The basic components of the Costa Rican National Health System (Sistema Nacional Salud, or SNS) were outlined in 1979. The roles of different organizations that constitute the Costa Rican health sector, including the Costa Rican Institute for Research and Teaching in Nutrition and Health (Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud, or INCIENSA), the Institute on Alcoholism and Drug Dependence (Instituto sobre Alcoholismo y Farmacodependencia, or IAFA), the National Insurance Institute (Instituto Nacional de Seguros, or INS), the Costa Rican Institute of Aqueducts and Sewers (Instituto de Acueductos y Alcantarillados, or AyA), the municipalities, and the private sector, were specified on February 15, 1983, in an executive decree. This decree detailed the functions of each institution within the sector, some of which had been created several decades earlier [1] . While the 1983 decree specified roles of these government organizations, the SNS was formally initiated in 1989 with the promulgation of Executive Decree No. 19276-S. This decree integrated government institutions and other entities, with their functions detailed in Article 11 of the health regulations (Executive Decree No. 19276-S of 1989) [2] . According to this decree, the specific functions include ( Figure 1 ):

The SNS comprises the MDS, the CCSS, and several quasi-independent institutions such as the INCIENSA, the IAFA, the INS, the AyA, municipalities, and private sector entities that offer various health services [2] . The objectives of the SNS are to provide quality health services to all, facilitate community participation in defining needs and using resources, promote effective and equitable resource management and intersectoral collaboration, and ensure coherent health legislation to support health goals and policies.

As stated in Article 42 of the health regulations, specific functions of the SNS include reducing disease, preventing death, and improving the physical and mental health of the population [3] . Additionally, these functions strive to: encourage and support community participation in health promoting activities; improve the administration and effectiveness of local health services; strengthen subsystems such as occupational health, environment, information, and planning; identify medical care-related financial needs; and develop programs for efficient resource use. The SNS includes institutions that are responsible for providing all health, some economic, and some social benefits to citizens, as follows:

Health Benefits:

Economic Benefits:

Social Benefits:

The CCSS was created as a semi-autonomous entity on November 1, 1941, by Law No. 17 during the administration of President Rafael Ángel Calderón Guardia. It underwent significant reform on October 22, 1943, becoming an autonomous institution dedicated to serving the working population through a tripartite financing system. The CCSS is the core of the SNS, governing, managing and administering health services [6] . CCSS also manages the public pension system. Its formation and operation are specified in Articles 73 and 177 of the Political Constitution of the Nation. Article 73 establishes that social insurance is provided for all workers, financed by mandatory contributions from the government, employers, and workers [3] . Insurance coverage for workers’ spouses, children, siblings, parents, and other dependents also is provided. These insurances cover costs for health care services associated with illness, disability, maternity, old age, and death. CCSS also provides support related to unemployment, adverse family situations, and burial costs unless death is due to a work-related illness or injury.

CCSS enrollment and coverage are mandatory for all workers who receive a salary from an employer. The amount paid is calculated based on total worker remuneration received. Employers are not required to make contributions for family members who are unpaid and live and work with the employer. In addition, they are not required to make contributions for most workers already retired or pensioned by the government unless certain criteria are met; if so, the employer is required to make contributions for illness and maternity insurance. CCSS legislation also allows the unemployed to purchase insurance (called Voluntario) if they wish. Independent (self-employed) workers are required to pay for insurance. The CCSS is not under the government’s mandate in terms of budget and policies, except for government employees. CCSS funds cannot be used for purposes other than those originally specified in Articles 73 and 177 of the Constitution. Health care insurance for work accidents is the exclusive responsibility of employers, with care provided by the INS.

As noted above, the CCSS manages the two main types of insurance programs: health insurance and pensions. It also offers the RNC, as described below.

Table 1 and Figure 3 display the distribution of categories for direct and pension insurance coverage. Figure 3 specifically shows the distribution of individuals by type of insurance [7] [11] . According to the 2020 CCSS institutional report, 92% of the population in Costa Rica had some form of health insurance. Of those, 34% had direct insurance 29% were dependents of a directly insured person, 17% were insured by the government, and 12% were covered through pensions. Special condition groups accounted for 8% of the insured population, and 1% had student insurance. Seventy-three percent of those with direct insurance were salaried workers. Only 8% of the population was uninsured.

Article 22 of the Constitution establishes a mandatory tripartite contribution (worker, employer, and government) to fund the CCSS. These contributions vary depending on the type of worker and aim to ensure the sustainability of the social security system in the country [3] [12] . These contributions collectively form the total funding of the CCSS, which amounts annually to about one billion dollars or 12.9% of the Gross Domestic Product of the country according to the Central Bank [12] . The contribution details for each sector are as follows:

Funding Structure of the CCSS ( Table 2 )

1) Salaried Sector: Workers contribute 10.67% of their gross salary and employers contribute an amount equal to 26.67% of the workers’ salary. The salaried sector makes the largest contribution to the CCSS.

2) Pensioners’ Sector: Pensioners contribute 5% of the total amount of their pensions; the Pension Fund contributes an amount equal to 8.75% of the total pensions paid; and the government contributes an amount equal to 0.25% of the total amount of pension paid.

3) Voluntary Sector: This sector enables individuals who are not covered through a government route and want to access CCSS health services to make voluntary contributions. Individuals making voluntary contributions only receive access to covered medical care; they do not receive other CCSS benefits like pensions. The amount of the voluntary contribution is calculated based on individuals’ incomes; if there is a difference between the insured’s contribution and the amount necessary to fund medication and care services, the government funds the difference. The government also contributes an amount equal to 0.25% of the amount paid by this group.

4) Independent Sector: This sector enables contributing individuals, unlike those in the voluntary sector, to obtain additional benefits such as pensions, economic advantages, and more. Independent workers pay a contribution based on a scale approved by the CCSS Board of Directors. Additionally, the government contributes an amount equal to 0.25% of this group’s contribution base.

*Percentage of contribution vary by profession or employ.

CCSS’ services are provided through administrative levels (central, regional, and local) and level of care (primary, secondary, tertiary). Figure 4 provides an overview of CCSS’ services.

Administrative Levels: The General Health Regulation, specified in Article 17 of the 1989 Executive Decree, establishes the administrative levels of the SNS.

Central Level

At the central level, the CCSS is governed by a Board of Directors, which is presided over by the Executive Presidency. There are representatives from each sector: two from the government, three from the employers, and three from the workers. The Board of Directors is responsible for establishing policies for the operation, improvement, and modernization of the Social Security Fund. It also supervises and monitors the Fund’s administration, deliberates and makes decisions in accordance with the law and regulations, and ensures that the Fund operates in a safe, continuous, efficient, profitable, and transparent manner. There are seven management areas: General Management, which acts as the highest administrative authority of the institution; Administrative Management; Medical Management; Financial Management; Infrastructure and Technology Management; Logistics Management; and Pension Management.

The central level is responsible for the centralized digital medical record System [1] [4] [13] .

The Centralized Digital Record System (Expediente Digital Único en Salud, or EDUS) was implemented by the CCSS in 2015 following a Supreme Court of Justice Order in May 2012. Patient information is stored centrally in EDUS, which enables access to medical and social security records from a single source for all levels of healthcare provision. EDUS demonstrates the CCSS’s commitment to leveraging technology to improve healthcare efficiency and patient care in Costa Rica. The EDUS management team includes people with expertise in medicine, nursing, and laboratory sciences as well as engineering, statistics, and project management. The main purpose of EDUS is to provide efficient, high-quality, and reliable support for the healthcare services of the CCSS. In addition to the integrated medical records, EDUS also provides systems for scheduling and appointments, hospital admissions and discharges, laboratory information (e.g., pathology, cytology), vaccination, pharmacy and epidemiological surveillance. EDUS also provides information on compulsory pensions and automatically generates digital death certificates. However, EDUS does not have information on healthcare utilization within the private sector [14] .

Regional Level [15]

Costa Rica is divided into seven health regions ( Figure 5 ). In each region, the Directorate of the Integrated Network is tasked with adopting and systematizing the strategies, plans, programs, and budgets established by the central level within its geographic area of influence. Furthermore, it is responsible for coordinating, supervising, and training local human resources, as well as managing the physical and financial resources allocated to the region.

Local Level

This level is responsible for planning, executing, and monitoring health actions through which the plans and programs defined by the central level and systematized by the regional level are operationalized. Additionally, local projects are formulated and implemented to address the specific needs of the area of influence, and the human, physical, and financial resources allocated to this level are managed.

Local level health services, encompassing facilities for health promotion, disease prevention, treatment, and rehabilitation, are distributed as follows: ( Figure 5 and Supplementary Figure 1 ).

Levels of Care: Article 18 of the Health Regulation establishes three levels of care in networks for health establishments [14] [16] :

Primary Level of Care

Primary care includes services relating to health promotion, disease prevention, medical treatment, and rehabilitation of least complexity. These services are carried out by the members of the EBAIS units. Outpatient consultations, including general medicine in clinics, health centers, and health posts, as well as in community consulting rooms, homes, schools, and workplaces are handled at the Primary level. As of 2017, the Primary level had 11,343 workers.

Currently, the CCSS has 1080 EBAIS units nationwide, of which 532 are EBAIS headquarters and 548 are periodic visit posts (Mobile trucks equipped with services that periodically visit the most remote communities). Each EBAIS covers an average of 4,584 inhabitants, and includes a general practitioner, a nursing assistant, and a primary health care technical assistant.

As noted above, each EBAIS is part of an AS unit. The AS units are led by an area director and a support team. Each EBAIS includes at least one member of the following professions: community family doctor, dentist, pharmacist, microbiologist, nurse, social worker, and nutritionist. AS units also have workers who carry out human resource and other administrative tasks. The average population coverage of each AS is 49,172 inhabitants.

Primary care includes comprehensive child, adolescent, adult (including woman’s) and elder care. Services are offered in outpatient consultations, home visits, schools, workplaces, and recreation centers. Additionally, EBAIS units promote and participate in health promotion projects aimed at improving the living conditions of the population. To do this, they coordinate with different stakeholders in their sectors and health areas. Stakeholders include persons from public and private sectors and organized community groups.

Second Level of Care (Secondary Level)

The secondary level of care offers outpatient and hospital interventions in medical specialties and certain subspecialties: internal medicine, pediatrics, obstetrics and gynecology, psychiatry, general surgery, neonatology, otolaryngology, orthopedics, cardiology, dermatology, and ophthalmology. Second-level institutions have operating rooms equipped for less complex major surgeries. As of 2017, these institutions had 20,943 workers.

Secondary care is available at three classes of facilities. Major clinics/complex AS units primarily provide outpatient services and have minimal inpatient capacity. Most clinics have no beds. Peripheral Hospitals offer higher care levels than major clinics and have moderate bed capacity. For example, Hospital Los Chiles has 35 beds, and Hospital Guápiles has 137 beds. Regional Hospitals provide comprehensive and specialized care and have significant bed capacity. Hospital San Rafael has the highest capacity, with 290 beds.

Third Level of Care (Tertiary Level)

The third level of healthcare includes specialized hospitals and national hospitals, and provides outpatient and hospital services that are more complex than those of the second level. This includes care in all medical subspecialties, such as allergy, urology, peripheral vascular surgery, hematology, oncology, nephrology, infectious diseases, neurology, and physical medicine and rehabilitation. Additionally, this level offers support, diagnostic, and therapeutic services that demand advanced technology and specialization. As of 2017, these institutions had 16,001 workers.

There are three general national hospitals and six specialized hospitals; the specialized hospitals are all located in San Jose (Costa Rica’s capital) and receive patients from the first and second levels ( Supplementary Table 1 and Supplementary Table 2 ). The third level has 2687 hospital beds available for patient care.

The patient referral flow progresses from the least complex level (primary) to the secondary level, and finally to the most complex level (third level), in that order of complexity according to the pathology (see Supplementary Figure 1 ).

According to the Organization for Economic Co-operation and Development (OECD) and the World Bank, for 2020, Costa Rica’s rate of 1.1 hospital beds per 1000 inhabitants indicates it is an intermediate position compared to other Central American countries. Although Costa Rica’s rate is greater than some of its close neighbors, such as Guatemala (0.4 beds), Honduras (0.6 beds), and Belize (1.0 beds), it lags behind Panama (2.3 beds) and El Salvador (1.2 beds). In a broader context, the Costa Rican rate is lower than that of the United States (2.9 beds), Canada (2.5 beds), Argentina (5.0 beds), Colombia (1.7 beds), Chile (2.1 beds), and Puerto Rico (3.3 beds), although it surpasses Mexico’s rate (1.0 beds). These data highlight the need to invest in health care infrastructure and resources to strengthen the system so that adequate care for the Costa Rican population in the future will be possible [14] [16] .

According to World Bank data for 2020 [17] , the availability of doctors per thousand inhabitants shows that Costa Rica is in a relatively strong position globally, with 3.3 doctors per 1,000 inhabitants. In the context of the Americas, Costa Rica surpasses several countries with regard to this metric, including El Salvador (2.9 doctors), the United States (2.6 doctors), Canada (2.4 doctors), Mexico (2.4 doctors), Panama (1.6 doctors), Guatemala (1.2 doctors), Belize (1.1 doctors), and Honduras (0.5 doctors). These data reflect the country’s commitment to medical care and the training of health professionals to meet the needs of its population.

The data provided by the OECD show that Costa Rica has a higher Gross Domestic Product (GDP) per capita compared to other Central American countries: $24,777 per inhabitant in 2022. Regarding health expenditure, Costa Rica allocated an average of $1658 per inhabitant in 2022. Of this expenditure, the government contributed about 75% percent of that figure, while patients contributed the remainder. The total health expenditure represented 6.69% of the country’s GDP.

As to be expected, there are significant differences in these metrics between Costa Rica and the United States. The United States has a much higher GDP per capita, reaching $76,360 per inhabitant in 2022. The average health expenditure per person in the United States was $12,555, with a government contribution 85% and patients contributing the rest. Total health expenditure in the United States represented 16.44% of its GDP. Clearly, there are notable differences in how medical care is financed and provided in the two countries.

Compared to Argentina, a country with a GDP per capita similar to that of Costa Rica ($23,650 in 2022), annual health expenditure was $2385 per inhabitant, with a government contribution of 78%. The total health expenditure in Argentina represented 10% of its GDP. Values for Chile, which also has a similar GDP per capita to Costa Rica ($29,866 in 2022) are similar to those of Argentina: annual health expenditure was $2699 per inhabitant, with a government contribution of 62.2% and total health expenditure representing 9.03% of GDP. For both of these countries, the proportion of GDP attributable to health expenditures is greater than that for Costa Rica.

In comparing health care expenditures among countries, it is critical to also consider differences in the quality of care delivered. The Medical Care Index [18] is a tool that evaluates country-specific quality of the healthcare system through various indicators including health infrastructure, competence of health professionals, per capita cost, availability of quality medicines, government preparedness, environmental factors, and public health policies. Costa Rica ranks 47^th out of 110 countries evaluated using this index. More highly ranked countries in the Americas are Canada (4^th place), the United States (15^th), Brazil (38^th), and Mexico (45^th) and from Central America the closest is Panama (62nd)

The Strategy and Action Plan on Health Promotion, part of the Pan American Health Organization’s Sustainable Development Goals 2019-2030 [19] focuses on strengthening health systems and services by incorporating a health promotion approach. Based on the Astana Declaration of 2018, health promotion and primary care are complementary strategies for strengthening health systems and achieving equitable access [18] [19] Given this perspective, strengthening primary care is critical to the future of the SNS. It requires improved community-level health education and promotion as well as a greater understanding of the social determinants of health and how they impact health. Furthermore, health promotion can help to sustain the solvency of the SNS through healthier aging and reduction of chronic disease and related healthcare costs.

The Costa Rican Health System includes multiple levels that addresses the health needs of its population across three levels of care, ranging from EBAIS, AS, Peripheral Hospitals, Regional Hospitals, National Hospitals, to Specialized Hospitals.

The financial viability of the system is a central concern, as the CCSS must ensure the availability of resources for the payment of pensions in the future. To achieve this, adjustments in contribution rates, retirement age, and other aspects of the system are necessary. The aging of the population, resulting from increasing life expectancy and the reduction of the birth rate, puts pressure on the pension system by increasing the proportion of elderly people and decreasing the proportion of working-age people in the general population.

As noted in the OECD’s Health System Studies (2017), the Costa Rican health system is commendable for its institutional stability regarding financing and planning. The system is characterized by strong primary care, a high degree of intersectoral coordination, and effective dialogue between users and administrators, as well as the implementation of EDUS [14] [20] . However, it is crucial for the system to adapt to the emerging needs of the population and to possess the necessary professional and technological resources to respond to current challenges. To accomplish this, it will be necessary to evaluate process and outcomes at differing administrative levels and levels of care and collect key information for organizational decision-making goals such as improving service wait times.

The financing of the Costa Rican health system takes into account the potential impacts of the served population’s demographic distribution on the system’s sustainability. There is also a need to address inequalities in healthcare access based on geographic location. Costa Ricans in rural or remote areas often face challenges in accessing medical care compared to those in urban areas. Urban zones typically have better infrastructure, including hospitals and health centers, while rural areas may have limited medical services, forcing residents to travel long distances for healthcare.

The focus on remote and socioeconomically disadvantaged regions, along with the implementation of EBAIS units to serve these populations, has positively impacted medical access and reduced disparities. The Costa Rican government’s efforts to improve healthcare access in rural areas by expanding health infrastructure, training health professionals, and promoting community health programs are commendable. Nonetheless, inequality in healthcare access remains a significant challenge in the country.

The Costa Rican Health System is robust and dynamic. Nevertheless, the immediate and long-term health needs of its population need to be addressed, and continuous improvements and strategic adaptations are essential. These include enhancing healthcare access in rural and remote areas, optimizing resource allocation, and embracing technological advancements to maintain high-quality, equitable healthcare services for all citizens.

The authors thank Yolanda L. Jones, National Institutes of Health Library, for editing assistance.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute.

The content of this paper is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the National Cancer Institute.

Supplementary Table 1. Second level of care classification by complexity.

Supplementary Table 2. Composition of the third level and region of coverage.

Supplementary Figure 1. Flow of referrals received by each national hospital.