Costa Rica

The health system in Costa Rica is mainly provided through the public health system of Social Security created in 1941 and known as the ”Caja Costarricense de Seguro Social”. The aim is to give equal attention to every citizen who has insurance. Every employer is obliged to pay this insurance for their workers. Self-employed workers can choose to pay voluntary insurance. The amount to be paid does not include medical history of the patient (so, for example, someone with diabetes will not pay extra insurance for having this condition). Children, adolescents under 18, pregnant women and adults over 65 years receive attention without requiring the payment of an insurance fee.

The health system is structured in levels of attention from low to high complexity. In primary care general medicine is provided. The second level has some general specialities such as internal medicine, gynaecology, paediatrics and others. The third care level has the capacity to serve more complex cases and has medical sub specialities. Emergency services are in the second and third level of care only. Costa Ricans also have access to private health service where the patient seeks attention and must pay for the service provided, including anything from a medical consultation, laboratory examination or ultrasound, X-rays, tomography, to a hospitalization or surgical procedure.

What happens if you need to see a doctor?
If it is not an emergency, the patient can get an appointment in primary care and the doctor is the one who decides whether it needs attention or if it should be escalated to a second or third level of care. All laboratory and imaging such as x-rays and ultrasounds that the patient needs are granted without any extra financial charge, but they will be subject to waiting lists. The required medications are given with no charge.

Type 1 diabetes is managed in the third level of care (as described above) and in most cases by endocrinologists. Paediatric patients attend the National children's hospital and adolescents and adults are assigned to different tertiary hospitals according to their place of residence. They have multidisciplinary management: nutrition, diabetes educators, psychological support and foot care.

Who decides what medicines a doctor can prescribe?
The National Regulatory Authorities for Medicines and Biologicals is part of the Ministry of Health and ensures quality and safety of drugs and health products. Social Security has an official list of the approved drugs and doctors can prescribe them, some of them are restricted so only certain specialists to prescribe.

Practically, what is like to live with type 1 diabetes in Costa Rica?
Besides the ability to get treatment there is the issue that in some hospitals the amount of supplies is not sufficient. For example they give you one box of 50 test strips every 3 months and that is not enough, so you need to buy extra supplies which are very expensive. Most hospitals have NPH and regular insulin, not ultra-rapid or analogues, which is a disadvantage in treatment. If you want or need to use other types or insulin you have to buy them. If you need to use different insulins or more test strips than are provided it is an economic burden to some families.

We are lucky to have Asociacion Dia Vida Pro Diabeticos that helps in education by doing monthly meetings with all of its members to talk about nutrition, psychology and self management but the association is not supported by the state nor the government and it only covers the metropolitan area (San José). There is a lot to improve in education and treatment coming from the hospitals.

What about getting admitted to hospital?
Patients attending a public health service through Social Security are never rejected from a hospital and are eligible for all services that the institution has without a cost. You can go to a private health service where you need to pay for everything. If you have private health insurance you can go to private services and the cost will vary depending on the type of insurance you have. In the case of a true emergency everyone is admitted regardless of their insurance.

How does diabetes care vary throughout the country?
Each hospital has a different budget so you can have bad luck to be assigned to a hospital where the budget is low and there are less supplies for people than in other hospitals. The principal hospitals have a higher budget in comparison with hospitals of other provinces where there is a higher rate of poverty. The service in hospitals that are not in the capital city of San José or that are not principal hospitals of other provinces sometimes give poor education in diabetes to the patients and could give the wrong diagnosis.

We are thankful to Paula Chinchilla from Costa Rica who provided this information.