Why was Costa Rica selected?
From March 6, 2020, when Costa Rica reported its first case of COVID-19, until the end of May 2020, Costa Rica maintained a remarkably low number of daily new confirmed COVID-19 cases and very few deaths.1, 2 In fact, between March and May 2020, Costa Rica had no registered community transmission.3 This early success may be attributed to a strong, preexisting integrated public health system that enabled a robust, data-driven response from the start of the COVID-19 pandemic. However, case counts increased rapidly from June 2020, and subsequent pandemic surges put a great deal of strain on Costa Rica’s health system. In spite of that additional pressure, the system was able to keep delivering essential and emergency health services throughout the country.
In mid-April 2022, Costa Rica experienced the first of many cyberattacks on its government agencies. These attacks continued into late May, affecting 27 government agencies and finally hitting the CCSS at the end of May. This forced the health system to shut down any digital record system, such as the Single Digital Health Record (Expediente Digital Único en Salud, EDUS), which affected the care of patients and the entire management of the health system. In light of this, researchers at INCAE Business School faced difficulties accessing data while completing this research. As of February 2023, many government pages are still shut down.
How did we select the countries we studied?
Differences in testing, surveillance capacities, and reporting criteria4 have made it difficult to quantify5 and compare the impact of COVID-19 in countries around the world. Yet some countries were able to strengthen and sustain health system capacity, maintain essential health services, and target public health and social measures to mitigate the overall impact of the COVID-19 pandemic. Identifying the strategies, policies, and practices that enabled these successes can give us a better understanding of health system resilience, adaptive health policies, and emergency response strategies that could be applied to other countries and future infectious disease outbreaks.
To select positive outlier countries with transferable lessons for pandemic preparedness and health system resilience, we used data from March 2020 through the end of 2020 to identify countries with best-practice responses to the early phases of the pandemic. This snapshot in time does not account for subsequent waves of the pandemic, nor for the later availability of COVID-19 vaccines in the selected countries.
The six countries were selected by evaluating COVID-19 indicators (including age-standardized death rates, cases per million, and testing rates) and essential health services indicators (including disruption to routine immunization) after screening for the availability of high-quality data and the transferability of the findings. After identifying potential Exemplar countries, we completed validation research including an examination of the COVID-19 epidemiological curve over time, testing policies and strategies, interventions to maintain essential health services, survey data, and interviews with local and regional health experts. The final six countries (Dominican Republic, Costa Rica, Sri Lanka, Thailand, Uganda, and Ghana) were selected after considering linguistic, demographic, and geographic diversity as well as government structure and data availability (see figure below).
Country selection methodology
For Costa Rica and the other five countries, we conducted a literature and policy review, key informant interviews, qualitative analysis, and quantitative analysis. We synthesized findings to develop key recommendations on health system resilience and pandemic preparedness. Through this country selection process we reviewed indicators through the end of 2020, but our research covers the time period at least through the end of 2021.
Key insights: Costa Rica
Several key interventions, summarized below and detailed in the following pages, contributed to Costa Rica emerging as a positive outlier in the COVID-19 response and the maintenance of essential health services.
Leadership and governance
Costa Rica’s health system works from the top down as a single cohesive unit. Even before the COVID-19 pandemic began, the country’s integrated approach to health service delivery allowed system-wide decision-making and resource allocation, such as need-based distribution of clinic supplies and patient transfers within the hospital network. This approach enabled a coordinated response to the COVID-19 pandemic and the continued delivery of essential health services nationwide starting in March 2020.
Data for decision-making
Costa Rica obtained comprehensive, high-quality data to make informed decisions about COVID-19 prevention and treatment and essential health services maintenance. Two preexisting data systems, the National Health Surveillance System (Sistema Nacional de Vigilancia Epidemiológica, SIVEI) and the EDUS system for digital health records, helped health centers and officials identify COVID-19 cases, track the pandemic’s evolution in real time, and make informed decisions about policy and practice.
The structure of Costa Rica’s health system predates the COVID-19 pandemic, but the flexibility built into its design enabled it to adapt quickly in response to the pandemic emergency. Likewise, a preexisting contingency fund made it possible to direct money to key interventions as they were necessary, without bureaucratic hurdles.
Intensive early response
In March 2020, Costa Rica’s Ministry of Health acted quickly to implement stringent public health and social measures to delay the spread of COVID-19. This includes strict social distancing and mobility restrictions that were implemented before Costa Rica’s first confirmed COVID-19 death. These restrictions were lifted over time but kept cases low in the early months of the pandemic.
Aggressive and early vaccine delivery
Costa Rica was one of the first Latin American countries to launch a COVID-19 vaccination campaign and achieve broad vaccine coverage for those willing to be vaccinated. Its vaccination campaign started with frontline health workers, which enabled a quick return to in-person delivery of key essential health services.
Service delivery adaptations
The flexibility in Costa Rica’s health system also enabled rapid innovation for COVID-19 response and essential health services maintenance. For example, by the end of 2020, nearly 5,000 health workers delivered services via telemedicine, enabling patients and providers to avoid health facilities where possible and preventing facility saturation during pandemic waves.
Despite the country’s early success in limiting the spread and severity of the COVID-19 pandemic, Costa Rica’s efforts to mitigate the pandemic while maintaining the delivery of essential health services encountered several challenges including the following:
- Personal protective equipment shortages early in the pandemic prevented health workers from safely providing emergency and essential care in person, undermining the delivery of health services nationwide. Likewise, the reassignment of community health workers and other health care providers to the pandemic response limited their ability to provide key routine health services. In addition, some fearful patients avoided health facilities, which delayed routine care for chronic conditions.
- Although Costa Rica’s health system adapted to deliver care via telemedicine and other alternative modalities, some patients and providers expressed doubts about the quality and equity of that care—mainly because of the lack of provider experience with virtual service tools, the lack of quality control in telemedicine, and low-income patients’ limited access to necessary technology. At the same time, a dearth of qualified personnel limited the delivery of intensive and urgent care for COVID-19 patients, especially in rural areas.
- Finally, some of the interventions Costa Rica implemented to prevent the spread of COVID-19, especially movement restrictions, had social and economic consequences. Because tourism is such a significant part of the Costa Rican economy (10.8% of the gross domestic product in 20196), officials made a deliberate decision to relax border controls and entry requirements in September 2020, thereby increasing opportunities for transmission. However, the government implemented mandatory testing and travel insurance to mitigate transmission with increased travel.
Center for Systems Science and Engineering, Johns Hopkins University. COVID-19 Dashboard. Accessed January 11, 2023. https://coronavirus.jhu.edu/map.html
Our World in Data. Costa Rica: coronavirus pandemic country profile. Accessed January 11, 2023. https://ourworldindata.org/coronavirus/country/costa-rica
United Nations. 5 reasons Costa Rica is winning plaudits for fighting COVID-19: a UN resident coordinator blog. UN News. May 24, 2020. Accessed January 11, 2023. https://news.un.org/en/story/2020/05/1064412
Mercer TR, Salit M. Testing at scale during the COVID-19 pandemic. Nat Rev Genet. 2021;22(7):415-426. https://doi.org/10.1038/s41576-021-00360-w
Alwan NA. Surveillance is underestimating the burden of the COVID-19 pandemic. Lancet. 2020;396(10252):e24. https://doi.org/10.1016/s0140-6736(20)31823-7
Statista. Travel and tourism as percentage of gross domestic product in Costa Rica from 2019 to 2021. Accessed January 11, 2023. https://www.statista.com/statistics/873744/costal-rica-travel-tourism-breakdown-contribution-to-gdp/