The Politics of Underdevelopment MANAGEMENT COMMITMENTS AND PRIMARY CARE: ANOTHER LESSON FROM COSTA RICA FOR THE WORLD? Werner Soors, Pierre De Paepe, and Jean-Pierre Unger

Maintained dedication to primary care has fostered a public health delivery system with exceptional outcomes in Costa Rica. For more than a decade, management commitments have been part of Costa Rican health reform. We assessed the effect of the Costa Rican management commitments on access and quality of care and on compliance with their intended objectives. We constructed seven hypotheses on opinions of primary care providers. Through a mixed qualitative and quantitative approach, we tested these hypotheses and interpreted the research findings. Management commitments consume an excessive proportion of consultation time, inflate recordkeeping, reduce comprehensiveness in primary care consultations, and induce a disproportionate consumption of hospital emergency services. Their formulation relies on norms in need of optimization, their control on unreliable sources. They also affect professionalism. In Costa Rica, management commitments negatively affect access and quality of care and pose a threat to the public service delivery system. The failures of this pay-for-performance-like initiative in an otherwise well-performing health system cast doubts on the appropriateness of pay-for-performance for health systems strengthening in less advanced environments.

PRIMARY CARE AND HEALTH SECTOR REFORM IN COSTA RICA Costa Rica began consolidating a public primary health care system aimed at universal coverage in the early 1970s. Population coverage by the national social security fund (Caja Costarricense de Seguro Social, or CCSS) rose to 76 percent International Journal of Health Services, Volume 44, Number 2, Pages 337–353, 2014 © 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/HS.44.2.j http://baywood.com

337

338

/ Soors et al.

in 1980 (1). Costa Rica kept its distance from the first wave of health sector reforms in the 1980s and increased health sector spending (2). Pressed by popular discontent with waiting lists, Costa Rica engaged in a second wave of health sector reforms and called for World Bank assistance in 1991. The Costa Rican negotiators dismissed the World Bank proposals for privatization and fragmentation, and instead made a point of reinforcing primary care, to be provided by doctor-led EBAIS (Equipos Básicos de Atención Integral en Salud) with preventive, educational, and curative tasks. The CCSS established 818 EBAIS between 1995 and 2002. In 2002, population coverage had risen to 88 percent and health indicators were outstanding. In its 2003 completion report, the World Bank acknowledged the EBAIS model as the most significant achievement of the Costa Rican reform process (3). THE ISSUE OF MANAGEMENT COMMITMENTS Having rejected both privatization and fragmentation of CCSS functions, Costa Rica accepted deconcentration and an internal purchaser-provider split, “to support the introduction of mechanisms oriented towards replacing the historical budget system with a performance-based resource allocation system” (3). At that time, the World Bank still dissuaded developing countries from pay-for-performance, “the benefits of which have yet to be demonstrated in the public sectors of developed countries” (4). Costa Rica drafted its own hybrid model: management commitments (Compromisos de Gestión, or MCs) in 1996. MCs consist of a yearly negotiation between a central CCSS administrative body and CCSS service providers on a list of indicators and targets. The CCSS laid out the marks for implementation of distinct MCs for primary care units and hospitals in 1997. A Health Services Purchasing Department (Dirección de Compra de Servicios de Salud) within the central CCSS administration was formally established in 1998. Legal conditions, lack of cost accounting, and union opposition led to a much less ambitious implementation of MCs than foreseen. Performance-based payment has not been introduced to a significant extent. Still, the inclusion of indicators and targets for a limited number of programs has been incremental (5). From 2000 on, all CSSS hospitals and health areas subscribe to and are evaluated on MCs once a year. Worldwide, pay-for-performance has received intensive promotion (6) as a managerial tool to improve quality, allegedly based on evidence. Yet after decades of implementation of pay-for-performance in a handful of developed countries, evidence of net benefit is still far from conclusive (7, 8–11). Evidence from developing countries is scarce and stems often from donor-dependent, smallscale experiences, mainly outside weakly performing public sectors (12–14). In fragile states, pay-for-performance relies heavily on the managerial capacity of international nongovernment organizations. By contrast, Costa Rica offers ideal

Costa Rica Management Commitments / 339 conditions for impact evaluation: strong government ownership and maintained implementation in a well-performing public sector, at a national scale. AIM OF OUR STUDY Assessment of Costa Rica’s MCs according to primary care prospects was and still is largely absent from the scientific literature, which concentrates on the initial implementation of MCs and barely addresses the interface between users and providers (2, 5, 15–17). After our analysis of the impressive achievements of primary care in Costa Rica (18), we now aimed at assessing the effects of MCs on access and quality of care, especially at the EBAIS level. In a wider sense, our aim was to assess the compliance of MCs with their designated goals: “to obtain health objectives and to improve service organization, quality, and efficiency” (19). With the consent of the Costa Rican health authorities, we conducted our research from 2005 on. METHODS To achieve a comprehensive picture of the effects of MCs on access and quality of care, we opted for an integrated combination of qualitative and quantitative methods. First, we used a qualitative approach, converting perspectives and claims of primary care providers¾gathered through two focus group discussions¾into a number of hypotheses. The formulation and selection of these hypotheses will be discussed in the next section. From this point on, data collection (observation of consultations, interviews with health care providers and officials, document search) and analysis were iterative by design. This implied systematic triangulation of findings from complementary sources for validation (20, 21). For the observational part of our data collection, we deliberately selected seven (out of 106) EBAIS in seven (out of eight) health areas in the Huetar Atlántica region (one of six medical regions in Costa Rica). We extended the remaining part of our data collection (documents and interviews) to health area, regional, and national levels. Peer-reviewed literature reflects only a fraction of the Costa Rican MCs’ complexity, so we extended our document search to registers, reports, surveys, and internal assessments. To allow a timeframe for fair evaluation (22), we included documents from before 1997 (the period of agenda setting and formulation in stages-heuristic terminology [23]) up to 2007 (encompassing one decade of gradual implementation). Field data collection took place in October 2005, March 2006, and December 2006. Each period concluded with a feedback of findings to health area directors and regional CCSS officials. Additionally, an exhaustive feedback was provided in May 2007 to health area and regional staff and to the national CCSS board. The authors conducted all data collection, verbatim transcription of digitally recorded interviews, coding (manually and through NVivo), and analysis.

340

/ Soors et al. FINDINGS AND DISCUSSION

Formulation of our Hypotheses We participated in a meeting of regional executives and health area directors (21 participants, on October 18, 2005) and primary care staff (Siquirres, 26 participants, October 19, 2005). Through focus group discussions, the providers freely expressed a series of perspectives and claims on the issue of MCs in their daily practice. Participants and researchers jointly converted the providers’ assumptions into hypotheses for verification. Table 1 presents the construction of seven hypotheses. Five more hypotheses were formulated but judged redundant or not suitable for verification in our research setting and were thus withdrawn. For each hypothesis, sources for verification were suggested, as well as possible implications on access and quality of care and ways to assess them. These aspects will now be discussed together with primary findings for each hypothesis. Hypothesis 1: MC programs consume an excessive proportion of consultation time. Data collection was based on the researchers’ registration of consultation time during direct observation and complemented with secondary data from existing registers. We developed a comprehensive matrix for systematic registration of all observations of consultations (Hypotheses 1, 2, 3, and 6). During the first period of data collection (October 2005), we observed 50 consultations (26 MC program consultations and 24 non-program consultations; MC program examples are diabetes, hypertension, prenatal control, under-5 consultations) in seven EBAIS and quantified the average consultation time: 12.7 minutes for a program consultation and 11.1 minutes for a non-program consultation. Using the consultation registers of the same EBAIS, we extrapolated that an estimated 56 percent of consultation time was spent on MC programs in October 2005, with extremes in individual EBAIS of 32 percent and 83 percent. The average consultation time for a program consultation is only slightly higher than for a non-program consultation. Still, this finding is striking, considering that most program consultations are subsequent (diabetes, hypertension, prenatal control) and could be expected to demand less time than non-program consultations. The proportion of total consultation time spent on MC programs (56%) may look unimpressive but can nevertheless be considered excessive. Indeed, whereas the selection of programs for MCs reportedly is based on predominant health problems, the actual selection may well fall short of real needs and demand. Statistics for outpatient consultations in 2002 reveal that prenatal, healthy child, and reproductive health programs (23%), hypertension (5%), and diabetes (4%)¾the bulk of program consultations¾account for only 32 percent of all consultations (24).

Costa Rica Management Commitments / 341 Table 1 Construction of hypotheses on Costa Rica’s primary care management commitments Hypotheses for Hypotheses verification

Examples of providers’ perspectives and claims

H1

MC programs consume an excessive proportion of consultation time.

We have to dedicate too much time to MC programs. (Provider, area level, October 18, 2005)

H2

MCs lead to an excessive proportion of consultation time dedicated to writing.

Little time is left for non-program consultations. (Provider, EBAIS level, October 19, 2005) With or without MCs, we have too much paperwork. (Provider, area level, October 18, 2005) The MCs make me write so much in front of my patients, I hardly find time to talk to them. (Provider, EBAIS level, October 19, 2005)

H3

MCs reduce the comprehensiveness of care during the consultation.

Patients want us to give ear to their suffering, but we just look at their hypertension. (Provider, EBAIS level, October 19, 2005)

H4

MCs have increased the burden of emergency consultations.

All those sick people we cannot attend no more now turn up in the emergency rooms. (Provider, area level, October 18, 2005)

H5

MCs’ quality norms are maximized, not optimized.

They want us to do so much, but they do not really check if the patient gets better. (Provider, EBAIS level, October 19, 2005)

H6

MCs lead to a gap between registered information and reality.

They check what we wrote, not what we did. Who knows I did what I wrote. (Provider, EBAIS level, October 19, 2005)

H7

MCs reduce physicians’ We are swallowed up by bureaucracy, no space self-esteem. left to feel like a doctor. (Provider, EBAIS level, October 19, 2005) By not appraising what I value, they make me feel a good-for-nothing. (Provider, EBAIS level, October 19, 2005)

342

/ Soors et al.

The imbalance between MC program and other consultations has a negative effect on patient access. The first Costa Rican patient satisfaction surveys at health area level¾conducted in Huetar Atlántica in 2005¾traced potential users in search of an appointment. The overall effect on access for the sick is obvious: up to 99 percent arrived at their EBAIS between 2 and 7 a.m., and for more than 90 percent this effort was in vain (25, 26). MC program users have programmed appointments, excluding other patients. Facing MC quotas, some providers have started giving a limited number of “easy” program users (mainly older chronic patients) more frequent appointments than requested by present norms. Our interviewees referred to this phenomenon as the merry-go-round (el carrusel). Hypothesis 2: MCs lead to an excessive proportion of consultation time dedicated to writing. During the 50 observed consultations (October 2005), we quantified the time spent on writing. The average time dedicated exclusively to writing was 46 percent of the total consultation time, ranging from 36 percent in non-program consultations to 53 percent in program consultations. Earlier research on MC has pointed out an ever-increasing variety of indicators (5, 17). A 2007 auto-evaluation by the Dirección de Compra confirms that over the preceding five years, for EBAIS level only, 25 new indicators had been introduced (19). The resultant requirements of forms to be filled out explain the higher proportion of consultation time spent on writing in program consultations. In addition to a profusion of details, unnecessary repetitions added up to loss of efficiency. Apparently, recordkeeping for regulation and control goes beyond the legitimate concern of quality in service provision. Throughout the world, how general practitioners manage their time depends on personal characteristics, patients’ demand, service organization (including recordkeeping), and culture (27). In the interviews we conducted in Costa Rica, primary care practitioners complained of strong time pressure due to MC requirements, with insufficient time left for interaction with their patients. Literature does not provide conclusive evidence on the ideal proportion of consultation time to be spent on writing. It does, however, suggest that lack of time is an important constraint on verbal communication in primary care consultations (28). On average, less than six minutes (47% of 12.7 minutes) and just over seven minutes (64% of 11.1 minutes) remain for effective consultation in program and non-program consultations, respectively. The risk that recording will hinder provider-patient dialogue seems real in both. MCs aggravate this risk, although to a lesser extent than our interviewees suggested. Both the persistence of preexistent bureaucratic culture and a spillover effect from MCs may account for the modest difference observed. An effect on providers’ self-esteem, discussed later, may explain their insistence on the issue.

Costa Rica Management Commitments / 343 Hypothesis 3: MCs reduce the comprehensiveness of care during the consultation. We consider a consultation as comprehensive when a caregiver offers a balanced and patient-centered response to the biomedical, psychological, and social needs and demands of a patient. Patient centeredness includes but is not limited to shared decision making and a holistic approach. During each of the 50 observed consultations, we registered the presence or absence of key elements of comprehensiveness. Table 2 presents the findings of this assessment. In both non-program and program consultations, shared decision making scores low, except for the explanation of treatment. This suggests the prevalence of doctor-centered care in a paternalistic culture. The assessment of a holistic

Table 2 Comprehensive care assessment at primary care level in Costa Rica

Shared decision making Non-program consultations Program consultations All consultations

Holistic approach Non-program consultations Program consultations All consultations

Consultations with diagnosis developed in dialogue

Consultations with diagnosis explained to patient

Consultations with treatment developed in dialogue

Consultations with treatment explained to patient

21.0%

38.0%

42.0%

83.0%

12.0%

42.0%

42.0%

88.0%

16.0%

40.0%

42.0%

86.0%

Consultations with inquiry about psychological determinants

Consultations with counseling on psychological issues

Consultations with inquiry about socio-familial determinants

Consultations with counseling on socio-familial issues

8.0%

8.0%

33.0%

8.0%

8.0%

0.0%

15.0%

0.0%

8.0%

4.0%

24.0%

4.0%

Note: All figures are proportions, based on the observations of 50 consultations (24 non-program and 26 program consultations) in the EBAIS of Suretka, Hone Creek, Liverpool, Zent, San Rafael, Cariari 2, and Rio Jiménez, Huetar Atlántica region, October 2005.

344

/ Soors et al.

approach offers an even more daunting picture. Three indicators score close to zero, with only inquiry about sociofamilial determinants of ill health present in one-fourth of all consultations. Predominance of a biomedical culture of care is unmistakable. Inter-provider variability is considerable, as expected. Differences between non-program and program consultations are less prominent. When there are marked differences, program consultations are at a disadvantage: the development of a diagnosis in dialogue with the patient and a doctor’s inquiry about sociofamilial determinants of ill health are only half as frequent; psychological and sociofamilial counseling are totally absent. These observations reinforce what was suggested by our analysis of Hypothesis 2: provider-patient dialogue is deficient. They also confirm that Costa Rican MCs reduce the (already weak) comprehensiveness of primary care consultations. Hypothesis 4: MCs have increased the burden of emergency consultations. To test this hypothesis, we reviewed statistics for primary care and emergency consultations over the longest possible time span, at the national level. Data were available from 1980 onward. MCs were gradually introduced from 1997 on and became normative for all CCSS service delivery levels as of 2000. Table 3 presents our findings. The number of primary care consultations per inhabitant per year has been fairly stable over time, keeping pace with population growth. This is not the case for emergency consultations, which increased by 32 percent over the 17 years before the introduction of MCs and again by 31 percent in only eight years of MC implementation. Two facts should be noticed here. First, the increase in emergency consultations started roughly a decade before the introduction of MCs for a number of reasons. First, Costa Rica has faced a steady influx of migrants, who mostly remain uninsured. To avoid fees, uninsured immigrants proceed to emergency rooms when sick. In addition, health centers have limited opening hours, pushing insured and uninsured alike to emergency care. A deficient referral system leads to substantial waiting lists for specialty consultations. People may then prefer a non-specialist consultation in an emergency room. Second, MCs have not improved the situation: the number of emergency consultations per inhabitant per year increased as much in the eight years after the introduction of MCs as in the 17 years before. The de facto exclusion of patients from attention in the EBAIS (Hypothesis 1) largely explains this phenomenon. Possibly the only factor positively influenced by MCs has been the availability of doctors at the EBAIS level. Where absenteeism was a common feature before 1997, MCs have forced physicians to be present Monday through Friday. This change does not seem to have relieved the burden on emergency services.

2.22

2.36

2.04

2.02

0.41

0.37

0.62

0.57

0.63

1995

0.36

1982

0.64

1996

0.37

1983

2.16

1996

2.36

1983

1998 0.75

0.69

0.40

1997

0.32

1985

2.27

2.25

1984

1998

2.30

1985

1997

2.32

1984

0.79

1999

0.40

1986

2.28

1999

2.27

1986

0.84

2000

0.43

1987

2.15

2000

2.26

1987

0.87

2001

0.48

1988

2.19

2001

2.17

1988

0.87

2002

0.56

1989

2.31

2002

2.09

1989

0.90

2003

0.51

1990

2.34

2003

2.08

1990

0.94

2004

0.54

1991

2.39

2004

2.10

1991

1.00

2005

0.53

1992

2.39

2005

2.08

1992

Note: Confidence intervals not available. Source: Gerencia de División Médica, Dirección de Información en Salud, Departamento Estadistica de Salud. Estadisticas generales de los servicios de atención de la salud, 1980–2005. San José, Costa Rica: Caja Costarricense de Seguro Social, Serie Estadisticas de la Salud No. 5-L, 2006.

1994

1993

cont.

1981

1980

2.09

1995

2.25

1982

Emergency consultations

1994

1993

cont.

1981

1980

Primary care consultations

Number of consultations per inhabitant per year

Evolution of primary care and emergency consultations, Costa Rica, 1980–2005

Table 3

Costa Rica Management Commitments / 345

346

/ Soors et al.

Overall, the overload of emergency services is considerable. Daily queues at hospitals are no exception, as we observed. Overload of emergency services has consequences on cost and quality of care. The cost could have been lower if more cases had been attended at the EBAIS level: on average, half of all emergency consultations are not considered real emergencies by the CCSS. In 2003, an emergency consultation had an approximate institutional cost of US$43, versus US$24 for a consultation at the EBAIS level (5). Quality of care for common health problems in emergency rooms is usually low, due to incomplete treatments (to make direct access less attractive) and lack of follow-up. Hypothesis 5: MCs’ quality norms are maximized, not optimized. To test this hypothesis, we compared Costa Rican quality norms for prenatal care and diabetes treatment with international quality norms. As for prenatal control, both the CCSS and the Ministry of Health recommend a total of 13 visits, with an acceptable minimum of five for low-risk pregnancies. Norms in other countries are divergent, with seven, 10, and 16 visits recommended in Belgium, Canada, and Argentina, respectively. A Cochrane Collaboration report found that four prenatal visits are sufficient for a low-risk pregnancy (29). We already know that the excess proportion of time taken by program consultations limits access for the general population (see our discussion of Hypothesis 1). We thus argue that there is both room and need for decreasing the number of recommended prenatal visits. For hypertension, the CCSS recommends two initial visits followed by a control every three or six months according to the risk profile of the individual patient. We consulted norms in Belgium, Holland, the United Kingdom (NICE and the British Hypertension Society), and Colombia. Most developed countries do not recommend a strict number of control sessions for hypertension. The frequency is determined by the treating physician and hypertension treatment assessed on its result: blood pressure. By contrast, in Costa Rica the yearly MC evaluations do not take into account the blood pressure attained. Hypothesis 6: MCs lead to a gap between registered information and reality. We quantified the extent to which the recording of activities in forms and registers by caregivers matched directly observed activities. We did so for clinical examination, diagnoses, treatment, and follow-up plans. Overall, 76 percent of registered activities were indeed performed. Regarding treatment and follow-up plans, 75 percent and 77 percent of registered activities matched the observed reality, in non-program and program consultations,

Costa Rica Management Commitments / 347 respectively. As for clinical examinations and diagnoses, MCs made a negative difference: 88 percent correspondence in non-program consultations and 65 percent correspondence in program consultations. Real-life correspondence might be even lower due to the Hawthorne effect (the biased behavior of study participants aware of being observed) (30). Triangulation with information from our interviews strongly suggests that coping through cheating is no isolated practice. Several of our interviewees expressed that “an experienced doctor knows exactly how to fill out his forms to score well in MC reports.” One of our interviewees said that written information could easily be “adapted” to result in a good evaluation report. In other words: when an EBAIS gets a good report, this does not mean that it did a good job, nor that it actually did the job. MCs have a problem for which the proliferation of indicators (5) offers no solution: the sources of information are not reliable. Hypothesis 7: MCs reduce physicians’ self-esteem. Evidence for this hypothesis abounded from the provider interviews throughout our field visits. Interviewees were asked to tell us their personal experience of MCs, from daily practice and annual evaluations. Table 4 offers a relevant selection of the opinions voiced. These opinions all confirm that both daily practice under MCs and yearly evaluation of these commitments has generated unease among primary care physicians. Discomfort from yearly evaluations seems to be stronger than discomfort from daily practice. Such discomfort is not limited to how a doctor feels as an individual. It also includes how he or she feels as a doctor. MCs affect personal and professional identity alike. The interviewed physicians did not limit themselves to criticism; they voiced recommendations for improvement as well. Many of them underlined the need for a patient’s perspective in quality management. As one of the interviewees put it: “Nobody is better placed than the patients to judge the quality of our services.” Beyond what people say, how they say it is potentially equally revealing (31). In the conversations we observed and the interviews we conducted, physicians referred to colleagues nearby or way up at a central level, favoring the “we” form. But when referring to the Dirección de Compra or to peripheral staff evaluating MCs on behalf of the department, they shifted to the use of “they.” One recognizes here a longstanding feature: the centralization of power in the Dirección de Compra. The CCSS’s central and regional Medical Departments¾ responsible for the elaboration of strategic and operational plans¾have been excluded from the elaboration of the MCs’ content from 1997 on (5). This has led to conflicting norms and plans, but seemingly also (beyond the technical purchaser-provider split) to a dichotomy of identities inside the CCSS.

348

/ Soors et al. Table 4 Physicians on management commitments and personal fulfillment

Physicians From daily practice Doctor, female, urban EBAIS

Experiences described “They compel me to go through so many details, while a patient might seek something totally else. I am sure the patients notice my discomfort.”

Doctor, male, rural EBAIS

“Why do they give me the tools to identify a population at risk, but no time, no training and no means to follow up on these patients?”

Doctor, female, rural EBAIS

“I studied medicine because I wanted to help people. But as often as not, all these constraints make me feel really mixed-up.”

Doctor, male, urban EBAIS

“This system really ties one; it prevents one from becoming a true professional. It is so frustrating . . .”

From yearly evaluations Doctor, female, rural “They do not check if you showed any interest. They do not EBAIS check if you comforted that poor guy.” Doctor, female, urban EBAIS

“You forgot to write down one test, they tell you your service quality is zero. That hurts.”

Doctor, male, rural EBAIS

“What they evaluate is our use of ink and paper. It is easy and I am good at writing, so I got high marks. There is my colleague in that EBAIS nearby. She is still very young, extremely dedicated, and we all know she is good with patients. But she is a careless writer, so she got low marks and they humiliated her in front of all of us. How do you think she feels now?”

Source: Quotes from unstructured interviews with individual caregivers. Huetar Atlántica, October 2005, March 2006, and December 2006.

INTERPRETATION Having tested seven individual hypotheses, we now interpret our findings to answer our broader research question: to what extent have MCs attained their immediate and long-term objectives: a purchaser-provider split, the creation of an internal market, and the improvement of service organization, quality, and efficiency?

Costa Rica Management Commitments / 349 As for the purchaser-provider split, formally it exists. The Dirección de Compra signs a yearly agreement with each facility, with negotiated targets for a series of programs. But this seems to have become a yearly routine, with little real negotiation of targets, an insignificant incentive for those facilities attaining the targets (commonly 2% or less of the health areas’ and EBAIS’s budget, 0% in 2001) (19), and no personal financial incentives or sanctions. An internal market has not been created: there is no competition at all between CCSS providers. Considering experiences with internal markets and managed competition in other countries, this is probably not to be regretted (32–34). Although Costa Rica embraced MCs to avoid privatization, declining access to public services has led to a booming private health sector. The middle class¾ linchpin of any social security system¾is moving away from the CCSS. In this sense, MCs can be seen as the Trojan horse inside a successful health care reform. Service organization has not improved, elimination of absenteeism being the big exception. While MCs have induced provider accountability (5, 19), undesirable coping mechanisms are now coming into view. When providing our feedback to the national CCSS authorities, one board member reacted by stating that Costa Ricans need lots of “sticks” to fulfill their job, besides a few “carrots.” Still, techniques relying on the development of professionalism might be more efficient and could produce more long-lasting results. Interface flow process audits (35) and supportive coaching (36) are both excellent candidates for this task. Moreover, MCs affect two core functions of service organization: planning and coordination. Planning tools¾Situational Health Analysis (37), Strategic Area Plans, and Annual Operational Plans¾that are potentially beneficial actually have a limited impact due to compulsory adherence to MC norms and targets. Coordination between CCSS purchasing and providing entities suffers from asymmetry. The Dirección de Compra acknowledges that it “generated a series of activities that by nature should have been carried out by other entities” (38). MCs did not improve the quality of service delivery. On the contrary, MCs led to a reduction in the comprehensiveness of primary care consultations. Rosero-Bixby (39), a noted authority on Costa Rican health care reform, recently argued that the introduction of EBAIS and MCs has led to better health outcomes, without differentiating their respective influence. We would argue that MCs might well have been a limiting factor. In parallel with unsatisfactory service organization and quality, efficiency did not improve. The boom in emergency consultations strongly suggests an efficiency loss. Moreover, the rising share of private providers and particularly the alienation of middle-class patients (and contributors) should be interpreted as a serious risk for the future of public service delivery. Costa Rican primary care MCs even fall short of being MCs. Neglecting outcome in favor of process, their measures are of performance and activities. As Maynard (2008) (7) has already noted, pay-for-performance practices based on process measurement are no guarantee of quality without complementary outcome

350

/ Soors et al.

measurement, preferably using patient-reported outcome measures. Multiplying their indicators while relying on untrustworthy sources, the MCs are failing as performance commitments, too. Costa Rican primary care MCs are little more than bloated vertical programs. The fact that financial incentives have remained insignificant can even be regarded as beneficial: it seems reasonable to assume that payment for performance would amplify the negative impact already noticed. LIMITATIONS AND VALIDITY We acknowledge that the long period over which the research extended might have influenced our view of MCs. No doubt, we became more critical of MCs while implementing the research. Nevertheless, our conclusions are based on solid evidence, not on personal opinion. We opted to focus our field collection in one region, Huetar Atlántica. As Huetar Atlántica is one of Costa Rica’s poorest regions, this focus risks painting a negative picture of the country as a whole. Nevertheless, the contrary could also be true, as Huetar Atlántica has had one of the strongest improvements in health service organization over the last decade. Moreover, no conclusions were drawn without triangulation or validation by data from the national level. Several of our findings (such as MCs’ failure to include both providers’ and patients’ perspective) were also recognized¾albeit with varying intensity and interpretation¾in the Dirección de Compra’s 2006 auto-evaluation report. Others (such as the impact on professional identity, or the practice of cheating) were not. This does not invalidate our findings. It does, however, reflect differences in design. While we delineated our objectives by study fields (i.e., access, quality), the authors of the auto-evaluation anticipated their main conclusion (the need for reinforcement of MCs) in the introductory justification for their study. While we assured the highest possible freedom for caregivers to express themselves, the auto-evaluation included relatively few caregivers from the EBAIS level. In a report in preparation of the auto-evaluation, the authors mention that numerous participants of their focus groups wondered if they would be penalized for voicing their opinion (38). CONCLUSIONS Costa Rica is an example of how to reach universal coverage and respectable health outcomes at a reasonable cost. Our research established a wealth of arguments in favor of a cautious approach to MCs: they have negative effects on access and quality of care, fail to reach their intended objectives, and pose a threat to an exceptionally successful public system. Such a Trojan horse should not be ignored. MCs need to be scaled down and fundamentally redesigned. The number of indicators and norms needs to be reduced and the norms need to be rationalized. MCs, thus reformed, could use provider motivation as the building block for quality, substantiated by patient-reported outcome measures.

Costa Rica Management Commitments / 351 Acknowledgments ¾ None of the authors hold any competing interest. No funders had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. REFERENCES 1. Rosero-Bixby, L. Socioeconomic development, health interventions and mortality decline in Costa Rica. Scand. J. Soc. Med. 46(Suppl.):33–42, 1991. 2. Martínez-Franzoni, J. ¿Presión o legitimación? Poder y alternativas en el diseño y adopción de la reforma de salud en Costa Rica, 1988–1998. [Pressure or legitimization? Power and alternatives in the planning and adoption of health reforms in Costa Rica, 1988–1998.] História, Ciências, Saúde – Manguinhos 13:591–622, 2006. doi: http://dx.doi.org/10.1590/S0104-59702006000300004. 3. Escobar, M. L., and Cercone, J. Implementation Completion Report (CPL-36540; SCPD-3654S) on a Loan in the Amount of US$22 Million to the Republic of Costa Rica for a Health Sector Reform Project. Report No. 25713. The World Bank, Washington, DC, 2003. 4. Nunberg, B. Managing the Civil Service: What LDCs Can Learn From Developed Country Reforms. Report No. WPS 945. The World Bank, Washington, DC, 1992. 5. Rodríguez Herrera, A. La reforma de salud en Costa Rica. Report No. 173. Naciones Unidas, Comisión Económica para América Latina y el Caribe (CEPAL), Unidad de Estudios Especiales, Santiago de Chile, 2006. 6. Loevinsohn, B. Performance-Based Contracting for Health Services in Developing Countries. A Toolkit. The International Bank for Reconstruction and Development/ The World Bank, Washington, DC, 2008. 7. Maynard, A. Payment for Performance (P4P): International Experience and a Cautionary Proposal for Estonia. World Health Organization, Regional Office for Europe, Geneva, Switzerland, 2008. 8. Alshamsan, R., et al. Impact of pay for performance on inequalities in health care: Systematic review. J. Health Serv. Res. Policy 15:178–184, 2010. doi: 10.1258/jhsrp. 2010.009113. 9. Friedberg, M. W., et al. Paying for performance in primary care: Potential impact on practices and disparities. Health Aff. 29:926–932, 2010. doi: 10.1377/hlthaff.2009.0985. 10. Peckham, S., and Wallace, A. Pay for performance schemes in primary care: What have we learnt? Qual. Prim. Care 18:111–116, 2010. PMCID: PM:20529472. 11. Scheffler, R. M. Pay For Performance (P4P) Programs in Health Services: What is the Evidence? World Health Report 2010 – Background Paper 31. World Health Organization, Washington, DC, 2010. 12. Meessen, B., et al. Reviewing institutions of rural health centres: The performance initiative in Butare, Rwanda. Trop. Med. Int. Health 11:1303–1317, 2006. doi: 10.1111/j.1365-3156.2006.01680.x. 13. Soeters, R., and Griffiths, F. Improving government health services through contract management: A case from Cambodia. Health Policy Plann. 18:74–83, 2003. doi: 10.1093/heapol/18.1.74. 14. Meessen, B., et al. Output-based payment to boost staff productivity in public health centres: Contracting in Kabutare district, Rwanda. Bull. World Health Org. 85:108–115, 2007. doi: 10.2471/BLT.06.032110.

352

/ Soors et al.

15. Clark, M. Reinforcing a public system: Health sector reforms in Costa Rica. In Crucial Needs, Weak Incentives: Social Sector Reform, Democratization, and Globalization in Latin America, ed. R. Kaufman and J. Nelson. Woodrow Wilson Center Press, Washington, DC, 2004. 16. Sojo, A. Los compromisos de gestión en salud de Costa Rica desde una perspectiva comparativa. CEPAL Rev. 66:73–103, 1998. 17. Sojo, A. Reformas de gestión en salud en América Latina. CEPAL Rev. 74:139–157, 2001. 18. Unger, J.-P., et al. Costa Rica: Achievements of a heterodox health policy. Am. J. Public Health 98:636–643, 2008. doi: 10.2105/AJPH.2006.099598. 19. Caja Costarricense de Seguro Social – Gerencia de División Administrativa – Dirección de Compra de Servicios de Salud. Los Compromisos de Gestión en la Caja Costarricense de Seguro Social: Desafíos de la Implementación 1997–2007. San José, Costa Rica, 2006. 20. Bryman, A. Quantitative and qualitative research: Further reflections on their integration. In Mixing Methods: Quantitative and Qualitative Research, ed. J. Brannen. Avebury Press, Aldershot, UK, 1992. 21. Hammersley, M. The relationship between qualitative and quantitative research: Paradigm loyalty versus methodological eclecticism. In Handbook of Qualitative Research Methods for Psychology and the Social Sciences, ed. J. Richardson. BPS Blackwell Publishing, Leicester, UK, 1996. 22. Sabatier, P. Theories of the Policy Process. Westview Press, Boulder, CO, 2007. 23. Brewer, G. D., and de Leon, P. The Foundations of Policy Analysis. Dorsey Press, Homewood, IL, 1983. 24. Caja Costarricense de Seguro Social. Cambios en la morbilidad y mortalidad por edad, y sexo Costa Rica 1987, 1992, 1997 y 2002. No. 8C. San José, 2003. 25. Rojas Vargas, G., and Mairena Amador, Z. Informe de evaluación área de salud de Cariari. Caja Costarricense de Seguro Social, Dirección Regional Servicios Médicos Huetar Atlántica, Puerto Limón, Costa Rica, 2005. 26. Solórzano Rodriguez, M. Informe de evaluación del área de salud de guápiles. Caja Costarricense de Seguro Social, Dirección Regional Servicios Médicos Huetar Atlántica, Puerto Limón, Costa Rica, 2005. 27. Groenewegen, P. P., et al. General practitioners’ use of time and time management. In Oxford Textbook of Primary Medical Care, ed. R. Jones et al. Oxford University Press, Oxford, UK, 2005. 28. Roland, M. O., et al. The “five-minute” consultation: Effect of time constraint on verbal communication. BMJ 292:874–876, 1986. 29. Villar, J., et al. Patterns of routine antenatal care for low-risk pregnancy (Review). Cochrane Database Syst. Rev. 1–39, 2001. doi: 10.1002/14651858.CD000934. 30. Delgado-Rodriguez, M., and Llorca, J. Bias. J. Epidemiol. Comm. Health 58:635–641, 2004. doi: 10.1136/jech.2003.008466. 31. Fairclough, N. Critical Discourse Analysis: The Critical Study of Language (Language in Social Life). Longman Group Limited, Essex, UK, 1995. 32. Andersen, R., et al. Cost containment, solidarity and cautious experimentation: Swedish dilemmas. Soc. Sci. Med. 52:1195–1204, 2001. doi: 10.1016/S0277-9536(00) 00239-2.

Costa Rica Management Commitments / 353 33. Sorell, T. Morality, consumerism and the internal market in health care. J. Med. Ethics 23:71–76, 1997. PMCID: PMC1377204. 34. Propper, C., et al. Competition and quality: Evidence from the NHS internal market 1991–1999. Econ. J. (London) 118:138–170, 2008. doi: 10.1111/j.1468-0297.2007. 02107.x. 35. Unger, J.-P., et al. Interface flow process audit: Using the patient’s career as a tracer of quality of care and of system organisation. Int. J. Integr. Care 4:1–9, 2004. PMCID: PMC1393263. 36. Levenson, R., et al. Understanding Doctors: Harnessing Professionalism. The King’s Fund, London, UK, 2008. 37. Caja Costarricense de Seguro Social – Centro de Desarrollo Estratégico e Información en Salud y Seguridad Social (CENDEISSS) – Proyecto Fortalecimiento y Modernización del Sector Salud. Curso especial de posgrado en gestión local de salud. Módulo seis. Análisis de situación de salud con enfoque de espacio-población para el nivel local. San José, Costa Rica, 2004. 38. Caja Costarricense de Seguro Social – Gerencia División Administrativa – Dirección de Compra de Servicios de Salud – Área de Investigación. Estudio de la percepción de los gestores sobre la influencia de los Compromisos de Gestión. San José, Costa Rica, 2006. 39. Rosero-Bixby, L. Evaluación del impacto de la reforma del sector de la salud en Costa Rica mediante un estudio cuasiexperimental. Rev. Panam. Salud Publica 15:94–103, 2004. doi: http://dx.doi.org/10.1590/S1020-49892004000200004.

Direct reprint requests to: Professor Jean-Pierre Unger Institute of Tropical Medicine Department of Public Health Nationalestraat 155 B-2000 Antwerpen, Belgium [email protected]