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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.
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