The World Bank Implementation Status & Results Report
Strengthening Universal Health Insurance in Costa Rica (P148435)
Strengthening Universal Health Insurance in Costa Rica (P148435)
LATIN AMERICA AND CARIBBEAN | Costa Rica | Health, Nutrition & Population Global Practice | Requesting Unit: LCC2C | Responsible Unit:
HLCHN
IBRD/IDA | Program-for-Results Financing | FY 2016 | Team Leader(s): Laura Di Giorgio
Seq No: 15 | ARCHIVED on 21-Dec-2023 | ISR58881 | Created by: Stephanie Alejandra Marzluf Quiroz on 20-Nov-2023 | Modified by: Laura Di
Giorgio on 20-Dec-2023
Program Development Objectives
PDO Table
Program Development Objective (from Program Appraisal Document)
The objectives of the Program are to contribute to: (i) improving the timeliness and quality of health services; and (ii) enhancing the institutional
efficiency of the CCSS.
Overall Ratings
Name Previous Rating Current Rating
Progress towards achievement of PDO Satisfactory Satisfactory
Overall Implementation Progress (IP) Satisfactory Satisfactory
Implementation Status and Key Decisions
The Strengthening Universal Health Insurance in Costa Rica Program-for-Results was approved by the Board of Directors on March 15, 2016. A
loan in the amount of US$ 420 million was signed by the Government of Costa Rica and World Bank on April 21, 2016 and the loan was declared
effective on November 17, 2016. The Project’s first restructuring to extend the closing date of the project to December 31, 2023 was approved on
April 29, 2022. The Project’s second restructuring to extend the closing date of the project to January 31, 2024 was approved on December 18,
2023. Project implementation is close to completion. As of December 2023, the loan has disbursed $420 million (100%), of which $400
million (95%) correspond to confirmed results. The program has a remainder of $20 million of results to be achieved. The Program has primarily
focused and achieved results on: (i) strengthening primary care with an emphasis on prevention, early diagnosis, and control of NCDs and
performing more procedures outside of hospital settings, (ii) creating integrated health care networks that facilitate coordination across levels of
care, (iii) improving institutional responsiveness to users and strategic decision-making, and (iv) improved strategic long-term planning and
monitoring of budget trends.
Data on Financial Performance
Disbursements (by loan)
Project Loan/Credit/TF Status Currency Original Revised Cancelled Disbursed Undisbursed % Disbursed
P148435 IBRD-85930 Effective USD 420.00 420.00 0.00 420.00 0.00 100%
Key Dates (by loan)
Project Loan/Credit/TF Status Approval Date Signing Date Effectiveness Date Orig. Closing Date Rev. Closing Date
P148435 IBRD-85930 Effective 15-Mar-2016 21-Apr-2016 17-Nov-2016 30-Apr-2022 31-Jan-2024
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The World Bank Implementation Status & Results Report
Strengthening Universal Health Insurance in Costa Rica (P148435)
DLI Disbursement
Achievement Disbursed amount in Disbursement % for
DLI ID DLI Type Description Coc DLI Amount
Status Coc DLI
Loan: IBRD85930-001
43% major surgeries from
1.1 Regular USD 30,000,000.00 Fully Achieved 30,000,000.00 100 %
Priority List
46% of major surgeries
1.2 Regular USD 30,000,000.00 Fully Achieved 30,000,000.00 100 %
from priorities l
Cumulative of 10% of
2.1 Regular USD 30,000,000.00 Fully Achieved 30,000,000.00 100 %
Target Population p
Cumulative of 40% of
2.2 Regular USD 30,000,000.00 Fully Achieved 30,000,000.00 100 %
Target Population p
41% of individuals
3.1 Regular USD 30,000,000.00 Fully Achieved 30,000,000.00 100 %
diagnosed with Diabet
43% of individuals
3.2 Regular USD 30,000,000.00 Fully Achieved 30,000,000.00 100 %
diagnosed with Diabet
4.1 Regular Pilot project approved USD 30,000,000.00 Fully Achieved 30,000,000.00 100 %
Evaluation of pilot publicly
4.2 Regular USD 30,000,000.00 Fully Achieved 30,000,000.00 100 %
disseminate
60% of total number of
5.1 Regular USD 30,000,000.00 Fully Achieved 30,000,000.00 100 %
primary health ca
80% of total number of
5.2 Regular USD 30,000,000.00 Fully Achieved 30,000,000.00 100 %
primary health ca
CCSS Board approval of
6.1 Regular USD 30,000,000.00 Fully Achieved 30,000,000.00 100 %
redesign of patie
Report on impact of
6.2 Regular USD 30,000,000.00 Fully Achieved 30,000,000.00 100 %
interventions to imp
Ten-year investment plan
7.1 Regular USD 20,000,000.00 Fully Achieved 20,000,000.00 100 %
approved by CCS
Actuarial valuation of
7.2 Regular USD 20,000,000.00 Fully Achieved 20,000,000.00 100 %
health insurance
Annual budget of CCSS
7.3 Regular USD 20,000,000.00 Not Achieved 0.00
approved by CCSS B
Program Action Plan
Action Description Contracting an Independent Verification Entity (IVE).
Source DLI# Responsibility Timing Timing Value Status
Technical CCSS Due Date 29-Jun-2018 Completed
Completion Measurement Contract signed
Comments PAHO has an active contract for verification of the DLIs.
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The World Bank Implementation Status & Results Report
Strengthening Universal Health Insurance in Costa Rica (P148435)
To achieve and verify the indicator related to cumulative percentage of target population personally invited to undergo
Action Description colon cancer screening in five priority counties.
Source DLI# Responsibility Timing Timing Value Status
Technical DLI 2 CCSS Due Date 30-Jun-2022 Completed
Completion Measurement Indicator Verified
Comments Indicator achieved and verified.
To achieve and verify the indicators related to the pilot project on integrated health networks approved by the CCSS
Action Description Board and implemented for a selected population and territory and evaluated with the results publicly disseminate
Source DLI# Responsibility Timing Timing Value Status
Technical DLI 4 CCSS Due Date 30-Dec-2022 Completed
Completion Measurement Indicator Verified
Indicator 4.1 achieved and verified. Indicator 4.2 achieved and disbursed, with dissemination of results of the pilot
Comments
completed during the mission carried out in October 2022. Verification took place in February 2023.
To achive and verify the indicators related to redesign, implementation and use of data collected by the new annual
Action Description survey to measure impact of new interventions to improve patient satisfaction.
Source DLI# Responsibility Timing Timing Value Status
Technical DLI 6 CCSS Due Date 30-Jun-2023 Completed
Completion Measurement Indicator verified
Comments DLI 6.1 and 6.2 have been verified. Verification of milestone 6.2 took place in October 2023.
To achive and verify the indicators related to the development and execution of a comprehensive medium- and long-
Action Description term plan to ensure the financial sustainability of the CCSS
Source DLI# Responsibility Timing Timing Value Status
Technical DLI 7 CCSS Due Date 30-Dec-2023 In Progress
Completion Measurement Indicator Verified
DLI 7.1. and DLI 7.2. have been achieved and verified. DLI 7.3 is expected to be achieved by the end of 2023 and
Comments
verified in Q1 of 2024.
Risks
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The World Bank Implementation Status & Results Report
Strengthening Universal Health Insurance in Costa Rica (P148435)
Systematic Operations Risk-rating Tool
Risk Category Rating at Approval Previous Rating Current Rating
Political and Governance Substantial Low Low
Macroeconomic Substantial Low Low
Sector Strategies and Policies Moderate Low Low
Technical Design of Project or Program Moderate Low Low
Institutional Capacity for Implementation and
Moderate Moderate Low
Sustainability
Fiduciary Moderate Moderate Moderate
Environment and Social Moderate Moderate Moderate
Stakeholders Moderate Low Low
Other -- Low Low
Overall Moderate Low Low
RiskComments
Comments
Given the closeness to project closure and that 14 out of 15 milestones have been achieved, and the only one pending (DLI 7.3) is soon to be
achieved and on the path to be accomplished in December 2023 /January 2024, risks have been lowered for the PforR.
Results
PDO Indicators by Objectives / Outcomes
Improving Timeliness and Quality of Health
IN01370651
►Percentage of major surgeries from priority list conducted in outpatient settings according to CCSS institutional guidelines (Percentage,
Custom)
Baseline Actual (Previous) Actual (Current) End Target
Value 18.00 49.80 49.80 46.00
Date 29-Feb-2016 31-Dec-2020 31-Dec-2020 29-Apr-2022
Indicator achieved its end of Project target.
Comments
IN01370653
►Cumulative percentage of target population personally invited to undergo colon cancer screening in five priority counties. (Percentage,
Custom)
Baseline Actual (Previous) Actual (Current) End Target
Value 0.00 36.80 36.80 40.00
Date 29-Feb-2016 31-Dec-2021 31-Dec-2021 29-Apr-2022
Indicator achieved and verified.
Comments
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The World Bank Implementation Status & Results Report
Strengthening Universal Health Insurance in Costa Rica (P148435)
Improving the institutional efficiency of CCSS
IN01370652
►Percentage of total number of primary health care units (Areas de Salud) with the Unique Digital Health Record e-health package (EDUS)
(Percentage, Custom)
Baseline Actual (Previous) Actual (Current) End Target
Value 50.00 90.10 90.10 80.00
Date 29-Feb-2016 31-Dec-2021 31-Dec-2021 29-Apr-2022
Indicator achieved its end of Project target.
Comments
IN01370654
►Development and execution of a comprehensive medium-and long-term plan to ensure the financial sustainability of the CCSS (Text,
Custom)
Baseline Actual (Previous) Actual (Current) End Target
Annual target expected Annual target expected Annual budget
Budget does not use
Value to be achieved by end of to be achieved by end execution using
prospective tools.
2023. of 2023. prospective tools.
Date 29-Feb-2016 04-May-2023 04-May-2023 31-Dec-2023
Indicator in progress.
Comments
Intermediate Results Indicators by Results Areas
Health Care Model
IN01370655
►Cumulative percentage reduction in average waiting days for selected procedures (tracers): hip and knee replacement. (Text, Custom)
Baseline Actual (Previous) Actual (Current) End Target
Value 1032 days 573 days 573 days 35% lower
Date 29-Feb-2016 15-Jun-2020 15-Jun-2020 29-Apr-2022
Indicator achieved its end of Project target.
Comments
IN01370658
►Percentage of individuals diagnosed with hypertension that are under optimal clinical control. (Percentage, Custom)
Baseline Actual (Previous) Actual (Current) End Target
Value 62.00 65.70 65.70 64.00
Date 31-Dec-2013 15-Jun-2020 15-Jun-2020 29-Apr-2022
Indicator achieved its end of Project target.
Comments
Institutional Management
IN01370656
►Percentage of households covered by the Family Socio-Economic & Health Risks Information File. (Percentage, Custom)
Baseline Actual (Previous) Actual (Current) End Target
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The World Bank Implementation Status & Results Report
Strengthening Universal Health Insurance in Costa Rica (P148435)
Value 70.00 100.00 100.00 100.00
Date 29-Feb-2016 31-Dec-2021 31-Dec-2021 29-Apr-2022
Indicator achieved its end of Project target. (II3)
Comments
IN01370659
►Percentage of households with Family Socio-Economic & Health Risks Information File digital geo-referencing data available online.
(Percentage, Custom)
Baseline Actual (Previous) Actual (Current) End Target
Value 0.00 66.90 66.90 16.00
Date 29-Feb-2016 17-Apr-2023 17-Apr-2023 29-Apr-2022
Indicator achieved its end of Project target.
Comments
IN01370661
►Use of institutional strategic intelligence system data to publish and disseminate two annual reports measuring progress of SASHI (Text,
Custom)
Baseline Actual (Previous) Actual (Current) End Target
System designed,
System designed,
approved and
System designed, approved by Board of
launched
Value - approved by Board of Directors and annual
Two annual reports
Directors report published and
published and
disseminated
disseminated
Date 29-Feb-2016 18-Nov-2022 19-Dec-2023 31-Dec-2023
Indicator achieved since last mission. Final report on the implementation of NOVAPLAN has been submitted
Comments by the CCSS in November 2023 and accepted by the Bank.
IN01370662
►Institutional Review of core institutional management functions, and operational plan for progressive implementation of streamlining central
level management. (Text, Custom)
Baseline Actual (Previous) Actual (Current) End Target
Approved by Board of
Approved by the Board of Approved by the Board
Value - Directors
Directors of Directors
Date 29-Feb-2016 31-Dec-2021 31-Dec-2021 29-Apr-2022
Indicator achieved its end of Project target
Comments
Financial Management
IN01370657
►Financial statements produced using new international public accounting standards, streamlined and digital automated processes. (Text,
Custom)
Baseline Actual (Previous) Actual (Current) End Target
Approved
Evaluation report of
first two years
Value - In progress In progress Annual Financial
Statement using
outputs from new
automated streamlined
system
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The World Bank Implementation Status & Results Report
Strengthening Universal Health Insurance in Costa Rica (P148435)
Date 29-Feb-2016 18-Nov-2022 18-Nov-2022 31-Dec-2023
Indicator in progress. Final report on the implementation of the NICSP has been submitted by the CCSS
Comments and is under Bank review.
IN01370660
►Shadow budget constructed based on gender and age risk adjusted capitations. (Text, Custom)
Baseline Actual (Previous) Actual (Current) End Target
Value - In progress Achieved Completed
Date 29-Feb-2016 31-Dec-2021 08-Dec-2023 31-Dec-2023
Indicator achieved its end of project target. Final report approved in December 2023.
Comments
Disbursement Linked Indicators
DLI_IND_TABLE
►DLI 1 Percentage of major surgeries from priority list conducted in outpatient settings according to CCSS institutional guidelines. (Outcome,
60,000,000.00, 100%)
Baseline Actual (Previous) Actual (Current) Year 2
Value 41.60 49.80 49.80 46.00
Date 29-Feb-2016 31-Dec-2020 31-Dec-2020 --
Indicator achieved its end of Project target. Verification of milestone 2 happened during verification of
Comments milestone 1.
►DLI 2 Cumulative percentage of target population personally invited to undergo colon cancer screening in five priority counties. (Outcome,
60,000,000.00, 100%)
Baseline Actual (Previous) Actual (Current) Year 2
Value 0.00 36.80 36.80 40.00
Date 29-Feb-2016 31-Dec-2021 31-Dec-2021 --
Indicator achieved and verified.
Comments
►DLI 3 Percentage of individuals diagnosed with Diabetes Type II that are under optimal clinical control. (Output, 60,000,000.00, 100%)
Baseline Actual (Previous) Actual (Current) Year 2
Value 39.00 45.70 45.70 43.00
Date 31-Dec-2014 30-Jun-2021 30-Jun-2021 --
Indicator achieved its end of Project target and was verified.
Comments
►DLI 4 Pilot project on integrated health networks approved by the CCSS Board and implemented for a selected population and territory and
evaluated with the results publicly disseminated. (Output, 60,000,000.00, 50%)
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The World Bank Implementation Status & Results Report
Strengthening Universal Health Insurance in Costa Rica (P148435)
Baseline Actual (Previous) Actual (Current) Year 2
Pilot Project on Pilot Project on integrated
integrated health health networks approved
Value - networks approved by by the CCSS Board of --
the CCSS Board of Directors and results
Directors. disseminated.
Date 29-Feb-2016 19-Nov-2021 19-Nov-2021 --
Indicator achieved and verified (4.2 was achieved in February 2023).
Comments
►DLI 5 Percentage of total number of primary health care units (Areas de Salud) with the Unique Digital Health Record e-health package
(EDUS). (Outcome, 60,000,000.00, 100%)
Baseline Actual (Previous) Actual (Current) Year 2
Value 50.00 90.10 90.10 80.00
Date 29-Feb-2016 31-Dec-2021 31-Dec-2021 --
Indicator achieved its end of Project target and was verified.
Comments
►DLI 6 Redesign, implementation and use of data collected by the new annual survey to measure impact of new interventions to improve
patient satisfaction. (Output, 60,000,000.00, 50%)
Baseline Actual (Previous) Actual (Current) Year 2
Redesign survey was
approved by the Board of
Directors [6.1] and the
Redesign survey was report on impact of
Value - approved by the Board of interventions to improve --
Directors patient satisfaction
approved by CCSS Board
[6.2, verified in November
2023].
Date 29-Feb-2016 31-Dec-2020 31-Dec-2020 --
Milestone 1: achieved and verified.
Comments Milestone 2: achieved and verified since last ISR.
►DLI 7 Development and execution of a comprehensive medium- and long-term plan to ensure the financial sustainability of the CCSS.
(Outcome, 60,000,000.00, 67%)
Baseline Actual (Previous) Actual (Current) Year 2
Milestone 7.1 and 7.2 Milestone 7.1 and 7.2
Value - --
verified verified
Date 29-Feb-2016 31-Dec-2020 31-Dec-2020 --
7.1 and 7.2 achieved and verified. 7.3 in progress (expected to be achieved in December 2023 and verified in
Comments first quarter of 2024).
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