Table 3

Reforms identified for Costa Rica’s PHC model

ReformDescriptionIllustrative quotes
Governance restructuringHealthcare provision was restructured so that all healthcare in the public sector (primary through tertiary) was provided solely through the CCSS rather than both the MOH and CCSS, which streamlined the healthcare system. MOH was responsible for stewardship of the healthcare system.‘Then we proposed an integration of the primary care services that the CCSS had with the Ministry and eliminate duplication. Instead of having Ministry of Health clinic and a CCSS clinic, let's make one (clinic) for the entire community…’
(Former CCSS Director)
Geographic empanelmentThe population was geographically empanelled, meaning each household was assigned to a multidisciplinary team (EBAIS) solely based on their geographic location. Approximately 4000 people were empanelled to each team. This supported the population’s geographic access to PHC.
Administratively, Costa Rica’s health system was divided into seven health regions, which were further divided into health areas. Health areas oversaw EBAIS clinics in communities.
‘…it was a tradition that came from 1972, to have the well-defined health area, with the households identified, and each household with the family health record in the archive, and the rural health worker…took those files and visited house by house, once or twice a year’. (Academic)
Multidisciplinary teams (EBAIS) Multidisciplinary teams were the centre of the PHC model. These teams, known as EBAIS, provided preventative and curative services to their geographically empanelled population.
 Each EBAIS included the following team members, who were trained in community-based medicine (see online supplementary table A in appendix):
Doctor: consulted with patients for PHC delivery
Nurse assistant: conducted preconsults with patients and educated patients about healthy lifestyles
Asistente Técnico en Atención Primaria (ATAP) or Primary Care Technical Assistentmade home visits for preventive care
Registros Estadísticas de Salud (REDES) or Health Statistics Records: managed medical records and patient data
 These teams worked together to provide integrated curative and preventative care. For example, ATAPs provided preventative care through home visits and referred sick patients to doctors for curative care. Nurses played both a curative and preventative role by assisting doctors in clinical visits and educating patients on health conditions and determinants.17
 EBAIS also had ‘support teams’ located at the health area level. The support teams could include a family doctor, nutritionist, social worker, nurse, pharmacist, microbiologist and an orthodontist. Together with the EBAIS team, they were known as the ‘Local Health Team’ (see online supplementary table A in appendix).
‘In the 90's, what was said was: How can we as a country develop a public health strategy with a focus on public health that emphasizes prevention and promotion, and addresses diseases, of course, because you need to attend to what’s urgent, but whose emphasis will be primary care. So this (idea) was consolidated into the EBAIS teams’. (Former CCSS Director)
  • CCSS, Costa Rica Social Security Administration; EBAIS, Equipo Básico de Atención integral en Salud; PHC, primary healthcare.