Separating financing from provision: evidence from 10 years of partnership with health cooperatives in Costa Rica.
OBJECTIVE
This article examines the impact of contracting health care provision to health care cooperatives in Costa Rica.


METHODS
The article uses a panel dataset on health care outputs in traditional clinics and cooperatives in Costa Rica from 1990-99.


RESULTS
Controlling for community socioeconomic characteristics, annual time trends and clinic complexity, the cooperatives conducted an average of 9.7-33.8% more general visits (95% confidence interval), 27.9-56.6% more dental visits, and 28.9-100% fewer specialist visits. Numbers of non-medical, emergency and first-time visits per capita were not different from the traditional public clinics. These results suggest that the cooperatives substituted generalist for specialist services and offered additional dental services, but did not turn away new patients, refuse emergency cases, or substitute nurses for doctors as care providers. Cooperatives authorized 30.4-60.5% fewer sick days (95% confidence interval), conducted 24.7-37.2% fewer lab exams, and gave out 26.7-38.3% fewer medications per visit than the traditional public clinics. Real total expenditure per capita in cooperatives was 14.7-58.9% lower than in traditional clinics.


CONCLUSIONS
The findings suggest that cooperatives might, with an appropriate regulatory framework and incentives, be able to combine advantages of public and private approaches to health care service provision. Under certain conditions, they might be able to maintain accessibility, a sense of mission and efficiency in service provision.
Development Research Group, The World Bank, Washington, DC 20433, USA. vgauri@worldbank.org
Varun
V
Gauri
James
J
Cercone
Rodrigo
R
Briceño
D000554:Ambulatory Care Facilities / Q000331:legislation & jurisprudence / Q000458:organization & administration* / Q000706:statistics & numerical data; D019058:Community Networks / Q000331:legislation & jurisprudence / Q000458:organization & administration* / Q000706:statistics & numerical data; D003284:Contract Services / Q000458:organization & administration*; D003299:Cooperative Behavior; D003364:Costa Rica / Q000453:epidemiology; D006265:Health Care Coalitions / Q000458:organization & administration*; D006302:Health Services Research; D006801:Humans; D009026:Mortality; D019982:Organizational Case Studies; D010067:Ownership; D017149:Private Sector; D017150:Public Sector; D019984:Quality Indicators, Health Care; D014600:Utilization Review