Abstract

PIP: The recent history of Costa Rica's health system is reviewed, emphasizing the health-related effects of the economic crisis of the 1980s. This economic crisis has stopped and in some instances reversed the marked health improvements Costa Rica realized during the decade of the 1970s. The effects of the economic crisis emerge in 4 areas: deterioration in health status, as poverty contributed to higher disease rates; reductions in the government's ability to maintain public health and medical services; increased reliance on foreign aid to finance the health system; and growing national debate over the role of the state in health care. The result of the economic crisis was a reduction in health services and a questioning of the Costa Rican health model. This occurred following the implementation of an expensive health infrastructure and at a time when people most needed health services. During the 1941-70 period, domestic initiative can account for much of the expansion of Costa Rica's social security system, but also at this time international agencies such as the US Agency for International Development (USAID) and the Inter-American Development began to assist in the expansion of the health system. In 1971 a plan was initiated to create a nationalized health system. By 1980 the success of the health sector reorganization was evident in the statistics: marked improvements in life expectancy, infant mortality, and infectious disease mortality had surpassed the goals set by the Pan American Health Organization (PAHO) and the Ministry of Health. Costa Rica's success was a vindication of both policy goals and funding priorities, for it has been "proved" that primary health care was capable of improving health indices, particularly where the agencies had the active and conscientious support of the national government. By 1977, foreign contracts for aid had expired, and the Ministry declared that the rural health program would be supported totally by the government. The Minister of Health continued in 1982 to champion self-sufficiency despite a changed economic climate, but by early 1984 Costa Rica had to abandon its plan to wean the health sector from outside aid. In 1982 the health sector became the center of a nationwide debate. Representatives of the large agricultural export sector, who usually support free-market solutions to economic problems, lobbied for "reprivatization" of medical care. Those committed to expansion of the welfare state argued from the other extreme. The government offered concessions to both groups. The debate did end in 1986, most likely because of the overall easing of the economic crisis. The government needs to maintain state control over the health system while not exceeding its austerity budget and not reducing health services.