The Costa Rican health system: low cost, high value.

In 2001 the World Health Organization ranked the small Central American nation of Costa Rica 36th out of 191 countries for health system performance. Experts hail this as the result of health care reforms which changed the structure of the Costa Rican system and dramatically improved primary health care (PHC). Costa Rica, which has a population of 3.8 million, famously abolished its army in 1947, which means that it can, at least in theory, spend on the social sector what other countries spend on arms and armed forces. The process of reform began nearly 40 years ago when it was decided that the health ministry should assume the role of steward rather than provider — formulating policy coordinating the services, and informing the public. The Costa Rican Social Security Institute (CCSS) was put in charge of financing and providing services to the population. The CCSS made a push towards universal health care coverage, replacing the previous system which only encompassed the working population. In 1970 47% of the total population was insured, today that figure is 89%. In 1996 the need to improve service and lower costs by strengthening the PHC system was recognized. Health spending had risen to almost 10% of gross domestic product (GDP) but without a corresponding rise in the volume and quality of services. The aim was to bring essential services closer to the population and to increase the capacity of district-level clinics. This was where the real process of reform began.