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close this bookThe Nutrition and Health Transition of Democratic Costa Rica (International Nutrition Foundation for Developing Countries - INFDC, 1995, 228 pages)
close this folder2. Development of the social security institute
View the document(introductory text...)
View the documentBackground
View the documentSocial security in Costa Rica
View the documentThe extension of direct insurance
View the documentExtension of insurance to the family
View the documentThe financial crisis
View the documentThe constitutional amendment
View the documentToward universalization
View the documentDevelopment of human resources
View the documentThe integration
View the documentThe new health care models
View the documentFinal comments

The constitutional amendment

The extensive discussion of the Institute's finances that took place in Congress had important consequences. Two representatives, lawyers Alfonso Carro and Enrique Obregón, played important roles. Alfonso Carro was a member of the Institute's Board of Directors during the Figueres administration and President of the Board during the Orlich administration. Together with the lawyer Enrique Obregón, he was one of the main promoters of universalization of the principles of social security. When the topic was being discussed, they gave their support to those measures that promoted the expansion of social security. At one point, Obregón, suggested that 10% of the national budget should be assigned permanently to finance the expansion.

TABLE 2. Health and Maternity Insurance, 1962-1991

Year

Workers Insured

Families Insured

Total Insured

Total Population

Total Employed

% Employed Covered

% Population Covered

1962

11,279

157,018

268,297

1,367,067

396,060

28

20

1964

126,435

214,362

340,797

1,464,437

419,819

30

23

1966

138,450

397,284

535,734

1,567,230

446,676

31

34

1968

176,148

528,300

704,448

1,664,581

499,374

35

42

1970

202,291

606,373

809,164

1,762,462

528,739

38

46

1972

254,696

764,088

1,018,784

1,867,045

560,114

45

55

1974

308,124

924,372

1,232,496

1,987,895

638,432

52

62

1976

381,727

957,665

1,239,392

2,025,763

664,805

51

61

1978

519,020

1,075,243

1,594,260

2,151,225

719,637

64

74

1982

603,393

1,045,286

1,648,679

2,423,835

835,422

64

68

1986

691,033

1,179,284

2,156,139

2,720,136

957,283

66

81

1990

1,496,268

1,373,127

2,537,423

3,032,394

1,074,205

68

84

1991

1,526,523

1,400,838

2,592,563

3,108,342

1,104,066

67

84

After multiple discussions, at the end of May 1961 his insistence prevailed and the Constitution was amended with Article 177, which advocated the inclusion of all Costa Ricans in the Illness and Maternity Initiative. This amendment gave the Institute 10 years to implement this measure and guaranteed that any budgetary needs would be covered from the national budget. This political decision, which was received with great reservations by the Institute, meant the birth of the true principle of social security, where the benefit is for all the population, going beyond the limited, exclusive, and discriminatory concept that had been applied before, following Bismarck's model.

When Congress approved this decision, only Cuba and Canada had taken steps such as this. Canada followed policies inherited from Great Britain, and Cuba took these measures as part of a new political system that justified a centralized economy. Costa Rica was the country that, based on a democratic ideal, incorporated social security as part of the mechanism of equal access to health care. From then on, a series of gradual modifications took place. The most important one was the opening of the School of Medicine to train the physicians required. A few years later a school for the training of medical technologists was established.

Ever since the extension of coverage in 1960, the shortage of hospital space became gradually more serious, not only for the number of beds required but also because of the need to establish specialized services outside of the metropolitan area that would function in accord within the standards of institutional medicine. This need was met by the inauguration of the Mexico Hospital in 1969. The Institute began the construction of its hospital with the generous support of the Mexican Social Security Institute. This effort represented a strong affirmation of principles as well as a commitment to excellent health care services.

In March 1969, the outpatient services were opened, and in September of thee year the hospital had 600 beds ready to be used. This gave the Social Security Institute the technical basis required to begin the universalization of services. Since rural areas also required hospital beds, a series of agreements was formalized at the beginning of the 1960s in order to provide peripheral hospitals with the infrastructure needed for hospital care, medical visits, medicines, and support services. This contrasted with the very limited services provided to charity patients and created the ethical need to achieve universalization and to erase, as soon as possible, the discriminatory differentials that were difficult for the health personnel working in hospitals to apply and to accept.

In addition, given the increase in expenditures of the rural medical centers, the government had for several years created fixed subsidies for each of them. These subsidies were distributed through the Social Medicine Technical Council under the direction of the Ministry of Health. The proceeds of the Asilo Chapui lottery, administered by the Social Protection Council of San José, were also made available for distribution by the Council and became a very important complementary mechanism of new income for the rural hospitals. In addition there were several specific taxes designated for these, especially a sales tax thee was sent by the Ministry of Finance for the use of the Social Security Council. A study at thee time showed that the government subsidy represented 40% of the budget of the hospitals, the Institute contributed 30%, and the lottery and ocher minor sources made up the difference.