pHILIp musgrOve the Five cs of universal Health care
When coverage is incomplete,
it is usually because of the difficulty
of reaching remote geographic
areas or minority groups.
for-profit or non-profit, that were created to take advantage of this promised funding.
This gave those insurers a strong incentive to advertise for and recruit customers. The push was not only
toward wider coverage but toward replacing traditional
supply-side funding—that is, financing hospitals and
clinics out of public budgets independently of the number of people served or the services performed—with
money that would follow the patient and reward services actually provided.
This was the most radical reform effort in the hemisphere for several reasons. It originally started from a situation of greater poverty and lower initial coverage than
in any of the other countries and with a more complicated mixture of funders and providers. It has not quite
achieved universal coverage yet, but already 85 percent
of the population is enrolled in one of the two regimes.
Access to health facilities and to basic sanitation services
has also improved, and there is some evidence of better health outcomes. Since 2006, the insurance reform
has also provoked reforms to other parts of the system,
particularly the public hospitals.
small and simple is Beautiful
Costa Rica is a relatively small and homogeneous country with only two important public agen- cies involved in health. The Caja Costarricense de Seguro Social (the Caja or CCSS), was a sin- gle social security service for the whole country, and the ministry of health similarly was the only
agency with nationwide responsibility.
The country’s chief reform, enacted in 1941, adopted
what in retrospect seems the obvious solution of merg-
ing the clinical or individual health service functions of
the ministry into the Caja. This prevented competition
between the two agencies and separated
the medical care provided to individuals
(previously provided by both institutions)
from the population-based public health
functions that remained with the minis-
try. Private insurance exists but occupies
only a small part of the system. Universal
coverage in Costa Rica basically means that
everyone is free to use the facilities belong-
ing to or financed by the Caja without the
link to employment that usually defines a
social security system. This means that the Caja is also
partly financed by general revenues and therefore does
not become underfinanced when clients not employed
in the formal economy and who do not pay social secu-
rity taxes use its medical services.
In every other country mentioned, some public funds pay private doctors and other providers, usually by fee-for-service. Cuba is an exception since its government does not allow the private practice of medicine. Neither does it allow private health insurance: the ministry of health assumes
complete responsibility for the population’s health care.
The government also pays for all medical training and
has trained so many doctors and nurses that it has sent
many of them abroad temporarily to provide medical
care or to train local providers, usually in poorer countries. The use of health personnel as an element of foreign policy does not appear to have come at the cost of
inadequate coverage at home or lack of funding. But
more important than the amount of resources devoted
to health is the insistence on equity and on delivering effective care to prevent infant, child and maternal deaths.