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How did Costa Rica respond to the COVID-19 pandemic?

The following section covers the interventions that were deployed in Costa Rica between March 2020 and December 2021 to respond to COVID-19 and maintain essential health services (EHS). Unlike context and systems factors which cannot easily be changed when an outbreak occurs, policies or interventions can. Interventions during the early months of the coronavirus pandemic in Costa Rica fell into three main categories: national, governmental, and population-level measures, health system-level measures, and patient-level measures.

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

Costa Rican officials began to implement some pandemic containment measures even before the country confirmed its first death from COVID-19 on March 18, 2020.

These measures subsequently became more stringent, especially during Holy Week (April 5–April 11, 2020)—a time when people often travel and gather in large groups. These restrictions were accompanied by financial penalties: for example, the Ministry of Health could revoke a business’s sanitary working permit if it did not comply.1

The main objective behind all these early containment measures was to give the Costa Rican health system time to prepare and adapt its systems before case counts began to rise.2 For example, hospitals in the Costa Rican Social Security Fund (Caja Costarricense de Seguro Social, CCSS) system had only 24 available intensive care unit (ICU) beds in January 2020. Without early restrictions limiting the spread of COVID-19, officials worried COVID-19 patients would overwhelm this limited ICU capacity.3

A public health worker records a woman’s temperature before she enters a health center, as part of preventive measure against COVID-19, in San José, Costa Rica, March 12, 2020.
A public health worker records a woman’s temperature before she enters a health center, as part of preventive measure against COVID-19, in San José, Costa Rica, March 12, 2020.
Credit: Juan Carlos Ulate. © Reuters

As the pandemic evolved and data quality improved, Costa Rican officials could replace these blunt measures with a more precise set of restrictions. (Writer Tomas Pueyo called this strategy the “hammer and the dance,”4 and many countries adopted some version of the same approach.) The Ministry of Health adjusted public health and social measures according to case counts and other epidemiological data.

Early in the COVID-19 pandemic, the CSSS injected almost US$200 million into its contingency fund to pay for many necessary service delivery adaptations and key pandemic supplies.5 ,6,7 For example, officials used US$36 million to pay salaries and social security costs for newly hired health workers and overtime for existing ones. In addition, nearly US$25 million was paid for durable medical equipment such as ventilators and ICU beds for existing hospitals and health facilities; to build out a new specialized treatment center for COVID-19 patients (Centro Especializado de Atención de Pacientes con COVID-19, or CEACO); and for mobile hospitals, tents, and open-air clinics.

Contingency fund spending on COVID-19 needs in Costa Rica, 2020, Millions, US$*

CCSS 2020

*Services: air transportation of PPE donated by China, outsourcing construction and cleaning services, and renting tents, Materials and Supplies: non-durable medical equipment (gloves, facial masks, personal protective equipment, hand soap, etc.), drugs (oxygen, bleach, alcohol, etc.), food, and other construction goods, Transfers: monetary transfers including medical leave for confirmed and suspicious cases of COVID-19 and workers in direct contact, Capital: durable goods including purchasing new durable medical equipment for the CEACO and other hospitals (ventilators, ICU beds, among others), financing remodeling, and adaptation of the physical infrastructure in several hospitals and clinics across the country, Renumerations: new job positions, paying for extra hours, and the accompanying social security costs.

This emergency budget, along with approximately US$40 million redirected from other Ministry of Health programs and US$52 million from the National Emergency Committee, enabled the CCSS to finance most of the country’s emergency response using domestic funds.

Costa Rica also implemented strategies to maintain essential health service delivery as soon as flagging performance across indicators made it clear they were necessary.

Interventions to limit the spread of COVID-19 and maintain essential health in Costa Rica fell into three main categories:

  • National, governmental, and population-level measures
  • Health system-level measures
  • Patient-level measures

National, governmental, and population-level measures

Starting on January 20, 2020, the Ministry of Health started holding weekly press briefings (on March 5, they began to take place daily8) carried by national news channels. “We cannot get too comfortable,” Minister of Health Daniel Salas often said in those press conferences. “We need to be very careful and follow all the health and physical distancing regulations.”9 These briefings discussed safe behaviors, case information, testing details, and new and ongoing social distancing measures.8

These briefings reached substantial and receptive audiences, in part because Costa Ricans have an unusually high degree of confidence in the country’s health system. Historically, health and healthcare have always been a priority to the Costa Rican government and constitution, and therefore citizens trust the health system to provide accurate and helpful information regarding their health.

For example, successful national campaigns against polio, tuberculosis, and measles reached almost everyone in the country. Additionally, by 2021, pentavalent vaccine coverage had reached 99%, and hepatitis B vaccine coverage had reached 93%.10 This confidence may help explain Costa Ricans’ compliance with the public health and social measures implemented early in the pandemic.11 ,9 High literacy rates may have also boosted awareness of and compliance with protective measures.12

Costa Rican authorities began to implement public health and social measures immediately after the Ministry of Health confirmed the country’s first case of COVID-19 on March 6, 2020.13 They asked all public institutions to allow staff to work from home; prohibited public gatherings such as church services, concerts, bullfights, equestrian activities, sporting events, fairs, and other community events; halved the capacity of public meeting spaces; and suspended trips abroad for public employees.14 On March 16, 2020, the government declared a State of National Emergency,15 closing the borders and suspending all classes in schools and educational centers.16 The State of National Emergency decree also enabled all public institutions, including the CCSS, to suspend ordinary decision-making processes and move quickly to activate emergency interventions.

After the country recorded its first death from COVID-19, on March 18, 2020,17officials added further restrictions. First they limited Costa Ricans’ ability to drive and travel at night18 in order to prevent the spread of COVID-19. At the end of Holy Week, on April 11, those vehicle restrictions were extended to cover the daytime hours as well.16 Holy Week restrictions also closed shops and businesses, except for grocery stores and pharmacies, and limited public transportation.19

After Holy Week, the Ministry of Health allowed all establishments holding a sanitary working permit—including movie theaters, sports fields, gyms, beauty salons and barbershops, and parking garages—to remain open between 5 a.m. and 7 p.m. at 50% or 25% capacity.16 To limit travel, officials allowed people to use their cars just once a week and once on weekends. These mobility restrictions were designed to limit the spread of COVID-19, but they also reduced the number of traffic accidents—there was a 32% reduction in traffic fatalities between 2019 and 202020 —which kept people out of intensive care units and emergency rooms. These restrictions were enforced by the Ministry of Health, which could suspend the sanitary permits for businesses that did not comply,21 and law enforcement.

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A police officer checks the identity card of a vehicle’s occupant following the imposition of restrictions by Costa Rica’s government to prevent the spread of COVID-19, in San José, Costa Rica, April 10, 2020.
A police officer checks the identity card of a vehicle’s occupant following the imposition of restrictions by Costa Rica’s government to prevent the spread of COVID-19, in San José, Costa Rica, April 10, 2020.
Credit: Juan Carlos Ulate. © Reuters

In June 2020, municipalities introduced differentiated restrictions (green, yellow, orange, and red) calibrated to case counts. For example, “orange” alerts brought additional mobility restrictions and closures of public places.16 Some officials called this strategy, which aimed to preserve the Costa Rican economy by swapping strict lockdowns for more flexible restrictions on vehicles and businesses, the “epidemiological fence,”22 and others described it as Costa Rica trabaja y se cuida (“Costa Rica works and takes care of itself”).23

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Mobility in Costa Rica, March 2020 – December 2021

IHME

In August 2020, as the pandemic evolved and data improved enough to give officials a more precise, localized picture of case counts and transmission rates, officials adopted a strategy that relied on epidemiological data, called “the hammer and the dance.”4 An initial phase restricted movement and limited economic activity in order to control the spread of the pandemic (the “hammer”), after which officials gradually lifted restrictions and reopened the economy (the “dance”).24

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At the beginning of the COVID-19 pandemic, Costa Rica did not have enough personal protective equipment (PPE) for its health workers. Key informants reported that the rapid consumption of initial PPE stockpiles, along with the worldwide increase in demand, forced health facilities to ration and even reuse key PPE, such as gloves and face masks. This may have undermined the maintenance of essential health services and the delivery of critical care for COVID-19 patients in the early months of the pandemic, because it kept health workers from performing their jobs safely.

However, by late March 2020, the CCSS had begun to procure essential equipment such as ventilators, hospital beds, gloves, and facial masks. The CCSS’s contingency fund directed US$16.5 million to the purchase of non-durable medical equipment such as gloves, face masks, and hand soap along with oxygen, bleach, and alcohol.25

The Ministry of Health ordered Costa Ricans to wear cloth or plastic face masks in public places with sanitary operating permits and on public transportation at the end of June 2020. This mask mandate was gradually expanded in subsequent months to cover all workers and patrons in indoor public places.16

Mask use in Costa Rica, March 2020 – December 2021

IHME

In response to the shortage of PPE in Costa Rica, public–private and public–public partnerships made it possible to obtain key supplies from abroad.26 These partnerships also enabled the domestic production of PPE, such as ventilators for intensive care. For example, ALEPP (Local Supply Initiative for Personal Protective Equipment)—a public–private partnership that included the Costa Rican Chamber of Commerce and the CCSS—helped coordinate local PPE production. ALEPP identified Costa Rican companies with production capacity and located necessary raw materials; it also produced designs and shared prototypes for health officials’ approval. ALEPP’s work enabled 600,000 face shields to be manufactured locally in San José by Grupo Vargas.27

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Costa Rica directed some of its COVID-19 funding to financial support for its most vulnerable population. For example, in the beginning of the pandemic, the CCSS’s contingency fund enabled the transfer of US$19 million to cover medical leave for confirmed and suspected COVID-19 patients and for health workers in direct contact with them.25

Likewise, starting in April 2020 the Bono Proteger program provided temporary financial subsidies to about 700,000 people (including independent and informal workers) who had lost jobs or had working hours reduced as a result of the pandemic).23,28   Workers who lost their jobs entirely or had their hours reduced by more than half received 125,000 Costa Rican colones (₡) (approximately US$208) per month for three months, while those who had their hours reduced by half or less received ₡62,500 (approximately US$104) per month for the same period.

According to interviews with key informants, CCSS officials also approved the extension of health insurance coverage to workers whose labor contracts were suspended through June 30, 2021.

Public health surveillance played a key role in Costa Rica’s early COVID-19 response, in part because the country’s health system was already set up to do this work. For example, community health workers (asistente técnico de atención primaria, ATAP) on primary health care teams (equipos básicos de atención integral de salud, EBAIS) already performed epidemiological surveillance and vaccination during home visits with patients, and they were able to pivot to focus on the emerging needs of the pandemic. Additionally, EBAIS specifically provided primary health care in targeted areas. As a result, during the COVID-19 pandemic, EBAIS team members were sources of key surveillance data on the ground. ATAPs provided case counts, implemented quarantine orders, and eventually delivered COVID-19 vaccines.29

Health officials also implemented new tracking operations specific to COVID-19. For example, in late May 2020, health care workers from the CCSS and Ministry of Health visited La Carpio, San José—one of the most densely populated, low-income areas in Costa Rica, and the country’s largest Nicaraguan community30 —where a cluster of COVID-19 cases had been identified.31 Sanitary, health, and other public services are limited in La Carpio, as is access to clean water and information about health risks and health-promoting behaviors. As a result, officials worried that the community was a “risk zone” for the spread of COVID-19. They identified 33 similar high-risk communities around the country and established strict surveillance mechanisms there, including testing.

These and other surveillance measures may have enabled Costa Rica to delay the onset of community transmission until July 2020.32 Even after community transmission was established, health officials continued COVID-19 surveillance via its National Epidemiological Surveillance System (Sistema Nacional de Vigilancia Epidemiológica, SIVEI).33 SIVEI is made up of health professionals from public and private facilities all over the country who are obliged to report public health events and patient laboratory results through the country’s national platform. This system gives health officials the information they need to intervene in a timely fashion when necessary.

On February 26, 2020, the Ministry of Health announced that the publicly financed Costa Rican Institute of Nutrition and Health Research and Education (Instituto Costarricense de Investigación y Enseñaza en Nutrición y Salud, INCIENSA) could conduct PCR testing for COVID-19.34 By the end of March, the Ministry of Health had coordinated with CCSS to allow the rest of its network of laboratories to conduct testing, increasing the country’s capacity beyond INCIENSA. It also allowed eight additional private laboratories to perform COVID-19 tests.35

By April 2020, PCR tests were available for free from the CCSS, but supplies were still limited and turnaround times were long (5–6 days in some cases, although guidelines dictated that results should be available in 24–48 hours).36 Consequently, the Ministry of Health issued guidelines for prioritizing tests and required people to request a medical order from their physician to receive a COVID-19 test from CCSS.

To reduce turnaround time and increase testing capacity, in September 2020 the Ministry of Health began to allow the CCSS to use faster, cheaper antigen tests for symptomatic patients.37

People could also pay out-of-pocket for a test in one of the private laboratories authorized by the Ministry of Health.38 Some private facilities implemented innovations at testing centers to maintain safe distances between patients and providers, such as drive-through testing.39

The private sector also helped expand the national testing capacity. For example, the Costa Rican–United States Foundation for Cooperation (CRUSA) promoted an initiative called Testeo Proactivo (“proactive testing”) alongside businesses and other private sector organizations including AmCham (The Costa Rican-American Chamber of Commerce), Asociación de Empresarios para el Desarrollo, the Ministry of Health, and the CCSS.40,41 The initiative mobilized resources to help increase the availability and geographic coverage of COVID-19 tests, slowing the spread of the virus and speeding the return to normal economic activities.

In May 2020, the Testeo Proactivo initiative sought to raise US$750,000 for COVID-19 testing equipment to decentralize the testing process in Costa Rica by the CCSS. The initiative raised US$1,849,741 in donations and purchased 46 PCR devices and 61,180 test kits for diagnostic laboratories in the Central Pacific, Chorotega, Brunca, and Atlántica regions.42

Daily COVID-19 tests per thousand people in Latin America

Our World in Data

In May 2020, the Ministry of Health identified criteria for close contacts with suspected, probable, or confirmed cases of COVID-19. A close contact was defined as a person who, without having used appropriate protective measures, has been in contact with a person with COVID-19 48 hours before the onset of symptoms and who has any of the following conditions: the contact has provided care to a person with COVID-19 symptoms, either in the home or health care setting; the contact has had direct exposure to mucus or saliva of a symptomatic person, the contact has been face-to-face with a person who has COVID-19 at less than about 6 feet (1.8 meters) away and for more than 15 minutes, the contact has been in an enclosed space (classroom, office, session room, waiting area, or room) with a symptomatic person at a distance of fewer than about 6 feet (1.8 meters) for 15 minutes or more; or in a flight, if the contact had been with passengers located within a two-seat radius of a symptomatic person or the crew who provided direct in-flight care to a symptomatic person. 43 By July 2020, community transmission had been established and contact tracing became extremely difficult; the Ministry of Health announced it was unable to trace the source of 65% of confirmed cases.22

In June 2021, Google, Apple, and the Ministry of Health introduced a contact-tracing tracker, known as Mascarilla Digital,44 that was built into a phone’s settings. (In other words, users did not need to download it as they would an app).45 The Ministry of Health explained how it worked: “If a person was 2 meters away from another person, for a minimum of 10 minutes, both phones will exchange secure and anonymous codes using Bluetooth. If the person with whom he was close obtains a positive Covid-19 test result, he can notify others through the application anonymously.”46 However, officials and programmers decided to install the tracker automatically on Costa Ricans’ Android phones without warning, although iPhone users received a notification.45 This caused Android users to feel their privacy had been breached and fostered a sense of distrust about the government’s motives behind the app. Conspiracy theories erupted around a possible government scheme and adoption of the tracing software stalled.

Costa Rica was one of the first Latin American countries, along with Mexico and Chile, to secure and receive vaccine doses for its population, to launch a mass COVID-19 vaccination campaign, and to achieve broad vaccine coverage for those eligible to be vaccinated. In November 2020, when President Carlos Alvarado signed an agreement with Oxford–AstraZeneca to purchase 1 million doses of the company’s vaccine, he said:47  

"This important advance in the task of preparing to vaccinate the population when vaccines are available is the result of the great work that the National Vaccine Commission has been developing and reflects our primary commitment to protect the health and life of citizens against the pandemic, using all the means at our disposal."

- President Carlos Alvarado, November 2020

By the end of 2020, Costa Rican health officials had agreed to buy 6 million vaccine doses from three suppliers: 3 million from Pfizer-BioNTech,48 1 million from Oxford–AstraZeneca,49 and 2 million from the World Health Organization’s COVAX initiative.50

These 6 million doses were meant to be delivered to 3 million Costa Ricans over the course of 2021 according to priorities established by the CCSS and the Ministry of Health. The first four people to be vaccinated in Costa Rica, at the Specialized Care Center for Patients with COVID-19 (Centro Especializado de Atención de Pacientes con COVID-19, CEACO) on December 24, 2020, were chosen to symbolize those priorities: two people older than age 58 and two health care workers.51

By June 2021, according to Our World in Data, Costa Rica’s daily vaccination rates were the second highest among Central American countries.52 According to researchers at the University of Costa Rica’s Central American Population Center (Centro Centroamerican de Población), the impact of the vaccination campaign in Costa Rica has been “enormous.” In just one week in June 2021, they hypothesized that approximately 90 deaths among older adults may have been averted because older people were vaccinated first. Over an extended period of time, this effect is even more remarkable.53

Costa Rican Social Security Fund’s (CCSS) vaccination campaign prioritization by population groups

INCAE

Community health workers (asistente técnico de atención primaria, ATAPS) delivered many of these vaccines, especially in rural and isolated areas.29 As time passed, the CCSS also relied on public–private partnerships to implement its mass vaccination campaign: private organizations provided physical spaces (such as malls and soccer stadiums), and the CCSS provided the vaccine along with health workers to administer it.54,55 By December 2021, at least 67.6% of Costa Rica’s population had received all doses of the COVID-19 vaccine.56

Share of people who completed initial COVID-19 vaccination protocol

Our World in Data

Health system-level response measures

Costa Rica’s health system-level response measures fell into two main categories: direct responses to COVID-19 and interventions to maintain essential health services while facing continued disruptions related to COVID-19.

Supply- and demand-side barriers to essential health services maintenance in Costa Rica during the COVID-19 pandemic

In many countries around the world, the COVID-19 pandemic and efforts to mitigate it caused supply- and demand-side barriers to essential health service delivery—including provider and patient fear of infection in health facilities; inability to travel due to lockdowns; budgetary shortfalls; and delays and stockouts of essential health commodities such as personal protective equipment (PPE), reagents, some vaccines, and critical diagnostic tools (such as GeneXpert cartridges).

Although the Costa Rican Social Security Fund (Caja Costarricense de Seguro Social, CCSS) made strategic investments in equipment and infrastructure to treat the leading causes of mortality in Costa Rica prior to the pandemic, such as deaths associated with heart disease and cancer, most essential health services were interrupted at the beginning of the COVID-19 pandemic. Health officials mandated a reduction in visits for in-person care early in the pandemic to protect health workers and patients, and they suspended or postponed all in-person medical consultations, elective surgeries, and procedures. Emergency department, respiratory, cardiology, and oncology services remained active in person, although many surgical and intensive care units were reassigned to COVID-19 response.8

Data from CCSS’s Annual Statistical Books confirms that the COVID-19 pandemic had different impacts on the delivery of different essential health services.57

Dentistry (odontology) is a major source of medical tourism in Costa Rica.59  Perhaps as a result, it saw the largest dip in service delivery during the COVID-19 pandemic. Medical specialties include cardiology, oncology, orthopedics, and ophthalmology.

Medical consultations per 1,000 people in Costa Rica by modality of care, 2011–2020

CCSS
Service delivery rates for other specialties and surgeries remained more consistent. For example, outpatient consultations decreased by 12% between 2019 and 2020, and inpatient admissions decreased by 29% in that same period.

Medical Consultations per 1,000 people by modalities of care (2011-2020)

CCSS’s Annual Statistical Books (2020)
The third level of care has consistently represented the majority of consultations in Costa Rica and has therefore been prioritized by the CCSS, rather than primary care. As a result, medical consultations for the third level of care have decreased relatively little, compared with primary and secondary level care.

Medical consultations per 1,000 people in Costa Rica by level of care, 2011–2020

CCSS

The overall increase in deaths (both from COVID-19 and other health issues) between 2019 and 2020 was 7.3%, above the 2011–2019 average growth of 2.7%.57 The cause of death that increased the most between 2019 and 2020 was infectious and parasitic diseases (+418.7%), followed by pregnancy, childbirth, and postpartum complications (+53.8%). On the other hand, the country saw substantial decreases in other causes of death, such as diseases of the respiratory system (-25.0%) and diseases of the skin and subcutaneous tissue (-22.2%).

In-school vaccination programs were paused while schools were closed. A 2019 in-school vaccination campaign against the human papilloma virus (HPV) was transferred to the primary health care teams (equipos básicos de atención integral de salud, EBAIS). However, parents had to take their children to get the vaccine, which was complicated by mobility restrictions that made it difficult to leave home. These barriers likely reduced the HPV program’s impact.

Key informants reported an increase in emergency department visits for illnesses that were previously treated at the primary level, such as diabetes or high blood pressure. More patients also sought critical medical attention because of decreased primary care access; for example, reported heart attacks increased.

Disruption in DTP3 vaccine doses in Costa Rica

IHME

Based on an analysis from the Institute for Health Metrics and Evaluation of administrative data, the figure above shows the ratio of the monthly number of doses of DTP3 vaccine (third dose of diphtheria, tetanus, and pertussis vaccine) given to children younger than one year old in 2020 as it compares with the same month in 2019. A value of 1 represents no change and values less than 1 indicate delivery disruption.

In March 2020, there was a slight decline in the number of children younger than one year of age who received the third dose of the diphtheria-pertussis-tetanus (DTP3) vaccine in Costa Rica. However, this rate bounced back in April 2020 and Costa Rica maintained consistent DTP vaccination rates throughout the pandemic, with the exception of a small dip in July 2020.

To maintain the delivery of health services, particularly essential health services, during the COVID-19 pandemic, Costa Rican health officials extended existing service delivery adaptations and developed new ones. Most of these modifications were aimed at encouraging people to avoid visiting health facilities whenever possible, especially early on when PPE for health workers and patients was scarce.

In March 2020, the CSSS mandated a reduction in visits for in-person services to protect health care workers and patients and avoid service interruptions caused by workers getting infected or sick.59 Because it is a public institution, every CCSS process is typically regulated and every decision is accompanied by a technical study; however, the State of National Emergency Declaration enabled health officials to streamline the decision-making process during the pandemic crisis.

The pandemic emergency made it possible for health officials and providers to scale up already emerging practices in the health system, such as the use of digital technologies for remote or telehealth care and the home delivery of medication. These adaptations helped health workers maintain COVID-19 care services as well as essential health services delivery.

Telehealth

Some health care providers in Costa Rica delivered services using telehealth technologies before the COVID-19 pandemic began, but the crisis accelerated widespread adoption of such technologies. For example, doctors used institutional or personal electronic devices to consult with patients by telephone or video call using tools such as Microsoft Teams, Zoom, or WhatsApp. This shift to remote care made it possible for health workers to continue providing critical but non-urgent health services—especially for specialties that do not require in-person assessment, such as psychology—and to follow up after laboratory tests or other diagnostic procedures, while reducing risks for older or vulnerable patients.60

However, amid this widespread shift to telehealth services during the pandemic, researchers found that patient absenteeism for these consultations was relatively high compared with in-person consultations, according to key informant interviews. Doctors reported that some patients did not answer the phone for their scheduled appointments or did not have the data plan they needed to make and receive video calls. Others had the necessary equipment, such as smartphones and video call applications, but needed help using it, according to key informant interviews.

Monthly Outpatient Consultations, In-person vs. Alternative Modalities per 1,000 people during 2020

CCSS 2021

Training organizations developed new curricula for telehealth, such as the Center for Strategic Development and Information in Health and Social Security (Centro de Desarrollo Estratégico e Información en Salud y Seguridad Social, CENDEISSS), which trained family doctors to perform video calls and virtual follow-ups, enabled by the nationwide EDUS digital record.61 The doctors could support any health areas in which there was a shortage of personnel, including rural areas.

Starting on March 13, 2020, an official call center line at emergency phone number 1322 began to offer remote care and monitoring to COVID-19 patients, provide information and guidance on COVID-19 symptoms, and support local follow-up efforts.62 This call center made it possible for health officials to keep people from visiting health officials unnecessarily.

By the end of May 2021, CCSS had also enabled 24/7 telehealth care for COVID-19 patients through the 2519-3001 CENDEISSS emergency line, which received an average of 600 calls per day.63 This emergency line provided:

  • Follow-up calls to patients who had tested positive for COVID-19
  • Daily monitoring of patients referred by their health area
  • Coordination efforts for patients who require hospitalization due to a deteriorating health condition

In addition, CCSS’s emergency line was available to COVID-19 patients recovering at home, people who needed clarification about symptoms and medication, and people who required emotional support.63

This emergency line was especially vital when the number of new daily cases exceeded the capacity of the country’s health facilities during the pandemic’s third wave in 2021.64 Patients could receive follow-up evaluations and discuss symptoms with a health care provider without leaving home isolation.

Home delivery of medication

The CCSS has long provided medicines to insured people without a copayment, but before the COVID-19 pandemic patients needed to visit a pharmacy inside an EBAIS clinic or public hospital to pick them up. Starting in March 2020, mobility restrictions made these pickups a challenge for many. Partnerships with the national post office, universities, rental car companies, and others helped the CCSS deliver medications to the homes of those who could not visit a pharmacy themselves.65 Patients with chronic diseases benefited the most because they were the most fearful of contracting COVID-19 and were at higher risk for severe illness if they did contract the virus. However, key informants reported that the initiative was temporary and only lasted for a brief period during 2020.

Between 2019 and 2020, the number of drugs dispatched (at home and in the pharmacy) decreased by 4.3% and the number of laboratory tests decreased by 20.8%. The use of alternative channels for drug delivery may have helped avoid a more substantial decrease.66

Number of laboratory tests and drugs dispatched per 1,000 people in Costa Rica, 2011–2020

CCSS

Adapting health facilities to reduce COVID-19 transmission among frontline workers

To ensure the continuity of health care services, health officials instructed administrators to carefully observe frontline health workers for COVID-19 symptoms. They also categorized health workers according to their risk of contracting COVID-19: those who worked directly with patients and those who worked in more than one health facility or department were at the highest risk of getting and spreading COVID-19, according to key informant interviews.

Starting in March 2020, health officials suspended all face-to-face meetings and trainings, trips abroad, and all non-essential activities that involved travel and contact with people outside their home institution. Administrators and non-frontline health workers used collaborative tools such as Microsoft Teams, Zoom, and Webex for meetings and day-to-day tasks, and the CCSS encouraged health workers to work from home where possible. About 400 CCSS workers worked from home before the pandemic, compared with almost 4,800 by the end of 2020.67

A member of the medical personnel wearing a protective face mask is seen at a tent triage prepared for suspected COVID-19 patients in San José, Costa Rica, March 13, 2020.
A member of the medical personnel wearing a protective face mask is seen at a tent triage prepared for suspected COVID-19 patients in San José, Costa Rica, March 13, 2020.
Credit: Juan Carlos Ulate. © Reuters
Using data for decision-making and essential health services maintenance

Early in the pandemic, the CCSS developed a COVID-19 menu for its widely used EDUS app. Using this tool, individuals could report possible COVID-19 symptoms and get further information about the disease. It also included a contact-tracing alert that anonymously indicated when a person was close enough to someone with COVID-19 (such as at work or while commuting) to be at risk transmission.

According to an interview with a key informant, EDUS also enabled key data analysis and visualizations for providers and administrators across the health system. For example, it generated a daily report of available and occupied ICU beds in every health facility in the system that was visible to administrators at every level. Likewise, because it stored and shared patient medical records, EDUS facilitated patient transfers by enabling communication between transferring and receiving hospitals and patient and provider follow-up; it also facilitated virtual visits with care providers working from home.

“...in 100% of the country’s hospitals, everything is monitored through EDUS, which allows us to concentrate the information and make decisions. So, from the central offices, I could know the real occupancy of the hospital and see how many beds there were and what type of beds they had. It allowed us to manage as a control tower and have daily information on the real situation at the national level… Every day I would ask for a report that would tell me, for example, we currently have 100 patients in the ICU, 50 of these patients are complicated, and we have seven beds left. This information was shared daily with all the directors. EDUS became a vital piece, the DNA of management because it allowed us to have that information."

- CCSS Medical Manager, February 10, 2022

To boost the delivery of essential health services during the pandemic emergency, the CCSS—ordinarily a bureaucratic institution—developed new strategies to temporarily increase the number of health workers and encourage flexibility in their deployment. For example, it allocated workers to key tasks that may have been outside their ordinary duties.

Early in March 2020, the CCSS budgeted US$12.5 million68 for a “vacancy-substitution scheme that guaranteed personnel in healthcare centers withdrawn from their original functions could be replaced by new temporary staff.”69 This scheme required health facility managers to prove an increase in demand for medical services before implementing the scheme, permitted just one replacement per position, and limited replacement personnel to a maximum of two months. Even with these guidelines and limitations, the scheme enabled officials to deploy new and reassigned pharmacists, nurses, general practitioners, and operational staff where and when they were required. According to CCSS data, from February 2020 to January 2022, temporary staff within the CCSS increased by 11%.70

At the same time, in response to pressure from unions and CCSS regulations, health workers in “inessential” specialties or specialties not amenable to teleconsultation were reassigned to general physician roles or pandemic response tasks; technical staff were likewise reassigned.

"If you can do more [complex consultations] being a specialist, so you can do less [complex] work as a general physician.”

- Medical center director in the Atlantic Region, personal communication, February 4, 2022

In total, CCSS added nearly 6,000 temporary health workers (at a cost of more than US$6.2 million) to the system between June 2020 and March 2021, including 784 positions at the new CEACO.67 These interim workers also strengthened the primary care network of clinics and national hospitals, especially the Rafael Ángel Calderón Guardia Hospital and the National Psychiatric Hospital (Hospital Nacional Psiquiátrico). The number of permanent workers in the CCSS saw a slight decrease from 2018-2021 that could be attributed to burnout, as well as COVID-19 impacts (e.g., illness and death).

Number of interim and permanent workers in the Costa Rican Social Security Fund, January 2018 – December 2021

INCAE

As part of its efforts to maintain essential health services during the first 18 months of the COVID-19 pandemic, CSSS improved coordination between health centers through the integrated network management strategy known as One Caja. One Caja’s main pandemic objective was to limit the transmission of COVID-19 by separating patients with COVID-19 from those with other health conditions, including via separate physical spaces, beds, health care providers, and equipment.71

The One Caja strategy also allowed the CCSS to take advantage of moments of lower hospital saturation to establish interventions aimed at providing essential health services.72

"...first of all, maintain care as far as possible and take advantage of these time windows when cases [of COVID-19] are decreasing."

- Key informant interview

"....initiate a controlled process to reach a balance in the care of COVID-19 patients and other pathologies."

- Key informant interview
Resource redistribution and phases of escalation and de-escalation

Early in the COVID-19 pandemic, officials developed an innovative “escalation and de-escalation” strategy to mitigate the negative effects of the pandemic and pandemic response strategies on the delivery of essential health services.

Key informants reported that each week, an Operational Coordination Council (Consejo de Coordinación de Operaciones) of health administrators met virtually (instead of the monthly physical meetings typical before the COVID-19 pandemic) to present each health facility’s specific needs and coordinate resources, patient movements, and priority specialties of care according to the demand for emergency and essential services. The One Caja strategy encourages medical facilities to collaborate and to use regional epidemiological data to determine health care priorities. For example, health facilities in the areas most affected by COVID-19 could choose to temporarily focus their efforts on serving those patients and avoid hospital saturation by transferring non-COVID-19 patients to other facilities in the integrated network. This strategy enabled different health care facilities to adopt different care specialties and increased the flexibility of resource allocation within the health system as a whole.71

"I saw what was happening in other places, for example, what the governor of New York said, that he would have liked all the hospitals in New York to operate at the same time in the same way because they had the problem that at some point there were hospitals full to the brim and there were other hospitals that were not so full; and also that the hospitals are from different systems. They didn’t have the flexibility we have."

- CCSS medical manager, February 10, 2022

Percentage of hospital discharges with a transfer to another public hospital in Costa Rica, 2011–2020

CCSS

This patient redistribution is possible because the pandemic affected various regions differently, and because the CCSS system is horizontally and vertically integrated. The CCSS can also transfer patients from the third, more specialized, level of care to the second level of care once they have been stabilized, which can free up more beds for people who need specialized care and mitigate the saturation of beds in the system.

Expanding health system capacity to meet increased demand by adding ICU beds and creating a specialized COVID-19 treatment center

One Caja also enabled the creation of an 88-bed Specialized Care Center for Patients with COVID-19 (Centro Especializado de Atención de Pacientes con COVID-19, CEACO) in March 2020. CEACO, which had absorbed the National Rehabilitation Center (Centro Nacional de Rehabilitación, CENARE), aimed to concentrate all COVID-19 resources in a single place and avert the collapse of essential hospital services elsewhere.73,74

Case study: CENARE to CEACO

As part of the March 2020 declaration of a State of National Emergency that allowed public agencies like the Costa Rican Social Security Fund (Caja Costarricense de Seguro Social, CCSS) to bypass typical bureaucratic processes, Costa Rican health officials proposed the transformation of the National Rehabilitation Center (Centro Nacional de Rehabilitación, CENARE) into a specialized hospital for COVID-19 patients.75

In just two weeks, dozens of CCSS staff and volunteers working 24-hour shifts completely renovated the CENARE hospital. They installed new internal walls, ceilings, plumbing, and electrical infrastructure along with a high-tech voice and data telecommunications network and equipment, such as monitors for vital signs, suited to the facility’s new function. Interinstitutional and public–private partnerships made this quick transformation possible.76 ,77,67

The new Specialized Care Center for Patients with COVID-19 (Centro Especializado de Atención de Pacientes con COVID-19, CEACO) got its first patient on April 2, 2020, less than one month after the detection of the first COVID-19 case in Costa Rica.68,78 By the end of 2020, CEACO had a team of about 1,350 workers who worked around the clock in three shifts. These workers included doctors from different disciplines (including medical emergencies, internal medicine, infectious diseases, and epidemiology), respiratory therapists, nursing staff, patient assistants, cleaning, and computer staff. According to data from the Health Statistics Area of the CCSS, by the end of 2020, 1,166 patients out of a total of 8,085 COVID patients hospitalized were discharged to CEACO (14.4%).

CEACO also served as the transfer coordination headquarters for patients with COVID-19. A trained working group known as the PRIME team oversaw the transport of severely ill patients with COVID-19 from different oversaturated health centers to CEACO (and vice versa, when their condition improved), additionally there was a dedicated transfer coordination team. In total, during 2020, more than 2,000 transfers were conducted.67

“No one was left without a bed, even in the most acute part of the emergency.” —Waiting list coordinator, February 16, 2022

Thanks to CEACO and the PRIME team, the CCSS was able to increase the number of ICU beds designated for COVID-19 patients from 24 in January 2020 to 359 by the end of 2020.3 The average daily number of occupied ICU beds in the CCSS increased from 4.1 in June 2020 to 227.1 in September 2020, reaching a 76% occupation level by September 9, when the CCSS had 304 ICU beds for COVID-19 patients 79 and 82.1% by September 17, according to a local newspaper.80 From October to December 2020, the average daily number of occupied ICU beds would be 213.0. (Data on the number of ICU beds for COVID-19 patients from October to November 2020 was unavailable at the time of our research; however, local news articles reported ICU bed capacity in September 2020 at 304 and 359 by December 2020,79,81which helped the CCSS avert hospital saturation at the end of the year.82 ) By April 2021, the number of ICU beds within the CCSS for COVID-19 patients increased to 384.83

Seven-day rolling average of daily COVID-19 patients occupying an intensive care unit bed in the Costa Rican Social Security Fund

INCAE

Patient-level measures

At the beginning of the pandemic, Costa Rica established measures for the quarantine and isolation of suspected, probable, and confirmed cases of COVID-19, and the Ministry of Health updated their guidelines as more scientific evidence became available.

At first, the guidelines for suspected, probable, and confirmed cases of COVID-19 were to isolate at home for 7 to 14 days. Isolation was discontinued for suspected cases (who had no contact with a positive person, nor a history of travel within 14 days before symptom onset) if they tested negative for COVID-19. People living in the same household who had been in direct contact with a confirmed COVID-19 case quarantined as a group to prevent transmission of the virus to others. Suspected, probable, and confirmed cases of COVID-19 were followed up by telephone to monitor whether they developed symptoms throughout the isolation period.43,84

Later on, suspected cases were defined as those who were symptomatic, in contact with a probable or confirmed case or linked to a cluster of COVID-19, or had a positive result on an antigen self-test. Probable cases were those who had inconclusive test results or negative PCR results but signs of COVID-19 from a chest X-ray. Confirmed cases had tested positive on PCR or antigen tests, regardless of symptoms, as well as close contacts who developed symptoms within seven days. Isolation requirements varied depending on the case: 7 days for asymptomatic individuals, 10 days for those with moderate symptoms and no fever, 14 days for those with more serious symptoms, and 20 days for immunocompromised individuals.

Patients who tested positive for COVID-19 or called the CCSS emergency line to report possible COVID-19 symptoms were encouraged to isolate at home. Community health workers followed up by phone on their condition. Health officials and the PRIME team directed severely ill patients to local COVID-19 ICU beds or to CEACO, keeping them isolated from other patients seeking inpatient and outpatient health services.

Additionally, because the economy was suffering and tourism is a key part of Costa Rica’s economy, the government made deliberate choices to adjust travel policies and enable tourism to continue more safely during the pandemic. International travel was restricted from March 2020 to August 2020, and starting in September 2020, international travelers were required to show a negative PCR test 72 hours before their flight. They were also required to have travel insurance that would cover any in-country expenses related to COVID-19 infection or illness, and to complete a health status form and symptom assessment before entering the country.16 After November 2020, incoming travelers who did not display symptoms of COVID-19 did not have to quarantine upon arrival.85 This timeline was relatively similar to other Latin American and Caribbean countries.

At the end of October 2021, officials eliminated testing requirements for international travelers altogether and soon replaced them with COVID-19 vaccination requirements. Travelers who were not fully vaccinated had to have insurance that would cover the costs associated with hospitalization for health problems related to COVID-19.

Costa Rica adopted the treatment and care protocols defined by the World Health Organization86 and the international community, and physicians were in constant communication with international networks of their peers as COVID-19 treatment and care protocols evolved.

The prestigious Clodomiro Picado Institute at the University of Costa Rica, one of the world’s foremost developers of snake anti-venoms, also began to develop two treatments for COVID-19 in April 2020. One focused on transfusions of convalescent plasma (plasma from people who have recovered from COVID-19 to patients who are currently ill). The other deployed equine immune plasma for human use. Their clinical trials created high expectations among the international community, but by December 2020, the university had discarded further research on convalescent plasma. Research on equine immune plasma continued through December 2021.87,88

Costa Rica was not immune to misinformation and “fake news” regarding local remedies, cures, and treatments that were not scientifically tested or proven. Misinformation about vaccines, masking, and other public health and social measures spread, from the beginning of the pandemic through the end of 2021.89

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Challenges

Sections

Appendix