Biombo (Costa Rica)
|Location: Costa Rica|
|Definition: An illegal payment made to a medical professional in exchange for providing preferential treatment to a patient or a patient’s family within the state-funded healthcare system|
|Keywords: Costa Rica – North America – Central America – Latin America – Public service – Payment – Health care – Doctor – Facilitation – Favour|
|Clusters: Redistribution – Substantive ambivalence – Sociability of instrumentality – Economies of favours – Amoral familialism|
|Author: Bruce M. Wilson and Evelyn Villarreal Fernández|
|Affiliation: University of Central Florida and Costa Rica Integra Civic Association, USA|
By Bruce M. Wilson and Evelyn Villarreal Fernández, University of Central Florida and Costa Rica Integra Civic Association, USA
|Biombo medico, more commonly referred to as biombo, is a term for a Japanese-style bamboo curtain, but in the Costa Rican context it is used to refer to an illegal payment made to a medical professional in exchange for providing preferential treatment to a patient or a patient’s family within the state-funded healthcare system. According to an official report on the Costa Rican healthcare sector finance, patients have increasingly used biombos medicos as a response to longer waiting times for consultations or treatments. The payments enable them to leapfrog waiting lists for surgery, to see specialist, and to receive diagnostic tests and treatments usually reserved for emergencies. The report defines biombos as ‘illicit agreements between doctors and patients, administrative barriers to access to certain benefits, recurring periods characterized by a lack of supply of certain medicines, including additional forms.’ The report argues that the practice ‘promotes corruption of the [health care] system in general and places the neediest people at a clear disadvantage’ (Organización Panamericana de la Salud, 2003:34).|
While the practice might be widely used within Costa Rica to secure preferential treatment from health care providers, and similar practices are to be expected in other countries with similar health care systems, the use of the term biombo appears to be limited to Costa Rica. This can be explained in part by the nature of the near universal state-owned and run health care system that exists in few other Latin American Countries (and no others in Central America), which mitigates against needing to pay public officials for personal medical benefits.
Although no formal method is used to measure the extent of the use of biombos by medical personnel, by 2008 it was believed to have become a sufficiently significant issue for the Código de Moral Médica (Medical Moral Code) to be modified to specifically prohibit the practice. As a deterrent, the state introduced penalties, which ranged from a verbal warning to the suspension of a medical license (Nuevo Código Moral Médica 2008).
Since the changes in the Medical Moral Code in 2008, the practice has, perhaps, become less common, but it remains virtually impossible to measure. It is a hidden practice, does not involve large amounts of money, there is an immediate benefit in return for the payment, and it is viewed by most people as a normal cost of doing business, rather than being considered a form of corruption. Consequently, the payment of biombos does not register on any of the government’s illicit income measurement mechanisms, nor does merit the attention of Costa Rica’s investigative journalists who have previously been able to expose major corruption scandals by tracking the spending habits of relevant government officials. The prohibition of biombos might also have changed the nature of the practice as it necessarily became more sophisticated. Currently, as an increasing number of doctors practice in both the private and state health care sector, they enjoy an increased level of control; patients might be obliged to pay for several private consultations and tests at a private clinic before they can undergo a major procedure at a public hospital.
Interestingly, the openness of access to the Constitutional Chamber of the Supreme Court may have helped limit the practice. The Constitutional Chamber provides two deterrents: firstly, individual patients who have to endure long waiting times for procedures, specialist visits or access to medication can petition the court (without hiring a lawyer) in order to pursue a quick, low-cost, personal resolution. In this context, there is no need to pay a biombo to move up the waiting list; instead they file a free, quick amparo (protection) claim with the Constitutional Chamber. This litigated approach may have the potential to produce similar results and ethical problems as the biombo. Although litigation is completely legal, it has been argued that it produces comparable unethical medical outcomes (Wilson 2014).
A second deterrent diminishing the incidence of biombos is related to the first; the low cost access to timely judicial resolutions. If medical personnel demand a biombo from a patient, the patient can denounce the doctor to the Constitutional Chamber of the Supreme Court. In this instance the court can level significant penalties against guilty medical practitioners, which increases the inherent risk of demanding a biombo.
- Organización Panamericana de la Salud. 2003. ‘Gasto y financiamiento de la salud en Costa Rica: situación actual, tendencias y retos’, Organización Panamericana de la Salud, Ministerio de Salud, Caja Costarricense de Seguro Social: San José, C.R.: OPS.
- Nuevo Código Moral Médica. 2008. Colegio de Médicos y Cirujanos de Costa Rica, http://www.unionmedica.com/ImagenesUp/documentos/Codigo%20Moral%20M%C3%A9dica.pdf
- Wilson, B. M. 2014. ‘D3.2.5. Background paper on Costa Rica. Costa Rica’s Anti-Corruption Trajectory: Strengths and Limitations.’ Work Package: WP3, Corruption and governance improvement in global and continental perspectives. Anti-Corruption Policies Revisited Project. EU/Hertie/GIGA. http://anticorrp.eu/wp-content/uploads/2014/03/Costa-Rica-Background-Report_final.pdf
- ‘Aniquilemos los biombos!’ 2012. Costa Rica Azul. June 25, Guerrero A. 2015. ‘Denuncian a cardiólogo quien habría hecho ‘biombo’ entre consulta privada y el Hospital México.’ Costa Rica Hoy. June 4, http://www.crhoy.com/denuncian-a-cardiologo-quien-habria-hecho-biombo-entre-consulta-privada-y-el-hospital-mexico/
- Norheim, O. F. and Wilson, B.M. 2014. ‘Health Rights Litigation and Access to Medicines: Priority Classification of Successful Cases from Costa Rica’s Constitutional Chamber of the Supreme Court’, Health and Human Rights: An International Journal 16:2.
- Sáenz, L. B. 2004. ‘Biombos’, un síntoma: Medidas para combatir actos delictivos. La Nacion, December 31, http://wvw.nacion.com/ln_ee/2004/diciembre/31/opinion7.html