Abstract
BackgroundThis paper explores the implementation and sustenance of universal health coverage (UHC) in Costa Rica, discussing the development of a social security scheme that covered 5% of the population in 1940, to one that finances and provides comprehensive healthcare to the whole population today. The scheme is financed by mandatory, tri-partite social insurance contributions complemented by tax funding to cover the poor.MethodsThe analysis takes a historical perspective and explores the policy process including the key actors and their relative influence in decision-making. Data were collected using qualitative research instruments, including a review of literature, institutional and other documents, and in-depth interviews with key informants.ResultsKey lessons to be learned are: i) population health was high on the political agenda in Costa Rica, in particular before the 1980s when UHC was enacted and the transfer of hospitals to the social security institution took place. Opposition to UHC could therefore be contained through negotiation and implemented incrementally despite the absence of real consensus among the policy elite; ii) since the 1960s, the social security institution has been responsible for UHC in Costa Rica. This institution enjoys financial and managerial autonomy relative to the general government, which has also facilitated the UHC policy implementation process; iii) UHC was simultaneously constructed on three pillars that reciprocally strengthened each other: increasing population coverage, increasing availability of financial resources based on solidarity financing mechanisms, and increasing service coverage, ultimately offering comprehensive health services and the same benefits to every resident in the country; iv) particularly before the 1980s, the fruits of economic growth were structurally invested in health and other universal social policies, in particular education and sanitation. The social security institution became a flagship of Costa Rica’s national development strategy which reinforced its political importance and contributed to its longer-term sustainability and that of UHC.ConclusionsUHC has been achieved in Costa Rica because it was supported at the highest political level within a favourable socio-economic and political context. Once achieved, UHC became an entitlement for the population and now enjoys broad public support.
Highlights
This paper explores the implementation and sustenance of universal health coverage (UHC) in Costa Rica, discussing the development of a social security scheme that covered 5% of the population in 1940, to one that finances and provides comprehensive healthcare to the whole population today
The Caja Costarricense de seguro social (CCSS) developed from a small institution created for less than 5% of the population into what is called the largest ‘company’ in Central America
The most important lessons observed are: i) population health was high on the political agenda in Costa Rica, in particular before the 1980s when UHC was enacted and the transfer of hospitals to the social security institution took place
Summary
This paper explores the implementation and sustenance of universal health coverage (UHC) in Costa Rica, discussing the development of a social security scheme that covered 5% of the population in 1940, to one that finances and provides comprehensive healthcare to the whole population today. Low- and middle-income countries are explicitly encouraged by the global health community to move towards UHC despite their relatively scarce resources. Within this context it is useful to explore how some of these countries have already moved in that direction. By the end of the century, Costa Rica had evolved into an upper-middle economy, and the CCSS transformed into the single, universal and comprehensive health care financer and provider it is today
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