The 1990s marked a crucial turning point in the organization and delivery of PHC in Costa Rica. Since this time, Costa Rica has undertaken a series of targeted reforms in pursuit of an integrated primary health care system that delivers comprehensive, coordinated, continuous, and person-centered care for all. The successful implementation of Costa Rica’s reforms was supported by strong measurement and management systems, including management contracts, that have been continuously adapted and refined to align with country values and norms. 

The Costa Rican health system is divided into distinct geographic health regions, or health areas, responsible for a geographically empaneled population.1 2 In the contract management system’s current form, Costa Rica’s Direccion de Compra de Servicios de Salud (DCSS), or the Department of Purchasing Health Care Services, assesses the health outcomes of each Health Area’s empaneled population as determined by a series of targets that promote universal access to high-quality PHC.(23)

Over time, the DCSS made iterative improvements to this system to better align with Costa Rican values and achieve healthcare goals. One major change involved the removal of pay-for-performance incentives and financial penalties from management contracts, as this system was considered to be at odds with the values of Costa Rican health care professionals and not cost-effective enough to maintain. To incentivize the delivery of quality care and adapt targets to local values, Costa Rica introduced innovative targets related to the quality of care and removed many of the process and performance-based targets. The process-based targets that remained were made more specific and measurable to promote quality of care and best practices.3Even though management contracts were not linked to financial incentives for the providers or facilities,  they have proved to be an important performance management tool of the Costa Rican reform and driver of continuous learning and improvement. This was in part due to an annual negotiation of targets between the Health Area and the DCSS that served to assess whether goals were meaningful and appropriate to the local context. 4 

In 2014, Costa Rica introduced another reform, called the Evaluación de la Prestación de Servicios de Salud (EPSS), to create a standardized way to compare the relative performance of different Health Areas.2 The EPSS established a set of national targets and indicators for a five-year period along the dimensions of access, continuity, effectiveness, efficiency, and user satisfaction.5 To promote continuous improvements, the EPSS targets increase annually by small, predetermined increments. Health Areas that perform in the bottom 20% must create an official remediation plan with the DCSS to improve their performance against established targets. 2 

Costa Rica’s iterative approach to reforming its performance measurement and management system is an important example of how embedding innovation and learning activities within reforms can help to improve overall health system performance. Costa Rica’s attention to local values and context as well as its commitment to continuous improvement and refinement have supported the implementation of sustainable and relevant reforms. Users can find detailed information about Costa Rica’s health system reform and system for measurement and monitoring for improvement here.


  1. Morgan LM. Community participation in health: the politics of primary care in Costa Rica. New York: Cambridge University Press; 1993.
  2. Pesec M, Ratcliffe H, Bitton A, Ratcliffe Msc H, Director C. Building a Thriving Primary Health Care System: the Story of Costa Rica. 2017;
  3. de Compra de Servicios de Salud D. Table de Indicadores 2010-2011. 2010;
  4. Vásquez Evangelisti C. In Person Interview. 2017 Jun;
  5. de Servicios de Salud DC. Informe de resultados de la evaluación de la prestación de servicios de salud 2016. 2017 Jul;