|The Nutrition and Health Transition of Democratic Costa Rica (INFDC, 1995, 228 p.)|
|Contributors to this volume|
|1. Health policies and strategies|
|A brief description of Costa Rica|
|Public health development|
|The decade of the 1970s|
|The decade of the 1980s|
|2. Development of the social security institute|
|Social security in Costa Rica|
|The extension of direct insurance|
|Extension of insurance to the family|
|The financial crisis|
|The constitutional amendment|
|Development of human resources|
|The new health care models|
|3. Development and characteristics of health and nutrition services for urban and rural communities of Costa Rica|
|Background information on community outreach programs|
|Methodological characteristics of the Costa Rican health programs|
|Impact of the programs on the health of children living in rural areas|
|4. Evolution of an epidemiological profile|
|Stages of a process|
|The first four decades of the century|
|The period between 1940 and 1970|
|The decade of the 1970s|
|The decade of the 1980s|
|The last decade of the century|
|5. Socioeconomic factors for the understanding of health policy during the 1970s|
|Recognition of social demands and the regulation of the conflict during the 1930s and 1940s|
|The social government in the new development strategy of Costa Rica during the 1950s and 1960s|
|The consolidated social government|
|6. Problems and challenges of the health sector during the 1980s|
|Some problems of the health sector in the 1980s|
|Balance of the 1980s and perspectives for the 1990s in the health sector|
|Appendix 1 - Glossary|
|Appendix 2 - Supplementary reading list|
|English-language supplementary reading list|
|Spanish-language supplementary reading list|
|Supplementary reading list - INCAP publications|
|Appendix 3 - Health conditions in Costa Rica 1994|
|Specific health problems|
Starting in the early 1930s, pediatrics services frequently observed severe protein-calorie malnutrition. The number and severity of the cases of kwashiorkor were so high that pediatricians considered the nutritional situation a true national calamity at that time.
In 1966, the first nutrition survey done at the national level revealed important nutritional deficiencies throughout the population. The main deficiencies were in protein, calories, iodine (endemic goiter), iron and folate (nutritional anemias), and vitamin A (Ministerio de Salud, 1978b).
Furthermore, 57% of the children showed some degree of malnutrition according to the weight for age classification; 18% of all school children had endemic goiter; and 32.5% of all preschool children had low or deficient levels of serum retinol. Iron and folate anemias affected mainly women and adolescents.
Complementary Food Programs in the 1950s and 1960s
One of the oldest nutrition programs to reduce protein and calorie malnutrition in is the Costa Rican complementary food program for children under six years of age, school children, pregnant women, and breast-feeding mothers. In 1951, the Ministry of Public Health signed an agreement with UNICEF to supply skimmed milk without charge to these population groups. In the same year, the first nutrition center was established in Barva de Heredia.
The Costa Rican complementary food program had the following objectives:
· To improve the nutritional status of the most vulnerable population groups (nursing infants, preschool children, and pregnant women) from the most needy social groups.
· To promote good food habits.
· To promote the consumption of foodstuffs of high nutritional value which are produced or could be produced in the country.
· To impress on the population the need for periodic medical checkups for children and pregnant women.
· To deepen community awareness of the nutrition problems of mothers and children and to foster community participation in the solution of these problems.
In the first half of the 1950s, the Ministry of Public Health created the Nutrition Department, which became responsible for designing, implementing, controlling, and evaluating the nutrition program of the health sector.
In its initial phases, the complementary food program was implemented by the medical and nursing staff of the Sanitary Units (later to be called health centers). Additionally, Nutrition Centers, attached to the Sanitary Units, were built progressively. In 1955, there were only 18 of them; by 1960 the number had increased to 45; by 1968 to 124; by 1978 to 471; and in 1990 there were 550 functioning Nutrition Centers or Integrated Centers for Child Health Care (CINAI) that included nutrition.
In the 1950s and 1960s, the Nutrition Centers were usually located in the capitals of provinces or counties. In a parallel manner to the evolution of the Rural Health Program, these centers were established in small villages. In some communities, the nutrition center and the health post even shared the same premises.
At the time, the Nutrition Center had two food services: a daily service, which included a mid-morning snack (one glass of milk, maize tortillas with margarine, and vegetables), and a semimonthly service, which provided beneficiaries with powdered milk (or a mixture of milk, soya, and maize) to be consumed at home. The mid-morning snack was served in the center's dining room to two- to six-year-old children as well as to pregnant and breast-feeding women, coverage was limited mainly to families living within 1 km of the center. The semimonthly food service distributed food items to zero- to six-year-old children who showed some degree of malnutrition. Children classified as having first-degree malnutrition received the equivalent of one glass of skimmed milk per day; children with second-degree malnutrition received the equivalent of two glasses of skimmed milk per day; and those with third-degree malnutrition received three glasses of whole milk per day.
The physician of the Nutrition Center authorized the amount of milk to be distributed by issuing food coupons. He also periodically checked children's growth and development and took care of all morbidity cases. The nursing staff of the health center planned and carried out the home visits, paying particular attention to families with children showing moderate or severe malnutrition or other health problems.
Local committees, run by volunteers, have administered the Nutrition Centers since their inception. The local Committee receives its food supplies from the Ministry of Health. In addition to this, it organizes different activities to raise funds, receives voluntary contributions, and in some cases collects subsidies from the counties. In the past, the committee also was in charge of preparing the food, taking care of the children in the centers, and distributing food to the homes. In 1967-1968, the program covered 30,500 children under six years of age and approximately 1,500 pregnant women. At that time, these figures represented a national coverage of 10% of the children and 3% of the pregnant women.
By the end of the 1960s, two other programs coordinated by the Nutrition Department of the Ministry of Health were functioning in Costa Rica: the Nutritional Recovery Program, whose aim was to treat children under six years of age with second- or third-degree malnutrition, and the Nutrition and Family/School Garden Program.
The axis of the Nutritional Recovery Program was the creation of two outpatient clinics in the City of San JosThey were attended by a pediatrician, a nurse's aide, and a social worker and nutrition assistants. Additionally, there were five day care centers which took care of children with second-degree malnutrition for 10 hours a day. Finally, a clinic-hospital, which is still functioning, became responsible for the nutritional recovery of severely malnourished children. It has 20 to 22 beds and continues to look after children who come from the whole country. The outpatient clinics and the five Day Centers functioned for 10 years, up to the mid-1960s, when the number of children with severe malnutrition decreased.
The Ministries of Health, Education, and Agriculture were involved in the Nutrition and Garden Program, the objectives of which included the following:
· To increase food production at the school and home levels.
· To promote better food utilization and conservation at the family level.
· To encourage nutrition education in schools, health centers, Nutrition Centers, and agricultural extension agencies.
· To improve food habits of the population.
· To improve the nutritional level of the population, especially that of children and mothers.
The program had a substantial educational component for health staff, teachers, and agricultural extension workers. In the beginning, the program benefited from the support of UNICEF for the procurement of seeds, fertilizers, agricultural tools, and teaching materials; the expertise of the Food and Agriculture Organization (FAO) in agriculture, agricultural extension, and nutrition education; and guidance from the Institute of Nutrition of Central America and Panama (INCAP) on the organization and development of educational activities.
This program strengthened an activity that had been incorporated for decades into the Costa Rican educational system, particularly in the rural zones of the country: school gardens. It also contributed to strengthening the ancestral tradition of keeping family gardens and domestic animals on a small scale (pigs, hens, and rabbits). The program has been able to survive the ups and downs throughout time and has contributed to maintaining the tradition of keeping small home gardens: two or three fruit trees, some plantain or banana trees, chayotes, some tubers such as cassava or i, four to six layer hens, and one or two pigs. This gardening tradition has helped to improve the diet of low-income families in several areas of the country.
Complementary Food Programs in the 1960s and 1970s
During the first half of the 1970s, CARE and the communities themselves funded the construction of Nutrition and Education Centers (CEN), which therefore continued growing. CARE also contributed foodstuffs (skimmed milk and vegetable mixes) and equipment for the CEN. In 1975, the Family Allotment Fund gave a great impetus to the program, as a result of which, by 1987 (Behm and Barquero, 1990) the country had 437 Nutrition Centers and 34 Integrated Centers for Child Health Care (CINAI). CINAI were established as of 1975-1976, financed by the Family Allotment Fund, to expand preschool to two-to six-year-old children. They are managed by the Nutrition Department of the Ministry of Health in coordination with the Ministry of Education. Each CINAI is run by one preschool teacher and two assistants, who take care of 60 to 100 children.
In the mid-1970s, the complementary food program included at least three of the following: warm meals, distribution of milk and food packages. There was also a school lunch program, which will be analyzed separately in this chapter.
Nutrition Centers provided a snack to preschool children (one to five years of age), pregnant women, breast-feeding mothers, and malnourished school children who lived in CEN-accessible areas and who were referred to the program by health centers and posts (Ministerio de Salud, 1979). This was replaced by a daily balanced breakfast and lunch. In 1977-1978, the program had approximately 32,000 beneficiaries, 72% of whom were preschool children. In 1978, the program served approximately 15 million warm meals: 9 million lunches and 6 million breakfasts. At the national level, however, this tremendous effort translated into a coverage of only 10% of all preschool children, and a coverage of barely 2% of all pregnant and breast-feeding women (Ministerio de Salud, 1979). It ought to be borne in mind, however, that the program targeted mother and child groups from low-income families in which social problems had been identified.
The implementation of the program required hiring additional staff: one or two cooks and a nutrition assistant per center. Local Nutrition Committees continued managing the funds and helping to take care of children.
Two kilograms of whole powdered milk were distributed monthly to one- to five-year-old children, pregnant women, and breast-feeding mothers who cannot go to the centers for breakfast or lunch. The program had approximately 39,000 beneficiaries in 1976 and had reached 113,000 by 1988. Approximately 85% of all recipients are preschool children. In 1978, at the national level, the program covered 36% of all preschool children, 10.4% of all pregnant women, and 10.9% of all breast-feeding mothers (Ministerio de Salud, 1979).
Distribution of Food Rations and Packages
A program that donated food rations [skimmed powdered milk, vegetable mix (CSB), vegetable oil, and flour] was established in the mid-1970s through the joint cooperation of the World Food Program (WFP) and the Costa Rican Mixed Institute for Social Aid (IMAS). The program targeted family groups showing nutritional vulnerability, which are chosen by staff of the health centers and posts. In 1978, there were 7,625 recipient families (Ministerio de Salud, 1979).
Another activity of this program was the semimonthly distribution of staple food rations (rice, beans, oil, wheat flour, and whole powdered milk) to families with at least one child showing third-degree malnutrition. It had an approximate value of 544.00 colones (US $63.25) per family per month (Ministerio de Salud, 1979). It was started in 1977 with 130 families, but operational and financial obstacles led to its suspension in 1979.
Nutritional Education and Social Communication
The complementary food program is associated with a series of educational activities specifically targeting program recipients as well as the population in general. Most of them are implemented at the CEN or CINAI and are the responsibility of the nutrition assistant.
Home visits. Home visits are oriented towards specific malnutrition cases, usually referred by other members of the health team, or towards beneficiaries who stopped attending one of the complementary food centers.
Educational talks. These talks target preschool children, mothers, and other organized groups.
Demonstrations of how to prepare different meals. This is one of the educational methods most accepted by mothers. At the same time, these demonstrations have a great impact on dietary habits. They use program foods as well as other locally produced foodstuffs.
Interviews during consultations. The objective of interviews is to provide guidance on food and nutrition to mothers of malnourished children and to others referred by health center physicians.
Activities in nutrition education implemented by other health staff. All other members of the health team (physicians, nurses, nurse's aides, and rural health assistants) also provide nutrition education as part of the general health education given to the population. This is done particularly in the form of direct and individual advice given during consultations or home visits. In this manner, topics such as the following are broached: breast-feeding, feeding during the first year of life, diets of pregnant women, balanced meals, and the preparation of milk formulas.
Social communication/dissemination. A social communication/dissemination program was started with the support of the Health Education Department. It includes the use of the following printed materials and radio programs:
"Salud Para Todos" Magazine. This annual publication of 120 to 130 pages includes short articles on health and nutrition written in simple language to address all population groups. It has been published for 12 years and now has a circulation of 50,000. It is frequently used in schools and rural zones.
"Salud y EducaciBulletin. This is basically reference material for the development of the educational component at the community level
Audiovisual Modules. These include a wide variety of teaching materials, such as recordings synchronized with slide shows, posters, pamphlets, flip charts, graphs, and bulletins. The purpose of these materials is to deliver educational messages that complement the educational activities for individuals or groups.
"Platicas de don Rafael." This program is based on five-minute recordings broadcast by radio stations with local or national coverage. According to a 1978 radio audience survey, the program was recognized by 49% of the women living in rural areas.
"Voces del Pueblo." This is a 10-minute program based on interviews with community members. It takes the form of a dialogue with the intention of clarifying, confirming, or giving advice on specific health topics.
The preschool education program complements the nutritional activities of the CENs and of the CINAI. Even though this program was started in 1976, by 1978 it had been implemented in 34 CINAI and 238 CEN (approximately 50% of all CEN) (Ministerio de Salud, 1979). The sole staff person running the Nutrition Centers is a teacher who takes care of an average of 20 children from three to six years of age. Preschool education in CEN and CINAI is a valuable area of support to achieve integrated care and full development for children. This goal becomes even more important considering that most children in this program come from poor families living in rural areas and deprived urban zones. Generally, these children do not have any other possibility of entering the formal educational system of the Ministry of Education.
The first school cafeterias were implemented in Costa Rica in the 1940s. In 1944, school foundations established and ran them to improve the well-being of school children between 7 and 13 years of age. At the beginning, the service only included a mid-morning snack that did not require expensive infrastructure. During the following two decades, the school committees continued to serve children mid-morning snacks using both local food and food donated by foreign agencies, especially UNICEF as of 1951.
Starting in 1975, the financial support provided by the Family Allotment Fund permitted the rapid expansion of cafeterias to most schools in the country, as well as the inclusion of a hot meal service that provided breakfast and lunch for 2- to 13-year-old children, following a menu recommended by the Ministry of Health (Novigrodt Vargas, 1986).
The school lunch program has the following objectives:
· To improve the physical and mental development of children;
· To foster sanitary eating habits, as well as good manners;
· To encourage the production and consumption of local foods.
Eighty-five percent of all food used by the school lunch program is distributed directly to the schools by National Production Council stores or by authorized cooperatives, taking the number of participating or benefiting children in each cafeteria into account. In some cases, school foundations receive a proportional amount of money and buy the food locally. Communities contribute approximately 15% of the program's costs for procuring locally grown fresh food (Novigrodt Vargas, 1986).
The school lunch program is closely linked to school garden activities, inasmuch as most of the vegetables, fruits, and eggs produced in school gardens are consumed in school cafeterias.
According to an evaluation study done in 1985 (Novigrodt Vargas, 1986), during the school year school cafeterias function 20 days per month. Lunch, the most common service, is provided in 69% of all schools, while lunch and breakfast are served in 30% of the schools, and breakfast alone in 0.5% of the schools. In 1985,84% of all school cafeteria beneficiaries were duly registered students, 7% were registered preschool children, 6% were nonregistered preschool children, and 3% were teaching or administrative school staff. From the onset, the program focused its attention on preschool children ranging between two and six years of age who live in communities that lack a Nutrition Center but have a school cafeteria.
Coverage. Each school cafeteria provides food to all children attending that school.
Table 3 summarizes the results from three different evaluations of school cafeterias done in 1975, 1981, and 1986 (Ministerio de Salud, 1979).
At present, school cafeterias are funded by the Family Allotment Fund and other funds raised by local school committees.
Iodization of Common Salt
Costa Rica is a mountainous country and the majority of its population lives in highlands. In the 1930s, Dr. Clodomiro Picado drew attention to the wide prevalence of goiter in the country, and his influence led to the government adopting an Executive Order in 1941 making the iodization of common salt compulsory as a preventive measure to reduce and eradicate goiter. However, this order was not implemented for many years. A nationwide survey of endemic goiter conducted between 1952 and 1955, under INCAP auspices, indicated an over all prevalence of 16.5% with a range of 10.2% to 25.6% depending upon county (Pz et al., 1956). In the mid-1960s, INCAP developed a practical way to iodize salt without special stabilizers and moisture-proof packaging using the relatively insoluble potassium iodate. INCAP continued to strongly urge implementation of the 1930s law until the Figures government did so in 1941. The few population groups without access to iodized salt still show evidence of enlarged thyroid glands.
Fluoridation of Common Salt
Caries and early tooth loss are widespread problems among Costa Ricans. One factor contributing to this condition is the high consumption of refined sugar, a common problem in Costa Rica since the country produces sugar. A compounding factor is the lack of fluoride in food and water. Although a water fluoridation program was established in the 1980s, it covered only the San Josetropolitan area. In 1988, another fluoridation project was started using the same infrastructure as for the iodization process: fluoride was added to common salt for human consumption. The project is still running, and as a result, 80% of all Costa Ricans consume salt enriched with iodine and fluorine.
TABLE 3. Development of School Cafeterias in Costa Rica, 1975-1986
School Cafeteria-Related Parameters
Schools covered (%)
a No data available
Source: Ministerio de Salud, 1979
Fortification of White Sugar with Vitamin A
The 1966 Central American Nutrition Survey revealed that all countries studied had a high prevalence of vitamin A deficiency, particularly in children. This finding, as well as the knowledge that vitamin A deficiency has negative repercussions on human health, motivated a group of scientists at the Institute of Nutrition of Central America and Panama (INCAP) to seek solutions to the problem. One of the solutions proposed was the addition of retinol to sugar, since the people in all the countries involved consume sugar. The fortification program was successfully launched in Costa Rica and Guatemala in 1975; 50 IU (15g) of retinol palmitate is added per gram of sugar.
Sugar producers assumed the cost of the program, and vitamin A was added to practically all sugar consumed. In 1979, a survey of preschool children indicated that only 2.5% had low or deficient retinol levels. Unfortunately, the international cost of retinol increased considerably in 1979 and the vitamin A fortification program was stopped. The consumption of foods rich in vitamin A has improved in Costa Rica. At present, however, the country lacks current data on serum retinol levels in children and high-risk population groups.
Iron and Folate Deficiencies
There are no specific large-scale programs to combat iron and folate deficiencies in Costa Rica. Nevertheless, all pregnant women attending prenatal monitoring receive iron and folic acid supplements. Approximately 60% of all pregnant women now receive prenatal care. Furthermore, two-thirds of all children under six years of age receive growth and development consultations, where they are given iron supplements.