Costa Rica Prioritizes Public Health

IMF News, March 9, 2022

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Article by Analisa Bala, March 9, 2022.
Highlights Costa Rica’s long-term emphasis on public health, social welfare, and well-being as factors underpinning high life satisfaction ("pura vida").
Notes Costa Rica’s ranking in the 2021 World Happiness Report: 16th happiest place on earth; aside from the Czech Republic, the only emerging market economy in the top 20.

Universal access:
- Costa Rica is one of the few countries in the region that offers universal health coverage.
- 100 percent of the population has access to electricity and a source of drinking water.
Historical investments and outcomes:
- In the 1970s, Costa Rica spent more on health as a proportion of GDP than some advanced economies, including the United Kingdom.
- By 1985, the nation’s life expectancy was the longest in Latin America and matched that of the United States.
- Child mortality: dropped from about 74 deaths per 1,000 in 1970 to 17 by 1989.
Primary health care model (EBAIS):
- Implemented in the 1990s, building on decades of rural and community health programs.
- Every Costa Rican is assigned to an equipo básico de atención integral en salud (EBAIS)—a local primary health care team of physicians, nurses, and community health workers.
- Health workers visit each household annually in their assigned area to assess needs; data are combined with electronic health records to set targets, track progress, and focus resources on higher-risk areas.
- EBAIS teams were first deployed to medically underserved rural areas before expanding to urban centers, enabling a robust information system on social determinants of health.
Measured impact:
- Life expectancy rose from 75 in 1990 to 80.
- Despite strong outcomes, Costa Rica spent less on health care as a percentage of GDP than the world average in 2017: 7.3 percent versus 10 percent.

"Social pact":
- Costa Rica maintains a political culture where successive governments build incrementally on prior reforms: “Regardless of the government that comes in, the one that follows must put in one more brick.”
- Emphasis on long-term vision and political will; replacing prior policies is seen as costlier than building on them.
Historical policy priorities:
- In 1869 Costa Rica made primary school education free and compulsory.
- The country provides free education and a guaranteed state pension.
Civic and elite orientation:
- Political science perspective: Costa Rica’s elites have maintained well-being through sustained poverty reduction efforts; percentage of people living in extreme poverty had fallen until the COVID-19 crisis hit.
- Environmental policy shift in the 1970s (addressing deforestation and hydropower concerns) contributed to Costa Rica’s emergence as a global green pioneer and to job creation linked to a greener environment.

Luis Alberto Vásquez Castro (former congressman): connects health, work, social time, and happiness to the "pura vida" ethos.
Professor Mariano Rojas (economist):
- Attributes high well-being to strong social relationships and a slower pace of life; links access to primary care with lower spending and longer life: “People who are happy live longer. That’s why you need to spend less.”
María del Rocío Sáenz Madrigal (former minister of health):
- Emphasizes community delivery of care, improving living conditions as part of investment in health, and the comprehensive vision of health and wellness.
Cristina Eguizábal (political science professor):
- Highlights enlightened elites and the role of public policies in maintaining well-being and reducing extreme poverty.

Prioritize community-oriented primary health care:
- Assign local multidisciplinary teams (EBAIS) to households, combine household assessments with electronic health records, and use data to target higher-risk areas.
Build durable, incremental reforms:
- Maintain a "social pact" approach where successive governments add to, rather than dismantle, prior investments—requiring long-term vision and political will.
Invest in social determinants of health:
- Address living conditions, education, and environmental sustainability as part of health investment to improve outcomes and contain health spending.
Leverage environmental policy for economic and health co-benefits:
- Protecting and greening the environment can sustain energy and jobs, contributing to overall well-being.

Source: "Costa Rica Prioritizes Public Health," Analisa Bala, March 9, 2022.