What Impact Do Global Actors Have on National Health Policy Processes in Costa Rica - Coursework Example

What impact do global actors have on National health policy processes in Costa Rica? What impact do global actors have on National health policy processes in Costa Rica Introduction The healthcare processes and system within Costa Rica is rated and deemed as one of the highest quality healthcare in the world, with the population having higher access to medical health at affordable prices. This has ensured higher health levels in the country for years, and has mainly been attributed to strong health insurance system that is equitable and excellent medical providers. Being a middle income country, the strong health care policies in the country that put an emphasis on human development, have mainly followed the principle of equal access to all citizens, whereas the highest performance to the healthcare system has mainly been attributed to the public sector (Unger, De Paepe, Buitrón, & Soors, 2008: 636). Over the years, Costa Rica has though been facing increased external pressure from a number of global actors to open up its healthcare processes and system to privatization. A key global actor has been in this pursuit has been the World Bank, and recently the DR-CAFTA (Dominican Republic – Central America Free Trade Agreement) for which Costa Rica is signatory, and which requires that the country open up its market for regional access and competition (Clark, 2011: 3). This paper analyses the impacts that global actors have on the National policy processes in Costa Rica with specific reference to the World Bank. Background to Costa Rica Healthcare Costa Rica is a small middle income country in Latin American and Caribbean Region with a population of 4,579,000 a gross per capital income of $10,960. The health care expenditures in the country per capita in 2009 was $1,165 with this expenditure representing 10.5% of the gross domestic product (GDP). In 2009, the life expectancy at birth was 77 years for males and 81 years for females, while infant mortality rate was 11 deaths per 1000 live births (World Health Organization, 2012). Costa Rica has one of the highly performing health care system of any middle income country which provides extensive medical service, effective healthcare coverage that is deep and broad, and financial protection for all its population including the poor (Cercone & Jimenez, 2008:185). In 1941, with incoming of a new government, a social health insurance scheme, the Caja Costarricense del Seguro Social (CCSS), that was based on equity and universality was established, the very first one in Latin America. By the year 2006, 88% of the Costa Rican population had health insurance coverage, with 93% of the population having adequate access to primary healthcare services (Section B3, 2011: 84-85). Such high achievements have been possible through a number of Health reforms that have taken place in the country, most importantly, the 1994 health reform that enhanced the essence of universality of health care services to the general population. Recent reform in healthcare services where Costa Rica has opened up the health care insurance more to privatization within the CAFTA region, Costa Rica continues to revamp its health care delivery system and enhancing its CCSS model of healthcare delivery (McIntyre, 2008). Global Actor Actors are those who play a certain role within a given society. Often humans live in social groupings within societies where such groupings are often governed by leaders or collective body which act as the uniting facto. These have more power and influence than the individual members of the social or political group (Damerow, 2009). A global actor in essence is a social structure which has international influence, and power, and is able to act and influence various global activities (Damerow, 2009; Emerson et al, 2011). Power and influence in this sense implies relational power. Rahman (2010:2) indicates that in international affairs, where most global actors seek to exert their influence, power rather than being the “strength of one actor or institution relative to another” it rather represents the power relations between the different actors and the extent to which they constrain each other in their influence. Examples of global Actors include various interstate actors such as Multinational organisations (Rahman, 2010), domestic level actors such as voluntary organizations or churches, individual actors such as celebrities or public officials, Trans-state actors such as United Nations, World Bank, World Health Organization, among others, and regional actors such as the European Union or DR CAFTA (Damerow, 2009). These actors play a wide array of role in influencing policies in various areas through their relational power influence. For instance, European Union used its political power to influence the enactment of the Lisbon treaty in December 2009, which further enhanced the union influence and gave it a base for a “common foreign policy” (Institute for Cultural Diplomacy, 2011; Emerson et al, 2011). As with regard to this study, a prominent global actor that has exerted influence on Costa Rica’s Health policy processes for years is the World Bank which has for years wanted Costa Rica to reform its health system and privatise it more (Unger, et al, 2008:637) Costa Rica’s Health policy/ Health policy process Costa Rica’s health policy system is said to be one of the most successful in the middle income countries of Latin America and the Caribbean region with the strong social security system within this country being a key contributor to the high health levels and political stability within the country. The system, promotes obligatory contribution to health financing, universal coverage, equal access to health care, and high quality health care (Section B3, 2011; McIntyre, 2008). The countries attention to the health of its citizen has ensured higher health indicators similar to those of OECD countries (McIntyre, 2008:4-5). The predominant player in Costa Rica’s health care system is the public sector which has a number of key actors that ensure high level health of the Costa Rican people. These are CCSS which is responsible for providing universal health care insurance to the people of Costa Rica, financial and social health benefits and comprehensive health care tot he people; Ministry of Health which exercises an oversees role in the health sector and monitors performance of key health functions in the country; Costa Rican Institute of Water supply and Sewerage system which ensures efficient supply of clean and healthy water for human consumption and effective waste disposal; and National Insurance Institute (INS) which covers insurance with regard to automobile and occupational accidents. The health care system in Costa Rica in essence is mainly regulated and provided by the public sector. CCSS is the ultimate body responsible for providing universal and equitable health care to the people of Costa Rica through its various hospital and outpatient facilities. It is also responsible for ensuring employment of highly qualified doctors and other health providers (McIntyre, 2008). Having been institute in 1941, various progressive measures have been made overtime to increase the efficiency of CCSS. CCSS extended its coverage to delivery of health services and also developed programs such as the Community Health Programme (Programa de Salud Comunitaria) and Rural Health Programme (Programa de Salud Rural) which ensured that the rural and semi urban areas had access to comprehensive healthcare (Unger et al, 2010; Unger, De Paepe, Buitrón, & Soors, 2008:638). In essence therefore CCSS ensures strong integration between health service provision and health financing thereby avoiding stratification of social insurance. In order to attain its key principle of providing universal health care to its citizens, CCSS has developed a contribution scheme that is both affordable and efficient. The current rates of contribution in health insurance for all workers is 15% of their salaries, whereby the employers contribute 9.25%, the government 0.25%, and the employee 5.5%. For those people who are self-employed, the government covers about 50% of the health insurance. As for the poor, elderly and handicapped, the government pays full health insurance from the tax funds (McIntyre, 2008:4; Unger et al, 2010). The government expenditures on health financing have been rising over the past years from 5% in the 1990s to 10.5% of GDP in 2009 (World Health Organization, 2012; Section B3, 2011: 84-85). Everyone in Costa Rica is expected to have insurance coverage and pay contributions as it is mandatory for all. Through this system of health care provision Costa Rica has been able to achieve near universal health coverage of its citizens, that is 90% (McIntyre, 2008:4; Unger et al, 2010). An analysis into the distribution of healthcare resources shows that the poorer families get the biggest share of CCSS spending. The poorest 20% of the Costa Rican population got 30% of the healthcare spending from CCSS, while the wealthiest 20% received only 11.1% of the CCSS resources. This is mainly because the poorer families benefited from programs such as nutritional programs which the wealthy most likely would not need (Cercone & Jimenez, 2008: 193-194). In essence therefore, the Costa Rica health care system enhances equity through progressive healthcare expenditure. Impacts a global actor can have on health policy As noted above, Costa Rica’s health policy processes are highly regulated and controlled by the public sector. Both the purchaser and provider of health care in the country is CCSS, where it ensures effective health care insurance for all the population, and also ensures that health care provision and facilities are equally available for all the people in the country. This system greatly contradicts the recommendations of the World Bank which recommends the privatisation of the health care services delivery (Unger, et al, 2008; Section B3, 2011: 84-85). With World Bank’s prominent role in international health policies, it has several impacts to Costa Rica’s health care policy processes. These are as elucidated below: Neoliberal health reforms Decentralisation The World Bank is a major and prominent health lender to various of the world’s health system. With these financial supports, the World Bank has often attached various conditionalities for the financial support requiring that countries reform their health systems based on neoliberal economic principles which view the private sectors as more efficient in delivery of services than do the public sectors (Homedes & Ugalde, 2005:83-84). And therefore, based on this principle, World Bank requires reduced government participation in the Health sector, and decentralise key functions of the health sector from CCSS to other private actors in the country. The very essence of Costa Rico’s health care sector is that it is mainly provided by the public sector, where the government plays a crucial role in ensuring efficient health care system. This clearly is contrary to World Bank’s neoliberal principles. With the Costa Rica’s government having taken the biggest role in providing health care for its population, providing high quality healthcare even for these who cannot afford to pay for the healthcare, the government spends a big portion of its GNP on healthcare, and this puts strains on the countries financials and budgets. With healthier populations growing into old age due to the success of the health system, the government have to spend even higher portions of funds to cure more expensive old age degenerative illnesses. With the rising costs of health care, government funding has not been rising at the same level and this provides financial strain in the health system. Other factors such as economics crisis over the past years, and also the recent one has also provided financial strains to the health financing system in Costa Rica. Having to accept financial assistance from a global actor such as the world Bank would require that Costa Rica do major reforms within its health system to fit with World Banks requirements. The difference between Costa Rica’s approach to health care and the reform requirements of the World Bank has been a cause of dissonance between the two for years. For instance, in 1994, Costa Rica rejected World Bank’s recommendations of splitting up the purchaser-provider health policy system and institute a more privatised healthcare system. This resulted in the World Bank withholding $100 million worth of financing funding it was supposed to lend to the countries health system (Unger et al, 2008: 639-642). In this sense, the conditionalities for neo liberal Health care reform grossly impacts the capability of Costa Rica’s chance of getting funding for its health care system. Though Costa Rica funds the system with out of pocket funds, the rising costs of health care is increasingly making this unsustainable, and may make the health care system vulnerable especially in cases of economic shocks or crisis. Privatisation The very essence of World Bank’s health reforms is privatisation of the health sector. The World Bank exerts this conditionality through provision or withholding of needed health care funds. Such conditionality puts Costa Rica at cross roads when it wants to obtaining funds from the global actor. World Bank’s attempts at increasing the private sector’s role in Costa Rica though has had limited success. A notable example is the early 1990’s use of market like cooperatives which provide health care services. In this, cooperatives were created by employees of given health facilities where by they acted as the autonomous legal entities in providing healthcare services within a given geographic region. These cooperatives mainly dealt specialty health care and received capitation payments from CCSS (Gottret, Schieber, & Waters, 2008:217). An evaluation on the success of the cooperatives in Costa Rican health care though shows that the cooperatives have been less efficient than CCSS in health care provision, with it more costly with no evidence of any improvements in the quality of health care (Homedes & Ugalde, 2005:85; Clark, 2002). In addition, it was found that though patient satisfaction was higher due to reduced waiting time for health care, the higher referrals from the Cooperatives to the CCSS’s health care clinics referred to as EBAIS (Equipos Básicos de Atención Integral en Salud), in a bid to reduce the cooperatives costs. This increases costs for CCSS and overall workload, which in turn reduces the overall efficiency of the Costa Rican health system (Homedes & Ugalde, 2005:85). This shows that attempts at privatization have an overall impact of reducing efficiency in health provision within the system. This could also explain why the cooperative idea has not been widely exploited and adopted in Costa Rica, but rather has remained stagnant, even falling with the past two decades, while CCSS roles has continued to register success amid financial strains. There has always been great concern within the Costa Rican public as to what greater exposure of the health care system to the international market, or its privatization would mean for the country. The recent DR CAFTA alliance attests to that with many within Costa Rica opposing the trade agreement which has the potential of impacting health social service provision in the country due to its potential of opening up the health care system to more external competition (Clark, 2011:3; Cordero Sala, 2007). DR CAFTA’s requirements of free trade and market liberalizations of the countries involved imply that it also would be pushing World Banks’ agenda forward. Clark (2011: 3,15) in her recent analysis on the possible impacts of DR CAFTA on Costa Rica’s Health care sector, showed that though in the long term Costa Rica’s health system may tend towards private sector participation in the Health care sector, in the short term, CCSS still had the upper hand. This is because though the private sector may be allowed to sell health insurance policies, the constitution still requires that all these funds be channeled through CCSS. As long as all Costa Ricans are obliged to make health insurance payments to CCSS, then the attractiveness of private insurance alternatives would mainly be determined by how well CCSS is performing in providing healthcare. Conclusion In conclusion, it can be noted that one of the key aspects that has contributed to the high success of Costa Rica’s healthcare policy processes in achieving equity and universal health coverage is mainly attributed to the government’s involvement and commitment to funding the health care in the country. Though this approach and ignorance to World Banks’ conditionality for a privatized sector has been disadvantageous in the sense that it has limited access to external healthcare funding from the World Bank, it has had positive advantages in that, it has enabled universal accessibility to quality healthcare for all people in the country, thereby increasing the country’s human development index. 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