GEOGRAPHY AND HEALTHCARE
Costa Rica is a country in Central America with 4 909 000 inhabitants living in an area of 51 100 km2. The country borders Nicaragua to the North, Panama to the South, the Caribbean to the East, and the Pacific Ocean to the West (Figure 1). Its Universal Social Security and Healthcare coverage, called La Caja Costarricense del Seguro Social (or simply “La Caja”) is an autonomous institution. This system has been implemented in 1940. Since its inception, and until today, “La Caja” has been a source of pride for Costa Ricans. “La Caja” is supervised by the Health Ministry that enacts decrees (and any secondary legislation) while coordinating societal healthcare efforts.
HISTORY OF TRANSPLANTATION
Kidney transplantation in Costa Rica began in 1970, followed by heart transplants in 1991, and liver transplant in 1994. Progress in kidney transplantation has been supported largely by living donor procedures, initially focusing on living related donors, and later expanded to nonrelated living kidney donors.
Before 2002, there had been limited activities in procuring organs from brain death donors with an imperfect communication system that was activated when the diagnosis of brain death had been made; subsequently, transplant teams had been informed. At that time, procurements and transplants had largely been limited to kidneys. Moreover, procurements and transplants have usually been performed at the same institution. Organs were rarely shared among different hospitals and if so, reasons were mostly circumstantial and based on personal relationships. Scientific and medical input from the Board of Directors of “La Caja” had traditionally been limited. In 2011, “La Caja” implemented an Institutional Coordinator for Organ Transplantation with the objective to structure organ donation and transplantation across the country. More recently, communication on identifying and proceeding with brain-dead donors has been streamlined. Reimbursement structures have been established to facilitate follow-up on potential donors by coordinators, contacting transplant teams, and allocating organs. Nevertheless, deceased donor transplant rates have remained low (Table 1).
The first transplant legislation (Act 5560) was enacted in 1974. This “Transplantation Law for Human Beings” has allowed “La Caja” to use organs for transplantation in patients with end-stage organ failure. This legislation has been refined in 1994 (New Law 7409) and included a framework for brain death donation. An additional revision was implemented in 2015 (Transplant Law 9222) that changed the system to an “opt-in” approach. Moreover, this latest legal modification granted permission for living unrelated donation established the role of a hospital-based transplant coordinator with transplant activities supervised by the secretary of organ donation and transplantation at the Ministry of Health.
Unfortunately, the many legal changes have thus far not contributed to an increase in deceased donor rates.
RESPONDING TO ORGAN TRAFFICKING
The most recent revision of the transplant law has been implemented after a complex situation of illegal kidney transplants; between 2009 and 2011, foreign nationals had received renal transplants from Costa Rican live donors with surgeries performed in private hospitals. Costa Rica responded to those criminal acts with legal modifications in 2015. Although the implementation of legal changes had the intention to prevent the illegal utilization of organs from brain dead donors, legal changes did not address all concerns in the absence of a strong clinical input. Notably, previous organ trafficking activities in Costa Rica had not involved deceased donors. Moreover, the current law does not also prevent organ trafficking from a nonrelated living donors. Nevertheless, the new legislation supports a hospital-based transplant coordinator, a secretary of Organ Donation and Transplantation within the Ministry of Health, a single transplant list, the registration of transplant personnel and programs, in addition to an organ allocation based on objective criteria based on waiting time and medical emergency.
CURRENT TRANSPLANT ACTIVITIES
Costa Rica has 5 kidney transplant programs; 3 in the major general hospitals of San José with an additional pediatric program in the capital; there is an additional adult program in a Provincial Hospital in Cartago; 2 private hospitals in San José have privileges to perform kidney transplants, although their programs are currently inactive.
There are 3 liver transplant programs in the country. Recently, the boards of directors of "La Caja" retracted the permission for the Liver Transplant and Hepatobiliary Surgery Center to perform transplants intending to merge human and financial resources. This has been an unfortunate decision, ignoring progress and achievements in an established center that had performed all pediatric and adult liver transplant in Costa Rica for the last 14 years.
Currently, there are 2 active adults and 1 pediatric liver transplant program, both with low volumes. Thus far, there has been no intention to structure transplant activities either based on financial and structural efficiencies or aiming to optimize outcomes. As with kidney transplant programs, 2 private hospitals have privileges to perform liver transplant; these, however, are currently inactive.
There is 1 program for cardiothoracic transplants; activities for intestinal and pancreas transplantation remain anecdotal.
Bone marrow transplants are performed in the 3 main general hospitals and at the pediatric hospital.
TRANSPLANT STRUCTURE AND REGISTRY
The Secretary of Organ Donation and Transplantation in the Ministry of Health supervises organ donation, transplantation and the registry since 2015, supporting evidence-based decisions.
Most recent transplant data (2009-2017) show a shifting ratio of living to deceased donor transplants. Although most renal transplants had been from living donors in 2011 (80.4%), the contribution of living donor transplants declined to 56% in 2017. Notably, the overall volume of kidney transplants has also declined, which is mainly attributed to structural insufficiencies and reimbursement issues that challenge clinical coverage (Table 2).
CHALLENGES AND OPPORTUNITIES
The institutional consolidation of the health system in Costa Rica has overall supported the structure of transplantation. During recent years, however, efforts have not yielded an overall increase in deceased donations. Although there has been a relative increase in deceased donor kidney transplants, living donor and overall kidney transplants have declined.
Moving forward, the Ministry of Health and the Board of Directors of “La Caja” have an opportunity to analyze available transplant data, structure the transplant system in an effective and cost-contained fashion, and to implement quality assurance, all with the goals to optimize transplant volume and outcomes.