Stephanie Raymond
Kristin Riddell
The Health Services Market of Costa Rica
Costa Rica’s health care system originated in 1949 under the establishment of the Costa
Rican Social Security System (CCSS). This program was established to assist Costa Rican
workers whose paychecks contributed to the national social security system. As health care
increasingly became regarded as a constitutional right, the Costa Rican Social Security System
took on the role of the main health care provider for the entire country. During the 1990s, health
care was unofficially declared a universal right. Currently, Costa Rica’s Ministry of Health
manages and coordinates all public and private health related policy while the newly reformed
CCSS covers the “prevention, recovery, and rehabilitation of health” (Saenz et al. 2010: 4).
The CCSS as a health insurer and provider of health related services functions through a
series of five established insurance regulations. The first of these series is direct insurance
maintained through employment between an employer and employee. The second addresses selfinsured persons, or people who are self-employed. The third consists of pensioned individuals.
The fourth targets families of employed, self-employed, pensioned, and various wage-earners.
The final regulation covers populations of economically dependent people who are entirely
insured through the state. A small percentage of the population, roughly 10%, is deemed
uninsured by the CCSS and are unable to contribute to the social security system due to poverty
(6-7).
Financially, the first series of payments constitutes 90% of the total Social Security
System which has aided in the reduction of state funding seen from 1999 at 9.2% to 2001 7.3%
(9). In 2010, these payments into the social security system accounted for 22.91% of each
insured individual’s paycheck (10). A system is in place which addresses the concerns of selfemployed or independent wage-earners. The percentage these workers pay into the social
security fund is adjusted to their income levels. In cases where the income is low, the state steps
in to provide funding for the deficit.
Costa Rican health care coverage is also distributed geographically within three tiers of
health care services. Chart 1 on page seven of “Universal Coverage...” outlines the levels of
health care and health services offered at each level. The first tier of clinics distributes its
attention primarily to children, women, and the elderly. The services offered through these
clinics are minimal and basic procedures. The second tier comprised of major clinics and
hospitals serves emergency patients, provides outpatient support, and offers minor surgical
procedures. The third and most specific tier, consisting of national and specialized hospitals
admits patients and conducts surgeries with high technology treatments readily available (7). All
citizens, regardless of which package they accept, (and excluding the minor population of state
dependent individuals), pays into this system of integrated health care (8). The national social
security system also specializes portions of its health care system to offer services specific to
maternity care, disability, old age, and death. Chart 2 of the packet examines the services offered
by the CCSS in distinct age categories with a category reserved for women of childbearing age
(9).
Constitutionally, the right to health and health care is received as an extension of national
social security, state legislation, and the Human Rights Doctrine. Costa Rica hosts both public
and private healthcare markets, with the unique feature of privatized health services issued and
regulated under state legislation. While healthcare is supplied by both the government and
private-sector, the health services market is funded through tripartite contributions. This three
payer system has helped to keep universal healthcare coverage in Costa Rica highly sustainable.
14.16% of funding is received through the private sector while 8.25% is received through
individuals and 0.5% is federally funded (8). Roughly 90% of the population is covered by
health insurance, with the remaining 10% not covered due to the fact that this population is
mainly comprised of migrants and undocumented citizens. According to the World Health
Organization’s published statistics, as of 2010 Costa Rica’s total expenditures of GDP on health
totaled 10.9%. The total healthcare expenditures per capita for the same year totaled $1,242 on
an international standard. Compared to the United States, which spends $8,362 per capita per
year on total healthcare expenditures, Costa Rica spends only an eighth as much of its GDP on
health services. However, the United States’ GNP is only four times the amount generated in
Costa Rica, so combining these two statistics leads one to conclude that the US spend
significantly more of its income on health care services. These ranging differences do not appear
to affect life expectancy between the two countries; in fact, males in Costa Rica enjoy a slightly
higher life expectancy than males in the United States while females of both the United States
and Costa Rica share a similar life expectancy.
The system in Costa Rica is probably most similar to the one in Germany, except for the
that there is only one fund for people pay into. Both systems require employers and workers to
split the insurance premium and there is a particular fund set aside for the poor and unemployed.
The plans that the population receive are very generous in both countries, covering everything
from preventive care to hospital expenses to maternal health care. Germany seems somewhat
more generous with dental and alternative medicines, however. Also, both countries
acknowledge the need for a separate fund or policy to address long-term care, and require the
population to pay some of their premiums toward policies that cover those services. The main
factor that makes the German and Costa Rican systems different is that Costa Rica has only one
insurer (a government agency) whereas Germany has many separate sickness funds. Because
they have only one payer, the CCSS uses rationing as a technique for controlling costs, while
German sickness funds do not. So Costa Rica has a health care system which resembles that of
Germany, though with similarities to Canada and the UK and their single-payer systems as well.
Long wait times for examinations, surgeries, specialized care and various problems with
quality of care also reflect the negative aspects of single payers systems like Canada. Recently,
Costa Ricans have expressed interest in private health care options. Unfortunately, this could
cause problems within a system that relies upon all citizens to fund its operations. In studies, it
was determined that the highest income bracket would remove themselves from the nationally
organized health care system in favor of a private option (16)
When comparing countries using health outcome measures, one interesting category is
the rate of vaccination that each country has achieved. In Costa Rica in 2011, about 85% of
children age 12-23 months had been vaccinated for DTP (diphtheria, tetanus, pertussis) and in
the US the same year 94% of children had been vaccinated (The World Bank). It is interesting to
note that over the past eight years, the rate of vaccination in both countries has fallen, from 88%
to 85% in Costa Rica and from 96% to 94% in the US. Because of the importance and power of
vaccines in our modern medical world to eradicate certain diseases, it seems like an important
thing to consider. It may also speak to the efficacy of the system in reaching their population,
especially in rural areas where hospitals and clinics may be scarce. Overall, the difference in
rates of DTP vaccines among children 12-23 months may be an indicator that Costa Rica is not
doing as well to provide care to new mothers and infants.
As of 2012, Costa Rica experienced a higher infant mortality rate, which was 9 out of
every 1000 live births. In the United States, the infant mortality rate per 1000 live births totalled
7 (World Health Organization). Maternal mortality rate in Costa Rica stood at 40 deaths per
every 100,000 live births, but in the United States only 21 women per every 100,000 live births
die in childbirth. This may be an indicator of access to health services. In addition to serving as
an indicator of the number of physicians and hospitals, it may also indicate discrepancies in the
quality of care being received in both nations. Maternal mortality rate may be a more effective
indicator of the quality of health services expectant mothers receive. Using the rates of maternal
mortality rates, it is visible the United States has a higher quality of prenatal and maternal health
services.
As for non-communicable diseases, United States leads Costa Rica in percentage of
deaths caused by cancers by 2% (World Health Organization). There is also relatively close
percentages in deaths from Cardiovascular disease, in which the United States again leads Costa
Rica by 5%. This is particularly interesting to note because the United States has specifically
integrated programs to combat cardiovascular disease while Costa Rica does not. The greatest
discrepancy in percentages of non-communicable deaths was accounted for under the term
“Injuries”. In Costa Rica, 13% of deaths occur from injury, while in the United States, injury
only accounts for 7% of total non-communicable deaths (World Health Organization). This may
be an indicator of access to health services, particularly hospitals and emergency clinics. It may
also display a discrepancy in number physicians or hospitals and technology. The United States
also has programs and policy to combat diabetes, chronic respiratory diseases, and tobacco use
while Costa Rica does not (World Health Organization). Also in Costa Rica there is not available
funding for prevention of noncommunicable diseases or promotion of health.
Socioeconomic factors include the high influx of a migrant population on the total
healthcare expenditures for Costa Rica. The undocumented status of these people skews
monitoring and utilization processes conducted through the CCSS and national Ministry of
Health. Many migrants travel to Costa Rica for economic opportunity. Foreigners comprise a
portion of the labor force in Costa Rica, which negatively affects the social security system and
its health related system. In 2008 alone, nearly 20% of all live births in Costa Rica were to
foreign mothers. These foreigners are legally restricted from joining the CCSS, and therefore
exist solely as a detriment to the system as a whole. Financial losses stem largely in part from a
migrant population that utilizes emergency room services offered in Costa Rica.
Poverty is also a looming problem within the Health Services Market of Costa Rica.
Especially concerning migrant workers, of which 38% consume unsanitary, or poor quality water
(16). Of this same migrant population, an astounding 77% of migrant children are reported to
have not received basic shots (16). Of the total migrant population, 35% reported they had not
received health services or care when they were sick (16).
In a country like Costa Rica, with plenty of rainfall every year, it is not hard to find
water, but clean water can often be a problem. Without clean water, there are many health risks
that may arise due to infectious diseases and parasites. The World Bank provides statistics on
access to what they call an “improved water source”, which refers to situations where people
have a household connection, public standpipe, borehole, protected well or spring, or rainwater
collection within one kilometer of their dwelling and which provides at least 20 liters per day per
person. On the whole, access to an improved water source is at 97% in Costa Rica and 99% in
the US (The World Bank). While this may not seem like a large difference, this amounts to
about 140,000 people who do not have easy access to relatively clean water in Costa Rica, and in
rural areas it is somewhat worse with only about 91% having access. This could be an
underlying reason for why there is still a difference in the rates of infectious disease between
Costa Rica and the US, though vaccinations and other sanitation measures have a lot of influence
as well.
Observed differences in health and the health care systems of Costa Rica and the United
States are contingent on the vast differences of each country. Population size, socioeconomic
factors, technological differences and environmental differences all have an effect on the health
and health services of each respective country. The health insurance system of Costa Rica is
operated by the government yet funded predominantly through a social security system based
heavily on employment relations. A single payer system appears to be much more sustainable
when serving a smaller population. While the federal government of the United States plays a
major role in the health insurance market through publicly funded programs such as Medicare
and Medicaid, the private sector of health insurance also comprises a major portion of America’s
health insurance market. This multi payer system reflects the consumption of a larger, more
diverse population within the United States and aims to reduce costs that probably would have
been unsustainable under a federal single payer system serving this population size.
Determining causation versus consequence of these discrepancies is a difficult task.
Often, differences that arise may be viewed as both a cause and a consequence of economic,
social, and environmental factors. Because of the strong connection between employment and
health insurance in Costa Rica, it is likely that the unemployed are at a disadvantage, despite the
fact that they still receive insurance through the government. However, economics related to
rising costs and health insurance premiums have the potential to lead to unemployment as well.
Another way in which difficulty of deciding on cause versus consequence is apparent is through
a close examination of maternal mortality rate. Extrapolations from this data may conclude that
Costa Rica’s high rate of maternal deaths, which nearly doubles that of the United States, stems
from a lack of access to hospitals and physicians. However, Costa Rica’s high maternal mortality
rate may be due to a lack of prenatal care. Social circumstances such as health education may
also play a role in this high maternal mortality. Likewise, environmental factors such as access to
clean drinking water may play a factor in the causation of poor health which could contribute to
maternal mortality.
On the other hand, poor maternal health may lead to strains on the finances within a
family, which can have economic, social, and health related consequences. The negative
comparative data between the US and Costa Rica may display a lack of quality care in the case
of the latter or it may simply be a consequence of lower economic status of the country as a
whole. Without specific studies to explore what causes poorer health statistics on some health
outcome measures in Costa Rica, it is extremely difficult to separate causation from
consequence.
The main difficulties in comparing the US to Costa Rica are the difference in national
population, geographical area, national income, and other lifestyle and social factors. As we
have discussed in this class, the implementation of a single payer system is a tricky matter and is
more appropriate when the market for healthcare is smaller. Environmental differences such as
the tropical climate of Costa Rica compared to the varied and often cold climate of parts of the
US lead to the potential for vastly different burdens of disease. There are also, only certain
agencies that study healthcare systems around the world, and they may not always provide data
for the things we would like to compare. Finally, the relative homogeneity of the population in
Costa Rica, despite the growing number of migrants, means that problems relating to disparities
in health outcome cannot be attributed to race/ethnicity in the way it is in the US. For these
reasons, there are significant limitations to any comparison between Costa Rica and the US
based solely on health outcome data.
Bibliography:
Saenz, Maria del Rocio, Juan Luis Bermúdez and Mónica Acosta. “Universal Coverage in a
Middle Income Country: Costa Rica”. World Health Report. Background Paper. 2010.
The World Bank. Data. accessed 1 May 2013 <http://data.worldbank.org/?display=graph>
World Health Organization. “Costa Rica” Countries. accessed 1 May 2013
<http://www.who.int/countries/cri/en/>
World Health Organization. “United States of America” Countries. accessed 1 May 2013
<http://www.who.int/countries/usa/en/>