Constitutional Framework

• Healthcare established as constitutional right (1949)
• Article 73 established CCSS as autonomous institution
• Core principles: universality, solidarity, equity
• Maternal-child services defined as essential, not optional

Impact for Citizens vs. Migrants

Citizens:

• Near-universal coverage (~95%) for prenatal care
• Standardized care protocols nationwide
• Geographic distribution ensures accessibility
• Integrated referral systems

Migrants:

• Legal protections extended regardless of status
• Emergency care cannot be denied to anyone
• Prenatal care and child services accessible
• Community focus to identify pregnant women

Persistent Barriers for Migrants

• Documentation requirements despite legal protections
• Geographic concentration in underserved areas
• Financial barriers beyond direct healthcare costs
• Information gaps about available services
• Fear of deportation deters care-seeking
• Language barriers, especially for indigenous populations
• Administrative discretion can create additional barriers

EBAIS Team Structure

• Interdisciplinary teams (physician, nurse, technical assistant, ATAP)
• Population-based responsibility (4,000-5,000 people)
• Geographic assignment ensuring accessibility
• Home visits to pregnant women and new mothers

Key Success Elements

• Proactive prenatal identification through community surveillance
• Continuity of care from pregnancy through early childhood
• Integration of clinical and social support services
• Early postpartum follow-up and breastfeeding support
• Protocol-driven care with clear referral pathways
• Community trust in healthcare providers

Adaptations for Migrant Communities

• Mobile EBAIS teams in high-migration areas
• Cultural mediators from migrant communities
• Linguistic adaptation of materials and services
• Documentation flexibility for limited paperwork
• Separation of healthcare from immigration enforcement
• NGO partnerships with trusted community organizations
• Border region service strengthening

Current Challenges

• Increased demand without corresponding resources
• Geographic concentration creating uneven pressures
• Epidemiological diversity requiring service adaptation
• Documentation and continuity challenges
• Cultural and linguistic complexity
• Financial sustainability concerns

Effects on Maternal-Child Outcomes

• Sullivan (2019): Slightly worse outcomes for migrants
• Later entry to prenatal care
• Higher complication rates from delayed care
• Vaccination delays for migrant children
• Challenges in postpartum follow-up due to mobility

Policy Adaptations for Sustainability

• Regional cooperation frameworks with sending countries
• Special funding mechanisms for migrant healthcare
• Documentation streamlining for pregnant women
• Portable health records for mobile populations
• Targeted resource allocation to high-migration areas
• Cross-border health initiatives with Nicaragua/Panama
• International support for shared responsibility

Cultural Differences in Maternal Care

Costa Rican Nationals: - Modern medicine blended with traditional beliefs - Strong family involvement in childbirth - “Cuarentena” (40-day postpartum period) traditions - Generally high trust in formal healthcare

Migrant Groups: - Nicaraguan: Female provider preference, traditional birth attendants - Indigenous: Distinct birth positions, rituals, language barriers - Venezuelan/Colombian: Expectations of technology-intensive care

System Adaptations

Successful Approaches: - Integration of traditional birth positions - Family presence during childbirth - Cultural mediators from migrant communities - Incorporation of safe traditional practices - Multilingual health materials

Ongoing Challenges: - Limited providers from migrant backgrounds - Insufficient cultural competence training - Standardized protocols limiting flexibility - Language barriers in many facilities - Resource constraints for comprehensive adaptation

Improvement Opportunities

• Systematic cultural competence training
• Migrant community inclusion in service design
• Documentation of cultural preferences
• Research on safe traditional practice integration
• Community-specific approaches rather than standardization
• Creating feedback mechanisms for service improvement

Current Sustainability Challenges

• Financial: Increasing costs, growing non-contributing beneficiaries
• Workforce: Rural specialist shortages, provider burnout
• Infrastructure: Aging facilities, capacity limitations
• Migration-Specific: Unpredictable flows, complex health needs

Technological Innovations

• Telemedicine extending specialist reach
• Mobile health applications for pregnancy monitoring
• Electronic health records improving continuity
• SMS-based appointment and health education
• Point-of-care diagnostics reducing referral needs

Workforce & Financing Solutions

• Task-shifting to nurses and technicians
• Training migrants with healthcare backgrounds
• Community health worker expansion
• International partnerships for migrant healthcare funding
• Public-private partnerships for specialized services

Policy & Community Approaches

• Regional agreements on healthcare for mobile populations
• Streamlined registration for pregnant women
• Integration across sectors (health, education, housing)
• Co-design of services with migrant communities
• Training community leaders as health advocates

Evidence-Based Priorities

• Maintaining EBAIS model while adapting to new populations
• Preserving universal access with sustainable financing
• Strategic technology use extending human connection
• Addressing social determinants within health strategy
• Building cross-sector and international partnerships