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close this bookThe Nutrition and Health Transition of Democratic Costa Rica (INFDC, 1995, 228 p.)
close this folder3. Development and characteristics of health and nutrition services for urban and rural communities of Costa Rica
View the document(introduction...)
View the documentIntroduction
View the documentBackground information on community outreach programs
View the documentMethodological characteristics of the Costa Rican health programs
View the documentNutrition programs
View the documentImpact of the programs on the health of children living in rural areas
View the documentConclusions
View the documentReferences
View the documentBibliography


During the first half of the 1970s, the convergence of a number of factors led to the political decision to develop a health and nutrition program for rural communities. The experiences of both the Mobile Health Unit program, started in the prior decade, and the successful malaria control program were used to design and implement the Rural Health Program.

TABLE 8. Height Trends in Children Attending First Grade in Costa Rica, 1979-1989.

Height Censuses Taken in 81 Counties

Stunted Children (%)

Height Census




































a Talamanca, Buenos Aires, and Upala counties.

b Talamanca and Leortcounties.

Source: Evolucie la situaciutricional pare as geogrcas DESAF-SIN, 1990 (M.E.P./OCAD/SIN, 1979, 1981, 1983, 1985, 1989)

The Rural Health Program was conceived for dispersed rural population groups that live isolated from population centers and that are less protected by health services and other services provided by the Costa Rican government. Three or four years after its inception, the program covered more than 80% of the target population, i.e., one-third of the total Costa Rican population.

The rural health model developed incorporated several elements of the malaria control program. New staff were rapidly trained to carry out the specific tasks required by the health program in the rural areas. Functions were designed to control the principal diseases and health risk factors of the target population. An outstanding feature of the Costa Rican Rural Health Program was the home visits by the health staff. No matter how isolated a home was, it was visited three or four times a year.

Through the home visit strategy, the health staff was able to identify and modify the main environmental problems, as well as to develop an ongoing sanitary health and nutrition education process for the family. By designing specific activities, having an adequate selection of equipment and supplies, and careful programming and supervision, program staff were able to identify dearly resources needed and program costs for each health area. Because of this, the program expanded rapidly and adequate financial resources were provided.

All of the experiences obtained during three years of the Rural Health Program, together with the observation that the program had a positive impact on the health conditions of rural populations, led to the political decision to implement a similar program for deprived urban groups. The new program expanded rapidly to most populous centers as well as to provincial and county capitals. In this manner, a greater impact on the health status of the whole population was achieved.

The nutritional situation of the Costa Rican population was evaluated in the mid-1960s. At that time, a severe protein and calorie deficiency, particularly among children, was detected. Other specific nutrition problems, such as iodine, iron, vitamin A, folic acid, and fluoride deficiencies, were also identified. Most children showed some degree of stunting. The fact that diets were deficient in these key elements and that intestinal infections and parasites were highly prevalent contributed to the deterioration of the already weakened nutritional status of the population.

The first programs to deliver foodstuffs, provide food education, and promote small-scale family food production were started in the 1950s. During the mid-1970s, they were expanded rapidly to rural communities. Additionally, the iodization of common salt and the fortification of sugar with vitamin A were established at that time. The main activities of the rural and urban health programs included the control and prevention of vaccine-preventable diseases (measles, polio, whooping cough, tetanus, diphtheria, and tuberculosis) and the prevention and treatment of intestinal parasitic diseases. These activities, in conjunction with other health measures targeting high-risk population groups, contributed to a dramatic improvement in the health status of Costa Ricans, especially the youngest generations. Complementary feeding programs were extended to the most vulnerable.

Several factors, during the 1970s, unrelated to the health sphere certainly favored the extraordinary impact achieved on health indicators by the end of that decade. According to L. Rosero (1984), at least 40% of the changes observed can be explained by the primary health actions undertaken. It must also be borne in mind, however, that these dramatic changes occurred in a very short period of time after the profound health reforms were instituted.

Health and nutrition programs for rural communities and deprived urban population groups have had the political and financial support of different governments in Costa Rica during the last two decades. Recently, however, programs deteriorated progressively. In 1995 they are emerging from a severe crisis. Insufficient supplies and transportation, a shortage of supervision, and the lack of training for new personnel to replace staff or to open up new areas are some of the major constraints on the nutrition and health programs. As a result the rate of improvement in health statistics has declined, but the gains have not been reversed.

This deterioration is related to the restructuring process of the Costa Rican government, including the health sector, which began in 1990 as a result of the external debt crisis. One premise of the restructuring process is that all human health care programs should be the responsibility of and managed by the Costa Rican Social Security Institute (CCSS). In the framework of primary health care, the model encouraged by the CCSS contemplates integrated care to individuals, families, and communities, the delimitation of geographic areas with 600 to 700 families, and the establishment of basic teams for integrated health care (EBAIS). The EBAIS are made up of a general practitioner or family physician, a nurse's aide, and a primary health care assistant. In other words, the model that already existed in urban and rural communities was reinforced by the permanent presence of a physician. Approximately one thousand EBAIS are needed in Costa Rica. At present, the new model proposed by the CCSS is being successfully implemented in a number of areas. As the economic situation improves and the government's commitments to health are renewed, it is hoped that Costa Rica's health progress will continue.