes. I'm going to give you some background because we can't separate our policies and systems from our history. Costa Rica started investing early in primary health care, creating the Secretariat of Hygiene in the 1920s, followed by law-protecting public health and programs to fight malaria, tuberculosis, leprosy, and other diseases that were major disease burdens in those days.
In 1941, a three-way agreement was reached among the administration in office, the Communist Party in the opposition, and the Catholic Church to create the institution that I lead today, the Caja Costarricense de Seguro Social. In 1947, the Social Security system added pensions and its coverage and mandate has increased from covering only workers in the beginning to later adding their families, the unemployed, the poor, legal migrants, undocumented migrants, and others.
Costa Rica started investing early in primary health care
In the 1960s, and 1970s, we had a national health plan and started to unify hospital care providers. In the 1980s, we established our national health system and in the 1990s, primary care also came under the Social Security system. Today, the Caja is the single provider of public health-care services. The Caja is an autonomous institution with a constitutional mandate to provide services to the entire population. We are financed primarily by payroll taxes and both employers and employees contribute to the system.
Viroj Tangcharoensathien, senior expert in health economics at the Ministry of Public Health, Thailand, and advisor to its International Health Policy Program and head of the research hub for the Asia Pacific Observatory.
More than 10 percent of households have some health spending, but only 2.2 percent have catastrophic health expenses. Thailand has a universal health coverage (UHC) service coverage index of 80 percent. This indicates that the benefits package for the whole population is very deep and, at times, free with no co-payment. Like Costa Rica, we too have progressively increased services and coverage since 1975.
During the 1980s, we expanded hospital coverage to each of the country's 800 districts. That was followed by health center development. Each district there now has a hospital that covers 50,000 people and a network of ten to 15 health centers each covering 5,000 people.
By 1990, coverage expanded to include the poor, the elderly, and children under 12 years. We have social insurance financed in part via a payroll tax. Capitation in primary care safeguards district hospital ambulatory care financing. Inpatient payment runs under a separate system. During the pandemic, comprehensive population access has helped investigate and control outbreaks.
A striking similarity between your two countries is the use of payroll taxes. Does the payroll tax cross subsidize care for unemployed people, the poor, and others not subject to the payroll tax?
In Thailand, primary funding is from general taxation. Payroll taxes cover less than 15 percent of the population, and the civil service medical benefits scheme is noncontributory as a fringe benefit. The remaining 75 percent of operations, covering almost 70 million people, are funded by general taxes.
In Costa Rica, it's a three-way financing system based on the principles of universal coverage and universal contribution. There is mandatory contribution for all workers and employers, including independent and self-employed workers. The state is the third source of financing. In addition to funding through general taxation that is independent of employment, the state as an employer contributes as any other private sector employer.
In Thailand, the benefits package for the whole population is very deep and, at times, free with no co-payment
How to balance hospitals and primary care is an issue all over the world. In the United States, we see hospitals gobbling up resources, but not delivering much health improvement compared with primary care.
We fund hospitals through a global budget and pay one single base rate. Primary care is funded separately, paid for on a capitation basis with a slightly higher capitation for the elderly. Primary care contracted providers also serve as gatekeepers.
Thailand cannot provide all new diagnostics or interventions to every citizen. It is based on cost effectiveness evidence and once it becomes a benefit package, the budget is allocated accordingly.
In Costa Rica, we have a network of clinics, but also of primary care teams throughout the country. These teams are designed to cover a community of about 4,500 people. With 1,057 primary care teams distributed throughout the country, and a population of about 5 million, we still have a gap. There's always political pressure at the grassroots level in the communities to fill in those gaps.
Everyone wants one of these primary care teams, which are composed of a general practitioner, a nurse, a pharmacist, and a primary care technical assistant. They're a real source of information and contact for the community and the gateway into our public system of care. We also have computer record clerks who constantly update registries, and an electronic record system that connects all of our primary care teams, clinics, and hospitals so we can bring up anyone's record anywhere in the country.
Our constitution also states there is a right to life—which our supreme court has defined as a right to health—and therefore a right to health care. So, whenever anyone has a need for a procedure or drug that might be very expensive, if we don't cover it and the treating physician has determined that the patient would benefit, we have an expedited review process that almost always rules in favor of the patient. To cover that we must increase hospital budgets, which is where we have all of these more sophisticated procedures and treatments.
There are two counterbalancing forces. One is this constitutional mandate to cover all healthcare needs, which drives more and more sophisticated and costly services. But there is also a drive at the political level to expand our primary care coverage throughout the country, with a population that is aging very quickly.
The reliance on community health workers in both countries is striking. In Thailand, there are something like one million health volunteers who perform very important functions. I believe perhaps capitation encourages the primary care system to use a wider range of team-based health services, nurses, pharmacists, data entry clerks, and community health workers.
Costa Rica is divided into what we call health areas; each area has a large primary care clinic that oversees all of these primary care teams. But we also have community-based and community-elected health boards that oversee and are sort of a community driver for improving quality and efficiency. They want to bring down waiting times for people to get appointments and basic primary care as well as hospital care, and they wield a lot of political power in our system.
How important is the private health sector in each of your countries?
The private sector can fill gaps in urban areas where local government is weak at providing primary care. In Bangkok, there is literally no primary care because all teaching hospitals focus on specialty care. Therefore, we have some Bangkok Metro authority centers that rely on contracting with private clinics.
The private health sector in Costa Rica is parallel to our public system. Everyone is obliged to contribute into the public system, you cannot opt out. If you choose to go to a private provider—whether a family physician or a hospital—you're either going to pay out of pocket, or you have your own private health care insurance as backup insurance.
There are no exclusions for preexisting conditions. There's no copayment, there's no deductible. Where our system does tend to fail is timely access to appointments or elective surgery. If it's an emergency, you'll be treated right away. But if it's elective, you can wait. And that's where the private sector comes into play.
If you're willing to pay and you have the option of paying out of pocket, or have private health insurance, then you go to the private sector, which many people do to get faster access. Our system has been making great strides on shortening waiting times, but it's still not available on demand, as it is in the private sector.
There are six lessons and one key challenge people can take away from this Q&A.
- Political consensus in both countries.
- They’ve developed capitation to pay for care.
- The important contribution of payroll taxes, at least in part, to fund the system.
- Extensive use of community health workers and the full healthcare team.
- Integration of clinical health care and public health so that the public health teams are integrated into the health-care system.
- The existence of a system of care in the community that is strong and effective and seen as a gateway which lets people greatly value the community health services in their area.
The challenge: which country will get to 50-, 60-, or 70 percent hypertension control first? This will reduce reliance on expensive care but also mortality. It won’t just reduce deaths, but will increase healthy life expectancy—life without dementia, without a stroke, without disability from cardiac or other causes. This is the number one challenge for primary care in the coming years. We think there are ways through it, and we think there are probably no countries in the world better positioned than Thailand and Costa Rica to show us the way.