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Changing health-care delivery organizations in Costa Rica: an inter-institutional approach
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Changing health-care delivery organizations in Costa Rica: an inter-institutional approach
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CHANGING HEALTH-CARE DELIVERY ORGANIZATIONS IN COSTA RICA: AN INTER-INSTITUTIONAL APPROACH by German Retana A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (Public Admin^istra-tion) August 1994 Copyright 1994 German Retana UMI Number: DP31373 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. DJssertalion Püb^lsWing UMI DP31373 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106 - 1346 UNIVERSITY OF SOUTHERN CAUFORNIA THE GRADUATE SCHOOL UNIVERSITY PARK LOS ANGELES, CAUFORNIA 90089 This dissertation, written by GERMAN RETANA under the direction of h.iJS. Dissertation Committee, and approved by all its members, has been presented to and accepted by The Graduate School, in partial fulfillment of re quirements for the degree of DOCTOR OF PHILOSOPHY ' • « ^ 1 Dean of Graduate Studies Da te ... .'î .? A ? ..I.? . ? . ft. D IS S E l^ T IO N COMMITTEE //r /a li • • • #V • • • T Chairperson ... 11 To all the men and women who dedicate their lives to improving the health of the disadvantaged. To my humble parents, who barely knew how to read but who inspired in me a quest for knowledge. To Olga Martha, Olga Melissa, Olga Natalia, and German Fernando who turned this learning process into a family project. Ill ACKNOWLEDGEMENTS The United Nations has recognized health care as human right. Converting this basic right into a reality requires the efforts of dedicated men and women working together to eliminate the barriers to equity and social justice. It is these people whom I wish to thank, especially all my friends at the Pan-American Health Organization, with whom I have shared this effort to link the fields of health care and management in concrete practical ways. I want to personally thank Miguel Segovia, José Maria Paganini, José Maria Marin and Diego Victoria, for initially sparking my interest in this topic and for their example of personal dedication to such noble causes as universal health care, democratization and the transformation of national health systems. I am deeply grateful to Leslie Hunter, whose tireless and unconditional collaboration was a source of inspiration to me. I could never have completed this study without her sensitivity, her solidarity and her team spirit. I also want to thank the Institute Centroamericano de Administracion de Empresas, INCAE, which has supported my professional development. The Inter-American Foundation granted me a scholarship to study at the U.S.C. At INCAE I have been fortunate to have enjoyed the encouragement and support of many colleagues. I am grateful to them all, but especially to Marc Lindenberg, Robert Mullins, Damaris Cordero, Francisco Hidalgo, Ernesto Ayala, Danilo Gutiérrez, Francisco Gutiérrez, Rocio Valenciano, Emilia Serrano, and Nobelty Sanchez. Finally, I was privileged to have had such exemplary professors at U.S.C. The enthusiastic, meticulous and constructive guidance of Dr. Gerald E. Caiden has caused me to reflect upon my relationship with my own students at INCAE. Sharing this personal and professional experience with him has been a joy. I am also grateful for the valuable suggestions of Drs. Robert E. Tranquada, Bruce H. Gross, and Herbert E. Alexander, who were kind enough to provide their input in this attempt to make a contribution to a more effective and meaningful public administration in Costa Rica. German Retana IV TABLE OF CONTENTS Page DEDICATION...................................... ii ACKNOWLEDGEMENTS.................................. iii LIST OF ABBREVIATIONS............................ vii LIST OF TABLES................................... viii LIST OF FIGURES.................................... ix Chapter , . INTRODUCTION........................................ 1 Overview of the Problem Focus, Scope and Purpose of the Study Research Methodology Constraints of the Study Organization of the Study HEALTH-CARE DELIVERY SYSTEMS............ 22 Determining Factors in the Organizational Modality Organizational Models of National Health Systems Problems and Challenges Common to Health-Care Organizations Social, Political and Economic Situation and Health Organizational Problems of Health Systems 3. SILOS: BACKGROUND AND CONTEXT...................... 74 Primary Care: A Global Strategy Local Health Systems (SILOS): An Operational Tactic V Systems Approach and Local Health Systems Spheres of Influence of the National Health System and the Local Health Systems Values and Social Objectives Implicit in the 4. SILOS: CHARACTERISTICS AND OPERATIONAL CONDITIONS........................................ 108 Reorganization of the Central Level Decentralization and Déconcentration Social Participation Development of Intersectoral Integration Reorganization of Financing Mechanisms Development of a New Model of Care Integration of Prevention and Control Programs Strengthening Administrative and Management Skills Training of the Work Force in the Health Sector Research and Local Health Systems 5. HISTORY OF HEALTH-CARE DELIVERY IN COSTA RICA..... 155 First Stage: Basic Health and Welfare Second Stage: Public Health and Institutional Development Third Stage: Social Insurance and Institutional Development Fourth Stage: National Health Plan and System 6. DEVELOPMENT OF THE NATIONAL HEALTH PLAN^AND SYSTEM.. 197 Division of the Country into Regions Levels of Care Transfer of Hospitals to the CCSS Universalization of Social Insurance Law on Health and Reorganization of the Ministry Rural Health and Community Health Programs Creation of the Health Sector Integration of Health-Care Services 7. STRATEGY OF TRANSITION TO SILOS IN COSTA RICA...... 262 Need to Change Health-Care Delivery Organizations Available Strategies for Change The Implementation of the SILOS in Costa Rica Émergence and Evolution of the SILOS VI 8. ANALYSIS OF THE STRATEGY OF IMPLEMENTATION......... 306 Parameters of Success and Failure Evaluation and Assessment of the Change Strategy Impact of the SILOS Implementation Strategy on the Transformation of the Health System 9. CONCLUSIONS AND IMPLICATIONS...................... 361 SELECTED BIBLIOGRAPHY.................................. 402 -vi-r- LIST OF ABBREVIATIONS CACM Central American Common Market CCSS Caja Costarricense de Seguro Social [Costa Rican Social Security Bureau] CEN Nutritional Education Centers CHP Community Health Program CINAI Nutritional Education and Infant Development Centers CTB Community Technical Councils ECLA Economic Commission for Latin America GDP Gross Domestic Product ICCA National Sewage and Aqueduct Institute INS National Insurance Institute LSM Local Strategic Management MHO Ministry of Health PAHO Pan American Health Organization PIES Integrated Health Teams Program PUMA Mobile Assistance Units Program RHP Rural Health Program SILOS Sistemas Locales de Salud (Local Health Systems) SNAA National Sewage and Aqueduct Service UNICEF United Nations Children’s Fund WHO World Health Organization Vlll LIST OF TABLES Table Page 1. Life Expectancy at Birth, Costa Rica............... 17 2. Coverage of the Rural Health Program............... 216 3. Coverage of the Community Health Program.......... 217 4. Expenditures of the Health Sector by Institution, Costa Rica 1987-1991 ........................... 290 5. Effective Expenditures of Health Institutions...... 329 6. New Cases of 15 Diseases Required by Law to be Reported in Costa Rica......................... 342 IV LIST OF FIGURES Figure Page 1. Chief Factors that Affect Health Indicators........ 5 2. Costa Rica: Principal Structural Problems of the Health Sector..................................... 7 3. Costa Rica: Problems in Functioning of the Health Sector............................................. 8 4. Natural History of Health and Disease in Humans.... 33 5. Social Systems at the Local Level................... 91 6. Local Health System................................. 92 7. Components of the Standard of Living................ 97 8. Strategic Orientations for PAHO 1991-1994 .......... 140 9. Regionalization of Health Care Programs, Costa Rica.202 10. Pyramid of the Levels of Health Care............... 203 11. Sectoral Organization, Costa Rica, 1990............ 223 12. Structure of Differentiation and Integration of Health-Care Management by Administrative Levels. 228 13. National Health System............................. 249 14. Sub-systems of the National Health System......... 249 15. Principal Causes of Death in Costa Rica 1970-1991.. 268 16. Sub-systems of the National Health System......... 294 17. Ministry of Health, Division of Regions by Local Health Systems.................................. 295 INTRODUCTION CHANGING HEALTH-CARE DELIVERY ORGANIZATIONS IN COSTA RICA AN INTER-INSTITUTIONAL APPROACH Health is supposed to be a human right, but the exercise of this right is dependent upon many complex factors. One of them is the model of health-care service delivery chosen by Ipublic-sector institutions. Services can be organized into national health systems that may change in response to external or internal demands. Some changes are profound in that they modify the strategic orientation and composition of the system. The subject of this study is the transformation of national health systems through the establishment of Local Health Systems (known by their Spanish acronym, SILOS, or Sistemas Locales de Salud), defined as follows: In addition to being a critical component of the strategy of change in the health sector, SILOS are basic political-administrative units in which a set of resources from distinct sectors are combined in order to lead to the improvement of the health of the population in a given region. SILOS also imply a modification of traditional approaches to care, emphasizing health promotion, the structuring of he a l.thy_commun it ie . s . , contr.ol oI th.e. environment, and the integration of programs with the family and the community as the principal focal points. In 1988, the Latin American ministers of health requested the technical cooperation of the Pan American Healt Organization (PAHO) to implement SILOS in their countries Since that time, each country has tried to advance in this new I process of transformation of their health-care institutions and systems in accordance with their national realities, possibilities and priorities. In doing so, they have experienced the complexity of the process and the need to learn to conduct it feasibly in order to have an impact on the health conditions of their populations. This study attempts to contribute to the learning process by analyzing the experience of Costa Rica, a country known for its achievements of health levels comparable to those of advanced industrialized countries and for its significant progress in the implementation of the SILOS. Basic information about the history of the Costa Rican health system is presented in chapter 5. 1.1 Overview of the Problem The two main agencies that comprise the Costa Rican health system are the Ministry of Health MHO) and the Costa Rican Social Security Bureau (Caja Costarricense de Seguro Social— CCSS). Other agencies and organizations also participate in this system, which, as in the case of the two organizations just mentioned, had also developed separately. Upon implementing the SILOS ^ these agencies must partially modify their policies, approaches and work methods so that they can formulate joint programs at the local, district and regional levels.^ These work plans must respond to the health conditions of the local population. Moreover, due to the importance of the Ministry of Health and the CCSS, they have signed agreements for the integration of programs, physical plants in the different regions and human and logistical resources. Within this integration, the institutions preserve their identity and legal autonomy. The problem that will be studied is how to conduct a process of inter-institutional change within national health systems. The basic premise of the study is that in this transformation, factors such as political, economic and social conditions, individual and collective attitudes, organizational culture, leadership, mutual experiences and perceptions, and the convergence of common interests and objectives, intervene simultaneously. The transformation has multiple origins and its feasibility is not dependent upon the fact that each institution or agency changes, but that they do so in a coordinated manner. They have to learn how to do this transformation as they move forward in the process, as there have been no other experiences of this nature and magnitude in these countries. Additionally, the process is occurring ------------------------- — — 4 simultaneously in various countries on the Latin American continent. Thus, the key issues in this analysis are (a) whether the 'nature of health-care institutions is determined by factors external to them, (b) whether the PAHO member countries share a common reality in their health-care services that warrants an exchange of experiences with regard to the implementation of a strategy such as SILOS with the appropriate adaptations, and (c) whether the ten conditions identified by the ministers of health for the functioning of the SILOS should occur simultaneously or whether there is a sequence in their implementation that makes the transformation of national health systems more feasible. 1.2 Focus, Scope and Purpose of the Study The focus of the study consists in analyzing the strategies employed by the two key organizations or agencies of the government health sector to implement the SILOS and their ihter-agency integration agreements. In 1988 the PAHO "identified ten conditions necessary for the functioning of the SILOS and this study analyzes the manner in which each of them was implemented in Costa Rica since that year. As Figure 1 illustrates, health indicators are influenced oy at least seven factors. The study attempts to identify the oehavior or historical evolution of the government's health- services system. --------------------------------------------------------------------------H Health status is a product of social, political and economic conditions, and as such, any study of it is necessarily very complex. None of the factors shown in Figure 1 alone can be considered to be determinant, because all are interrelated. Figure 1 Chief Factors that Affect Health Indicators in a Population ECONOMIC CONDITIONS (family, country) INDIVIDUAL BEHAVIOR (habitats, customs, examples)______ HEREDITARY EDUCATIONAL LEVEL OF THE POPULATION PHYSICAL CONDITIONS HEALTH INDICATORS COMMUNITY BEHAVIOR (obedience, cooperation, collective) ADEQUATE GOVERNMENT HEALTH-CARE SERVICES AND PROGRAMS Source: Juan Jaramillo, Salud y Seguridad Social (San José, Costa Rica: 'Edit, de la Universidad de Costa Rica, 1993), 33. Although the study examines external factors, its emphasis is on the organizational component, the evaluation of the institutions up to the point where a national system was formalized and, since 1988, local health systems. The purposes of the study are to: (a) add to existing knowledge' by identifying factors that should be taken into consideration in leading inter-agency change processes, (b) confirm whether there is congruence among the ten conditions for the functioning of the SILOS and the evolution of health care institutions in Costa Rica, and (c) point out characteristics peculiar to health-care agencies that require a particular management of any administrative reform within and between them. The study was conducted at a point in time characterized by structural and functional problems within the health sector that are analyzed in subsequent chapters but which are summarized in figures 2 (structural) and 3 (functional). 1.3 Research Methodology Given the problem, focus and purposes described, the study includes a conceptual analysis on (a) the determining factors of the organizational model of services of a given country and (b) the theoretical bases and conditions for the functioning of the SILOS. To comprehend the context in which the model of the national health-care system functions and will be transformed by means of the SILOS, the evolution of health care services in Costa Rica from the nineteenth century up to 1992 is described, placing greater emphasis on the period 1970-1992 when the national system was formed and the SILOS approach was incorporated into it. o 0) CO <0 0) X o CO E 0) c l 3 — 0> <0 o 3 k. CO 75 Q. Ô c CO o £ CO GO o Ü 09 il e e I N -j ■ I k s ^ l i f l c . il # • o V « s II « z 2 c 0 - o il a 1 5 o » i | c : If e * . . " O 2 . e # II a . w O «9 8 O 0) CO (0 0) X 0> o CO I <D .?5 CO E 0) jD o CO o £ CO CO o Ü * ■ C O I s a t X a . « O o a • o n a > * • a w C O o * •o U J - o I L e u e a To comprehend the context in which the model of the lational health-care system functions and will be transformed cy means of the SILOS, the evolution of health care services in Costa Rica from the nineteenth century up to 1992 is jiescribed, placing greater emphasis on the period 1970-1992 when the national system was formed and the SILOS approach was incorporated into it. The strategy of implementation of the SILOS will be described and analyzed within the context of the ten Londitions for their functioning identified by the PAHO, which are the following: (1) reorganization of the central level, (2) decentralization, (3) social participation, (4) intersectoral development and action, (5) reorganization of the financing and budgeting system, (6) development of a new lealth-care services m.odel, (7) integration of preventive and control programs, (8) development of administrative and m^anagerial capacities, (9) training of the health-sector labor iforce, and (10) research on health services. All of these elements will be analyzed as they apply to Costa Rica in order to establish their sequence and priority within the global strategy in operation since 1988. From this critical analysis of the implementation process, ten lessons for implementing changes in national nealth systems have been drawn, which will be described in Chapter 9, Conclusions and Im.plications. — — lu The information was gathered from three principal sources: (a) the literature on the subject, including studies in health and social security in Costa Rica and diagnostic studies on the health situation and the system of services, (b) extensive interviews with key national and PAHO officials in Washington, D.C. and Costa Rica who have led and participated in the im.plementation process, as well as members of diverse SILOS teams, and (c) participatory and non- participatory observation of various health-sector management development programs in several countries; international meetings of PAHO officials, practitioners and public officials involved in SILOS, held in Chile, Costa Rica, El Salvador, Guatemala, and Washington, D.C. 1.4 Constraints of the Study The evaluation of a change implementation strategy such as the one described would be more rigorous if the real im.pact if the agencies on health conditions as a result of the changes could be quantified. However, since the initiation of this process is so recent, and since health is the product of many other factors, it is not possible to determine precisely whether there is a correlation between the SILOS and health indicators. The SILOS strategy is based on what is known as Primary Health Care, and in the case of Costa Rica, when intensive primary care programs were implemented in the 197 0s, indicators showed a notable improvement, as will be analyzed 11 in Chapters 5 and 6. Despite this, these results cannot be attributed solely to the primary health-care system. The activity of the Ministry of Health covers a wide variety of areas, but this study will analyze only those related to the services it provides in the areas of prevention, education and health promotion. Similarly, the CCSS provides services in broad areas such as recovery of lealth, rehabilitation and social benefits (insurance programs) . For the purposes of this study, only those preventive and curative medical services offered by the CCSS in accordance with the principles of universality of coverage, solidarity in financing, and equity of access, will be included. Part of the information comes from interviews of national bfficials and former officials and PAHO advisers located in San José, Costa Rica, and Washington, D.C. The opinions jOxpressed by them are their own, and as such are influenced by ■factors beyond the control of the researcher but are part of the elements that determine the way in which a strategy is implemented. The study is oriented prim.arily toward changes in policy, structure and composition of the public health sector, and the global functioning of the system as a result of the introduction of the SILOS. Due to the purpose and focus of this study and the magnitude and complexity of the change. IT change, there are related phenomena that are mentioned but not analyzed in detail. It would be interesting to complement this study with others that examine areas suggested by Paul Nutt and Robert Backoff such as equity (if officials are treated justly), preservation (maintenance of the traditional and fundamental culture to preserve enthusiasm in organizations), transition (adaptation to new external requirements) and productivity (improvement in real effectiveness). In their view, the combination of these four elements could produce six types of internal tension that would be worth analyzing in greater detail: (1) meeting demands during change (transition versus productivity), (2) determining who gets what during change (equity versus transition), (3) fairness clashing with transition (equity versus preservation), (4) squeezing a stressed tradition-ridden system (preservation versus productivity), (5) reconciling cost cutting with human commitments (equity versus productivity), and (6) dealing with inertia during change (preservation versus transition), The last of these six themes coincides with the last factor analyzed in this study, but it warrants separate study due to its impact on the viability and- feasibility of changes. Those factors related to organizational behavior need to be better understood in large and complex organizations such as public health and social security organizations, and any contribution made in this area would contribute to the i J achievement of an even more significant impact by these institutions. Finally, the evolution of Costa Rican health systems and the method employed in the implementation of the SILOS process is clearly not replicable in other countries. Epidemiclogically, Costa Rica has passed through a number of stages and has attempted to respond to each of them by reorganizing its health services system. The speed and the conditions in which the country has experienced these transitions are also not replicable. However, practically all Latin American countries share the need to transform their health systems, for which reason the lessons or propositions derived from, this study may be useful to them. 1.5 Organization of the Study The study is presented in eight chapters in addition to the introduction. It begins with the theoretical fram.ework on health-care delivery systems and local health systems. It then presents the Costa Rican context in which the SILOS approach was implemented, and it concludes with an analysis of the im.pl em.en tat ion strategy and lessons learned in the process. These constitute an attempt to make a contribution to the Latin American health sectors and the Pan American Health Organization in its role as adviser in this process of transformation of national health systems. 14 Chapter 2: Health-Care Delivery Systems The purpose of this chapter is to establish a conceptual framework that facilitates an understanding of the nature of lealth-care delivery systems. It presents factors that ^etermine their modality of organization. It compares models existing in certain countries with diverse ideologies with the aim of establishing challenges and problems common to them. The modality of health-care delivery systems is determined by economic, social and political conditions, which are summarized in the chapter according to the perspective of the Pan American Health Organization. The chapter concludes by presenting organizational problems of health systems, which are the backdrop against which SILOS are im.plem.ented in Latin America. Chapter 3: Local Health Systems: Background and Context The aim of this chapter is to define the SILOS approach and explain its background. The World Health Organization (WHO) set forth the goal of "Health for All in the Year 2000" and has suggested that Primary Care is the best strategy to Lchieve it. The Primary Care concept is described, and the premise that the SILOS are the means to im.pl ement this (objective and strategy is presented. The chapter also analyzes how SILOS can be a means to. transform the national health systems. This study emphasizes T5 the fact that the point of departure to modify health systems and their organizations are the values and principles that underlie their activities. The chapter concludes with an analysis of this aspect. Chapter 4: SILOS: Characteristics and Operational Conditions In 1988, the ministers of health from PAHO member countries approved a concept of SILOS that included ten conditions for their functioning. These ten aspects are analyzed in this chapter with the aim of establishing whether they must occur simultaneously or whether it is possible to initiate a process of implementation with the presence of some of them. The chapter attempts to show that even if the process begins under the latter assumption, its evolution can bring about the need to establish the other conditions, in order to avoid a crisis or stagnation in the development of the local health systems. This chapter concludes the exposition of the conceptual factors about health, health-care delivery systems, and SILOS. The rest of the study consists of the analysis of their application to a very visible and concrete reality in Latin America, since Costa Rica has the second best health indicators in this part of the continent. -------------------------------------------------------------------------- T6" Chapter 5: History of Health-Care Delivery in Costa Rica The purpose of this chapter is to examine the evolution of health services and demonstrate that in addition to the ten conditions established by the ministers of health, there must exist a set of national values and a history that provides fertile ground for the im.plementation of the SILOS. This history is divided into four stages which run from the nineteenth century through 1992. In each stage, the existing institutional arrangements and results are described in terms of health conditions of the population. As will be shown, the more that is invested in primary care programs, the greater the improvements in the health of the population. This chapter also demonstrates that the organization of health-care services is not static, but rather it must change in accordance with economic, political and social progress of a given country and according to the will of the leaders in order to make the country's guiding principles and values about health a reality. Chapter 6: Development of the National Health Plan and System The historical period of health care in Costa Rica between 1970 and 1992 has been the most revolutionary, because of the drastic changes in health indicators. In less than a decade, the country reached levels of health _ lY comparable to those in many developed countries. For example, infant mortality dropped from 61.6 per thousand in 1970 to 19.1 in 1980 and to 13.9 in 1991. Life expectancy at birth increased from 68.1 in 1970 to 75.2 in 1990, as shown in Table 1. The purpose of the chapter is to examine the strategy of health-care institutions during this period which culminated in the formation of a health sector within public administration, the constitution of a national health system and the promulgation of the first national health plan. In this period, all public hospitals were transferred to the Costa Rican Social Security Bureau (CCSS), and the country was divided into political-administrative regions. TABLE 1 LIFE EXPECTANCY AT BIRTH, COSTA RICA Average Annual Gains ( 19 6 0 -1995) PERIOD LIFE GAINS IN ANNUALLY EXPENTAHCY YEARS AT BIRTl 1960 - 1965 65.6 2.6 0.52 1965 - 1970 68.1 2.5 0.50 1970 - 197 5 71.4 3.3 u. Ob 1975 - 1980 73.0 1.6 0.32 1980 - 1985 73.7 0.7 0.14 1985 - 1990 74.7 1.0 0.20 1990 - 1995 / ■ o . z 0 . 5 0.10 Source : Sectoral Planning Unite, Ministry of Health. : 18 All of these transformations were essential to comprehend the SILOS process, as the chapter concludes that the institutions have been gradually preparing them.selves to initiate integrated actions. The chapter emphasizes that it is vital to understand the evolution and the culture of institutions in order to formulate the change implementation strategy such as those implicit in the SILOS, which are aimed at transforming the national health system. Chapter 7 : Strategy of Transition to SILOS in Costa Rica The objective of this chapter is to demonstrate the need to change the organization of health services. The most important reasons for the complexity of the transformation are identified. Available options are identified, and the selection of SILOS as the strategy chosen to change health care organizations and the national health system is justified. Another aim of the chapter is to present the principal components of the change strategy, which included actions in four areas: administrative-m.anagerial, financial, information systems, and legal. It also presents a method for the general leading of the strategy employed in which interdisciplinary action and political will enabled officials to initiate a "bottom-up" model in the implementation of the SILOS. — ------------------------------------------- rgr Chapter 8: Analysis of the Strategy of Implementation The degree of progress of each of the ten conditions for the functioning of the SILOS is evaluated here as the result of the strategy employed in Costa Rica. In this way, the chapter is intended to contribute by noting those factors that come into play in their implementation. This is important because each country has its own particular reality which influences the sequence and emphasis placed on these ten conditions. Additionally, its purpose is to identify new challenges in each of these areas which will shape the agenda for the near future. From this chapter, useful lessons are drawn both for Costa Rica and for the other countries that are attempting to transform their national health systems to respond to the new epidemiological conditions, the need to promote integrated health care and to respond to the reduction in financial resources within the health sector. Chapter 10: Conclusions and Implications In accordance with the objective of this study, it concludes by proposing a set of ten strategic elements that can be taken into consideration when leading processes of change within organizations and national health systems. The implications of practicing or not practicing these propositions are suggested, and in this way the study attempts to contribute to institutional development, and " 2 1 ] ' consequently to the mission of these institutions: increasing the integral well-being of the population, which is the real reason behind the transformations. ZT INTRODUCTION REFERENCE NOTES Organizacion Panamericana de la Salud, Los Sistemas Locales de Salud en las Americas, Una Estrategia Social en Marcha (Washington, D.C.: Organization Panamericana de la Salud, 1993), 3. 2. Costa Rica is divided geographically into provinces and these in turn are divided into districts. For public planning purposes, it is also divided into regions that may include districts within different provinces. 3. Paul C. Nutt and Robert W. Backoff, Strategic Management of Public and Third Sector Organizations (San Francisco : Jossey-Bass Publishers, 1992.), 135.22 22 CHAPTER 2 HEALTH-CARE DELIVERY SYSTEMS The purpose of this chapter is to analyze some of the factors that determine the manner in which health care services are organized in different countries. Common problems among national health systems and health-care organizations will be identified, with particular emphasis on Latin American countries. This chapter also establishes the context for the subsequent discussion of the Local Health Systems (Sistemas Locales de Salud— SILOS). 2.1 Determining Factors in the Organizational Modality A review of the organization of health-care services in different countries reveals the diversity of systems that exist with respect to policy, principles and institutional arrangements. It is useful to note the key characteristics of each. According to Francis Netter, the differences are not due so much to-different concepts of social security, but rather they are the expression of an unequal development resulting from the historical evolution of the social -------------------------—----------------------------------23 institutions, political structure, and level of economic development reached in each country.^ In Roberto Capote's view, the logic of health-care organizations is not to be found in health care itself; rather, it is always external to it. The three factors that determine the nature of these organizations are the country's history, its political development and its economic system.^ In addition, the evolution of each modality or system results from the guiding principles of a given society. These give rise to the institutional arrangements that each society selects to implement its ideals. Economic conditions can facilitate or hinder the implem.entation of these principles. In this context, what occurs in health care is typical of what occurs in society as a whole. Superimpositions, juxtapositions, and frequent and sometimes contradictory changes in organizational structures are all part of the dynamic of any society. These are reflected in the organizational structures of its health care services and systems. This can best be seen by reviewing some principles that underlie the organizational design of health-care services.^ Concept of health. For the World Health Organization, health is a state of complete well-being (physical, psychic, and social) and not merely the absence of disease. In Hernân San Martin's view, in reality this definition is closer to an objective that is difficult to achieve even in the most -------------------------------------------------------------------------- highly industrialized countries and completely unattainable by the less-developed countries where the majority of the population lives in unsanitary environments. It is not possible to define health in absolute and only objective terms. For him, the concept of normality and abnormality, of health and disease, implies a complex group of notions in which biology, physiology, ecology, sociology, and the economic dimensions of the notion of health are integrated with the experience of each individual and the value that each individual places on human life. In any case, the notions of health and disease are always expressed, and controlled, in relation to the interdependency of individuals with the society and their environment.^ Health, viewed this way, encompasses subjective aspects (mental and social well-being, happiness), objective aspects (functional abilities) and social aspects (adaptation and the ability to perform socially productive labor). The concept of health has evolved from the mere absence of disease to a more holistic definition that includes such factors as protection of the environment. If health is seen primarily as the absence of disease, efforts should be directed priimarily toward developing hospital and outpatient infrastructures designed to maintain, restore, and to prevent occurrence of illness. If health is understood in its more holistic context, as an integral condition, a lifestyle which can be developed, then efforts should be aimed at promoting health and reducing the number of hospital beds; although prouioting health does not necessarily reduce the number of .ho s pl.t a 1— beds In— this— ca se.,— re spon s ibil ihy— for— heahth. -------------------- 25 promotion would not fall solely on the m.inistry of health but rather would be shared by all agencies having to do with ensuring the well-being of the whole person, such as the ministries of education, housing, natural resources, com.muni cat ions and others. This difference in approach determines the organizational system, the relationships, and the functions of agencies within the health-care sector. Various Latin Am.erican countries are already modifying their concept of health and the missions and strategies of their ministries of health. The SILOS have been promoting a more integrated vision of health that involves the community in its prom.otion, thus contributing to the transformation of agencies at the local level. Health as a social value. When a society assigns a very high social value to the health of its population, it could be expected to make considerable investm.ents of hum.an resources, materials and money to balance the supply of health-care services against the demand for them.. In this scenario, society as a whole is responsible for the health of all of its m.em.bers. When a society assigns a moderate value to health, one could expect to find the responsibility for the cost of health care shared between the individual and society. When it assigns a very low social value to health, it would most likely establish few institutions to address the problems of specific population groups. Instead, individuals would be responsible for their own health care. Individualism versus collectivism. A society can choose to seek higher levels of health for its population through private initiatives or through collective arrangements. The freedom to choose a service provider can vary from situations of low individual choice, in societies where the state has created only one institution, or this decision could be viewed as an issue to be resolved by individuals when many service providers are available. Under the individualistic concept, state intervention is limited to the establishm.ent of general regulations and to the provision of services in case of epidem.ics. When collectivist concepts predominate, agencies regulate the modalities of services, and individual choice is subordinated to institutional prerogatives. Certain situations that affect individuals can become collective problem.s. To the extent that people do not have access to health-care services, they expose themselves to greater risks of contracting diseases, some of which when transmitted become social problems. In a society with an individualistic orientation, the risk of the spread of diseases that can affect public health is always present. Health care as charity and as a right. The provision of health-care services can be an act of charity or welfare on the part of providers, or it can represent the exercise of the legal rights of those demanding services. , ---------------— ----------------------------------------------------27 In some countries, people have been instructed that [ medical care is a right which they are encouraged to I exercise, particularly when they are insured. In the absencej of adequate education and awareness, this has created a! demand that exceeds supply. The custom of burdening socialj security agencies with excessive demands for medical care has caused a financial crisis within the health-care system.^ Shared responsibility. When a society assumes a high degree of responsibility for the health care of its population, its agencies must ensure equity in the quality of services provided and in access to those services. In fact, a common objective of health-care agencies has been to broaden the coverage of services offered. With social security, there is the danger that even with a legal 1 broadening of coverage, real access to services will continue ! to be limited particularly for populations living far from the service centers. Thus, although coverage exists, equity measured as access may be lacking. When the state does not assume responsibility for the distribution of services, its agencies exist merely to perform planning surveillance and regulatory functions, as well as education, promotion, and research, leaving the work of service delivery to the private sector. In the former instance, the state provides a good part of the services and owns the infrastructure that provides the greatest coverage to the most extensive geographic area of the country. The SILOS constitute a means to combine both extension of coverage and more equitable access on the part of the population through a more rational distribution of available resources. Unity versus m.ultiplicity. A society may determine that all services should be offered by one agency or that a number of different organizations should participate, each one specializing in a specific problem. In a pluralistic arrangem.ent, many public and private institutions exist, which in many cases renders coordination more complex, thus incurring high costs to society. There are exceptions; Canada has a pluralistic system with relatively low costs. One recurring question regards the administrative capacity to manage a very large institution while at the same time improving efficiency, effectiveness and equity of access. This managerial capacity becomes crucial when considering any project designed to integrate the health-care sector. In Costa Rica, this capacity has been formed from the bottom up; that is, it has begun at the community level, which helps to explain the surprising development of the SILOS there. Public versus private services. According to Lenin Saenz, it would not be surprising to find that in a socio political context in which the state exercises considerable power and private enterprise has very little freedom of action, the government would assume all of the responsibility ------------------- — 29 in the area of health care, leaving very little room for the private practice of medicine, while in a totally opposite context, private medical care and hospital services would predominate and the state health program would be weak.® Roberto Capote adds that the boundary that separates the public from the private in health care is not very clear and that it is a m.istake to insist on such a distinction. In his view, private health care is so expensive that it has become a public issue because health is a m.atter of public safety. The question is how to provide services to the greatest number of people, that is, how to create a coherent national strategy in whose implementation all sectors participate." He advocates shared responsibility between public and private entities, offering the example of childhood vaccinations: all schools should require that the children attending them, be vaccinated (public health), and family physicians (private m.edicine) should perform, the task. In this case the public and the private, the social and the individual, would function in an integrated manner. Centralization versus decentralization. In some countries, supervision, regulation and even the implementation of health-care policy is coordinated by a central body. Many Latin American countries have adopted this modality. In others, financing, hospital supervision and other services have been decentralized. Decentralization is a necessary part of the process of consolidation of 30“ democracy currently underway in Latin America. It implies a modification of the methods long employed by the state, in order to involve the citizenry to a greater degree in the administration of development. This represents a considerable challenge for the state. Social insurance plans, social security and public health. Social security can be construed in various ways. A society may frame its responsibility and its organization basing itself on the principles of insurance plans or social security. Insurance plans, first introduced in 1893 by Chancellor Otto von Bismarck in Germany, were based on employment. There were : a) separate programs to deal with different social risks (especially professional risks, pensions and illness); b) coverage of the labor force employed in dependent relationships (wage earners), essentially in urban areas; c) three-part salary deductions (paid by the insured, the employer and the state); d) services directly related to salary deductions; and e) technical-financial capitalization regimes.® According to the Economic Commission for Latin America (ECLA), the concept of social security was strengthened by William Beveridge in 1942 when he suggested a special plan in ------------------------------ — ---------------------------------------31 this regard.^ The plan included all citizens without limitation or regard for their income and extended to all persons and to all types of needs. "In addition, the plan was based on three presumptions: first, the initiation of a program of subsidies for children; second, the organization of a complete health-care service; and third, the possibility of avoiding massive forced work stoppages. ECLA considered social security to be based on the following principles: a) the unification, under a single coordinating body, of the diverse social security programs with public assistance and health care (integrating the preventive and the curative) and with employment and family benefit programs (unity principle); b) the uniformiity of the conditions of acquisition of rights and the elimination of unjustified inequalities among the insured (equality); c) total coverage of the population, regardless of whether its members are employed or not (universality) and of all social risks (integration); d) financing through taxation, the minimum basic but sufficient services, unrelated to contributions, and the progressive distribution of income (solidarity); and e) technical-financial programs of benefits distribution. This illustration of principles and values has sometimes been presented as extreme. To be sure, the reality of different countries reveals a broad, varied and sometimes ambiguous combination of these values. This classification 32 should be understood as a continuum along which it is impossible to characterize precisely the modality of organization of health-care services in the different countries. It is more feasible to identify national experiences that differ considerably among each other in order to understand the complex nature of the organizations that provide health-care services in very dissimilar political and economic contexts. Additionally, the organization of health care services has in common a consideration of the health- disease process, which includes several stages of health that determine, in large measure, the role of institutions in each. Hernân San Martin calls this process the natural history of health and disease in humans as it is shown in Figure 4. Each country, through its health-care system, attempts to address each of the stages m.entioned in the previous table, assigning priorities according to criteria stated earlier. But it would be too much to expect congruence between these factors and the conditions of the system, as the latter cannot change to adapt itself to new requirem.ents. As has been mentioned, political, economic and historical factors determine the approach, priorities and behavior of this system. The experience of many countries has been that attempts to bring about adjustm.ents in their national health systems, specifically those requiring organizational change. 33 Figure 4 Natural History of Health and Disease in Humans HEALTH- -> PRE-PATHOGENIC— > PATHOGENIC PERIOD PERIOD RESOLUTION T Ecological relationship normal or favorable to human biology within a permanent process of biological variation and adaptation dysadaptation of persons to their total environment. Y People are apparently healthy and normal, but in reality the state of health is changing to a state of disease due to a dysadaptation (physical, mental or social). There is a causal relationship between environmental and individual factors. I Y The human organism can overcome thé pathogen by mobilizing its defenses of the envifbîimërit may not produce the necessary factors. In this case the disease does not continue its course If the opposite happens, the disease advances to the pathogenic period; Early disease Y Disease not apparent, cannot be clinically diagnosed i Subclinical disease Y Y Restoration of health i Can be diagnosed with the aid of a laboratory 1 Y Déâth Advanced disease Complete symptomatology ëâh bè diagnosed serious disease i Convalescence Y Disability L Y Ecological relationship between humans/environment is paralyzed and destroyed. Y Chronic Pathogenesis Fuente: Hernân San Martin,- Salud y Enfermedad, - IV Edicion (Mexico: La Prensa Médica Mexicana^ 1983), 9, 3T have been slow and difficult to put into effect, because decisions to change can encounter legal, budgetary, and regulatory obstacles the removal of which may be beyond the control of the health sector. This explains why duplication and superimposition of functions sometimes exist in the ministries of health, social insurance and other entities which, although technically unnecessary, may be the lesser of two evils in light of the impossibility of substantially reforming their organizational design. The m.odel described in Figure 4 fails to incorporate a hew element in the health care field in Latin America, the area of health promotion. It is one thing to attempt to restore health from situations of disease and quite another to promote it as a lifestyle, a policy that is beginning to appear in the region, prompting agencies to reformulate their esponsibilities. The modality of organization of a health system is thus determined by factors external to it. The prevailing political and economic ideology underlies its design. The SILOS must be understood in this context. The efforts toward democratization underway in Latin America are reflected in the SILOS, the intention of which is to bring together agencies and communities and encourage community participation in the development of health-care services. 2.2 Organizational Models of National Health Systems This relationship between the modality of the system and political context can be illustrated by briefly reviewing some models of national health systems existing in countries with different ideologies, histories and levels of resources: China, Cuba, the former Soviet Union, England, and Chile. People's Republic of China Health care in China is an essential part of its national culture. Both the existence and the regulation of medical practice there are among the oldest in the world. The size and dispersion of its more than one billion population and a shortage of trained physicians has necessitated the establishment of a system that includes a large number of paramedical personnel throughout the country. The system is guided by the Ministry of Health which formulates policies and provides services through a subsystem for the rural sector and another for the urban areas. These subsystems provide services at various levels of complexity according to population density. Most people pay for some or all of their care. In addition, some industries have their own hospital services. The population participates through the so-called mass organizations. "Patriotic health campaigns" are conducted to address national health problems. — Jg- Cuba Cuba's National Health System is unique, integrated and regional. It is unique because it provides services to the entire population, integrated because it provides both preventive and curative services, and regional because each geographic level has a separate authority. Private health care ceased to exist after the system was nationalized in 1960 . The State Committee for Labor and Social Security (CEETSS), the maximum health-care authority, has greater authority than a m.inistry because it oversees several areas of public services. The system is administered by a minister of health and organized at the municipal, provincial and national levels. Primary health care is administered by the municipal health directorates, which include hospitals, clinics, and maternity homes. Secondary health-care services, provided at the provincial level, consist of specialized hospitals, epidemiological centers, blood banks, and senior citizens homes. The Ministry of Health is responsible for health care at the national level. Popular participation characterizes the Cuban health care system. The municipal health directorates are members of the Municipal Assem.blies of Popular Power, decision-making bodies with high levels of popular representation. The rovincial health centers participate in the Provincial Assemblies of Popular Power; and the maximum authorities of -------------------------------------------------------- — — — — — 3 7 the Ministry are members of the National Assembly of Popular Power, the Council of State, and the Council of Ministries. Former Union of Soviet Socialist Republics Following the disappearance of the USSR, changes in the health system in the republics can be expected. Nonetheless, it is interesting to examine the modality of the system that prevailed in a confederation of republics with a Marxist- Leninist ideology. Health care was considered to be a basic right of the citizens. Although services were provided free of charge, their modality and quality depended on economic, social and political factors. The population was divided into geographical units of between 40,000 and 80,000 inhabitants, and then into groups of 2,000 to 5,000 persons assigned to one to three physicians and one to three nurses. Care was provided in health centers (model basic units) according to the age of the patient. Labor unions played an important role in the administration of social insurance funds, as they controlled the distribution of subsidies and old-age pensions. England The system is managed by the Ministry of Health, which receives policy guidelines from the National Health Council. fp is a decentralized system, managed by diverse Administrative committees" with the participation of local physicians and the local authority. __________________________ Probably the most distinctive characteristic of the English system is the doctor-patient relationship. All British citizens are entitled to receive medical care. They register their names in a patient list of a general practitioner (a "family doctor") who then assumes responsibility for the health of those persons and their families. The choice is free for both patient and physician. The relationship between local physicians and hospitals in England is also unique. General practitioners refer to specialists based in the hospital who may order hospitalization and the hospital then subm.its a report to them for appropriate follow-up. This model is under review in countries such as Costa Rica and may be adopted in modified form, which would have a considerable effect on the m.odel of service delivery. Chile The Chilean experience in health care has greatly influenced Costa Rica and other Latin American countries. The last 15 years have witnessed major changes in its health system, such as contracting from the private sector for the provision of services, decentralization as a means to grant greater participation to municipalities, and the allocation of public funds to high-risk population groups. The health system, offers three basic alternatives: the governmental or General Health Care Program, composed of 27 -------------------------------- 39 divisions; free choice; and a modality encouraged since the 1980s, the private-sector companies (instituciones de salud Iprevisional— ISAPREs). A National Health Fund plays a regulatory role in the financing of these three alternatives. According to Robert E. Tranquada, there is growing tension 'between the public system of health care which cares for 80% of the population and the private system. The government is limiting its support for the public system at the same time that those with private insurance are using public emergency rooms and other service without charge. The government allows more and more resources and duplication of complex systems to occur in the private sector, and therefore the incentives of the voters to support public sector is diminishing.12 Chile's health-care system is both deconcentrated and decentralized. Communities are encouraged to participate, which strengthens local health systems. This trilogy of municipality-community-health system is an experience that is gaining acceptance in countries such as Costa Rica. An analysis of the various national systems described above illustrates considerable diversity in such factors as the degree of community participation, the nature of the doctor-patient relationship, the relationship of power between the central and m.unicipal governments; and the degree to which preventive versus curative approaches are emphasized. SILOS also address issues of geographic distribution, decentralization and popular participation. 40 stratification of services, linkage of municipalities and planning of local services with involvement of community institutions and organizations. 2.3 Problems and Challenges Common to Health-Care Organizations For Roberto Capote, the fundamental problem in public health is the search for appropriate financing models. There has been a tendency not to accord public health its due importance, but this is changing as a result of situations such as the outbreak of cholera in several countries on the American continent. The common challenge facing all of the countries in the region is how to satisfy the needs of the population with the greatest efficiency, effectiveness and equity despite financial limitations. The supply of health care services can only approach satisfaction of the demand to the extent that the limited financial resources perm.it. But the manifestation of need is complex because the very definition of the concept of health is so relative, and it is practically impossible to reach agreement on what is required to reach it, if indeed it is possible. In the following pages, some of the common problems and challenges facing health-care providers are presented. Imbalance between need, supply and demand for services The broader the definition of health, the greater the 41 needs that institutions must satisfy in order for the population to be considered healthy. In practice, national health systems attempt to satisfy not needs but the demand for services.According to Lenin Sâenz, faced with insufficient resources to satisfy (with optimal quality of care) all the needs of the population, in practice the concept of "need" must be lim.ited to cases of preventable or treatable diseases. In this way it is possible to quantify the magnitude and nature of need through morbidity surveys. Demand, on the other hand, can be quantified through registries of health-care consumers. Need thus relates to the biological and technical basis of health-care activities, while demand is linked to the economic and social base of the population.!^ Both need and demand are key sources of information when deciding upon the modality of organization of services to be established in a given community. Disparities may arise between the need and the demand for services for the following reasons: a) Needs produce demand but cannot always be satisfied due to scarce resources, e.g., patients are turned away in a clinic or primary care center; b) Needs are met despite a lack of demand, e.g., when the community is unaware of available services; c) Demands are met although they may not be based on true need; and d) Some unnecessary demands do not receive attention ------------------------- gg. but nevertheless exert pressure on health-care organizations.i® The challenge is to implement mechanisms that can satisfy these needs and demands as efficiently, effectively and equitably as possible. National health systems are responsible for utilizing resources and transforming the available technology to produce actions of prevention, promotion, recovery and rehabilitation. The manner in which this is accomplished is determined by the political, social and economic context of each country. The role of the state is vital whether as a regulator or as a direct service provider. One of most significant challenges for all countries is getting their national health systems to function as such, i.e., allocating resources in accordance with national plans in which health care is considered a key component of developm.ent. Organizational Model Emphasizing Curative Medicine Just over a decade ago, the World Bank put forth an argument that has not changed much since then: despite significant expenditures and the possibility of eradicating many of the most frequently occurring health problems, efforts to improve the situation have had little effect on the health conditions of the great majority of the population of almost all of the developing countries. --------------------------------------------------------- 43' This is usually attributed to two major factors: first, activities have concentrated typically on modern care dispensed in hospitals while neglecting preventive public-health programs and simple primary care delivered by conveniently-located services. Second, even when these installations have been geographically and economically accessible to the poor, deficiencies in terms of logistics, inappropriate training of personnel, inadequate supervision and the lack of social acceptability have often compromised the quality of the care provided and thus limited its utility.!' The World Bank argues that the principal problems of the health sector are not due to the complexity of the technology nor to the shortage of financial resources. Rather, they originate in the conception and application of policies, management practices, and logistics. In other words, more could be done with the same resources if they were managed differently. With respect to the model of care, the World Bank has identified the principal problems to be the following: - Geographic inaccessibility of health-care agencies for the miajority of the population. For mothers and children, access to health centers is often difficult. The existence of economic barriers that exclude many people. Even when users are not charged for services, the cost of transportation and the tim.e away from work may be prohibitive, particularly for the urban poor. The preponderance of emphasis on curative care to the di treatmient. to the detriment of prevention and early Excessive hospital services in relation to the number of primary care centers. Often, inadequate training of physicians for .the conditions pr.ev.ailina in— the— countr-v-..- 44 Scant attention is paid to the most frequently- occurring health problems and to appropriate technology. Rare diseases and the use of costly equipment are given undue emphasis. Auxiliary personnel, particularly in rural areas, often receive insufficient training, supervision or support. The provision of services is erratic, especially in the more isolated areas, due to an uncertain supply of medicines, pesticides and other essential materials. In some instances, services offered lack social acceptance; in other cases the beneficiary population does not consider them to be effective. Community participation and integration with other sectors are insufficient.^^ Finally, the World Bank believes that these deficiencies originate at the national level, in the policies, agencies, and procedures employed, as well as in the way the programs are implemented by the service provider. This complements the view of primary health care as the correct way to rectify the problems common to the current models of health systems prevailing in many developing countries. 2 .4 Social, Political and Economic Situation and Health Before discussing the organizational problems of Latin Am.erican health systems, it will be useful briefly to review the economic and political situation as well as the general health conditions prevailing in the region. 45 Social, political and economic outlook In the 1980s, Latin America experienced the worst economic crisis of its history. As a result of economic stabilization programs, the average inflation rate was reduced from 1,200% in 1989 to 200% in 1991. There has been a slight reduction in foreign debt service payments. The decline in international interest rates has enabled Latin America to attract more foreign investment. However, unemployment remained constant in 1990 and 1991. In its annual survey of the region for 1991, the Pan American Health Organization (PAHO) concluded the following: The new economic base of the region is characterized generally by a stronger orientation toward exports, trade liberalization, austerity in fiscal mtatters, a more prudent management of monetary policy and a greater reluctance to resort to government regulation of economic activity. However, these new rules of public policy doubtlessly engender even greater income inequalities, a more precarious employment situation, a more restrictive fiscal environment and less freedom than in the past to implement economic policies . In the political arena, this region of more than 450 million inhabitants is in the midst of a transition toward democratic regimes with greater ideological pluralism. Democratization has provided the impetus to transform public- sector agencies in order to make them more responsive to the popular will. But despite greater institutional stability, the situation within the health sector has not improved in t,h e . , 1 . 3 . St.., tw.o—ye a . r.s_.,^------------------ ------ ------------------- 46 The limited room for m.anoeuver of the public- health sectors and the lesser political importance accorded them, due to their total dependency, along with the education sector, on economic policy decisions, is creating a situation of chronic instability among government authorities in the health sector. With few exceptions (the outbreak of cholera), public health and medical care in Latin America and the Caribbean have not become part of real political or economic realities.-- The majority of Latin American countries are experiencing a process of economic and political change which has brought about institutional changes within the health care sector, supported and promoted in large measure by the international organizations that participate in the financing of structural adjustment and economic stabilization programs. José Maria Paganini^^ insists that the new models designed to produce economic growth must also address the issue of distribution of the benefits of that growth. He argues that health-care services are called upon to play a fundamental role in the promotion of growth with equity. Reflecting upon historical development and political and economic events as determinants of the logic and behavior of health-care organizations, Roberto Capote offered these proj actions : a) Recently, the purchasing power of Latin Americans has been declining. Those who once enjoyed it, as well as those who never did, are turning to the health system in search of services, thus raising the demand for them. b) Despite changes in socio-economic and political conditions, social insurance systems have attempted to respond to this demand with modalities and capacity for service delivery _________that w.er.e designed for a v.e r.y— di.f.f er.ent_____ --------------------------------------------------------- 4T reality. The existing models have entered into a crisis and have not innovated to respond to the new circumstances. c) The countries of the region are beginning to emerge fromt the political and economic crisis, and this crisis has helped Latin American populations to view health as a social good, because they are more informed. Access to information about phenomena such as the cholera outbreak and contact with health-care services make the need for them all the more pressing. d) Faced vvith this new urgency, it is likely that governments will use health care as a means to maintain social peace. There are already several examples of this. This political will could translate into allocation of more resources, even if they are used to reinforce the weaker components of the existing system. e) Public health will become more imiportant than models that emphasized hospital care. As the concept of health itself is now much broader, this will require a change in the way agencies provide services and function. Health Situation The director of the PAHO summarizes the health situation .n the American continent as of 1991 as follows : changes in mortality indicators are continually occurring, characterized by a rise in the importance of cardiovascular diseases, tumors and other chronic-degenerative diseases, against a backdrop of a reduction in mortality in global terms and a rise in life expectancy at birth. In several countries, such as Brazil and Colombia, violent deaths, particularly homicides, have risen at an alarming rate. Many infectious diseases have been on the rise in the last two years, in term.s of morbidity although not mortality; cholera is spreading for the first time in this century; there are more than a million cases of malaria per year; dengue continues to claim victims; the pandemic of AIDS continues, and other sexually transmitted diseases are on the rise (especially in the United States); pulmonary tu be r.cu.lo.s,is_i s_b e ginnin g t o—a pp e a — p a r.t i.cul a.rly----- — ----------------------------------------------------- 41" combined with the infection of human immunodeficiency virus (HIV); 95 mdllion people, one-fifth of the global population, run the risk of contracting the infection caused by Trypanosoma cruzi, and yellow fever continues to be active. It should be noted, however, that cholera and other infectious diseases have mainly affected those population groups living in the greatest poverty, that lack safe drinking water, adequate sanitation and the appropriate means of food preparation and storage, and that have very limited access to basic health-care services. Latin America presents a very uneven epidemiologic profile. Some countries have pathologies characteristic of underdevelopment such as infectious and parasitic diseases and malnutrition. Others show patterns sim.ilar to those in the industrialized countries; degenerative and cardiovascular diseases and diseases due to overeating and sedentary life styles. To this must be added problems caused by alcoholism, drug addiction, poor working conditions, AIDS, and environmental contamination. This complicates the task of providing efficient, effective and equitable health-care services because new demands are added to old problems.It also renders the cooperation of international organizations such as the PAHO more complex because national policies and [models of care vary from country to country. 2.5 Organizational Problems of Health Systems Absence of a Single Strategy The m.ajority of Latin Am.erican countries do not have a national strategy in whose implementation all health-care ----— ... 49- agencies participate. Each organization follows its own policies and procedures with predictable inefficiencies in the use of scarce resources. This is the most serious problem at this stage in the history of social insurance and public health in the region. Although there is greater awareness about health as a social good, and although efforts are being made to improve coordination between agencies and communities, the absence of a global strategy is a true obstacle to the strategic development of health-care services. This situation originated, in part, in the lack of political will to develop a single strategy, since doing so would have required changes in the m.ission, objectives and policies of many entities that wish to protect their autonomy. A considerable political investment would have been required. Some countries are willing to support health care programs but not to establish a single strategy. In this regard, it is common to see ministries and social insurance agencies marching to different tunes. One cannot have a health-care system in which it is unclear who defines the strategies. There are policies but no strategies. This defies logic, because sometimes no one is clear about what needs to be done. The European countries resolved this many years ago. Those Latin American countries that have defined a single strategy--Cuba, Chile and Costa Rica— have solved the problem. What is lacking is political decisiveness and an understanding that health is a public safety issue, a political issue. The problem of cholera clearly illustrated the need for a single strategy. They should erect a monument to cholera for that. 50 A common strategy presupposes the function of som.ething that Graham Allison has called a national actor: The nation or governm.ent, conceived as a rational, unitary decision-maker, is the agent. This actor has one set of specified goals (the equivalent of a consistent utility function) , one set of perceived options, and a single estimate of the consequences that follovv from each alternative. Such a rational model also presupposes the presence of an agency with sufficient leadership and legitimacy to formulate such a strategy and bring about coordination between national and local agencies. That agency cannot be the ministry of health if it does not have authority over other entities such as social security, and vice versa. In presidentialist political regimes such as those existing in Latin America, the strong hand of the maximum political authority will be required to ensure that this single strategy is formulated and legitimately implemented. However, in the absence of a single strategy and clear institutional leadership, and as long as duplication of services and expenditures persists, the SILOS constitute a means to rationalize the role of agencies and resources, at least at the local level. Costa Rica is among the few countries in Latin America that has a national health system with a health sector comprising all of the agencies that provide health-care services. Valuable lessons can be learned from Costa Rica's experience in this area. Costa Rica has attempted to redefine the function of the political— leadership— of— the- — ------------------------------------ health sector and establish guidelines reached by consensus that facilitate the establishment of a new single strategy in the face of serious financing problems and changes in the epidemiological profile of the population. Other limitations have emerged in the process of carrying out strategic planning and impact evaluation studies, facilitating the modernization of agencies, and promoting greater efficiency in the use of resources. Epidemiologic Profile, Models of Care and Organizational Focus One organizational problem common to all Latin American countries has been the management of the relationship between the needs (epidemiologic profile) of the population, the model of care, the supply of health-care services (institutional strategy), and intra- and inter-institutional organization. Since the 197 0s, attempts have been made, with varying degrees of success, to modify models of care in order to broaden the coverage of services provided. That transition presupposes a significant organizational change in the role of agencies and in the strategy for implem.enting programs such as primary care. As Hesio Cordeiro and Herman Zavaleta have pointed out. The extension of coverage has been targeted to semi- urban and urban marginalized groups, by way of a movement sim.ilar to the Community Medicine programs tried in the miajority of Latin American countries in previous decades. However, broadening of coverage goes_against_the_polioy_that_has-long_guided_medical_____ practice— the hospital model, highly specialized, which employs sophisticated technology and is therefore very costly. These analysts also believe that the policy of extension of coverage is spreading rapidly in Latin America but the possibility of its becoming a reality is quite low precisely because health-care organizations are outmoded. In other words, organirational transformation is not advancing at the same rate as the ideological discourse regarding the need to extend services beyond hospitals. The implementation of this change in approach toward a primary care model requires a change in the internal culture of agencies, as it implies moving away from a model of organization based on hospital care to one emphasizing close collaboration with communities in the determination of priorities. This change in approach also implies administrative reform. This is not always possible to carry out in an orderly and rational fashion given the frequent changes of government in the last 20 years due to political- military conflicts and the economic crisis, which had the effect of divorcing priorities from possibilities in some countries. The relationship between population health status and the organirational model is particularly complex in the case of Latin America. The PAHO classifies health status in three stages. The first is characterized by the predominance of infectious diseases linked with poverty, malnutrition, high ------------------------------------------------------— ------------------53 infant mortality, and precarious sanitary conditions in the environment and the workplace. At this stage, central health-care organizations provide basic services in nutrition, regulation of public health, extension of access to safe drinking water, pre-natal care, sanitation and vaccination. Some organizations may set up specific departments to address each basic need and may mount national campaigns to combat these diseases, assigning the task to a specific section. There is specialization of functions, rather than an integrated approach to health care. The second stage focuses on cardiovascular diseases and accidents, cancer, mental disorders and degenerative diseases such as diabetes. In this situation, public-health organizations concern themselves with establishing norms and m.odels of individual care as means to prevent these diseases. They make greater use of preventive medicine. Under this m.odality agencies do not wait until the sick patient enters the system, but rather they go out into the community to conduct educational and preventive activities. In fact, the approach is somewhat more integrated because the relationships between some departments within a ministry of health become closer, with some internal fusion and efforts at inter-institutional coordination occurring. Patients are more frequently transferred to more specialized hospitals according to the level of care required. Each level of care 54 requires specialized personnel; the organizational structure is thus more complex. The third stage focuses on health problems that result from environmental and occupational exposure to chemical products and toxic substances originating partly in the inadequate organization of the workplace, as well as those associated with violence, alcoholism., and drug addiction. The chief task of agencies is promoting health through education, improving the quality of life in the workplace, and preventing disease. Organizations must change in order to develop capabilities in this area. The formation of complex networks of inter-institutional coordination becomes paramount, and a more integrated approach to health problems is attempted. Organizational change between each of these stages is a common characteristic in Latin American countries, because their agencies face a huge challenge, summarized as follows : The industrialized countries have passed through these three stages during a period of more than a century. Developing countries face the challenge of living with these three models simultaneously. Among the poorest populations, which are the majority, the problems characteristic of the first stage predominate; among the better-off, particularly in urban areas, the second-stage diseases are most common, while in the large cities, problems typical of the third stage are beginning to appear, due to the environmental and social decay that accompanies disorderly urban growth and unemployment. Roberto Capote sees in these transitions a challenge to organizations to learn to conduct their new activities. ■ - ■ ■- - - - ■ . . i r | - | - r - r - ^ T j i - . , - I " Until recently, the problem was infant mortality. When this changed and the problem became health promotion, leaders found themselves totally disarmed. The system has entered into a tremendous crisis now that priorities have changed. New methods of evaluation will have to be developed, for example. The trend toward democratization in Latin America implies equity in access to health services. If the population is s im.ul t an e ou sly at. different stages of health, it is not difficult to imagine the complexity involved in designing a national health organization that manages to achieve equity with efficiency and effectiveness. The key factors for achieving this are bringing the agencies closer to the population by means of a primary care strategy and the functioning of the SILOS in which all community organizations and agencies represented at the local level would be involved in order consensually to arrive at the best possible actions using available resources. Health-Care Planning versus Planning of Health-Care Services Political decisions regarding new priorities are not always accompanied by the political will required to produce the organizational transformations necessary to make their implem.entation viable. Both politicians and the public could respond to demands for legislation by considering the costs of response, in terms of time, votes and voter influence. Robert Adizes and Paul Zukin state that in less-developed . . ' — — . . . . . . ■ ■ I l — countries, health-care services are beyond the reach of the majority of the population, because efforts are concentrated in the construction of costly installations that provide care to very few. They note that this is due to the following: a) Health-care planning is concerned with the health sector not with the service providers. b) A national planning institution plans changes, and sometim.es the ministers of health themselves place limits on this task. c) The majority of service providers offer services according to their own criteria, without concerning themselves with the needs present in the environment. d) Health-care service delivery organizations are generally doiminated by physicians who want large hospitals that satisfy their needs and those of politicians. e) This behavior tends to isolate the health sector from others that also perform health- related activities.^! In summary, some countries have imbalances and lack of coordination between health-care planning (goals, priorities, resources, etc.) and the planning of health-care services (services, equipment, supplies and institutional functions). Integrated Health Care, Inter-institutional Separation and Financing Levels of health and epidemiological transitions make it necessary for countries to have systems that can intervene in the different phases and needs of the health system according to a single strategy, which is non-existent in the _ma jjo%i.ty_o.f _Lat in_Amer.i.can_count r.i e s I n_th e_ab sen ce—o,f__a. 57 strategy, one could at least hope for the existence of functional relationships between agencies, particularly between the ministries of health and the social insurance organizations. However, frequently social insurance agencies cover less than a third of the population, and the ministries of health concentrate their efforts on primary care, without any mechanism., in the majority of cases, for patient referral between the two agencies. This shortcoming prevents consumers from. receiving integrated care that covers everything from their primary needs (health information) to treatment in specialized hospitals. To limited coverage and resources must be added inadequate mechanisms of inter- institutional relationships and inadequate patient referral systems despite the infrastructure that exists. Practically without exception, social insurance agencies face very serious problems of retrenchment. Hospital care is expensive for these entities. This could be reduced through a more rational model that cooperates in the reduction of demand for hospital services through prim.ary- care programs with broader coverage, an effort in which the countries are the region are increasingly engaged. Robert E. Tranquada argues that increased primary care programs will not lead to reduce need for hospital services. In his opinion, increased primary care will initially result in case-finding which will increase the dem.and for hospital care: "Preventive care does not reduce hospitalization. --------------------------------------------gg because sooner or later everyone gets sick and needs hospitalization. Hospitalization is reduced by providing incentives both to provide preventive care and to limit the use of the hospital as a means of care."32 Organizations such as the World Bank, the Inter-Am.erican Development Bank and the U.S. Agency for International Developm.ent are supporting some countries in their effort to redefine those mechanisms and sources of financing, considered to be one of the most serious problem.s of the health systems and, in particular, of the social insurance agencies. Conflicts over leadership and turf battles have also hindered the developm.ent of relationships and joint actions between ministries of health and social insurance entities. On occasion, this has caused a separation of curative from preventive medicine, to the detriment of a more integrated approach. Costa Rica has attempted to confront this problem.. The Ministry of Health and the Costa Rican Social Security Bureau (Caja Costarricense de Seguro Social— CCSS) have implemented agreements for integrating services and have operationalized the SILOS despite budgetary restrictions of both agencies. Democratization versus Administrative Centralization Policies and strategies in the health-care field are an important component of goals adopted by governments to guide ------------------------------------------------------------- 1 gg- the process of national development. These goals are not independent of the political processes in these countries. The consolidation of democracy is now on the agenda of Latin American countries. One essential element of this ideology is the participation of the people in the decisions that affect them, which represents a clear challenge to public- sector agencies: how to open up their system.s to facilitate popular participation. Despite the progress made in the direction of decentralization, a very centralized type of organization prevails. Centralization, which is hindering the achievem.ent of substantive changes in the organizational model, has historical roots in the following: a) The presidentialist system of government. This system was adopted in order to institutionalize the oligarchic form of political power predominant since colonial times. Unlike U.S. presidentialism, the Latin American variety was not accompanied by a federal system. Thus, power remained concentrated in a few hands, with a considerable quota of that power held by the President. b) The unitary structure of the government. The political-administrative structure of the majority of Latin American countries was already centralized when they became independent. The autochthonous oligarchy designed a model of government with very few political separations of power and with hardly any autonomy for the provinces and the local governments, whose governors were also chosen by the central power. The implementation of political-administrative or territorial decentralization is feasible within democratic _z:ules_of_the_game___T.heref ore,—it_is_to-be-expe.cted—tha^t—the. gg- greater the political will to consolidate the process of democratization, the greater the possibility that organizational changes will be implemented in the direction of the type of decentralization required by health-care systems to make them accessible and equitable. Concurring with this, Sergio Boisier argues that the reasons for the current trend toward decentralization can be grouped into four categories : 1. The technological revolution. Geographical distances are constantly being shortened by the modernization of information systems. The dispersion in the production of goods and services characteristic of modern business will have to be supported by the state and must therefore be decentralized. New technology makes centralized schemes less necessary and less functional. 2. "Redemocratization" ■ in Latin America is generating a new modality in the relationships between civil society and the state. The population needs concrete mechanisms of representation in the state apparatus. Local and regional officials and agencies should serve as the channel for that representation. They need decision-making power to process popular demands. 3. Decentralization is also m.otivated by privatization of public enterprises and deregulation of government activities. Privatization is being implemented under the guise of achieving greater efficiency. However, this can lead to the mistake of seeking profit at the expense of the social function. In its zeal not to relinquish its role, the government itself is decentralizing as a means to recover its reputation for efficiency and effectiveness and, in this way, diminish the possibility of privatization. 4. The economic crisis and the neo-liberal policies that today provide the context for the _________ ao.v.e rnment_!_s a ct i.vit i e s reveal— the— need— for----- — — — -------------------------------------------------------------------------------------------------------------------------------— wi-------------- government reform. Such policies seek to discredit the regulatory role of the public sector in the economic and social spheres. Common issues in Latin America.today are the reduction of the size of the state, the transfer of functions to local governments, and the redefinition of its role.^ Alejandro Rofman offers additional reasons for investing resources in decentralization, having to do with granting civil society a role in the decision-making system through popular participation.^^ Popular participation is the .mechanism by which citizens are taken into consideration in the policy-making, program implementation, and the control of national, regional and local resources. Accordingly, decentralization contributes to greater visibility for the government by making it more accountable and by enabling the citizen to participate in the management of public affairs. Popular Participation: A Change in the Strategy of Health-Care Organizations The health sector is probably the most active of any in promoting efforts to incorporate citizens’ participation. In many Latin American countries, social promoters work as volunteers organizing local health committees. Since the mid-1980s, SILOS have brought agencies into contact with the local population. This transition toward decentralized schemes presupposes attitudinal changes on the part of public officials who, after years of making decisions, will become facilitators for the community. SILOS represent a — -------------------------------------------------------------------------------------------------------- substantial change not only for the agencies but also for the communities themselves, many of which are unfamiliar with participatory democracy. One factor that complicates popular participation is the fact that the population with the greatest need for health care services is generally not organized, making collaboration between the state and the population more difficult. The state needs good local counterparts because in their absence it will revert to playing the role of sole decision-maker. It is not surprising that despite the desire on the part of local health officials, the response received in terms of community involvement is still not satisfactory. Jorge Mera attributes this to ignorance, disinterest, and the lack of information on the part of the citizens about how, where or why they should participate. Democratization is a joint learning process for public agencies, political parties and communities. All three must change in order to learn to work together. This requires the capacity to satisfy and negotiate mutual demands. The state must be considered to be democratic, efficient, equitable and must have very ambitious and motivating programs. Otherwise, citizen participation will not work, since it seeks tangible benefits. This participation cannot be conditioned on any administrative or partisan dependency. —— — — — — — — —— — — — — — -— ■ ■ - — • - - The achievement of positive results in the process of inter-institutional integration and the functioning of SILOS depends in part on the attitudes and capabilities of health- sector officials. However, it is precisely here where resistance to change can be expected. One limiting factor is the attitude of the techno-bureaucracies in the ministries or organizations involved in implementation, which habitually resent change because it obliges them to change more or less crystallized customs and routines. One conspicuous case of this resistance is opposition to any policy of administrative decentralization that aims at greater efficiency and connection with local authorities and groups. Bureaucracies view this as a threat to their source of power, and they tend to oppose its adoption either directly or indirectly. Lack of Vision and Intersectoral Action The improvement of the health status of a country does not depend exclusively on the actions of the health sector. Other entities, such as the ministries of education, transportation, public works, labor and social welfare, play relevant roles. The organization of agencies by sectors is already a difficult task, as is the achievement of intersectoral coordination and the promotion of community participation. Establishing such relationships represents a profound cultural change. Lack of coordination and superimposition of agencies and functions represent significant obstacles to the smooth functioning of the political system.. Institutional rigidity, stagnation and corpor,ate_preiedices.-.Drev_ent_the_establl.shment of_____ ----------------------------------------------------------------g4' transforma-tions in the state structure which would enable interconnection among the various ministries and agencies, rationalizing resources and functions and improving technical quality through inter disciplinary mechanisms. Another factor, at least in the case of Costa Rica, is the leadership assumed by the health sector over the last 20 years in the area of inter-institutional coordination and community organization (e.g., committees and health boards). This accentuates the visibility of activities carried out by health-care agencies and confers upon them a quota of responsibility in the quality of intra- and inter- institutional changes. In Costa Rica, health and education are two key factors in the implementation of organizational changes thanks to their level of coverage and their constant contact with the population. Costa Rica is one of the few countries to draw up national integrated development plans decided by consensus among various sectors. A sectoral or institutional approach to health problems significantly hinders the ability of some countries to establish true national plans and health system.s. Discontinuity in Government Policies The countries of the region frequently face difficulties in consolidating medium- and long-term plans due to the constant changes of government or rotation of officials within a single term of government. Simply changing the 6 5 minister of health causes profound disruptions. This illustrates the considerable power of these officials, in keeping with the presidentialist system common in Latin America. The m.ulti-party system and the co-government between various political parties that occurs in some countries make the task of form.ulating national medium.- and long-term health policies that garner the necessary support very difficult. One of the Central American Management Institute’s most difficult challenges has been to attempt to help health-care organizations, recogni zing the turnover rate of their officials, the absence of consensus on key policies and the limited long-term, vision regarding activities designed to promote institutional development. Some organizations invest heavily in the training of mid- to. upper-level managers who in less than a year are removed from their posts due to a change in the party in power. Even with some stability, it is difficult to arrive at a consensus regarding priorities and approach toward the task at hand. This uncertain tenure of officials not only introduces an element of discontinuity in institutional strategies but also an atmosphere of uncertainty that affects long-term vision. It is possible that in very fragile democracies, political parties attempt to profit rapidly during their term in power as a m.eans to assure their continued existence as an organization. This motive may lead them not to look gw beyond short-term planning, which is not conducive to meeting the challenge of transforming health-care agencies, which can only be accomplished over the long term. Organizational Subcultures and Strategic Development Organizational changes are changes in the organizational culture. The essential change which health-care agencies are experiencing today is a change in their internal cultures. Health-care organizations, especially m.inistries of health and the entities responsible for social insurance, are among the largest organizations in Latin America. What occurs in them has major repercussions in the societies as a whole. Bringing about changes within them, for their very complexity, is extremely difficult. In other words, the origins of the great changes in the health-care field can be found outside of it, but the organizational innovations within the sector are very visible and tend to influence other public-sector agencies. The complexity typical of health-care organizations is not only due to their size. Other factors are the diversity of the professions participating in the health system; the sometimes conflicting schools of thought, such as between curative and preventive medicine; the different m.edical specialties, each one with its own method and approach; differences of opinion among medical, technical and administrative personnel; differences in reward mechanisms -------------------------------- and therefore goals and incentives; the geographical dispersion and the existence of numerous hierarchical levels. To these can be added the external relations within the health sector and the political games played among agencies in their competition for scarce resources. External influences include the processes of democratization, decentralization, popular participation, economic adjustm.ent and epidemiological transitions. This complexity likens the majority of health-care organizations to the model that Henry Mintzberg has called machine bureaucracy, characterized by him. as highly specialized, routine operating tasks, very formalized procedures in the operating core, a proliferation of rules, regulations and formalized communication throughout the organization, large sized units at the operating level, reliance on the functional basis for grouping tasks, relatively centralized power decision making, and an elaborate administrative structure with a sharp distinction between line and staff. This is important in the context of the formulation and implementation of strategies. Ensuring that a strategy in the health sector is apt, feasible, acceptable and motivating requires an internal process that may take several years despite the political power that exists at the top levels of the organizations. In formulating a national health-care plan, scientific, economic, ethical, social and cultural elements come into play, in addition to unavoidable administrative, organizational and partisan restrictions. Another factor which in practice has a significant impact is that medical_per.sonne 1_.often _ lack management skills . For 68 this reason the decisions they make may not be viable. Conflicts often arise between medical directors and administrators because they are not speaking the same language. Addressing health problems requires simultaneous action on the part of various agencies. If organizational change is a change in the internal culture, then inter-institutional change cannot be viable without a modification in the suppositions that the entities of the various sectors hold among themselves, in their mutual perceptions and in the notion that they are participating in a common task. Thus, the constitution and functioning of a health sector or the national health plan does not depend only upon political will. Legal, economic and administrative restrictions also intervene, as well as the behavior of the internal culture of the agencies participating in the sector or national plan. Obviously, changes in the health-care field will vary depending on the level of development of the country. This is also a determining factor in the organization of the health-care system at the national and local levels. The challenge of organizational transformation is common to all Latin American countries, just as is the limitation of resources. This challenge has been expressed in the following terms: Then the global economy went into an unanticipated tailspin accompanied by inflation, large-scale public borrowing and shrinking markets _w,hi.ch_meant_that„D remised, re s our ce s^ws re-unava ilabl e- --------------------------------------- ^ gg when expected. Alterations in administrative systems had not gotten to the essence but merely tampered with formalities. They had not gone far enough or deep enough. In some countries, they had actually made things worse not better. Insufficient attention had been paid to administrative reform. Governments had been lulled into a false sense of security, believing that systems which had performed well in the past would continue to perform well and that alterations being made by managerial experts would enable them to perform better in the future. Bernardo Kliksberg shares the viev/ that transformations must be more substantive (correlations of power, interaction among factors of pressure, attitude and m.otivation) than formal (number of organizations, redistribution of functions, m.odification of organizational charts and m.anuals).^^ In summary, health-care agencies in Latin America face two essential challenges: administrative reform and change in their administrative culture. Moreover, these changes m.ust be congruent with a strategic development of the health sector that places a high priority on social participation and a more intense interrelationship among all the agencies of the government. Government initiatives in the health area are not the sole responsibility of those organizations that comprise the health sector. îü" CHAPTER 2 Francis Netter, La Seguridad Social Principios (Mexico, D.F.: Instituto Mexicano de Seguro Social, 1982), 9. 2. Doctor Roberto Capote, Adviser on Health-care Services delivery, Pan American Health Organization, interview by author, Washington, D.C., 9 December 1992, tape recording. 3. Organizational design refers to (a) the agencies and agencies created to address health care needs and desires of the population, (b) the level of care provided, (c) geographic coverage, and (d) the relationship between the different public and private agencies. 4. Hernân San Martin, Salud y Enfermedad, 4th ed. (Mexico D.F.: La Prensa Medica Mexicans, 1983), 108. 5. Msc. Miguel Segovia, Regional Adviser in Health Services Administration, Pan American Health Organization, interview by author, Washington, D.C., December 8, 1992, tape recording. 6. Lenin Saenz, Administracion de Servicios de Salud (San José, Costa Rica : Universidad Estatal i Distancia, 1988), 163. 7. Doctor Roberto Capote, Adviser on Health-care Services Delivery, Pan American Health Organization, interview by author, Washington, D.C., 9 December 1992, tape recording. 8. Economic Commission for Latin America (ECLA), El Desarrollo de la Seguridad Social en America Latina. Estudios e Informes de CEPAL 43. (Santiago: ComisiOn Economisa para .Amé,r-i.ca_Latina_y_el_Car.ibe., 1.9.8.5A, 3------------------------- ----------------------------------------------------- T r 9. In June, 1941, when Great Britain faced the risk of aerial bombardments or an enemy invasion, the government invited Beveridge to conduct a complete study of all existing social insurance systems. That study was the source of the initiative to establish an im.proved health system, that included subsidies to families when the breadwinners became ill or lost their jobs, or could not support their children. Under this plan, the state contributed to the financing of these subsidies. 10. Ministry of Reconstruction of Great Britain, El Seguro Social en la Gran Bretaha (Mexico D.F.: Ediciones Minerva, 1945), 81 11. Economic Commission for Latin America (ECLA), El Desarrollo de la Seguridad Social en América Latina, 4. 12. Dr. Robert E. Tranquada. School of Public Administration, University of Southern California, interview by author, Los Angeles, 18 January 1994. 13. Dr. Roberto Capote. Pan American Health Organization, interview by author, Washington, D.C., 9 December 1992, tape recording. 14 . The demand indicator is estimated by dividing real utilization of services required by the total population in a given geographical area. In this estimate, the unsatisfied demand due to the unavailability of institutional resources 15. Lenin Saenz, Administracion de Servicios de Salud, 16. Ibid., 139. 17. The World Bank, Salud, Docum.ento de Politica Sectorial, 2d ed. (Washington, D.C.: World Bank, 1980), 7. 18. Ibid., 7-8. 19. Ibid., 50. 20. Carlyle Guerra de Macedo, Informe Anual del Director (Washington, D.C.: Organizacion Panamericana de la Salud, 1992), 1. 21. Ibid., 31. 22. José Maria Paganini, "Los Desafios de Los Servicios de Salud en la Década de los Noventa," in Descentralizacion de los Servicios de Sa 1 ud_como_Esbrateg.ia_para_el_Desarnolio. ---------------------------------------------------------------------------72’ de les Sisternas Locales de Salud, ed. Iveta Ganeva (Caracas: Centre Latinoamericano de Administracion para el Desarrollo, 1991), 4 1. 23. Dr. Roberto Capote, Pan American Health Organization, interview by author, Washington D.C., 9 December 1992, tape recording. 24. Carlyle Guerra de Macedo., Inform.e Anual del Director, 5-6. 25. José Maria Paganini, "Los Desafios de los Servicios de Salud en la Década de los Noventa," 46. 26. Dr. Roberto Capote, Pan American Health Organization, interview by author, Washington D.C., 9 Decem.ber 1992, Tape recording. 27. Graham T. Allison, Essence of Decision (Boston: Little, Brown and Co., 1971), 32. 28. Hesio Cordeiro and Herman Savaleta, "Analisis de la Prâctica Médica Actual en América Latina: Alternativas y Tendencias," in Analisis de las Organizaciones de Salud (Washington, D.C.: Organizacion Panam.ericana de la Salud, 1987), 2 1 3. 29. Organi zacion Panamericana de la Salud, Desarrollo y Portal ecim.iento de los Sistemas Locales de Salud, (Washington, D. C. : Organi zacion Panamiencana de la Salud, 1989), 9. 30. Dr. Roberto Capote, interview by author, Washington D.C., 9 December 1992. 31. Ichak Adi zes and Paul Zukin, "Un Enfoque Adm.inistratiVO de la Planificacion de la Salud en los Paises en Vlas de Desarrollo," in Analisis de las Organicaciones de Salud, 136-7. 32. Dr. Robert E. Tranquada, School of Public Admiinistration, University of Southern California, interview by author, Los Angeles, 18 January 1994. 33. Mario Fernandez, "Aspectos Institucionales en la Formulacion de las Politicas de Salud," in Politicas de Salud en América Latina (Caracas : Centro Latinoamericano de Administracion para el Desarrollo, 1988), 21. 34. Sergio Boisier, La Decentralizacion: Un Tema Difuso y Confuse (Santiago: Instituto Latinoamericano de _P.lani.f,i.caci.ôn_Econômi,ca_v_S.o.cial., l.R9Ll_, 4__________________ ^ 7 3 ’ 35. .Alejandro Rofman, "Aspectos Conceptuales sobre Decentralizacion Politico-Administrativa en America Latina," in Descentralizacion de los Servicios de Salud como Estrategia para el Desarrollo de los Sistemas Locales de Salud, 20. 36. Jorge Alberto Mera, "La ImplementaciOn de Politicas de Salud," in Politicas de Salud en America Latina, 32. 37. Ibid., 34. 38. Alejandro Rofman, "Aspectos Conceptuales sobre Descentrali zacion Politico-Administrativa," 23. 39. Mario Fernandez, "Aspectos Institucionales en la Formulacion de las Politicas de Salud," Politicas de Salud en América Latina, 26. 40. Henry Mintzberg, The Structuring ot Organizations (Englewood Cliffs, NJ: Prentice-Hall, Inc., 1979), 315. 41. Gerald E. Caiden, Administrative Reform Comes of Age. (Berlin; New York: de Gruyter, 1991), 27 42. See Bernardo Kliksberg, La Reforma Administrative en América Latina : Una Revision del Marco Conceptual, (Caracas: Centro Latinoamericano de Administracion para el Desarrollo, 1984). 74 CHAPTER 3 SILOS: BACKGROUND AND CONTEXT According to the PAHO, the most important challenge facing the Latin American and Caribbean national health systems is restructuring themselves in order to strengthen their Local Health Systems (SILOS) as a means to achieving equity in access to health-care services. The goal enunciated by member countries is "Health for All by the Year 200 0" and their strategy is an emphasis on Prim.ary Care, both of which will require a process of genuine decentralization of the public sector.^ This chapter will discuss the origin of the SILOS as the operational tactic selected to implement the primary care strategy. It will define the model of care and describe the conceptual basis for the SILOS, whose functioning in Costa Rica is the central subject of this study. It will explain how the SILOS are at the center of efforts underway in Latin America to democratize access to health-care services. The principles, values and historical context underlying the implementation process will be emphasized. -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --7 5 ' 3.1 Primary Care: A Global Strategy Concept and Areas of Activity At the m.eeting of the General Assembly of the World Health Organization (WHO) in 1977, the goal of "Health for All in the Year 2000" was put forward. In 197 8, the International Health Conference, held in Alma-Ata, USSR, under the sponsorship of the WHO and UNICEF, concluded that in order to implement this policy, a different strategy would be required. The delegates designed a global strategy, called Primary Health Care, defined as follows : Prim.ary Health Care is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country’s health system of which it is the nucleus and of the overall social and economic development of the community. Primary Health Care addresses the miain health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly. Since these services reflect and evolve from the economic conditions and social values of the country and its communities, they will vary by country and community.... In order to make Primary Health Care universally accessible in the community as quickly as possible, maximum community and individual self- reliance for health development are essential.^ Specifically, this strategy has the following characteristics : a) It conceives the health system as a component of social development and an instrument of social justice. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -7 6 ' b) It applies to the entire population without restrictions. It is based on the principle of universality. c) It gives priority to economic, cultural and geographic accessibility of the neediest, according to the principle of equity. d) The community is the prim.ary actor in decisions about its own health care and participates actively in the entire system. e) Health-care services address problems originating in environmental conditions and individual and collective behavior. f) Primary care encompasses the following vertical public health programs defined at Alma-Ata: Education about prevalent health problems and methods of prevention and control. The promotion of appropriate food and nutritional supplementation. Drinking water supply and basic sanitation. Maternal and child health, family planning and mental health. Vaccination against major communicable di seases. Prevention and control of local endemic diseases. ----------------------------------------------------------------------- 77' - .Adequate treatment for common diseases and accidents. Supply of essential medications. This global strategy requires the presence of these elements for its implementation : * political decisiveness and support to make reorientation of national health systems viable. * a new organization of services characterized by decentralization, regionalization, functional integration and strengthening of the local levels. * access on the part of consumers to the different levels of care. * development of appropriate technology, coordination between the diverse institutions and public services among themselves and with the local level. * institutional and managerial development within health-care institutions. Background of Primary Care^ i I The concept of "primary care" was first discussed in j j England in 1920 by Bertrand Dawson, who defined primary j I I I health centers as facilities equipped to provide preventive î I and curative services by a district general practitioner. > I i I He laid very important theoretical foundations for the development of primary care. 78 The turn of the century was a period of considerable innovation and important discoveries in the biological sciences in Europe and the United States. At that time, proposals to improve the distribution of health-care services and medical training were also put forward. Two of them., the Flexner Report and the Dawson report, summarized below, had a significant impact on the development of these areas: The Flexner Report In 1910, Abraham Flexner presented a report on Canadian and American medical schools that has had a notable influence on curricular and organizational design of both medical schools and hospitals. The report stated that physicians must be educated in schools that met high standards of scientific excellence at the graduate level with adequate laboratories and dedicated teaching hospitals (which was where the sickest patient were, in those days, when nothing was known of control or care for chronic disease, and most patient died of infectious disease in the hospital) where the faculty should supervise the experience. According to Humberto Movaes, these recommendations have been followed, almost without exception, in Latin American teaching hospitals. He believes that Flexner’s views on I medical school faculty also correspond exactly with those of today’s Latin American professors, who continue to influence an entire generation of physicians. He also believes that --------------------------------------------------------------791 Flexner's approach fails to recognize the necessary elements that link public-health education to community needs, because his primary concern was for technical excellence in specialties directed at treating individuals.^ However; it can be argued that the Flexnerian model had nothing to do with specialization because specialties were just beginning to em.erge and had not really reached common identity. Analyzing the influence of the Flexner Report on the education of Costa Rican physicians, Miranda has criticized the Flexner model : It was always too expensive for our possibilities and unsatisfactory for the psychology of our communities. The visceral dissection of the human being, such that specialists concerned themselves with individual organs, not only was beyond the possibilities of the majority of the population, both here and in all Latin American countries, but it also unleashed the process of depersonalization of the system., which ended up destroying the beneficent relationship that our communities had always enjoyed with their community doctors.^ In the United States in the 1960s, departm.ents of public health were replaced by those of preventive medicine began to appear in medical schools, and students studied concepts of social medicine. Novaes has argued that this tendency had a considerable influence in Latin Am.erica thanks to the support of the Pan American Health Organization for the "new” discipline of preventive and social medicine, which constituted an important departure from the Flexner model. Probably one notable influence of the Flexner model was the emphasis on curative care and on the so-called 8 0 "scientific medicine" in health-care institutions up until the 1960s. Carlyle Guerra de Macedo summarized this impact as follows : [T]hey were, furthermore, and continue to be, contributing factors to some of the fallacies that we have to face today in Latin America. Based on a fundamentally biological and almost instrumentalist paradigm for the interpretation of vital phenomena, this movement created, among other things, a cult of disease rather than of health, and a devotion to technology with the illusion that it would be the future of scientific activity and health care. The Dawson Report In 1920, Bertrand Dawson, physician to the King of the British Empire, formulated a proposal to restructure health care services. The four basic principles of his proposal were : a) the state as provider and controller of health policies b) the coordination of team efforts in health-care services c) the establishment of specifically designated sites for providing diagnostic services and treating acute cases, and d) no separation between curative and preventive medicine, whether with regard to medical education n or the organization of health-care services. England has had legislation regulating health-care services since the seventeenth century when it attempted to provide protection for the poor. Its first Public Health 81 Act, promulgated in 1848, established community health councils. In 1920, Dawson proposed the regionalization of services as a measure to link prevention and therapy in a given geographic area. This could be considered to be one of the earliest precursors of the SILOS. In order to en^^^TT^^ the general availability of medical services, health-care providers had to distribute their resources according to the needs and plans drawn up for each community. In addition, interdisciplinary efforts were essential in order to be able to offer the range of services required by the population. The physician, he argued, must provide both curative and preventive services and address both individual and community needs. Preferably, physicians should come from the community itself. Finally, a group of primary care centers should have access to a secondary-level care center which should in turn be linked to a hospital. In this way, the care of the patient could be integrated and the physician could provide better follow-up. These ideas formed the basis of the National Health Service established in the United Kingdom in 1948. Its influence has been so strong that almost all of the national health plans in Latin America and the Caribbean are based on them. Humberto Novaes has pointed out the following differences between the Flexner and the Dawson models : 82 a) On the physician’s place in the hierarchy: Dawson: there must exist an institutional and disciplinary hierarchy of which physicians are a part. Flexner: individuality of physicians and the absolute and direct physician-patient relationship, without any government intervention. On primary care: Dawson: advocated a system that ensured access Flexner: main concern was with professional- technical excellence, not with the immediate improvement of the population's general health conditions, c) On ambulatory care : Dawson: university hospitals and communities should maintain an active relationship Flexner: physicians in university hospitals normally refuse outside consultation unless the purpose is to admit specific pathologies for study or research.® These theoreticians began two schools of thought known as Flexner ism. and Daws on i sm.. Each has had considerable influence in shaping the development of health-care services. -------—— ---------------------------------------------------83 With the adoption of Primary Care as a strategy, the need to adjust, accommodate and reorganize physical, human and material resources and achieve community participation in the identification and solution of health problems became clear. The SILOS are an attempt to address this need in the region.^ The ideas about the functioning of the SILOS have also been influenced by the two approaches described above. An examination of how this is so is useful when analyzing issues of inter-institutional integration and coordinated action between health systems and communities. Difficulties in implementing comprehensive health care programs must be shared by those who have been educated under Flexner's model, with views limited to individual curative and intra-hospital medicine, and by the public health group, which advocates the principles proposed by Dawson. For a long time during the ongoing transition, the management of the clash between these two viewpoints has been one of the greatest challenges impeding the integration of health-care services in Latin America. 3.2 Local Health Systems (SILOS) : An Operational Tactic After the declaration of Alma-Ata, the task facing ^ mem.ber countries was to find ways to implem.ent Primary Care. I The result was the operational tactic known as Local Health I = Systems (SILOS). SILOS is a concept that dovetails perfectly \ I ; with current regional trends such as efforts at | i I I reorganization, the reform of the role of the state, t I decentralization and democratization. --------------------------------------------------------------8 4 - SILOS were originally designed as subsystems of national health sectors, capable of coordinating all existing resources by establishing a network of services within a given urban or rural population. In the process of their development, variations have arisen in the definition as well as in the names given to SILOS, e.g. "Sanitary Health Systems" and "Health Districts." Nevertheless, the substantive ideas and objectives have remained intact. In the experience of several countries, this operational tactic has become the means by which national health systems have transformed them.selves. The particular history and reality of each country in the region has determined the nature of its primary care programs and the adaptation of the SILOS concept to its own priorities and levels of resources. For this reason it is difficult to arrive at a single definition of SILOS that is at once norm.ative and common to all countries. The World Health Organization (WHO) proposed a definition of health districts that encompasses its essential components as they were understood in 1986. As described in the introduction, the current definition of SILOS evolved from, this of WHO: Health districts are based on Primary Health Care, which necessitates reorganization and reorientation of National Health Systems by means of a process of decentralization and local development. They cover populations living in clearly delineated urban or rural geographical and administrative areas. They include institutions and individuals that provide health care within the sector, whether fromi the ministry of health, social security, the non-governmental or the private . _ _sector ..The SILOS, consist, there fp.re., of a great, _ -----------------------------------------------------------85- - - variety of interrelated elements that must be well coordinated with the aim of providing health care services in the areas of promotion, prevention, cure and rehabilitation, seeking equity, efficiency and efficacy. According to Miguel Segovia, the conceptual bases of the SILOS were discussed formally for the first time in Costa Rica, in 1987, in an international meeting convened by the PAHO to analyze decentralization of health services. This meeting began a process of awareness and dissemination of the concept that can be characterized as the period of introduction of the SILOS. On September 30, 1988, the m.inisters of health of the PAHO member countries approved what is known as Resolution XV, "Developm.ent and Strengthening of Local Health Systems in the Transformation of National Health Systems." This historical agreem.ent marked the form.alization of efforts for the implementation of the SILOS. Chapter 2 of Resolution XV stipulated the following; 2: Encourage member states to: a) continue and reinforce their definitions of policies, strategies, programs and activities aimed at transforming national health systems based on the development of local health systems; b) ensure the coordinated participation of all government institutions responsible for the delivery of services, especially social security, as well as those providing international cooperation in the process of strengthening local health systems; c) prom.ote, in accordance with their institutional realities, the concept of coordination at the programmatic level between the public sector, rm- _________governmental oroa ni z at ion s_a n d_t h e_pr i va t e_s e c to r _ ; , ___ 86 d) place special emphasis on integration of resources and on decentralization for the strengthening of the operational capacity of local health systems, as well as on those specific programs providing attention to priority health problems; e) pay special attention to aspects defined in Section IV of Document CD33/14 to achieve greater equity, efficiency, efficacy and participation; f) define and apply the pertinent indicators and processes that facilitate evaluation of the development of the SILOS and the advances achieved; g) emphasize research over health services in local systems. The aspects mentioned in clause (e) refer to desirable conditions for the development of the SILOS, such as reorganization of the central level to ensure adequate management of the sector and development of the SILOS, decentralization and déconcentration, social participation, intersectoral integration, the adjustment of financing m.echanisms, the development of a new model of care, the integration of prevention and control programs, the strengthening of administrative capacity, the training of the work force, and research. These elements will be analyzed in greater depth in Chapter 4. Expected Impact The countries that are implementing SILOS are experimenting with different organizational models. They are experiencing constant processes of change, the results of --------------------------------------------------------------8 7 ' which lead to new initiatives to improve coverage and access to services. Nevertheless, there are certain areas of agreement on the expected im.pact of the functioning of the SILOS. They must: a) provide health care using a global approach, integrating available resources at the local level. This model implies prevention, cure and rehabilitation of the integral state of the person. b) facilitate the application of national policies of decentralization of national health systems. c) promote social participation in health and in the SILOS through sectoral, community and political organi zations. d) provide appropriate venues for local programming. e) define responsibilities to ensure equitable coverage of the population. f) improve administrative efficiency, simplifying and optimizing management processes. g) support the development of local service networks h) provide feedback on national health policy in j order to make it more responsive to the needs of | the population. j The functioning of the SILOS constitutes a complex cultural change for health-care institutions. The opening up of the institutions to permit community participation is 88 a process from which there is much to learn. Costa Rica has advanced further in this area than the majority of the countries in the region, and for this reason its strategy has been chosen for study. It is likely that a culture that supports consensus and development of managerial capacity in its institutions has been the key to the Costa Rican experience. 3.3 Systems Approach and Local Health Systems The size of the health system is difficult to define precisely, because in almost all countries it consists of three sub-sectors: a) the public or official sector, frequently organized into national, provincial, and m.unicipal jurisdictions; b) the social security sector, also with different jurisdictions, which provides financial contributions and has its own installations, and c) the private sector, with a variety of m.odalities ranging from individual professional practice to institutions with the most advanced technology. One difficulty in defining the magnitude of a health I ! I system is that the concept of health itself has various I j connotations that in turn affect the definition of the system j I and the inputs required to reach a state of health. For the j i j I PAHO, a- state of complete physical, social and mental well- | i . I ' being can be considered to be the essence of health. j ' I I However, the relativity inherent in the definition of well- | gg- being further illustrates the limitations in any definition of health. What is clear, in the opinion of Gustavo de Roux, et al., is that it is an open system, that is, one for which interaction with the environment is a necessary condition for its survival, reproduction and transformation. Its openness enables the system to be placed in a context or suprasystem within which it is but one component. In this sense, the health system is a component of the global social system of which its differentiation is arbitrary and only functional, since the majority of the other components have an effect on health.-® Apart from the close relationship between the health status and environmiental factors, some other distinctions regarding the components or systems related to the health of the population miust be made in order to understand the areas in which concrete changes can be effected. Below are four systems, identified by Gustavo de Roux et a^., in descending order of magnitude: a) Global social system, consisting of the whole of society and culture, with its distinct forms of organization, within a context of values, beliefs and behaviors, which make up a particular way of life. A community is nothing more than a social system on a reduced scale. b) Health system, representing an arbitrary cross- section of the social system, but one which includes those elements or components of the social system related directly or indirectly to the health of the population. It should not be confused with the so-called health sector, which generally includes only those institutions whose specific mission is to provide services in the area of health care. c) Health-care system, consisting of those elements _________ _op_CLomppnent.s_of_t.he_social_s,ysbam_tha.t_fo.rmally____ 90 or informally provide health-care activities to the population. d) Health-care services system, a sub-system or component of the health-care system consisting of institutional services whose mission is to provide health-care services. In many countries it is divided into three sub-systems; public or state, social security and private.^® Figure 5 depicts the social system at the community level. It illustrates the close relationship between educational, economic, political, cultural and health-care factors. De Roux et al. concur with the PAHO’s conceptualization of the local health system as a set of health resources ] ooth sectoral and extrasectoral. interrelated. responsible for the health of a given population in a given geographic area. They em.phasize that the existence of a social structure that supports health both on an individual and a collective level is a requisite element for its functioning. The inclusion of extrasectoral resources and a social support structure make the SILOS approximate the health-care system, applied to the local level and with the population as its subject. This interpretation is represented in figure 6. As conceived by the PAHO, SILOS should be understood as basic organizational units within a fully articulated global entity which is the national health system. That is, they are the focal point of peripheral planning and management of health services, under the integrating and normative influence of the national coordination of the system, the level at which global policies are formulated and the processes of logistical, technical and administrative support required for the implementation of programs and the deliverVOf services_at_the_l.ocal_le]tel_are_def,ined..iZ___ -91- F i gu r e 3 Som m ai .S y s te m s tJaB Lo^_aJ X b v b J Educational System Local Educational Sub-System Local Health Care Sub- System Local Economic Sub system Pnmary Groups Population Ethnic Groups Local Political Sub-System Local Cultural Sub-System Political System Cultural System .Sour^îB.: GjASi^y.o û b JLoüx, Bt jJ , ' '.Rar±paj:j. an B o bIb I y JSisiBiïias û b SaJxid" l.n Xas _S ls t,enias Lo^JLas û b aalud,. Conjcepjbos , MBtodos , Exper iencias . 3â.. 92' J i gur e 3 Xo-CâJ- .HfiâJ-th .Sy.siem Educational S ystem School Others University Technical Public Pnvate Coopératives Industy ^rad^ sub>Syst«ii Sociil Primtfv Sfcunti Groups Populir Sub-Systs smsuts ssM b Ssnriess Population others Sociil isttbc F«% Mfldictifl Sib-Systsni Groups Groups Ethnic Organizations Autontie Cutturslano Ricrustionsl rpanizitio Raligiua Organizations Labor Political Partie Union Community Organizations Political System Cultural System |_S,o_uT-Cb: Gustavo 31b JRoiix., M l - f "JP-axiJ.x3j.p.am.Qii y Sl-StBiaas Lo^aJjas dB In Los SJ-stemas Locales Mb Salud. ConcBPtos. Mbtodes. Experiencias, 3â. José Maria Paganini has emphasized the need to reject any interpretation that envisions the central level as the place where major decisions are made and the local level as the place where they are carried out. The local level has the responsibility to respond to. the epidemhologic reality of the population under its jurisdiction, attempting to administer the existing resources in the com.munities them.selves, without waiting until solutions are handed down from above. The PAHO has also repeatedly affirm.ed that the SILOS will facilitate the transformation of national health systèmes. Segovia, for example, has stated that the transformation of national health systems need not originate in ideas such as modernization or administrative reform but rather that this transformation should be based on the strategy of the SILOS with all that this im.plies. The sphere of influence of this system must be identified, as well as the possible values that are basic for its functioning. 3.4 Spheres of Influence of the National Health System and the Local Health Systems From the preceding section, it is clear that the functioning of the SILOS requires the involvement of all those public and private entities responsible for the health status of a given population in a given geographic area. This involvement is necessarily gradual and begins with the 94 leadership of institutions such as the ministries of health and the social security administration. Traditionally, and in accordance with the structures in the region, it was held that the organizations within the ministry of health, the social security and private medicine of a country formed what was called the health sector. Later, all entities related to the physical and social m.ilieu and individual and collective behavior were incorporated. In other words, there is a relationship between health and development which produces an intersectoral opening, placing greater em.phasis on relationships with entities regulating agriculture, industry, education, housing, etc. An institutional perception of health as a set of interrelated parts, a "network" within which institutions interact with the com.munity and other organizations thus begins to emerge. Obviously, these relations imply a commitment to a common objective and the possibility of linking efforts and social resources to achieve certain obj ectives. In the countries of the region, the national health system usually comprises the following institutions: ministry of health - social security institution other public-sector organizations such as the ministries of agriculture, planning and those | responsible for community development 95 non-governmental charitable organizations: welfare, health cooperatives or foundations that treat specific diseases such as cancer in children or tuberculosis private sector international organizations. Once a national health system establishes SILOS, other essential actors enter into the process. The involvement of the community is required not as a simple recipient of health programs but as a co-designer of them. In conclusion, the sphere in which the SILOS develop and interact is much larger than that of the agencies that comprise the national health system, and it will be necessary for them gradually to increase their network of relationships. 3.5 Values and Social Objectives Implicit in the Functioning of the SILOS Health is a state of complete well-being, which includes biological, environm.ental and social aspects. This concept implies that health is both an objective in and of itself and a component of individual and social well-being and, as such, it is a responsibility to be shared with the community. In this context, biomedical models have great I limitations in terms of equity, efficacy and efficiency in jachieving such a state of well-being. Significant changes : are needed in the area of mobilization of multi- -------------------------------------------- — — — --------------------9 6 institutional, multi-organizational and m.ulti-disciplinary resources. The United Nations considers that a population’s standard of living is an indirect expression of the collective well-being. It recognizes the difficulty in arriving at a precise measurement, but that by evaluating each component an approxim.ation can be reached. As figure 7 illustrates, health can be considered as a synthesis of the various components of well-being. The central values that orient the activities of the SILOS according to the Latin American and Caribbean ministries of health, are equity, efficiency, efficacy and participation in the delivery of services. Popular participation is considered to be an element that supports the process of democratization in Latin America. f A \ F,nn 1 t V iquity is the rational distribution of benefits in such that they are accessible to people at greatest risk of disease and with the greatest need due to their socioeconomic conditions. One of the discussions that has generated this principle regards how decisions about the distribution of resources are | j made and who makes them. A society normally has a multitude of priorities and interest groups. This warrants a process of diagnosis and consensus among the various actors. SI' Figure 7 Components of the Standard of Living Source: L. Saenz, Administration de Servicios de Salud. 83. As Eugenio Vilaca has noted, equity cannot be compared to universalization of health systems, because often times this conceals the possibility of variable access to differentiated services for different population groups. The equity dimension of a local health system cannot deny the fact that the population is heterogeneous in terms of needs ---------------------------------------------------------------------------98 “ | and access to services. It is thus vital to establish political priorities to diminish gradually the degrees of relative inequality. (b) Social efficiency Social efficiency is the productivity of health services under conditions of optimal utilization of available or added resources. A variety of factors may condition efficiency, such as management styles and the prevalence of biomedical over social components. It also implies a review of historical distribution of resources, characterized by their concentration in large urban centers, in tertiary institutions and in sumptuous technology. Efficiency cannot be reached merely by maximizing products per unit of inputs, but also by minimizing inputs per unit of product. However, in the case of the SILOS, there are intangible inputs and products for which reason the operative category is a much broader, which Eugenio Vilaca has called social efficiency: the ratio of social result of production/social cost of resources employed. (c) Social efficacy This refers mainly to the quality of the response to each health problem, with a level of technology appropriate to the characteristics of the specific problem and compatible with the values and aspirations of the community. 99 The concept of social and epidemiologic efficacy substitutes that of economic efficacy. An agency can have an optimal economic efficacy without modifying the levels of health of the population. Moreover, social efficacy includes the notion of political efficacy, which transcends economic efficacy, broadening it to incorporate resources of power as an element of evaluation. In this sense, the political efficacy of a local health system consists in its capacity to win support and form, alliances with different social forces. (d) Democrati zation It is difficult to im.agine the functioning of the SILOS without the joint participation of public servants and the population in the implem.entation of program.s designed to benefit it. Latin America is making an effort to democratize its political, economic and social systems ; the SILOS are but one expression of this process. The strengthening of the SILOS is also a mechanism to support larger democratic processes. Therefore, there is a close relationship between the logic of health services and the more general behavior of the society. The agencies that promote democracy have to be democratic in them.selves in order to facilitate the participation of the population in the direction of the use of resources administered by public entities. roo' The SILOS attempt to strengthen these four central values: equity, social efficiency, social equity and democratization. Achieving these objectives also requires certain approaches and attitudes within the health sector, such as an integrated vision of health, flexibility in national and local system.s, universality of services, team, work and a long-term view of the actions of the SILOS: Integrated Vision This refers to a continuum, of care within a fam.ily or social environment, which complements curative efforts with a growing number of actions of promotion and maintenance of health. Integrated vision includes not only an appropriate balance between health promotion activities, prevention and the treatment of illness; it also seeks to satisfy all aspects of people’s needs so that they can work in harmony and fully develop their vital and social capabilities. Flexibility This is the capacity of the system, to adapt to the changing needs of the community. It will redound in greater rationality and effectiveness in the allocation o.f resources and in a greater disposition and capacity to incorporate j innovative processes and technologies. 101 Universality This is the right of all people, granted by the state, to equality of opportunity to seek the full development of their physical, social and labor capacities. This implies coverage of 10 0% of the population, which is fully compatible with the goal of "Health for All by the Year 2000." The search for universality has transform.ed the concept of social assistance to one of social security. For Bonilla, assistance was an act of altruism, and charity and only applied to the truly indigent or needy. With social security, the insured contribute through their payroll deductions, which grants them a true right, independent of their economic situation. The universality of services which the SILOS attempt to achieve transcends that which is already guaranteed by Latin American social security systems which made great gains notably in the first half of this century but w^hich today face serious financial lim.itations that impede their expansion. Teamwork This is the principle of collaboration among all organizations, whether directly or indirectly, permanently or tem.porarily connected to health care. It im.plies inter and intrasectoral coordination as a means to link the different actors without sacrificing their autonomy. It ------------------- -------------------------------- — roz" attempts to achieve harmonious development at the political and operative decision making levels. José Maria Paganini has noted a relationship between the humanization of health-care services and teamwork. The integrated health care m.odel has as a fundam.ental component the humanization of the relationship between medical specialists and the population. This means making the relationship more personal to prevent health care from becoming anonymous and m.echanical. In his view, this individual, humanized practice must be complemented by a team approach that ensures the best quality in health care. The SILOS facilitate individualization and promote team work at the same time . Long-term, visioi The development and strengthening of the SILOS is a complex and delicate process that necessarily im.plies a long term vision. The process has advanced at different rates in different countries. However, even in those countries where it is the most advanced, certain aspects still need to be introduced. For exam.ple, in som.e cases decentralization has been achieved in administrative but not in financial aspects, or a good m.odel of care has been developed but it lacks full i ■community participation. ‘ Involving all of the actors and providing them, with all of the conditions necessary for the development of the SILOS ---------- — -------------------------------------- ros is a delicate process of change which requires a long-term approach and plan of action. Moreover, there are entities that do not have an internal culture that is open to change. One limitation comes from hospitals, since as Humberto Novaes has pointed out, "organizational changes interfere directly with already established control mechanisms in hospitals, which were structurally, physically and functionally planned to remain in a stable system with no extramural relationships with other community health services. The development of the SILOS is a process which does not end abruptly but rather responds to the changing needs of the population. Its results with respect to integrated health care will be tangible only in the long term., but once achieved., they will remain constant, provided that the SILOS adapt their tactics according to the wishes of the population. Based on what has been stated in this chapter, it should be clear that the implementation of the SILOS is more than a technical m.atter. It is essentially a process of transformation that involves other professional fields such as public management. The SILOS require a change in organizational culture and the genuine practice of new values, particularly in the relationship between the state and the community and among segments of government. The values described will rem.ain mere concepts if not translated to concrete "artifacts" such as policies, --------------------------------------------------------------------------rQ-4' procedures and mechanisms for action. Nor is it possible to explain the SILOS without placing them within a context of Prim.ary Care, the goal of "Health for All by the Year 2000" and the processes of democratization in progress throughout Latin America today. This background, definitions and implicit values are not the same for all countries. However, the ministers of health approved certain basic conditions for the functioning of the SILOS. These conditions will be analyzed in the following chapter. ro5' CHAPTER 3 REFERENCE NOTES 1. Organizacion Panamericana de la Salud, La Administracidn Estratégica Local, Vol. 2, Desarrollo y Fortalecimiento de los Sustemas Locales de Salud (Washington, D.C.: Organizacion Panamericana de la Salud, 1992), vii. 2. World Health Organization. Primary Health Care. Report of the International Conference on Primary Health Care (Alma-Ata, USSR, 6-12 September, 197 8 (Geneva: World Health Organization, 1978), 34. 3. This section is based on the historical overview of the conceptual bases of primary health care presented by Humberto Novaes in Development and Strengthening of Local Health Systems, Vol. 6, Development and Strengthening of Local Health Systems (Washington, D.C.: Pan American Health Organization, 1990), 4-16. 4. Humberto Novaes, Development and Strengthening of Local Health Svstems, 6-8. 5. Guido Miranda, La Seguridad Social y el Desarrollo en Costa Rica (San José; Editorial Nacional de Salud y Seguridad Social-Caja Costarricense de Seguro Social, 1988), 2 . 6. Carlyle Guerra de Macedo, "La Universidad y Salud para Todos en el Aho 2000," Boletin de la Organi zacion Panamericana de la Salud, No. 99 (1985): 209-216. 7. Humberto Novaes, Development and Strengthening of Local Health Systems, 4. 8. Ibid, 13. --------------------------------------------------------------------------ï o ' l ' 9. In the terminology of the Pan American Health Organization, the "region" includes the Caribbean countries as well as those of North, South and Central America. Humberto Novaes, Development ans Strengthening of Local Health Systems, 15. 11. World Pan American Health Organization, Global Programme Committee, GPC 2 0/WP/4, (Geneva: World Health Organization), 4. 12. Msc. Miguel Segovia, Regional Advisor on Administration of the Pan Am.erican Health Organi zation, interview by author, Washington D.C., Decemiber 8, 1992, Tape recording. 13. Organizacion Panamericana de la Salud, "Resolucion XV:- Desarrollo y fortalecimiento de los Sistemas Locales de Salud en la Transformaci6n de los Sistemas Nacionales de Salud," Desarrollo y Fortalecimiento de los Sistemas Locales de Salud, vi-vii. 14. Ibid., 10. 15. Gustavo de Roux, Duncan Pedersen, Pedro Pons, and Horacio Pracilio, "Participadon Social y Sistemas Locales de Salud," in Los Sistemas Locales de Salud. Conceptos. Métodos.Experiencias, ed. José Maria Paganini and Roberto Capote Mir (Washington, D.C.: Organi zacion Pa nam.e ricana de la Salud, 1990), 31 16. Ibid., 33-34. 17. Organizacion Panamericana de la Salud, Desarrollo y Fortalecimiento de los Sistemas Locales de Salud, 16. 18. José Maria Paganini, "Sistem.as Locales de Salud: Un Nuevo Modelo de Atencion," in Sistemas Locales de Salud. Conceptos. Métodos. Experiencias, 50. 19. Msc. Miguel Segovia, Regional A.dm.inistrative Advisor, Pan American Health Organization, interview by author, Washington D.C., December 8, 1992, tape recording. 20. Organi zacion Panam.ericana de la Salud, Desarrollo y Fortalecimiiento de los- Sistemas Locales- de Salud, vii. 21. Eugenio Vilaca Méndes, "Importancia de los Sistemas Locales de Salud en la Transf orm.acion de los Sistemas nacionales de salud, " in Los Sis-tmas Locales de Conceptos. Métodos. Experiencias, 24-25. 107 22. Ibid., 24. 23. Gabriel Bonilla M. , Teorla del Seguro Social (México, D.F.: Compania Editora Nacional S.A., 1945), 24. 24. A historical review of the development of social security in Latin America can be found in Carlos Marti, El Seguro Social en Hispanoamérica (Madrid: Hijos de E. Minuesa, 1949), 25-50. 25. José Maria Paganini, "Sistemas Locales de Salud: un Muevo Modelo de Atencion," 53. 26. Humberto Novaes, Developing and Strengthening of Local Health Systems in the Transformation of National Health Systems, 15. 108 CHAPTER 4 SILOS: CHARACTERISTICS AND OPERATIONAL CONDITIONS In 1988, the PAHO’s Board of Directors (composed of the Latin American and Caribbean uiinisters of health) identified ten essential conditions that must be met in order for the SILOS to function. The order of priority of these conditions is different for each country, and each also employs distinct modalities of implementation as a result of its national realities. This chapter will begin to analyze these ten conditions. The implementation of each condition represents an organizational change and, as such, it affects institutional culture. Without changes in the organizational culture, the administrative reformis necessary for the functioning of the SILOS are likely to fail. In this regard. Most administrative reformis fail. Reform movements and reformers begin well enough but usually find that they cannot get much beyond a sympathetic hearing, symbolic backing, and polite formalities. Thereafter vested interests and bureaucratic inertia continue to defy reform intentions. Even though maladministration i.s^f.r.eel.y„acknow.lBdged., the_condi.tion.s_tha.t_gave_r.i.se___ IÛ'9 to it are not altered enough to make a real difference. Laws are changed, structures reorganized, people moved around, manuals altered, and instructions revised, but the same behavior patterns are continued. The administrative culture— its beliefs, values, priorities, norms--is hardly touched.- Following is an analysis of the ten key elements required to facilitate the functioning of the SILOS. 4.1 Reorganization of the Central Level The central level is defined as the set of authorities that make decisions regarding the political and administrative direction of each institution or agency. At this level it is necessary to have leadership within the health sector that possesses the capacity to orient the activities of the rest of the government departments and private organizations in accordance with national health guidelines. Currently, the majority of countries do not have such leadership, and many do not even have a duly constituted health sector. The processes of decentralization and déconcentration (delegation of authority from higher to lower levels) required set in motion the development of the SILOS must be encouraged from the central level. This presupposes a redefinition of both the social missions of the various departments and bureaucracies within the sector and the relationships among them. Without leadership from the top it will be impossible to reach consensus and bring about a sharing of resources. In most countries, it is assumed that _t he_mi n i.ste r_o.f _healt h_w.i.l l_pr.o.vi de_t he_le ade r.s h ip.,_aut ho r.i.ty_ --------------------------------------------------------------------------rro' and policy direction within the sector. However, putting this notion into practice has proved almost impossible in Latin America. For this reason, an examination of this issue becomes particularly relevant as the SILOS are about to be implemented. The role of the central level, particularly of the m.inister of health and the entities that comprise the Social Security system, is to ensure coherence between all the activities of the national health system on three planes, as defined by Eugenio Vilaca: a) a political-juridical plans (which includes the ini t ion of basic functioning of the system definition of basic regulations for the b) a political-administrative plane (which includes upper-and intermediate-level structures and functions of the system in accordance with policies of decentralization and social participation: it m.ust take the institutional culture into account) c) a political-operative plane (which establishes the relationships between operational units and the populations in a given time and space. It stipulates the linkages between agencies and between the internal units of each agency).^ If the three planes are not considered simultaneously, there is a risk of a failed administrative reform, since efforts are directed only to parts of the system when what is required is prompting profound transformations which are consistent in their political, administrative, operational and organi zational-culture aspects. Some clamor for a redesign of the entire sector as they confront the task of ope r.at i.ona l,i.z.ing_.the„S,ILOS..___________________________________ --------------------------------------------------------------------------rrr This is not to imply that there should be a separation between the central level (political-administrative leadership) and the local level (SILOS). PAHO's Coordinator of Health Services Development has emphasized that the SILOS require a model of health care and management capable of integrating the central and the local levels. The rigid division of labor in which the central level set policies and the local level carried them out is no longer acceptable.^ Reorganization of the central level requires inter departmental coordination. Roberto Capote has observed that the SILOS cannot coexist wmth the existence of institutional enclaves organized by function that have vertical administrative structures and that control resources in order to carve out self-perpetuating spheres of institutional 4.2 Decentralization and Déconcentration 4.2.1 Decentralization In Latin American ministries of health, decision making is centralized with respect to policy and administration. Decentralization in decision m.aking and déconcentration of resources are two elements without which the SILOS cannot adequately fulfill their mission. Decentralization im.plies a transfer of functions, authority and decision-making capacity to local levels for the execution of programs, negotiation with the community and mobilization of resources. -------------------------------------------------------------------------- rr2‘ The aim of decentralization is to ensure that decisions are smoothly made and executed close to the situation which gave rise to them. Decentralization is designed to bring about closer contact between the National Health System and the population, which increases the likelihood that health strategies correspond to the real needs of the population. For the PAHO, at least four conditions must be m.et in order for decentralization to have a significant impact on the new model of health services management. They are : 1) a strong political will to decentralize all government entities 2) the real transfer of political power and resources to the local level 3} the development of local political power for the management of resources and for the purpose of forming a political base through the participation of community organizations 4) the development of management skills in the administration and delivery of services.^ According to Oscar Oszlak, et ad., effective decentralization involves a dislocation in the flow of political power and cannot occur without the existence of adequate administrative capacity at each level of activity. Moreover, there is no such thing as pure centralization or decentralization, only situations along a continuum between one and the other. Decentralization may also (a) revert decision-making capacity to the community, thus making them subjects rather than objects in the preservation of their own health, (b) enable the broadening of coverage with equity and --------------------------------------------------------------------------TO" efficiency, (c) promote a process of debureaucratization of existing administrative structures, and (d) prevent the tendency toward bureaucratic hypertrophy.® David Tejada has observed that, although decentralization is implemented in stages, there must exist from the outset a local planning process involving public and private organizations and the community in order to consolidate the decentralization process. This is not easy because of the "historical inertia" of centralization, concentration of responsibilities and bureaucratization typical of the health sector.^ 4.2.2 Déconcentration The PAHO defines déconcentration as delegation of responsibilities to distinct levels of a given organization while maintaining a hierarchical dependency on the central level in decision making. David Tejada considers that there are at least three forms of déconcentration: horizontal (from one domain to another at the same level), vertical (from one domain to another at a different level), and functional (when the transference or delegation does not refer to hierarchical levels and is made to persons within the departm.ental/organizational administrative structure, to informal or non-institutional groups) .® In the case of the SILOS, déconcentration is primarily vertical. nw“ Decentralization and déconcentration complement each other and can coexist within health systems. The need to pluralize decision-making power supports the notion that both modalities can occur simultaneously within agencies. Decentralization is a m.eans to facilitate déconcentration, and it is a necessary condition for the functioning of decentralized models. Decentralization and déconcentration should not be construed to imply the creation of separate admini strative systems for the SILOS. As José Maria Marin has noted, additional structures need not be created; rather, existing procedures within each organization need to be adj usted.® 4.2.3 Decentralization, déconcentration and democracy Latin American countries are in the process of broadening their democratization processes. The involvement of the population in the determination of the activities of' agencies is an essential component of democracy. Concrete mechanisms are required to bring agencies into contact with the people they serve. Public agencies cannot assist the process of democratization if they do not first democratize themselves, which is only possible when their own officials are not objects but rather subjects of the goals of the I organization; for this, decentralization and déconcentration I ! are required. Finally, decentralization avoids the application of standard national solutions to local problems. 115 thus creating a diversity of internal modalities of work within agencies. 4.3. Social Participation Through social participation communities and public agencies share the responsibility for health. Gustavo de Roux a^. argues that agencies and SILOS must be sufficiently flexible to incorporate the community in order to make deliberation, consensus and m.utual accountability among all the participating actors viable.As these authors note, social participation in the health field is very complex, because: a) People are motivated more to organize them.selves to cure illnesses than to promote health. b) It is difficult to separate health conditions from other social conditions. This can make it difficult to establish who should participate in the SILOS. c) Comm.unities have their own power issues and, therefore, it may be too much to expect them to have a unified stance. Democrati zation and pluralism have prompted this phenomenon. d) Community participation is determined not only by the will of community organizations but also by the credibility of the public institutions in the community. lib To these considerations must be added the complexity of the environment in which the SILOS operate, which contains different types of people, families, and other groups, as well as the physical environment itself, a factor that partly determines the state of health of a given population. Moreover, many countries do not have a tradition of popular organization or popular participation. The redistribution of power within agencies and between them and the communities is among the more significant changes that will occur in the culture of the agencies that comprise the health sector in the process of implementation of SILOS. Involving the population is not easy because, as Carole Pateman has observed, ”[t]he outstanding characteristic of most citizens, especially those in the lower socio-economic status groups, is a general lack of interest in politics and political activity and further, that widespread non- democratic or authoritarian attitudes exist, again particularly among lower socio-economic status groups. The concept of participation in the health field goes beyond Joseph Schumpeter's assertion according to which the democratic method consists of the institutional arrangement for arriving at political decisions in which individuals acquire the power to decide by means of a competitive struggle for the people's vote. The community does not restrict its participation to the exercise of the vote; it also participates in health-promoting activities. ------------------------------------------------------------------------- rr?' Interests within a community are generally so diverse that public institutions or agencies can run the risk of not being able to bring about consensus on any issue. Bernard R. Berelson argues that limited participation can increase the likelihood of disagreem.ent among local organizations and public institutions. This could apply in the case of the SILOS, m.aking their im.pl em.entation more feasible. Another factor that lessens this risk is that very few existing community organizations occupy them.selves exclusively with health matters, and the socio-political process that Robert Dahl calls polyarchy (the rule of multiple minorities that have reached a consensus on norms) does not arise.Rather, organizations having other purposes tend to add health promotion as one more task. Through its support for social participation, the health sector contributes to the strengthening of democracy. Institutions play a central role in the education of the citizenry and, as Carole Pateman asserts, the evidence indicates that the experience of a participatory authority structure may also be effective in diminishing non-democratic tendencies in individuals.^^ Participation is more effective when participatory planning models take the interests of the actors involved and the power arrangements in the community ! into account. These models are based on consensus in the im.pl em.entat ion of programs, and they consider the real possibilities of people affected to carry them out. ---------------------------------------------------- ITS' 4.4 Development of Intersectoral Integration Achieving an integrated approach to health presupposes much m.ore than curing illness, as it encompasses very different areas which require the participation of the entire society. Health is the result and synthesis of human rights, housing, nutrition, education, employment, labor and other conditions outside of the purview of health-care agencies. As Roberto Capote has noted, health problems cannot be corrected through actions undertaken exclusively by the health sector. In order to achieve intersectoral integration, the following conditions must be met: a) There must be awareness on the part of numerous sectors regarding the importance of health as a m.easure of well-being of the population. b) Health-sector leaders (especially the minister of health) must possess sufficient leadership and credibility to get other sectors to pool resources. c) Sufficient political will must exist in all of the agencies involved to carry out joint programs, and the other sectors must be formally constituted so that the health sector can negotiate with them.. d) A congruence of interests and strategies within the health sector must exist in order to negotiate its needs and priorities with the other sectors. - e) A sufficient degree of local organization of other relevant government functions similar to that of the health sector m.ust exist. That is, similar policies of decentralization and regionalization m.ust exist in order to achieve reciprocity at the decision-making level. One serious limitation to intersectoral integration is that currently the majority of Latin American countries do not have organized health sectors. Indeed, it is sometimes difficult to identify which agencies consider themselves to be part of the sector. All of this complicates the role of the principal or policy-making institution. The effect is that inter-institutional or inter-departmental coordination functions more as a result of whatever good will and favorable disposition exists on the part of officials at the local level than any strategic agreement among ministries, other public institutions, and municipalities. However, as Allen Barton has observed, this personal willingness on the part of officials can m.eet with obstacles owing to situations beyond their control : The structure of public bureaucracy is said to make it impossible even for well-motivated people to do a good job. Red tape--rigid rules and lack of managerial diseretion--orevents efficient and innovative action bv public officials, in contrast to the flexibility o f action in the private sector. Municipalities are also called upon to play a key role in intersectoral action. However, according to Amy Mosquera _a nd„Ju a n_B.._ As t ipa.,_o.f _t he_Or aan i.z at ion_o,f _Ame r.i.ca n_St a t,e s.,_ T Z l T in several countries there is a generalized prejudice against the local government participation in public policy, which leads to a progressive diminution in their operational capacity and their real autonomy. Intersectoral action presupposes the existence of a national development plan. The lack of a common strategy m.akes it more difficult to achieve consensus on program.s and resources. The PAHO estimates that the greatest obstacle to intersectoral action are national developm.ent models that emphasize economics and a centralized vision of problems while discounting the social impact of policies, local participation and intersectoral action. Intersectoral action also represents a change within the organizations themselves. According to Louis Gawthrop, each agency can respond to situations of change either in a reactive or an anticipatory manner.The reactive response engenders a more , incrementalist attitude, which tends to minimize the impact of change on the existing situation. The anticipatory response attem.pts innovation, experimentation, and the achievement of new objectives. What of necessity occurs in intersectoral integration is a combination of these two types of behavioral responses. Finally, as Humberto Novaes has pointed out, one of the most important factors that facilitates the process of change toward inter-institutional integration and intersectoral action is the leadership capacity of the coordinators of the ------- 1-2T organizations involved. In his opinion, these coordinators need to possess management skills, technical excellence and a commitment to validate the Dawson model. It is difficult to imagine an efficient change without the involvement of leaders. Management skills again emerge as a key factor in the functioning the SILOS. Intersectoral integration implies the promotion of administrative reform that will have a real and lasting im.pact on the culture of the agencies that com.prise the participating sectors. This is an extremely arduous task because, "[c]hanges in ethos and attitudes cannot be forced : they must come from within, from a genuine change of heart.Intersectoral integration is essentially a question of attitudinal change. 4.5 Reorganization of Financing Mechanisms Among the many reasons why financing m.echanism.s need to be reorganized are the economic crisis, institutional inefficiency and the development of a new model of care that can respond to changes in the epidemiologic profile. 4.5.1 Financing and the Economic Situation In Latin Am.erican countries, the so-called crisis of the 1980s was characterized, in general, by high rates of inflation; greater unem.ploym.ent; a reduction in the gross domestic product; a foreign debt crisis which led, in some --------------------------------------------------------------------------r2'2‘ cases, to a suspension of foreign credit; a rise in interest rates; a decline in export prices and, consequently, an increase in poverty. The fiscal deficit led governments to reduce public expenditures, including those allocated for social programs. In light of this situation, it was not advisable to tax businesses and workers to raise revenues, as such a policy would have rendered the economies less competitive in international markets by raising labor costs. The reduction in public expenditures in health care prompted agencies within the sector to evaluate their levels of efficiency and efficacy. Evaluating health-care financing. Hector Sanchez has observed that health-care systems are currently under review because they are no longer capable of responding effectively to the needs of the population. This is due in part to the fact that they have been affected financially by (a) a crisis of rising costs and decreasing financial contributions, (b) the existence of financing needs that are beyond the financial capability of the countries, and (c) a steady deterioration in the quality of the environment and of health care. Arm.ando Cordera and Manuel Bobenreith have noted that despite rising costs, the quality of medical care has not improved significantly. This rise in m.edical care costs is causing social problems the world over, and the notion that they can be contained is considered optim.istic. 12 3 David Dunlop and Michael Zubkoff, of the World Bank, have pointed out the relationship between inflation and demand for health services, noting that inflation can adversely affect real income and raise the price of health care services. It can also contribute to changing patterns of demand for health care through its potential impact on the perception of the state of health to the extent that adverse economic conditions may reduce incentives for health-care providers to establish provider organizations. Finally, inflation can affect demand by changing relative prices of services, including (a) hospital versus outpatient care, and (b) emergency hospital services versus general medicine outpatient care. The health-care system is addressing this situation through such initiatives as rationalization, restructuring, integration, decentralization and implementation of SILOS. 4.5.2 Financing and Organizational Inefficiency Traditionally, economic aspects involved in the organization of health systems were subordinated to medical care and public health criteria. However, sectoral economic restrictions and rising costs are now demanding greater efficiency in the management of resources. The drive toward global competitiveness is motivating countries to curb their costs of production, including health care expenditures. Increasing productivity with resources 124“ remaining constant is a challenge that the health sector cannot escape. The Director of the PAHO believes that there has been considerable negligence in the management of resources. He argues that if existing waste were cut by fifty percent, coverage of services could be extended to some forty to fifty m.illion inhabitants who currently receive no medical care. The search for efficiency and efficacy has, simultaneously, another purpose: equity. Population coverage of social security programs in several Latin American countries is less than twenty-five percent. Medical care provided by the ministries of health frequently does not adequately serve rural areas, and when it does, «essential materials and technical resources are lacking. Even in industrialized countries, high costs are a pressing issue. President Clinton made health care one of the central concerns of his Administration. Changing the way in which the health sector has traditionally operated and reorganizing its financing m.echanism.s are two of the PAHO' s highest priorities for the 1990s. Equity and social solidarity should be among the considerations when designing health-care financing mechanisms. 4.5.3 Financing and Models of Care Chapter 2 described the different health status stages through which developing countries pass. One characteristic --------------------------------------------------------------------------r2’ 5 - of several Latin American countries is the s im.u 11 a ne ou s occurrence in time and space of various stages. Although infectious diseases have been controlled, they have not altogether disappeared and, at the same time, chronic and degenerative diseases, the product of the rise in life expectancy, psychoemotional factors and environmental conditions, are on the rise. This fact has conditioned both the models of care and the mechanisms of financing, because the definitive care of chronic or degenerative diseases requires greater per capita expenditures than infectious diseases. The fight against illnesses that result from negative environmental conditions requires new categories of investm.ent. The sim.ul taneous existence of different epidemiological stages complicates the financing model, particularly when the principle of equity should not be negotiable. Latin Am.erican countries are thus attem.pting "to reorganize their health care models to address new epidem.iologic realities. The new m.odel of care required puts greater emphasis on health promotion and education, prevention, and a m.ore integrated focus. This leads to the need to change the current structure of financing described by Hector Sanchez as follows : In many countries, a considerable part of health expenditures finance direct services such as curing patients, in figures that fluctuate between seventy percent and eighty-five percent of total health-care expenditures. At the same time, programs that promote he a lib_and_p rey_e.nl:_d i s e a se s_reee.i_ve_no_rnare_t h an_ten_to___ ----------------------------------------------------------------------r2’ 6 twenty percent of the expenditures and finally, those programs that provide benefits to people through environmental programs receive no more than five to ten percent of the total. The situation that prevailed until recently led to the development of an infrastructure based on hospitals, which bore the brunt of the demand for services, since at the primary, or community, level, institutional resources are very limited. In addition, due to a perception that only in hospitals can the population receive the care that it needs, the opportunity to prevent disease at the local level is lost and unnecessary pressure is created on hospitals. 4.6 Development of a New Model of Care The development of a new model is contingent upon health-care agencies giving up their strong bio-medical orientation in favor of approaches that give greater weight to the physical-social milieu and to behavior. The SILOS are a mie chan ism for the transformation of national health systems. As such, they must promote significant changes in the areas of technical procedures, the integration of knowledge, the utilization of resources and the modality of social participation. It is hoped that the SILOS will bring about real changes in the local epidemiologic profile, that I lis, in the types of health risks and problems that occur. Following the SILOS model, the hospital would join the network of services promoting health, rather than limiting _t hem selves to the ta sk o.f r.ey o_ve ry o.f__hea lbh..2f Sjzhoo%sJ 12 f would also participate by providing technical and management training to health-care personnel. The tasks required to implement the new model vary according to the country. However, certain realities common to all of the countries make it possible to establish a common work agenda. José Maria Paganini believes that these tasks include the following: (a) overcoming the dichotomy between political and technical criteria, (b) creating a legal framework that supports the SILOS and enforcing existing legislation, (c) establishing categories of health care services by age groups and pathologies, (d) integrating vertical and horizontal programs, (e) promoting both health prom.otion and treatm.ent of illness, (f) organizing multidisciplinary teams to promote an integrated vision of health care, and (g) establishing the first SILOS in the most underserved areas in accordance with the principles of equity and solidarity, gradually extending them throughout the c o u n t r y . According to a World Bank analyst, "Inequity, especially in the provision of health-care services to poor and vulnerable groups, is the most pressing problem associated with Latin American social security services, and it is in turn linked to a finding that dual systems of health care are inequitable."^^ The diversity of this agenda reflects the complexity of the task before the health sector in the implementation of the SILOS. --------------------------------------------------------------------------r2‘ 8 ' 4.7 Integration of Prevention and Control Programs There are some diseases that can be prevented and others that, although latent, can be controlled through appropriate programs in order to prevent them from spreading. Health care agencies can achieve much in the area of prevention and control of diseases provided that there exists internal agreement and the support of the community in promoting its own health. The SILOS are designed to serve as the agencies in which both of these processes can occur. The integration of prevention and control activities requires a convergence between clinical skills, knowledge of epidemiological conditions and administrative abilities. The risk factors for the appearance and developm.ent of some diseases are, in most cases, found in local conditions, and it is there where they can be eliminated or at least controlled. Each geographic area has its own disease characteristics. Thus, the effectiveness of institutional prevention and control programs depends on their degree of integration with and adaptation to the conditions of the communities themselves. The PAHO member countries have established specific goals in the areas of reinforcing knowledge of epidemiological analysis and health information I systems and increasing the capacity to incorporate the content and actions of prevention and control of risks to SILOS programming systems at the local level. --------------------------------------------------------------T2’ 9’ 4.8 Strengthening Administrative and Management Skills The transformations described in the preceding pages can be implemented only by upgrading the administrative processes and the management skills of those who provide leadership at both the central and the local levels. As a number of studies have concluded, the insufficient operational capacity of health-care services and non-productive expenditures are consequences of deficient administrative and management system.s, procedures and practices. Proper functioning of the SILOS will require the training of work teams in state-of- the-art technical and management skills as well as installing up-to-date information systems to facilitate epidemiological analysis of the geographical areas in which the SILOS operate. As stated by Robert E. Tranquada, in most of Latin America almost all administrators in the health sector, from the minister to the hospital director, to regional and area directors are medical doctors who have had no training at all in administration. This com.plicates the situation even m.ore, because the basic education of these physician- "administrators" was in the bio-medical m.odel of health and disease, and most automatically reject the social models.39 4.8.1 Administrative and Managerial Capacity Although these two concepts are related, they should not be confused. Managerial capacity refers to the development 13U of knowledge, skills and attitudes in persons responsible for the task of management of public institutions. Administrative capacity refers to the support that operational policies and procedures can provide to the SILOS. It includes elements such as the design of the organizational structure, norms and regulations governing the use of resources, personnel policies, and strategic and administrative decision-making processes. To ensure that the existing administrative and managerial capacities in health-care agencies are effective, they m.ust possess decision-m.aking authority, defined by Miguel Segovia ejb al. as the ability of organizations to contribute to an im.provem.ent in living standards, resolve health problems of the population and alter situations considered to be detrimental to health or to conserve the state of health that has been reached.There may exist situations in which human resources have received m.anagement training but the agency does not possess decision-making authority due to internal or external policy limitations, legal impediments, or the organizational culture. Raul Penna considers that there is widespread acceptance of the theoretical concepts regarding decentralization, local programming, integration and new form.s of administering resources, but, he cautions : the attempt to put these principles in practice under current conditions has been extraordinarily frustrating. So frustrating that it has led to many repipna 1 dir.epbor.s to put them s.e Ixes in an___ ------------------------------------------------------- T3T administratively derelict position in their zeal to make the experience work. How many times have we had the unfortunate experience of seeing technically brilliant and politically impeccable arguments put forth by young health professionals full of enthusiasm., fail when confronted . . . with the reality of an administrative structure that will not permit new methods of ooeratina.^^ 4.8.2 Political Viability and Managerial Capacity It is hard to find a public leader who opposes administrative modernization and the reforms mentioned in the preceding pages. Why, then, has the process of implementation been so slow? One possibility is that, faced with such a profound change, a consensus must first be reached among all of the actors involved. In many countries a democratic culture is just beginning to emerge, and the custom of dialogue and negotiation does not exist. Another reason m.ight be that adm.inistrative systems are so deeply entrenched that their leaders do not possess the vision, the ability nor the intention nor the incentive to change them, especially when faced with a possible loss of power due to the obsolescence of their skills and/or erosion of authority. There are reforms that, however appropriate, have such a high political cost that the political party in power would prefer to avoid them. In his analysis of the need to take on the problems of health-care financing, Carm.elo Mesa-Lago has found that, without denying the importance of economic issues, it is the existence (or absence) of political will and power what has been crucial in the execution (or 132 avoidance) of necessary reforms. He also, identified inter- organizational conflicts as a source of the current situation : Often, interest groups have successfully opposed reforms in order to preserve the status quo. In the end, personal and political conflicts between leaders within the ministry of health and the social security administration in many countries are traditional and, with a few notable exceptions, continue despite the tendency toward rapprochement of both agencies prompted by international organizations . An additional reason why decision-making authority does not accompany political will or vice versa may be that certain initiatives, such as the SILOS, are identified with or promoted by a particular political party in power, and when a different party comes to power, changes in process are stymied or interrupted. These partisan considerations may result in the election of people with limited managerial capacity to occupy positions of considerable responsibility. This is why a high turnover rate in the leadership is common in a number of Latin American countries, with the added disadvantage that the resources invested in training them are not used to optimial advantage in the health sector. These limitations within the health sector must be considered when planning for the development of managerial capacity. 4.0.3 Innovation in Managerial Capacity High costs are another reason to seek innovation in managerial capacity. A study by the Economic Commission for Latin America (£CLA) nevieal.ed that admini.strati-V.e. r33’ expenditures for social security in Latin America are much higher than in developed countries. Carmelo Mesa-Lago has suggested that improved budgetary norms and controls be implemented, strong sanctions be applied and educational campaigns designed to address high adm.inistrative costs (especially in social security), waste and corruption. High costs notwithstanding, the most important reason to seek a change in the managerial capacity is the change in the health-care model. As Jose Maria Marin has pointed out, traditional administrative practices in health-care systems are no longer considered adequate to stim.ulate the increase in the level of decision-making authority required by the SILOS. Diego Victoria has argued that the change in administrative capacity required is so profound that any partial reform, should be rejected and that the transformation must have a new, integrated systems approach that can lend political, financial, administrative and technical viability to the process of implementation of the SILOS. Officials with the most experience in the implementation of SILOS in Central America point out that this new m.anagerial capacity is not developed and that this becomes an obstacle in the case of the more politically, socially, financially and adm.ini strati vely complex national health systems. The existing capacities are increasingly obsolete. T3A 4.8.4 Managerial Capacity and SILOS The need to improve capacities is more dramatic at the local level, since officials are not accustomed to making their own decisions about how to administer policies and procedures. Moreover, centralization has encouraged strong dependence on administrative structures and mechanisms at the central level. The transfer of decision-making authority to the SILOS in an attempt to achieve efficiency, efficacy, equity and social participation is one of the greatest challenges facing the health sector in this decade. According to Diego Victoria, four factors that determine the decision-making authority of the SILOS are: (a) the level of organizational autonomy, (b) departmental and sectoral coordination, (c) broad social participation, and (d) the capacity to orient the models of organization and administration of available resources. Considering these four factors, the design of the administrative systems of the agencies participating in the SILOS should be: decentralized/deconcentrated; capable of coordinating with the different administrative processes of each organization in the local system; and flexible enough to respond to opportunities, embrace citizen participation and support the new model of care. r35“i 4.8.5 SILOS and Local Strategic Management The development of managerial capacity is a process that must be carefully planned so that it advances according to the need and potential for institutional transformation. The tactic currently in use is to conceive of the SILOS as the basic change units, while instituting more gradual changes at the other levels, in order to facilitate their functioning. This is change from the bottom up, intended to create the conditions for the operation of the SILOS through an administrative modality known as local strategic management (LSM), defined as a means to connect health problems and needs in a given geographical area with institutional and community know-how and resources, thus making it easier to define priorities, consider alternatives of action, allocate resources and manage the process through to resolution or control of the problem. The modality is called "strategic" because it is not simply reactive with respect to health or management problems. Rather, it promotes a proactive approach and a close relationship between organizations in order to create a shared vision with respect to the transformation of the local reality. LSM is designed to accomplish three key functions key for SILOS: direction, planning and management. Direction is defined as the capacity to promote consensus and coordinate rsT efforts for the purpose of reaching one or more established objectives- Planning is defined as the activity designed to determine the type, num.ber and recipients of the services of promotion, recovery, and rehabilitation as well as the social arrangement required to solve problem.s and satisfy priority needs. Management is the activity developed by all of the constituents within a given health-care system designed to organize and coordinate the available resources for the efficient and effective im.plementation of actions within the total system. The emphasis on equity, the presence of ambiguities and uncertainties in the transition phase and the fact that the management area has been viewed as secondary in health-care agencies, all underscore the im.portance of this particular function at this stage of change within in the sector.A change in the epidem.iological situation of the population requires a change in the management capacities and approach employed to address the new health status. 4.9 Training of the Work Force in the Health Sector 4.9.1 Change of Approach in the Modality of Work All of the eight conditions described above point to the need for new skills and attitudes on the part of officials, particularly those working at the local level. Public institutions must become learning organizations, to use Peter Senge's term, and learning must be ongoing and flexible.To comprehend the magnitude of the changes expected in the type 13 7 of training to be provided, it would be useful to review some of the changes that occur when the SILOS are implemented: Planning of activities are conducted at the local rather than at the central level. Planning is not based exclusively on the individual strategies of each agency; rather, it is guided by the principle of intersectoral integration. Vertical programs give way to an integrated health-care model. The very concept of health is m.odified to incorporate promotion, which result in a broadening of individual responsibilities. Decentralization demands that the personnel that acquire new responsibilities receive a level of management training that they never before needed or utili zed. The promotion of social participation requires a profound change in the skills of personnel unaccustomed to opening up their agencies to this type of contact with the community. Local officials become responsible not only for short term activities but also for the management of a process of institutional, sectoral and social transformation. This requires the ability to think and act strategically. The balance between the status and m.edical and administrative personnel is another important change. -------------------------------------------------------------------------- rre- since it is necessary to reach a shared vision, and thus a complementarily, between these two areas. Typically, managerial or administrative activity is not considered to be on a par with medical or technical activity in m.any health-care agencies. The change in the organizational culture that will occur with the functioning of the SILOS is truly profound. Between sixty and eighty percent of the health budget will be invested in personnel. Yolanda Arango estim.ates that in the first half of the 1980s the labor force employed in the health sector in .Latin America numbered some 1,050,000 workers, of which fifty-eight percent were professionals, eleven percent were technicians and thirty-one percent were auxiliary personnel. 4.9.2 Areas for Training and Development As Jorge Haddad et ad . have observed, the most important characteristic of health-care delivery is its dependence on human labor. The development of human resources must be intimately related to the SILOS. Therefore, priorities must be set in the areas of training and developm.ent. The decision-making authority and the decision-making analysis at the local level are crucial at this mom.ent. It is necessary to improve local leaders' capacity to apply the epidemiological approach to knowledge of the state of health of the population in order to define priorities at the local 139 level, with respect not only to current health problems but also to risk factors. Increasing efficiency is a also key issue, as it is estimated that some twenty-five percent of health-care resources are currently wasted. Raul Penna advocates improving negotiating skills and the ability to analyze strategically the political, social, economic and financial environment in which the officials must interact. With the SILOS, greater integration and coordination must be developed between the health sector and the universities. To achieve this, the PAHO has established a Health Services Management Skills Development Project in Central America, which attempts to link the health-care entities (training needs and management skills) with educational agencies (sources of training and support for organizational development). Figure 8 summarizes the current strategic orientations of the PAHO. It is noteworthy that all of them imply greater levels of training and development for workers within the health sector. In Central America, conditions do not yet exist for the development of a human-resources strategy consistent with the functioning of the SILOS. Representatives of the health-care agencies of these countries concur that there are constraints such as the lack of job security of the work force, the lack of a tradition of careers in management as such, inequities in benefits and incentives and the lack of a JFigure _8 Siraljegii: QrXani^ilans J.or ihe PAHO f ox the Period 1991-199à ITO' Utlllzatloo o f so ci a l e o m t n m u a i e a t l Q O I n h e a M h Integration of women In health care and development Administration of knowledge Health promotion Focus on high-risk groups Mobilization of resources Health as a Component of Development Cooperation among coutrfes Reorganization of the health sector Reduction of the Major problems faced by health care and the transformation of the sector In the 1990s. Source; Pan American Health Organization^ Orie.ntaciones Estratégicas y Prioridades Programmâticas. 1991-1994 (Washington,-. D.C.: Pan American { Health Organization, 1991), 70. ) -------------------------------------------------------------------------- lÂî-r relationship between the characteristics of the position and the type of education available."® 4.9.3 Profile of Training Curriculum There is broad consensus among health-care agencies, the PAHO and Latin American educational agencies regarding the need to strengthen knowledge and skills in the following areas: analysis of the political, social, economic and technological dimensions of national and international environments; sectoral and strategic analysis; institutional development and management of change; personnel management techniques and skills; administrative techniques, and im.plementation of the SILOS. From, this consensus a general profile of the academic content of a course for functionaries of the agencies charged with im.plem.enting the SILOS, which could be modified according to the needs of each country, can be designed. This course would em.phasize m.anagerial and participatory aspects rather than technical (epidemiological and health), aspects, which are more widely available. 4.9.4 Modalities of Training Changes in the type of training available are necessary not only on the demand side (health-care agencies) but on the supply side (universities) as well. Experts in management development in the health sector suggest that the methodology should be based on real-life situations that are typical of --------------------------------------------------------------------------r4'2" the experience of health official s. Miguel Segovia ^ al. propose that training programs designed to support SILOS incorporate the following el em.en ts : (a) in-service programs or courses that examine problems currently faced by officials in their agencies, (b) innovative methodologies aimed at increasing the number of participants benefitting from the course, (c) training should be included in incentives and remuneration packages, (d) training programs should produce a multiplier effect, and (e) training programs should be oriented more toward teams than toward individual in order to curb personnel rotation. 61 Jorge Haddad et a]^. propose that the pedagogical process should include permanent, m.ultidisciplinary training within a real-life context (which will vary according to country and health-sector strategy), and ongoing follow-up courses. Participatory and experiential methods are considered to have the greatest potential. 4.9.5 Im.pact of Training: Revitalization? The most important impact of training may be the activation of efforts at adm.inistrative reform, ’ ’from, within” with the involvement and the creativity of the officials working in the SILOS. Adm.inistrative reform in an agency can be induced either externally or internally. Usually, reform processes have originated outside an organization and enhance the power of influence of its leaders. -------------------------------------------------------------------1T3---- The strategy for reform in public administration was obvious: to convince leaders that changes in the machinery of government were imperative to improve the performance of government and increase the efficiency and efficacy of public organizations. Once the leaders were so convinced, the only question left was that of specific details to be worked out with civil servants who would have to implement them. The key was to convince the public leaders who ruled over the machinery of government. Not much consideration was given to approaching the civil servants directly and getting them to change themselves or convincing them that they ought to assume the initiative in administrative reform. Health-care agencies are so large and complex that even when they have the necessary political power, change ”from above” is difficult to bring about. Those most able to transform institutional performance at the local level are those who know what really happens at that level: obviously, political support is necessary but not sufficient. Training should be oriented not only toward the acquisition of new knowledge but also toward strengthening skills that enable people to ”learn how to learn” to do things differently. That is, to create a permanent capacity for self-learning, self-transformation. These teaching- learning processes can cooperate in the creation of this capacity to achieve revitalization. The capacity is needed so that local teams can review their own processes and practice ’ ’reengineering.” Social participation is one mechanism of feedback through which public servants can identify and determine the skills, knowledge and attitudes that they need to develop. .How.ev.er.,_it_sho.uld_not_be_as.sumed_that_pr.ov.iding_tr.aining_for_ --------------------------------------------------------------------------R T these officials and encouraging their participation answers all problems. Acquiring new techniques does not in itself solve problems. With respect to budgeting, for example, Naomi Caiden has pointed out, The assumption of neutral techniques has come under strain as the importance of outside forces in shaping budgets has become increasingly evident. Budgeting practices represent the consequences of interactions among a variety of participants. The budget process is as much a set of relationships as a series of techniques. Whatever techniques are adopted will be shaped by those relationships.^^ Training should not be restricted to public servants within the health sector. People who make decisions about the allocation of resources and the budgeting process should also receive training. Induced reform and revitalization, must go hand in hand. 4.10 Research and Local Health Systems Latin American countries have very limited experience with modalities of work such as those required for the SILOS. They have been learning along the way in recent years. Research can be a valuable tool to shorten the learning time as well as to generate innovations in the delivery of services. The ministries of health have established clear guidelines in this regard, emphasizing that the implementation of the SILOS should be evaluated in order to ensure that the principles of equity, efficiency, efficacy and social participation are being applied. 1-4 -5 ' However, the PAHO realizes that in order to achieve these goals it will have to eliminate or reduce the existing im.pediments to research. These include the practice of orienting research more toward the supply of services than toward the demand, com.rn.unication gaps between researchers and professionals in the health sector, weaknesses in the collection and dissemination of information, the insufficient number of agreements for studies conducted jointly by health-care and research agencies, and the lack of clarity with respect to intellectual property issues. The Central American officials most closely linked to the SILOS advocate a modality known as applied research which produces concrete suggestions to resolve immediate problems in the new organizational structures of services. Abraam Sonis has suggested that studies which (a) explain the developm.ent of service providers and their impact on local health conditions, and (b) analyze the diverse organizational and epidem.iological factors that influence productivity, coverage, impact, accessibility, universalization, efficiency, efficacy, client satisfaction and quality of services delivered, should be given priority. In the opinion of Adolfo Chorny et ^., the areas that warrant study include: the superstructure or suprasystem. related to the SILOS (understood as the set of determinants ------------------------------------------------------------ 14 b and conditioning factors that lead to a given configuration in the SILOS), the SILOS itself considered as a "black box," and its relationships with the health sector and the diverse subsystems that comprise the SILOS. Obviously, these studies should be m.ultidi sciplinary. Direct participation in the studies by officials involved in the SILOS would be a learning experience that could help them bring about needed changes. As Chris Argyris has argued, "It is individuals who will do the actual implementing, the acting, even though they may be serving as agents for an organization or group."®® If SILOS represent change, then research on SILOS is also research on change. Assessing organizational change is difficult and often violates traditional notions of what constitutes good scientific research. For this reason, close cooperation between practitioners and researchers can produce useful results for both theory and practice. Research on SILOS is complex. There are many factors that condition their performance, which makes the task of explaining it difficult. Hackman has observed that searching for a single cause of performance effectiveness can make it harder, not easier, to learn about the organizational conditions that foster good perform.ance. The rigid policies and procedures in the health sector can hinder the ability of officials to im.pl ement their own ideas for the management of the SILOS. However, experience ------------------------------------------------------------ R'7' has shown that these officials find ways to implement the SILOS even when fewer than the ten conditions described in this chapter are present. Research could also be oriented toward documenting how these people have managed to im.plem.ent their visions and gradually transform an organizational culture.Ethnographic methods may be useful in this regard. The ten conditions do not occur in the same manner in every country because their historical, political, economic, sociocultural and technological situations are distinct. The point of departure is political will and concerted efforts in the area of administrative reforms in the direction of decentralization of health-care agencies, as well as the promotion of cooperation among them at both the central and the local levels. The SILOS will produce a significant change in the complex organizational culture of the health sector.This change could in turn result in significant improvements in the health of the Latin Am.eri can peoples, which would constitute an important contribution to their development. ‘ 14'8' CHAPTER 4 REFERENCE NOTES 1. Gerald E. Caiden, Administrative Reform Comes of Age, 151. 2. Eugenio Vilaca Mendes, "Importancia de los Si sternas Locales de Salud en la Trans formiaci on de los sistemas Nacionales de Salud," in Sistemas Locales de Salud. Conceptos. Métodos.Experiencias, 22. 3. Jose Maria Paganini, "Sistemas Locales de Salud: Un Nuevo Modelo de Atencion", 50. 4. Roberto Capote, "Sistem.as Locales de Salud : Organizacion, Regionalizacion, Principios Générales," in Sistemas Locales de Salud. Conceptos. Métodos. Experiencias, 132. 5. Organi zacion Panamericana de la Salud, Desarrollo y Fortalecimiento de los Sistemas Locales de Salud fWashinaton, D.C.: Oraanizacion Panamericana de la Salud, 1989), 19. 6. Oscar Oszlak, Horacio Boneo, Ana Garcia de Fanelli, and Juan José Llovet, "Descentralizacion de los Sistemas de Salud: el Estado y la Salud, " in Los Sistemas Locales de Salud. Conceptos. Métodos. Experiencias, 64. 7. David Tejada de Rivero, "Descentrali zacion y Sistemas Locales de Salud: una Cooperacion a la Unidad de Doctrina," in Los Sistemas Locales de Salud. Conceptos. Métodos. Experiencias, 83 . 8. Ibid., 83. -------------------------- 9. José Maria Marin, "Consideraciones sobre Desarrollo de la Capacidad Gerencial en el Proceso de Desarrollo y Funcionamiento de los Sistemas Locales de Salud," in Descentralizacion de los Servicios de Salud como Estrategia para el Desarrollo de los Sistem.as Locales de Salud, 74. 10. Gustavo de Roux ejt , "Participacion Social y Sistemas Locales de Salud", 39-40. 11. Carole Pateman, Participation and Democratic Theory (Cambridge: Cambridge University Press, 1970), 3. 12. Joseph Schumpeter, Capitalism, Socialism and Democracy (London: Geo. Allen & Unwin, 1943), 269. 13. See Bernard R. Berelson, Paul F. La zarfeld, & William. N. McPhee, Voting (Chicago: University of Chicago Press, 1954). 14. See Robert A. Dahl, Preface to Democratic Theory (Chicago: University of Chicago Press, 1956). 15. Carole Pateman, Participation and Democratic Theory, 105. 16. Gustavo de Roux eju a^. , "Parti cipaci on Social y Sistemas Locales de Salud," 42-44. 17. Roberto Capote, "Sistemas Locales de Salud: Organizacion, Regionalizacion, Principios Générales," in Los Sistemas Locales de Salud. Conceptos. Métodos. Experiencias, 129. 18. Organi zacion Panamericana. de la Salud, Talleres Subregionales : Experiencias y Conclusiones, Vol. 1, Desarrollo y Fortalecimiento de los Sistemas Locales de Salud (Washington, D.C.: Organi zacion Panamericana de la Salud, 1989), 32. 19. Allen H. Barton, "A Diagnosis of Bureaucratic Maladies," in Making Bureaucracies Work, eds. Carol H. Weiss and Allen H. Barton (Beverly Hills: SAGE Publications, 1979), 28. 20. Amy Mosquera and Juan B. Astica, "La Integracion de la Planificacion al Desarrollo Nacional: la Instancia Regional,” in La Planificacion y Gestion del Desarrollo Nacional : el Rol de los Gobiernos Locales (Quito : Centro de Capacitacion y Desarrollo de los Gobiernos Locales, 1988), 109. 150 21. Organizaciôn Panamericana de la Salud, La Administracion Estratégica Local, 20-22. 22. Louis C. Gawthrop, Public-Sector Management Systems and Ethics (Bloomington: Indiana University Press, 1984), 40-57. 23. Humberto de Moraes Novaes, Development and Strengthening of Local Health Systems in the Transformation of National Health Systems, 140. 24. Gerald E. Caiden, Administrative Reform Comes of Age, 312. 25. Hector Sanchez, "Sistemas de Financiamiento de Salud," in Nuevas Modalidades de Atencion Ambulatoria Urbana en Costa Rica, eds. Rodrigo Bustamante, Luis B. Saenz, and Diego Victoria (San José: Programa de Preparatives para Situaciones de Emergencia y Coordinacion del Socorro para Casos de Desastre, 1992), 34. 26. Armando Cordera and Manuel Bobenreith, Administracion de Sistemas de Salud, Vol. 11 (México, D.F: Privately printed, 1983), 514. 27. David Dunlop and Michael Zubkoff, "Inflacion y Comportamiento del Consumidor en el Sector Salud," in Analisis de Costos, Demanda v Planificacion de Sistemas Locales de Salud, Vol. 11, Desarrollo v Fortalecimiento de los Servicios de Salud (Washington, D.C.: Organizaciôn Panamericana de la Salud, 1990) 250-251. 28. Héctor Sanchez, "Sistemas de Financiamiento de Salud," 39. 29. Carlyle Guerra de Macedo "Mensaje del Director : Eficiencia," Boletln de la Oficina Sanitaria Panamericana. Vol. 101, No. 1 (1986): i. 30. Organizaciôn Panamericana de la Salud, Orientaciones Estratégicas v Prioridades Programaticas 1991- 1994. (Washington, D.C.: Organizaciôn Panamericana de la Salud, 1991), 42. 31. Héctor Sanchez, "Sistemas de Financiamiento de Salud," 38. 32. Ibid.. 46. 33. Organizaciôn Panamericana de la Salud, Desarrollo V Fortalecimiento de los Sistemas Locales de Salud, 22-23. 151 34. José Maria Paganini, "Sistemas Locales de Salud: Un Nuevo Modelo de Atencion," 51-55. 35. William P. McGreevey, Social Security in Latin America: Issues and Options for the World Bank. (Washington, D.C.: The World Bank, 1990), 9. 36. The document Desarrollo v Fortalecimiento de los Sistemas Locales de Salud en la Transformaciôn de los Sistemas Nacionales de Salud was included in the Resolution XV of the Latin American and Caribbean ministers of health of the Latin American at their meeting as the Board of Directors of the PAHO on September 30, 1988. Since that time, the condition of integration of prevention and control programs for the functioning of the SILOS has evolved, and health promotion has now been added to prevention and control. Health promotion promotes a life style rather than the mere prevention of disease. The population is encouraged to develop habits (physical exercise, mental health, recreation, preservation of the environment, etc.) and not merely to avoid problems such as alcoholism, smoking and infectious- contagious diseases. 37. Organizaciôn Panamericana de la Salud, Orientaciones Estratégicas v Prioridades Programaticas 1991- 1994, 93. 38. Organizaciôn Panamericana de la Salud, Desarrollo V Fortalecimiento de los Sistemas Locales de Salud, 24-25. 39. Dr. Robert E. Tranquada, School of Public Administration, University of Southern California, interview by author, Los Angeles, 18 January 1994. 40. Miguel Segovia, et ^. , "La Capacidad Gerencial en el Proceso de Desarrollo de los Sistemas Locales de Salud." in Sistemas Locales de Salud. Conceptos. Métodos. Experiencias, 203. 41. Raul Penna, "Concepto de Modelo de Atenciôn y su Relaciôn con el Desarrollo Social," in Nuevas Modalidades de Atenciôn Ambulatoria Urbana en Costa Rica, 19-20. 42. Carmelo Mesa-Lago, Financiamiento de la Atenciôn a la Salud en América Latina y el Caribe, con Focalizaciôn en el Seguro Social (Serie de Estudios de Seminaries del Institute de Desarrollo Econômico, No. 42) (Washington D.C.: Banco Mundial, 1988), 54. 43. Iveta Ganeva, ed. Descentralizaciôn de los Servicios de Salud como Estrategia para el Desarrollo de los Sistemas Locales de Salud, 140. 44. Economie Commission for Latin Am^erica and the Caribbean. El Desarrollo de la Seguridad Social en América Latina, No. 43, Estudios e Intormes de CEPAL (Santiago, Chile: Comisiôn Econômica para América Latina v el Caribe, 1985), 25. 45. Carmelo Mesa-Lago, Financiamiento de la Atenciôn de la Salud en América Latina y el Caribe, con Focalizaciôn en el Seguro SociaR 59. 46. José Maria Marin, "Consideraciones sobre Desarrollo de la Capacidad Gerencial en el Proceso de Desarrollo y Funcionamiento de los Sistem.as Locales de Salud, " in de los Servicios de Salud como Estrategia para el Desarrollo de los Sistemas Locales de Salud, bS. 47. Diego Victoria, "El Desarrollo Institucional de los Sistemas Locales de Salud," in Descentralizacion de los Servicios de Salud como Estrategia para el Desarrollo de los Sistemas Locales de Salud, 62. Organizaciôn Panamericana de la Salud, Talleres Subregionales : _____Experiencias y Conclusiones, Vol. 1, Desarrollo v Fortalecimiento de los Sistemas Locales de Salud, 33. 49. José Maria Marin, "Consideraciones sobre desarrollo de la Capacidad Gerencial en el Proceso de Desarrollo y funcionamiento de los Sistemas Locales de Salud," 72. 50. Diego Victoria, "El Desarrollo Institucional de los Sistemas Locales de Salud," 63. 51. Organizaciôn Panamericana de la Salud, La Administraciôn Estratégica Local, 4 8. 52. Ibid., 96. 53. Peter M. Senge, The Fitth Discipline (New York: Doubleday, 1990), 3. 54. Yolanda Arango, "El Subsisterna de Personal en los Sistemas Locales de Salud," in Los Sistemas Locales de Salud. Conceptos, Métodos, Experiencias, 24 8. 55. Jorge Haddad, Carlos Linger, José Paranaguâ and José Rodriguez, "Desarrollo de la Fuerza de Trabajo para los Sistemas Locales de Salud," in Los Sistemas Locales de Salud. Conceptos. Métodos. Experiencias, 2 60. ---------------------------------------------------------------------- T53' 56. Organizaciôn Panamericana de la Salud, Orientaciones Estratégicas y Prioridades Programaticas 1991- 1994, 18. 57. Yolanda Arango, "El Subsistem.a de Personal en los Sistemas Locales de Salud,", 247. 58. Raûl Penna, "Concepto de Modelo de Atenciôn y su Relaciôn con el Desarrollo Social," 22. 59. Organizaciôn Panamericana de la Salud, Talleres Subregionales: Experiencias y Conclusiones, 38. 60. Organizaciôn Panamiericana de la Salud, "Taller sobre Sistemas Locales de Salud en los Paises del Area Andina, Bolivia, August 15-19, 1989," in Talleres Subregionales: Experiencias y Conclusiones, 15. 61. Miguel Segovia et ^ . , "La Capacidad Gerencial en el Proceso de Desarrollo de los Sistemas Locales de Salud," 2 06. 62. Jorge Habbad et aA., "Desarrollo de la Fuerza de Trabajo para los Sistemas Locales de Salud," 272.- 63. Gerald E. Caiden. "Reform or Revitalization?" in Strategies for Administrative Reform, eds. Gerald E. Caiden and Heinrich Siedentoof (Lexinaton, MA: Lexinaton Books, 1982), 86. 64. Naomi Caiden. "Dilemmas of Budget Reform." in Strategies for Administrative Reform, 94. 65. Organizaciôn Panamericana de la Salud, Desarrollo y Fortalecimiento de los Sistemas Locales de Salud, 26 66. Organizaciôn Panamericana de la Salud, "Taller sobre Sistemas. Locales de Salud, Honduras: January 24-27, 1989." in Talleres Subregionales: Experiencias y Conclusiones, 3 9. 67. Abraam Sonis, "La Investigaciôn de servicios de Salud, Problemas Actuales," in Sistemas Locales de Salud. Conceptos. Métodos. Experiencias, 443. 68. Adolfo Chorny et aA.,. "Investigaciones y Sistemas Locales de Salud," in Sistemas Locales de Salud. Conceptos. Métodos. Experiencias, 451. 69. Chris Argyris, "Making Knowledge More Relevant to .P .r a. c .t ice.: Maps_for_Act ion.,_Y_in_Doi ng_Re.se a r.ch._t h at-i.S—Usef u 1. 154 for Theory and Practice, eds. Edward E. Lawler III, and others (San Francisco: Jossey-Bass Publishers, 1985), 80. 70. Edward E. Lawler III, "Challenging Traditional Research Assumptions," in Doing Research that is Useful for Theory and Practice, 13 71. J. Richard Hackman, "Doing Research that Makes a Difference," Doing Research that is Useful for Theory in Practice, 136. 72. James Spradley, The Ethnographic Interview (New York: Holt, Rinehart and Winston, 1979), 3. 73. See German Retana and Damaris Cordero, "Consultorla de Procesos: Una Cooperacion al Proceso de Cambio," in Temas de Discusion, Vol 17, Desarrollo y Fortalecimiento de los Sistemas Locales de Salud. (Washington, D.C.: Organizaciôn Panamericana de la Salud, 1993). 1-27. 155 CHAPTER 5 HISTORY OF HEALTH-CARE DELIVERY IN COSTA RICA Social security has played a key role in Costa Rica’s development. But its future role will depend on the transformation of the current national health system. Although in the past there have been duplications of :es, [T] his will not be possible in the future. The high cost of health care demands an integration of plans and program.s that result from clearly defined policies. In addition, all agencies or institutions in the health care sector, both public and private, must be incorporated into the new system in order to bring about a rational utilization of all available resources.^ According to Cesar Vallejo and Roberto lunes, consultants for the World Bank, "the miost important challenge facing Costa Ricans with respect to health care is preserving and increasing the high levels of coverage and equity reached in the past."^ This challenge cannot be met without effective integration of the policies and activities of the various agencies that comprise the health sector. Costa Rica’s achievements and dilemmias in health care cannot be understood without takina into account the orocess ------- - — - 156 of transformation it has undergone throughout its history. This chapter presents the historical evolution of the health care delivery system of the country and attem^pts to demonstrate that there are cultural elements that have influenced and determined values or principles of action that, without a doubt, will strongly influence the im.plementation of the SILOS. As will be noted, the last stage, which encompasses the period 1970 through 1992, will be presented in an abbreviated form and will be described in greater detail in Chapter 5. Chapter 6 will describe the formation of the National Health System and the beginning of the process of inter-institutional integration, which is the essential basis for the development of the SILOS. This historical overview of the health sector will emphasize its institutional evolution, which can be divided into four stages. In each, the most relevant characteristics of the form of health-care service delivery, the most significant events and those organizational transformations that have had the greatest impact on the current situation will be identified. Beginning with the second stage (which began in 1900), the life-expectancy indicator will be included since it is commonly employed to describe the state of health in a given country. Edgar Mohs described the institutional evolution of the health-care sector in Costa Rica as a process with four identifiable stages, as follows: ' 157 The first [stage] appeared in the middle of the last century, and [during this stage] basic health care was provided, particularly to the needy. The second, covering the period from 1900 to 1940, was characterized by the introduction of public-health programs and the concept of welfare to help the poor. During this period, the institution that would later become the Ministry of Health was created. The third, from 1940 to 1970, was characterized by a marked interest in preventive medicine, the attempt to form a national hospital system and the creation of the Costa Rican Social Security Bureau. The fourth stage began in 197 0 with the development and implementation of a National Health Plan whose main objectives, were the development of a national health system which would provide coverage to the entire population and control common infectious diseases and malnutrition. 5.1 First Stage: Basic Health and Welfare From colonial times to the beginning of the twentieth century, medicine was rudimentary and had a charity orientation. The first two physicians who arrived in Costa Rica with Governor Juan Vasquez de Coronado in 1562 did not settle there. In the two centuries that followed, the presence of physicians was sporadic. Later, in the mid eighteenth century, the physician and priest Juan de Pomar y Burgos, who resided in Panama, began to make periodic visits. It was not until 17 90 that the first physician, an Italian, Dr. Esteban Courti, arrived and established residency. In those years Costa Rica was the most backward province in the kingdom of Guatemala, its 50,000 inhabitants vegetated miserably in great isolation; in all the land there was not a print shop, a physician, or a pharmacy.^ The work of Dr. Courti was not very successful, since "our simple and ignorant people attributed their cures to magic, and this pioneer of Costa Rican medicine was sent to Guatemala to be tried by the Inquisition."®' Later on, other foreign doctors arrived, and the first Costa Rican physician graduated in Europe, who began a private medical practice. The earliest events in the history of Costa Rican health care were the opening of the San Rafael Hospital in Puntarenas, where emergencies caused by the invasion of William Walker's troops from Nicaragua in 1856 were treated; the establishment of a hospital in Cartago at the end of the eighteenth century, which closed a few years later for lack of resources; and the founding of the San Juan de Dios Hospital, by decree dated July 3, 1845, issued by Governor Jose Rafael de Gallegos, although it did not begin to provide services until 1852. At first, the San Juan de Dios Hospital was run by volunteers organized in a Charity Board. This first board was formed after Bishop Anselmo LLorente y Lafuente called together several people from the community to participate. The composition of this board is significant because it served as a model for the formation of similar groups that established and managed other hospitals in the country with the active participation of people outside the government. __ 159 This was one of the earliest examples of a relationship between the state and the community for the purpose of providing medical care. This relationship subsequently continued to develop, as will be described in the following sections. One hundred years later, it has come to exert considerable influence in the functioning of the SILOS. This same Charity Board administered the first hospital for the mentally ill, which opened its doors in 1893, ten years after it was approved, due to' the lack of resources. To finance this hospital a national lottery was established, the proceeds of which were used to support the Charity Boards in other provincial capitals. In 1857 the Protomedicato and the Medical Society were formed. These early physicians' organizations promoted medical and pharmacological training. In 1889 the School of Obstetrics was founded. An important event occurring in this period was the discovery by Dr. Carlos Duran® of the parasite known as ancylostoma, which caused a common and severe anemia found among the peasant population. A campaign was launched to combat it. This was the first of a number of programs and campaigns in other areas such as environmental sanitation, health education and social protection.^ At the turn of the century, in 1806, 1821, and 1830 only a few vaccination campaigns had been carried out, and public-health efforts 160 were under the responsibility of the Secretary of Government and Police. The first examples of models of community participation in the management of health-care services and social assistance and of co-responsibility of the municipalities in health promotion are embodied in a decree issued October 13, 1894, known as the Law on People's Physicians. This law granted the executive branch the authority to divide up the national territory into "medical circuits," each one of which was under the direction of a professor of medicine. In addition, it approved the nomination of "people's physicians" whose various functions included the following: Advise on regulations to be issued by the political authorities and precautions that the public should observe. Notify the.Ministry of the Police and take action in the event of the appearance of any epidemic. Keep statistics on all cases and inform the Ministry of the Police on the causes that give rise to unsanitary conditions and the measures to be adopted. - Visit places where articles of daily consumption were sold, hotels and inns, and prohibit the sale of articles hazardous to public health. Inspect medicines dispensed in pharmacies, liquors, canned goods, and other items sold in public establishments and determine if their sale should be prohibited. Visit hospitals, ordering measures to be taken in the area of hygiene, and assist the sick. - Perform the functions of hospital physician. Visit the towns on their circuit once a month to observe their public health situation and take note of any sick persons not receiving adequate care.® Another of their key functions was the organization of the district neighborhood boards, which were responsible for determining the level of poverty in the communities. Hiring and payment of these people’s physicians in the provincial capitals was the responsibility of the municipalities. This citizen participation the district boards, the municipalities and the hiring of people’s physicians and the functions that they performed are considered to be the beginning of social medicine in Costa Rica.® Citizen participation was organized by health officials themselves, thus creating an internal culture oriented not only to offer health-care services but also to organize the population to be more receptive to them. This has occurred since the birth of the first institutional model that years later would become the Ministry of Health. This historical background may help to explain why SILOS have managed to develop more rapidly in Costa Rica than in many other countries that do not have such a tradition of links between health-care agencies and the community. This first stage thus had a welfare orientation toward the poorest sectors of the population. However, at this time the basis for processes such as territorial division (medical circuits), curative care (hospitals), citizen participation (district boards), social protection (the fight against ancylostomiasis), the involvement of municipalities (the payment of the people’s physicians) and the existence of 162 private and public medicine, both with greater emphasis on curative than preventive measures, began to appear. This was also a stage in which "as in all poor countries Of the last century, Costa Rica had its quota of overall as well as infant mortality, malnutrition and parasitosis."^® 5.2 Second Stage: Public Health and Institutional Development The second stage covered the first forty years of the current century. During this period, the first health-care principles begin to appear, which subsequently gave rise to preventive medicine in Costa Rica. Until that time, hospitals and other agencies had a merely curative focus. They were based on principles of welfare and charity and were managed by various religious orders. The Health Services first appeared in 1907 when for the first time funds were allocated in the national budget to organize a campaign against ancylostomiasis. In this period several laws and decrees were promulgated which established the legal basis for the delivery of services. One of the most important was the creation of what is now known as the Ministry of Health, as well as the rise of departments offering diverse public-health services. International cooperation first appeared in the country with the support of the Rockefeller Foundation in 1914 for the creation of the School Health Department, whose primary mission was the prevention of diseases in school children from ages seven to fourteen. In 1915, the Foundation supported the establishment of the Department of ---------- - - - 163 Ancylostomiasis, which was under the Secretary of the Police. In that same year, the creation of the Tuberculosis Sanatorium was decreed and the outpatient program for lepers was established. In the following year, the School of Nursing was founded. Another important precursor of public-health programs was the creation of pre-natal and infant clinics in 1920, since they ensured the protection of human beings from conception. The birth of social preventive medicine was completed in 1915 with legislation for activities to prevent venereal disease and tuberculosis. According to Edgar Mohs, The lack of unity in the management of health services, the degree and the nature of the problems, the multiplicity..of laws, the incorporation of more physicians, professionals and. technicians,, training of the personnel, etc., were instrumental in the creation of the Under-Secretariat of Hygiene and Public Health on July 12, 1922, under the jurisdiction of the Police. This initiative was fostered by Dr. Solon Nunez, who became the first and only under-secretary.^^ The institution began with three departments; Ancylostomiasis, School Health, and Control of Epidemics. Additionally, the following year Law No. 52 on the Protection of Public Health was promulgated. It stipulated that it was the responsibility of the government to ensure the health of the population at the national level and the municipalities at the local level. The municipalities were required to allocate fifteen percent of their revenues for public-health activities. This law also emphasized the ' --- " 164 normative and monitoring role of the Under-Secretariat of Hygiene and Public Health. The founding of the National Insurance Bank (today known as the National Insurance Institute) was another relevant event in the history of social insurance. With the creation of this public entity, life insurance was nationalized and monopolized in 1924, and occupational and fire insurance in 1926. This bank was in part the product of a debate on worker safety. This was a very poor country without a population of industrial workers, whose labor groups were small and weak because of their piecework techniques and their very limited economic significance. The rural labor force, generally characterized as brute force, was not sufficient . in numbers . to be included in protection programs because of its low cost, despite its constituting the majority of the labor force. Thus, there was no protection for workers who, in the event of an occupational injury or illness, depended on the good will of their employers. However, the influence of events and movements in other parts of the world, where workers’ health was a burning issue, began to be felt. To Henry Sigerist the rise of worker protection policies was a response to the fear of communism. Industrialization and the organization of workers into political parties and movements, as in Russia, meant that many countries accelerated the passage of laws creating social insurance as a means to stave off the "red scare".-® ------ -------- - ' .. 165 Presenting the draft legislation to create the Insurance Bank, its chief sponsor, Tomas Soley Giiell noted: Private companies cannot provide services in the way they are offered under the modern concept of insurance, which is the concept of social prevention in the broadest sense, which implies justice and the good of the community. Private insurance selects the lucrative part of the risks; the State, on the other hand, makes the lucrative insurance, by way of compensation, derive from all of the other types of insurance having greater social utility, such as those originating in work accidents and retirements or pensions. This concern for insurance coverage for occupational injuries was the basis for the promulgation in 1926 of the Snakebite Law, according to which snake bites were recognized as an occupational hazard of agricultural workers. It established that if a worker died from a snake bite due to the lack of an antidote on the farm, the owner was required to compensate the family with the equivalent of the worker’s salary for one year. Curative health care (hospitals), preventive care (campaigns) and insurance (Insurance Bank) were managed from that moment on by three different public institutions or agencies that developed separately during the following decades, creating serious problems of duplication and lack of integration. SILOS represent an effort to rectify this tendency but the task is not easy when faced with more than sixty years of history that has reinforced another paradigm. The health of school children also became an issue in this period. Services such as dental care, correction of physical defects, promotion of normal mental development, vaccination and immunization, medical visits to the homes of sick children, and correction of hearing and vision problems, were established. Free medical care was extended to school teachers and by 1927, teachers and professors were required to obtain a certificate of good health as a prerequisite for employment. During that year, the Under-Secretariat of Hygiene and Public Health became the Secretariat of Public Health and Social Protection. The President at that time, Ricardo Jimenez, and the Secretary, Dr. Solon Nunez, granted the new institution the political authority to draft new legislation and promote public health in the country. This was an attempt to exercise greater control over the hospitals, sanatoria and homes that were under the Secretariat of Foreign Relations. The law creating the Secretariat emphasized the standard setting and oversight roles of the new institution, with implementing functions to be delegated to the Sanitary Chiefs (local level) and the municipalities. This law also demonstrated the political will of the government to intervene more directly in the area of public health. From an organizational standpoint, this entity was strengthened through the creation of new departments such as Vital Statistics, Sanitary Engineering, Dental Prophylaxis, Tranquilizing Drugs, and outpatient dental services. In 1928, the establishment of a social insurance program and a Ministry of Labor in the country was discussed, but the prevailing political and economic conditions prevented the these early initiatives from coming to fruition. The 1930s witnessed important and historic events. The people’s physicians became Official Physicians and acquired the functions of public health chiefs, welfare physicians and forensic physicians, which amounted to an extension of their social role. The first Public Health Unit was a clear manifestation of a new emphasis toward preventive medicine. This was not unusual. This process of implementation of health-care services in Costa Rica followed a pattern that was occurring on a worldwide scale in which preventive medicine always follows the development of curative activities. Additionally, the Charity Boards changed their name to Social Protection Boards, to make manifest the new protective role of the government toward the health of the citizens. This transformation was evidence that the charity approach toward the indigent and the poor characteristic of the mid eighteenth century had gone out of fashion. With the founding of the Communist Party in 1934, the subject of social insurance came to the fore. The communique announcing its creation mentioned the need to establish social insurance programs. Its founding members organized the first strike of banana plantation workers, and workers’ health and medical care figured prominently among the points to be negotiated. Law No'. 3 0 of December 19.34 stipulated that one percent of the profits from the sale of bananas would be retained to finance hospital services for banana workers. This was the first attempt to finance health care other than work-related accidents by requiring contributions from those who benefitted from the workers labor. For Fernando Trejos, this was the beginning of sickness insurance within a social insurance program. An important institutional change occurred in 1936 with the establishment of the National Council on Health, Welfare and Social Protection, which attempted to promote uniformity among the social protection boards in their technical and economic activities. Other entities tried to do the same and, in this way, the problems of welfare and social protection received a more integrated treatment. For Lenin Saenz, one of the few periods in the history of health care in the country in which a clearly defined policy was maintained for more than a decade was 1920s and part of the 1930s, and it was characterized by continuous efforts to create organisms to address the principal health problems of the country and enact a series of laws and regulations to enforce their existence. The results obtained are evidence of the existence of a policy of --------- — -— — - — — ---------------------------- - 169 institutionalization of health-care services in that period. Lenin Saenz analyzes and summarizes the health situation of the population during those forty years as follows : The epidemiological profile was characterized by high rates of infant and child mortality and by a notable irregularity in their pattern. In those forty years, general morality fell only from 24 to 27 per thousand population, and infant mortality from 196 to 160 live births, with great fluctuations in their rates, specially in the first three decades, which in 1920 brought the latter up to 248 per thousand. The proportional mortality of children under five years of age, traditionally related to the existence of sanitary and nutritional deficiencies, is very high (between 4 7 and 52% of total deaths), and during this period it tends to rise slightly. On the other hand, proportional mortality of persons 50 years and older is so low that at the end of the period only 23% of the population reaches that age before dying. Despite these rather unsatisfactory indicators, life expectancv at birth rose from 35.1 years in 1910 to 46.9 in 1940. Among the causes of death, infectious and parasitic diseases constituted the great majority, causing 65% of the total number of deaths in 1920. Their average annual reduction was only. 0.6% . percent, and its behavior is so irregular that the rate fluctuated between 186.1 and 81.3 per ten thousand. Among those, intestinal parasitism, malaria, tuberculosis and other bronchial and pulmonary infections were leading causes of death. This second stage thus concluded amid the discussions about social insurance, the attempt to consolidate the Secretariat of Health and with the development of more formal programs of social and preventive health care. These would require a supreme effort of coordination within and among ■ -------- 170 agencies, a task which was undertaken in the period between 1940 and 1970. The strategies of the country in the two preceding stages seemed to be contrary to what is sought today with the SILOS. There was no integrated central level, decision making was centralized, there was an institutional separation between curative medicine and preventive health-care, and there was very little organizational development of the public sector at the local level. Of course, the social, economic, political and epidemiological conditions help to explain this situation. However, gradually a culture has been created with these characteristics, which has continued to solidify with the implementation of the SILOS in the 1990s. 5.3 Third Stage:____ Social Insurance and Institutional Development In the preceding stage, the country had suffered the economic crisis of the 1930s. Its main source of revenues was the export of agricultural products. Health had a social- welfare focus. Private practice predominated, while the government limited its activities to the promulgation of laws and decrees, the creation of hospitals and the fight against epidemics. In the third stage, which went from 1940 to 1970, the government assumed a more active role, creating agencies and a social insurance system that covered the workers as well as their families. One of the most significant events of the period was the creation of the Costa Rican Social Security Bureau, by Law No. 17 of November 4, 1941 (Law on the Creation of Social Insurance Programs). In this law, social insurance programs were based on the principle of solidarity among the employers, the workers and the state. When the President, Dr. Rafael Angel Calderon Guardia, sent the draft legislation to Congress, he made the following arguments, among others: Thus appears the state, first controlling and then organizing the existing charity public programs, as well as creating new agencies as circumstances warranted; when the state invested large sums for their maintenance and later assumed total responsibility for them, the second stage was born; that is, the concept of charity was complemented by that of social assistance. This in turn was revealed to be insufficient. The state alone could not assume the enormous responsibility for the growing needs of the proletariat, and it necessarily had to seek the cooperation of the . workers themselves and the employers. This was the formula of social insurance that was imposed definitively, because it is based on the principle of solidarity between the state, capital and the worker for the benefit of the latter. . This cooperation is nothing less than the result of the principles of social justice. The creation of the Costa Rican Social Security Bureau (Caja Costarricense de Seguro Social— CCSS) was one of the most controversial events in the political and social history of the country. While the government justified the decision in terms of social justice, other sectors saw it differently. Dr. Guido Miranda, ex-president of the CCSS, -believes that. 172 in addition to these principles, a difficult political juncture led President Calderon to introduce this legislation. The world war that began in 1939 closed the coffee markets in Europe, which had particularly strong repercussions in Costa Rica, whose entire coffee crop was sold to England and Germany. Faced with such negative circumstances. President Calderon, who was seeking a way to recover the popular political support that he had rapidly lost due to measures taken in the financial area and in international relations, attempted to regain political leadership by introducing social reforms. To that effect he embarked on an important program of projects of great social and economic significance, which enjoyed the support of the Church and left-wing political sectors. The most important projects were the enactment of the Labor Code, the Social Guarantees (constitutional), the creation of the University of Costa Rica and the establishment of the Costa Rican Social Security Bureau. That law established mandatory insurance for sickness, maternity, disability, old age, death and involuntary unemployment for all manual and white-collar workers under the age of sixty-five. It was first implemented in 1942 through sickness and maternity programs, and five years later, in 1947, disability, old-age and life insurance programs were put into effect. These measures adopted by the Calderon government were not easily accepted by the more prosperous sectors of the population. As Oscar Aguilar noted, "[t]hese agencies were immediately attacked by the Costa Rican conservative and capitalist sectors, which for the first time were required to relinquish a part of their profits and share them with ---------- their workers and peons through the monthly quota they were required to pay, for example, to the Social Security Bureau.Despite this opposition. President Calderon argued that it was vital to "find an appropriate and peaceful solution to the conflict between capital and labor, which cannot withstand a process of growing disequilibrium without bringing about the ruin of our internal peace and unleashing a struggle among the different economic groupings that coexist in our social milieu. This opposition, paradoxically, did not come only from the most conservative groups. Most physicians also opposed it and organized themselves in a union known as the National Union of Physicians to defend their interests. According to Fernando Trejos, other causes of opposition on the part of physicians were lack of awareness about the nature of social medicine, the privileges they enjoyed owing to their small numbers, and the loss of status they feared would result from becoming public officials. All sectors of society took sides in the birth of the Costa Rican Social Security Bureau. "The bosses clamored about the dangerous rise in the costs of production in wartime; the workers perceived the quotas as a reduction in their salaries ; one sector of the government interpreted the project as a left-leaning measure; the medical community feared losing their right to engage in private practice"^® The Church, on the other hand, not only supported the initiative but also justified it based on the Encyclical "Quadraggesimo Anno" issued by Pope Pius XI in 1931. Health was a favorite theme of the catholic church. As the CCSS began to offer services to the population, support for it increased. In 1944 it had 25,710 insured which was equivalent to 3.75% of the total population of the country. In 1992 this figure was 3,273,897, which represented eighty-four percent of the population. The CCSS began providing medical services in clinics in some provincial capitals, in the central hospitals (founded in 1945) and in the William Allen Hospital in Turrialba, whose inhabitants had requested in 1944 that the hospital be managed by the CCSS. Additional medical services were purchased from the social protection boards, which administered the hospitals located in all of the provinces of the country. Although these hospitals were administered by the social protection boards, technical and financial management was under the direction of the General Directorate of Medico- Social Assistance of the Ministry of Health. Hospiatls were financed by the National Lottery and other public funds. In the early years, the population covered by social insurance was limited to those workers with the lowest wages. Its was clearly oriented toward assisting the poorest families, while the more privileged sectors went to private physicians. Social insurance was incorporated in the Constitution in 1943 when Law No 24 went into effect which amended Section III "On Social Guarantees" to the Constitution. Its Article 63 stipulates: [S]ocial insurance plans are established for the benefit of those manual and intellectual workers regulated by the government's mandatory contribution system, with the aim of protecting them against the risks of sickness, maternity, disability, old age, death and any other contingencies determined by law. The administration and the government of these insurance plans will be the responsibility of an autonomous institution known as the Costa Rican Social Security Bureau. Thus, by 1943 the country had a Ministry of Public Health with 20 years of experience, a Costa Rican Social Security Bureau and a constitutional mandate requiring the government to provide health care as a right of all the citizens. At that time a new stage began in which these agencies sought to consolidate their role. The Ministry had responsibility for prevention and cure (through the social protection boards), while public health activities and the CCSS also had responsibility for curative services (for the workers) provied by doctors employed by CCSS. Beginning with this stage, an important difference in the institution-community relationship emerged between the Ministry and the CCSS. The Ministry was born and developed taking community participation as a necessity and as an element of its strategy; the CCSS had a different approach since its inception, as its orientation toward the traditional medical model did not warrant the creation of a culture similar to that at the Ministry. As will be seen in 176 subsequent chapters, these differences had repercussions in the implementation of the SILOS. Health-care legislation began to take shape during this period through the enactment of Law No. 33 of April 18, 1943, which established the first Sanitary Code. This law superseded the previous law of 1923 on "Protection of Public Health" and established new organizational structures within the Ministry. The Inter-American Public Health Cooperative Service of the United States provided important support through a $1,000,000 donation in 1943 with which ten public-health units (non-hospital health care centers which also provided preventive education), seven water treatment plans and sewage and drainage systems for the cities of San José, Heredia and Limon, were built. 1950 was a threshold in which all the principles of public health and the legislation created to implement them began to come together in the form of coordinated activities carried out in new areas of the country. Also in that year, the most complete population census ever taken was carried out (May 22), which provided the government with reliable information with which to plan new services. The year 1950 also marked the rise of a new concept of public health with the establishment of the World Health Organization as a specialized agency of the United Nations. The work of the Organization begin to be felt in the Americas through a special arrangement reached with the Pan-American Health Organization, which became the implementing arm of the new organization. Costa Rica continued to fall under the old Zone III of the Office, headquartered in Guatemala. Through the original zone office, cooperative health programs were begun and the country received technical assistance in the implementation of certain projects and in the expansion of existing activities. UNICEF also began operations in the country and provided support to the government in various programs aimed specially at children. A significant institutional change occurring that year was the creation of the General Directorate of Medico-Social Assistance within the Ministry of Public Health with an advisory body known as the Technical Council of Medical- Social Assistance, whose functions included coordination of all medical-assistential and social protection agencies, technical direction and fiscal control over centers that utilize public funds, and technical supervision of analogous private organizations. Delegates from the social protection boards (at the provincial level), the College of Physicians and the Director General of Public Health himself were named to the Technical Council. It attempted to coordinate and broaden the network of hospitals in the country. Note the presence of a policy that attempted to link or coordinate health-care agencies within a more general plan. This tradition of inter-institutional action also constituted a key element to the comprehension of the manner in which the different agencies attempted to generate joint actions through the SILOS. Since that time the Ministry of Health took the lead in promoting these initiatives. In the 1950s, the banana companies continued to manage their own hospitals, providing services to workers and their families. The municipalities continued to share responsibility with the Ministry in the area of environmental health, and the provision of drinking water was the responsibility of the Department of Sanitary Engineering of the Ministry. The country’s health-care infrastructure in 1952 could be described as follows: (a) The Ministry of Public Health was comprised of: 33 Sanitary Units and 4 nationwide campaigns which fell under the General Directorate of Public Health. - The General Directorate of Assistance was responsible for three national sanatoria, twelve rural medical centers, five regional hospitals and the San Juan de Dios Hospital in San José. (b) There were 30 social protection boards and other committees that collaborated in the management of a number of different centers such as the Orphan’s - ' 2 7 9 Home, Special Education School, Nutrition Centers, the Costa Rican Red Cross, the National Children’s Institute, the San Dimas Reformatory for youth and the Buen Pastor for women. (c) The CCSS managed two hospitals (Central and Turrialba) and various clinics. (d) The banana companies had hospitals in Quepos, Golfito and the Province of Limon. (e) Two private clinics, the Mater and the Biblica, were founded in 1929. The relationship between the social protection boards, which controlled the hospitals, and the CCSS intensified after 1956 when sickness and maternity insurance was modified to introduce mandatory family coverage for the legal or common-law wife, minor children under twelve years of age, and dependent parents of the insured. With this step the CCSS ceased to be a traditional institution following the social security model and became a true social insurance institution. This measure, which was enormously significant, radically changed ' the administrative structure of assistentialist services, generating a demand for health care that covered the entire national labor force from that time on. The two CCSS hospitals were insufficient, and in rural areas services had to be purchased from the hospitals of the social protection boards, which was a way to finance the small budgets of those charity centers. In 1961, the Legislative Assembly again amended the Constitution to impose upon the CCSS the requirement to extend sickness and maternity insurance to the entire population. This was to be accomplished over a ten-year period. This change was based on the principle of universalization of social insurance. "This was a real and a very great challenge for the institution, since it was and remains the first time in Latin American that such a task was undertaken and completed. Luis Rosero and Leonardo Mata considered the 1950s to be an important decade in the development of health-care policy : A new stage in the country’s public-health policy was initiated in 1950 when a modern, complex, and to a certain extent holistic approach was adopted. Advised by the newly created World Health Organization, the Ministry of Health was reorganized, incorporating a Central Assistance Office in charge of interactions with hospitals and the General Health Office for coordination of preventive medicine programs.... The 1950’s witnessed an extraordinary improvement in health conditions as a consequence of intense activities to improve the quality of life. These changes presented new challenges to the institution which gradually improved the quality of its services although, their quantity was insufficient due to the limited resources available. In the 1950s there were difficulties related to the duplication of functions between the Ministry and the CCSS. The social protection boards sometimes acted too independently, creating inequities in labor conditions among the different hospitals. Services tended to be concentrated in urban areas. Other organizations such as the municipalities and ministries that sponsored health-related programs were inefficient. The local health boards were not able to generate funds in addition to those provided by the government. In such a climate, despite the existing legislation, the Ministry was unable to consolidate its role as the supreme administrator of health care in the country, and planning efforts began to be dispersed. The 1960s began with the founding of the Faculty of Medicine at the University of Costa Rica (1961), which increased the number of available physicians. The National Sewage and Aqueduct Service (SNAA), a public entity charged with supplying drinking water was created, as well as the Center for Nutrition (1963) and the National Children’s Hospital (1964) . As a response to the problem of the lack of leadership and coordination of health programs, on June 30, 1962, the Health Planning Unit (at that time called the Office of Planning) was created, which had the following responsibilities : Establish short- and-long-term objectives in the area of health care along the lines of general government policy. Define program priorities. Coordinate action plans at the ministerial level designed to promote the integration of assistential services, prevention programs and public-health campaigns. Evaluate the services and development of public- health campaigns. Formulate plans for the training of personnel, orienting the training in accordance with previously established objectives and programs. The issue of coordination and especially of the supreme administrative function of the Ministry was much discussed in the mid-1960s. Inside the Ministry it was believed that it lacked sufficient political clout to impose a single set of guidelines and plan services. The relationship between the Ministry and other agencies was not normative and was not always very positive. B y that time there were many public entities involved in the issue of health care, and duplication of effort increased. The Ministry did not have control over the health sector, and other entities involved in providing health-care services did not fulfill their obligations efficiently. The Ministry of Public Health did not carry out its potential functions. Quite the contrary, its direct responsibilities in the management of health care were minimal. This would not have been so important were it not for the fact that those state organisms that were responsible for carrying out public-health activities did not do so, particularly the municipalities."^’ ^ Ironically, 30 years later the issues of the overcharging administrative role of the Ministry and its relations with other agencies are still paramount in the discussions on the strategic development of this institution. --------------- _ — 283 In 1965, the first attempts to develop joint plans between the Ministry and the CCSS occurred in the area of preventive medicine. The National Sewage and Aqueduct Service and the Office of National Planning, a dependency of the Presidency, later joined in this effort. A working group was created with representatives from the departments of planning of all organizations having to do with health care. This group’s mission was to develop coordinated proposals such as program budgets, evaluation and control mechanisms, and norms for delivery of services. In all of these attempts at inter-institutional coordination, the autonomy of each participating entity was emphasized. Despite these efforts, by the end of the 1960s the lack of coordination between the preventive and the hospital programs persisted. In 1967, by Executive Decree No. 16 of November 4, a National Coordinating Commission on Health-Care Activities, consisting of the Ministry of Health, the Office of National Planning and Political Economy, the CCSS and the National Sewer and Aqueduct Service, was established. The most important result of this commission was that it formalized the inter-institutional relationship in the areas of conducting national needs assessments in public health, health-care services and social insurance. In addition, it attempted to rationalize resources and thus avoid duplications in the development of infrastructure and services. ---------------------... 784 One concrete by-product of these initiatives was regionalization, which began to be practiced in the delivery of health-care services. The country was divided into health districts following criteria related to assistential needs, medical and legal issues, population, and channels of communication. In 1970, the country was divided into eleven districts, and in 1971 into six areas. In 1977, these were reduced to five large zones. In summary, in the stage between 1940 and 1970 legislation in health care was strengthened and important public institutions were created that became part of the reorganization of the Ministry in order to broaden the coverage of services. Curative medicine continued to predominate over preventive. Several hospitals were built. The authority of the Ministry over the rest of the system was still weak.^® Lenin Saenz described the health indicators that prevailed during this stage: This stage coincided with the development of significant technological advances that led to notable improvements in health care, with new vaccines, insecticides that proved efficient against vectors of various illnesses; new and improved equipment and diagnostic techniques, and more.effective treatments and drugs such as antibiotics, which were decisive in treating infectious diseases. During this period, particularly during the first two decades, infant mortality was reduced significantly. General mortality dropped from 17.1 to 6.6 per thousand live births, and infant mortality dropped from 132.4 to 65.5 per thousand. Although still quite high, the proportional mortality of minors under five years of age fell from 52% to 41%, while that of persons 50 ------ 185 years of age and older increased from 23% to 42% of all deaths.. As a result of these changes, life expectancy at birth rose to 68.1 years. This period witnessed a measurable decline in infectious and parasitic diseases as the principal causes of death, and a relative decline in their importance as a percentage of total deaths (from 48% to 21%) and a decrease in rate (from 81.3 to 13.6 per ten thousand). Mortality resulting from malaria fell drastically, and by the end of this stage malaria was considered to be practically eradicated. In contrast, automobile accidents emerged as a significant cause of death. After more than 7 0 years, the Costa Rican health-care system could not really be called a system, given the problems described above. Duplication was rife, growth occurred without balance between the curative and preventive aspects, and there were no organizations or instruments that gave direction to the country’s efforts in this area. The reduction of illiteracy from 26.7% in 1940 to 11.2% by 1979 helped to improve health indicators, but the management of growth and the expansion of coverage with efficiency and efficacy was the most pressing priority on the agenda for the twenty years following 1970. 5.4 Fourth Stage: National Health Plan and System This stage was transcendental for the country, because between 1970 and 1992 the first National Health Plan was established, the health sector was formed, the universalization of social security was achieved and certain processes of integration of services between the Ministry and the Social Security Board were set in motion, as evidenced _ — 186 in the functioning of the Local Health Systems. Moreover, in this period community health programs and rural health programs enabled the country to achieve levels of health far superior to those registered in other Latin American countries. Chapter 6 will examine this period in greater detail, but for now it is sufficient to note that the situation at the beginning of this period was characterized by a marked lack of coordination between health-care agencies, an insufficient coverage of services at the national level and a bureaucratic agency development in which autonomy was the most common banner. One novel experience was the transfer of the hospitals of the Social Protection Boards to the Costa Rican Social Security Board, which represented an advance along the path to creating the first National Health Plan 1971-1980, which attempted to establish a functioning health system with national coverage. To this must be added the achievements in the processes of regionalization through which agencies divided the country into geographical areas according to demographic and epidemiological criteria, infrastructural and administrative resources. All this with the aim. of being more effective in the attention paid to the problems of each region. The country was divided into regions, and health care into levels, with an allocation of resources that went from the simplest (community level) to the most complex (national level). Bringing programs closer to the communities they served was emphasized, which paved the way for the introduction of the SILOS. The Ministry of Health was reorganized, and the General Health Directorate was created, which diminished duality of command and established uniform policies for the entire Ministry. The Ministry started two programs that were key for the extraordinary improvement in the health of Costa Ricans in the past twenty years: the rural health program and the community health program. Both programs contained a high degree of participation of the community as users and as disseminators of preventive health care. The formation of a health sector within Costa Rican public administration was another strategic step that occurred in this period. This brought about the rapprochement among public institutions responsible for the population’s health, with the aim of formulating national policies, systems for coordination of services, rationality in public expenditures and common actions for health-care both at the preventive and the curative levels. This was, formalized with the signing of various agreements between the Ministry of Health and the Social Security Board. All of these important steps and facts comprise the background to the formation of the Local Health Systems. Despite the mistakes made and the barriers encountered along the way, this current of intensification of the relationships “ ' ■ " 188 between the public agencies and between them and the communities, the impact on health indicators was truly surprising, as will be described in the next chapter. This period has been the most significant one in the history of health indicators in Costa Rica as evidenced by the enormous improvements that they have experienced. The lessons that can be drawn from this period could be valuable for other sectors within the country as well as for other nations that are also attempting to reach the goal of "Health for All in the year 2000". As with the analysis of the three preceding stages, this section is based on the analysis of Lenin S ae nz . This stage can be subdivided into two decades in order to emphasize the most important changes that occurred in each and their relationship to two quite different economic situations. 5.4.1 Health in the 1970s As has been described, during this decade the government intensified its activities in the area of health through political, organizational, and structural transformations which enabled it to broaden coverage of services considerably. Key programs were established such as Rural Health and Community Health. The universality of the sickness and maternity insurance programs was completed and the preventive focus was emphasized. Health care 289 expenditures as a percentage of Gross Domestic Product reached 7.6%. CCSS coverage reached 7 8%, twice the 197 0 level. The Ministry managed to cover 60% of the rural population and 40% of the marginal urban population. Intensive health education programs were developed, as well as immunization, basic environmental clean-up, and school food and nutrition programs. Funds resulting from the Law on Social Development and Family Allotments enabled the government to concentrate institutional activities on those sectors of the population with the greatest propensity to become sick. General mortality dropped from 6.6 to 4.1 per thousand and infant mortality from 61.5 to 19.1 per thousand live births. To put these achievements into perspective, developed countries such as Denmark, France, England, Norway, Holland, Sweden and the United States required three decades to obtain indicators like these. Costa Rica achieved it in one decade. The period was also characterized by an accelerated process of transformation in the area of epidemiology. Infectious and parasitic diseases gave way to heart disease and cancer as leading causes of death. Total deaths caused from diarrhea, septicemia, tetanus, tuberculosis and ascaridiasis were reduced by' 92%. Proportional mortality of children under five passed from 41% to 17%, and that of persons 50 years or older rose from 41.8 to 61.4%. Life expectancy at birth rose to 73 years. These indicators are recognized as being linked to a country’s level of development. The availability of safe drinking water remained 100% in urban areas and rose to 68% in urban areas. In a retrospective review of these significant achievements in the 1970s, Lenin Saenz put forward the following thesis: The way in which the health situation improved in Costa Rica in the 1970s. enabled it to achieve the majority of the goals defined by PAHO to reach a state of "Health for All in the Year 2000", despite the fact that the existing conditions made it appear impossible to have achieved changes of such magnitude.... It can be stated with a wide margin of certainty that the health situation can be improved through specific actions in the sector, much more , than had been traditionally thought possible in relation to the level of economic growth of a country, and that these actions, as an institutional response of the Costa Rican government faced with its health problems, constitutes a magnificent example of what can be achieved with the political will to assign a high priority to the protection the most vulnerable and marginal population groups, and with the technical decision to concentrate efforts on the most vulnerable health problems using the available resources. 5.4.2 Health in the 1980s In the first half of the 1980s, the country suffered probably its worse economic crisis in its history. Expenditures on health care as a percentage of GDP declined from 7.6% in 1980 to 5.7% in 1983. Simultaneously, health indicators reduced their rate of improvement with respect to the preceding decade. According to Saenz, the diminution in the rate of improvement of the majority of health indicators and their stagnation in the middle of the decade originated in the reduction of the per capita expenditures on health care. However, faced with the argument that this deceleration could be attributed to the difficulty in improving the levels achieved, Saenz says that this reasoning does not explain "the abrupt and sudden way in which, beginning in 1980, the improvement in the majority of health indicators was reduced, nor does it take into account the possibility of reaching even lower rates than those that some developed countries have achieved . In those years more than 250,000 persons entered the country from neighboring countries in the midst of civil wars (Nicaragua, El Salvador and Guatemala), which coincided with a deterioration in morbidity caused by diminished environmental health conditions. A number of infectious and vector-borne diseases such as malaria, malnutrition, communicable diseases preventable through immunizations, pediculosis, scabies, diarrheal diseases, etc., all previously eradicated or drastically diminished, are re-emerging as health problems. These conditions relate directly to the influx of refugees and undocumented aliens. For example, of the 245 cases of malaria reported in 1983, sixty percent were diagnosed among foreigners and twenty-one percent of all cases were diagnosed in refugee camps. In 1984, of the 569 cases reported, forty-nine percent were imported. A study of 289 refugee camp children under six years of age revealed that over seventy percent were suffering from some degree of malnutrition- (19.3 percent moderate and 6 percent severe) ^^2 In the second half of the decade, the country’s economy improved. The GDP began an upturn, inflation continued but at a slower rate, the rate of open unemployment was reduced and wages rose slightly. At the end of the decade, life expectancy at birth, a key indicator of the health situation of a country, rose to 74.7 years. The principal causes of death were due to circulatory diseases and cancer. Morbidity caused by diseases preventable by vaccines continued to improve in this period. The experience of Costa Rica in the past twenty years supports Saenz’ thesis that without denying the indisputable influence of economic development on the health situation of a country,... a considerable proportion of it has to do with the availability of resources allocated to the sector, which can be increased substantially when there exists a clear political will to do so and, through the equitable and rational use of those resources, they can lead to the achievement of health conditions superior to those traditionally believed to correspond to a given level of economic development.^® This behavior of health indicators places Costa Rica in a privileged situation with respect to the other countries on the continent. According to Juan Jaramillo, ”[t]he diseases typical of a developing country have ceased to be a grave problem, and on the contrary, we are witnessing pathology profiles derived from an increase in life expectancy similar to those of the more industrialized countries. 193 CHAPTER 5 REFERENCE NOTES 1. Guido Miranda, La Seguridad Social y el Desarrollo en Costa Rica, 266. 2. César Vallejo and Roberto Tunes, "El Sector Salud en Costa Rica" (Washington, D.C.: World Bank, 1990), 1, photocopied. 3. Edgar Mohs, La Salud en Costa Rica (San José: Editorial Universidad Estatal a Distancia, 1983), 37. 4. See Constantino Lascaris, Desarrollo de las Ideas Filosoficas en Costa Rica, (San Josél Ed. Studium, 1984). 5. Fernando Trejos E., Libertad y Seguridad (San José: Asociacion Nacional de Fomento Economico, 1963), 82. 6. The contribution of Dr. Carlos Duran to the health care field is well known. As a public official he promoted the establishment of the San Juan de Dios Hospital, in which he personally introduced anesthesia, unknown prior to that time. He established the School of Obstetrics (1889), the National Lottery (1885), the School of Nursing (1916), and the Tuberculosis Sanatorium (1915) . He was president of the Municipality of San José, Deputy, Secretary of State, and served an interim term as President of the Republic. 7. Edgar Mohs, La Salud en Costa Rica, 39. 8. Rodrigo Salas, Rodrigo Meneses and Maria de los Angeles Gomez, Memoria del Ministerio de Salud y de la Salud Pùblica de Costa Rica (San José: Ministerio de Salud, 197 7), _ _ 9. Leonardo Mata and Luis Rosero, National Health and Social Development in Costa Rica:____ A Case Study of " 2 94 Intersectoral Action (Washington, D.C.: Pan American Health Organization, 1988), 36. 10. Guido Miranda, La Seguridad Social y el Desarrollo en Costa Rica, 32. 11. Rodrigo Salas, _et ^., Memoria del Ministerio de Salud y de la Salud Pùblica en Costa Rica, 10. 12. Edgar Mohs, La Salud en Costa Rica, 39. 13. Ibid., 4 0. 14. Dr. Solôn Nûhez was a pioneer in the field of public health in Costa Rica. He was Under-Seeretary and Secretary of Health for almost 20 years (1922-1936 and 1943- 1948). He promulgated numerous public-health decrees and laws, including the establishment, of what is now the Ministry of Health. Historians consider him to be an innovator in the organization of public-health services in Costa Rica. 15. Guido Miranda, La Seguridad Social y el Desarrollo en Costa Rica, 45. 16. See Henry Sigerist, Hitos en la Historia de la Salud Pùblica (Mexico: Siglo XXI Editores, 1987) . 17. Taken from the speech submitted to the Constitutional Congress in 1924 by Tomas Soley Guell, Minister of Finance. Quoted in Fernando Trejos, Libertad y Seguridad, 112-113. 18. The topic of social insurance was foremost in the 1928 electoral campaign. . Candidate Cleto. Gonzalez Viquez (who was elected) received a formal proposal from Max Koberg, a German engineer and businessman living in Costa Rica, to create a "Board for the Care of Medical Emergencies of Workers". This insurance would be financed by the workers and bosses. Koberg ’ s idea was based on the experience of his native country. At that time, the creation of a Ministry of Labor was also proposed. Economic limitations and political circumstances prevented either of these ideas from materializing. 19. These were health centers providing non-hospital services to the community. They emphasized preventive health care and an integrated approach to health care services for the population. The directors of the public health units had the same functions and responsibilities as the Official Physicians. 295 20. Juan Jaramillo, "Resumen Historico del Ministerio de. Salud de Costa Rica" (San José: Facultad de Medicina, Universidad de Costa Rica, 1985), 8, photocopied. 21. Fernando Trejos, Libertad y Seguridad, 106. 22. Lenin Saenz, Hacia un Sistema Nacional de Salud en Costa Rica (San José, Costa Rica: Ministerio de Salud, 1983), 19. 23. Lenin Saenz, "Relaciones entre Economia y Salud: Evolucion en Costa Rica en el Siglo XX" (San José, Costa Rica : Ministerio de Salud, 1992), 5, photocopied. 24. Social insurance was initially financed through a triple contribution. For the sickness and maternity plans, the employer contributed 2.5% of the salary of the worker, the state. 1% and the worker 2.5%. In October 1952 this contribution was raised as follows : 3% from the worker, 3% from the employer and 1% from the state. 25. Excerpt from the exposition of reasons behind the draft Law on Social Insurance. Cited in Fernando Trejos E., Libertad y Seguridad, 128-129. 26. Guido Miranda, La Seguridad Social y el Desarrollo en Costa Rica, 36-37. 27. Oscar Aguilar Bulgarelli, La Constitucion de 1949 (San José, Costa Rica: Editorial Costa Rica, 1978), 31. 28. Rafael A. Calderon Guardia, El Gobernante y el Hombre ante el Problema Social Costarricense, (San José : n.p., 1942), 14. 29. Fernando Trejos, Libertad y Seguridad, 137. 30. Guido Miranda, La Seguridad Social y el Desarrollo en Costa Rica, 57. 31. Fernando Trejos, Libertad y Seguridad, 136. 32. Costa Rica, Asamblea Legislativa. Ley No. 24 24 : Adicion del Capitule de Garantias Sociales a la Constitucion Politica. La Gaceta: Diario Oficial, No. 147, July 7, 1943. 33. Guido Miranda, La Seguridad Social y el Desarrollo en Costa Rica, 61. 34. Ibid., 64. — ----— -----— ------— ------------------------------------------196 35. Leonardo Mata and Luis Rosero, National Health and Social Development in Costa Rica:____ A Case Study of Intersectoral Action! 36-37. 36. Rodrigo Salas e^ aj_., Memoria del Ministerio de Salud y de la Salud Pùblica de Costa Rica, 65. 37 . Ibid., 56. 38. Lenin Saenz, Hacia un Sistema Nacional de Salud en Costa Rica, 48. 39. Lenîn Sâenz, "Relaciones entre Economia y Salud: Evoluciôn en Costa Rica en el Siglo XX," 6-7. 40. Ibid., 12. 41. Luis Rosero, "Déterminantes del Descenso de la Mortalidad Infantil en Costa Rica," in Demografia y Epidemiclogia en Costa Rica, by the Asociacion Demografica Costarricense (San José, Costa Rica: Asociacion Demografica Costarricense, 1985), 30. 42. Lenin Saenz, "Relaciones entre Economia y Salud: Evolution en Costa Rica en el Siglo XX," 13. 43. Some indicators of this crisis were the diminution in the GDP, the constant decline in the value of the national currency, inflation rates that reached eighty-two percent in 1982, 9.4 percent open unemployment, reduction in real wages by forty percent, a fifty-three percent increase in the number of families under the poverty line. In 1982 the value of the basic food basket was greater than the per capita income. The foreign debt consumed more than fifty percent of exports of goods and services. 44. Saenz, "Relaciones entre Economia y Salud: Evolucion en Costa Rica en el Siglo XX," 14. 45. Catherine Overholt and Peter Cross, "Costa Rica Health Sector Overview" (San José, Costa Rica : U.S. Agency for International Development, 1985), 16, photocopied. 46. Lenin Saenz, Logros de una Politica e Impacto de una Crisis en la Salud de un Pais (San José, Costa Rica : Ministerio de Salud, 1989), 21. 47. Juan Jaramillo, Los Problèmes de la Salud en Costa Rica, 2d ed. (San José, Costa Rica : Ministerio de Salud, 1984), 55. 197 CHAPTER 6 DEVELOPMENT OF THE NATIONAL HEALTH PLAN AND SYSTEM At the beginning of the period 1970-1992, morbidity and mortality rates in Costa Rica were similar to the average in other developing countries on the continent. Organizationally there were no major differences. There was little coordination among technically and administratively autonomous and semi-autonomous programs and agencies, which based their claims to autonomy on laws and regulations established in a former era.^ Within the Ministry the situation in 1970 was not very different. There were two General Directorates; the Health Directorate and the Medical-Social Assistance Directorate, which functioned as two independent entities. Their norms, activities and approaches were very different. There were duplications and considerable autonomy, especially between those- programs that addressed specific diseases such as cancer, tuberculosis, and others. For its part, in 197 0 the CCSS covered approximately fifty percent of the population (under its sickness and ------- 198 maternity programs) . It had only two central and two provincial hospitals. The Ministry of Health (MOH) and the CCSS attempted to respond to the situation described above by creating the first "National Health Plan of 1971-1980". This event was a milestone in health care in the country, since it marked the beginning of a formal relationship between two institutions or public agencies. The first National Health Plan had the following obj ectives: The creation of a single and integrated health care system; nationwide coverage/ under the direction of the Ministry of Health, of a primary-care program concentrating on the control of infectious diseases, malnutrition and environmental sanitation; and universal medical care for the entire population', under the direction of the CCSS, as well as the extension of the disability, old-age and life insurance programs.^ In addition, the Plan included a number of concrete goals for the period 1971-1980. Among these were to increase life expectancy by eight years, reduce infant mortality by fifty percent, and supply one hundred percent of the urban population and seventy percent of the rural population with safe drinking water. Clearly, achieving these goals required the participation of a number of different agencies in addition to the Ministry of Health and the CCSS. This paved the way for a new stage in the relationship among the - - - - — - - 199 eighteen agencies that were involved to some degree in health care at that time. Costa Rica’s public sector had very little experience in this type of institutional system. The National Plan thus proved to be at once an innovation and a learning experience. This represented a relinquishing of Graham Allison's "paradigm of the organizational process," which explains government actions as follows: The actor is not a monolithic "nation" or "government" but rather a constellation of loosely allied organizations headed by government leaders. This constellation acts only when component organizations perform routines.^ The obvious intention of the government presided by José Figueres (1970-1974) was rather to establish a "rational model" of behavior of the agencies according to which they would establish a plan that maximized objectives and goals. In this model the government is conceived as a rational actor, a unitary decision-maker, an agent.^ It is assumed that there will be an adjustment made within each entity to facilitate new common objectives. As a result of this Plan, eight key policies, reforms and programs were implemented to make it viable: Formalization of the division of the country into regions. Organization of health services by levels of care. 200 Transfer of hospitals administered by the Social Protection Boards to the Costa Rican Social Security Board. Universalization of sickness and maternity insurance. Enactment of a new General Law on Health and the reorganization of the Ministry of Health. Rural Health and Community Health Programs. Creation of the health sector Integration of health-care services Each of these policies and processes is analyzed below, as they constitute the essential background necessary for the understanding of the birth and development not only of the National Health System but also of the SILOS. 6 .1 Division of the Country into Regions (Regionalization) Regionalization for the delivery of services and application of levels of care went into effect in 1971. It consisted of dividing the country into regions according to demographic and epidemiological criteria, infrastructure, statistics, administrative resources, etc. Each region was assigned professional, technical, and administrative personnel. Although both the Ministry and the CCSS proceeded to regionalize their activities, the criteria were not uniform. _ — 201 [T]he Ministry of Health used geographic accessibility, concentration of the beneficiary population and the increase in the number of health centers as criteria for regionalization, while the CCSS used accessibility and the decision-making authority at the different levels of complexity, which result from the demographic concentration and social and economic development, as criteria for regionalization.^ The Ministry divided the country first into five regions and later into four. Subsequently, successive efforts were made to adjust both sets of criteria for regionalization. This affected the internal structures of the two organizations, which had to incorporate actions not only agreed upon between them, but also in accordance with the characteristics of each of the health regions. In 1979, both agencies adopted the regionalization scheme established by the government to conduct socio economic development planning.® The country remained divided into five regions. One of these, the Central Region, was subdivided into three subregions to facilitate intra- and inter-agency coordination (See Figure 9). Initially, both the CCSS and the Ministry presented objections to the regionalization scheme established by the Government through its Ministry of Planning because, according to its two chief authorities, the Minister of Health and the President of the CCSS, this prevented these public-sector agencies from having their own criteria.^ The SILOS would present an even greater challenge to the public agencies, as their area of influence was smaller than a region. However, both the positive and the negative " 2Ü2 experiences resulting from regionalization were useful at the end of the 1980s and the beginning of the 1990s for the coordinated efforts at thé local level required to implement the SILOS. Figure 9 Regionalization of Health-Care Programs Costa Rica 1 .1 Western Central Region njr-i 1.2 Eastern Central Region 1.3 Northeast Centrai Region 2 Chorotega Region 3 Atlantic Huetar Region 4 Huetar Northern Region 5 Brunca Region Source: Edgar Mohs, La Salud en Costa Rica, 55. 203 6.2 Levels of care Through the organization of medical services by levels of care, the responsibility of each agency was established according to the type of service it provided the population. The model of care remained divided into five levels, as shown in Figure 10. Personel Figure 10 Pyramid of the Levels of Health Care (MOH-CCSS) Place of Care Specialized Hospital Care Hospital Ambulatory Care (General. Dental, Nursing. Laboratory) Care provided by auxiliary personnel Health promotion and preventive activities^ Epidemiologic control Detection of diseases Public Health Enviromental Control Care provided by auxiliary personnel Ministry of Health 5.000 employees CCSS 22.000 employees Specialized Hospitals Hospital General Primary (Community level) Family level 27.000 en^ploy^es Regional Hospltus (Area hospitals) Health Centers (MOH) Dispensaries and Clinics (CCSS) Rui at Health Posts Education Centers (CINAI) Nutrition Centers (CEN) Clinics and Dental Centers All Costa Rican families Population of Costa Rica: 2.300.000 Provinces 7 Districts 81 Sub'Dlstricts 415 Source: Juan Jaramillo. Los Problemas de Salud en Costa Rica. (San José, Costa Rica: Ministry of Health, 1984), 71. 204 One important aspect of this model was the division of institutional responsibilities. The Ministry assumed the responsibility for levels one and two, and the CCSS for the others. Regionalization and the division of services into levels were two conditions existing within the organizational culture of the Ministry and the Social Security Board that created the conditions for the implementation of the SILOS, as they produced an awareness of regional needs and of the division labor at the community and home level. These elements will have to mature within the SILOS in order to make local programming of health-care activities viable. 6.3 Transfer of Hospitals to the CCSS The third component of the strategy adopted in 1971 was the transfer of the hospitals to the CCSS. Hospitals had formerly been administered by the Social Protection Boards and the banana companies. Law No. 5349 of October 1973 stipulated that this transfer would occur gradually and at the convenience of the CCSS.® The physical plants would be transferred, as well as the equipment, the personnel, and the financial resources. Implementing this political decision was an arduous process, because discussions at every level had taken ten years, and fifteen years had passed since the topic was first broached at a national medical congress.^ This law protected the non-insured population since it required the CCSS to provide services and the central — — 205 government pay for them. According to Lenin Saenz, ten years after the promulgation of this law the latter aspect was not always complied with in the spirit Of social solidarity in which it was conceived, despite the fact that, in order to guarantee care for disadvantaged groups, these were later considered to be insured at the government’s expense and their care was financed by resources granted to the CCSS through the Law of Transfer. This process tested the negotiating capacity of the leadership of the health-care agencies, since a transfer of this magnitude implied the management of multiple interests. For example, labor conditions varied among the various hospitals, since they were administered by different, autonomous boards. This complex took several years to complete. Some 5,000 beds located in twenty-four different hospitals administered by different social protection boards and three managed by a multinational company that produced bananas in the southern and Atlantic coast areas of the country had to be transferred. The workers employed by the transferred entities retained their rights, and the government was required to finance any operating deficits that might occur as a result of the transfer. This was not an easy task given the diverse sources of opposition to the transfer. However, improvements in the units being transferred were made with the support of the officials themselves and the affected communities. One of the main reasons for promulgating this law on transfer of hospitals was to facilitate the establishment of ~ 206 an integrated health-care system for the entire population, which included regionalization, the provision of services at different levels, and the universalization of social insurance. The implementation of this transfer of hospitals led to a division of responsibilities between the Ministry and the CCSS. Accordingly, the MOH would be responsible for the overall management of the sector, epidemiological monitoring, environmental sanitation and other preventive services. That is, the MOH took charge of primary care. For its part, the CCSS assumed the task of recovery and rehabilitation and of specialized care. According to Saenz, there was an intermediate level of general care in which the functions were not so well delineated, producing duplication of services and tasks. What would later become known as the health sector put its capacity for self-transformation to the test in this hospital transfer. The complexity of such an operation, with so many different actors involved, granted security to the agencies to confront equal or greater challenges. The SILOS represent not only a structural transformation but also a strategic and cultural one. The fact that the transformation inherent in the transfer of hospitals was able to take place may bolster the faith of the leaders and managers of the agencies facing the implementation of greater changes at both the local and central levels. 207 6.4 Universalization of Social Insurance The fourth important change that occurred at the beginning of this stage was the universalization of social insurance coverage. Law No. 2738, passed in May 1961, required the CCSS to extend mandatory social insurance programs to the entire population within a period of no more than ten years. This law promoted a national spirit of solidarity in which the entire population had access to integrated and universal medical care. According to Edgar Mohs, the law was designed to improve medical care, eliminate the services delivered through charity and democratize medicine. Through the new "Law on Breaking the Ceiling" No. 4750, of April 1971, the law establishing the CCSS was modified to enable mandatory coverage and membership in the Social Security program for all salaried workers. Universalization of coverage was implemented in three stages. In the first stage, vertical extension, or "breaking the ceiling," was established. When the CCSS was created, a mandatory quota or contribution for workers with incomes of no more t h a n 400 col ones was established. Vertical extension meant that the quotas (payroll taxes) of the insured were a percentage of their total salary. This rule was applied progressively as a way of lowering resistance to it. Sickness and maternity programs were extended to all manual laborers and white-collar workers. The second stage 208 consisted of horizontal, or geographic, extension of sickness and maternity insurance programs throughout the country. In the third stage, coverage was extended to all sectors of the population, including independent workers and the indigent. An indigent person was defined as an insured person covered by the government, and a consumer of health-care services not included under any of the CCSS’ programs and who, in addition, did not have the ability to pay. That same Law No. 4750 of April 1971 for the first time empowered the CCSS not only to provide services to the indigent but also to participate in sickness prevention programs, which it had been prohibited from doing since its creation. The law creating the CCSS stipulated a categorical separation of functions between it and the Ministry. Thus, according to Guido Miranda, Costa Rica was the first democratic Latin American country to view medical and social insurance services in this light.The previous decisions made regarding regionalization, levels of care, and transfer of hospitals were essential in order to implement the universalization of social insurance. Without this legal infrastructure the political will to implement changes would not have existed. The functioning of the SILOS requires that participating organizations and agencies possess an integrated vision of health. These advances may explain why the Ministry and the CCSS participate so actively in the promotion of integrated 2 0 9 health care. The culture and the legislation of the CCSS became more flexible as a result of these reforms, which fostered the creation of the SILOS. 6.5 Law on Health and Reorganization of the Ministry In 1973, two laws were enacted which further shaped the delivery of health-care services in general and the role of the Ministry in particular. Law No. 5395 of October 30, 1973, known as the "General Law on Health," established health care as a right of all persons as well as the role of government agencies in the delivery of services.^® Accordingly, the role of the Ministry was to define and direct national health policy, and to regulate, plan, and coordinate all public- and private-sector health-related activities. In addition, it was to be responsible for implementing preventive health-care programs. Practically since its creation, the role of the Ministry as the supreme authority was mentioned in various official documents. However, it was blocked in the exercise of this role by legal and administrative barriers during the first fifty years of its existence. By the beginning of the 1990s, this had not changed much, and effective leadership in the Ministry remains an issue. According to Oscar Arias, when autonomous agencies enjoyed considerable prestige and power, they refused to recognize that any higher authority might be capable of managing their programs. As Pedro Munoz has noted, "by claiming such absolute independence, they completely ignored the principle of the programmatic unit, which demands a certain degree of general leadership at least along basic lines of the management of each autonomous entity."^® The second law that made a contribution along these lines was Law No. 5412 of November 8, 1973, known as the "Organic Law of the Ministry of Health." The name of the Ministry of Health, formerly the Ministry of Public Health, became official at that time. This law modified the internal organization of the Ministry. The Public Health Directorate and the Directorate of Medical-Social Assistance were integrated into a single General Health Directorate. The National Health Council and the Sectoral Planning Unit were created as advisory organs of the Ministry. It is interesting to note the variety and depth of the legislation and the reforms made in the 1970s, which established the basis for the functioning of public-sector institutions for the following twenty years. These transformations facilitated the expansion of coverage of services and consolidated the role of each agency. Contrasting this situation with that which existed in the 1940s and 1950s illustrates how the evolution of service delivery was gradually bringing the Ministry and the CCSS closer together. In fact, integration had been an issue since the end of the 1950s, as was inter-agency coordination. - 211 even though it was not until the beginning of the 1970s that sufficient political support could be garnered to enact the necessary legislation. In addition to the efforts already described, the economically disadvantaged continued to preoccupy the government. Thus in 1974, the Law on Social Development and Family Allotments was passed.Its far-reaching effects on society can be summed up as follows: A special fund was created for the development of social programs. These funds would be utilized to benefit economically disadvantaged persons and families and managed by public agencies that administered social programs. Twenty percent of the fund would be allocated to financing a "Non-Contributive Pension Program" which would protect citizens not covered under other CCSS pension plans. - This non-contributive program would also be administered by the CCSS, which already managed the mandatory disability, old-age and life insurance programs. - Cash payments would be granted to low-income workers with minor or handicapped children. If the worker had children under twenty-five who were --- — 212 enrolled in a university, the worker could also receive the cash payment. The funds would be derived from sales taxes and a five-percent surtax on the total monthly wages paid by all employers in the country. One of the areas of activity of the Family Allotment Program was rural and community food and nutrition programs. These funds also financed medical care for the neediest sector of the population. The transfer of the hospitals to the CCSS enabled the Ministry to concentrate on preventive medicine, especially in the rural areas, utilizing resources from the Family Allotment Fund. In 1974 the National Health Plan went into effect, enabling the government to set clear policies and strategies for the remainder of the decade. This helped agencies to orient their work in similar directions, which is not to say that a high level of coordination among them had been reached. In the same year, the government established executive presidencies in the autonomous agencies, nominated by the Council of Government. This was the highest post in the hierarchy of an agency such as the CCSS. According to Lenin Saenz, "[t]he appearance on the institutional scene of such people, obliged by their political position to have a more global picture of the relationship between the interests and needs of the agency under their direction and those of the executive branch, favored dialogue among those autonomous - 213 entities and the Ministries. In his view, there had always existed an extreme lack of coordination in both policy aspects and implementation of programs and activities. The SILOS presuppose the integration of curative and preventive programs in order to consolidate an integrated approach toward health care. Since these strategies were under the responsibility of two different public institutions or agencies, these legal reforms created certain conditions that could aid the implementation of the SILOS. Authority was unified under the Ministry and clear leadership was established within each agency, thus facilitating inter agency representation and negotiation. 6.6 Rural Health and Community Health Programs In accordance with the National Health Plan, the Ministry's mission included continuing its educational and preventive work at the first levels of care. Even before this time, in 1972, a program to provide basic services first to the rural population (communities of less than 500 inhabitants) and later, in 1976, to the concentrated rural communities (from 500 to 2,000 inhabitants), had been developed. This program, known as the Rural Health Program (RHP), complemented another program aimed at marginal urban communities, known as the Community Health Program (CHP) . Through these two programs, health-care services were extended throughout the country, creating the basis of a -------------- 214 truly national health system. In 1978, the National Hospital System was established, which was a very important step in the rationalization of hospital services by specialties and regions. Although the RHP was formally begun in 1972 and the CHP in 1976, health-care entities already had some experience in similar types of activities. For example, at the beginning of the century various campaigns had been conducted with the support of the Rockefeller Foundation. The Mobile Assistance Units Program (PUMA) had been financed from 1961 on by the Alliance for Progress under the Kennedy Administration. Simultaneously with the PUMA Program, Health and Development Com.mittees were organized in different communities, which served as local counterparts of the mobile assistance units. From that time on, the communities worked together with the Ministry as a team. Each PUMA consisted of a physician, a nurse, and a health inspector who visited communities to address primary-care, education and public- health needs. At the end of the 1960s the campaigns against malaria had yielded excellent results. One of their key planners, Dr. Hugo Villegas, together with Dr. Antonio Rodriguez, formulated a new community-based primary health-care plan. Subsequently this plan gave rise to the RHP and the CHP. Other physicians closely linked to these initiatives were Lenin Saenz and Eliécer Valverde, an official of the PAHO. According to Gonzalez, "[h]ealth improvements have reflected the growth-cum-equity policies generated by political stability, homogeneity, and democratic traditions. Despite this history and the concern for equity, the introduction of the RHP did not enjoy the support of the College of Physicians and Surgeons, and high-level officials within the Ministry itself questioned its effectiveness. Some physicians believed that the training of health promoters amounted to the illicit practice of medicine. These health promoters worked in prevention, education, and information in the following areas: - Organization of health committees - Census-taking and community mapping - Immunizations - Treatment for parasites - Family planning - Promotion of breastfeeding - Nutritional education - Prenatal care - Oral rehydration - First aid - Referrals of cases to higher levels of care - Environmental.control : water supply, personal hygiene, fecal waste and food hygiene. While the Ministry of Health worked in the area of preventive medicine, the CCSS delivered services through the Sickness and Maternity Program. The transfer of hospitals continued during the 1970s under the coordination of Dr. Luis Asis, and other hospitals were built. A new satellite and rural clinics program performed services for the CCSS. The support of the Inter-American Development Bank was vital for the creation of this national infrastructure. 216 In 1971, Law No. 4750 extended the CCSS ' s activities to preventive medicine, which contributed to the expansion of services provided to the rural population. Tables 2 and 3 show the patterns of coverage of the Rural Health Program and the Community Health Program. Both programs grew steadily except between 197 9 and 1982, à period of severe economic crisis. Explaining this situation, after assuming the presidency of the CCSS from 1982 to 1990, Guido Miranda observed that part of the reason for this pattern was the way in which the government that ( 1) (2) (3) Source ; TABLE 2 COVERAGE OF THE RURAL HEALTH PROGRAM MINISTRY OF HEALTH 1973-1988 YEAR RURAL POPULATION PERCENT LOCALITIES # HOMES HEALTH POPULATION COVERED COVERED COVERED COVERED POSTS (1) ■(*) 1973 (2) 955,065 115,000 11 800 30,000 50 1974 971,920 200,000 19 1, 250 46, 800 78 1975 992,557 360,000 34 2,240 84,000 116,400 140 197 6 1,015,487 490,000 45 3, 104 194 1977 1,039,943 650,000 58 3,750 144,000 251 1978 1,065, 442 690,000 60 3, 880 152,500 268 1979 1,091,517 717,500 61 4,018 160,970 287 1980 1,117,710 717, 50.0 60 4, 018 160,976 293 1981 1,144,213 640,934 52 3, 050 156,758 294 1982 1,171,307 722,778 57 2, 888 174,658 294 1983 1,198,667 777,099 60 4, 008 185,423 301 1984 1,224,876 812,378 61 4, 065 194,755 305 1985 1,252,935 834,463 62 4.163 201,176 318 1986 1,279,749 836,901 61 4,174 201,676 322 1987 1,520,895 859, 140 61 4,272 202,028 344 1988 (3) 1,520,895 982,886 65 4, 966 236,840 393 Rural population calculated based on the Second Census of CELADE, Year of initiation of the program. These data do not include areas covered by the Rural Health Program of San Ramon, This includes all areas of the country. Basic Data and Balances. Primary Health Program, Information Sub system Commission. Office of Sectoral Planning, Ministry of Health. 217 (1) (2) Source : TABLE 3 COVERAGE OF THE COMMUNITY HEALTH PROGRAM MINISTRY OF HEALTH 1976-1987 YEAR URBAN POPULATION (2) POPULATION COVERED PERCENT COVERED NUMBER OF HOMES COVERED N° WORK AREAS COVERED 1976 (1) 843,730 84,018 10 15,030 IB 1977 876,568 195,000 22 35,100 78 1978 911,044 317,500 35 98,600 205 1979 946,802 600,000 63 124,245 240 1980 983,475 538,542 55 104,854 216 1981 1,021,258 527,651 52 129,245 224 1982 1,060,428 462,012 44 111,091 219 1983 1,100,729 439,313 40 106,629 217 1984 1,143,178 486,751 43 115,439 225 1985 1,183,649 550,651 47 136,971 2 67 1986 1,226,198 605,963 49 147,971 289 1987 1,269,739 602,289 47 146,094 281 Beginning of the program. Populations were calculated based on the 2nd. Census Evaluation of CELADE. The index urbanizations were based on the Urban Census. Basic Data and Balances. Primary Health Program, Information Sub system Commission. Office of Sectoral Planning, Ministry of Health. assumed power in 1978 managed health policy and programs. In his opinion, there were contradictions in the government’s actions, and some officials even tried to weaken the agencies. Despite their inherent difficulties, the impact of these programs on the health of the population is widely recognized nationally and internationally. Luis Rosero and Leonardo Mata conducted a study covering the period between 1972 and 1980 to determine the relationship between the infant mortality rate and other factors such as the socio-economic context, hospital services, ambulatory care, health and fertility. They concluded that ’ 'among the changes that occurred in the decade, the increase in primary health care (basically community preventive medicine) and secondary health care (outpatient services), showed the highest and strongest association with the phenomenon under study... It can be concluded, therefore, that they are genuine determinants of the reduction in infant mortality. Hugo Villegas found that the decline in the infant mortality rate and the increase in life expectancy at birth is proportional to the coverage and the number of years that the RHP was present in a given community. In 1977, the World Health Organization, convened in Alma-Ata, declared the goal of "Health for All in the Year 2000", and in 1978, the Pan American Health Organization enunciated a strategy to. achieve it: primary care. The strategy of primary care reaffirms that health is a fundamental human right and that the achievement of the highest levels of health is an extremely important social objective all . over the world, requiring the intervention of many other social and economic actors in addition to the health sector. Also, it is both, the right, and the duty of the people to participate individually and collectively in the planning of their own health care and in requiring governments to ensure the health of their people. That is, fully five years prior to the WHO’s historic declaration, Costa Rica had already implemented primary care programs. Furthermore, the indicators established by the WHO to measure attainment of the goal had already nearly been reached in Costa Rica. The participation of the population. especially in rural areas, is considered by all experts to be another significant achievement in Costa Rica. A review of the policies of organization and popular participation for the rural sector in Costa Rica prepared by the United Nations Food and Agriculture Organization in 1985 discussed the difficulties involved in achieving this. type of participation : However, even when decentralization and planning efforts include mechanisms of popular participation, in practice these have not produced an effective participation of the population in the planning, formulation, decision-making and implementing stages of rural development programs, since regional and sectoral planning system is extremely complex. A great many organizations and institutions participate in it, whose competencies and functions do not always appear to be clearly defined, the level of information and decision making capacity of the representatives of such organizations is not homogenous, and not all institutions cover the same territory. According to Claudio Gonzalez-Vega, one factor that has contributed to the success of the Rural Health Program has been the high level of education of the population. "Costa Rica’s primary concern with education over many decades has been another major factor. Schooling and low illiteracy have increased receptiveness to new ideas and the ability to implement them. " Evidence of the impact of the RHP and the CHP can be found in the reduction in the number of pediatric beds in the National Children’s Hospital, which in 1972 had 504 beds and in 1986, with an increase in the population of 800,000, had only 412. Vaccination and nutritional educational programs ■ - — 220 conducted by the CHPs resulted in a reduction in the demand for hospitalization of infants. Three characteristics of the strategy utilized in the Rural Health Program provide valuable lessons for future actions. In the first place, its implementation was centripetal, initially covering the most distant and the smallest communities; second, services were brought to people’s homes without waiting for them to come to the health centers; and third, the program had an effective administrative and logistical support structure, including mechanisms for referral of patients to other levels of care, defined earlier. An important component in the successful implementation of the National Health Plan was the integration of services between the CCSS and the Ministry. One step in this direction was the integration of the RHPs and the CHPs within the Ministry itself, formalized on July 13, 1987 through Executive Decree No. 17 636-S. The new program was called Primary Care. By the end of November 1992, the Ministry had established 552 Nutritional Education Centers (CEN), 54 Nutritional Education and Infant Development Centers (CINAI), 86 Health Centers, and 528 Health Posts. In addition, there are some 52 mobile medical units, staffed by physicians and other professionals, which provide occasional services in the most remote areas. The Nutrition Education and Primary Care Centers (CEN-CINAI) provide care to children and pregnant or - 221 nursing mothers in the following areas: day-care services, complementary feeding, hygiene and nutrition education, growth and development, primary care, stimulation for integral development, education and social work activities, development of vegetable gardens and community participation. 6.7 Creation of the Health Sector. Background The form^ation of a health sector, consisting of agencies that conduct health-related activities, was first attempted in 1979. Unfortunately, it did not prosper, according to Garcia, due to the lack of a clear definition of the functions of the President of the Republic and the Ministry of Health over the agencies that belonged to the system. According to the National Office of Planning and Political Economy, the 1971-1980 National Health Plan attempted to address three problems : a) incomplete coverage and unequal care of the population, b) the low priority given to prevention, and c) the marked autonomy of health agencies. The responses to these problems included the integration of medical care services, the transfer of hospitals, the universalization of sickness and maternity programs, and the implementation of the rural and community health programs. These integration processes were supported by inter- institutional agreements and the positive political will to 222 seek their implementation. Beginning in 1983, the government adopted the strategy of "sectoral integration" to organize inter-institutional relations. This contributed to strengthening the ties among the various health entities. In 197 9, an executive decree created a modality of national planning by areas of activity.They encompassed two large areas : the social and the economic. In this way, most agencies attempted to coordinate and divide up the work according to their areas of competency. It was also assumed that this integration into sectors would facilitate coordination among and between them. The health sector is still part of the social area (See Figure 11). Each group of agencies or sector has a Minister who, together with the President of the Republic, is responsible for promoting national policies in each case, and who guides the actions or activities of the public entities involved. This Minister acts as the policy director of each sector. In the health area, 1982-1986 National Development Plan included the formation of a National Health System with the health sector forming its operational basis. The formation of a health sector was aimed at rationalizing the use of resources in order to continue to broaden coverage and equity. It was a deliberate action designed to predict the need to reorient the role of the agencies. 223 = | l 111 CO CO CO u il I u Q ) cn 03 o "O c o •H U ( Q k l c 0 ) u c o u 03 (D Q ( Q ■P 0 CT 0 •P 0 U P 0 o'“ I u -p 0 0 u 0 T3 O 3 r H r H P 0 ( 0 CO o 0 •o 0 0 u o P *H 3 U O -H CO > T 3 3 H 0 CO 0 •o 0 0 H 0 U 0 PI 0 1 p 0 ■H CO Costa Rica's economic crisis, most severe in the first half of the 1980s, meant that funds available in the medium term would be insufficient to finance the cost of the, sector's service infrastructure. At this point it is necessary to distinguish the concept of health sector from that of national health system. Public entities make up the health sector, each playing a specific and direct role in health care. Also included in the system are other entities or elements of society having indirect links to health care. Nor should "national health system" be confused with the "National Service". According to Edgar Mohs, a national service presupposes the fusion of the Ministry and the CCSS, which would be an error because the capacity existing in the country in this field is too limited to manage such a large organization. Additionally, a sizable institution or agency would be created, leading to bureaucratization, inefficiency and de-humanization.^^ Instead, he supported the establishment a national health care system that would organize and coordinate agencies participating in a national health care and development plan. As Minister of Health from 1986 to 1990, Dr. Mohs attem.pted to reinforce this approach. Extra-sectoral activities were also important in meeting the stated objectives. Intersectoral activities were necessary not only for the health sector but for other 225 sectors as well. In 1985, the United Nations Food and Agricultural Organization affirmed: In order to improve the quality of services and extend coverage in a manner compatible with existing resources, it is necessary to increase the operational capacity of the health sector , and strengthen its infrastructure, a task that can be achieved in Costa Rica within the existing legal framework. To that end, the sector must first be restructured. It has been noted that the best way to achieve a restructuring is to establish a national health system, articulated both intra- and inter-sectorally through health programs that guarantee access to the entire population, especially to the most disadvantaged groups in terms of levels of health and well-being. The process of integration of services between the Ministry and the CCSS represents an additional effort in the direction of establishing a national health system having a primary-care focus, and will emphasize rural and marginal urban communities.^^ Despite the virtues attributed to a national health system, it was not formally constituted until 1989, as will be described in another section. Process of Formation of the Sector Although the creation of a national health sector was de-creed in 1979, it was not until 1983 that it was definitively formed through Executive Decree No.14313-SPPSS of February 15. Initially, the sector consisted of the following agencies: 226 Organization Activity Ministry of Health (MOH) Social Security Bureau (CCSS) Costa Rican Aqueduct and Sewer Authority (INAA) National Insurance Institute (INS) University of Costa Rica (UCR) Ministry of National Planning (MIDEPLAN) Ministry of the Presidency National health policy Health services Primary health care Rural medical services Medical care Hospitalization, maternity Rehabilitation, care of handicapped and the aged Pension and death insurance Construction and administration of and aqueducts. Care of workers injured in accidents at work. Education and research in health sciences National planning Coordination of intersectoral action Representative of the President In order to make the sector concept more functional, a number of working groups were established.^^ These were: a) The National Health Council as the advisor of the Ministry of Health and the supreme authority within the sector. b) The Committee of Executive Presidents of the agencies. c) The Executive Secretariat of Planning as the entity which controls implementation of the activities carried out within the sector. 22 7 d) The Technical Sectoral Committee as the coordinator and promotor of the process once the plans are established. The officials participating in these working groups were further divided according to their place in the hierarchy; political, normative, and executive (See Figure 12). Efforts to form the health care sector were parallel and complementary to the process of integrating the CCSS and the Ministry of Health. This process in fact facilitated the work of implementing the sector in the early years. The physical infrastructure of the Ministry and the Bureau enabled the reinforcement of this network of health centers which facilitated the functioning of a national health-care system. In 1985, the sector already had 1274 establishments throughout the country. The Ministry was in charge of 1132, the CCSS 131, and the National Insurance Institute had seven. In addition, there was a National Institute of Rehabilitation and three private health centers. External Relations of the Sector The achievement of higher levels of health is not the exclusive task of the health sector. Nor is it possible to isolate health from the process of economic, political, and social development of the country. That task is the responsability of the government, of communities, and privade 2 2 8 Figure 12 Structure of Differentiation and Integration of Health-Care Management by Administrative Levels Costa Rica Policy Authority Social Y / Economic' iommisslon f * (CommWom National Sectoral Council (Health) Normative Authority Executive Authority Presidency o 1 the Republic Sectorial Minister (Health) Sectorial Minister (Health) Economic-Social Council iViinistiy ot National Planning and Political Economy Ministry of the Presidency Council of Government Executive Secretariat Sectoral Planning Other Institutions INS- Profeslonal Risks UnN. of Costa Rica Inlsa and Nodical Sdaocas Costa Rica Aqueducts and Sewer Auhortty Costa Rican SocMI Security Bureau Ministry of Health Source: L. Saenz, Administracion de Salud, p. 1987. 229 organizations. Nevertheless, it is the responsibility of the sector, with the Ministry as its supreme authority, to obtain external cooperation. Cooperation is not simply the procurement of financing. It also implies keeping health care on the national and institutional development agendas. Intersectoral cooperation is not new. Since the beginning of the century, close relationships have existed among other sectors such as education, transportation, and agriculture. At that time, for example, health education was instituted in urban and rural schools. According to Leonardo Mata and Luis Rosero, "the Costa Rican primary-school program pioneered health education in the Americas and has been one of the most consistent examples of intersectoral cooperation. The relationship between the community and health-sector agencies operates through the Boards of Health and Social Security, present in all districts since 1983, in which representatives of the communities, the municipalities and the principal dependencies of the Ministry and the local CCSS participate. The functions of these boards were changed in 1988 to the following: Serve as a liaison between the community health committees, the Ministry's health centers and the CCSS Clinics, in order to channel local problems to higher levels of these agencies; promote health, promotion and education programs at the district level; raise funds to support health programs; — 230 participate in monitoring quality of services; assist in the classification of those insured by the state and of those uninsured who have the ability to insure themselves or pay for services rendered; name a voting community representative to the Local Technical Council. At the district level, the boards may have nine members; a) For the Ministry, the highest ranking official in the health center; b) for the CCSS, the highest-ranking official in the clinic or dispensary; c) for the municipality, the president of the municipal corporation or that person's,delegate, or the local representative before the municipality; d) six persons participating in the SILOS, representing the community. The role of top-level managers of sectoral agencies transcends the area of health because the health sector, "as the leading sector in national integrated development, will generate progress in the search ■ for equity and social justice, to satisfy the basic needs of integral health, understood not only as the absence of illness, but rather as bio-social welfare. International cooperation has been essential for the development of the health sector in general, and of primary care programs in particular. The PAHO has been the primary facilitating agency in this transformation process. The 231 World Bank and the Inter-American Development Bank also conduct cooperative programs at the sectoral level. Community participatio.n and the relevance of government action at the local level presuppose that agencies are organized internally in accordance with the regionalization established by the Ministry of Planning (by Executive Decrees No. 9-501-P-OP of January 15 of 1979, and No. 10653-P-O-P of October 5 of the same year) and that each entity has been decentralizing and de-concentrating its programs so that the decision-making power is increasingly closer to the geographical zones of influence. Regionalization is defined by the Ministry of Planning as the process of organization of the territory that aims to achieve a more, dynamic and balanced socio economic development through the participation of individuals in the definition and implementation of this development, and the rational utilization of available resources in each area of the country. The regions are thus well-defined but not immutable geographical spaces, which contain adequate levels of both population and natural resources sufficient to ensure an effective and efficient internal organization and a certain level of functional independence.^^ The pioneering role of the Ministry of Health in the regionalization of the country has already been mentioned in a previous section. With the functioning of the health sector, regionalization, integration agreements between the CCSS and the Ministry of Health, and with community organizations, and with political support at the highest level, the bases for creating a national health-care system were established. 232 6.8 The Integration of Health-Care Services The Concept of Integration The Ministry of Health and the President of the CCSS, who promoted the integration of services, defined integration in the following manner: By integration we mean the harmonious and systematic development of inter-institutional efforts in order to meet the needs and the effective demand for services, defining and coordinating rationally the level of commitment and participation of the respective government agencies in the process within a juridical- administrative context which while respecting institutional individuality aims to establish a mechanism that enables the creation and consolidation in the short- and medium-term of a national health care system. ^ Integration can occur at various levels, anywhere from the central level down to the original or local levels. In Costa Rica a "bottom-up model" has been promoted in which integration begins at the local level. This has undoubtedly been key to achieving the functioning of the SILOS, because their implementation has also followed a "bottom-up model." The definition of levels of care, regionalization, the existence of a hospital network, the universality of services and the primary care programs were all strategic elements necessary for the consolidation of an integrated health service. The aim of an integrated health system is to offer the citizens preventive and curative medical services in a ■ '— - ' 233 coordinated manner. The ideal situation, according to Juan Jaramillo, would be that primary care workers (at health posts) would send patients requiring more sophisticated medical care to the CCSS health centers or the clinics, and from there, if necessary, to national hospitals. These, in turn, would send back the sick after reviewing their charts, diagnosing or treating them, thus ensuring follow-up at the peripheral facility. Justification of integration Costa Rica’s economic crisis at the beginning of the 1980s forced it to seek more feasible solutions to the high cost of services. This, together with the need to. orient expenditures toward prevention were two important factors that facilitated the process of integration between the CCSS. and the Ministry of Health.The population could more easily understand and use health-care services if they were provided under a single national policy. Additionally, it was vital to increase the population’s awareness of its own responsibility in participating in the prevention programs as well as in promoting it own health without waiting until they were sick and the government would take care of them. In this way, expenditures on specialized medicine could be reduced. According to Juan Jaramillo and Guido Miranda, the main objectives of the integration of services and requirements for achieving them can be summarized in the following way: ---------------------— - 234" ■ ■ a) That institutional resources be utilized ! rationally;- : b) that scientific methods be used to obtain the greatest possible utilities from the resources expended; c) that the investments and contributions in health care be proportional to the needs in order to guarantee their full utilization. In order to achieve these objectives, there must exist: , a) Firm and well-defined policies; b) agencies organized to provide health-care services within the same sector ; c) a coordinated program of integrated services which functions as a national system in which all Costa Ricans have the same access and opportunity to receive both preventive and curative services; d) understanding on the part of all institutional officials regarding their participation and responsibility in the new model of service delivery; e) communities organized efficiently so that they can participate in the National Health Svstem. Background The health-care model in Latin American countries has certain characteristics particular to it. Each agency involved in health care addresses a different problem. In addition, consumers are referred to specialty areas (psychiatry, ophthalmology, urology, dermatology, etc.). Consequently, the doctor-patient relationship is not personal but functional and sporadic. This is reflected in the ------------------— — - - 235 dispersion of agencies and medical specialties. The result is that responsibility for health is also dispersed. The first antecedents of a government response to this problem appeared in the well-known "Friessen Report". In 1957, an American consulting firm, Gordon A. Friessen, conducted a national study of the hospital situation which confirmed the need to. establish a national hospital system because of the disorganization that existed among them. This system had to be integrated with a national health-care policy.The report referred to the modality employed by the British national health care systems in existence since 1944 and that of Chile, established in 1954. However, conditions did not exist in Costa Rica to achieve this type of inter-organizational transformation. During the 1960s various discussions were held regarding integration projects, at least at the hospital level. Attempts were made during the decade to. coordinate preventive and curative medicine. For example, in 1965, the CCSS and the Ministry signed an agreement for the development of preventive medicine aimed at the insured as well as the non-insured population. For some analysts, the lack of a prior program and the lack of understanding on the part of many prevented some defects from being corrected which would have permitted its continuation, and this agreement was only in effect for one year. — --- 23'6 One very important political and technical step, occurred j I in 1966 with the integration of two commissions known as the "High-Level Group" and the "Working Group". The first, a policy group, consisted of the Minister of Public Health, the , managers of the CCSS, the managers of the National Aqueducts ! and Sewer Authority, and the director of the Office of National Planning. The Working Group, for its part, was ■ comprised of the coordinators of the planning offices of those same agencies, headed by representative of the National Planning Office. These two teams disintegrated in less than a year due to personnel changes, leaving their task unfinished. However, it should be noted that an attempt was made to incorporate the political decision-making and technical planning levels as well as to achieve inter-institutional participation. In the 1970s, there were a number of attempts at ' integration which did not prosper much due to changes of both ' personnel and priorities in government agencies. The experience of the integration process in those years was based more on political will and on the good faith of the officials than on legislation. At the beginning of the 1970s, a National Health Plan was promulgated, regionalization was begun, the transfer of hospitals was completed, levels of care were determined, various projects to integrate services were tried, and at the ------------------------------------- - — ■ 237 end of the decade a formal attempt was made to constitute the health sector. All this contributed to establishing the basis for proceeding to a second stage on the road toward integration with greater legal and political backing. The universalization of social insurance and primary care were part of the government's strategy to broaden coverage of health services to the entire population, and both strategies required institutional change. In the mid- 1980s, a USAID mission evaluated the organizational situation of the CCSS and the Ministry, arriving at the following conclusions : In general, the CCSS, has well-defined program objectives^ norms and procedures as well as the basic human, physical, technical resources and management systems to provide services. However, the CCSS suffers form sporadic, inadequate and/or inopportune distribution of medicines and materials, as well as from ineffective and inefficient maintenance systems for preserving and upgrading facilities and equipment. While the Ministry of Health provides an impressive outreach program for family and community preventive and primary health care to large segments of rural and marginal areas of the country, its overlapping and uncoordinated programs and services at the national level result in inefficient utilization of its dwindling resources. Despite an impressive network of services, it faces a severe challenge to coordinate, plan, manage, and evaluate its resources. Almost every program experiences deficiencies in human, physical and financial resources, inadequately defined programs and objectives, and deficiencies in communication and coordination within the agency. In response to. this situation, the Ministry was reorganized, which enabled it to unify programs and leadership and establish a General Health Directorate, as has ---------------------------------------------------------------------- 23'8“ been analyzed. The agency was thus better prepared to modify its external relations as well. Process toward integration According to Lenin Saenz, efforts were oriented toward integration and not toward unification of these agencies due to: the following: In the past it was considered that, in order to correct structural and functional defects of the institutions of the sector and to rationalize the use of their resources, the optimal solutions would be the creation of a National Health Service; however, the experience acquired through the transfer of hospitals to: the Bureau taught us that such a solution has consequences that involve legal problems and high costs due to, among other things, the resistance of the personnel to changing the status of the institution or agency in which they work and the corresponding legal fees. Faced with this situation, one logical alternative would be to integrate health-care agencies in a joint system in which, while preserving their individuality, they interact in such a way that the satisfaction of their interests and their needs is subordinated to those of the sector, that is to say, adjusting the concept of system. In November 1982, by Executive Decree No. 14222, an inter-institutional committee was created between the Ministry of Health and the CCSS to develop a proposal for integration. First Integration Agreement: December 1984 Finally, the Inter-institutional Commission bore fruit and on December 21, 1984 the "Agreement for the Integration of Services...between.. the Ministry of Health and the CCSS" was 239 signed. This agreement, which enjoyed the political backing of the highest authorities of the two agencies and the President of the Republic, became mandatory for the two agencies. In synthesis, the Agreement stipulated the following : 1) The Ministry will be responsible for prevention and the CCSS for medical care and social services. Both entities will coordinate planning, teaching, and research. 2) The Ministry will reimburse the CCSS for the costs of its "insured by the government" and the Bureau will reimburse the Ministry for the cost of care of patients insured in its preventive medicine clinics. 3) The use of common physical plants will be encouraged for both agencies in order to provide integrated services. 4) Each institution or organization will retain ownership of its goods, equipment and materials, but they will be available to Costa Ricans who need them regardless of their condition. 5) The vehicles assigned to the integrated areas can be used by either agency subject to joint planning. 6) Workers retain their rights, will continue to be employed by the same employer and will be subject to the regulations of their agency. 2 4 0 7) Both agencies will use their financial resources more flexibly in order to support the integrated care of the population. 8) In order to ensure adequate delivery of services at the local level, agencies must reorganize themselves and function in accordance with the necessary regionalization and sectoralization. Highly specialized equipment will be concentrated and basic services will be de-concentrated through health establishments available to the entire population. In addition, joint commissions will be established in each health region, composed of officials of the Ministry and of the CCSS, who must attempt to find solutions to the problems of implementing this agreement. One of the aspects that could hinder the functioning of an integrated model such as the one described was the leadership in the management of the Integrated Centers which began to function under this agreement. The ideal situation would be to have a unified leadership in each region, area, or center. However, the agreement does not facilitate nor supersede legal situations which make it impossible to count on this single leadership in a short-term. The signers of the Agreement, Dr. Jaramillo, Minister of Health, and Dr. Guido Miranda, President of the CCSS, consider in this respect that "it is possible to continue advancing toward the integration of services if leadership ---------------------------------------------------------2'4T is exercised through actions of coordination and cooperation without this implying that there must necessarily exist one single head with authority over the personnel of both organizations. That, instead of speaking at this point about heads, we will use the term Coordinator".^^ A National Coordinator was named in each agency to make recommendations to the Minister and to the President of the CCSS regarding the election of regional coordinators and integrated centers. These local coordinators could be from any of the entities participating in the Agreement. Following are some of the factors that facilitated the signing of this Agreement that may serve as useful lessons for public agencies that face similar situations in this dr other sectors of public administration. a) Before .the establishment of a very formal Agreement, several integrated centers were experimented with in order to evaluate their viability. b) The chief political authorities of the two agencies and the President of the Republic offered their greatest support to this initiative in which political will was very much present in the implementation of the strategic changes. c) The Agreement was signed after many years of intense interaction between officials of both -------------------------------------------------------- 2T2' agencies in working commissions, workshops, seminars, joint evaluations, etc. d) Wherever possible, consensus was sought in the strategic decision-making process in order to minimize resistance to change. The previous experience of the transfer of hospitals was taken into consideration in the management of labor relations. e) A large margin of flexibility was granted when adapting the integration to the conditions of each region or care center and to community participation through the Health and Social Security Boards. f) An attempt was made to refine certain internal structural and functional adjustments in each agency in order to prepare it for greater inter- institutional coordination. g) Finally, the entire process was accompanied by sectoral policies (National Health Plan), principles of social solidarity (sickness and maternity programs with higher income ceilings), social participation (district health boards) and greater awareness o the part of the officials involved (joint working groups for the preparation I of the Agreement). --------------------------------------------------------------2T3' For some leaders of the health sector, this was the epilogue of a unique process in Latin America, which took years to develop and which articulated, for the first time, voluntarily and democratically, activities to provide integrated medical services between a social security administration and a ministry of health. As will be explained in subsequent chapters, these conclusions are also valid and essential for the establishment of the SILOS, which constitute the most advanced example of integration and coordination, as they include other public and community organizations. Five years later, in 1989, the experience gained led to a second agreement between the Ministry and the CCSS. Second Integration Agreement: 19.87, Ratified in late 1989 At the end of 1989, two events occurred in the process of inter-agency coordination. The creation of a National Health Care System was decreed and a second agreement between the Ministry of Health and the Costa Rican Social Security Bureau was signed. This second agreement aimed at supporting the process of consolidation of the National Health System through the development and strengthening of the Local Health Systems.It emphasized that both agencies should promote community participation in everything from the identification 244 of problems to the determination of priorities and action plans. The Agreement ratified the active participation of both entities in the structure established to implement the National Health Care System: Health and Safety Boards, Integrated Development Associations, the Technical Councils at the national, regional, and local levels, and Local Health Systems, SILOS. Third Agreement:_____Agreement of the Delivery of Integrated Health-Care Services, 1992. This "Agreement for the Delivery of Integrated Health Care Services between the Ministry and the CCSS" ratified the objectives and the spirit of the previous agreements. One notable political factor was that this agreement was signed in a period in which a president from the Social Christian Unity Party was in power, while the two previous agreements were signed during governments of the National Liberation Party. This demonstrates the support of both major political parties for the integration process. This agreement established the responsibility of both institutions in the areas of promotion, prevention, cure and recovery. In addition, it stipulated that priority must be given to basic environmental clean-up, health education, research, epidemiological monitoring, training and planning at all levels of activity of the sector. Finally, it ------------------------------------------------------------------------ — 2 - 4 - 5 - I instructed both entities to conduct reviews and reforms of the administrative and legal conditions in order to facilitate their joint efforts. The four specific objectives of this Agreement were: a) Coordinate the action of both institutions, consolidate the National Health System, promote primary care strategies and strengthen the development of the Local Health System, with active community participation, from identification of problems through the determination of priorities and the formulation of action plans. b) Establish legal and administrative mechanisms for the equitable and rational distribution of the resources of both agencies; put into effect sectoralization, regionalization and operational and administrative decentralization of services, and to complement this with an appropriate organization of the levels of care in a service network. c) Promote the development and evaluation of new models of integrated health care, emphasizing outpatient services that take into consideration all levels of care to individuals, the family and the community. d) Guarantee universal health care to the Costa Rican population and enforce their right to receive integrated services in clinics administered by the Ministry and the Bureau. Thus, services cannot be denied to any person. In compliance with this Agreement, in 1992 both agencies, with the support of the World Bank and the PAHO, formulated a "Project on Reform of the Health Sector." Creation of the National Health System The National Health Plan established the objective for this period as follows: 246 To maintain and improve the morbidity and mortality health indicators achieved to date and to prevent increases in the chronic and degenerative diseases characteristic of the industrialized countries. A secondary goal is to create and consolidate an integrated National Health System which can provide harmonious coordination of all health sector agencies and foster rational and efficient use of resources. The objective of establishing a National Health System was based on the premise that government actions in this area should be based on the following eight principles: 1) Health care is a right. 2) The Ministry of Health is the highest authority in the health field, and the government is responsible for providing for the nation’s health. 3} The population must be cared for in an integrated way, with emphasis on primary care. 4) Prevention, cure and rehabilitation must be offered through the integration of services. 5} Within the system, outpatient care has priority. 6) The highest priority is promotion and prevention. 7) The essential basis for the functioning of a National Health System is community participation. 8} The main criteria for the distribution of resources must be the priorities of care. --------------------------------------------------------------------- 2T7 An overriding consideration in these objectives and principles was the emphasis on the extension and equity of coverage, as emphasized by Cesar Vallejo and Roberto Junes: The model which brought Costa Rica’s health sector to a position of privilege and which has made it a model for developing countries and even for industrialized countries, is the result of a clear commitment on the part of national leaders and citizens to a persistent sectoral policy inspired in the principles of universality and equity, to a successful financing scheme and to an institutional formula of health care delivery which has demonstrated efficiency. On November 9, 1989, through Executive Decree No. 19276- S, the "General Regulation on the National Health System" was established. The sector was broadened to include private and public organizations whose goals were to improve the level of individual, family and community health. Other objectives included the following: a) Guarantee high-quality, integrated health services to the entire population; b) develop and apply strategies and programs that encourage community participation in the determination of needs and priorities, orientation of resources, and control over the use of those resources; c) establish and promote sub-systems and administrative processes for the management of the resources of the system at each level in ah effective, efficient, equitable and participatory manner and promote the mobilization of the other sectors in order to guarantee a sufficient availability of the resources; d) pass national health-care legislation which would be coherent and up-to-date, in order to facilitate compliance with the goals, objectives and functions of the National Health System and the National Health Policies. ■ The following table indicates the constitution of the health sector: Organization Function 1) Ministry of Health 2) Costa Rican Social Security Bureau (CCSS) 3) National Insurance Institute 4) Costa Rican Aqueduct and Sewers. Authority 5) Universities 6) Private medical services, cooperatives, and self-management 7). Municipalities 8) Communities Highest authority over policies and strategies. Defines National Health Policy. Implements public and private'health care activities. Health promotion. Disease prevention. Environmental control. Application of mandatory social security. Services of recovery and rehabilitation. Collaboration in the promotion and prevention of disease. Prevention of work and accidents. Medical and hospital services to accident victims. Integrated rehabilitation for work-related accidents. Supplies drinking water. Sanitary waste disposal and runoff. Train professionals and technicians. Health promotion. Health recovery. Administration of community services promoting integrated development of their districts. Participation through groups organized to determine needs and priorities. Orient and control available resources. Foment self-help health care. Graphically these components can be represented as in Figure 13. This National Health System is subdivided into four sub-systems responsible for the organization of all activities. These are: a) Health Services, b) Health Insurance and Occupational Health, c) Environmental Affairs d) Community Participation. Rossana Garcia et aA divide the National System into five sub-systems, depicted in Figure 14. The National Health System stipulates that the agencies shall operate on three administrative levels : 249 Figure 13 National Health System Costa Rican Social Security \ Bureau / Costa Rican\ Aqueduct and Sewer authority / National Insurance Institute Ministry Health Universities Communities Private Medical Services Municipalities Source-: Rossana Garcia, El Proceso de Desconcentracion en el Ministerio de Salud de Costa Rica, 89. Figure 14 Sub-systems of the National Health System Environmental and Sewer Maintenance Subsystem Education and Training Subsystem Individual Care Sub-system Production Sub-system Research Subsystem Source: Carlos Castro, et al., Desconcentracion de los Servicios de Salud como Estrateqia para el Desarrollo para los Sistemas Locales de Salud. 250 a) Central : Responsible for decision-making on mandatory health policies. It also provides for teaching, research, and fiscal and financial control. b) Regional : Responsible for coordination, supervision, and training in a particular geographical area in accordance with the regionalization of the public sector. c) Local : Responsible for local programming and implementation. In order to. facilitate the organization of these health establishments into networks of services, the following levels of care were defined: Primary Level: provides basic health-care services including health promotion, disease prevention, cure ehabilitation of minor complexity, practiced in the home, outpatient clinics, and general ambulatory care. These activities will be oriented towar persons and their behaviors regarding health and the environment in which they live, work, or play. The health establishments at this level are : the CEN-CINAI, Health Clinics, Mobil Health Units and Mobil Health and Dental Units, School Dental Clinics, Health Centers and Dispensaries. Secondary Level : charged with supporting the primary care level through preventive, curative and 251 rehabilitative services with varying degrees of complexity of specialization. The health establishments at this level are general hospitals, temporary hospices, the health center (Casa de Salud) and clinics having more sophisticated facilities than those found at the primary level. Tertiary Level: delivers preventive, curative, and rehabilitative services at the highest level of specialization and complexity to take care of certain health problems. Its area of influence can extend beyond the secondary level to various provinces. The health establishments at this level are central hospitals, national hospitals, and specialized hospitals. The coordination of this system and its internal relations are facilitated by diverse units, some of them already existing at the level of the health sector and others that would be created specifically to attempt to implement the decisions and strategies of the system. These units are : National Sectoral Council: composed of the maximum authorities of the agencies that comprise the health sector. --------------------------------------------------- 252 Inter-institutional Technical Council: coordinates the design, development, implementation, and control of the processes of the functioning of the National Health System, following the orientation of the National Sectoral Council. It is composed principally of the Vice-Minister of Health, the Medical Director of the CCSS, the General Health Director and the Regional Health Chiefs. Regional Inter-institutional Technical Council : the highest authority at the regional level. It is responsible for supervising implementation of the Integration Agreement between the Ministry and the CCSS in each region. It is coordinated by one of the regional chiefs of the signatory agencies of the Agreement and serves as the liaison to the Regional Development Council in which other sectors participate. It supervises technical functions of the Local Health Systems. The Area Technical Council: consists of the Regional Chiefs of the Ministry of Health and the CCSS, the Director of the Hospital, Directors of the Clinics, Health Centers, and the Chief of the Agency or the Physician of the Clinic of the National Institute of Insurance. Coordination is alternated each year between the Regional Chief of the Ministry and the CCSS. ------------------------------------------------------------------------ Local Technical Council: responsible for ensuring maximum efficiency and efficacy of the network of services at the community level. It is made up of the Director of the Health Center, a member of the Basic Technical Council of the Ministry of Health the Director of the Clinic, a representative of the National Institute of Insurance, a representative of the municipality and other representatives of similar institutions or agencies in the community. Basic Technical Council : the technical organ having a number of specialties participating with the leadership of the Health Center in the planning of health-care activities, in its area of influence. It is made up of the Director of the Health Center and the representatives of each of the medical specialties present in the area and with the member of the community. This council promotes teamwork, the establishment of Local Health Systems, relationships with other institutional levels, conducts an annual evaluation of the health of the area, structures an operational work plan, coordinates, orients and controls the annual programming of activities of the health establishments which function in their geographic area and encourages community participation in its activities. The General Regulation on the National Health System summarized in previous paragraphs stipulates that the --------------------------------------------------------2'5T primary care is the basic strategy for improvement of health, for which reason it is necessary to promote the SILOS. The institutional situation prevailing at the end of the 1972-1990 period enabled not only basic coordination between the Ministry of Health (MOH) and the CCSS at the local level but also a certain degree of involvement of community organizations, particularly in rural areas. The MOH had experienced organizational change, having adapted itself to such significant transformations as: from an organization with small, independent departments and programs, or "campaigns" it became a formal ministry with a single policy and administrative direction; it became decentralized; it went from being an organization focused on health services to one that coordinated popular participation through rural and community health programs ; without experiencing frequent turnover at the central level, it achieved a certain flexibility to broaden services at the local level; despite the emergence of other agencies, it maintained leadership in preventive health care; the pioneering and innovative spirit has persisted, enabling the implementation of --------------------------------------------------------2 ' 5 ' 5 ‘ processes such as regionalization, sectoral integration and popular participation. In subsequent chapters, other characteristics that help to understand the emergence of the SILOS in Costa Rica under the initial leadership of the MOH will be identified. These factors help to support the idea that the great improvements in health at the local level have not depended on frequent structural transformations at the central level but rather on the capacity to implement, the attitude of officials and the constant relationship with local communities. For its part, the Costa Rican Social Security Bureau has also experienced changes. However, these changes are more significant in their approach than in their formal structures. The CCSS has become actively involved in prevention and health education. Since it took charge of hospital care, it has attempted to expand coverage to levels that are a source of pride for Costa Rica and, despite its initial distance from the Ministry, today both agencies are integrated more at the local than at the central level. The greater relative flexibility of the CCSS in the use of financial resources and its strengths in the area of specialized care are complemented by the tradition, experience and greater amount of information at the MOH. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - — - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2'5'6' Changes in the epidemiologic conditions of the population also required a change in the role of agencies at the beginning of the 1990s. The search for efficiency, efficacy, equity and participation in a climate of financial crisis within the institutions was a formidable challenge. There had been certain advances in legal reform, but the implementation of all of this effort into the SILOS was still pending. The following two chapters will analyze the process followed by Costa Rica in the transformation of the National Health System through the SILOS. - 2 ' 5 ' 7 ' CHAPTER 6 REFERENCE NOTES 1. See Herman Weinstock, et al., Coordinaciôn e Integraciôn del Sector Salud. (San Jose, Costa Rica. Ministerio de Salud, 1972.) z . . Guido Miranda, La Seguridad Social y el Desarrollo en Costa Rica, 66. 3. Graham T. Allison, Essence of Decision. (Boston: Little, Brown and Company, 1971), 79-80. 4. Ibid., 32 . 5. Juan Jaramillo and Guido Miranda, "La Integraciôn de Servicios de Salud en Costa Rica," (San José, Costa Rica : Ministerio de Salud-Caja Costarricense de Seguro Social, 1985), 33, photocopied. 6. Costa Rica. Ministerio de Planificacion. Decreto Ejecutivo No. 10653-P-O-P. La Gaceta: Diario Oficial No. TW] (October 24, 1979) . 7. Juan Jaramillo and Guido Miranda, "La Integraciôn de Servicios de Salud en Costa Rica,” 33. 8. Costa Rica, Asamblea Legislative. Law No. 5349. Tranferencia de Hospitales a la Caja Costarncense de Seguro Social. La Gaceta: Diario Oficial, No. 18 6 (October 3, 1973). 9. In the National Medical Congress of 1955, Doctors Guido Miranda and Rodolfo Cespedes presented a paper in which they suggested this initiative. Fifteen years later. Dr. Miranda himself, representing the CCSS, Dr. José Luis Orlich, the Minister of Health, and his Chief of Planning, ------------------------------------- 2 - 5 ' 8 ' Dr. Lenin Saenz, and other ministers, worked jointly on the task of implementing the transfer. 10. Lenin Saenz, Hacia un Sistema Nacional de Salud en Costa Rica, 4 3. 11. Ibid., 43. 12. Costa Rica, Asamblea Legislative. Ley No. 2738 Universaiizacion de los Seguros Sociales Qbligatorios. La Gaceta: Diario Oficial, No. Ill, (May 17, 1961}. 13. Edgar Mohs, La Salud en Costa Rica, 143. 14. Costa Rica, Ministerio de Salud. Decree No. 15133-E (January 4, 1984) [Based on Law No. 5349 of "Transfer of Hospitals to the CCSS" promulgated in 1973]. Coleccion de Leyes y Decretos, Tomo I (San José, Costa Rica: Imprenta Nacional, 1984), D-73. 15. Guido Miranda, La Seguridad Social y el Desarrollo en Costa Rica, 67-60. 16. Costa Rica. Asamblea Legislative. Ley General de Salud, No. 5395. La Gaceta: Diario Oficial, No. 222. (Alcance No. 172) (November 24, 1973). 17. Oscar Arias, "Relaciones entre Dependencias Nacionales Administraderas de Servicios de Seguridad Social El Caso de Costa Rica)", Revista Juridica de Seguridad Social, No. 2, July 1992. (San José, Costa Rica : Caja Costarlicense de Seguro Social, 1992), 10. 18. Pedro Munoz Amato, Introduccion a la Administracion Publica. Vol.l. (México: Fondo de Cultura Economica, 1954), 211. 19. Costa Rica. Asamblea Legislativa. Ley No. 5662 de Desarrollo Social y Asignaciones Familiares. La Gaceta: Diario Oficial, No. 248, (December 28, 1974) . 20. Lenin Saenz, Hacia un Sistema Nacional de Salud en Costa Rica, 39. 21. Claudio Gonzalez-Vega, Health Improvements in Costa Rica : The Socio-economic Background. Economics and Sociology. Occasional Paper No. 1182 (Ohio: The Ohio State University, 1985), 6. 22. The health promoter was not a physician but a person with basic training in health and community -----------------------______--------------------------- 2 ' 5 ' R education. The College of Physicians initially maintained that prevention could only be carried out by physicians. 23. Guido Miranda, La Seguridad Social y el Desarrollo en Costa Rica, 151. 24. Leonardo Mata and Luis Rosero, National Health and Social Development in Costa Rica: A Case Study of Intersectoral Action, 156. 25. Hugo Villegas, "Extension y Cobertura de Salud en Costa Rica," Boletin Oficina Sanitaria Panamericana, No. 83. (1977), 537-540. 26. José Maria Paganini, Los Sistemas Locales de Salud. Conceptos. Métodos. Experiencias, xiii. 27. Mision Interagencial sobre el Seguimiento de la Conferencia Mundial sobre Reforma Agraria y Desarrollo Rural [Inter-Agency Mission on Follow-up of the World Conference on Agrarian Reform and Rural Development] , "Examen de las Politicas y Estrategias para el Desarrollo Rural en Costa Rica" (Rome: Food and Agricultural Organization, 1985), 65-66, photocopied. 28. Claudio Gonzalez Vega, Health Improvements in Costa Rica : The Socio-economic Background, 29 29. Rossana Garcia, "El Proceso de Desconcentracion en el Ministerio de Salud de Costa Rica : El Caso de la Sub- Region Central Norte 1985-1989" (M.P.A. diss., Institute Centroamericano de Administracion Publica, 1990), 84. 30. Vinicio Gonzalez, Considéraciones en torno a los Problemas Sectoriales de Salud en Costa Rica, (San José, Costa Rica: Oficina de Planificacion Nacional y Politica Economica, Departamento Sectorial Social, 1981), 4. 31. Costa Rica, Ministerio de Planificacion y Politica Economica. Executive Decree No. 9644-P-OP, Creacion del Subsistema de Planificacion Sectorial. La Gaceta: Diario Oficial. No. 46, (March 1979). 32. Rossana Garcia, "El Proceso de Desconcentracion del Ministerio de Salud de Costa Rica: El Caso de la Sub- Region Central Norte 1985-1989," 84. 33. Edgar Mohs, La Salud en Costa Rica, 116. 34. Mision Interagencial sobre el seguimiento de la Conferencia Mundial sobre Reforma Agraria y Desarrollo -------------------------------------------------------- — 2 - g - o ' Rural, "Examen de las Politicas y Estrategias para el Desarrollo Rural en Costa Rica," 89. 35. Juan Jaramillo and Guido Miranda, La Integraciôn de Servicios de Salud en Costa Rica, 54. 36. Mision Interagencial sobre el Seguimiento de la Conferencia Mundial sobre Reforma Agraria y Desarrollo Rural, "Examen de las Politicas y Estrategias para el Desarrollo Rural en Costa Rica," 89. 37. Diego Victoria, ed. , Foro: Salud y Desarrollo en Costa Rica (San José, Costa Rica: Organizacion Panamericana de la Salud, 1988), 60. 38. Leonardo Mata and Luis Rosero, National Health and Social Development in Costa Rica : A Case Study of Intersectoral Action, 74 39. Costa Rica, Ministerio de Salud. Executive Decree No. 14222-SPPS, Juntas de Salud y Bienestar Social, in Colecciôn de Leyes y Decretos, Vol. 1, (San José, Costa Rica : Imprenta nacional, 1983), D-90. 40. Costa Rica, Ministerio de Salud. Executive Decree No. 18596. La Gaceta: Diario Oficial, No. 222 (November 22, 1989). 41.Diego Victoria, ed., Foro: Salud y Desarrollo en Costa Rica, 60. 42. Oficina de Planificaciôn Nacional y Politica Econômica, La Planificaciôn Regional del Desarrollo, la Desconcentraciôn y la Descentrali zaciôn de la Administraciôn Publica en Costa Rica (San José, Costa Rica : Oficina de Planificaciôn Nacional y Politica Econômica, 1985) , 13. 43. Juan Jaramillo and Guido Miranda, La Integraciôn de Servicios de Salud en Costa Rica, 13. 44. Juan Jaramillo, Los Problemas de la Salud en Costa Rica, 64. 45. Guido Miranda, La Seguridad Social y el Desarrollo en Costa Rica, 126-127. 46. Juan Jaramillo and Guido Miranda, La Integraciôn de Servicios de Salud en Costa Rica, 60-61. ------------------------— — -------------------- 2'6T 47. See Gordon Friessen, Plan de Coordinaciôn Hospitalaria en Costa Rica, (San José, Costa Rica: Ministerio de Salud, 1958). . 48. Some proposals were made in this regard in 1962 by the ex-Minister of Health Dr. Rodrigo Loria and the Chief of Medicine of the then Central Hospital, Dr. Guido Miranda. Also Dr. Oscar Tristan, ex-Minister of Health, presented a project reorganizing medical services in 1966. Two physician-deputies, Fernando Trejos Escalante and Fernando Guzman Mata, presented a project to the Legislative Assembly to create a national health service. The discussion of these and other initiatives, because of their importance, took practically ten years until the enactment of the first National Health Care Plan in 1971. 49. See Humberto Flisfisch, Lenin Saenz and Antonio Rodriguez, Analisis del Sistema Hospitalario Nacional en Costa Rica, (San José, Costa Rica: Ministerio de Salud, 1967) . 50. Catherine Overholt and Peter Cross, op. cit., 34. 51. Lenin Saenz, Hacia un Sistema Nacional de Salud en Costa Rica, 4 6. 52. Juan Jaramillo and Guido Miranda, La Integraciôn de los Servicios de Salud, 5-6. 53. See Ministerio de Salud, Convenio de Integraciôn y Coordinaciôn de Servicios entre el Ministerio de Salud y la Caja Costarricense de Seguro Social, (San José, Costa Rica: Organizaciôn Panamericana de la Salud, 1989). 54. Ministerio de Salud, Caja Costarricense de Seguro Social, "Convenio para la Prestaciôn de Servicios Intégrales entre el Ministerio de Salud y la Caja Costarricense de Seguro Social," (San José, Costa Rica, 1992),-3-4, photocopied. 55. Catherine Overholt and Peter Cross, Costa Rica, Health Sector Overview. 17. 56. César Vallejo and Roberto lunes, "El Sector Salud en Costa Rica : Financiaciôn y Eficiencia," 3. 57. Costa Rica, Ministerio de Salud. Executive Decree No. 19276-S, Reglamento General del Sistema Nacional de Salud. La Gaceta: Diario Oficial, No. 230, (December 5, 1989). ^ ^ “ "2'6% CHAPTER 7 STRATEGY OF TRANSITION TO SILOS IN COSTA RICA One of the principal objectives of this study is to draw lessons from the processes of inter-institutional integration and the implementation of the SILOS. These lessons are valuable for agencies or institutions in Costa Rica as wall as other Latin American countries that are attempting to provide health care more effectively. This chapter will analyze the strategy followed by Costa Rica to transform its modality of service delivery. It will begin with the identification of the need to change the manner in which the agencies function and will describe some, of the options employed to implement change. It will discuss the reasons for the selection of SILOS and how this modality was introduced and implemented. 7.1, Need to Change Health-Care Delivery Organizations The explanation for a particular health-care system cannot and should not be separated from the political, economic, social and cultural context of the country in which it emerged. Moreover, each system evolves in its own way and may not have the capacity to meet the demands placed on it -------------------------- 2 ' 6 ' 3 ‘ by that context. The origins of the need for change may thus be either extrinsic or intrinsic to the. health-care system. 7.1.1. The search for equity, efficiency and efficacy Two causes that are essentially extrinsic to the system are the process of democratization underway in Latin America, particularly since the mid=1980s, and the economic crisis of 1980s and the early 1990s. Both situations have been described in previous chapters. Nonetheless, it is important to emphasize the impact of these two phenomena on health-care agencies. Democratization can be defined as providing all citizens the opportunity to exercise their rights and responsibilities. On December 10, 1948, the United Nations General Assembly included health in the Universal Declaration of Human Rights: All persons have the right to an adequate standard of living that.ensure the health and well-being of them and their families, particularly the right to food, clothing, shelter, medical care and the necessary social services; they have the right to insurance to protect them in case of unemployment, sickness, disability, widowhood, old age or other causes of loss of their means of subsistence due to circumstances, beyond their will.^ To make this human right a reality, health-care systems must promote equity in access to services. Bringing agencies closer to the population is a necessary step to achieve equity. However, the extreme concentration of Accidents Respiratory System political power at the highest levels of the state bureaucracy, typical of many Latin American ------------------------------------------------------------------------------------- ------------------------— ---------------------- 2'6T countries, has been a barrier to equity. Political, administrative and territorial decentralization was thus identified as an way to broaden and consolidate democracy and redistribute political power.^ Decentralization was the means chosen to transform health-care agencies, strengthen democratization and achieve real equity. Probably the constant discussion of Latin America's political, military and economic crises led to greater awareness about the need to attack these problems at their roots, one of which was inequality in the enjoyment of basic rights. Although in Costa Rica the crisis did not have a military dimension as it did elsewhere in Central America, the economic impact of the civil wars in Nicaragua and El Salvador sensitized political leaders to the need to improve the delivery of certain basic services such as health care. In the 1980s, the increase in the demand for services was not accompanied by a corresponding rise in financial resources. According to César Vallejo and Roberto lunes, financial projections in the health sector in Costa Rica for the 1990s show a growing reduction in the ratio of income versus expenditures. In their view, the financial situation in the 1980-1990 period had the followLng characteristics: a. Reduction in per-unit expenditures. Real income in the sector grew at an average annual rate of less than half (1.19%) of the rate of growth of the population (2.8%). Per capita expenditures in health care --------------- — 265 in 19.85 were sixteen percent lower than in 1980 . In that year, health-care expenditures represented 8.55% of GDP, while in 1990 they represented 7.8%. In 1990, the sector was operating with a deficit of more than seven hundred million colones. ($6.7 million). b. Financing difficulties. The health sector is financed principally through payroll deductions for social security and insurance premiums. In 1990, these represented seventy-five percent of its revenues, which is evidence of its vulnerability to the vicissitudes of the economy. All other sources of financing have steadily diminished. Contributions from the national budget in 1990 were thirty-four percent lower than in 1980, and those from the national lottery were ninety percent lower than in ,1980. c. Financial situation of the public agencies. In 1990, the MOH, the CCSS and the National Insurance Institute operated with deficits in their cash flows. The situation of the CCSS was the most critical, as it went from a surplus of 1,764 million colones ($15 million) in 1987 to a deficit of 364 million colones ($3.5 million) in 1990. This is due to various factors, among them government noncompliance in the payment of its quotas, internal inefficiency, inadequate control over the use of human and physical resources, and transfers of funds to other agencies. The administrative inefficiency within the CCSS was evident — 2'6 6 in its inability to collect contributions from the private sector and in excessive expenditures for personal services (fifty-five percent in 1990) . Payroll deductions for social services in Costa Rica represent about fifty percent of salaries, for which reason it is unlikely that this source of income will rise due to its negative impact on the national economy resulting from increased costs. of production.^ The demand for more and better services according to the principle of equity and the. reduction in economic resources make the search for administrative efficiency and efficacy central issues for the health sector and important reasons for transforming the modality of service delivery. While it is true that the greater efficiency being sought depends on technical skills in the area of health care, the lion's share of the changes need to come on the management and administrative side so that existing resources can be better managed. Without improving management, and administrative, skills and abilities, the changes would have to occur through increased productivity. 7.1.2. Modification in Epidemiological Conditions The. typical patterns of epidemiological transition were described in Chapter 2. In the specific case of Costa Rica, this evolution is particularly notable in the last twenty years. As Dr. Juan Jaramillo, Minister of Health (1982-1986) has noted,, the epidemiological phenomenon of greatest importance in recent times has been the rapid change in the health profile of the. Costa Rican population. He observed — --------------------------- that while it is laudable that a poor country such as Costa Rica has the life expectancy of some rich countries, this creates pressures, because reaching these indices so rapidly without simultaneous development of adequate economic and social structures can lead to an untenable overburdening of the social security system. Costa Rica has a predominantly young population. Thirty-six percent of the population is comprised of people younger than fifteen years of age, and an additional ten percent is between fifteen and nineteen years of age. For now, this is a great advantage.... But as time goes by, the population will age (currently 6.2% of the population is over sixty), but these groups will tend to increase in the short term, they are not relatively healthy people. Many suffer from the consequences of alcoholism, smoking, environmental pollution, obesity, emotional stress and years of overwork, as is the case with farmers. ^^ill we have a generational stratum of old, infirm, emphysematous, cancerous, arthritic, cardiac patients in the future? I fear that, in many aspects, this will be the reality.^ Along these same lines, another minister of health (1986-1990), Dr, Edgar Mohs, identified some of the biggest challenges facing the health sector in the future as environmental control, the regulation of the use of pesticides, the improvement of health in the workplace, the use of new vaccines and technologies, the reformulation of the concept of healthy lifestyles and healthy cities, the promotion of mental health and the fight against drug addiction, obesity, smoking and alcoholism.^ The issue now is not so much recovery of health but health promotion through education. 268 Figure 15 shows the significant change in causes of death in Costa Rica, which is a concrete manifestation of the change in the epidemiologic profile. Figure 15 Principal Causes of Death In Costa Rica 1970-1991 (rates per 10,000 inhabitants) •H I O O o 0 > O . Circulatory Systems Tumors : v Accidents respiratory system Infections and parasitic infections 1 — IfTO : * T % — I — I»74 [ — I«t0 — r t9t2 T 19(9 19.92 Source: Ministry of Health, Department of Statistics, 1992; Memoria 1982 (San José: Ministry of Health, 1993). ----------------------------------------------- — — 2'6'9' To further complicate the change in the epidemiologic profile, it does not occur uniformly throughout the country because, as Juan Jaramillo has noted, while the national infant mortality rate is at fourteen per thousand live births, there are still districts with rates as high as forty-seven per thousand, as in Turrubares, or thirty-one, as in La Cruz.® In his view, the health of a community is the result of interactions between susceptibility and exposure to different risks (environmental influences) and the genetic and physical constitution (both congenital and acquired) of each individual, as well as available resources. This demands a considerable degree of flexibility within the sector to adapt its services to the distinct regional and local epidemiologic profiles. Thus, the transformation of the sector is justified in the change in profile and in its diversity throughout the country. Decentralization and adequate training of human resources within health-care agencies must thus be one of the most important responses to the diversity and the superimposition of epidemiological conditions. The new epidemiologic profiles require activities in the areas of education, promotion and prevention. In order to carry them out, public agencies or institutions must become closer to the populations they serve. A better understanding of the characteristics of each community is required. Additionally, the results from the attention to new problems ---------------------------------------------------------------- 27 ' 0 ' will depend greatly on the communities themselves. All this requires a change in the nature and modality of service delivery, which will influence the relationships among agencies and between them and the community. 7.1.3. New Approaches and Status of Health Care The traditional definition of health as the absence of disease has changed in the last twenty years, and it is now defined in terms of well-being. This change was already evident in the United States in the 1970s. Health began to be seen as a basic social objective on a par with housing, nutrition, education and others, which reflected changes in U.S. social policies.^ The World Health Organization defines health as the state of complete physical, mental and social well-being. When the population broadens its concept of health, it also broadens its needs and consequently its demands. The problem, as Miguel Segovia has observed, is that health-care services can be abused, creating considerable and unnecessary pressure on health-care agencies, specifically the CCSS in the case of Costa Rica. In his view, the population was. not educated about the proper exercise of its rights, and indeed an error was made in emphasizing the supply of services, which has led to an excessive demand for them.® Norma Ayala et a^. have argued that health care in Costa Rica has followed the Flexner model, divided into areas of 27 i specialization (for organs and systems) and types of actions, whether in health promotion, prevention of disease, medical care or rehabilitation. This produced a disjointed approach to health-disease.^ It contributed to the development of a costly model of care given the duplications among institutions. This must change in the direction of an integrated approach to health at the local level and, in this way, lead to changes in the national health system and in the relationships among agencies at the local level. 7.1.4. Absence of Leadership and Strategic Sectoral Focus In August 199.2, a high-level commission comprised of officials of the CCSS, the Ministry of Health and the Pan American Health Organization conducted a diagnostic study of the situation within the sector. Its most important conclusions were the following : There was no single authority responsible for integrated planning, control and evaluation which, from a sectoral perspective, defines its further institutional disaggregation. It had not been possible for the Ministry to exercise its leadership role within the sector because existing legislation did not approach health from an integrated perspective. Moreover, the Ministry did no.t possess the instruments for sectoral coordination nor did it ------------------------------------------------------------------- 272 participate in the decisions of autonomous agencies such as the CCSS and the Costa Rican Aqueduct and Sewer Authority. There was a lack of coordination on issues of work- related hazards, and there was no clear delineation of responsibilities in the care of work-related accidents or occupational diseases. There was a lack of integration, timeliness and reliability in the management of data provided by the various information systems. There was no clear process to establish human-resource policies, norms and procedures on salaries, incentives, recruitment and selection, distribution and training. The modality of budgeting had followed traditional procedures due to rigidities in its management, and no analysis was conducted to determine the most rational use of resources, effective control of expenditures in accordance with real costs, or compliance with pre- established objectives. There was an effective reduction in coverage of the Ministry of Health’s programs due to structural rigidities and budgetary limitations. Consumers were unsatisfied with outpatient consultations in the CCSS clinics due to slowness and rudeness. --------------------- ■ ---------- -— ---------------------2 ' 7 ' 3 ’ There was a lack of broad and informed social participation regarding the role of the communities in the promotion of their own health and prevention of disease. Organizations were compartmentalized, resulting in large measure from an abundance of legal norms and a lack of consistent and appropriate management procedures . It is important to emphasize the fact that the solution to these problems is predominantly political and managerial rather than technical and medical. The more profound the reforms in the health sector, the more management capacity and ability to reach consensus will be required to carry them out. From this brief overview of the situation within the sector and its principal organizations, it can be concluded that the solution is equally complex, as it implies consolidating modifications in very diverse areas but in an orderly sequence that will facilitate an evolution that follows a concrete direction. 7.2 Available Strategies for Change During the 1980s, the agencies within the health sector tried to react to the reality summarized in the preceding section in a number of ways. According to recent Minister of Health Mohs, the possibility of fusing the Ministry with -------------------------------------- 274 the CCSS was discounted, because it was necessary to keep each organization performing in its area of competency: the MOH would see to public health and primary care, while the CCSS would be responsible for high-quality individual care. A single agency would be incapable of attending to all problems, and their administrative complexity would be an even greater barrier to achieving equity, efficiency, efficacy and democratization. 7.2.1. Ambulatory Health Care Modalities In place of this fusion, it was decided to implement the SILOS, whose characteristics were described in Chapters 3 and 4. Other modalities of urban ambulatory care were put in practice in Costa Rica in the 1980s as well, which are currently in a process of expansion. These modalities are briefly summarized below. (a) Private Medical System. In this modality, employers provide medical services to their employees and to their families on the premises, while laboratory, pharmacy services and economic subsidies are provided by the CCSS. This modality was instituted on an experimental basis in 197 0, and in 1981 the Private Medical Program or System was formed with its own regulations. The program has produced savings for all three parties : employers, employees and the CCSS. --------------------------------— 27 5 According to Javier Alfaro and Berny Fernandez, despite its advantages, the initial objective of reducing unproductive time, which emphasizes curative over preventive medicine, has persisted.Other limitations are that many of the physicians lack expertise in occupational medicine and patients are often unable to begin their treatments because of delays in the distribution of their medicines. In 199.2 there were 945 companies registered in the Private Medical System. ( b ) . Joint Public/Private modality. As defined by the CCSS, this modality consists of the right of the insured or their family members to seek, on their own initiative, an outside consultation with a private physician, and the right to receive medicines and ancillary diagnostic services from the CCSS. This system was begun in 19.80. Physicians participating in this system must receive the prior approval of a Coordinating Council of CCSS Medical Services. Although the initial intention was to facilitate outside consultations for the CCSS and promote free election of physicians, the results have been limited. In 1990 and 1991, consultations sought through this modality represented a mere 1.8% and 2.2%, respectively, of the total number of consultations within the CCSS. This system is also limited to curative medicine. '21'6 (c) The capitation modality. This modality began with a project in 1987. The CCSS pays doctors on a monthly basis according to the number of direct or indirect (family members) insured that they are responsible for in a given community or geographical area. These professionals are responsible for integrated health care within their area. In cases where there are various physicians in the community contracted under this modality, they compete for subscribers. The physician is responsible for the overall health of the population registered, and a closer relationship is fostered between the physician and the insured. Patient evaluation of the quality of service affects the incentives received by the doctors. Maria Ethel Trejos considers that this modality helps to consolidate the integration between the CCSS and the Ministry at the local level, since activities at this level are under a single leadership. Moreover, it strengthens community participation and the functioning of the SILOS and achieves higher levels of consumer satisfaction. She argues, however, that Ministry and CCSS regulations hinder more effective performance, local officials do not have much discretion, and one of the chief limitations of this model is that the CCSS only hires physicians, not other professionals who also participate in health promotion. ---------------------------------- 2-77‘ (d) Self-managing cooperatives. This is a more advanced model than capitation. Health professionals do not depend hierarchically on the CCSS or the Ministry but rather are integrated into a self-managing cooperative organization which is hired and supported by the health-care agencies to provide integrated health care in a specific geographic area. This modality was implemented in 1988 with a cooperative in Pavas, Costa Rica, which was the first experience of its kind in Central America. The health-care professionals are the owners of the enterprise and its guarantors of the efficiency, efficacy and equity in service delivery. Additionally, the cooperative enterprise administers and coordinates the SILOS in its geographic area and assumes the responsibility for the health of the population through the Family and Community Health- Care Model. The free election of physicians and community participation in diagnostic studies, planning, control and evaluation of services are part of this modality. Revenues come from the CCSS, which pays the cooperative an amount for each insured person registered at the clinic which serves as the cooperative's base of operations. The MOH contributes a fixed monthly budget. In 1992, one of the cooperatives, COOPESALUD, R.L, had a total operating budget of $1.5 million, with which it met its payroll, purchased supplies and administered the SILOS. ----------------------------- ■ ■ ■ 2'7'S’ According to Fernando Marin, manager of COOPESALUD R.L., this experience has demonstrated that it is possible for a SILOS to be managed by private entities and that decentralization and other desirable characteristics of a SILOS can be implemented with very positive results in terms of integrated care. Javier Becerra, manager of another cooperative, concurring with Marin, has noted that the weaknesses of this modality are the lack of an appropriate legal framework for contracting with public health agencies and the absence of an expeditious mechanism for rate changes with the CCSS and the MOH. Some of the drawbacks in this modality are possible non-compliance or delay in payments on the part of the MOH, opposition among CCSS mid-level managers and technicians, and the public-health services monopoly, which limits the expansion of these cooperatives.^® (e) Modality of family and community medicine. This modality attempts to coordinate and integrate health-care activities (promotion, prevention, recuperation and rehabilitation) of the community, the Ministry of Health and the CCSS . The first experience began in 19.88 with the Integrated Health Center of Coronado (CSIC), in the Province of San José. The CSIC is one of the most highly developed examples of the integration between the MOH and the CCSS. Both agencies conduct joint diagnostic studies and formulate -------------------------------- 27 9 integrated plans and budgets. Other features of this modality include the following: Families select the physician of the CSIC of their choice within their area of residence. The physician provides continuous care to the family. The community participates in diagnostic studies and in the definition of district plans which are later reported to the municipality. The CSIC personnel is made up of Basic Teams for Integrated Health Care (EBAIS) which consist of a general or family physician, a nurse's aid, a primary care technician and a secretary or clinic aide. Two or more EBAIS provide care to a district, and support services (pharmacy, laboratory, social work, dentistry and nursing) also, participate. The CSIC is directed by a Technical Council consisting of all local CCSS and Ministry department heads. This Council meets weekly and makes decisions by consensus. Each physician is responsible for between 2,500 and 3,000 persons. The principal problems with this modality, according to the director of the CSIC, are the lack of medical and primary care personnel, the lack of incentives and the lack of ---------------------- — -----------------2'8D’ knowledge about it at the intermediate levels of the agencies. The CCSS and the Ministry are attempting to learn from these modalities of ambulatory care, which are complementary to and compatible with the establishment of the SILOS throughout the country. With so few years of experience, it is premature to evaluate their results, although some field studies demonstrate a high level of user satisfaction with the cooperative and CSIC modalities. An important fact is that while the CCSS assumed the leadership in the development of these experiences, the Ministry was the leader in the area of the SILOS. 7.2.2. Structural Changes in the Health Sector The state could have restructured the entire sector during the 1980s, but as has been mentioned, there were political, legal, technological and administrative reasons that tended to discourage a transformation of that magnitude. Instead, during the past decade an attempt was made to alter the relationships between the agencies, as was described in Chapter 6. The changes implemented were part of a process begun in 1961 with the promulgation of Law No. 2738, which directed the CCSS to universalize social security. In 1972, an economic element was added to this universalization by means of the removal of vertical and horizontal limits on charges, and in 1973, Law No. 5349 decreed the transfer of ------------------------- . “2'8T hospitals from the Social Protection Boards to the CCSS, with the intention of establishing an integrated health system. Inter-institutional relations between the CCSS and the MOH intensified in 1973 when a General Law on Health was promulgated, establishing policies and responsibilities for the provision of preventive and curative medical services. In 197 9, the Costa Rican public sector experienced an important change when procedures for sectoral planning were established and the existence of a minister for each sector was decreed. That year, an initial agreement was signed between the CCSS and the Ministry regarding the system of cost reimbursement for medical and hospital services for the uninsured. During the 1970s, the CCSS attempted to consolidate the hospital system and the MOH through its rural health and community health programs. This evolution continued with the formal and legal constitution of the health sector in 1983. Despite the laws and decrees that supported this process, by the beginning of the 1990s the efficiency of the sector began to be questioned. According to the Executive Secretariat of Planning of the Health Sector, it has not been able to organize itself to function as an harmonious unit; rather it has simply routinized certain existing structures. Regional planning is weak and inoperative because it lacks areas of common agreement. 2-8'2‘ Since its founding, the CCSS has maintained its organizational autonomy and, consequently, the Ministry cannot exercise any decision-making power over it. The validity of the leadership of the MOH and the real impact of its decisions depends on something more than legal statutes. The degree of political and even personal concordance between their highest authorities, the professional relationships at the managerial levels and between functionaries of both agencies, are essential factors to ensure the smooth functioning of sectoral activities. These characteristics of the culture of the organizations are key determinants in the integration process that occurred subsequently and in the manner in which the Local Health Systems were implemented. One event which paved the way for the subsequent appearance of the SILOS was the establishment in 1983 of the Health and Social Security Boards in every district in the country. The Ministry and the CCSS promoted the promulgation of legislation that year, which regulated them and granted them the responsibility to serve as a link between the Ministry, the CCSS and the community to implement those policies, programs and activities that both institutions agreed to develop locally. These Boards were comprised of the highest authorities of the CCSS, the Ministry, the municipality and four delegates from the community. In reality, in the case of Costa Rica, the SILOS could be viewed as a more advanced phase of the Health and Social Security ----------------------------------------------- 283 Boards since the principles of social participation, local programming, new models of integrated care and others, which are essential in the SILOS, were already present in these Boards. One notable and illustrative fact is that the process of forming a health sector with the participation the highest authorities of the agencies occurred simultaneously with a modality of organization at the district level which, as with the Health and Social Security Boards, facilitated a formal link which rationalized government activities in health at the local level. This process continued with the signing of an agreement in 1984 between the CCSS and the Ministry. In it, the Ministry assumed responsibility for the actions of promotion and prevention and the CCSS for the functions of recuperation and rehabilitation of the insured and uninsured population. The agreement regulated the combination of installations and equipment and technical, human and material resources of both agencies, particularly at the local and regional levels. Although autonomy is mentioned, the greatest possible degree of complementarity of functions was attempted without violating the legal restrictions of either agency. 7.3 The Implementation of the SILOS-in Costa Rica According to ex-Minister Mohs, the strategy followed to implement the SILOS consisted of a sequence of actions in --------- — ----------------------------— ------------------------------- 2'8“ 4‘ four areas: administrative, financing, information systems and legal. The SILOS did not begin on a precise date; rather, they were a stage within a process initiated in Costa Rica several decades earlier. However, there are precedents directly related to the SILOS that offer valuable lessons in the managing both intra- and inter-organizational.change. At the beginning the MOH was directly responsible for implementation of SILOS. 7.3.1 Actions in the Administrative-Managerial Area_ Direct Antecedents of the SILOS The Arias Administration (1986-1990) prioritized the reorganization of the health sector in order to consolidate a national health system. In order to advance the process, decentralization of services with delegation of authority and responsibility at all levels of care was encouraged. It attempted to increase community participation in various health committees and experimented with new models of integrated care. All this implied the strengthening of activities at the local level. In 1986, the Ministry's General Health Directorate proceeded to form five commissions or working groups responsible for promoting new areas : Teamwork; Health Education; Information Sub-systems; Control and Management ; and Community Participation. Each of these commissions was composed of persons from diverse departments of the Ministry who, without relinquishing their positions. --------------— --------------------------------------------------------- 2-Q3 implemented actions at the local level. The work of liaison and supervision of these groups was conducted by the General Health Director. The strategy followed in this phase was directed by the Commission on Teamwork, whose principal objective was to strengthen this modality of work in the Health Centers and with the personnel of the Ministry placed in the communities. To accomplish this, it had the technical assistance in the administrative area of a specialist from the Costa Rican Technological Institute and financial support from the Pan American Health Organization. According to the Commission's coordinator, the tactic followed during 1986 was the following : (a) The commission traveled to all the regions to conduct training and motivation workshops in teamwork, leadership, local programming, negotiation, human relations, and general administration. The product of the workshops was commitments on the part of local personnel to carry out certain activities in which they would apply the knowledge gained before the next workshops. (b) Personnel from their own regions served as workshop facilitators in order to obtain greater commitment to the objectives, reduce the resistance to change and a create a multiplier — 2 8 6 effect in disseminating the contents of the training and motivation workshops. (c) No pilot projects were conducted; rather, it was decided to work on a national scale, adapting the strategy of implementation to the conditions and capacities of the MOH in each region. (d) Local rather than regional personnel were involved in the process, because it was thought that resistance to change could be lessened if the work began with those most interested in local planning and there were a certain degree of discretionality in the use of resources. (e) Wherever possible, teams of facilitators composed of local and regional personnel collaborated in areas other than their own in order to stimulate cooperation and teamwork. According to Francisco Golcher, the response at the local level was positive although at first there was a certain degree of skepticism arising from the fact that some officials considered this to be one more initiative that would have little impact. A real process of local planning was begun, which reduced the doubts. At the regional level (supervisors of the local levels), resistance was greater, because other interests and priorities came into play, as well as the perception on the part of some that they could lose power if the local level were strengthened.^^ ------------------------— - 287 Once the Commission on Teamwork began its work at the local level, the other commissions soon followed suit, especially the Commission on Social Participation, which attempted to modify the prevailing concept of participation that existed among Ministry officials. The important thing was not that the community would support the programs, but that they were involved in conducting diagnostic studies and prevention programs. The Information Sub-system Commission implemented a system that helped increase the number of diagnostic studies in health and facilitated local planning. This helped to raise the level of motivation and acceptance of this teamwork and participation initiative among local officials, as it was obvious that this time they would have greater possibilities to act on their own priorities, which represented a break with the previous central planning model. Parallel to the work of these commissions, the Ministry and the General Health Director also encouraged administrative déconcentration processes and development of managerial capacity at all hierarchical levels of the agency. From the perspective of the local officials, the situation had become complicated, because each program that had its headquarters at the central level and each of these commissions demanded services which created pressures for dispersed activities. The policy response from the Ministry was the fusion of the programs, including Rural Health and — — — ^ 2 ' 8 ' 8 ' Community Health, into a single program, the Integrated Health Program. Additionally, the Integrated Health Teams Program (PIES) was created to coordinate the work of all of the commissions mentioned above. The Integrated Health Program established that local coordination would be done by Community Technical Councils (CTB), located in the district health centers throughout the country. These councils are collegiate organizations designed to achieve consensus among the officials to decide on and implement local strategies. This prompted a profound change in the culture of the Ministry, because the doctors at this level became members of a multi-disciplinary, decision-making team, and ceased to be the central figures in the system and the only or the highest-level people in charge of planning. Secondly, this planning model altered the relationships of decision-making authority, emphasizing internal negotiation among the central, regional and local levels. The various medical, technical and administrative disciplines thus have greater representation in the CTBs, which makes the management of the Ministry more democratic. As Emmette Bedford argues, "the attainment of the democratic ideal in the world of administration depends much less on majority votes than on the inclusiveness of the representation of interests in the interaction process among decision makers. The strategy thus consisted of ----------- — ---------------— -------' 2 8 9 initiating a change in the culture "from below" without modifying structures either at the regional level or the Central level. In this way, already by 1991, eighty-six CTBs had been formed throughout the country. In the case of Costa Rica, these CTB can be considered to be the phase prior to the SILOS, because the missing element was the participation of other public agencies in the process. 7.3.2 Actions in the Financing Area In these first two years of strengthening the local level, certain decisions regarding the use of supplies were decentralized. However, this did not advance due to limitations imposed by administrative regulations and the fact that the change began at the lowest levels of the Ministry rather than the central level. For this reason, there was no process underway in this area that enjoyed the support of the middle managers of the agency. As was mentioned in the preceding chapter, in 1989 an agreement was signed between the Ministry and the CCSS which facilitated the combining of resources at the regional and local levels and produced a synergistic effect and greater rationality in expenditures. The bureaucratic delays within each agency did not change much between 1986 and 1990, but the management training programs helped to encourage greater efficiency. For example, budgets were prepared jointly in those districts where the agencies had integrated programs. ---------------------------------- 290 The use of assets such as automobiles, laboratories, and buildings was regulated through the 1989 agreement and their use was made more flexible so that they could be combined in integrated programs. Given the autonomy of these two agencies, this was an area in which the integration process experienced a greater level of development. There is a significant difference in the levels of resources between the CCSS and the Ministry (see Table 4) . The participation of the CCSS in the provision of preventive medical services has enabled the transfer of resources that previously were used for curative medicine (CCSS) to prevention, which had been assumed to be within the exclusive purview of the Ministry. TABLE 4 EXPENDITURES OF THE HEALTH SECTOR BY AGENCY Costa Rica, 1987-1991 (millions of current colones) TOTALS M.O.H C.C.S.S. I.C.A.A. I.N.S MUNICIPALITIES EXPEDITURES YEAR AMOUNT •% AMOUNT % AMOUNT % AMOUNT % AMOUNT % AMOUNT % 1987 19, 139, 9 100 2,706,8 14, 1 13,565,6 2,499,1 13, 1 36^4 1,9 0,0* 0,0* 1988 24,302,3 100 3,172,0 1^^ 16, 678,8 6^V 3,436,3 14, 1 42^1 1,7 592,1 2,4 1989 31,270,6 100 3,486,2 11, 2 24,647,3 7^^ 1,688,0 5,4 672,0 2,1 777,1 2,5 1990 37, 841,8 100 4,305,8 11, 4 29,175,8 77,1 3,444,8 6, 4 98^9 2,6 93U^ 2,5 1991 46, 662 100 5,042,7 10, 8 35,704,8 7^^ 3,398,6 7,3 1,395,2 3,0 1,120,7 2,4 15^21^6 100 18,713,5 11, 8 119,772,3 75,2 13,466,8 8, 5 3, 842,6 2,4 3, 421, 4 2,1 *NOTE: IN 1987, MUNICIPAL EXPEDITURES WERE NOT REPORTED Source: Ministry of Health, Memoria Anual 1991 (San José, Gbsca Rica: Ministerio de Salud, 1992), 95. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - — - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2'9T 7.3.3 Actions in the Area of Information Systems and Birth of the Priority Districts Program The intensification of activities at the local level also encompassed the development of an information system that could facilitate local planning by providing reliable information for decision making. An information system was established, adapted to the local conditions, making it possible to conclude that health conditions were not uniform throughout the country and that the Community Technical Councils needed to recognize this problem and develop appropriate responses. With the utilization of seven mortality indicators and five social indicators, thirty districts were identified as "priority districts." These were mainly located in the northern and southern border areas and on the Atlantic coast. The differences between these districts and those of the rest of the country were significant. For example, in 1970 the infant miortality rate in the priority districts was 22.1 per thousand, as compared to the national average of 13.5 per thousand. The Ministry's response was the establishment of a Program to Develop and Strengthen the Priority Districts, whose objective was to improve the efficiency and efficacy in integrated health-care service delivery, based on the health policies, the strategy of extension of coverage and primary care. The program’s goal was the develop an administrative ' process that strengthened the health infrastructure of the Local Health Systems. This was one of the first occasions in which the SILOS were mentioned in a Ministry planning document.The purpose of this program was to strengthen the health centers, specifically to improve diagnostic studies in health, develop operational plans utilizing more local planning, increase community participation, and improve information systems. The Ministry provided these districts with more material, logistic, human and technical resources. 7.3.4. Actions in the Legal Area From 1988 and 1989, attempts were made to create the legal conditions necessary to support or facilitate the functioning of the SILOS. Specifically, at the end of 1989, three agreements were promulgated in which SILOS are first mentioned as the tactic to be used to implement primary care: Decree No. 19265-S. Stipulates that the Ministry will provide basic health care through a single Integrated Health Program in the areas of health promotion, disease prevention and environmental control. The Local Health Systems will conduct diagnostic studies and will organize, administer and coordinate available resources through the development of an operational plan and a local budget. It stipulates that in order for to this "2V3' to happen, the Ministry must develop and strengthen a decentralized management structure and community participation.^® Decree No. 19276-S, "General Regulation on the National Health System." Defines the National Health System (NHS) as the set of public and private sector organizations and establishments whose specific objective is to provide for the health of persons, families and the community. It emphasizes that the NHS seeks universalization and déconcentration of health services. It divides the system into functional and integrating sub systems (see Figure 16). This decree stipulates that the organizational base of the NHS is the Local Health System, defined as the set of establishments and organized representatives of the community, located in a given geographic and population area, that utilizes resources rationally and coordinates its activities in accordance with a local plan based fundamentally on the Primary Care strategy. It also divides the regions of the country in order to establish the identification of the geographic areas of influence of each SILOS (see Figure 17). '2'9T Figure 16 Sub-systems of the National Health System Integration Function Health Services Planning Infonnation Standard setting Social Security and Work-related ^— Risk Services Studies Epidemiologic Monitoring Emdronmental -^ Control Supplies Hurnan Resources < - Comunity Finance Participation investments Engineering and Maintenance Transportation Subsystems of Services and Participation Substems of Norms and Procedures Source: Ministry of Health. General Regulation on the National Health System. Serie Politica y Legislacion Sanitaria, Representacion OPS/OMS. No. 7-89 (San José, Costa Rica: Ministry of Health, 1989), 21. '2 9'5l fllliJll O ^ t S g j f»i P3 tzi sn S f III l<Sb ---------------------2'9T Agreement between the Ministry of Health and the Costa Rican Social Security Bureau for the Integration and Coordination of Services. This agreement was signed on November 20, 1989, with the aim of strengthening the process of consolidation of the National Health System through the development and strengthening of the Local Health Systems. It also defines the areas of responsibility of each entity and the mechanisms by which they will relate to each other in the technical, administrative, logistic and managerial areas. In order for the SILOS to function, the distribution of authority must be clearly established. Thus, the decision making power was distributed according to geographic areas. The MOH, which is responsible for the formulation of policies and strategies, continues to exercise this power at the national level. To regulate the exercise of decision making authority at the regional, area and local levels, three decrees were issued which are summarized below and which form the legal basis for the operation of the SILOS. Regional level: Decree No. 19610-S. "Regulation on the Organization and Functioning of the Regional Technical Council.It regulates the regional decision making authorities within the Ministry and establishes ---------------------------------- - ' 2 ' 9 ' 7 ' as its first function the coordination and execution of actions in support of the strengthening of the SILOS. Area level : Decree No. 19675-S, "Regulation on Organization of the Health Area. The area was defined as a group of SILOS that coordinate the planning of their activities with the local hospital to resolve the health problems of that area. An Area Technical Council was formed, which was the technical- administrative organ responsible for the control and the supervision of the operational plans of integrated health care in the area. Local level: Decree No. 19609-S, "Regulation on the Organization and Functioning of the Community Technical Councils of the Health Centers. It established the Community Technical Councils (CTB) comprised of the director of the Health Center an the representatives of all the medical, technical and administrative specialties of these centers. Among other functions, it was responsible for coordinating the functioning of the SILOS and the other tactics established in the National Health System as those of the Ministry. It was the local decision-making and coordinating authority of the Ministry. Finally, the legal framework for the SILOS contains an Agreement for the Delivery of Integrated Health Services between the Ministry of Health and the CCSS. In this ------------------------------------------------^ ■ ~ “2Y8' agreement, made in 1992, both agencies decided that in order to promote integrated health and coordination of their activities, an Inter-institutional Technical Council should be established, made up of high-level authorities of the two organizations to promote the necessary measures to guarantee efficiency, efficacy and equity in the coordination and technical management of the deconcentrated and decentralized activities of the CCSS and the Ministry, as well as the evaluation of their results. This 1992 Agreement also stipulated that a Regional Technical Council be formed, made up of officials of the two agencies, whose mission was to seek the integration and coordination of services at that level. To achieve this same purpose at the local level, a Local Technical Council was established, with the same modality of membership. This agreement explains the administrative and logistical arrangement that will govern each of these three levels. In summary, these laws, decrees and agreements laid some of the groundwork for the development of the SILOS in Costa Rica. There is no other country in Latin America that has legislated so much and in such detail in this field. However, as will be discussed further on in this study, this legislation was necessary but not sufficient to guarantee the smooth functioning of the SILOS. Organizational autonomy was not at all modified with this legislation, and some experts -------------------------------- — -— — 2T9' estimate this to be a serious limitation of the National Health System. These laws and Agreements were thus the result of the experience gained from before the term SILOS was coined. It was through agreements that the CCSS joined an organization that already existed previously when the Program to Integrate Health Teams (PIES) was established and which was part of the Community Technical Councils and later the Regional Technical Councils. 7.4 Emergence and Evolution of the SILOS In the case of Costa Rica, the idea of SILOS began to be disseminated by the PAHO at the beginning of 1988, a few months before the Latin American and Caribbean Ministers of Health approved Resolution XV, "Development and Strengthening of the Local Health Systems in the Transformation of National Health Systems" in September 1988. On July 5, 1988, the chief political authorities and specialists of the Ministry and the CCSS held a meeting, sponsored by the PAHO, in which they agreed that the SILOS must become the operational unit for the development of a new concept of health care. It was also emphasized that the SILOS must constitute the central strategy for the reorientation and reorganization of the national health system. In order to facilitate the start-up of the SILOS, the Ministry again resorted to its modality of forming a multi --------------------------------------- — 3 W disciplinary commission known as the National SILOS Commission, which began its work in January 1989 and was composed of various persons who had already participated in the Commissions on Teamwork, Social Participation, and Priority Districts, in order to take advantage of the experience acquired within the agency. The Ministry also turned to the universities, signing an agreement with the University of Costa Rica Medical School for the development of teaching m^aterials on SILOS aimed at all of the personnel of the agency and other health-sector entities. For the strengthening of managerial capacities, intensive management training programs were conducted at the Central American Institute of Business Administration (INCAE) . All of these initiatives had the support of the Pan American Health Organization, which had already established the Sub-regional Project on Development of Managerial Capacity. This project attempted to serve as a link between the demand for training (health sector) and the supply (universities) throughout Central America. The Latin American ministers of health had designated this support mission to the PAHO in September 1988 as part of Resolution XV. At the end of 1989, relations between the CCSS and the Ministry of Health intensified with respect to the SILOS. They agreed on the formal involvement of the CCSS in the process of the SILOS, taking advantage of the experience. methodology and instruments already developed by the Ministry. They supported the CCSS' participation in broadening the Community Technical Councils and converting them, with community participation, to Local Technical Councils.As part of the inter-institutional strategy, work teams were formed at the regional level, called Inter- Institutional Regional Councils (COREIN), to coordinate the implementation of the SILOS. The regional levels became facilitators of the process. In 1990, eleven regional workshops were held with the participation of more than 2,500 persons, which produced a significant level of support for the SILOS initiative. By the end of that year, eighty-six SILOS had been formed throughout the country. The period between 1990 and 1992 was fundamentally one of putting the SILOS into operation. The legal and administrative frameworks had been laid, although they were not sufficient given the autonomy of the institutions and the fact that a simultaneous change in the culture of the two organizations could not be completely regulated, as they were learning along the way. The organizational structure of the Ministry hardly changed, except that the leadership and the management capacity of the General Health Directorate was strengthened. Parallel commissions were created for this purpose. The Ministry opened itself as a system to formal relationships with the CCSS once it had developed a base of knowledge about --------------------------------- ■ 3 ' 0 ' 2 ' this operational modality. Its close relationship of mutual support with the PAHO enabled it to receive conceptual inputs from this continental organization, particularly from the Health Services Development Program. In the following chapter, the results obtained in this process of implementation will be analyzed, with the aim of identifying lessons to be learned to benefit greater levels of development of the SILOS and inter-institutional integration. "3'Û3 CHAPTER 7 r e f e r e n c e n o t e s 1. Pan American Health Organization. Documentos Basicos, 14th Edition, No. 188 (Washington, D.C.: PAHO, 1983), 23. 2. Centro Latinoamericano de Administracion para el Desarrollo, Coloquio sobre Descentralizacion Politico- Administrative en America Latina ; Discurso Politico vs. Realidad Concrete, Serre Eventos Informes Finales No. 7, Septiembre, 1989. (Caracas: Centro Latinoamericano de Administracion para el Desarrollo, 1989), 6. 3. César Vallejo and Roberto lunes. El Sector Salud en Costa Rica: Financiacion y Eficiencia (Washington, D.C.: World Bank, 1990) , 5-9. ~ ~~ ~~~ ~~ 4. Juan Jaramillo, Salud y Seguridad Social (San José, Costa Rica : Editorial de la Universidad de Costa Rica, 1993), 19. 5. Dr. Edgar Mohs, Minister of Health 1986-1990, interview by author, San José, Costa Rica, January 10, 1993, tape recording. 6. Juan Jaramillo, Salud y Seguridad Social, 18. 7. Robert E. Tranquada, "Participation of the Poverty Community in Health-Care Planning," Society, Science & Medicine, Vol. 7 (London : Pergamon Press, 1973), 720. 8. Msc Miguel Segovia, Regional Adviser in the Administration of Health-Care Services of the Pan American Health Organization, interview by author, Panama, August 23, 1993, tape recording. -------------------------------------------------------------------------- ^ 3 ' 0 4 9. Norma Ayala, Jorge Fonseca, Rossana Garcia, Leyla Garro, Ana Leon, Grado de Desarrollo de la Estrategia SILOS en Costa Rica : Segunda Evaluacion, Febrero 1992 (San José, Costa Rica : Ministerio de Salud/Caja Costarricense de Seguro Social, 1992), 5-6. 10. Ministerio de Salud, "Proyecto Rectoria y Fortalecimiento del Ministerio de Salud" (San José, Costa Rica: Ministerio de Salud, 1992), 10-11, photocopied. 11. Dr. Edgar Mohs. Minister of Health of Costa Rica 1986-1990, interview by author, San José, Costa Rica, January 10, 1993, tape recording. 12. Javier Alfaro and Berny Fernandez, "Modalidad de Medicina de Empresa," in Nuevas Modalidades de Atencion Ambulatoria Urbana (San José, Costa Rica: Organizacion Panamericana de la Salud, 1992), 96. 13. Ibid., 103 . 14. Maria Ethel Trejos, "Modalidad de Capitacion de Barva," in Nuevas Modalidades de Atencion Ambulatoria Urbana, 109-112. 15. Fernando Marin, "Modalidad de Cooperative de Pavas," in Nuevas Modalidades de Atencion Ambulatoria Urbana, 126-128. 16. Javier Becerra, "Modalidad de la Cooperative de Tibas," Nuevas Modalidades de Atencion Ambulatoria Urbana, 132. 17. Zeirith Rojas, "Modalidad de Medicina Familiar y Comunitaria de Coronado," Nuevas Modalidades de Atencion Ambulatoria Urbana, 118. 18. Secretaria Ejecutiva de Planificacion del Sector Salud, "Principales Problèmes del Sector Salud Clasificados por Institucion y Area Critica" (San José, Costa Rica : Ministerio de Salud, 1990), 4, photocopied. 19. In 1988, Decree No. 18898, "Reglamento de Juntas de Salud y Seguridad Social" was issued and published in La Gaceta No. 222 of November 22', 1988 . This decree stipulated that these boards would coordinate with the Health Committees in the different communities, which would be under the jurisdiction of the Board at the district level. 20. Ministerio de Salud de Costa Rica, "Desarrollo de los Sistemas Locales de Salud Mediante el Proceso de Programacidn_Loca l_y_De scon ce nt raci.6 n_ Admi n i st rat iva-de_loc. Servicios de Salud en Costa Rica," in Los Sistemas Locales de Salud. Conceptos. Mètodos. Experiencias, 651. 21. Dr. Francisco Golcher V., Coordinator of the Commission on Teamwork and of the National SILOS Commission, Ministry of Health, interview by author, San José, Costa Rica, August 20, 1993, tape recording. 22. Ibid. 23. Emmette S. Redford, Democracy in the Administrative State (New York: Oxford University Press, 1969), 44 24. Ministerio de Salud, Memoria Anual 1989 (San José, Costa Rica: Ministerio de Salud, 1990), 31 25. Ministerio de Salud, Desarrollo y Fortalecimiento de los Cantones Prioritarios (San José, Costa Rica: Ministerio de Salud, 1988), 14. 26. Costa Rica, Ministerio de Salud. Decreto No. 19265- S. La Gaceta: Diario Oficial, No. 219, (November 20, 1989 27. Costa Rica, Ministerio de Salud. Decreto No. 19610' La Gaceta: Diario Oficial, No. 91, (May 15, 1990), 3. 28. Costa Rica, Ministerio de Salud. Decreto No. 1967 5- La Gaceta: Diario Oficial, No. 98, (May 24, 1990), 51 29. Costa Rica, Ministerio de Salud. Decreto No. 19609- S. La Gaceta: Diario Oficial, No. 91 (May 15, 1990). 30. Juan Jaramillo, Salud y Seguridad Social, 294. 31. Diego Victoria, ed., Foro: Salud y Desarrollo en Costa Rica:_______ Dimensiones Politrcas y Aspectos Intersectorrales (San José, Costa Rica: Organizacion Panamericana de la Salud, 1988), 68-69. 32. Francisco Golcher, Antonieta Lopez, Roger Ballestero y Mario Leon, "Los Sistemas Locales de Salud, estrategia para la consolidacion del sistema nacional de salud en Costa Rica," in Boletin de la Oficina Sanitaria Panamericana, Vol. 109. Nosl 5 and 6, (Nov/Dec. 1990) , 54 3. 33. German Retana, and Damaris Cordero, "SILOS, Una Tactica Operacional," in Temas de Discusion, Vol. 17, Desarrollo y Fortalecimiento de los Sistemas Locales de Salud, 15 ( ( ) . " 3 ' 0 " 6 ' CHAPTER 8 ANALYSIS OF THE STRATEGY OF IMPLEMENTATION The transformation of the National Health System is a permanent process which attempts to respond to the changing needs of a country. As such, it requires flexibility to embrace change. From the preceding chapters it can be concluded that there is a close relationship between the political, social, economic and epidemiological conditions and the evolution of the National Health System of Costa Rica. Each stage within this process has been influenced by the political objectives of the governments in power, the available financial resources, and the m.anagerial capacity to implement the changes. From. 1988 to 1992, the emphasis was on the establishment of SILOS as a methodology. The purpose of this chapter is to analyze the strategy used in this process with the aim of identifying lessons about inter-institutional change that can contribute to the Costa Rican case and to efforts in other countries that are attempting to implement SILOS. These ----------------------------------------------- 207 lessons will be presented in the concluding chapter of this study. This chapter is divided into three sections. The first identifies certain parameters for evaluating the success or failure of the strategy followed. The second evaluates the strategy according to these parameters, and the third identifies the most important lessons of the strategy of implementation of SILOS in the transformation of the National Health System 8 .1 Param.eters of Success and Failure Two types of parameters can be used to analyze the implementation of the SILOS. The first are process parameters, which consist of evaluating how the ten criteria were im.pl emented according to the conceptual framework outlined in Chapters 3 and 4. The second type of parameter, results, is useful for analyzing the behavior of health indicators during this period. An inherent limitation in evaluating results or im.pact on the health situation is that it is difficult to establish a direct and short-term relationship between advances in the implementation of SILOS and the behavior of health indicators. Not all aspects of the health situation are dependent on the health sector, and not all results are attributable to the SILOS. For this reason, the first group of parameters will be examined. The behavior of health 208 indicators will also be reviewed, taking the methodological limitations mentioned above into account. The ten conditions necessary for the functioning of the SILOS as defined by the Latin American and Caribbean Ministers of Health and discussed in Chapter 4, are : 1. Reorganization of the central level. Decentralization and déconcentration. Social participation. Development of inter-sectoral integration. 5 7 Reorganization of financing mechanisms. Development of a new m.odel of cars. Integration of prevention and control programs 8. Strengthening of admini strative and management skills. 9. Training of the work force in the health sector. 10. Research. According to an inter-institutional commission that has been coordinating the SILOS implementation process, in 1990 eighty-six SILOS had been established which were providing coverage to almost all of the country. ^ It is important to evaluate which of the ten criteria have been key in the Costa Rican process, as well as the chief obstacles to progress in the im.plementation of som.e of them. From, this analysis, the strategy to be followed in the future can be reformulated. Before analyzing results, it is important to em.phasize the difficulty in evaluating them against specific goals. ---------------- 3U'9' since the implementation of the SILOS has been considered to be a gradual process in which many factors come into play. The most that can be done is to analyze accomplishments in each case. Moreover, the change of administration in 1990 brought with it a change in political strategies and priorities.^ When the Latin American and Caribbean ministers of health identified the ten conditions in 1988, they advised each country to adapt them, to their own conditions. Their application was deemed necessary but not obligatory. Although this complicates the analysis, it enables an understanding of those aspects that have been developed in Costa Rica, as well as the advantages and disadvantages of uneven progress in the implementation of the ten conditions. In Costa Rica, there was considerable coincidence between the principles and policies that guided the government’s actions in the health area and the ten conditions necessary for the functioning of the SILOS.’ In summ.ary, these coincidental policies were the following: 1. Reordering of the health sector to consolidate the national health services system. Reordering was defined as the clarification of each agency’s mission within the process of integrated care and the search for equity. ------ ------------------- — - — ---------------------— 310 One condition for the functioning of the SILOS is reorganization at the central level as a means to provide direction, leadership and congruence to the entire strategy, avoiding duplications and gaps in services. Moreover, integration of prevention and control programs as well as intersectoral action were considered to be ways to bring about greater coherence in the strategies of public agencies, including municipalities. 2. Déconcentration of health services and the respective delegation of authority to the different levels throughout the system.. To achieve-this, the managerial capacity necessary to deliver services efficiently and efficaciously must be strengthened. Decentralization and déconcentration of health-sector agencies were also considered to be necessary conditions for the functioning of the SILOS. The strengthening of managerial capacity and training of the work force within the sector were elem.ents included in Resolution XV of the PAHO passed in 1988. 3. Social participation in the so-called health process as a means to increase the mutual commitment between the population and the agencies for the overall improvement of health. This is another elem.ent of coincidence between the political objectives of the Costa Rican government and Jll Resolution XV, as social participation is considered in both cases to be a responsibility shared between the government and the community for the conducting of diagnostic studies, prevention, education and health promotion. 4. Development of integrated models of care to bring about greater efficiency and humanization of services and facilitate the introduction of new technologies. Condition 6 for the functioning of the SILOS is the development of a new model of care that takes new epidemiologic realities into account, promotes a more holistic concept of health and moves beyond the definition of health as the absence of disease. 5. Maintenance of the primary care strategy as the means to satisfy basic needs of the population, and of the goal of "Health for All." Here, too, there is significant coincidence, as SILOS were the tactic chosen to implement and extend the primary care strategy while seeking equity. SILOS were designed to be the means to extend coverage based on a modality of local planning which guarantees that the actions of the state and the community correspond as much as possible to local needs. From, this it can be concluded that the presence of an explicit political will is the first element necessary to pave the way for the im.plementation of the SILOS. In Costa Rica, two years before Resolution XV, the government had already issued a policy that subsequently made use of SILOS for its implementation. This political will was key; without it, the ability to lead the sector as such and the coincidence of views between health-care agencies and within them, would have been reduced. In the following pages, the strategy for implementing each of the ten conditions for the functioning of the SILOS will be analyzed. As has been noted, despite the presence of political will, the process confronted significant limitations which constitute lessons for the future of the strategy of im.plem.entation. 8.2 Evaluation and Assessm.ent of Change Strategy Reorganization of the Central Level During the period under analysis, existing legislation not only mandated the formal existence of a health sector but also identified the Ministry as its chief political authority. ^ The Preparatory Unit for the Project on the Reform, of the Health Sector^ has affirmed that this chief political authority is non-functional due to the following: Absence of a global health policy. Non-fulfillment of the role of chief political authority of the health sector. Lack of a sectoral vision in planning. Duplications in the role of the Ministry as planner and executor. Influence of pressure groups on decision making. Lack of an information system that supports decision making. Duplications and lack of coordination systems in the functions of sector institutions or agencies.® According to this commission, the concept of chief political authority, the degree of autonomy of the CCSS to develop its programs and policies and the role of the Ministry in the im.pl ementat ion of preventive and public- health programs all must be defined. Moreover, there is no authority responsible for integrated planning, control and evaluation.’ Prior to this reform effort, which began in 1990, the relationship between the CCSS and the Ministry was governed by the cooperative agreements for the integration of services. The role of other public institutions is even weaker, as they do not even participate as coordinators in the Project Implementation Unit on Reform of the Health Sector. The implementation of the SILOS began without a formal or real reorganization of the central level. No reorganization was carried out even within the Ministry itself. The Ministry's General Health Directorate formed interdisciplinary commissions parallel to the organizational structure and did not become involved at the beginning of the process either at the central or at the regional level to the ----------- un' extent it did at the local level. In this way, the process of change was "from the bottom up," beginning with the level at which the SILOS could count on the greatest support. Another key element of the strategy was to begin reorganizing the local level of the Ministry without linking itself at that phase with the local level of the CCSS; in fact, the Ministry's early definitions of a method of work such as that of the SILOS did not emphasize inter-agency action; it only referred to the relationship between the Ministry and the community.® This enabled it to concentrate efforts and technical resources on the task, avoiding the dispersion of effort that would have been implicit in the reorganization of the sector or at least of the Ministry. Through the inter-institutional agreements, an attempt was made to integrate services and coordinate actions at the local, regional and national levels. The link between the two agencies was formalized in 1987 through the Inter- institutional Technical Council comprised of the Vice- Minister of Health, who presided over it, the Manager of the Medical Division of the CCSS, a regional coordinator from each region and other officials from both agencies.^ This has not affected the autonomy of the CCSS, which is identified by specialists as one of the factors that brought about the Ministry's non-fulfillment of its function as chief political authority. Ex-Minister of Health Edgar Mohs .................................. 315 believes that this relationship must be intensified, introducing certain strategic changes, such as: Restructuring of the Ministry of Health, transferring programs such as Tuberculosis, Clinical Laboratories and production of drugs to the CCSS. Restructuring of the CCSS, admitting the Ministry of Health onto its Board of Directors and assuming the administration of the work-related accident insurance which is currently administered by the National Insurance Institute. Edgar Mohs also stated that as minister, he could not advance further .in the implementation of the SILOS because certain mid-level officials within his organization did not understand the need to restructure the Ministry and broaden déconcentration.^^ The option of starting at the local level was the most viable one at that time. Nor did the CCSS carry out any reorganization at its central level with respect to the SILOS. Its connection to the SILOS process was through agreements that influenced the relationship of its local personnel with their counterparts at the Ministry. The health sector as such did not vary its original composition nor did it assume leadership in the implementation of the SILOS. Indeed, the participation of other health sector agencies in the SILOS has been sporadic since 1988. In the opinion of the coordinator of the Inter- institutional SILOS Commission established in 1989, the fact _tha.t_a__res.tr.uctur.ina^a.t-^ the..-central- devel—w.as—announced—in- — - 316 1990 but has still not been implemented in 1993 has caused stagnation and even a lowering of morale at the local level, because it has introduced an element of uncertainty.^^ The degree of development of the SILOS in 1990 already required a reorganization at the central level that would facilitate leadership and the imposition of clear and mandatory policies for agencies within the sector. This reorganization is at an incipient phase. The reorganization of the central level as a condition for the operation of the SILOS has not advanced in Costa Rica more than with respect to the bilateral agreements between the CCSS and the Ministry. In 1992, the Ministry conducted an evaluation of the degree of development of the process of integration and coordination between the CCSS and the Ministry. Among its conclusions were the following: - Mechanisms of integration and coordination have been defined but there are difficulties in their implementation because the advance of the integration is considered to be an intermediate phase in the process. Officials of both agencies are well aware of the objectives of the integration and coordination process. - Although the National, Regional and Local Technical Councils have been formed, most officials believe that they are not functioning effectively. Most officials believe that joint planning has not been functioning, and joint program evaluation even less so. Training has not had an integrated focus, and the community has not been taken into account in the planning of training programs. Problems have arisen between the two _________o.r.gan i.z at ion s . .regarding___the— utill.zation— and--- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 317 distribution of resources, equipment and installations. Most officials support -the integration and coordination of services and are aware of the benefits of the process. Other sectoral agencies and programs have not even been mentioned in this section, since their connection to the process of implementation of the SILOS has been peripheral; no agreements "have been signed with themi that would facilitate the work of the SILOS. It could be argued therefore that whatever progress has been made at the central level is due more to the Ministry-CCSS agreements than to planning regarding the development of the SILOS by the health sector. At the end of 1993 the Costa Rican Congress approved a law ratifying once again the role of the MOH as chief political authority of the health sector and stipulating that the CCSS will be responsible for all care of individuals. This mieans transferring the MOH ’ s Primiary Care Programi to the CCSS. Months or even years will transpire before this law is put into practice. Moreover, the result of the 1994 presidential elections could significantly affect the viability of this initiative. Decentralization and Déconcentration In 1987, the Ministry began forming the Basic Technical Units, to which it delegated the responsibility for local _pLanning., w.i.th broad guidelines^ .from— the— central— level— --------------------------- Additionally, a number of procedures for the management of supplies were delegated to lower levels. That year, the regions took on greater responsibility for the m.anagement of certain funds.The strategy at that time was to begin with two or three activities to generate learning and a gradual accommodation. The Ministry already had a tradition of regional planning, which was utilized to reinforce teamwork in this specific area. The Basic Technical Councils (CTB) existed before the emergence of the SILOS, and they can be considered to be a broadening of the CTBs, incorporating first CCSS officials and later officials from other agencies and organizations. The SILOS thus did not represent a significant cultural change for the Ministry but rather a stage in its evolution toward more déconcentra ted m.anagement m.odalities. The incorporation of the CCSS into the SILOS process occurred in 1989. To support the process, new déconcentration policies were issued in the areas of human resources (delegation of hiring of personnel), purchasing, and management information. It also formed, jointly with the Ministry, the regional and local councils and carried out what is known as "programmatic opening" which represented the beginning of a change in culture, through the encouragem.ent of local planning. Both the CCSS and the Ministry have im.plemented administrative and technical déconcentration processes --------------------------------- — 319 through which they have transferred certain prerogatives to the local and regional levels without losing the prerogative of each agency over the decisions delegated. If decentralization is defined as the transfer of decision making powers to an organization separate from the m.other institutions (CCSS and Minister), then what occurred were essentially déconcentration processes. More specifically, the déconcentration that has been implemented in the health sector is, as Rossana Garcia has noted, geographical or territorial : What is being attempted is a déconcentration of institutional activity to the regions, whose department heads are responsible for all relevant line functions for their region, thus reducing the work of the central level to activities of planning, coordination and control. This déconcentration can be carried out down to the local levels by delegation on the part of the regions themselves or directly from the central level. Progress in this area has been dependent on the regionalization existing in the country to carry out activities in the public sector. It has enabled the CCSS and the Ministry to have counterpart officials in each region or district. It also facilitated the establishment of the Regional Technical Councils in 1989. In the case of the Ministry, Rossana Garcia argues that there has been more technical than administrative déconcentration and that the regional level has gone further in this regard than the local level. In her view, what is .l.a.cking_i.s_more_political .w.il,l_and---a—more—orderdy—pl-anning- ---------------------------------- 320 of the process of déconcentration.^® She also emphasized the need to increase managerial capacity as a prerequisite to broadening the déconcentration process. Carlos Castro et ad. believe that déconcentration faces problems such as resistance to change, traditional and bureaucratic organizational-functional schemes, obsolete procedures, fear of loss of power, and legislation that impedes transformations.^^ In the case of the CCSS, a "Master Decentralization Plan" was developed in the period 1990-1992 that attempted to simplify administrative transactions. Regional management offices have also been created and given more authority to plan, administer and manage health care services for individuals. However, the institutional modernization processes that are being implemented face a challenge in the culture of the CCSS: "The administrative organization of the agency was based on a centralist organizational and functional structure, with considerable verticality in the command structure, hierarchical and very bureaucratized. Decision making and allocation of resources were concentrated at the central level, to the detriment of the regional and local levels. A progress report on the implementation of fifty-eight SILOS found that the participating officials considered themselves to have greater discretion to interpret and apply guidelines of national health policy than to administer resources inputs and equipment. One conclusion of the study -------------------------------- 3ZI was that in 19 92, covert mechanisms to concentrate decision making power at the central and regional levels were still in use, since greater advances had been made in the delegation of authority for substantive or technical decisions than for the administration of the means for carrying out these decisions, and that this is one limitation for the development of the SILOS The development of the managerial capacity to delegate and receive delegation again emerges as an essential elem.ent for advancing the process of the SILOS. Déconcentration has not advanced at the same rate in the CCSS and in the Ministry of Health. The Ministry has a greater tradition of local planning than the CCSS, which in recent years began the so-called "programmatic opening" at the local levels and with greater diversity of areas of action. There is no perceived sectoral strategy in this area, which could have its origins, again, in the absence of a real leadership or political authority to provide direction in this area. The reform of the health sector was announced in 1990, but while it is being debated and implemented, within certain circles a "wait-and-see" attitude has developed. Finally, as part of the administrative reform, processes, plans to retire officials have been encouraged. One area in which a significant number of officials will retire is prim.ary health care, which could be detrimental to the efforts of --------------- jZZ déconcentration toward smaller and smaller team.s. This will eventually result in limitations in the implementation of a culture of déconcentration with a long-term, vision. Social Participation The participation of the community in health care in Costa Rica did not begin with the SILOS. In Chapters 5 and 6, stages in the history of health services in which the population was involved were identified. What is different in the case of the SILOS is the modality of participation, as the intention is that there be joint responsibility between the state and the citizens. In 1987 the General Health Directorate reinforced the activities in the area of social participation by forming a work team which traveled throughout the country training and motivating local officials so that they would not limit their participation to the contribution of certain inputs or sporadic services to the health centers, as had been the custom. The expectation was rather that the community would become involved in actions that would have greater impact, such as diagnostic studies, local planning, prevention and implementation of activities of care to the community and the environment. The work of the Commission on Social Participation was designed to encourage a change in culture at the local level of the Ministry in relation to this issue. The concept of community participation, understood as assistance and logistical support from the comm.unity, gave way to the concept of social participation, which assigns a more active role to the com.m.unities. It was hoped that the SILOS would become the vehicle through which the community and the agencies could share the joint responsibility for health. Opening agencies to community participation is one of the most profound attitudinal changes that public officials experienced. The Ministry's strategy consisted of holding several workshops with facilitators who were specialists in social work, administration, psychiatry, group dynamics and related fields. Once a SILOS is established, one of the first tasks is identifying and prioritizing local health problems. According to Irene Rojas, this required a mutual learning process on the part of the community and the officials. The participation of the community was significant and provided considerable feedback in this phase... because what was important for the health official was not necessarily so for the community and vice versa. This generated the need to implement educational programs for the community, training for the functionaries in order to prioritize problems in a joint and participatory way. To strengthen the relationship between the Ministry and the communities, formal authorities had been created such as the Health Boards, the Health Committees and the Nutrition Committees. Some of these, such as the Health Boards, had legal backing, so that they could function as pressure groups to strengthen the local level. By 1992, the results do not seem to be as positive as it was hoped they would be. An evaluation of the progress of the SILOS yielded the following _c o n,c l.u sion s . : __________________________________________________ ------- — 324 In just over half of the Local Technical Councils (coordinating bodies for the SILOS) there were no community representatives, and in the majority of the rest, their representation was scant. In some 95% of the SILOS, social participation is considered to be average or low. Participation is sporadic, and in nearly two- thirds of the SILOS the community practically does not participate in the activities. When it does, its involvement is very high. Community participation and local planning are two of the least developed processes in the SILOS when compared with déconcentration, organization and -lanagement, coordination and knowledge, and application of global policies According to the inter-institutional commission that conducted this evaluation, the reason that local planning and community participation are so limited is the absence of express political will and a method that would enable the local levels to operationalize the SILOS strategy. They also ascribe it to the absence of an adequate program of social prouiotion and health education that promotes community participation. It could be argued that this situation is normal since the SILOS experience is only five years old and still in a promotion phase. But another evaluation conducted in November 1990 noted that participation was less developed than other aspects although some 2 9% experienced high participation as had been expected in 198 8 This would indicate that there are conditions that favor or hinder the process of social participation. Among these could be the attitude and the aptitude of the health officials themselves. 325 Another reason for this uneven progress could be the adjustment that has to occur among agencies and between them and the communities. SILOS have required the joint action of various institutions but principally of the Ministry and the CCSS; this is not an easy task after forty years of working separately. Here also, a gradual change in culture is required in the inter-institutional relationships, and little by little, it will include other organizations and the community itself, provided there is an explicit strategy in this regard, which seems unlikely. Development of intersectoral integration Despite the formal and legal existence of diverse sectors in the Costa Rican public administration, there is no written evidence or testimonies of health sector authorities that indicate that health care activities are carried out with the formal participation of diverse sectors. What has occurred both at the central and the local levels is contact and coordination between agencies of the health sector and some from other sectors. Indeed, there are various opinions regarding whether the health sector has functioned as it was supposed to, because, for example, the issue of the chief political apthority is still discussed. If the sector is not effectively formed and operating, it will be very difficult to formalize actions with other sectors. According to Francisco Golcher, in 1988 the — 3 2 6 priority task was to "put the house (the Ministry) in order" before attempting external links within the sector itself. It would seem necessary to get the health sector to operate as such before attempting intersectoral linkages. The leadership of the Ministry within and outside the health sector is an essential element for the formalization of cooperation among the diverse sectors. As chief political authority, the Ministry would have two principal functions: the direction and the managem.ent of the social production of health. Conceptually, the Ministry itself has defined these two functions as follows: Direction is the process by which viable objective and feasibly achieved goals are defined, formalized in the act of form.ulating and evaluating the National Health Policy.... Leading is the capacity of the Ministry of Health to arrive at a consensus on interests, m.obilize resources and coordinate actions of the different public and private organizations and of other social actors committed to the production of health, for the fulfillm.ent of the National Health Policy, through the formulation, control and evaluation of strategic plans, based on the mechanisms of existing relationships.^® Although in practice the chief political authority of the Ministry has not been formalized, there have been efforts to establish cooperation between the SILOS and organizations outside the health sector. The outbreak of cholera in 1991 practically forced the Ministry of Education, the Ministry of Agriculture, the Costa Rican Aqueduct and Sewer Authority, and other organizations to work together. Diverse public and private universities have also participated supporting the jZ / SILOS through management training programs. One important contribution of the University of Costa Rica was the joint development with the health care agencies and the PAHO of a collection of self-learning texts in the administration of SILOS. According to Irene Rojas, some of these achievements can be attributed more to good will of people who work in the agencies at the local level than to a predetermined inter sectoral plan. Local private enterprise occasionally links itself with SILOS, particularly when private medical programs or joint programs are established. The evaluation of the SILOS implementation process through 1992 found that the participation of other sectors and private and non-governmental organizations in the search for solutions to health problems at the local level was considered to be non-existent for about a third of the Local Technical Councils and below average for the remainder. In summary, the advance in the implementation of the SILOS has been achieved without the significant level of development of intersectoral integration, but the more the SILOS consolidate and the more they diversify their activities, the more important it will be to increase intersectoral coordination. Reorganization of financing mechanisms In Chapter 4 the reasons behind reorganizing the financing mechanisms or the orientation of expenditures in light of a change in the epidemiological conditions were described. Costa Rica presents a health situation in which, despite the persistence of certain infectious diseases which have for the most part been brought under control, the greatest challenges are now in the area of chronic and degenerative diseases. With the epidemiologic situation having evolved toward these types of diseases, the actions of health-care agencies and the strategy of the health sector m.ust be adjusted in order to offer new services in the areas of health education, health promotion, environmental control and behavior modification. This presupposes considerable willingness to change agency tactics and financing mechanisms. Traditionally, the Ministry has been responsible for prevention, promotion and education programs, while the CCSS took care of recuperation and rehabilitation. If the new epidemiologic profile requires an intensification of activities in those fields traditionally within the purview of the Ministry, spending in the health sector has not reflected this. It is largely due to the inadequacy of activities at the first levels of care (promotion of health in the home, community and environment) that the CCSS is facing a demand for hospital and outpatient services. In recent years, the CCSS has ventured into the area of prevention, education and promotion, but these still fall within the purview of the Ministry of Health. Not only have ------------------------------------------------------------- 32'9“ expenditures not been redirected toward education and prevention programs; these programs represented a lower percentage of total sector expenditures and a lower percentage of expenditures of the Ministry, which in 1990 spent a tenth of what it had spent in 1980 as shown in table 5. TABLE 5 EFFECTIVE expenditures OF HEALTH SECTOR AGENCIES (millions of constant colones 1966 = 100) Year MOH ^ CCSS ASA* * N SI * * TOTAL 1980 364 560 b b Z4 1, Old 1981 131 486 53 21 691 1982 72 397 33 13 516 1983 8 0 436 51 12 580 1984 82 388 101 13 584 1985 77 423 72 12 585 1986 75 434 104 14 627 198 7 56 4 62 94 14 62 6 1988 61 520 81 14 676 1989 62 476 96 19 654 1990 59 441 73 19 592 (*) Ministry of Health National Aqueduct and Sewer Authority ' * * ^ j National Insurance Inst1tute Source: César Vallejo, Roberto lunes, Estudio Financiero del Sector Salud: Informe Final (Washington, D.C.: World Bank, 1990), 5. The CCSS also reduced its expenditures, but in to a lesser extent. In 1990, CCSS expenditures were about three- quarters of what they had been ten years before. According to César Vallejo and Roberto Tunes, this is evidence that the --------------------------------------------------------------------------BJO* health sector is spending less and less to solve the necessities of preventive and basic care for Costa Ricans: When the participation of the Ministry within the health sector diminishes, the participation of the CCSS increases. This leads us to suppose that when fewer resources are allocated to preventive health care (Ministry), the CCSS increases its expenditures in curative care. In 198 0 the Ministry’s participation was 35.9% while the CCSS’ was 55.2% of total expenditures. In 1990, the Ministry reduced this percentage to a total of 10%, while in the CCSS, the relation appeared to be indirectly proportional to that of the Ministry: In 1980 the CCSS participated with 55.2%. In 1990 it increased its participation by 19.3%, reaching a level of participation of 74.5% of the health sector.®® In the 198 6-19 92 period, there were no changes in the financing structure of the sector, except for those agreed to on a bilateral basis between the Ministry and the CCSS according to which the CCSS has taken on the purchase of medicines for both agencies. The financial information systems, budgets and control of expenditures continue to be separate. At the local level, the CCSS has greater flexibility than the Ministry because it has rotating funds. For Edgar Mohs, this reduction in expenditures has ethical implications. He considers that "currently, many colones are wasted due to lack of organization, decentralization and excess bureaucracy. Also for lack of patriotism., honesty and knowledge. For exam.ple, the daily theft of public property is unacceptable. Tardiness and incompetence mean that 30% of the work force is permanently absent. "®^ -------------------------------------------------------------33T Ministry and CCSS authorities have identified certain other problems associated with sources of financing and social costs : a) Financing primarily obtained from middle and low income workers. b) Financing subsidized for the high income population, particularly employers. c) Absence of participation in financing on the part of an important sector of the economically active tax-paying population (22%). d) Progressive deterioration in the participation of the state in financing of the protection of the poor and other groups that require state subsidies. e) Progressive weakening of resources destined to health programs with externalities. f) Progressive deterioration in fulfillment of the commitments of the government as such and as an employer to the Costa Rican Social Security Bureau. As will be analyzed in the next section on new models of care, these situations have created an excessive demand for outpatient care financed by the CCSS. In synthesis, this condition for the financing of the SILOS has not been modified structurally to adjust itself to local plans of action. Agency independence persists, although some efforts at integration have been carried out in certain areas already mentioned, but the global orientation regarding the sources and allocating of financing is still under discussion. The SILOS thus do not have their own budget; rather, resources are derived from the total funds that each agency distributes according to its own policies and priorities. Naturally, this affects the possibilities of implementing more strategic and inter-institutionally coordinated local planning. '332 Development of a new model of care Within the health sector, a health care model is being defined as the representation or theoretical characterization of the system of health services of a country, based on its principal political, philosophical, ethical, cultural, structural, organizational and functional elements, especially those that define, condition or affect the form in which society develops, organizes, distributes and controls the resources that it allocates to attending the health-care needs of its citizens."®® The SILOS have gotten CCSS and the Ministry of Health to work together within a formal framework at the central, regional and local levels. From their inception in 1988, they became the scenario of convergence of these and other organizations. In 1990, eighty-six SILOS were functioning. Based on the idea of the SILOS, self-mianaging cooperatives emerged in Pavas and Tibas, which have led to a better understanding of local health problems. Without a doubt, this bringing together of the CCSS and the Ministry is an imiportant achievement, especially if the traditional history of separation of functions is taken into account in the health field both in Costa Rica and in other Latin Amierican countries. The contribution of the SILOS has high political and technical impact, as they have managed to catalyze and raise awareness about the need to readjust the model of care so that it truly responds to the epidemiological conditions of the country. On the other hand, the national health systemi has not been transformed. The_principle.s_of_e.q.uity-,_ef.ficiency_and- ------------------------------------------------------------- 3'33‘ efficacy described in Chapter 3 presuppose that each SILOS will be able to orient its work according to local requirements, with the flexible support of the central level. But the central level has not reorganized itself, and déconcentration is still lim.ited, thus reducing the potential impact of the SILOS and stagnating their development, which may also diminish the m.otivation of local and regional officials. The design of a model of care is based on its principles. In the Costa Rican models there are three main principles: universality (coverage of the entire population), solidarity (financial contributions from those with the means to make them.) , and equity (absence of social, political or economic barriers to access to services). Each principle has been im.plem.ented despite the fact that none of them has been fully achieved. These principles are part of the national character of Costa Rican society, and any redesign of the model must ensure their incorporation. Health sector specialists consider that one serious limitation of the current model is that it conceives individuals as isolated from their fam.ilies and work environments and does not take into account their biological, sociological and social characteristics. An exception to this, in their view, are the MOH's efforts in primary care. The organizational structure of the sector is very representative of this vision, since each agency or program 33^- is responsible for one part of the care without there existing an integrated approach. Legal reforms that have been achieved in relation to the SILOS have not been accompanied by structural, administrative and financial reforms that enable the consolidation of a more holistic model of care.®" The CCSS, for example, is in charge of approximately ninety percent of the curative actions and of a small percentage of preventive. With no more than fifteen percent of global health care expenditures, the Ministry must manage preventive, educational and health promotion programs, despite the fact that the epidemiological conditions indicate that these have changed and that the actions of the Ministry must be intensified and integrated with care at the secondary and tertiary levels. The result of this imbalance has been growing congestion at the secondary and tertiary levels, gaps in coverage of low-income groups and inefficient administration of resources and strategies in the sector. This, together with the decline in resources for preventi programs, has been called the crisis of the health sector, which has been a frequent mass media topic recently. Nor has the current model contemplated educational program.s for the population so that it can learn to use the services at the different levels according to their needs. The physical infrastructure of the CCSS, especially the hospitals, has been widely publicized, as it is politically ------------------------------------------------------------------------- SG-S" advisable that the population be aware of their availability. When the epidemiological conditions change, the mission of this physical infrastructure must also change. Despite the quantitative progress in the number of SILOS established, the model of care has not been modified qualitatively, which has been a frequent topic of discussion between the political parties and the governments since 1986. The following is a brief analysis of the perspective of the health sector authorities in the current Administration on the current model of care: (a) Strengths of the Model: Social security as a collective and inalienable achievem.ent of the Costa Rican people. Positive experience in the development of primary High degree of political commitment to health care. High degree of universality and solidarity in financing of the health-care system.. Infrastructure and highly-trained human resources. Broad development of physical infrastructure, b) Weaknesses of the Model: Centralized adm.inistration and planning. Deficiencies in administration, budgeting, management, and evaluation at the local, and central levels. ------------------------------------------------------------ 3*33 Low effectiveness in the achievement of qualitative goals such as the gain in life expectancy, avoidable hospital expenditures and over-utilization of specialized and support Little user choice. Trend toward cost increases and Absence of quality control system. Under-utilization and inadequate distribution of human, physical and technological resources. Lack of user and creditor satisfaction. Planning based mainly on free demand. Biological approach to health care. Limited social participation. - Deficient intra- and inter-institutional coordination. (c) Opportunities for the Model : Political will to change. Experiments with new form.s of administration and service delivery that encourage development of a new model. Tradition of community participation in the solution of its own problems. (d) Threats to the Model: Resistance to change on the part of groups involved. --------------------------------------------------------------------------------------------337' - Trend toward privatization in sources of financing. - Scarcity of trained managers. Evasion of payment of quotas to Social Security.®® In synthesis, the SILOS have made an important contribution to the process of adjustment of the model, because they have revealed the need to promote a holistic approach to health which is manifested in the function of the national health system, itself. What requires greater consensus is rather the manner in which responsibilities must be distributed among public organizations. The two majority political parties that are vying for power in the 1994-1998 period coincide in identifying health as one of their first priorities. Their differences have to do with the model of care. The Social Christian Unity Party (PUSC) believes that the community m.ust organize itself to contract some m.edical services under the supervision of the CCSS and the MOH and that primary care must be the complete responsibility of the CCSS. This party, currently in power, considers that the MOH must perform, its role as chief political and strategic authority of the sector. The Ministry has been working to this end.'^^ For its part, the National Liberation Party proposes that primary care should be intensified with the creation of 8 00 Basic Integrated Health Care Units (EBAIS) throughout the -------------------------------------------------------- 3 3 - 8 - country. This does not suggest that the program be transferred to the CCSS."® Indeed, ex-Minister Edgar Mohs asserts that what should be done is to deconcentrate within the Ministry the Integrated Health Program through the strengthening of the SILOS. These differences between the majority parties and the proximity to the forthcoming 1994 elections have slowed down the development of the SILOS, whose officials are awaiting decisions on changes at the central level. Those aspects on which there is the greatest convergence of views between the political parties have to do with the principles that m.ust underlie the model of care: universality, solidarity and equity. Both parties support the philosophical basis and the strengthening of an integrated care model. The differences between them, are more structural and organizational and have to do with the modality for implementing the changes. The process of reform, of the health sector is part of the process of reform of the state, which in turn is a component of the economic and social restructuring of the country. The discussion of these topics has become more lively in the last three years. The MOH ’ s technical team in charge of the implementation of team work and social participation (1988), and priority districts and SILOS (1989), has now turned to analyzing adjustments in the model of care. For this reason, attention to implem.entation has lessened, with the attendant risk of losing the impetus with which it began. — ---------------------------------------------------------- 339" Integration of Prevention and Control Programs The Community Technical Councils (only the Ministry) and later the Local Technical Councils (including the CCSS) were formed with the intention of encouraging interdisciplinary work and group decision making in each district. In this sense, from the beginning of the SILOS implementation process, specialists in prevention and control of diseases needed to join forces. This integration is intended to facilitate rapid decision making in order to prevent, control or fight outbreaks of diseases. One of the most serious limitations in reaching this goal is the lack of an information system on local health conditions that did not support decision making in a timely manner. In 1987 the General Health Directorate developed an information system for the local level that confirm.ed that there were districts with health indicators below the national averages. This enabled it to take action through the Priority Districts Program described previously. The SILOS have not been backed by a single information system. Each agency has its own data requirements and has developed its own systems. Normally, the integration of information systems at the national level requires several months and even years, which makes strategic decision making very cumbersome. This reinforces the convenience of having local inform.ation sub-systems that are being used by the SILOS. ------------------------------------------------------------- 3T0‘ One obstacle to prevention and control of diseases and health promotion is the imbalance between financial resources allocated to prevention (Ministry) compared to those allocated to cure (CCSS). The Ministry of National Planning (1990-94) argues that it is necessary to invert the financial pyramid of the sector and allocate more resources to prevention. The current governm.ent ’ s response has been to attempt to integrate the CCSS and the Ministry in prevention programs. According to the president of the CCSS, both agencies are making efforts to eliminate the distinction between preventive and curative actions, favoring a more integrated approach to service delivery.” However, the reforms needed to transfer prevention programs to the CCSS are opposed by diverse professional, labor and community groups that have formed the so-called "Broad Democratic Front in Defense of the Health of Costa Ricans." These groups argue that the CCSS does not possess the technical and financial capacity to assume these functions. But in 1987 the CCSS established a Department of Preventive Medicine, which represents a certain degree of duplication of functions with the MOH in this area. This integration of the CCSS and the Ministry in the prevention area has facilitated the developm.ent of health education and promotion programs that consider the behavior of the population and the abuses of diseases and situations characteristic of the new epidemiologic profile; infectious- ------------------------------------------------------------------------- 3-4T ccntagious pathologies, smoking, teenage pregnancy, drug addiction, heart disease, diseases of adults and the elderly, and traffic and work accidents. There is a marked difference in the strategies of the governments in the 198 6-19 90 period from that of the 19 90- 1994 period for the management of the agencies. The Commjunity Technical Councils, the SILOS and health at the local level were central themes of the National Liberation direction of the system, financing schemes and organizational developm.ent are those emphasi zed by the current Social Christian Unity government. A study designed specifically for that purpose could help to understand whether the differences between the two major parties has affected the development of the SILOS and the emphasis on preventive strategies, control and health promotion. One cause for concern is the resurgence in Costa Rica in the last two years of diseases such as dengue (3,000 cases reported in 1993), measles (from 81 cases in 1990 to 6,341 in 1991), and others that were assumed to be eradicated or under control. The causes for the appearance or resurgence of these diseases cannot be simplified, because health is not simply the result of public policies but also of so ci o-economic and political conditions, the level of education of the population, individual behavior and environmental conditions. — ................ 3A"2- Epidemiologist ascribe these negative changes to health conditions (see Table 6). The integration of the prevention, control and promotion ______ v..__ been more feasible when it results from the ■ P 4 — T.T/^ 1 global integration or services netween tn< Ministry at the local level, which is occurring via the CCSS MOH Integrated Medical Centers.- By December, 1992, forty seven Centers had been integrated under different modalities TABLE 6 NEW CASES OF 15 DISEASES REQUIRED BY LAW TO BE REPORTED IN COSTA RICA (1975, 1980, 1990 and 199L) (rate per 100,000 population) 1975 Ko. R a t s 193 Kg . 3 R a ts 1935 1990 K o . R a t s 1991 K o. Influenza 1 0 ,0 3 1 5 0 9 ,6 2 m ^ 6 3 9 2 4 ,2 17,277 6 5 3 ,9 4 7 ,7 9 5 1,585,4 57,957 1, 8 7 7 ,0 Measles 708 36, 0 940 41,8 1 0, 04 81 2,7 6, 340 205, 3 Gonorrhea 2, 813 1 4 2 ,9 8 ,6 7 7 3 8 6 ,2 ^ ^ 8 6 313, 6 4 , 2 7 4 1 4 ^ 8 3, 693 119, 3 Whooping cough 1, 165 5 ^ ^ 883 3 9 ,3 149 5, 6 75 2,5 19 0,6 Syphilis (all forîâs) 1,471 74,7 1, 714 7 6 , 3 1 ,5 1 4 5 ^ ^ 1, 939 64, 3 1 ,2 7 0 41,1 Hepatitis (all forms) 724 36, 8 1 ,3 2 8 5 9 ,1 2, 510 9 ^ ^ 2 , 5 6 7 85, 1 1 ,2 2 7 3 9 ,7 'Tuberculosis (all forms) 552 2 ^ 0 4 60 2 0 , 5 367 1 3 , 9 50 1, 6 201 6,5 Malaria 304 15,4 368 16, 4 722 2 7 , 3 1,442 3 7 ,9 3 ,2 4 7 1 0 5 ,2 Meningitis (all forms) 233 r c 8 447 15, 9 68 6 26, 0 630 2 ^ ^ 556 1 9 ,3 Tetanus 46 2,3 14 0,-6 6 0,-2 3 0,-1 1 0 ;0 3 Scarlet fever 54 2,7 308 13,7 321 12, 1 39,594 1 , 3 1 3 , 4 4 3 ,5 3 3 1, 4 0 9 ,9 'Typhoid 27 1,4 5 0 ,2 11 0,4 8 0, 3 10 0, 3 Dyphtheria 6 0,-3 — — — — -- — — — Poliomyelitis — — — — — — -- — — — Leprosy 17 0, 9 47 2, 1 30 1, 1 10 0, 3 16 0, 5 Note: a) Meningitis was not among the diseases required by law to b) Includes all streptococcic diseases. be reported in 1970. Source: Epidemiologic tontrol Section , Department of Statistics, Ministry of Health. The strategy utilized was to work in teams of specialists from the Ministry at the local level to integrate functions of prevention, control and health education, and others (1987). Later, CCSS officials joined the process (1988-1989), maintaining the institutional autonomy of the CCSS and the Ministry as well as separate information and budgeting systems. Finally, integration was attempted at the central and regional levels in order to incorporate health promotion. The process has been gradual, not the product of a strategic plan during the 1988-1992 period but rather the result of the political priorities of each government. Currently, the resurgence of dengue, measles, malaria and cholera is putting the capacity of coverage and impact of prevailing policies in this area to the test. The current government has utilized part of the primary care personnel for other tasks such as the implem.entation of nutrition programs. It has devoted considerable effort of the MOH ’ s authorities on the formulation of the reform, of the health sector, and it has encouraged the voluntary early retirem.ent of officials in order to reduce the size of the state. It may be useful for public health specialists to study the possible relationship between these policies and strategies and the deterioration of the health indicators noted in the preceding table. --------------------------------------------------------------------------3UT Strengthening administrative and management skills The implementation of SILOS is fundamentally a political and managem.ent process. The political will to implem.ent the Community Technical Councils and the SILOS was expressed in formal agreem.ents between the Minister of Health and the General Health Director to form task forces and assign specific logistical and financial resources to begin the phase of promotion, awareness and training of local officials. In the opinion of the coordinator of the commissions on Team Work (1987-1989) and SILOS (1989-1990), there were two key factors in bringing about the changes at the local level: the attitude and the aptitude of the officials. Attitude was created through motivational methods. The fact that the decisions at the Health Centers had to be made by consensus and the introduction of tools for local programming were very- encouraging for local officials. Aptitude w^as developed through an intensive management training program in every MOH health center in the country. The motivation of officials at the local level was vital to begin the process. In that phase, they could make certain decisions about their work plans which were previously adopted at higher levels within the hierarchy. Greater local decision-making authority was thus encouraged, complemented by m.anagem.ent training. Although this decision-m.aking authority was limited to basic aspects, it was useful in the ------------------------------------------------------------ 3T5" process of encouraging a change in attitude and in areas of responsibility of local officials. This increased expectations among these officials about greater discretion, déconcentration, responsibility and room for innovation, which exerted pressure on the regional and central level of their agencies. As the inter-institutional commission that led the process of reform of the health sector indicated, "The decision making authority and the level of complexity of the establishm.ents is m.ore a function of the interest, commitment and enthusiasm of its officials than of the need defined by the epidem.iological profile of the user population. Managerial capacity refers to the ability of the local levels to resolve situations using their own judgment and established policies. Strengthening m.anagerial capacity requires modifying the decision-making process to make the decentralization and déconcentration processes more viable. Decentralization without improving local managerial capacity will have little chance of affecting health conditions. The development of this capacity must be ongoing and its level of complexity must intensify to facilitate the gradual growth and consolidation of the SILOS. However, these positive steps in the early years did not continue because of the lack of greater decision-making authority at the local level. In 1992, officials from all levels of the MOH and CCSS were consulted about what they ---------------------------------------------------- ^3T6^ considered to be the most important limiting factors to making the SILOS more operational. Those factors they identified were the lack of greater decentralization and managerial capacity.” It is not possible to increase m.anagerial capacity if officials at the local level do not receive more discretionary power as the SILOS advance in their developm.ent. These same officials consulted stated that the factors that had most facilitated the development of the SILOS up to February 1992 were: motivation of officials, the willingness of both agencies to coordinate, political support, and the CCSS-MOH integration process. At the beginning of the nineties, the CCSS continued granting greater responsibility to the regional levels and promulgated a number of policies oriented toward broadening their discretion. For its part, the MOH reoriented the work of technical personnel which in previous years had been connected to the SILOS process in the formulation of health sector reform, projects. The financial resources of the Ministry continued to decline in those years, making resources for the strengthening of m.anagerial capacity even more scarce. Training of the work force in the health sector As has been m.entioned, the im.pl em.ent at ion of the CTBs and the SILOS began with training and motivation of officials ------------------------------------------------------------- 3T7" at the local level. From the beginning, the MOH was assisted by specialists in administration from the Institute Tecnologico de Costa Rica (ITCR) and the Pan American Health Organization (PAHO) in the design of the contents and strategy of the training, but management specialists at the Ministry were few and far between. In 1988 there were only five professionals in this field that held management positions. The initial strategy consisted of conducting three-day workshops in each health center at the end of which the officials undertook projects to apply the knowledge and modify their management and administrative styles and procedures. They then repeated the process with additional workshops and projects. A single team of facilitators integrated by technicians from the MOH, ITCR and PAHO covered the entire country in one year. These workshops included managem.ent themes : leadership, team work, decision making, planning, negotiation, feedback, management of m.eetings, management of change, organization and basic budgeting. Management as a topic of study was foreign to many local officials, which meant that the process proceeded at a pace that each local team could assimilate, but with the technical assistance of the commissions comprised of the Ministry's General Health Directorate. This work at the local level was com.pl emented by training activities at the central and regional levels, which ■3T8n helped to introduce management as an im.portant concept. This lack of professional managers at either the MOH or the CCSS, the organization with the largest work force in the country, denotes the low level of appreciation for these skills. In 1988 the PAHO introduced a project to develop managerial capacity in the health care agencies which provided constant support through courses, publications, international meetings and technical assistance. It emphasized increasing managerial capacities to im.plement the SILOS. The CCSS also intensified development of managerial capacities in its m.id- and upper-level m.anagers and initiated a number of courses given by the Central American Institute of Business Administration (INCAB). The strengthening of individual skills with its complement of motivation was thus a necessary condition for the functioning of the SILOS. But these two factors alone were not sufficient. The capacity to resolve situations and make decisions locally was essential. For this, throughout the implementation process, the PAHO has insisted on differentiating training (acquisition of skills) from managerial capacity (decision- m.aking authority) . One of the greatest challenges of health agencies, particularly the MOH and the CCSS, is reorienting their organizational culture toward a more managerial focus, one that is more administrative and more concerned with efficiency and efficacy. If the political will for the establishment of the SILOS and the CCSS-MOH - existed, the chief task would be the translation of these policies into concrete actions, which is an eminently managerial task. Ex-Minister Edgar Mohs believes that another important contribution of the SILOS has been their emphasis on the importance of management, because the existing institutional culture did not accord it the importance it deserved. Research Research is the least developed of the ten components. The intention of the Ministers of Health in Resolution XV was that the SILOS would be supported with studies on new operational models of health services, as well as evaluations of the equity, efficiency and quality achieved, the coverage obtained and the efficiency gained in the use of resources. The degree of social participation would also be a subject for study. Yet the health sector and more specifically the Ministry of Health had only carried out two national evaluations and three local evaluations on the specific topics of the impact of the SILOS by the end of 1992. There was no department with direct responsibility over this type of study in either agency. The research process was sporadic. Some operations research has led to the implementation of reforms in purchasing and distribution of pharmaceuticals. Initial efforts have been made to evaluate the experiences ------------------------------------------------------------------------- 3^tn of new modalities of ambulatory care such as self-managing cooperatives and the Integrated Health Center of Coronado. Segovia believes that the absence of research can be attributed to the absence of an organizational culture that encourages research beyond that which has a biomedical or academic focus. There is little awareness about the usefulness of research to improve health services. 8.3 Impact of the SILOS Implementation Strategy on the Transformation of the Health System The developm.ent of the SILOS in Costa Rica can be divided into two stages. The first covered the period 1988- 1990 under the National Liberation government, which emphasized a certain ordering of the actions of the CCSS and the MOH at the local level. The second began with the Social Christian Unity government in mid-1990 in which the effort has been oriented toward the reorganization of the central level of both agencies, with a reduction in technical support of the central level toward the consolidation of the SILOS. The technical team supporting the SILOS spent considerable time conceptualizing the reorganization of the central level. Despite this change in the strategy of action, it is possible to identify important contributions that the SILOS process has made to the task of the transformation of the National Health System. When the Ministers of Health approved Resolution XV, they defined the SILOS as a tactic 3 * 5 r that could contribute to this transformation. In the case of Costa Rica, according to the analysis in the preceding chapters, the principal contributions have been the following : 8.3.1. The CCSS and the MOH ceased to act separately and began a process of coordination of service at the local level which has enabled them to work under a more integrated approach to health. 8.3.2. The separation between curative and preventive medicine has been reduced and has incorporated a multi-disciplinary approach to health care in which the clinical physician is one of many actors and not the most important one. 8.3.3. Health care ceased to be the sole responsibility of the CCSS and the MOH and has begun to involve municipalities and other public and private organizations. 8.3.4. Despite the limitations noted above, the community has been brought into the process through the Health Boards and projects in which it does more than simply offering m.aterial or logistical support. What is being attempted is a more permanent -------------------------------------------------------------------3 ^ participation in the attention to health matters. This is a substantive contribution to social participation. Nonetheless, much remains to be done in this area. 8.3.5. The SILOS have contributed to improved local statistics on the health situation. Although the information system still has many limitations, efforts are being made to develop means of inform.ation that enable the planning of activities more in accordance with local needs and resources. 8.3.6. The implementation of the SILOS has revealed the importance of introducing management into the health sector and has contributed to the institutionalisation of programs designed to develop managerial capacity. Never before in the history of the CCSS and the MOH had so many projects in this area been carried out, which has also strengthened the relationship between university management programs and health-care agencies. 8.3.7. The consolidation of the Nation al Health System has been another important contribution of the SILOS, since hierarchical levels of responsibility and geographic areas in which the basic unit is the SILOS have jb j been established. This has been supported by legislation that regulates the functioning of the National Health System and that began after two years of experience in the functioning of the SILOS. A National System that was regulated by a number of decrees was converted to a concrete system that, despite persisting limitations, has managed to get diverse organisations to work together in a common task at the local level. 8.3.8. The SILOS have had an impact on the transformation of the culture of health-care agencies in four principal areas: the need to work in teams within organisations; the opening up of cultures to work with other agencies and organisations, especially in the CCSS and the MOH; the incorporation of mechanisms of social participation that demand a change in attitude on the part of public officials; and the institutionalisation of management alongside of health as a topic worthy of attention. 8.3.9. The SILOS created the conditions for the emergence of alternative models of care such as the seIf-managing cooperatives and the integrated health centers. The cooperatives 354 represent a change in the culture and tradition of two agencies that believed the state had the monopoly on public health services. Traditional patterns were broken, and today the possibility of extending this type of cooperative to other zones of the country is being analyzed. Their future functioning will depend on whether they manage to develop comparative advantages which, according to Coddington and Moore, might consist of high-quality, low-cost integrated services, use of a network of community organizations, diversification of services, and aggressive marketing. 8.3.10-. Finally, the most important contribution of the SILOS has been philosophical, and this may be what has provided the impetus for the transformation process. In the words of Raul Penna, the PAHO representative in Costa Rica, "SILOS are a way to think about health services organized in such a way that they have the administrative and technical decision-making authority that enables officials, together with other social actors, to take actions to promote the health of the population. The implementation of the SILOS has been an adaptive process resulting from the political will and strategies of successive governments. The political, social, economic and epidemiological conditions have been determining factors in the implementation m.odality. For the 1994-1998 period, the two majority parties agree that it is absolutely necessary to continue the transformation of the National Health System, based on actions at the local level. It is for this reason that the lessons learned from the process that has occurred to date is so important. 3 3T CHAPTER 8 REFERENCE NOTES Francisco Golcher, Antonieta Lopez, Roger Mario Leon, "Los Sistemas Locales de Salud, Estrategia para la Consolidacion del Sistema Nacional de Salud," 544. 2. The National Liberation Party was in power in the 198 6=1990 period under the Administration of Dr. Oscar Arias. In May 1990, Rafael Angel Calderon, of the Social Christian Unity Party, became president. 3. Ministerio de Planificacion Nacional y Politica Economica, Plan Nacional de Desarrollo 198 5-1990 (San José, Costa Rica: Ministerio de Planificacion Nacional y Politica Economica, 1987), 128-133. 4. Although there is disagreement about the term "chief political authority," here it is defined as the exercise of the political and strategic direction, the maximum authority of the management of the sector, the leadership in the coordination of all organizations, and supervision of the execution of national health policies. Its authority is derived from the Presidency of the Republic through delegation to a minister or other member of the government. 5. The Government of the Republic for the period 1990- 1994 established as one of its objectives in the health care field the restructuring of the health sector. For this, it formed a high-level commission which is drafting reform legislation. The coordinating commission of the process is comprised of the maximum authorities of the Ministry of Health, the CCSS, the Ministry of Planning and the PAHO r ep resentative in Co.s.t a Rica.. At the techni.cal Le : v-el.,_ ------------------------------------------------------------------------------------- _ 337" experts from these agencies are participating, and the result has been the formulation of a project sponsored by the World Bank. 6. Unidad Ejecutora del Proyecto [Project Implementation Unit], "Proyecto Reforma Sector Salud," (San José: Ministerio de Salud and Caja Costarricense de Seguro Social, 1992), 20, photocopied. 7. Unidad Ejecutora del Proyecto [Project Implementing Unit], "Proyecto Rectoria y Fortalecimiento del Ministerio de Salud," (San José, Costa Rica: Ministerio de Salud, Caja Costarricense de Seguro Social, 1992), 10, photocopied. '8. Ministerio de Salud, Memoria Anual 1988 (San José, Costa Rica: Ministerio de Salud, 1989), 45. Ministerio de Salud, Proceso de Universalizacion. Desconcentracion y Atencion Primaria en Costa Rica, Serie Politica y Legislacion Sanitaria: Représentacion OPS/OMS. No. 2-88. (San José, Costa Rica: Ministerio de Salud, 1988), 10. Edgar Mohs, "Restructuracion del Sector Salud, Atencion de Menores y la Famdlia," (San José, 1992), 2-3, photocopied. 11. Dr. Edgar Mohs, Ministry of Health 1986-1990, interview by author, January 10, 1992, San José, Costa Rica, tape recording. 12. Dr. Francisco Golcher, Coordinator of the National SILOS Commission, interview by author, August 20, 19 93, San José, Costa Rica, tape recording. 13. Direccion de Desarrollo de Sistemas de Servicios de Salud, Evaluacion del Grado de Desarrollo del Proceso de Integracidn y Coordinacidn entre el Ministerio de Salud y la Ca]a Costarricense de Seguro Social (San José, Costa Rica: Ministerio de Salud, 1992), 46-47. 14. Ministerio de Salud, Memoria Anual 198 8 (San José, Costa Rica: Ministerio de Salud, 1989), 46. 15. At the local level, an attempt was made to form "health téamis, " defined as a permanent structure within the organization, in which its members interact in equality of conditions to plan health actions in accordance with their area of influence. See Nuria Madrigal et a^. , Cur so Administracidn de Sistemas Locales de Salud, Traba]o en Modulo 9 (San José, Costa Rica: Seccion de Ministerio de Salud de Costa Rica: El Caso de la Region ------------------------------------------------------------------------- 353 Tecnologias Médicas, Eseuela de Medicina, Universidad de Costa Rica, 198 9), 81. 16. Caja Costarricense de Seguro Social, Memoria CCSS 198 9-1990 (San José, Costa Rica: Caja Costarricense de Seguro Social, 1990), 124. 17. Rossana Garcia, "El Proceso de Desconcentracion del erio de Salud de Cost; Central Morte 1985=198 9," 50. 18. Ibid., 155. 19. Carlos Castro et "Desconcentracion de les Servicios de Salud como Estrategia para el Desarrollo de los Sistemas Locales de Salud," 46. 20. Ministerio de Salud, Memoria_ Anua 1 19 92 (San José, Costa Rica: Ministerio de Salud, 1995), 42. 21-. Unidad Ejecutora del Proyecto-, "Proyecto de Reforma del Sector Salud," 42. 22. Direccion de Desarrollo de Sistemas de Servicios de Salud, Grado de Desarrollo de la Estrategia SILOS en Costa Rica: Segunda Evaluaciôn, 29. 23. Unidad Ejecutora del Proyecto [Project Implementing Unit], "Propuesta de Readecuaciôn del Modelo de Atencion: Informe de Avance" (San José, Costa Rica: Ministerio de Salud, Caja Costarricense de Seguro Social, and Organizacion Panamericana de la Salud, 1992), 7, photocopied. 24. Irene Rojas, Autoevaluacidn del Sistema Local de Salud de San Carlos - Région Huetar Morte (San José, Costa Rica: Ministerio de Salud, Caja Costarricense de Seguro Social, and Organi zacion Panamericana de la Salud, 1990) / f 2d. Norma Ayala, et al. , Grado de Desarrollo de la Estrategia SILOS en Costa Rica: Segunda Evaluaciôn, Febrero 1992, 45-49 26. Ibid., 47. 27-. Roger Ballestero, et al - . , Grado de Desarrollo de .a Estrategia SILOS en Costa Rica: Evaluaciôn de la Ease de Promocion, Noviemore 199U (San José, Costa Rica: Ministerio de Salud, Caja Costarricense de Seguro Social, and Organi zacion Panamericana de la Salud, 1991), 41. 28. Dr. Francisco Gôlcher, interview by author, August 2 0,1993. — -----------------------------------------------------------339- 29. Ministerio de Salud, "Sistema de Rectoria en Salud y Perfil Estructural Bâsico para su Gestion" (San José, Costa Rica: Ministerio de Salud, 1993), 12. 30. Caja Costarricense de Seguro Social, Memoria CCSS 1989-1990 (San José, Costa Rica : Caja Costarricense de Seguro Social, 1990), 235. 31. Irene Rojas, Autoevaluaciôn del Sistema de Salud de San Carlos - Region Huetar Morte, 11 32. Norma Ayala et al., Grado de Desarrollo de la Estrategia SILOS en Costa Rica: Segunda Evaluaciôn, Febrero 1992, 4 0. 33. César Vallejo, Robert lunes, "Estudio Financiero del Sector Salud: Informe Final" (Washington, D.G.: World Bank, 19 90), 5-6. 34. Edgar Mohs. "Reestructuraciôn del Sector Salud, la Atencion al Menor y la Familia," 2. 35. Unidad Ejecutora del Proyecto [Project Implementation Unit], "Proyecto Reforma Sector Salud" (San José, Costa Rica: Ministerio de Salud, Caja Costarricense de Seguro Social, and Organizacion Panamericana de la Salud), 1992), 35-36, photocopied. 36. Unidad Ejecutora del Proyecto [Project Preparatory Unit], "Propuesta de Readeouaciôn del Modelo de Atencion, Informe de Avance" (San José, Costa Rica: Ministerio de Salud, Caja Costarricense de Seguro Social, and Organi zacion Panamericana de la Salud, 1992), 3? photocopied. 37. Ibid., 5. 38. Msc. Miguel Segovia, Regional Advisor on Administration of Health Services, Pan American Health Organization, interview by author, Washington, D.C., December 8, 1992, tape recording. 39. Unidad Ejecutora del Proyecto [Project Preparatory Unit], "Propuesta de Readecuaciôn del Modelo de Atencion, Informe de Avance," 11-12. 40. See Partido Unidad Social Cristiana, "Plan MAR 94. La Salud: Bienestar para Todos" (San José: Partido Unidad Social Cristiana, November 1993). 41. Ministerio de Salud, Memoria Anual 1992 (San José, Costa Rica: Ministerio de Salud, 1993), 40. ------------------------------------------------------------------------- 3301 42. Partido Liberaoion Nacional, "Programa Liberacionista para el Bienestar de los Costarricenses; Gobierno de José Maria Figueres 1994-1998" (San José, Costa Rica; Partido Liberaciôn Nacional, 1993), 8. 43. Carlos Vargas Pagan, "La Reformia del Sector Salud, " La Naciôn (San José, Costa Rica), 29 August 1993, 18A. 44-. Elias Jim.énez Fonseca, "Reform.a del Sector -Salud y Atencion Integral," La Naciôn (San José, Costa Rica), 29 August 1992, ISA. 45-. "Objetan Cambios en el Sector Salud," La Repùblica (San José, Costa Rica), 8 November 1992, 6A. 46. Dr. Francisco Gôlcher, Coordinator of the National SILOS Commission [in 1989], interview by author, August 20, 1993, tape recording. 47. Unidad ejecutora del Proyecto [Project Preparatory Unit], "Propuesta de Readecuaciôn del Modelo de Atenciôn, Informe de Avance," 7. 48. Norma Ayala, et al., Grado de Desarrollo de la Estrategia SILOS en Costa Rica; Segunda Evaluaciôn Febrero 1992, 97 49. Dr. Edgar Mohs, Minister of Health 1986-1990, interview by author, January 10, 1993, San José, tape recording. 50. Msc. Miguel Segovia, Regional Adviser in Health Services Administration, Pan American Health Organization, interview by author, November 8, 1993, San José, tape recording. 51. See German Retana, "Reuniôn de Consulta Formaciôn en Capacidad Gerencial, Santiago de Chile, April 1-3, 1991; Informe y Conclusiones" (Washington, D.C.: Organizaciôn Panamericana de la Salud, 1991), photocopied. 52. Dean C. Coddington and Keith D. Moore, Market- Driven Strategies in Health Care (San Francisco: Jossey-Bass Publishers, 1987), 65-73. 53. Dr. Raùl Penna, Representative of the Pan American Health Organization in Costa Rica, interview by author, November 10, 1993, tape recording. 361 CHAPTER 9 CONCLUSIONS AND IMPLICATIONS The implementation of a strategic change in a public sector institution or agency is a very complex process, but guiding a process in which various organizations are involved is even more so. The Costa Rican health system has experienced this complexity since it began to transform the way in which it provided services to the population. What has been happening with the SILOS is not only a political and administrative change; it is essentially a change in culture. The concept of health, the agency mission, the approach to services, values such as equity and democratization, as well as inter-institutional relationships, are all involved in this process. When the SILOS concept first emerged in 1988, the Pan American Health Organization emphasized three strategic premises : (a) SILOS are a method of work for public agencies, private organizations and communities at the local level. They are neither a structure nor an aaency. ______________________________________________ ..... (b) There are ten conditions necessary for SILOS to function, but their application must be adapted to the reality of each country. (c) SILOS' are the tactic chosen to facilitate the transform.ation of national health systems and to implement the Primary Care strategy. All of the PAHO member countries adopted these premises and are, to a greater or lesser degree, in the process of im.plem.enting them.. The purpose of this study has been to identify the lessons that can be learned in order to make adjustm.ents in subsequent phases of the transf orm.ation process. Obviously, the Costa Rican experience is not precisely replicable in other countries. Mo adm.inistrative reform process can be. The health of a population is a social result, the product of political decisions about priorities in the allocation of resources and the role of the state. It is conditioned by technological and economic realities as well as by the behavior of the population. These factors vary from country to country. This does not mean that the lessons of the Costa Rican process are not useful for other countries. Conditions common to all Latin American countries make the lessons learned in one country valuable for others. Among these are (a) the efforts to achieve political, social and economic democratization; (b) reform, processes in the public sector underway in various countries with the support of 363 international organizations; (c) economic crises and the resulting decline in resources available for the health sector; (d) the worsening of health indicators and the reappearance of epidemics; and (e) the implementation of 1o ca1 health sy stems. The lessons are mainly in the area of the leadership of multi-agency change that leads to the implementation of local health systems and the integration of services provided by two or more government agencies. In the Costa Rican process, no "institutional transformation models" or operational guidelines for facilitators of change were followed; rather, the process of change has evolved gradually, guided by certain principles and strategic objectives. The following is a summary of the more important lessons that might be derived from the analysis presented in the preceding chapters. (1) Health-sector reform processes should be guided by Q1oba1 pr i n ciples that reflect the society' concept of health. In Costa Rica, three principles have been the common denominator in all stages of health-care service delivery: universality, solidarity and equity. Since the 194 0s, the main political forces have concurred on this philosophical orientation, and since then, all efforts at adm.inistrative reform have been motivated by the attempt to make them a ------------------------------------------------------------------------- 35T reality which, despite the broad consensus, has not been completely achieved. When the health-disease dichotomy prevailed, agencies were created to address each component of it. The notion of integrated health care leads to the need to integrate services, which should not be confused with consolidation of agencies. Without this consensus on principles and concept of health, reforms could be short-lived, subject to the changes in political leadership. The viability of the decisions made would be periodically questioned, lessening security and long-term vision. The fact that efforts are being made to democratize Latin American countries opens possibilities for consensus at the highest levels of the political parties and certain sectors of the population on the principles that should guide health-service strategies. When the leaders of health care agencies perceive that these principles are not present or that they do not enjoy the political and social consensus that legitim.ates them, their principal responsibility will be to put these issues on the agenda of the political parties and other public agencies. In Chapter 2, several concepts of health were analyzed, as well as different values and approaches to health-care service delivery. Organizational modalities of health-care systems in countries with different political ideologies were presented to show that the logic of a health-care system is 365 to be found in the socio-political context. The idea that health is a social, political and economic phenomenon has been emphasized. In Costa Rica, health care began as charity and today is understood to be a right of the citizens and an obligation of the state. Universality of coverage is an expression of this right, accompanied by solidarity on the part of the population in the form of financial contributions that guarantee equity in access to services. The problems inherent in a national health system are related to the degree of compliance with its underlying principles and values. The discussion over the last five years in Costa Rica has not been about principles but about their relation to resource allocation. If health is produced by eliminating disease, then society should invest in curative services (CCSS), but if health is produced by preventing disease, investment should favor primary care (Ministry). If health is overall well-being, then both approaches should be combined in accordance with epidemiologic profiles, the needs of education and health promotion and characteristics of the population. This requires a health system that is able to take local and regional realities into account and that adjusts the mix of services accordingly. (2) The possibility of successful intra- and inter- institutional change depends on the political and public support it can garner. ------------------------------------------------------------------------- 3-6*6^ This political support can be achieved when the change proposed within the health sector is congruent with global public sector reform policies. A change in the organizational mission and, therefore, in the models of service delivery of health-care agencies, should take three factors into account: (a) political visibility to meet a basic need and provide a basic service, which enables it to attract many stakeholders; (b) size of health organizations are among the largest in countries such as Costa Rica; and (c) tradition, when the modality of services changes, consumers are implicitly being asked to change their expectations regarding the organization and the national health system. These elements illustrate the magnitude of resources necessary to shift a public-health organization in a different direction. Health care agency depend on considerable external support in financial resources and legitimacy in order to transform themselves. The possibilities of implementing the transformation are greater when it is part of a larger project of public sector reform, so that political leaders are duly sensitized about the merits of the changes and are thus better disposed toward providing the resources to make them operational. As was analyzed in Chapters 4 and 5, health care reforms made progress when they were consistent with and part of larger public sector reforms, e.g. the division of countries into ------------------------------------------------------------ 3'6T regions, the formation of sectors among public organizations, the policy of decentralization and the expansion of coverage of public services. As a political issue, the status of health care reform within the hierarchy of national and public sector priorities depends in large measure on whether it is able to marshall the necessary resources. Some countries will thus be more successful than others with approaches such as SILOS if they are consistent with the political priorities not only of the health sector (if it exists) but also of the rest of the government. The SILOS are more than an approach to health services. They embody intrinsic values such as equity, universality, democratization, integrality of health, and solidarity, among others. These values are derived from the goal of "Health for All in the Year 2000," established by World Health Organization member countries. When the Latin American and Caribbean ministers of health signed Resolution XV in 1988, they were ratifying the validity of these values, but there is some doubt as to whether they are universal for Latin America and the Caribbean. Chapter 3 discussed the philosophical and sociopolitical context in which SILOS will be implemented. Public health agencies in Costa Rica employ a total work force of over 30,000 and serve a population of 3,000,000. The broader the reforms chosen, the more the agencies will --------- T 6 B 1 have to rely on external forces, as political will and expectations beyond their control will be crucial in developing viable and feasible alternatives. According to Raul Penna, the changes in the health sector have enjoyed political support, which has made them possible, but they still have to be made feasible through organizational transformations and the search for congruency between strategic objectives and the institutional capacity to respond to them.^ In the 1988-1990 period, the General Health Directorate of the Ministry led the SILOS implementation process. The so-called health sector was not really the mastermind behind the initiative, and CCSS participation in that period was a new experience for its institutional culture. The Ministry of Health could make use of its power and its influence over other agencies, but its orientation was more internal than external to the Ministry. The municipalities were approached individually by local and in some cases regional officials, but there was really no strategy to link the national health system to the municipal system and other organizations in the SILOS process. ( 3) The culture of health care agencies, the antecedents in the leadership of the change, and national values are major determinants in the selection of the method of institutional reform. ------------------------------------------------------------------------- T631 This study has affirmed that the Local Health Systems are an approach in which various organizations must necessarily converge. The results not only depend on resources but also on the compatibility of their cultures. Organizational culture is the basis for understanding the behavior of its members. The SILOS have caused two agencies that functioned separately for forty years to enter into an active relationship. Together they are attempting to establish a work modality in which openness to social participation requires them to open themselves not only to partnership between them but also to interaction with the community in a different way than they were accustomed to. This is a very complex cultural change. As an illustration of this complexity, it is interesting to compare the perception of some MOH and CCSS officials regarding elements of the culture of their organizations. Self-perception of Ministry of Health officials: - Public-health orientation - Works with the community - Personnel visit families - Interdisciplinary approach - Limited resources - Social services with small installations - Enthusiasm and spirit of sacrifice to cover all areas of the country --------- — ------------------------------------------------------------3T01 - Emphasis on prevention, education - Supreme authority but without real power - Concern for health indicators - Health-care services for individuals, society and the environment. Self-perception of CCSS officials: - Curative, hospital-based approach - Work with persons, individual care - Individuals visit clinics and hospitals - Predominantly medical model - More resources than the Ministry - Modern infrastructure - Very little care provided outside the installations - Cure, recuperation and rehabilitation - Institutional autonomy - Concern for efficiency in services Services in health care, pensions, and social security. The CCSS was founded twenty years later than the Ministry and has four times the number of officials. A SILOS-based integration, as was analyzed in Chapter 7, enabled an integration "from the bottom up" through local personnel : it enabled a gradual integration of functions, later of installations and services and later still of programs and policies that are currently being unified (e.g. -------------------------------------------------------- Y7T primary care) . The process is an innovation for both agencies, and given the highly conservative disposition of most public organizations, innovation permeates too slowly. Even when a better way of doing things has been found, there is reluctance to try it. Always, somebody else has to demonstrate the effectiveness of innovation. Always, the evidence has to be examined and reexamined until any shadow of doubt is removed. Always, it takes considerable time, effort, energy and conviction to incorporate innovations. In the meantime, the outmoded and the outdated persist and they are perpetuated unless firm and drastic action is taken all the way down the line to see that things are changed.^ Starting in 1988, a combination of local efforts was emphasized, but since 1990, the effort of the authorities of both agencies and the PAHO have been oriented to reforms at the central level which affect the identity, mission or role, management and work modality of the two organizations. Possibly if reform at the higher levels had been tried in 1988, the SILOS would not yet have begun to function. Although there was already a significant decline of resources for the health sector, there was no disposition toward reform of the state nor a strong and frequent questioning about the financial viability of social security. The manner in which the country has gone about institutional change in the past must also be taken into account, and here what has been called "national culture" or the "Costa Rican way" has a strong influence. The health system is an open one, and as such it includes elements of national culture. There is no consensus among analysts in amâ__abjD.uJ:_t h^e_cv Itv ra. l__id.ent i ty.-.o.f _Cc.sJ:a_Eix.an^s.,_huJd. there are definite patterns which influence institutional behavior. According to Constantino Lascaris, in Costa Rica there is peaceful coexistence thanks to a certain political "prudence" defined as the capacity to adapt plans to circumstances ; moreover, he notes, there is a legislatory psychosis, which he defines as a tendency to resolve problems by passing laws.^ From his analysis of political attitudes of Costa Ricans, Mario Carvajal concludes that there is a tendency toward both major political parties alternating in office, which may inhibit change because every four years proposals on necessary transformations are modified.^ Mario Fernandez has noted that the governing style in Costa Rica is intuitive, accommodated to circumstances and that there is no real political doctrine beyond the defense of the status quo. ^ Given this manner of conducting public affairs, the implementation of the SILOS will continue to be subject to the impact of the changes of the political party in office, creating uncertainty about the long-term stability of this approach. This may be normal in a democracy, but in order to guarantee the effectiveness of reforms in the health sector, the political parties will have to negotiate to arrive at the greatest possible consensus on the strategy to be followed in the area of health care. -------------------------------------------------------------3T3’ Another subject that warrants a special study is the supposed contrast between the curative vocation of the CCSS and the preventive orientation of the Ministry. This difference may affect the behavior of the medical personnel of each agency, since it is well known that approaches, skills, technology and attitudes are different among professionals involved in curative medicine from those characteristic of professionals principally involved in preventive medicine, and an adaptation of roles and status in the short term cannot be assumed. Carlos Zamora, a specialist in research on health services at the CCSS, has stated that within certain circles of the medical profession, there is resentment over the decline in social status and income as a result of the changes in approach and modality of services that have been implemented by the CCSS.^ A tendency toward overrégulâtion is particularly marked in the areas of public health and social security. In the specific case of the SILOS, laws were promulgated as part of the implementation strategy, e.g., the decrees on primary care programs, health areas, the Community Technical Councils, the Regional Councils, the National Council, and the Health Boards. To these can be added the decrees on regionalization, sectorization, the Regulation of the National Health System and the Agreements on Integration of Services between the CCSS and the Ministry in 1987, 1989 and 1992. -------------------- 37'r Subjective factors play a very important role in the process of change, because it is individuals who either make it work or obstruct it. The larger the health-care agencies and the more diverse their internal groupings, the greater the role of underlying principles and values to unite them as an organization. If they do not agree with the new culture and are dispersed throughout the country, it is very difficult for change to flourish despite political will and resources allocated. The leadership within each agency is thus a key success factor for the consolidation of the SILOS. Robert E. Tranquada argues that a key factor in this process is the motivation of the individuals involved, and in most circumstances, this can be significantly influenced by the provision of appropriate incentives and disincentives to specific lines of action. If a new orientation is desired, but the incentives and disincentives of bureaucrats remain the same as they were, there is little chance that change will occur. He states that simple training in management principles, without changing the motivating factors will not be successful.7 Knowledge of the internal and external culture, of the evolution of the agencies and the mentality and self-concept of medical and other personnel can facilitate the introduction of a change in that culture, for which the support of an interdisciplinary team may be necessary. When the General Health Directorate formed the Commissions on . _ " ""....... . ........................... ................... ................ ......... .............................................■ m il * Teamwork, Social Participation and others promoted by the Community Technical Councils in 1987 and later by the SILOS in 1988, this factor was considered and the teams were composed of professionals in administration, psychiatry, social work, public health, information systems and certain medical specialties. (4) Those who participate in a process of institutional or inter-institutional change are not merely legally constituted organizations but essentially persons and groups that will determine its feasibility. One particular characteristic of health care agencies is the presence of numerous professional organizations within them. Within the medical community in Costa Rica there are several different pressure groups. It is natural that faced with a transformation that affects their interests, skills and approaches, these groups attempt to exert influence in order to preserve their interests. The rational and emotional reactions vary. In the case of the SILOS, physicians no longer have all of the technical decision making power they once had. They are now part of a team in which decisions are made by consensus. It is common that levels of support for these initiatives vary. As Melville Dalton indicated. Variations in the emotional ties of personnel with their firms ar.e unavoidable. Dl.f.ferences In a g .e. ?___ 376 ability, expectations, and personal and community responsibilities lead to a differential identification. Given human agents in close association, with similar standards of what is desirable, and obviously they will clash over available rewards.° He also emphasized the importance of cliques within organizations. In his opinion, "they are indispensable promoters and stabilizers— as well as resisters--of change, they are essential both to cement the organization and to accelerate action.Along these same lines, it has been argued that structural properties are characterized by relations between parts rather than by the parts or elements themselves. There is great diversity in the types of groups and characteristics of officials in the national systems: (a) differences in professional field. For example, the structure of the CCSS is divided into medical services, administration, finance and operations. (b) differences according to geographic location, whether at the main headquarters or in rural areas (c) differences among medical specialties (e) differences according to whether they belong to the CCSS or the Ministry (f) differences according to seniority and benefits In short, leading a transformation process requires considerable political skill on the part of its promoters to achieve the greatest support possible from the internal groups. In the implementation phase, divergences within the -- 37V" groups themselves should not be discounted. As has been observed, "since groups possess forms of stratification, it cannot be tacitly assumed that all individuals, or all positions in the system of stratification exert equal influence on those decisions from which bureaucratization emerges as a planned or unanticipated consequence. The implementation of the SILOS began precisely with groups of local officials who shared close personal relationships. Normally these teams had an average of ten persons. That is, there were factors in common that enabled these people to support the SILOS more easily. (5) Although the SILOS are a "bottom-up" strategy to transform the national health system, the leadership at the highest level determines the viability and feasibility of the change. Given the size, age, specialization and a tendency to overregulate health-care agencies, leadership might be thought to be relatively unimportant. But leaders are needed at the head of these organizations precisely to carry out processes different from those conservative traditions. In Costa Rica, there is a legally-constituted health sector and a national health system, as was described in Chapter 6, but it is not their legality that has made them operational. Moreover, while the CCSS preserves its status as an autonomous institution, its effectiveness as supreme — --- 3T8- authority over the Ministry will not be determined by the number of decrees issued. Political will and interpersonal relations among the institutions’ leaders may prove more meaningful than decrees. If a minister of health does not assume the leadership within the sector or the national health system, no one else will, since the minister is legally designated to perform this function. This does not mean that transformation is an illegal process, but rather that some aspects cannot be managed through laws and decrees because they are determined more by good will, management decisions, real allocation of resources and the presence of a promoter at the highest level who leads and who is accountable for the results. As Gerald E. Caiden has observed, c] learly there has to be somebody in charge of administrative reform, to promote it, to be identified with it, to direct reform campaigns and to answer for nonperformance, i.e. maladministration. In Costa Rica, the SILOS were initially implemented by an ad hoc commission without power based on authority or formal position in the Ministry’s organizational chart. But its dependence on the General Health Directorate (the chief administrative authority), which followed policy guidelines set forth by the Minister, provided access to the basic levels. When there was a change in the minister, this commission ceased to function. ------------------------------------------------------------------------- 3 7 - ^ 9 ' In the history of health care services presented in Chapter 5, it was emphasized that since their inception, these services have had the support of leaders that have left a recognizable mark for their capacity to implement change. This emphasizes the role of leaders as developers of organizations and responsible for their performance, as catalyzers of group development, as mediators between organizations' and members' needs, as creators of conditions to combine people and resources, as the pivotal force behind successful organizations, and as the transformative and visionary persons at the top of modern organizations.^^ Ex- Minister Mohs, who was in charge of policy direction at the inception of the SILOS believes that the selection of the minister may be more important than the government's agenda of priorities, because the feasibility of implementing the agenda depends on the minister. Chapters 7 and 8 described how the SILOS approach could be initiated in a country thanks to the action of the Ministry and through agreements between it and the CCSS, not to the determination of the health sector's coordinating commission or any rational decision on the part of representatives of the National Health System. The functioning of these policy coordinating organizations has not been regular. Thus, personalities become all-important, which can mean that ideas are identified with persons and persons with parties. There is the risk that the programs .. 3'g'Q- become partisan and that their duration may be affected by the alternating of political parties in power characteristic of the Costa Rican system. The reforms necessary to implement the SILOS or any other modality of services that implies a change in the rules of the game is eminently administrative; but before the administrative system can be improved, attention should be given to improving the policy-making system to which it is subordinate. One common theme in Latin American countries is that of the supreme authority over health policy. In the majority of countries, there is no health sector or even a formal or legally constituted system. Miguel Segovia, an expert on the administration of health services, defines the current situation as follows : There are many health care and social security agencies that are amorphous, undefined, that do not sense the need for a review of their performance; they tend to seek efficiency for efficiency's sake, to see modernization as synonymous with transformation. They are institutions subject to the political winds, which is what has prevented them from consolidating. Unfortunately, this has occurred in countries in which social development has not been a priority, for which reason there are high percentages of the population that do not have access to health services. The definition of the role of the chief political authority is another important step in organizational development that the health sectors have in Latin America. The implementation of the SILOS would appear to be a management or administrative issue, but as has been analyzed in this_s_t_udv,_i_t_is fundamentall_v_a_po.l.i.tical_issue.,_sln.ce_ ---— ------------------------------------------------------------- 3-HT it is a way that the health sector operates and a strategic concept about the way the state should function. As long as there is no single real authority within the health sector with the legal mandate to orient the work of all the agencies, it will be difficult to implement successfully a strategy such as the SILOS over the long term. A president of the Republic cannot devote much time to the task of mediating between two or more institutions. If they insist on their legal autonomy, significant resources will be wasted on negotiations and on the search for good will in the absence of strong, formal leadership within the health sector. ( 6) In order for the SILOS to achieve the desired impact, the principles that sustain them must be present not only at the local level but also throughout the structure and administrative process of the National Health System. The raison d ' etre of a health care agency is to facilitate improvement in the health of the population even though the agency does not control all the determining variables. The ^more leadership it has within the public sector, the more influence it will have in the allocation of resources for health. But its most important activity occurs when it enters into direct contact with the population. It is here where it resumes its mission. — ---------------------------------------------------------- 3 ' 8 ' 2 ‘ The SILOS are an attempt to provide services with efficacy, efficiency and equity. Moreover, they are a means to implement decentralization policies and democratize services. If they are truly a way to transform national systems toward the practice of those principles and those of solidarity and universality, this should be reflected in all of the strategies of each organization. Although their impact occurs at the local level, their importance should be reflected throughout the structure and the procedures at the middle and central levels of the agencies. This has not occurred, at least in the Costa Rican experience. The programs headquartered in the Ministry were not transformed during the first two years (1988-1990), and because of this, there were confrontations between local and central planning, which helps to explain why local planning is one of the processes that has evolved the least within the SILOS. Local, integrated planning requires financial support, but the budget is neither decided nor controlled at this level. Although there is a degree of integration of services, there is no integration of budgets. One serious implication is that, despite the good will and technical capacity that exists at the local level, the rest of the system can be discouraging. This is akin to implementing a new strategy without modifying the previous one, and then expecting that both coexist in the same place and with the same actors. The real impact of the SILOS as ------------ —---- 303 catalyzers of transformation could run the risk of remaining in the past, unless they are accompanied by budgetary viability, an aspect which until now has not been modified. Regulatory limitations in administrative areas, such as the management of the budget and the allocation of human, technological and logistical resources, vary among agencies. This makes utilization of resources to implement integrated care processes more complex. If the philosophy of organizational behavior implicit in the SILOS is real and a political priority, then the rest of the agency must work constantly to adjust itself to the needs of the local level. In the alternative, where the health system comes into direct contact with the population, the lacunae and contradictions of the rest of the system will be evident. In presenting these contradictions, the inability of agencies to improve health becomes clear. Here they are unmasked, and their loss of legitimacy lessens their importance at the moment of making decisions about budgetary allocations. With fewer and fewer funds, the health situation also tends to deteriorate, with little possibility of this cycle being broken. ( 7 ) The implementation of a multi-institutional change is novel, and as such it requires continuous monitorincT of a permanent team. -------------------------------------------------------------------------3’ 8^' A number of situations characterize the process of change that will have to occur if the SILOS approach is to function. Following are some of them: (a) Due to the nature of their work and the constant demand for services, health-care agencies cannot stop to change their modalities of care while they implement organizational changes; these must be carried out simultaneously. (b) The SILOS are a change from a production to a marketing approach in which local needs of the population are considered to be key inputs. The mentality of public officials must be reoriented because, as in any other business, client satisfaction, and even client participation in the management of the service, is a cultural change. (c) Even though the importance of coordination has been emphasized, the SILOS need something more than synchronization of activities. They require that two or more organizational cultures converge to produce an impact that none of them would achieve in isolation. (d) The variables that come into play are not only many and complex, but also new for the majority of officials. These four factors can be reduced to one: the success of SILOS depends largely on the institutions' capacity to ------------- 3^-5- learn. Then the SILOS implementation and inter-institutional integration processes need to ensure that learning occurs and that organizations are able to apply the lessons effectively. In the case of Costa Rica, as was analyzed in Chapters 7 and 8, a team within the Ministry facilitated the process between 1988 and 1990 and later worked on the development of projects to reform the sector to be presented to the World Bank and the Inter-American Development Bank. This team functioned temporarily. The two evaluations that have been produced so far (1990 and 1992) were conducted by another temporary team of Ministry and the CCSS officials. Neither agency has a permanent work team that guides the internal process and is dedicated to learning from it; nor is there a permanent team that contributes to the learning process on inter-institutional integration. These teams that motivate organizational learning must be comprised of analytical and reflective practitioners who monitor the process on a permanent basis, encouraging a culture of learning to improve the functioning of the health system. If there is no traditional of learning and even less of integration, the process could lose impetus, leadership and clarity with respect to the new stages. To political leadership must be added technical capacity to lead the transformation process. In 1993 the conceptual and technical support at the central level in the SILOS consolidation phase --- -------------------------------------------------------3TT was not still reflected in the structures nor in the allocation of permanent human resources to facilitate the process. If the process remains at the local level but without having consolidated mechanisms of support such as the budget, which is not under its control, what could occur is what has been called an inability to command resources and internal support : Reform is an investment, requiring substantial resources of time, energy, creativity and finance. Whereas the reformers may have sufficient for their needs, the operating units may not be able to divert or attract sufficient for implementation. Usually at the outset the reformers get all they request.... In time, they too run into difficulties as they try to keep the initial momentum going.... Without additional resources, the extra demands may not be met at all (the reforms area ignored) or met perfunctorily (the reforms are paid lip service) or sacrificed (the reforms are adopted at the expense of operational standards) . Technical cooperation provided to the local levels and the rest of the agencies to broaden the process may also cause a breakdown of evaluation and feedback mechanisms that may cause potential failure of the transformations. The challenge that organizations face is to learn from themselves and their relationships with others. If this learning process does not happen, it is likely that each time a reform process is attempted, the same mistakes will be made. The most important source of support that health care agencies have received in relation to the SILOS has been the Pan American Health Organizations, mandated by the ministers of health themselves. The PAHO is also learning from this _prpce_s^.,_and__it_fac.es__t:he_chal,lenge_of_f±nding_the_m.&a.n.S—o.f_ -------------------------------------------------------------------------3^87' cooperation that are consistent with each country's realities. The conditions for SILOS to function can be generalized for the countries of Latin America and the Caribbean, but each reality is distinct, and consequently, the priorities of those conditions are also different. In summary, if the PAHO and the national agencies want the transformation of national health systems to be based on the real functioning of the SILOS, they will have to encourage a culture of permanent and formal learning at all levels of their organizations. ( 8 ) A radical change in (a) the definition of the magnitude of the transformation, (b) the authorities that lead the process, and (c) the resources allocated for the operation of SILOS, could lower confidence within the participating agencies regarding the survival of the current initiatives and the useful life of those that are just beginning to be introduced. Chapter 8 analyzed what could be interpreted as a difference in emphasis between the strategies of two Costa Rican governments to strengthen health services. The Arias Administration (1986-1990) attempted a strengthening "from the bottom up" allocating technical resources to facilitate the implementation of the Community Technical Councils and the SILOS. The current government has oriented those same ---------- 3'8‘ S" technical resources (Health-Services Development Directorate of the Ministry of Health) to the conceptualization of the Project on Health Sector Reform, which includes, for example, the redefinition of the role of the Ministry as the supreme authority of the health sector and the CCSS as responsible for integrated care of individuals, incorporating the Primary Care Program which is currently housed within the Ministry. The CCSS has not experienced strategic changes with the exception of its incorporation into the SILOS in 1989 and the advances in regionalization and decentralization of some of its programs. These sector reforms have been widely debated within the current government, but their final approval depends on the Legislature, which will continue its analysis over a period of several years among diverse actors both internal and external to the sector. In the meantime, naturally there is (a) uncertainty among the officials of the Primary Care Program, the one most heavily involved in the SILOS, (b) diversification of efforts on the part of technical personnel originally dedicated to facilitating the process of the SILOS, (c) reorientation of the technical cooperation of the PAHO to support the formulation of the Projects on Health Sector Reform, (d) doubts about the local level regarding the advisability of increasing the number of SILOS when it is not known how the sector will be structured in the future, and (e) limited intellectual investment in the middle levels of ---------------- 3T9' the institutions (CCSS and the Ministry) in processes such as the SILOS, new modalities of ambulatory care and any other transformation that could be modified in case the Project on Sector Reform is approved in the Congress. In synthesis, the debate on new changes has not ended, and a degree of uncertainty has been introduced that can affect the SILOS implementation process. Leading a process of strategic change such as that involved in SILOS is slow and even more so when there are so many intervening factors. The importance of a permanent team that guides it with the technical capacity and with the necessary authority has already been mentioned. To this must be added the importance of maintaining the original momentum, even if other changes emerge along the way which are compatible with what already exists. This uncertainty in the face of potential changes also occurs in the face of a possible rotation of political authorities resulting from elections. The less consensus that exists between the political parties around health-care strategies, the greater will be the uncertainty on the part of officials. An appreciable improvement in health will not be achieved in a short four-year term of government. Since it is such an essential issue for the population, the discussion on reforms should not remain inside the agencies, because it will not necessarily be there that long-term strategic decisions will be made. The Costa Rican democratic -------------------------------------------------------------------------33tn system facilitates dialogue between parties on issues such as this one, but in the case of health care it has not occurred. The lack of multi-party commitment ensures that the useful life of the reforms will only be guaranteed for somewhat less than four years. The less profound the reforms, the more agreement will be needed between political parties and between the legislative and the executive branches. Labor unions cannot be left out of the debate. Within the Costa Rican national character, any imposition would be repelled by the impulse to change the government, and the candidates would be the losers. The more that consensus is required, the more political leadership is required within the Ministry and the CCSS that has credibility as negotiators and a democratic and long-term approach. ( 9 ) An integration process is not the sum of its parts nor the absorption of one by the other. It is the unification of efforts to produce something different or better than the sum of the actions of two or more participants in the integration. Almost all the countries on the continent have divided public health and social security into two or more agencies. The concept of health, the changes in the health conditions of the population and the financial crisis of these organizations have brought them closer together and today, ------------------------------------------------------------------------- 3 ^ n as in the Costa Rican case, the advisability of maintaining the division of responsibilities is being widely discussed. The SILOS are a scenario in which the organizations converge without losing their identity or the validity of their mission. They contribute their competitive advantages and adapt their operations to produce an integrated service to society. It is thus not a simple summation of functions nor of planning. The intensity and modality through which each agency intervenes is governed by the fundamental principles discussed at the beginning of this chapter. Once integrated plans and strategies are developed, the officials' task is to adapt the resources and procedures of their original organizations. Although this is considered important, what is even more important is the integration of two or more cultures as was discussed in the preceding chapter. It is here where the integrated work model encounters the biggest problems. Culture can be defined as consisting of "the rules, written and unwritten, of the organization's game, that is, who gets ahead and why, what it takes to succeed 'around here'; its special language and dictionaries of terms; its jokes; history; myths; rituals; special awards and rewards; ceremonies; and symbols. Although integration could be seen superficially as restricted to tangible factors, in fact it encompasses much more, especially due to its permanent and dynamic nature, the CCSS and the Ministry coincide on principles but have — — --- 2^- different cultures, resources and policies. The interpersonal and professional relationships between their officials that make integration real at the local level will be healthy if: (a) they perceive that the treatment they receive from their organization is equal to that received by their counterparts; (b) they perceive that the relationship enriches them mutually and there is no sense of illegitimate power or absorption of one agency by the other; (c) there is a concrete product that satisfies them and that neither of the parties could generate in isolation from the other, i.e., if there are mechanisms to receive feedback from the community and its agencies; (d) the experience represents a challenge and a stimulus for their personal and professional development, i.e., if the organizations together have developed equitable career plans that diminish professional jealousies between officials due to perceived inequalities ; (e) the officials feel truly motivated by the SILOS approach, the integration of services and the permanence of this integration over the long term. Whether these initiatives work depends on them in the end, even given resources and political 393 support. And here it is important, once again, to point out that unless the incentives and desincentives for these officials provide true motivation to adopt the SILOS approach, it will nçver happen. Ian Mitroff emphasizes the obsolescence of the notion that the behavior of organizations could be understood in terms of a relatively small and limited number of internal and external stakeholder forces.^* The functioning of the SILOS thus requires attention not only to the direction that global reforms of the health-care system must take but also on subjective and emotional factors on the part of those participating in the process. A decline in motivation on the part of local officials may emerge, especially when the progress of the SILOS confronts budgetary, logistical and administrative barriers that have not been adapted to the new work methods. In 1987 the Ministry initiated the process where it found the most support. At that point it did not involve the middle managers so that they could modify their support, but rather it assumed that this would occur in 1989 after having provided them with management training. This could lead to acceptance of the idea that change occurs at different rhythms within a single agency and that resistance may arise on the part of those who believe that they should have at least been consulted on the strategy to be followed. -------------------------------------------------------------------------T9T If this political management is not done carefully in the participating agencies, each one could generate foci of resistance, and subsequently significant technical and political resources would have to be invested in order to manage the different manifestations of resistance, some of which, as was indicated earlier, may originate in emotions that could have been foreseen. The mutual perceptions between organizations, expressed in the attitudes of their officials, is another factor that will influence the quality of implementation of the agreements on integration and the SILOS. Given the power that centralization has accorded to the directors of agencies such as the CCSS and the Ministry, they have a responsibility for the necessary bringing together and breaking down of barriers between their organizations. For example, one topic of broad discussion has been whether the Primary Care Program should be transferred to the CCSS so that it can take over integrated care of individuals. If in this analysis preconceived notions, stereotypes and mutual projections intervene, then the discussion on the technical quality and the political advisability of the idea will be tainted. Transparency in the management of these processes, including frankness about the subjective elements, is a wise investment to stimulate healthy and lasting reforms. -----------------------------------------------------------------s ' g ' S ' 10) It is not possible to achieve perfection in a process of inter-institutional integration or change toward a SILOS approach. A global vision of a change process and flexibility in directing it will increase the feasibility of achieving the desired results. Transformations are not born from manuals for success and for this reason, the intensification of decision-making authority at all levels is vital for the creative and effective management of the changes and for the application of the values that gave rise to them. An organization's achievements are not anonymous. They are caused by persons that utilize their own values, capabilities and creativity. This is true for any organization. However, the impact of the organization also depends on the values of its members such as in health care agencies. Their raison d'etre is the mental and physical well-being of individuals. This is a transcendental value. Health workers, as they call themselves, need to possess a very special commitment, because they give their maximum effort to achieve the well-being of humanity. Just by imagining the pilgrimage that primary health promoters make, from house to house, in the most remote corners of the country, their sensitivity and values are evident. This characteristic of a health care agency must be considered when leading a process of change. ■ --— -----------------------------------------------------------3T61 When a health care institution represses these values in its culture in exchange for efficiency, modernization and productivity, paradoxically it may be dehumanizing itself at the same time as it attempts to provide a very human service. There are distinctive factors in the culture of health-care agencies that must be taken into account in the design of reforms. The reduction of the size of the state and the search for greater administrative efficiency of organizations are much discussed topics in Latin America. But there are risks involved if the human factor and the social mission of the agencies are not also taken into account. In this regard, Donald A. Schon warns: Large-scale social service agencies, hospitals, and architectural offices have also come to function in the technical, bureaucratic world. Here too professional work tends to be channeled within a specialized task system and subjected to objective measures of performance and control. Within these systems, practitioners are increasingly constrained by technical advances in the measurement and proceduralization of work. The work of health-care personnel who decide and implement strategies to improve the well-being of the population must be characterized by a high degree of reflection and a capacity for constant learning. In order for organizations to act this way, they must meet several extraordinary conditions : In contrast to the normal bureaucratic emphasis on uniform procedures, objective measures of performance, and center/periphery systems of control, a reflective organization must place a high priority on flexible procedures, differentiated responses, qualitative appxejAi.ai:,io.n_o.f_compl.ex_pr.o.ces.s.e.s., a.ad—decÆiitriaI.i-z.ed___ --------------------------------------------------------------------- rr?---- responsibility for judgement and action. In contrast to the normal bureaucratic emphasis on technical rationality, a reflective organization must make a place for attention to conflicting values and purposes. But these extraordinary conditions are also necessary for significant organizational learning. Another characteristic of health-care agencies already analyzed is the diversity of professions that intervene, which demands considerable flexibility to incorporate widely divergent perspectives. It is essential, therefore, that when promoting the SILOS approach, the broadening of a learning culture is encouraged. This culture will facilitate the disposition of professionals to learn from other fields; for example, physicians will learn management and managers will attempt to understand the health-care field. This will contribute to fomenting integration of the subcultures that prevail in these organizations. Learning makes sense if it is used to act on concrete situations that inhibit institutional development. This capacity for action depends in turn on the decision-making authority of officials at different levels of the agencies. If learning and training exist but not commensurate decision making authority, frustration will result and the national health system will be incapable of responding to the changing demands of the population. Without this decision-making authority, officials will feel less a part of the organization, less active, less participants, less accountable for results, less motivated _tp__shar.e_the_mi.s.sio.n_and„the_chal,leng.e,s.. W.he n_t hls^ojccn ns^_ -------------------------------------------------------------------------33*8’ the road to disloyalty and corruption is shorter, muddying the values that gave rise to the institution in the first place. In the transformation of the national health system through the SILOS, there is much to be learned by the public agencies. Each country will have to attempt it in accordance with its national values, its history, its concept of health and well-being of the citizens, its expectations for development and its creative capacity. Therefore, there are no useful recipes that serve all countries, except for two : persistence in attempts to improve, and the institutionalization of change. As has been stated: Governments that value themselves recognize that they must have some means of heading off trouble.... They must institutionalize administrative reform based on three basic premises, namely, that all human arrangements are imperfect and therefore capable of betterment, that large-scale organizations suffer from innumerable bureaupathoiogles that are capable of corrective treatment, and that public maladministration should be minimized as a necessity to improve the quality of contemporary living. Such important matters can no longer be left to chance or professional good will or good intentions. They have to be incorporated as part and parcel of the machinery of government When countries share their experiences, they become closer and they learn more. As in the case of cholera, dengue and AIDS, the health situation of a country affects its neighbors. The Pan American Health Organization is the living symbol of this necessary cooperation for the exchange of experiences. This study has presented the experience of Costa Rican public officials who, throughout the nation's -------------------------------------------------------------------------3-9’ 9~ history, have demonstrated a vocation of service and commitment to national development for the purpose of achieving the greatest possible level of well-being for the population. 400 CHAPTER 9 REFERENCE NOTES 1. Raul Penna, PAHO Representative in Costa Rica and member of the coordinating committee of the Project on Reform of the Health Sector, interview by author, November 9, 1993, San José, tape recording. 2. Gerald E. Caiden, Administrative Reform Comes of Age (Berlin, New York: Walter de Gruyter, 1991), 94-95. 3. Constantino Lascaris, El Costarricense (San José, Costa Rica: Editorial Universitaria Centroamericana, 1975), 468. 4. Mario Carvajal, Actitudes Politicas del Costarricense (San José, Costa Rica : Editorial Costa Rica, 1978), 242. 5. Mario Fernandez, Comunicacion e Ideologla (San José, Costa Rica : Editorial Fernandez Arce, 1988), 319. 6. Dr. Carlos Zamora, Researcher on Health Services, Costa Rican Social Security Bureau, interview by author, November 10, 1993, San José, tape recording. 7. Dr. Robert E. Tranquada, School of Public Administration, University of Southern California, interview by author, Los Angeles, 18 January 1994. 8. Melville Dalton, Men Who Manage (New York: John Wiley & Sons, Inc., 1959), 54. 9. Ibid.. 68. 10. Alvin W. Gouldner, Patterns of Industrial Bureaucracy (Illinois : The Free Press, 1954), 98. --------------------------------------g-cm 11. Gerald E. Caiden, "Institutionalizing Administrative Reform," (Washington, D.C.: Washington Public Affairs Center, 1991), 12, photocopied. 12. Warren G. Bennis and Burt Nanus, Leaders: The Strategies for Taking Charge (New York: Harper & Row, 1985). 13. Gerald E. Caiden, "Institutionalizing Administrative Reform." 14. Msc. Miguel Segovia, Regional Advisor in Health Services Administration, Pan American Health Organization, Interview by author, San José, Costa Rica, November 9, 1993. 15. Donald A. Schon, The Reflective Practitioner (New York : Basic Books, Inc., Publishers, 1983), 338 . 16. Gerald E. Caiden, Administrative Reform Comes of Age, 161-162. 17. Ian I. Mitroff, Stakeholders of the Organizational Mind (San Francisco : Jossey-Bass Publishers, 1983), 120. 18. Ibid., 151. 19. Donald A. Schon, The Reflective Practitioner, 336. 20. Ibid., 336. 21. Gerald E. Caiden, "Institutionalizing Administrative Reform," 3. 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Creator
Retana, German
(author)
Core Title
Changing health-care delivery organizations in Costa Rica: an inter-institutional approach
School
Graduate School
Degree
Doctor of Philosophy
Degree Program
Public Administration
Degree Conferral Date
1994-08
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
health and environmental sciences,OAI-PMH Harvest,social sciences
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application/pdf
(imt)
Language
English
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Digitized by ProQuest
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Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c36-653469
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UC11252050
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DP31373.pdf (filename),usctheses-c36-653469 (legacy record id)
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DP31373.pdf
Dmrecord
653469
Document Type
Dissertation
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application/pdf (imt)
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Retana, German
Type
texts
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University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
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The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...
Repository Name
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USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA
Tags
health and environmental sciences
social sciences