is the first health cooperative created and integrated as a provider of social insurance system in Costa Rica, with this entity opening the way for the development of the cooperative model as an alternative for health care areas in a decentralized manner with emphasis on primary care. We present an account of the process which resulted in her pregnancy and later development:
Background.
adjustments initiated in the 80s in Costa Rica, proposed the redefinition of the social role of the state and created the conditions to promote and propose new ways of managing health services traditionally provided by the State. At that time, a group of experts on the subject conducted a series of seminars and forums to address issues that had the medical services of the Social Security outpatient looking to give a concrete answer to the serious problems of access to health services especially at the level of outpatient clinics and hospitals, finding little support among academics, entrepreneurs and workers organized in unions. This led to the Social Security Fund (CCSS) pilots agreed to implement plans to develop ways to provide alternatives to existing ambulatory care model, where the very CCSS is the funding body, acting as the sole purchaser and provider of medical services, as they were known then [1] , context in which it was born COOPESALUD RL, the first health cooperative in the second half of the eighties. 
Costa Rica were already important precedents for the reorganization of primary care. One was the call "Hospital Without Walls" in San Ramon , originally a thriving coffee region, 60 km from San José. It was a program of health care outside hospital walls, which achieved significant accomplishments in improving health conditions but at a very high cost, and diversion of resources toward primary care hospital. From that experience was introduced later in a semirural town experience that health services were offered to the community by an association called Acepromazine , consisting of doctors to attend a Barva area, village north of the Central Valley, the Social Security Fund (CCSS) paid to the association of medical services per capita, and the association paid doctors in terms of services provided to patients. The CCSS and Ministry of Health gave the local team and put the rest of the staff, this model faced a number of management challenges for its experimental nature, not by the quality of service and the problems of management: staff CCSS , the Ministry of Health and doctors of the association had different schedules and institutional cultures that failed to harmonize. Despite the failure of the pilot, the experience gained in Barva de Heredia was the basis for the CCSS introduced the Cooperative for the provision of health services and this is how in the year of 1988 promoted the creation Cooperative COOPESALUD the RL. to administer the new Pavas Clinic and served under this mode of payment and the family medicine approach Pavas community, and somewhat paradoxically, the last place where it has consolidated Model Health Cooperative is precisely in Barva de Heredia, which hosted the pilot project. It is
Cooperative
The decision to form a cooperative was communicated to the workers who worked in the area and this is how Thirty-four (34) forty (40 ) members of the CCSS they were providing services in the area left their jobs and were the "self-managed cooperatives Comprehensive Health Services - COOPESALUD" on 8 October 1987, it is a company cooperative self-management (the equivalent of a Labour Cooperative Association), nonprofit, regulated by the Law of Cooperative Associations in General and in Particular Statutes. Implementation of the first cooperative health
The introduction of the District Cooperative Pavas, the Canton of San José, was a clear response to cyclical the serious problems of access and equity that was living at the time, however, to make possible this experience, is required to comply with the essential requirements of change.
- First, was necessary to develop an extensive outreach program and comprehensive explanation on the scope of the project, the neighbors organized in marginal urban community Pavas where be carried out the project (a district of the Capital), and the politicians and leaders of the health sector and the Legislature.
- Secondly, it promoted an extensive review of existing legal framework that would accommodate the pilot, which was possible thanks to the tenacity and high clarity of the project leaders, and
- Thirdly, the political decision of the government (administration of President Oscar Arias Sanchez) to urgently seek ways to improve the delivery of health services.
COOPESALUD RL , under the agreement with the Ministry of Health and the CCSS , took responsibility from August 1988 to the attention of the district clinic Pavas (which is part of San José Canton and is located at the southern end of this canton, capital of the province San Jose), which at that time had a population of 30,000 (although for the year 2001, according to national census, had 77,469 inhabitants, due to rapid urbanization and insecurity in the area). Under this arrangement the cooperative managed assets (Department of Health with their respective envelope) and services while maintaining state-owned property assets, can use the facilities that are CCSS, Maintenance, Repair and acquisition of new equipment, pay utilities and officials. The community wanted COOPESALUD RL assume all services health, but this was impossible because of the cost of infrastructure and equipment of hospital care. After the Reformation, the mode of recruitment began expanding the concept to be generalized, since the clinics will not only cover an area of \u200b\u200bmajor influence, but also were responsible for the administration of Ebais. Thus, by the late nineties, the clinics began to take on areas of health and administration.
Operating the
Although the service is privatized, this did not mean any change to the user who continue trading at the CCSS , and a Cooperative Agreement between the and CCSS defines the services to be provided, standards and controls to be observed, the User fees pay for on a capitated by the CCSS (recruitment scheme has a geographical basis and is based on a rate per capita falls within the health area served), and not by activity paid with funds from of the CCSS ; users do not pay for the services they receive at the Cooperative.
In the area of \u200b\u200bhuman resources should be noted that RL had COOPESALUD to October 2006 with 360 staff of whom 330 were members and the rest temporary. By law, cooperatives are not allowed to impose "stringent conditions" on admission of new partners, "should be encouraged" even officials not associated with a contribution can do ¢ 125,000 two-year term (approx. U.S. $ 240 .) Wages of workers is higher between 5 and 15 percent than those paid in state health institutions.
COOPESALUD Other business.
Trying to reduce its dependence on CCSS and generate resources from other sources (sometimes surplus ¢ only reach 7 million), COOPESALUD RL. Company created the "Servisalud" offering private medical services in downtown San Jose and sell drugs in Homeless. 11% of its workers are depending on this company. Separate accounts are maintained on the contract you have with the CCSS , which is not touched a weight and officers of the CSSS are aware of private operations. also involved through the consortium Consalud in control of the Cooperative Hospital operating in the city of San Carlos Quesada of the Canton of the province of Alajuela.
[1] Many years later, he started talking about health care and more recently, as health services are developed, comprehensive health services.
To complement and understand the role of RL COOPESALUD in the Health System of Costa Rica, please consult the following links:
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