San José, Costa Rica, since 1956

Costa Rica's public health system in critical condition

Costa Rica’s public health system is in critical condition, on the verge of collapsing from a potentially terminal form of financial illness. Its condition requires immediate attention in the form of continual auditing, effective funding and active citizen involvement if the 62-year-old state-run system is to survive, experts warn.

As of February 2010, the Social Security System, known as the Caja, has accrued an $82 million deficit, which could ultimately place at risk the quality of health-care coverage for the 1.4 million people currently enrolled in the system. The Caja’s annual budget totals $1.8 billion.

In addition to budget shortcomings, an internal audit made public March 6 also revealed that the Caja owes $46 million in overdue payments to service providers and medical equipment suppliers, a dangerous debt that could paralyze the entire public health-care network should creditors decide to stop doing business with the Caja.

The Caja’s financial woes have worsened an already troubled public health system. On March 14, the Public Health Ministry ordered the gradual closing of all 15 operating rooms at the San Juan de Dios Hospital in San José (TT, March 18). Authorities closed the operating rooms after finding broken pipes, rusted lamps, ceiling leaks and other problems at the facilities that could have compromised patient safety.

Patients are waiting for the hospital to perform a backlog of 14,000 surgical operations, most of them orthopedic in nature. Patients have temporarily been diverted to other clinics and hospitals, and further delays in patient care are likely.

To some observers, these and other problems are warning signs that the country’s health-care system could actually go broke if the government fails to take immediate action to correct it. Ironically, even the central government owes the Caja money, to the tune of $220 million.

“For many years now, the Social Security System has worked under tight budgets,” said Amaral Sequeira, secretary general of the Union of Medical Science Professionals. “Unfortunately, the Caja has been forced to reduce its resources, including doctors, drugs and even working hours. We could say the Caja works at 70 percent of its total capacity.”

However, money is not the only cause of the Caja’s current crisis. Social changes during the past 15 years have also put pressure on the system and the Caja hasn’t kept apace with the change.

Costa Rica’s aging population has a higher life expectancy today than it did just two decades ago. The Human Development Index, published yearly by the United Nations, ranks Costa Rica’s life expectancy at 79.1 years, 15 years more than the same figure in the early 1990s.

One consequence is increasing demand for health services related to treating chronic illness and other health-related problems, including diabetes and high blood pressure, among others.

“The population has been growing at steady rates, so we are more people living for more years,” said former Caja Executive Director Guido Miranda. “Such phenomena should have been taken into consideration years ago, but that didn’t happen.”

According to research conducted by Miranda, 30 years from now, one-third of the population will be over age 65.

The Caja offers several options for medical coverage. Salaried workers pay slightly more than nine percent of their monthly gross income, while employers pay almost 27 percent of the same salary.

If a household income depends on a single worker, then the entire family receives insurance. Contract workers are also free to enroll, paying only a monthly flat fee that varies according to the worker’s occupation. The government foots the bill for coverage of students and people living in extreme poverty.

These options comply with the “universal” nature of Costa Rica’s health system. As with any state-run system, loopholes exist that create the potential for abuse.

“It’s not uncommon to find cases where wealthy people enroll in the Caja for a short period of time and then receive expensive treatments,” explained Luis Villalobos, researcher for the School of Public Health at the University of Costa Rica. “Once these people receive the medical attention required, they drop off the system.”

Higher immigration rates have also tested the Caja’s capabilities. However, despite the common belief that foreign workers somehow “drain” resources from the health-care system through free medical attention without being enrolled, usually employers are the ones who fail to comply with payments, not immigrants, Villalobos said.

“I would also include an increase of violence as one of the challenges Caja officials face,” Villalobos said. “Violent crime means expensive treatment for the victims and increased pressure on the system as a whole.”

Those who have been closely involved in managing the Caja in recent years agree that public policies are partially responsible for the system’s financial misfortune.

“It all may be part of a privatization crusade,” said former Caja Executive Director Alberto Cañas, “It’s no secret that private practices would benefit if Costa Rica’s Social Security System goes broke. It’s time to hold former [Caja] directors accountable for the damage they have caused and imprison some of them.”

Bringing the Caja to a full recovery requires civil society to become actively involved in the fate of the institution, and transparency from officials who manage it, experts say. It also requires a better understanding of the new paradigms emerging in modern times.

“We are not used to strongly protesting against these situations. People don’t go any further than sending a complaint letter to the newspapers and that’s it. Workers need to acknowledge how much they need the Caja,” said Sequeira.

“If Caja executives would start listening to what members of civil society have to say in order to understand what today’s reality looks like, then the Social Security System would be safe,” said Villalobos.

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