Long-term care has a cost even when no invoice is issued. An older person may receive help with bathing, meals, medication, mobility and supervision every day without appearing in a formal care budget because a daughter, spouse or other relative provides that support without pay. Another household may purchase assistance privately. Elsewhere, public resources may support home care, a day center, residential provision, tele-assistance or another service while healthcare needs are met separately through Costa Rica's social security system.
Understanding who pays therefore requires looking beyond government expenditure. Across the developing system explored through the Costa Rica Aging, Long-Term Care & Community Support Knowledge Hub, financing is distributed between public institutions, social programs, households, communities and unpaid caregivers. The Sistema Nacional de Cuidados y Apoyos para Personas Adultas y Personas Adultas Mayores en Situación de Dependencia (SINCA) is intended to bring greater coherence to that landscape, but it does not transform long-term care into a single insurance program or eliminate the financial contribution already being made by families.
The central policy challenge is consequently broader than finding additional money. Costa Rica needs to decide progressively how the economic responsibility for dependency should be shared, which forms of support public resources should prioritize, how access can become more equitable, and how expenditure can generate greater independence and quality rather than simply responding when families reach exhaustion.
Long-term care sits outside a simple health-financing model
Costa Rica's Caja Costarricense de Seguro Social (CCSS) provides the country with an extensive social health insurance architecture. That matters enormously to older people and adults with disabilities, particularly where dependency coexists with chronic disease, rehabilitation needs or other clinical conditions.
But healthcare financing and long-term-care financing answer different questions.
A health system can fund treatment for a stroke, diabetes or infection without assuming responsibility for every hour of assistance a person subsequently needs with dressing, eating, mobility or supervision. Dependency can continue for years after acute treatment has ended. Its economic consequences therefore extend beyond healthcare expenditure into personal assistance, housing, transport, equipment, community support and the time contributed by relatives.
The distinction is fundamental. Treating long-term care primarily as an extension of healthcare risks overlooking both its social purpose and its true cost. Conversely, separating the two too rigidly can create gaps where appropriate continuing support might prevent deterioration or reduce avoidable healthcare use.
Costa Rica's financing challenge is therefore partly about connecting resources around the person without assuming that every form of support should be financed through the same institution.
Public care funding is distributed rather than contained in one budget
SINCA was created as an interinstitutional system. Its financing environment reflects that architecture.
Public resources relevant to care and support can sit across institutions with different statutory responsibilities, target populations and funding mechanisms. IMAS has a central role in SINCA's coordination. CONAPAM is important within services and programs for older people, while CONAPDIS has responsibilities relating to people with disabilities. CCSS finances healthcare through its own social insurance arrangements. Other public bodies, community organizations and service providers also contribute to the wider care infrastructure.
FODESAF, the Fondo de Desarrollo Social y Asignaciones Familiares, is another important part of Costa Rica's social financing landscape. It finances social programs targeted principally toward poverty and vulnerability, and IMAS itself receives resources from FODESAF alongside central-government transfers and other legally designated income.
Law No. 10192 recognizes this fragmented financial reality. Among the responsibilities assigned to SINCA's Technical Secretariat are evaluating financing, viability, cost-benefit, monetization and social return, and coordinating with the Dirección de Desarrollo Social y Asignaciones Familiares when evaluations concern services financed through FODESAF.
That makes funding and payment models a governance issue as much as a fiscal one. A national care system needs visibility over how different resources combine even when those resources do not become one centralized budget.
Unpaid care is part of the financing system
The largest conceptual mistake in care financing is to treat unpaid support as free.
Recent OECD analysis describes Costa Rica's long-term-care workforce as having a large base of unpaid family caregivers alongside a much smaller formal workforce. Estimates cited in that analysis identify around 214,000 people providing unpaid care, with women forming the majority. The same work reports that approximately 85% of older adults with dependency receive assistance from somebody within their household, while a smaller group remain without help despite needing it.
Those figures reveal an economic structure as well as a social one.
When a relative provides several hours of support each day, the State may not record an equivalent service expenditure. Yet the household absorbs time, foregone employment, reduced earnings, pension consequences, travel, emotional pressure and sometimes direct expenditure on equipment, transport or privately purchased assistance.
The economic value of care has therefore not disappeared. It has changed payer.
This is why family caregiving and care burden must be considered within financing policy. If expansion of formal care merely assumes that families will continue absorbing any unmet demand, public expenditure may remain contained while household costs become progressively less sustainable.
Operational scenario: the care package that appears to cost nothing
An older man with moderate dependency lives with his wife. She prepares his meals, assists with dressing and bathing, organizes medication, accompanies him to appointments and remains nearby because he is unsafe when walking alone. Their daughter visits several evenings each week and manages shopping and administrative tasks.
On paper, the formal long-term-care cost may be very small. In practice, a substantial care package is operating every day.
If his wife previously undertook paid work, her caring role may have reduced household income. If their daughter changes her working hours, a second household absorbs part of the cost. Neither contribution is necessarily visible in institutional expenditure data.
A dependency assessment should therefore examine more than the tasks the man cannot perform. It should establish which support is currently being provided, by whom, whether that arrangement is sustainable and what would happen if either caregiver became unavailable.
Targeted formal support might appear to increase public spending because an unpaid activity becomes a funded service. Yet the wider economic effect could be different. Respite or home assistance might preserve the wife's health, allow the daughter to remain in employment and delay the need for more intensive provision.
For financing governance, the relevant comparison is not simply public expenditure before and after intervention. It is the combined cost and outcome across the person, household and wider system.
Gender makes the distribution of care costs unequal
Care financing cannot be separated from gender equality in Costa Rica because unpaid domestic and caregiving responsibilities remain distributed unevenly.
OECD analysis has highlighted a substantial gender gap in unpaid domestic and care work in Costa Rica. Women spend considerably more time on these activities than men, affecting their capacity to participate in paid employment and accumulate income over their working lives.
Long-term-care policy can therefore redistribute both services and economic opportunity.
Expanding formal home care, respite, day services and other support does not necessarily remove family involvement. It can change the intensity of that involvement from an unavoidable full-time responsibility toward a relationship that families have greater capacity to sustain.
This is particularly important as population aging increases the number of people likely to require support while family structures and labor-market participation continue to change. A model that depends upon an effectively unlimited supply of female unpaid labor may become progressively less viable even before public budgets register the pressure.
Care policy consequently has labor-market, pension, poverty and gender implications. Those effects should be visible when Costa Rica evaluates the long-term system impact of investment in SINCA.
Public responsibility does not require public provision of everything
Debates about long-term-care financing can become unnecessarily binary: either families are responsible or the State is responsible. In practice, sustainable systems commonly involve several contributors and multiple forms of provision.
The stronger question is what responsibilities should be guaranteed collectively and how people can access an appropriate mix without facing unacceptable financial or caregiving burdens.
Costa Rica's National Care Policy envisages an ecosystem that includes existing and new modalities rather than a single standardized service. Home-based care, tele-assistance, day services, long-stay residential care and the Red de Cuido de Personas Mayores can perform different functions. Public, private and community actors can participate within that wider landscape.
Public responsibility can therefore include financing, subsidizing, regulating, coordinating, assessing need, developing workforce capacity and monitoring quality even where government does not directly employ every worker or operate every service.
The distinction matters because expanding care capacity requires more than increasing public payrolls. Costa Rica also needs a sustainable provider and community infrastructure capable of translating resources into reliable support.
Organizations considering similar questions can use the Governance Maturity Assessment to structure discussion about financial responsibility, oversight and assurance. It is not a Costa Rican funding framework, but it can help distinguish who controls resources, who is accountable for outcomes and where cross-system risks require escalation.
Means, dependency and entitlement are different concepts
Financing systems also need to distinguish between how much support somebody needs and whether public resources will pay for that support.
SINCA's Baremo de Valoración de la Dependencia y la Intensidad de los Apoyos is designed to provide a standardized assessment of dependency and support intensity. That can create a clearer national picture of functional need.
It should not automatically be interpreted as evidence of a comprehensive universal financial entitlement to every service associated with that assessed level. Costa Rica is progressively building and expanding its care system, and practical access continues to depend on programs, resources, eligibility arrangements and available capacity.
This distinction is essential for public understanding.
A transparent system should make clear where dependency assessment establishes need, where socioeconomic information affects access to particular publicly financed programs, what support is actually available, and whether personal or family contributions remain necessary.
Otherwise, assessment can create an expectation that services cannot yet meet.
Over time, stronger financing policy can reduce the distance between recognized need and practical access. But doing so requires explicit decisions about coverage and affordability rather than allowing scarcity to be managed invisibly through waiting, geography or increased reliance on families.
Private purchasing creates capacity but can also widen differences in access
Households with sufficient income can respond to gaps in public or community provision by purchasing support privately. This can include domestic assistance, personal care, residential services, equipment or other forms of help.
Private spending can increase choice and contribute valuable capacity to the wider system. It can also produce unequal experiences when ability to pay determines how quickly a household can supplement publicly available support.
The policy question is not whether private provision should exist. It is whether the underlying system provides sufficient protection that dependency does not translate into unacceptable hardship for people without equivalent purchasing power.
This is where budget impact and affordability need to be considered together. Government affordability cannot be secured simply by transferring costs to households if the consequence is unmet need, caregiver withdrawal from employment or later demand for more intensive public services.
Likewise, increasing public expenditure without understanding unit costs, outcomes and provider capacity does not guarantee sustainable coverage.
Financing reform therefore requires a whole-system view of who pays, what is purchased and what outcomes that expenditure produces.
Operational scenario: two households with the same dependency, different purchasing power
Two women in their late seventies are assessed as having similar levels of dependency. Both need assistance each morning and evening and would benefit from regular social participation outside the home.
The first has sufficient retirement income and family resources to purchase additional home support while waiting for publicly supported services. Her daughter coordinates appointments but can remain in full-time employment.
The second lives on a much lower income. Her son provides the assistance himself because the household cannot afford equivalent private support. He repeatedly arrives late for work and eventually reduces his hours.
The women's functional needs are similar, but their financing environments produce different outcomes for two generations.
A system concerned with equity needs to see this difference. Socioeconomic targeting can help direct scarce public resources toward households with less capacity to purchase support, but targeting also needs sufficient service supply behind it. Financial eligibility is of limited practical value if no worker or service is available locally.
At national level, aggregated information about dependency, income, caregiver availability, service use and waiting times can help reveal whether public financing is narrowing these differences or leaving households to compensate for them.
Financing home care requires understanding the real cost of delivery
Costa Rica's emphasis on enabling people to remain at home creates a strong case for developing home-based support, but home care has its own cost structure.
Workers need to be recruited, trained, supervised and paid. Travel between households consumes time. Rural routes can make apparently short visits expensive to deliver. Scheduling needs to accommodate peaks in demand because many people require assistance at similar times of day. Equipment, digital systems and management infrastructure also carry costs.
Underfunding those components does not make care cheaper. It can shift pressure into low wages, informal employment, high turnover, shortened visits or reliance on relatives to fill gaps.
This is why sustainable financing needs to consider the workforce as part of service infrastructure. Recent evidence indicates that Costa Rica's formal paid care workforce remains substantially smaller than its unpaid caregiving base and is overwhelmingly female. The National Care Policy recognizes the importance of occupational profiles, training, certification and improved employment quality.
As formal coverage expands, workforce, care teams and skill mix will increasingly affect what each additional unit of public investment can actually deliver.
Financing therefore needs to support not only hours of care but the organizational capability required to make those hours reliable.
Low prices can create expensive consequences
There is an understandable incentive in publicly supported care to maximize the number of people reached from a constrained budget. But the lowest apparent service cost is not necessarily the lowest system cost.
If reimbursement or purchasing arrangements do not cover reasonable workforce, travel, supervision and quality costs, providers may struggle to maintain continuity. Families then compensate for missed or limited support, or people deteriorate until they require more intensive intervention.
Conversely, excessively generous prices without corresponding expectations for quality and outcomes can reduce the number of people who can be supported from available resources.
The policy challenge is therefore to understand the relationship between cost, quality, intensity and outcome.
This becomes increasingly important as SINCA develops information about service supply and levels of dependency. Knowing that a person requires moderate or severe support is only one side of capacity planning. The system also needs to understand the realistic cost of delivering the corresponding support in different settings and territories.
Geography matters. The cost of providing an hour of home support cannot always be separated from the travel required to reach the person. Rural areas may therefore require different operational assumptions from densely populated communities.
Financing models that ignore those differences can unintentionally make some populations less attractive or practical to serve.
Prevention and independence change the economics of care
Long-term-care financing is sometimes treated as expenditure that begins once dependency exists and then rises as needs become more intensive. A stronger approach also considers whether investment can alter that trajectory.
Rehabilitation, falls prevention, accessible housing, assistive technology, chronic-disease management, nutrition, social participation and caregiver support can all influence how people's needs develop. None guarantees that dependency will disappear, but maintaining function can reduce the intensity or duration of assistance required.
This gives preventative value and early intervention a direct financing dimension.
For example, expenditure on appropriate equipment may reduce the number of people required to support a transfer. Rehabilitation after illness may restore enough function for somebody to manage part of their personal care independently. Respite may prevent caregiver exhaustion from precipitating an avoidable move into residential care.
The financial case needs to remain evidence-based. Not every preventive intervention generates cashable savings, and improved quality of life is valuable even where total expenditure does not fall.
Nevertheless, a care system that measures only the immediate cost of services risks undervaluing interventions whose benefits emerge elsewhere or later.
The Community Impact Report Builder can help organizations structure evidence about wider outcomes and community value. In Costa Rica, decisions about public investment should remain grounded in the country's own data, policy objectives and institutional responsibilities.
Operational scenario: spending earlier to preserve independence
An older woman begins falling regularly at home. She remains largely independent but has stopped bathing without assistance because she is frightened of falling. Her daughter has begun visiting every morning before work.
A narrow financing approach could wait until the woman's dependency becomes sufficiently severe to justify a larger package of formal support.
A preventive approach asks whether earlier intervention can preserve function. Clinical assessment may identify medication or health factors. Rehabilitation could address strength and balance. Appropriate equipment or modifications could reduce environmental risk. Short-term support could rebuild confidence while her ability is reviewed.
The outcome may not be a permanent reduction in public expenditure. She may eventually need continuing care as she ages. But delaying avoidable functional decline has value to her and may reduce the intensity of assistance required in the intervening period.
Financing governance should therefore distinguish between expenditure that substitutes for an existing need and investment that changes future need. Both can be legitimate, but they answer different questions.
If SINCA can connect dependency assessment with outcome and service-use information over time, Costa Rica will be better placed to identify which interventions preserve autonomy and where preventive investment produces the greatest personal and system value.
The $250 million IDB operation creates an opportunity to strengthen the financing architecture
The Inter-American Development Bank approved a $250 million policy-based loan for Costa Rica in June 2025 to support the strengthening and expansion of SINCA. The operation aims to improve living conditions for older people with functional dependency and people with disabilities with high support needs, while improving caregiver wellbeing.
Its objectives include strengthening SINCA's institutional framework and increasing the coverage and quality of care services. Costa Rican authorities have also identified improved monitoring, implementation of the dependency assessment framework and stronger system efficiency among the areas supported.
This financing is substantial, but it should be interpreted carefully. A policy-based loan can help enable reform and expansion; it does not itself constitute a permanent long-term-care financing settlement.
The longer-term question is what happens as demand continues to rise after reform milestones have been achieved.
That makes the current investment period an opportunity to improve the information needed for future fiscal decisions: how many people have different levels of dependency, what support they receive, what services cost, where unmet need persists, how much care households provide and which interventions produce meaningful outcomes.
Without that evidence, future financing debates risk becoming arguments about aggregate spending. With it, Costa Rica can ask more useful questions about what additional resources would purchase and which parts of the system generate the strongest value.
Financing needs an evidence architecture
Sustainable care systems cannot be managed from expenditure totals alone.
A finance ministry may know how much a program costs. A provider may know how many hours it delivers. A health service may know how often a person is admitted. A household may know how many hours of unpaid care are required. The strategic value lies in connecting those perspectives sufficiently to understand the whole pathway.
For SINCA, a stronger evidence base could progressively connect:
- the number and distribution of people at different dependency levels;
- service availability, utilization, waiting and unmet need;
- formal workforce capacity and the contribution of unpaid caregivers;
- public and, where measurable, household financial contributions;
- quality, continuity and personal outcomes; and
- changes in healthcare utilization, independence and caregiver wellbeing over time.
Not every dataset needs to be physically combined. Privacy, proportionality and institutional responsibilities remain important. But decision-makers need enough shared intelligence to understand whether money is producing the intended result.
The Quality Dashboard Builder offers organizations a practical way to think about connecting activity, quality and outcome measures. It does not define Costa Rica's national indicators, but the underlying discipline is relevant: financial oversight becomes stronger when cost can be interpreted alongside access and outcomes.
Operational scenario: a cheaper service produces a higher system cost
A local home-support arrangement is redesigned to reduce expenditure per visit. Visit duration becomes shorter and worker schedules become more tightly packed.
Initially, the financial indicators improve. More visits can be recorded from the same nominal budget.
Over several months, however, workers have less flexibility to notice changes in people's condition. Turnover increases because schedules are difficult to sustain. Families report that visits are less reliable. Several people with complex needs begin using emergency health services more frequently.
No single event proves that the pricing decision caused those outcomes. But the pattern warrants investigation.
A mature funding system would examine the service saving alongside continuity, workforce retention, complaints, incidents, caregiver pressure and healthcare utilization. If the apparent saving is repeatedly associated with higher costs or poorer outcomes elsewhere, the service specification or financing assumption may need to change.
This illustrates why cost control and value are not synonymous. Strong financial stewardship means understanding the consequences of how resources are deployed, not simply reducing the price of individual inputs.
Accountability must follow public money without losing sight of people
As public investment in care expands, accountability becomes increasingly important.
Government and participating institutions need assurance that resources reach their intended populations, services are actually delivered, quality is acceptable and public expenditure is used for its authorized purpose. Providers and community organizations receiving public resources need proportionate requirements for records, financial control and performance information.
But assurance can become counterproductive if reporting systems measure only what is easiest to count.
A service might demonstrate that thousands of hours were delivered without showing whether people maintained independence. A program may meet its expenditure target while waiting times increase. A funding stream can be fully disbursed while families continue providing unsustainable levels of care.
Effective quality assurance and oversight should therefore connect financial accountability with service and outcome accountability.
Where weaknesses are identified, the purpose should not be limited to retrospective compliance. Information should support corrective action, resource decisions and improvement.
Organizations examining that relationship can use the Quality Improvement Action Plan Builder to translate identified gaps into responsibilities and follow-up actions. It is a general improvement tool rather than a Costa Rican assurance mechanism.
Population aging will make the financing question progressively more important
The economics of care will become harder to leave implicit as Costa Rica ages.
The IDB reported in 2025 that approximately 11 in every 100 people in Costa Rica were aged 65 or older and projected that this could rise to around 25 in every 100 by 2050. Population aging does not translate mechanically into dependency, but it increases the number of people exposed to ages at which functional limitations, dementia and multiple chronic conditions become more common.
At the same time, relying on families to absorb a proportionate increase in care demand is unlikely to be straightforward. Household structures, women's labor-force participation, migration, geographic separation and the aging of caregivers themselves can all affect the supply of unpaid support.
The financing problem is therefore dynamic. Future demand will be shaped by both the number of people requiring assistance and the amount of informal care available to them.
That makes outcomes, value and system sustainability increasingly important. A sustainable model is not necessarily one that minimizes public spending. It is one that can continue producing acceptable access, quality and outcomes without placing untenable costs on government, workers or households.
What should count as value?
The answer to who pays for long-term care ultimately depends partly on what society believes care is intended to achieve.
If the objective is simply to complete essential tasks at the lowest possible public cost, unpaid family labor can appear extremely efficient. If the objective includes autonomy, caregiver wellbeing, gender equality, labor-market participation, prevention and social inclusion, the calculation changes.
Likewise, residential care can appear more expensive than home support when only service prices are compared, but the comparison becomes more complex for a person requiring intensive round-the-clock supervision. Home care is not inherently cheaper in every circumstance, just as institutional care is not inherently the most appropriate response to high dependency.
Financing should therefore follow need and outcomes rather than predetermined assumptions about which setting is cheapest.
This requires a mature concept of value: appropriate support at the right intensity, delivered in a way that protects dignity and independence while using collective resources responsibly.
International learning lies in making hidden costs visible
Costa Rica's financing architecture is shaped by its own social security system, public institutions, social programs and history of family and community care. A country operating compulsory long-term-care insurance, municipal social services or a tax-funded universal care entitlement cannot simply transplant Costa Rica's mechanisms.
The transferable lesson lies elsewhere.
Every care system pays for dependency somehow. Where formal public financing is limited, costs do not disappear; they may emerge as unpaid family labor, reduced employment, private expenditure, unmet need, hospital use or premature institutionalization.
Making those transfers visible improves policy decisions.
Costa Rica's developing SINCA framework creates an opportunity to examine care as a system of economic and human contributions rather than a series of isolated program budgets. Its statutory emphasis on financing, viability, cost-benefit and social return is particularly relevant because it invites analysis across institutional boundaries.
Other countries can adapt the same principle without adopting Costa Rica's structures: assess the full distribution of costs before concluding that one financing model is cheaper than another.
Conclusion
Costa Rica's long-term-care financing challenge cannot be reduced to identifying a single payer. CCSS finances healthcare; social institutions and programs contribute to care and support; FODESAF resources form part of the wider social-financing architecture; households purchase some services privately; communities contribute capacity; and families provide an enormous volume of unpaid care that conventional expenditure figures can easily obscure.
SINCA creates an opportunity to make those contributions more coherent and visible. The stronger direction is not simply to transfer every cost to government, nor to preserve public affordability by assuming that families will continue absorbing unmet demand. It is to develop a sustainable balance in which dependency is assessed consistently, public support is targeted and expanded transparently, caregivers are recognized, provider and workforce costs are understood, and expenditure is evaluated against quality, independence and wider social value.
Population aging will increase the importance of those choices. The $250 million IDB-supported reform provides significant capacity to strengthen the system, but long-term sustainability will depend on the financing architecture Costa Rica builds around that investment.
The central test is ultimately human as well as fiscal: whether the cost of dependency is shared in a way that allows people to receive appropriate support without requiring families—particularly women—to function as the invisible financial mechanism of the care system.