Summary

In the past, Costa Rica was characterized by a duplicative and fragmented public primary healthcare system. In 1994, the country initiated a sweeping reform of the health system, including primary health care. Bureaucratic reorganization of the Ministry of Health (MOH) and the Social Security Agency (CCSS) led to the integration of all healthcare delivery under the CCSS, from public health activities to tertiary care. Comprehensive multidisciplinary primary healthcare teams (EBAIS)—comprised of a doctor, nurse assistant, community health worker, and data specialist—were created to care for approximately 5,000 patients each. A system of geographic empanelment was implemented to assign every Costa Rican to one of the newly-formed EBAIS teams. Finally, quality assurance mechanisms were initiated and promoted data collection and feedback central as a central function of the EBAIS teams. The first EBAIS team was established in 1995 and by 2002, there were 818 active teams throughout the country. Today, these teams provide comprehensive, continuous, coordinated, and first contact access to nearly 95% of Costa Ricans. Over the first 9 years of the reform, areas with EBAIS teams saw a 9% decrease of infant mortality and a 2% decrease in adult mortality.

Description of practice

The problem

During the 1980s, Costa Rica struggled with decreased funding to the main providers of primary healthcare including the MOH and the CCSS. Responsibility for primary care service delivery was shared between the MOH and CCSS and overlapping charters made responsibilities unclear and efforts duplicative. After the 1982 global financial collapse, resources devoted to primary care dwindled. Financing was also a concern, and there were calls to privatize the healthcare system entirely. Because of the perceived lack of primary care services, the demand for secondary care increased, exacerbating long wait times. From 1985 to 1990, primary care visits decreased by 17%.

As a result, public dissatisfaction with the country’s health care system was high and growing. A measles outbreak in 1991 brought these issues to a head. Employers, who were a major funder of the public healthcare system, threatened to stop paying their contributions if something wasn’t done to fix the system.

The solution

In the face of this public dissatisfaction, financial strains, and duplicative care, Costa Rica developed a major reform to its national healthcare strategy, of which primary healthcare was the foundation. There were two main goals of the 1994 reform: first to extend coverage to achieve universal healthcare coverage and second to provide comprehensive care to all Costa Ricans. The 1994 reforms included four main components that impacted primary health care service delivery:

1) Responsibility for primary health care service delivery was moved from the MOH and consolidated within the CCSS 

2) Multidisciplinary Integrated Basic Healthcare Teams (EBAIS) were created as the principle provider of primary health care services

3) Every Costa Rican was empaneled to an EBAIS team

4) Continual quality improvement measures were initiated to support system-wide learning and adaptation as well as the ability to proactively adjust to changing population health needs.

Implementation of these reforms began in 1995, with the transfer of all personnel in the MOH who previously participated in direct healthcare provision to the CCSS. This made the CCSS the sole public healthcare provider in the country and allowed Costa Rica to integrate preventive care (previously championed by the MOH) and curative care (previously provided by both the MOH and the CCSS). The MOH became the overseer and strategist of the healthcare system.

EBAIS teams—comprised of a doctor, nurse assistant, community health worker, data clerk, and sometimes a pharmacist—were formed beginning in 1995. By design, members of EBAIS teams work together to serve as the first point of contact with the health care system, capable of providing comprehensive, continuous care. As EBAIS teams were formed, every Costa Rican citizen was geographically empaneled to a specific team. This process required mapping the location of each home in the country before satellite imaging and GIS were developed.

Finally, as a part of creating a new primary healthcare delivery model, a process for quality assurance was developed. At first it was based on a pay-for-performance scheme but it has evolved over the past 20 years to be an internal system without financial incentives. The process relies on a chart-audit process and a public ranking of the quality performance of every Health Area. The data collection and feedback underlies a central effort for continual quality improvement. 

Costa Rica’s reforms have seen remarkable success over the last 25 years. EBAIS teams and clinics were rapidly established. By 2002, over 818 EBAIS clinics had been established and 88% of the Costa Rican population was empaneled to an EBAIS clinic. Today, there are over 1,030 EBAIS clinics and 94% of the population is empaneled to an EBAIS team.

Implementation of practice

What stage is the practice currently in?

Fully implemented and scaled up

Who was/is responsible for the implementation of the practice?

The EBAIS model was developed by a small group of Costa Rican healthcare professionals in the early 1990s. The model was based on previous healthcare programs in the country. Once the reform proposal was fully developed, Costa Rica brought its proposal to the World Bank Group to seek funding. After negotiations, the WBG agreed to finance $22 million dollars. After seeking funding from other sources including the Inter-American Development Bank, Costa Rica was able to raise a total of $123 million dollars.

The president of Costa Rica from 1994-1998 was in support of the reform and appointed a president of the CCSS who would promote the implementation process. The reform survived the presidential transfer of power in 1998 and the reform has continued until this day. 

Impact

Today, EBAIS teams provide care for 80% of Costa Rican’s health needs. The reform has led to increased access to primary healthcare; before the reform, only 25% of the population had access to PHC; by 2006, this had reached 93%. EBAIS teams have also increased the equity of the primary healthcare system. The geographic distribution of clinics in the country improved and the reform invested 30% of its funds on the poorest 20% of the population. Subsequent to these efforts, the potential years of life lost decreased by 48% in the poorest 20% of the population as compared to 39% in the richest 20%.

As part of the primary healthcare surveillance system that was established, deaths from communicable diseases dropped from 65 per 100,000 people in 1990 to 4.2 in 2010. A 2004 demographic study used a regression model to study the impact of the reform on mortality and showed that implementation of the reforms resulted in an 8% reduction in infant mortality and a 2% reduction in adult mortality in the first 9 years of the reform. 

Additional information

For more information on Costa Rica’s primary health care reform, please refer to:

https://www.ariadnelabs.org/wp-content/uploads/sites/2/2017/12/CostaRica-Report-12-19-2017

https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.1319

Contact information

Name:

Hannah Ratcliffe

Organization:

Ariadne Labs

Email:

hratcliffe@ariadnelabs.org

Phone:

Role:

Researcher

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