COSTA RICA

Costa Rica has a health system which, as a part of its reform, makes the Ministry of Health the managing body and the Costa Rican Social Security Fund responsible for direct care to the people. The Fund's coverage has expanded from 86.2% of the population in 1994 to 90.4% in 1997. The rest of the population also has a right to all the health services, making the system universal, equitable, compulsory and in accordance with the criterion of solidarity.

The Costa Rican Social Security Fund was created in 1942 and its criteria of affiliation are open and universal. It has a benefits plan that includes high complexity care and its coverage includes 43% of affiliates. The rest of the country are beneficiaries.

Contributions are based on income (15%). The affiliate contributes 5.5%, the employer 9.25% and the State 0.25%. The government assessment, however, has never been paid. The debt at the present time is approximately 60 billion colons.

The Fund provides all its services in its own facilities, although in recent years there has been discussion as to whether investments should be made in their infrastructure or a move made towards purchasing services from the private sector. Views favoring the continuation of the official scheme appear to be holding the upper hand.

The social security system includes pharmaceuticals. Prescriptions must be written in the generic form and drugs chosen from a list. There were 400 principal active ingredients on the list in 1997, in 547 pharmaceutical presentations, in 54 therapeutic groups, matching the causes of morbidity/mortality present in the country.

The per capita allocation for drug purchases by Social Security was US$13.90 in 1994 and had grown to US$14.40 by 1997, an increase of 3.4% in the per capita allocation.

Social Security expenditures on medicines in relation to per capita income were 0.52% in 1995 and 0.54% in 1997.

The system buys the medicines in a centralized manner, to cover requirements for twelve months, by means of bidding between registered manufacturers, listed in the registry of bidders, the products of which must be registered and valid in the Ministry of Health. With this system they obtain high discounts on the sale price, reaching levels close to the international supply price in a broadly competitive system, as much as 890% below prices on the private market. If manufacturers included in the Institution's Registry of Bidders do not take part in the bidding a new competition is carried out inviting pharmaceutical manufacturers registered only in the Ministry of Health.

Analysis performed by the Department of Pharmacotherapy in 1997 showed that, in the purchase processes, 16% were priced above the budget and 84% of purchases were bought less than the previous outlay. That means a saving of US$4,735,920 with respect to the budget, which allowed new drugs included on the official list to be bought.

The decision on quantities to buy begins with the assignment of responsibilities to each executive unit, which is responsible for maintaining an ongoing control of inventory. Each operating unit is assigned a level of use by the Department of Pharmacotherapy and the Department of Programming, Control and Evaluation of Supplies, in accordance with the level of complexity of the center and the care it offers the patients. Institutional requirements are collated in the Department of Programming, Control and Evaluation of Supplies. In accordance with the information compiled, the purchase is planned for the year whenever a medication reaches the level of an 11-month supply, including the amounts on hand and the deliveries pending.

Payment for the centralized purchases of medicines is made directly by the Fund, in accordance with the guidelines of the Administrative Contract Law.

Some of the problems that may come up in purchasing have to do with lack of stock on the part of the pharmaceutical manufacturers, for medicines out of production, including in their headquarters, so that there is a need to replace them. Temporary out-of-stock problems may present themselves as well, due to increased sales and in some cases to planning errors derived from therapeutic replacements and failures to comply with delivery dates or non-acceptance due to quality problems. Also, since the purchase is for a year, in view of the rapid pace of innovation, it is common for new medicines to appear that are not included, so that applications from manufacturers to include or replace often appear. In cases of urgency, and when there are no stocks on hand in the Fund, the hospital may be authorized to purchase from a pharmacy, to be reimbursed later, after the justification has been certified by the Central Pharmacotherapy Committee.

When medicines must be supplied, Social Security always delivers them, with a prior medical prescription. They are all free to the patient. The average annual expenditure on drugs per insured is calculated at US$14.40. The average number of drugs dispensed for each outpatient consultation in 1997 was 2.8 drugs. Emergency room consultations dispensed 1.8 drugs and each hospitalization results in 12 drugs being dispensed (country survey).

Some problems with delivery may be related to the volume of prescriptions dispensed by the pharmacy of a large hospital, where there may be congestion. Thus an attempt has been made to decentralize hospital pharmacies into satellites for each specialty.

In certain cases the problem of excess prescribing may exist, with patients who accumulate medicines, since treatments are exclusive and there is no control on delivery. That situation may give rise to a certain black market in some products, such as NPH insulin, or diversion to a neighboring country, such as Nicaragua, where the costs are higher.