Costa Rican Health Care

A Maturing Comprehensive System

Greg Connolly  12/8/02

Global Health Council

 

A history of commitment to health and social reform has yielded for Costa Rica the best health outcomes of any country in Latin America.  These outcomes are the result of a well-developed publicly funded comprehensive health care system built on the principals of universal coverage and equity.  While the fundamentals of this system were becoming entrenched, several predictable challenges arose.  Costa Rica is confronting those problems with outside aid in a period of reform, which began in 1994.  Now, the World Bank has decided to support Costa Rica with its Second Health Sector Strengthening and Modernization Project, which will build off of existing initiatives and trends toward improvement of the health care system.  While Costa Rica occupies a tight niche as a small country of middle wealth and high social solidarity, the development of its health care system still holds lessons for some of the most complex nations of the world. 

 

The Costa Rican Health Care System

 

Framed by Nicaragua to the north, Panama to the south, and the Pacific Ocean and Caribbean Sea, the small country of Costa Rica (area 51,100 sq. km)[i] stands out from its neighbors with a deep history of commitment to social reform and a thriving economy.  With a population of only 3,810,179, 59% of which live in urban areas,[ii] the nation is not only small, but also it has been able to hold social solidarity.  This solidarity arose from the nation’s agricultural history in which the upper and lower classes were dependent upon each other.[iii]  In the past decade the ratio between the income of the upper 20% and the lower 20% held stable.[iv]  The democratic government composed of executive, legislative, and judicial branches, and a four-year rotating presidency, has also shown remarkable stability.  Sustained economic growth has built a GDP per capita of USD$8,500 in 2001 with the primary industries being services, industry, and agriculture.  The development model, “Based on promoting exports and tourism and modernizing state institutions in the 1990’s,”[v] has landed Costa Rica in 41st position in a 1999 development survey of 162 of the world’s wealthiest countries.[vi] 

 

A primary contributor to Costa Rica’s success has been its focus on the well being of its people.  For Costa Rica, health and education are priorities for the success of their nation.  The World Bank highlights this priority:

 

“The Government of Costa Rica sees the health sector as an essential determinant of the country’s economic and social development, giving it a priority that is manifested in sustained high levels of spending and active policy attention at the highest levels.”[vii]

 

The attention to health has brought this middle-wealth country’s health indicators in line with those of OECD countries.[viii]  In 2001 the average life expectancy at birth in Costa Rica was 76.6 years.[ix]  In 2000, 97% of births were attended by skilled professionals, 89% of the pregnant women were given prenatal care, and 93% of children under 1 had health insurance.[x]  From 1990 to 2000 life expectancy increased by 0.8 years, the fertility rate dropped, and the population grew due to an influx of Nicaraguan immigrants.[xi]  In 2000 there were 16 physicians and 3.2 nurses per 10,000 population.[xii]  In 1999 there were 12,000 people living with HIV/AIDS, giving an adult prevalence rate of 0.54%.[xiii]  However, Costa is the only Central American country to provide antiretroviral treatment to all patients through its social security system.[xiv]  The leading causes of death were cardiovascular disease and neoplasms, which is comparable to many OECD countries.[xv]  Spending on health care has increased steadily over recent years, and in 2000 it composed 9% of the national GDP.[xvi]

 

These outcomes are the result of one of the world’s most successful “universal” health care systems.  “Universality” in the Costa Rican system means that 100% of the population is given equal comprehensive public health insurance with equal access to services.  The success of the system is built upon a history of stalwart determination by the national government to ensure high quality health care for its entire people.  In 1941 social security legislation was passed in Costa Rica, establishing the Costa Rican Bureau of Social Security (CCSS).  This legislation set the provisions for medical insurance that through the gradual expansion of the CCSS would eventually become a universal health insurance system.  Costa Rica wrote a new constitution in 1949.  The most significant component of the Constitution was the abolishment of a national army.  This opened funding and allowed more attention to go toward social programs, such as education and health.  Gradual health sector improvement ensued until 1973, when the health sector was given a dramatic boost.  The General Health Law of 1973 placed all health treatment services, including all health care areas and hospitals, under the control of the national social security program.  In the next decade public health care coverage extended to reach 78% of the population in 1982.  By this point, all those employed, regardless of their socioeconomic status, received health care.[xvii]  The Ministry of Health (MOH), which was established in 1907[xviii], at this time was responsible for public health programs such as prevention and promotion, and provided primary care for the uninsured.  The MOH and the CCSS, working together to provide national health care, continued to refine their roles.  In the early 1990’s the MOH turned over primary health care provision responsibilities to the CCSS.[xix]  The MOH has since been in charge of all public health programs, and the CCSS has been in charge of all health provision programs.

 

The public sector is the predominant health care sector in Costa Rica.  It is composed of the following branches:

 

“The Costa Rican Social Security Fund (CCSS), which provides health insurance, including comprehensive health care and financial and social benefits; the National Insurance Institute (INS), which covers occupational and automobile accidents; the Costa Rican Institute of Water Supply and Sewerage Systems (AyA), which regulates the supply of water for human consumption and wastewater disposal; and the Ministry of Health (MOH), which monitors the performance of essential public health functions and exercises the steering role in the sector.” [xx]

 

The CCSS provides universal health care insurance to employed Costa Ricans.  Workers contribute 15% of their salaries to health insurance, broken down in this manor: 9.25% from the employers, 0.25% from the total national wages, and 5.5% from actual worker wages.[xxi]  Universal coverage means that even those who are unemployed are able to obtain public funding for all health services, including prescription drugs.  By law, the CCSS must cover 100% of the population, and it achieves this with the following strategy: 

 

“The CCSS is aware that only 80% of the population is insured either through the compulsory or voluntary system, or as pensioners or their dependents.  Of the remaining 20%, 10% are insured through state subsidies, given that this population group is under the poverty line.  The other 10% can request public services when necessary and pay for them directly.”[xxii]

 

Not only is the insurance coverage universal, but also the access to comprehensive health care is nearly equal throughout the country:

 

“A 1998 study showed that…access was practically the same in rural and urban areas (average distances to the nearest facility of 1.28 km and 1.10 km, respectively).”[xxiii]

 

A large reason why the quality of coverage and access to care are so strong is that the CCSS employs a large number of mid-level health workers:

 

“[There is] a relatively modest supply of doctors, which apparently serves the country’s needs quite well because of extensive use of auxiliary nurses and health assistants; these personnel work in the rural health posts, health centers, and hospitals.”[xxiv]

 

Mid-level health workers with little training are very effective at extending access to rural areas.  The relatively small amount of training necessary makes it easier for people from villages to become medically certified and contribute to the health care provision in their villages.  The usage of mid-level health workers also reduces the overall cost of the health care system because the government doesn’t have to pay for expensive medical educations, and it doesn’t have to pay high doctors’ salaries.  South Africa is looking to use more mid-level health workers for just this reason.

 

The CCSS has a very innovative way of organizing its health care professionals.  It provides five comprehensive care programs for children, adolescents, women, adults, and the elderly.[xxv]  It operates through 93 health areas and 783 Basic Comprehensive Health Care Teams (EBAIS).[xxvi]  Each EBAIS is composed of a physician, a nurse, and one or more primary care technical assistants (ATAP’s).  Currently each EBAIS serves an average of 3,500 people.[xxvii]  Teamwork is an overarching theme in the health care system.  The branches of the centralized public health sector must work together, the states must cooperate with national mandates, and the health care providers work in teams.  Working in teams allows each EBAIS to develop comraderie and refine its skills as a unit to provide better health care than if the members were working in inconsistent groups.  These teams serve set groups of people.  In the Costa Rican system, a person is assigned to providers and a medical center based on place of residence.[xxviii]  Lack of choice may be perceived as a problem, but consistency gives each patient the best care he can receive in a centralized publicly funded system.  Consistency also nurtures Costa Rica’s highly developed information collection system.  There is a very extensive amount of information available in the public health sector.  However, the private sector lacks an efficient information collection system.  This is a significant problem because of the increasing importance of the private sector in health care.[xxix]

 

Thirty percent of the population used the private sector in 2001, and 24% of doctors worked at least partly in the private sector.[xxx]  The CCSS does not cover the costs of private sector usage.  Mixed Medicine, in which a patient will pay for a private consultation with the physician of his choice, and the CCSS will pay for the diagnostic services and drugs, is playing an increasing role.[xxxi]  Another new trend is the usage of Corporate Medical Officers.  In this type of program a company will hire a private physician to care for its workers and their families, and the CCSS pays for diagnostic and drug services.[xxxii]  A more direct form of Public-Private Partnership (PPP) arose in 1998 when the CCSS began purchasing services from private providers called health cooperatives.  “In 2001, four cooperatives and a foundation at the University of Costa Rica were already contracted, serving a total population of 400,000.”[xxxiii]  11% of the population now gets coverage from PPP’s.[xxxiv]  Incorporating the private sector has alleviated some of the strain on the public system.  The private sector does not threaten the public sector because people are happy with the public insurance they already pay for, the quality of public health care is very high, and publicly employed providers are well compensated.[xxxv]  A major problem that is arising with the incorporation of the private sector is the difficulty of regulating it.  It has been suggested that:

 

“There are opportunities for the CCSS to use its purchasing power to require minimum performance as it contracts more with private providers.”[xxxvi]

 

Strengthening the CCSS’s central power will make it more effective.  In a country where interests are do not deviate far from general consensus, centralizing power is the most effective way to guide social programs to achieve equity and public satisfaction and monitor outcomes. The CCSS has wielded its power throughout its existence to effect change.  The CCSS uses its central purchasing power to maximize cost-effectiveness of drug purchases by making mass orders to international pharmaceutical companies for all the nation’s pharmaceutical needs. Another example of how the CCSS has been able to affect a positive change is the recent implementation of management contracts. 

 

In 2001, all health areas signed management contracts, which set outcome-based goals for performance to be evaluated at the end of each year.[xxxvii]  This is a significant step toward giving health sector administration more of a business-like approach.  Hospital and clinic directors are now getting managerial education.[xxxviii]  This will hopefully increase efficiency in medical facilities.  Management contracts are the primary new tool to guide the reallocation of public funds on a performance-based system, where case mix, adjusted production, and quality outcomes will determine hospital revenues.[xxxix]  This gives incentives to hospitals and providers to be more efficient and have better patient outcomes.  The result is that finally, half of the accountability for health sector performance is now taken off of the CCSS and put onto the hospitals and clinics.[xl]  The evaluation of management contracts will be aided by a Diagnostic Related Groups (DRG) system, which is set up in Costa Rica but has not yet been used.[xli]  The DRG system is a way of monitoring the services rendered by each hospital or clinic monthly.  It is a helpful guide, but it only gives quantitative measures.  Therefore qualitative evaluation will have to be made separately when evaluating each hospital’s annual performance.  There will need to be a large amount of new support for the CCSS to successfully monitor this program and link pay to performance.[xlii] 

 

In parallel, the MOH has recently developed a regulation program for the accreditation of hospitals based on quality assurance.  The program is currently a pilot project, which requires all maternity hospitals to adhere to standards set by the MOH in order to earn accreditation.[xliii]  However, “The ministry’s ability to enforce sector regulation is weak,”[xliv] and will need support to make this program effective on a national scale.

 

The Ministry of Health has recently maintained a low profile.  With the transfer of many of its programs to the CCSS in the 1990’s, the MOH lost power.  However, throughout the history of the Costa Rican health care system, the Ministry of Health’s public health programs have been crucial to the success of the system.  Milton Roemer praises the MOH’s prevention programs:

 

“The benefits of prevention were dramatically demonstrated.  Their strength and effectiveness probably contributed to the harmonious relationships that the MOH developed later with the social security program.”[xlv]

 

Indeed, the MOH’s prevention and promotion programs have contributed greatly to Costa Rica’s overall health outcomes.   The following two departments give examples of what the MOH contributes:

 

“Sanitary controls for and registration of drugs, food, and hazardous toxic substances are the responsibility of the Department of Drugs and Narcotics Controls and Registries of the MOH.  Health regulation and surveillance, which includes the monitoring of air and soil quality, housing, chemical safety, and hazardous waste are the responsibility of the Environmental Sanitation Division of the MOH.”[xlvi]

 

There are several other programs that contribute to Costa Rica’s health sector success.  By 1995 the National Institute of Aqueducts and Sewers (AyA), had provided potable drinking water to 99.6% of the population, and had given 95.7% of the population a sewerage system.  Electricity was available to 93% of the population at that time.[xlvii]  The Costa Rican Demographic Association does extensive work in sex education and family planning.[xlviii]  Roemer states, “Health-related research, to produce new knowledge in fields of special importance, is exceptionally well-developed in Costa Rica.”[xlix]

 

The specialization of duties created by dividing the MOH and the CCSS and their collaboration has lead to a very successful health care system.  Milton Roemer says, “According to conventional measurements of health status, the results [of the Costa Rican health care system] have been phenomenal.”[l]  However, nothing makes a more decisive statement about the success of a health care system than the satisfaction levels of its users.  A 2000 SUGESS survey found that 88% of health system users reported receiving proper medical treatment and 81% said the physicians educated them properly.[li]  And a national survey in 2000 showed that over 70% of health system users were satisfied with their care.[lii]

 

Reform

 

The Costa Rican health care system has matured through several waves of challenge and reform.  Despite its impressive health outcomes, Costa Rica is now in a period of reform intended to refine its successful programs, and improve efficiency by building off of trends that have been developing for years.  A period of reform starting in 1994 was successful, and now the World Bank will provide an extra surge to finish implementing positive reforms. 

 

The reform period from 1994-2001 was funded by the Inter-American Development Bank (USD$4.3 million), and the World Bank (USD$22 million).  Technical support was also given by the Pan-American Health Organization/World Health Organization.[liii]  This reform had a four part agenda:

 

“A steering role for the Ministry of Health and its strengthening; institutional strengthening of the CCSS; a new system for the reallocation of financial resources; and adaptation of the health care model.”[liv]

 

The new World Bank reform project is entitled, “Costa Rica – Second Health Sector Strengthening and Modernization Project.”  This project will allocate nearly USD$33 million to: “Improve health system performance and financial sustainability by supporting the ongoing policy changes in the health sector in Costa Rica.”[lv]  The Costa Rican government’s reform priorities are to: “Develop high levels of regulatory capacity and to implement the most important regulations during the next five years.”[lvi] 

 

Many of the problems with the health care system can be better addressed by first strengthening the centralized power of the MOH and the CCSS.  PAHO states:

 

“Steering role functions [in the MOH] need to be further strengthened, and it is necessary to improve the performance of certain essential public health functions, the management of services [by the CCSS], the quality of care, and equity in the allocation of resources.”[lvii] 

 

Once the MOH and the CCSS have been strengthened, then the CCSS will be better enabled to fulfill its responsibility of facilitating the reform projects.   A major objective is to improve the financial state of the health care system by enacting efficiencies and reallocating funds. 

 

We have already reviewed the reform mechanisms for reallocating funds; namely, using management contracts to create performance-based allocation of funds.  Another movement to save money is to reduce the amount of inpatient care by transferring more patients to ambulatory care.  Inpatient care is far more expensive than ambulatory care.  But ambulatory care requires higher quality health service initially, and better mechanisms for providing home care.  The World Bank makes this statement about increasing ambulatory care:

 

“In 1999, fewer than 5 percent of all hospital discharges were resolved in an ambulatory setting.  With minor investments in training, equipment and infrastructure (remodeling), the CCSS could increase ambulatory interventions to nearly 20 percent of all discharges.  Benefits would include cost savings of more than USD$12 million per year, improved quality, and greater patient satisfaction.”[lviii]

 

Another area where financial improvements can be made is in purchasing pharmaceuticals.  “Pharmaceuticals represent 12% of CCSS health expenditure (nearly 1% of the GDP).”[lix]  There needs to be improved monitoring of drug usage through improved communication between health centers and the central purchasing power of the CCSS, so that the correct amounts and types of drugs are purchased. 

 

The need for better communication calls for an improvement in health care information systems.  For reasons referred to above:

 

“Implementation of an integrated [information] management system for health care providers, hospitals and health areas is a continuing obstacle to improved efficiency.”[lx]

 

Better access to information will be needed to monitor health outcomes, which is especially important to the new performance-based funding allocation system.  The natural counterpart to improving communication is improving technology.  In the past ten years technology has made astronomical advances.  However:

 

“The CCSS has not built a new hospital in the past 30 years, and during the 1990’s investment [in hospital infrastructure] was reduced to less than 3 percent of total expenditure.”[lxi]

 

More money will clearly have to be invested into hospitals and technology if Costa Rica is to achieve the high potential for health care that its excellent system has set it up for.  While Costa Rica has impressive outcomes for its region and its economy, it still lags behind the best systems in the world in terms of performance.  But it may work its way up in the pattern of gradual improvement that it has traditionally followed. 

 

A major problem with health care access is that there are long waiting lines for specialty care such as orthopedics, surgery, and gynecology.  PAHO reports:

 

“[At the start of 2001 the waiting list for surgical hospitalization numbered nearly 14,000 patients][lxii]…75% of hospitals have one or more specialties with…waiting lists longer than three months.”[lxiii]

 

Another area where access can be improved is in rural areas.  Although Costa Rica does an excellent job of extending services to all, there is still room for improvement toward equity.[lxiv]  As the demographics change, approaches toward equity will have to follow suit.  There is an increasing elderly population, which will benefit from establishing better home care and hospice care mechanisms.[lxv]  Likewise, the leading causes of death have changed in Costa Rica, and the MOH needs to adjust its prevention and promotion programs to address non-communicable diseases and healthy lifestyles.[lxvi] 

 

Medical education also needs to adjust to the changes of the times.  In particular the medical education curriculum needs to better address the most advanced technologies, pharmaceutical advances, and the new primary health care model.  At the same time, continuing medical education needs to be enforced and the same topics need to be taught to keep the current physicians up to date.[lxvii]

 

These reforms are being made to Costa Rica’s strong comprehensive health care system to help it achieve its potential for reaching and sustaining goals of universality, quality, and affordability. 

 

Implications

 

One of the World Bank’s statements of purpose for funding the second health sector reform in Costa Rica is:

 

“Provision of assistance to expand knowledge of international experiences in similar topics, emphasizing and facilitating the dissemination of the Costa Rican experience to other countries.”[lxviii]

 

Costa Rica’s health care system will serve as an example to other countries.  There are very few countries that match Costa Rica’s profile of small size, small population, social and political solidarity, and gradually growing middle-wealth economy.  But it was not these factors that led to Costa Rica’s excellent health care system.  It was how Costa Rica used these factors that has aligned it for success.  When one looks at Costa Rica in the Latin American context, the nation’s achievements become very impressive.  The factors listed above did not come with the land, but were arrived at through social development.  It becomes apparent that steadfast commitment to social reform with priorities on education and health may lead a nation to social success.

 

Costa Rica can be looked at as a pilot project for Latin America.  This is analogous to looking at the health care system in one state of India as compared to the entire nation.  When segmented down to a manageable region, a centralized health care system works best if one agrees with the Costa Rican model.  Centralization allows for decisive management, and power to effect the changes necessary to building a successful health care system.  However, when dealing with a larger region, the South African and Canadian systems point to centralization within states, and a decentralized national approach under the control of a central authority. 

 

There are several components of the Costa Rican health care system, which should be of special notice to India.  Primarily, management contracts are an excellent way to share accountability, promote the monitoring of information and health outcomes, promote improved quality of care through incentives, and reduce costs by leading to more efficiency.  Mid-level health workers are very valuable for extending care to underserved regions and for reducing overall medical costs.  Costa Rica’s use of Public-Private Partnerships may carry some lessons about how to better incorporate India’s 80% private sector into a national health care system.  And Costa Rica’s ability to harness and utilize external aid could be a good example to India, which will rely heavily on external funding to alleviate its problems with HIV/AIDS, and to build its national health care system. 


 

Works Cited

 

Bossert, Thomas, PhD.  “Phone Interview – December 5, 2002.”  Harvard School of Public Health.

 

Clark, Mary A.  “Health Sector Reform in Costa Rica: Reinforcing a Public System.” Tulane University.  Nov. 1, 2002.

 

“Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/

 

IHCAI Foundation. “Costa Rican Health Care System Profile.” http://www.ihcai.org/Health%20System%20of%20Costa%20Rica_Learn%20Spanish%20in%20tropics%20.htm

 

Infoplease Atlas. “Map of Costa Rica.” http://www.infoplease.com/atlas/country/costarica.html

 

Pan American Health Organization – Country Profile: Costa Rica.  http://www.paho.org/English/SHA/prflCOR.htm

 

Politicas Nacionales De Salud.  “Procedimiento Para Incluir o Modificar Politicas Nacionales De Salud.” http://www.netsalud.sa.cr/ms/ministe/politicas/proce3.htm

 

“Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. 

 

Roemer, Milton.  National Health Systems of the World – Volume I.  Oxford University Press.  New York, NY: 1991.

 

UNAIDS. “National Response Brief – Costa Rica.” http://www.unaids.org/nationalresponse/result.asp

 

 

 



 

[ii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 1.

[iii] Roemer, Milton.  National Health Systems of the World – Volume I.  Oxford University Press.  New York, NY: 1991.

[iv] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 4.

[v] Pan American Health Organization – Country Profile: Costa Rica.  http://www.paho.org/English/SHA/prflCOR.htm.  Pg. 3.

[vi] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 1.

[vii] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 5.

[viii] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 1.

[ix] Pan American Health Organization – Country Profile: Costa Rica.  http://www.paho.org/English/SHA/prflCOR.htm.  Pg. 1.

[x] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 2.

[xi] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 2.

[xii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 7.

[xiii] UNAIDS. “National Response Brief – Costa Rica.”  http://www.unaids.org/nationalresponse/result.asp

[xiv] UNAIDS. “National Response Brief – Costa Rica.”  http://www.unaids.org/nationalresponse/result.asp

[xv] Pan American Health Organization – Country Profile: Costa Rica.  http://www.paho.org/English/SHA/prflCOR.htm.  Pg. 4.

[xvi] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 2.

 

[xvii] Roemer, Milton.  National Health Systems of the World – Volume I.  Oxford University Press.  New York, NY: 1991.

[xviii] IHCAI Foundation. “Costa Rican Health Care System Profile.” http://www.ihcai.org/Health%20System%20of%20Costa%20Rica_Learn%20Spanish%20in%20tropics%20.htm.

[xix] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 1.

[xx] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 5.

[xxi] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 2.

[xxii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 6.

[xxiii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 24.

[xxiv] Roemer, Milton.  National Health Systems of the World – Volume I.  Oxford University Press.  New York, NY: 1991.

[xxv] Pan American Health Organization – Country Profile: Costa Rica.  http://www.paho.org/English/SHA/prflCOR.htm.  Pg. 12.

[xxvi] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 15.

[xxvii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 6.

[xxviii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 26.

[xxix] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 3.

[xxx] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 6.

[xxxi] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 20.

[xxxii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 21.

[xxxiii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 6.

[xxxiv] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 2.

[xxxv] Bossert, Thomas, PhD.  “Phone Interview – December 5, 2002.”  Harvard School of Public Health.

[xxxvi] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 4.

[xxxvii] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 2.

 

[xxxviii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 21.

[xxxix] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/. Pg. 5.

[xl] Bossert, Thomas, PhD.  “Phone Interview – December 5, 2002.”  Harvard School of Public Health.

[xli] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 5.

[xlii] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 2.

[xliii] Pan American Health Organization – Country Profile: Costa Rica.  http://www.paho.org/English/SHA/prflCOR.htm.  Pg. 13

[xliv] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 3.

[xlv] Roemer, Milton.  National Health Systems of the World – Volume I.  Oxford University Press.  New York, NY: 1991.

[xlvi] Pan American Health Organization – Country Profile: Costa Rica.  http://www.paho.org/English/SHA/prflCOR.htm.  Pg. 13.

[xlvii] Pan American Health Organization – Country Profile: Costa Rica.  http://www.paho.org/English/SHA/prflCOR.htm.   Pg. 3.

[xlviii] Roemer, Milton.  National Health Systems of the World – Volume I.  Oxford University Press.  New York, NY: 1991.

[xlix] Roemer, Milton.  National Health Systems of the World – Volume I.  Oxford University Press.  New York, NY: 1991.

[l] Roemer, Milton.  National Health Systems of the World – Volume I.  Oxford University Press.  New York, NY: 1991. Pg. 420

[li] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg.27.

[lii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 17.

[liii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 2.

[liv] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 2.

[lv] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 6.

[lvi] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 6.

[lvii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 2.

[lviii] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 4.

[lix] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 4.

[lx] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/.  Pg. 4.

[lxi] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/. Pg. 4.

[lxii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 6.

[lxiii] “Profile of the Health Services System of Costa Rica.”  PAHO.  May 27, 2002. Pg. 26.

[lxiv] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/. Pg. 4.

[lxv] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/. Pg. 4.

[lxvi] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/. Pg. 5.

[lxvii] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/. Pg. 4.

[lxviii] “Costa Rica – Second Health Sector Strengthening and Modernization Project.” World Bank.  2001.  http://www-wds.worldbank.org/. Pg. 7.