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.
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. 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.
As the pandemic evolved and data quality improved, Costa Rican officials could replace these blunt measures with a more precise set of restrictions. (,” 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 to pay for many necessary service delivery adaptations and key pandemic supplies. ,, 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$25 million was paid for durable medical equipment such as ventilators and ICU beds for existing hospitals and health facilities; to build out a new specialized treatment center for COVID-19 patients (); and for mobile hospitals, tents, and open-air clinics.
Contingency fund spending on COVID-19 needs in Costa Rica, 2020, Millions, US$*
Costa Rican Social Security Fund (Caja Costarricense de Seguro Social, CCSS). COVID-19 expenses. San José: CCSS; 2020. Accessed January 11, 2023.
*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 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
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.
Data from CCSS’s Annual Statistical Books confirms that the COVID-19 pandemic had different impacts on the delivery of different essential health services.
Dentistry (odontology) is a major source of medical tourism in Costa Rica. 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
Costa Rican Social Security Fund (Caja Costarricense de Seguro Social, CCSS). Open data. Accessed January 11, 2023.
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)
Costa Rican Social Security Fund (Caja Costarricense de Seguro Social, CCSS). Open data. Accessed January 11, 2023.
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
Costa Rican Social Security Fund (Caja Costarricense de Seguro Social, CCSS). Open data. Accessed January 11, 2023.
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%. 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
Causey K, Fullman N, Sorensen RJD, Galles NC, Zheng P, Aravkin A. Estimating global and regional disruptions to routine childhood vaccine coverage during the COVID-19 pandemic in 2020: a modelling study. Lancet. 2021;398(10299):P522-P534.
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.