Costa Rica's 570-Day Wait: Why CAJA Can't Fix Your Chronic Illness Alone: The Hybrid Health Strategy Costa Rica Needs

Costa Rica's primary health care system is one of the most studied and, by several measures, one of the most successful in Latin America. The Equipos Básicos de Atención Integral de Salud (EBAIS) model succeeded at the disease burden it was designed to address in 1995. It has not been structurally redesigned to manage the disease burden Costa Rica actually carries in 2026. That gap, a mismatch between its design and today's epidemiology, is where Strata operates.

1. What EBAIS Achieved, and Why That Matters

Following the 1995 reform that transferred primary care responsibility from the Ministry of Health to the Caja Costarricense de Seguro Social (CCSS), EBAIS teams were assigned geographically to cover roughly 4,000–5,000 people each, with the poorest districts prioritized first. A quasi-experimental study exploiting this staggered rollout found that districts with EBAIS coverage saw an 8 percent reduction in child mortality and a 2 percent reduction in adult mortality relative to districts without coverage, controlling for other factors.

Communicable disease (an illness that spreads from one person to another, through direct contact, contaminated water or food, or a vector like a mosquito; tuberculosis, dengue, and influenza are examples) mortality fell from 65 to 4.2 deaths per 100,000 between 1990 and 2010, and Costa Rica's life expectancy at birth (81.5 years for women, 76.7 for men) trails only Canada in the Americas.

This performance is not incidental. EBAIS teams operate under annually negotiated "Management Commitments" (compromisos de gestión) with CCSS, and each Health Area's performance is tracked through several overlapping data systems, most substantially the Local Management Plan, a yearly document of over 300 indicators covering vaccination coverage, maternal and child health, communicable disease control, and physician attendance, alongside a smaller, publicly ranked set of 15 core quality indicators independently verified each year by direct patient-chart audit. The system is, in effect, extremely good at the specific things it is measured on and paid for.

2. The Structural Gap: Built for 1995, Operating in 2026

Independent health-policy researchers have documented a consistent limitation in this same Management Commitment structure: EBAIS teams are incentivized toward the preventive indicators the commitments measure, largely vaccination and communicable disease control, and are correspondingly under-resourced for curative and behavioral interventions that fall outside them: obesity, depression, tobacco use, and substance dependence among them.

This is not a hypothetical risk. In a 2021 peer-reviewed study based on structured interviews across the CCSS system, one Health Area director reported having to postpone a planned multidisciplinary psychiatric clinic specifically to redirect resources toward improving the Health Area's ranking on the national quality index, a documented, first-hand instance of exactly this crowding-out effect: measured conditions get resourced, unmeasured conditions do not.

This is precisely the wrong gap to have in 2026. Non-communicable disease (a chronic condition that is not passed from person to person, but develops instead from genetics, lifestyle, and environment, diabetes, hypertension, cardiovascular disease, and cancer are the leading examples) now accounts for an estimated 83 percent of all deaths in Costa Rica, with cardiovascular disease alone responsible for roughly 29 percent.

Diabetes prevalence among adults aged 20–79 stands at approximately 9.8 percent, and hypertension affects an estimated 37.2 percent of adults over 19 (32.4 percent diagnosed).

Circulatory disease mortality rose from 25 to 120 deaths per 100,000 between 1990 and 2010, and cancer incidence increased 48 percent between 2003 and 2013.

These are chronic, multi-system, lifestyle-modifiable conditions that require continuity of care across months and years, with coordinated monitoring, cross-provider communication, and a structured plan the patient can execute between visits. EBAIS, as designed, does not fund or measure that function. Vertical integration, meaning the coordinated hand-off of a patient's records, test results, and care plan as they move from a primary care clinic (EBAIS), to a specialist (secondary care), to a hospital (tertiary care), between primary, secondary, and tertiary care remains weak, and no party in the public system is currently accountable for what happens to a patient in the interval between a diagnosis and the next available specialist appointment.

3. The Current Access Crisis (2025–2026)

This structural gap has widened, not narrowed, in the past year. CCSS's own Executive President, Mónica Taylor, told the Legislative Assembly in 2025 that it is "impossible to bring down the wait lists at this time."

As of 2025, more than one million cases sit on CCSS wait lists: 200,844 pending surgeries (average wait 430 days), 792,981 pending diagnostic procedures (average wait 192 days), and 345,580 pending outpatient specialist consultations (average wait 573 days).

Costa Rica has an estimated shortfall of approximately 189 EBAIS teams relative to population coverage targets, and many existing teams serve populations well beyond the intended 4,000-person panel.

In 2025 alone, CCSS recorded 108 specialist resignations against only 25 new hires, concentrated in radiology and imaging, anesthesiology, and gynecology-obstetrics.

Researchers have linked this constrained specialist and curative access directly to emergency-room overuse: CCSS itself estimates that roughly half of emergency visits are not true emergencies, a pattern consistent with patients seeking urgent care because scheduled specialist access is functionally unavailable.

4. The Consequence for Patients — and the Case for Strata

A patient leaving an EBAIS visit or a specialist consultation with a diagnosis, diabetes, an autoimmune condition, a cardiac event, or a fragmented record spanning a relocation between countries, receives a treatment plan and is then, in practical terms, on their own to execute it for months and often more than a year before the next specialist slot opens. Nothing in the current structure translates that plan into a trackable, cross-provider protocol, monitors biomarker trends over time, or reconciles conflicting guidance when the patient sees more than one provider or system.

Strata occupies a function the public system was never financed or measured to perform: translating fragmented records across providers, languages, and health systems; building the structured plan a client follows between visits; tracking response to treatment over time; and serving as the continuity and accountability layer that the Management Commitment framework does not fund and the current specialist shortage makes physically unavailable on any reasonable timeline.

The gap is structural. It follows from how EBAIS is financed and measured, not from any single administration's competence, and it will not close on its own even if the current wait-list crisis eases. That durability matters to you directly because it's not a passing crisis that you can simply wait out until the system catches up. It is a permanent feature of how the system is built and paid for. Which is exactly why having someone whose only job is to close that gap for you, consistently, between every visit, is not a luxury. It is the missing piece that makes the rest of your care actually work.

Sources Full citations appear as footnotes throughout this section. Primary sources include: PHCPI/World Bank (improvingphc.org), the American Journal of Public Health, the International Journal of Health Services, Health Policy and Planning (Pesec et al. 2021, DOI 10.1093/heapol/czab043), Trading Economics/World Bank diabetes data, CCSS national NCD surveillance data, and Costa Rican outlets Observador.cr and Global Salud (globalsalud.cr) reporting on the 2025 CCSS wait-list and staffing crisis.