Cover Image
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

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


1970

1986

1991

Total Consultations

340,025

7,673,049

7,031,818

Ministry of Health

1,160,396

753,160

374,039

Costa Rican Social Security Institute

2,279,629

6,919,889

6,657,779

Consultations Per Inhabitant

195

303

226

Location:


Hospital

23

31

31


Ministry of Health

19

3

3


Costa Rican Social Security

4

28

28


Beds

7,000

6,950

6,825

External Clinic Consultations:


Costa Rican Social Security Institute

-

157

274

Ministry of Health:


Rural Assistance Centers

17

5

4


Health Centers

62

85

90


Education and Nutrition Centers

147

560

534


Complete Infant Care Centers

-

37

58


Health Stations

-

344

414


Dental School Clinics

44

65

97

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.