Country Report: Costa Rica
Costa Rica is located in Central America, between the Atlantic and Pacific Oceans; it borders Nicaragua and Panama. It is divided politically into 7 provinces, 81 cantons, and 463 districts. Its 8 indigenous populations are distributed across 24 territories. Of the total population, 2.42% describe themselves as indigenous, 1.9% as Afro-Costa Ricans, and 0.5% as Chinese.
Between 1990 and 2015, the population grew by 55.3% and its pyramid shifted from an expansive one toward a regressive one through population aging. In 2015, the population was 4.8 million (76.8% in urban areas).
In 2016, life expectancy at birth was 79.16 years (81 for women and 77 for men).
Costa Rica is among the countries with high human development and is ranked fifth in Latin America on this scale as a result of heavy public social investment.
- The 75th anniversary of the Costa Rican Social Security Fund (CCSS) represents a major milestone in health. The CCSS has become an emblematic institution with a record of remarkable results in the health arena.
- The country is in the process of formulating policies and practices with a view toward universal health coverage.
- The successive reforms in the country’s health service delivery model are a touchstone for all who work in the public health sector.
- Both the universalization of social security in the 1970s and the formation of Basic Comprehensive Health Care Teams (EBAISs), which began in the 1990s, were major milestones in the evolution of the Costa Rican health system toward primary health care, a process in which the CCSS has been instrumental as an organizational framework.
- The Strategic Institutional Plan 2015-2018 of the CCSS is addressing these challenges through reforms of the management, delivery, and financing models, as well as through several strategic projects.
- In 2016, 242 public health institutions registered to use telemedicine services and improve electronic connections among clinical services in order to increase access to health care.
Figure 1. Distribution of the population by age and sex, Costa Rica, 1990 and 2015
Proportional mortality (% of all deaths, all ages, both sexes), 2014
Source: Pan-American Health Organization, World Health Organization, and PAHO Health Information Platform (PHIP).
SELECT BASIC INDICATORS
Source: UN Population and Statistics Divisions, 1990; PAHO Health Information Platform (PHIP), 2013, 2014, and 2015.
SOCIAL DETERMINANTS OF HEALTH
- In 2015, 21.7% of households were living in poverty, and 7.2% in extreme poverty. The highest-earning quintile received 54.4% of all income, while the lowest-earning quintile received 4.1%.
- The indigenous population, 47% of which is concentrated in 22 territories, exhibits high levels of poverty and marginalization, especially among women.
- In 2015, the literacy rate was 97.8%, and nearly 90% of children completed primary school. The mean educational attainment was 8.4 years of schooling.
- Almost the entire Costa Rican population has access to improved water sources and improved sanitation facilities. The informal economy employs 45.3% of the workforce. In 2011, 69.5% of men and 34.9% of women were employed; in the indigenous population, this rate was 56.2% and 16.9%, respectively. In 2015, 10.1% of the workforce was unemployed. Women’s wages were, on average, 14% less than those paid to men with similar roles and responsibilities.
- 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.
- The country is facing challenges related to the preservation of water resources, rational use of marine resources, waste management, mechanisms for adaptation to climate change, and the use of clean energy sources to reduce dependence on fossil fuels.
- Natural disaster emergencies are associated with the rains and winds that occur throughout the year.
- Public insecurity is related to social tensions and criminality, associated especially with drug trafficking and organized crime, leading to high rates of homicide, theft, and drug addiction.
- In 2011, immigrants—mostly from Nicaragua—comprised 9.0% of the population.
- In the process of constructing the post-2015 development agenda, the Government conducted a broad-based national consultation in which citizens expressed their main desires for the future: achieving a more inclusive and equitable society; a sustainable health system that meets health needs with userfriendly, high-quality services; comprehensive education; and a secure society.
HEALTH SITUATION AND THE HEALTH SYSTEM
- In 2014, the maternal mortality ratio was 29.0 deaths per 100,000 live births, associated mainly with direct obstetric causes, such as complications of labor (33.3%), complications of the puerperium (9.5%), and hypertensive disorders in pregnancy, childbirth, and the puerperium (9.5%).
- The infant mortality rate was 8.0 per 1,000 live births in 2014. Conditions originating in the perinatal period and congenital malformations caused 50.9% and 32.9% of deaths of children under 1, respectively.
- In 2014, the overall mortality rate was 4.4 per 1,000 population (4.9 in men and 3.2 in women). Diseases of the circulatory system were the leading cause of death (29%), followed by neoplasms (24%); together, these two groups accounted for more than half of all deaths.
- In 2010, the overall underreporting of causes of death was 6%, with ill-defined causes at 1.8% and deaths assigned to "garbage codes" at 12.6%.
- Between 2002 and 2012, the incidence of HIV infection increased from 8.2 to 14.2 cases per 100,000 population, respectively.
- Dengue has remained a concern since its reemergence in 1993. Between 2013 and 2016, 95,047 cases were reported, 230 of which were severe; 1 death was reported. The incidence of chikungunya virus infection was 42 cases per 100,000 population. Zika virus disease was detected for the first time in 2016, and 1,518 cases were ultimately confirmed.
- In 2013, two autochthonous cases of malaria were reported; since the elimination of transmission in Limón province, the country has been in the elimination stage of the disease.
- In 2008-2009, 29.4% of children under 5 suffered from chronic malnutrition and 8.3%, acute malnutrition, for an overall malnutrition rate of 16.3%.
- The prevalence of overweight (36.8%) and obesity (29.4%) increased in all age groups, being highest in women.
- The leading causes of death from chronic noncommunicable diseases (NCDs) in men are ischemic heart disease, cerebrovascular disease, road traffic injuries, cirrhosis, and chronic respiratory diseases. In women, the main causes of death from NCDs are chronic respiratory diseases, diabetes mellitus, hypertensive diseases, and breast cancer.
- In the population over age 19, the prevalence of diabetes and hypertension is 10.0% and 31.2%, respectively. The prevalence of dyslipidemia is 25.0%; overweight, 36.8%; and obesity, 29.4%.
- As of 2010, ischemic heart disease, road traffic injuries, and interpersonal violence were the leading causes of potential years of life lost.
- Regarding chronic kidney disease, there has been a 35.5% increase in the years of potential life lost (YPLL) between 2005 and 2016, affecting mostly young men in the Chorotega region.
- The right to life is enshrined in the Costa Rican Constitution. The General Health Law (1973) defines the health of the population as a public good and makes the State responsible for maintaining it through the health system.
- The national health system is made up of the State health sector, private health care services, community health organizations, universities, municipalities, pharmaceutical companies, the National Commission on Emergencies, and international cooperation agencies.
- The public health system is composed of the Ministry of Health, the Costa Rican Social Security Fund, the Costa Rican Water Supply and Sewerage Institute, and other public institutions charged with protecting and improving the health of the population. The Ministry, as the steering agency in the system, provides management and political leadership, health regulation, research guidance, and medicine and technology development.
- Health insurance is funded on a contributory basis; the objective is to move toward universal funding, without losing sight of the potential impact of new forms of employment on the financial sustainability of health insurance.
- The Social Security Fund provides comprehensive services to its beneficiaries, from health promotion to palliative care. There are no copayments in Social Security. As of 2013, the social health insurance coverage rate was 84.9%.
- 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.
- In 2014, Costa Rica had 22.8 physicians, 24.4 nurses, and 9.3 dentists per 10,000 population.
- The primary 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). The secondary level of care is represented by large clinics, 7 regional hospitals, and 13 peripheral hospitals that offer medical specialties, inpatient care, and surgery in core specialties. The tertiary level is represented by 3 national general hospitals and 6 specialty hospitals providing higher-complexity care.
ACHIEVEMENTS, CHALLENGES AND PERSPECTIVES
- The country has made substantial progress in overall conditions and health status, including high social security and health coverage, as well as social guarantees that influence the determinants of health. Life expectancy at birth has increased, infant mortality and maternal mortality have declined, and advances have been made in communicable disease control.
- Leading health problems include nutritional deficiencies in children; overweight in adults; and the prevalence of chronic diseases and the rising cost of their treatment.
- Inequalities persist among the various population groups. The health system is facing the challenge of contributing to higher levels of equity and solidarity.
- Another problem is the weakening of leadership in the Ministry of Health, due to problems related to organization, monitoring, and evaluation; incomplete separation of functions; and weak coordination with the Costa Rican Social Security Fund (CCSS), among other causes.
- In recent years, the quality of care and productivity of the health services have become a concern, as have the financial situation and the risk that the CCSS may eventually become unsustainable.
- Within this context, several studies have been conducted and national consultations have been promoted by the political and health authorities, who have concluded that the main problems are structural and that it is important to strengthen the model of care and improve financial, technology, and human resource management.
- Growing violence and its implications for health and health services demand will require not only action against crime, but initiatives to foster social harmony, safeguard the rights of vulnerable groups, ensure a decent income for all citizens, promote education that respects diversity, and create safe gathering spaces for the public.
- Population aging and rising rates of chronic NCDs will require the implementation of strategies to promote healthy lifestyles, improve urban living, and strengthen social protection for older adults.0
WEB / SOCIAL MEDIA
Regional Office for the Americas of the World Health Organization
525 Twenty-third Street, N.W., Washington, D.C. 20037, United States of America
© Pan American Health Organization. All rights reserved.