Latin America Upper-middle-income countries

Achieving universal health coverage in Costa Rica

The last of GNHE’s country assessments was published today. Written by Pablo Slon, it examines the progress of Costa Rica towards universal health coverage.

As Pablo Slon writes, one of the main features of the Costa Rican health system is the existence of a single health insurance fund, just as in the United Kingdom, France and Canada. Prepayment is mandatory for the whole working population and employers, and health insurance coverage in 2011 was 86%. Health services are provided mainly by this health insurance fund, with the coexistence of private sector provision. Health services are free at the point of access.

There is equal access to public health services because there is high coverage in terms of provision. There is also equality of financial risk protection.. The factors explaining these achievements include various institutional factors and health system characteristics.

One of the explanatory factors is the fact that Costa Rica ‘started small’ with an early political agreement to develop a Bismarck-style insurance system for the working class. A gradual process of including progressively more groups into this insurance system played a major role.

The existence of a tripartite financing scheme – involving employers, employees and the state in contributing to a common fund – creates cross-subsidies that allow access to health care across different population groups. Having a single risk pool is also a key factor. The existence of a private sector that complements the public sector allows those who do not want to use public services to reduce the demand on the public system. Last, but not least, low income-inequality and poverty within the country helps to reduce economic barriers to accessing health services. Democratic institutions and the rule of law support the performance of the health system through accountability, supervision, law enforcement and regulation.

However, the fact that the public health insurance fund is the main revenue collector, purchaser and provider creates some conflict of interests from the perspective of regulation. This is because the lack of separation of functions weakens the allocation process and oversight of performance. It also gives the fund enormous economic and political power, constraining the stewardship role that should be played by the Ministry of Health.

A future challenge is to ensure the financial sustainability of the National Health System in the face of demographic changes, with the proportion of elderly people growing. There is also an epidemiological challenge because chronic diseases are becoming more prevalent. Finally, there is a portion (14%) of the population that is not insured. Although they can access care if they require services, they have to pay fees for these services, which can impoverish them as they could incur into catastrophic expenditures. An additional problem is that this segment of the population mainly accesses emergency services, and they are not able to get appointments for outpatient services. Insuring this remaining portion of the population and charging for services properly after they have been used are important challenges.

Finally, more data are needed to understand whether the Costa Rican health care system is closing the gap between health care needs and health care provision, especially across all socio-economic groups. There are some indications that there are remaining differentials in actual and perceived health status across different income quintiles, and that waiting lists prevent some patients receiving prompt attention.


Pablo Slon. 2017. Universal health coverage assessment: Costa Rica. Global Network for Health Equity.