Pan American Health Organization

Costa Rica

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of Costa RicaThe Republic of Costa Rica extends for 51,100 km2 and is structured into three political levels: seven provinces, 81 cantons, and 463 districts. The country is located between two oceans in the Central American isthmus, a geologic formation that is considered young, with high tectonic and volcanic activity, and a landscape of plains and mountains. All these features pose a continuing risk. Most emergencies affecting the country are associated with rain and wind, which may occur at any time of year ().

Demographics

The country’s total population in 2016 was 4.8 million inhabitants (76.8% urban and 23.2% rural), of whom 8.9% were over 65 years of age and 22.3% were children under 15, according to data from the preceding year. The demographic bonus will last until 2045, but by 2035 the proportion of the population over age 65 will surpass that of children under 15 (). Between 1990 and 2015, the population grew by 55.3%. Figure 1 shows Costa Rica’s population structure in 1990 and 2015.

Figure 1. Population structure, by age and sex, Costa Rica, 1990 and 2015

Between 1990 and 2015, the population grew by 55.3%. In 1990, the age structure of the population showed rapid expansion. By 2015, with the aging of the population, the population pyramid had acquired a regressive structure, with a smaller proportion of the population under age 35, as a result of the significant decline in fertility and mortality rates over the past three decades.

Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Population Division. New York; 2015.

Overall life expectancy was 79.16 years. With a life expectancy of 81, women live, on average, four years longer than men, but they live 10 years with disease and disability; while men, with a life expectancy of 77, live the last nine years of their lives with disease and disability ().

Of the total population, 2.42% describe themselves as indigenous, 1.9% as Afro–Costa Ricans, and 0.5% as Chinese (). Of the indigenous group, 52,434 are men (50.3%) and 51,709 are women (49.7%).

The Economy

Costa Rica is among the countries with high human development and is ranked fifth in Latin America on this scale as a result of strong social public investment. However, when calculation of the Human Development Index (HDI) is adjusted for inequality, the country falls 11 places from its world ranking on the 2014 HDI.

Gross domestic product (GDP) per capita grew 2.8% in 2015, a moderate rate, although slower than in the four preceding years. Public spending on health represented 6.8% of GDP. As a percentage of total government spending, health expenditure decreased by 0.71 percentage points between 2013 and 2014.

The employment rate is 69.5% for men and 34.9% for women. For indigenous people living in their own territories, the rates are 56.2% and 16.9% for males and females, respectively ().

Violence and Security

Security is a matter of concern due to high rates of homicide, theft, and violation of the Psychotropic Substances Law. In 2014, the homicide rate increased by 14.6% over 2013; 69% of murders were committed with firearms, with victims disproportionately between 20 and 29 years of age, a group that represented 34% of all victims.

This deterioration in security is concentrated in certain communities and is directly related to societal breakdown problems associated in particular with drug trafficking and organized crime (). There are also groups that commit petty crime and subsistence crime, generally in vulnerable, densely populated areas where drugs are sold and distributed.

Leading Environmental Problems

Costa Rica has environmental strengths, and is committed to becoming a carbon-neutral country by 2021. However, in light of challenges such as the preservation of water resources, the rational exploitation of marine resources, waste management, ways to adapt to climate change, and use of clean energy sources to reduce dependence on fossil fuels, Costa Rica ranked 54th among 178 countries on the Environmental Performance Index in 2012, with an ecological debt of 8% in 2014 ().

Health Policies, Plans, and Programs

While constructing the post-2015 development agenda, the government carried out a nationwide consultation in which most Costa Rican citizens expressed their desires for the future: a more inclusive, equitable, and secure society; a sustainable health system that meets health needs with user-friendly, high-quality services; and comprehensive education.

Meanwhile, the National Health Policy 2014–2018, which forms the basis for the development of the National Health Plan, calls for actions to achieve equity and universality in health services by strengthening primary care and addressing critical problems in health.

Social Determinants of Health

The government has made a commitment to a development model based on equity, social inclusion, knowledge, innovation, and sustainable development. The National Development Plan 2015–2018 calls for actions to promote economic growth and create high-quality jobs, combat poverty while reducing inequality, and ensure open, transparent, and efficient government (). Toward this end, a high-level council has been formed for the implementation and monitoring of the Sustainable Development Goals (SDGs).

In 2012 the country promulgated the General Law on the Control of Tobacco and Its Harmful Effects on Health (Law No. 9028), whose purpose is to enact the measures necessary to protect people from the health, social, environmental, and economic consequences of tobacco consumption and exposure to tobacco smoke.

Vulnerable Populations

In 2015, 21.7% of households in the country were living in poverty, and 7.2% in extreme poverty; however, in the Brunca region these figures were 35.4% and 13.7%, respectively (). At the same time, income inequality persisted, with 54.4% in the highest quintile and 4.1% in the lowest quintile.

Open unemployment affected 10.1% of the workforce (12.3% of women and 8.8% of men), while 45.3% of the employed workforce was in the informal sector () that year. Women on average are paid 14% less than men for equivalent work.

In 2015, the literacy rate was 97.8%, and almost 90% of girls and boys completed primary education. Although mean years of schooling for the adult population reached 8.4 over the past five years, 2013 data for adults show 83% coverage of diversified secondary education for men and 68% for women. Moreover, data for that year also show low performance in reading comprehension and mathematical problem solving, which has an impact on the availability of skilled human resources in the most dynamic sectors of the economy.

Indigenous people, people with disabilities, seasonal workers, and migrants are the most vulnerable populations. The indigenous population, 47% of which is concentrated in 22 territories, shows high levels of poverty and marginalization, especially among women.

Persons with disabilities have restricted access to education and the labor market, in addition to suffering discrimination.

At the national level, 24.6% of Costa Ricans have at least one unmet basic need, and 70.1% live in indigenous territories. The groups with the highest levels of unmet needs are the indigenous Cabécar (92.6%), Téribe (87.9%), and Ngöbe (79.2%) peoples.

The Health System

The Political Constitution of the Republic of Costa Rica recognizes the right to life. The General Health Law (1973) defines the health of the population as a public good and holds the State responsible for maintaining it, through the health system.

The national health system comprises the health sector, private health care services and entities working to protect and improve the human habitat, community organizations concerned with health, universities, municipalities, pharmaceutical companies, the National Commission for Risk Prevention and Emergency Management, and international cooperation agencies.

The health sector, for its part, includes the Ministry of Health, the Costa Rican Social Security Fund (CCSS), the Costa Rican Water Supply and Sewerage Institute, and other public institutions in charge of protecting and improving the health of the population. The Ministry, in its leadership role, provides management and political leadership, health regulation, research guidance, and technological development. Its regulatory function includes standards and regulations regarding the environment, food supply, and medicines.

Additionally, bodies attached to the Ministry of Health include the Education and Nutrition Centers (CEN), the Child Nutrition and Comprehensive Care Centers (CINAI), the Institute on Alcoholism and Drug Dependence (IAFA), the Institute for Research and Education on Nutrition and Health (INCIENSA), and the National Insurance Institute (INS), which is responsible for coverage of occupational and transportation risks and for providing relevant care.

Health care services are offered by both the public and private sectors. The main actor in the public sector is the CCSS, an autonomous institution in charge of financing, purchasing, and providing individual services, without caps or copayments at time of service. It is financed through contributions from members, employers, and the State. The CCSS administers three plans: sickness and maternity insurance; disability, old age, and death insurance; and the noncontributory scheme. It offers services in its own facilities as well as in private sector facilities through outsourcing contracts.

The CCSS model of health services delivery is based on the principles of social security: universality, solidarity, unity, equality, comprehensiveness, social participation, progressive benefit formula, and accordance with economic reality. It aims to provide access, continuity, acceptability, effectiveness, and efficiency, using a people-centered approach.

The private sector, for its part, encompasses a broad network of providers who offer ambulatory and specialized services, both financed through cash payments or private insurance premiums.

The country’s laws require health insurance to be offered on a progressive basis to the entire population. This contributory insurance plan currently covers five groups with different types of coverage: i) active direct beneficiaries; ii) family members of direct beneficiaries; iii) the poor and their family members, who are insured at State expense; iv) pensioners; and v) uninsured people. The first level of care is organized into 104 health areas, divided into 1,041 sectors, each of which is assigned a Basic Comprehensive Health Care Team (EBAIS) that carries out promotion, prevention, treatment, and rehabilitation. There are also 718 basic health care posts. The second level consists of larger clinics: seven regional hospitals and 13 peripheral hospitals that offer specialized consultation, hospitalization, and surgery in core specialties. The third level includes three national general hospitals and six specialized hospitals of higher complexity ().

Although the population has access to medicines and other health technologies, achieving their rational use remains a challenge, given the weakness of coordination and regulatory mechanisms. Moreover, there are gaps in the implementation of the legal framework, as well as administrative barriers to effective access to health services for the population in extreme poverty, for certain indigenous groups, and for seasonal and migrant workers.

Leading Health Challenges

Critical Health Problems

The National Development Plan identifies as leading health and nutrition problems the disparities between regions of the country in reduction of neonatal mortality; nutritional deficiencies in children; overweight in adults; and the prevalence of chronic diseases and increasing cost of their care. The weakening of the Ministry of Health’s leadership is considered to be another problem, mainly due in part to flaws in organization, monitoring, and evaluation, as well as unclear separation of functions and weak coordination with the CCSS.

Furthermore, the service delivery model does not adequately meet the needs and expectations of the population, given limitations of equity, quality, and timeliness and a lack of emphasis on disease prevention and health promotion approaches to health. The infrastructure and equipment in some health facilities has deteriorated so seriously that it creates problems of effectiveness and efficiency in the supply of health services ().

Chronic Conditions

In 2012, the most frequent cancers in men were cancers of the skin (56.14 per 100,000 population), prostate (47.91), stomach (18.29), colon (9.58), hematopoietic system (8.43), and lungs (7.28). All have shown a rising trend since 2000, except for stomach cancer, which declined by 47%. Among women, the most frequent types of cancer in 2011 were skin (44.64 per 100,000 population), breast (41.96), cervix (27.10), thyroid (20.14), stomach (11.64), and colon (9.27). None of these have shown great rate changes since 2000, except for cervical cancer, which declined by 46% ().

Diseases of the circulatory system, especially ischemic heart disease and chronic obstructive pulmonary disease, are a major cause of demand for care and hospitalization.

Human Resources

In 2014, Costa Rica had 22.8 physicians, 24.4 nurses, and 9.3 dentists per 10,000 population, a figure that meets the density of health human resources specified by the Pan American Health Organization’s Regional Goals for Human Resources for Health. The country also met the targets for proportion of primary care physicians in the medical workforce, ratio of nurses to physicians, reduction of the gap between rural and urban areas in distribution of health personnel, and recruitment of health workers from their own communities. The targets for public health and intercultural competencies in care were not met, however.

Costa Rica has regulations for the accreditation of degrees obtained in universities abroad; employment in the health field is regulated by the Labor Code, which establishes minimum wages and labor rights for different categories of workers. All professionals must be duly registered with their respective professional associations and oversight bodies that regulate the practice of the profession and provide protection for its members. The Labor Code also has established an Occupational Health Council and requires the presence of an occupational health unit at any job site that employs more than 50 workers. There is a regulation pertaining to the resolution of labor disputes, as well.

The dropout rate at medical and nursing schools does not exceed 20%. Costa Rica does not require the accreditation of health sciences schools, nor is there an intercultural approach to professional training.

Several studies and diagnoses carried out during 2011–2014 by experts from the Pan American Health Organization/World Health Organization and Costa Rica’s Commission of Specialists, the Ombudsman’s Office, and the Legislative Assembly, among others, found challenges affecting the governance of health human resources, the system of wages and bonuses, and comprehensive planning, including coordination with the training sector.

Health Knowledge, Technology, and Information

Costa Rica ranked 49th worldwide on the Networked Readiness Index in 2015, ranking 5th in Latin America and the Caribbean. A year earlier, the government had formulated the National Broadband Strategy aimed at making Internet connectivity available to hospitals and other health centers of the CCSS, and to all Ministry of Health headquarters in the country. There is currently a network of interlinked health facilities where teleconsultations are offered in 43 medical specialties, coordinated by the telehealth area of CCSS medical management ().

The Environment and Human Security

Changes that alter the country’s precipitation patterns have already caused extraordinary crop loss in the wake of prolonged droughts and torrential rains that have caused widespread flooding. The country’s size is a factor that affects its vulnerability to the effects of global warming. The areas at greatest risk are high mountain areas, mangrove swamps, and reefs, as well as forested areas in hot zones. The country’s tropical rainforests are especially vulnerable to rising temperatures.

Nearly all Costa Ricans have access to improved water sources and improved sanitation facilities. However, according to the National Household Survey of 2013, the lowest water coverage was found in the Huetar Caribe region; in rural areas (such as Brunca and Huetar Norte), sanitation coverage was under 10%. Septic tanks are the most widely used option in all regions of the country, but there are no regulations governing their use, and only 3.6% of discharge is treated. Although solid waste sorting in homes is a growing practice, not all municipalities have appropriate collection and recycling programs.

Aging

Population aging has resulted from reductions in the birth, fertility, and mortality rates, reflected in increased life expectancy in the second half of the 20th century. This change has occurred very rapidly, as shown by Costa Rica’s score on the aging index, which was 25 in 2010 and is projected to reach 40 in 2020 ().

Migration

The 2011 Census reported that immigrants represented 9.0% of the country’s total population. Nicaraguans made up 74.5% of the immigrant population, with little change in this percentage since 2000 (). With respect to internal migration, San José province doubled its rate of net out-migration, from -2.41 per 1,000 population in 1995–2000 to -4.94 in 2006–2011. Guanacaste province went from net out-migration to net in migration. Limón, which had net in-migration in previous censuses, became an area of low net out-migration. Meanwhile, Puntarenas reduced its out-migration rate ().

Monitoring the Health System’s Organization, Provision of Care, and Performance

Costa Rica has made great progress toward the achievement of universal health coverage. In 2013, coverage of social health insurance was 84.9% according to the National Household Survey, and 94.4% according to the Actuarial and Economic Directorate of the CCSS. The variation between these estimates stems mainly from differing figures on insured family members and persons insured by the State. The country is in the process of developing a database of the population insured at State expense.

Because health insurance is financed on a contributory basis and considering current forms of employment and insurance, as well as data from the 2015 Household Survey, it is evident that the country needs to advance toward universal financing, without losing sight of the possible impact of new forms of employment on the financial sustainability of health insurance. The CCSS provides comprehensive services to its beneficiaries, from health promotion all the way to palliative care. There are no copayments in social security, and out-of-pocket expenditure (for services and drugs purchased in the private sector) as a proportion of total health expenditure was 24.9% in 2014.

That same year, a performance evaluation of essential public health functions (EPHF) was carried out, looking at the system’s capabilities, particularly those of the Ministry of Health. The evaluation pointed to several functions that need improvement, such as: i) equitable access to health services; ii) health promotion; and iii) human resources development and training in public health. Based on these results, the Ministry prepared a plan to: i) strengthen institutional planning, the development of human capabilities (clearly defined technical and administrative functions, competences, and capabilities), and infrastructure development; ii) strengthen institutional capacities in management, regulation, and control; and iii) improve access to services and strengthen technological management and research.

In recent years, questions have been raised about the quality, user-friendliness, and productivity of the health services, as well as about the financial situation of the CCSS and the risk of unsustainability. National studies and consultations initiated by the Presidency of the Republic, the Comptroller General of the Republic, and authorities of the Ministry of Health and the CCSS have concluded that the critical problems are structural, dealing with the model of care, the model of human resources management, technological management, collections, and financial management. A subject that comes up frequently is the average time spent on wait lists for diagnostic and surgical procedures; also mentioned, if less frequently, are infections associated with the provision of care. The continuity of care across the three levels of care remains an important challenge (). The Strategic Institutional Plan 2015–2018 of the CCSS is addressing these problems through reforms of the management model, the delivery model, and the financing model, as well as through several strategic projects ().

Prospects

The country has advanced significantly in increasing life expectancy through the reduction of infant mortality and maternal mortality, as well as through advances in communicable disease control. This progress is explained by the population’s high health coverage, health insurance benefits, and social guarantees that influence the determinants of health. However, inequalities persist between the central region and the rest of the country, and these are expressed in human development indicators, including those for health and its determinants. Since an exclusionary development project is not sustainable, there is an urgent need to begin a social dialogue aimed at finding solutions tailored to the country’s conditions and priorities. Box 1 summarizes the country’s achievements and challenges in health.

Population aging and the increase in chronic NCDs will require embarking on effective strategies to promote a healthy lifestyle, upgrading urban centers, and strengthening social protection for older persons. A culture of health must be fostered through policies designed to promote and encourage self-care throughout the life course, as well as environments that favor people’s health and well-being. These efforts will enable Costa Ricans, individually and collectively, to cope with the burden of disease affecting the population. Among other benefits, such achievements would help reverse the trends in chronic illnesses that, on average, deprive the population of 10 years of healthy life.

The health system must adapt to the country’s new social, political, and economic situation. The great challenge in the 21st century will be to offer the best health care possible to the population without compromising the resources necessary to ensure the well-being of future generations, especially in a context of technological advances and growing societal expectations. Given the current level of investment in health, it is essential to strengthen institutional management to achieve the efficient and effective use of resources and to enable the institutional services to have a greater impact on the population.

In light of the dropout rate, the State needs to take steps to improve the quality of public education, especially at the secondary level, and keep students in school. Improvements to education also are key to shaping a workforce that is prepared for better-paid jobs that, in turn, can contribute to the financial sustainability of health insurance.

The high mortality from road traffic injuries should be addressed through an intersectoral approach focused on health promotion, an approach that includes driver education, measures to strengthen the applicability and enforcement of road safety laws (especially with regard to alcohol consumption), and prehospital trauma care.

The increase in violence, given its impact on the population and on the demand for health services, will require not only actions to curb criminality, but also initiatives to foster social harmony, protect the rights of vulnerable groups, guarantee a decent income to all citizens, promote education that respects diversity, and create safe gathering spaces for people.

The steadily decreasing age of first sexual relations and the prevalence of sexually transmitted diseases will demand a major effort to implement sexual and reproductive health strategies, especially with respect to adolescents.

With respect to the environment, there is a need for strategies to support renewable energy sources, protect water resources, improve waste treatment, reduce the impact of economic activities, strengthen land management, and reduce the risk of disasters, including through adaptation to climate change.

Box 1. Costa Rica’s Achievements and Challenges in Health

While there is no single path to achieving universal health, reaching this goal will require a sustained effort. Regardless of the resources available, a great deal can be achieved by adhering to a vision and maintaining social agreement that can be translated into policies and actions to benefit the population, especially if these actions are guided by principles of equity and solidarity. Within this framework, an important milestone for Costa Rica is the 75th anniversary of the CCSS, an emblematic institution with a record of significant positive results in the health arena.

The successive reforms to the model of health services delivery in the country are a touchstone for all those who work in the public health sector. Both the universalization of social security in the 1970s and the formation, starting in the 1990s, of Basic Comprehensive Health Care Teams (EBAIS) were important milestones in the evolution of the Costa Rican health system toward primary health care, a process in which the CCSS has been instrumental.

References

1. Comisión Nacional de Prevención de Riesgos y Atención de Emergencias (Costa Rica.). Política Nacional de Gestión del Riesgo 2016–2030/ La Comisión. San José: CNE; 2015. Available from: https://www.cne.go.cr/Documentos/planificacion/POLITICA_NACIONAL_DE_GESTION_DEL_RIESGO.pdf.

2. United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: the 2015 revision [Internet]. New York: UN; 2015. Available from: https://esa.un.org/unpd/wpp/publications/files/key_findings_wpp_2015.pdf.

3. Ranero VM. Diferencial entre sexos en la Esperanza de vida (Eo) y Esperanza de vida saludable (EVAS) por paise, año 2007. Available from: http://public.tableau.com/profile/virginia.maria.ranero#!/vizhome/EVSaludable/Dashboard3.

4. Instituto Nacional de Estadística y Censos (Costa Rica). X Censo Nacional de Población y VI de Vivienda 2011: resultados generales. 1st ed. San José: INEC; 2012. Available from: http://www.inec.go.cr/sites/default/files/documentos/inec_institucional/metodologias/documentos_metodologicos/mepoblaccenso2011-02.pdf_0.pdf.

5. Instituto Nacional de Estadística y Censos (Costa Rica). Encuesta nacional de hogares Julio 2015: resultados generales. San José: INEC; 2015. Available from: http://www.inec.go.cr/wwwisis/documentos/INEC/ENAHO/ENAHO_2015/ENAHO_2015.pdf.

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7. Instituto Nacional de Estadística y Censos (Costa Rica). Encuesta continua de empleo: indicadores del mercado laboral costarricense: primer trimestre 2015. Vol. 1. Year 4. San José: INEC; 2015. Available from: http://www.inec.go.cr/sites/default/files/documentos/empleo/estadisticas/resultados/reempleoece2015-ltri-12.pdf.

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19. Consejo Nacional de Rehabilitación y Educación Especial (Costa Rica). Resultados relevantes de discapacidad: Censo 2011. San José: CNREE; 2015. Available from: http://www.cnree.go.cr/documentacion/estadisticas/Analisis%20datos%20censo%202011%20discapacidad.pdf.

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21. Wong McClure R, editor. Vigilancia de los factores de riesgo cardiovascular: segunda encuesta, 2014. San José: Editorial Nacional de Salud y Seguridad Social-Caja Costarricense del Seguro Social; 2016. Available from: http://www.binasss.sa.cr/informesdegestion/encuesta2014.pdf.

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Reference/Note:

1. Ecological debt: the difference between the current rate of resource consumption by a population (its ecological footprint) and the biocapacity of the territory (its available resources, considering its productive capacity and rate of natural regeneration).

2. Increases for the national health system.

3. Wage “bonuses” are various benefits that health professionals can receive, and they do not apply uniformly to all disciplines. They include benefits for seniority, a ban on the outside practice of one’s profession while holding a position in an institution, service in remote areas (may include provision of housing), and hazardous duty, as well as incentives for continuing education and for publications.

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