Data updated for 2001

COSTA RICA

GENERAL SITUATION AND TRENDS

Socioeconomic, Political, and Demographic Overview

In 1995 Costa Rica had an area of 51,100 km2 and a population of 3.4 million inhabitants. There were seven administrative provinces and 81 cantons and nine planning regions. The country has enjoyed sustained economic growth, political stability and social progress. It has had no army for 49 years.

The economic crisis of the 1980s made it necessary to redesign the development model based on promoting exports and tourism and modernizing state institutions in the 1990s. In 1994, the per capita gross domestic product (GDP) was US$ 2,150, rising by 4.7% in 1995. At the end of 1995, the public foreign debt was US$ 3,255 million. In 1995, the foreign debt was equal to 37.5 % of GDP, while in the previous decade it was 67%.

It is estimated that 14.7% of households in 1995 lived in poverty. In 1989, that proportion was 21.9%. Approximately 80% of poor households are located in rural areas. The economically active population in 1995 numbered 1.2 million. Women make up 30% of the economically active population and young people aged 12-19 years, 13%. Among those aged 5-17 years, 13% work, but 34% of that group receives no remuneration. Open unemployment reached 5.2% in 1995. Among the poor more than 10% live in extreme poverty and 36% of the openly unemployed are women.

In 1991, the national dietary caloric availability was 2,261 kcal per person and it was higher in rural (2,355 kcal) than in urban (2,170 kcal) areas.

At the end of 1995, 99.6% of the population had access to water suitable for human consumption, 95.7% had a sewerage system or a system for sanitary disposal of excreta, and 93% had electricity.

Education is free and compulsory through the ninth grade, and the illiteracy rate is 7%. In 1994, illiteracy in persons over 13 was estimated at 8.8% in rural areas and 3.6% in urban areas. School enrollment rates are very high, and the dropout rate was 5% in 1995, the highest rate in recent decades.

The housing shortage is a problem—in 1994 it was estimated at 160,000 units; 91% of urban dwellings have basic services, compared with 81% of rural dwellings.

The last national census was conducted in 1984. According to estimates from the Department of Statistics and Censuses, the population density in 1995 was 65.8 inhabitants per km2. The annual growth rate fell from 3.0% in 1992 to 2.2% in 1995. Slightly over one-third of the population (34.4%) are children under 15, and 4.7% are over 65. Women make up 49% of the population, and 56.3% of the country’s inhabitants live in rural areas.

In 1996, international immigration was just under a quarter of a million people—51% from Nicaragua and 66% from other Central American countries.

Life expectancy at birth in the period 1990–1995 was 75.2 years and it is estimated at 75.6 for the period 1995–2000 (78.1 in women, 73.3 in men). The total fertility rate was 3.1 in the period 1990–1995. The crude birth rate was 23.9 per 1,000 population in 1995.

Mortality and Morbidity Profile

The total death rate was 4.2 per 1,000 population in 1995. Of the 13,278 deaths registered in 1994, 62.9% were persons aged 60 and over, 57.2% were male. The causes of death have not changed considerably in recent years. Only 2.1% of deaths were attributed to ill-defined causes. The leading cause of death was cardiovascular disease, with a death rate of 12.4 per 10,000 population in 1995. Ischemic heart disease was responsible for 47.2% of those deaths. The second leading cause of death was neoplasms, 8.4 per 10,000 population in 1995. In 1994, stomach cancer ranked first among neoplasms for both sexes, with prostate cancer ranking second for men and breast and cervical cancer in second and third place for women. External causes occupied third place as a cause of mortality, 5.0 per 10,000 population in 1995. This group of causes is responsible for the most years of potential life lost (YPLL), with 21.8% of all YPLL in 1994. Diseases of the respiratory system ranked fourth as a cause of death in 1995, with a rate of 4.6. Diseases of the digestive system ranked fifth, with a rate of 2.7.

The infant mortality rate was 13.0 per 1,000 live births in 1994. In seven cantons, infant mortality exceeded 20 per 1,000 and eight cantons had a rate of 15 to 20 per 1,000. In 1994, 69% of infant deaths were neonatal. Disorders originating in the perinatal period are the leading cause of infant mortality, 6.4 per 1,000 live births, followed by congenital anomalies, at 3.6. Maternal mortality ranged from 15 to 39 per 100,000 live births between 1990 and 1994. Among its causes, eclampsia ranked first.

The Social Security Fund survey in 1992, showed that there were 6.1 million consultations and an annual average of 1.9 consultations per inhabitant; 64.6% female. Respiratory diseases ranked first as a reason for consultation, followed by hypertension. In the 20-44 year age group, the leading cause was respiratory diseases, followed by back problems in men and gynecological disorders in women. to a sample of three hospitals, one of which is a national hospital, in 1995 respiratory diseases, injuries, childbirth, and asthma were the most frequent reasons for visits to emergency services.

The CCSS recorded 297,941 hospital discharges in 1994; 68.4 % female. In the 15-44 year age group 84% of discharges were women; in children under 15, 57% of discharges were boys and in older adults there were similar proportions of men and women. One-tenth of discharges was for emergencies.

In general, the number of discharges has remained stable since 1991. In 1994, the most frequent diagnoses at discharge were gynecological and obstetric causes, perineal trauma, intestinal infections, asthma, and hernias. In children, the leading causes were acute intestinal infections, asthma, chronic tonsillitis, and acute appendicitis. In adults 45 and over, hospitalizations for diabetes mellitus, inguinal hernias, prostate hyperplasia, and ischemic heart disease predominated.

SPECIFIC HEALTH PROBLEMS

Analysis by Population Group

In 1995, it was estimated that children under age 5 comprised 11.9% of the total population. There were 80,306 live births and 1,064 infant deaths, 13.3 per 1,000 live births and a neonatal mortality rate of 8.5. Disorders originating in the perinatal period were the leading cause of death in children under one, with a rate of 6.5; congenital anomalies, 3.7, and lung diseases, 1.3. Infectious and parasitic diseases were responsible for 4.4% of infant mortality, 0.6 per 1,000 live births.

In 1994, the CCSS registered 25,772 hospital discharges of children under one, 8.7% of the total; 56.2% male. The leading causes of hospitalization discharge were healthy newborns, jaundice, intestinal infections, and acute respiratory infections. In 1992, there were 242,641 consultations by children under one year at the CCSS, representing 4% of all consultations; 15% were for check ups.

In 1995, the deaths registered in the age group 1-4 years corresponded to 1.3% of all deaths, with a mortality rate of 5.9 per 10,000. Congenital anomalies were the leading cause of death in this group, followed closely by infectious and parasitic diseases and diseases of the respiratory system.

The population aged 1-4 years received 10% of total consultations with about equal numbers of boys and girls: 7 % were checkups; registered hospital discharges were 16,801, 5.6% of the total, and 41% of those discharged were girls. In this age group, the leading causes of hospitalization discharge were intestinal infection, asthma, bronchopneumonia, and inguinal hernias.

In 1995, 11.7% of the population was 5-9 years of age; 10.9 % was 10-14 years; and 9.8% was 15-19 years. The 5-14 year age group accounted for 1.6% of all mortality in the country and had the lowest mortality rate, 3 per 10,000. The leading causes of death were external causes—injuries and poisonings—followed by neoplasms and diseases of the nervous system.

In children aged 5-9 years, the leading reason for consultation was respiratory problems. The 10-14 year age group accounted for 4.8% of the total consultations. The leading reasons for consultation were acute upper respiratory infections, mental disorders in males and dermatoses in females; roughly 6% of were for checkups. The 15-19 year age group registered 5.2% of total consultations; 75.4% were women. The leading reasons for consultation in adolescents were related to menstruation, acute disorders of the upper respiratory system, gastroduodenitis, and obstetric complications; 15.7% of consultations in women were checkups. In this age group, the leading cause of consultation was acute disorders of the upper respiratory system; 5.9% were checkups.

The group aged 5-9 years was responsible for 4.4% of all hospital discharges; 60% were boys, where asthma was the leading cause of hospitalization, followed by chronic tonsillitis, which was also the leading cause in girls, followed by asthma.

The population aged 10-14 years comprised 3.1% of the total discharges, 54.5% males, in whom the leading causes of hospitalization were acute appendicitis, chronic tonsillitis, congenital anomalies, concussions, and asthma. In females, the leading cause of hospitalization was also acute appendicitis, 8.7% of discharges, followed by normal deliveries, 5.5%, chronic tonsillitis, premature deliveries, and asthma. Obstructed labor was the seventh leading cause of hospitalization, while unspecified complications of abortion was tenth.

The population 15-19 years of age registered 8.8% of hospital discharges, 84.7% females. The principal reason for hospitalization was gynecological and obstetric. Normal deliveries were 33%; premature, 11%, dystocial, 6%. Unspecified complications of abortion were 5% and others 4%.

In 1995, population aged 20-59 years was estimated at 1.6 million, 48.8% of the total. The population 60 years and over was estimated at 233,000, 6.9% of the total, 109,000 men and 124,000 women.

The leading causes of death in the group aged 15-34 years were external causes—injuries and poisonings—followed by neoplasms. In women, the third leading cause of death was cardiovascular disease, and in men it was endocrine and metabolic diseases and immunological disorders.

Among those aged 35-49 years, the leading causes of death in women were neoplasms, followed by cardiovascular disease and external causes. In men, external causes ranked first and cardiovascular disease was second.

Among those aged 50-69 years, the leading causes of death in women were neoplasms, cardiovascular and blood diseases, and diseases of the hematopoietic organs. In men 50-69, the predominant causes of death were cardiovascular disease, endocrine and metabolic diseases, immunological disorders, and external causes.

In the age group 70 and over, mortality was 644 per 10,000 in women and 850 per 10,000 in men. The leading causes of death in both sexes were cardiovascular diseases, neoplasms, and diseases of the respiratory system.

In 1992, 3.3 million consultations of persons aged 20-59 were registered, 53% of the total.

In the age group 20-44 years 73% of all consultations were by women, 15.6% for checkups. The leading causes of consultation were inflammatory diseases of the uterus, vagina, and vulva, followed by acute upper respiratory infections and direct obstetric complications. In men aged 20-44 years, checkups accounted for 4.7% of the total, and the leading causes of consultation were acute upper respiratory infections and upper and lower back problems.

The age group 45-59 years represented 14.2% of the total consultations, in 1992; 69.8% females. Hypertension was the leading cause of consultation, followed by diabetes in women and upper and lower back problems in men. The third leading cause was joint disorders in women and diabetes in men. Approximately 4.5% of consultations were checkups among men and 4.9% in women.

The age group 60 years and over comprised 14.2% of consultations at the CCSS. Hypertension was the leading reason for consultation, followed by diabetes mellitus and joint disorders.

Hospital discharges of population 20-44 years of age were 48.1% of the total in 1994. Of the 143,000 discharges in this group, 83.9% were women. The 10 leading causes of hospitalization among women were related to reproduction. Normal deliveries were 21.5% of discharges, obstructed labor, 8.0%, and premature deliveries, 7.3%. In men, the leading causes of hospitalization were acute appendicitis and inguinal hernias, less than 10% of all discharges.

The age group 45-59 years represented 7.1% of the population and accounted for 8.3% of all discharges. Women were 59.3% of hospital discharges and menstrual disorders were the leading cause of hospitalization, 5.6%, cholelithiasis, 4.9% and diabetes mellitus, 4.5%. In men diabetes mellitus, inguinal hernias, and ischemic heart disease were the three leading causes of hospitalization, accounting for 4.7%, 4.0%, and 3.1% of all discharges, respectively.

In the age group 60 and over, discharges were 4.4% of this group and 12.9% of all discharges. Men comprised 51% of hospital discharges where prostate hyperplasia comprised 7.2%, ischemic heart disease, 5.7%, cataracts, 4.6%, and chronic obstructive pulmonary disease 4.5%. In women, the leading causes of hospitalization were diabetes mellitus, 7.8%, cataracts, 5.6%, chronic obstructive pulmonary disease, 4.8%, ischemic heart disease, and fractures of the neck of the femur, 3.4%.

In the 1993 reproductive health survey, 75% of sexually active women use contraception. Of these, 28% use modern methods, 21% have been sterilized, 16% use barrier methods, and 10% use traditional methods. With regard to pregnant women, 75% begin prenatal checkups during the first trimester and 97% of deliveries are in hospitals; physicians attend 56 % of deliveries and nurses attend 41%.

Occupational health services coverage is around 25% for salaried workers, but near zero in the informal sector, representing approximately 30% of the working population. Agricultural workers are at high risk of exposure to pesticides. This trend is on the rise, but may be due in part to decreased underregistration, 43%. The risk of accidents for female agricultural workers may be 1.7 times higher than for male workers.

Indigenous population, 35,850 or 1% of the total is distributed among eight groups. Their infant mortality, birth, and total mortality rates are high compared to national averages. They experience major shortages of housing, drinking water and electricity. In 1995, social security was extended to them and the Department of Indigenous Education and the Technical College was established.

Analysis by Type of Disease

Communicable Diseases

Infectious and parasitic diseases were responsible for about 2.7% of all deaths registered between 1992 and 1995, with an annual mortality rate of about 1 per 10,000 population. Acute intestinal and respiratory infections are a major cause of hospitalization only in children under 5 and generate few outpatient services. However, in recent years, several communicable diseases have re-emerged.

Malaria cases were 6,951 in 1992, with an annual parasite index (API) of 7.9 per 1,000 population. Since 1991, malaria has shifted from the Pacific coast to the northern region and the Atlantic coast, coinciding with the development of the banana industry, deforestation, and migratory movements of temporary workers, which are factors that hinder case follow-up and control. There were 5,480 cases in 1996, with an API of 4.8 per 1,000. Plasmodium vivax was the infectious agent in 99.9% of the cases up through 1995. In 1996, 65 cases of imported Plasmodium falciparum were recorded. Although no deaths from malaria had been registered in over 20 years, in 1996 two deaths occurred. from P. falciparum.

Since 1992 the Aedes aegypti mosquito has been detected in localities where it had never previously been found at altitudes over 700 m above sea level. In 1994, rates of infestation of up to 32.2% were detected in the south central region. In late 1993 there was a dengue outbreak with 4,612 cases; 13,929 cases were reported in 1994 and 5,135 in 1995, including the first case of dengue hemorrhagic fever. In 1996, 2,309 cases and the first two deaths from dengue were registered. Serotype 1 started the epidemic. Two cases of serotypes 2 and 4 were detected, but not isolated again. In 1995, serotype 3 was detected in several regions of the country; in 1996 its presence increased. The majority of cases were in areas with high population density, in the age group 20-40 years, and in women.

A measles epidemic that began in 1990 in Guanacaste spread to the rest of the country and did not subside until December 1993. In that period, 9,292 cases and 56 deaths were registered. Many cases were in adolescents and young adults; however, the incidence and case-fatality rates were higher in children under 1 year of age. In 1994, 103 cases and no deaths were registered; in 1995, 250 cases were reported, but 86% were not measles. In 1996, 148 cases were reported, 84 % of which were not measles.

In the period 1992–1996, rubella exhibited a downward trend. Laboratory confirmation has been available since 1995. That year 67 cases were confirmed—7 in the laboratory. In 1996, 37 cases were confirmed—15 in the laboratory. There were no cases of congenital rubella syndrome, 1992-1996.

Since 1973, no cases of poliomyelitis have been registered, and eradication of the circulation of wild poliovirus was confirmed in 1994. In the period 1990–1995, there were no known cases of diphtheria, and the last case of neonatal tetanus was reported in 1988. The incidence of whooping cough has been low since 1991, with a downward trend, dropping from 1.1 per 100,000 population in 1992 to 0.2 per 100,000 in 1996, with only one death, in 1995, in the entire period.

Cholera was detected in Costa Rica in 1992. That year 12 cases were reported. In 1996, 36 cases were recorded, 19 of which were imported. As of 1996, 123 cases had been reported, 74% of which were imported. That year multiple antimicrobial resistance of Vibrio cholerae in all the isolates was detected, as was the first death from cholera. The most affected area was the northern border. In 1992, the predominant biotype was the Tor, Inaba serotype; the Ogawa serotype was predominant in later years.

Tuberculosis has shown a dramatic increase with incidence rates of 11.4 per 100,000 in 1992 and 19.0 per 100,000 in 1996. However, the incidence of tuberculous meningitis in children under 5 is stable and low. Twice as many cases are diagnosed in men as in women. Roughly 90% of cases are pulmonary tuberculosis. In 1994, 80 deaths from tuberculosis were registered, representing 25% of all deaths from infectious and parasitic diseases that year. In 1995, the national mortality rate from tuberculosis was 2.1 per 100,000. There are no data on treatment effectiveness and none linking tuberculosis and HIV.

Leprosy is no longer a public health problem. In late 1996, there were 158 registered cases. However, the cases are concentrated in the central Pacific coast, Huetar Atlántica, and Huetar Norte regions, all three of which have prevalence rates of over 1.2 per 10,000; 78% of the cases are multibacillary; the ratio of men to women is 2; and cases in children under 15 are unusual. In 1996, disability, primarily of the hands, was detected in 35% of the diagnosed cases.

No cases of human rabies have been registered for almost 30 years. Epidemiological surveillance activities, vaccination of dogs, and joint activities along the northern border are being carried out. There are no efficient reporting and surveillance systems for other zoonoses.

The first known cases of AIDS in Costa Rica, in the first half of the 1980s, occurred in hemophiliacs. In 1985, cases began to be recorded in homosexuals, and in the 1990s heterosexual and vertical transmission have emerged, with a growing trend in recent years. Parenteral transmission was never significant (0.6% of the cases are in intravenous drug users and another 0.6% were people exposed through blood transfusions). In recent years, 100% of transfusions have been screened for HIV.

In 1990, 94 AIDS cases were diagnosed, jumping to 207 in 1995. According to preliminary data from 1996, 202 cases of AIDS were registered, with an incidence rate of 5.3 per 100,000; 90.5% of the cases were in men. For men, the group most widely affected was homosexuals, 37.4%, followed by heterosexuals, 20.6% and bisexuals, 19.6%. From the onset of the epidemic through 1996, 1,156 AIDS cases and 621 deaths were registered in Costa Rica.

There has been a gradual reduction in the reporting of cases of other STDs, particularly gonorrhea, whose incidence plummeted from 433.8 per 100,000 population in 1982 to 123.7 in 1990 and 68.6 in 1995. The incidence of syphilis also decreased from 99.8 per 100,000 in 1983 to 54.3 in 1990 and 44.7 in 1995. The persistence of congenital syphilis is noteworthy. In recent years, some 90 to 150 cases have been registered annually.

Noncommunicable Diseases and Other Health-Related Problems

The 1996 National Nutrition Survey showed results by gender for children aged 1-6, with to the Waterlow classification: 92% normal; 2% acute malnutrition; 5.7% chronic malnutrition; and 0.3% acute and chronic malnutrition. The body mass index was used: 16.4% had a nutritional deficit and 14.9% were overweight. Excess weight occurred in 16.3% of girls and 13.6% of boys. No differences in nutritional deficiencies by sex were observed, while the proportion of low birthweight infants was 6.1% in 1995. There were 1,292 cases of endemic goiter reported in 1994, 91% female, 63% in the childbearing age.

Diabetes mellitus was the ninth leading cause of death, 258 deaths in 1994. It was the eighth leading reason for medical consultations in men and fourth in women and appeared as the fourth leading cause of hospitalization. In 1995 it was cited in 4,421 discharges, mostly women.

Cardiovascular disease was the leading cause of death in Costa Rica. It had a mortality rate of 12.5 per 10,000 population in 1994, 31% of all deaths, with deaths increasing at an annual rate of 4.4% between 1992 and 1994. Together with neoplasms, they are responsible for half of all deaths; add injuries and diseases of the respiratory system and they account for 75% of deaths in Costa Rica. It is estimated that 15% of the Costa Rican population over the age of 15 is hypertensive. In a 1992 survey of causes of medical consultations, hypertension ranked second in both men and women.

Among cardiovascular diseases, the leading cause of death is ischemic heart disease, followed by cerebrovascular disease and then diseases of pulmonary circulation and other forms of heart disease. In 1994, ischemic heart disease was the third leading cause of hospitalization in men 45-59 years of age. In the population 60 and over, it ranked second in men and fourth in women.

Deaths from cardiovascular disease usually occur at relatively advanced ages; therefore they rank fourth as a cause of YPLL. Cardiovascular diseases produce half as many YPLL as unintentional injuries or accidents, which rank first as a cause of YPLL.

Malignant neoplasms are the second leading cause of death. In the period 1992–1994, they were responsible for 8.1 deaths per 10,000 population annually and were the third leading cause of YPLL. The most frequent forms are neoplasms of the stomach, lung, prostate, breast, cervix, and uterus. In general, mortality from malignant neoplasms remained stable in the period 1985–1995, except for prostate cancer in men, which increased, and stomach cancer in women, which decreased.

In general, the incidence of cancer from1985–1994 remained stable, although in women there was a decrease in cancer of the stomach, lung, cervix, and hematopoietic and reticuloendothelial systems and an increase in breast cancer. In men, the incidence of lung and prostate cancer increased and that of the stomach and the hematopoietic and reticuloendothelial systems decreased.

Neoplasms were the sixth leading cause of hospitalization from 1988–1995. Lymphomas, leukemias, and cancers of the stomach and reproductive system are the most frequent cause associated with hospital discharges of men. In women, the most frequent types of cancer as a cause of hospitalization are those of the reproductive system, particularly cervical cancer.

Accidents, injuries and poisonings ranked third as a cause of death, in 1994. They produced 12.2% of deaths with a rate of 48.9 per 100,000 population, and 21.8% of YPLL . They were the leading cause of loss of healthy life.

In 1994, mortality from traffic accidents had a rate of 17.5 per 100,000; deaths from motor vehicle accidents involving pedestrians were 44%, followed by collisions between vehicles. Injuries from motor vehicle accidents involving pedestrians were 47.1% of deaths from external causes.

In 1994, homicide and intentionally inflicted injuries were responsible for 183 deaths and 3% of YPLL; firearms caused 54% and stabbings 38%. In 1994, there were 162 suicides or 2.5% of YPLL.

The health sector has no registry for health problems stemming from domestic violence. Partial data, are presented here. In 1994, the Office of Women’s Affairs, a judicial arm of the Ministry of the Interior, treated 2,299 women victims of violence. In 1995, such complaints rose to 5,597 and by May 1996, 4,221 complaints had been registered. This increase may be related to the establishment of a National Plan against Family Violence in 1995 and the promulgation of a law punishing assaults on women. According to this same source, in 1995 and through May 1996, 715 complaints were handled from young people 15- 20 years of age who were victims of domestic violence.

In the first quarter of 1997, the National Children’s Foundation, a government agency specializing in the protection of children, reported treating 24,044 children and adolescents. The leading reasons for treatment were family conflicts 5,423 cases and abandonment 5,639 cases.

The National Geriatrics Hospital is the only center that has begun recording domestic violence against the elderly. In 1995–1996, 92 cases of abandonment were handled, 87 of which were women.

In the last national study in 1992, there was a DMFT (decayed, missing, and filled teeth) Index of 4.9 in the 12 year old population.

Between 1992 and 1996, the geological instability of the country, climatic phenomena, and damage to the ecological balance caused by the urban-rural distribution and economic development have led to floods, landslides, earthquakes, volcanic eruptions, and other disasters. In that period, the 1992 earthquake in Pejibaye and the August 1993 tropical storm Bret were declared national emergencies. In 1995, there were 32 floods resulting from hurricanes or other storms. In 1996, the flooding in Limón and in the south left a death toll of nine. That same year, as a result of hurricane Cesar, there were floods in the central and southern Pacific coast that affected 451,496 people, leaving 4,560 persons in shelters and 39 dead. In October 1996, the floods caused by hurricanes Lili and Marco caused seven deaths in Guanacaste and the northern area of the country.

RESPONSE OF THE HEALTH SYSTEM

National Health Plans and Policies

The national health policy and the strategic plan of the health sector, 1994–1998 incorporate the social policies of the national development plan. That plan states that the State will play a central role to ensure favorable conditions for improving health and delivering services, based on the following criteria: solidarity of financing; equitable access; universal coverage; high levels of quality, opportunity, and flexibility; efficient use of resources; and compassionate treatment of patients.

Health sector reform includes leadership of the Ministry of Health with the development and monitoring of health and scientific research and technology. It also means adjusting care at the primary level to handle local health problems, promoting community participation, and trimming public spending. The model uses health teams that provide basic services, subdivided into five comprehensive care programs for children, adolescents, women, adults, and the elderly.

Organization of the Health Sector

Institutional Organization

In 1983, the health sector was defined as the Ministry of Health, the Ministry of National Planning and Economic Policy, the Ministry of the Presidency, the Costa Rican Institute of Water and Sewerage Systems, the CCSS, and the University of Costa Rica. In 1989, the health sector definition was expanded to include participation by municipalities, private services, communities, and other universities.

Agreements defining sectoral reform include the 1993 Loan Agreement and Health Sector Reform Project with the World Bank, the 1994 law on the loan contract between the Government of Costa Rica and the IDB to finance the steering role of the Ministry of Health, improve the physical infrastructure of health centers and health posts, and build the Alajuela hospital.

The Ministry of Health is playing a leadership role within the framework of sectoral reform, with strategic management, leadership, and regulatory functions; the CCSS is responsible for service delivery. Financing for maternity and health insurance is tripartite, with contributions based on wages from employers (9%), the State (0.3%), and workers (6%). In the case of voluntary beneficiaries, workers contribute 13 % and the State contributes 0.3%. The poor are covered by the State. A small sector of the population uses private health services, whose supply has increased in recent years. There are no data on the demand for and coverage of private services. The CCSS must cover 100% of the population. Currently 90% of the population is insured; the rest is covered by the State.

The decentralization process is being implemented for three levels of care, based on separation of financing and service delivery functions. Private participation in the national health system is regulated by the General Health Act and the General Health Regulations. Regulating health facilities has begun as a pilot project, with an accreditation process for public and private maternity hospitals, adhering to standards set by the Ministry of Health.

The respective professional associations established by law regulate certification and practice in the health professions. Sanitary controls for and registration of drugs, food, and hazardous toxic substances are the responsibility of the Department of Drugs and Narcotics Controls and Registries of the Ministry of Health. Health regulation and surveillance, which includes the monitoring of air and soil quality, housing, chemical safety, and hazardous waste, are the responsibility of the Environmental Sanitation Division of the Ministry of Health. The surveillance system is being organized, and the formulation of national standards on water quality and regulations governing effluents and the recycling of wastewater has already been completed. Food is included in this program, but is not yet developed. There are currently no health controls or registries for biomedical equipment and materials.

Health Services and Resources

Since 1995, the Ministry of Health has had a National Program for Health Promotion and Protection in place that promotes social participation and links together its education and mass communication components. In 1995, the vaccination was over 84% for all vaccines, although there is great disparity among cantons. In 1997, coverage with the three-dose oral polio vaccine was over 80% in 67 of 81 existing cantons; coverage with the diphtheria, tetanus, and whooping cough (DTP) vaccine was under 88% in 72 cantons; and coverage with the measles vaccine in 1-year-olds exceeded 88% in 72 cantons. At present, all newborns in CCSS medical units receive the BCG and hepatitis B vaccines, which represents 99% coverage at the national level.

In 1996, there was little epidemiological surveillance for a number of reportable diseases and for pesticide poisoning. Entomological surveillance is conducted to combat malaria and dengue, and monitoring of water quality is the responsibility of the special basic sanitation program.

Investigating and detecting suspected cases of disease or circumstances subject to epidemiological surveillance are carried out at the local level, the CCSS, hospitals, and laboratories. There is little coordination at the local and regional levels of the two institutions, and there is insufficient capacity for data analysis at those levels. However, there is a growing operations research capability and rapid response to epidemic outbreaks. Data are published in the Weekly Epidemiological Bulletin.

The capacity for diagnosing dengue, cholera, leptospirosis, meningococcal meningitis, measles, and rubella is ensured by the national reference laboratory. A research center (ICMRT) linked to the University of Louisiana, in the United States, which offers diagnostic services to the CCSS, has the capacity to diagnose hepatitis and cytomegalovirus. Diagnosis of malaria is concentrated in the laboratory at the central level, although in 1996 it began to be decentralized to some local services in priority areas. The AIDS Control Department has a diagnostic and reference laboratory for public and private laboratories that diagnose HIV and for blood banks. There is diagnostic capacity for Escherichia coli and rotavirus in the National Children’s Hospital.

Deaths in children under one began to be monitored in 1996 and maternal mortality was monitored in 1997. There are standards and instruments for investigating every death in each establishment. Surveillance of pesticide poisoning was implemented experimentally in some areas in 1995, and in 1997 it began to be extended to the entire country.

By law, the Costa Rican Institute of Water and Sewerage Systems (AyA) is responsible for designing and building water and sewerage systems. Municipalities have the primary responsibility for water and sanitation, and many of them manage their systems without the AyA.

The AyA administers 141 water supply systems, which cover approximately 63% of the population. In addition, there are 2,214 water supply systems operated by 150 municipalities, 1,664 community committees, and 400 private businesses. The quality of the water in these systems is unknown and is neither controlled nor monitored by the Ministry of Health.

With respect to wastewater, it is estimated that the effluents from only 3% of the population are treated before being discharged. The Tárcoles river receives raw sewerage from the metropolitan area in addition to virtually untreated wastewater, most of which is from tanneries and from the food, coffee, and textile industries.

The municipalities are legally responsible for solving the problem of domestic solid waste. The Executive Unit for Solid Waste of the Ministry of the Environment and Energy collaborates with the municipalities in this area. Some private firms also provide urban services for refuse collection and elimination in controlled sanitary landfills. Solid waste from hospitals is the responsibility of the CCSS and, for the time being, is sent to landfills or municipal dumps.

With regard to solid waste collection, coverage reaches 62 % of the population. Roughly 62 municipalities (70%) deposit their solid waste in dumps, 55 of which are in the open air throughout the country. According to the National Waste Management Plan, approximately 11,764 tons of waste are generated daily in Costa Rica, 86% of which is agroindustrial waste, 13.6% is ordinary waste, and 0.4% is hazardous waste. Hospital waste is almost always sent to municipal dumps, burned in the open air, thrown away, or sold.

The Ministry of Health is responsible for monitoring and controlling air pollution in general, and the Ministry of the Environment is responsible for environmental protection, but there are no air quality standards. The current standards for regulating the emission of contaminants were prepared to support an environmental management program in the metropolitan area.

The main measures adopted by the Ministry of Health to reduce the emission of air pollutants include the installation of emission control equipment in the main industries, sampling conducted by specialized laboratories, direct sampling from chimneys, and the corresponding analyses. The Environmental Control Department verifies the efficiency of contaminant removal and requests improvements and controls when necessary. Furthermore, the Ministry of Public Works and Transportation, through the Transit Police, conducts a program for controlling motor vehicle pollution. In 1994, regulations on vehicle emissions were promulgated. By law, only unleaded gasoline is produced. The "Ecomarchamo" program, whose purpose is to reduce vehicle emissions, is under the jurisdiction of the Ministry of the Environment and Energy, the Ministry of Public Works, and the Transit Police. The Environmental Sanitation Bureau, a unit of the Ministry of Health, operates a network to monitor air quality in the San José metropolitan area. The work of the National University in laboratory studies and testing has been very important. It has technical and financial support of ProEco, financed with Swiss funds.

Several years ago, a decree was issued prohibiting smoking in public places. The CCSS and the Ministry of Health are conducting educational programs and anti-smoking campaigns. The occupational safety and health regulations and those governing enclosed spaces include guidelines on ventilation as well as control of asbestos sale and use.

There is no defined policy on food safety or plan of action to coordinate the institutional food protection programs. By law, the responsibility for the coordination, orientation, execution, supervision, and evaluation of the programs lies with the Ministry of Health. Other participants are the Ministry of Agriculture and Livestock, through the Plant Health, Meat Inspection, and Animal Quarantine Departments, and the Ministry of Economics, Industry, and Commerce, through the National Office on Standards and Units of Measure, which regulates metrology, labeling, and quality control. All these institutions have well-equipped laboratories.

The country has technical policy instruments for food regulation, and the Ministry of Health is a member of the Joint FAO/WHO Codex Alimentarius Commission. Costa Rica has also signed the World Trade Organization agreements on health. The University of Costa Rica and the Costa Rican Institute for Research and Teaching in Nutrition and Health have conducted several studies of fresh livestock products, particularly with regard to pesticides, hormones, and heavy metals.

Continuing education courses with national coverage were established for food-handlers. Food vending on the street is not a major health problem, although it is on the rise. The Program for Supplementary Feeding in educational centers has broad coverage, especially in rural and marginal urban schools.

The CCSS consists of a central level responsible for institutional policies, a regional level of seven regional medical service offices, and a local level comprising health areas and sectors. At the tertiary level, the CCSS has three national general hospitals and six national specialized hospitals. At the secondary level, there are 7 regional hospitals, 13 peripheral hospitals, and 38 type 3 and 4. The primary level is made up of 103 clinics, as well as health centers and health posts. Each level of care covers a given territory, and the facilities make up a clearly defined service network with levels of care based on the degree of complexity and response capacity. The system for transfer and return of patients among peripheral, regional, and national hospitals has been defined.

The strategy for strengthening the primary care level has the goal of forming 800 health sectors with basic comprehensive care teams. In July 1996, 306 sectors were already in operation, covering 1.13 million inhabitants. This infrastructure is located in areas of lesser socioeconomic development. The Ministry of Health still operates some health centers and health posts, mobile medical and dental units, dental school clinics, comprehensive health care centers, school lunchrooms, and comprehensive child health and nutrition centers.

The Ministry of Health has provided preventive oral health services to schoolchildren and pregnant women, whereas the CCSS offers more complex services to direct insurance subscribers and less complex procedures to their dependents. In recent years, dentistry programs have been established in three private universities, and private practice has proliferated in this area.

Psychiatric care in the country is provided in all the national and regional hospitals and type IV clinics, as well as in some peripheral hospitals. The main psychiatric center is the National Psychiatric Hospital, with 800 beds, 600 of which are for chronically ill patients. Another hospital for chronically ill has 300 beds. Decentralization is in progress. The Institute on Alcoholism and Drug Dependence treats drug addiction on an outpatient basis. There are three schools of psychology, two are private; a state school of social work; and a graduate specialization in psychiatry at the national university.

Since 1994, adolescents have actively participated in the planning and execution of activities and projects targeted to this age group.

Reproductive health services, which were traditionally the responsibility of the Ministry of Health, were transferred to the CCSS. The Costa Rican Demographic Association, a nongovernmental organization with external financing, supports CCSS services with family planning offices and activities to detect cervical and breast cancer.

The CCSS has a comprehensive care program for the elderly and a geriatric hospital. There is a graduate program in gerontology and geriatrics and a master’s program in gerontology.

The Official Drug List is an integral part of the National Drug Formulary. In the CCSS, drugs are selected based on their effectiveness and safety, as well as their price. In 1997, the CCSS allocated 7.6% of its budget for drugs, for a total of US$ 49.49 million. Per capita spending on drugs in the CCSS was US$ 16 in 1997. In 1997, the country had 161 pharmacies.

Hospital medical equipment is centralized in the three national hospitals, which have over one-third of the total; the 13 peripheral hospitals have only one-fifth. One in 10 pieces of equipment in the country is not in good condition, and over 6% of equipment is underutilized. In general, surgical and emergency units are considered to be well equipped and well structured. However, space is sometimes lacking in intensive care units. Furthermore, the procurement and use of equipment is not coordinated.

There are no clear policies or coordinated human resources programs for health. In 1995, for every 10,000 Costa Ricans there were 12.7 physicians, 3.8 dentists, 9.6 nurses, 3.6 pharmacists, 20 nursing auxiliaries, 0.3 sanitation engineers, 2.5 community assistants, and 0.6 nutritionists.

Education for the health professions is provided in several public and private teaching, university, and para-university centers. In 1989, the university established a master’s degree in public health. Sector institutions have the responsibility for continuing education and training, and the Center for Strategic Development and Information on Health and Social Security plays a very important role in human resources education for health services. The Costa Rican Institute for Research and Education in Nutrition and Health and the School of Public Health of the University of Costa Rica are the institutions that conduct the bulk of health research.

Inputs for Health

Total public expenditure on health in 1996 was US$ 889 million. In that same year, public expenditure in health as a percentage of GDP was 9.8%, 0.7% of which corresponded to the Ministry of Health, 8.0% to the CCSS, 0.5% to the Costa Rican Institute of Water and Sewerage Systems, 0.4% to the National Insurance Institute, and 0.2% to the municipalities. Public expenditure in health in 1996 was distributed in the following manner: 81.9% for the CCSS, 6.4% for the Ministry of Health, 5.3% for the National Institute of Water and Sewerage Systems, 4.2% for the National Insurance Institute, and 2.1% for the municipalities.

In Costa Rica, the public sector has been the predominant sector in financing and delivering health services, a trend that continues. Up-to-date information on private sector participation is not available.

The CCSS has a modernization and hospital infrastructure development program financed by the World Bank. Cooperation projects are also under way with the IDB for institutional strengthening of the Ministry of Health, development of the steering role of the sector, and upgrading of the health services infrastructure for primary care. With other agencies of the United Nations, such as the UNDP, UNICEF, UNFPA, and PAHO, there are broad cooperation programs for healthy communities, service delivery, the steering role, the quality of care and disease prevention, and the control of environmental degradation.

To review the Health Systems and Services Country Profile of the Health Sector Reform click here