Table 5

Strategies for sustaining Costa Rica’s PHC model over time

StrategiesDescriptionIllustrative quotes
Autonomy of CCSSSince the CCSS is an autonomous organisation with its own financing system, it has insulated PHC delivery from politics and allowed the PHC model to sustain through the changing priorities of political leaders.‘It has continuity. And even when another government comes in, this government doesn’t have all of the power. Why? Because here (CCSS) there are seven (on the board of directors)… there are four people who are not with the government, so… here there’s an equilibrium, let’s say of interests, of forces’. (Health Area administrator)
Compelling vision for PHC modelThe vision of the PHC model, to provide comprehensive preventative and curative services to all, was understood across stakeholders. This clear message helped form a new identity for PHC, ultimately generating widespread public support for the PHC model that has sustained over time.‘Primary health care began to have a little of its own identity. They began to see that primary level of care could be something really interesting, really useful’. (CCSS stakeholder)
Use of data to generate political willData were used to convince government leaders to continue the PHC model. Ongoing data collection and research ultimately demonstrated improved health outcomes. The CCSS used this evidence to advocate for the PHC model through political turnover.‘In 1998 what happened? Some studies began to come out, some that I did, others that others did, that began to show hard data that this was working, and that was what prevented this from being cut… with the government that entered the presidency in 1998’. (Academic)
Preservice training for EBAIS doctorsIntegrating community-based medicine into the medical school curriculum enabled sustainment of the model to the next generation of medical students. Additionally, a mandatory year of service is completed by each newly graduated medical student before any specialty training is pursued. This year is spent providing primary care in a rural and underserved area of the country, engraining primary care principles and practice into each Costa Rican physician.‘One (education block) is community medicine, so the student internists come here and they have to go out (into the community) with the ATAPs and see what they do and see what the doctors do’. (Health Area administrator)
  • CCSS, Costa Rica Social Security Administration; EBAIS, Equipo Básico de Atención integral en Salud; PHC, primary healthcare.