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Balance of the 1980s and perspectives for the 1990s in the health sector

By the end of the 1980s, the two most important institutions in the health sector were submerged in a profound crisis. On its part, the Ministry of Health, after receiving constant budgetary cuts beginning in 1980 and facing a population increase of 700,000, had become basically paralyzed and was only able to pay the salary of its employees.

The preventive activities were reduced to a minimum due to the lack of resources, such as cash flow, transportation, fuel, and per diem expenses. The programs based on the primary health care strategy (Education and Nutrition Centers [CEN], Integrated Centers for Child Health Care [CINAI], dental prevention school program, and the so-called primary care) substantially reduced their coverage, which weakened the first level of health care in the country.

On its part, CCSS was able largely to overcome the economic crisis through the increase in fees and the implementation of measures for the control of internal expenses, which limited even more the capacity of the institutional response to meet the demand of the beneficiaries. During the second half of the 1980s and the first two years of the 1990s, CCSS suffered an unprecedented economic crisis worsened by the country's large external debt, and by the lack of satisfaction of the beneficiaries with the services provided, particularly those related to outpatient care. This indicates that the modest efforts that have been devoted to developing alternative models have not yielded the expected results and are far from becoming the short- and medium-term solution to the complex problems facing the institution.

The two most important efforts carried out by the Ministry of Health and CCSS in response to the crisis were the integration of services during the first half of the decade and the implementation of the SILOS strategy during the second half. These efforts were not able to meet their goals, in part due to administrative, legal, and financial restrictions present in both institutions.

The integration of CCSS and Ministry of Health services was proposed as a strategy to create a new model of health care in the country that would culminate in an integrated National health Care System (Jaramillo and Miranda, 1985). However, the goals of this process, which was initiated in 1983, were defined very broadly. The integration of the institutions consisted only of placing the CCSS and the Ministry of Health centers in the same location. Moreover, there were no established goals for the distribution of resources or the quality of services. The results show lack of coordination and cooperation among the personnel in both institutions, as represented by duplication of activities, schedule conflicts, and the absence of a hierarchical structure (Sanguinetti et al., 1988). Unfortunately, the process of integration did not anticipate the need for structural adjustments in the organization of clinics and health centers with the goal of establishing a unique administrative system that would facilitate the process. At the end of the government administration that promoted it, the level of integration was far from the goals originally proposed.

The SILOS strategy launched in 1987 was also far from reaching its intended objectives, and by 1990 it was no longer considered a viable health policy for the new government. As with the integration of CCSS and the Ministry of Health, an important limitation for the development of SILOS has been the absence of changes in the administrative and financial organization of both institutions that would allow them to decentralize and consolidate true community participation The limitations imposed by the adjustment process made it more difficult to provide human resources for the implementation of SILOS, diminishing the medium- and long-term possibilities of survival of this model. In 1988, faced with the urgency of supporting the administrative sector of SILOS with human resources, the personnel working on primary health care were transferred to meet these functions. This caused the breakdown of the whole supervision system of the primary health care program without resolving the administrative problem of SILOS.

During the 1980s, CCSS experimented with the implementation of several alternative health care models, including mixed, private, capitation, and health cooperatives, but none of them emerged as a viable alternative to the prevailing models in CCSS and in the Ministry of Health.

The mixed and private models essentially reproduce the health care model based on curative medicine and the prescription of medications, and are far from being integrated models. The cooperatives of Pavas and Tibás have been great individual successes. However, the replicability of the model is in question, and after four years of experience it does not seem to be a viable alternative for the whole country.

Capitation has had even greater problems, and calls into question the idea that the Costa Rican model corresponds to the European capitation model. After five years, there is no indication that this model can become a viable alternative for the whole country. In conclusion, by the end of the 1980s none of the alternative models implemented by CCSS seemed to be a viable alternative to the existing ones.

At the beginning of the 1990s, the Ministry of Health became severely decapitalized and its main programs weakened. CCSS was undergoing its most severe financial crisis without the option of increasing the fees paid by its beneficiaries or their employers, and facing ever-increasing complaints about the deterioration of its services and health care. These problems, are becoming more difficult on a daily basis and a new restructuring seems necessary. In the meantime the achievements and momentum of the preventive medicine and nutrition initiative of the 1970s continue to be reflected in favorable health statistics for Costa Rica compared with the rest of Central America.


Alfaro J. Chaves M. 1986. "Proceso de Integración de Servicios de Salud en Costa Rica. 1983-1984. " Tesis de grado, Universidad de Antioquía, Medellín.

Ayala N. et al. 1992. Grado de desarrollo de la estrategia de SILOS. Segunda Evaluación. Febrero 1992. Caja Costarricense Seguro Social. Ministerio de Salud. March 1992.

Bustelo E, Isuani E. 1990. "El ajuste en su laberinto. Fondossociales y política social en América Latina." Seminario de Fondos de Desarrollo Social UNICEF-PREALC-OEA-PNUD-ILPES-GRUPO ESQUEL, Santiago de Chile, November 1990.

CIIAS-CIID. 1990. Análisis del desarrollo e investigación de los programas basados en la estrategia de atención primaria en salud en los países de América Central y República Dominicana. Memoria Taller Internacional, Roberto Alvarado, Coordinador, San José, January 1990.

CCSS. 1988. "Evaluación del programa de atención médica por capacitación en el Cantón de Barva durante 1987." San José, 1988.

CCSS. 1991. "La Caja Costarricense de seguro social en la coyuntura crisis." Documento presentado por la CCSS al "II Foro de salud y desarrollo. Ajuste estructural y bienestar social en la crisis." San José, March 1991.

CCSS and Ministerio de Salud. 1992. Proyecto Reforma Sector Salud, Unidad Preparatoria del Proyecto. San José, May 1992.

García R. et al. 1992. Evaluación del grado de desarrollo del proceso de integración/coordinación entre el Ministerio de Salud y la CCSS. August-September 1991. San José, January 1992.

Jaramillo J. Miranda G. 1985. La Integración de servicios de salud en Costa Rica. CCSS, San José, 1985.

Marín F, Vargas M. 1991. SILOS y empresas cooperativas de salud. El cave de Costa Rica. San José, February 1991.

Ministerio de Planificación Nacional y política Económica 1987. "El gasto público en los sectores sociales - aspectos metodológicos." Documento 9. MIDEPLAN, San José, July 1987.

Ministerio de Planificación Nacional y política Económica. 1987. "Propuesta de indicadores sobre salud - aspectos metodólogicos." Documento 3. MIDEPLAN, San José, June 1987.

Ministerio de Salud. 1989. "Resumen de propuesta de desarrollo institucional." November 1989.

Ministerio de Salud. 1990. "Sistemas de Salud en Costa Rica." Aporte del MS al Seminario-Taller: "Presente y futuro de los sistemas de salud en Centroamérica." San José, 25-26 October 1990.

Ministerio de Salud. 1991. "El gasto de operación de los servicios de la salud al nivel local del Ministerio de Salud de Costa Rica." Documento preliminar. OPS/OMS, Costa Rica, December 1991.

Ministerio de Salud. 1990. Sistema de Información, Departamento de Atención Primaria, 1990.

Miranda G. 1992. Entrevista al presidente ejecutivo de la CCSS en el período 1982-1990. August 1992.

Miranda G. 1988. La Seguridad Social y el desarrollo en Costa Rica. Editorial EDNASS-CCSS, San José, 1988.

Mohs E. 1991. "Políticas y estrategias de salud durante dos décadas. 1970-1990 (documento inédito)." San José, 1991.

Novygrodt R. 1992. Deterioro de indicadores de salud, nutrición y la pobreza. Costa Rica, September 1992.

Sanguinetti JA, et al. 1988. Los servicios públicos de salud de Costa Rica. Integración y coordinación. Development Technologies. Pragma Corp, San José, April 1988.

Sanguinetti JA. 1988. "La salud y el seguro social en Costa Rica. " Informé de Consultoría Presentado a MIDEPLAN por Development Technologies Inc., San José, 1988.

Trejos ME, Villalobos R. 1992. Lo aparente y lo oculto del ajuste estructural en Costa Rica. Projecto por una Opción de Desarrollo Alternativa, Escuela de Economía, Universidad Nacional, Costa Rica, 1992.

Ugalde A and Ruede. 1988. Estudio del consulta externa. Development Technologies, Inc., San José, Costa Rica, April 1988.

Valadez J. Vargas W. et al. 1987. La calidad de la atención primaria de salud en áreas periféricas de Costa Rica. Ministerio de Salud, Harvard University, and Organización Panamericana de la Salud. San José, November 1987.

Vallejo C, Lunes R. 1991. El sector salud en Costa Rica: Financiamiento y eficiencia. Informe de Consultoría pare el Banco Mundial, San José, 1991.

Valverde JM. 1990. Crisis y política social en Costa Rica 1980-1988: Tendencias y perspectivas. Informe final de projecto. Instituto de Investigaciones Sociales, Universidad de Costa Rica y Confederación Superior Universitaria Centroamericana, Costa Rica, February 1990.

Vargas W. 1992. Los servicios de salud en Costa Rica. ¿Hacia donde vamos? Caja Costarricense de seguro social. División Técnica de Servicios de Salud. Departamento Medicina Preventiva, April 1992.

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