Int J Health Serv. 2014;44(2):337-53. doi: 10.2190/HS.44.2.j.
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.
哥斯达黎加一直致力于初级保健，由此建立了一个公共卫生服务体系，取得了优异的成果。十多年来，管理层的承诺一直是哥斯达黎加医疗改革的一部分。我们评估了哥斯达黎加管理层的承诺对医疗服务的可及性和质量以及对实现其预期目标的遵守情况的影响。我们就初级保健提供者的意见提出了七个假设。通过混合定性和定量方法，我们检验了这些假设，并解释了研究结果。管理承诺占用了过多的咨询时间，增加了记录保存工作，降低了初级保健咨询的全面性，并导致对医院急诊服务的过度使用。这些承诺的制定依赖于需要优化的规范，其控制依赖于不可靠的来源。它们还影响了专业精神。在哥斯达黎加，管理承诺对医疗服务的可及性和质量产生了负面影响，并对公共服务提供系统构成威胁。在一个表现良好的卫生系统中，这种类似于按绩效付费的举措失败，这让人对在欠发达环境中加强卫生系统的按绩效付费的适当性产生了怀疑。
