Pursuing universal health coverage

Red Cross Costa Rica
The LEAF Project/Creative Commons
In 1941, Costa Rica established Caja Costarricense de Seguro Social (CCSS), a social security insurance system for wage-earning workers [3]–[5]. In 1961, coverage was expanded to include workers’ dependents and from 1961 to 1975, a series of expansions extended coverage for primary care and outpatient and inpatient specialized services to people in rural areas, the low-income population, and certain vulnerable populations [6]. Further expansions during the late 1970s extended insurance coverage to farmers, peasants, and independent contract workers. Additionally, CCSS mandates free health service provision to mothers, children, indigenous people, the elderly, and people living with disabilities, regardless of insurance coverage [6]. By 2000, 82 percent of the population was eligible for CCSS [3], which has continued to expand in the ensuing period. By covering all population groups through the same system, Costa Rica has avoided social insurance stratification and inequity common in many other countries in the region [3].

CCSS is funded by a 15 percent payroll tax, as well as payments from retiree pensions [6]. Taxes on luxury goods, alcohol, soda, and imported products also help to cover poor households who do otherwise pay into the system. All CCSS funds are merged into a single pool, which is managed by the central financial administration of CCSS [6]. In 1973, the Ministry of Health decided to move away from direct service provision and adopt a steering role [3], [6]. Responsibility for the provision of most care was transferred to the CCSS, although the Ministry retained responsibility for disease control, food and drug regulation, environmental sanitation, child nutrition, and primary care for the poor [7].  Through the CCSS, health care is now essentially free to nearly all Costa Ricans [8].

Expanding Access

In addition to expanding financial access to health care services, Costa Rica also undertook significant reforms to improve geographic access to care. Until the mid-1990s, provision of primary health care in Costa Rica was somewhat disjointed. In 1987, a Division of Primary Health Care within the Ministry of Health was formed that combined two existing units: the Rural Health Program and Community Medicine Program, which had been providing primary care to rural indigenous peoples and the urban poor, respectively [3]. Although these programs had achieved success in improving outcomes during the 1970s, the 1980s led to significant cutbacks in funding in the wake of the economic crisis. By 1990, only 40% of the population was covered by governmental primary health care services [9]. Furthermore, user satisfaction with the quality and timeliness of care was low [6].

In 1995, the Ministry of Health transferred responsibility for all primary health care services to the CCSS [9]–[11].

Primary Health Care Teams (Equipos Básicos de Atención Integral de Salud, or EBAIS) became the central component of the Costa Rican primary health care system."

EBAIS teams provide a first point of contact for all health services, and initially consisted of a doctor, nurse, and public health worker and were assigned to specific geographic regions. Each EBAIS team is generally responsible for providing care to 1000 families, or approximately 4000 patients [1], [3], [9]. The first EBAIS teams began working in 1995, and the poorest districts were targeted first with a specific aim of reducing inequities [8]. By the end of 2001, 80 percent of the population was covered by an EBAIS team and nearly the entire country was covered by 2006 [6], [9].

In the 1990s, most teams operated out of existing buildings, but in 2000 EBAIS began to construct new buildings to house their services, and the majority of EBAIS are now in their own buildings [12]. Today, EBAIS teams typically also include an administrator, pharmacy assistant, and primary health technician responsible for conducting home visits for the elderly and immobile populations, and are supported where possible by social workers, dentists, nutritionists, laboratory technicians, and medical records specialists [3], [6], [9], [13]. Beyond provision of direct care services, EBAIS teams also conduct health surveys and contribute to civil registration and vital statistics data collection.

To help manage EBAIS teams, the Costa Rican government introduced performance agreements, known as management commitments (MC), in 1996 [3], [4]. Through yearly negotiations between the CCSS administrators and regional EBAIS teams, MCs set targets for priority health areas, including indicators of coverage, quality, efficiency, and user satisfaction [10] . Data are collected on up to 260 different measures annually [6]. These measures allow for greater accountability and prioritization of nationally agreed upon indicators, processes, and performance markers. Although the scope and large number of MCs have been difficult to implement at times, the process has shown promising results. For example, an MC requirement that physicians be present at their primary care center Monday through Friday has notably reduced physician absenteeism [4].

Improved coverage and outcomes

Together, the expansion of universal health coverage and the strengthening of primary health care have greatly improved effective service coverage and health outcomes in Costa Rica:

  • By 2003, insurance coverage had increased from 47 percent to 89 percent [1], [4];
  • Individual rates of catastrophic health expenditure declined from 1.56 percent to 0.31 percent in 2004 [14].;
  • The life expectancy at birth in Costa Rica is 81.5 years for females and 76.7 years for males, ranking Costa Rica second in the Americas behind Canada [3], [6];
  • Perinatal mortality decreased from 12 deaths per 1000 live births in 1972 to 5.4 deaths in 2001;
  • Under-5 mortality decreased from 14.4 deaths per 1,000 live births in 1995 to 10.6 deaths per 1,000 live births in 2009 [3], [6].;
  • Communicable diseases mortality declined from 65 per 100,000 in 1990 to 4.2 per 100,000 in 2010 [6].

Because EBAIS teams were rolled out in a step-wise fashion across the country, a natural experiment exists to assess their impact on health outcomes. An important 2004 study found that districts with an EBAIS presence had an 8 percent lower mortality among children and 2% lower mortality among adults compared to districts without EBAIS, as well as a 14 percent decline in deaths by communicable diseases, controlling for other relevant factors [15]."


Despite its strong primary health care system, Costa Rica still has many challenges to address. Like many countries, Costa Rica is experiencing a continued epidemiological transition toward an increased burden of non-communicable diseases and a demographic transition toward an ageing population [6]. Mortality from circulatory diseases increased from 25 per 100,000 deaths in 1990 to 120 in 2010, and there was a 48 percent increase in all types of cancers from 2003 to 2013 [6]. Consequently there is a need to increase health care capacity to provide comprehensive and integrated services to address these major causes of mortality [14].

Malaria medication
Arturo Sanabria/Courtesy of Photoshare
There is also a concern that the EBAIS teams emphasize their efforts too heavily upon the preventative measures required by the MC system and do not focus enough on curative treatments that are not included in MCs, such as obesity, depression, tobacco use, and drug addiction [3]. Waiting times for in-person visits to PHC facilities are long, as are those for specialist referrals for elective procedures. Some scholars have suggested that this relative lack of accessible curative treatment has pushed more patients to the emergency room for care [4]. Emergency treatment costs up to twice that of a primary care consultation, and use has been increasing since the 1990s [4]. Weak vertical integration of care between primary, secondary, and tertiary care also contributes to the high rates of emergency department use and relatively long waits for specialty care, and the CCSS estimates that up to half of emergency room visits are not for real emergencies [3], [4]. Additionally, migrants remain frequently uninsured and “cumbersome” enrollment processes make it difficult for poor and vulnerable populations to enroll in the EBAIS program, further adding to the burden of emergency care services [4], [6]. Nonetheless, Costa Rica has achieved near-universal health coverage and strong PHC service coverage through ubiquitous EBAIS community health teams that use data to drive health outcome achievement.



  1. I. de Bertodano Id, “The Costa Rican health system: low cost, high value.,” Bull. World Health Organ., vol. 81, no. 8, pp. 626–627, 2003.
  2.  “Costa Rica | Data,” The World Bank. [Online]. Available: http://data.worldbank.org/country/costa-rica. [Accessed: 12-Sep-2015].
  3. J.-P. Unger, P. De Paepe, R. Buitrón, and W. Soors, “Costa Rica: Achievements of a Heterodox Health Policy,” Am. J. Public Health, vol. 98, no. 4, pp. 636–643, Apr. 2008.
  4. W. Soors, P. D. Paepe, and J.-P. Unger, “Management Commitments and Primary Care: Another Lesson from Costa Rica for the World?,” Int. J. Health Serv., vol. 44, no. 2, pp. 337–353, Apr. 2014.
  5. F. Knaul, G. Nigenda, and P. Zuñiga, “Case Study: Costa Rica,” in Long-term care in developing countries: ten case-studies, J. Brodsky, J. Habib, and Hirschfield, Eds. Geneva: WHO, 2003.
  6. F. Montenegro Torres, “Costa Rica Case Study: Primary Health Care Achievements and Challenges within the Framework of the Social Health Insurance.” World Bank, 2013.
  7. J. W. McGuire, Wealth, Health, and Democracy in East Asia and Latin America. Cambridge University Press, 2010.
  8. L. Rosero-Bixby, “Spatial access to health care in Costa Rica and its equity: a GIS-based study,” Soc. Sci. Med., vol. 58, no. 7, pp. 1271–1284, Apr. 2004.
  9. J. W. McGuire, “Politics, Policy and Mortality Decline in Costa Rica,” in Politcs, policy and mortality decline in East Asia and Latin America, Cambridge University Press, 2010.
  10.  “WHO | World Health Organization Assesses the World’s Health Systems,” WHO. [Online]. Available: http://www.who.int/whr/2000/media_centre/press_release/en/. [Accessed: 10-Sep-2015].
  11. F. Lehoucq, The Politics of Modern Central America: Civil War, Democratization, and Underdevelopment. Cambridge University Press, 2012.
  12. L. R. Bixby, “Assessing the impact of health sector reform in Costa Rica through a quasi-experimental study,” Rev. Panam. Salud Pública, vol. 15, no. 2, pp. 94–103, Feb. 2004.
  13. K. Bowman and F. Arocena, Lessons from Latin America: Innovations in Politics, Culture, and Development. University of Toronto Press, 2014.
  14. R. Sáenz, J. Bermudez, and M. Acosta, “Universal Coverage in a Middle Income Country: Costa Rica,” World Health Organ. Backgr. Pap., no. 11, 2010.
  15. L. R. Bixby, “Evaluación del impacto de la reforma del sector de la salud en Costa Rica mediante un estudio cuasiexperimental,” Rev Panam Salud Publica, pp. 94–103, 2004.