This report puts forward policy recommendations for strengthening the performance and sustainability of the health care system in Costa Rica. There is much to praise in Costa Rica’s health care system: institutional stability; a closely integrated but well-differentiated provider arm, with strong primary care; a degree of inter-sectoral co-ordination that serves as a model of good practice; detailed and effective dialogue between users and health service managers; and, innovation around professional roles and the use of ICT that other health systems could learn from. All this leads to health outcomes on a par with several OECD economies: life expectancy is 79.9 years (compared to the OECD average, 80.6) and less than 1% of the population report failing to seek care because of financial reasons. Nevertheless, serious strains are evident: spending is rising steeply, fuelled by salaries, fees and facility payments based on last year’s outlay. This increase is not associated with improvement in services: waiting lists are excessively long and growing. The system is perhaps too stable: institutional rigidity and vested interests have stalled vital reforms, meaning that Costa Rica still lacks systematic application of DRGs and health technology assessment, despite attempts to bring them in. The OECD is an international organization that consists of 30 Member countries from the developed world that accept the principles of representative democracy and free market economy. It originated in 1948 as the Organization for European Economic Cooperation (OEEC) to help administer the Marshall Plan for the reconstruction of Europe after World War II. Later its membership was extended to non-European states, and in 1961 it was reformed into the OECD. The organization provides a forum where governments can compare policy experiences, seek answers to common problems, identify good practice and co-ordinate domestic and international policies. With active relationships with some 70 other countries and economies, NGOs and civil society, the organization has a global reach. Renowned for its publications and statistics, its work covers economic and social issues from macroeconomics, to trade, education, environment, development and science and innovation.