By Dr. Francisco Echeverría
Article 73 of the Political Constitution of the Republic of Costa Rica guarantees health care for Costa Ricans, and administration of this care is the responsibility of the Social Security System, or Caja. In order to finance this expensive undertaking, a system of solidarity was established based on a worker’s gross salary: Eight percent of Caja fees is contributed by the employee, 14 percent by the employer and 0.5 percent by the government. Together with the Health Ministry, this system has been very successful over the years, yielding health indexes at the same level as top countries around the world, including life expectancy of about 80 years. It is a well-thought system with very good and measurable results.
In time, though, the system began experiencing financial difficulties that have today reached a critical point. Expenses outgrew revenue, a classic combination for bankruptcy. To illustrate the situation, it’s worth mentioning some examples:
Income stagnation: Because of its large debt, the government does not pay its respective percentage of fees. Plus, gross salary underreporting means that the percentages of monthly contributions by employers and employees are less.
Increasing expenses: Among fixed costs, a recent substantial increase in administrative costs coupled with a large number of retirees who entered the system are a burden. Variable costs include everything related to medical treatment; the situation worsens when those costs are combined with deficient logistics and planning, as was recently revealed in news reports regarding excessive stockpiles of expired medicines that were disposed of at an enormous cost.
Among the growth of variable expenses, we find my colleagues.
In a difficult financial environment, resources are allocated according to an importance-urgency matrix, and generally, urgent issues take precedence over maintenance, prevention, safety and other important, but not urgent, issues – that is until something collapses, like the bridge over Tárcoles River, which collapsed a few years ago and caused several deaths.
At the Caja, this process has resulted in deteriorating working conditions, and eventually the Health Ministry recommended closing several operating rooms. Much of the Caja hospitals’ equipment is also in a state of disrepair. Because of this, specialists began switching to private medical practice, but weren’t appropriately replaced by new specialists, even though President Laura Chinchilla made the issue a priority during her campaign.
The situation went from bad to worse, until it exploded during the recent anesthesiologists strike. Less than 100 specialists on strike made the system collapse. We must understand that the system is very complicated, like a clock that needs even the smallest parts to work properly as a whole.
Assuming that both striking doctors and government representatives had valid reasons for their actions, and considering that Article 13 of Costa Rica’s Medical Ethics Code states that a physician can refuse to see or treat a patient if conditions are not adequate to provide good service, I still believe the strike was bad for everyone and resembled more of a media show that diverted attention from the fact that the government is to blame for the Caja’s current situation.
It is extremely unfair to ask a patient to pay for inefficient service that isn’t delivered as expected. In the worst-case scenario, a patient could conceivably pay for this inefficiency and conflict with his own life. Morally, I do not accept this and never will.
Regarding physicians, we all have to suffer the consequences of the strike in terms of damage to our reputation. There is no distinction between striking doctors and even specialists who do not work for the Caja, like me. To the general public, this strike enhanced our bad image as moneymakers who are insensitive to patients’ needs, something that is terrible for a physician.
At the end of the day, this ridiculous strike is like a book with a circular plot. In a few months, we will be exactly in the same position as we are now, because the real problem is the Caja’s financial situation, which makes it impossible for the Caja to comply with all of its commitments.
Added to that, the promise to catch up with the thousands of postponed surgeries is a myth. Anesthesiologists play only a partial role in a system that requires surgeons, inpatient facilities, nurses, laundry, etc.
Finally, how can a system of solidarity, where those who earn more compensate for those who earn less (assuming honest salary reporting), and that rests on three contributing pillars – government, employer and employee – survive if one of those pillars fails to contribute to the general welfare of Costa Rican health? At the end of the day, the patient will always pay for the inefficiency of any of the system’s parts. This time it was a physicians’ strike; tomorrow it could be a failure of any of the other components. And we mustn’t forget that the government’s debt jeopardizes life exactly in the same manner as does a physicians’ strike.
Francisco Echeverría, M.D., M.B.A., is a specialist in pediatrics. After working 20 years in the pharmaceutical industry, he is now a professor of human embryology at the Autonomous University of Central America.
