Today was C-Day. "C" - for Caja, that is. The day we got down to the business of test-driving the Costa Rican national healthcare delivery system. We approached the day with more than a little trepidation.
We’d heard the horror stories about long waits to get an appointment (and sometimes getting turned away with getting one!), followed by long waits to see the doctor even with an appointment, followed by long waits to get prescriptions filled. We also had language concerns. How on earth would we ensure that we received the right care if we couldn’t communicate with our doctor?
That was then. This is now. And now we know we could have saved ourselves a lot of worry – thanks to the help of our Tico friend and a system that turned out to have a bigger bark than bite. Here’s how it went down.
2:45 a.m. – Forced ourselves out of bed. Drank a quick cup of coffee and downed a piece of breakfast bread. Dressed quickly. Met our friend at the gate at precisely 3:30 a.m.
3:35 a.m. – Took our place in line at the Caja clinic behind eight other souls who had awakened even earlier. Chatted between ourselves and gave thanks that we had our friend there to instruct us about where to stand and explain what was happening around us.
5:00 a.m. The rising sun provided enough light that I was able to read a few chapters of The Divinci Code while we waited.
5:40 a.m. Our friend’s father arrived and took his place in the Golden Citizens line ahead of us, nearer to the door. Because mi esposo is over sixty-five, we can do the same thing for our next appointment. This time around, even that advantage couldn’t pry us from the side our amigo.
6:00 a.m. The doors opened and the line began to move to the inside. One by one, each person stepped to a window, presented his/her Caja ID (carnet), orden patronal (a document that remains a mystery to me), and Costa Rican ID card (cedula). Once their paperwork was verified, they could chose an appointment time. Our friend proceeded to the window ahead of us and chose an 8:00 a.m. appointment. When it was our turn, we followed suit and received two tickets: one for our appointment and one for our pre-consultation (file-opening process).
6:20 a.m. Parted company with our friend. He returned home to get a shower and pick up his wife, for whom he had also made an appointment. (The way it works is that each person in line can make an appointment for him/herself and/or one other family member. Lucky her, she got to sleep in while her loving and generous husband waited in line!) We headed toward the bus stop to have breakfast at our favorite soda.
7:35 a.m. Arrived at Caja and sat down to wait for our friend and his wife to join us.
7:40 a.m. An English-speaking nurse approached us and asked if we had appointments. (Obviously, she very astutely assumed that we were unfamiliar with the process.) We answered in the affirmative, but she asked to see our tickets just to make sure. Then she told us that we should go ahead inside so they could prepare our files. Concerned that our friends would worry when they arrived and didn’t find us waiting, we called them and let them know that we were in the capable hands of a very helpful nurse who promised to help us every step of the way.
7:45 a.m. Entered an exam room where we were weighed, had our height recorded, and our blood pressure taken by one nurse, while another wrote the information on our new charts.
7:55 a.m. We were taken to a waiting area just outside an exam room labeled “Ebais Esquipulas,” where we waited less than two minutes before we heard our names called.
7:57 a.m. Entered a small office where a doctor was seated behind a desk. She answered with an emphatic “No,” when I asked if she spoke English. I showed her my husband’s records and started to explain as best I could that his doctor put him on a new medication right before we left and had instructed that he have a follow-up blood test when we were settled. She flipped through the papers and indicated that we should wait until she came back. I thought she had left to fetch our English-speaking nurse. Not.
8:02 a.m. Doctor returned and explained in Spanish that we would be seeing an English-speaking doctor. As usual, most of the words she spoke remained meaningless to us, but her picking up our charts and walking out the door with them, accompanied by a few hand gestures, effectively conveyed her intent. We waited where instructed until our names were called a second time.
8:05 a.m. Entered another exam room and were greeted by a very nice, young English-speaking doctor. Again, I presented our medical records and this time we were on our way. A few questions. A few answers. The old light in the ears, stethoscope to the chest, and then we got down to business.
Yes, he could provide prescriptions for most of our medications. They could be filled at the pharmacy upstairs. Mi esposo’s blood pressure prescriptions, however, were not on the formulary. We would have to continue filling them at a local pharmacy at our own expense.
Yes, he could write lab orders for all of the tests the private doctor had recommended. He added a couple more of his own.
8:30 a.m. Left the doctor’s exam room with a fistful of paperwork and proceeded to a clerk seated at a desk nearby. She asked us for our fathers’ and mothers’ names and our address in Esquipulas, adding the new information to the chart that had been initiated by the two nurses during our pre-consultation. Then she handed us our prescriptions, lab orders, receipts, and a paper indicating that we should return in one month.
8:35 a.m. Joined up with our friends and proceeded to the pharmacy, where a man seated at a window received our prescriptions, compared the names with our carnets, and instructed us to return in 90 minutes to pick them up.
10:00 a.m. Returned to pharmacy.
10:05 a.m. Picked up prescriptions and left.
For sure, the hardest part about the whole process was getting out of bed at 2:45 a.m. so that we could be in line as close to 3:30 as possible. Mind you, there was no requirement to do so. But when the clinic opens its doors in the morning, there are a finite number of appointment slots available, based on the number of doctors on duty that day. In our opinion, that little bit of extra sleep would have made for poor comfort if they turned us away before even reaching the appointment window when the slots filled up mid-way down the line.
If you're thinking that waiting in line for more than two hours is a real drudge, you'd be absolutely right. And waiting alone would be even worse. But then a little planning (like bringing a folding sling chair or small stool like one man did, as well as a book with one of those battery-operated book lights) would make a world of difference. As for us? The time passed quickly because we had each other to chat with – something I will try to remember when I am tempted to let mi esposo do the waiting while I catch a few extra ZZZZs at some point in the future.
In the end, our over-riding conclusions revolve around the courteous and helpful staff and the surprising efficiency of the process - not to mention the relief to find English-speaking staff! Granted, being able to pick up the phone and make an appointment would be a welcome improvement, but the arguments against streamlining the system are easily understood.
Any free healthcare system (make that free, aside from an affordable monthly premium that, in most cases is deducted from your paycheck) is ripe for over-use and abuse. Much of that risk has been reduced by simply inserting a degree of inconvenience into the process.
This way, folks who can afford to use a private doctor or clinic usually avoid Caja as much as possible, freeing up those resources for the people who need it the most. Then, when they are faced with an expensive procedure or long-term treatment, they too can crawl out of bed in the middle of the night and take their place in line in front of Caja. Or, they can opt for yet one more alternative. They can avail themselves of the services of a professional line-waiter. Yes, there is such a thing.
Costa Rica is a country with a strong entrepreneurial spirit. And for certain there are always people with more money than patience. This pairing goes a long way to explain why we weren’t the first ones in line at 3:30 in the morning. At least some of the eight people ahead of us had been paid the equivalent of a mere $5 USD to let someone else sleep a little later, enjoy a leisurely cup of fine Costa Rican coffee, and time their arrival at Caja for just before the doors opened at six. It’s a win/win proposition all the way around.
One final caveat: The information included here is based on our experience in the small town of Palmares, Alajuela. One thing we have learned is that generalization simply don’t work in Costa Rica (and perhaps nowhere else, for that matter). The same process might unfold quite differently in any other city or town, which is one more reason we are likely to make this our home for the foreseeable future.
Pura Vida
