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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

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.