Costa Rica: The Challenges of Maintaining Universalism in a Strong State

Abstract

Chapter 6, the final country case-study chapter, focuses on Costa Rica, the quintessential “strong state” in health. Costa Rica distinguished itself from many other Latin American countries by being a leader in terms of both initiatives and outcomes in health and other social domains. Touted as a story of “health without wealth,” it boasts life expectancies and an epidemiological profile more similar to those of advanced welfare states than its regional neighbors. However, it has faced difficulties in the continued financing of its universal system which draws from employer, employee, and government subsidies for the poor. Because of increasing costs associated with chronic illnesses and new medical technologies, the Caja (Costa Rican Social Security agency) has found itself needing to readjust its structure because of budget deficits. The challenge for the Costa Rican health system is maintaining (rather than establishing) universal coverage, and it has drawn on World Bank funds for some of its most important reforms, including the creation of primary health teams and centers (EBAIS) in the mid-1990s. This chapter demonstrates that even strong states in health—with high autonomy and capacity—face challenges, particularly budgetary constraints because of recessions and the changing landscape of diseases and health technology. Harkening to the theoretical framework of the book this chapter demonstrates that even, or perhaps especially, in strong states, with solidary, redistributive health systems, the market can offer some solutions to inefficiencies. The World Bank and other international financial institutions can play helpful advisory and funding roles even in such strong states, given increasing health care costs, extended life expectancies, and the increased prevalence of chronic diseases.

Countries have the ability, even if there is pressure from above, if you have sufficient and conclusive information you can better negotiate … we have to break the technical dependence and defend what belongs to us … but defending does not mean staying the same, sometimes.

— interview with a former Minister of Health, responding to a question about the impact of the World Bank on health reforms in Costa Rica . (Interview #82)