Universal Healthcare: The Costa Rican System
Aubrey Hagen
Official symbol of the Caja Costarricense de Seguridad Social
Health and Equity Indicators for Costa Rica, the United States, and Mexico
While many look to the United States as the pinnacle of health and biomedical achievement, Costa Rica has proven that they can achieve better health outcomes with lower expenditures. As recently as 2008, Costa Rica’s per capita income is approximately one-fourth of that of the U.S., but their total health expenditures per capita are one-ninth of what the U.S. spends (Unger et al., 2008). To top it off, Costa Rica’s life expectancy at birth currently hovers around 81 years, which has consistently been above the United States and is “second only to Canada in the Americas” (Unger et al., 2008, p. 636). Costa Rica has instituted and reformed a program of social insurance and universal health coverage that has resulted in impressive health outcomes and social progress for their citizens due to an integrated approach focused on equity and universal accessibility.
In their in-depth history of Costa Rica's health system, Pesec, Ratcliffe, and Bitton write: “While Costa Rica ranks 101st in Gross National Product (per capita) globally, it ranks 62nd in the Human Development Index, outperforming on social indicators compared to what would be expected given its level of economic development” (2017, p. 8). Costa Rica did not move up the ranks overnight; the quality of their infrastructure today is the result of long-term investment and labor that started when President Rafael Angel Calderón Guardia (1940-44) created Costa Rica’s social security system, the “Caja Costarricense de Seguridad Social” otherwise known as the CCSS (Clark, 2002). The implementation of the social security program in 1941 was the foundation of what became a bottom-up model of social insurance, as coverage was provided through the CCSS to salaried workers first (Pesec et al., 2017). The CCSS was essential to the formation of the greater welfare state in Costa Rica, as it was “founded on the principles of solidarity, equity, justice, universality, and equality; values that would continue to guide the Costa Rican health system for decades” (Pesec at al., 2017, p. 15).
Costa Rica rolled out social insurance coverage first, and improved healthcare infrastructure followed, later on. Although universal coverage started with a small sector of Costa Rica’s population, it now covers 87.6 percent of its total population, in comparison to 47 percent being insured in 1947 shortly following the formation of CCSS (Bertodano, 2003; del Rocío Sáenz et al., 2010). This progress lends itself as evidence that “population health was high on the political agenda in Costa Rica,” which is visible in the General Law of Health established in 1973 stating that “all residents have the right to healthcare provisions and the obligation to contribute with the preservation of health and to maintain the health of his/her family and community” (Vargas & Muiser, 2013, p. 1; del Rocío Sáenz et al., 2010, p. 5). However, while universal coverage expanded relatively quickly, this was not equivalent to everyone having access to care. According to Pesec, Ratcliffe, & Bitton (2017), 25 percent of Costa Rica’s population had access to primary healthcare prior to reforms during the 1990s, in comparison to 93 percent of the population having access to primary health care services as of 2006.
Primary healthcare is an essential component of the Costa Rican system. Two notable moments in Costa Rica’s prioritization of primary health care were the establishment of the Rural Health Program in 1973 and the healthcare reform that took place during the 1990s (Pesec at al., 2017). McGuire (2001) calls the Rural Health Program the “most important healthcare innovation of the 1970s” (p. 1681). Costa Rica collected mortality data geographically and “realized that most of the deaths in the country were coming from small, rural areas and were largely due to infant mortality and other preventable causes” (Pesec et al., p. 18). Following the realization of this health disparity, the Rural Health Program was implemented to address primary healthcare needs and reduce mortality. The bottom-up approach appeared again during reforms the CCSS took on during the 1990s, which began with a team-based model of primary care clinics being rolled out to rural areas first, known to be the poorest areas of the country (Clark, 2002). These reforms were prompted by a variety of institutional issues as well as the need for expanded geographical coverage of primary health care (del Rocío Sáenz et al., 2010). Geographic data evidences that accessibility has improved, as “the share of Costa Rican population living farther than 25 km from a hospital has declined from 30% to 22%” since 1995 (Savedoff, 2009, p. 10). Costa Rica improved health outcomes by focusing on geographic accessibility to primary healthcare and universal coverage to attain equitable access and availability to care.
One of the pillars of Costa Rica's primary healthcare infrastructure today is the Equipo Básico de Atención Integral en Salud system (EBAIS). This model was designed to "to create primary health care teams that cared holistically for a specific, geographically ordered group of citizens" (Pesec et al., 2017, p. 28). Each EBAIS consists of a physician, nurse, technical assistant, medical clerk, and certified pharmacist and serves approximately 4,000-5,000 patients in its region (Pesec et al., 2017). The EBAIS team model was introduced during the 1990s reforms and is still an integral part of providing basic health services to all of Costa Rica's citizens. As of 2016, there were 1,030 EBAIS teams serving throughout Costa Rica (Pesec at al., 2017).
An EBAIS clinic in rural Upala, Costa Rica
Unger et al. (2008, p. 637) opine that Costa Rica “avoided the social insurance stratification typical of other Latin American countries” because Costa Rica was focused on reducing health inequities in addition to increasing accessibility to healthcare. Research done by Salas & Llanas on determinants of healthcare utilization in Costa Rica supports this as they report that “We found no multivariate association between the use of outpatient visits and income or insurance status. This result suggests that there is no problem with access in the public – almost universal – Costa Rican health system” (although other factors such as education, self-assessed health, and geographic region of residence did present themselves to be determinants) (2010, p. 414). Socioeconomic inequities are clearly a priority of the CCSS. Financial data show that 29 percent of health expenditures in Costa Rica target the poorest income quintile and expenditures targeting the richest quintile only account for 11 percent of government health spending (Unger et al., 2008).
While its progress deserves recognition, Costa Rica must focus on maintaining and improving public health policy and infrastructure to adapt to the changing needs of their citizens. As primary health care access has improved health outcomes in Costa Rica, the life expectancy has increased accordingly (Clark, 2002). However, with this demographic shift comes a shift in the healthcare needs of the population, as “this older population presents a greater proportion of expensive, chronic, and degenerative diseases. The treatments for these maladies increase the cost of hospital stays, outpatient drug regimens, and physical therapies” (Clark, 2002, p. 5). Public health policy in Costa Rica must address this epidemiological shift and adapt their infrastructure in order to reduce the burden of non-communicative diseases as well as to keep care affordable and accessible. Another pressing issue is long wait times for care: “Waiting times for in-person visits to primary health care facilities are long, as are those for specialist referrals for elective procedures. Some scholars have suggested that this relative lack of accessible curative treatment has pushed more patients to the emergency room for care” (Primary Health Care Performative Initiative, 2015). As more patients are pushed to the emergency room, this also increases healthcare expenditures for the healthcare system.
Additionally, privatization of healthcare services is a potential threat to the stability and success of the universal care system. According to Pesec, Ratcliffe, and Bitton, “Since 2000, there has been an increase both in the number of private clinics that provide primary health care and the percentage of primary health care visits that occur in private clinics. A growing proportion of the population uses private primary health care over the course of a year, and increasingly private secondary care services as well” (2017, p. 65). Most people who access private care must pay out of pocket, but some purchase private health insurance in addition to their payment contributions into the universal system (Pesec, Ratcliffe, & Bitton, 2017). Another potential threat to the stability of the public healthcare system is medical tourism. Warf writes that “motivated by fear of litigation the costs for procedures performed in Costa Rica typically run between 25 and 60 percent of those done in the U.S., although for a very few procedure Costa Rica is actually more expensive” (2010, p. 56). While most medical tourists do not withdraw resources from the public sector, they do invest into the private healthcare sector. The main concern with the growing private healthcare sector is that it could potentially undermine the universal health care system by acting as a catalyst in coordination with other factors that threaten the stability of Costa Rica’s universal healthcare policy (Martínez Franzoni & Sánchez-Ancochea, 2016).
However, especially after reforms during the 1990s that addressed systemic flaws, Costa Rica has made accelerated progress in primary healthcare outcomes and health equity, and it is in no danger of collapsing anytime soon. One reason for its stability is the general public support and appreciation for universal healthcare; although it is not perfect, Costa Ricans continue to access public healthcare services and contribute to universal healthcare. In fact, for many Costa Ricans, their exceptional healthcare system is a source of pride and national identity. It is undeniable that Costa Rica has experienced great success with their model for social insurance and universal health coverage. The question that presents itself, however, is whether the Costa Rica model is transferable to other countries and if so, what conditions are necessary for successful implementation. Scholars, policy experts, and public health specialists do not have the answer yet. While it is relatively straightforward to identify the single-policy factors that were successful in Costa Rica’s case, it is much more complicated and subjective to identify the interacting contextual factors that primed Costa Rica for success. Whether or not Costa Rica has formatted the model for universal health coverage for the rest of the world, they have most definitely provided goals and achievements for other governments to aspire to reach.
Health regions in Costa Rica
References
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Primary Health Care Performative Initiative. (2015) Costa Rica: Universal health coverage and community-based health teams create effective care. (2015, September 24). Retrieved April 15, 2019, from https://improvingphc.org/promising-practices/costa-rica
De Bertodano, I. (2003). The Costa Rican health system: Low cost, high value. Bulletin of the World Health Organization,81(8), 626-627.
Del Rocío Sáenz, M., Luis Bermúdez, J., & Acosta, M. (2010). Universal Coverage in a Middle Income Country: Costa Rica. World Health Report.
Martínez Franzoni, J., & Sánchez-Ancochea, D. (2012, March). The Road to Universal Social Protection: How Costa Rica Informs Theory. Retrieved March 26, 2019, from https://kellogg.nd.edu/documents/1700
Mcguire, J. W. (2001). Social Policy and Mortality Decline in East Asia and Latin America. World Development,29(10), 1673-1697.
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Salas, M. M., & Llanos, A. A. (2010). Determinantes de la utilización de servicios de salud en Costa Rica. Gaceta Sanitaria,24(5), 410-415.
Unger, J., Paepe, P. D., Buitrón, R., & Soors, W. (2008). Costa Rica: Achievements of a Heterodox Health Policy. American Journal of Public Health,98(4), 636-643.
Vargas, J. R., & Muiser, J. (2013). Promoting universal financial protection: A policy analysis of universal health coverage in Costa Rica (1940–2000). Health Research Policy and Systems,11(1).
Warf, B. (2010). Do You Know the Way to San Jose? Medical Tourism in Costa Rica. Journal of Latin American Geography,9(1), 51-66.
William D. (2009). A moving target: Universal access to healthcare services in Latin America and the Caribbean, Working Paper, No. 667, Inter-American Development Bank, Research Department, Washington D.C.
Upala estrena ebais que beneficiará a más de 12 mil habitantes
Building a Thriving Primary Health Care System: The Story of Costa Rica https://www.ariadnelabs.org/wp-content/uploads/sites/2/2017/12/CostaRica-Report-12-19-2017.pdf