This dissertation examines middle-class health care professionals’, providers’, and patients’ perceptions and experiences of the ideologies and practices of health care in San José, Costa Rica. More specifically, this study examines health care as a human right and health care as a commodity, as experienced in public and private health care and their mixing. Furthermore, it examines how Costa Ricans mix these ideologies and systems of care. Costa Rica is particularly important for the study of a mixed health care system because it not only has a successful public health care system that is facing important challenges but also a private sector that is intensifying and mixing with the public health care system in significant ways. In addition, it is well documented that the population holds strong beliefs about publically provided health care, but little is known about what happens to those beliefs when individuals use a mix of public and private health care.To date, although globally most health care systems commonly mix public and private health care, there is a paucity of research on experiences and perceptions of this mix. In order to examine this phenomenon, I conducted participant observation, focus groups, along with interviews with 74 health care professionals, providers, and patients who use a mix of public and private health care for their work and health care needs. This study found five key strategies for resolving the public–private health care tension in San José:1. Individuals struggled with problems of public health care, primarily long waits for care.2. In response, individuals found ways to manipulate the public health care system to make it work for them.3. Individuals also used informal networks of family and friends to address health issues without waiting.4. Individuals chose to use only the private health care system.5. Finally, some individuals used a mix of public and private health care.In sum, the perceptions and experiences of how individuals engage in these strategies indicate that as individuals in this study used a mix of public and private health care, they came to view health care, doctors, and the clinical experience as a commercial marketplace. Flexible medical citizenship is proposed as a means to understand the uncertainties, vulnerabilities, and inequalities that emerge as the ideologies and practices of public and private health care are mixed in daily life. Taken together, these findings illustrate the impact of neoliberal ideologies on health care, and how the once taboo topic of health care privatization has become more tenable.
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