Alexander Chaverri-Carvajal (University of Costa Rica)

Leonardo Obando Viquez (Tax attorney at Ministry of Human Development and Social Inclusion)

The long-term care system in Costa Rica is in its nascent stage. It was established through Executive Decree in 2021 and subsequently formalized by national law in 2022[1]. It represents the first national LTC system in a middle-income country. The system inherits a pre-existing landscape of public services that are underdeveloped, fragmented, and primarily limited to day centres and a limited number of publicly funded residential care facilities. Private provision of LTC services is limited, resulting in most services being informally provided by women within families. Community-based care for older people, which forms the core of elderly care services in Costa Rica, is decentralized in terms of service delivery, with all services being provided by non-governmental organizations (NGOs), albeit with funding originating from the central government. The inception of the system was marked by the fiscal tightness faced by the country, which implies a shortage of public funding. In a comparative context with other OECD member countries that normally allocate an average of 1.5% of GDP[2], Costa Rica begins the implementation of its National Care System (NCS) by investing approximately 0.1% of its GDP in social LTC[3]. Key challenges for implementation include coordination and identification of new sources of funding.

The governance framework of the system is based on Executive Decree 42878-MP-MDHIS, the National Care Policy 2021-2031 titled “Towards the progressive implementation of a Care and Dependency Support System”[4] and Law No. 10192, which establishes the “Creation of the National System of Care and Support for Adults and Older Adults in Situations of Dependency (SINCA)”[5].

The system brings together different institutions that must adjust their programs to include care for people who are dependent on care by others. The target population are adults assessed as being dependent. The NCS is run under the umbrella of the Ministry of Human Development and Social Inclusion, with technical support from the Mixed Institute of Social Assistance (IMAS).

The National Care System (NCS) is managed by the National Care Secretariat, based in the Ministry of Human Development and Social Inclusion. Its primary function is to organize and coordinate measures and resources of the different institutions that make up the NCS for inter-institutional coordination in the system to fulfill its functions. The Ministry of Labor and the National Apprenticeship Institute are part of the system. Their inclusion, in conjunction with the National Women’s Institute, is intended to generate a mechanism to facilitate women’s (re-)entry into the labor market both as trained caregivers and if they had to leave their jobs to care for a dependent person at home because they had no other alternative. The NCS has two levels of organization. At the national level, the NCS brings together the management of the institutions that make up the system. This is where high-level decisions are taken. At the regional level, the Regional Intersectoral Councils of the social area coordinates everything related to coverage and adequacy of benefits. Before the enactment of the NCS, care programs were restricted only to poor or vulnerable people. The new policy will progressively advance towards universality of care. Through co-payments, also non-poor people in need of care can access the NCS offer. The scale of co-payments will be family income-related and will be published in November 2023; poorer people will be exempted from payment.

Within the National Care System, the institutions are organized in 4 sections:

• Coordination. The Ministry of Human Development and Social Inclusion and the National Care Secretariat are in charge.
• Inter-institutional Committee. This has four subgroups of institutions sorted according to function. These are a) Service Provision; b) Quality and Employability; c) Resource Management and d) Data Intelligence. This section comprises institutions with a steering role on disability, seniors, public health, the formation of capabilities, and labour intermediation.
• Regional coordination. Six regional intersectoral councils are distributed throughout the national territory.
• Evaluation. This is carried out in the inter-ministerial council of the social area chaired by the President. It is technically accompanied by the Ministry of Human Development and Social Inclusion and the Ministry of Planning and Economic Policy.

All services for dependent people within the National Care System (NCS) are financed through general taxes and co-payments. The major source is public funding through government revenues. Additionally, as of 2023, income-based co-payments will be implemented. The amounts have not yet been determined. Currently, total public LTC spending for people aged 18 and over is estimated at 0.1% of GDP[6]. The NCS is scheduled to invest 0.48% of GDP in the fifth year of implementation.

The system aims to avoid institutionalization and promotes a move towards home-based services. To this end, it emphasizes the development of home-based services that enable dependent persons to remain at home for as long as possible. It comprises five services: home care, long-stay residences, telecare, day centres, and caregiver training, plus certain other benefits for women caregivers. The National Care System prioritizes people in greatest (severe) need of care; it fully or partially covers residential care, promotes a home care network, and includes some respite and cash-for-care services for women caregivers in poverty. It also creates training opportunities, labor intermediation, and quality certification mechanisms to improve dependent people’s care.

Besides services for dependent persons, the National Care Service also offers the following services/benefits to carers:

• Formation and training: provided by the Instituto Nacional de Aprendizaje (National Learning Institute).
• Insurance for formal caregivers: The Costa Rican Social Security Fund (CCSS) will promote social security insurance for paid carers.
• Cash-for-care: paid by IMAS. It is aimed at women who meet the following three characteristics: 1) they care for a person assessed as dependent and entitled to the home care service; 2) they have no poten­tial to enter the labor market according to the criteria developed by the Ministry of Labor and the Minis­try of Gender Equality; 3) they are in a situation of extreme poverty. The stipulated amount is $184 (USD) per month.
• Respite care: these services will be developed by public institutions responsible for the elderly, people with disabilities, women, poverty, and health.

Home-based care is established as the principal service. It comprises a maximum of 80 hours per month and aims at covering 80% of the needs of those with significant dependency in 2021-2031. The remaining 20% will be progressively covered through the expansion of residential care. Telecare aims to achieve full coverage (100%) of the needs of those with the highest degree of dependency (critical) and 70% of severe dependents’ needs. It is envisaged that a telehealth tool will be incorporated in 2024. Daycare facilities are reserved for older adults with severe and critical dependency, and 10% of this population is expected to use them. In brief, the system is designed to cover the needs of 55.9% of the total dependent population by 2031.

• Home care: provided by people who have completed the LTC assistant training of the National Learn­ing Institute. They can register independently with the National Employment Program (PRONAE) of the Ministry of Labor and Social Security (MTSS) or do so through non-/for-profit agencies accredited by the Ministry of Health.
• Daycare centres: non-/for-profit agencies accredited by the Ministry of Health.
• Home teleassistance or assistance line: This initiative will be executed by the Ministry of Science, Innovation, Technology, and Telecommunications (MICITT) in collaboration with the National Communications Fund (FONATEL).

Residential care is provided by not-for-profit or for-profit agencies accredited by the Ministry of Health.

There are 129 throughout the country. There are approximately 3,670 older individuals in them. All of them are administered and managed by non-profit organizations, which receive public funding from the central government and occasionally from municipal governments. The Ministry of Health pre-authorizes the operation of all of them. With the establishment of the SINCA, the Ministry of Health was also assigned the responsibility of creating and verifying quality standards. This will be finalized in November 2023.

The National Learning Institute (INA) offers three distinct training programs for formal caregivers. The first, dedicated to the care of elderly individuals, has graduated 667 individuals. The second program, focused on the training of personal assistants for people with disabilities, has certified 705 individuals. The third program, which is open to those who have completed the first two, is intended for individuals in situations of dependency and has graduated 96 individuals. Official data as of July 2023 indicates that there is a total of 1,372 formally trained caregivers in Costa Rica[7].

Since 2013, the country has had the National Information and Unique Registry System (SINIRUBE), which provides updated information on the population using social services and establishes prioritization criteria to ensure equitable access to services. The OECD has pointed out that SINIRUBE should become the cornerstone of social policies and be the central tool for selecting beneficiaries for all social programs[8]. In the case of care services, the Minister of the Social Sector and the Technical Secretariat of the National Care System plan to incorporate into SINIRUBE, in March 2024, a module for the application of the Scale of Assessment of Dependency and Intensity of Support (BVD) to centralize in SINIRUBE the qualification of dependency of users and to refer people who are eligible for support based, on their dependency level, to the services available through the National Care System.

In the final quarter of 2023, the country intends to launch a home telecare pilot project for individuals with mild or moderate dependency, in collaboration with the municipality of Heredia. This initiative will assist in outlining the features, content, standards, and expenses related to scaling the telecare service for the national population. Additionally, the pilot project presents a promising prospect to engage municipalities in the delivery of National Care Services (NCS) services.

Another pilot project to evaluate a connectivity platform for matching the demand for care services for dependent persons with the supply of carers who graduated from technical training programs is scheduled to be developed in the last quarter of 2023 and throughout 2024. The project serves the purpose of identifying data points to be integrated into public employment services, thus easing the process of formalizing work in the care sector.

The implementation of the National Care Sysytem (NCS) has encountered difficulties that have prevented the timely execution of the services contemplated in the National Care Policy and the SINCA Law. The first challenge has been the articulation of the current supply of services through the Baremo (BVD), a tool that will make it possible to standardize the services received by users according to their degree of dependency.

This has also meant matching the specific institutional approaches of the different institutions articulated by the NCS (disability, older people, poverty, among others) with a transversal approach to care for people in situations of dependency, which also implies transcending the traditional inter-institutional coordination approach to progressively universal systemic approach. Another challenge was the creation of the Technical Secretariat of the NCS (SINCA), considering the budgetary restrictions faced by the public sector in Costa Rica. Regarding the quality of services, although progress has been made in improving the accreditation standards of the centres that provide care services, the legislation that created the NCS did not foresee oversight mechanisms that would allow the Technical Secretariat to carry out inspections or audits of service providers.

Finally, the main challenge for the consolidation of the NCS is to achieve the social and health integration of its range of services, i.e., an NCS that involves the country’s robust Social and Health Security System (CCSS).

A proposal for constitutional reform has been presented to incorporate the recognition of the right to care in the Political Constitution, establishing as an obligation of the State the creation of public care services, as well as the recognition of work dedicated to care as an essential source of social protection and the generation of goods and services for economic activity [9].

In 2023, a proposal to reform the Law for the Creation of the National System of Care and Support for Adults and Older Adults in a Situation of Dependency (SINCA)[10] was presented to the National Congress, which aims to improve the governance model established by this law, specify the general lines of the NCS programs, create oversight powers, as well as create a series of incentives for the creation of companies dedicated to providing care services. The initiative also seeks to improve the sources of funding for NCS services.

For its part, the national government expects to soon publish the Regulations of the SINCA Law, to implement the pending service components contemplated in the National Care Policy and the SINCA Law. It is also expected that the Scale for the Assessment of Dependency and the Intensity of Support (BVD), a central instrument of the NCS, which will be used to determine the dependency status of users, will soon be made official, making it possible to adapt the services offered to the specific situation of the person requesting them.

Chaverri-Carvajal, A. and Obando Viquez, L. (2023) Long-Term Care System Profile: Costa Rica. Global Observatory of Long-Term Care, Care Policy & Evaluation Centre, London School of Economics and Political Science.https://goltc.org/system-profile/long-term-care-system-profile-costa-rica/ 

Chaverri-Carvajal, A., & Matus-López, M. (2023). Impact Evaluation of Cash-For-Care in Latin America’s New Long-Term Care Policies: A Randomized Controlled Trial Pilot Study in Costa Rica. Journal of applied gerontology : the official journal of the Southern Gerontological Society, 7334648231188284. Advance online publication. https://doi.org/10.1177/07334648231188284

Chaverri-Carvajal A, Matus-López M. Cuidados de larga duración en Costa Rica: enseñanzas para América Latina desde la evidencia internacional. Revista Panamericana de Salud Pública. 2021; 45: e146. https://doi.org/10.26633/RPSP.2021.146

Chaverri Carvajal A. Costa Rica y los cuidados de larga duración: las costuras revientan en tiempos de Covid-19. Sur Academia: Revista Académica-Investigativa De La Facultad Jurídica, Social Y Administrativa. 2020; 7(14): 44–55. https://doi.org/10.54753/suracademia.v7i14.761

Chaverri-Carvajal A, Matus-López M. The long-term care system in Costa Rica. SFB 16 Globale Entwicklungsdynamiken von Sozialpolitik 2021;1342. https://doi.org/10.26092/elib/935

Jara Maleš P, Matus-López M, Chaverri-Carvajal A. Tendencias y desafíos para conformar un sistema de cuidados de larga duración en Costa Rica; Nota Técnica IDB-TN 1878; Inter-American Development Bank: Washington, DC, USA. 2019. http://dx.doi.org/10.18235/0002214

Jara Maleš P, Chaverri-Carvajal A. Servicios de apoyo al cuidado en domicilio: Avances y desafíos para la atención de la dependencia en Costa Rica. Nota Técnica IDB-TN 2031; Inter-American Development Bank: Washington, DC, USA. 2020. http://dx.doi.org/10.18235/0002767

Matus-López M, Chaverri-Carvajal A. ¿Cuántos adultos mayores necesitarán atención a la dependencia en América Latina? Actas de Coordinación Sociosanitaria. 2022; 31(1), 74-94. Recuperado a partir de https://www.fundacioncaser.org/actividades/actas-de-coordinacion-sociosanitaria/actas-de-coordinacion-sociosanitaria-n-31

Matus-Lopez M, Chaverri-Carvajal A. Population with Long-Term Care Needs in Six Latin American Countries: Estimation of Older Adults Who Need Help Performing ADLs. International Journal of Environmental Research Public Health. 2021; 18(15):7935. https://doi.org/10.3390/ijerph18157935

Matus-López M, Chaverri-Carvajal A. Progress Toward Long-Term Care Protection in Latin America: A National Long-Term Care System in Costa Rica. Journal of the American Medical Directors Association. 2022; 23(2):266-271. https://doi.org/10.1016/j.jamda.2021.06.021

Matus-Lopez M, Chaverri-Carvajal A, Jara Maleš P. O desafio de envelhecer na América Latina: cuidados prolongados na Costa Rica. Saúde E Sociedade. 2022; 31(1): e201078. https://doi.org/10.1590/S0104-12902022201078

[1] Matus-López M, Chaverri-Carvajal A. Progress Toward Long-Term Care Protection in Latin America: A National Long-Term Care System in Costa Rica. Journal of the American Medical Directors Association. 2022; 23(2):266-271. https://doi.org/10.1016/j.jamda.2021.06.021

[2] OECD (2021), Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris. https://doi.org/10.1787/ae3016b9-en.

[3] Matus-Lopez M, Chaverri-Carvajal A, Jara Maleš P. O desafio de envelhecer na América Latina: cuidados prolongados na Costa Rica. Saúde E Sociedade. 2022; 31(1): e201078. https://doi.org/10.1590/S0104-12902022201078

[4] Government of Costa Rica. Executive Decree 42878-MP-MDHIS, 3 March 2021. Ministry of Human Development and Social Inclusion of Costa Rica. http://www.pgrweb.go.cr/scij/Busqueda/Normativa/Normas/nrm_norma.aspx?param1=NRM&nValor1=1&nValor2=94029&nValor3=125029&strTipM=FN

[5] Law No. 10192. “Creation of the National System of Care and Support for Dependent Adults and Older Adults (SINCA).” Available at: http://www.pgrweb.go.cr/scij/Busqueda/Normativa/Normas/nrm_texto_completo.aspx?param1=NRTC&nValor1=1&nValor2=97181&nValor3=130901&strTipM=TC

[6] Ministerio de Desarrollo Humano e Inclusión Social. Política Nacional de Cuidados 2021-2031: Hacia la implementación progresiva de un Sistema de Apoyo a los Cuidados y Atención a la Dependencia en Costa Rica. San José: IMAS/MDHIS; 2021.

[7] Instituto Nacional de Aprendizaje. (2023). Programas de Formación. Available at: https://www.ina.ac.cr/SitePages/nucleos/saludculturaartesanias.aspx

[8] OECD. (2023). Estudios Económicos de la OCDE: Costa Rica 2023. OECD Publishing, Paris, 58: https://doi.org/10.1787/09d84187-es

[9] Bill 23.448. “Addition of a second paragraph to Article 51 and Article 56 of the Political Constitution for the recognition of care as a constitutional right.” Legislative Assembly, Republic of Costa Rica. Available at: http://www.asamblea.go.cr/Centro_de_informacion/Consultas_SIL/SitePages/ConsultaProyectos.aspx

[10] Bill 23.719 “Law for the promotion of the care economy and the strengthening of care services, attention to dependency, and support for personal autonomy.” Legislative Assembly, Republic of Costa Rica. Available at http://www.asamblea.go.cr/Centro_de_informacion/Consultas_SIL/SitePages/ConsultaProyectos.aspx

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