Puerto Rico's indigent population has relied exclusively on the local government for their healthcare needs since the start of the island's commonwealth status. The government maintained several hospitals, emergency centers, and free clinics, including the Rio Piedras Medical Center ("Centro Médico" in Spanish) which is considered the largest hospital on the island and one of the largest in the Caribbean. However, this system presented substantial costs to the government while generating increasing criticism from the public and media citing a sluggish bureaucracy and poor services from unprofessional government workers.