|The Nutrition and Health Transition of Democratic Costa Rica (INFDC, 1995, 228 p.)|
|1. Health policies and strategies|
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.