Knowledge Brief Health, Nutrition and Population Global Practice Lessons Learned through the Health Program for Results in Costa Rica Micaela Mussini, Ana Maria Lara, Ana Lucia Rosado Valenzuela, Ashley Sheffel, Laura Di Giorgio August 2023 KEY MESSAGES: • The Program for Results (PforR) is one of the three financial instruments available at the World Bank, which differs from other instruments by focusing on the achievement of specific results. • Costa Rica was one of the first countries in the Latin American and Caribbean region to choose this type of financing, through the "Programa Por Resultados Para El Fortalecimiento Del Seguro Universal De Salud En Costa Rica", approved in 2016 and still being implemented. • The choice of the PforR instrument to support the implementation of the Strategic Agenda for the Strengthening of Health Insurance by the Costa Rican Social Security Fund, in retrospect, was a very wise decision. The analysis of the reasons for success serves as a basis for the implementation of this instrument by other countries. • The PforR in Costa Rica promoted the achievement of critical and complex health sector reforms and results, such as the implementation of integrated health networks, the digitalization of the health system through the Single Digital Health Record (EDUS), and the reduction of waiting lists, among others. • The continuation of the reforms initiated by the PforR will be of great importance in order to continue to achieve the potential gains in efficiency and quality of care that they imply. Agenda for Strengthening Health Insurance by the Costa Introduction Rican Social Security Fund (CCSS, for its name in Spanish, The Program for Results (PforR) is one of the three Caja Costarricense de Seguro Social). The "Results-Based financial instruments available at the World Bank, which Program for Strengthening Universal Health Insurance in complements financing for investment projects and Costa Rica" was approved by the World Bank's Board of development policy operations. This type of financing Executive Directors in February 2016, with an original began to be offered by the World Bank in 2012. It is an duration of six years and with the aim of improving the instrument with program-oriented characteristics, in availability and quality of the universal health insurance which governments seek to improve the use of general system, as well as improving the institutional efficiency of public expenditures or improve their performance using the CCSS. (1) their own processes and institutions. The PforR focus on During its implementation, the PforR has implemented the achievement of specific results and not on inputs or critical and complex reforms to the health sector, with processes, aiming to promote the sustainable implications for the quality and equity of care and the development of countries and to improve the efficiency efficiency of the health sector in Costa Rica, such as (i) and effectiveness of expenditures. implementation of integrated health networks, (ii) a Costa Rica was one of the first countries in the Latin reform of resource allocation in the CCSS for both America and Caribbean region to choose this type of primary health care units and hospitals, (iii) the financing to support the implementation of the Strategic digitalization of the health system through the Single Page 1 HNPGP Knowledge Brief Digital Health Record (EDUS). Other notable Third, it was necessary to improve and modernize achievements of the PforR are the improvement in the financial management within the CCSS to allocate management of non-communicable diseases and the resources more efficiently and equitably, i.e., based on reduction of waiting lists for priority procedures through the needs of the population rather than on historical the shift of major surgeries from inpatient to outpatient values. (1) care. (1) In this context, to improve efficiency, equity and quality This knowledge report, part of a larger series of of care, the CCSS decided to present a comprehensive knowledge reports developed by the World Bank, seeks program in its Strategic Agenda for Strengthening Health to describe the main reasons for success, challenges and Insurance (SASHI). This agenda included three priority key lessons learned during the design and areas: (i) strengthening the health care model to better implementation of this PforR, with the objective of integrate primary health care (PHC) with secondary level providing a roadmap for other projects in Costa Rica and care in a given catchment area and provider network to other countries interested in implementing similar improve prevention, early diagnosis and timely programs. management of NCDs and ensure more efficient use of health care resources; (ii) improving the institutional Background management of the CCSS while increasing accountability and responsiveness to users; and (iii) adopting The CCSS is the administrator of Costa Rica's public health international best practices relevant to Costa Rica to insurance system and is the country's largest health care improve the financial management of health insurance. provider. With the exception of a small set of health (1) services covering occupational injuries, the CCSS is the sole public provider of health services at all levels of care The PforR in Costa Rica was created to support the and is also responsible for the collection and pooling of implementation of SASHI originally for the six-year public health insurance revenues. Costa Rica's health duration of the program, comprised in the period 2016- insurance model provides truly universal coverage and 2022. (1) The PforR was restructured in 2022, to add an has many strengths. Health insurance provides health additional 20 months to implementation, due to services to the entire population, as the percentage of implementation challenges caused by the COVID-19 the population with formal insurance is around 95 health emergency and the institutional data hack in May percent. CCSS services are used by the majority of the 2022. (3) population at substantially high rates in all income groups. (2) In Costa Rica, all public health services are provided under the management of the CCSS, opening Characteristics of the Results-Based opportunities for efficiency gains in the public sector. Program Despite its strengths, around 2016, the system was experiencing some challenges that prompted the need to In general terms, the PforR offered by the World Bank are promote several changes in order to respond to multiple characterized by: public health challenges in a financially sustainable • to finance specific development program manner.(2) expenses; • disbursed based on the achievement of key An evaluation conducted by the CCSS, between 2014- results under these programs; 2016, identified three priority areas that needed to be • using and, in some cases, improving program addressed. First, health care delivery had not fully systems to ensure that funds are used adapted to the changing needs of the Costa Rican appropriately; and population, given its aging and the increase in non- • strengthen institutional capacity for the program communicable diseases (NCDs). Second, the CCSS to achieve the expected results (3). required more effective institutional capacity to manage an increasingly complex system faced with new needs. Page 2 HNPGP Knowledge Brief • Thus, PforRs have defined expenditures, activities and In operational terms, the CCSS was defined as the PforR results that seek to promote the sustainable implementer, as it is the sole executing agency of SASHI. development of countries in accordance with their own In accordance with the characteristics of the financing systems. PforR funding is disbursed against the instrument, the PforR was implemented using the achievement and verification of results specified as institutional arrangements of the CCSS, in line with SASHI disbursement-linked indicators (DLIs). Such guidelines and priorities. The CCSS Board of Directors, disbursements are not dependent on or attributable to which is the highest hierarchical body of the institution, individual transactions or expenditures, which greatly oversees the overall implementation of SASHI, while differentiates PforR from other types of financial selected members of the CCSS Management instruments offered by the World Bank, such as Departments support the implementation according to Investment Project Financing, where disbursements are the specific area of Program implementation. In turn, a made on the basis of specific eligible expenditures. To project team, composed of CCSS staff, was formed within enable the program to begin implementation, the Bank the CCSS for the overall coordination of the PforR. Since and the counterpart may agree to disburse a portion of the loan agreement is signed with the Ministry of Finance the PforR financing funds as an advance for DLIs that have (MH), a subsidiary implementation agreement was not yet been achieved. (4) signed between the MH and the CCSS to guarantee the flow of funds and the implementation of PforR activities (1). EVIDENCE OF THE SUCCESS OF THE IMPLEMENTATION OF THE PROGRAM FOR RESULTS IN COSTA RICA The PforR has achieved substantial and critical changes for the positive transformation of CCSS service delivery. Some of the major achievements referenced in the DLIs are as follows: • Single Digital Health Record (EDUS): In just three Disbursement Indicators (DLIs) of the "Program by years, the EDUS was installed at all levels of care, Results for the Strengthening of Universal Health covering even remote areas without electricity or Insurance in Costa Rica". internet connectivity in the country. Costa Rica has one of the most comprehensive electronic In the specific case of the PforR for Costa Rica, the health records in Latin America, becoming a project's development objectives were defined as: (i) to cornerstone and innovator in guaranteeing the improve the timely supply and quality of health services right to universal health coverage and improving and (ii) to improve the institutional efficiency of the CCSS. the quality, effectiveness and efficiency of health Based on these development objectives, the PforR has 7 services. DLIs (see Figure 1). In turn, each DLI is made up of • The Integrated Family Record System (SIFF): The between two and three sub-indicators (milestones). digitization of family records into the Integrated Thus, each time the target associated with a sub-indicator Family Record System has potentiated the is achieved, the country can request payment of the benefits for the direct users of the tool, for the associated amount from the Bank, after completing a operation and administration of the CCSS, as well verification report by an independent verification as for institutions of social interest in the country institution. (1) for the priority follow-up of vulnerable populations. The integration of data collection Implementation of the Program for through electronic tablets has allowed the Results georeferencing of the country's households, an important step that will generate information on Page 3 HNPGP Knowledge Brief the concentration of epidemiological profiles and needs of the population. The positive results of risk maps by communities, and will facilitate the the implementation of the network are reflected management of future epidemics and natural in the CCSS initiative to extend the disasters. implementation of the model to the rest of the • Major Outpatient Surgeries: The CCSS country. progressively increased the percentage of major outpatient surgeries in six selected procedures, In addition to these specific successes, the CCSS staff in to more than 43% of the major surgeries charge of planning, implementation, and achievement of performed in these procedures in the system. DLIs recognizes that the arrival of the PforR catalyzed the With the increase in major outpatient surgeries, processes of these improvements in the institution and Costa Rica reduced waiting list times for other boosted the political will to achieve them. For example, major surgeries by 60%, improving one of the through initial discussions with the Bank and its team of main issues that plague Costa Ricans. health experts, priority issues for improving CCSS services • Satisfaction surveys: CCSS satisfaction surveys were identified and placed on the institutional agenda. At make visible and improve users' perceptions the same time, the joint follow-up and active regarding inpatient and outpatient services. They communication between the two parties has been a have been successfully applied for five great incentive to address barriers to the implementation consecutive years, including during the COVID-19 and timely compliance with the DLIs. Some managers of pandemic. The application of the surveys has the interventions covered by the PforR even refer to the increased the staff's interest in knowing the fact that without the arrival of the PforR, these users' perception of the service. Now, the institutional breakthroughs would not have been services of different units can be improved and possible. compared based on quality dimensions, FACILITATORS improvement plans focused on patient priorities are developed, and satisfaction data from In retrospect, the choice of the PforR as the financing indigenous populations are made visible. instrument chosen to support the CCSS in the • Preventive and health promotion activities: The implementation of SASHI was a very wise decision. Some PforR promoted preventive and health of the most important factors that acted as facilitators promotion activities, which led to improved are the following: control rates of non-communicable diseases. For example, a massive colorectal cancer screening Existence of a comprehensive strategic program owned program was implemented in five priority by the implementing institution: The CCSS had already cantons in the North Central Region; an increase developed and had full ownership of the comprehensive in the percentage of individuals diagnosed with program designed to improve the health insurance model type 2 diabetes with optimal clinical control from that was supported by the PforR, the SASHI. Thus, there 39% (2014) to 45.7% (2021), and an increase in was a commitment on the part of the implementing the percentage of individuals diagnosed with institution (the CCSS) to achieve the indicators agreed hypertension with optimal clinical control from upon in the PforR, as there was prior agreement at the 62% (2013) to 65.7% (2020) was achieved. institutional level regarding their importance. • Integrated Health Networks: The implementation of an Integrated Health Services Emphasis on results: The CCSS sought, through SASHI, to Network (IHSN) model was initiated as a pilot in shift the emphasis from managing program inputs to the Huetar Atlántica Region, resulting in the managing program results and risks. The fact that the provision of more coordinated and better quality funding provided by the PforR functions as an additional services to the population, and better utilization operating budget for the CCSS, by disbursing against of resources. This model is based on the primary results at specific times, provides the necessary health care strategy, which seeks to strengthen incentives to achieve results. This, in turn, contributed to the first level of care and integrate with improved accountability and cultural change in the specialized care as and when required by the organization itself. Page 4 HNPGP Knowledge Brief • Existence of robust national systems: The PforR allowed Difficulty in accessing data: There were political the Government to use its own national systems in the challenges in sharing CCSS data with the Bank. This held implementation of the PforR in support of SASHI. World back the progress of the technical advice provided in the Bank assessments (technical, fiduciary, and context of the PforR and the achievement of certain environmental and social), conducted during project relevant reforms related to improving the institutional preparation, confirmed the capacity of the national efficiency of the CCSS. It is relevant for future systems to successfully implement the operation. engagements to work proactively with the CCSS and the Ministry of Health (MOH), to improve the governance of Technical assistance from the World Bank and global experience: The PforR was accompanied by technical health data with data protection guarantees, which assistance from the World Bank and exchanges with would make the entities feel comfortable sharing data experts from other countries to support the design and with the Bank. implementation of complex strategic reforms. The combination of financial incentives, with ad-hoc technical THE ROAD AHEAD assistance provided by the Bank, has made it possible to overcome technical challenges encountered in the path As mentioned above, the PforR in Costa Rica initiated of reforms to achieve the program's objectives. very relevant reforms in the Costa Rican health sector. Among them, the design of integrated health networks and the reform in the allocation of resources to hospitals CHALLENGES ENCOUNTERED AND SOLUTIONS and health centers within the CCSS, both of which were APPLIED initially implemented as pilots by the PforR. The While there is no doubt about the success of the PforR continuation of these reforms will be of great importance implementation, some factors that acted as challenges in to continue to achieve their benefits and generate this process are the following: enormous gains in efficiency and quality of care. The PforR also led to a change in the CCSS's mentality, Difficulties in allocating budget and verifying the scope focusing on improving care and the need to measure and of process indicators: The emphasis on results meant act based on results. This continues to inform the that compliance with a DLI did not necessarily reflect the Institution about the planned reforms, and at the same implementation of all key processes for the time, has made it possible to facilitate new agreements institutionalization of certain changes. and achieve better communication with the MH, an indispensable actor to guarantee the continuity of the projects promoted by the PforR, once it ends. Page 5 HNPGP Knowledge Report • References 1. World Bank. Project Evaluation Document. Programa por Resultados Para El Fortalecimiento Del Seguro Universal De Salud En Costa Rica Program-for-Results. 2016. 2. Pacheco Jimenez, JF; Alvarado-Prado, R. Health System Financing in Costa Rica. Experiences and options from international evidence. 2022 3. World Bank. Project Restructuring Document - Programa por Resultados Para El Fortalecimiento Del Seguro Universal De Salud En Costa Rica - P148435. 2022. 4. World Bank. Bank Policy Program-for-Results Financing. 2022 The World Bank's Health, Nutrition and Population Knowledge Briefs are a quick reference on key aspects of specific HNP-related topics that summarize new findings and information. They can highlight a problem and key interventions that have proven effective in improving health, or disseminate new knowledge and lessons learned from the regions. For more information on the topic, visit: www.worldbank.org/health. Generous funding support for this series of Knowledge Briefs was made possible by The Access Accelerated Trust Fund. Page 6