Spending increases have been almost entirely consumed by increases in the number and salary of CCSS employees, without clear evidence of benefit to patients. Costa Rica should consider expenditure ceilings and spending reviews in the short term to control spending. In the longer term, better use of performance data and innovative payments systems will be needed, as well as a shift away from employment-linked contributions as the main source of health system revenue. Prospects for improvement are bleak -informal employment is increasing in Costa Rica, contrary to many Latin American economies, and now' accounts for almost half of all employment (Figure 1.5).