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publicationOctober 23, 2023

How the World Bank's financed Program for Results incentivized pioneering health interventions in Costa Rica

The World Bank

Health professional. Source: World Bank

World Bank

Costa Rica was one of the first countries in the Latin America and Caribbean region to choose the World Bank Program for Results (PforR) financing instrument to support the implementation of the Strategic Agenda for Strengthening Health Insurance by the Costa Rican Social Security Fund (CCSS, for its name in Spanish, Caja Costarricense de Seguro Social).

The PforR’s unique features include using a country’s own institutions and processes and linking disbursement of funds directly to the achievement of specific program results, which helps building capacity within the country, enhances effectiveness and efficiency and leads to achievement of tangible, sustainable program results.

The CCSS is the primary provider of health care in the country. The PforR "Strengthening Universal Health Insurance in Costa Rica" was approved by the World Bank's Board of Executive Directors in 2016, with the aim of improving the availability and quality of the universal health insurance system while boosting the institutional efficiency of the CCSS.

Through the PforR, the CCSS successfully undertook strategic and complex health sector reforms that have had significant impact on quality of care, equity, and efficiency in Costa Rica’s health sector. These reforms encompassed:

  1. The piloting of  integrated health networks.
  2. Reforming the resource allocation formula both for primary health care and hospitals.
  3. Digitalization of the health system via the Single Digital Health Record (EDUS).
  4. Enhanced management of non-communicable diseases.
  5. Reduction of waiting lists for priority procedures by shifting major surgeries from inpatient to outpatient care.

This series of knowledge reports, developed by the World Bank in collaboration with the CCSS, aims to document the drivers of success, how challenges were faced, and crucial lessons learned during the design and implementation of the PforR and its associated transformative reforms. The overarching objective is to provide a practical guide for other countries interested in implementing similar programs.

The series comprises five knowledge briefs:

The first knowledge brief delves into the PforR as a financing instrument, offering insights into the key drivers of its success, how challenges were addressed, and main lessons learned from its design and implementation. The brief provides a roadmap for countries interested in using the same World Bank financing instrument.

The second knowledge brief provides insights on the implementation of ambulatory surgeries by the CCSS. The institution increased the percentage of major outpatient surgeries to more than 43 percent of the major surgeries. This transformation resulted in a significant 60 percent reduction in the waiting period (measured in days) for other major surgeries. Major outpatient surgeries have potential for substantial gains in the health system, contributing to cost reductions, enabling to focus limited resources on more severe cases, helping to reduce waiting list, and allowing patients to recover at home, mitigating the risk of nosocomial infections.

The Costa Rican electronic health record, known as EDUS, is a cornerstone and innovator in guaranteeing the right to universal health coverage and improving the quality, effectiveness, and efficiency of healthcare services in Costa Rica. Remarkably, the implementation of EDUS across all levels of care was accomplished just three years after the initiation of the PforR. The third knowledge brief summarizes the experience of Costa Rica in successfully implementing one of the most comprehensive electronic health records in Latin America.

The fourth knowledge brief provides an overview of the implementation of the Integrated Family Record System, which captures socioeconomic and health information from users of the health system. These data, which is digitized and gradually incorporates geo-referencing information, serves as a key input in the country’s public multisectoral strategy aimed at tackling risk factors and health determinants affecting the population. This information can also be used to generate insights on the concentration of epidemiological profiles and risk maps at the community level to better target preventive measures and facilitate the management of future epidemics and natural disasters, among other benefits.

The fifth knowledge brief summarizes the CCSS’ experience on the use of satisfaction surveys as a tool for improving the delivery of health services to the population. Client satisfaction surveys have been successfully deployed in the country for over five consecutive years, even during the COVID-19 pandemic. Among others, the institutions leverage surveys’ results to develop facility specific improvement plans focused on patients' priorities, and to capture specific insights on indigenous populations’ experience in their interaction with the health system.  

More information about World Bank's work in Costa Rica.

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