|The Nutrition and Health Transition of Democratic Costa Rica (INFDC, 1995, 228 p.)|
|1. Health policies and strategies|
Dr. Edgar Mohs
He who is healthy has hope;
and he who has hope has everything.
- Arab saying
Costa Rica was discovered by Christopher Columbus in 1502; it became politically independent in 1821, and started its life as a republic in 1825. The first heads of government were school teachers. The Costa Rican territory has an area of 51,100 km² and is located on the isthmus of Central America (Figure 1). In 1992, it had approximately 3 million inhabitants, mostly whites and mestizos; other races represent less than 5% of the population and show a strong trend towards integrating with the rest. Around 10% of the total population consists of immigrants and Central and South American refugees.
The Costa Rican economy is based on agricultural products, such as coffee, bananas, sugar, and meat. A light industry has emerged in the past 20 years, and tourism has been developing recently. The country is known for having a well-established Western democratic political system, which has been interrupted only twice in the last 100 years. All governments have stressed education and health, which has resulted in a literacy rate of less than 10% and one of the lowest overall mortality rates in the world. Thanks to the convergence of these factors and the historical evolution of the country, Costa Ricans share a strong spirit of solidarity and a deep respect for law, social justice, and freedom. The constitutional abolishment of the army in 1949 made possible a further increase in social sector investment. Law enforcement and security were turned over to a civilian police force, which comes under the Supreme Electoral Tribunal during election periods and changes every four years with the government.
In the 1970s, there was a sharp increase in the country's commitment to making health services available to everyone. This emphasis on investment in health is another feature that distinguishes Costa Rica.
Table 1 presents some milestones of Costa Rican history.
The development of public health in Costa Rica took place in four main phases:
· First phase (1850-1900): characterized by isolated efforts to provide basic health care, especially to needy groups.
· Second phase (1900-1940): characterized by the introduction of health programs and the expansion of a welfare concept to assist poor groups; creation of the Ministry of Public Health.
· Third phase (1940-1970): appearance of a pronounced interest in preventive medicine; attempts to establish a National Hospital System; creation of the Costa Rican Social Security Institute (CCSS).
· Fourth phase (1970- ): a National Health Plan was drafted and implemented in the 1970s to provide health care to the whole population and to control or eradicate malnutrition and common infections.
TABLE 1. Milestones of Costa Rican History
Discovery of Costa Rica by Christopher Columbus
Abolition of slavery
Political independence from Spain 1821
Establishment of first university
Universal compulsory primary school
Abolition of death penalty
Coeducational secondary education
Creation of the Ministry of Public Health
Eradication of smallpox
Constituent law of the Costa Rican Social Security Institute
Abolition of the army
Eradication of yellow fever
Universal Social Security
Eradication of poliomyelitis
Eradication of diphtheria
Active and permanent neutrality
The National Health System was consolidated in the 1980s. In the same decade, new health care models were initiated and the integration of the Ministry of Health and the CCSS progressed; new programs for the prevention of chronic diseases were started.
1850-1900: Basic Care Medicine
From pre-Columbian times up to the seventeenth century, the practice of medicine was in the hands of native healers. When the Spaniards arrived in the Americas, however, these practices were combated and the so-called witch doctors were persecuted. In 1790, Esteban Corti, who graduated in Europe, became the first physician to come to Costa Rica. He was soon accused of practicing witchcraft and sent to Guatemala, where he was judged by the Inquisition.
Some of the oldest pieces of health legislation in the country are the Decrees dated duly 3 and September 29, 1845, which established the San Juan de Dios Hospital and the First Charity Board, respectively.
The Constitutional Congress of the Republic issued Decree No. 69 on July 12, 1852, to allow further functioning of the San Juan de Dios Hospital, which was facing serious setbacks, particularly of a financial nature. Later on, a psychiatric center was planned for the mentally ill who at that time had no place to go and were mistreated and misunderstood by the people. Decree No. 24 allocated funds for the construction of the mental institution. Subsequently, the Bureau for the Promotion of the National Lottery, under the administration of the Charity Board, also contributed to the mental center. (The Charity Board was later called the Board for the Social Protection of San Jos
1900-1940: Public Health and Welfare
During the first decades of this century, several laws, regulations, executive decrees, and general resolutions were adopted on issues related to public health. In the beginning, they were isolated efforts without appropriate coordination. As time went by, an organic infrastructure independent management were achieved that responded to the ideals of improving the health situation. As can be seen in the following public health legislation, avant-garde health criteria inspired the political decisions at the time.
The Decree dated September 1, 1914, created the Public School Hygiene Department to protect the health of children between 7 and 14 years of age. The Department hired the first school hygiene assistants trained in the country. It was in charge of medical, dental, and ophthalmological school clinics. It also took care of hygiene in schools and summer school camps, the latter created in 1920 to shelter temporarily abandoned children or orphans.
Subsequently, legislation for the prevention and treatment of public health problems was enacted and gradually expanded. It approached problems as varied as tuberculosis, malaria, venereal diseases, smallpox, leprosy, yellow fever, typhoid, and narcotics abuse. The first steps toward setting up a vital statistics system were also taken. The first prenatal and child medical clinics, considered the foundation of public health because of the protection they provide to human beings from conception onwards, were established in 1920.
Undersecretary's Office for Hygiene and Public Health
The Undersecretary's Office for Hygiene and Public Health, attached to the Police Secretariat, was created on July 12, 1922, to overcome prevailing lack of unity in the management of all health activities, the degree and nature of the health problems, the abundant accumulation of health legislation, the incorporation into the health field of a large number of physicians and other professionals and technicians, and the training of health staff and other professionals. (Many years later, the Undersecretary's Office became the present Ministry of Health.)
Law No. 52 on Public Health Protection, enacted on March 12, 1923, was an important complement to this organic restructuring. It recognized national health as a government obligation and local health as a municipal responsibility.
To comply with all the provisions of this law, it was essential to have trained staff, and therefore efforts were concentrated on this goal. In 1924 the School for Health Inspectors was created, and in 1926 the role of the school assistant for health was redefined.
In 1927 the lack of school assistants for health resulted in the school assignment of nurses graduating from the Faculty of Medicine and the Max Peralta Hospital of Cartago, that offered a three-month practical apprenticeship in the School and Children's Clinic of San Jos
At the same time, these training institutions incorporated courses on puericulture and school hygiene into the nurses' study plan. The same 1927 law created the category Social Worker to Combat Tuberculosis, and in 1928 another law created the first employment for obstetric nurses to compensate for the lack of physicians in villages.
All tasks previously assigned to the Welfare Secretariat under the Office of Foreign Affairs were transferred to the Office of the Undersecretary for Hygiene and Public Health. These tasks were related to hospitals, lazarettos, shelters, maternity homes, and child protection institutions. Strengthened in this manner, the Office of the Undersecretary became the Secretariat for Public Health and Social Protection through Law No. 24, dated June 4, 1927. This gave the new Secretariat the political authority and consequently, the support necessary for the projects submitted to the Congress of the Republic.
The profession of Official Physician was created in 1931, replacing the profession of Village Physician. Official Physicians had broader functions based on work criteria of social protection and well-being of the community and not just treatment and charity. The position of Director of Health Units was created in 1936 with qualifications similar to those of Official Physicians: health directors, coroners, school physicians, and those responsible for assisting the needy and taking care of work accidents.
Another significant law was Executive Decree No. 5 dated October 8, 1935, which repealed the Decree creating the Charity Brotherhood for the Limospital and replaced the Charity Board with the Board for Social Assistance. The Decree shows how the "charity" concept which had prevailed for such a long time began to change into social protection with the participation of the government.
National Insurance Institute
Originally, this autonomous government institution, created by Law No. 12 dated October 30, 1924, was called the National Insurance Bank. It represents the culmination of an interesting chapter of our history, which goes back to the nineteenth century.
Before 1924, all insurance was in the hands of foreign companies. At the beginning of this century, insurance was necessary because of the industrial and commercial boom; businessmen, for example, were investing tremendously in imported goods and had to protect them. This gave rise to a plague of arson as some businessmen set their businesses on fire to collect the insurance, endangering property and life. It became necessary to regulate the relationships between the insurance companies and the insured and to stop the flight of foreign exchange. It should be noted that the creation of the National Insurance Bank was closely linked to the attempt to legislate on the responsibility of employers for work accidents.
Even though the law proposing disability protection and workmen's compensation as responsibilities of the employer was drafted in 1907, it took years to finalize and was finally enacted in 1925. The year following its establishment, the National Insurance Bank assumed the whole responsibility for the fire fighters. Only in this manner could a certain level of security for citizens be guaranteed and bank losses minimized.
The National Insurance Bank started offering life insurance in 1925. In 1926 it monopolized fire and work accident insurance. Progressively, the Bank took over other insurance, such as fidelity bonds to cover the risk of losing money and other securities, motor vehicle insurance in 1943, and crop insurance in 1969. In 1940 it was authorized to grant construction loans accepting life insurance policies as security.
As of 1948, the National Insurance Bank became known as the National Insurance Institute. At present it is governed by a Board of Directors and an Executive President appointed by the Government Council.
1940-1970: Institutionalized Preventive Medicine
This period includes the creation of the National Hospital System and the Costa Rican Social Security Institute.
Consolidation of the Ministry of Health
The implementation of preventive medicine requires a solid health organization, as well as excellent intra- and interinstitutional coordination. The final consequence of several measures taken in these decades was the progressive strengthening of the Health Secretariat: different departments or divisions were created or reorganized, international cooperation was channeled, structural changes were made, and better financing was arranged. Some of these measures, as discussed below, were important for many health achievements of the country.
The first General Regulations on Foundations and Boards for Social Protection were promulgated May 20, 1941, giving these social entities public status. At the same time, it entrusted them with the administration of hospitals, homes, cemeteries, and other centers, the technical direction and economic supervision coming under the Directorate General of Medical and Social Assistance. Health centers, also operating under the administration of these Boards, were supported to a large extent by governmental subsidies, the Charity Tax, and the National Lottery.
The first Health Code was published December 18, 1943, according to Law No. 33, which repealed Law No. 52 on Public Health Protection of 1923. The 1943 Health Code summarized the abundant legislation passed throughout the years and the ample experience on health aspects. The Code also made reference to the organic structuring of the Health Secretariat, and to local and international health standards and controls.
Another important law, passed in 1950, was the General Medical-Social Assistance Law. It created the Directorate General of Medical-Social Assistance, which, with the aid provided by the Technical Council on Medical and Social Assistance, an advisory body created by the same law, had the following functions:
· Coordination of all medical assistance and social protection institutions.
· Provision of technical and financial management and of the above public centers.
· Technical supervision of privately owned analogous institutions.
The General Medical-Social Assistance law called for a modification of the distribution of funds from the National Lottery and, years later, the General Regulations for National Hospitals were promulgated.
At the end of the 1940s, the Health Secretariat changed its name to the Ministry of Health with three directorates: the Health Directorate, in charge of all tasks related to public health; the General Directorate of Medical-Social Assistance, responsible for all medical assistance institutions; and the Administrative Directorate.
The Costa Rican Social Security Institute
Law No. 13 of 1926 classified snakebites as an occupational disease of farm workers and could thus be considered the first harbinger of today's Costa Rican Social Security Institute. In this sense, other laws that also heralded Social Security were Executive Decrees No. 2, dated July and November 8, 1935, which regulated Law No. 30 of December 1934 on hospital admissions of banana industry workers and the utilization of the 1% withholding on banana sales specified by the law.
The Law on Compulsory Social Insurance was enacted in 1941. On July 7, 1943, Law No. 24 came into effect, thus incorporating Section III "On Social Guarantees" into the Political Constitution, whose Article 63 provides for
... the establishment of social insurance, regulated by the compulsory contribution system by the government, employers and employees, for the benefit of laborers and intellectual workers, to protect these against the risks of disease, maternity, disability, old age, and death, and other contingencies determined by the Law. The administration of the insurance would be entrusted to an autonomous institution called Costa Rican Social Security Institute.
The Constitutive Law of the Costa Rican Social Security Institute was issued on October 22, 1943.
As of September 1, 1942, the Illness and Maternity Program was gradually implemented. Initially, it was limited to the economically active group of the metropolitan urban area and provincial capitals with higher population density. It was quoted on the basis of 400.00 colones per month and it covered only directly insured persons. From 1944 to 1947, when the rural population was included and family insurance was established, its coverage was expanded to the Central Valley. The Disabled, Elderly, and Death initiative came into effect on January 1, 1947, to give compulsory protection to wage earners.
At the end of the 1950s, the Illness and Maternity Program covered 27% of the economically active population and 18% of the total population of the country, while the Disabled, Elderly, and Death initiative covered 8% of the economically active population and 7% of the total population.
Through Law No. 2738, the obligation of universalizing all insurance under its responsibility, including family protection in the Illness and Maternity Program, within a time frame not to exceed 10 years, was imposed on the Costa Rican Social Security Institute by the Legislative Assembly. This goal, however, was not achieved. At the end of the 1960s, only 38% of the economically active population, 45% of the total population of the country, and 60% of wage earners were protected by the Illness and Maternity Program, while only 24% of the economically active population and 28% of the total population were covered by the Disabled, Elderly, and Death initiative. Family protection in the metropolitan area only materialized in 1965.
Law No. 4750 reformed Article No. 3 of the Social Security Constitutive Law, thus eliminating contribution ceilings for the Illness and Maternity Program. This measure was the manifestation of the political decision to expedite the insurance universalization process.
At the end of the 1970s, the Illness and Maternity Program already covered 84.3% of the total population (2,162,080 inhabitants), and the Disabled, Elderly, and Death initiative covered 17.6%.
Costa Rican Aqueduct and Sewerage Institute
During the first part of the colonial period, the city of San Josas a small and very poor town with a serious water supply problem. The water problems were the result of remote water sources, topographic conditions, dense forests nearby, and the poverty of San Jos inhabitants. Wells were initially dug. Subsequently, an 8-km ditch was dug, which ran along First Avenue and, once it reached the corner of the present National Bank, turned to the north to flow into the Torres River.
The land for the Aranjuez water tanks was bought in 1866. It was not until 1968 that the water pipeline was inaugurated and its management turned over to the Municipality.
As time went by, other aqueducts were built in the urban areas. They were not, however, a response to established national priorities but were the result of municipal initiatives with municipal funds and, in only a few instances, by the Ministry of Health.
The first steps to control water quality in Costa Rica were taken in the 1940s, in a small laboratory installed for the Tres Rios Water Treatment Plant, administered by the Municipality of San JosThe water laboratory of the Ministry of Public Health (its name at that time) started doing bacteriological and physical-chemical water analyses in 1951. Water chlorination started in 1952 at the Tres Rios Water Treatment Plant; the process was a failure, because the necessary technical and economic resources were lacking.
The fact that financial and technical resources were scarce and that the water service was scattered made it impossible to coordinate the use of hydrographic sources on more rational terms and to standardize the water treatment and quality control to guarantee water potability. As a result of this situation, the National Service of Aqueducts and Sewerage was created on April 14, 1961, by Law No. 2726.
In 1976, its name was changed to the Costa Rican Institute of Aqueducts and Sewerage by Law No. 5915. It is a public and autonomous entity in charge of solving all problems related to the drinking water supply and to the collection and assessment of sewage and liquid industrial wastes. It is also in charge of standardizing storm water sewers in urban areas.
The year 1970 was a critical one for the health transition in Costa Rica. The National Health System was established to provide health coverage of the total Costa Rican population, and to control the most common infectious diseases, and eliminate child malnutrition. In the early 1970s, the Ministry of Health did exhaustive research with a view of assessing the population's health status, the availability and productivity of the existing human and physical resources, and the degree of integration and coordination of the health services. Thus, the Ministry of Health established the premises for the provision of health services (see Table 2) and, after having made a national health diagnosis, formulated the National Health Plan for the decade 1971-1980. For the purpose of achieving the new objectives, the Ministry also proceeded to make several important political decisions that are discussed later.
According to our own classification of the development of Health Sector institutions, the fourth stage started in 1970 with the formulation of a National Health Plan.
TABLE 2. Premises for the Provision of Health Services
· Health care is a right of the population and the government has the responsibility to organize it properly.
· Health services should be integrated and cover disease prevention, cure, and rehabilitation.
· Health services should be organized according to regions and sectors in order to expand health coverage and improve the supply of local health care.
· Priority should be assigned to good outpatient health care provided in a well-organized outpatient clinic.
· Training of human resources at the professional, technical, and auxiliary level should be widely promoted, as well as ongoing education, in-service training, and research on medical and administrative problems.
· Service costs should be in agreement with the economic capabilities of the country
Although several institutions participated in the preparation of the National Health Plan, the Ministry of Health and the Costa Rican Social Security Institute assumed a greater responsibility. As already mentioned, the goals of the Plan were to provide health services to the Costa Rican population as a whole through the reorganization of the health sector and the establishment of a National Health System, to facilitate the eradication or control of common infectious diseases and the drastic reduction of malnutrition. Some of the specific goals established by the Plan were the following:
· To increase life expectancy by eight years.
· To decrease infant mortality by 50%.
· To decrease the prevalence of endemic goiter to less than 10%.
· To supply potable water to 100% of the urban population and 70% of the rural population.
A number of political decisions had to be made in order to achieve the stated specific goals of the Plan, as well as its general ends. Thus, several remarkable laws were passed and a rural health program was created.
We now discuss the main characteristics of these laws.
Principal Legal Measures
· Law No. 5349 on the Transfer of Hospitals to the Costa Rican Social Security Institute: its purpose was to universalize Social Security, and thereby ensure that all the people enjoyed medical services of good quality.
· Law No. 5395, also known as General Law on Health. It replaced the 1949 Health Code and clearly defined the relationships among the government, individuals, and businesses. It incorporated a series of compulsory principles concerning individual and community health, oriented towards the achievement of the best possible health status. It made the Ministry of Health responsible for the definition of national policies on planning, coordination, and control of health-related public and private activities.
· Law No. 5412 or Organic Law of the Ministry. It decreed that from then on, the Ministry should be called the Ministry of Health. It provided for the internal restructuring of its agencies. The Directorate General of Health and the Directorate General of Assistance became a single unit under the name Directorate General of Health. The Technical Council for Medical-Social Assistance was attached to the Minister's Office, and its functions were limited to collecting and distributing funds allocated to care for patients insured by the government (until then known as indigents). Advisory bodies, such as the National Health Council and the Sectoral Planning Unit, were also created at this time.
An important additional component of the National Health Plan was the creation of the Rural Health Program and the substantial strengthening of programs for environmental sanitation, clean drinking water, immunizations, and nutrition.
Reorganization of the Social Security Institute
As we have already seen, several important decisions were required to reorganize the Health Sector according to the National Health Plan. The most important element relating to the Social Security Institute was the transferral, according to Law No. 5349, to the Costa Rican Social Security Institute of all hospitals managed by Boards and Foundations for Social Protection. Article 2 of this Law refers to the compulsory care to be provided by the Costa Rican Social Security Institute, at the government's expense, to persons without insurance and unable to pay for medical services, a group known as Persons Insured by the government.
Article 6 of Law No. 5349 states that all health care actions related to preventive medicine that are not legally assigned to the Costa Rican Social Security Institute come under the responsibility of the Ministry of Health.
Article 7 states that all revenues or income of any kind received by institutions of the Ministry of Health, the Boards of Social Protection, or the Foundations are to be transferred to the Costa Rican Social Security Institute, with the provision that if the funds are insufficient, the government will establish specific revenues for the complete payment of the health care provided to its insured persons.
Article 8 of the same Law declared that it is national policy and supercedes all prior legal provisions insofar as these are opposed to it.
Law No. 5541 complements Law No. 5349 and defines the working conditions of people employed in centers that would be transferred to the Costa Rican Social Security Institute.
Other essential actions required by the Costa Rican Social Security Institute with a view to structural readjustment and internal organization were based on the following:
· Executive Decree No. 6919, dated April 4, 1977, established the National Committee on Human Resources, whose main goal was to determine the need for medical professionals in the coming years.
· The 1979 Executive Decree No. 10653-P-OP ordered the division of the national territory into five regions for the purpose of investigating and planning socioeconomic development.
· The Board of Directors of the Costa Rican Social Security Institute, on June 7, 1978, agreed on the internal organic restructuring of the medical services it provided, including measures of decentralization to the Regional Health Directorates.
· The 1978 Executive Decree No. 9283-P created the System for Administrative Reforms as a component of the National Planning System for the fundamental purpose of achieving efficiency and productivity in the Public Administration.
· The 1979 Executive Decree No. 109157P-OP created the Subsystem for Regional and Urban Planning and Coordination to orient and coordinate governmental actions at the regional level and to balance the development of the different regions.
The above-mentioned Subsystem is part of the National Planning System.
On July 15, 1978, the Board of Directors of the Costa Rican Social Security Institute created the Coordinating Council for Medical Services and resolved to divide the national territory into five program regions, matching the regionalization process referred to in Executive Decree No. 10653-P-OP. The regions thus created were Northwestern, Western, Eastern, Central, Northern Huetar, Chorotega (Dry Pacific), Alantic Huetar, and Brunca (South Pacific).
The coordinating council initiated decentralized regional administration of coverage and collection of fees. Geographically this coincided with the regionalized medical services.
During the 1969 political campaign, Josigueres, the presidential candidate running for the National Liberation Party, proposed to expedite the social and economic development of the country and stressed that it was possible to eradicate extreme poverty in Costa Rica. When he became President of the Republic in May 1970, he and his cabinet immediately started to work towards his promised goals. President Figueres succeeded in motivating several of his collaborators and a substantial sector of the population; at the same time, he gave hope to the most needy sectors.
Figueres, probably aware that this would be his last chance to serve the country as President (he had been Chief of State in 1948-1949 and President in 1954-1958), decided to use his power and experience to give impetus to momentous transformations, particularly those with social content. The opposing political party (Conservative) and the Communist Party were rather skeptical about Figueres' statements, which they considered sometimes to be extravagant. In general terms, however, the President's thoughts were truly reformist, with a social democratic ideology adapted to the environment.
The group heading the Health Sector, imbued with the President's reformist ideas, knew that it had the President's total trust and support. Thus, it approached child health problems seriously and rapidly, since children were the most vulnerable and affected population group.
The Health Sector group set two general objectives:
· To break down economic barriers to universal medical care.
· To eradicate and control common infectious diseases, since they constituted another powerful barrier on the road to better health status.
A prerequisite to President Figueres' idea of eradicating extreme poverty was the establishment of mechanisms to improve gross national product redistribution and to increase production.
The first objective took the form of two institutions: the Mixed Institute for Social Assistance (IMAS) and the 1971 Social Development and Family Allowance Fund.
The Mixed Institute for Social Assistance created by Law No. 4760, dated May 8, 1971, had the following goals:
· To formulate and implement a national policy for social and human promotion among the most needy sectors of Costa Rican society.
· To lessen or eliminate the causes and effects of poverty.
· To transform social stimulation programs into a means to obtain, in the shortest possible time, the incorporation of marginal human groups into the economic and social activities of the country.
· To prepare the indigent sectors, in an appropriate and rapid manner, so that they can improve their capability to do remunerative work.
· To attend to the needs of social groups or persons who should be provided with means of subsistence when they lack these.
· To obtain the participation of the private sectors, as well as public, national, and foreign institutions specialized in these tasks, in the creation and development of all kinds of systems and programs oriented towards improving the cultural, social, and economic conditions of groups affected by poverty, and obtaining maximum participation of the groups themselves.
· To coordinate the national programs of the public and private sectors that have similar goals to those expressed in this law.
The main source of financing for IMAS is the 0. 5% monthly surcharge on ordinary and extraordinary wages and salaries paid by all enterprises registered with the National Institute of Learning, the Social Security Institute, or the Popular Bank.
Law Number 5662, the Law for Social Development and Family Allowances, was published in La Gaceta on December 18, 1971. It created a special fund, and a specific Directorate General to manage it, for GNP redistribution purposes, to foster social development and family allowances. Even though the fund was actually discussed during the Figueres government, it was created by President Daniel Oduber, who was in office from May 1974 to May 1978.
The objective of the Social Development and Family Allowances Fund was to promote and complete socioeconomic programs and services favoring low-income persons and families. This fund was managed by institutions such as the Ministry of Health (nutrition programs managed by School Committees and by local education and nutrition centers), the Mixed Institute for Social Assistance, the National Foundation for Children, the National Nutrition Clinic, the Institute for Agrarian Development, first known as the Institute of Land and Settlements, and the National Institute of Learning.
Twenty percent of the fund is used for capital formation, which finances the Noncontributory Pension program for a basic number of persons not entitled to benefits of contributory plans of the Costa Rican Social Security Institute either because they have not paid or because they have not completed the required number of contributions. The law specifies that this money be remitted to the Costa Rican Social Security Institute, which administers the Noncontributory Pension program along with the Disabled, Elderly, and Death initiative.
The fund also gives loans either in cash or as family allowances to low-income workers with handicapped children or children under 18 years of age, or children between 18 and 25 years of age, as long as they study at an institution of higher learning.
The fund is derived from the Reform to the Sales Tax Law No. 3914 dated July 17, 1967, and its amendments, as well as from a 5% surcharge on the total amount of wages and salaries paid monthly by public and private employers, with legally specified exceptions. The exceptional fact that in Costa Rica the same political party, the National Liberation Party (social democratic), won two consecutive elections allowed the momentous reform in the social sector to continue eight years after its inception in 1970. This time frame allowed the reform's goals to be achieved and the political and technical process to be perfected. It was then followed by the ambitious project contained in the National Health Plan.
When he became President in 1978, President Oduber endorsed the programs started in 1970 by energetically strengthening them vigorously with political support and financial resources.
In addition to President Oduber's strong leadership, the dramatic results achieved in the health field in such a short amount of-time probably contributed to the political will needed to maintain reformation of the health sector for eight consecutive years. In view of the deep-rooted assumption in our country that health improvements require long latency periods, it was an unexpected and most important finding to have concrete results after a few years. Through this experience we became aware that political sponsorship is important in the initial phases of the program, but it was the impressive results that provided a fundamental feedback and served to stimulate and activate both the health staff end the population, giving them a certain degree of vital autonomy within the framework of the existing natural interdependency. After many years of disappointment and apathy, the staff accelerated health progress with positive and enthusiastic attitudes.
The Role Played by Pressure Groups
During the 1970s, particularly in the first part of the decade, the different Costa Rican pressure groups played a very limited role in the life of the country. Although associations for community development were aware of their immediate needs, they did not have a clear idea of actions to be implemented in order to satisfy those needs. This explains, on the one hand, their surprise and astonishment at the different initiatives started by the Ministry of Health and, on the other hand, their timid support of health initiatives.
The professional associations were belligerent in opposing the Ministry of Health. Arguing that the utilization of auxiliary staff to expand health service coverage was an attempt on the lives of those receiving these services, they clearly stated their opposition to the Rural Health Program. These associations defended the principle that health care should be in the hands of fully qualified physicians and nurses. Unfortunately, at that time they were not aware that a health system reaching all inhabitants implies the development of primary health care which operates with auxiliary staff, guided by defined standards and under professional supervision.
Even the Costa Rican Association of Public Health Specialists expressed its total disagreement with the Rural Health Program. Nevertheless, the firmness of the Ministry of Health in promoting the changes and its repeated explanations of the program in conferences, round tables, and bulletins neutralized the statements of the opposing groups. The activities were first implemented in San Ramheaded by Dr. Juan Guillermo Ortiz, and in zones affected by malaria. The health staff was especially trained to assume their new tasks, which targeted health problems considered to be a priority as of that moment.
Another important decision, which started heated discussions, was the reorganization of hospital management. It implied the transfer of all hospitals to the Costa Rican Social Security Institute and, therefore, the elimination of Boards and Foundations for Social Protection. The members of these organizations and some media opposed the decision, arguing that Social Security universalization was uncontrollable and, hence, could overlook the indigents. High-ranking officials from the Costa Rican Social Security Institute, aware that this attitude could ruin their institution, were very much concerned.
Law No. 2738 of 1961 established the compulsory universalization of Social Security within a time frame no longer than 10 years. Several Costa Rican Social Security officials interpreted this law as implying universalization of obligatory insurance only, i.e., covering wage earners and not the non-wage-earning population. After many discussions and negotiations, the Ministry of Health and the Costa Rican Social Security Institute reached an agreement in which representatives of the Legislative Assembly from the National Liberation Party and the Second Vice President of the Republic, Dr. Manuel Aguilar Bonilla, participated.
Another hindrance to the project was the opposition stated by highest authorities of the Pan American Health Organization, who exerted tremendous pressure on the Minister of Health and the President of the Republic to withdraw the law. Both the President and the Minister listened to all arguments against the project but, nevertheless, supported the national technicians who implemented it. As of 1974, President Oduber, VicePresident Dr. Carlos Manuel Castillo, and the Minister of Health developed the Family Allowances Program quickly. Furthermore, in the health sector they gave a significant momentum to the reform project, which allowed the active participation of organized communities, particularly in the rural areas. The population changed its traditional demand for education services to a demand for health services, once it discovered the feasibility of obtaining them in the short term and at a reasonable cost.
Within the health sector, other outstanding laws were passed during this agitated period: Laws No. 4750, 5395, and 5412. Law No. 4750, dated March 30, 1971, made Social Security contributions, calculated over total individual remunerations, compulsory. Law No. 5395, dated November 24, 1973, the General Health Law, replaced the 1949 Sanitary Code. Law No. 5412, dated January 18, 1974, the Organic Law of the Ministry of Health, reorganized and updated the Ministry, thus providing it with the necessary conditions to play a leading role in the health sector. These three laws were not as controversial as others discussed before.
In retrospect, it is worth noting that throughout this major health reform, a traditionally Costa Rican trait was illustrated: to change progressively with the goal of achieving well-being for all of the population, but acting within the legal framework and seeking consensus through conviction rather than though force or brutal actions.
It is pleasing to note that the health reform led to dramatic improvements in the health status of the population in such a short time, an achievement that previously had been considered absolutely impossible.
In 1980, only 10 years after initiation of the Figueres health reforms, the general mortality rate in Costa Rica dropped to 4.1/1,000 and infant mortality had fallen to 20/1,000. Morbidity and mortality were associated with chronic diseases in adults as well as in children. It was generally felt, at this time, that the country had reached its limit of achievement in the health area.
At this time, one of the most severe economic crises of the century hit the country: the Costa Rican colon was devalued by 600%, inflation increased by 100%, foreign exchange reserves were exhausted, unemployment reached 10%, and the fiscal deficit was 14% of the gross domestic product.
The First Part of the 1980s
The future for the health sector seemed ominous. People started to note the deterioration of key sanitary and medical assistance programs. All international experts visiting Costa Rica agreed that the country would not be able to maintain the health services intact; therefore, morbidity and mortality, particularly due to infectious disease and nutritional deficiencies, would increase.
During the second part of the 1970s, the country's health outlays reached the impressive figure of 10% of the gross domestic product, dropping to 7% in the first part of the 1980s. Thus investments, machinery, and common supplies were drastically curtailed.
The economic crisis suddenly impoverished a vast sector of the population. At the same time, it substantially decreased budgets financing operating costs of different public health, environmental, and preventive medicine programs.
A great fear arose among the people, because it seemed as though the gains achieved during the 1970s would be lost, and infectious diseases and malnutrition - problems of misery and underdevelopment - would ravage the country once more. Common health supplies became scarce; health service users and health staff started complaining about the management of the institutions providing health services.
The economic and financial crisis was compounded by a severe problem of immigration from the Central American countries, mainly made up of indigents, illiterates, and sick people. The very poor population of the country increased not only as a result of the underlying economic problem but also because of the large number of indigent immigrants. Health problems that had been eliminated or controlled in Costa Rica returned to the country with the immigrants, thus worsening the general situation.
There was an increase in the incidence of malaria, tuberculosis, scabies, malnutrition, some parasitic diseases, and certain vaccine preventable infections. A slight increase in the mortality rates associated with some of these conditions was also observed.
The large negative impact on health in Latin America, predicted by some national and international groups because of the economic crisis, did not occur in Costa Rica because of the success achieved by a health infrastructure and health services, that was accessible to all of its people, developed during the 1970s. Even though it suffered some deterioration it functioned well during the crisis and served the population with limited resources from a real catastrophe that would have incited disorder in the country. This tested the National Health System and demonstrated its value.
In the mid-1980s, the country reacted vigorously and partially solved its economic problems. Tranquillity replaced fear, and trust was reborn. A structural adjustment program stimulated exports. The health sector intensified its actions directed toward protection of the most needy and improvement of the coordination among institutions of the health system.
Impact on Health
It is noteworthy that the turmoil of the early 1980s was not significantly reflected in infant mortality which rates remained stationary. In 1982, however, coinciding with the economic crisis, infant mortality rates due to diarrhea showed a slight transient increase, which disappeared the following year.
In summary, the economic crisis had only a minimal impact on the health situation in Costa Rica, and this was rapidly corrected. In fact, the immediate and effective reaction of the health sector solved a problem that could have become a serious obstacle to the country's development. This response demonstrated the capacity of the National Health System and the capacity of its three basic levels, and its different institutions.
On the other hand, there is no doubt that communities and individuals were organized better and contributed directly to minimizing the predicted negative impact on the health sector. As discussed in the following, the crisis was actually helpful, because it allowed the implementation of clear and decisive adjustments which, in spite of budgetary curtailments, rapidly led to a strong positive impact despite the budget cuts. Throughout the last decade, there was no correlation between per capita income and infant mortality.
The Later Part of the 1980s
The economic crisis taught us the need to review and transform the structure and functioning of the public sector to make it more solid, efficient, and modern. It brought into the open problems of scale, competence, and technical weakness, as well as the organizational obsolescence of several institutions and concepts. Through the crisis, we became aware that the government had to become smaller and more efficient, and improve its management of resources and knowledge. The theory of systems, including the principle of complementarily between the public and private sectors, also gained ground.
After having overcome the results of the earthquake during the early 1980s, we committed ourselves to the restructuring and consolidation of a universal decentralized National Health System, based on primary health care programs, with marked involvement of the organized community. Several decrees and resolutions firmly established a truly integrated system of health services which did away with the contradictions and mistaken interpretations of the past. The new health system also opened the door to a deluge of innovations which greatly improved the quantity and quality of the health services, in spite of budgetary curtailments.
The experiences of the latter part of the 1980s showed the presence of three actors in the crisis: economic depression, massive immigration of Central Americans, and an obsolete government structure needing changes. To change it, we realized that the public sector could achieve more with less money, and that broad unifying bridges between the private and public sectors should be built. The only responsible response could be deep reflection followed by obstinate actions to renew the National Health System to make it more dynamic.
As the crisis began, the people who had never believed in Costa Rica from the beginning now loudly proclaimed that at last the country would sink. Their ominous predictions were mere wishful thinking. Those of us who believed in Costa Rica, however, always contended that the crisis gave us an opportunity to review, change, and improve our country. History proved us right.
From 1986 to 1989, child mortality decreased by a further 25%, and severe malnutrition practically disappeared. The country remained free of poliomyelitis, diphtheria, human rabies, yellow fever, and dengue. Other conditions, such as xerophthalmia, scurvy, and pellagra, were no longer considered public health problems; maternal mortality, immunopreventable diseases, deaths related to food-borne disease, and the health problems aggravated by the massive immigration of Central Americans decreased by more than 50%. Moreover, between 1986 and 1989, deaths caused by traffic accidents decreased by 16%, and those caused by drowning decreased by 50%.
Child growth and development continued to improve; it was observed that 18- and 20-year-old young adults had increased in height. As compared to 1966 height data, men increased by 6 cm and women by 4.5 cm.
As a natural consequence of these changes, the Costa Rican general mortality rate dropped to 3.7/1,000, among the lowest in the world, and life expectancy increased to 76 years.
The Political Context
In the first part of the 1980s, the main struggle of the Costa Rican government was to save the National Health System and to protect the health status of the population in the severe economic crisis that affected the country. In the late 1980s, however, the main objective was to return to progress.
From the beginning, the idea of restructuring on pragmatic rather than ideological bases prevailed. In the public sector, the principles of efficiency, rationality, prioritization and complementarily, as well as the need to reduce the size of the government reached the National Health System.
During the 1985 political campaign, the desire for new qualitative progress on two fronts developed at the governmental level:
· Internationally, there was an effort to contribute to the Central American peace process in order to obtain the stability needed for development.
· Nationally, there was a commitment to modernizing the productive and social structures of the country, including the government; to improve the standard of living of the population groups most affected by recession (employment and housing); and to strengthening a process of participatory democracy.
As of 1986, the following fundamental objectives were established:
· Regarding public health, to improve the quality of the environment and to eradicate some parasitic disorders, and as many other infectious diseases as possible, and malnutrition. In preventive medicine, to consider the problems of women, children, and young adults, as well as the occupational health of adults as a priority; and to strengthen the programs for the elderly. Special attention was directed to the "Dental Health for Everyone" project.
· Regarding medical care, to foster the decentralization process of hospitals and clinics and to promote the participation of health staff, their organizations, and the communities themselves. Furthermore, to make a maximum effort to humanize the health services for the patient and to expand the program in mixed medicine.
· Regarding the Disabled, Elderly, and Death plan of the Costa Rican Social Security Institute, to generalize its benefits through appropriate financial provisions, following similar administrative steps as those taken for the Illness and Maternity Program. To establish an overall National Institute for Social Security, with the participation of all relevant institutions, and to support and foster policies on health for everyone on a more solid footing.
On the other hand, a National Health Policy was defined on the following terms:
· Health for everyone as a social goal and national and international commitment.
· The development of the National Health System and all of the institutions making up the Health Sector.
· The strengthening of the infrastructure of the health services.
· The consolidation of prior health gains; the tackling of new health problems and the implementation of new approaches within the framework of integrated care for the population.
· The participation of the community in all activities pertaining to the Health Service System.
· Give priority to providing health services to the:
· Prevention and control of communicable diseases.
· Prevention and control of chronic diseases.
· Mother and child health.
· Environmental health.
· Disaster and emergency preparations.
· Development of physical infrastructure.
From the 1970 experiences, we learned that in spite of economic limitations, progress was possible in the health field and time should not be wasted. In 1986, when I was appointed Minister of Health, we started to work hard on the following aspects:
Ministry of Health
· Health policy
· Health promotion
· Prevention of diseases and eradication of malnutrition and some infections
· Integration of Primary Health Care
· Definition of health areas
· Community participation
· Emphasis on the most vulnerable groups
· Development of technical and administrative subsystems
· Training and education at a distance
· Coordination and cooperation versus confrontation
· Paradigm of the chronic diseases
· Health education
· Stimulation of staff (recognition)
· Physical infrastructure
· Environmental sanitation
· Intelligence on epidemiology
National Health System
· Coordination with the Costa Rican Social Security Institute
· Universal coverage
· New forms of medical care
· Joint programming
· Integration of facilities and certain services
· Development of local health systems
· Aqueducts and sewage systems
· Labor and accident medicine
· Transformation of compulsory social services
· Involvement of the private sector
· Increased involvement of the municipalities
· Increased involvement of the communities
National Health Council
· Medium- and long-term planning
· Monitoring and assessment
· Political guidance
· Matching of regions and provinces
· Regulation and deregulation
· Scientific knowledge
· Data processing
I feel that since the 1980s, the following elements have contributed the most to improving the work of the Ministry of Health:
· The clear message of dedication conveyed to the health staff.
· The permanent and strong support given to primary health care programs.
· The decentralization of functions and authority of primary health care programs, with their integration at the local level; the strengthening of epidemiological surveillance, prenatal care, and environmental sanitation.
· Efficient budgetary outlays that allocate the limited monetary resources to the most needy counties, communities, and families.
I also sought the widest possible consensus on my ideas, concepts, and strategies and always took the initiative and accept full responsibility for my own actions.
Although academically trained and specialized staff are desirable, it is possible to achieve health advances without them. The Ministry of Health, nevertheless, was able to improve the figures on infectious problems and malnutrition substantially, to expand health coverage and the protection provided to mothers and children, and to ameliorate basic environmental sanitation and personal hygiene.
Contrary to what has been frequently stated, the contribution of pressure groups and labor organizations was very limited. Furthermore, the measures that have overcome the great national health problems of Costa Rica tended to meet with opposition from these groups. Similarly community participation, although, contributing more positively, has been weak and intermittent.
Defining clear policies, identifying the obstacles to achieving them, utilizing communication media to reach all personnel frequently with encouraging messages, and systematically monitoring key activities are all valuable means of mobilizing health works and the public in general and developing in them a mystique and faith that these efforts are worthwhile. When people are convinced that they have the strength to move forward and destroy enemies of health in their daily life, a Pygmalion-like phenomenon occurs. When people believe that it is impossible to advance, a generalized feeling of defeat, sterility of thought, and paralysis are immediately produced.
The accumulated heuristic experience of 20 years of thought and participation in practically all levels in the field of health have led me to formulate general theories of health that explain the evolution of health in Costa Rica. These range from the scientific advances that support the great change in whatever area of human health that are the result of changes in the interpretation of global reality, abandoning interpretations that proved erroneous and substituting others more valid in a process of continual formulation and reformulation.
Based on these concepts, we have recognized and described three stages in the last 50 years that explain the reasons and causes of the improvement in the health of Costa Ricans over this period. The capacity to change one approach to another was the key to making possible what appeared to be impossible. During the 1986 to 1989 period the goals for reducing infant mortality were first established (Table 3) and the necessary interventions to achieve these goals were identified (Table 4). Similar strategies were formulated for interventions to reduce mortality in children 1-4 years of age (Table 5). Similarly, for the prevention of malnutrition, infectious diseases, and chronic diseases analyses were done of the causes, the specific problems and desirable strategies. These included developing a philosophical basis and analyzing psychological attitudes to overcome. To change one paradigm for another is the key to making possible what seems impossible.
TABLE 3. Goals for the Improvement of Infant Health (1986-1990 Costa Rican Government)
· Decrease child mortality to 14/1,000
· Reduce undesired pregnancies by 50%
· Reduce endogamy by 50%
· Provide prenatal care to 100% of pregnant women
· Detect 100% of the high-risk pregnancies and refer them to a specialized center
· Improve quality of birth
· Decrease cesarean sections by 20%
· Decrease prematurity and low birth weight by 30%
· Decrease neonatal hypoxia by 50%
· Decrease incidence of hyaline membrane disease by 90%
· Decrease intracranial hemorrhages by 50%
· Decrease congenital malformations by 20%
· Monitor growth and development in 100% of the child population (use of Childrens' Health ID)
TABLE 4. Strategies and Interventions Identified to Achieve These Goals
· Improvement of family integration
· Promotion of optimal age for pregnancy
· Promotion of optimal birth spacing
· Universal prenatal care and classification of birth risks
· High-quality institutional birth
· Transportation system for the sick newborn
· Enrollment at home of the newborn into health programs
· Growth and development surveillance (Childrens' Health ID)
· Breast-feeding, iron supplements, and appropriate diets
· Introduction of new vaccines
· Primary and secondary health care of good quality and accessible to all. Excellent tertiary health care. Early detection of health problems
· Organization and active participation of the community
· Basic environmental sanitation
· Emphasis on eradication or control of infectious diseases and prevention or control of perinatal disorders and congenital malformations
· Educational health package promoting the elimination of certain harmful habits, as well as chronic disease and accident prevention
· Suitable housing
TABLE 5. Interventions to Reduce Mortality of Children 1 to 4 Years of Age
· Control of infectious diseases
· Eradication of severe intestinal parasites
· Appropriate nutrition to improve growth and development
· Control of accidents and poisonings
· Early detection of changes and illness
· Early stimulation of learning
· Prevention of abuse
· Establishment of kindergartens and child care centers
· Environmental safety
· Good quality primary and secondary education accessible to all. Availability of excellent tertiary education
· Introduction of a health education package that includes elimination of undesirable habits and prevention of chronic disease
· Introduction of new vaccine
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