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In 1941, Costa Rica established Caja Costarricense de Seguro Social (CCSS), a social security insurance system for wage-earning workers345. In 1961, coverage was expanded to include workers’ dependents and from 1961 to 1975, a series of expansions extended coverage for primary care and outpatient and inpatient specialized services to people in rural areas, the low-income population, and certain vulnerable populations6. Further expansions during the late 1970s extended insurance coverage to farmers, peasants, and independent contract workers. Additionally, CCSS mandates free health service provision to mothers, children, indigenous people, the elderly, and people living with disabilities, regardless of insurance coverage6. By 2000, 82 percent of the population was eligible for CCSS3, which has continued to expand in the ensuing period. By covering all population groups through the same system, Costa Rica has avoided social insurance stratification and inequity common in many other countries in the region3.
CCSS is funded by a 15 percent payroll tax, as well as payments from retiree pensions6. Taxes on luxury goods, alcohol, soda, and imported products also help to cover poor households who do otherwise pay into the system. All CCSS funds are merged into a single pool, which is managed by the central financial administration of CCSS6. In 1973, the Ministry of Health decided to move away from direct service provision and adopt a steering role36. Responsibility for the provision of most care was transferred to the CCSS, although the Ministry retained responsibility for disease control, food and drug regulation, environmental sanitation, child nutrition, and primary care for the poor7. Through the CCSS, health care is now essentially free to nearly all Costa Ricans8.
In addition to expanding financial access to health care services, Costa Rica also undertook significant reforms to improve geographic access to care. Until the mid-1990s, the provision of primary health care in Costa Rica was somewhat disjointed. In 1987, a Division of Primary Health Care within the Ministry of Health was formed that combined two existing units: the Rural Health Program and Community Medicine Program, which had been providing primary care to rural indigenous peoples and the urban poor, respectively3. Although these programs had achieved success in improving outcomes during the 1970s, the 1980s led to significant cutbacks in funding in the wake of the economic crisis. By 1990, only 40% of the population was covered by governmental primary health care services9. Furthermore, user satisfaction with the quality and timeliness of care was low6.
In 1995, the Ministry of Health transferred responsibility for all primary health care services to the CCSS91011.
Primary Health Care Teams (Equipos Básicos de Atención Integral de Salud, or EBAIS) became the central component of the Costa Rican primary health care system."
EBAIS teams provide a first point of contact for all health services, and initially consisted of a doctor, nurse, and public health worker and were assigned to specific geographic regions. Each EBAIS team is generally responsible for providing care to 1000 families, or approximately 4000 patients139. The first EBAIS teams began working in 1995, and the poorest districts were targeted first with the specific aim of reducing inequities8. By the end of 2001, 80 percent of the population was covered by an EBAIS team and nearly the entire country was covered by 200669.
In the 1990s, most teams operated out of existing buildings, but in 2000 EBAIS began to construct new buildings to house their services, and the majority of EBAIS are now in their own buildings12. Today, EBAIS teams typically also include an administrator, pharmacy assistant, and primary health technician responsible for conducting home visits for the elderly and immobile populations, and are supported where possible by social workers, dentists, nutritionists, laboratory technicians, and medical records specialists36913. Beyond the provision of direct care services, EBAIS teams also conduct health surveys and contribute to civil registration and vital statistics data collection.
To help manage EBAIS teams, the Costa Rican government introduced performance agreements, known as management commitments (MC), in 199634. Through yearly negotiations between the CCSS administrators and regional EBAIS teams, MCs set targets for priority health areas, including indicators of coverage, quality, efficiency, and user satisfaction10. Data are collected on up to 260 different measures annually6. These measures allow for greater accountability and prioritization of nationally agreed upon indicators, processes, and performance markers. Although the scope and large number of MCs have been difficult to implement at times, the process has shown promising results. For example, an MC requirement that physicians be present at their primary care centre Monday through Friday has notably reduced physician absenteeism4.
Together, the expansion of universal health coverage and the strengthening of primary health care have greatly improved effective service coverage and health outcomes in Costa Rica:
Because EBAIS teams were rolled out in a step-wise fashion across the country, a natural experiment exists to assess their impact on health outcomes. An important 2004 study found that districts with an EBAIS presence had an 8 percent lower mortality among children and 2% lower mortality among adults compared to districts without EBAIS, as well as a 14 percent decline in deaths by communicable diseases, controlling for other relevant factors15."
Despite its strong primary health care system, Costa Rica still has many challenges to address. Like many countries, Costa Rica is experiencing a continued epidemiological transition toward an increased burden of non-communicable diseases and a demographic transition toward an ageing population6. Mortality from circulatory diseases increased from 25 per 100,000 deaths in 1990 to 120 in 2010, and there was a 48 percent increase in all types of cancers from 2003 to 20136. Consequently, there is a need to increase health care capacity to provide comprehensive and integrated services to address these major causes of mortality14.
Arturo Sanabria/Courtesy of Photoshare
There is also a concern that the EBAIS teams emphasize their efforts too heavily upon the preventative measures required by the MC system and do not focus enough on curative treatments that are not included in MCs, such as obesity, depression, tobacco use, and drug addiction3. Waiting times for in-person visits to PHC 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 care4. Emergency treatment costs are up to twice that of a primary care consultation, and use has been increasing since the 1990s4. Weak vertical integration of care between primary, secondary, and tertiary care also contributes to the high rates of emergency department use and relatively long waits for speciality care, and the CCSS estimates that up to half of emergency room visits are not for real emergencies34. Additionally, migrants remain frequently uninsured and “cumbersome” enrollment processes make it difficult for poor and vulnerable populations to enroll in the EBAIS program, further adding to the burden of emergency care services46. Nonetheless, Costa Rica has achieved near-universal health coverage and strong PHC service coverage through ubiquitous EBAIS community health teams that use data to drive health outcome achievement.