Costa Rica’s strong, integrated health system helped it weather the early months of the COVID-19 pandemic with relatively low case counts and deaths. Even so, the country’s efforts to mitigate the COVID-19 pandemic and its effects while maintaining the delivery of essential health services encountered a number of challenges, as follows.
Costa Rica had insufficient personal protective equipment (PPE) and other supplies to protect health care workers from infection, especially in the early part of the COVID-19 pandemic.
At the beginning of the COVID-19 pandemic, Costa Rica (along with other countries around the world) experienced a shortage of vital PPE such as gloves and face masks, which prevented health workers from safely providing in-person emergency and essential care. Where possible, health facilities had to ration and reuse these goods. Public–private partnerships soon established processes for producing and importing essential protective goods.
Primary care delivery was dramatically reduced at the beginning of the pandemic.
For example, because community health workers (asistente técnico de atención primaria, ATAPS) on primary health care teams (equipos básicos de atención integral de salud, EBAIS) and other health care providers did not have the PPE they needed to perform home visits safely, they paused those follow-ups and consultations—especially for patients with chronic diseases such as high blood pressure and diabetes. The reassignment of community health workers and other primary care providers to the COVID-19 response (and later, COVID-19 vaccination) also limited their ability to provide other essential health services. In addition, these limitations affected the Costa Rican Social Security Fund (Caja Costarricense de Seguro Social, CCSS) referral system, which allows patient transfers to specialists and hospitals at the second level of care.
People avoided health care facilities out of fear.
Because people were afraid of contracting COVID-19 in health facilities, they avoided those facilities whenever possible—especially for routine non-urgent care. Consequently, many people did not receive the care they needed, and in some cases this avoidance aggravated chronic conditions. (Key informants reported an increase in the number of emergency department visits for conditions that were previously treated at the primary level, such as high blood sugar or high blood pressure.) Emergency department visits for critical but preventable conditions such as heart attacks also increased.
"[Chronically ill patients had a] fear of dying from COVID-19 in the case of the population at risk, immunosuppressed or with comorbidities. Fear of dying alone, due to the isolation of patients with COVID-19 without being able to see their relatives once they are seriously ill... also when the staff was reassigned, some physicians were changed. Fear because they didn’t know the next steps they had to take and had no help from volunteers in the hospital."- Interview with coordinator of a cancer patients’ forum, February 8, 2022
Some in-person services, such as laboratory blood draws for diagnostic testing, were still offered during the pandemic, but the number of patients served was reduced when mobility restrictions and fear kept people away from their scheduled appointments. Because the CCSS did not adapt its laboratory service delivery to the pandemic context (e.g., health workers did not take blood samples at patients’ homes) these auxiliary services were considerably more affected than services that were adapted for the pandemic context, such as prescription drug delivery.
Patients, providers, and administrators questioned the quality and equity of alternative methods of care delivery.
Although health officials and providers embraced virtual and other alternative modalities of patient care during the COVID-19 pandemic, administrators and physicians expressed some doubts about the quality of that care. They were especially concerned about the lack of provider experience with these tools, the lack of quality control in virtual service delivery, and the limited access to necessary technology among low-income populations that exacerbated inequities in access to health care. Fear of health facilities and reduced follow-up at the primary care level also made it difficult to encourage patients to use virtual tools, such as glucometers, to manage chronic conditions on their own. These problems did not abate as the pandemic continued.
During pandemic case surges and other periods of high demand for urgent care, waiting lists for routine and secondary care such as inpatient consultations, scheduled and ambulatory surgeries, and specialty care including orthopedics, ophthalmology, pediatrics, and gynecology meant that many patients reported feeling neglected and poorly cared for during the pandemic. Some patient associations developed virtual patient support groups but reported losing contact with patients who did not have the skills or tools to access such groups. Similarly, the mandate to reduce in-person health services left diagnosed patients without face-to-face support from hospital volunteers. As a result, doctors and nongovernmental organizations reported that patients sometimes felt left behind by the health system.
Coordination gaps increased within and outside Costa Rica’s public health system during the COVID-19 pandemic.
The CCSS’s vertically and horizontally integrated system still struggled to transfer patients seeking routine or secondary care, in part because of restrictions in ambulance traffic and capacity.
"[Before COVID-19 outbreaks] … patients were brought by ambulance, so what happened before was that five or six people could come in an ambulance, now because of the COVID issue they could not come in an ambulance. The situation complicated things because they were people without [economic] resources."- Interview with the director of an oncology patient association, February 8, 2022
Likewise, coordination gaps between public and private health facilities grew. The pressure on the public health system between April 2021 and October 2021 pushed administrators from the public and private systems to formulate a plan to transfer non-COVID-19 patients from the public sector to the private sector, while covering private facilities’ operating costs with public funds. The private sector offered up to 100 beds for patient transfers, but only 11 patients were ultimately transferred. Even so, the potential for this kind of collaboration is a crucial step forward for Costa Rica’s public and private health systems.
Costa Rica’s health system lacked qualified personnel in key disciplines, especially in rural areas.
Although Costa Rica’s public health system had the resources to purchase equipment for new intensive care units, it still had a limited number of intensive care practitioners—and those practitioners had limited capacity to attend to more beds in the face of increased demand for intensive care. Finding trained, qualified health care providers to staff and operate the new Specialized Care Center for Patients with COVID-19 (Centro Especializado de Atención de Pacientes con COVID-19, CEACO) was also a challenge.1
The high demand for additional staff also exposed the limitations of existing human resources in some direct-care positions such as health therapists and critical care nurses. To meet the demand, the CCSS opened internships for these types of professionals and maximized the use of current specialists in internal medicine, emergencies, and intensive care—the scarcest resources in the system. CCSS administrators also redeployed resident physicians to COVID-19 patient care.
Despite the CCSS’s efforts to coordinate staffing within the public health system, the pandemic-induced demand for health workers across Costa Rica underlined preexisting recruitment problems: the social, economic, and quality-of-life differences between different regions of the country and between urban and rural areas often leave rural and remote regions without physicians and other care providers.
"…National hospitals absorbed many doctors and health professionals, but all levels and almost all health facilities required more health professionals."- Interview with a rural health director, October 30, 2021
Private health care providers were likewise affected by these increased staffing needs.
"We had the same staff to attend both regular care and vaccination, at points vaccination competes with normal care. In addition to emergency care and follow-ups to COVID-19 patients, all in the same staff, although new positions were hired, it was not easy because everyone in the system was also looking to hire. In the case of private providers, there was no access to a contingency fund, so there was no access to added resources for hire."- Interview with general manager, private primary health care provider, February 3, 2022
The measures Costa Rica implemented to control the spread of COVID-19 had social and economic consequences.
The COVID-19 pandemic—and the public health and social measures implemented to control it, such as mobility restrictions—had an adverse effect on the economy of Costa Rica.2,3,4 Because tourism is an important part of the Costa Rican economy, authorities chose to maintain comparatively lax entry, testing, isolation, and vaccination requirements for travelers.
Aguilar-Tassara R, Leal-Ruiz C, Acuña-González R. CEACO y la amplicación de la capacidad hospitalaria. In: Zamora-Zamora CA, Ed. La Caja y la pandemia por COVID-19: experiencias durante la crisis del 2020. San José: CCSS; 2021. pp. 71-76. Accessed January 12, 2023. https://www.binasss.sa.cr/covid2021.pdf
Moreno M. New high-frequency data highlights COVID-19’s major impact on livelihoods and food insecurity in Costa Rica. United Nations High Commissioner for Refugees. April 5, 2022. Accessed January 12, 2023. https://www.unhcr.org/blogs/high-frequency-data-covid19-impact-on-livelihoods-food-insecurity-in-costa-rica/
Ruiz Hidalgo H. Impacts of covid-19 on the Costa Rican and in the world economy. Universidad Estatal a Distancia Costa Rica. Accessed January 12, 2023. https://www.uned.ac.cr/ocex/index.php/124-boletines-articulos/557-impacts-of-covid-19-on-the-costa-rican-and-in-the-world-economy%20
Economic Commission for Latin America and the Caribbean (ECLAC). Costa Rica. In: Economic Survey of Latin America and the Caribbean 2021: Labour Dynamics and Employment Policies for Sustainable and Inclusive Recovery Beyond the COVID-19 Crisis. ECLAC Digital Repository; 2021. Accessed January 12, 2023. https://repositorio.cepal.org/bitstream/handle/11362/47193/74/EI2021_CostaRica_en.pdf