The remarkable improvement in health and nutrition statistics in
Costa Rica from those of a developing country to those of industrialized
countries in a single decade in the 1970s is without precedent. In 1970 the
infant mortality rate in Costa Rica of 68 per 1,000 did not differ markedly from
that of other Central American Countries and, in common with these countries,
less than 10% of the health budget was allocated to preventive health measures
At the end of the decade the infant mortality rate had dropped
to 19.1 (World Development Report, 1993) and health posts emphasizing prevention
of communicable diseases, mother and child health, environmental sanitation, and
health education covered 84% of the total population. Moreover, it was done with
social harmony by the democratic government of a poor agricultural country that
resolved to devote more adequate resources to the social contract. Although the
improved economic circumstances of the 1970s helped to make a major increase in
support of the health sector possible, it was no greater than in the other
Central American countries that failed to utilize this opportunity. Today,
despite the structural adjustment crisis of the 1980s, its infant mortality rate
of 13.9 per 1,000 is the lowest on the mainland of Latin America and is as low
as that of some industrialized countries. It compares with a range of 48.4 to
71.8 for the other countries of Central America.
This book, written almost entirely by Costa Rican officials who
were intimately involved in this health revolution explores what was
accomplished, how it was done, and why it was done. It describes
the background and the astonishingly wide range of social initiatives taken by
the governments of the 1970s not only in the health sector but also in primary
and secondary education, technical colleges, the national university, distance
learning, the development of cooperatives, consumer protection measures, and
physical infrastructure improvement. It also analyzes the response of the health
system to the economic crisis of the 1980s and discusses its evolution and
sustainability. One point not emphasized in the text is that Costa Rica has
achieved the health transition with only an incomplete demographic transition.
The crude birth rate was 33 in 1970 and 27 in 1991 (World Development Report
1993). The impact that this has on current economic problems is scarcely
The first chapter by Dr. Edgar Mohs, Vice-Minister of Health
from 1975 to 1978, and Minister of Health from 1986 to 1990 recounts that when
Josigueres became president of Costa Rica in 1970, he and his cabinet
immediately started work toward their promised goal of eradicating extreme
poverty in Costa Rica. While increased productivity was seen as the means of
achieving this objective, it was approached by focusing on the health and
education sectors. Aware that, after two prior separated terms, this would be
his last chance to serve the country as president, Figueres used his power and
experience to give impetus to momentous social transformations. Costa Rica
became the only country in the Americas to abolish its armed forces and to do so
in order to devote more of its resources to social welfare and development.
Professional associations opposed the new plans for the health
sector, some arguing that a diversion of funds from curative to preventive
medicine would result in an increase in mortality. There was even strong
opposition from the officials of the regional office for the Americas of the
World Health Organization (PASB) to the transfer of all hospitals to the Social
Security Institute as noted by Mohs in Chapter 1. The decisions were taken and
implemented despite such opposition. The improvement, actually achieved in such
a short period of time, had been previously considered absolutely impossible.
Throughout, these major health reforms were achieved by acting within the legal
framework and by seeking consensus through conviction rather than by force.
In the 1980s the growing debt burden precipitated an economic
crisis which also seriously affected Costa Rica. The price of further support
from the International Monetary Fund and the World Bank was "structural
adjustment." One aspect of this was pressure to streamline social services and
eliminate or privatize many of them. Thus the first part of the 1980s was a
struggle to save the National Health System and to protect the health status of
the population during the severe economic crisis. Mohs describes how this was
achieved and states how by the late 1980s, while he was still Minister of
Health, the main objective was to return to progress. Carlos Mureturns to
this theme in Chapter 6.
The second chapter by Guido Miranda, Assistant Director of the
Costa Rican Social Security Institute from 1970 to 1978 and later Executive
President, describes the evolution of the social security system. Unlike the
pattern in other countries, it expanded from the initial traditional coverage of
the employees of large farms and industries to include first all members of
their families and then by the end of the 1970s virtually all of the population.
The transfer of all hospitals in the country to the Social Security Institute
was essentially complete by 1977. In this hemisphere only Cuba, with a
centralized economy, and Canada, which adopted a universal health insurance
plan, achieved similar population coverage.
A key factor in Costa Rica's success was its development of
primary health care and preventive medicine services that reached both rural and
urban communities. In Chapter 3 William Vargas, Director of the Preventive
Medicine Department of the Social Security Institute and of the Public Health
Department of the School of Medicine of the University of Costa Rica, explains
how primary health care was made an integral part of the social security
coverage. It was claimed that offering health services would lead to increased
usage and costs. For the medical care of children the opposite occurred.
Pediatric beds are now barely two-thirds those required in 1934 although the
child population has doubled.
The three initial chapters discuss the basis for the Costa Rican
health transition. Chapter 4 on the Evolution of the Epidemiological Profile by
Lenin Sz, Chairman of the Sectorial Planning Unit of the Ministry of Health,
describes the impact of the programs described in the previous chapters on
patterns of disease and death. The evidence for the rapid decrease in disease
associated with infection and malnutrition is presented in detail. However,
"health transition" in the title of this book has a double meaning. It can be
seen first and foremost as a change from the high morbidity and mortality due to
the synergism of malnutrition and infection, particularly during the early years
of life, characteristic of most developing countries, to the low rates of
industrialized countries. It is also a transition to the emergence of chronic
diseases associated with the dietary patterns of the more affluent countries.
One reason for this is that as mortality associated with
nutritional deficiency and infectious diseases decreases, that due to chronic
diseases becomes a relatively more important part of the total mortality.
Another is an actual increase in these diseases, particularly hypertension,
ischemic heart disease, and diabetes as a result of higher caloric intakes
leading to overweight and obesity and to more fat in the diet. A third reason
has been suggested by the studies of DJP Barker and colleagues (Barker, 1992)
who found that individuals in England and Wales whose birth weight and weight
for age at one year of age had been low are more susceptible to diseases of
dietary excess in later life.
In Chapter 5, MarEugenia Trejos, Professor of Economics at
the University of Costa Rica, reviews the socioeconomic factors associated with
the health policy advances of the 1970s. Recognition of social demands followed
by efforts to respond to them was the prevailing style of government in the
1930s and 1940s. The governments of the 1950s and 1960s continued this social
tradition but believed that it would be best served by measures that would
stimulate agricultural and industrial production. The social actions of the
period included the promotion of agricultural and industrial technology,
training of workers and technicians, and development of infrastructure including
water supply, urban sewage disposal systems, postal and port administration, an
autonomous railroad, building of highways, bridges, rural roads, telephones, and
the nationalization of banks.
This approach did result in increased internal market
production. However, the other authors repeatedly emphasize a social rather than
an economic motivation for the policy. There is a consensus that the
entrepreneurial governments of the 1970s were strong and decisive and willing to
intervene in different social spheres when the private sector could not or would
As Carlos Mu the Director of the Department of Primary
Health Care of the Ministry of Health, and Josanuel Valverde point out in the
final chapter, there were three stages in the development of the health delivery
system in Costa Rica. The policies and programs within each account for the
improvements in the health of Costa Ricans over this period. The first period
laid the groundwork for the rapid changes resulting from the development of new
policies and programs and the dedication of vastly increased resources in the
decade of the 1970s.
The second period was one of rapid expansion of the primary
health care system and hospital access with falling infant and child mortality
rate and striking improvement of other social indicators. It was a period of
increasing expenditure by the health delivery system.
In the third period new goals for reducing infant and preschool
mortality, malnutrition, and infectious disease were formulated. Additional ones
for the prevention of chronic degenerative diseases of later life were
identified and applied. As a result the Costa Rican health system must now also
be concerned with the promotion of diets and other aspects of a healthy life
style for the prevention of these diseases that are the major health concerns in
the industrialized countries. The increased life expectancy and decreased
mortality and birth rate are changing the demographic profile of the country.
Mubelieves that the capacity to change one paradigm for
another in order to adapt to a rapidly changing national health picture was the
key to the continuing overall effectiveness and current health achievements of
Costa Rica. This permitted an effective response even to the structural
adjustments required in the third period. The health system in Costa Rica is now
evolving toward a mixed model. In 1994, 15% to 19% of social security services
were subcontracted to private providers.
A chapter reviewing international and other external influences
on the health and nutrition policies of Costa Rica during the period of
transition was planned but never obtained. References to these influences are
scattered throughout the chapters. It is noteworthy that the seminal health
event of the period, the WHO Alma Ata Conference on Primary Health Care in 1977,
came after Costa Rica had already embarked on the path of its recommendations.
The goals enunciated in 1973 were also more comprehensive than those enunciated
in the UNICEF sponsored Summit for Children in 1990.
At a workshop in Costa Rica in 1991 to discuss the manuscripts
for this book, Dr. Luis Asis, Director of Planning of the Costa Rica Social
Security Institute, reviewed the way in which the formulation of clear
government policies helped to attract and channel international assistance. He
also mentioned external skepticism as to the feasibility of the Figueres
government proposals. Negotiation with donors to insure programs consistent with
national needs and priorities was critical as was the governments rejection of
The Interamerican Development Bank, the World Bank, and other
lending agencies played a role in accord with global trends of the times. The
United Nations Development Program (UNDP) provided technical support. UNICEF
supplied large quantities of dried skim milk (DSM) for school feeding as well as
agricultural implements and educational materials. It also furnished the medical
equipment for a network of information centers. CARE provided DSM milk as well
as vegetables and equipment for the nutrition centers. Donated food furnished by
the World Food Program included DSM and a corn-soy blend. FAO provided
agricultural extension consultant help and training. The program of mobile
medical units, created in the early 1960s was financed mainly through the U.S.
sponsored Alliance for Progress.
The Pan American Health Organization (PAHO) provided technical
cooperation in health planning, a special information system for monitoring the
progress of health and made significant investments in education and training of
professionals and nonprofessionals in the health sciences and disciplines. It
also cooperated in the control of acute communicable disease particularly the
vectors responsible for malaria, yellow fever, and dengue and in environmental
health programs with emphasis on water supplies and basic sanitation. Dr.
Abraham Horwitz, the Director of PAHO, recalls that during the decade of the
1970s external resources were readily available for health programs,
particularly from the Interamerican Development Bank. "Good ideas and sound
projects could usually be financed and Costa Rica had plenty of them."
The 1991 workshop pointed out that the Institute of Nutrition of
Central America and Panama (INCAP) was responsible for much of the definition of
the national nutrition problems, nutrition policy formation, technical
assistance in the iodation of salt and enrichment of sugar with vitamin A,
information on dietary habits and food composition, the elimination of
protein-calorie malnutrition, and the training of nutrition and health personnel
at all levels. A separate list of some 26 INCAP publications relating to Costa
Rica during the period appears in Appendix 2.
Costa Rica is not the only developing country to achieve health
statistics rivaling those of the industrialized countries despite a low per
capita income. In Latin America two other countries, Chile and Cuba, also
achieved this without major economic improvement. Both deserve great credit for
this, but in the case of Chile (Hakim and Solimano, 1978) it was achieved
gradually over many decades. In Cuba the process occurred rapidly after the fall
of Batista at the end of 1958 as the consequence of government policies but with
a different ideological approach (Amador and Pe1991). Because the health
improvements in Costa Rica were not entirely dependent on economic development,
and were achieved rapidly within a democratic framework, they serve as an
inspiring challenge and example to other developing countries.
It is not difficult to give reasons why most other Latin
American governments experienced little improvement in the health of their
people during this same period. They are the antithesis of the characteristics
of Costa Rica - lack of political stability and government motivation, resources
devoted to the military or diverted by corruption instead of being applied to
education and health, poor educational system, badly administered and financed
institutions, and when rural health posts exists, they usually lack essential
supplies, medical support, and supervision.
Finally, it has been quite impossible to present all of the
different perspectives on the Costa Rica experience in this volume. For this
reason supplementary reading lists in both English and Spanish are appended
(Appendix 2). Some of these articles give quite different insights or assign
different weights to the factors responsible. It is hoped that some will be
stimulated by the unusual nature of this case study to pursue the further
insights represented by these additional writings.
Nevin S. Scrimshaw
Amador M, Pe. 1991. "Nutrition and health issues in Cuba:
Strategies for a developing country." Food Nutr Bull 13(4):311-317.
Barker DJP, ed. 1992. Fetal and infant origins of adult
disease. British Medical Journal, London.
Hakim P, Solimano G.1978. Development, reform, and
malnutrition in Chile. M.I.T. Press, Cambridge, MA.
PAHO. 1994. Health conditions in the Americas. Volume I.
Pan American Health Organization, Washington, DC.
World development report 1993 - Investing in health, world
development indicators. 1993. Oxford University Press,