Pursuing universal health coverage
CCSS is funded by a 15 percent payroll tax, as well as payments from retiree pensions . 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 CCSS . In 1973, the Ministry of Health decided to move away from direct service provision and adopt a steering role , . 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 poor . Through the CCSS, health care is now essentially free to nearly all Costa Ricans .
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, 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, respectively . 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 services . Furthermore, user satisfaction with the quality and timeliness of care was low .
In 1995, the Ministry of Health transferred responsibility for all primary health care services to the CCSS –.
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 patients , , . The first EBAIS teams began working in 1995, and the poorest districts were targeted first with a specific aim of reducing inequities . By the end of 2001, 80 percent of the population was covered by an EBAIS team and nearly the entire country was covered by 2006 , .
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 buildings . 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 specialists , , , . Beyond 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 1996 , . 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 satisfaction  . Data are collected on up to 260 different measures annually . 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 center Monday through Friday has notably reduced physician absenteeism .
Improved coverage and outcomes
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:
- By 2003, insurance coverage had increased from 47 percent to 89 percent , ;
- Individual rates of catastrophic health expenditure declined from 1.56 percent to 0.31 percent in 2004 .;
- The life expectancy at birth in Costa Rica is 81.5 years for females and 76.7 years for males, ranking Costa Rica second in the Americas behind Canada , ;
- Perinatal mortality decreased from 12 deaths per 1000 live births in 1972 to 5.4 deaths in 2001;
- Under-5 mortality decreased from 14.4 deaths per 1,000 live births in 1995 to 10.6 deaths per 1,000 live births in 2009 , .;
- Communicable diseases mortality declined from 65 per 100,000 in 1990 to 4.2 per 100,000 in 2010 .
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 factors ."
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 population . 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 2013 . Consequently there is a need to increase health care capacity to provide comprehensive and integrated services to address these major causes of mortality .
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