History:

Primary health care has been a priority in Costa Rica for decades, dating back to before the international call for strengthened primary health care in the 1978 Declaration of Alma-Ata. The Rural Health Program and Community Health Program, established in 1973 and 1976, respectively, were eventually merged into a primary health care department.1 However, an economic downturn and subsequent unemployment in the 1980s and early 1990s prompted inefficiency, dissatisfaction, and a lapse in the quality of care, catalyzing a wave of reforms.23

What are the considerations for forming multidisciplinary teams?

Team-based care organization has been a component of many primary health care reforms in the last few decades. There are two central considerations for policy makers when forming care teams: the size and composition of the team as well as the processes to promote a team-based culture. Pursued together, multidisciplinary teams can promote greater comprehensiveness of services and improve accessibility.

How facility organization and management was integrated into health reform:

The available literature focuses on the specific improvements Costa Rica has made in team-based care organization, information systems use, and performance measurement and management. Reforms in the 1990s established Equipo Basico de Atencion Integral de Salud (EBAIS) teams consisting of a doctor, nurse, technical assistant, medical clerk, and a pharmacist. These teams collaborate to serve an empaneled population of approximately 4500 individuals, demonstrating the value of linking multidisciplinary teams with a patient panel to efficiently leverage their individual skills and responsibilities.2 EBAIS teams are capable of providing public health, preventive, and curative services both in facilities and in communities and homes. The second integral component of Costa Rica’s primary health care reform was the creation of a system for data feedback whereby the EBAIS teams collect demographic and epidemiological data in communities, send it to the health area and the CCSS and, in turn, receive information on their performance. These data focus on access, continuity, effectiveness, efficiency, and user satisfaction and are used to set performance targets, assess progress towards these targets, and allocate resources according to need.4 In order to achieve this, policy makers needed to consider the functionality of information systems to achieve successful communication between EBAIS team members who are often delivering services or performing tasks in different places as well as data transmission.

Outcomes and impact:

The diverse expertise of EBAIS team members enables comprehensive service coverage. Approximately three quarters of the medical consultations in Costa Rica occur between patients and EBAIS teams, and in 2012, EBAIS teams coverage reached 94% of the population.(2) Management contracts have become integrated into performance management structures, and EBAIS teams have reliable and consistent access to data on the performance of their team and health of their panel. Maternal, infant, and under-five mortality have decreased since the early ‘90s, and life expectancy is the third highest in North America. Costa Rica demonstrates remarkable efficiency with per capita spending on health less than the world average.(2)

Suggested citation: “Facility Organization and Management: Costa Rica.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, https://improvingphc.org/costa-rica-0. Accessed [insert date].

References:

  1. Unger JP, De Paepe P, Buitron R, Soors W. Costa Rica: Achievements of a heterodox health policy. Am J Public Health. 2008;98(4):636–43.
  2. Pesec M, Ratcliffe HL, Karlage A, Hirschhorn LR, Gawande A, Bitton A. Primary Health Care That Works: The Costa Rican Experience. Health Aff (Millwood). 2017 Mar;36(3):531–8.
  3. Lee T, McKee D. An Empirical Evaluation of Devolving Administrative Control to Costa Rican Hospital and Clinic Directors. Int J Heal Serv [Internet]. 2015;45(2):378–97. Available from: http://journals.sagepub.com/doi/10.1177/0020731414568515
  4. Pesec M, Ratcliffe H, Bitton A, Ratcliffe Msc H, Director C. Building a Thriving Primary Health Care System: the Story of Costa Rica. 2017; Available from: https://www.ariadnelabs.org/wp-content/uploads/sites/2/2017/12/CostaRica-Report-12-19-2017.pdf