Exploring international patients’ access to healthcare in Central America
Mike Robertson takes a look at the tapering isthmus of Central America, detailing how access to healthcare for expatriates and travellers varies across the region, and uncovering some of the issues that insurers and medical providers operating here come up against
Central America is a narrow land bridge that connects Mexico with the diversely expansive continent of South America. Comprising Guatemala and Belize in the north, El Salvador, Honduras and Nicaragua in the centre, and Costa Rica and Panama in the south, the region is typographically rich and home to a thriving expat community, as well as a steady stream of international tourists. This is a vast amount of ground to cover, especially when considering medical treatment in the region. Despite the area’s obvious attraction, the distribution of wealth and quality of healthcare infrastructure varies drastically across the seven countries, with often large disparities between urban areas and their regional counterparts.
An unlevel playing field
Historically, emergency medical care for internationals in Central American countries has been limited to capital cities, but even in these locations, patient access to routine procedures can vary dramatically. The entire region is beset with issues relating to bed and medicine shortages, long wait times and a lack of medical professionals. Rural areas across the region are affected by inadequate road infrastructure and very few Western-standard clinics, with insurers sometimes having to transfer patients to other countries for various treatments.
According to Sebastian Kaisin, Head of Providers at travel insurance and assistance provider MAPFRE: “An analysis of medical claims in the region shows that gastro-intestinal and other abdominal problems are the most widespread. The second most common category was infections – all types, whether bacterial or viral – followed, a long way behind, by animal and insect bites, allergies, skin problems and even altitude sickness, including decompression problems. Tropical countries show the highest incidences of insect and other animal bites, although their share in total claims is still modest.”
Costa Rica welcomes almost two million tourists alone, according to its Embassy’s statistics, the majority of whom come from the US and Canada
Indeed, the Central American region provides constant work for insurers and hospitals alike. The World Tourism Organization puts last year’s tourist figures in the region at just over 11 million, with each country receiving varying degrees of attention. Costa Rica welcomes almost two million tourists alone, according to its Embassy’s statistics, the majority of whom come from the US and Canada. In fact, the whole of Central America follows this trend, with the addition of those travellers who enter from neighbouring countries. Out of nearly 2.3 million cruise passengers arriving by ship to the region, almost 650,000 come into the Honduran port of Roatan in Mahogany Bay. With this ever-growing influx of travellers, however, the medical landscape is evolving to adapt.
According to the United Nations’ 2018 figures, public hospital numbers vary greatly. Costa Rica's socialised healthcare system, the Costa Rican Social Security System (or 'Caja' as it is popularly known), includes approximately 30 hospitals(1); while countries like Nicaragua and Panama possess around 31 and 63 respectively(2). And overall, these were all built more recently. Honduras has seven national hospitals (located in Tegucigalpa and San Pedro Sula), but with a majority of these hospitals established in the 1980s. The number of local medical clinics in the region are difficult to accurately determine, but amount to over 3,500 in Honduras and Guatemala combined, and around 1,000 in the other five countries collectively. But what do these figures mean in regard to quality of care for expats and travellers to the region?
The differences are stark. While assistance providers often have to transfer international patients requiring treatment in countries such as Guatemala for example, Pacífica Salud Hospital Punta Pacífica (Punta Pacífica), a private hospital in Panama City, is affiliated with Johns Hopkins, certified by Joint Commission International (JCI), and prides itself on delivering world-class healthcare to a large number of expat residents. And it’s not the only JCI-accredited organisation in the country: Clinica Hospital San Fernando, located in Panama City has also been JCI accredited since 2011.
The fact that Panama possesses the highest per-capita income in Central America is seemingly reflected in Migration Policy Institute (MPI) data, which places figures at some 13,000 American, near 100,000 Latin American, and 20,000 Chinese expats living in the country. Marco Vuarambon of Pacific Prime puts the country’s efficiencies in modern healthcare facilities down to its size: “Hospitals and clinics are located in hubs around the country,” he said. Hospital Chiriqui in Boquete, for example, has been selected by Viva Tropical [Latin American expat real estate organisation], as one of the country’s best, and is continuing to improve due to these high expat numbers.
Eighty per cent of Punta Pacifica’s treatment, according to its Medical Director Antonio Cachafeiro, is for privately insured patients, mostly for hip and knee joint replacements, and general surgeries. This particular demographic, says Vuarambon, has long-term plans that see more claims related to maintenance and control of chronic conditions.
Elsewhere, Dr Fernando Llorca Castro, Former Minister of Health of Costa Rica, Chair of CCSS (The Costa Rican Social Security Fund) and current Ambassador to the United States of America, told ITIJ that Costa Rica has both a strong public and private healthcare system, whereby health access is universal and jointly financed by the State, employers and employees. As such, he explains, the country’s private healthcare system delivers excellent care through a network of around 20 main medical centres across the country, with many of these having been accredited by various authorities, as well as JCI. Dr Llorca Castro suggests that healthcare is better developed in Costa Rica than many of the other countries of Central America – though there are some exceptions. “For example," he said. "Costa Rican private hospitals serve as preferred providers for social security systems like Nicaraguan INSS.”
Dr Llorca Castro noted that expats living in Costa Rica typically required a wide range of medical services, both emergency and non-emergency, but generally, geriatric, traumatology, paediatric and gynaecology care are most commonly demanded by expat families. For international travels, he asserted that emergency medical assistance was most often related to adventure (rafting, canopy, among others) and water activities. He added: “Also, car accidents and trauma from chronic conditions are common cases that require medical emergency assistance.”
But it’s not just Panama and Costa Rica that offer reputable medical treatment for foreign nationals and visitors. Honduras has numerous facilities with international departments (four located in both Tegucigalpa and San Pedro Sula, one in both La Ceiba and Roatan) while Nicaragua boasts a JCI-accredited facility in Managua, Hospital Vivian Pellas. El Salvador also has high-standard facilities in Soyapango and San Salvador.
A shortage of doctors
Despite having well-trained doctors in many capital cities in the region, many hospitals are still too short-staffed, underequipped and under-supplied to deal with the influx of patients these various conditions create. Indeed, Dr Llorca Castro notes that in Costa Rica for example, in the public system, elective procedures like orthopaedics may have a waiting list of two years.
Moving doctors between hospitals and countries is a strategy used to help equalise care. “This type of practice is common, and for some specialities it is positive because it allows the surgeon to have a larger volume of patients and generate a caseload that is not necessarily achieved in private,” Cachafeiro stated. He adds, however, that as health costs are continually increasing, staying ahead with technology and trained professionals is expensive.
Whilst doctor sharing between public and private sectors can help equalise care, it exposes the collective insufficiencies of medical professionals in the region. For example, despite having a large number of hospitals, Guatemala and Honduras respectively contain just 3.55 and 3.15 physicians per 10,000 people (see Fig 1). These figures, according to the World Health Organization, fall short of their desirable 1:1,000 doctor to population ratio required to achieve adequate coverage rates for primary healthcare.
Kaisin explains that MAPFRE has its own team of medical advisors that liaise directly with treating doctors in order to determine the quality of local medical facilities. “If we think the local public healthcare is inappropriate, we won’t hesitate in directing our patients to private facilities,” he said. This decision can often be affected by patient location, which he cites as often being challenging.
Dr Llorca Castro points out that, for Costa Rica at least, where the public healthcare system falls short, the private system pulls through. “The private healthcare system has around 30 to 40 per cent of unused hospital beds to ensure quick and effective care to both domestic and international travellers,” he told ITIJ. “The private sector accounts for roughly 300 beds and, despite this small number, is far from reaching full capacity. This is attributed to the fact that hospital stays are typically very short and demanded surgeries by international patients are ambulatories.”
Kaisin reasoned that insuffucient healthcare infrastructure in Central America can often necessitate patient evacuation: “If they [local medical facilities] do not have the infrastructure for comprehensive care, we may have to evacuate by helicopter or road ambulance, depending on the circumstances and severity of the situation.”
There are additional barriers to accessing care, however, including some rural hospitals not accepting guarantees of payment. Obtaining medical reports and billing information can also be difficult, as can communication between doctors and patients. “Language capability can be a problem since our customers don’t always speak Spanish and are not accustomed to local healthcare services. Managing [patient] expectations can sometimes be difficult and requires patience, empathy and understanding to achieve the desired outcome,” said Punta Pacifica’s Cachafeiro.
Hefty billing costs can also affect patient placement on behalf of assistance companies and insurers. Indeed, Dr Llorca Castro explains that Costa Rica, which has a long tradition of business collaboration with international insurers and assistance companies, identifies costs and consistency of care as the most prominent issue in the region. As such, he notes that the Costa Rican Health Chamber took it upon itself to create its own ‘PROMED medical network’. “This joint initiative between hospitals associated with the Chamber is to provide business partners with a comprehensive network that is compliant with the highest standards of quality and patient safety, while also guaranteeing access to usual, customary and reasonable prices in the country,” he explained. “The network includes 15 medical care providers and more than 200 doctors.”
Still, MAPFRE’s Kaisin notes that more and more medical facilities in the region of Central America have agreements with US billing agencies, which tend to significantly inflate the cost of local medical treatment. He explains that there is, however, hope for some tourist-heavy regions: “Other countries such as Honduras, El Salvador and Nicaragua still remain relatively untouched by this practice, possibly due to the comparative lack of tourism volume.”
As a result, hospitals are constantly looking for national support to provide quality care without raising prices. The government of Nicaragua, for example, is pumping US$60 million into the healthcare sector this year to improve the country’s emergency response and ambulance services, as well as increasing the number of facilities. For individual hospitals, however, the outlook may not be so sweet. Cachafeiro cites that ‘so far too little’ has been done by local governments in promoting or investing in the medical industry in Panama.
Moving doctors between hospitals and countries is a strategy used to help equalise care
As international interest in the Central American region increases, national governments continue to balance the priority of healthcare for locals with the ever-growing needs of tourists and expats. Well-known by Westerners as the place to get various operations and dental work at a fraction of the price, the insufficiencies in more routine treatments are ultimately passed onto local citizens, and second, travellers in the region. There is still a large focus on providing free healthcare in a lot of countries, like Honduras, but with almost 90 per cent of the population here receiving care from the Ministry of Health, their outdated facilities are ultimately oversubscribed. In Guatemala, where healthcare is free, even local citizens in rural areas struggle with communication, as their regional indigenous languages are not understood. One might put this down to the imbalance of doctors in areas outside of Guatemala City, which contains around 80 per cent of the nation’s total.
With foreign investment in the region’s healthcare system strengthening, we will inevitably see an increase in patients’ access to medical services. But, as traveller culture is slowly moving away from capital cities to off-the-grid, it is essential that medical development in more rural areas is prioritised. There is potential for countries like Panama and Costa Rica to alleviate the strain on their less fortunate neighbours by taking in transferred international patients, and with that we could see some respite for the undersupplied, oversubscribed hospitals that exist in the north.
For the moment, continuing to strengthen communication lines with facilities of an international standard will undoubtedly better serve patients requiring treatment. It is this hands-on, collaborative relationship with emergency departments, as they invest in staff and equipment, that will remain essential going forward.