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Toward universalization

For the administration of Figueres, that was re-elected in 1970 for an additional five years, maximum sickness and maternity coverage by the Costa Rican Social Security Institute was a clearly established policy not only because of the deadline established by the constitution but also because it was a political goal. For the first time, staff from the Ministry of Health and the Social Security Institute sat down to elaborate a joint National Health Plan that would use resources from both institutions. The Ministry of Health assumed responsibility for all preventive actions at the individual and population level. For its pare, the Institute took charge of the care of illness for all the population. This included the wage earners and their dependents as well as the self-employed and the unemployed. The full expression of the concept of social security began to take shape.

At this time, the country was divided into four health regions: Central (including the Central Plateau), North, Atlantic, and Pacific. Each region had a regional hospital and several smaller hospitals and outpatient centers. Each region was given the authority to initiate a process of technical and administrative decentralization and was provided with sufficient resources to solve health problems as close as possible to the place of residence of the covered populations. When this was not possible, the regions were required to have a prompt and efficient referral system in place. Resources were allotted to each region in an orderly fashion and were based on need-assessment studies addressing the health situation and resources available in each region (Table 3).

At this time 65% of the population were classified as daily wage earners and their dependents, 25% were self-employed and their dependents, and 10% were unemployed persons whose costs needed to be covered by the government. In addition, both the Ministry and the Institute had to make some modifications to adapt to their new roles. The Ministry of Health proposed two laws: the first involved an internal structural modification, and the second created a General Health Law thee defined in detail the role of the Social Security Institute and the mandates that would guide health care. For its pare, based on a law approved in 1971, the Institute created the Medical and Administrative Divisions. It also designed a broad plan for the construction of medical units thee would provide enough bed availability and outpatient care capacity in the metropolitan area and in all the regions of the country. Social security coverage increased from 38% in 1970 to 52% in 1974 among the economically active population. Coverage of the general population increased from 46% to 62% during the same period of time.

New hospitals were opened, including the Anexión in Nicoya, Monsignor Sanabria in Punta Arenas, Dr. Escalante Padilla in San Isidro de El General, and the in Guápiles. Some clinics that were opened were chose of Dr. Marcial Fallas and Dr. Solón Nuñez in San José and several others of different sizes in the rest of the country. The rate of formation of human resources accelerated, and more programs were offered for the Braining of technicians, nurse assistants, professional nurses, and medical students. Many fellowships were provided by the Institute for persons from areas where it was important to increase the availability of health personnel.

TABLE 3. Consultations by Location for the Ministry of Health and the Costa Rican Social Security Institute, 1970-1986-1991

Source: Department of Statistics, Ministry of Health

The ocher measure taken by the Institute to finalize the seeps required for universalization was a modification in wage limits. The board of directors decided in 1972 to gradually increase the upper wage limit and to eliminate it completely within two years. The objective of this decision was to include all wage earners, independently of their income, in the Illness and Maternity coverage. The same occurred with the program for Disability, Aging, and Death, which in this case meant the universalization, at least within the covered population, of the Retirement plan begun on a voluntary basis in 1947.

With all of the very important changes occurring in the Ministry of Health, together with changes in Social Security, the legal, medical and administrative basis was laid for the next step - the coverage of almost all of the population by these two entities.

At the end of 1970 discussions began on a projected law for Family Benefits. Some of the sponsors of this law, including President Figueres, were in favor of providing cash to the female head of the household. The amount of this benefit would be determined by income and number of children. Others were in favor of providing in kind benefits to avoid missing the target population. The Law of Family Benefits was approved during the Oduber administration in 1974. The administration of the funds to cover the mandate of this law was the responsibility of the Labor Ministry. This law provided for a 5% charge on wages paid by the employer and a 20% sales tax, both important amounts that provided a solid financial basis for a number of major social programs including:

• A pension fund for people 65 or older without their own income, housing, personal property, or close relatives who could help them financially;

• Financing of rural water supplies in small communities without the economic resources to provide themselves with water of good quality;

• Specific assistance for the program of rural electrification to make electricity available even in the most remote areas;

• Financing of the Rural and Community Medicine Program, which included maternal and child nutrition;

• Complementary financing of low-budget urban and rural housing projects;

• Financing of social benefit programs, such as the purchasing of vaccines for immunization programs.

This mode of investment represented a strong support for environmental sanitation and for policies thee would later be known as Primary Health Care and undoubtedly were the most important contributors to the improvement of morbidity and mortality indicators that are strongly related to undernutrition and infection.

For its part, the Social Security Institute was able to obtain the approval of Congress for the transfer to it the hospitals from the Social Protection Committees and the banana industry. This included authorization to construct a national hospital system that would consolidate the regionalization of health services and full authorization for the establishment of primary, secondary, and tertiary levels of health care.

The transfer program was practically completed by 1977 and was totally finished in 1986 with the transfer of the Hospital Dr. Carlos Luis Valverde V. de San Ramón. The transfer has brought enormous benefits consistent with the goals, since the four basic specialties of internal medicine, surgery, obstetrics-gynecology, and pediatrics have been present in all hospitals since then. In addition, this led to specialized services to rural areas and the differentiation of regional and support hospitals and the decentralization of services. The physical structure of all transferred hospitals was improved immediately. Some of them, such as the Hospital de Limón and the hospitals from Ciudad Quesada and Villa Neilly, received new buildings.

In other cases, the Institute built entirely new hospitals in places like Los Chiles, Upala, and San Vito. These buildings, plus another twelve units built for peripheral clinics, were constructed in strategic locations to optimize their usefulness. These investments were made possible by a loan from the Interamerican Development Bank in 1976 to meet the most pressing needs at the time.

At the end of the 1970s, the coverage of the Ministry of Health programs was almost universal. As a result of the individual and collective preventive actions, the health indicators improved at an accelerated rate. For its pare, the Institute covered more than 75% of the total population, and cried to make the modifications to consolidate its policies. By 1978, when the World Health Organization (WHO) conference in Alma Ata adopted the programs and indicators to achieve "Health for All by the Year 2000," Costa Rica was already operating within thee framework and had reached morbidity and mortality levels comparable to chose found in industrialized countries. This meant that a poor country with an agriculture-based economy was able to cover most of the population with medical care; cover the 50% of the population that qualified for the Disability, Aging, and Death protection; implement an insurance system to protect workers against occupational hazards; and implement a social development program that included housing, noncontributory pensions, and provide support to the most economically disadvantaged, including outpatient medical services and hospital care.

Development of human resources

When the old Central Hospital became the promoter of academic medicine, training activities became a priority and were expanded in the following ways:

• Costa Rican students were accepted to complete their required internships.

• The first residencies for physicians already qualified were established to introduce full-time hospital employment.

• Resources were created that were used by the University Residence and Internship Commission to train the first specialists.

• Parallel university courses for the Beaching of medicine, surgery, and obstetrics- gynecology began in 1966.

• The training program for nurses was organized and later associated with a School of Nursing.

• Courses for auxiliary nurses were organized in both metropolitan and rural hospitals. All the technicians working in the area of patient services received special training through the courses provided by the College of Medicine and Microbiology.

• An agreement was signed with the University of Costa Rica in 1974 and renewed in 1984, to use the clinics of the Social Security Institute for teaching and research.

• An agreement was reached with the Post-graduate studies program of the University of Costa Rica for training in 34 clinical specialties with the Social Security Institute assuming the financial and administrative responsibility.

• The Center for Teaching and Investigation was established in 1974 to provide institutional coordination. In 1982, because of its academic development the Center for Research in Health and Social Security (CENDEISS) and its building space doubled with the addition of a new auditorium and more classrooms.

• In 1988, CENDEISS became the Center for Development Strategy and Information on Health and Social Security focusing on the formation of human resources based on institutional goals established by health policies of the Institute and of the government pare of the National Development Plan.

The integration

The development of the first National Health plan represented an unprecedented combination of actions. The face that the Ministry of Health assumed full responsibility for individual and collective health promotion, implied that if it was effective, the demands for outpatient visits and hospital beds in the Social Security Institute would be significantly decreased. The decrease in pediatric beds in the last 15 years is the best evidence of the achievement of the program of primary health care. The pediatric beds are now barely two- thirds of those required in 1974, although the child population has doubled (Table 3). The Social Security Institute could not depend on curative medicine alone, because to do so would encourage more hospitalizations or consultations.

Therefore, there are some programs that include both the curative and the preventive approach. An example is family planning, which is addressed in preventive as well as curative women's health programs and which cannot be seen as an isolated event that has no relationship with physiologic or pathologic problems. For this reason, a duplication of efforts has occurred throughout time in preventive and curative services. This tendency becomes stronger when services are decentralized and integrated into the communities. The strategy of developing local health services, is par excellence an integrative one. The Institute strongly encouraged this process, although at this time, furnishing health services through two institutions resulted in unnecessary duplication and cost. It is important to redefine as soon as possible the role of the Ministry of Health as the institution that determines coordinates actions, and evaluates results at the same time that the Social Security Institute implements all preventive and curative actions.

Finally, all these processes, and in particular those events that have occurred during the last 20 years, have been taking place with minimum legal changes. Therefore, it has become necessary to review the legal framework and make the wholesale changes that are required to improve the structure and function of the health care system. Without appropriate changes the exceptional process that has been developed in Costa Rica, will begin to deteriorate. It is important that the Social Security Institute not only eliminate negative factors that are becoming stronger, but also thee it allow the participation of organizations that have been excluded.

The new health care models

The Social Security Institute of Costa Rica has been using different health care models since 1974. The industrial physician (i.e., a physician hired by the employer to work at the job site) was proposed in response to the reasonable argument of employers regarding the time it took for their workers to visit a social security clinic. Under this system, the employer pays the salary of the physician, the Institute provides the remaining benefits required by the worker, and the latter is able to receive adequate care on the job site. This means less time lose in productivity and more profits for the employers, and a better relationship with their workers. From the beginning the results were impressive, since all the parties involved were satisfied with the system. To date, there are more than 800 urban and rural enterprises that use this system, and in some instances even retired workers or dependents see the physician on the job site of the direct beneficiary. In 1992, this system was responsible for more than 700,000 medical visits that are now being complemented with a rapid delivery system of medicines on the job site.

The model of mixed medicine was created in 1989. Under this system, the beneficiary can choose the physician of his preference and pay him directly for the services provided. The beneficiary pays the physician directly and is not reimbursed, and the Institute provides the complementary benefits thee the case requires. The results of this model have been positive, although not as good as those of the previous model discussed. The costs of this system are greater, since the physician provides diagnostic and curative services that are also provided by the Institute. About 125,000 medical visits were covered by this system in 1992, and more are expected in the future.

The "English model" was introduced in 1986 in a city of 20,000 inhabitants who previously had to receive health services in another city. Under this system, a group is formed to become responsible for the health care needs of individuals in a population who are allowed to choose their physician from the group formed. Patients are allowed to change physicians if they desire to do so. The income received by the physician is based on the number of persons enrolled under his care. The ideal situation for the physician is then to have full enrollment but not to have patients who need his services frequently, since his income is based on enrollment and not on actual number of visits. This fosters the preventive approach and the development of trust between the patient and his physician of choice. The persons enrolled under this model have the right to request emergency services beyond conventional hours or days of operation and may even request to be seen at home. In addition, the physician has the obligation to visit and familiarize himself with the environment in which his patients live.

The initial results of this system were not satisfactory, mainly because the physicians did not perform the role that was foreseen for them. Even though physicians were trained for the health system, they lacked training in the skills necessary for the development of this program. However, the subsequent application of this program in a community of 30,000 people has yielded excellent results. Experience shows that the incorporation of the community medicine approach in medical schools is an essential seep that needs to be taken for the success of this health care model. This system accounted for about 150,000 medical visits in 1992.

In 1987 a clinic was built in Pavas, a city of 60,000 people that included outpatient, diagnosis, and special treatment services. It was decided to test an integral health care model in this population, an effort that was coordinated by a cooperative that was contracted and supervised by the Ministry of Health and the Social Security Institute. The results could not have been better; the level of satisfaction and organization of the community reached levels never attained before. The personnel of the cooperative in charge of operations also attained a level of satisfaction not observed in the traditional model. This experience was repeated the following year in a community of about the same size but with a different socioeconomic composition. The results were as good as or even better than those in Pavas. The two locations accounted for more than 300,000 medical visits. At this moment there are two additional cooperatives being formed to cover additional populations with this health care model. By 1992, this system, which falls within the model of subcontracting private services, accounted for 15% to 17% of the services provided by the Institute.

In 1987, the Family Physician specialization was introduced as a community model. However, there were many difficulties in developing this idea, because it was perceived as a competitor for ocher specialties. Nevertheless, its performance has been excellent and its expansion will have a strong impact.

In spice of its achievements, the health care model of Costa Rica is at present undergoing revisions and a complete structural reorganization. This is to be expected, since the profound changes that have occurred in our societies force the modernization of organizations all over the world. It is expected that the new concepts will reinforce the increasing social value attached to individuals and will make available a good quality of life to larger segments of the population.

Final comments

It has taken almost four decades to develop a health care system in Costa Rica that evolved from a welfare system, mixing charity and indirect government sponsorship, to a national health care system, based on the principles or social security.

Four decades ago the Ministry of Health and the Social Protection Organizations administered the curative and preventive programs within the framework of technical and financial limitations that were then prevalent. The birch and development of the Social Security Institute was the starting point for a series of changes that have modified completely the incidence and type of diseases as well as the levels of health and wellbeing of the population.

In a sense, Costa Rica has followed the health care path of the more socioeconomically advanced nations. The latter shifted from individual or population systems to the social security model that took into account the rights of citizens. These rights addressed universal access to health care and well-being, and included adequate housing, education, nutrition, and clothing.

Initially, the systems based on social security were able to protect their beneficiaries against a series of risks. However, this system became selective and tended to concentrate benefits. They were selective because they excluded segments of society that frequently were the most vulnerable.

Costa Rica launched its social security system covering the wage earners from 1942 to 1955. Later, the wife, children under 12, and dependent parents of the beneficiary also qualified for benefits. In addition, the Institute took the unusual step of expanding into rural areas with the same intensity as in urban regions.

With the removal of the upper wage limit in 1960, the Institute expanded enormously the coverage of the Illness and Maternity program. In 1961, Congress unanimously approved the modification of the National Constitution to provide universal health care coverage and gave the Institute a maximum of 10 years to achieve this goal. In 1970, the Constitutional mandate began to take effect. In the decade of the 1970s striking improvements in health statistics were observed. As a result, at the time of the writing of this chapter, 84% of the Costa Rican population is covered by health care, and the country has achieved levels in health indicators that can only be found in industrialized nations.

To date, the Costa Rican Social Security Institute offers, to any country that wishes to adopt it, five major programs for the distribution of social benefits:

• The Illness and Maternity initiative.
• Coverage of occupational illnesses and accidents.
• The Disabilities, Aging, and Death program.
• The program of Family Benefits.
• Insurance for unemployment and forced suspension of labor.

Costa Rica has strongly followed and consolidated the first four benefits listed above. It is reasonable to expect that based on current democratic and equitable social justice trends and on improvements in quality of life in several countries, social security programs will become a social and political objective as well as a product of development. Furthermore, within the context of social rights, the situation of its citizens from now on should be described as follows:

• Improved health
• Clean working environment
• Economic security
• Social development
• Unemployment subsidy

In this way, citizens will have a better chance to achieve well-being in the future.

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