1. VII Regional Forum Strengthening Health Systems Based on PHC Health Systems Responses Programmatic- and Population- Based Approaches Quito, Ecuador 29-31 October 2007 Ministry of Health Costa Rica

2. Table of Contents  Background of Health Sector Reforms  National Quality Assurance Program  Results  Conclusions

3. Guatemala Honduras El Salvador Nicaragua Costa Rica Panama Total population: 4,501,845 52,000 Km 2

4. History of a Transformation Transforming the Role of the State Development Model Crisis Rethinking of State’s Role Phase II: Expanding Coverage Phase III & IV: Integrating Services & New Models Phase V Steering Role Adjusting Model of Care Programs to expand coverage Universal SS Coverage Epidemiological transition Increase in the cost of care Separation of preventive-curative care Aging population New models of care Integrated Care Health Promotion Breaking up concentrated areas Assessing systems & services Epidemiological Accumulation ‘70s ‘70s‘80s‘90s 1998 …21st Century..... ‘30-’40s Phase I: Beginning of State’s Role Health Secretariat Ministry of Health Social Security

5. CCSS FIGURE 2: LIFE EXPECTANCY AND THE PROBABILITY OF DYING IN THE FIRST YEAR OF LIFE AND BETWEEN THE AGES OF 20 TO 59 COSTA RICA 1912-2002 FIGURE 2: LIFE EXPECTANCY AND THE PROBABILITY OF DYING IN THE FIRST YEAR OF LIFE AND BETWEEN THE AGES OF 20 TO 59 COSTA RICA 1912-2002 Probability of dying (logarithms) Life expectancy (years)

6. Integrated Care Model in Social Security –Universality –Solidarity –Equity –Unity and Efficiency Adjusting Supply –Health Areas and sectors (EBAIS) –Program titled Integrated Health Services for the Public –Outsourcing contracts 88% of population insured 2006 Substantive Functions of Ministry of Health Governance (2006) –Health Policy Bureau –Marketing the health promotion strategy and the culture of nonexclusion –Health Surveillance –Strategic Health Planning –Modularization of health financing –Harmonization of health service delivery –Health Regulations –Assessment of impact of actions in health –Scientific research Health Sector Reform 1994-2007 …

7. 4,000 Inhabitants Population Sector GENERAL PRACTITIONER NURSING AUXILIARY PRIMARY CARE TECHNICIAN MEDICAL RECORDS TECHNICIAN INTEGRATED HEALTH CARE: HOME VISIT CARE IN FACILITIES AND THE COMMUNITY 40,000-60,000 Inhabitants SUPPORT TEAM EBAIS Fields: Medical specialties Nursing Social Work Laboratory Dentistry Diagnostic Imaging Health Records

10. Historical Evolution Health Insurance Coverage, Costa Rica 1944-2005 %

11. Indicator196019701984199420002005 Coverage of services 15.462.6100 Contribution-based coverage 15.462.671.186.281.787.6 National population by type of coverage (%) Directly insured 7.611.719.21918.719.6 Voluntary4.556.63.4 Pension Recipients 88.66.3 Insured's Family7.735.144.64541.544.4 State & Family Account 71112.2 Other type0.10.42.821.11.7 Uninsured84.652.828.91412.512.4 Source: Office of the Actuary, CCSS & Census Bureau Health Insurance Coverage by Insurance Modality, Costa Rica, 1960,1970,1984,1994, 2000 & 2005

12. Life Expectancy at Birth Source: State of the Nation and State of the RegionWomen81.03Men76.5 2005 Source: INEC

13. Average: 9.78 per 1,000 births in 2006 Infant Mortality Rate for Quintiles of Cantons Grouped according to Social Lag Index for the Quadrenniums 1994-1997, 1998-2001 & 2003-2006 Costa Rica 16.35 13.85 12.21 12.65 11.68 11.08 10.12 9.64 9.48 8.95 05101520 Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 Rates per 1,000 births 2003-2006 98-2001 94-97

14. Strategies  Standardization of integrated care for people in Level I and care for priority health problems of public health interest  Evaluation of coverage in participating population areas  Evaluation of quality of care based on meeting basic quality standards  Household Survey

15. Total Coverage and Quality Coverage Level I – Health Care Programs CCSS, 2005 0.0 20.0 40.0 60.0 80.0 100.0 120.0 < 1 yr. old 1 to 6 yrs. Adolescents Prenatal Postpartum Diabetics Hypertensive Elderly Cytology % Total Coverage % Quality Coverage

16. Ministry of Health: Quality Assurance with a Systemic Approach  Qualification: Structure - basic level  Accreditation: Structure - Processes - Outcomes  Evaluation of Health Systems and Services: Structure, Process, and Outcomes in the EEP service network  Tracer Events: Infant/Maternal Mortality Infant/Maternal Mortality Other health problems of public health interest (hypertension, diabetes mellitus, screening for cervical cancer) Other health problems of public health interest (hypertension, diabetes mellitus, screening for cervical cancer) Care Programs for the public (prenatal check-ups, integrated care for children under 2 years) Care Programs for the public (prenatal check-ups, integrated care for children under 2 years)

17. Structure Outcomes Processes Certification of Facilities Accreditation of Facilities Quality Assurance Evaluation of Systems in EEP Public&PrivatePublic&Private

18. Assessment of Level I integrated Care, EBAIS Headquarters Costa Rica, 2000-2006 CATEGORY 20002006 TOTAL7480 I. Physical Plant7473 II. Material Resources8794 III. Human Resources6167 IV. Standards & Procedures6686 Boys & Girls7190 Adolescents4580 Prenatal6994 Postpartum & Post-abortionnd83 Women aged 20-496974 Elderly6478 V. Programming & Management7762 VI. Supplies8395 VII. Education for Health8189 VIII. Social Participation5761 Source: Office of Health Services and Regional Offices, Ministry of Health

19. Results of the Standards and Procedures Assessment for the Integrated Care Program for the Public, 1st Level of Care; Costa Rica 2000-2004 0102030405060708090100 Boys & Girls Adolescents Prenatal Postpartum and Post-abortion Integrated care for women aged 20 to 59 Elderly % 20002001 20022003 2004

20. Evaluation of Level I Integrated Care Household Survey, Costa Rica, 2000-2005 1900 1000 1555 1300 2120 1917 45 20 39 19 35 33 500 900 1300 1700 2100 2500 2000200120022003*20042005 Year Nº 15 25 35 45 55 * Only 2nd Semester Source: Regional Offices and Office of Health Services, Ministry of Health, 2006 Graph 1. Assessment of Level I Care at the Homes Visited as part of the Survey on Family Health Needs, Costa Rica 2000-2005

21. Household Survey: Assessment of Satisfaction of Basic Needs by Country of Birth, Costa Rica 2005 Type of Deficiency Non-MigrantsMigrants % (N) Total # of Homes Visited 100 (1,729) 100 (188) No educational support for children under 15 5.2 1 5.2 1 6.1 1 6.1 1 Have worked less than 12 years 0.9 2 0.9 2 0.0 2 0.0 2 Do not have water in home 8.613.3 Do not have waste disposal service 7.224.5 Deficient housing 14.534.6 High Economic Dependency 33.653.7 Overcrowding17.637.8 Homes with one or more than one basic need unmet 50.778.7 1 Of the total # of homes with children under 15: 908 and 115 2 Of the total # of homes with children under 12: 885 and 117 Source: Regional Offices and Office of Health Services, Ministry of Health, 2006

22. Insurance Average 88% Graph 3. Assessment of Level I Integrated Care Household Survey: Distribution of type of insurance by Satisfaction of Basic Needs, Costa Rica 2005 25.6 16.9 22.0 15.9 7.7 13.0 58.5 75.4 65.0 01020304050607080 Unmet Met Total Percentage UninsuredState InsuredAll other types of insurance Source: Regional Offices and Office of Health Services, Ministry of Health, 2006

23. Results of Household Survey Utilization and Access to Level I Health Services in Populations Living in Poverty, Household Survey, Ministry of Health, Costa Rica, 2006 Variable% Pregnant women with prenatal care 95 Women >49 yrs. with Pap test in 2 years 78 Check up of boys and girls < 6 years 76 Complete vaccination series in children < 1 95 Medical monitoring of hypertension and diabetes mellitus 93 Source: DSS, Regional Offices, Ministry of Health The poorest and even the uninsured population gained access to Level I health services in 2006

24. Household Survey: Perception of Illness and Need for Medical Visit in the Past Year, Costa Rica 2005 Non-MigrantsMigrants No.%No.% Total Households Surveyed 1,729100.0188 100. 0 Households seeking care at public clinic 1,13165.412667.0 Care actually provided 1,06894.411692.1 Source: Regional Offices and Office of Health Services, Ministry of Health, 2006

25. 14% required a medical visit at EBAIS in the past 15 days 10% of requests for care from EBAIS are rejected: The main reasons were: “ There wasn’t enough space and they were told to return the next day.” (44%) “ Were not insured, so they were charged.” (41%) Source: Ministry of Health, Household Survey, 2006 Assessment of Level I Comprehensive Care. Household Survey: Quality of Morbidity Care, Costa Rica 2005 79.9% 11.5% 8.7% Good Fair Poor

26. Graph 4. Household Survey on Family Health Needs: Opinions on the quality of health care received by group of migrants, Costa Rica 2005 5.7% 76.6% 17.7% Good Fair Poor

27. Hypertension Tracer: Screening Clinical file of level I and II facilities: Individuals 20 years and older with hypertension value recorded in the last year. Costa Rica, 2005. Range: 65-70% fulfillment Files Reviewed: 1073 Source: Interinstitutional Commission of Hypertension Tracer, Ministry of Health. 95% 5% YesNo

28. Table 22. Hypertension drugs available at health facilities, by level of care. Costa Rica, 2004. Total3 to 45 %No.% % Level of care 18 32 14 10 16 14 8 16 - Hypertension Drugs Available * 10056 44 Third 10050 Second 100 - First Source: Interinstitutional Commission of HT Tracer. Regional Offices, Ministry of Health. Established Range: 100%. * By level of care

29. File: Hypertensive individuals reaching optimal treatment goal (<140/<90), by level of care. Costa Rica, 2005. TotalNoYes Number%Level of care 568 131 263 174 Reached optimal treatment goal 54 46 National total 3565Third 7030Second 4258First Established Range: 40%

30. Care Coverage for Costa Rican and Immigrant Women Costa Rica, 2000 Coverage, by type of care CR Immigrant Insurance 78 48 Prevalence of birth control 80 70 Childbirth % % Care during CCSS Hospital delivery 96 84 Care during home birth 2 15 Professional care during delivery (physician or nurse) 96 91 Has had a PAP test at least once 79 75 Medical visit CCSS Medical visit in the past year 71 79 Private medical visit in the past year 22 8 Immunization of children ages 1 to 4 yrs. Basic system 9580 Source: CCEP. National Survey on Sexual and Reproductive Health, 1999

31. Health Care Challenges MAIS Forum, 2005  Control of risk factors beyond the scope of medical care and environmental health determinants  Emphasis on health promotion and disease prevention  Long-term care  Care for complex problems  Sexual & reproductive health care  Mental health care  Communication & education skills  Pain management, and death and grief counseling services  Interdisciplinary approach & communication between the different levels of complexity  Knowledge of bioethics  Persistence of a biology-based, individualistic model of care.  Weak teamwork  Normative approach to planning centered on productivity and not on health needs  Incongruity between education of HR for health and the requirements of the model  Lack of coordination between levels and institutions  Reactive environmental protective action  Lack of clarity in defining the functions of health sector institutions  Activistic and utilitarian concept of social participation in health DEMANDCURRENT SUPPLY Source: DSS, Ministry of Health

32. CONCLUSIONS  The integrated care model was applied on a geographical-population basis, thus incorporating the concepts of public health and conceiving Level I as the gateway to the health system.  The service package tends to unify the entire insured population, since it includes first-level and highly specialized services for all.  The public system de-commercializes the system to a high degree.

33. CHALLENGE  Financial sustainability and preserving a universal, collective health system that ensures the delivery of equitable quality services

34. Osa Peninsula, channels of Río Sierpe, Costa Rica