The Costa Rican Social Security System (Caja) is under continuing financial stress, placing at risk the country’s much-heralded universal health coverage. Facing budget shortfalls, Caja officials last week resorted to taking on new debt to meet operating costs.
For public hospitals, the Caja’s cost-cutting measures mean direct budget cuts that began this month, and hospital employees say medical services have already been affected.
“It’s really a shame that steps the government supposedly took to save the Caja will inevitably force the institution to take a loan,” said Luis Chavarría, secretary general of the Social Security Workers’ Union.
The Caja’s new debt, totaling ₡35 billion ($70 million), will be used to pay salaries and medical suppliers, the daily La Nación reported last week. Caja officials will also seek a new line of credit from Banco Nacional, after the entity was unable to capitalize on ₡52 billion ($104 million) in government bonds issued Dec. 27. The central government owes the Caja ₡123.2 billion ($246.4 million), and the bonds were issued as partial payment.
Banco Nacional extended the Caja credit at an interest rate of 10.5 percent, with the bonds used as collateral. Interest on the 60-day loan will likely cost the Caja $1.2 million.
Last week, the National Medical Union warned that doctors could no longer be held responsible for emergencies that arise in understaffed hospitals, after hospitals began cutting overtime pay. Doctors were asked to remain within an hour’s distance of hospitals in case of emergencies, the union said during a press conference.
“We’re worried because we’re beginning to see these budget cuts affecting patients at different hospitals,” the medical union’s José Federico Rojas said. “All public health care facilities are concerned about this problem, and eventually it will affect patient services.”
One hospital that is already feeling the pinch is the San Francisco de Asís Hospital in Grecia, a Central Valley coffee town west of San José. Despite its small-town location, the Grecia hospital’s area of coverage includes 200,000 residents from nearby towns including Naranjo, Zarcero, Poás and Sarchí.
This year, the Caja cut the hospital’s budget by 48 percent, a decrease of ₡478 million ($956,000) compared to last year. The cuts will affect on-call physicians, night-shift staff and specialists.
“We no longer leave a gynecologist on call after 4 p.m. One of us is asked to remain close enough to the hospital to be there in an hour. In certain cases, this can be detrimental to the patient,” said Oscar Montero, head of the hospital’s gynecology department.
The hospital is facing other setbacks. Emergency-room staff has been cut by two doctors after 4 p.m. on weekdays, and three doctors on weekends. Before the budget cuts, a radiologist was on-call between 4 p.m. and 7 a.m., and could arrive in 20 minutes during emergencies. That on-call post was eliminated, and patients needing radiology after 4 p.m. are transferred to a hospital in Alajuela, northwest of San José.
In internal medicine, the day-shift staff was reduced from four to three doctors in the morning, with one doctor covering night shifts. The result is less care for patients, as the hospital lacks administrative personnel to schedule appointments in internal medicine at night. Night-shift doctors offer only emergency care. The changes affect some 450 patients per month.
On Thursday evening, Grecia residents held a vigil in the town’s park to draw attention to the issue.
Caja officials say the cuts are necessary. “We are calling for a rational and effective use of resources by giving priority to the main activities and postponing those not directly related to patient care,” Caja Medical Director Zeirith Rojas said.
Caja Budget Director Sergio Gómez said adjustments could be made throughout the year, allowing more funding in urgent areas.
Caja officials also point out that despite cuts to some areas, the Caja’s 2012 general budget – mandated by the Comptroller General’s Office – increased by 8.6 percent over last year, totaling ₡2.3 trillion ($4.6 billion).
San Rafael de Alajuela Hospital Director Francisco Pérez told La Nación last week that with a budget cut of ₡1 billion ($2 million), the hospital only has enough funding to operate through May.
At Escalante Pradilla Hospital in the Southern Zone canton of Pérez Zeledón, doctors face cutbacks similar to Grecia’s. General practitioner Carlos Jiménez said that with 49 percent less money to pay doctors after 4 p.m., the hospital would not be able to provide sufficient care for its coverage area.
“We will continue functioning normally until we have no money left. From then on, we have told the hospital’s director that the problem is out of our hands, and we are telling residents that if they don’t receive medical attention, it’s because of the budget,” Jiménez said.
Members of the medical union say Caja officials need to do a better job collecting payments from employers who fail to pay coverage for their workers, including the central government.
On Saturday, activist Roberto Mora filed a case before the Constitutional Chamber of the Supreme Court against the government for failing to pay its debt to the Caja.