CAPITAL INJECTION.

Private hospitals make a business out of making people well in Latin America. Here's a look at one such institution is Costa Rica.

EIVOR JACOBSON LOOKS QUITE AT HOME UNDER A BLUE comforter in her brightly decorated room with its view of a distant mountain sprinkled with the tiny lights of homes and the signs of biusinesses long-since closed at this midnight hour.

The 50-something Swede had planned for a bit more excitement when she left home for a Latin American dream tour that was to culminate with a visit to the Galapagos Islands in Ecaudor. But her itinerary changed drastically when she awoke gasping for breath in a Costa Rican hotel.

She checked into the Hospital Cima San Jos[acute{e}], one of the newest members of a growing chain of hospitals, clinics and health centers run by International Hospital Center, a Texas-based company affiliated with Baylor University Medical Center in Dallas. The US$40 million hospital with 110 rooms opened in the beginning of this year.

The Costa Rican institution is an example of how International Hospital and other healthcare companies are building and operating hospitals for profit in Latin America. They are using a host of novel approaches, including sophisticated administration techniques, strict accountability, doctor ownership and even niche marketing.

That means catering to the needs of foreign travelers like Jacobson. "This place is better than anything we have back home," she says.

Record hounds. While Jacobson is sleeping through her last nights in the Cima hospital, her nurse, Anabell Mena, is clicking away at the computer, updating Jacobson's chart--and checking to make sure her day-shift colleagues made their entries correctly.

The nurses keep at the entries all night, stopping only for the hourly checks on patients and a 3 a.m. dinner break--there is no food or drink allowed at the shiny new nurse's station, uncluttered except for journal books and the computers.

Mena shakes her head, saying half to herself, "We never had to worry about this [accounting] at the other hospitals here. They don't have computers like this. This is an American thing," She should know--the 35-year-old registered nurse worked for several years in the healthcare industry in Texas, Virginia and other areas in the United States. Many nurses and doctors in the hospital have also worked and trained in the United Sates.

The employees spend so much time clicking away at their computers because the key to running a hospital like a business lies in the small things--such as keeping accurate records to make sure the patients are getting the required care at a competitive price, while also ensuring that none of the medicine or other supplies are wasted, misused or pilfered. That means tracking of every pill, every shot and just about every official conversation concerning the patient.

"Training our nurses to use our computers, that's one of the hardest things," says International Hospital Chief Operating Officer Alfonso Chapa, and the company executive overseeing the Costa Rican operation. "They're not used to it. But it's one of the most important steps."

Room service. A 17-year-old girl we'll call Jill, for privacy reasons, had been in Costa Rica a few short months when her appendix burst, making her another of the hospital's first 300 patients. Her sister has been sitting by her bedside throughout the night--some of the hospital suites even have separate rooms and beds for visitors--but the IV wires and general pain are weighing on Jill, and the missionary's daughter is having trouble sleeping. "Can I have a little something for the pain?" she asks a nurse.

She promptly receives her medicine, which would be a rarity in many Latin American hospitals where service and supplies are often lacking. But, unlike most institutions in the region, the Cima San Jos[acute{e}] charges between near $100 and $150 a night for its rooms. As a result, the hospital pampers its patients, delivering medicine promptly and providing a place to stay for family members and friends.

Babies, not least of all. Little Jos[acute{e}], barely a couple of hours old, lets out a small cry as a nurse carries the blanketed baby past Jill's room to the maternity ward. Jos[acute{e}], of course, is the darling of the staff--after a successful cesarean delivery using the new equipment in the operating room.

All told, at least $10 million in new equipment has been installed in the new hospital, which itself cost about $40 million to build. Thanks to the investments, the hospital offers an array of expensive procedures not generally available--such as chemotherapy or MRIs--and it boasts advanced endoscopy technology.

But right now the little things are what quiet Jos[acute{e}]'s cries--the round-the-clock nursing attention, his warm bassinet and his mother, resting nearby. He barely lets out a peep the rest of the night.

Dr. MBA. Mena and the other night nurses are just packing it in as Dr. Francisco Gonz[acute{a}]lez Jinesta arrives in his midnight blue Porsche about 6:30 in the morning. The hospital's general director will remain at the hospital for the next 16 hours or so--his usual schedule. It's tough on his marriage and his relationship with his 8-year-old daughter. "I am afraid that my daughter will not understand," he says.

The Cima San Jos[acute{e}] executive has to work such long hours not only because he is starting a hospital from the ground up, but also because he is creating a job-his--from scratch, too.

"The challenge in this country is that hospital management is not a formal career in Costa Rica," explains Gonz[acute{e}]lez. "We really don't have professional administrators in health," In fact, the typical Latin American hospital administrator is an experienced physician who is simply thrust into a management role and must then figure it out.

International Hospital did not want to do that. So it tapped Gonz[acute{a}]lez, who not only has the medical expertise, but also worked for the past couple of decades as an executive for the local offices of Merck, Sharpe and Dohme and Pfizec He's U.S.-trained in medicine and administration with an MBA in marketing and strategic planning from the National University in San Diego.

"I have the chance to blend the parts--the physician and the administrator," he says. "The two parts generally are at war, in conflict. But I can talk with physicians using physicians' language, and I can talk to administrators using administrators' language."

The problem, Gonz[acute{a}]lez says, is that he has nothing to benchmark against or follow in Latin America. This, he says, spotlights the importance of having a group like International Hospital looking over his shoulder. The Texas company has been down this road before.

Financial Fit. Carlos Alvarado Moya pauses to admire the shiny Cima San Jos[acute{e}] and smiles like a proud father. This truly is his baby and he keeps close watch over it, as a hospital board member, investor and tenant--his bank, which brokered the initial hospital partnership, has a branch in the doctors' office building adjoining the hospital.

The idea for a hospital came to Moya about five years ago. "Costa Rica wanted foreign investors for tourism," he recalls. "At the same time, our hospital system here was in a crisis." He saw an opportunity to marry the two--develop a first-world hospital that would attract international patients as well as middle-class Costa Ricans. He used his business savvy and pull as Costa Rica Chamber of Commerce president to form an investor group, Grupo Promotor, and look for foreign investors for the hospital project.

International Hospital was the best fit, having started or acquired hospitals in Mexico and Brazil. Its board members and officers include doctors and executives who cut their medical teeth at Baylor. The company first looked across the border to export private hospital operations in Mexico before moving farther south.

In other countries, the company has targeted the same type of clientele that Cima San Jos{acute{e}] is reaching for in Costa Rica. So far, it's been a success. "The numbers have been better than expected here:' said Larry Meagher, International Hospital's chief executive officer, surveying the hospital during a break in a meeting of its board of directors. "We hope to use this hospital as a base and model for the Central America."

International Hospital's U.S. roots also helped assure a comfort factor for foreign visitors and Costa Ricans, or ticos as the locals are known, who love the "Made in the USA' stamp.

A tummy tuck and a tan. Few, if any, U.S. hospitals could guarantee a rainbow with your evening meal. Here, the nearby rainforests create the perfect conditions for such a sight almost daily. And the rainforests figure prominently in Cima San Jos[acute{e}]'s promotion, particularly aimed at clients seeking to combine plastic surgery and similar operations with rest and relaxation at those rainforests, the small country's beaches and other points of interest.

Half of the afternoon's scheduled surgeries this particular day are liposuctions--evidence that the hospital is already succeeding at reaching some of its target audience. Jacobson and Jill represent another type of patient that Cima is trying to attract: middle- to upper-class people with some type of foreign connection. In a country with more than 40,000 U.S. retirees, a smattering of foreign corporate outposts and a growing U.S. military presence--as the United States pulls out of Panama and shores up anti-drug efforts in the region--the hospital has a readymade patient pool.

"We think we have a good opportunity with that kind of patient," says Gonz[acute{a}]lez, who has worked to ensure that Cima meets all the standards for U.S.-accredited hospitals, even though there are no similar standards to meet in Costa Rica.

By any standards, Cima San Jos[acute{e}] is a showcase. The hospital's fountains and restaurant and the marble staircase of the entryway resemble the lobby of a pricy hotel--sharp contrast with the main competition, the old Cl[acute{i}]nica B[acute{i}]blica, set at a busy intersection in downtown San Jose, with its dark green lobby, shadowy corridors and distinctly old-hospital odor. The Cima, oddly, has no smell.

Gonz[acute{a}]lez says the hospital's all-too-clean atmosphere may make many in the community, even local middle-class residents who live nearby feel that the hospital is too expensive for them. The whole place appears almost too perfect, from its unsmudged mustard-brown exterior to its polished lobby staircase.

Gonz[acute{a}]lez says the hospital's marketing problem is to prove that it's not just for wealthy foreigners. "We need to show that we are here to serve our community," he says.

Is there a doctor in the boardroom? While Gonz[acute{a}]lez is finishing a slice of toast in the lobby restaurant, Dr. Roberto Herrera Guido, the chief medical doctor at Cima, checks to see what surgeries are scheduled for the day. He's already been working for hours--he's the former head of state-owned Children's Hospital and he goes there about 6 every morning to make rounds. "I came up through the state system," he says. "And I have to stay in touch with that." If anyone is the social conscience of the new hospital, it's Herrera. "When we worry more about the numbers, the risk is that we forget the poor people," he says.

Like most doctors, Herrera puts his patients first. But also like many doctors at Cima San Jos[acute{e}], Herrera has a vested interest in making sure that the treatment for his patients is fiscally sound. The hospital's chief medical physician and some 250 doctors are partners in the hospital, controlling almost half of its board of directors' seats.

While International Hospital and Grupo Promotor investors each put up $10 million to get the $40 million hospital going, the remaining $20 million came from doctors who joined the project as partners with a minimum $40,000 investment. Although another 50 doctors put in money just to be linked to the project, the hospital invited only a select group of doctors to be partners.

His blue gown is spotted with blood. Nurses move expertly to provide instruments. He is performing a hysterectomy and he is concerned because he has seen this patient before. "This now is five times for her," he will say later. "This is very grave."

Tricky Operation, Dr. Mario Pacheco, one of the doctor/shareholders, begins the first operation of the day. It's a normal day for him, a morning of back-to-back surgeries. However, the perspiration gathers on his brow as his hands move gently and deftly inside his patient.

Before, a patient like this would likely have gone abroad for a serious operation like this. But now, because there is a hospital she can trust to perform such a procedure, she chooses to stay in Costa Rica for the operation.

It takes more than just an expensive new building or state-of-the-art equipment to build and maintain that trust. It takes doctors and other healthcare workers who care, says Moya. "That," Moya says, "is what has made the difference for us."