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close this bookThe Nutrition and Health Transition of Democratic Costa Rica (International Nutrition Foundation for Developing Countries - INFDC, 1995, 228 pages)
close this folder3. Development and characteristics of health and nutrition services for urban and rural communities of Costa Rica
View the document(introductory text...)
View the documentIntroduction
View the documentBackground information on community outreach programs
View the documentMethodological characteristics of the Costa Rican health programs
View the documentNutrition programs
View the documentImpact of the programs on the health of children living in rural areas
View the documentConclusions
View the documentReferences
View the documentBibliography

(introductory text...)

Dr. William Vargas

Introduction

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.

Background information on community outreach programs

Organization of the Health Services Prior to 1970

In 1970, 18 borrowing institutions were in charge of health care in Costa Rica (Ministry of Health, Costa Rican Social Security Institute, Manager's Office for Medical and Social Assistance, Boards for Social Protection, Insurance Institute, and others). Unfortunately, all of them had different regulations, management, and financial sources. Furthermore, they barely coordinated their activities and, over and above the already complex health structure at the time, there was improper utilization and unequal distribution of resources. All of this produced a chaotic situation in public health: incomplete health coverage of the population, all kinds of differences in health services as to quantity and quality, preventive health programs considered of little importance, while stressing curative assistance and a marked autonomy of all health institutions based on the laws that established them. In 1969, less than 10% of the total health budget was allocated to preventive health measures.

Additionally, regionalization of the health services was unknown in Costa Rica. All health resources, which were mainly directed toward curative actions, were allocated to San José, the capital. The national territory was divided into 19 Sanitary Districts in 1969 with a view to improving the management of the health services. Five health zones were established in 1971 but were changed to seven health regions in 1983. Prior to 1970, communities had limited participation in the health process. Early in the 1970s, however, the government launched an initiative seeking to mobilize community resources. Its goal was to support malaria programs and mobile medical care units in the rural areas.

Prior to 1970, environmental sanitary activities targeted densely populated nuclei. At the time less than 50% of the rural population had potable water (mainly from public fountains) and less than 40% had any sanitary means for disposing of excrete. In fact, intersectoral involvement in health was limited to health promotion activities sponsored by the Ministry of Public Education (sanitary education, school gardens).

In 1970, Costa Rica had the following human resources working in the health sector per 10,000 inhabitants (Ministerio de Salud, 1978a): 5.2 physicians, 1.4 dentists, 4.2 nurses, and 13.6 nurse's aides; these numbers were insufficient to meet the health needs of the population. In the same year, the country had only 2.9 hospital beds per 1,000 inhabitants. Health per capita expenditure was US $29.5 in 1970, 5.1% of the gross domestic product (Sáenz, 1985b). Consultations and hospitalizations used up most of the health budget.

Mobile Medical Units

The Costa Rican Program of Mobile Medical Units was created in the early 1960s. It was funded mainly from foreign sources through the Alliance for Progress Program. At the end of the decade, Costa Rica had nine mobile units on land and one at sea. The health teams were made up of a general practitioner, a nurse's aide, a sanitary inspector, and a driver, and had a four-wheel drive jeep at their disposal. The basic health team was stationed in a health center located at the capital of a county. Each mobile unit covered 12 to 18 communities, all of them between 5 and 20 km away from the health center, generally visiting for one day, on a monthly schedule. In the most distant and in the most densely populated communities, the mobile unit stayed two or three days.

The main functions of the mobile units were medical consultation for the sick, environmental sanitary actions (construction of latrines, sanitation of houses, and improvement of water sources), educational actions, creation of health committees, and promotion of food production in family and community gardens. Even though the Program of Mobile Medical Units had strong political backing and solid foreign resources, it had several limiting factors. On the one hand, some communities were practically inaccessible by car during the rainy season. On the other hand, higher-risk populations, i.e., the most distant communities, did not have access to the program: poor road conditions badly affected the unit's vehicles, compelling the team to interrupt their visiting schedule each time the vehicle broke down or when it had to be replaced (every two or three years). Another important restriction to the mobile unit program was its limited coverage: only 130 of the 3,000 communities with fewer than 2,000 inhabitants. Furthermore, the program had a predominantly curative approach: the health team had to cover a patient demand of 60, 80, or even more patients per day, which limited their time for other health actions.

Some communities with severe restrictions on basic health services benefited from the Program of Mobile Medical Units. However, in the county, where the program was implemented for several years (Puriscal, San Carlos, Perez Zeledón, Nicoya, Santa Cruz, and Buenos Aires) no significant changes in infant mortality could be interpreted as a positive impact of the program (Vargas, 1976).

Mobile units continued working throughout the 1980s and are still active today. Their main function continues to be curative, since they visit health posts to support health activities developed by the local staff. Thus, units increased the supply of health care and curative services to the population.

Searching for a New Health Care Model

In the second half of the 1960s and the beginning of the 1970s, several Latin American countries discussed ways to expand their health services to dispersed rural populations, particularly to communities with fewer than 500 inhabitants, as well as to families living on river banks and along roads. The concept of "simplified medicine" emerged from these deliberations. The concept is implemented by auxiliary personnel, who, after a training course that lasts only a couple of months, are capable of looking after and solving most of the common health problems of the population. At that time, Venezuela established a "simplified medicine" program for rural populations. In Chimaltenango, Guatemala, Dr. Carroll Berhorst trained Indian leaders to participate as "health helpers" in their communities. During the same time frame, Latin American scholars studied and disseminated information on primary health care models used in other parts of the world

Political Support

In May 1970, a new social democratic government came into power. President José Figueres, who had a profound knowledge of the problems affecting rural areas, committed his political program to changing the fate of the rural population.

In October 1972, the Special Meeting of Ministers of Health of the Americas made a recommendation

to expand minimum coverage of integrated health services to all persons living in villages with less than 2,000 inhabitants, allowing auxiliary health personnel - duly trained for this purpose - to take over health services. It is understood that this basic health care, with different quality levels, should be complemented with a coordination and referral system permitting access of all of the population to more specialized health care (Ministerio de Salud, 1973b).

The basic reference paper of the Ministers' Meeting recommends the establishment of "minimum integrated health services" that should cover the following elements: tending the sick in emergencies; health care for mothers and children under five years of age, including family and community education on sanitary topics, as well as on food and nutrition; immunizations; basic sanitation; recording of statistical data; and patient referral to more complex health units. The paper also states that these health services should be in the hands of elementary health units, run by trained auxiliary personnel and supervised by higher levels. Furthermore, they should each have the capability to take care of 5,000 inhabitants.

When Costa Rica implemented the community outreach strategy of mobile units in the early 1960s, it destroyed the traditional health care scheme and created new needs among the population groups that had traditionally been forgotten by governments. The country, nevertheless, did not obtain the impact it was looking for. In the first half of the 1970s, various technical groups in Latin America and other parts of the world analyzed alternative strategies and activities to develop a health program targeting rural communities. Their efforts led to the 1978 Alma Ata Declaration.

From this it can be inferred that the development of community outreach programs for rural and urban areas in Costa Rica was facilitated by different circumstances. On the one hand, President Figueres supported the new health initiatives targeting rural population groups. On the other hand, the Ministers of Health of the Americas adopted the expansion of "minimum integrated health services" for rural populations on the basis of trained auxiliary personnel as a regional health policy.

Working Group

In view of all health and political elements discussed above, the Ministry of Health in Costa Rica became the ideal entity to develop a new health program for rural population groups. As a matter of fact, this power was formally vested in it through the tripartite convention signed by the government of Costa Rica, PAHO/WHO, and UNICEF in March of 1972.

With a view to developing the new health program, the Pan American Health Organization (PAHO) appointed a public health specialist and a sanitary engineer who had been working several years in Costa Rica in the Malaria Control Program. Both of them knew the country and particularly rural communities located at low altitudes, all of them typically malaria endemic zones, which were considered priority areas for the rural health program. The Costa Rican counterparts to the PAHO staff were a Manager for Field Operations, chosen from the Malaria Control Program, and a graduate nurse trained in public health. Lack of financial resources, however, led to the decision to limit activities in 1972 to staff training only. That year, two three-month courses on rural health were given to 34 evaluators and 17 volunteers working for the Malaria Control Program.

During the first half of 1973, the Ministry of Health appointed a public health specialist as manager of the program, a post which he held for only a few months, as well as another nurse trained in public health. During 1973, the central team was made up by the two advisors appointed by PAHO/WHO, the Field Operations Manager, two nurses, one secretary, and a driver. In May 1974, a physician was incorporated into the staff as program manager. Shortly thereafter, two more public health nurses joined the team. The work team had the following functions: to prepare the program, to train field staff, to design an information system for the program, to supervise the program, and to implement the new health care model, developed by the central team, for rural population groups.

Because concrete outreach programs targeting rural communities were practically unknown at the time, none of the team members felt motivated to visit similar programs in other countries. As a result of this situation, the Costa Rican Rural Health Program was launched, developed, and consolidated using strictly Costa Rican rural resources.

The central team had the task not only of designing the program, but also of directing and implementing it. Several program elements that at the beginning were considered logical, at least from a theoretical standpoint, were later found to clash with reality when put into practice. Fortunately, the team was able to react to this situation and to correct all the mistakes observed in the field.

Characteristics of the Costa Rican Population

According to the 1973 National Population Census, Costa Rica had a total of 1,872,000 inhabitants living in 4,245 communities. The country's population can be subdivided into the following categories: urban, concentrated rural, and dispersed rural. The urban population, distributed in 77 population groups with more than 2,000 inhabitants, represented 47% of the country's population. The concentrated rural population, a total of 418,000 persons living in 494 population groups with 500 to 2,000 inhabitants, represented 22%. The dispersed rural population, a total of 574,000 persons living in 3,684 population groups of fewer than 500 inhabitants, represented 31 % of the country's total population. The latter group became the target population of the first phase of the Costa Rican Rural Health Program (Ministerio de Salud, 1973b).

An in-depth analysis of the Costa Rican rural environment permitted the identification of the following factors that limit the access of the population to health services (Ministerio de Salud, 1978a).

Geographic Inaccessibility

Geographic inaccessibility was directly related to the tremendous population dispersion found in the country, especially in the low coastal and border areas. In the rural areas, access roads were lacking and/or inappropriate; usually, they were blocked during the rainy season, which may last up to eight months a year. As a result of this, much time and effort were required to reach regions where the only means of transportation were horses, carts, and rowboats. The most peripheral health centers were located in the capitals of counties with more than 2,000 inhabitants; the majority of them were accessible by paved or unpaved roads.

Economic Inaccessibility

This factor was determined by the production characteristics of the community. There was a high proportion of landless peasants and small farmers using traditional agricultural practices, i.e., very little technology, for subsistence crops. In several cases, they were wage earners who migrated during the sugarcane and coffee harvest seasons. While poverty levels were estimated at 39% for the whole country, in rural zones they reached 46%. In other words, nearly one of every two persons living in rural areas was classified as poor (Trejos, 1990).

Sociocultural Inaccessibility

This factor is expressed in terms of the community's traditions, inadequate information on the health and disease process, high illiteracy rates or low schooling, and ignorance regarding the benefits derived from health services. In the countryside, the deeply rooted traditional concepts regarding health and the origins of disease, on the one hand, and the lack of rural health services, on the other, fostered native healers and self-medication with traditional medicines. At the same time, alcoholism, machismo, and irresponsible parenthood resulted in a large number of single mothers with small children.

Functional Inaccessibility

This factor was related to sporadic health services, inadequate work schedules, low coverage, and a predominance of curative over preventive health actions. Health care provision in Costa Rica was concentrated in establishments (health centers and hospitals) located either along the main roads or in the most densely populated cities with the most developed economies. Dispersed rural areas received very limited attention from the mobile health units, which provided occasional services and merely treated morbidity aspects. A positive point was that other volunteer groups (ONGs) and the staff of the Malaria Eradication Program were already aware of the health isolation in the rural areas. To summarize, all health problems occurring outside the schedule of the mobile units had to be treated in urban communities, which implied further expenses for the population. Also, patient follow-up was sporadic or nonexistent, and vaccinations were implemented though vaccination campaigns, nearly always as emergency actions.

Technological Inaccessibility

The technological inaccessibility of rural areas was due to inadequate utilization of techniques to meet the prevailing health problems, inappropriate staff training, inadequate management and development, and deficient community organization.

Since its inception, the Costa Rican health program for rural communities has had the goal of eliminating these problems of rural accessibility. For this purpose, it pursued different strategies, such as the creation of small health units that built a health service network for the purpose of reaching the smallest communities, stressing home visits. Thus, each household, regardless of how far away or isolated it was, was periodically visited by the rural health assistant or by a nurse's aide.

Methodological characteristics of the Costa Rican health programs

The Rural Health Program

The health program for dispersed rural communities was conceived and structured within the framework of malaria programs. In the first half of the 1970s, malaria was under control in Costa Rica. Almost all low coastal zones were classified as being in the consolidation phase. In other words, even though no malaria cases were detected in the area, ongoing epidemiological monitoring, implemented by staff specifically trained for that purpose, was required. For the first phase of the Rural Health Program, malaria staff was trained to implement other health actions. In point of fact, malaria staff received the first courses for rural health assistants. As explained later, however, only a small group of the malaria personnel who were so trained kept a specific post within the Rural Health Program.

It is important to mention that the methodological structure of the Costa Rican Rural Health Program was designed following the premises of a Malaria Control Program which had had undeniable success in the second half of the 1960s. It was known that the program had been successful because of its excellent organization and its outstanding staff discipline at all levels.

This article presents a detailed analysis of the principal methodological elements of the program, with a view to drawing some important conclusions. There is no doubt that the most important components for the success of the Costa Rican Rural Health Program were, on the one hand, that it was implemented at the right time and in the right place (within a given geographic area), and on the other hand, that it was implemented in a disciplined manner over a long period of time. The conceptual methodological bases established during the first years of the program are still observed today. Nevertheless, starting in the 1980s, the program had to face a severe crisis, which has worsened since then.

Objectives of the Rural Health Program

The Rural Health Program established a series of objectives to be achieved between 1973 and 1980. The objectives aimed mainly at increasing health coverage and health conditions (morbidity, mortality), particularly among mothers and children. The program also established goals regarding the development of the physical and managerial infrastructure of the program itself, which were needed to achieve future changes in the population profile. Both the health care model and the health involvement of various social and economic community sectors prior to 1973 were once more taken into consideration with a view to providing integrated solutions to problems of the community.

Objectives Presented in 1973 Regarding Health Coverage (Ministerio de Salud, 1973b):

· To provide integrated health services to rural population groups living in communities with fewer than 2,000 inhabitants, in two stages:

First Stage. 1973-1977: To cover 80% of the dispersed rural population groups (villages of fewer than 500 inhabitants), to reach 550,000 persons living in 3,300 communities.

Second Stage. 1978-1980: To cover the other 20% of the dispersed rural population groups and the concentrated rural groups living in villages ranging from 500 to 2,000 inhabitants (580,000 additional inhabitants in 988 communities).

· To vaccinate 80% of all children between 9 months and 4 years of age against measles.

· To vaccinate 80% of all children between 2 months and 6 years of age with DPT (diphtheria, pertussis, and tetanus) vaccine.

· To vaccinate 80% of all children between 2 months and 6 years of age against poliomyelitis.

· To vaccinate 80% of all children between 7 months and 14 years of age with DT (diphtheria and tetanus) vaccine.

· To vaccinate 80% of all persons over 14 years of age against tetanus.

· To keep an adequate epidemiological surveillance system of malaria (10% of blood samples).

· To monitor 80% of all pregnant women.

· To monitor 80% of all children under 5 years of age.

· To promote institutional deliveries, striving for a coverage of more than 60%.

· To promote responsible parenthood, striving for a 20% coverage of women 15 to 44 years of age, offering appropriate family planning methods.

· To increase connections of piped water into homes to 80% in concentrated rural population groups and to 50% in dispersed rural population groups.

· To provide 80% of the population with latrines.

Objectives Presented in 1973 Regarding Health Status Changes in Costa Rica

· To increase the 1980 life expectancy at birth to 71 years (i.e., a 6-year increase over 1971, when life expectancy was 65.4 years).

· To decrease deaths among the general population, reducing mortality rates by 20% (for a mortality rate of 5.3/1,000 inhabitants by 1980).

· To decrease the infant mortality rate by 35% (±5%), reaching an infant mortality rate of 36.9 to 43.5/1,000 live births by 1980.

· To decrease mortality rates in children 1 to 4 years of age by 55% (±5%), to attain a child mortality rate of 1.8 to 2.2/1,000 children 1 to 4 years of age by 1980.

· To decrease proportional mortality of children under 5 years of age by 35%, to attain figures ranging from 34.5% to 28.6% by 1980.

· To decrease maternal mortality rate by 25% (±5%), achieving a maternal mortality rate of 0.66 to 0.76/1,000 live births by 1980.

· To keep malaria incidence levels below 0.1/1,000 inhabitants.

· To decrease the incidence of diphtheria by 80% to obtain incidence rates below 0.66/100,000 inhabitants by 1980.

· To decrease the incidence of poliomyelitis by 100%, thus eradicating polio by 1980.

· To decrease the incidence of pertussis by 80%, to obtain incidence rates below 14.2/100,000 inhabitants by 1980.

· To decrease the incidence of measles by 80%, to obtain incidence rates below 53.1/100,000 inhabitants by 1980.

· To decrease mortality rates for acute diarrheal diseases by 50%, to attain rates below 35.1/100,000 inhabitants by 1980.

· To eradicate tetanus neonatorum by 1980.

· To decrease measles mortality rate to less than 53.1/100,000 inhabitants by 1980.

· To eradicate tuberculous meningitis in children and young adults under 15 years of age by 1980.

Activities Rural Health Program

All activities of the Rural Health Program were based on the analysis of health problems and their conditioning factors affecting the rural population. Program activities were implemented by auxiliary health personnel who were either rural health assistants (with a four-month training course) or nurse's aides (with an 11-month training course). From the beginning, program staff recognized the need to establish a minimum activity "package." The package then became the basis for establishing the logistics of four fundamental program aspects: staff training, supervision, adaptation of equipment and supplies, and design of an information system. Bearing these aspects in mind, training modules, as well as equipment and supply modules, were established for each health post.

The following activities were implemented (Ministerio de Salud, 1973b):

Prevention and control of communicable diseases: malaria, intestinal parasites, tuberculosis, and immunopreventable diseases (measles, tetanus, pertussis, diphtheria, tuberculosis, and poliomyelitis) through the application of measles and polio vaccines, as well as DPT and BCG (bacillus Calmette-Guérin) vaccines.

Mother and child health activities: stressing detection and monitoring of pregnant women, promotion of institutional deliveries, family planning (provision of barrier methods), and periodic monitoring of children under six years of age.

Treatment of common diseases (diarrhea, respiratory infections, and skin infections) and first aid for accidents: The staff was trained in these subjects and was provided with the necessary equipment to identify common health problems in children and adults. The staff was also trained to refer patients needing medical consultation to the nearest health post or Center and to refer special cases to the corresponding hospital.

Rural health personnel were also involved in the discovery of traditional midwives, who were then referred to health centers for periodic training.

Environmental sanitation: mainly oriented towards the promotion and use of latrines, sanitary garbage disposal, sanitation of dwellings and their surroundings, and provision of information on the correct use of available water. In some areas, rural health staff also promoted the use of water pumps for schools and community groups, which they also supplied to the people.

Health education and promotion of community organization: educational activities on health topics, organization of community groups, implementation of an information system, and development of physical infrastructure for the program. A health post, a health committee, or an association for the development of the community had to be established in each health area.

Health Areas

The health area is a functional working unit with an average area of 150 km². It contains 12 to 16 villages or small population centers, 600 to 650 dwellings, and approximately 3,000 persons. Each health area has a health post located in a specifically chosen village, frequently the district capital. The selection of the village takes into account the road network to neighboring communities within the same health area with a view to facilitating users' access to the health post, on the one side, and to facilitating health staff's access to the village dwellings, on the other. The operating range of the health post, considering the distance to the most remote houses, usually does not exceed 10 km.

Health Posts

In several cases, health posts were actually community houses provided by the population, equipped to take care of the basic health needs of the area. In the first phase of the Rural Health Program, prefabricated modular health posts were installed in a period of two weeks. They were wooden structures (55 m² in area) with cement floors and zinc sheeting roofs. In some villages, larger facilities made of cement blocks were built for use simultaneously as Education and Nutrition Centers (CENs). The CENs, discussed later, are part of the nutrition program Network of the Ministry of Health.

Each health post was provided with basic furniture and modular medical equipment. Generally, the community made the furniture or paid for it, while UNICEF donated the medical equipment. The Rural Health Program also prepared a list of 20 basic drugs to be used by nurse's aides and rural health assistants. To store vaccines, all health posts were equipped with an electric refrigerator in villages with electricity or a kerosene refrigerator in villages without electricity.

Health Staff

A nurse's aide and a rural health assistant (now called a primary health care assistant) are in charge of the health areas. Nurse's aides spend most of their time visiting houses in the village and the communities within 1 to 2 km from the health post. To deliver medical care to individual persons, the nurse's aide works half a day three times a week and a physician visits the post once or twice a month.

The primary health care assistants are in charge of all other villages not visited by the nurse's aide. They work five days a week visiting all houses in rotation. On Saturdays, the primary health care assistant stays at the health post and, together with the nurse's aide, provides medical care to individuals and prepares reports.

Nurse's aides have a basic 11-month training course that qualify them to work in hospitals or health centers under the supervision of a graduate nurse. To work in a health post, the nurse's aide requires four more weeks of training that stresses environmental sanitation, drug use, and local programming. At the beginning of the Rural Health Program, all persons applying for the training course for nurse's aides were required to have nine years of schooling; this requirement was later modified to a high-school diploma (11 years of schooling in Costa Rica).

The first rural health assistants were malaria workers, most of whom had ample field experience in the Malaria Control Program. The staff of the Rural Health Program assumed that it was feasible to hold four-month training courses for malaria workers, at the end of which they would be able to implement the program's activities satisfactorily. Unfortunately, this assumption did not prove to be correct. The limited basic education of the malaria workers, most of whom had not finished primary school, was identified as a limiting factor; in four months they were not able to learn all the information and skills required by the Rural Health Program. Therefore, after the first courses, only malaria workers with nine years of schooling were accepted as candidates for the training. Three years later, only high school graduates were considered.

Staff at this level came from rural areas, although not necessarily from the county or village in which they were working. Some did not want to go back to their places of origin because they feared that their own people would not accept their advice, quoting the saying that no one is a prophet in his own country. Although some women were trained as rural health assistants, they resigned because they felt that they could not fulfill the post's functions. As a matter of fact, rural health assistants have to take isolated roads or mountain paths and travel on foot, horseback, motorcycle, or boat. They also have to perform strenuous physical work carrying medical equipment and a thermos flask for vaccines.

All rural communities accepted the home visits made by male rural health assistants, as well as nurse's aides (generally women), and rapidly trusted them. The rural staff is characterized by its work mystique, its involvement in community organizations and groups, and its desire to help people, all of which are factors that allowed rural health assistants and nurse's aides to identify completely with rural communities in Costa Rica. Throughout the years, rural health staff have been respected the people and are known to respect the religious, political, and cultural beliefs of the communities. Thus, few conflicts between health staff and the population have required the intervention of health supervisors or transfers.

Education and Training

As indicated, the first rural health assistants were chosen among malaria workers. During the initial phases, as the Rural Health Program did not have any staff selection criteria (i.e., neither admission requirements nor passing of specific aptitude tests), the groups we requite heterogeneous and difficult to train. The program also lacked adequate teaching facilities and experienced teachers to develop the skills of the future rural health assistants. The first courses lasted only three months. In 1974, they were expanded to four months and included selection criteria, of which two of the most important were the applicant's age (between 18 and 3 5 years) and nine years of schooling (later increased to 11 years).

In 1977, personality traits were incorporated into the selection criteria. In 1984, courses were increased to five months and a single training course for rural and urban health assistants was implemented The same year, the Nursing School of the University of Costa Rica recognized the courses as part of their own Teaching Extension Programs (Garro et al., 1989) and gave them university credits.

Thirty courses (with an average of 30 students per course) were given from 1971 to 1991 for a total of 915 graduates. At present, 550 of those who attended the courses are still working for the health program.

Since the beginning of the program, graduate nurses and program officers, working at the central level of the Ministry of Health, coordinated and gave the courses. Physicians, nutritionists, and social workers were also invited to participate in the courses, but to a lesser extent. The teaching staff generally had field experience in the program, particularly as supervisors.

All students who pass the course receive a certificate and are recognized as rural health assistants. The course certificate provides them with the possibility of working for the Ministry of Health. When they finish the course, they are committed to work in the Rural Health Program for three years. The training of the nurse's aides includes an 11-month Basic Course for Nurse's Aides taught by the Ministry of Health. They also receive a four-week public health course which includes in-service training at a rural health post. Annually, rural health assistants and nurse's aides - under the coordination of the health region - receive refresher courses and meet in small groups for learning purposes.

Through the years, the staff of the Rural Health Program has modified and adapted the training curriculum of health assistants to the changing health conditions of the population. Costa Rica is a small and relatively homogeneous country as regards its health problems and cultural traits. Two markedly different population groups, however, live in well-defined geographic areas: the African-Caribbean community on the Atlantic coast, and the Indian community in dispersed mountain villages with rudimentary means of communication.

The Indian community of Costa Rica consists of approximately 20,000 persons who speak four different Indian languages. About half of them have some knowledge of Spanish. It has been quite difficult to provide them with any government health care. Some health posts have been established, but Indian houses are geographically so dispersed that very little has been accomplished.

Health staff for the Indian community is chosen on the basis of its Indian origin. They almost always have less schooling than the staff working in other parts of the country, because the Indians usually have low education levels: once more, their geographic dispersion is an obstacle to the work of the school system.

The Rural Health Program is constantly developing specific handbooks and brochures for learning purposes and/or to be used as visual teaching aids. The standards and procedures of all teaching materials are subject to periodic updates. In 1989, a team of nurses on the teaching staff of the program edited the book Técnicas Básicas para la Atención Domiciliaria (Basic Techniques for Health Care at Home), which summarizes the subjects to be learned by primary health care assistants (Garro et al., 1989).

Local Programming

The starting point of all health activities in each health area is a diagnosis that is made by the staff of the health post on the basis of a family survey and specific sets of data collected for each community. The health staff then records the family survey data on a printed family record card that summarizes basic information on family members and characteristics of their home.

During the survey, the health staff numbers houses sequentially by village. Later, they record the house number on the family record card, which is then filed at the health post. The same process is carried out in the 12 to 16 communities of each health area. Family record cards are used by the rural health assistant or the nurse's aide whenever a person comes to the health post seeking medical care. Since all family groups know their own house number, it is relatively easy to find their card.

The health post staff also keeps a village record card, which covers the following information for each community: presence (or absence) of schools and community centers, all kinds of construction, organizations, businesses, public transportation, etc. With this information, the health staff prepares a map showing all access roads, numbered houses, and specific geographic landmarks, such as rivers and creeks. The health staff then hangs the map on a suitable wall at the health post and uses it as a constant reference to determine the health post's sphere of action, to locate families, to determine distances between communities and houses, and to locate families at risk or persons with chronic diseases who require medical follow-up (identification with different-colored pins).

The health staff analyzes all information collected and makes a diagnosis which is used to prepare the health post's annual program. For example, by combining village and family record cards, the health staff may determine that in a given village, 20 families are lacking latrines or that a specific group of children under six years of age has not completed its vaccination program. To give another example, if the health staff knows that the health area covered by it has 3,000 inhabitants and a birth rate of 33/1,000, it may calculate that approximately 100 births are expected per year; in practical terms this means that the health post will have to order polio, DPT, and measles vaccines for 100 children.

Community health diagnoses are updated annually with information collected during the last home visit. This information is also used to program the activities of the health post for the coming year.

As already described, one of the most outstanding characteristics of the Rural Health Program in Costa Rica is the house-to-house visits made by its health staff. Programming of the visits is therefore crucial. Both rural health assistants and nurse's aides plan between 8 and 12 home visits per working day, depending on the geographic dispersion or concentration of the houses. The numbering of the dwellings permits the staff to program a specific number of home visits per day, to keep track of all houses visited (using six-month forms), and to set up a work calendar that ensures an efficient system for home visits.

In conjunction with health area personnel, the field supervisors set up the local programming according to the coverage guidelines, goals, concentration standards, types of service, and other elements established in the Guidelines for Programming. The plan of activities enables the identification of the different activities to be implemented by each village.

Supervision

The supervision of all activities undertaken by the health staff is an important element of the Rural Health Program. Supervision ensures work quality, continuity of actions, and the possibility of introducing any necessary adjustments.

Two modalities of supervision were established: operational/managerial and technical supervision. A field supervisor takes care of the former, while graduate nurses or physicians take care of the latter.

The operational/managerial modality is in the hands of an auxiliary health staff member who, in recognition of his or her capacity and interest in the work, has been promoted to Sectoral Director, later called Field Supervisor. Each Field Supervisor is in charge of five to seven health areas and visits each of them every four or five weeks according to an itinerary. They have appropriate transportation at their disposal, generally a four-wheel-drive jeep, and all necessary logistic support to facilitate their field work.

The Field Supervisors are the principal links between auxiliary health staff and health centers and are in charge of a whole range of activities. They see to it that all health posts are supplied in a timely manner with drugs, forms, and basic equipment. They participate in data analyses and in the preparation of the local programming. They also indirectly supervise communities and family groups visited by the local health staff and are included in their itinerary. They are responsible for granting leaves of absence (for illness or other causes) and applying minor sanctions to their subordinates, looking after transportation equipment, transporting supplies, and analyzing reports. Once a month, the Field Supervisor drives the graduate nurse in charge of the technical supervision and the physician in charge of selected medical consultations to the rural health centers. Finally, the Field Supervisors coordinate health actions with other institutions working in the geographic area under their command.

The technical supervision is assigned to nurses or physicians, who visit health posts periodically. This supervision is oriented toward ensuring quality in the health services provided to the population. Physicians and nurses of the central level are assisted in this task by staff working in health regions or health centers.

To do their work, operational/managerial and technical supervisors are specifically trained in courses or meetings held for each health region, which use a simple supervision guideline developed by the Rural Health Program. They maintain a close relation with all staff members working in health centers, which rank above health posts. Their goal is to keep the medical and nursing team informed of its compliance with their health work and of the problems arising from it, with a view to implementing immediate solutions. Personnel of health centers in conjunction with Field Supervisors usually execute the technical supervision, using the means of transportation of the Field Supervisors.

Transportation

The staff of the Costa Rican Rural Health Program is characterized by its constant mobility. One of its principles is that no matter how distant or isolated a house may be, it must be visited periodically. The program has provided each health area with transportation suitable to its geographic conditions and means of access, such as horses, motorcycles, bicycles, or motorboats. Supervisors also have jeeps. A preventive maintenance and support system ensures good functioning of the vehicles and gives orientation periodically to field staff on how to take care and profit most from the available means of transportation.

Supplies

Basic equipment and materials are assigned to each work area. For this purpose, different supply modules are prepared containing clinical equipment, drugs, office supplies, clothing, and staff equipment. A quarterly module specifies clinical equipment, drugs, and office supplies. Finally, a specific annual module contains a shipment of clinical equipment, drugs, and forms.

The Rural Health Program uses these modules to program the opening of health posts and equip them fully according to annual schedules, to ensure future health post supplies by registering the number of health areas that are to operate in the coming years, and to adapt and update the allotment of future equipment and supplies according to the situation of each area and the activities to be implemented there. The field health staff is responsible for verifying all allotted equipment and materials upon reception, for giving proper maintenance, and for making good use of them.

Community Participation Organization

Since its very beginning, community participation has been an essential element of the Rural Health Program. The health staff discusses the results of village and family surveys with community representatives, who then commit themselves and the community to participate in the implementation of the program.

At the beginning of 1970, the Costa Rican government fully endorsed popular organizations for the integrated development of urban and rural communities (Villegas, 1978). Governmental support was channeled through the National Director's Office for Communal Development (DINADECO), an agency of the Ministry of the Interior. DINADECO engages promoters to organize communities, to make them aware of their social and developmental problems, and to prompt them into action. The rural health staff coordinates these actions with DINADECO's promoters, with the goal of creating Community Development Committees which, through an organizational maturation process, become Associations for Integrated Development (ADIs). ADIs are made up of at least 100 citizens of both sexes, from one or more communities, linked by common problems, geographic closeness, or political and administrative territorial unity.

In the 1970s, the ADIs obtained legal status and gained partial access to the 1.25% of the income tax allotted to communal programs. At the same time, they had easier access to loans from the National Banking System, so that they received donations in a more expeditious manner and the management of their own activities was facilitated. One or two Development Committees, which progressively evolved into Development Associations, were established in each health area. By the end of the 1970s, Costa Rica had approximately one thousand Development Committees or Associations.

Communities organized in this fashion became involved in the Rural Health Program in analyzing the results of the initial diagnosis, donating sites for health facilities, constructing health posts, and providing furniture for the health post, fuel for refrigerators, forage for horses, and other supplies necessary for the development of the program.

Communities and field health personnel at periodic meetings analyzed the progress of the program and the community participation in communal activities, such as the construction of small aqueducts, latrines, wells, and other infrastructure.

To keep the community better informed of its development situation and more involved in the health program, the Rural Health Program designed one-week training courses for community leaders in each health area.

Home Visits

Systematic and planned home visits seem to be the only alternative to make home environments sanitary and to develop disease prevention and health promotion activities among dispersed rural populations and underprivileged urban groups. Since individual housing facilities are considered the first level of service in the primary health care strategy, sanitary actions are undertaken here first. Home visits are important for the following reasons:

· The observation of home and family conditions makes it possible to determine changes to be achieved to improve the home, to prevent or detect diseases early, and to induce healthier attitudes and behavior among the population.

· The educational level and the cultural conditions of these population groups do not permit the people to recognize the importance of the preventive and curative health actions implemented by staff of the health center (vaccinations, pregnancy monitoring, growth and development monitoring in children, etc.). This explains why a many families go to health centers only during advanced stages of a disease.

· Frequently, it takes one or more hours, using poor transportation, to get to the health center. It is more logical, therefore, to have a single healthy person (i.e., the rural health worker) visit the homes of neighboring villages instead of having sick persons, pregnant women, and children go all the way to the health center.

· Home visits permit the detection and proper follow-up of patients with chronic diseases.

· The information obtained from home visits and family surveys may be helpful in designing other development programs and in orienting and supporting operational research studies.

· Home visits may promote health self-care among the people. Further more, home visits may foster the transfer of appropriate technology which allows an active family involvement in health preservation and caring for the ill who require prolonged health care.

The home visit is the key activity of the nurse's aides and rural health assistants working in the Rural Health Program. Even though program staff is aware that volunteers may also be proficient in this task, in Costa Rica only health personnel perform it.

Each health area includes a group of villages or neighborhoods with target groups for which it is responsible. Houses are numbered sequentially either by quadrants or by streets. The number so assigned is painted with a black marker in a visible place at the entrance of the house; an arrow indicates the direction taken by the numbering.

A small card recording the visit is placed inside the house door. It contains the date and name of the health staff member making the visit. The house number is also used for the family record card, which is filed in the health post. Home visits generally last 30 to 45 minutes and are made every two or three months, depending on the time available to the rural health staff.

Actions to Be Undertaken During the Home Visit

Health workers undertake a series of actions during home visits for the purpose of studying the people and their surroundings. They follow a scheme of observation that covers the most important problems of the population group surveyed. Home visits permit the identification of health risks and the design of specific priority activities for each family group. Each home and each family group has special characteristics. In this context, however, the task of the health worker is to identify and stress any special home or family situation that is likely to be improved.

Depending on the resources available and the development stage of the program, home visits may include more complex activities, such as taking the blood pressure of pregnant women and adults, the determination of urine glucose in diabetics, and visual acuity tests.

In a survey done in a specific geographic area in 1988 (Ministerio de Salud, 1976), 77% of the landless and 72% of the landholding peasants considered the home visit of the Rural Health Program very important. Only 2% and 3%, respectively, did not consider it of any importance. Regarding the quality of the home visit, 72% of the landless and 74% of the landholding peasants considered it good. Twenty-five percent and 21%, respectively, considered it fair and 3% and 5%, respectively, considered it poor.

Information System

The Rural Health Program developed its own data system using the model established by the Department of Statistics of the Ministry of Health as a reference. It provides information for assessing and monitoring health activities at the local, regional, and central levels. It also generates information for community and family diagnoses, for programming of activities in health centers, villages, and health areas, for implementation of activities, and for control and assessment of results.

The health staff records all health activities that have been implemented using specific forms, such as vaccination forms to record the number and type of shots given, as well as the age group vaccinated; mother and child forms to register weight and height of children under five years of age, prenatal monitoring, and family planning; population forms to record basic demographic information such as births and deaths in the community; medical care forms to keep track of all health services provided to individuals; and daily activity forms to record health services provided for each house. Every month, the health staff transfers the data contained on the daily activity forms to the monthly report forms, which provide an overview of all health activities broken down by date, village, and type of work. The health staff sends the monthly report forms to the corresponding health center and regional office, where they are analyzed for purposes of control.

Costs and Financial Resources

During the 1970s, the income redistribution mechanism implemented by the government led to a remarkable increase of financial resources assigned to health and nutrition (Table 1). As a matter of fact, from 1970 through 1980, per capita expenditure in the health sector increased constantly from US $29.5 to US $155.0. Costa Rica's severe economic crisis during the first half of the 1980s, nevertheless, resulted in a marked curtailment of the country's health budget. In 1983, per capita expenditure had dropped to US $72.5 (Sáenz, 1985).

In 1973, the total cost of the Rural Health Program represented 0.4% of the country's health budget, reaching a 2.5% peak in 1977. Later, this figure started to decline despite rising absolute costs of Table 1. In 1982 it had fallen to 1.97% and was expected to continue dropping; no updated data are available, however, to confirm or reject this estimate.

Per capita cost of the Rural Health Program was estimated at US $2.5 at the beginning of the program. In 1975, this figure had increased to US $5.5, reaching US $9.5 in 1980 (Sáenz, 1985). Data include program outlays to acquire and install water pumps and latrines, particularly after 1976. However, direct per capita cost of the program was US $2.72 in 1973 and US $3.21 in 1982; these figures do not include wages of professional staff at the central level, drugs, laboratory materials, or construction of facilities.

Extension of Coverage

At the end of 1973 and the beginning of 1974, the Rural Health Program already had 70 working health posts covering 230,000 persons. By the end of 1975, another 70 health posts had been installed and the program was covering 437,000 persons living in 2,240 communities (see Table 2).

Beginning in 1973, the coverage of the program and the number of installed health posts increased steadily up through 1989, to cover approximately one million inhabitants with 371 functioning health posts.

TABLE 1. Total Expenditure on Health and Primary Health Care Programs in Costa Rica, 1973-1983

Year

Expenditure on Health (colones)

Rural Health

Primary Health Care Programs




Community Health

Total

Expenditure on Health (%)

1973

616.4

2.4

-

2.4

0.4

1974

739.4

4.2

-

4.2

0.6

1975

998.4

15.9

-

15.9

1.6

1976

1,230.7

21.5

0.8

22.3

1.8

1977

1,508.3

35.8

1.7

37.5

2.5

1978

1,852.0

34.5

5.8

40.3

2.2

1979

2,533.3

44.7

6.7

51.4

2.0

1980

3,157.3

57.8

8.1

65.9

2.1

1981

3,784.9

60.6

9.6

70.2

1.9

1982

6,255.3

98.7

18.1

116.8

1.9

Source: Sáenz 1985a, pp 42-44

From 1982 to 1979, 1 US$=8.60 Costa Rican colones; in 1980, 1 US$=9.2 colones; in 1981, 1 US$=21.2 colones; in 1982, 1 US$=40.0 colones.

The Community Health Program for Urban Areas

The Community Health Program for Urban Areas started in 1976. Two years later, the Ministry of Health analyzed the health situation of the San José metropolitan area and the country's medical care system. At that time, the Ministry became aware that large underprivileged areas had emerged in conjunction with the recent Costa Rican urbanization process. Furthermore, the Ministry recognized that in the deprived areas, most families were very poor, lived in improvised dwellings, had high unemployment rates, and showed marked social pathology. Fathers were missing in many families and mothers were responsible for raising their numerous offspring. Their adult educational level was below the national average. As a result of poverty, overcrowding, and undesirable sanitary conditions, the population, especially children, had a high prevalence of infections and malnutrition. Not only the capital city, San José, but also other urban centers, particularly the ports of Limón and Puntarenas, had similar problems.

The traditional health care system was not able to cope with the situation. Health centers, accustomed only to providing health care on demand, responded inefficiently to the health needs of the communities. Additionally, the social characteristics determined that the majority of the population sought health care only when people were very sick, in other words, when the harm caused by the disease was already advanced. None of the preventive health actions, such as vaccines, prenatal control, reproductive health measures, and others, were reaching their goal. As a result of this, sanitary conditions at the home and community levels did not spontaneously improve, and the health system was not able to introduce any corrective actions in this regard.

TABLE 2. Indicators of the Costa Rican Rural Health Program

Years

1973-1974

1975

1980

1985

1989

Population covered

230,000

437,000

728,000

834,000

968,000

Homes covered

43,800

79,700

160,900

201,200

247,500

Communities covered

1,250

2,240

4,018

4,174

5,013

Health poses

70

140

290

318

371

Rural population covered (%)

19

33.6

59.5

61.6

67

Source: Ministerio de Salud (1975), and records from the Primary Health Care Department

Faced with this dramatic health situation in San José and other urban centers, and recalling the positive experience with the rural health posts as opposed to the static role of the health centers, the Ministry of Health decided, at the end of 1974, to seek a new health care strategy for deprived urban communities.

A priority action of the 1974-1978 National Plan for Economic and Social Development was the improvement of the health status of Costa Ricans. It was considered fundamental "to close the social gap" and to improve their standard of living. The Social Development and Family Allotment Law, enacted at the end of 1974, provided the economic resources to implement health and nutrition programs in deprived urban and rural communities. Funding for this law comes from contributions paid by employers, amounting to 5% of the salaries and wages of all employees. Whereas in 1975 this fund provided 20.0 million colones (US $2.3 million) to health and nutrition programs, in 1980 it reached 154.0 million colones (US $18.0 million).

In 1974, the Ministry of Health started a health diagnosis survey using information collected from family record cards in a suburban population group of San José with 8,000 dwellings. The Ministry prepared the Community Health Program for Urban Areas during 1975. With a view to implementing it, the Ministry trained staff, established work methods, and developed standards for the program. Additionally, the Ministry of Health expanded the same diagnostic survey to other zones of the San José Greater Metropolitan Area. It also delimited health areas including 750 to 800 homes each. In 1976, 18 urban community health areas started to function, containing approximately 15,000 homes and 84,000 inhabitants.

The health program for urban communities was based on 12 principles, which deserve emphasis:

Service mystique. Program staff must be convinced of the need and importance of the program in order to dedicate themselves fully to its implementation.

Extramural work. All health actions aiming at knowing and improving the health situation of families and communities and at solving detected health problems require staff work at the home and community levels, i.e., outside the health centers.

Active involvement of the community. If a community is properly motivated, it will participate fully in the search for solutions to undetected problems. Program staff should focus the community's attention on health, social, economic, and cultural issues, always trying to profit maximally from available community resources.

Coordination. Actions should be coordinated with other health care and social welfare agencies working in the community. In this way duplication of services can be avoided and integrated solutions will be achieved at a lower cost.

Diagnostic survey and definition of health areas. A diagnosis of families and communities is necessary to ensure effective solutions to local problems. All areas chosen for the program should be surveyed before any program activity is implemented. A community health survey card should be used for this purpose. The card allows the collection of information needed to make the health diagnosis and to plan future activities at the local level.

Holistic approach. The solution to community health problems requires a holistic approach, which should take health promotion, prevention, and recuperation into account, as well as rehabilitation of physical, mental, and social damage to individuals and to the community as a whole.

Consultants in specific areas. The work done by the staff of the health centers as well as by primary health personnel must be complemented with the expertise of advisors for specific areas, such as experts on community organization and development.

Redistribution of functions. The solution to health problems in urban deprived communities requires the redistribution of health functions and activities of all the staff working at the basic intermediate level. In this context, auxiliary personnel should take care of problems of low complexity, thereby increasing the program's usefulness and coverage.

Continuous in-service education. A continuous in-service educational program for all the staff should train the human resources needed to implement the Community Health Program for Urban Areas efficiently.

Supervision. The program needs permanent supervision to see to compliance with the established standards and the achievement of its initial objectives and goals.

Evaluation. The program objectives and goals should be evaluated periodically in terms of costs, coverage, impact, quality, and performance, with a view to making the necessary adjustments.

The activities of the Community Program for Urban Areas are similar to those of the Rural Health Program, but they give priority to health and nutrition of children and women, as well as to basic sanitary and health education. During its first year, the program had as basic staff nurse's aides who had 11 months of training. At present, nurse's aides are stationed at the health centers, from which they go daily to their health areas to visit 12 to 14 homes each, for a monthly average of 200 to 225 homes per nurse's aide.

Nurse's aides organized Committees of Neighbors by obtaining the participation of other government agencies that also worked with deprived population groups. Volunteer workers, called block leaders, were identified through the Committees of Neighbors and were trained in health promotion, detection of persons with chronic illnesses, detection of pregnant women and children who were not being monitored by the health center, and environmental sanitary measures. In 1977, health volunteers received a three-month formal course, thus becoming community health assistants and acquiring the status of auxiliary institutional personnel of the Ministry of Health. Since then, they have become the program's basic staff.

In 1977, the number of homes per health area had to be decreased to 450-500 to give basic staff additional time for activities with schools and organized groups. The same year, the program was progressively expanded to other urban centers. By 1979, the program had already established 240 health areas and was covering 600,000 persons; this coverage was maintained during the 1980s.

A graduate nurse working at the health center undertook the technical and administrative supervision of the program. Usually, she was in charge of four to six community health assistants, thus establishing community health sectors for population groups of approximately 10,000. Medical directors of the health centers, with few exceptions, were not directly involved in the program's development. Nurses promoted and supervised the program from its inception and were also responsible for in-service staff training.

As in the Rural Health Program, home visits are also a priority activity of the Community Health Program for Urban Areas. In both programs, home visits are made systematically and in rotation, and have similar objectives. The reader should be aware, nevertheless, that urban and rural areas face different problems, particularly regarding social pathology (drug addiction, aggression against children and women, juvenile prostitution, and others).

Even though the Community Health Program for Urban Areas planned the construction of premises for health posts, this was not put into practice. The already existing urban health centers and the clinics built by the Costa Rican Social Security made the construction of the health posts unnecessary. Staff working the Community Health Program, including graduate nurses supervising it, have no vehicles available. They generally walk or use public transportation. In contrast to the male rural health assistants, community health assistants are predominantly female.

The following example illustrates how the Community Health Program for Urban Areas actually works:

Rita is a 23-year old community health assistant who has been working two years in the program. When she finished high school three years ago, she immediately applied for the course on community health, and received full-time training for four months. Rita comes from a working family and lives in the Los Hatillos Housing Development south of San José. At present she works in the Hatillo health center, 1 km from her home, and her work area is Aguantafilo, a deprived neighborhood located 500 m from the center. At the health center, Rita has a small desk and an outline of her work area on the wall. The layout is a detailed representation of all houses and buildings (numbered sequentially and by block), as well as higher risk sections or problem areas (indicated by different-colored pins) which require special attention, e.g., areas with chronic patients, pregnant women, malnourished children, or homes in poor condition. Rita has a file with family record cards of the 535 homes in her work area.

Every day before leaving the health center for community work, she reviews the corresponding record cards and prepares a small case with the following items: report forms, thermometers, a sphygmomanometer, referral sheets, educational material, and a small thermos bottle containing DPT, polio, and measles vaccines, as well as tetanus toxoid. She comes back to the health center at approximately 13:00, where she does work such as recording the results of her visits on the family cards, reviewing family record cards of all homes visited to verify the families' vaccination status and other social or health problems, and preparing a daily report, which includes a standard form listing all vaccinations given. Furthermore, she usually discusses with the supervising nurse, the social worker, or the basic sanitary inspector the problems identified that may require further interventions.

Rita's daily activities also include analyzing the conditions of families and homes, reviewing health cards of children and mothers, inquiring about non-monitored pregnancies or about the use of family planning methods, checking medical appointments and drugs used by chronic patients, and informing people on how to prevent home accidents. Finally, Rita is in charge of keeping in touch with community leaders and of meeting once or twice a week with the main committees of the community.

The San Ramón Hospital Without Walls Program

In 1972, the director of a 110-bed rural hospital located in the county of San Ramón decided to establish a community outreach program, which he called Hospital Without Walls (Ortiz Guier, 1974). With this term, Dr. Juan Guillermo Ortiz Guier wanted to describe an open-door hospital committed to projecting its staff, mainly physicians and nurses, to the 40,000 people living in the rural communities of the county. In the three to four years after 1972, the Hospital Without Walls Program expanded to three more counties - all of them coffee-producing counties with the lowest per capita income in Costa Rica - within the area of influence of the San Ramón Hospital. The program reached a peak coverage of approximately 80,000 people living in dispersed rural population groups, without taking into account the residents of the four county capitals. By the end of 1976, there were 44 functioning health posts.

The basic idea of the program is the establishment of health posts, each run by a nurse's aide, conveniently located in small rural communities covering 1,000 to 1,500 persons (200 to 300 homes). The nurse's aides were trained to carry out mother and child health activities, to handle emergencies and common uncomplicated diseases in adults, and to follow up chronic patients. Furthermore, they were trained to implement basic sanitary measures, as well as community organization and development activities. The health posts of the program were properly equipped to permit nurse's aides to do their work and to give medical or nursing consultations to the population once a week.

One of the strengths of the Hospital Without Walls Program was that it organized communities into development associations or health committees. These associations participated actively in constructing, equipping, and later maintaining the health posts. They were also involved in a series of activities for the well-being of the community, such as the construction and improvement of roads, bridges, and electrical networks, and agricultural and animal husbandry activities. The program fostered the organization of cooperatives in different areas of the four counties. It also contributed to integrating the representatives of the associations and committees into a federation of associations, which is represented and empowered to make decisions in the Health Council, the governing body of the Hospital Without Walls Program.

The program included a weekly medical visit to each health post by physicians of the local hospital, general practitioners, pediatricians, gynecologist-obstetricians, and internists. Most of the consultations, even for patients with complex conditions, were given at the health posts. Physicians and graduate nurses working at the health centers of the program area also participated in the medical visits to the health posts of the program. In this manner, the program structured and developed an excellent health service network which covered 100% of the population, while implementing a series of decentralization actions at the community level.

The Hospital Without Walls Program visited families living in the sphere of influence of all program health posts even though home visits were not planned in a cyclic manner. The families that were visited were those considered at high-risk because of deficient housing conditions or the presence of malnourished or low-birth-weight children, elderly family members, or patients with chronic illnesses (diabetes, hypertension, psychiatric conditions, cerebral lesions). Occasionally, nurse's aides replaced graduate nurses or even physicians on the home visits.

The program also included the training of health volunteers, who became very involved in the health process by participating in the health post activities, visiting homes, and implementing environmental sanitary measures. Graduate nurses assigned to the Director's Office for the program in San Ramón or to the health centers in the other three counties were responsible for supervising field staff.

The Hospital Without Walls Program developed importantly after its initial years until the mid-1980s, due above all, to the unquestioned leadership of its founding director for fifteen years. During this period the program achieved an important national impact. It was presented and analyzed by various groups at medical congresses and specific meetings. However, only one additional hospital, La Anexion, in Nicoya implemented a similar project. Since the first director, the program has had four more directors, none of whom were directly linked to the hospital. It also has the drawback that hospital physicians have had a limited participation in the program, and that the hospital's administration was transferred from the Ministry of Health to the Costa Rican Social Security Institute. At present, the program continues to work on community organization and the promotion of community participation. Graduate nurses and general practitioners of the health centers continue to visit the health posts. However, the strength and dynamism of the program, which were derived from its founding leader and which characterized the program for nearly 15 years, are no longer present.

The Rural Health Program of San Antonio de Nicoya

San Antonio is a district of the Nicoya County in the northern region of the country. In 1974, when a rural hospital in the capital of Nicoya County was inaugurated, two pediatricians - a recently graduated specialist and a professor of the Costa Rican School of Medicine - decided to establish a community health program in San Antonio (Becerra-Gómez et al., 1976-1977). At the time, the district had approximately 7,500 inhabitants distributed among 1,200 families living in small villages and in dispersed rural population groups. The San Antonio program emulated the San Ramón health community model and established small health posts run by trained nurse's aides in five different communities. The program stressed the importance of periodic home visits for the purpose of improving sanitary conditions of the homes and implementing some health actions for the people. Health education and mother and child activities were also considered important. Once a week, each health post was visited by a general practitioner from the hospital or by a pediatric resident who was doing two months rotation of field work as a postgraduate student at the National Children's Hospital. As in San Ramón the staff of the San Antonio program fostered the integration of health committees, community development associations, and cooperatives. The program also trained volunteers to do health work and promoted community participation with such an impetus that productive projects started to develop and the health status of the community began to improve. During its first 10 years, the San Antonio program showed a tremendous growth. Even today, it continues growing, but with less force.

This rural health initiative had an extraordinary impact on the country. On the one hand, it was the first community health program run by the Costa Rican Social Security Institute. On the other hand, it had a strong teaching component which was used by the School of Medicine of the University of Costa Rica for medical undergraduates and pediatric students doing postgraduate work. According to Dr. Guido Miranda, Medical Administration of Social Security:

We knew that difficulties would confront us in attempting to initiate changes in traditional practices responsible for environmental sanitation, that all countries, and ours is no exception, face extremely closed circles traditionally opposed to change. It was even more fascinating to the health team, in association with other necessary disciplines, to propose and receive support from the community to stimulate the flourishing of small artisans and of agricultural programs with better nutritional yields. (Becerra-Gómez et al., 1976-1977)

There is no doubt, as confirmed by different evaluations, that the San Antonio community health program led to momentous changes in the health status of the population and to improvements in the well-being of the communities. Its most significant achievement, however, was to change the attitude of some professionals in medicine who experienced this. Since then, they have played a leading role in reorienting our health system towards a family and community medicine.

Main Changes Achieved by the Rural Health and Community Health Programs

In the 1970s, the Rural Health and Community Health Programs did not change substantially. As already stated, in 1977 a health technician with a three-month training course replaced the nurse's aide taking care of urban communities, and the nurse's aide assigned to other functions in the health centers. In 1979, a political change in the country's administrative system gave the health committees an extraordinary impetus through the Ministry of Health. The government created the Community Participation Unit at the central level of the Ministry of Health and gathered financial and human resources to promote the creation and follow-up of health committees throughout the country. During the following three years, the programs promoted the establishment of health committees in all rural and community health areas and trained a considerable number of health volunteers to assist institutional staff in carrying out health activities. The programs started to undermine the population's support of DINADECO and to weaken the health involvement of the Community Development Associations. In several communities, DINADECO and the Community Development Associations started to compete against each other, creating conflicts. As of 1982, DINADECO once more became the most important government agency promoting community organization and development. At the community level, health committees usually were members of the Community Development Associations; the health staff worked with them closely.

During this decade, the staff training course was increased by 1 month and later by another month, thus reaching its present duration of five months. Educational requirements for both programs were increased from 9 to 11 years, i.e., a high school diploma in Costa Rica. The trend still persists of having more women working as urban health assistants and more men working in rural areas.

In 1979, information and data processing systems of both programs were unified. This measure permitted the standardization of data forms, information analysis, and comparative analyses.

During the 1980s, both programs underwent important changes, some of which contributed to their improvement, whereas others had questionable advantages or were simply negative.

Prior to 1984, each program implemented its own staff training course. The unification of both courses in 1984 brought advantages to teaching by increasing the availability of teaching staff and the amount of teaching materials, handbooks, and field work areas.

In 1985, a study on urban impoverishment contributed to the definition of urban operational areas. In 1986, a scoring system based on 10 social and health indicators permitted the identification of 30 priority counties from a total of 81 in the country. In the five years thereafter, UNICEF's Child Survival Project and other national and international agencies strengthened the health programs by targeting people and the environment in the 30 priority counties. The underlying strategy was "to close the existing gap" in health indicators. The Family Care Project Using the Risk Approach was implemented in 1986 by selecting 40 community health areas and 20 rural health areas. Its goal was to decrease the number of homes visited by a health assistant by classifying homes according to family risk categories: higher-risk families were visited more frequently, whereas lower-risk families were either visited once a year or excluded from the program.

Even though the project was put into operation in many urban and rural health areas, it has neither been properly followed up nor assessed. Apparently, health staff did not use the family risk classification system adequately and misinterpreted the home visit criteria.

In 1987, a ministerial decree officially integrated Rural and Community Health Programs. The 1987 decree established joint headquarters at the central level of the Ministry of Health, as well as the name primary health care program. Auxiliary personnel, working at the operational level, became primary health care assistants. The new nomenclature created some confusion in regard to the classical concept of primary health care, because it had the connotation that primary health care was equivalent to the health program implemented by auxiliary personnel. For this reason, another ministerial decree in 1989 changed the name of the program to its present one: Integrated Health Program. It includes rural and community health, nutritional and dental components, and malaria control.

Nurses took on the supervision of technical and administrative aspects of the Rural Health Program in 1989. This meant the elimination of the Field Work Supervisor, who was formerly in charge of supervising administrative activities, transporting supplies, assisting in the annual programming, and giving impetus to the program in various ways. Because there was a lack of graduate nurses, most of the supervisors appointed in 1989 depended specifically on each health center. Unfortunately, means of transportation decreased progressively: the supervision system, which had been an important element of the Rural Health Program, deteriorated to such an extent that it disappeared totally in some areas of the country.

A six-month training course was established in 1989 for primary health care assistants, which conferred the Nurse's Aide Certificate on participants. The fact that the certificate allowed them to work in health centers, hospitals, and clinics of the Social Security Institute, however, had negative consequences: a large number of staff trained in this course did not stay with the program but preferred to work for other health agencies.

The health regionalization process also had an impact on the program. As of 1988, health regions had a greater bearing on budget and program management; furthermore, the central level started to play progressively the role of a standardizing and consulting entity to the health regions. This process, unfortunately, also implied the exclusion of the regional rural health supervisor (replaced by a supervising nurse who, in most cases, was not able to fulfill this task), who had been an excellent link between Field Work Supervisors and the central level. At present, the technical team working at the central level is practically excluded from all direct actions related to the program. Team functions are concentrated on standardization aspects and ongoing educational activities.

Nutrition programs

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 José. They 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 ñampi, 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.

Warm Meals

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.

Milk Distribution

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 Educación "Bulletin. 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.

Radio Programs

"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.

Preschool Education

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.

School Cafeterias

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.

Food Fortification

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 (Pérez 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 José metropolitan 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

1975

1981

1986

Educational institutions

2,600

2,905

2,905

School cafeterias

1,194

765

2,792

Schools covered (%)

44.4

95.3

94.6

Beneficiaries (No.)

a

a

434,700

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.

Impact of the programs on the health of children living in rural areas

Much research and many reports have analyzed the health and nutrition status of the Costa Rican population during the two decades covered by this study (González-Vega, 1985; Ministerio de Salud, 1976; Sáenz, 1985b; Sandiford et al., 1991; Villegas and Ozuna, 1979). Most of them analyze the trends of national health indicators either as a whole or broken down into urban and rural categories. There are two health and nutrition indicators, however, which have been followed through the years by locality (broken down into counties and even smaller geographic units, such as districts). These indicators are infant mortality and height of children entering school. Both indicators reflect the health and nutrition situation during childhood, including the impact on the mother and child of the environment and the health services.

Infant Mortality

Toward the end of the 1960s, infant mortality in Costa Rica was greater than 70/1,000 live births. In 1970, the national average was 68.2/1,000 live births; the Huetar Atlantic Region, however, attained 110/1,000 live births (Behm and Robles, 1988). At the time, Costa Rican infant mortality did not differ considerably from that of other Central American countries (Behm and Robles, 1988; Behm and Barquero, 1990).

All health regions showed a dramatic drop in infant mortality during the 1970s. The drop was proportionally greater in those regions which had higher infant mortality figures initially (see Table 4).

Infant Mortality by Degree of Urban Density

The higher the degree of "rurality," the more unfavorable living conditions are for the population. Therefore, infant mortality is expected to be higher in rural than in urban areas. As shown in Table 5, this difference was noticeable in 1970; however, it began to disappear by the end of the 1970s.

Infant mortality rates were stable from 1980 through 1985 and then dropped further. Thus all population groups studied, and particularly those from rural areas, showed a significant decrease in infant mortality rates. The absolute difference between urban and rural infant mortality rates, therefore, tends to decrease with time. All this implies that in both absolute and relative terms, the infant mortality rates of rural areas decreased more than those of urban areas.

Causes of Death in Children Under One Year of Age

By 1986,82% of all deaths of children under 1 year of age were certified by a physician, and nearly all deaths were duly registered (Behm and Barquero, 1990). In 1970, the main cause of death in this age group was infectious disease: approximately 25% of the children died of intestinal infections and 20% of respiratory infections. Ten years later, infant mortality rates had decreased as a result of the control of diarrheal diseases (36% of the total decrease in infant mortality rates), control of acute respiratory tract infections (22%), and vaccinations to prevent other infectious diseases (9%). Perinatal causes of death also decreased during the same time, but to a lesser degree. At present, perinatal events continue to be the most frequent cause of infant mortality (see Table 6). It should be noted, however, that they decreased significantly in both rural and urban populations between 1985 and 1989.

TABLE 4. Trends in Infant Mortality by Costa Rican Health Region, 1970-1990

Year

Region


Central

Northern Huetar

Chorotega

Atlantic Huetar

Brunca

1970

68.5

87.5

88.9

110.1

84.0

1975

38.7

53.8

52.9

81.9

58.2

1980

21.7

21.2

26.4

31.5

22.0

1985

21.0

19.5

19.8

25.7

24.6

1990a

13.3

19.3

18.4

19.4

18.2

a Office of the Director of Statistics and Surveys; tabulations of deaths, 1990

Source: Behm and Robles, 1988

TABLE 5. Infant Mortality in Costa Rica by Degree of Urban Density, 1970-1989

Degree of Urban Density

Infant Mortality per 1,000 Live Births


1970

1980-1981

1984-1985

1988-1989

Total urban

50.1

16.8

16.9

13.5

Metropolitan area

45.8

16.3

16.1

12.6

Intermediate citya

57.4

17.0

17.9

14.5

Remainder of urban population

54.5

17.9

18.0

14.8

Total rural

70

21.7

20.7

16.3

a Includes 10 cities with more than 12,000 inhabitants

Source: Behm and Robles, 1988; Behm and Barquero, 1990

Trends in Infant Mortality Rates by Counties

In 1970, 71 out of 75 counties in the country had infant mortality rates greater than 30/1,000 live births, and some of these even had rates greater than 100/1,000. In 1981, however, only 7 out of 81 counties had infant mortality rates of more than 30/1,000, and 51 had rates of less than 20/1,000.

Infant mortality rates continued to improve in 1988. More than one-third of all counties (31 out of 81) had rates below 10/1,000, and only two had rates greater than 30/1,000 (see Table 7).

Nutritional Status of Children: Height Censuses of Children Attending First Grade

The height of seven-year-old children is an indicator that reflects the nutritional and health history of children in a population. In the early 1970s, Bengoa proposed height for age in seven-year-old children as a nutritional indicator to measure how social problems affect early childhood. Stunting at this age reveals, both the impact of nutrition, infections, and the effectiveness of health services. The first height census with national coverage was implemented in Costa Rica in 1979, as part of a national information system on nutrition. At the time, studies were being initiated in other Central American countries on stunting in seven-year-old children and its relation to other social indicators (Valverde et al., 1981). It was concluded that height at age 7 was a highly significant indicator of the social, nutritional, health, and environmental factors that have an adverse impact during the first years of life and, prevent children from developing their full growth potential.

TABLE 6. Infant Mortality Rates by Cause of Death, 1970-1989

Cause of Death

Infant Mortality Rate per 10,000


1970

1980

1985

1989

Contagious and parasitic diseases

250

22

13

10

Intestinal infections

170

15

10

8

Immunopreventable diseases

42

1

0

0

Malnutrition

21

2

2

2

Acute respiratory infections

23

26

16

12

Perinatal causes

143

83

92

63

Congenital abnormalities

30

40

40

44

Trauma and accidents

4

4

2

2

Other causes

48

13

11

6

Source: Behm and Robles, 1988; Behm and Barquero, 1990

The national height censuses included all children registered in first grade throughout the country. Altogether, five censuses of this kind have been done in Costa Rica, in 1979, 1981, 1983, 1985, and 1989.

The growth standard recommended by the World Health Organization (WHO) has been used to compare height data among countries and within a single country in different time frames. Variations between average growth and the reference standard are expressed in terms of standard deviations (Z scores) and are classified according to the following break points or risk levels:

· Severe stunting:

-3.00 SD or less

· Moderate stunting:

-2.99 to -2.00 SD

· Normal height:

-1.99 to +2.00 SD

· Above normal height:

over +2.00 SD

In this analysis, all children under -2.00 SD are considered stunted.

Table 8 summarizes the height trends of Costa Rican children as perceived in the five height censuses done in the country's 81 counties (M.E.P./OCAD/SIN, 1979, 1981, 1983, 1985, 1989).

Counties with less than 5% are considered to have no public health stunting problems. Those with 21% or more stunted children entering first grade (about age 7) are considered to have high prevalences of stunting. Counties in the three intermediate categories, i.e., 6-10%, 11-15%, and 16-20%, are considered to have low, medium, and high stunting prevalence rates, respectively. In 1979, there were no counties without height deterioration, and 60 of the 81 counties had either a low or high prevalence of stunting.

TABLE 7. Infant Mortality Rates by Counties in Costa Rica, 1970-1988

Infant Mortality Rate per 1000 Live Births

Number of Counties


1970

1981

1988

£10

1

10

31

10.1-20

0

41

36

20.1-30

3

23

12

>30

71

7

2

Source: Sistema Nacional de Salud, 1990, p. 28

Table 8 shows that the height status improved progressively in time up to the last height census taken in 1989. As a matter of fact, in 1989 only three counties fell into the high stunting prevalence category and none had a very high prevalence of this condition; 45 had a low stunting prevalence. Without exception, all counties show a trend toward a decrease in the percentage of stunted children. Whereas in 1979 most counties had very high stunting prevalences, as time went by they moved into the no deterioration or low stunting categories. The three counties that still had a high prevalence of stunting in 1989 were highly rural counties with very dispersed populations that were predominantly Indian (Talamanca and Buenos Aires) or indigent Nicaraguan emigrants (Upala).

Conclusions

During the first half of the 1970s, the convergence of a number of factors led to the political decision to develop a health and nutrition program for rural communities. The experiences of both the Mobile Health Unit program, started in the prior decade, and the successful malaria control program were used to design and implement the Rural Health Program.

TABLE 8. Height Trends in Children Attending First Grade in Costa Rica, 1979-1989.

Height Censuses Taken in 81 Counties

Stunted Children (%)

Height Census


1979

1981

1983

1985

1989

£5

0

1

4

5

23

6-10

2

11

25

32

45

11-15

19

31

29

28

20

16-20a

25

26

17

14

3

³21

35

12

6

2b

0

a Talamanca, Buenos Aires, and Upala counties.

b Talamanca and León Cortés counties.

Source: Evolución de la situación nutricional pare áreas geográficas DESAF-SIN, 1990 (M.E.P./OCAD/SIN, 1979, 1981, 1983, 1985, 1989)

The Rural Health Program was conceived for dispersed rural population groups that live isolated from population centers and that are less protected by health services and other services provided by the Costa Rican government. Three or four years after its inception, the program covered more than 80% of the target population, i.e., one-third of the total Costa Rican population.

The rural health model developed incorporated several elements of the malaria control program. New staff were rapidly trained to carry out the specific tasks required by the health program in the rural areas. Functions were designed to control the principal diseases and health risk factors of the target population. An outstanding feature of the Costa Rican Rural Health Program was the home visits by the health staff. No matter how isolated a home was, it was visited three or four times a year.

Through the home visit strategy, the health staff was able to identify and modify the main environmental problems, as well as to develop an ongoing sanitary health and nutrition education process for the family. By designing specific activities, having an adequate selection of equipment and supplies, and careful programming and supervision, program staff were able to identify dearly resources needed and program costs for each health area. Because of this, the program expanded rapidly and adequate financial resources were provided.

All of the experiences obtained during three years of the Rural Health Program, together with the observation that the program had a positive impact on the health conditions of rural populations, led to the political decision to implement a similar program for deprived urban groups. The new program expanded rapidly to most populous centers as well as to provincial and county capitals. In this manner, a greater impact on the health status of the whole population was achieved.

The nutritional situation of the Costa Rican population was evaluated in the mid-1960s. At that time, a severe protein and calorie deficiency, particularly among children, was detected. Other specific nutrition problems, such as iodine, iron, vitamin A, folic acid, and fluoride deficiencies, were also identified. Most children showed some degree of stunting. The fact that diets were deficient in these key elements and that intestinal infections and parasites were highly prevalent contributed to the deterioration of the already weakened nutritional status of the population.

The first programs to deliver foodstuffs, provide food education, and promote small-scale family food production were started in the 1950s. During the mid-1970s, they were expanded rapidly to rural communities. Additionally, the iodization of common salt and the fortification of sugar with vitamin A were established at that time. The main activities of the rural and urban health programs included the control and prevention of vaccine-preventable diseases (measles, polio, whooping cough, tetanus, diphtheria, and tuberculosis) and the prevention and treatment of intestinal parasitic diseases. These activities, in conjunction with other health measures targeting high-risk population groups, contributed to a dramatic improvement in the health status of Costa Ricans, especially the youngest generations. Complementary feeding programs were extended to the most vulnerable.

Several factors, during the 1970s, unrelated to the health sphere certainly favored the extraordinary impact achieved on health indicators by the end of that decade. According to L. Rosero (1984), at least 40% of the changes observed can be explained by the primary health actions undertaken. It must also be borne in mind, however, that these dramatic changes occurred in a very short period of time after the profound health reforms were instituted.

Health and nutrition programs for rural communities and deprived urban population groups have had the political and financial support of different governments in Costa Rica during the last two decades. Recently, however, programs deteriorated progressively. In 1995 they are emerging from a severe crisis. Insufficient supplies and transportation, a shortage of supervision, and the lack of training for new personnel to replace staff or to open up new areas are some of the major constraints on the nutrition and health programs. As a result the rate of improvement in health statistics has declined, but the gains have not been reversed.

This deterioration is related to the restructuring process of the Costa Rican government, including the health sector, which began in 1990 as a result of the external debt crisis. One premise of the restructuring process is that all human health care programs should be the responsibility of and managed by the Costa Rican Social Security Institute (CCSS). In the framework of primary health care, the model encouraged by the CCSS contemplates integrated care to individuals, families, and communities, the delimitation of geographic areas with 600 to 700 families, and the establishment of basic teams for integrated health care (EBAIS). The EBAIS are made up of a general practitioner or family physician, a nurse's aide, and a primary health care assistant. In other words, the model that already existed in urban and rural communities was reinforced by the permanent presence of a physician. Approximately one thousand EBAIS are needed in Costa Rica. At present, the new model proposed by the CCSS is being successfully implemented in a number of areas. As the economic situation improves and the government's commitments to health are renewed, it is hoped that Costa Rica's health progress will continue.

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