For an adult who begins to need substantial help with everyday life, the practical question is rarely which institution owns the policy. The immediate questions are more personal: who assesses what support is needed, which services exist locally, how they are accessed, who pays, how healthcare connects with continuing support, and what happens when a family can no longer provide the care on which daily life has depended.
Costa Rica's response is increasingly being organized through the Sistema Nacional de Cuidados y Apoyos para Personas Adultas y Personas Adultas Mayores en Situación de Dependencia (SINCA). The system sits at the center of the country's attempt to move from fragmented programs toward a more coordinated approach to dependency. Within the wider Costa Rica Aging, Long-Term Care & Community Support Knowledge Hub, SINCA is particularly important because it provides an institutional framework through which health, social protection, disability, aging, community provision and family care can increasingly be connected.
The ambition is significant, but integration should not be confused with administrative consolidation. Costa Rica has not replaced its existing institutions with a single national care agency. SINCA instead creates a framework for coordinating responsibilities, resources, information and services that remain distributed across different organizations. Its effectiveness therefore depends on whether integration becomes visible in the experience of people needing support rather than existing principally between institutions.
From a care policy to a national system
Costa Rica's Política Nacional de Cuidados 2021–2031 established the direction for a progressive system of support for adults and older adults experiencing dependency. Its underlying argument was that existing provision was fragmented, formal care coverage was limited, and too much responsibility was being absorbed invisibly by households—particularly by women.
The policy envisaged a broader continuum incorporating existing and developing forms of support including home-based care, tele-assistance, day services, long-stay residential services and services associated with the Red de Cuido de Personas Mayores. It also placed considerable emphasis on allowing people to remain at home where appropriate rather than treating institutional care as the automatic response to dependency.
Law No. 10192, enacted in 2022, gave SINCA a statutory foundation. Its purpose is not simply to create additional services. The law describes a system intended to optimize existing resources and coordinate general and specialized services provided by public and private institutions, with quality of life for people requiring care and for caregivers at its center.
This distinction matters. Creating another program inside an already fragmented landscape would not necessarily produce integration. SINCA's deeper purpose is to make multiple forms of provision function more coherently around the person.
That places Costa Rica's reforms within the broader challenge of system integration and multi-agency working: institutions retain different legal responsibilities, budgets and professional expertise, but the person should experience a pathway rather than a collection of disconnected administrative boundaries.
Dependency provides the organizing principle
One of the most important features of the developing model is its focus on dependency rather than age alone, diagnosis alone or poverty alone.
A person may require care because physical, cognitive or other limitations affect their ability to undertake everyday activities independently. This can apply to an older person experiencing frailty, an adult with significant disability or somebody whose chronic condition results in substantial functional support needs.
Costa Rica has therefore developed the Baremo de Valoración de la Dependencia y la Intensidad de los Apoyos, a standardized instrument intended to determine whether a person has no dependency or a mild, moderate or severe level of dependency and to inform the support required.
This creates the possibility of a more coherent national language for need. Without a shared approach, different institutions can assess the same person through different eligibility concepts, producing duplication, gaps and inconsistent access.
A common dependency framework can help answer three distinct questions: how much assistance a person requires, which capabilities and autonomy should be preserved, and what combination of support is proportionate to that need.
Those questions should remain connected. A dependency assessment that merely classifies deficits risks becoming an administrative gatekeeping exercise. A stronger model identifies both the assistance required and the abilities that should be maintained, restored or enabled.
Integration does not mean that every institution does the same thing
SINCA is inherently interinstitutional. Its architecture recognizes that dependency cannot be managed effectively by one part of government because people's needs cross conventional boundaries.
Different actors bring different functions. The Instituto Mixto de Ayuda Social (IMAS) has a central coordinating role through SINCA's technical arrangements. The Caja Costarricense de Seguro Social (CCSS) remains fundamental to healthcare. The Consejo Nacional de la Persona Adulta Mayor (CONAPAM) and Consejo Nacional de Personas con Discapacidad (CONAPDIS) bring responsibilities and expertise relating to their respective populations. Other public bodies, community organizations and private providers contribute through their own functions and services.
The purpose of integration is therefore not institutional uniformity. It is clarity about how those functions connect.
At operational level, a mature pathway needs to establish:
- where a person or family first seeks help and how that request enters the system;
- how dependency and wider circumstances are assessed;
- which organization is responsible for each part of the response;
- how referrals and information move between participating services;
- how changes in need trigger reassessment or escalation; and
- how the system knows whether the resulting support actually improved the person's life.
These connections matter more to people using services than the organizational chart behind them.
Operational scenario: one person, several institutional boundaries
An older woman lives with her daughter and has gradually become more dependent following repeated falls and increasing difficulty with bathing, dressing and preparing meals. She also has diabetes and hypertension managed through the health system. Her daughter has reduced her working hours to provide support but is beginning to struggle with the intensity of care.
No single issue necessarily creates the whole response. Her medical conditions involve healthcare. Her reduced functional ability creates a continuing support requirement. Her daughter's circumstances raise caregiver sustainability questions. Falls create both clinical and environmental risks. The family's income may influence access to particular benefits or subsidies, while the severity of dependency should inform the intensity of care required.
An integrated pathway should prevent the family from having to reconstruct the same story separately for every institution. A dependency assessment can establish the level of functional need, while relevant health information informs safe care planning. Available home support, respite, rehabilitation, tele-assistance or other services can then be considered around the person's circumstances.
The important governance test is not whether every participating organization completed its individual procedure. It is whether the combined response is coherent. If repeated falls continue, the system needs a route for reassessment and learning rather than treating each episode as an isolated event.
That is the difference between institutional coordination and integrated care.
The Technical Secretariat is critical to making the system operational
Law No. 10192 gives SINCA's Technical Secretariat responsibilities that go considerably beyond convening meetings. They include coordinating interinstitutional technical and operational activity, monitoring implementation of policies and agreements, supporting programs, using administrative and socioeconomic information, developing the dependency assessment framework with relevant institutions, mapping available services and undertaking research and technical evaluation.
The law also envisages attention to service coverage, waiting times, modernization, technology, financing, cost-benefit considerations and the processes through which people move from requesting support to receiving it.
This creates an important governance function: somebody must be able to see across the system.
Individual institutions can know whether their own programs are operating. System governance requires different intelligence. It needs to identify whether people are being lost between services, whether particular territories lack provision, whether assessment produces timely support, whether one service is absorbing unmet demand from another, and whether resources are aligned with changing patterns of dependency.
Organizations examining comparable cross-system governance can use the Governance Maturity Assessment to structure questions about responsibility, assurance and escalation. It is not a Costa Rican regulatory framework, but its underlying principle is relevant: integration requires explicit decision rights and evidence that coordination works beyond formal governance structures.
Health and continuing care need a functional interface
Costa Rica's universal healthcare architecture provides SINCA with an important foundation, but healthcare and long-term care perform different functions.
The CCSS can diagnose and treat illness, provide primary and specialist care, and support rehabilitation and management of chronic conditions. A person experiencing dependency may nevertheless require daily assistance long after a clinical episode has ended.
The interface becomes particularly visible after hospitalization. An older person may no longer need an acute bed but may be unable to resume their previous life without personal assistance, rehabilitation, equipment, family support or changes to the home environment.
If continuing support is unavailable, the boundary between health and care becomes a source of risk. Families may accept responsibilities they are not equipped to sustain. Discharge may be delayed. A person may return home without sufficient support and deteriorate again.
Strengthening care coordination across health and social care therefore requires more than referrals. The services on each side of the interface need sufficiently clear information, responsibility and follow-up to know that the transition has actually been completed.
Home is becoming a strategic location for care
The National Care Policy places deliberate emphasis on home-based services and avoiding unnecessary institutionalization. That direction has practical as well as rights-based significance.
Many people prefer to remain within familiar homes and communities. Home support can preserve relationships, routines and participation while allowing formal assistance to supplement rather than replace personal autonomy and family involvement.
Yet home care is not automatically simpler than residential care. It disperses service delivery across hundreds or thousands of individual environments. Travel time, worker availability, supervision, emergency arrangements, housing conditions and family capacity all affect whether the model is safe and sustainable.
The effectiveness of home- and community-based support therefore depends on infrastructure around the visit itself. A care worker providing personal assistance may be only one element within a package that includes primary healthcare, rehabilitation, meals, assistive technology, respite and informal support.
Integration at home means those elements reinforce one another rather than requiring the person or family to coordinate the system themselves.
Caregivers are participants in the system, not an unlimited resource
SINCA's statutory purpose explicitly includes quality of life for caregivers as well as people receiving care. This is significant because Costa Rica's move toward formal care is partly a response to the limits of relying predominantly on unpaid household labor.
Family involvement can be invaluable, but it needs to be visible within assessment. A support plan based on the assumption that a daughter, spouse or sibling will provide unlimited care can appear affordable while transferring substantial cost and risk into the household.
Caregiver availability should therefore be distinguished from caregiver capacity and willingness. The fact that a relative currently performs a task does not demonstrate that the arrangement is sustainable.
Respite, education, emotional support, social protection and formal assistance can preserve family care rather than displace it. Costa Rica's policy framework recognizes services such as respite as part of this wider approach.
This is particularly important for family caregivers and care burden. An integrated system should be able to recognize deterioration in the caregiver relationship before exhaustion produces an emergency for both people.
Operational scenario: support changes when the caregiver's circumstances change
An adult with severe physical dependency receives extensive daily assistance from his mother, supplemented by limited formal support. His dependency level itself remains broadly stable, so a service model focused only on the person receiving care might see no reason to reassess the package.
His mother then develops her own health problems and can no longer safely provide transfers several times each day.
The underlying support requirement has changed even though his diagnosis and functional impairment have not. The system needs to recognize caregiver capacity as a dynamic part of the care environment.
A coordinated response could involve reassessing the intensity and timing of formal support, reviewing equipment and transfer arrangements, considering personal assistance and ensuring that the mother's own healthcare needs are not subordinated to her caring role.
The wider lesson for SINCA is that dependency management cannot rely on static eligibility decisions. People's needs exist within changing households. Review arrangements need to detect material changes in informal support as well as deterioration in the person receiving care.
If repeated cases show that families are reaching similar points of breakdown before additional support becomes available, that pattern should become system intelligence. Governance then moves beyond resolving individual cases toward adjusting service design.
Funding integration is harder than service integration
A national care system can have a shared policy while resources remain distributed across multiple institutional budgets. That is one of the central implementation challenges facing SINCA.
Costa Rica's National Care Policy was designed around progressive expansion rather than the immediate creation of a fully funded universal long-term care entitlement. Existing institutional expenditure forms part of the resource base, while additional investment is required as coverage and service modalities expand.
This creates a fundamental distinction between coordinating services and coordinating incentives.
An intervention funded by one institution may generate benefits elsewhere. Effective home support may reduce avoidable pressure on hospitals. Respite may help a family caregiver remain in employment. Rehabilitation may reduce future personal-care requirements. Tele-assistance may delay the point at which somebody requires more intensive supervision.
If each organization evaluates value only through its own expenditure, those wider effects can remain invisible.
This is why funding and payment models matter to integrated care even when Costa Rica is not operating a single pooled long-term care fund. System leaders need to understand where expenditure occurs, where benefits emerge and whether financial arrangements create gaps between formally available services.
The 2025 announcement of a $250 million Inter-American Development Bank loan to support SINCA is important in this context. The financing is intended to strengthen the system, improve efficiency, expand the coverage and quality of services, and support monitoring of implementation. It should therefore be understood as part of an ongoing strengthening process rather than evidence that a fully mature national care system is already in place.
Operational scenario: discharge exposes a funding and pathway gap
An older man is admitted to hospital following a stroke. After acute treatment and rehabilitation, he can walk short distances but needs assistance with bathing, dressing and meal preparation. Before the stroke he lived alone and required no formal support.
The clinical team can determine that acute hospitalization is no longer necessary. That decision does not answer whether returning home is sustainable.
An effective transition requires the health and care pathway to converge. Functional needs need to be understood, the home environment considered, available family support established and relevant community or home-based services identified. Equipment or further rehabilitation may reduce the amount of personal assistance required.
If the available support is determined mainly by which institution currently holds responsibility, the person can encounter a gap precisely when continuity matters most. If assessment and referral mechanisms operate across that boundary, discharge becomes a transition rather than an administrative endpoint.
The case also illustrates why hospital-to-community transitions are useful indicators of system integration. Repeated delayed discharges, unsuccessful returns home or rapid readmissions can reveal capacity and coordination problems that are not visible from examining individual organizations separately.
A national dependency scale can improve consistency, but implementation matters
The Baremo de Valoración de la Dependencia y la Intensidad de los Apoyos offers Costa Rica an important mechanism for making need more comparable across the country. Its value, however, depends on how consistently it is applied and what happens after assessment.
Standardization can reduce arbitrary variation, support prioritization and produce valuable population intelligence. It can also create a clearer connection between level of dependency and the type or intensity of support that may be appropriate.
But assessment consistency is only one dimension of equitable access.
Two people assessed at the same dependency level may experience different practical access if one lives close to a developed service network while another lives in an area with limited formal provision. A standardized assessment can reveal that disparity; it cannot by itself create the missing capacity.
This makes the implementation of the Baremo both a service-access and planning issue. Aggregated assessment data can help show where different levels of dependency are concentrated and whether the supply of services corresponds with that distribution.
IMAS's current SINCA documentation includes a national plan associated with applying the Baremo and catalogs of services linked to dependency levels. That continuing implementation work illustrates why the system should be understood as developing progressively rather than as a finished national entitlement architecture.
Information integration is becoming part of care integration
Law No. 10192 gives the Technical Secretariat responsibilities for using socioeconomic records, administrative information and beneficiary data, within Costa Rica's data-protection framework, to support policy and system operation. It also requires information about available services and institutional, regional and cantonal connections to be systematized.
These functions matter because fragmentation is often informational before it is organizational.
A service cannot coordinate effectively with another service it cannot identify. A referral cannot be closed reliably if the originating organization cannot determine what happened next. National leaders cannot assess access if different institutions count need and provision in incompatible ways.
The objective should not be indiscriminate data sharing. Personal information about health, disability, income and family circumstances requires proportionate protection. Integration instead requires clear purposes, appropriate permissions and sufficiently reliable information to support continuity and accountability.
The wider principles of data governance and information accountability are therefore highly relevant. Better data can make SINCA more person-centered only when people can trust how information about them is used.
Organizations exploring comparable digital integration can use the Digital Transformation, AI and Cybersecurity Readiness Assessment to examine whether governance, systems and operational capability are developing together. It does not assess compliance with Costa Rican requirements, but it provides a practical way to test whether digital ambition is supported by adequate controls.
Quality needs to follow the person across the pathway
A coordinated care system also changes the meaning of quality.
Traditional quality assurance often examines individual services: whether staff are trained, records are complete, care is delivered safely or an organization meets applicable requirements. Those measures remain important, but integrated care introduces another level of quality—the quality of the pathway between services.
A technically strong home-care service cannot compensate fully for an assessment that took too long. An effective hospital cannot guarantee a successful discharge if community support is unavailable. A well-designed dependency tool does not improve someone's life if assessment does not lead to an appropriate response.
SINCA therefore needs evidence at several levels: service quality, pathway quality, population access and personal outcomes.
Useful system questions include whether people receive support appropriate to assessed dependency, whether access varies materially by territory, whether transitions are completed safely, whether caregivers can sustain their role and whether support maintains autonomy rather than merely recording service activity.
A Quality Dashboard Builder can help organizations structure operational and outcome measures around comparable questions. For SINCA itself, national indicators would need to be defined through Costa Rica's own policy objectives, institutions and data systems.
Operational scenario: a national rule meets local capacity
Two adults in different parts of Costa Rica receive comparable dependency assessments. Both require regular assistance to remain safely at home.
In one location, an established network of services can assemble home support, family assistance and relevant health follow-up reasonably quickly. In the other, formal provision is limited and workers must travel significant distances between households.
The assessment framework has produced consistency in identifying need, but the resulting experience remains unequal.
The immediate response may require creative coordination with the services and community resources actually available. The strategic response is different. SINCA needs visibility of the recurring mismatch between assessed need and territorial capacity.
If geographic disparities remain hidden inside individual case management, national standardization will coexist with unequal practical access. If assessment, waiting time, service availability and outcome information are examined together, the same cases become evidence for workforce development, resource allocation and service expansion.
This illustrates an important principle of equity and access: equal assessment does not automatically produce equitable support. National consistency has to be matched by sufficient local capacity to make entitlement or policy meaningful in practice.
Workforce integration is as important as institutional integration
Services do not integrate themselves. People do.
Costa Rica's developing care system will depend on paid caregivers, health professionals, rehabilitation staff, social-sector personnel, community organizations, family caregivers and others understanding how their roles connect.
This requires more than increasing workforce numbers. Workers need clarity about boundaries of responsibility, escalation, information sharing and the contribution of other disciplines. Home-based workers may be particularly important because they see changes in people's daily functioning that are not visible during occasional clinical encounters.
Professionalization also matters. Expanding formal care without strengthening competence, supervision, working conditions and progression risks creating capacity that is difficult to retain or inconsistent in quality.
The care workforce should therefore be understood as infrastructure for SINCA rather than simply a variable cost of individual services.
Integration can also improve productivity when designed carefully. Better information can reduce duplicated assessment. Clearer referral pathways can reduce time spent navigating institutions. Technology can support scheduling and specialist consultation. Defined roles can prevent highly qualified professionals undertaking tasks that could safely be performed by appropriately trained care workers.
None of those changes eliminates the need for human care. They help scarce human capacity operate more effectively.
Governance has to detect fragmentation rather than merely coordinate institutions
The success of SINCA will ultimately depend on what its governance arrangements can see and change.
Interinstitutional meetings are necessary, but meeting regularly is not itself evidence of integration. Strong governance needs to convert operational experience into decisions.
That means being able to identify patterns such as repeated referral failures, long waits after dependency assessment, shortages at particular levels of need, territorial gaps, caregiver breakdown, unsuccessful transitions or differences in outcomes between service models.
The critical step comes after identifying variation. Responsibility for responding must be clear, and the effect of the response needs to be reviewed.
This creates a learning loop:
- people and services generate operational evidence;
- information reveals recurring gaps or variation;
- the appropriate SINCA institutions examine the underlying cause;
- policy, process, capacity or resource decisions are adjusted; and
- subsequent evidence shows whether the change improved the pathway.
The quality assurance and oversight challenge is therefore system-wide. Accountability should demonstrate not only that each institution performed its assigned function but that those functions combined into an effective response for people experiencing dependency.
Technology can make integration visible at the point of care
Costa Rica's policy framework includes technology-enabled modalities such as tele-assistance, while SINCA's legal functions explicitly recognize modernization and technology as areas for evaluation and improvement.
The strongest digital opportunity is not simply to add devices. It is to make a distributed system easier to navigate and manage.
Digital service directories can improve referral decisions. Shared or interoperable information can reduce repeated data collection. Tele-assistance can support people living at home. Geographic information can identify underserved areas. Digital workflows can show whether a referral remains open rather than disappearing between organizations.
Artificial intelligence may eventually support demand forecasting, risk identification or administrative processes, but those applications require careful governance. Algorithms built on incomplete data can reproduce existing gaps, while increased information sharing can create privacy and cybersecurity risks.
Technology should therefore follow service design rather than substitute for it. Digitizing an unclear pathway simply makes an unclear pathway electronic.
The operational test is whether technology makes responsibility clearer, access easier, decisions better informed and people's support more continuous.
Integration should be judged through people's outcomes
Institutional coordination is valuable only insofar as it improves people's lives.
For a person experiencing dependency, meaningful outcomes may include remaining at home, preserving mobility, participating in community life, maintaining relationships, exercising choice and receiving reliable support without placing an unsustainable burden on relatives.
This makes person-centered planning more than a statement of principle. It changes what the system needs to measure.
Coverage remains important. So do expenditure, workforce numbers and service volumes. But an integrated care system also needs to understand whether support is timely, proportionate, continuous and effective in maintaining autonomy.
People using services and caregivers should contribute to that evidence. Complaints, experience information and qualitative accounts can reveal navigation problems that administrative datasets miss. A pathway may appear successful because every referral was recorded while families describe repeated calls, contradictory information and long periods without clarity.
Organizations wanting to connect operational activity with wider outcomes can use the Community Impact Report Builder to structure evidence about reach, outcomes and community effect. In Costa Rica, the specific measures should arise from SINCA's national objectives and the experiences of the people the system exists to support.
The next phase is implementation at scale
Costa Rica has moved beyond discussing whether a national care system is necessary. It has a National Care Policy, statutory architecture through Law No. 10192, a dependency-assessment mechanism, interinstitutional governance arrangements and an expanding implementation agenda.
The harder stage is making those components work consistently at scale.
Current SINCA materials show continued work on the 2024–2026 Action Plan, service catalogs, the Baremo, monitoring arrangements and interinstitutional governance. Additional financing announced in 2025 is intended to strengthen capacity and implementation. These are indicators of a system being built, not reasons to assume that all intended coverage, coordination or service availability has already been achieved.
The strongest opportunity lies in using this implementation period to build integration into operating practice from the beginning. Assessment should connect to service capacity. Service data should connect to planning. Caregiver experience should inform support design. Health transitions should connect with continuing care. Territorial variation should influence investment.
If these relationships mature together, SINCA can become more than an umbrella over existing programs. It can progressively create a recognizable pathway through them.
What Costa Rica's approach offers international care systems
Costa Rica's model should not be treated as a structure that can simply be exported. Its universal health system, social-protection institutions, public administration and community arrangements are specific to the country.
The more transferable lesson is architectural.
Costa Rica has recognized that long-term care cannot be developed effectively as an isolated service sector. Dependency intersects with healthcare, disability, aging, poverty, employment, gender, family life and local community capacity. SINCA attempts to create coordination across those boundaries while existing institutions retain their substantive responsibilities.
That approach highlights a question relevant far beyond Costa Rica: does integration require a new organization, or can stronger governance make existing organizations function as a system?
The answer will vary between countries. Costa Rica's experience suggests that coordination requires more than a national strategy. It needs shared assessment concepts, mapped services, operational pathways, information, accountability, financing visibility and a mechanism capable of learning from gaps between institutions.
Other systems can adapt that principle without replicating SINCA itself.
Conclusion
Costa Rica's National Care System represents an important shift in how dependency is understood. Rather than treating continuing care solely as a private family responsibility or as a collection of disconnected institutional programs, SINCA creates a framework in which the State, families, communities, civil society and private provision can contribute within a more coordinated system.
The statutory architecture matters, but implementation will determine its significance. A standardized dependency assessment needs available services behind it. Interinstitutional governance needs information capable of revealing gaps. Home-based care needs a sustainable workforce. Health and long-term support need reliable transitions. Caregiver involvement needs to be supported rather than assumed. National consistency needs sufficient territorial capacity to become meaningful locally.
The strongest direction is therefore not integration for its own sake. It is integration around the life of the person experiencing dependency. Success should become visible when people encounter fewer administrative boundaries, receive support proportionate to their needs, retain greater autonomy and can move between health, care and community services without repeatedly rebuilding the pathway themselves.
Costa Rica has established many of the foundations required to pursue that objective. The next test is whether policy, financing, information, workforce and local delivery mature together. If they do, SINCA can progressively turn institutional coordination into something much more consequential: continuity of support in everyday life.