Is the public health system of Costa Rica facing a financial crisis? This is the opinion of several professionals from the Global Health Commission of the National Academy of Sciences.
A democratic society requires a social protection and security system based on universal, equitable, and supportive principles. Among other areas, healthcare is at the heart of this aspiration, and in our country, the Costa Rican Social Security Fund (CCSS), an institution whose strengthening requires critical reflection and effective actions to ensure its sustainability.
Contributory health insurance evolved toward universality with the progressive expansion of the number of insured persons covered by this system, and with the gradual increase in benefits at different levels of care. In addition, a non-contributory subsidized system was created, with benefits similar to those of the contributory system, but entirely funded by the State with fiscal resources.
However, the State has repeatedly failed to fund the CCSS over time, resulting in significant accumulated debt. This seriously compromises the sustainability of universal benefits and threatens equitable access to health care.
The current administration has also weakened the principles of solidarity and universality by promoting the provision of services in the private market, but without price regulation by the CCSS and ignoring existing regulations, which risks generating exclusion. The institution’s governance has also been weakened, and strategic investments have been temporarily suspended.
Financial Crisis in the Public Health System
Although financial reserves for health insurance have been accumulated and significant investments in infrastructure and personnel have been promoted, there remains an urgent need to strengthen health insurance policies.
Prevention, as well as improving the quality and timeliness of benefits. It is necessary to reach a national agreement on the fulfillment of the State’s financial obligations that contributes to the overall viability of health insurance, as well as to strategically analyze the CCSS’s financial model to ensure its sustainability. At the same time, it is essential to guarantee the efficient use of the institution’s resources.
The country is experiencing an aging process, with the working-age groups set to decline, while the group of people over 65 will increase. This demographic pattern will contribute to a structural imbalance between income and expenses at the CCSS. A plural and technically rigorous debate is required on options to address this problem, such as paying off the state debt, a progressive tax policy, taxes on products harmful to health, reducing informality, promoting greater and better integration of women into the labor market through care policies, and raising the retirement age, among other alternatives.
Financial Crisis in the Face of NCDs
The epidemiological transition toward chronic non-communicable diseases (NCDs) imposes new demands on the health system, making it necessary to strengthen primary care, reduce territorial inequalities, and improve access for vulnerable populations. Scientific and technological research must play a central role in understanding and addressing these challenges through national and international inter-institutional partnerships.
The CCSS’s management is facing serious problems, such as a leadership crisis, a breakdown in institutional governance regarding its autonomy under the law, and turbulence in the composition of the institution’s board of directors, which complicates decision-making; unstable appointments of the institution’s highest authority and management; politicization; weakening accountability; and demotivated staff. Improving management is a necessary condition for any reform to be successful. Otherwise, the CCSS will not be able to face the enormous challenges ahead.
The shortage of specialists, exacerbated by the brain drain and workload overload, requires new training strategies, adequate incentives, and the use of technologies such as telemedicine and artificial intelligence. Furthermore, the waiting list crisis, which reflects deficiencies in planning, could be significantly reduced with better management. It is crucial to reform the extraordinary hiring system to focus on efficiency and thus avoid distorted incentives.
Costa Rica must move toward a model that overcomes the reactive approach that prioritizes disease care and evolves toward a model focused on the social production of health and health promotion. Ultimately, health is a social product, and the consolidation of our social security must be strengthened with broad citizen and institutional participation.
Our country must renew the social pacts that allow for the consolidation of social security in health and other areas of national life. It is essential to strengthen the values of universality, equity, and solidarity that have been the foundation of our public health.
*This statement was prepared by José María Gutiérrez Gutiérrez, Rolando Herrero Acosta, Edgardo Moreno Robles, Henriette Raventós Vorst, and Catharina Wesseling, members of the Global Health Commission of the National Academy of Sciences. The text is based on the analyses presented at the forum organized by this commission entitled “Social Security and the CCSS: Current Situation and Future Challenges,” held on June 19, 2025, with the participation of María Luisa Ávila Agüero, Luis Rosero Bixby, Ana Sojo Martínez, and Carlos Zamora Zamora as panelists.
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