Costa Rica was one of the first countries in the Latin America and Caribbean region to choose the World Bank Program for Results (PforR) financing instrument to support the implementation of the Strategic Agenda for Strengthening Health Insurance by the Costa Rican Social Security Fund (CCSS, for its name in Spanish, Caja Costarricense de Seguro Social).
The PforR¡¯s unique features include using a country¡¯s own institutions and processes and linking disbursement of funds directly to the achievement of specific program results, which helps building capacity within the country, enhances effectiveness and efficiency and leads to achievement of tangible, sustainable program results.
The CCSS is the primary provider of health care in the country. The PforR "" was approved by the World Bank's Board of Executive Directors in 2016, with the aim of improving the availability and quality of the universal health insurance system while boosting the institutional efficiency of the CCSS.
Through the PforR, the CCSS successfully undertook strategic and complex health sector reforms that have had significant impact on quality of care, equity, and efficiency in Costa Rica¡¯s health sector. These reforms encompassed:
- The piloting of integrated health networks.
- Reforming the resource allocation formula both for primary health care and hospitals.
- Digitalization of the health system via the Single Digital Health Record (EDUS).
- Enhanced management of non-communicable diseases.
- Reduction of waiting lists for priority procedures by shifting major surgeries from inpatient to outpatient care.
This series of knowledge reports, developed by the World Bank in collaboration with the CCSS, aims to document the drivers of success, how challenges were faced, and crucial lessons learned during the design and implementation of the PforR and its associated transformative reforms. The overarching objective is to provide a practical guide for other countries interested in implementing similar programs.
The series comprises five knowledge briefs:
The first knowledge brief delves into the PforR as a financing instrument, how challenges were addressed, and main lessons learned from its design and implementation. The brief provides a roadmap for countries interested in using the same World Bank financing instrument.
The . The institution increased the percentage of major outpatient surgeries to more than 43 percent of the major surgeries. This transformation resulted in a significant 60 percent reduction in the waiting period (measured in days) for other major surgeries. Major outpatient surgeries have potential for substantial gains in the health system, contributing to cost reductions, enabling to focus limited resources on more severe cases, helping to reduce waiting list, and allowing patients to recover at home, mitigating the risk of nosocomial infections.
The Costa Rican electronic health record, known as EDUS, is a cornerstone and innovator in guaranteeing the right to universal health coverage and improving the quality, effectiveness, and efficiency of healthcare services in Costa Rica. Remarkably, the implementation of EDUS across all levels of care was accomplished just three years after the initiation of the PforR. The third knowledge brief in Latin America.
The fourth knowledge brief , which captures socioeconomic and health information from users of the health system. These data, which is digitized and gradually incorporates geo-referencing information, serves as a key input in the country¡¯s public multisectoral strategy aimed at tackling risk factors and health determinants affecting the population. This information can also be used to generate insights on the concentration of epidemiological profiles and risk maps at the community level to better target preventive measures and facilitate the management of future epidemics and natural disasters, among other benefits.
The fifth knowledge brief . Client satisfaction surveys have been successfully deployed in the country for over five consecutive years, even during the COVID-19 pandemic. Among others, the institutions leverage surveys¡¯ results to develop facility specific improvement plans focused on patients' priorities, and to capture specific insights on indigenous populations¡¯ experience in their interaction with the health system.
The and how the CCSS is moving from using historical budgets to a new resource allocation model focused on strategic purchasing. This model was developed with the help of global experts and includes the introduction of prospective budget allocation elements at hospital level and a capitation model for primary care. Initiated under the Program for Results (PxR), this resource allocation model aims to align resources with population health needs and service delivery, while incentivizing the achievement of specific goals such as increasing productivity, accessibility and quality of services. Pilot programs are underway in a selected region (Huetar Norte Region), with plans for phased national implementation based on results. Key challenges addressed include data availability and resistance to change, and future objectives focus on the allocation of standardized basic rates in primary care, the continued improvement of risk adjustment, and improved performance indicators.
The authoring team of these briefs was composed by Laura Di Giorgio (Senior Economist), Micaela Mussini (Health Specialist), Ana Luc¨ªa Rosado Valenzuela (Health Specialist Consultant) and Ashley Sheffel (Heath Specialist Consultant).
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