Most countries in the world have set themselves the goal of
expanding health services to all their people. However, few have achieved this
goal or shown any substantial progress. There is no question that Costa Rica
belongs to these few privileged countries. In the early half of the 1970s, Costa
Rica had developed health services in the cities, but did not have any in the
rural areas. At that time, not even 20% of the rural population had access to
minimal health services. By the end of that decade, however, health services
covered more than 90% of the country's population, and all health indicators
improved significantly nationwide.
During this period, approximately 400 health posts were
established in rural zones. In the urban areas, health centers oriented their
activities toward the identification of priority and high-risk areas - called
Community Health Areas - thus merging the extramural and intramural work of
auxiliary health staff. Additionally, more than 500 urban and rural nutrition
centers were built. All these facilities serve to implement a health and
nutrition program covering dispersed population groups in the rural areas, as
well as deprived urban groups. They also manage a community-based environmental
program, run by auxiliary personnel, which uses socially acceptable, low-cost
This chapter analyzes the main methodological characteristics,
strategies, and results of the following health and nutrition programs, all of
which were begun or were strengthened in the first half of the 1970s:
· The Rural Health
Program (for rural communities);
· The Community Health Program
for underprivileged urban population groups;
· Two Rural Health Programs
implemented in specific geographic areas: the Hospital Without Walls program of
San Ramnd the Rural Health Program of San Antonio de Nicoya;
· The nutrition program
targeting children under six years of age, school children, and pregnant and
These programs, each one with methodological and financial
differences, are the foundations of primary health care in Costa Rica. The staff
of the Costa Rican Ministry of Health has coordinated and implemented all of
them, with the exception of the one in San Antonio de Nicoya. The structuring of
the Rural Health Program was started in 1972, and that of the Community Health
Program in 1974. The nutrition program had its inception in the 1950s and was
strengthened in 1975, when it started to receive substantial national and
international financial resources.
All the programs are in agreement with the 1974-1980 Costa Rican
National Health Plan, which defined the following key concepts in health
(Ministerio de Salud, 1973a):
· The right of the
population to health care and the obligation of the government to organize and
provide health services.
· Holistic health care, taking
into account health promotion and prevention, as well as the cure of disease and
· Regionalization and
decentralization of health services.
· Expansion of health services
to all the population.
· Outpatient care as a priority.
· Promotion of educational and
training activities in the area of health.
· Compatibility of health
expenditures with the country's economic capabilities.
Parallel to the Community Outreach Program, encompassing health
and nutrition in rural and underprivileged urban populations, a more complex
process started to develop within the health services. As of 1974, and during
the following three years, all hospitals managed by the Ministry of Health and
the Costa Rican Banana Company were transferred to the Costa Rican Social
Security Institute (CCSS). In this manner, 25 hospitals, ranging from highly
sophisticated to small rural hospitals, were transferred to the CCSS. During the
1970s, social security coverage increased to 80%. Thus, low-income population
groups stopped receiving charity health care and obtained the right to health
care on the basis of social