|The Nutrition and Health Transition of Democratic Costa Rica (International Nutrition Foundation for Developing Countries - INFDC, 1995, 228 pages)|
|3. Development and characteristics of health and nutrition services for urban and rural communities of Costa Rica|
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 technologies.
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 Ramón and the Rural Health Program of San Antonio de Nicoya;
· The nutrition program targeting children under six years of age, school children, and pregnant and breast-feeding mothers.
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 rehabilitation.
· 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 security.