The Construction and Institutionalization Process of Health Policy in Costa Rica as a Universal Policy and Its Main Challenges Today

Costa Rica's health policy has been widely recognized for its favorable outcomes at relatively low costs. While the general characteristics and outcome of its universal health care system have been described previously, in-depth analyses of the health policy process are scarce. This study, that forms part of a larger research project, presents the findings of an exploratory public policy analysis focused on the role of the Health Ministry. Using qualitative data collection instruments, the analysis found principal differences between two periods: before the 1990s, when consecutive governments were strongly committed to the pursuit of universal health coverage (UHC); and afterwards, when power resources moved away from the government and Health Ministry to the Caja Costarricense de Seguro Social (CCSS) and the private sector respectively. The power shift caused a chain of effects that complicated the search for financial sustainability of the scheme.The 1990s health system reforms were a turning point in Costa Rica's UHC construction process. Searching for increased efficiency at times of economic hardship, primary health care, until then a Health Ministry's job, was integrated into the CCSS scheme. The process sparked off an implicit boom in private sector activity also related to changes in the political-economic context. The plan to strengthen the Health Ministry's stewardship role did not really succeed and a further series of reform projects got implemented only partially. While the political sustainability of UHC in Costa Rica seems guaranteed by its strong popular support, the findings of this study indicate that its financial sustainability needs concerted action from the side of the government focused, among other things, on improved institutional coordination