Alberto Alfaro
Ashoka Fellow since 2017   |   Costa Rica

Alberto Alfaro

Alberto Alfaro is increasing medical accessibility in Costa Rica through connecting patients with private-sector, expedited and specialized medical treatment, and complementing treatment with…
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This description of Alberto Alfaro's work was prepared when Alberto Alfaro was elected to the Ashoka Fellowship in 2017.


Alberto Alfaro is increasing medical accessibility in Costa Rica through connecting patients with private-sector, expedited and specialized medical treatment, and complementing treatment with preventative education. Through building partnerships and connections with private hospitals, patients, and financial institutions, he is able to provide opportunities for those waiting far too long for care under the overburdened public health system. While decreasing the burden of the public health, he simultaneously reduces the negative consequences of long waits and empowers patients to take control of their own health care.

The New Idea

Alberto Alfaro is reimagining healthcare in Costa Rica by creating a platform to negotiate lifesaving surgeries with private hospitals, and through this, he is able to offer affordable surgeries to patients on the public system´s surgery waiting list. Through in-hospital negotiation, connecting patients with additional financing options, and providing preventive health education, Alberto is able to offer an alternative to the limited options currently available through the public health system.

Alberto’s system combines the needs and interests of three distinct actors: The patients, the private health system, and the public health system. This business model benefits the patients who have certain medical conditions and are in need of a timely and inexpensive surgery. Alberto also takes into account the interests of the private medical service providers, who are looking to reinvent themselves to be able to increase their institutional income in the context of an increasingly competitive market. This intermediary system also has the improvement of the Costa Rican government in mind, who has, to this point, not been able to propose or implement any real solution to effectively reduce the waiting time for the overburdened and underfinanced public health system. Understanding market and stakeholder needs, Alberto has been able to bring these three actors together and introduce a system that benefits all involved parties. Redistributing patients to facilities with greater medical and financial resources and human capital, and away from an overburdened and underfinanced system creates two functional and separate systems, working together, that can adequately provide the kind of efficient and quality care that all patients deserve.

In addition to the expedited and discounted surgeries, Alberto´s program offers supplemental educational and financing services in order to start a more participatory, informed and involved citizen movement surrounding health and medical decisions.

The Problem

Although Costa Rica's public healthcare system is rated among the best in Latin America in terms of quality of care and affordability by the World Health Organization, it is deeply overburdened and the backlog of vital medical operations has created a serious public health problem. Over 122,400 people covered by public insurance are currently waiting for medical procedures and the wait time is often excessive-- up to ten years for one procedure. The average wait to even get a surgery scheduled is 452 days, and almost all patients must wait a minimum of 90 days for any given surgery.

The public system is backlogged, and lacks the financial resources and medical personnel to be able to adequately address the medical needs of 90% of the population covered by government health insurance. The costs of private health coverage are preventative for many Costa Ricans requiring surgeries, and thus they remain in the waiting list. The Caja Costarricense de Seguro Social (CCSS), or the Costa Rican public health care system was universalized in 1977 and gained the international reputation of providing the best universal, quality care in in Latin America. This reputation has attracted medical tourism and has served as an example for other countries. Since the universalization, however, the number of the system´s patients has grown through immigration and normal population growth, and the infrastructure has not grown accordingly. In 1960, the largest hospital of San Jose had 15 surgery rooms and 1,200 beds. Today, 55 years later, the same 15 rooms and 500 fewer beds attends an increasingly growing patient pool. The result of a growing population and stagnant infrastructure is that the financial and capacity burden on the public system is only increasing. The available resources are limited and focused on a few number of centrally located hospitals, and the medical personnel are additionally strained and over-burdened by the growing number of patients waiting to be attended to.

CCSS has had various initiatives in the past decade, attempting to more effectively and expediently respond to patients, most of which have failed. One such proposal was the short term surgery initiative. This initiative reserved certain beds within each specialized area for patients with emergency medical needs to reduce the time patients spent in medical facilities waiting for operations (a system of medical need prioritization). This initiative failed because incoming patients with urgent medical needs outnumbered the number of reserved beds, and thus the system of need prioritization did not reduce waiting time as hoped. The second major proposal was extending the hours of surgeries into the night, so that hospitals would be fully functional 24 hours a day. This proposal did not come into fruition, as this plan was not financially viable, working under an already fiscally strained system.

The private insurance sector is relatively new and used by a small minority of the population for various reasons. One is that everyone must pay the CCSS taxes, even if the services are not utilized by the taxpayer. This, in addition to steep private insurance rates, allows only wealthier Costa Ricans to be able to afford this coverage. This underutilization of the private insurance and overburden on the public system creates Costa Rica´s unsustainable national health situation.

The Strategy

Alberto´s entire strategy is centered on the goal of increasing patient accessibility to health care. To do this, he connects public system patients with private system surgeons to relieve unnecessary suffering and lightening the burden of the public system´s waiting list. In 2015, he created the online platform, Lista de Espera, to facilitate these connections and create a more informed and active citizenry.

In order to reach a greater number of Costa Ricans, Alberto decided to create Lista de Espera as an online resource, where he makes affordable options available on the website, mainly for hernia, gallbladder, and arthroscopic surgeries—the surgeries with the longest public waiting lists. Patients arrive to the website and can solicit more information about the various surgery options and pricing, and discuss their specific situation with Lista de Espera. Once eligible patients contract these services, Alberto takes the proposition to the private hospitals in San Jose and creates competition between the medical centers to offer a ¨group rate¨ for Lista de Espera patients. 40-60% discounted prices from full-cost private hospital surgeries are negotiated and an operation date is scheduled within the following few days or week. Looking forward, Alberto is working to automate the system and create an phone application to increase accessibility, reach, and replicability.

In this way, through Alberto's intermediary system, patients arrive at a modestly priced operation, scheduled in a reasonable timeframe. Lista de Espera receives a commission from the private hospital, and the patient pays nothing more than the discounted surgery price directly to the hospital. Patients are given financing options and assistance to be able to pay the remaining 40-60% of the surgery. As of now, this typically takes the form of pledges, credits, and soft loans from various sources, but Alberto is looking into impact investment options for surgery financing in the near future, with far less aggressive interest rates than traditional loans. The project's goal is to create a sustainable health fund with donors who are willing to receive little or no profit for their investment by lending money to patients who need care.

Alberto knows that facilitating surgeries without citizen empowerment is not a sustainable solution. Alberto has begun a movement to put the decisions and control of patient health into their own hands. The citizen-based education and empowerment movement of Alberto´s project involves free workshops and events that educate the public about their condition, pain management, as well as alternative financing options for medical operations. Alberto motivated private hospitals to lend their space and personnel to assist in the events. In the first pilot event, 25 families were educated about pain management related to gallbladder issues, and in 2016 there should be one workshop a month, condition-specific, and done in partnerships with hospitals. Lista de Espera´s web page has downloadable guides to pain management for various medical conditions. So far there have been 500 downloads of these medical guides in the three months of operation. This initiative is creating a participatory community of patients in Costa Rica who are taking control of their health education and medical decisions.

This project is possible only through forming strong, strategic alliances. So far, Alberto has been able to connect and work with the four largest private hospitals in San Jose, and is expanding to other regions in Costa Rica, with the plan to move the initiative abroad. Alberto is pursuing a partnership with the CCSS, which would allow for increased involvement and reach in the area of public health education. Alberto knows that the CCSS alliance will be crucial, and is demonstrating the savings this new system brings to the underfunded public system. Each patient that needs to be operated on costs the CCSS approximately $6,000: $1,500 a night with an average of two nights per patient before a surgery, and $3,000 for a standard surgery without complications. Through showing this significant savings and utility, Alberto is strategically finding ways to incentivize the CSSS to participate in the project. Alberto is currently in conversation with government officials regarding federal cooperation and support of his project, and has investigated 10 countries that have a severely burdened public health system that would benefit from the presence of an intermediary such as Lista de Espera.

Although a new business, Lista de Espera has a sustainable financial model. Lista de Espera generates income from private hospital operation commission, which averages 10% of the surgery cost, and other private financing sources. The total investment for the first year should amount to $30,000. Using the for-profit business model allows for small and incremental but sustained growth, a broader beneficiary reach, and permits scalability both within Costa Rica's borders and abroad.

Through these public hospital alliances and sustained contacts, Lista de Espera is able to act as an intermediary between patients who would not be able to contract the services directly at a modest price. By relieving the list through this redistribution, those who cannot afford to pay for any private system service are able to be treated more quickly and efficiently through the public health system. The various elements and strategic aspects of Lista de Espera come together to create a comprehensive and practical approach to attending the medical needs of Costa Ricans.

The Person

Alberto Alfaro comes from a family of doctors in Costa Rica, which from an early age, gave him a deep sense of empathy for the suffering of patients and a desire to improve the country's public health sector. His father was the chairman of the department of surgery in Costa Rica's largest public hospital, and growing up, Alberto witnessed his father's tireless efforts throughout his career to reduce the waiting times for patients in need of important operations. Throughout his childhood, Alberto learned about the institutional challenges of the public health system and was given the knowledge and connections to eventually start his project with the hope of changing the reality for thousands of patients on the waiting list.

Alberto decided to take a very different professional route from his parents, creating his own digital marketing company and dabbling in other careers. Through this experience, he learned of the great potential benefit that digital media can add to business, and if executed and managed well, to society. After trying his hand as a restaurant owner, a consultant, an employee of the Costa Rican-USA Foundation, and as a business owner of this digital marketing company, he began brainstorming ways to utilize and synthesize these diverse experiences.

Combining his digital media background, business-owning and operating know-how, understanding of the philanthropic sector, and his knowledge of public and private health fields, he decided to put his skills to better use and help improve the lives of patients from a private-sector strategy. This idea for Lista de Espera came to him after a conversation with a private hospital director, during which they discussed the lack of a comprehensive citizen-initiated and citizen-focused effort to improve the medical situation and bridge the gap between the private and public health sectors. He presently dedicates himself to Lista de Espera, working tirelessly to see a significant positive change in the health systems globally that currently do not adequately attend to the needs of suffering patients.

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