Grace Herrera, 52, doesn’t like San José. She prefers the salty sea air of the Pacific port town of Puntarenas, which she and her family call home. But after being diagnosed with uterine cancer in April, Herrera spent the month of May looking out at the streets of San José while hospitalized at San Juan de Dios Hospital to avoid losing her space on the waiting list for the hysterectomy surgery she was told she needed.
Her situation is not uncommon – many Costa Ricans wait years for a surgery or specialized medical appointment, and doctors, government officials and the Constitutional Chamber of the Supreme Court (Sala IV) agree the country’s public hospitals’ long waiting lists are a troubling predicament.
“Everything about the waiting list worries us,” said Rosa Climent, advisor to the president of the Social Security System (Caja). “There are people whose conditions have gotten worse because they’ve had to wait so long and others who have resolved their problems by paying for private care.
There are even cases of people who have died waiting to see a doctor.”
The Caja, Costa Rica’s socialized healthcare system, is funded by deductions from workers’ paychecks and contributions from employers and the government, according to Caja spokeswoman María Isabel Solís. It covers approximately 88% of the country’s 4 million inhabitants.
All Costa Ricans who depend on the Caja for their medical needs follow the same process, Climent explained. First, they go to the community health clinic they are assigned to geographically by the Caja to make an appointment with a general practitioner. If that doctor determines that the patient needs to see a specialist or receive a diagnostic test, the hospital schedules the appointment by evaluating the urgency of the case, Climent said. This means a patient with a non-urgent condition could end up getting an appointment at the end of the waiting list – as much as a year or more down the road – while those with pressing problems are given sooner appointments. The process is the same for scheduling surgeries, Climent said.
Long waiting lists are a result of “bottlenecks” throughout the public hospital system, Climent said. The most troubling is the lack of doctors in certain specialties, particularly anesthesiology, which results in patients like Herrera waiting months for a surgery simply because no anesthesiologist is available.
Radiology, ophthalmology, cardiology, urology, vascular surgery and orthopedics are other specialties with doctor shortages, according to reports the Caja prepares every March and September that calculate the number of patients who have been waiting at public hospitals for more than 90 days, at which point the Caja dubs their situation “critical.”
According to the March 2006 report, 21,773 patients nationwide had been waiting for more than 90 days for an orthopedic, vascular, urology, ophthalmologic or general surgery. Additionally, 134,277 people had been waiting more than 90 days to see a specialist, and 129,354 people had been waiting this long to receive diagnostic tests such as mammograms, electrocardiograms, gynecological exams, CAT scans and other general tests.
Regional hospitals in Costa Rica’s provinces often lack the necessary equipment to perform certain tests or surgeries, so these patients end up getting sent to San José. In other cases, broken equipment is to blame.
“Hospital México (in San José), for example, is saturated with cases that could have been attended in the province’s primary hospitals if they had had the right equipment,” Climent said.
Patients Forced to Wait
Herrera has experienced this first-hand. With help from a friend in San José, she ended up in the capital’s San Juan de Dios Hospital after a biopsy at a Puntarenas hospital confirmed she had uterine cancer. San Juan de Dios doctors told her she needed hysterectomy surgery and that she would have to remain hospitalized until a space opened up, which ended up being one month.
“There were so many people waiting on the list behind me that I couldn’t even walk across the street or I would lose my space and move to the end of the list again,” said Herrera, a mother of three adult children, grandmother and teacher for 22 years.
It is up to each doctor to determine whether patients must remain hospitalized while waiting for surgery, Climent explained. However, because unnecessary hospitalization is costly, cases like Herrera’s are unusual, she added.
Herrera told The Tico Times that during her stay in San Juan de Dios’ sterile, gray women’s oncology ward, she befriended many women who had been through similar ordeals, one of whom is Rebecca Chávez, 22, diagnosed with thyroid cancer.
Chávez, a university student who has had to put her studies aside until she is finished with cancer treatments, had been through a slow and frustrating process that began with waiting six months to receive the results of a biopsy of a lump in her neck.
Doctors at San Juan de Dios operated on Chávez one month after the biopsy showed the lump was cancerous and prescribed radiology treatment. However, because of the hospital’s long waiting list for radiology, she waited four months to be treated. By that time, the cancer had spread to her neck, shoulder area and lungs, making another surgery necessary, Chávez told The Tico Times.
“The frustrating thing was knowing there was something growing inside me and not being able to get the appointment to find out if it was cancer,” said Chávez, a resident of Heredia, north of San José.
Like Herrera, Chávez spent a month in the hospital before her surgery, and faces two more weeks of hospitalization in August, when she is scheduled to undergo radiotherapy for the tumors in her lungs.
“My cancer wouldn’t have spread if I had received the radiotherapy in time,” Chávez said. “That’s the problem here (at San Juan de Dios) – the doctors and nurses are wonderful, but the waiting is terrible.”
Herrera agreed the wait was difficult, but also praised doctors and nurses who “do the best with what they can” and the volunteer women who come every day to provide company and entertainment and bring personal supplies like soap and toilet paper to patients who don’t have family to do so (San Juan de Dios does not provide these supplies).
Shortening the List
Shortening the waiting lists has been high on Climent’s agenda since she was assigned to her position by President Oscar Arias when he assumed office in May, and the Sala IV also called attention to the issue with a June 20 ruling that ordered San Juan de Dios to give medicine to a terminal cancer patient who had waited almost four months to receive it, according to a statement from the court.
“Clinics and hospitals of the Caja are obligated to adopt and implement organizational changes, contract medical personnel and acquire equipment required to provide efficient, effective and rapid treatment,” the statement said.
The Caja and Public Health Ministry are working with the Pan-American Health Organization to accomplish this, Climent said.
Foremost on the agenda is hiring doctors in specialties where there are shortages. Programs are under way with medical schools to encourage students to study certain specialties by guaranteeing them jobs upon graduating.
The Cuban government has also offered to set up a program to train Costa Rican medical students in radiology, and the Foreign Ministry is looking into this option, Climent said. Bringing in specialists from other countries is also a possibility.
“We’re even working with the Health Ministry to evaluate the possibility of making an emergency declaration about the doctor shortage,” Climent said.
Finding ways to finance improvements is another task at hand for the Caja, which hopes to get funding from the Costa Rican government, international organizations and foreign governments.
“We’re already making progress and we hope that by 2010 we really start to see the waiting lists diminish. We’ve had a lot of offers from organizations and foreign governments that are willing to help by donating equipment and even funds,” she said.
Despite the list woes, Climent says she believes Costa Rica has one of the best public health-care systems in Latin America, maybe even in the world.
“Our public health system is a treasure that we have to take care of, protect and support because we deserve it,” she said. “There are many Costa Ricans, some of whom are no longer living, who have worked hard so that we have this system today. Now we have to fight to maintain it.”