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Context

The following information is on the context and system factors in Costa Rica that may have played a role in the response to COVID-19 and the maintenance of essential health services. Context and systems factors cannot easily be changed when an outbreak occurs, whereas policies or interventions can.

Exemplars in COVID-19 conceptual framework for assessing epidemic preparedness and response

Contextual factors

Although our research focuses primarily on the policy choices made by officials throughout the pandemic, a country’s ability to limit COVID-19 transmission and related deaths could also be attributed to contextual factors, including those below.

A country’s population demographics, such as age structure and population density, may contribute to pandemic outcomes, such as the number of cases and deaths (see figure below).

Pre-pandemic health context in Costa Rica, 2019

IHME

Underlying population-level health characteristics that may have shaped Costa Rica’s experience in the early months of the COVID-19 pandemic include:

Age structure

In 2019, nearly 70% of Costa Rica’s population was between the ages of 15 and 64. About 20% of the population was younger than 15 and about 10% was older than 64.1

Elderly adults are significantly more likely to die from COVID-19 than younger adults and children.2 Countries around the world vary widely in their age structures: in some African countries, fewer than 2 percent of the population is 70 years or older, while in some European countries that share is more than 15 percent.3 Some research suggests that accounting for variation in age structure between countries may explain nearly 50 percent of the variation in COVID-19 mortality.4

Chronic health conditions

In Costa Rica, noncommunicable diseases such as heart disease, stroke, chronic kidney disease, chronic obstructive pulmonary disease, Alzheimer’s, and cancer are the most prevalent causes of death.5 Their prevalence has held steady, for the most part, since 2009.6

A variety of chronic health conditions like high blood pressure, diabetes, and cardiovascular disease are associated with greater rates of mortality from COVID-19.2 HIV can make individuals susceptible to infectious diseases because of how it impacts the immune system. Similarly, cancer and cancer treatments like chemotherapy frequently disrupt the immune system, leaving individuals vulnerable to severe infection.7

 

read more

 

Age-standardized prevalence of major noncommunicable diseases in Costa Rica, 2019

IHME

Fine particulate matter8, especially matter small enough to reach the deepest part of the lungs, causes chronic pulmonary injury and inflammation.9 Individuals exposed to these particles may be more likely to be infected with respiratory pathogens and to have more severe outcomes.2

Costa Rican President Carlos Alvarado Quesada greets a local citizen with a fist bump at a site where the government is administering vaccines, including to migrants regardless of their legal status, to fight the spread of COVID-19, in San José, Costa Rica, October 13, 2021.
Costa Rican President Carlos Alvarado Quesada greets a local citizen with a fist bump at a site where the government is administering vaccines, including to migrants regardless of their legal status, to fight the spread of COVID-19, in San José, Costa Rica, October 13, 2021.
Credit: Mayela Lopez. © Reuters

The World Bank considers Costa Rica to be an upper-middle-income country.10 Its economy, which once depended on agricultural exports such as bananas and coffee,11 has grown and diversified steadily in recent years. Since the late 1990s, manufacturing (of goods such as medical devices, pharmaceuticals, and electronics) and services (including data processing, software development, and tourism) have dominated the economy.12 The country has one of the highest adult literacy rates in the Americas: 98% in 2018.13

Costa Rica also has a long history of political stability. The Constitution of 1949 established the executive, judiciary, and legislative branches and regular democratic elections in a multiparty system to keep power from concentrating in any single person or party. Along with direct universal suffrage and a robust rule of law, Costa Ricans enjoy freedoms of expression and association. In May 2020, it became the first Central American country to legalize same-sex marriage.14 Additionally health and healthcare are stated as rights in the constitution, which has translated to the government’s robust investment in the public health system.

Because of this economic and political stability and a steadily rising gross domestic product (GDP) per capita,15 Costa Rica has had one of the lowest poverty rates in Latin America and the Caribbean.16 GDP decreased and the poverty rate increased considerably in 2020, with 30% of Costa Ricans living below the national poverty line.16 However, GDP rebounded in 2021.17 As the labor market improves, the World Bank anticipates that poverty rates will soon drop as well.10

Costa Rica has decades of experience developing and updating epidemic preparedness and response plans and simulation exercises, including for avian flu, swine flu, and Ebola virus disease.18 The Costa Rican Institute of Research and Teaching in Nutrition and Health (Costarricense de Investigación y Enseñanza en Nutrición y Salud, INCIENSA) and the Ministry of Health have developed guidelines for the control of prevalent vector-borne diseases such as dengue,19 Zika,20 and chikungunya.21,,22

Read more about the plans and guidelines published by health officials for various epidemics:

System factors

Beyond policy interventions, other modifiable factors under the short-term control of countries and governments that can help shape countries’ pandemic outcomes (such as testing strategies, disease surveillance, laboratory capacities, contact tracing programs, case management, mobility restrictions, and surge response coordination), it is also important to consider preexisting system factors, such as the strength and structure of a country’s health care system and supply chains, in any analysis of a country’s COVID-19 preparedness and response.

This topic was not a priority in our research; however, you can read more about Costa Rica’s work in pharmaceutical manufacturing below.

read more

Costa Rica’s life expectancy is among the highest in the Western Hemisphere,26 despite lower health expenditures and a smaller GDP per capita than many other countries in the region.27 Researchers attribute the strength of these health outcomes to Costa Rica’s sustained public investment in its health and education sectors as well as the quality of the country’s highly integrated public health system.

Life expectancy at birth vs health expenditure in the Western Hemisphere, 2019

World Bank

Even before the COVID-19 pandemic, however, the national health system struggled with long waiting lists, rising spending, and funding instability.28 For example, payroll taxes from workers and employers in the formal sector 29 pay for the Costa Rican Social Security Fund (Caja Costarricense de Seguridad Social, CCSS), and their share of the workforce decreased throughout the 2010s.28

When breaking down current health expenditures by type (government, private, and external), Costa Rica spends more on domestic general government health expenditure than any other sector, proving the sustainable investment in their public health system.

Health expenditure, per capita PPP, by type in the Western Hemisphere, 2019

World Development Indicators – World Bank

In 1941, Costa Rica established the CCSS to provide health coverage and pensions for low-paid wage workers in cities.30 In 1949, the “right to protection of… health” was written into the country’s new constitution.31However, CCSS coverage was still restricted to low-paid workers until 1961 when the constitution was amended to “universalize” health coverage and the system began to expand—to workers’ dependents, people in rural areas, and members of other vulnerable groups.32, 33 As of 2021, around 90% of people in Costa Rica receive CCSS insurance coverage.34

CCSS is Costa Rica’s primary provider of health care. In 2019, government spending represented about 73% of current health expenditures in Costa Rica,35 and CSSS spending represented about 72% of those health expenditures.36 Private institutions funded by out-of-pocket patient payments provide the rest.

The Costa Rican national health system

Sáenz et al. 2011

The CCSS provides general and specialized medical services and manages public hospitals and primary care clinics throughout the country. It is horizontally integrated, which means it controls several primary care clinics, hospitals, and specialized centers in different regions throughout Costa Rica. It is also vertically integrated, which means it provides health care at all levels—primary, secondary, and tertiary.37

Costa Rica’s Ministry of Health is separate from the CCSS. The ministry oversees and regulates health care service delivery and is responsible for epidemiological surveillance, health research, and technological development.32

Case study: Primary care in Costa Rica

After an outbreak of measles that overwhelmed the public health system in 1991, the Costa Rican Social Security Fund (Caja Costarricense de Seguridad Social, CCSS) and the Ministry of Health developed a plan for reform that had two primary goals: to extend CCSS coverage to more people, and to expand the capacity of the public system to provide more comprehensive care, especially at the primary level.30

To enable integration within the public health system—that is, to provide a range of services including curative and preventive care, rehabilitation, and health promotion—the reformers developed a new model for service delivery known as integrated primary health care teams (equipos básicos de atención integral de salud, EBAIS). EBAIS teams provide lifetime comprehensive primary care, including preventive and acute care and care for chronic health problems, to people across Costa Rica.30

The EBAIS model divides the country into geographic health regions (seven as of 2021), which are subdivided into 104 health areas.38  Each health area is served by multidisciplinary EBAIS care teams (on average 10 teams per health area) that include a general physician, nursing assistant, trained community health worker (asistente técnico de atención primaria, ATAP), and medical clerk. Health areas also employ support staff including nutritionists, psychiatrists, social workers, dentists, laboratory assistants, X-ray technicians, and pharmacists. These primary care teams work together to provide essential care to the residents of their health area, detect severe health problems as early as possible, and ease the navigation of patients through the system when necessary. By 2019, EBAIS teams covered more than 94% of the population.

EBAIS teams are integrated into the broader CCSS network of health facilities and hospitals. When patients need more specialized care, they can be referred to regional clinics and hospitals across the country. Likewise, providers at the secondary level may refer patients to tertiary hospitals that provide even more specialized care. In 2020, the CCSS system included three national hospitals, six specialized hospitals, and six specialized centers.37

 

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Distribution of health care facilities from the Costa Rican Social Security Fund by level

INCAE

"Bureaucratic integration at the highest levels of the health care system enabled the CCSS to manage service delivery more efficiently and ensure the vertical and horizontal integration of public health, preventive care, and curative care. Few countries have achieved this level of integration at the national level. To begin to match all the functions of the CCSS, for example, the United States would need to merge the Centers for Disease Control with the Department of Veterans Affairs and the Centers for Medicare and Medicaid Services. The success of the bureaucratic merger in Costa Rica allowed the country to build its new primary health care system."

- Pesec et al. Primary health care that works: the Costa Rican experience. Health Aff. 2017;36(3):531-538.

CCSS uses an integrated network management strategy known as One Caja to improve institutional communication and enable small-scale network coordination. This integrated network management enables the CCSS to generate efficiencies, reduce waiting lists, and increase transfer capacity for better and faster care within the public network.37

Universal health care coverage index for Costa Rican health care services

GBD 2019 Universal Health Coverage Collaborators

read more

Because Costa Rica’s national health system is able to provide high-quality health care to many of its citizens, it scored high on the universal health coverage index for many key routine health services.

Costa Rica has long had systems in place to enable it to respond quickly and comprehensively to a large-scale health emergency such as a pandemic. For example, in 2016, the CSSS’s Board of Directors created a contingency fund that officials can deploy in case of emergencies.39, 40

Additionally, Costa Rica’s 2015 General Health Law gives the Minister of Health the authority and resources to organize a multidisciplinary approach to the promotion of health and sanitation. According to this law, CCSS also has the authority to coordinate public health and patient care across the health system. For example, the CCSS’s Operational Coordination Council (Consejo de Coordinación de Operaciones), composed of administrators in the public health sector, meets monthly since its establishment as part of the Integrated Network Strategy to coordinate resources and patient movements according to demand for services.

Costa Rica had an existing culture of data use for decision-making before the pandemic. In 2012, the country established the Single Digital Health Record (Expediente Digital Único en Salud, EDUS), an app and database that tracks information (such as physician notes) from patient visits to health facilities in the CCSS system.41,42 EDUS also records and monitors information about the health system itself, such as occupancy rates of beds and ICU beds by medical specialty, and can produce real-time dashboards for sharing this information with users.

EDUS also works for patients themselves. For example, it includes an app that people can download to their smartphones and tablets to view their medical records and medical appointments (both past and upcoming) anytime. By the time the COVID-19 pandemic began, EDUS was widely used by patients and health care workers across Costa Rica. By September 2021, it had been downloaded almost 4.7 million times.43

Finally, the National Emergency Commission (Comisión Nacional de Emergencia) has established preparedness committees at the regional and community level throughout the country. These committees develop preparedness strategies for natural disasters such as earthquakes and flooding.44 When necessary, they coordinate with local CCSS representatives to streamline efforts and direct support during health emergencies.

Outbreak factors

Researchers identified three main waves of the COVID-19 pandemic in Costa Rica between March 2020 and December 2021. The first (and least intense) wave of cases and deaths lasted from March 2020 to February 2021, and was characterized by stringent public health and social measures and restrictions that enabled health authorities to flatten the epidemiological curve for several months. The second wave lasted from March to July 2021, and the third wave was from August to December 2021.

Daily new confirmed COVID-19 cases per million people in Costa Rica, March 11, 2020 – December 31, 2021

Our World in Data

Daily new confirmed COVID-19 deaths per million people in Costa Rica, March 11, 2020 – December 31, 2021

Our World in Data

Between March and August 2020, Costa Rica’s case counts were among the lowest in Latin America. This may be attributed to stringent public health and social measures like mobility restrictions that were implemented very early in the pandemic, even before Costa Rica identified its first COVID-19 case on March 8, 2020.

Starting in August 2020, however, Costa Rica’s case counts increased rapidly until they were among the highest in Latin America. This increase may be due to new variants (e.g., alpha, beta, and gamma, which were more transmissible45 ) and “COVID-19 fatigue” among citizens, whose compliance with mobility restrictions and protective measures waned accordingly. Increased case counts could have also been a result of improved surveillance and testing in Costa Rica. Stronger testing capacity could have resulted in higher detection rates and seemingly more cases, especially in the early months of the pandemic.

Daily new confirmed COVID-19 cases per million people in Costa Rica and other Latin American countries, March 6, 2020 – December 31, 2021

Our World in Data

Costa Rica’s second wave, from March to July 2021, was shorter and more intense (with more cases) than the first. On March 3, 2021, the seven-day rolling average of daily new COVID-19 cases in the country was 73; by May 14, that number had spiked to 475, and the pressure on Costa Rica’s health system was so intense that health authorities warned about hospital saturation for the first time.46 On April 24, the occupancy rate of ICU beds was 94%47and two weeks later it was 121%.48 Six weeks later, on June 8, it was 145% before case counts began to decrease.49 When the ICUs were at full capacity, there were not enough health care workers for patients; however, through strategies such as Escalada y Desescalada del Sistema de Salud, ICUs were added to support COVID-19 care and surgeries were postponed to reprioritize staffing capacity.

Observers point to three factors to explain this rapid increase:

  • At the beginning of the 2021 Holy Week (March 29–April 3, 2021), daily case counts were low. As a result, authorities did not implement any stringent containment measures even though population mobility during that week was considerably higher than average and people were more likely to attend large gatherings such as church services.50
  • Early in 2021, more transmissible variants of COVID-19 (alpha, beta, and gamma) began to appear in Costa Rica. According to scientists from the University of Costa Rica, the “Central American” lineage appeared in January.51  The alpha variant appeared in February, and the gamma variant appeared in April.45
  • Costa Rica rolled out a comprehensive vaccination campaign targeting high-risk individuals in spring 2021—by the end of June 2021, 32% of Costa Ricans had received at least one shot —and mobility restrictions and other public health and social measures had been stringent during the first wave of the pandemic. Possibly as a result, compliance declined as perceived safety from vaccines and public fatigue with restrictions increased.50, 53

A third wave of cases began in August 2021, triggered by the presence of the highly transmissible delta variant.54, 55, 56 By September 2021, Costa Rica’s hospitals and ICUs were saturated,57 health care workers were fatigued, emergency services were congested, and key medical supplies were limited.58 The delta variant would become the most prevalent variant in Costa Rica until the end of 2021, when the omicron variant replaced it (see figure below).

The relative importance of the drivers of outcomes of interest during an epidemic or pandemic will depend on the nature of the specific pathogen. In the case of the COVID-19 pandemic, the SARS-CoV-2 virus is characterized by respiratory transmission by both symptomatic and asymptomatic individuals. The virus disproportionately impacts older adults and those with compromised immune systems and comorbidities. Although vaccines and therapies to reduce severe disease and fatal outcomes from SARS-Cov-2 were developed relatively quickly, this is not always the case for other pathogens with epidemic and pandemic potential.

For more information, please see How Does COVID-19 Compare With Past Epidemics and Pandemics?

Global and regional factors

Costa Rica shares borders with Nicaragua and Panama, and it has two coasts. Officials in its neighbor to the north, Nicaragua, declined to take precautions in March and April 2020 to prevent the spread of COVID-19.59 Nicaragua’s casual approach to the COVID-19 pandemic likely had health and social consequences for neighboring countries—particularly Costa Rica, which traditionally receives an annual influx of economic migrants from Nicaragua. For example, Costa Rica saw an increase in the relative incidence of COVID-19 in the first two months of 2021 in districts with high numbers of Nicaraguan migrants, and it is possible this increase radiated to nearby areas.60

To avert a potential crisis, the Costa Rican government and CCSS allowed thousands of immigrants, regardless of their legal status, to receive COVID-19 treatment and vaccination from the public health system.61

It is not possible to know if weather conditions played a role in the transmission of disease in Costa Rica. The country has a well-defined annual pattern climate, with a prolonged dry season from November until April or May and a wet season during the rest of the year. COVID-19 infection peaks occurred in both dry (in 2020 and 2022) and rainy seasons (in 2021).

Respiratory viruses spread more easily through thin, dry air (and consequently at higher elevations) than through humid air.62 In different climates, outdoor temperature ranges can lead to increased congregating in climate-controlled indoor settings that can increase viral transmission potential.2 All these factors may influence how rapidly COVID-19 spreads in different countries and at different times of the year.

As climate change worsens, the risk of infectious disease outbreaks has increased, with climatic conditions becoming increasingly fertile ground for pathogenic transmission.63 Research has shown that many infectious diseases are susceptible to climate variability, flooding, droughts, and the animal and human migratory impact of a changing climate, leading to a rise in vector, food, and water-borne illness.64

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