Can there be universalism with outside options? Costa Rica in comparative perspective

• In Event: Towards universal social policy trajectories in Latin America? Reach, determinants and implications. Part 2.

Abstract

Delivering universal outcomes does not only depend on the public sector but also on effectively regulating outside private options. We draw from health care in Costa Rica—one of the few countries in the South capable of promoting universalism—to explore relations between public provision and the private sector in recent decades.
Between 1950 and 1980, Costa Rica consolidated a unified policy architecture (i.e. the set of instruments that define who receives benefits and how) capable of delivering similar and generous health care benefits for all. Despite international and domestic neoliberal pressures, this architecture has changed relatively little regarding four of its dimensions: access, funding, benefits and provision. Following a path dependent explanation, we argue that Costa Rica’s previous policy legacies limited the possibilities of radical change through three channels: (a) promoting cross-class support for social security; (b) strengthening doctors in the public sector, which were against radical changes —even if, at the same time, were protecting dual practice; and (c) creating a powerful bureaucracy at the helm of the Costa Rican Social Security Board (CCSS), which sought to maintain control of an exclusive public provision .
Yet growing fragmentation of decision making in the CCSS resulting from a failed managerial reform in the 1990s and the difficulties to regulate outside options has led more Costa Ricans to rely on private hospitals. Simultaneously, more doctors are also combining public and private practices—sometimes adopting conflicting if not illegal practices. As a result, delivering universalism has been jeopardized.

Author

• Diego Sánchez-Ancochea, University of Oxford