title: Management commitments and primary care: another lesson from Costa Rica for the world?
abstract: 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.
authors.forename: Werner
authors.initials: W
authors.lastname: Soors
authors.forename: Pierre
authors.initials: P
authors.lastname: De Paepe
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Unger
mesh_terms: D001291:Attitude of Health Personnel; D003364:Costa Rica; D003695:Delivery of Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data; D003906:Developing Countries; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000706:statistics & numerical data; D018166:Health Care Reform / Q000458:organization & administration / Q000706:statistics & numerical data; D006801:Humans; D008329:Managed Care Programs / Q000458:organization & administration*; D009313:National Health Programs / Q000458:organization & administration* / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000458:organization & administration / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000458:organization & administration / Q000706:statistics & numerical data; D014600:Utilization Review