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Explanatory Factors of the Deficient
Service of Promotional and
Preventive Health at the Primary
Care Level in Costa Rica
Factores Explicativos del Deficiente Servicio de Salud
Promocional y Preventiva en el Nivel Primario de
Atención en Costa Rica
Christy Quesada Segura
1
Dennis P. Petri
2
Recibido: 12 de julio del 2024 / Aceptado: 10 de febrero del 2025 / DOI: 10.35485/rcap88_8
Como citar:
Quesada, C. y Petri, D. (2025). Explanatory Factors of the Deficient Service of Promotional and Preventive Health at the
Primary Care Level in Costa Rica. Revista Centroamericana de Administración Pública, 88, 153 -171. DOI: 10.35485/
rcap88_8
The main objective of this research is to analyse the effectiveness, efficiency and equity of integral
health promotion and disease prevention at the primary health level in Costa Rica. The methodological
framework proposed by Scha et al. (2013) was used to analyse the structure, processes and results
to best comprehend the degree of promotional and prevention initiatives at the primary level. This
research was limited to a general study of the South-Central Region which is comprised of 45 health
areas and 367 EBAIS (Basic Equipment of Integral Health). The data was obtained using qualitative
instruments: in-depth interviews, surveys and an expert panel session. The main findings of this
research regarding management deficiencies at the primary health care level are the following. Firstly,
the operationalisation of the international and national laws concerning an integral health perspective
1 Independent researcher, Alajuela, Costa Rica. Holds a master’s in international management with a specialization in the Management of Health
Systems from The University of Liverpool. Currently she is Manager of Mi Ciudad Studio. Email: christyqs20@gmail.com
2 Latin American University of Science and Technology, San José, Costa Rica. Professor in International Relations and Humanities at the Latin American
University of Science and Technology (Costa Rica), and Executive Director of the Foundation Platform for Social Transformation. Email: dp.petri@gmail.
com
Abstract
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is an ongoing challenge for the Costa Rican health system. The identified deficiency is explained by
three main aspects: a) misuse of concepts, establishing the same concept for both health promotion
and disease prevention, b) implementation of promotional activities as part of prevention programs,
c) limited conceptualization of health promotion. Secondly, a problem regarding the concept of health
was identified. Indeed, health culture has tended to be curative. Thirdly, this research reveals that
health services from the CCSS (Costa Rican Social Security Fund) should be based on an integral care
model, but to date, preventive programs have more support and priority than promotional programs,
and the “integral” dimension of the concept has been neglected. Moreover, it was argued that planning
processes do not respond to the approach of health promotion and is limited to prevention only.
Fourthly, there is a great deficiency in health promotion projects. Her available capital is oriented
towards the implementation of preventive programs. The resistance of doctors to promotional
programs prevails. In addition, many of the professionals assigned tasked with management do not
possess the necessary skills to allocate resources and manage them appropriately.
Keywords: PRIMARY HEALTH, HEALTH PROMOTION, DISEASE PREVENTION, CCSS,
EFFICIENCY, INTEGRAL CARE, MANAGEMENT DEFICIENCIES
El objetivo principal de esta investigación es analizar la efectividad, eficiencia y equidad de la promoción
integral de la salud y la prevención de la enfermedad en el nivel primario de salud en Costa Rica.
Se utilizó el marco metodológico propuesto por Scha et al. (2013) para analizar la estructura, los
procesos y los resultados con el fin de comprender mejor el grado de las iniciativas de promoción y
prevención en el nivel primario. Esta investigación se limitó a un estudio general de la Región Centro
Sur, que comprende 45 áreas de salud y 367 EBAIS. Los datos se obtuvieron utilizando instrumentos
cualitativos: entrevistas en profundidad, encuestas y una sesión de panel de expertos. Las principales
conclusiones de esta investigación en relación con las deficiencias de gestión en el nivel de la atención
primaria de salud son las siguientes. En primer lugar, la operacionalización de las leyes internacionales
y nacionales relativas a la perspectiva de salud integral es un reto permanente para el sistema de
salud costarricense. La deficiencia identificada se explica por tres aspectos principales: a) mal uso
de los conceptos, estableciendo el mismo concepto tanto para la promoción de la salud como para
la prevención de la enfermedad, b) implementación de actividades de promoción como parte de los
programas de prevención, c) limitada conceptualización de la promoción de la salud. En segundo lugar,
se identificó un problema relativo al concepto de salud. En efecto, la cultura de la salud ha tendido a
ser curativa. En tercer lugar, esta investigación revela que los servicios de salud de la CCSS deberían
basarse en un modelo de atención integral, pero hasta la fecha, los programas preventivos tienen más
apoyo y prioridad que los de promoción, y se ha descuidado la dimensión “integral” del concepto.
Además, se argumentó que los procesos de planeación no responden al enfoque de promoción de
la salud y se limita únicamente a la prevención. En cuarto lugar, existe una gran deficiencia en los
proyectos de promoción de la salud. El capital disponible se orienta a la implementación de programas
preventivos. Prevalece la resistencia de los médicos a los programas de promoción. Además, muchos
de los profesionales encargados de la gestión no poseen las competencias necesarias para asignar
recursos y gestionarlos adecuadamente.
Palabras clave: SALUD PRIMARIA, PROMOCIÓN DE LA SALUD, PREVENCIÓN DE LA
ENFERMEDAD, CCSS; EFICIENCIA, ATENCIÓN INTEGRAL, DEFICIENCIAS EN LA GESTIÓN
Resumen
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Introduction
3
Like many health systems around the world, the Costa Rican Health System is facing management
challenges while attempting to provide good health care for its population. It has encountered serious
problems in terms of effectiveness, efficiency and equity of services (Whitehead, 2007; Kawachi, et.al,
2002).
Health is both a right and “a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity” according to the World Health Organization (WHO, 2003).
This statement justifies the importance of the primary health care level since it is the first point of
contact with the population.
This research focuses on the primary health care level (specifically the Basic Equipment of Integral
Health Care) which offered through the Costa Rican Security Fund (CCSS in Spanish), an autonomous
state institution which is a part of the Costa Rican Health System. The study explores the extent to
which the primary level is focused on health promotion and disease prevention (Kawachi, Subramanian
&Almeida, 2002).
Preventive and promotional health have evolved. The strategies offered in documents like
the Lalonde Report 1974 (Lalonde, 1981), the Alma-Ata Report 1978 (WHO, 1978), the Ottawa
Conference 1986 (WHO, 2013) and more recently, the Health Program for All 2000 (WHO, 1998)
highlight this evolution. Health systems in many countries have encountered serious problems in
terms of effectiveness, efficiency and equity of services (Whitehead, 2007; Kawachi et.al., 2002).
Historically, the National Health System in Costa Rica had already gone through care model reforms
since its foundation (Herrero & Collado, 2001), but just after the 80’s better definitions of tasks for the
Health Ministry (MS in Spanish) and the Costa Rican Social Security Fund (CCSS) were established to
address high levels of demand and need. However, the model which came about as a result was still
insufficient. The Health Ministry oversaw the control and monitoring of the health sector and the CCSS
handled the provision of health services provided to the population. Since then, the CCSS has been
working as an autonomous institution focusing on promotion, prevention, healing and rehabilitation.
Nonetheless, health promotion activities seem to be ignored, preventive and curative programs prevail
over health promotion, a biologist care approach is adopted, merely based on medicine (García, 2004;
Avila, et.al., 2010). This posed a challenge because of demand and inefficient organization.
Due to several issues, a national health policy for the years 2010-2020 was formulated (Avila
et.al., 2010). The policy highlighted three clear objectives in the promotion and prevention field: a)
individual and collective care culture, b) individual health care services, c) strengthening of health
workforce development and its impact on health promotion and prevention. The research is based on
the CCSS’s local level which encompasses three health care levels. The study considers the primary
health care level: it is responsible for health promotion and disease prevention, low-complexity healing
and rehabilitation to elucidate the reasons behind management deficiencies regarding promotion and
prevention issues at the Basic Equipment of Integral Health (EBAIS in Spanish). Since the primary
health care level is the first point of contact with the health system it should solve most health issues
following integral initiatives that transcend the biologist and medical approaches and adopt social
3 This article is based on Christy Quesada Segura’s master’s thesis, Explanatory Factors of the Deficient Service of Promotional and Preventive Health
at the Primary Care Level in Costa Rica, which she successfully defended at the University of Liverpool in 2014.
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determinants of health (e.g. employment, housing and environment).
After outlining the methods used for this study, we present our theoretical framework in two
parts: definitions of health and integral health, as well as health promotion and prevention. To provide
additional context, we describe the management model of primary health care in Costa Rica. We then
transition to the empirical findings, discussing the challenges faced by Costa Rica’s primary health
care system, before concluding with key insights.
Research methods
To analyse the effectiveness, efficiency and equity of integral health promotion and disease prevention
at the primary health level in Costa Rica, i.e. the Basic Equipment of Integral Health (EBAIS) the
following questions were posed:
» To what extent is the focus on disease prevention and integral health promotion at the primary
health care level (Basic Equipment of Integral Health Care) deficient in Costa Rica?
» Does the primary health care level allocate its financial and human resources efficiently to
promote integral health and prevent disease?
» Does the Basic Equipment of Integral Health Care (EBAIS) have a proper internal management
and organizational culture?
» To what extent are the tasks of the EBAIS in terms of prevention of disease and promotional
health well defined?
The methodology which was chosen uses critical realism as an epistemological model where
reality is seen from a human perspective. The methodological framework used was the one proposed
by Scha et.al. (2013) which analyses the structure, processes and results to understand the promotion
and prevention initiatives at the primary health care level. This research was limited to a general
study of the South-Central Region of Costa Rica, which is comprised of 45 health areas and 367
Basic Equipment of Integral Health (EBAIS). Qualitative instruments were used for analysis, mainly “in-
depth interviews” with 15 experts and officials from the Ministry of Health and the Costa Rican Social
Security (CCSS).
In addition, surveys to a small sample of 100 health users residing in the area being studied and
interviews comparing past research results and conclusions were used; and a qualitative questionnaire,
which was applied to an expert panel of authorities of the health sector was also used, based on the
model developed by the Ministry of Labour and Social Affairs of Spain and the National Institute
for Safety and Health at Work in Spain (Solé, 2003): European Business Excellence Model (EFQM
model). The model allowed us to assess the performance evaluation system of the organization using
assessment criteria.
The study focused on the 45 health areas and 367 Basic Equipment of Integral Health (BEIH) units
that comprise the South Central Region of Costa Rica. These units were selected as they represent
the totality of the region’s primary healthcare system, ensuring a comprehensive analysis of health
promotion and disease prevention initiatives at this level. The South Central Region was specifically
chosen due to its diverse characteristics, encompassing both urban and rural areas with varying
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socioeconomic conditions and health challenges. This approach allows the findings to reflect the
overall performance and challenges within the region’s primary healthcare system. While the results
are primarily specific to the South Central Region, the representativeness of the sample provides
valuable insights that could be applicable to other regions with similar healthcare structures and
socio-demographic profiles. It is important to note, however, that the study’s conclusions may not be
fully generalizable to all regions of Costa Rica or to other countries with differing healthcare contexts.
Future research could expand the scope to include other regions to further validate and compare the
findings across diverse healthcare settings.
The data and the main sources used were divided into two categories. The primary sources
included interviews with officials from the CCSS; interviews with health researchers; interviews with
officials from the Ministry of Health; the realization of panel group discussion with Ministry of Health
and CCSS authorities and interviews with other health social actors.
The secondary sources used in this study included documents’ review of the Centre for Strategic
Development and Information in Health and Social Security (CSDIHSS) and the Institute for Research
and Education on Nutrition and Health (NIRENH); journal articles, findings obtained from literature
reviews, including a document review of the National Health System and the Primary Care Policy and
existing research and data; technical documents/statistical data; government plans; official reports;
national and international bibliography and bibliography from Health experts.
Results and analysis discuss the main findings regarding management deficiencies in health
promotion and disease prevention at the primary health care level. Data was obtained from three
main sources: a) panel sessions with experts from the Ministry of Health and the Costa Rican Social
Security Fund, b) interviews with management specialists in the public health system (open and closed
interviews) and c) a survey about health promotional topics filled by users of primary health care. This
information was supported by secondary sources: bibliographic documents on specialized issues.
According to experts, there are international and national laws as well as public policies that
determine the course of promotion and prevention initiatives clearly supported by documentation
although its operationalization is complex and messy. Planning with a focus on promotion and impact
on initiatives is still low. Additionally, it is difficult to distinguish the terms promotion and prevention,
where the latter is more privileged compared to the promotion intervention resulting in management
deficiency of promotional and preventive issues and the operationalization of the social determinants
of health that seek a broader approach to truly comply with promotion.
The research is focused on Costa Rica’s health system, which adopted the World Health
Organization’s (WHO) definition of health: “health is a complete physical, mental and social
wellbeing and not merely the absence of disease or infirmity” (WHO, 2003, p.1; Callahan, 2012).
This conceptualization surpasses the physical aspect and integrates what is called “the social
determinants of health”, defined as the circumstances in which people are born, grow, live, work and
age, etc., which in the end may play the same role as health promotion, helping people discover how
to best cater for their health needs at different levels: social, political, cultural, etc. The focus of this
research is health promotion, characterized as a multidimensional and inter-sectorial field. The health
promotion approach transcends the biological approach because it considers the social determinants
of health. In Costa Rica, the National Health System has undergone various reforms in its care model
(Mosh, 1983; Herrero & Collado, 2001), in which tasks for the Health Ministry (MS) and the Costa
Rican Social Security Fund (CCSS) were not clear; the roles were later defined, assigning to the
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MS the responsibility of controlling and monitoring the health sector and assigning to the CCSS the
responsibility of providing health services to the population.
Knowing that the Costa Rican Social Security Fund (CCSS) is the organization responsible for
health services, the study is based at a local level which is comprised of three health care levels. At the
primary care level, the Basic Equipment of Integral Health Care (EBAIS) is responsible for prevention
and health promotion, low-complexity healing and rehabilitation. The secondary care level provides
support to primary care, outpatient and hospital procedures (basic specialties and subspecialties).
The tertiary care level provides outpatient and hospitalization services with complex specialties and
subspecialties. Due to the purpose of this research the primary health care level is the object under
study which allows us to better understand the management deficiencies in terms of health promotion
and prevention. According to the WHO, the first primary health care is the “main gateway” (WHO,
1998, p.12) of the whole system where most health issues should be solved, focusing more on
integral initiatives.
Definitions of health and integral health
Turning to our conceptual framework, it is important to define the concepts of health and integral
health. Since the 1950s, the World Health Organization (WHO) adopted the term ‘health’ (Sequeira,
2010, p.26) contending that the human being transcends the merely physical aspect of life and is
involved with a multi-causal process (Sequeira, 2010, p.26), which integrates the person to the social
world (Corrales, Urrutia y Porras, 2007, p.6). This conceptual evolution emerged replacing health as
the absence of biological illnesses (Callahan, 2012); doctors and health workers had been trained to
treat disease, not to build integral health, understanding ‘integral’ as “total, complete, global” (Torres,
et.al., 2004, p.14).
The WHO was the first organization to agree on a standard and universal definition established in
1946 and ratified in Alma Atta (1978) by asserting that integral health is “a complete physical, mental
and social well-being and not merely the absence of disease or infirmity” (WHO, 2003, p.1; Callahan,
2012). Health and illness are related concepts which should not be seen as segmented variables.
The definition that seems most realistic is given by O’Donnell (2009):
Health Promotion is the art and science of helping people discover the synergies between their
core passions and optimal health, enhancing their motivation to strive for optimal health, and
supporting them in changing their lifestyle to move toward a state of optimal health. Optimal
health is a dynamic balance of physical, emotional, social, spiritual, and intellectual health.
O’Donnell’s definition is like the one provided by Costa Rican Social Security Fund, which defines
health as a political and social process, in which people have better control over factors that determitheir
health. This is achieved through their abilities and capabilities, strengthening and developing actions
aimed at modifying social, political, economic, and environmental conditions to help decrease its
impact on health. People are responsible, transforming agents; and developers of individual and
collective health (Corrales, Urrutia & Porras, 2007, p.11)
Integral health receives little priority within health systems. Based on the previous information, an
inclusive theoretical framework is suggested by the author, in which “health promotion” is the term
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this research explores and examines. It is characterized as a procedural, multidimensional and inter-
sectorial field. The former means that health is not static; on the contrary, it goes through constant
movement and change. Multidimensional refers to the fact that it is determined not only by biological
elements but also by social, economic, cultural, geographical, psychological and spiritual, among
other factors. This requires an inter-sectorial process where the impact must be on the individual
and collective level to cover its multidimensionality, which complies with the social determinants of
health (Medicus Mundi, 2011, p.4; p.8). Figure 1 shows a comparison between the medical model vs.
inclusive health, the first one contemplates a more biological view, and the latter one is closer to the
ideal of integral health.
Figure 1.
Medical Model vs. Inclusive Health
Concept from the Medical Model Concept of Inclusive health
Biologist
Individual
Historical
Multidimensional
Individual, Family, Community,
Environment
Procedural
Note. Medicus Mundi, 2011, p. 3
These two concepts have been reviewed and discussed. The first one attempts to merely treat
physical disease, it has a more preventive focus, or according to the Centre for Strategic Development
and Information in Health and Social Security (p.12) quoted in Avendaño, Cruz, et al. (2010) “The
biologist conception is a restrictive health term. It reduces the disease phenomenon to cause-effect,
which may have different origins; the disease always refers to the biological level and clinical level”
(p.100)
The second concept refers to a more integral health that works with promotion and a better
wellness model including social, environmental, emotional factors and so forth. The last one is more
holistic and attempts to help people improve their lifestyles. Gabriela Salguero (2006) quoted in
Avendaño, Cruz, et al. (2010), contends that:
Man has become less dependent on the biological state and increasingly into the social state, i.e.,
its degree of social integration, social inclusion, the conditions of life and the answers given by the
society to different problems and needs with which man is confronted (p.12)
We neither intend to solve this debate nor have the final word on the subject. Since the latter
concept seems to be most realistic, it is used in conjunction with the WHO’s concept to explore and
analyse practices in Costa Rica. Due to the consensus reached among countries when applying the
ambiguous concept of integral health, each health system, particularly in Costa Rica and especially
in terms of promotion and prevention at the primary health level, has been attempting to achieve the
current goal. Drawing on the former, the following sections of this research explore to what extent
management at the primary health care level undertakes promotion and prevention tasks while
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adhering to the concept of integral health.
Health promotion and prevention
As part of our conceptual framework, a clear understanding of health promotion and prevention is
essential for this research. Due to the way health is conceptualised, these terminologies vary depending
on explicit idealism (Callahan, 2012), bearing in mind that people will not reach the ideal level, but will
go from one extreme (health) to the other (disease). As it is difficult to agree on a particular concept,
an ideal and perfect practice, the health concept has evolved (Lopes, Saraiva, Fernandes & Ximenes,
2010). In 1986 the first International Conference on Health Promotion was held in Ottawa (Canada)
where the Ottawa charter was presented (WHO, 1998, p.7). Currently it is the basis to elaborate on
other issues related to health policies.
This charter essentially incorporates the concept and application of Health Promotion (Lalonde,
1981) once the need arose to investigate new strategies to tackle multiple health problems, though
as an integral work, requiring a process through which people would be trained on how to increase
control on and improve their health. Some of health conditions and resources are peace, education,
housing, economic incomes, stable ecosystems, sustainable resources, social justice and equity. This
requires coordinated action by all actors: government, health services, social and economic sectors,
NGOs, media, private sector, etc. The commitment suggested was to introduce a healthy public policy
that worked with health differences, to acknowledge human beings as the main source of health, to
redirect resources to promotional initiatives and finally to acknowledge that health equals investment.
The 20th century changed and challenged both organisations and people worldwide to adopt
other ways to work on health issues. In 1997, the WHO established and approved its Jakarta
Declaration on Health Promotion through a glossary in order to allow the planning of better action
strategies in promotional issues (WHO, 1998, p.6), by promoting coherent policies, investments and
partnerships between governments, international organizations, civil societies and the private sector
(Lopes, Saraiva, Fernandes & Ximenes, 2010), but, above all, to think about how to integrate the health
promotion approach “into existing structures and processes” (Meyer, et.al., 2008) within management
systems.
The progress in medicine was noticeable, it changed from a purely medical approach to a more
centralised one which includes prevention and promotion, resulting in a holistic approach to health
worldwide and that is committed to health promotion. This effort has linked and challenged states
in modifying the reform by developing other strategies in public health (Unger, et.al, 2008) and to
rearrange the relevance of health services (WHO, 1998, p.7), even going from being a purely private
issue to acquiring a public and political dimension.
Health promotion, according to the WHO (WHO, 1998, p.10) is defined as the process that
allows people to increase control on their health and to improve it (Ferguson & Spence, 2012, p.523;
Lopes, Saraiva, Fernandes & Ximenes, 2010). Moreover, it considers a political and social worldwide
process, guiding society towards improving a) its skills and b) its economic, social, personal and
environmental conditions. It consists of working on the social determinants of health firstly (Sequeira,
2010), defined as the circumstances in which people are born, grow, live, work and age, including
the health system (Wilkinson & Marmot, 2003), since multiple factors impact health. Picado (2011)
explains that it involves health protection, education, and prevention.
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Furthermore, preventive tasks are targeted actions that serve to prevent diseases from occurring
and to decrease progressing diseases (Corrales, Urrutia & Porras, 2007, p.8). Authors Donev,
Pavlekovic & Zaletel (2007; WHO, 2002) have also discussed the relationship between promotion
and prevention. They claim that, despite their similarities, they are different. The prevention of disease
encompasses “measures not only to prevent the onset of disease, but also to stop its progress and
reduce its consequences once established” (WHO, 1998, p. 13 based on Health for All series of 1984;
Redondo, 2004, p.7) as opposed to promotion which seeks to implement initiatives and improve
people’s health by providing them with information, education, influence and assistance to achieve a
better responsibility in their lives and well-being (Donev, Pavlekovic & Zaletel, 2007).
Disease Prevention can be split into three levels: primary (to avoid the beginning of a disease),
secondary and tertiary (to stop or slow the progression of disease). For all practical purposes,
prevention is used as a complementary term for promotion, especially because there is no such thing
as perfect health, only tool to improve or control it. Prevention (2004, p.15; Mendes and Costa, 2011)
allows to make risk factors of contracting a disease innocuous, by using control tools to anticipate
possible effects. Table 1 shows the main differences between promotional health and prevention of
disease according to Redondo (2004) and Hernández (2010).
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Table 1.
Differences between promotion and prevention.
Promotion Prevention
Process: provides tools to exercise
greater control over health
Population approach
Efforts to maintain and improve individual,
family and community’s health
Requires good social structures
Great potential to improve health
indicators
More effective if started early
Measures designed to change attitudes
and behaviours
Low individual perception of Benefit
Social, political and community auditors,
for groups and individuals to act, be
empowered and make decisions.
Information, communication, education,
social marketing, strengthening
participation, political action to implement
public policies
The action comes from the health sector; individuals and
populations are exposed to risk factors
Risk approach
Direct measures to prevent disease
Specific measures for the control of certain diseases
Identifying modifiable causes of disease
More effective if it is stopped early
Measures designed to prevent the onset of disease and
/ or stop its progress
High patient and doctor motivation
Primary prevention (social, political and community
auditors). Secondary and tertiary prevention (clinical
auditors to prevent complications and death. Scientific
and technical faculties)
Primary prevention (information, communication,
education, social marketing, strengthening participation,
political action to
implement public policies). Secondary and tertiary
prevention (discriminatory tests and early diagnosis of
the disease, clinical management)
Note. Redondo, 2004, p.16; Hernández, 2010
According to the WHO, adopting a broader promotional approach could be more relevant for
countries that have just one axis, i.e., the countries that put greater emphasis on preventive approaches.
Strategies should be based on five action areas according to the Ottawa Charter Principles (McManus,
2013, p.16; (Corrales, Urrutia & Porras, 2007, p.10; Ferguson & Spence, 2012, p.523; Lopes, Saraiva,
Fernandes & Ximenes, 2010):
» To establish a healthy public policy
» To create environments that support health
» To strengthen community action towards health
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» To develop personal skills
» To redirect sanitary services
Adopting these 5 lines of action aided the WHO to further clarify its objectives, which are considered
essential in the integration of the concept of “new public health” as “the science and art of promoting
health, preventing disease and prolonging life through organized efforts of society” (WHO, 1998,
p.12). Additionally, these features were critical for the establishment of strong inter-sectorial action for
mobilization and social transformation (Corrales, Urrutia & Porras, 2007). Since then, the relationship
between public health promotion and disease prevention has been seen as a consistent and harmonic
convergence of social and political destiny. It should be noted there is a distinction between “public
health” and “new public health”. The latter refers to the social determinants of health and how lifestyles
and life conditions determine the health state (Corrales, Urrutia & Porras, 2007).
The selection of this framework was based on its alignment with the specific objectives of this
article, particularly in addressing the complexities of health promotion and disease prevention within
the context under discussion. While other frameworks, such as systems theory and public health
management theory, offer valuable insights, this framework was chosen for its ability to more effectively
capture the dynamic interactions and broader social determinants influencing health outcomes. Its
focus allows for a more nuanced understanding of how health interventions can be tailored to diverse
populations.
Health promotion is considered a means or resource to help people in their economic, social
and personal lives, and it should not be presented as an abstract condition. In other words, health
promotion can be considered tantamount to “new public health”. New public health considers the
social determinants needed to improve health promotion from an integral perspective.
Thus, the following question arises: who is responsible for promotion and prevention issues? The
World Health Organization has proposed a series of actions to help countries achieve a decent level
of health care. However, achievement of goal is often hindered by practical obstacles. This study does
not seek to stress or debate the meaning of promotion and prevention, but to analyse the extent to
which there are deficient management practices at the primary level (Callahan, 2012).
Management Model: Primary Health Care
To provide further context for our study, we now analyse Costa Rica’s primary health care management
model. According to the WHO, primary health care is the “essential health care, accessible, at a cost the
country and community can afford, with practical methods, scientifically sound and socially acceptable”
(WHO, 1998, p.12). This issue was addressed in the Alma Ata Declaration, held in Geneva, 1978. It
stressed that all people should have access to primary health care (WHO, 1998, p.12) through equity,
inter-sectorial participation, education, preventive methods, etc. Since this declaration, the strategy of
Primary Health Care (PHC) was promoted (Medicus Mundi, 2011, p.7), including new initiatives such as
the Ottawa charter for Health Promotion, the Millennium Declaration and the Social Determinants of Health
perspective.
Since primary health care is the first point of contact with the population, the WHO considers this
level as the one responsible for health promotion, advocacy, and influence in the formulation of policies
and programs (WHO, 1998, p.13). As mentioned above, primary health care is the main gateway to
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health care or prevention and promotion and it is where most concerns should be solved (Beaulieu,
et.al., 2013, p.1). In this research, the model of the Costa Rican health system is studied, specifically
focusing on the first level of care. This way, the analytical characterisation of the primary care level
of the public health system is analysed: its health/disease conception, promotion and prevention
knowledge and practices, as well as organisational resource allocation and processes.
The core components of the Costa Rican primary level are:
» The local concept of health and illness and its approaches.
» The programmatic / normative level.
» The administrative level (management processes, planning, organization, staffing, human and
financial resource allocation, assessment / measurement).
» The instrumental/operational level in promotion and prevention activities.
It was previously explained that the understanding of health has evolved from a medical model
(medicine) to a broader concept based on health care (McManus, 2013, p.15), but only defined
as sanitary assistance accessible to the whole population. The WHO defined it as promotional and
preventive initiatives, however there was a need to expand on the concept to consider the social
determinants of health, arguing that health systems cannot be responsible for many factors that are
the responsibility of other actors. This means that not all health problems are caused by medical
factors, they might be caused by employment, housing, environment, among others.
Accordingly, Health Systems were given the responsibility for one essential task: to promote health
and healthy lifestyles and prevent disease (Corrales, Urrutia & Porras, 2007, p.8). But how can this
be possible if there is no consensus on basic concepts? Health promotion has often been confused
with education (knowledge transfer) the idea that just by sharing information health can be improved.
Health promotion refers to the dissemination of certain actions that encourage good health providing
a broader perspective, from a campaign to the development and implementation of public policies,
whereas regarding education, once the actions are known, they can be applied in a timely fashion
by teaching people to take control and improve their health. The World Health Organization (WHO)
is responsible for defining the basis to guide Health Systems world-wide. Essentially, the terms have
been accepted in many health documents and laws but making them a reality has posed a challenge
(Baldock, Manning & Vickerstaff, 2012). The question remains: how to put theory into practice?
There are different international and national laws regarding health and health promotion. In
addition, the Costa Rican health sector is made up of several heterogeneous actors which all have
a role in dictating the course in which the health process unfolds such as: General Health Law, Law
for Ministries, the Political Constitution, Executive Orders, International Conferences, etc. Despite
these guidelines, there are some deficiencies in compliance regarding the institution that provides
health care services, the Costa Rican Social Security Fund (CCSS) has its own internal policies as an
autonomous institution, as well as strategic plans.
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Challenges of Costa Rican primary health care
level
Against the backdrop of the conceptual framework and the broader institutional context of Costa
Rica’s primary health care level presented above, we now turn to the empirical part of our research
and present the main findings of our qualitative work. The findings presented below are based on
extensive empirical research conducted in 2014 and 2015, which included in-depth interviews with
15 experts and surveys with 100 health users. Due to space limitations, only the main conclusions
are discussed here, and as such, the detailed analysis of the interview and survey results is not
fully explored in this article. While some perspectives from the interviewees are presented, a deeper
examination of the reasons behind these views and their broader implications for the health system
is available in the original research report (master’s thesis). For those seeking a more comprehensive
understanding of the data, the complete thesis (Quesada, 2014) provides full access to the empirical
findings.
Due to many issues, one of them being the evident overemphasis on prevention and healing
processes, a national health policy for 2010-2020 was formulated (Avila, et.al., 2010) which stressed
three objectives for promotion and prevention: a) individual and collective care culture, b) individual
health care services, c) strengthening of the development of a healthy workforce and its impact on
health promotion and prevention. The Costa Rica Social Security Fund (CCSS) would continue with
its functions but divide them among three administrative levels, delegating its tasks for execution,
programming and monitoring of health actions and health promotion / disease prevention activities to
a local level representative. Its structure was also divided into different care levels, the Basic Equipment
of Integral Health Care (EBAIS) being responsible for prevention and promotion, low-complexity healing
and rehabilitation (García, 2004; Flores, 2003).
Costa Rica has improved its management models in some of its primary care centres (EBAIS),
its aims now emphasise care. When analysing the issue of health promotion and disease prevention,
there is still a lack of concrete initiatives. Additionally, both management and promotion / prevention
are not given enough importance in the South-Central Region: a) there is an abuse of the medical
profession (promotion and prevention as curative medicine), b) problems related to “social well-being”
are delegated only to medical professionals (Callahan, 2012) taking responsibility for social, political
and economic problems of the population and c) management fails to adopt good practices that
utilise available resources and efficient planning strategies (Ferrinho & Dal Poz, 2003).
A real improvement to date has not worked in many centres of primary health care. Despite the
existence of difficulties in most centres, the area being studied (the South-Central Region) is facing
major deficiencies. The main problem being that the care provided to the population is insufficient
due to bad management; health promotion suffers due to limited resources at all levels of healthcare
(Ferrinho & Dal Poz, 2003) and in EBAIS centres particularly (García, 2004). EBAIS are still focusing on
a sort of health care that cures disease, rather than on health promotion initiatives. They act as small
hospitals, causing service saturation (Comino, et.al., 2012, p.1); they prioritize the disease and thus
do not fulfil their duties when it comes to quality, equity, efficiency and care (Picado, 2010; Hernández,
2014).
The inefficiency problem is also accompanied by a lack of communication, information and
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community relations. From this perspective, national health systems should develop a public health
policy that balances welfare, promotion and prevention (Leon, Walt & Gilson, 2000; Kawachi,
Subramanian & Almeida, 2002) and that change the management model. It is a way to influence and
fight for the rights of the population. There are many obstacles in management practices.
Primary care depends on factors like “time, financial support, payment reform, health policy support
and physician support” (Arar, et.al., 2011, p.290), all of which are interconnected and affect practice.
Due to this reason and others, understanding the situation of the Basic Equipment of Integral Health
Care (EBAIS) in the South-Central Region of Costa Rica is essential in order to analyse how health
initiatives are implemented and to explore the main factors influencing the readiness to introduce new
procedures at the primary care level management, applied to three main aspects: (a) a vision put into
practice, (b) needs for practice improvement and (c) obstacles that hinder practice improvement as
explained by Arar, et.al. (2011, p. 292) at the three levels of care: structure, process and outcome of
care (Scha, et.al, 2013). Despite the progress, public health systems face critical situations regarding
people’s care and illnesses. Health institutions still focus on curative health (curing the disease), rather
than on promoting health (Baldock, et.al., 2012). Additionally, the primary health management level
still works with traditional bureaucratic practices (Picado, 2000), which translates to serious problems
in terms of effectiveness, efficiency and equity of services (Bambra, Fox & Scott-Samuel, 2007).
This situation stresses the need to rethink management methods. The gap that had caused the
transformation of the health sector, i.e. the delegation of operational tasks to the CCSS by the Ministry
of Health, was intended to be corrected. Since their focus is to cure diseases, the staff is insufficiently
prepared to be involved in health promotion.
From the conducted interviews, it was found that it is a challenge to establish a unique definition
for promotion and prevention, they are often thought of as synonyms. Many promotional projects are
combined with prevention initiatives. Costa Rican citizens do not understand what promotion means,
they think of medicine and doctors. In addition, there is no awareness of the importance of health
and promotional issues are limited to healthy food and exercise. All interviewees agreed there are
differences between both concepts. Health is not just the absence of sickness, but an integral well-
being of the person: the physical, mental, social, spiritual well-being of the individual. Since the ‘70s
health promotion have been defined from five lines of action with Ottawa Charter roots but has not
received sufficient support:
1. Healthy public policy creation.
2. Establishment and improvement of environments.
3. Development of skills and attitudes of the citizen.
4. Ensure social participation.
5. Reorganization of health services.
The questions used for the research at the beginning can be largely answered positively. It
became very clear from the conducted fieldwork that there is indeed a deficient focus on preventive
and promotional integral health at the primary health care level (research question # 1). This issue had
already been mentioned in the literature by several authors (Picado & Quesada, 2011 and Avendaño,
Cruz, et al., 2010), and this research clearly laid out the difference between what is stated in policy
documents and what happens at the level of the EBAIS. Moreover, the conceptual confusion about
prevention and promotion is shared not only by the medical personnel but also by the users of the
EBAIS, which naturally has repercussions on the type of care that is delivered at the local level. It also
strongly impacts the way tasks of the EBAIS are defined when it comes to prevention and promotion
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(research question # 4).
The issue of effective allocation of financial and human resources (research question # 2) was
also confirmed by the interviews conducted in this research. Although it has not been possible to
review budgets of EBAIS, the qualitative observations of all interviewees refer to this issue, which
applies not only to prevention and promotion, but to the health care system in general. As for internal
management and organisational culture of the EBAIS (research question # 3) what was highlighted in
literature (Carpio & Villalobos, 2001) was confirmed: it is insufficiently in tune with the requirements of
a holistic vision of health.
Conclusions
Health is a complex concept. It certainly carries several characteristics and dimensions that require
a broad classification, either on welfare terms, or strengthening of people’s abilities. International
statements have established a set of guidelines that should be reflected in national laws and the
operationalization of the health sector. As this research has shown, the Ministry of Health in Costa
Rica and the Costa Rican Social Security Fund (CCSS) have clear international guidelines and they
both have action plans as autonomous institutions. The former is the governing body, and the latter
is an institution in charge of providing health services, including those related to health promotion and
disease prevention.
This research revealed that due to poor planning, duplication of tasks, lack of coordination,
mismanagement at local level on issues of promotion and prevention, among others, there is still much
work to be done to reorganize this model at the primary level. Prevention is still prevalent in the EBAIS
and this is reflected in the programs and resource allocation. This research also found that promotion
is still ignored and the concept of a complete physical, mental and social well-being state proposed
by the World Health Organization is not operationalised and measured, in fact, indicators are mainly
preventive. This explains why people see the EBAIS as small hospitals, rather than facilities for the
implementation of disease prevention and health promotion initiatives that improve their lifestyles, as
the conducted survey indicated.
At the beginning of this research an inclusive theoretical framework was proposed in which health
promotion should be seen as a procedural, multidimensional and inter-sectorial field. Health promotion
means that health evolves and is determined not only by biological elements but looks to comply
with social determinants of health (environment, housing, employment, etc.) which requires an inter-
sectorial process.
This research discusses the numerous restructuring processes aimed at better defining tasks
following the duplication of functions related to promotion and preventive roles between the Ministry
of Health and the Costa Rican Social Security Fund. The Ministry of Health retained control over
coordination and monitoring responsibilities, while the Costa Rican Social Security Fund was tasked
with health promotion, disease prevention, and rehabilitation. Its main role at the primary care level
should, therefore, be health promotion, as it is the first point of contact with the population. However,
despite the existence of specific laws, the primary health care level (EBAIS) is not currently fulfilling its
health promotion mission.
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