(introduction...)

Editors: Carlos Muand Nevin S. Scrimshaw

© Copyright 1995 International Foundation for Developing Countries (INFDC). Boston, MA USA. All Rights Reserved.

ISBN number: 0-9635522-4-4

This project and its publication were supported by grants from the Pew Charitable Trusts and the United Nations University.

The digitalization of this publication was made possible by a grant from the Nestloundation

Contributors to this volume

Guido Miranda is with the Costa Rican Social Security Institute (CCSS) and former Assistant Director (1970-1978) and Executive President (1982-1990).

Edgar Mohs was the Costa Rican Vice-Minister of Health from 1975 to 1978 and Minister of Health from 1986 to 1990.

Carlos MuRetana is the Director of the Department of Primary Health Care of the Ministry of Health in Costa Rica.

Lenin Sz is the Chair of the Sectorial Planning Unit of the Ministry of Health of Costa Rica.

Nevin S. Scrimshaw is the Director of the United Nations University, Food and Nutrition Programme for Human and Social Development, Boston, MA USA, and Institute Professor Emeritus, Massachusetts Institute of Technology. He was Director of the Institute of Nutrition of Central America and Panama (INCAP), 1949-1961.

MarEugenia Trejos is a Professor at the School of Economics of the National University in Costa Rica.

William Vargas is the Director of the Preventive Medicine Department, Costa Rica Social Security Institute and Director of the Public Health Department of the Costa Rican School of Medicine at the University of Costa Rica, and former director of the Costa Rican Health Program (1974-1975).

Introduction

The remarkable improvement in health and nutrition statistics in Costa Rica from those of a developing country to those of industrialized countries in a single decade in the 1970s is without precedent. In 1970 the infant mortality rate in Costa Rica of 68 per 1,000 did not differ markedly from that of other Central American Countries and, in common with these countries, less than 10% of the health budget was allocated to preventive health measures (PAHO, 1994).

At the end of the decade the infant mortality rate had dropped to 19.1 (World Development Report, 1993) and health posts emphasizing prevention of communicable diseases, mother and child health, environmental sanitation, and health education covered 84% of the total population. Moreover, it was done with social harmony by the democratic government of a poor agricultural country that resolved to devote more adequate resources to the social contract. Although the improved economic circumstances of the 1970s helped to make a major increase in support of the health sector possible, it was no greater than in the other Central American countries that failed to utilize this opportunity. Today, despite the structural adjustment crisis of the 1980s, its infant mortality rate of 13.9 per 1,000 is the lowest on the mainland of Latin America and is as low as that of some industrialized countries. It compares with a range of 48.4 to 71.8 for the other countries of Central America.

This book, written almost entirely by Costa Rican officials who were intimately involved in this health revolution explores what was accomplished, how it was done, and why it was done. It describes the background and the astonishingly wide range of social initiatives taken by the governments of the 1970s not only in the health sector but also in primary and secondary education, technical colleges, the national university, distance learning, the development of cooperatives, consumer protection measures, and physical infrastructure improvement. It also analyzes the response of the health system to the economic crisis of the 1980s and discusses its evolution and sustainability. One point not emphasized in the text is that Costa Rica has achieved the health transition with only an incomplete demographic transition. The crude birth rate was 33 in 1970 and 27 in 1991 (World Development Report 1993). The impact that this has on current economic problems is scarcely mentioned.

The first chapter by Dr. Edgar Mohs, Vice-Minister of Health from 1975 to 1978, and Minister of Health from 1986 to 1990 recounts that when Josigueres became president of Costa Rica in 1970, he and his cabinet immediately started work toward their promised goal of eradicating extreme poverty in Costa Rica. While increased productivity was seen as the means of achieving this objective, it was approached by focusing on the health and education sectors. Aware that, after two prior separated terms, this would be his last chance to serve the country as president, Figueres used his power and experience to give impetus to momentous social transformations. Costa Rica became the only country in the Americas to abolish its armed forces and to do so in order to devote more of its resources to social welfare and development.

Professional associations opposed the new plans for the health sector, some arguing that a diversion of funds from curative to preventive medicine would result in an increase in mortality. There was even strong opposition from the officials of the regional office for the Americas of the World Health Organization (PASB) to the transfer of all hospitals to the Social Security Institute as noted by Mohs in Chapter 1. The decisions were taken and implemented despite such opposition. The improvement, actually achieved in such a short period of time, had been previously considered absolutely impossible. Throughout, these major health reforms were achieved by acting within the legal framework and by seeking consensus through conviction rather than by force.

In the 1980s the growing debt burden precipitated an economic crisis which also seriously affected Costa Rica. The price of further support from the International Monetary Fund and the World Bank was "structural adjustment." One aspect of this was pressure to streamline social services and eliminate or privatize many of them. Thus the first part of the 1980s was a struggle to save the National Health System and to protect the health status of the population during the severe economic crisis. Mohs describes how this was achieved and states how by the late 1980s, while he was still Minister of Health, the main objective was to return to progress. Carlos Mureturns to this theme in Chapter 6.

The second chapter by Guido Miranda, Assistant Director of the Costa Rican Social Security Institute from 1970 to 1978 and later Executive President, describes the evolution of the social security system. Unlike the pattern in other countries, it expanded from the initial traditional coverage of the employees of large farms and industries to include first all members of their families and then by the end of the 1970s virtually all of the population. The transfer of all hospitals in the country to the Social Security Institute was essentially complete by 1977. In this hemisphere only Cuba, with a centralized economy, and Canada, which adopted a universal health insurance plan, achieved similar population coverage.

A key factor in Costa Rica's success was its development of primary health care and preventive medicine services that reached both rural and urban communities. In Chapter 3 William Vargas, Director of the Preventive Medicine Department of the Social Security Institute and of the Public Health Department of the School of Medicine of the University of Costa Rica, explains how primary health care was made an integral part of the social security coverage. It was claimed that offering health services would lead to increased usage and costs. For the medical care of children the opposite occurred. Pediatric beds are now barely two-thirds those required in 1934 although the child population has doubled.

The three initial chapters discuss the basis for the Costa Rican health transition. Chapter 4 on the Evolution of the Epidemiological Profile by Lenin Sz, Chairman of the Sectorial Planning Unit of the Ministry of Health, describes the impact of the programs described in the previous chapters on patterns of disease and death. The evidence for the rapid decrease in disease associated with infection and malnutrition is presented in detail. However, "health transition" in the title of this book has a double meaning. It can be seen first and foremost as a change from the high morbidity and mortality due to the synergism of malnutrition and infection, particularly during the early years of life, characteristic of most developing countries, to the low rates of industrialized countries. It is also a transition to the emergence of chronic diseases associated with the dietary patterns of the more affluent countries.

One reason for this is that as mortality associated with nutritional deficiency and infectious diseases decreases, that due to chronic diseases becomes a relatively more important part of the total mortality. Another is an actual increase in these diseases, particularly hypertension, ischemic heart disease, and diabetes as a result of higher caloric intakes leading to overweight and obesity and to more fat in the diet. A third reason has been suggested by the studies of DJP Barker and colleagues (Barker, 1992) who found that individuals in England and Wales whose birth weight and weight for age at one year of age had been low are more susceptible to diseases of dietary excess in later life.

In Chapter 5, MarEugenia Trejos, Professor of Economics at the University of Costa Rica, reviews the socioeconomic factors associated with the health policy advances of the 1970s. Recognition of social demands followed by efforts to respond to them was the prevailing style of government in the 1930s and 1940s. The governments of the 1950s and 1960s continued this social tradition but believed that it would be best served by measures that would stimulate agricultural and industrial production. The social actions of the period included the promotion of agricultural and industrial technology, training of workers and technicians, and development of infrastructure including water supply, urban sewage disposal systems, postal and port administration, an autonomous railroad, building of highways, bridges, rural roads, telephones, and the nationalization of banks.

This approach did result in increased internal market production. However, the other authors repeatedly emphasize a social rather than an economic motivation for the policy. There is a consensus that the entrepreneurial governments of the 1970s were strong and decisive and willing to intervene in different social spheres when the private sector could not or would not.

As Carlos Mu the Director of the Department of Primary Health Care of the Ministry of Health, and Josanuel Valverde point out in the final chapter, there were three stages in the development of the health delivery system in Costa Rica. The policies and programs within each account for the improvements in the health of Costa Ricans over this period. The first period laid the groundwork for the rapid changes resulting from the development of new policies and programs and the dedication of vastly increased resources in the decade of the 1970s.

The second period was one of rapid expansion of the primary health care system and hospital access with falling infant and child mortality rate and striking improvement of other social indicators. It was a period of increasing expenditure by the health delivery system.

In the third period new goals for reducing infant and preschool mortality, malnutrition, and infectious disease were formulated. Additional ones for the prevention of chronic degenerative diseases of later life were identified and applied. As a result the Costa Rican health system must now also be concerned with the promotion of diets and other aspects of a healthy life style for the prevention of these diseases that are the major health concerns in the industrialized countries. The increased life expectancy and decreased mortality and birth rate are changing the demographic profile of the country.

Mubelieves that the capacity to change one paradigm for another in order to adapt to a rapidly changing national health picture was the key to the continuing overall effectiveness and current health achievements of Costa Rica. This permitted an effective response even to the structural adjustments required in the third period. The health system in Costa Rica is now evolving toward a mixed model. In 1994, 15% to 19% of social security services were subcontracted to private providers.

A chapter reviewing international and other external influences on the health and nutrition policies of Costa Rica during the period of transition was planned but never obtained. References to these influences are scattered throughout the chapters. It is noteworthy that the seminal health event of the period, the WHO Alma Ata Conference on Primary Health Care in 1977, came after Costa Rica had already embarked on the path of its recommendations. The goals enunciated in 1973 were also more comprehensive than those enunciated in the UNICEF sponsored Summit for Children in 1990.

At a workshop in Costa Rica in 1991 to discuss the manuscripts for this book, Dr. Luis Asis, Director of Planning of the Costa Rica Social Security Institute, reviewed the way in which the formulation of clear government policies helped to attract and channel international assistance. He also mentioned external skepticism as to the feasibility of the Figueres government proposals. Negotiation with donors to insure programs consistent with national needs and priorities was critical as was the governments rejection of unwanted assistance.

The Interamerican Development Bank, the World Bank, and other lending agencies played a role in accord with global trends of the times. The United Nations Development Program (UNDP) provided technical support. UNICEF supplied large quantities of dried skim milk (DSM) for school feeding as well as agricultural implements and educational materials. It also furnished the medical equipment for a network of information centers. CARE provided DSM milk as well as vegetables and equipment for the nutrition centers. Donated food furnished by the World Food Program included DSM and a corn-soy blend. FAO provided agricultural extension consultant help and training. The program of mobile medical units, created in the early 1960s was financed mainly through the U.S. sponsored Alliance for Progress.

The Pan American Health Organization (PAHO) provided technical cooperation in health planning, a special information system for monitoring the progress of health and made significant investments in education and training of professionals and nonprofessionals in the health sciences and disciplines. It also cooperated in the control of acute communicable disease particularly the vectors responsible for malaria, yellow fever, and dengue and in environmental health programs with emphasis on water supplies and basic sanitation. Dr. Abraham Horwitz, the Director of PAHO, recalls that during the decade of the 1970s external resources were readily available for health programs, particularly from the Interamerican Development Bank. "Good ideas and sound projects could usually be financed and Costa Rica had plenty of them."

The 1991 workshop pointed out that the Institute of Nutrition of Central America and Panama (INCAP) was responsible for much of the definition of the national nutrition problems, nutrition policy formation, technical assistance in the iodation of salt and enrichment of sugar with vitamin A, information on dietary habits and food composition, the elimination of protein-calorie malnutrition, and the training of nutrition and health personnel at all levels. A separate list of some 26 INCAP publications relating to Costa Rica during the period appears in Appendix 2.

Costa Rica is not the only developing country to achieve health statistics rivaling those of the industrialized countries despite a low per capita income. In Latin America two other countries, Chile and Cuba, also achieved this without major economic improvement. Both deserve great credit for this, but in the case of Chile (Hakim and Solimano, 1978) it was achieved gradually over many decades. In Cuba the process occurred rapidly after the fall of Batista at the end of 1958 as the consequence of government policies but with a different ideological approach (Amador and Pe1991). Because the health improvements in Costa Rica were not entirely dependent on economic development, and were achieved rapidly within a democratic framework, they serve as an inspiring challenge and example to other developing countries.

It is not difficult to give reasons why most other Latin American governments experienced little improvement in the health of their people during this same period. They are the antithesis of the characteristics of Costa Rica - lack of political stability and government motivation, resources devoted to the military or diverted by corruption instead of being applied to education and health, poor educational system, badly administered and financed institutions, and when rural health posts exists, they usually lack essential supplies, medical support, and supervision.

Finally, it has been quite impossible to present all of the different perspectives on the Costa Rica experience in this volume. For this reason supplementary reading lists in both English and Spanish are appended (Appendix 2). Some of these articles give quite different insights or assign different weights to the factors responsible. It is hoped that some will be stimulated by the unusual nature of this case study to pursue the further insights represented by these additional writings.

Nevin S. Scrimshaw

References

Amador M, Pe. 1991. "Nutrition and health issues in Cuba: Strategies for a developing country." Food Nutr Bull 13(4):311-317.

Barker DJP, ed. 1992. Fetal and infant origins of adult disease. British Medical Journal, London.

Hakim P, Solimano G.1978. Development, reform, and malnutrition in Chile. M.I.T. Press, Cambridge, MA.

PAHO. 1994. Health conditions in the Americas. Volume I. Pan American Health Organization, Washington, DC.

World development report 1993 - Investing in health, world development indicators. 1993. Oxford University Press, Oxford.

(introduction...)

Dr. Edgar Mohs

He who is healthy has hope;
and he who has hope has everything.

- Arab saying

A brief description of Costa Rica

Costa Rica was discovered by Christopher Columbus in 1502; it became politically independent in 1821, and started its life as a republic in 1825. The first heads of government were school teachers. The Costa Rican territory has an area of 51,100 km² and is located on the isthmus of Central America (Figure 1). In 1992, it had approximately 3 million inhabitants, mostly whites and mestizos; other races represent less than 5% of the population and show a strong trend towards integrating with the rest. Around 10% of the total population consists of immigrants and Central and South American refugees.

The Costa Rican economy is based on agricultural products, such as coffee, bananas, sugar, and meat. A light industry has emerged in the past 20 years, and tourism has been developing recently. The country is known for having a well-established Western democratic political system, which has been interrupted only twice in the last 100 years. All governments have stressed education and health, which has resulted in a literacy rate of less than 10% and one of the lowest overall mortality rates in the world. Thanks to the convergence of these factors and the historical evolution of the country, Costa Ricans share a strong spirit of solidarity and a deep respect for law, social justice, and freedom. The constitutional abolishment of the army in 1949 made possible a further increase in social sector investment. Law enforcement and security were turned over to a civilian police force, which comes under the Supreme Electoral Tribunal during election periods and changes every four years with the government.

FIGURE 1. Map of Central America

In the 1970s, there was a sharp increase in the country's commitment to making health services available to everyone. This emphasis on investment in health is another feature that distinguishes Costa Rica.

Table 1 presents some milestones of Costa Rican history.

Public health development

The development of public health in Costa Rica took place in four main phases:

· First phase (1850-1900): characterized by isolated efforts to provide basic health care, especially to needy groups.

· Second phase (1900-1940): characterized by the introduction of health programs and the expansion of a welfare concept to assist poor groups; creation of the Ministry of Public Health.

· Third phase (1940-1970): appearance of a pronounced interest in preventive medicine; attempts to establish a National Hospital System; creation of the Costa Rican Social Security Institute (CCSS).

· Fourth phase (1970- ): a National Health Plan was drafted and implemented in the 1970s to provide health care to the whole population and to control or eradicate malnutrition and common infections.

TABLE 1. Milestones of Costa Rican History

Milestone	Date
Discovery of Costa Rica by Christopher Columbus	1502
Abolition of slavery	1803
Political independence from Spain 1821	1821
Establishment of first university	1843
Universal compulsory primary school	1869
Abolition of death penalty	1822
Universal ballot	1882
Universal ballot	1889
Coeducational secondary education	1907
Creation of the Ministry of Public Health	1927
Secret ballot	1928
Eradication of smallpox	1939
Constituent law of the Costa Rican Social Security Institute	1943
Social reform	1942
Women's vote	1949
Abolition of the army	1949
Eradication of yellow fever	1952
Universal Social Security	1970
Eradication of poliomyelitis	1974
Eradication of diphtheria	1974
Active and permanent neutrality	1983

The National Health System was consolidated in the 1980s. In the same decade, new health care models were initiated and the integration of the Ministry of Health and the CCSS progressed; new programs for the prevention of chronic diseases were started.

1850-1900: Basic Care Medicine

From pre-Columbian times up to the seventeenth century, the practice of medicine was in the hands of native healers. When the Spaniards arrived in the Americas, however, these practices were combated and the so-called witch doctors were persecuted. In 1790, Esteban Corti, who graduated in Europe, became the first physician to come to Costa Rica. He was soon accused of practicing witchcraft and sent to Guatemala, where he was judged by the Inquisition.

Some of the oldest pieces of health legislation in the country are the Decrees dated duly 3 and September 29, 1845, which established the San Juan de Dios Hospital and the First Charity Board, respectively.

The Constitutional Congress of the Republic issued Decree No. 69 on July 12, 1852, to allow further functioning of the San Juan de Dios Hospital, which was facing serious setbacks, particularly of a financial nature. Later on, a psychiatric center was planned for the mentally ill who at that time had no place to go and were mistreated and misunderstood by the people. Decree No. 24 allocated funds for the construction of the mental institution. Subsequently, the Bureau for the Promotion of the National Lottery, under the administration of the Charity Board, also contributed to the mental center. (The Charity Board was later called the Board for the Social Protection of San Jos

1900-1940: Public Health and Welfare

During the first decades of this century, several laws, regulations, executive decrees, and general resolutions were adopted on issues related to public health. In the beginning, they were isolated efforts without appropriate coordination. As time went by, an organic infrastructure independent management were achieved that responded to the ideals of improving the health situation. As can be seen in the following public health legislation, avant-garde health criteria inspired the political decisions at the time.

The Decree dated September 1, 1914, created the Public School Hygiene Department to protect the health of children between 7 and 14 years of age. The Department hired the first school hygiene assistants trained in the country. It was in charge of medical, dental, and ophthalmological school clinics. It also took care of hygiene in schools and summer school camps, the latter created in 1920 to shelter temporarily abandoned children or orphans.

Subsequently, legislation for the prevention and treatment of public health problems was enacted and gradually expanded. It approached problems as varied as tuberculosis, malaria, venereal diseases, smallpox, leprosy, yellow fever, typhoid, and narcotics abuse. The first steps toward setting up a vital statistics system were also taken. The first prenatal and child medical clinics, considered the foundation of public health because of the protection they provide to human beings from conception onwards, were established in 1920.

Undersecretary's Office for Hygiene and Public Health

The Undersecretary's Office for Hygiene and Public Health, attached to the Police Secretariat, was created on July 12, 1922, to overcome prevailing lack of unity in the management of all health activities, the degree and nature of the health problems, the abundant accumulation of health legislation, the incorporation into the health field of a large number of physicians and other professionals and technicians, and the training of health staff and other professionals. (Many years later, the Undersecretary's Office became the present Ministry of Health.)

Law No. 52 on Public Health Protection, enacted on March 12, 1923, was an important complement to this organic restructuring. It recognized national health as a government obligation and local health as a municipal responsibility.

To comply with all the provisions of this law, it was essential to have trained staff, and therefore efforts were concentrated on this goal. In 1924 the School for Health Inspectors was created, and in 1926 the role of the school assistant for health was redefined.

In 1927 the lack of school assistants for health resulted in the school assignment of nurses graduating from the Faculty of Medicine and the Max Peralta Hospital of Cartago, that offered a three-month practical apprenticeship in the School and Children's Clinic of San Jos

At the same time, these training institutions incorporated courses on puericulture and school hygiene into the nurses' study plan. The same 1927 law created the category Social Worker to Combat Tuberculosis, and in 1928 another law created the first employment for obstetric nurses to compensate for the lack of physicians in villages.

All tasks previously assigned to the Welfare Secretariat under the Office of Foreign Affairs were transferred to the Office of the Undersecretary for Hygiene and Public Health. These tasks were related to hospitals, lazarettos, shelters, maternity homes, and child protection institutions. Strengthened in this manner, the Office of the Undersecretary became the Secretariat for Public Health and Social Protection through Law No. 24, dated June 4, 1927. This gave the new Secretariat the political authority and consequently, the support necessary for the projects submitted to the Congress of the Republic.

The profession of Official Physician was created in 1931, replacing the profession of Village Physician. Official Physicians had broader functions based on work criteria of social protection and well-being of the community and not just treatment and charity. The position of Director of Health Units was created in 1936 with qualifications similar to those of Official Physicians: health directors, coroners, school physicians, and those responsible for assisting the needy and taking care of work accidents.

Another significant law was Executive Decree No. 5 dated October 8, 1935, which repealed the Decree creating the Charity Brotherhood for the Limospital and replaced the Charity Board with the Board for Social Assistance. The Decree shows how the "charity" concept which had prevailed for such a long time began to change into social protection with the participation of the government.

National Insurance Institute

Originally, this autonomous government institution, created by Law No. 12 dated October 30, 1924, was called the National Insurance Bank. It represents the culmination of an interesting chapter of our history, which goes back to the nineteenth century.

Before 1924, all insurance was in the hands of foreign companies. At the beginning of this century, insurance was necessary because of the industrial and commercial boom; businessmen, for example, were investing tremendously in imported goods and had to protect them. This gave rise to a plague of arson as some businessmen set their businesses on fire to collect the insurance, endangering property and life. It became necessary to regulate the relationships between the insurance companies and the insured and to stop the flight of foreign exchange. It should be noted that the creation of the National Insurance Bank was closely linked to the attempt to legislate on the responsibility of employers for work accidents.

Even though the law proposing disability protection and workmen's compensation as responsibilities of the employer was drafted in 1907, it took years to finalize and was finally enacted in 1925. The year following its establishment, the National Insurance Bank assumed the whole responsibility for the fire fighters. Only in this manner could a certain level of security for citizens be guaranteed and bank losses minimized.

The National Insurance Bank started offering life insurance in 1925. In 1926 it monopolized fire and work accident insurance. Progressively, the Bank took over other insurance, such as fidelity bonds to cover the risk of losing money and other securities, motor vehicle insurance in 1943, and crop insurance in 1969. In 1940 it was authorized to grant construction loans accepting life insurance policies as security.

As of 1948, the National Insurance Bank became known as the National Insurance Institute. At present it is governed by a Board of Directors and an Executive President appointed by the Government Council.

1940-1970: Institutionalized Preventive Medicine

This period includes the creation of the National Hospital System and the Costa Rican Social Security Institute.

Consolidation of the Ministry of Health

The implementation of preventive medicine requires a solid health organization, as well as excellent intra- and interinstitutional coordination. The final consequence of several measures taken in these decades was the progressive strengthening of the Health Secretariat: different departments or divisions were created or reorganized, international cooperation was channeled, structural changes were made, and better financing was arranged. Some of these measures, as discussed below, were important for many health achievements of the country.

The first General Regulations on Foundations and Boards for Social Protection were promulgated May 20, 1941, giving these social entities public status. At the same time, it entrusted them with the administration of hospitals, homes, cemeteries, and other centers, the technical direction and economic supervision coming under the Directorate General of Medical and Social Assistance. Health centers, also operating under the administration of these Boards, were supported to a large extent by governmental subsidies, the Charity Tax, and the National Lottery.

The first Health Code was published December 18, 1943, according to Law No. 33, which repealed Law No. 52 on Public Health Protection of 1923. The 1943 Health Code summarized the abundant legislation passed throughout the years and the ample experience on health aspects. The Code also made reference to the organic structuring of the Health Secretariat, and to local and international health standards and controls.

Another important law, passed in 1950, was the General Medical-Social Assistance Law. It created the Directorate General of Medical-Social Assistance, which, with the aid provided by the Technical Council on Medical and Social Assistance, an advisory body created by the same law, had the following functions:

· Coordination of all medical assistance and social protection institutions.
· Provision of technical and financial management and of the above public centers.
· Technical supervision of privately owned analogous institutions.

The General Medical-Social Assistance law called for a modification of the distribution of funds from the National Lottery and, years later, the General Regulations for National Hospitals were promulgated.

At the end of the 1940s, the Health Secretariat changed its name to the Ministry of Health with three directorates: the Health Directorate, in charge of all tasks related to public health; the General Directorate of Medical-Social Assistance, responsible for all medical assistance institutions; and the Administrative Directorate.

The Costa Rican Social Security Institute

Law No. 13 of 1926 classified snakebites as an occupational disease of farm workers and could thus be considered the first harbinger of today's Costa Rican Social Security Institute. In this sense, other laws that also heralded Social Security were Executive Decrees No. 2, dated July and November 8, 1935, which regulated Law No. 30 of December 1934 on hospital admissions of banana industry workers and the utilization of the 1% withholding on banana sales specified by the law.

The Law on Compulsory Social Insurance was enacted in 1941. On July 7, 1943, Law No. 24 came into effect, thus incorporating Section III "On Social Guarantees" into the Political Constitution, whose Article 63 provides for

... the establishment of social insurance, regulated by the compulsory contribution system by the government, employers and employees, for the benefit of laborers and intellectual workers, to protect these against the risks of disease, maternity, disability, old age, and death, and other contingencies determined by the Law. The administration of the insurance would be entrusted to an autonomous institution called Costa Rican Social Security Institute.

The Constitutive Law of the Costa Rican Social Security Institute was issued on October 22, 1943.

As of September 1, 1942, the Illness and Maternity Program was gradually implemented. Initially, it was limited to the economically active group of the metropolitan urban area and provincial capitals with higher population density. It was quoted on the basis of 400.00 colones per month and it covered only directly insured persons. From 1944 to 1947, when the rural population was included and family insurance was established, its coverage was expanded to the Central Valley. The Disabled, Elderly, and Death initiative came into effect on January 1, 1947, to give compulsory protection to wage earners.

At the end of the 1950s, the Illness and Maternity Program covered 27% of the economically active population and 18% of the total population of the country, while the Disabled, Elderly, and Death initiative covered 8% of the economically active population and 7% of the total population.

Through Law No. 2738, the obligation of universalizing all insurance under its responsibility, including family protection in the Illness and Maternity Program, within a time frame not to exceed 10 years, was imposed on the Costa Rican Social Security Institute by the Legislative Assembly. This goal, however, was not achieved. At the end of the 1960s, only 38% of the economically active population, 45% of the total population of the country, and 60% of wage earners were protected by the Illness and Maternity Program, while only 24% of the economically active population and 28% of the total population were covered by the Disabled, Elderly, and Death initiative. Family protection in the metropolitan area only materialized in 1965.

Law No. 4750 reformed Article No. 3 of the Social Security Constitutive Law, thus eliminating contribution ceilings for the Illness and Maternity Program. This measure was the manifestation of the political decision to expedite the insurance universalization process.

At the end of the 1970s, the Illness and Maternity Program already covered 84.3% of the total population (2,162,080 inhabitants), and the Disabled, Elderly, and Death initiative covered 17.6%.

Costa Rican Aqueduct and Sewerage Institute

During the first part of the colonial period, the city of San Josas a small and very poor town with a serious water supply problem. The water problems were the result of remote water sources, topographic conditions, dense forests nearby, and the poverty of San Jos inhabitants. Wells were initially dug. Subsequently, an 8-km ditch was dug, which ran along First Avenue and, once it reached the corner of the present National Bank, turned to the north to flow into the Torres River.

The land for the Aranjuez water tanks was bought in 1866. It was not until 1968 that the water pipeline was inaugurated and its management turned over to the Municipality.

As time went by, other aqueducts were built in the urban areas. They were not, however, a response to established national priorities but were the result of municipal initiatives with municipal funds and, in only a few instances, by the Ministry of Health.

The first steps to control water quality in Costa Rica were taken in the 1940s, in a small laboratory installed for the Tres Rios Water Treatment Plant, administered by the Municipality of San JosThe water laboratory of the Ministry of Public Health (its name at that time) started doing bacteriological and physical-chemical water analyses in 1951. Water chlorination started in 1952 at the Tres Rios Water Treatment Plant; the process was a failure, because the necessary technical and economic resources were lacking.

The fact that financial and technical resources were scarce and that the water service was scattered made it impossible to coordinate the use of hydrographic sources on more rational terms and to standardize the water treatment and quality control to guarantee water potability. As a result of this situation, the National Service of Aqueducts and Sewerage was created on April 14, 1961, by Law No. 2726.

In 1976, its name was changed to the Costa Rican Institute of Aqueducts and Sewerage by Law No. 5915. It is a public and autonomous entity in charge of solving all problems related to the drinking water supply and to the collection and assessment of sewage and liquid industrial wastes. It is also in charge of standardizing storm water sewers in urban areas.

The decade of the 1970s

The year 1970 was a critical one for the health transition in Costa Rica. The National Health System was established to provide health coverage of the total Costa Rican population, and to control the most common infectious diseases, and eliminate child malnutrition. In the early 1970s, the Ministry of Health did exhaustive research with a view of assessing the population's health status, the availability and productivity of the existing human and physical resources, and the degree of integration and coordination of the health services. Thus, the Ministry of Health established the premises for the provision of health services (see Table 2) and, after having made a national health diagnosis, formulated the National Health Plan for the decade 1971-1980. For the purpose of achieving the new objectives, the Ministry also proceeded to make several important political decisions that are discussed later.

According to our own classification of the development of Health Sector institutions, the fourth stage started in 1970 with the formulation of a National Health Plan.

TABLE 2. Premises for the Provision of Health Services · Health care is a right of the population and the government has the responsibility to organize it properly. · Health services should be integrated and cover disease prevention, cure, and rehabilitation. · Health services should be organized according to regions and sectors in order to expand health coverage and improve the supply of local health care. · Priority should be assigned to good outpatient health care provided in a well-organized outpatient clinic. · Training of human resources at the professional, technical, and auxiliary level should be widely promoted, as well as ongoing education, in-service training, and research on medical and administrative problems. · Service costs should be in agreement with the economic capabilities of the country

Although several institutions participated in the preparation of the National Health Plan, the Ministry of Health and the Costa Rican Social Security Institute assumed a greater responsibility. As already mentioned, the goals of the Plan were to provide health services to the Costa Rican population as a whole through the reorganization of the health sector and the establishment of a National Health System, to facilitate the eradication or control of common infectious diseases and the drastic reduction of malnutrition. Some of the specific goals established by the Plan were the following:

· To increase life expectancy by eight years.
· To decrease infant mortality by 50%.
· To decrease the prevalence of endemic goiter to less than 10%.
· To supply potable water to 100% of the urban population and 70% of the rural population.

A number of political decisions had to be made in order to achieve the stated specific goals of the Plan, as well as its general ends. Thus, several remarkable laws were passed and a rural health program was created.

We now discuss the main characteristics of these laws.

Principal Legal Measures

· Law No. 5349 on the Transfer of Hospitals to the Costa Rican Social Security Institute: its purpose was to universalize Social Security, and thereby ensure that all the people enjoyed medical services of good quality.

· Law No. 5395, also known as General Law on Health. It replaced the 1949 Health Code and clearly defined the relationships among the government, individuals, and businesses. It incorporated a series of compulsory principles concerning individual and community health, oriented towards the achievement of the best possible health status. It made the Ministry of Health responsible for the definition of national policies on planning, coordination, and control of health-related public and private activities.

· Law No. 5412 or Organic Law of the Ministry. It decreed that from then on, the Ministry should be called the Ministry of Health. It provided for the internal restructuring of its agencies. The Directorate General of Health and the Directorate General of Assistance became a single unit under the name Directorate General of Health. The Technical Council for Medical-Social Assistance was attached to the Minister's Office, and its functions were limited to collecting and distributing funds allocated to care for patients insured by the government (until then known as indigents). Advisory bodies, such as the National Health Council and the Sectoral Planning Unit, were also created at this time.

An important additional component of the National Health Plan was the creation of the Rural Health Program and the substantial strengthening of programs for environmental sanitation, clean drinking water, immunizations, and nutrition.

Reorganization of the Social Security Institute

As we have already seen, several important decisions were required to reorganize the Health Sector according to the National Health Plan. The most important element relating to the Social Security Institute was the transferral, according to Law No. 5349, to the Costa Rican Social Security Institute of all hospitals managed by Boards and Foundations for Social Protection. Article 2 of this Law refers to the compulsory care to be provided by the Costa Rican Social Security Institute, at the government's expense, to persons without insurance and unable to pay for medical services, a group known as Persons Insured by the government.

Article 6 of Law No. 5349 states that all health care actions related to preventive medicine that are not legally assigned to the Costa Rican Social Security Institute come under the responsibility of the Ministry of Health.

Article 7 states that all revenues or income of any kind received by institutions of the Ministry of Health, the Boards of Social Protection, or the Foundations are to be transferred to the Costa Rican Social Security Institute, with the provision that if the funds are insufficient, the government will establish specific revenues for the complete payment of the health care provided to its insured persons.

Article 8 of the same Law declared that it is national policy and supercedes all prior legal provisions insofar as these are opposed to it.

Law No. 5541 complements Law No. 5349 and defines the working conditions of people employed in centers that would be transferred to the Costa Rican Social Security Institute.

Other essential actions required by the Costa Rican Social Security Institute with a view to structural readjustment and internal organization were based on the following:

· Executive Decree No. 6919, dated April 4, 1977, established the National Committee on Human Resources, whose main goal was to determine the need for medical professionals in the coming years.

· The 1979 Executive Decree No. 10653-P-OP ordered the division of the national territory into five regions for the purpose of investigating and planning socioeconomic development.

· The Board of Directors of the Costa Rican Social Security Institute, on June 7, 1978, agreed on the internal organic restructuring of the medical services it provided, including measures of decentralization to the Regional Health Directorates.

· The 1978 Executive Decree No. 9283-P created the System for Administrative Reforms as a component of the National Planning System for the fundamental purpose of achieving efficiency and productivity in the Public Administration.

· The 1979 Executive Decree No. 109157P-OP created the Subsystem for Regional and Urban Planning and Coordination to orient and coordinate governmental actions at the regional level and to balance the development of the different regions.

The above-mentioned Subsystem is part of the National Planning System.

On July 15, 1978, the Board of Directors of the Costa Rican Social Security Institute created the Coordinating Council for Medical Services and resolved to divide the national territory into five program regions, matching the regionalization process referred to in Executive Decree No. 10653-P-OP. The regions thus created were Northwestern, Western, Eastern, Central, Northern Huetar, Chorotega (Dry Pacific), Alantic Huetar, and Brunca (South Pacific).

The coordinating council initiated decentralized regional administration of coverage and collection of fees. Geographically this coincided with the regionalized medical services.

Political Context

During the 1969 political campaign, Josigueres, the presidential candidate running for the National Liberation Party, proposed to expedite the social and economic development of the country and stressed that it was possible to eradicate extreme poverty in Costa Rica. When he became President of the Republic in May 1970, he and his cabinet immediately started to work towards his promised goals. President Figueres succeeded in motivating several of his collaborators and a substantial sector of the population; at the same time, he gave hope to the most needy sectors.

Figueres, probably aware that this would be his last chance to serve the country as President (he had been Chief of State in 1948-1949 and President in 1954-1958), decided to use his power and experience to give impetus to momentous transformations, particularly those with social content. The opposing political party (Conservative) and the Communist Party were rather skeptical about Figueres' statements, which they considered sometimes to be extravagant. In general terms, however, the President's thoughts were truly reformist, with a social democratic ideology adapted to the environment.

The group heading the Health Sector, imbued with the President's reformist ideas, knew that it had the President's total trust and support. Thus, it approached child health problems seriously and rapidly, since children were the most vulnerable and affected population group.

The Health Sector group set two general objectives:

· To break down economic barriers to universal medical care.

· To eradicate and control common infectious diseases, since they constituted another powerful barrier on the road to better health status.

A prerequisite to President Figueres' idea of eradicating extreme poverty was the establishment of mechanisms to improve gross national product redistribution and to increase production.

The first objective took the form of two institutions: the Mixed Institute for Social Assistance (IMAS) and the 1971 Social Development and Family Allowance Fund.

The Mixed Institute for Social Assistance created by Law No. 4760, dated May 8, 1971, had the following goals:

· To formulate and implement a national policy for social and human promotion among the most needy sectors of Costa Rican society.

· To lessen or eliminate the causes and effects of poverty.

· To transform social stimulation programs into a means to obtain, in the shortest possible time, the incorporation of marginal human groups into the economic and social activities of the country.

· To prepare the indigent sectors, in an appropriate and rapid manner, so that they can improve their capability to do remunerative work.

· To attend to the needs of social groups or persons who should be provided with means of subsistence when they lack these.

· To obtain the participation of the private sectors, as well as public, national, and foreign institutions specialized in these tasks, in the creation and development of all kinds of systems and programs oriented towards improving the cultural, social, and economic conditions of groups affected by poverty, and obtaining maximum participation of the groups themselves.

· To coordinate the national programs of the public and private sectors that have similar goals to those expressed in this law.

The main source of financing for IMAS is the 0. 5% monthly surcharge on ordinary and extraordinary wages and salaries paid by all enterprises registered with the National Institute of Learning, the Social Security Institute, or the Popular Bank.

Law Number 5662, the Law for Social Development and Family Allowances, was published in La Gaceta on December 18, 1971. It created a special fund, and a specific Directorate General to manage it, for GNP redistribution purposes, to foster social development and family allowances. Even though the fund was actually discussed during the Figueres government, it was created by President Daniel Oduber, who was in office from May 1974 to May 1978.

The objective of the Social Development and Family Allowances Fund was to promote and complete socioeconomic programs and services favoring low-income persons and families. This fund was managed by institutions such as the Ministry of Health (nutrition programs managed by School Committees and by local education and nutrition centers), the Mixed Institute for Social Assistance, the National Foundation for Children, the National Nutrition Clinic, the Institute for Agrarian Development, first known as the Institute of Land and Settlements, and the National Institute of Learning.

Twenty percent of the fund is used for capital formation, which finances the Noncontributory Pension program for a basic number of persons not entitled to benefits of contributory plans of the Costa Rican Social Security Institute either because they have not paid or because they have not completed the required number of contributions. The law specifies that this money be remitted to the Costa Rican Social Security Institute, which administers the Noncontributory Pension program along with the Disabled, Elderly, and Death initiative.

The fund also gives loans either in cash or as family allowances to low-income workers with handicapped children or children under 18 years of age, or children between 18 and 25 years of age, as long as they study at an institution of higher learning.

The fund is derived from the Reform to the Sales Tax Law No. 3914 dated July 17, 1967, and its amendments, as well as from a 5% surcharge on the total amount of wages and salaries paid monthly by public and private employers, with legally specified exceptions. The exceptional fact that in Costa Rica the same political party, the National Liberation Party (social democratic), won two consecutive elections allowed the momentous reform in the social sector to continue eight years after its inception in 1970. This time frame allowed the reform's goals to be achieved and the political and technical process to be perfected. It was then followed by the ambitious project contained in the National Health Plan.

When he became President in 1978, President Oduber endorsed the programs started in 1970 by energetically strengthening them vigorously with political support and financial resources.

In addition to President Oduber's strong leadership, the dramatic results achieved in the health field in such a short amount of-time probably contributed to the political will needed to maintain reformation of the health sector for eight consecutive years. In view of the deep-rooted assumption in our country that health improvements require long latency periods, it was an unexpected and most important finding to have concrete results after a few years. Through this experience we became aware that political sponsorship is important in the initial phases of the program, but it was the impressive results that provided a fundamental feedback and served to stimulate and activate both the health staff end the population, giving them a certain degree of vital autonomy within the framework of the existing natural interdependency. After many years of disappointment and apathy, the staff accelerated health progress with positive and enthusiastic attitudes.

The Role Played by Pressure Groups

During the 1970s, particularly in the first part of the decade, the different Costa Rican pressure groups played a very limited role in the life of the country. Although associations for community development were aware of their immediate needs, they did not have a clear idea of actions to be implemented in order to satisfy those needs. This explains, on the one hand, their surprise and astonishment at the different initiatives started by the Ministry of Health and, on the other hand, their timid support of health initiatives.

The professional associations were belligerent in opposing the Ministry of Health. Arguing that the utilization of auxiliary staff to expand health service coverage was an attempt on the lives of those receiving these services, they clearly stated their opposition to the Rural Health Program. These associations defended the principle that health care should be in the hands of fully qualified physicians and nurses. Unfortunately, at that time they were not aware that a health system reaching all inhabitants implies the development of primary health care which operates with auxiliary staff, guided by defined standards and under professional supervision.

Even the Costa Rican Association of Public Health Specialists expressed its total disagreement with the Rural Health Program. Nevertheless, the firmness of the Ministry of Health in promoting the changes and its repeated explanations of the program in conferences, round tables, and bulletins neutralized the statements of the opposing groups. The activities were first implemented in San Ramheaded by Dr. Juan Guillermo Ortiz, and in zones affected by malaria. The health staff was especially trained to assume their new tasks, which targeted health problems considered to be a priority as of that moment.

Another important decision, which started heated discussions, was the reorganization of hospital management. It implied the transfer of all hospitals to the Costa Rican Social Security Institute and, therefore, the elimination of Boards and Foundations for Social Protection. The members of these organizations and some media opposed the decision, arguing that Social Security universalization was uncontrollable and, hence, could overlook the indigents. High-ranking officials from the Costa Rican Social Security Institute, aware that this attitude could ruin their institution, were very much concerned.

Law No. 2738 of 1961 established the compulsory universalization of Social Security within a time frame no longer than 10 years. Several Costa Rican Social Security officials interpreted this law as implying universalization of obligatory insurance only, i.e., covering wage earners and not the non-wage-earning population. After many discussions and negotiations, the Ministry of Health and the Costa Rican Social Security Institute reached an agreement in which representatives of the Legislative Assembly from the National Liberation Party and the Second Vice President of the Republic, Dr. Manuel Aguilar Bonilla, participated.

Another hindrance to the project was the opposition stated by highest authorities of the Pan American Health Organization, who exerted tremendous pressure on the Minister of Health and the President of the Republic to withdraw the law. Both the President and the Minister listened to all arguments against the project but, nevertheless, supported the national technicians who implemented it. As of 1974, President Oduber, VicePresident Dr. Carlos Manuel Castillo, and the Minister of Health developed the Family Allowances Program quickly. Furthermore, in the health sector they gave a significant momentum to the reform project, which allowed the active participation of organized communities, particularly in the rural areas. The population changed its traditional demand for education services to a demand for health services, once it discovered the feasibility of obtaining them in the short term and at a reasonable cost.

Within the health sector, other outstanding laws were passed during this agitated period: Laws No. 4750, 5395, and 5412. Law No. 4750, dated March 30, 1971, made Social Security contributions, calculated over total individual remunerations, compulsory. Law No. 5395, dated November 24, 1973, the General Health Law, replaced the 1949 Sanitary Code. Law No. 5412, dated January 18, 1974, the Organic Law of the Ministry of Health, reorganized and updated the Ministry, thus providing it with the necessary conditions to play a leading role in the health sector. These three laws were not as controversial as others discussed before.

In retrospect, it is worth noting that throughout this major health reform, a traditionally Costa Rican trait was illustrated: to change progressively with the goal of achieving well-being for all of the population, but acting within the legal framework and seeking consensus through conviction rather than though force or brutal actions.

It is pleasing to note that the health reform led to dramatic improvements in the health status of the population in such a short time, an achievement that previously had been considered absolutely impossible.

The decade of the 1980s

In 1980, only 10 years after initiation of the Figueres health reforms, the general mortality rate in Costa Rica dropped to 4.1/1,000 and infant mortality had fallen to 20/1,000. Morbidity and mortality were associated with chronic diseases in adults as well as in children. It was generally felt, at this time, that the country had reached its limit of achievement in the health area.

At this time, one of the most severe economic crises of the century hit the country: the Costa Rican colon was devalued by 600%, inflation increased by 100%, foreign exchange reserves were exhausted, unemployment reached 10%, and the fiscal deficit was 14% of the gross domestic product.

The First Part of the 1980s

The future for the health sector seemed ominous. People started to note the deterioration of key sanitary and medical assistance programs. All international experts visiting Costa Rica agreed that the country would not be able to maintain the health services intact; therefore, morbidity and mortality, particularly due to infectious disease and nutritional deficiencies, would increase.

During the second part of the 1970s, the country's health outlays reached the impressive figure of 10% of the gross domestic product, dropping to 7% in the first part of the 1980s. Thus investments, machinery, and common supplies were drastically curtailed.

The economic crisis suddenly impoverished a vast sector of the population. At the same time, it substantially decreased budgets financing operating costs of different public health, environmental, and preventive medicine programs.

A great fear arose among the people, because it seemed as though the gains achieved during the 1970s would be lost, and infectious diseases and malnutrition - problems of misery and underdevelopment - would ravage the country once more. Common health supplies became scarce; health service users and health staff started complaining about the management of the institutions providing health services.

The economic and financial crisis was compounded by a severe problem of immigration from the Central American countries, mainly made up of indigents, illiterates, and sick people. The very poor population of the country increased not only as a result of the underlying economic problem but also because of the large number of indigent immigrants. Health problems that had been eliminated or controlled in Costa Rica returned to the country with the immigrants, thus worsening the general situation.

There was an increase in the incidence of malaria, tuberculosis, scabies, malnutrition, some parasitic diseases, and certain vaccine preventable infections. A slight increase in the mortality rates associated with some of these conditions was also observed.

The large negative impact on health in Latin America, predicted by some national and international groups because of the economic crisis, did not occur in Costa Rica because of the success achieved by a health infrastructure and health services, that was accessible to all of its people, developed during the 1970s. Even though it suffered some deterioration it functioned well during the crisis and served the population with limited resources from a real catastrophe that would have incited disorder in the country. This tested the National Health System and demonstrated its value.

In the mid-1980s, the country reacted vigorously and partially solved its economic problems. Tranquillity replaced fear, and trust was reborn. A structural adjustment program stimulated exports. The health sector intensified its actions directed toward protection of the most needy and improvement of the coordination among institutions of the health system.

Impact on Health

It is noteworthy that the turmoil of the early 1980s was not significantly reflected in infant mortality which rates remained stationary. In 1982, however, coinciding with the economic crisis, infant mortality rates due to diarrhea showed a slight transient increase, which disappeared the following year.

In summary, the economic crisis had only a minimal impact on the health situation in Costa Rica, and this was rapidly corrected. In fact, the immediate and effective reaction of the health sector solved a problem that could have become a serious obstacle to the country's development. This response demonstrated the capacity of the National Health System and the capacity of its three basic levels, and its different institutions.

On the other hand, there is no doubt that communities and individuals were organized better and contributed directly to minimizing the predicted negative impact on the health sector. As discussed in the following, the crisis was actually helpful, because it allowed the implementation of clear and decisive adjustments which, in spite of budgetary curtailments, rapidly led to a strong positive impact despite the budget cuts. Throughout the last decade, there was no correlation between per capita income and infant mortality.

The Later Part of the 1980s

The economic crisis taught us the need to review and transform the structure and functioning of the public sector to make it more solid, efficient, and modern. It brought into the open problems of scale, competence, and technical weakness, as well as the organizational obsolescence of several institutions and concepts. Through the crisis, we became aware that the government had to become smaller and more efficient, and improve its management of resources and knowledge. The theory of systems, including the principle of complementarily between the public and private sectors, also gained ground.

After having overcome the results of the earthquake during the early 1980s, we committed ourselves to the restructuring and consolidation of a universal decentralized National Health System, based on primary health care programs, with marked involvement of the organized community. Several decrees and resolutions firmly established a truly integrated system of health services which did away with the contradictions and mistaken interpretations of the past. The new health system also opened the door to a deluge of innovations which greatly improved the quantity and quality of the health services, in spite of budgetary curtailments.

The experiences of the latter part of the 1980s showed the presence of three actors in the crisis: economic depression, massive immigration of Central Americans, and an obsolete government structure needing changes. To change it, we realized that the public sector could achieve more with less money, and that broad unifying bridges between the private and public sectors should be built. The only responsible response could be deep reflection followed by obstinate actions to renew the National Health System to make it more dynamic.

As the crisis began, the people who had never believed in Costa Rica from the beginning now loudly proclaimed that at last the country would sink. Their ominous predictions were mere wishful thinking. Those of us who believed in Costa Rica, however, always contended that the crisis gave us an opportunity to review, change, and improve our country. History proved us right.

From 1986 to 1989, child mortality decreased by a further 25%, and severe malnutrition practically disappeared. The country remained free of poliomyelitis, diphtheria, human rabies, yellow fever, and dengue. Other conditions, such as xerophthalmia, scurvy, and pellagra, were no longer considered public health problems; maternal mortality, immunopreventable diseases, deaths related to food-borne disease, and the health problems aggravated by the massive immigration of Central Americans decreased by more than 50%. Moreover, between 1986 and 1989, deaths caused by traffic accidents decreased by 16%, and those caused by drowning decreased by 50%.

Child growth and development continued to improve; it was observed that 18- and 20-year-old young adults had increased in height. As compared to 1966 height data, men increased by 6 cm and women by 4.5 cm.

As a natural consequence of these changes, the Costa Rican general mortality rate dropped to 3.7/1,000, among the lowest in the world, and life expectancy increased to 76 years.

The Political Context

In the first part of the 1980s, the main struggle of the Costa Rican government was to save the National Health System and to protect the health status of the population in the severe economic crisis that affected the country. In the late 1980s, however, the main objective was to return to progress.

From the beginning, the idea of restructuring on pragmatic rather than ideological bases prevailed. In the public sector, the principles of efficiency, rationality, prioritization and complementarily, as well as the need to reduce the size of the government reached the National Health System.

During the 1985 political campaign, the desire for new qualitative progress on two fronts developed at the governmental level:

· Internationally, there was an effort to contribute to the Central American peace process in order to obtain the stability needed for development.

· Nationally, there was a commitment to modernizing the productive and social structures of the country, including the government; to improve the standard of living of the population groups most affected by recession (employment and housing); and to strengthening a process of participatory democracy.

As of 1986, the following fundamental objectives were established:

· Regarding public health, to improve the quality of the environment and to eradicate some parasitic disorders, and as many other infectious diseases as possible, and malnutrition. In preventive medicine, to consider the problems of women, children, and young adults, as well as the occupational health of adults as a priority; and to strengthen the programs for the elderly. Special attention was directed to the "Dental Health for Everyone" project.

· Regarding medical care, to foster the decentralization process of hospitals and clinics and to promote the participation of health staff, their organizations, and the communities themselves. Furthermore, to make a maximum effort to humanize the health services for the patient and to expand the program in mixed medicine.

· Regarding the Disabled, Elderly, and Death plan of the Costa Rican Social Security Institute, to generalize its benefits through appropriate financial provisions, following similar administrative steps as those taken for the Illness and Maternity Program. To establish an overall National Institute for Social Security, with the participation of all relevant institutions, and to support and foster policies on health for everyone on a more solid footing.

On the other hand, a National Health Policy was defined on the following terms:

· Health for everyone as a social goal and national and international commitment.

· The development of the National Health System and all of the institutions making up the Health Sector.

· The strengthening of the infrastructure of the health services.

· The consolidation of prior health gains; the tackling of new health problems and the implementation of new approaches within the framework of integrated care for the population.

· The participation of the community in all activities pertaining to the Health Service System.

· Give priority to providing health services to the:

· Prevention and control of communicable diseases.
· Prevention and control of chronic diseases.
· Mother and child health.
· Environmental health.
· Disaster and emergency preparations.
· Development of physical infrastructure.

Final reflections

From the 1970 experiences, we learned that in spite of economic limitations, progress was possible in the health field and time should not be wasted. In 1986, when I was appointed Minister of Health, we started to work hard on the following aspects:

Ministry of Health

· Health policy
· Health promotion
· Prevention of diseases and eradication of malnutrition and some infections
· Integration of Primary Health Care
· Definition of health areas
· Decentralization
· Community participation
· Emphasis on the most vulnerable groups
· Development of technical and administrative subsystems
· Management
· Automation
· Training and education at a distance
· Research
· Coordination and cooperation versus confrontation
· Paradigm of the chronic diseases
· Health education
· Publications
· Stimulation of staff (recognition)
· Physical infrastructure
· Environmental sanitation
· Intelligence on epidemiology

National Health System

· Coordination with the Costa Rican Social Security Institute
· Universal coverage
· Decentralization
· New forms of medical care
· Joint programming
· Integration of facilities and certain services
· Development of local health systems
· Aqueducts and sewage systems
· Labor and accident medicine
· Transformation of compulsory social services
· Involvement of the private sector
· Increased involvement of the municipalities
· Increased involvement of the communities

National Health Council

Executive Secretariat:

· Medium- and long-term planning
· Budget
· Monitoring and assessment
· Political guidance
· Matching of regions and provinces
· Rationalization
· Regulation and deregulation

Working Areas

· Politics
· Administration
· Finances
· Scientific knowledge
· Data processing
· Law
· Sociology

I feel that since the 1980s, the following elements have contributed the most to improving the work of the Ministry of Health:

· The clear message of dedication conveyed to the health staff.

· The permanent and strong support given to primary health care programs.

· The decentralization of functions and authority of primary health care programs, with their integration at the local level; the strengthening of epidemiological surveillance, prenatal care, and environmental sanitation.

· Efficient budgetary outlays that allocate the limited monetary resources to the most needy counties, communities, and families.

I also sought the widest possible consensus on my ideas, concepts, and strategies and always took the initiative and accept full responsibility for my own actions.

Although academically trained and specialized staff are desirable, it is possible to achieve health advances without them. The Ministry of Health, nevertheless, was able to improve the figures on infectious problems and malnutrition substantially, to expand health coverage and the protection provided to mothers and children, and to ameliorate basic environmental sanitation and personal hygiene.

Contrary to what has been frequently stated, the contribution of pressure groups and labor organizations was very limited. Furthermore, the measures that have overcome the great national health problems of Costa Rica tended to meet with opposition from these groups. Similarly community participation, although, contributing more positively, has been weak and intermittent.

Defining clear policies, identifying the obstacles to achieving them, utilizing communication media to reach all personnel frequently with encouraging messages, and systematically monitoring key activities are all valuable means of mobilizing health works and the public in general and developing in them a mystique and faith that these efforts are worthwhile. When people are convinced that they have the strength to move forward and destroy enemies of health in their daily life, a Pygmalion-like phenomenon occurs. When people believe that it is impossible to advance, a generalized feeling of defeat, sterility of thought, and paralysis are immediately produced.

The accumulated heuristic experience of 20 years of thought and participation in practically all levels in the field of health have led me to formulate general theories of health that explain the evolution of health in Costa Rica. These range from the scientific advances that support the great change in whatever area of human health that are the result of changes in the interpretation of global reality, abandoning interpretations that proved erroneous and substituting others more valid in a process of continual formulation and reformulation.

Based on these concepts, we have recognized and described three stages in the last 50 years that explain the reasons and causes of the improvement in the health of Costa Ricans over this period. The capacity to change one approach to another was the key to making possible what appeared to be impossible. During the 1986 to 1989 period the goals for reducing infant mortality were first established (Table 3) and the necessary interventions to achieve these goals were identified (Table 4). Similar strategies were formulated for interventions to reduce mortality in children 1-4 years of age (Table 5). Similarly, for the prevention of malnutrition, infectious diseases, and chronic diseases analyses were done of the causes, the specific problems and desirable strategies. These included developing a philosophical basis and analyzing psychological attitudes to overcome. To change one paradigm for another is the key to making possible what seems impossible.

TABLE 3. Goals for the Improvement of Infant Health (1986-1990 Costa Rican Government) · Decrease child mortality to 14/1,000 · Reduce undesired pregnancies by 50% · Reduce endogamy by 50% · Provide prenatal care to 100% of pregnant women · Detect 100% of the high-risk pregnancies and refer them to a specialized center · Improve quality of birth · Decrease cesarean sections by 20% · Decrease prematurity and low birth weight by 30% · Decrease neonatal hypoxia by 50% · Decrease incidence of hyaline membrane disease by 90% · Decrease intracranial hemorrhages by 50% · Decrease congenital malformations by 20% · Monitor growth and development in 100% of the child population (use of Childrens' Health ID)

TABLE 4. Strategies and Interventions Identified to Achieve These Goals · Improvement of family integration · Promotion of optimal age for pregnancy · Promotion of optimal birth spacing · Universal prenatal care and classification of birth risks · High-quality institutional birth · Transportation system for the sick newborn · Enrollment at home of the newborn into health programs · Growth and development surveillance (Childrens' Health ID) · Breast-feeding, iron supplements, and appropriate diets · Introduction of new vaccines · Primary and secondary health care of good quality and accessible to all. Excellent tertiary health care. Early detection of health problems · Organization and active participation of the community · Basic environmental sanitation · Emphasis on eradication or control of infectious diseases and prevention or control of perinatal disorders and congenital malformations · Educational health package promoting the elimination of certain harmful habits, as well as chronic disease and accident prevention · Suitable housing

TABLE 5. Interventions to Reduce Mortality of Children 1 to 4 Years of Age · Control of infectious diseases · Eradication of severe intestinal parasites · Appropriate nutrition to improve growth and development · Control of accidents and poisonings · Early detection of changes and illness · Early stimulation of learning · Prevention of abuse · Establishment of kindergartens and child care centers · Environmental safety · Good quality primary and secondary education accessible to all. Availability of excellent tertiary education · Introduction of a health education package that includes elimination of undesirable habits and prevention of chronic disease · Introduction of new vaccine

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(introduction...)

Dr Guido Miranda

Background

The direction that human history had taken over many centuries radically changed toward the end of the eighteenth century Within the short span of 20 years, three events occurred that transformed man's way of life, placing him under new conditions that previously had only formed part of his dreams The first event was the introduction of the steam engine by James Watt in 1769, which led to the substitution of mechanization for labor and the opening of the process of industrialization The second event took place in 1776 when the thirteen North American colonies declared their independence from the British crown and established the first democratic model in which "government of the people, by the people, for the people" became a modern political system The third event took place in 1789, the initiation of the French Revolution, which marked not only the beginning of the end of the absolutist monarchy but also the beginning of a new government approach in which the government began to assume the responsibility of protecting the most vulnerable individuals and population groups in society.

These events are related to the social and economic conditions that determined the life-style of humans and that gradually generated individual and collective security and a better quality of life Nevertheless, in spite of this enormous progress, the problem of disease remained as intractable as before, without knowledge of its causes, evolution, and final outcome Therefore, the advances achieved in other fields did not significantly effect the burden of disease

The rapid population growth generated an excess of labor that was not needed by the process of industrialization The impoverishment of the workers that followed led to extreme poverty and increased morbidity The use of machines caused work-related accidents responsible for temporary or permanent disabilities. The process of territorial domination and the control of markets through military campaigns produced deaths, disabilities, widows, and orphans.

Meanwhile, a unique phenomenon, which would revolutionize political systems, arose in Germany, which at that time was the least democratic country in Europe. After the Franco-Prussian War of 1879, the economic conditions of the German population worsened. This forced Chancellor Bismarck and Kaiser Wilhelm I to search for measures that would attenuate the popular discontent that resulted from poverty, disease, and difficult working conditions. Bismarck elaborated and sent to Parliament a proposal for a law that would protect workers involved in occupational accidents through indemnification for health damages. He also sent a proposal for a law to protect workers against common illnesses by providing free medical care and an economic subsidy that would cover missed working days as a result of illness. This law covered pregnancy and delivery; pregnancy was equated with a disease because it had a predictable duration and a physiologically established recovery period. The concept of family benefits appeared much later.

Even though both laws arrived at parliament together, the law for Required Insurance for Occupational Accidents was approved one year later than the Illness and Maternity law, which was approved in 1883. This happened because of the detailed discussion of the former law by the unions. When the laws were presented, it was stated that the problem of the elderly and the disabled would be addressed later. In fact, a law approved in 1889 provided a retirement fund for workers who had had 30 years of experience and were 75 years of age or who, at any aye, had become disabled.

These three laws that covered the so-called nonmodifiable risks transformed the situation of the workers in the industrialized world. Their content was so important that it pushed the Catholic Church to attempt to regulate the relationship between labor and capitalism through an extraordinary encyclical document known as Rerum Novarum authored by Pope Leo XIII.

From then on, all the countries started working on their own legislation. The relevance of this issue was confirmed when the terms of the World War I amnesty were being drafted. They included the affiliation of all signatory countries to the Treaty of Versailles with a new organization to regulate the working conditions of European workers. This is the origin of the International Labor Organization (ILO) and social security was introduced by all the countries that became affiliated with ILO. During the Fifth Pan American Conference in Santiago, Chile in 1923 attended by Costa Rica, a recommendation was made "to establish social security in each country, mainly for accidents, illness, and disability."

ILO recommended that each country create a ministry in charge of the administration of social security and that a Labor Code be created on which to base labor regulations. Between 1920 and 1923, all Latin America complied with this recommendation. Costa Rica followed all of these recommendations, establishing in 1927 its Ministry of Health and Social Assistance, and approved its first sanitation code. In 1928 it established the Labor Ministry and promulgated a set of regulations that in 1942 would become the Labor Code.

This brief summary explains why social security has been directly linked with the mechanisms of production and the Labor Ministry. This became clearer with the introduction of regulations covering occupational accidents and retirement funds that were never under the control of the Ministry of Health.

World War II began in September 1939, and in six years it produced the most technological advances as well as sixty million deaths, the largest number of total casualties in any war. As the British said, it was a total war because not only soldiers but also civilians died when the cities were bombarded to destroy the defense industry. It was the impact of the war that led to proposals advocated by the social and political thinkers of Great Britain that were universal rather than group specific.

The crisis of World War II produced at least four major changes that transformed societies worldwide in a short period of time:

· The technological advances achieved provided individuals with a variety of goods that improved the quality of their lives, the economy, communications, and education.

· The social value of the citizen increased because the political mechanisms for better land distribution and social equity strengthened the majority, which translated into political actions that had a strong democratic effect.

· The conceptualization, formulation, and implementation of structural reforms of the governments and their regulatory role for society.

· The political organization of the countries created instruments for the search for universality and solidarity, closing the wide gaps that the different stages of development generated.

The document known as the Beveridge Report was published in the middle of the war when the British began to feel victory at hand. For its social and economic effects, this document can be compared with those that produced the three German laws of social security or the political content of the Treaty of Versailles.

The Beveridge Report contains five important concepts that were developed at different speeds in different parts of the world:

· Social security can be modeled in a way that covers all the population with its programs.

· A stronger economy, increased efficiency, and improved social equity can be achieved when the social security funds are united.

· Health care can be a right of all citizens.

· The best solution to unemployment is an active labor market.

· A minimum national wage should be established to strengthen wage policy.

Based on these fundamental premises and the political consequences of World War II, the concept of social security was established as universal, pro-solidarity, equitable, just, and unifying, in order to counteract the unequal benefit to various social groups resulting from laissez-faire capitalistic concepts. The two immediate consequences were the creation of the National Health Service in Great Britain as a way to protect all the population and the Letter of Human Rights with the organization of the United Nations in San Francisco, which established, in Articles 22 and 25, the right of all citizens to access to social security and health, respectively. Both events occurred after the end of the war in 1945.

From then on, changes were implemented gradually. As part of a new structure, the World Health Organization (WHO) emerged as the technical and political organism that establishes the world standards that all countries should follow to improve health indicators. In 1976, the WHO assembly proposed the goal of "Health for All by the Year 2000," which was a programmatic proposal based on the democratic and equitable concept that perceives health as an individual and universal benefit. Two years later, in 1978, health goals were established with specific indicators, and primary health care was proposed as the strategy of choice to achieve them. The social and political progress that has occurred during the last four decades in almost all European countries has placed social security as a development priority that supports the principles of equity and social solidarity proposed in the Beveridge Report.

The countries of the Western Hemisphere have not progressed in the same way. There, the union movement began early, even though the process of industrialization nowhere reached the levels found in Europe. The United States orientation was to allow private health insurance with no relation to the government. This made health care a competitive market where the pressures to increase consumption always have the edge over the economy of use by consumers. Canada adopted the British system.

Although Chile was the first Latin American country that approved a system of Required Workers Insurance, it collapsed because this country was unable to merge this system with those of smaller health care providers. Nevertheless, Chile had the advantage of creating its National Health Service in 1953, which worked very efficiently until political turmoil broke it apart to establish private services that after several years did not cover more than the 21% of the population that was able to pay their fees.

The brutal economic recession in Argentina and Uruguay severely hurt a multi- institution system that was brought from nineteenth-century Europe by immigrants. In the rest of the countries, the social security institutions have had only limited development. Almost all of them were initiated between 1930 and 1950 and, following Bismarck's model, have been unable to cover more than 20% of the total population. Family coverage is still very limited, and participation in integrated health programs is almost unknown and it continues to be rare for the Ministries of Health to share responsibility for health care.

Social security in Costa Rica

The only noticeable action that took place toward the end of the last century was carried out by the Church when Monsignor Thiel, Archbishop of San Jospublished a pastoral letter called the Fair Wage. There is no doubt that this letter was directly influenced by the encyclical Rerum Novarum. However, it was an isolated event without significant impact on the small and isolated Costa Rican society of those days, when the Government relied completely on the export of coffee and bananas.

In 1906, Representative Enrique Pinto presented a project to the National Congress to protect the population against occupational accidents and profession-related illnesses. This law was not even discussed, and when it was reintroduced three years later it was rejected without substantive discussion. Artisans worked in the production of crafts, and the only industries that began to develop were the banana plantations whose production and marketing were in the hands of the transnational United Fruit Company.

Several popular political parties were founded after World War I, the most important of which was the Reformist Party. This party introduced a political program that underscored the health conditions of the workers and their families, including the need to create an organization that strengthened the fight against parasites, poverty, malaria, undernutrition, and tuberculosis. This was in response to the perception that poverty and underdevelopment were the background against which the subsequent pathologies developed. The Reformist Party, headed by Jorge Volio, faced two opposition parties during the presidential political campaign of 1923.

Since none of the three candidates obtained the majority needed to become President, Jorge Volio accepted a deal in which Ricardo Jimz would become President in exchange for the creation of an institution that would protect workers against occupational accidents and illnesses. President Jimz supported the establishment of an insurance bank that would take care of the administration of all commercial insurance available in the market. Insurance involving occupational accidents and illnesses was included, but with the characteristic that coverage was individual and each worker could expand his coverage based on his ability to pay for it and his level of education to identify the advantages of different insurance schemes.

The surprising aspect of this decision was that the Insurance Bank was created as a monopoly that favored commercial insurance policies despite a liberal philosophy of government of which President Jimz was one of the strongest exponents and that was unopposed. This situation remained unchanged until 1980, when the bank became the National Insurance Institute, which promoted the responsibility of the employer to cover the health care of his workers. Neither the bank nor this institute created their own hospital medical services. They always obtained them from the hospitals and afterwards from the Costa Rican Social Security Institute. The National Insurance Institute has always kept its distance from its homologous institution and has preserved a profitable duplication of efforts by avoiding transferring its programs to the Social Security Institute.

During the political campaign of 1928, health of the population was again among the central themes. President - elect lawyer Cleto Gonzs Vez requested a German - born engineer named Max Koberg to develop a health care project. The outcome was the introduction to Congress of the project for the creation of an Emergency System that would take care of treatment for common illnesses affecting the worker and his family. Meanwhile, protection against occupational hazards was still provided by the Insurance Bank. Congress approved the project, but the whole world became immersed in the economic crisis of 1929. Our poor country saw the prices for its exports drop to critical levels that paralyzed the economy and the possibility of financing this new project.

Other authors, such as Carlos MarJimz, mentioned the possibility of creating a Social Security Institute, but lack of experience with social security resulted in lack of support. Nevertheless, in the neighboring valley of Turrialba, 75 km from San Joswhich was considered a very long distance in those years, the owners of the coffee and sugarcane plantations established a cooperative for the provision of health services to the workers and their families. This effort was funded by the plantation owners and workers and the county, and represented an organizational scheme that was unique in the country.

In 1913, the encyclical Quadraggesimo Anno was published, complementing Rerum Novarum. It put forward the concept of organization schemes involving employers and workers that would prevent capital-labor struggles. This contrasted with the radical proposals of the Marxist organizations that were gaining ground in most countries.

After all, the concern of the Church for the workers was a political position well defined by Rome. The encyclical promoted the formation of blue-collar Catholic worker groups that could develop benefit actions in conjunction with their employers. In Europe, the German Catholic unions had established very clear guidelines that produced good results. Our Costa Rican ecclesiastical authorities sent the young and promising Father Victor Manuel Sanabria to Rome to obtain his doctorate in canon law. Upon his return he became the Archbishop of San Josnd head of the Church, which promoted the formation of Catholic unions in the country. He supported the training of Father Benjamin Nuin the social arena to promote and develop this idea and to establish health care services and a retirement and indemnification program for the disabled and for widows.

In 1928, the first group under the leadership of Manuel Mora Valverde was established in the School of Law. Within a short time, this gave birth to the Communist Party of Costa Rica and the presence of Manuel Mora as Communist representative in the National Congress. Point two in the Minimal Program of Political Action proposed to the nation the need to establish Social Security Institutions to cover the workers and their families. In 1934 this political group organized the first large strike of workers and selected for this purpose the banana plantations in order to obtain better wages and working conditions.

In 1932, Dr. Rafael Angel Calderuardia, a young physician who graduated from the Catholic University of Lovain, where he had been a student of Father Mercier, arrived in San Joss an emissary from Rome. As a result of his knowledge of the social and labor sectors he eventually became a cardinal. In the political campaign of 1936 he was elected a representative and eventually became the President of the Congress. Four years later he was almost the only presidential candidate, and officially became President in May 1940. At the same time Manuel Mora was elected a new representative to Congress and Monsignor Sanabria became head of the Church.

A few months before, in September 1939, World War II began, closing once again the markets for Costa Rican coffee and sending the country into a profound economic crisis. In addition, the policy derived from the radicalization of the groups that had close ties with the European countries involved in the conflict soon created an unstable environment. The lawyer Guillermo Padilla Castro, who was a friend and counselor of President Calderwas responsible for drafting the law that created the Social Security Institute. The idea was to establish a new institution responsible for its administration and that would meet not only the needs of the workers but also improve the political climate, and reduce the tensions that had developed. When the lawyer Padilla had the project ready, there was no one to discuss it, since the country had no previous experience with this type of institution. Therefore he requested permission from President Calderto go to Santiago to consult his friend, the lawyer Arturo Etchebarne, who was the director of Workers Insurance Program of Chile. Upon his return, the project was sent to the national Congress, which immediately began to discuss it.

Two groups opposed it from the beginning, the business sector and physicians. The business sector argued that due to the poor economic situation it was not appropriate to consider adding new costs to products, since this would limit their access to international markets. The physicians warned that this law would hurt their profession, since it would decrease their income by absorbing part of their current private patients. A large number of labor groups also opposed this law, although to a lesser extent than the other two groups. Their argument was that the fees that would be required from them were equivalent to a salary reduction in exchange for a service that was completely unknown to them.

The law that created the Costa Rican Social Security Institute was approved in November 1941, with important changes that transformed the original project. A board of directors was named the following January, electing the lawyer Padilla as assistant director. During 1942 the administration of the Institute moved with great care and organized its administration without a great deal of attention to the provision of services related to the section on Illness and Maternity, the only section that had been authorized initially.

The board of directors was worried about four issues that were not solved by the original law:

· The institution was not autonomous, since it was established as an organism linked to the executive power.

· The institution lacked its own infrastructure to provide health services. Therefore to meet the demand for hospital care, it was obliged to refer all patients to the San Juan de Dios Hospital through an agreement reached with the Council for the Social Protection of San JosProfessional services, however, were charged by the physicians as if they were part of their private practice.

· The institution's reserve funds were administered by a board formed by the manager of the Insurance Bank, the manager of the National Bank, and a representative of the President of the Republic. This undercut completely the financial and administrative autonomy of the institution.

· The maximum salary allowed for beneficiaries of 400 colones, meant that the poorer workers who needed more services were going to be the customers of the institution. This was precisely the reason why the Chilean Social Security had just closed its clinics.

To solve these problems, it was essential to modify the law, a task that was achieved the following year. The new 1943 law established institutional autonomy, and the board of directors acquired the authority to develop its own rules. With the inclusion in the 1949 constitution of the article that gave the institution the right to administer the Social Security system, the rulings and decisions of the board of directors acquired the strength of law. The Institution also assumed responsibility for the administration of its own reserve funds.

In its first year 12,000 workers were covered by the Costa Rican Social Security Institute. Almost all of them were government employees, since the executive branch provided the first contingent and a seed capital of 100,000 colones for basic operations before the Institute began to collect fees. Since the Institute was organized within the classic social security framework, it only covered wage earners. The women who were provided with services were not family members of wage earners but mainly teachers and office workers.

The Institute lacked infrastructure and therefore had to adapt a room in the San Juan de Dios Hospital to receive the first insured under the care of Dr. Esteban L, who was hired for this endeavor. Surgical services were provided by the hospital surgeons, who sent their bills to the Institute. From the beginning, the administration understood that it required its own beds and pharmacy, since the bills for medicines were of the same nature as those for professional services. For this reason, the construction of a Social Security Hospital was accelerated as much as possible, but it was not until March 5, 194 5 that the first 29 beds were available in the hospital that would later be known as Central Hospital. The Institute began to offer its outpatient services in a small building located in the city's downtown. As soon as it was possible, the a Polyclinic was opened to offer services in family medicine, specialized medicine that was highly in demand, and minor surgery.

Nevertheless, its institutional growth was slow and difficult: slow because the upper wage limit acted as a financial constraint, and difficult because the Institute did not have the empathy of the employers, target workers, physicians, or professional workers. In addition, the country experienced very difficult political times during the 1940s. Because of the upper wage limit, only the poorest workers were created, and this population with low incomes and higher health care needs represented a disproportionate financial burden for the Institute.

The difficult economic situation caused by the war in Europe decreased the ability of the employers to pay. The workers were unaware of the benefits, and the negative comments had more weight than the positive ones. In addition, the Government had lost popular support very rapidly, and the Communist Party was almost the only defender of this type of project, which also created resistance. The support provided by Monsignor Sanabria was not enough to counteract these negatives.

The physicians openly opposed the establishment of the Institute, and in 1944 they founded their first union under the leadership of Dr. Antonio Pehavarr who was the director of the San Juan de Dios Hospital. Soon, working for the Social Security Institute was not considered a professional achievement. In 1946, the board of directors approved the administration's proposal to increase the wage limit for eligibility to 1,000 colones. This led to the first medical strike and collective resignation of the physicians. The conflict was solved only when the board of directors rescinded the order. The physicians claimed that their economic interests would be inure because they would lose part of their private clientele. They also added that the wage limit could not be increased until all the workers earning less than 400 colones were covered by the Institute.

When the national assembly, in 1949, discussed the proposal to introduce legislation that would have been a ewe social advance, it rejected the proposal.

The extension of direct insurance

To understand the process of the extension of the Illness and Maternity law, it is important to understand two factors that were important determinants. The first was the growth of the population, and the second was the behavior of the government with regard to its financial obligations with the Institute.

Population growth has occurred at a very fast pace in Costa Rica during the second half of the century. This phenomenon coincided with the birch of the Social Security Institute, even though the two processes were not related. During the so-called period of demographic explosion, Costa Rica experienced one of the highest rates of population growth, and by 1942 it had the highest birth rate in the world. In 1942, when the first seeps coward the creation of the Social Security Institute were being taken, the total population was less than 650,000. However, this figure began to double every 20 years, and during the 50 years of existence of the Institute, the population has increased fivefold and, by 1991, consisted of more than 3,100,000 people.

The ocher issue was the behavior of the government as a financial contributor to the Institute, It is known that delayed payments from government have been a major problem for most of the Social Security Institutes in Latin America. Although Costa Rica is no exception to this, it is important to recognize that most administrations have cried to correct this problem. The 100,000 colones that the government offered as seed capital for the Institute was not received in cash, but the government compensated by facilitating the importing of materials for the construction of the Central Hospital. The obstacles posed by World War II made it necessary to rely on the collaboration of the government to facilitate these acquisitions. Nevertheless, a debt accumulated, which was paid by the Junta Fundadora. (The Junta Fundadora of the Second Republic governed for 18 months starting in April 1948.) However, the problem did not disappear, and the debt began to grow again until 1957, when the Figueres administration made the first payment arrangement, but did not pay the entire debt.

The financial changes introduced by the Echandi administration in 1958 partially improved the situation. It consolidated the direct financial system of the Institute through specific taxes that were received directly by the Institute. In spite of this effort, the debt continued to grow. When this financing mechanism disappeared with the creation of the Treasury Department, part of the government payments depended on the budget and expenditures approved as the National Budget.

When the Institute began its coverage, it lacked both an infrastructure of its own and support from public opinion. The figures presented in Figure 1 clearly show that during the first 12 years of operation, the Institute served only daily wage earners. During this period, the population that was served increased sixfold but only reached 24% of the economically active population. Since dependents were not included, the coverage of the total population remained constant at 7%.

Extension of insurance to the family

The growth in coverage of wage earners as well as the initiation of medical services to the beneficiaries made evident the need for coverage of their dependents as well. The board of directors listened to the requests for services, in particular those coming from the coffee plantations. Soon after the Ley Constitutiva de la Caja was approved, almost all the social protection organizations in the country explored the possibility of a closer relationship with the Social Security Institute in order to obtain financial support for the hospitals under their jurisdiction. Local interests, however, quickly stopped the initiatives from these organizations. The exception was in Turrialba, where distance and other factors had created a unique situation. The Municipal Council obviously with external advice, established a system to cover the populations of large farms. The system was funded through a wage tax (3% provided by the worker and 2% by the employer), to provide health care to the farm workers and their families. It included medicines, and financed the small local hospital. All this was achieved in 1944. The community requested the transfer of the William Allen Hospital in Turrialba and the inclusion of workers and their families for maternity as well as medical care. The Institute now experienced a paradox, since it now offered services beyond the Central Plateau and provided family medical coverage in a rural area. Both events were an exception to the traditional development followed by Social Security Institutions.

As a result of this precedent, the rural populations of the Central Plateau began to request service for their families as well. In 1955 the Board of Directors of the Council adopted the provision of medical services to dependents as a permanent policy. An analysis of the coverage (Table l) shows clearly thee the inclusion of family members resulted a rapid increase in the number of persons covered. By 1960, five years later, although there had been very little increase in the number of insured workers there were now an equal number of ocher family members covered. The total increase reflected well the coverage of the total population that increased from 12% to 15%.

FIGURE 1. Total Population, Economically Active Population (PEA), Illness and Maternity Insurance (SEM), and Old Age and Life Insurance (IVM) Costa Rica, 1950-1990

Source: Memoria Institutional 89-90

The financial crisis

The rapid rate of increase in the covered population precipitated a financial deficit, since the upper wage limit of 400 colones was still in place. In May 1958, Mario Echandi became President of Costa Rica and named Franklin Solno Salas, who was a lawyer and President Ex-officio of the board of directors of the Institute, as Labor Minister. In his inauguration address, President Echandi surprised many when he expressed his desire to expand social security services on a large scale. Since new financial resources would be needed, the Treasury Minister, lawyer Alfredo Hernez Volio, proposed the elimination of the upper wage limit, and a redistribution of the government contribution. The latter was opposed by the board of directors in order to maintain the symbol of the government as benefactor. In August 1958, the Echandi administration proposed a massive extension of the Illness and Maternity law. For this purpose, it would be necessary to remove wage limits, redistribute the government's contribution, and transfer the Professional Risk system and the Insurance Bank to the Social Security Institute, which would receive their contributions. In addition, the government would recognize and pay the accumulated debt, dependent coverage would be universal, and rural areas would benefit from the Disabled, Elderly, and Death initiative.

This proposal was the broadest that the Institute had ever considered, and it reacted with caution because it lacked physical infrastructure and personnel to assume these new responsibilities. On the other hand, the redistribution of the government contribution provoked reactions from private sector employers who considered the financial charge to them excessive, since in principle it meant the removal of the upper wage limit of 400 colones. Minister Solno personally took charge of processing the law that was drafted for this purpose. On its pare, the board of directors of the Institute, sent a different law to Congress that would allow autonomous institutions to pay their contributions directly to the Institute, and independently of the government, which would be relieved of this burden.

Under this proposal, the Institute would have been allowed to increase the upper wage limit from 400 to 1000 colones immediately and would have been given the authority to increase it even more in the future if it deemed it necessary. In reality, however, an excellent financial opportunity was lost by the Institute. Of all the proposals, the only one that was approved, mainly because of direct intervention of the Labor Ministry, was the increase in the upper wage limit to 1,000 colones, which was immediately applied and followed by an expanded coverage. At the time, the National Physician's Union did not oppose this measure, since unemployment among its members was running high and the strengthening of finances of the Illness and Maternity initiative could help create new jobs. The number of eligible workers and dependents doubled in four years as a result (Tables 1 and 2).

TABLE 1. Health and Maternity Insurance, 1942-1962

Year	Workers Insured	Families Insured	Total Insured	Total Population	Total Employed	% Employed Covered	% Population Covered
1942	12,000	0	12,000	N.A.	N.A.	N.A.	-
1943	14,000	0	14,000	N.A.	N.A.	N.A.	-
1944	25,710	0	25,710	685,305	233,003	10	4
1945	43,472	0	43,472	704,434	239,507	18	6
1946	47,192	5,000	52,192	725,222	246,575	19	7
1947	50,333	N.A.	N.A.	745,924	253,614	20	7
1948	52,750	N.A.	N.A.	766,064	261,096	20	7
1949	57,398	N.A.	N.A.	788,852	268,798	21	7
1950	63,317	N.A.	N.A.	812,056	272,774	23	8
1951	65,900	N.A.	N.A.	838,084	282,434	23	8
1952	70,189	N.A.	N.A.	868,741	290,159	24	8
1953	71,876	N.A.	N.A.	971,312	297,347	24	7
1954	73,072	N.A.	N.A.	1,008,766	306,035	24	7
1955	79,290	42,813	122,103	1,048,512	315,133	25	12
1956	81,348	51,935	133,283	1,089,570	326,563	25	12
1957	84,390	58,351	142,741	1,131,762	335,739	25	13
1958	86,019	72,308	158,327	1,176,480	347,588	25	13
1959	92,215	56,265	148,480	1,226,895	359,802	26	15
1960	94,304	94,802	189,106	1,276,001	371,726	25	15
1961	105,562	119,983	225,545	1,320,662	384,179	27	17
1962	111,279	157,018	268,297	1,367,067	396,060	28	20

The constitutional amendment

The extensive discussion of the Institute's finances that took place in Congress had important consequences. Two representatives, lawyers Alfonso Carro and Enrique Obregplayed important roles. Alfonso Carro was a member of the Institute's Board of Directors during the Figueres administration and President of the Board during the Orlich administration. Together with the lawyer Enrique Obreghe was one of the main promoters of universalization of the principles of social security. When the topic was being discussed, they gave their support to those measures that promoted the expansion of social security. At one point, Obregsuggested that 10% of the national budget should be assigned permanently to finance the expansion.

TABLE 2. Health and Maternity Insurance, 1962-1991

Year	Workers Insured	Families Insured	Total Insured	Total Population	Total Employed	% Employed Covered	% Population Covered
1962	11,279	157,018	268,297	1,367,067	396,060	28	20
1964	126,435	214,362	340,797	1,464,437	419,819	30	23
1966	138,450	397,284	535,734	1,567,230	446,676	31	34
1968	176,148	528,300	704,448	1,664,581	499,374	35	42
1970	202,291	606,373	809,164	1,762,462	528,739	38	46
1972	254,696	764,088	1,018,784	1,867,045	560,114	45	55
1974	308,124	924,372	1,232,496	1,987,895	638,432	52	62
1976	381,727	957,665	1,239,392	2,025,763	664,805	51	61
1978	519,020	1,075,243	1,594,260	2,151,225	719,637	64	74
1982	603,393	1,045,286	1,648,679	2,423,835	835,422	64	68
1986	691,033	1,179,284	2,156,139	2,720,136	957,283	66	81
1990	1,496,268	1,373,127	2,537,423	3,032,394	1,074,205	68	84
1991	1,526,523	1,400,838	2,592,563	3,108,342	1,104,066	67	84

After multiple discussions, at the end of May 1961 his insistence prevailed and the Constitution was amended with Article 177, which advocated the inclusion of all Costa Ricans in the Illness and Maternity Initiative. This amendment gave the Institute 10 years to implement this measure and guaranteed that any budgetary needs would be covered from the national budget. This political decision, which was received with great reservations by the Institute, meant the birth of the true principle of social security, where the benefit is for all the population, going beyond the limited, exclusive, and discriminatory concept that had been applied before, following Bismarck's model.

When Congress approved this decision, only Cuba and Canada had taken steps such as this. Canada followed policies inherited from Great Britain, and Cuba took these measures as part of a new political system that justified a centralized economy. Costa Rica was the country that, based on a democratic ideal, incorporated social security as part of the mechanism of equal access to health care. From then on, a series of gradual modifications took place. The most important one was the opening of the School of Medicine to train the physicians required. A few years later a school for the training of medical technologists was established.

Ever since the extension of coverage in 1960, the shortage of hospital space became gradually more serious, not only for the number of beds required but also because of the need to establish specialized services outside of the metropolitan area that would function in accord within the standards of institutional medicine. This need was met by the inauguration of the Mexico Hospital in 1969. The Institute began the construction of its hospital with the generous support of the Mexican Social Security Institute. This effort represented a strong affirmation of principles as well as a commitment to excellent health care services.

In March 1969, the outpatient services were opened, and in September of thee year the hospital had 600 beds ready to be used. This gave the Social Security Institute the technical basis required to begin the universalization of services. Since rural areas also required hospital beds, a series of agreements was formalized at the beginning of the 1960s in order to provide peripheral hospitals with the infrastructure needed for hospital care, medical visits, medicines, and support services. This contrasted with the very limited services provided to charity patients and created the ethical need to achieve universalization and to erase, as soon as possible, the discriminatory differentials that were difficult for the health personnel working in hospitals to apply and to accept.

In addition, given the increase in expenditures of the rural medical centers, the government had for several years created fixed subsidies for each of them. These subsidies were distributed through the Social Medicine Technical Council under the direction of the Ministry of Health. The proceeds of the Asilo Chapui lottery, administered by the Social Protection Council of San Joswere also made available for distribution by the Council and became a very important complementary mechanism of new income for the rural hospitals. In addition there were several specific taxes designated for these, especially a sales tax thee was sent by the Ministry of Finance for the use of the Social Security Council. A study at thee time showed that the government subsidy represented 40% of the budget of the hospitals, the Institute contributed 30%, and the lottery and ocher minor sources made up the difference.

Toward universalization

For the administration of Figueres, that was re-elected in 1970 for an additional five years, maximum sickness and maternity coverage by the Costa Rican Social Security Institute was a clearly established policy not only because of the deadline established by the constitution but also because it was a political goal. For the first time, staff from the Ministry of Health and the Social Security Institute sat down to elaborate a joint National Health Plan that would use resources from both institutions. The Ministry of Health assumed responsibility for all preventive actions at the individual and population level. For its pare, the Institute took charge of the care of illness for all the population. This included the wage earners and their dependents as well as the self-employed and the unemployed. The full expression of the concept of social security began to take shape.

At this time, the country was divided into four health regions: Central (including the Central Plateau), North, Atlantic, and Pacific. Each region had a regional hospital and several smaller hospitals and outpatient centers. Each region was given the authority to initiate a process of technical and administrative decentralization and was provided with sufficient resources to solve health problems as close as possible to the place of residence of the covered populations. When this was not possible, the regions were required to have a prompt and efficient referral system in place. Resources were allotted to each region in an orderly fashion and were based on need-assessment studies addressing the health situation and resources available in each region (Table 3).

At this time 65% of the population were classified as daily wage earners and their dependents, 25% were self-employed and their dependents, and 10% were unemployed persons whose costs needed to be covered by the government. In addition, both the Ministry and the Institute had to make some modifications to adapt to their new roles. The Ministry of Health proposed two laws: the first involved an internal structural modification, and the second created a General Health Law thee defined in detail the role of the Social Security Institute and the mandates that would guide health care. For its pare, based on a law approved in 1971, the Institute created the Medical and Administrative Divisions. It also designed a broad plan for the construction of medical units thee would provide enough bed availability and outpatient care capacity in the metropolitan area and in all the regions of the country. Social security coverage increased from 38% in 1970 to 52% in 1974 among the economically active population. Coverage of the general population increased from 46% to 62% during the same period of time.

New hospitals were opened, including the Anexin Nicoya, Monsignor Sanabria in Punta Arenas, Dr. Escalante Padilla in San Isidro de El General, and the in Gules. Some clinics that were opened were chose of Dr. Marcial Fallas and Dr. Soluin San Josnd several others of different sizes in the rest of the country. The rate of formation of human resources accelerated, and more programs were offered for the Braining of technicians, nurse assistants, professional nurses, and medical students. Many fellowships were provided by the Institute for persons from areas where it was important to increase the availability of health personnel.

TABLE 3. Consultations by Location for the Ministry of Health and the Costa Rican Social Security Institute, 1970-1986-1991

		1970	1986	1991
Total Consultations		340,025	7,673,049	7,031,818
Ministry of Health		1,160,396	753,160	374,039
Costa Rican Social Security Institute		2,279,629	6,919,889	6,657,779
Consultations Per Inhabitant		195	303	226
Location:
	Hospital	23	31	31
	Ministry of Health	19	3	3
	Costa Rican Social Security	4	28	28
	Beds	7,000	6,950	6,825
External Clinic Consultations:
	Costa Rican Social Security Institute	-	157	274
Ministry of Health:
	Rural Assistance Centers	17	5	4
	Health Centers	62	85	90
	Education and Nutrition Centers	147	560	534
	Complete Infant Care Centers	-	37	58
	Health Stations	-	344	414
	Dental School Clinics	44	65	97

Source: Department of Statistics, Ministry of Health

The ocher measure taken by the Institute to finalize the seeps required for universalization was a modification in wage limits. The board of directors decided in 1972 to gradually increase the upper wage limit and to eliminate it completely within two years. The objective of this decision was to include all wage earners, independently of their income, in the Illness and Maternity coverage. The same occurred with the program for Disability, Aging, and Death, which in this case meant the universalization, at least within the covered population, of the Retirement plan begun on a voluntary basis in 1947.

With all of the very important changes occurring in the Ministry of Health, together with changes in Social Security, the legal, medical and administrative basis was laid for the next step - the coverage of almost all of the population by these two entities.

At the end of 1970 discussions began on a projected law for Family Benefits. Some of the sponsors of this law, including President Figueres, were in favor of providing cash to the female head of the household. The amount of this benefit would be determined by income and number of children. Others were in favor of providing in kind benefits to avoid missing the target population. The Law of Family Benefits was approved during the Oduber administration in 1974. The administration of the funds to cover the mandate of this law was the responsibility of the Labor Ministry. This law provided for a 5% charge on wages paid by the employer and a 20% sales tax, both important amounts that provided a solid financial basis for a number of major social programs including:

· A pension fund for people 65 or older without their own income, housing, personal property, or close relatives who could help them financially;

· Financing of rural water supplies in small communities without the economic resources to provide themselves with water of good quality;

· Specific assistance for the program of rural electrification to make electricity available even in the most remote areas;

· Financing of the Rural and Community Medicine Program, which included maternal and child nutrition;

· Complementary financing of low-budget urban and rural housing projects;

· Financing of social benefit programs, such as the purchasing of vaccines for immunization programs.

This mode of investment represented a strong support for environmental sanitation and for policies thee would later be known as Primary Health Care and undoubtedly were the most important contributors to the improvement of morbidity and mortality indicators that are strongly related to undernutrition and infection.

For its part, the Social Security Institute was able to obtain the approval of Congress for the transfer to it the hospitals from the Social Protection Committees and the banana industry. This included authorization to construct a national hospital system that would consolidate the regionalization of health services and full authorization for the establishment of primary, secondary, and tertiary levels of health care.

The transfer program was practically completed by 1977 and was totally finished in 1986 with the transfer of the Hospital Dr. Carlos Luis Valverde V. de San RamThe transfer has brought enormous benefits consistent with the goals, since the four basic specialties of internal medicine, surgery, obstetrics-gynecology, and pediatrics have been present in all hospitals since then. In addition, this led to specialized services to rural areas and the differentiation of regional and support hospitals and the decentralization of services. The physical structure of all transferred hospitals was improved immediately. Some of them, such as the Hospital de Limnd the hospitals from Ciudad Quesada and Villa Neilly, received new buildings.

In other cases, the Institute built entirely new hospitals in places like Los Chiles, Upala, and San Vito. These buildings, plus another twelve units built for peripheral clinics, were constructed in strategic locations to optimize their usefulness. These investments were made possible by a loan from the Interamerican Development Bank in 1976 to meet the most pressing needs at the time.

At the end of the 1970s, the coverage of the Ministry of Health programs was almost universal. As a result of the individual and collective preventive actions, the health indicators improved at an accelerated rate. For its pare, the Institute covered more than 75% of the total population, and cried to make the modifications to consolidate its policies. By 1978, when the World Health Organization (WHO) conference in Alma Ata adopted the programs and indicators to achieve "Health for All by the Year 2000," Costa Rica was already operating within thee framework and had reached morbidity and mortality levels comparable to chose found in industrialized countries. This meant that a poor country with an agriculture-based economy was able to cover most of the population with medical care; cover the 50% of the population that qualified for the Disability, Aging, and Death protection; implement an insurance system to protect workers against occupational hazards; and implement a social development program that included housing, noncontributory pensions, and provide support to the most economically disadvantaged, including outpatient medical services and hospital care.

Development of human resources

When the old Central Hospital became the promoter of academic medicine, training activities became a priority and were expanded in the following ways:

· Costa Rican students were accepted to complete their required internships.

· The first residencies for physicians already qualified were established to introduce full-time hospital employment.

· Resources were created that were used by the University Residence and Internship Commission to train the first specialists.

· Parallel university courses for the Beaching of medicine, surgery, and obstetrics- gynecology began in 1966.

· The training program for nurses was organized and later associated with a School of Nursing.

· Courses for auxiliary nurses were organized in both metropolitan and rural hospitals. All the technicians working in the area of patient services received special training through the courses provided by the College of Medicine and Microbiology.

· An agreement was signed with the University of Costa Rica in 1974 and renewed in 1984, to use the clinics of the Social Security Institute for teaching and research.

· An agreement was reached with the Post-graduate studies program of the University of Costa Rica for training in 34 clinical specialties with the Social Security Institute assuming the financial and administrative responsibility.

· The Center for Teaching and Investigation was established in 1974 to provide institutional coordination. In 1982, because of its academic development the Center for Research in Health and Social Security (CENDEISS) and its building space doubled with the addition of a new auditorium and more classrooms.

· In 1988, CENDEISS became the Center for Development Strategy and Information on Health and Social Security focusing on the formation of human resources based on institutional goals established by health policies of the Institute and of the government pare of the National Development Plan.

The integration

The development of the first National Health plan represented an unprecedented combination of actions. The face that the Ministry of Health assumed full responsibility for individual and collective health promotion, implied that if it was effective, the demands for outpatient visits and hospital beds in the Social Security Institute would be significantly decreased. The decrease in pediatric beds in the last 15 years is the best evidence of the achievement of the program of primary health care. The pediatric beds are now barely two- thirds of those required in 1974, although the child population has doubled (Table 3). The Social Security Institute could not depend on curative medicine alone, because to do so would encourage more hospitalizations or consultations.

Therefore, there are some programs that include both the curative and the preventive approach. An example is family planning, which is addressed in preventive as well as curative women's health programs and which cannot be seen as an isolated event that has no relationship with physiologic or pathologic problems. For this reason, a duplication of efforts has occurred throughout time in preventive and curative services. This tendency becomes stronger when services are decentralized and integrated into the communities. The strategy of developing local health services, is par excellence an integrative one. The Institute strongly encouraged this process, although at this time, furnishing health services through two institutions resulted in unnecessary duplication and cost. It is important to redefine as soon as possible the role of the Ministry of Health as the institution that determines coordinates actions, and evaluates results at the same time that the Social Security Institute implements all preventive and curative actions.

Finally, all these processes, and in particular those events that have occurred during the last 20 years, have been taking place with minimum legal changes. Therefore, it has become necessary to review the legal framework and make the wholesale changes that are required to improve the structure and function of the health care system. Without appropriate changes the exceptional process that has been developed in Costa Rica, will begin to deteriorate. It is important that the Social Security Institute not only eliminate negative factors that are becoming stronger, but also thee it allow the participation of organizations that have been excluded.

The new health care models

The Social Security Institute of Costa Rica has been using different health care models since 1974. The industrial physician (i.e., a physician hired by the employer to work at the job site) was proposed in response to the reasonable argument of employers regarding the time it took for their workers to visit a social security clinic. Under this system, the employer pays the salary of the physician, the Institute provides the remaining benefits required by the worker, and the latter is able to receive adequate care on the job site. This means less time lose in productivity and more profits for the employers, and a better relationship with their workers. From the beginning the results were impressive, since all the parties involved were satisfied with the system. To date, there are more than 800 urban and rural enterprises that use this system, and in some instances even retired workers or dependents see the physician on the job site of the direct beneficiary. In 1992, this system was responsible for more than 700,000 medical visits that are now being complemented with a rapid delivery system of medicines on the job site.

The model of mixed medicine was created in 1989. Under this system, the beneficiary can choose the physician of his preference and pay him directly for the services provided. The beneficiary pays the physician directly and is not reimbursed, and the Institute provides the complementary benefits thee the case requires. The results of this model have been positive, although not as good as those of the previous model discussed. The costs of this system are greater, since the physician provides diagnostic and curative services that are also provided by the Institute. About 125,000 medical visits were covered by this system in 1992, and more are expected in the future.

The "English model" was introduced in 1986 in a city of 20,000 inhabitants who previously had to receive health services in another city. Under this system, a group is formed to become responsible for the health care needs of individuals in a population who are allowed to choose their physician from the group formed. Patients are allowed to change physicians if they desire to do so. The income received by the physician is based on the number of persons enrolled under his care. The ideal situation for the physician is then to have full enrollment but not to have patients who need his services frequently, since his income is based on enrollment and not on actual number of visits. This fosters the preventive approach and the development of trust between the patient and his physician of choice. The persons enrolled under this model have the right to request emergency services beyond conventional hours or days of operation and may even request to be seen at home. In addition, the physician has the obligation to visit and familiarize himself with the environment in which his patients live.

The initial results of this system were not satisfactory, mainly because the physicians did not perform the role that was foreseen for them. Even though physicians were trained for the health system, they lacked training in the skills necessary for the development of this program. However, the subsequent application of this program in a community of 30,000 people has yielded excellent results. Experience shows that the incorporation of the community medicine approach in medical schools is an essential seep that needs to be taken for the success of this health care model. This system accounted for about 150,000 medical visits in 1992.

In 1987 a clinic was built in Pavas, a city of 60,000 people that included outpatient, diagnosis, and special treatment services. It was decided to test an integral health care model in this population, an effort that was coordinated by a cooperative that was contracted and supervised by the Ministry of Health and the Social Security Institute. The results could not have been better; the level of satisfaction and organization of the community reached levels never attained before. The personnel of the cooperative in charge of operations also attained a level of satisfaction not observed in the traditional model. This experience was repeated the following year in a community of about the same size but with a different socioeconomic composition. The results were as good as or even better than those in Pavas. The two locations accounted for more than 300,000 medical visits. At this moment there are two additional cooperatives being formed to cover additional populations with this health care model. By 1992, this system, which falls within the model of subcontracting private services, accounted for 15% to 17% of the services provided by the Institute.

In 1987, the Family Physician specialization was introduced as a community model. However, there were many difficulties in developing this idea, because it was perceived as a competitor for ocher specialties. Nevertheless, its performance has been excellent and its expansion will have a strong impact.

In spice of its achievements, the health care model of Costa Rica is at present undergoing revisions and a complete structural reorganization. This is to be expected, since the profound changes that have occurred in our societies force the modernization of organizations all over the world. It is expected that the new concepts will reinforce the increasing social value attached to individuals and will make available a good quality of life to larger segments of the population.

Final comments

It has taken almost four decades to develop a health care system in Costa Rica that evolved from a welfare system, mixing charity and indirect government sponsorship, to a national health care system, based on the principles or social security.

Four decades ago the Ministry of Health and the Social Protection Organizations administered the curative and preventive programs within the framework of technical and financial limitations that were then prevalent. The birch and development of the Social Security Institute was the starting point for a series of changes that have modified completely the incidence and type of diseases as well as the levels of health and wellbeing of the population.

In a sense, Costa Rica has followed the health care path of the more socioeconomically advanced nations. The latter shifted from individual or population systems to the social security model that took into account the rights of citizens. These rights addressed universal access to health care and well-being, and included adequate housing, education, nutrition, and clothing.

Initially, the systems based on social security were able to protect their beneficiaries against a series of risks. However, this system became selective and tended to concentrate benefits. They were selective because they excluded segments of society that frequently were the most vulnerable.

Costa Rica launched its social security system covering the wage earners from 1942 to 1955. Later, the wife, children under 12, and dependent parents of the beneficiary also qualified for benefits. In addition, the Institute took the unusual step of expanding into rural areas with the same intensity as in urban regions.

With the removal of the upper wage limit in 1960, the Institute expanded enormously the coverage of the Illness and Maternity program. In 1961, Congress unanimously approved the modification of the National Constitution to provide universal health care coverage and gave the Institute a maximum of 10 years to achieve this goal. In 1970, the Constitutional mandate began to take effect. In the decade of the 1970s striking improvements in health statistics were observed. As a result, at the time of the writing of this chapter, 84% of the Costa Rican population is covered by health care, and the country has achieved levels in health indicators that can only be found in industrialized nations.

To date, the Costa Rican Social Security Institute offers, to any country that wishes to adopt it, five major programs for the distribution of social benefits:

· The Illness and Maternity initiative.
· Coverage of occupational illnesses and accidents.
· The Disabilities, Aging, and Death program.
· The program of Family Benefits.
· Insurance for unemployment and forced suspension of labor.

Costa Rica has strongly followed and consolidated the first four benefits listed above. It is reasonable to expect that based on current democratic and equitable social justice trends and on improvements in quality of life in several countries, social security programs will become a social and political objective as well as a product of development. Furthermore, within the context of social rights, the situation of its citizens from now on should be described as follows:

· Improved health
· Clean working environment
· Economic security
· Social development
· Unemployment subsidy

In this way, citizens will have a better chance to achieve well-being in the future.

(introduction...)

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 Ramnd the Rural Health Program of San Antonio de Nicoya;

· The nutrition program targeting children under six years of age, school children, and pregnant and 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 Josthe 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 (Sz, 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 ZeledNicoya, 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 Josigueres, 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-Gun) 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 Ticas Bcas para la Atenciomiciliaria (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 (Sz, 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 (Sz, 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: Sz 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 Josetropolitan 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 Josbut also other urban centers, particularly the ports of Limnd 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 Josnd 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 Josith 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 Josreater 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 JosAt 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 Ramospital Without Walls Program

In 1972, the director of a 110-bed rural hospital located in the county of San Ramecided 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 Ramospital. 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 Ramr 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-G 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 Ramealth 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 Ramhe 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-G 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 JosThey were attended by a pediatrician, a nurse's aide, and a social worker and nutrition assistants. Additionally, there were five day care centers which took care of children with second-degree malnutrition for 10 hours a day. Finally, a clinic-hospital, which is still functioning, became responsible for the nutritional recovery of severely malnourished children. It has 20 to 22 beds and continues to look after children who come from the whole country. The outpatient clinics and the five Day Centers functioned for 10 years, up to the mid-1960s, when the number of children with severe malnutrition decreased.

The Ministries of Health, Education, and Agriculture were involved in the Nutrition and Garden Program, the objectives of which included the following:

· To increase food production at the school and home levels.

· To promote better food utilization and conservation at the family level.

· To encourage nutrition education in schools, health centers, Nutrition Centers, and agricultural extension agencies.

· To improve food habits of the population.

· To improve the nutritional level of the population, especially that of children and mothers.

The program had a substantial educational component for health staff, teachers, and agricultural extension workers. In the beginning, the program benefited from the support of UNICEF for the procurement of seeds, fertilizers, agricultural tools, and teaching materials; the expertise of the Food and Agriculture Organization (FAO) in agriculture, agricultural extension, and nutrition education; and guidance from the Institute of Nutrition of Central America and Panama (INCAP) on the organization and development of educational activities.

This program strengthened an activity that had been incorporated for decades into the Costa Rican educational system, particularly in the rural zones of the country: school gardens. It also contributed to strengthening the ancestral tradition of keeping family gardens and domestic animals on a small scale (pigs, hens, and rabbits). The program has been able to survive the ups and downs throughout time and has contributed to maintaining the tradition of keeping small home gardens: two or three fruit trees, some plantain or banana trees, chayotes, some tubers such as cassava or i, four to six layer hens, and one or two pigs. This gardening tradition has helped to improve the diet of low-income families in several areas of the country.

Complementary Food Programs in the 1960s and 1970s

During the first half of the 1970s, CARE and the communities themselves funded the construction of Nutrition and Education Centers (CEN), which therefore continued growing. CARE also contributed foodstuffs (skimmed milk and vegetable mixes) and equipment for the CEN. In 1975, the Family Allotment Fund gave a great impetus to the program, as a result of which, by 1987 (Behm and Barquero, 1990) the country had 437 Nutrition Centers and 34 Integrated Centers for Child Health Care (CINAI). CINAI were established as of 1975-1976, financed by the Family Allotment Fund, to expand preschool to two-to six-year-old children. They are managed by the Nutrition Department of the Ministry of Health in coordination with the Ministry of Education. Each CINAI is run by one preschool teacher and two assistants, who take care of 60 to 100 children.

In the mid-1970s, the complementary food program included at least three of the following: warm meals, distribution of milk and food packages. There was also a school lunch program, which will be analyzed separately in this chapter.

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 EducaciBulletin. This is basically reference material for the development of the educational component at the community level

Audiovisual Modules. These include a wide variety of teaching materials, such as recordings synchronized with slide shows, posters, pamphlets, flip charts, graphs, and bulletins. The purpose of these materials is to deliver educational messages that complement the educational activities for individuals or groups.

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 (Pz et al., 1956). In the mid-1960s, INCAP developed a practical way to iodize salt without special stabilizers and moisture-proof packaging using the relatively insoluble potassium iodate. INCAP continued to strongly urge implementation of the 1930s law until the Figures government did so in 1941. The few population groups without access to iodized salt still show evidence of enlarged thyroid glands.

Fluoridation of Common Salt

Caries and early tooth loss are widespread problems among Costa Ricans. One factor contributing to this condition is the high consumption of refined sugar, a common problem in Costa Rica since the country produces sugar. A compounding factor is the lack of fluoride in food and water. Although a water fluoridation program was established in the 1980s, it covered only the San Josetropolitan area. In 1988, another fluoridation project was started using the same infrastructure as for the iodization process: fluoride was added to common salt for human consumption. The project is still running, and as a result, 80% of all Costa Ricans consume salt enriched with iodine and fluorine.

TABLE 3. Development of School Cafeterias in Costa Rica, 1975-1986

School Cafeteria-Related Parameters	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 (Gonzz-Vega, 1985; Ministerio de Salud, 1976; Sz, 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 Leortcounties.

Source: Evolucie la situaciutricional pare as geogrcas 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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McHugh A. 1990. "Situaciociolaboral y acceso a los servicios de salud: el estado de os programas de salud rural en Costa Rica." Contribuciones No. 7, Instituto de Investigaciones Sociales, Universidad de Costa Rica.

Ministerio de Salud. 1980a. Encuesta Nacional de NutriciB>. 1978. Informe sobre hallazgos antropomicos, lactancia materna, alimentaciuplementaria y uso de servicios del Ministerio de Salud. San JosCosta Rica.

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Vargas W, Quesada E, Carrillo G. 1972. Manual pare el Asistente (Auxiliar) de Salud Rural. Ministerio de Salud. Casa Grca, San JosCosta Rica.

Villegas H, Valverde CA. 1980. "Tendencia de la esperanza de vida en Costa Rica." Bol Of Sanit Panam 29:189-194.

Villegas H, Vargas W, Alfaro L, Amat A. 1974. "Programa de salud pare comunidades rurales." Ministerio de Salud, San JosCosta Rica.

(introduction...)

Dr. Lenin Sz

Introduction

Health has been a highly valued asset in the culture of Costa Rica, and throughout the twentieth century the government has paid an ever-increasing amount of attention to improving the health of the country. Government intervention in health was particularly successful during the 1970s, when health policies and strategies focused primarily on the protection of chose human groups that were more vulnerable and unprotected. During thee period, resources were used to solve the most vulnerable problems with the available technology. The outcomes of these actions were a substantial improvement of the public health and an accelerated process of epidemiological transition, under which the pathologies that characterize underdevelopment gave way to the diseases prevalent in industrialized nations in the absence of an equivalent economic growth. Under these conditions, mortality among youth declined substantially and shifted to older subgroups. This was accompanied by a decline in infectious diseases and an increase in chronic diseases, such as cardiovascular disease and cancer, and in accidental and violent deaths. These latter currently constitute about 60% of all deaths. In addition, the annual population growth rate, which in the 1960s was the second highest in the world at 4%, declined substantially to 2.5%. The fertility rate also declined and reached 119/1,000 coward the end of the 1980s. As a consequence of these changes, the population aged and the age structure was modified accordingly. Whereas the proportion of the population under 15 years of age declined from 45.7% at the beginning of the 1970s to 36.5% by the end of the 1980s, the proportion aged 50 years and older increased from 10% to 12% during the same period.

In order to have a better understanding of this transition and its acceleration during that decade, it is important to review the antecedents and the outstanding aspects of thee evolution. Although it would have been ideal to have morbidity data to make such an analysis, this is not possible, because the data for medical visits and hospital discharges are not easily obtained for the entire period and might not be sufficiently reliable. Even though the epidemiological surveillance systems that have been in place during the last two decades continuously provide information on those diseases that have to be reported routinely, similar information is not available for a considerable number of ocher diseases. For these reasons most of the statistics presented in this chapter are based on mortality estimates obtained from annual reports and internal documents from the Ministry of Health and from annual reports and other documents from the General Directorate of Census and Statistics. Even though during the first decades of this century there were problems with underreporting and the use of a different disease nomenclature that complicates their interpretation, birch and death records have been improving constantly; during the last four decades, their quality and coverage have been satisfactory, and they have been particularly reliable during the last three decades. An estimated 1% of births are recorded with a delay, 5% of deaths are not recorded or are recorded with a delay, and 71% of deaths are documented with a medical certificate. During the last 15 years, the proportion of reports with an improper definition of cause of death has declined substantially.

Since the beginning of this century, general and infant mortality estimates have allowed the evolution of these health phenomena to be documented and general conclusions to be reached regarding the possible impact of health policies and strategies. Throughout most of this century, infant mortality, which is one of the most sensitive indicators, has represented a very significant proportion of the total deaths.

Stages of a process

In order to facilitate the analysis of the events that have taken place in the area of health during this century, the author considers that it is convenient to divide them into several stages based on specific characteristics involving the behavior of health indicators as well as the socioeconomic situation and the response of the country institutions to what at the time were considered the most important health problems:

· In an initial stage, which covers the first four decades of this century, mortality rates were high and fluctuating, with a clear predominance of infectious and parasitic diseases among children under five years of age. The predominant health activities involved the creation and institutionalization of entities whose mission was to solve specific problems.

· A clear mortality decline can be observed between 1940 and 1970 at the same time that infectious and parasitic diseases continued to be prevalent. During this stage, health actions were based on the treatment approach.

· During the 1970s, a dramatic decline in mortality and morbidity due to infections and parasites can be observed in all age groups. During this stage, a cohesive see of policies and health strategies guided the activities following a broad preventive approach.

· During the 1980s, the country experienced the worst socioeconomic crisis, and the government reduced the resources allocated to the health sector. Whereas during the first half of the 1980s the rate of decline in mortality decreased, during the second half of the past decade a greater improvement in health indicators was observed coinciding with a resolution of the crisis, a modest increase in resource allocation and continuing decentralization of the health sector.

· The last decade of this century will be the final stage. The trends observed during the last decade allow for the prediction of the probable evolution of the health status and principal causes of death in all age groups and geographic regions, assuming that new factors do not cause a deviation from past trends.

The first four decades of the century

During the first four decades of this century, the health situation was characterized by high mortality rates among infants and the population as a whole and by an erratic behavior of these indicators. The overall mortality rate declined only from 24.0 to 17.1/1,000, an average annual rate of reduction of 0.7%. Mortality rates fluctuated widely, particularly during the first three decades, reaching as high as 28.7/1,000 in 1920 (Sz, 1990). It is noticeable thee the increase in mortality that took place between 1900 and 1920 (4.7/1,000) is higher than the total mortality rate recorded in the country during 1980 (4.1/1,000).

Infant mortality followed a similar pattern, characterized by an increase during the initial decades that reached 248 infant deaths per 1,000 live births in 1920. The reduction in infant mortality during this stage was only 0.8% per year. Traditionally, malnutrition and unsanitary environments have been associated with high mortality rates among children under five years old. During this stage, under-five child mortality was very high, and instead of declining, it increased from 47% to 52%. By contrast, the mortality among people aged 50 years or older was very low, because only 23% of the population reached this age. Nevertheless, life expectancy at birch increased from 35.1 years in 1910 to 46.9 years in 1940.

Mortality caused by infectious and parasitic diseases represented the main health problem, and these conditions accounted for 65% of all deaths in 1920. The behavior of this parameter was very erratic, and its rate fluctuated between 186.1 and 81.3/10,000, with an annual rate of reduction of only 0.6% between 1910 and 1940. Intestinal parasites, malaria, tuberculosis, and respiratory infections accounted for a large proportion of deaths during this period.

The national economy, which was very vulnerable at this stage, experienced a series of crises thee led to the fall of the liberal economic system and the economic impoverishment of the country, which affected the low-income groups more severely. The emerging middle class was unable to fulfill its expectations of improvements, many small-land workers lost their land, and the people who received a steady income either lost their jobs or experienced a net reduction in their salaries (Rosero, 1984). The educational level was very low, with an illiteracy rate of 54.8% at the beginning of this period that declined to 26.7% by the end.

Most health-related welfare activities were undertaken by the private sector and charity organizations. The government levied a "welfare tax" thee was used to finance existing hospitals that were run by organizations formed by community leaders; these organizations in face acted with a great deal of autonomy. In addition, several counties in the country had health centers thee provided poor people with medical care and preventive services for the control of epidemics.

Preventive health policy was oriented coward legislation and the creation of organizations for the resolution of specific problems. This process culminated in 1927 with the creation of the Ministry of Public Health and Social Protection.

The period between 1940 and 1970

Mortality decreased substantially between 1940 and 1970 (down from 17.1 to 6.6/1,000, during these 30 years, representing an average annual reduction rate of 2.1 %) than infant mortality (down from 132.4 to 61.5/1,000, representing an average annual reduction rate of 1.8%). The under-five mortality remained high but nevertheless decreased from 51.8% to 40.9%, while mortality among people aged 50 years and older increased from 22.9% to 41.6%. Life expectancy at birch increased from 46.9 years at the beginning of the period to 68.1 between 1965 and 1970.

Mortality caused by infections and parasites began to decline. Infectious and parasitic diseases accounted for 47.6% of coral deaths in 1940 and 20.5% in 1970. The prevalence of these diseases declined from 81.31 10,000 in 1940 to 13.6/10,000 in 1970, representing an annual reduction rate of 2.8%. Malaria declined so much thee by the end of this stage it was considered to be practically eradicated.

By contrast, motor vehicle accidents became an important cause of death. During this period, particularly during the 1950s, the economy grew in a sustained and substantial fashion and a new style of development was adopted. The government expanded its field of action and adopted policies that allowed it to provide a large number of jobs and to allocate a substantial amount of resources for the provision of public services. Illiteracy declined from 26.7% to 11.2%.

The enormous technological advances that took place throughout the world provided useful insecticides for the fight against several pathogen carriers, new vaccines for the prevention of some diseases and effective drugs for treating diseases, as well as new and better equipment for diagnosis and treatment. This period represents the beginning and rapid development of the era of antibiotics.

The government of Costa Rica defined a group of social policies. Among them, chose that led to the creation and expansion of the Social Security Institute deserve special mention. Health coverage was expanded with the construction of new hospitals and the replacement of the old hospitals that were incapable of satisfying the demand. A large variety of government, private, and volunteer health organizations remained, which were not adequately coordinated even though they received some funding from the government (Sz, 1983).

Even though the health policies were still based on the curative approach, as indicated by the face that 80% of the budget was allocated to hospital care, legislation was created to protect public health, new specialized entities were created for preventive health, and new organizations were created at the local level.

The decade of the 1970s

During this period, the evolution of the health situation in Costa Rica took on special characteristics. The health improvements were much greater than would have been predicted based on previous trends and the growth of the national economy. Mortality declined among all age groups, but the decline was particularly strong among children. As a result, the process of the epidemiological transition accelerated. There was a spectacular absolute and proportional decline in mortality associated with infections and parasites and a proportional increase in diseases of adults and the elderly. Cardiovascular diseases and cancer became the two leading causes of death, followed by accidental and violent deaths.

The Indicators That Were More Affected

In contrast with the previous period, infant morality declined more than overall mortality, and neonatal mortality became the largest component of infant mortality. The proportion of mortality, among people aged 50 years or older increased substantially, and life expectancy at birth increased to 73 years by 1975-1980. The incidence of preventable communicable diseases decreased dramatically, and there have been no reports of polio in the country since 1974 or diphtheria since 1977. With these achievements, most of the goals proposed in the initiative "Health for All by the Year 2000" were achieved 20 years before the deadline. The behavior of the main health indicators during this period is analyzed in the following sections.

Overall Mortality

Overall mortality declined from 6.6 to 4.1/1,000. In addition to the reduction in mortality rates, the principal causes of mortality also changed. While infectious and parasitic diseases moved from second to eighth place, cardiovascular diseases and cancer became the first and second causes of death, respectively. Prematurity and some diseases of early infancy moved up to fourth place, and birth anomalies occupied fifth place. Among the first five specific causes of death, mortality due to diarrhea moved from second to seventh place and pneumonia and bronchopneumonia from fourth to fifth place.

Infant Mortality

Infant mortality declined during the decade from 61.5 to 19.1/1,000 live births. The rate of decline was 7.7% per year in the first half of the decade and 9.9% in the second half, a spectacular decline when compared with the 1.1% decline during the previous decade.

A comparison of the infant mortality trends between 1930 and 1980 in Costa Rica with those observed in developed nations (an average of Denmark, Norway, Holland, Sweden, France, England and Wales, and the United States) shows that by 1930 the more advanced nations had already reached the rate of 63/1,000 that was found in Costa Rica in 1970 (Figure 1). The decrease from this rate to 18 per 1,000 in the developed countries required more than three decades, this same reduction took place in Costa Rica in less than 10 years. This illustrates the enormous speed at which the infant mortality rate declined in Costa Rica as a result of the policies and programs adopted in 1972.

FIGURE 1. Infant Mortality in Costa Rica Compared with Industrialized Countries, 1910-1980

This reduction had a much greater effect on postneonatal mortality, which declined during the decade from 36.3 to 7.9/1,000 live births (an annual decline of 7.8%). By contrast, neonatal mortality declined from 25.2 to 11.2/1,000 (an annual decline of 5.6%), as shown in Figure 2.

Taking into account that these indicators represent national averages and that there are wide variations among counties with respect to quality of life, it is important to study the infant mortality patterns at the county level, where this information is available using triennial rates, to avoid biasing the results due to the low number of births and deaths in a small population. Table 1 presents the 1972-1988 patterns. This table as well as Figure 3 shows that during this period there was a decrease in infant mortality in counties throughout the country, which is a reflection of the efforts that made to achieve a greater equity in the provision of health services.

FIGURE 2. Indicators of Infant Mortality in Costa Rica, 1970-1988

During 1972-1974, the national average infant mortality rate was 44/1,000, with a range of 20 to 69.9/1,000 in 85% of the counties. Ten percent of the counties that had a lower quality of life had an infant mortality rate of 70/1,000. Between 1975 and 1977, the national average was 32.8/1,000 and the spread of the range narrowed. The range in 85% of the counties was 10 to 49.9/1,000, and only 6.4% of them had a rate of 50/1,000 or more. Finally, between 1980 and 1982, the national average was 19.5/1,000, with 96.4% of the counties falling between 10 and 29.9/1,000 and only 2.4/1,000 with 30/1,000 or more.

In this decade, birth anomalies, immaturity and certain diseases of early infancy became the leading causes of death among this age group. Among the main specific causes of death, gastroenteritis and colitis moved from first to fifth place, representing a reduction from 16.7 to 1.4/1,000.

Mortality Among Children One to Four Years Old

Child mortality among one- to four-year-olds declined rapidly from 5.1 to 1.0/1,000 between 1970 and 1980. The annual rate of reduction increased from 4.7% during the last five years of the previous decade to 11.8% during the first half of the 1970s. Among one- to four-year-old children, accidents and violence became the leading causes of death, accounting for 20% of deaths in this age group compared to 5.5% before this period.

TABLE 1. Infant Mortality Rates in the Counties of Costa Rica

Rate Per Thousand Live Births	No. of Counties in Which the Rates Were Registered
	1972-1974		1975-1977		1980-1982		1986-1988
	No.	%	No.	%	No.	%	No.	%
<10	0	0	0	0	1	1.2	2	2.5
10.00-19.99	4	5.1	8	10.5	51	63	62	76.5
20.00-29 99	13	16.4	27	34.2	27	33.4	17	21.0
30.00-39.99	22	27.8	24	34.2	27	33.4	0	0
40.00-49.99	14	17.7	15	19.0	1	1.2	0	0
50.00-59.99	9	11.4	1	1.3	1	1.2	0	0
60.00-69.99	9	11.4	1	1.3	1	1.2	0	0
70.00-79.99	7	8.9	1	1.3	0	0	0	0
³80	1	1.3	0	0	0	0	0	0
National	44.1		32.8		19.5		17.3

Source: Anuarios y tabulaciones de la Direccieneral de Estadica y Censos y del Departmento de Estaduca de la Unidad Sectorial de Planificaciel Ministerio de Salud.

Birth anomalies moved from the eleventh to the fourth leading cause of death as the mortality rate from birth anomalies increased from 0.4 to 1.1/10,000. Among the main specific causes of death, gastroenteritis and colitis moved from first to fifth place, representing a reduction from 11.9 to 0.74/10,000.

Mortality Among Children Under Five

Between 1970 and 1980, the percentage of overall mortality due to mortality among children under five declined from 41 % to 17% at the same time that its rate declined 32.5% during the first half and 37.7% during the second half of the decade. Figure 4 shows the steepness of the slope when compared with the trends in the previous decades.

FIGURE 3. Infant Mortality in the Counties of Costa Rica, 1972-1974, 1975-1977, 1980-1982, 1986-1988

Infectious and Parasitic Diseases

The decline in deaths attributed to infectious and parasitic diseases was so dramatic that it represented a 92% reduction (from 13.6 to 1. 5/10,000). The proportion of total deaths explained by these diseases declined from 20.5% to only 3%. Among the infectious and parasitic diseases that were particularly important at the beginning of the decade were septicemia, tetanus, tuberculosis, ascaris, and diarrheal diseases. The latter declined from 7.0 to 0.5/10,000 and moved from second to seventh place in the ranking of causes of death. The proportion of total deaths explained by these diseases declined from 10.5% to 1.2%.

FIGURE 4. Mortality of Children Under Five Years Old in Costa Rica, 1910-1988

The improvements in record-keeping of diseases that by law had to be reported by the end of the 1960s, in addition to the implementation of an epidemiological surveillance system at the beginning of the 1970s, allow an assessment of the notable reduction that took place in the vaccine-preventable diseases. The rate of measles declined from 262.5 to 44.5/100,000 between 1970 and 1980. During the same period, the rate of pertussis (whooping cough) declined from 74.4 to 39.3/100,000 and the rate of tetanus from 4.9 to 0.1/100,000. The rate of tuberculosis also declined from 28.6 to 19.6/100,000. Polio and diphtheria were eliminated by immunization during this period. Morbidity that could be prevented through improvements in basic sanitation also declined substantially. The rates of typhoid went from 3.6 to 0.2/100,000, paratyphoid from 0.5 to 0.2/100,000, salmonellosis from 13.4 to 0.9/100,000, and shigellosis from 18.4 to 0.2/100,000.

Mortality-Among Children 5 to 14 Years Old

Mortality rates among 5- to 14-year-old children also declined substantially from 9.0/10,000 in 1970 to 4.6/10,000 in 1980. The annual rate of reduction in mortality in this group increased from 0.4% in the previous five years to 7.5% during the first half of this decade.

During this period, the rate of diarrheal diseases declined from 7 to 0.1/1,000 and moved from second to twelfth place in the ranking of causes of death, and measles showed a similar pattern. By contrast, malignant tumors moved from fifth to second place and birch anomalies from seventeenth to fifth place. Accidents and violence remained the leading causes of death, increasing from 1.6 to 2.0/10,000 and also causing a larger proportion of deaths (from 16.9% to 42.5%).

Mortality Among the Population 15 to 49 Years Old

Mortality rates among the 15- to 49-year-old population also decreased, although to a lesser extent than infant and child mortality, from 20/10,000 in 1970 to 15.1/10,000 in 1980. For this age group, accidents and violence were the main causes, but chronic degenerative diseases were also a major cause of death. Ischemic heart disease moved from fourth to second place as a cause of death, and cerebrovascular disease moved from fifth co third. Mortality from suicide and self-inflicted injuries moved from twelfth to sixth place.

Mortality Among the Population 50 or More Years Old

Although mortality among chose aged 50 years and older declined from 28.7/1,000 in 1970 to 22.6/1,000 in 1980, the proportion of deaths in the total population attributed to this age group increased from 41.8% to 61.4%. The causes of death in this age group were similar to those of the 15- to 49-year-old group, with a predominance of chronic degenerative diseases. Pneumonia and bronchopneumonia moved from fourth to sixth place, and their rate declined from 2.0 to 0.9/1,000.

Nutritional Status Patterns

Nutritional surveys conducted in the country between 1966 and 1975 showed a small decline in the proportion of malnourished children younger than six years. The proportion declined from 57.4% to 53.2%, and (using the G classification)¹ the proportion of children with degrees II and III malnutrition declined from 13.7% to 12.3%. However, a survey conducted only three years later (i.e., in 1978) showed reduced rates of 45% for malnourished children and 8.7% for children with degrees II and III malnutrition. Four years later, in 1982, a new survey recorded a rate of overall malnutrition of 34.2% and a rate of 3.6% for children with degrees II and III malnutrition. This survey also showed that 88.7% of the children younger than six years had an adequate weight for height.

¹ Degree 175-90%, degree II 60-75%, degree III < 60% of normal weight for age.

In 1966, the prevalence of endemic goiter and retinol deficiency was 18% and 32%, respectively. During the 1970s, these two nutritional disorders were controlled to a point that they were no longer considered a public health problem.

Factors That Might Have Been Responsible for the Success

The economies of the Central American countries have grown at a steady pace since the 1950s. The prosperity of the export sector facilitated the mutual free trade of regional produces, which in turn favored an incense process of industrialization. The importance of the foreign trade sector grew during the following two decades. This sector began to change its structure by including among its exports a series of nontraditional produces and by expanding the imports of intermediary produces as well as capital goods. The gross national produce (GNP) increased substantially, and a middle class emerged, in association with progressive urbanization, the increasing importance of secondary economic activities and the increased diversification of the productive sector. However, the new economic and social classes simply replaced the previous ones through a process of change and modernization thee did not threaten the existing economic structure (Sz, 1988).

During the 1970s, the situation in Costa Rica was similar to that in the rest of Central America. The GNP showed a substantial increment from US $ 656 to US $ 892, and government health expenditures increased from 5.1% to 7.6% of the GNP. However, the health improvements in Costa Rica during that decade were so impressive and so different from chose found in ocher Central American nations that economic factors alone cannot account for the dramatic improvement in health status.

Based on a model developed by the United Nations to study fecundity determinants, it is possible to establish, for different economic, social, and demographic indicators, the correspondence of the value of each indicator with a theoretical index of development that ranges from 0 to 100. Using this model with seven economic and three social indicators, Rosero (1985) estimated the proportion of infant mortality that could be attributed to each indicator in Costa Rica between 1950 and 1980. When comparing the expected with the observed rates, it is possible to observe a trend of improvement for both the observed infant mortality and the two sees of expected indicators. This trend, however, changes sharply in 1970 because the improvements in infant mortality accelerate precipitously while the two sees of indicators continue to follow the past trend.

In view of the discrepancy between the patterns of health and the social and economic indicators in Costa Rica when compared with ocher countries in the region, it becomes important to assess the role of government in these positive health outcomes. This issue is summarized in the following discussion.

Health policy and a National Health Plan were developed at the beginning of the decade based on the concept of "narrowing the social differences" proposed in the National Development Plan. The outcomes of the National Health Plan were:

· Substantial changes in legislation and the structure of health services;

· Coverage in services provided by the Social Security Institute increased from 39% to 78% and included new economic groups and geographic areas;

· Large increments in coverage for services provided by the Ministry of Health that included new programs for the dispersed rural and disadvantaged urban populations. With the new coverage it was possible to reach 60% of the rural population, including 95% of the dispersed rural, and 40% of the urban population. The activities included health education and disease prevention through immunizations and sanitation;

· Development of extensive food supplementation programs for preschool and school-aged children and of food fortification programs for the prevention of specific nutritional deficiencies; and

· Financing of new programs and more investment of resources to broaden nutritional programs based on a new law for social development and family assistance that served as an instrument for the distribution of the nation's wealth by facilitating the participation of the socioeconomically deprived.

The large improvements in health observed during this decade, which were unexpected based on previous trends, coincided with the implementation of primary health care strategies, with emphasis on prevention and health education (Sz, 1985a), and the investment of increased resources thee targeted the most vulnerable subgroups.

At the beginning of this decade, the coverage of health services was very poor, and nutritional deficiencies and immunopreventable and sanitation-preventable diseases were very common. The response to these problems was a large increase in food and nutrition programs and a substantial increase in the coverage of health services. This was particularly true among the dispersed rural and the disadvantaged urban populations, where immunization coverage reached 80% and access to water supplies in the rural areas increased from 56% to 68% (the percentage of households with water within the household increased from 39% to 64%). Throughout this time, universal access to water in urban areas was sustained, and the percentage of households with adequate facilities for fecal disposal increased from 60% to 96% in urban areas and from 41% to 88% in rural areas (Sz, 1985b).

Once the response to the problems is understood, it is easier to understand the rapid decline in mortality, particularly among children under five years old: more than a 94% reduction in morbidity associated with immunopreventable diseases and with typhoid, paratyphoid, salmonellosis, and amoebic dysentery. In addition, it is possible to assert with confidence that, the health situation of a country can be improved much more than expected from the level of national economic growth by taking appropriate actions. In the case of Costa Rica, the government response, including the see of actions that culminated in the Health Policy and the National Plan, allowed for vase health improvements that went far beyond expectations based on the economic situation of the country. The case of Costa Rica in this period is a very good example of what can be achieved when there is political will to prioritize the protection of chose human beings who are more vulnerable and to base efforts on targeting the most important health problems with the available resources.

The decade of the 1980s

Evolution of the Situation

The pace of progress that occurred during the 1970s was interrupted during the 1980s, when the country was hit by the most severe economic crisis in its history. The mortality declines slowed down considerably in most age groups, eventually stagnating at the levels reached during the first five years and slightly improving during the second half of the decade. Since this pattern coincided with the crisis and its consequences, it is worthwhile dividing this period into halves to make a better assessment of the relationship between the health indicators and the national economy.

Overall Mortality

Even though overall mortality continued to decline, it declined at a slower rate than in the second half of the previous decade, and it reached 3.8/1,000 by 1989.

The distribution of causes of death remained basically the same. Cardiovascular diseases and cancerous tumors remained as the two leading causes of death. The proportion of deaths attributed to these conditions increased, and the proportion attributed to pneumonia and bronchopneumonia decreased.

Life expectancy at birch increased gradually and eventually reached 75 years in 1985-1990 compared with 76 in the United States in 1989-1991 (UNICEF, 1991, 1994).

Infant Mortality

The enormous average annual reduction in infant mortality observed during the second half of the previous decade decreased dramatically during the first half of the 1980s, from 9.9% to 1.6%, but increased again during the second half of this decade to 5.2%. Infant mortality declined from 19.1 to 13.9/1,000 during this decade. This deceleration had a greater effect on neonatal mortality, which was 11.2/1,000 throughout the first half of the decade and reached 8.8/1,000 by the end of the decade. Postneonatal mortality declined to 5.0/1,000 by the end of the decade, as shown in Figure 2.

The distribution of causes of infant death remained basically the same. Prematurity, certain diseases of early infancy, and birch anomalies remained the leading causes of death. Diarrheal diseases moved in the ranking from fourth to fifth place.

Mortality Among Children One to Four Years Old

Mortality among one- to four-year-old children declined from 10.1 to 7.4/10,000 during the first half and to 7.2/10,000 during the second half of the decade. In contrast to infant mortality, the rate of improvement declined in the second half of the decade.

Birth anomalies became a more important cause of death, reaching second place by the end of the decade, with a rate of 1.4/10,000. Violence and accidents remained the leading causes of death, and the proportion of deaths attributed to them increased from 19.8% to 23.6%.

Mortality Among Children Under Five

Child mortality declined from 17% in 1980 to 16% in 1985 and 12% in 1989. The average annual rate of reduction was only 1.2% during the first half, but it was 4.7% during the second half of the decade.

Infectious and Parasitic Diseases

The prevalence of infectious and parasitic diseases continued to decline from 1.7 to 0.9/10,000, and their impact on overall mortality declined. Diseases that were particularly important causes of death in the 1970s, such as diarrhea, tetanus, septicemia, and tuberculosis, continued to decline, although at a much slower pace.

Morbidity resulting from immunopreventable diseases continued to decline throughout the decade. In 1990, measles reached 2.7/100,000, pertussis 2.5/100,000, tuberculosis 1.7/100,000, and tetanus remained at 0.1/100,000. There were no polio or diphtheria cases reported during this decade. Meanwhile, morbidity that could be prevented by basic sanitation followed a more erratic pattern. Typhoid showed a moderate increase during the first half until it reached 0.6/100,000 in 1986, but declined to 0.3/100,000 in 1990. Paratyphoid remained at 0.2/100,000 during the first half, but no cases were recorded during the following four years. Salmonellosis remained at 3.4/100,000 during the first half but later declined until it reached 0.9/100,000 in 1990. Shigellosis followed an increasing trend and reached 2.4/100,000 in 1986 and 6.4/100,000 in 1990.

Mortality Among Children 5 to 14 Years Old

Mortality changes among 5- to 14-year-old children during this decade contrasted with chose in the previous decade. During the first half of the decade, the average annual rate of decrease in mortality accelerated from 3.6% to 7%. Mortality in this age group reached a rate of 3/10,000 and remained almost constant during the second half of the decade, as shown in Figure 5.

Two important changes in the structure of the causes of mortality were the absence of deaths attributed to measles in 1988 and 1989 and the reduction in the diarrheal disease rate, which shifted from third to ninth place. By contrast, congenital disorders moved from seventeenth to fourth place. Although the rates of accidents and malignant tumors decreased, the proportion of deaths attributed to them increased.

FIGURE 5. Mortality of Children 5 to 14 Years Old in Costa Rica, 1970-1988

Mortality Among the Population 15 to 49 Years Old

Mortality among the 15- to 49-year-old population steadily declined throughout the decade. The decline was faster during the first five years, when mortality reached 12.2/1,000, than during the second five years, when it reached 11.8/1,000.

Along with accidents, which, as in the previous decade, were the leading cause of death, chronic degenerative diseases became strongly predominant during this decade. Ischemic heart disease remained in second place; cerebrovascular diseases were displaced from third to fourth place by stomach cancer. Meanwhile, suicides and self-inflicted injuries moved up to fifth place in the ranking as coral mortality declined.

Mortality Among the Population 50 or More Years Old

The mortality rate among the population 50 and older ranged only between 22.6 and 22.3/1,000, although the proportion of deaths represented by this age group increased from 61.4% to 70. 1%. The main causes of death were chronic degenerative diseases, particularly cardiovascular disease and cancers, which occurred at increased rates, while pneumonia and bronchopneumonia became less important as causes of death.

Factors That Affected the Situation

Some have cried to explain the deceleration in improvements in health indicators by the difficulty of increasing even more the vase improvements in health that had already been achieved. This explanation, however, might not be valid, since some industrialized countries have achieved even better health outcomes and the health indicators. Therefore, it is important to look for another explanation.

The model of economic development of the Central American countries stagnated during the 1970s. The favorable economic trends deteriorated due to the serious repercussions of the economic crisis not only on the economy but also on the social and political structures. Within this context, at the beginning of the 1980s, Costa Rica suffered the full impact of the economic crisis. The steady growth of the GNP deteriorated dramatically between 1980 and 1982. Real production declined 9.1%; the national currency was devalued; prices increased 179.5%; overt unemployment reached 9.4%; real wages declined 40%; the proportion of poor families increased 53% in both urban and rural areas; the cost of essential foods increased more than income, and in 1982 they cost more than the average wage. Foreign debt, which was 114.5% of the GNP in 1982, exceeded the country's resources to pay for it, and the interest payments on this debt represented more than 50% of the value of exports of goods and services.

To restore economic stability, the government increased taxes and limited the expansion of public expenditures. This caused a net reduction in constant colones in health investments, which declined from 7.6% of the GNP in 1980 to 5.7% in 1983.

The significant decline in the rate of improvement in health indicators coincided with the negative influence of the social and economic deterioration. Furthermore, the reduction in per capita health expenditures forced the government to reduce its efforts to improve the health situation in the country. This reduction in investment, together with the drop in per capita national income, coincided with a slowdown in the pace at which infant and child morality was improving. Nevertheless, this slowdown in health improvement was not as severe as would be expected based on the socioeconomic crisis. Figure 6 shows how the drop in income per capita coincided with an interruption in the rate of decline in infant mortality.

Mortality patterns among subjects 5 to 14 years of age were unexpected, because there was an acceleration in the pace of improvement during the first half of the decade, when the economic crisis was most severe, and a deceleration in these improvements during the second half, when the crisis was becoming less severe. A possible explanation for these findings is that there were two cohorts that reached the 5- to 14-year-old group between 1980 and 1985 and benefited during the previous decade from programs that reduced their risks of morbidity and mortality. A cohort thee suffered the impact of the crisis during the previous five years reached this age group in 1985.

The last decade of the century

The progress achieved in improving the health status of Costa Ricans has generated trends and patterns that make it possible to predict and analyze future developments. It is thus possible to identify probable scenarios and to design strategies for improving them. It is also possible to evaluate opportunities for changes thee will produce better health policies on modifications of situations that effect the socioeconomic development of the country. In addition, problems can be identified that are hidden in a current analysis but that may arise in the future in order to determine where to concentrate future resources to obtain the greatest impact in combatting specific health problems. Confronted with the acceleration of the epidemiological transition that began in the 1970s, this type of analysis needs to pay special attention to the evolution of emerging pathologies and to the most vulnerable subgroups.

The following sections summarize some important aspects of the health situation that is likely to develop in Costa Rica during the last decade of this century, assuming thee no significant events modify the trends observed up to 1989. Since the epidemiological transition does not develop at the same rate in all the regions of the country, the analysis will be based on the comparison of three populations: the national average, the vulnerable counties, and the less vulnerable counties. The latter are further subdivided based on geographic, cultural, and economic characteristics.

FIGURE 6. Per Capita Income and Infant Mortality in Costa Rica, 1970-1978

Trends at the National and County Level

Among all age groups, mortality rates are expected to decline throughout the decade. With the exception of overall mortality and perinatal and neonatal mortality, mortality rates in the vulnerable counties are likely to exceed the national and less vulnerable county average.

At the national level, deaths attributed to communicable diseases are likely to continue to decrease, and deaths due to accidents and chronic degenerative diseases are likely to increase.

With the exception of acute respiratory infections (ARI), mortality caused by communicable diseases will decline more in the vulnerable counties than in the less vulnerable groups and the country as a whole. Deaths attributed to chronic degenerative diseases and accidental and violent deaths are likely to increase in all three populations. Although at the moment the rates are lower in the most vulnerable counties, current trends suggest thee this pattern might reverse in the near future.

Mortality in Some Age Groups

The finding that mortality rates in some of the counties, that did not receive priority attention in the 1970s, are now higher than the national average is the reverse of the situation in the 1970s and of what is seen for the vulnerable age groups. This may be due to aging of the population as a result of lower mortality among youth and to an increase in chronic degenerative diseases that have replaced nutritional, infectious, and parasitic disorders as causes of death in adults. Nevertheless, these patterns vary in different areas. Even though in two areas the actual rates are below the national average, the current ascending trend will lead to rates that are above the national average by mid-decade.

On the other hand, it is expected that infant and postneonatal, neonatal, and perinatal mortality will continue to decline. Whereas infant and postneonatal mortality rates are highest in the vulnerable counties, neonatal and perinatal mortality rates are highest in the less vulnerable counties. In ocher words, they are shifting from a developing country pattern of high infant mortality dominated by infections to a low infant mortality dominated by neonatal and congenital disorders characteristic of industrialized countries.

Mortality among children one to four years of age is highest in the vulnerable counties and is likely to continue to decline at a moderate rate in all of them.

Mortality Caused by Infectious and Parasitic Diseases

Mortality associated with diarrheal diseases is highest the vulnerable counties and is likely to continue to decline at the national level. In 1989, mortality associated with ARI was slightly higher in the less vulnerable counties, where it is likely to decline more rapidly than in the vulnerable counties. Mortality rates associated with ocher infectious and parasitic diseases will vary in different areas, and the rate of decline is likely to be similar in vulnerable and less vulnerable counties.

Gastric Cancer

Mortality associated with gastric, cervical, and breast cancer is likely to show moderate increases at the national level. The increase in prostate cancer is likely to be higher. The rates of cervical and prostate cancer are higher in the vulnerable than in the less vulnerable counties. Gastric and breast cancer rates are lower in the vulnerable than in the less vulnerable counties, but current trends suggest that the vulnerable counties will soon have rates above the current national average.

Mortality Associated with Other Emerging Diseases

Although the proportion of total mortality due to ischemic heart disease and cerebrovascular disease is expected to increase, absolute rates are likely to show a modest decline at the national level. In the less vulnerable counties the rates are high but will decrease while in the more vulnerable ones they will increase.

Hypertension and diabetes mellitus-associated mortality is likely to increase substantially in both the less vulnerable and the vulnerable counties, with higher rates in the latter. Mortality caused by accidents, injuries, and poisoning shows an increasing trend in the three populations that are being analyzed.

Epidemiological Profiles in 1989 and 2000

Based on 1989 mortality trends, it is expected that ischemic heart disease, accidents and violence, cerebrovascular diseases, and gastric cancer will be the leading causes of mortality for the remainder of the century. It is also expected that deaths attributed to cardiovascular and cerebrovascular diseases will decrease slightly and those related to accidents and violence will show a moderate increase. Current trends also suggest that infectious and parasitic diseases will continue to decrease and eventually will be displaced from fifth place by diabetes in the ranking of causes of mortality.

In the less vulnerable counties, four leading causes of mortality in 1989 were the same as chose at the national level. The fifth place in these counties was occupied by diabetes. If current trends are sustained, this pattern will remain unmodified for the rest of the century. Whereas the rates of cerebrovascular and ischemic heart disease will show a moderate decrease, the rates associated with the other chronic diseases will increase.

In the vulnerable counties, the five leading causes of death in 1989 were accidents and violence, ischemic heart disease, cerebrovascular diseases, infectious and parasitic diseases, and gastric cancer. If current trends are sustained, by the year 2000 the first two causes of death will trade places, cerebrovascular diseases will move from third to fourth place, gastric cancer from fifth to third place, and breast cancer from twelfth to fifth place. The burden of infectious and parasitic diseases on mortality will decline.

Final comments

The study of the evolution of the Health situation in Costa Rica shows that when the Health sector takes appropriate actions that are supported by an institutional response of government, Health indicators can improve beyond expectations, based on national economic growth, and in shore periods of time, as occurred in the 1970s. This analysis also allows for an appreciation of the heterogeneity in improvement of different Health indicators and causes of mortality among different age groups as a result of the actions taken by the country. It also shows how the economic crisis that began in 1980 affected the Health situation. The mechanisms underlying the impact of the crisis were related not only to changes in those factors that directly affect health outcomes, but also to a reduction in available government resources for Health investment.

Given these faces, even though there is no doubt that economic development affects health outcomes at the national level, these analyses show thee even limited economic resources can be invested wisely in Health improvement when the political will exists. If this investment is done in a rational and equitable fashion, the outcome will be health improvements that go beyond predictions based simply on economic growth (Sz, 1989).

These analyses show that Health improvements can occur as a result of political decisions regarding budgetary allocations even when these are scarce. This finding discredits the premise thee economic development is an essential factor without which it is impossible to improve the Health of a nation and indicates that poor nations have the ability to achieve health for all if they have the political will and devote enough well planned efforts to achieve this goal.

References

Rosero L. 1984. "Las polcas socio con y su efecto en el descenso de la mortalidad costarricense. " In: Mortalidad y fecundidad en Costa Rica. Asociaciemogrca Costarricense, March 1984, p. 38.

Rosero L. 1985. "Determinantes del descenso de la mortalidad infantil en Costa Rica. " In: Demografy epidemiologen Costa Rica. Asociaciemogrca Costarricense, March 1985, p. 18.

Sz, L. 1983. Hacia un sistema nacional de salud en Costa Rica. San JosCosta Rica, Ministerio de Salud, February 1983, pp. 15-17.

Sz, L. 1985a. Salud sin riqueza. El cave de Costa Rica. Ministerio de Salud de Costa Rica, p. 45.

Sz, L. 1985b. "Health changes during a decade. The Costa Rican Case. " In: "Good health at low cost." Proceedings of a conference held at the Bellagio Conference Center, Bellagio, Italy, April 29-May 3, 1985, p. 142.

Sz, L. 1988. "Administracie servicios de salud." Editorial UNED. San JosCosta Rica, p. 91.

Sz, L. 1989. Logros de una polca e impacto de una crisis en la salud de un Pa/B>. Ministerio de Salud, Costa Rica, 1989. pp. 20-21.

Sz, L. 1990. "Mortalidad y programas de salud (La experiencia de un pade la Subregi" In: La mortalidad infantil en Honduras. La Facultad de Ciencias Econas, Tegucigalpa, Honduras, 1990, p. 70.

UNICEF. 1991. The state of the world's children. New York: UNICEF.

UNICEF. 1994. The state of the world's children. New York: UNICEF.

(introduction...)

MarEugenia Trejos

Introduction

From 1950 to 1980 a social policy was implemented in Costa Rica that achieved current outcomes that compared favorably with the social indicators of most developed nations. These outcomes developed particularly rapidly during the 1970s. The reasons for this phenomenon, although extensively studied, still require further clarification. This chapter analyzes some factors that help to explain these results. The intent is to provide new insights for understanding this process.

Costa Rica began to apply a development strategy in the 1950s with a social policy taking into account the specific issues of importance to a developing country. This strategy has had success, not only because of a historical accident, but also because it combined with the improvement of factors related to the current history of the country. This process was accelerated during the 1970s with governments oriented toward the generation of public profits that required the building of consensus among the different sectors in society.

In order to analyze the process and link it with world trends as well as with the historical trends of the country this chapter is divided into three parts. The first part analyzes the emergence of the social government in Costa Rica. This section also analyzes the characteristics of the social and economic development of Costa Rica that help to understand the emergence of this type of government during the 1950s. The second part analyzes the fundamental characteristics of the social government in relationship to other spheres of society that integrated the same socioeconomic strategy in Costa Rica. The third part analyzes the outcome during the 1970s of the accelerated emergence of a government with strong social goals.

Recognition of social demands and the regulation of the conflict during the 1930s and 1940s

During the 1930s and 1940s in Costa Rica there were several phenomena that provided the basis for the subsequent development in the country. This section analyzes these series of events. During the 1930s and 1940s, organizations and social efforts played an important role in Costa Rica. As a result, the government recognized popular demands and took actions to avoid an escalation of hostilities that would jeopardize the existence of the regime.

Since the end of the last century organizations for social improvement had existed in Costa Rica. These became stronger during the 1930s as a result of the 1929 financial crisis that negatively affected the popular sectors. Faced with increasing popular demands, the government responded by mediating and regulating the relationship among different sectors to avoid worsening the existing social conflict. The result was a style of government that recognized popular demands and satisfied some of these demands to ensure its viability.

During this decade the Institute for the Protection of Coffee was established to regulate the relationship between small owners and exporting beneficiaries. Other organizations created in this period were Rural Credit Unions to provide credit for small and medium producers and the Labor and Employer Council, which sets minimum wages and salary commissions in different counties of the country. The Law of Associations was approved in 1939, "a decision that allowed the legalization and creation of many associations in the cities of Heredia, Alajuela and San Jos(Valverde et. al., 1989, p. 73). Other government actions included the creation of several regulations dealing with working conditions, open registration for labor organizations, and the implementation of public projects whose objective was to create jobs, since unemployment was one of the worst consequences of the crisis.

During the 1940s, Rafael Angel Calderuardia, who was President of Costa Rica from 1940 to 1944, proposed the search for cooperation among different social sectors and became known as the "social reformer" when he stated:

"...only through balanced cooperation of all social forces, within a regime of law that emphatically rejects improper abuses of power, will it be possible to achieve the conciliation of interests that is necessary for all members of the community to feel solidarity towards the supreme task of ever increasing the spiritual and material level of Costa Rica.” (Rojas, 1980, p. 44)

This interest in social reform was presented as an alternative to communism, since at that time the Communist Party had acquired substantial strength in the country. However, a series of circumstances that led to the loss of support from different social sectors forced the government to establish an alliance with the Communist Party, which supported the measures that had already been taken in favor of the labor sector and influenced subsequent social measures. This alliance included the Catholic Church within the framework of alliances against Nazism during the Second World War. The first measures included the Costa Rican Social Security Institute (CCSS), which offered protection during illness, maternity, disability, aging, and death. They also included the Social Guarantees in the Constitution that addressed the right to strike, the eight-hour working day, minimum wages, and freedom to unionize and reach collective agreements. The second set of measures (i.e., those taken in agreement with the Communist Party) included the approval of the Labor Code that regulates the Social Guarantees.

Other important measures taken during this period were the Centers for rural assistance and public health, the opening of the University of Costa Rica and the Music Conservatory, and other social projects (Rojas, 1980, p. 78; Salazar, 1982, pp. 84-92). In the field of mediation of social conflicts, the relationship between tobacco and sugar cane producers and industry was regulated (Rojas, 1980, p. 50). As can be seen, these two decades were the antecedent of what would become an advanced social policy during the decades that followed.

First, the social actions taken during these two decades were an important precedent for the further development of later social policies. This is not to suggest that were no large social needs that were not being met, resulting in important social differences, but that it was important to pay attention to social demands that if unmet would lead to an escalation of social conflict.

Second, they created the basis for a government style that took into account some demands of the people it served, recognizing their organizations in order to maintain social harmony and avoid conflicts and discontent.

Third, the government showed interest in the regulation of social conflict, avoiding repressive means (although repression was sometimes used, as shown during the Banana Strike in 1934 and the expatriation of government opponents during the 1940s). This allowed the abolition of the Army by the end of the decade. It was the abolition of the Army in 1949 that released decisive resources for social actions.

In conclusion, during the 1930s and 1940s, Costa Rica underwent a process that led to the acknowledgment of autonomous popular organizations as well as their demands. Also, the government intervened to regulate social conflict, following a government style that took social measures to avoid the escalation of social conflicts.

The social government in the new development strategy of Costa Rica during the 1950s and 1960s

The growth of transnational businesses within the predominantly international strategies served as a framework for the development of the social government in Costa Rica. This government returned to the social intervention tradition of the 1930s and 1940s, but within the framework of national-level implementation following the development strategy previously mentioned. In doing so it favored the growth of transnational investments.

In 1948 a civil war took place in Costa Rica, which resulted in access to power of new social sectors and the establishment of a new development strategy. During the decades that followed, attention to social issues acquired a new dimension that led to the establishment of the social government. For this to happen, it was necessary to combine the antecedents related to the internal or specific situation and history of Costa Rica with the development strategy that was predominant at the international level. The former made it possible to effectively apply the latter, with outcomes that resemble more those found in developed than in developing countries.

As we have seen, these antecedents are the specific social measures that were taken during the 1930s and 1940s and that were further expanded and developed during the decades that followed. These antecedents included a government style that took into account several demands of the people it served, recognizing their organizations in order to maintain social harmony and avoid conflicts and discontent. Also, the government tried to minimize social conflict, giving priority to consensus building over repressive means. The development strategy required increased production, and this required substantial government participation that led to the establishment of the social government.

The social tradition, initiated in previous decades, was reemphasized in Costa Rica during the 1950s, but social actions were now linked to an economic policy oriented towards the growth of markets. This approach combined an interest in the creation of purchasing power of the population with improvement in health and education of the labor force and negotiation and regulation of social conflicts. Nevertheless, there was a tendency to discourage the development of autonomous popular organizations.

Production and Expanding Markets

From an economic point of view, measures were taken to favor increased production and productivity, the development of physical infrastructure and the training of workers and technicians, and the development of the internal market. This in turn resulted in an increase in employment and a concentration of production and wealth.

Increase in Production and Productivity

Costa Rica did not have the capacity to carry out the massive production characteristic of industrialized nations. However, the government stimulated the application of technology to agricultural and industrial production and paid a great deal of attention to increasing productivity. It was Josigueres (President of Costa Rica 1948-1949, 1953-1958, 1970-1974, and head of the National Liberation Party created in the 1950s by the sectors that won the 1948 civil war) who emphasized modern approaches to production and insisted on salary incentives that would motivate hard work and provide job satisfaction. These policies achieved the collaboration of different social classes (Sol 1992, p. 248). He stated:

"Study, technique, and science represent the only viable solution for the social problem. Low-cost production and efficient industries must use technical methods... The social reform must start in the coffee plantations with more production per area; in the corn fields with more tractors, better seeds, more fertilizer, and less manual labor; in industry with more electricity, better machinery, and more planning. The reform must consist of liberating man from rough work, to end the motor-man and replace him with the thinking man. Rough work debilitates and produces little. Technical work enhances and increases production. " (Hidalgo and Monge, 1991, p. 149)

As a result of this effort, an annual 6% to 7% increase in production was observed in the 1950s. Productivity per worker increased at an average annual rate of 5% between 1950 and 1970 (Reuben, 1982).

Development of Physical Infrastructure

As a way to the above effort, a series of institutions and sectors were created in the country to develop the infrastructure necessary for the enhancement of production and productivity. Some of the institutions created were the Electric Institute of Costa Rica for the production of electricity for industrial development, the National Water Service for the distribution of potable water and urban sewage disposal, the Atlantic Port Administration to manage the port system of the Atlantic, and the Pacific Electric Railways as an autonomous institution (Salazar, 1982). The Ministry of Public Works and Transportation, in charge of the building of bridges, highways, and rural roads, was reorganized.

These actions resulted in a substantial increase in physical infrastructure that favored the development of markets and production.

Development of the Internal Market

To provide an outlet for the increasing national and foreign production, the markets were expanded during the period under consideration. The process followed the Keynes's model of increasing aggregated demand to stimulate production. The measures to develop the internal market included the stimulation of production for the market as well as the creation of demand for the increased production.

The stimulation and protection of production for the internal market was reflected in the process of integration of Central America, which protects and stimulates an industry that serves the region. Fostering an increase in purchasing power as a stimulator of efficiency and an incentive for economic growth is promoted by the following argument:

"...everywhere, and particularly in Latin America, if there is no pressure to increase wages from either organized labor or progressive governments, nations tend to adopt inefficient working methods that only produce, through the labor of everybody, the well-being of a few." (Figueres, taken from Gamier et al., 1991, p. 26)

This approach resulted in increased internal market production, purchasing power, and quality of life. The expansion of the internal market can be seen from the 6% average annual growth between 1950 and 1970 (OFIPLAN, 1982, p. 46). The 70% in the middle class benefited the most, since their income participation increased from 48% to 60% between 1961 and 1971, at the same time as the 20% at the bottom end of the income scale moved from 6% to 5.4% and the top 10% moved from 46% to 34% (Vega, 1986, p. 364).

Other Complementary Measures in the Economic Arena

During the 1950s and 1960s, other complementary measures that also favored the development of productivity and the growth of internal markets were taken, including:

· The nationalization of the banks, which allowed government control of savings and loans. It guaranteed the implementation of the desired production approach within the new strategy.

· Training of workers and technicians mainly through the creation of the National Institute of Learning. This institute trained workers for industry, a process that was mainly stimulated through the incorporation of Costa Rica within the system of Central American integration in 1963. In fact, the Institute was founded in 1965 (Rovira, 1988, p. 110).

We should not believe that the measures taken to improve production (productivity) and markets prevented a process of concentration of wealth and an increased dependence on foreign investment. This was observed in the displacement of small coffee and sugarcane producers by their larger counterparts. Similarly, the contribution in terms of industrial production of small and medium-sized industries diminished and became increasingly controlled by the larger enterprises, including transnationals (see Paz, 1976; Izurieta, 1979).

In conclusion, beginning in the 1950s, the implementation of a new development strategy in Costa Rica required the intervention of the government to facilitate the expansion of production and productivity, physical infrastructure, markets, financing, and the training of the labor force.

Emergence of the Government and Social Policy

The government that was formed in Costa Rica beginning in the 1950s favored production and required an institutional development that would allow it to implement social activities in favor of the majority of the population. The social government, which meets the demands of the new development strategy, became a very complex system in Costa Rica by combining new demands with the social policies of the previous decades.

The government intervened to foster increased production and productivity, training of the labor force, adequate health conditions of workers, production in specific areas of interest, foreign investment, growth of internal markets, regulation of transactions among different social sectors, and a stable social environment that would allow growth while avoiding serious conflicts.

In addition to fostering production and market growth, the government also worked under a broad social policy that allowed it to buy internal production and to increase the purchasing power of large segments of the population.

The Expansion of Social Aspects in Government Actions

The social policy that began in the 1950s included the expansion of education at the elementary, high school, technical, and university level. It also involved the expansion of health coverage; the provision of electricity, water, and telephones; the regulation of markets involving basic products, the previously mentioned policy to increase real wages, the provision of housing, and land distribution. The government was able to achieve labor stability with both the private and public sector, the latter through the Civil Service regulations.

Two examples illustrate increased public investment during these decades. The CCSS expenditures increased from C11 to 23 million constant Costa Rican colones between 1950 and 1958 (Valverde et al. 1990). The second example is the number of social institutions that were created during this period: the National Production Council, which already existed but which became an autonomous institution; the National Fund for the Blind; the Costa Rican Institute of Electricity; the National Water System; the Land and Settlement Institute; the National Children's Hospital; the National Institute of Learning; and the National Rehabilitation Program.

As a result of this growth, the government had an increased demand for labor and became an important source of employment. In addition, the increased government participation stimulated the creation of new entities in the civil sectors (nonprofit organizations, cooperatives, etc.) that also fostered the quality of life and the general well-being of the population.

The Regulation of Conflict

In the field of social conflict, the policy launched in the 1950s was designed to favor organizations that worked closely with the government and to repress those that tended to operate independently of the government. The proposals of the National Liberation Party (PLN), which has governed the country since the civil conflict of 1948, include the search for harmony and solidarity among social classes that would always be guided by the entrepreneurs (Sol 1992). Figueres stated the need for the

"...substitution of the class struggle by harmonious and enthusiastic cooperation. Instead of war, peace; instead of struggle, solidarity; instead of hatred, love. This tendency is called solidarity." (Sol 1992, p. 255)

It is important to note that the search for this solidarity and harmony stimulated the development of popular organizations that were under the control of PEN without real power of decision.

With respect to unions, after the victory of 1948, the workers confederation was repressed and instead the Rerum Novarum was recognized. In the field of community development, in 1967 a law was approved that, as a result of the weakening of the Progressive Cooperatives, created the National Community Development Department (DINADECO). The societies for community development that were created as a result received financial support from the government and were also strengthened by "inducing or forcing other community organizations to adopt this model of development." (Valverde et al., 1989, p. 77). In the field of agriculture, the protests of the small producers were answered with the creation of cooperatives and the channeling of discontent through different entities such as the County Agricultural Committees (Valverde et al., p. 78).

On the other hand, social policy and all the apparatus that surrounded it institutionalized the demands, answered them individually, and fostered passivity and paternalism by developing an attitude in which the government had to solve the problems.

Nevertheless, there was a margin for negotiation that remained open due to the legal status of the Social Guarantees and the Labor Code. As a result, some entities were created to negotiate issues such as wages and prices. Some public institutions mediated labor disputes and conflicts between small- and large-scale producers. Therefore the legal framework existed for the discussion of agreements and collective conflicts involving the labor force mostly within the public sector. Within the private sector, due to strong repression, it was only in the banana industry that it was possible to develop union movements and collective agreements.

The Jump from the 1930s-1940s to the 1950s-1960s

The social policy that was developed beginning in the 1950s deviates from the policies developed during the previous decades in at least three respects.

First, during the decade of the 1940s there was not a clear correspondence between social and economic policy, since the former did not modify the fundamentals of the liberal economic policy. During the second half of the century, social policy became a complement of the economic policy that required an expansion of the internal market. This is how many of the activities that were performed by the government through its institutions favored production and entrepreneurs as well as low-income workers and consumers. Training programs, education, health, policies, etc. that favored workers also benefited enterprises that could recruit a healthy and alert labor force.

Second, the social policy of the 1940s was, on the one hand, a product of the government reform resulting mostly from the need to establish alliances with the popular movement which was then headed by the Communist Party. After the events of 1948, the Communist leaders were exiled or thrown into jail and the Communist Party became illegal. This meant a serious weakening of the autonomous popular movement and favored the birth of new organizations controlled by the government. Therefore, social policy had an important component of social conflict prevention and favored the development of nonautonomous popular organizations.

Third, policy coverage broadened during the second half of the century and benefited not only the wage earners but also a large middle class that grew and became stronger during these decades.

Fourth, the social policy that was initiated in the 1950s had more internal as well as external resources available. On the one hand, the abolishing of the army in 1949 meant the release of resources that could be used, among other things, for social expenditures. On the other hand, there was a greater availability of external resources for the development of infrastructure as well as for social programs.

In conclusion, the development of the social government in Costa Rica is the result of the needs of the new development strategy together with the historic antecedents of the country and a greater availability of resources. The development, as previously described, required the existence of expanding markets. The historic antecedents included a social policy already in the process of development and a government style that incorporated public needs and mechanisms of negotiation to avoid conflicts among different sectors of society. Finally, the greater availability of resources was the result of the dissolution of the army and foreign assistance through loans and donations.

The consolidated social government

During the 1970s, the Costa Rican development strategy, which had achieved such impressive gains, underwent a crisis due to international events and events in the Central American Common Market, and the persistence of high levels of poverty. The crisis in the Central American Common Market was the result of a breakdown (precipitated by the war between Honduras and El Salvador) in the intergovernmental arrangements that had been established. In Costa Rica, the industry that had been developed showed limitations in its ability to create jobs, expand markets, integrate the productive process, and be less dependent on foreign raw materials, machinery, technology, and patents. It also did not prevent a further concentration of wealth.

In the agricultural sector, increased mechanization and consolidation generated unemployment and under employment. Poverty not only did not diminish but actually became worse among the most disadvantaged. In light of this situation, Figueres, who was reelected President in 1970, ran for office with the slogan "fight against extreme poverty" and strengthened the participation of government in the economy.

The governments of the 1970s, in particular the 1974-1978 administration of Daniel Oduber Quirthe main promoter of entrepreneurial government, modified several aspects of the development strategy in a direction that was conducive to a strengthening of the social government that had been developing since the 1950s. The control of the government apparatus and of the so-called entrepreneurial government provided the government of the 1970s with more control over the rest of society and a stronger influence in the social arena. In the following section we will discuss the characteristics of this new entrepreneurial government and its impact on the development of stronger social policies.

The Entrepreneurial Government as a Response to the Crisis

To confront the above crisis, a stronger government interventionist policy was proposed to compensate for the weak national economic resources. This is why during the early 1970s several measures were taken that led to the entrepreneurial government of the period 1974-1978.

The formation of the entrepreneurial government was possible because of the support of owners of industry, whose development depended heavily on government, and of public employees, who were themselves part of the government apparatus. Daniel Oduber, who was the main ideological and political leader of this model, stated:

"It was necessary to nationalize many things to launch a more integrated and, thereby, more democratic Costa Rican socialism."

The issue was to create in Costa Rica an institution able to develop large and new industries that later would be owned by Costa Rican shareholders to avoid having transnational firms guiding industrial development on a large scale in Costa Rica. This applied to cement, aluminum, fisheries, navigation, etc. (UCID, 1981, pp. 9-10)

During the government of Figueres between 1970 and 1974, some important measures that led to the entrepreneurial government were approved, but it was not until Oduber's term that this new style of government was fully established. The Figueres administration took measures such as the nationalization of the oil company, but it was the Oduber administration that established the Corporation for the Development of Costa Rica (CODESA) with the intention of creating enterprises that would take advantage of the natural resources of the country, become modernized, and thrive in an international market. CODESA acquired many enterprises but by also supporting and channeling resources to the private sector, it assumed some banking functions as well.

The development of productive activities by the government with the purpose of generating profits did not imply the disappearance of other activities that had been carried out since the 1950s, such as developing private enterprises, transportation, physical infrastructure, and markets; fostering exports; and improving training and productivity.

During the 1970s, the government worked in favor of internal markets through the strengthening of the National Production Council (CNP), which was created in 1948 for the purpose of stabilizing prices. During the 1970s, CNP participated in sales, establishment of prices, and purchasing of industries for processing rice. This trend of the entrepreneurial government was supported by the international financial organizations, which at the time preferred to deal directly with governments rather than with private enterprises.

In conclusion, during the 1970s, the most important change influencing development was the emergence of an entrepreneurial government, which carried out activities for the purpose of generating profits and competing with the private sector. At the same time, actions were taken to foster exports and to strengthen internal markets, mainly those associated with the consumption of basic products, always taking into account the international trends that were prevalent in those days.

The Strengthening of Social Policy

The changes in government participation that took place during the 1970s resulted in some institutional transformations that allowed a stronger social role of the government. Forty-seven percent of the institutions created between 1950 and 1980 were formed during the 1970s (Valverde et al., 1990). It should be noted that these transformations did not mean a break in the central characteristics of the development strategy that prevailed in the country during the 1950s and 1960s. Furthermore, the social government that is required to meet the need of expanded markets and the government style that tries to avoid conflict by taking social measures not only continued but became stronger during the 1970s.

The combination of factors that led to the strengthening of the social policy, to the point where the results reached a level comparable with the industrialized countries included previous experience with social measures that formed a basis for their broadening, the social measures taken, and a reconciliatory government style; the international crisis and the Central American integration crisis; continued poverty levels, unemployment, and social inequity that led to discontent; and lastly, the entrepreneurial government, which represented a strong and decisive government willing to intervene in different social spheres where the private sector could not or would not intervene.

The social policy of the 1970s was a deeper and more effective continuation of previous social policy. This was possible due to the institutions that had already been created and the greater control of the government over social life. This greater control over society is manifested not only by the existence of government enterprises but also by a greater concentration of power in the executive. This was achieved through a series of measures taken to achieve control of public institutions. Among these measures were the law that allowed the party in power to name four of the seven directors of institutions, and the law that granted permission to the President of the Republic to name an executive director who would be the chief authority in each institution.

This process was also extended to social conflicts, where the government tried to achieve greater control of the popular movement. In agriculture, the government dealt with latifundism (the establishment of large estates with workers in a state of partial servitude) through the Land and Settlement Institute (ITCO), which attempted to avoid conflicts taking into account the interests of large owners, but demonstrating the illegal nature of latifundism, and avoiding any control of the left over popular agricultural movements. The ITCO ended up being a large owner that converted industrial workers into agricultural employees for the purpose of producing grains for the internal market and facilitating incorporation of Costa Rica into the international agroindustrial market (UCID, 1981, pp. 78-89).

It was during the 1970s that the National Community Development Department (DINADECO) took the previously described actions to attempt to control the community movement. With respect to labor unions, the Oduber government established a "tacit alliance" (UCID, 1981, p. 114) with the Communist Party of Costa Rica which controlled the principal popular organizations, although it simultaneously strongly repressed the more independent unions.

The most important social measures that were taken during this period were extended to other areas such as housing, education, health and nutrition, price control, culture and recreation, as well as the expansion of many other existing programs.

A housing deficit had been evident since the beginning of the decade, particularly among the low- and middle-income sectors. To face this problem, the government created or strengthened some institutions and programs. Two of these were devoted to the building of housing for low-income sectors: the Mixed Institute for Social Assistance (IMAS), which concentrated on the indigent, and the National Institute for Housing and Urban Planning (INVU), which concentrated more than ever before on programs targeting low-income segments of the population. Other institutions and programs targeted housing for the middle class through institutions such as the National Savings and Loans System, the National Insurance Institute (INS), the Costa Rican Social Security Institute (CCSS), public banks, and the Popular and Community Development Bank. These actions confirm that in the field of housing major resources were committed which increased the number of institutions dedicated to housing and expanded the programs (see Valverde et al., 1990, pp. 96-97).

In education, a study done in 1971 uncovered the deficiencies of elementary and high school education, providing the basis for the approval of the National Education Development Plan in 1971. The purpose of this plan was to modernize the education system and improve the average educational levels of the Costa Rican population. At the same time, diversified education began to be introduced in the technical colleges and institutions that young people attended after elementary school. The Technological Institute of Costa Rica was opened, and since the beginning it has had a strong linkage with industrial enterprises, The National University, and the State University, which absorbed students who had difficulties entering the National University of Costa Rica.

With regard to health and nutrition:

... the year 1970 marked the beginning of a National Health System that provided universal coverage and the control of common childhood infectious diseases and malnutrition. (Valverde et al., 1990, p. 82)

The National Health System achieved the integration of services in its field and developed primary health care in rural and marginalized urban areas. Furthermore, health coverage became universal and the National Health Plan was approved to increase health coverage.

Prices of products for basic consumption were controlled. The National Production Council, as described before, had the function of stabilizing prices, providing price guarantees for producers and consumers and opening retail stores with the intention of establishing ceiling prices that would not be surpassed by the other commercial outlets. The law for Consumer's Defense was also approved with the objective of protecting consumers against speculators.

During this decade, other public services that were already in place were expanded. These included electric power, which was extended to most of the country, as well as access roads, and water and sewage services, which also were also markedly increased.

The concept of social development was expanded to include culture and recreation. This involved extensive effort that created and strengthened entities such as the National Dance Company, the National Theater Company, the Youth Symphony Orchestra, the Ministry of Culture, Youth, and Sports, the La Sabana Recreation Park, and the National Park System.

To cover some needs of the most disadvantaged population by providing housing, food, and education, the Mixed Institute for Social Assistance was created at the beginning of the decade. Later, the Fund for Family Benefits was approved to

"provide assistance for nutrition, poor or disabled people without income, and education and welfare programs for the worker and his or her family." (Valverde et al., 1990, p. 133)

The funds of this program were channeled through several different social institutions and included health programs, food and nutrition, housing, productive activities and employment, training of professionals, and protection of minors and the elderly (see Valverde et al., 1990, pp. 133-151).

In conclusion, new elements were added to the social measures that had previously been approved. The new elements modified the social concept and tended to improve the training of workers and technicians; the quality of housing, health, and nutrition; access to culture and recreation; and the basic consumption of the most disadvantaged population. All this was done with the purpose of preparing and maintaining under adequate conditions the workers and technicians required for the development of the new forms of production. Another important objective was for the government to avoid the emergence of social conflicts that would threaten social peace, productivity, and the ability to compete at an international level.

Nevertheless, the 1970s ended with the deepening of a series of problems that affected both the economic and the social sectors. This situation cast doubts over the development strategy that had been followed since the middle of the century and that led the country into a crisis that it would attempt to solve through the process of structural adjustment.

Final reflections

The emergence and the consolidation of the social government in Costa Rica cannot be explained without knowing the historical tradition of the country and its relationship with the international dynamic. The analysis of the historic tradition of Costa Rica allows us to observe the process that led in the 1940s to the acknowledgment of popular autonomous organizations and their demands and a government style in which the government intervened to mediate social conflict. By the same token, it allowed us to identify several factors that released funds for social development, such as the elimination of the armed forces towards the end of the 1940s and the financial assistance of international organizations that during the 1970s preferred to deal directly with governments.

During the 1950s, the factors that previously existed combined to permit implementation of a social and economic strategy. This required the participation of a government that facilitated improved productivity and market development, the creation of physical infrastructure for production, training of workers, and bank participation. This is the origin of the social government that reached its culmination in Costa Rica in the 1970s.

During the 1970s, to the factors already existing before it is necessary to add the international and Central American crisis and the limitations of the development strategy that was being followed. These limitations involved both an inability to stimulate production, to create enough jobs, and an observed increase in poverty. The entrepreneurial government was developed in response to this situation. The strong and centralized entrepreneurial government inserted Costa Rica into the international markets, and facilitated the expansion of the social government in order to maintain social peace and avoid unrest.

Therefore, the combination of the historic tradition of Costa Rica with the higher availability of funds and the formation of a strong government that worked towards the generation of profits in the 1970s allowed the successful application of an international development strategy that achieved the social indicators of an advanced country. This did not, however, protect Costa Rica from the international financial crisis towards the end of the 1970s and the beginning of the 1980s from which it has since tried to escape through a weakening of social policy as part of the structural adjustment.

Acknowledgement

I thank Josanuel Valverde for his multiple comments and suggestions for the preparation of this manuscript.

References

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Hidalgo R, Monge G. 1991. "Los recursos cientcos y tecnolos y la transformaciroductiva." In: Garnier J. et al. Costa Rica entre la ilusi la desesperanza. Una alternativa pare el desarrollo. CEDAL, Guayac Maestren Polca Econa pare Centroamca y el Caribe, San Jos

Izurieta C. 1979. "La concentracindustrial en Costa Rica (1964-1975) y las actuales formas de mercado dominantes." IIE/UCR, documentos, April 1979.

OFIFPLAN. 1982. Evoluciocioecona de Costa Rica 1950-1980. EUNEDA, San Jos

Paz G. 1976. "Estudio sobre el universo cafetalero." (mimeographed) Reuben S. 1982. Capitalismo y crisis Econa en Costa Rica. Treinta ade desarrollo. Editorial Porvenir, San Jos

Rojas M. 1988. Lucha social y guerra civil en Costa Rica. 1940-48. 2nd ed. Editorial Porvenir, San Jos

Rovira, J. 1988. Estado y polca Econa en Costa Rica. 1948-1970. 3rd ed. Editorial Porvenir, San Jos

Salazar JM. 1982. Polca y reforma en Costa Rica. 1948-1958. 2nd ed. Editorial Porvenir, San Jos

Sol MA. 1992. Costa Rica. Reformismo Socialdemta o liberal? FLACSO, San Jos

Trejos JD. 1990. "Pobreza y Polca social en Costa Rica." MIDEPLAN, Proyecto regional pare la superacie la pobreza en Amca Latina, documento 1, May 1990.

UCID. 1981. De los empresarios polcos a los polcos empresarios. Oficina de Publicaciones, Universidad Nacional, Heredia.

Valverde JM, Donato E, Rivera R. 1989. "Costa Rica: movimientos sociales populares y democracia." In: Rojas M, et al. La democracia inconclusa. DEI, San Jos

Valverde JM, Jean Pierre B. Araya C. 1990. Crisis y Polca social en Costa Rica 1980-1988. Tendencias y perspectivas. Informe final de investigaciB>. CSUCA/IIS-UCR, San Jos

Vega JA. Hacia una interpretaciel desarrollo costarricense. Ensavo sociolo. Editorial Porvenir, San Jos1986.

(introduction...)

Dr. Carlos MuRetana and Josanuel Valverde

Introduction

A systematic intervention of the government of Costa Rica in the health sector began in 1940 through the formation of the Social Security Institute (CCSS) and the strengthening of the Ministry of Health. Beginning in the 1950s, the government increased its participation in the social sector as part of a new development strategy. The health sector was not an exception, and in fact, at this time, government intervention became more intense, culminating in the 1970s, when Costa Rica was considered a model country in the area of health.

At the beginning of the 1980s, the country entered a period of economic crisis that had enormous consequences for the quality of life of the population. Some of the consequences in the health sector were deterioration in some services, economic difficulties in meeting the new demand for services, and government pressure to adopt measures that reduced expenditures.

The problems that were generated by this situation supported the view that the health sector needed to be restructured. This process coincided (at the beginning of the 1980s) with the emergence of neoliberal ideas and the implementation of structural adjustment and stabilization policies that had a strong influence on the evolution of the health sector.

With the purpose of understanding the events of the 1980s that took place in the health sector as a result of the crisis and the structural adjustment, our main objective in this chapter is to analyze the main problems in the health sector, experiences in institutional reorganization, and new models in health care. The last section summarizes the evolution of the health sector in the 1980s and discusses some issues related to the possible situation in the 1990s.

Some problems of the health sector in the 1980s

The crisis under which Costa Rica initiated the decade of the 1980s shows a change from the development style that predominated in previous decades. Trejos, in Chapter 5, describes the development strategy that was followed in the country from 1950 to 1980 and, in particular, the promotion of social welfare. The crisis of the 1980s manifested itself in a lower industrial output (-4.3% and- 7.7% in 1981 and 1982, respectively) and in the main exports in the agricultural and animal sector (-8.3%) in 1982 as well as in price inflation (65.1% and 81.8% in 1981 and 1982) that provoked a significant deterioration in the quality of life and the working conditions among blue-collar workers and peasants and among the urban middle classes.

The crisis was also felt in other sectors, for example, in diminished public and private investment, increased unemployment and underemployment, increased fiscal deficit, decline in foreign trade, increased foreign debt, and a strong imbalance in international payments. In a sense, this was a crisis that affected the development strategy followed during the previous decades.

To some degree, the government response to the crisis was accompanied by stabilization and, simultaneously, by a process of structural adjustment that was slow and gradual. This process also emerged as the mechanism through which the government has responded to the new international trend toward the globalization of production in order to solve the economic problems of Costa Rica.

This process of structural adjustment consists of a governmental and economic restructuring that allows Costa Rica to function within the new environment of the international globalization and flexibility of production. Detailed analyses of this process can be found in Trejos end Villalobos (1992). Some measures that were taken were decreased protection of production for internal markets, reduction and elimination of subsidies for public services, opening of borders for both imports and exports, devaluation of the colon, restructuring of the public sector, and cuts in the government budget to reduce the fiscal deficit and pay the foreign debt. In order to carry out this process, letters of intent were signed during the 1980s with the International Monetary Fund (IMF) (in 1982,1985,1987, and 1989) and two agreements of structural adjustment with the World Bank, one in 1985 and the other in 1987.

As a result of the crisis in 1982-1983, the initial response of the health authorities was to take the following actions: press the government to meet the financial agreements that it had previously reached with the health sector, reduce the number of medicines considered as basic, forbid the purchase of new equipment, retire employees early, eliminate benefits and privileges received by CCSS workers, and eliminate high-cost services such as contact lenses and sophisticated dental procedures. Additional actions were taken afterwards as part of the adjustment process. These actions involved expenditure control, efficiency improvements, service coordination and integration between CCSS and the Ministry, and decentralization of operations through a process of administrative regionalization of health services.

This process was conceptualized by Dr. Edgar Mohs, who was the Minister of Health between 1986 and 1990:

The crisis showed us that it was necessary to revise and transform the structure and operation of the health sector to make it more solid, efficient, and modern. It also exposed problems of size, competition, and technical weaknesses as well as the organizational flaws of many concepts and institutions. It became clear that the government had to become smaller, more efficient, and a better administrator of knowledge and resources. System theory also gained ground, including the principle of competition between the public and the private sector. (Mohs, 1991, p. 2)

In that sense, the actions taken by the health authorities during those years are evidence of a radical change in the way the health problem was perceived. This is perhaps the most peculiar situation that began to surface during those years. It involves two essential aspects that are deeply related: the need to restructure the institutions and the revision of the model used for the provision of health services. In the following sections we will find out what happened during those years with respect to the general function and financial situation of the health sector and the evolution of the epidemiological profile.

Deterioration of the National Health System

During the 1980s, the health sector presented problems that were the outcome of the low efficiency in the system, which resulted in part from the crisis and the process of structural adjustment and in part from intrinsic problems in the administrative model that was being followed in the provision of health services.

In the case of the Ministry of Health, there was a series of factors that converged to generate a low efficiency level in most of the programs. On the one hand, the loss of political interest regarding the function of this institution resulted in budgetary cuts. On the other hand, the reduction in social investment caused by the process of structural adjustment (PSA) had a severe effect on the Ministry, since this institution relies heavily on the federal budget. Whereas in 1980 the Ministry contributed 17.25% of expenditures, in 1990 this figure was only 11.13%. Meanwhile, the population increased from 2,284,495 in 1980 to 3,014,596 in 1990. This represents an increase of 730,101 inhabitants whose increased demand for health services from the Ministry has not been fully met.

The budgetary deficits had immediate implications for the functioning of preventive programs for the general population. One of the first indicators that became affected was coverage. The primary health care program, which reached 60% of the rural and high-risk urban population in 1980, only covered 40% of these populations in 1990. The situation might have been even worse than it appears, since the health workers who are responsible for this program have to carry out their work without adequate equipment, transportation, and economic resources to cover households in their areas of concentration.

The Immunization Program also suffered an important loss in coverage. A survey carried out in 1987 (Valadez et al., 1987, p. 12) found a coverage of only 44% for measles vaccine (following the standard procedures of PAHO/WHO). This situation might explain the severe measles epidemic in 1989-1991 in Costa Rica.

The Dental Prevention Program also suffered an important loss in coverage. Table 1 illustrates how the increased level of school enrollment is associated with a decrease in the number of children served. Indeed, coverage declined from 45.9% in 1980 to 25.5% in 1990.

Another preventive program that has been severely affected is the Nutrition and Integral Care Program. Whereas in 1987 this program served 105,813 beneficiaries, this figure decreased to 59,110 in 1991. This decline represented a 44% reduction in coverage from 1987. The expenditures for this program declined from 55 million colones in 1986, when the program showed the maximum expenditures down to 33 million colones, adjusted to the 1966 value, in 1991. The component that was most affected during this period was the provision of food products. Expenditures for food declined from 27 million colones in 1986 to 11 million colones in 1991. By contrast, personal services increased during the same period from 13 million colones in 1986 to 20 million colones in 1991. It is obvious that the reduction in expenditures in the Nutrition and Integral Care Program has been achieved by reducing the number of rations and also very likely by a lower quality of the food received by the beneficiaries.

Inefficiency also affects the services provided by the CCSS at different levels. The high proportion of administrative workers found in the clinics (almost 30%) is almost twice the level found in the national and regional hospitals (Vallejo and Lunes, 1991).

Inefficiency in the use of resources is a factor that diminishes the quality of the services offered in the national hospitals Mexico (HM), San Juan de Dios (HSJD), and Calderuardia (HCG). These hospitals utilize resources of the health sector that could be used at the primary health care level (based on information provided by the System of Administrative Information of the CCSS). These three hospitals are located in the national capital of San Josnd are highly specialized. The medical services in HSJD have a cost per discharge of 137,298 colones, whereas in the HCG this figure is 60,125 colones; the cost is 2.3 times higher in HSJD than in HCG, although the average stay was similar in both hospitals. The differences in expenditures were even higher in the gynecology service, where the cost per discharge in HM was 113,278 colones versus 24,963 colones in HCG.

A similar situation occurred in the surgical and obstetrics area. In the latter we observed that a vaginal delivery costs 3.7 times more in HM than in HCG. The cost per day per bed occupied also showed significant differences that can only be explained by poor efficiency. In HSJD the cost per day per bed occupied in the medical service was twice as much as in HCG, and in HM the cost per day per bed occupied in the gynecology service was 4.3 times more than in the HCG.

TABLE 1. Dental Coverage of School Children 1980,1985, and 1990

Year	Children Enrolled	Children Treated	Coverage (%)
1980	348,674	150,153	45.9
1985	362,877	154,944	42.7
1990	410,091	104,672	25.2

Source: Ministry of Public Education and Department of Dentistry of the Ministry of Health

There is a substantial variability in costs, which may be highly significant: the cost of a surgery is 22,024 colones higher in HM than in HCG, and the cost of a food ration in HSJD is 2.4 times higher than in HCG. In the case of HSJD, the cost of a food ration is so high (592 colones) that there is no doubt that it would be cheaper for the hospital to provide this service through a restaurant in the capital.

In order to understand the financial implications for the health sector of this low level of efficiency, an estimate was generated using the four services, surgery, laboratory, pharmacy, and nutrition. HCG was used as a reference because it had lower costs than the other two hospitals. Based on the volume of production in each hospital and the costs of HCG, we estimated savings of 860,833,870 colones in 1991 if all the hospitals had the same level of expenditures as HCG.

Even though some of these problems were already present, the crisis and the adjustment process deepened them, justifying the proposal for revision of the way the health sector operates.

Evolution of the Epidemiologic Profile

During the 1970s, the health sector developed and was able to provide the population with substantial health benefits. The infant mortality rate declined from 61.6/1,000 in 1970 to 19.1/1,000 in 1990. Life expectancy at birth increased from 68.1 years in 1965-1970 to 73 years in 1975-1980. Mortality associated with infectious and parasitic diseases moved from first place as cause of death in 1970 (6/10,000) to eighth place in 1980 (1.5/10,000). Gastroenteritis and colitis, which was the leading specific cause of death in 1970, moved to fifteenth place as specific cause of death in 1980.

Unexpectedly, chronic degenerative diseases emerged as important. During that decade, cardiovascular disease became the leading cause of death in the country, and myocardial infarction became the leading specific cause of death. The rate of cancers increased from the levels in 1970, and these diseases became the second specific cause of death. During that decade, the mortality rate from metabolic disorders increased from 1.6 in 1970 to 2.4 in 1975, and congenital anomalies became more important as causes of death.

During the 1980s, the downward trend in infectious and parasitic diseases continued, although at a slower pace when compared with the previous decade. The infant mortality rate declined until it reached 13.9/1,000 in 1989, and life expectancy at birth increased to 74.7 years in 1985-1990.

In agreement with the information provided by the nutritional monitoring system of the Primary Health Care Program, moderate malnutrition increased from 1.91% in 1987 to 2.6% in 1990. In fact, there were 15 counties where the number of cases with this type of malnutrition increased more than 100%. Severe malnutrition also increased during this period, and between 1987 and 1990, there were 14 counties that showed an increase of 100% or more in the number of cases with this type of malnutrition. There were only three counties where severe malnutrition declined (Novygrodt, 1992).

Not only did chronic degenerative diseases become the leading cause of death, but their rates increased during the decade. The rate of circulatory diseases increased from 10.3/10,000 in 1980 to 11.0/10,000 in 1989. The rate of tumors increased from 6.8/100,000 in 1980 to 8.1/100,000 in 1989. In 1989 more than 61% of recorded mortality (64% of male mortality and 58% of female mortality) was due to circulatory diseases, tumors, and accidents.

In spite of this clear change in the epidemiological profile of the country, there were no substantial changes in either the organization or the policies and strategies of the health sector. In reality, the efforts for change were more related to the new conditions that were imposed by the process of structural adjustment of the 1980s than to any of the changes in the epidemiological profile of the country.

By the end of the 1980s, the health sector seemed to be moving backward instead of forward as it had been doing in the previous decades. The proportion of the population reached by primary health care strategies dropped, health investments concentrated on curative services, some infectious diseases became important (malaria, measles), and nutrient deficiency disorders, such as iron deficiency anemia and severe malnutrition, showed signs of increasing.

Evolution of the Financial Situation of the Health Sector

The economic crisis and the structural adjustment measures that are implemented by governments to face it affect the health sector very quickly. Government expenditure on health is one of the components that is most affected. Between 1960 and 1980, in Costa Rica these expenditures increased significantly, reaching the highest level between 1979 and 1980 at 8.6% of the gross national product. From then on, expenditures declined to 6.1 % of the gross national product in 1982. The following year, expenditures recuperated slowly, but they never reached the levels of 1980. By 1990 health expenditures represented 7.8% of the gross national product.

Per capita health investments were also affected. In 1980 the investment was 6,698 colones per inhabitant (in constant colones based on 1985). This investment declined to 3,534 colones per inhabitant in 1982, and at that point it began to recover slowly, never reaching the level of 1980. In 1990 the per capita investment reached 5,640 colones. The proportion of the total government budget devoted to health declined. Whereas in 1980 the expenditures for health represented 14.5% of the total government budget, this figure declined to 13.0% in 1982 and to 12.0% in 1984, and due to a slow recovery, this figure increased to 14. 0% in 1988. The money received by the health sector was also affected during this period. Whereas in 1981 the federal budget provided 13.9% of the budget of the health sector, this figure declined to 10.4% in 1986 and to 9.6% in 1988.

During this decade, the Ministry suffered severe budgetary- cuts. The Ministry receives funds mainly from three sources: the federal budget, the General Directorate of Family Resources (DESAF), and the national lottery. These three sources provided 2,400.9 million colones to the health sector in 1982, 2,836.5 million in 1985, and 2,086.4 million in 1990. In other words, in real terms the budget of the Ministry has been declining because the value of the colon dropped during this time.

The financial weakness of the Ministry has increased the relative importance of CCSS as a financial source for the public health sector. CCSS has made transfers co the Insurance Institute and to the Ministry to help them finance their services and has incorporated many of the preventive activities of the Ministry within its own institutional activities. Nevertheless, CCSS also suffered financially at the beginning of the decade. In 1981 CCSS had a deficit of 239 million colones, and by 1982 the surplus was only 79 million colones. The deficit accumulated in 1982 was greater than 2,000 million colones. This situation forced the institution to increase the fees charged to its members from 6.8% to 9.3%, and therefore the following measures had to be taken (based on an interview in August 1992 with Dr. Guido Miranda, Executive President of CCSS 1982-1990):

· Payment of benefits to 2,000 employees; many of whom were qualified technical personnel

· Establishment of a basic package of required medicines

· Requiring the exclusive use of this package

· Prohibition of prescription of patent medicines and a maximum of three prescriptions per visit in outpatient care

· Controls to reinforce compliance with the norms establishing the patients per hour per doctor allowed (five patients/hour for family practitioners and four patients/hour for specialized doctors)

· Establishment of norms for the length of hospital stays

With the fee increases and the measures taken to control expenditures during 1982-1986, CCSS showed a financial recovery that was sustained until 1987. During this period (1983-1987) an excess of incoming funds was generated in relationship to expenses under the Illness and Maternity Program which allowed this institution to modify the effects of the crisis and to become an increasingly predominant financial force in the health sector. In 1990 the contributions from CCSS represented 75% of expenditures in the health sector.

After 1987, CCSS showed a significant financial weakening, going from a surplus of 1,764 million colones in 1987 to a deficit of 364 million in 1990. One factor determining this situation was the public debt accumulated by the government. During the decade, the government went from having a debt of 319,245 million colones in the Illness and Maternity Insurance in 1980 to a debt of 3,799,731 million in 1990. The debt for Handicapped, Elderly, and Death Insurance was 584,619 million colones in 1990.

The government payments have been partial, delayed, without full compensation for inflation, and often provided as government certificates. Therefore, CCSS has financed part of the adjustment measures, shifting part of the surplus of the institution toward other financial priorities of the Costa Rican government.

Organizational Response to the Crisis and the Process of Structural Adjustment

The issues mentioned above raise questions concerning the structure and the operation of the health sector and require a search for solutions for the problems. The Ministry of Health is the institution in the health sector that was most affected by the economic crisis, and it needs to search for alternative models of organization that will allow it to adjust to the new situation.

Proposal for the Integration of Health Services

In their book La Integracie Servicios de Salud en Costa Rica (The Integration of Health Services in Costa Rica), Jaramillo and Miranda state:

The strategy revolves around the intention to create and consolidate a new model for health care in the country, a National Health Care System that functions following an integrated approach, with better efficiency than the existing services and above all at a lower cost.... It is intended to offer health benefits that are integral and with enough quality and quantity to cover the demands of these services throughout the country based on the existing financial resources. (Jaramillo and Miranda, 1985, pp. 10 and 11)

The economic and fiscal crisis of the country created conditions at the beginning of the 1980s requiring the search for alternatives that allowed a better utilization of existing resources without affecting the coverage and quality of the services. The integration of services represents one of these alternatives.

Between 1982 and 1985, the integration of services became the most important policy in the health sector, fully backed by CCSS and the Ministry of health. In 1985, 80 out of 198 (40.4%) health units (health centers and clinics) of the Ministry of Health and CCSS were integrated (Alfaro and Chaves, 1986).

With the change of government in 1986, the integration of health services was no longer a priority. Although, in 1989 and 1992, new agreements involving the integration of health services were signed. However, in reality this process had political and technical limitations that hindered its development in the last two administrations. In an evaluation carried out in August-September 1991 (Garcia, 1992) only 31 of 53 centers of the Ministry of Health were integrated in the same physical location, and only nine of them had a single head. These numbers reflect the fact that during the last two administrations there have not been important advances in the process of physical and functional integration of the health services of the two institutions.

In summery, 10 years after the process was launched, the progress in the integration of the CCSS and the Ministry of Health is still limited and far from reaching the goals proposed by Jaramillo and Miranda in 1985. The process did not contribute to the development of a new model, given that each institution continued working under its own rules, and in the majority of the cases they simply shared physical space, following the same regulations and procedures that were already in place before the process of integration began.

The consolidation of a National Health Care System was also not attained, largely because the authorities insisted on maintaining the functional autonomy of the institutions, which made it very difficult to develop an integral approach for health. Contrary to the integration approach, there is evidence that curative approaches were given priority, relegating preventive measures to a less important role. This was detrimental to the visualization of strategies necessary to approach the national health problems (Sanguinetti, 1988, p. 130).

Most of the integrated centers lacked operational plans and the intention to carry out joint activities. In addition, the procedures that were followed to guarantee a rational utilization of resources were far from being cost-effective. Lastly, it is worthwhile to note that beginning in 1986 there has been a lack of political pressure to carry out and consolidate the process of integration as it was originally planned.

The Local Health Care Systems (SILOS)

The second important experience of the Ministry of Health and CCSS in response to the crisis and the programs of structural adjustment was the development of the so-called Local Health Care Systems (SILOS). At the beginning of the administration of President Arias (1986-1990), the strengthening of the National Health Care System (SNS), equity in services, decentralization, and community participation became part of the national health policy. The operationalization of this policy involved strong support for the SILOS model and the relegation of the proposal of service integration to a second plane of importance. At this moment, the SILOS were conceived within this new policy as the alternative for the reorganization and reorientation of policies and technical and administrative procedures for the National Health Care System.

In 1987, as part of this process, Decree No. 19,265-S ordering the creation of SILOS in Costa Rica was signed. This decree establishes that the

Ministry of Health will provide basic health care services through a program called "Program of Integrated Health" that guarantees the provision of basic services for health improvement and promotion, the prevention of diseases, and an integral control of the environment, the individual, the family, the community and its environment.

Article No. 6 of this decree establishes that the SILOS will "organize, administrate, and coordinate" the resources available through the elaboration of an operational plan and a local budget. Nevertheless, the decree does not establish the decentralization of human and financial resources to implement the operational plan of the SILOS and the administration of the budget.

Parallel to the signature of the decree by the Ministry of Health, the CCSS assumed the PAHO document (CD 33/14) "Development and Strengthening of the SILOS" as its own. The general norms for the National Health Care System were established in 1989. The organizational basis of the National Health Care System is the SILOS, which are defined as

the group of establishments and organized representatives of the community located in a predefined geographical area that utilize resources in a rational way and that coordinate or carry out their activities following a local plan based on the primary health care strategy.

During this same month, the Ministry of Health-CCSS agreement for the integration and coordination of services was signed, which basically added the strategy of the SILOS to the 1984 agreement. This agreement maintained the functional autonomy of both the Ministry and CCSS and assigned the responsibility for promotion, health improvement, and disease prevention to the Ministry of Health and for health recuperation and rehabilitation to CCSS. Both institutions maintained separate budgets, norms, and material goods.

An important event during this period was the establishment of mechanisms for interinstitutional coordination. The general norms of the National Health Care System propose different coordinating committees: the National Sectorial Council, the Technical Interinstitutional Council, the Regional Technical Interinstitutional Council, and the Area Technical Council. The Ministry of Health-CCSS agreement for the integration and coordination of services establishes the following coordinating mechanisms: Local Technical Council, Basic Technical Council, Health and Social Security Council, and the Local Health Committees.

In November 1990 and February 1992, the development of the SILOS was evaluated. These evaluations identified some achievements and the persistence of important difficulties for health care at the regional and local level. With respect to decentralization:

...there are hidden mechanisms that are still being utilized to concentrate the power of decision at the central and regional level, because there were more advances with the delegation of authority and responsibility... than with the delegation of administration of resources.

Other areas that showed little development were social planning and community participation. This last observation is very significant, since these evaluations were unable to detect any progress in this area, which is the cornerstone of the SILOS strategy (Ayala et al., 1992).

Perhaps the factor that most affected the development of this new strategy of health care was the decision of the 1990-1994 government to consider as a political priority the idea of carrying out a global restructuring of the health sector. For this reason, the policy advocating the strengthening of the SILOS was relegated to a second priority, as illustrated by the dissolution of the commission that was responsible for this process (COMINSILOS). The process is restricted to the isolated efforts of some regional heads of the CCSS and the Ministry of Health.

Mixed Private and Institutional Health Care System

As part of the process, during the 1980s CCSS also developed some alternatives to the prevailing model. Specifically, during the first half of the 1980s, the so-called Mixed Health Care System was developed and the Private Sector System was strengthened.

In the Mixed System the physician sees patients in his or her own office and has the concession from CCSS to provide prescriptions, direct laboratory and radiologic examinations, and refer patients to CCSS hospitals and clinics. Under this system the patient pays the physician and is not reimbursed by CCSS.

This system was established in April 1981 with the objectives to:

· Reduce the outpatient burden in clinics and hospitals (CCSS Five-Year Plan, 1986-1990).

· Establish a closer physician-patient relationship (CCSS Report, July 1987, p. 3; cited by Ugalde and Ruede, 1988).

On the other hand, the Private Sector Health Care System consists of medical facilities installed voluntarily by private businesses and is usually run by part-time personnel (physicians, nurses, secretaries, etc.) working for two to three hours.

As with the Mixed System, services involving laboratory, pharmacy, radiology, and specialist referrals are received by patients without cost from CCSS.

This system was created with the objectives to:

· Reduce the load of outpatient care in clinics and hospitals.

· Reduce the economic loss for businesses associated with the time their employees spend visiting the CCSS clinics.

This program was initiated in 1970 with one business; it increased to 371 businesses in 1983 and to 613 in 1986.

Even though these two systems have had an important development during the period, they also suffer from limitations of the prevailing model for the provision of health services:

· Both systems reproduce the outpatient care model of the CCSS, which is based on curative medicine and prescription of medications.

· In both systems, laboratory exams, prescriptions, and specialist referrals are the responsibility of CCSS, which increases the demand on these services.

· In spite of the enormous potential of the private sector system, it does not carry out preventive efforts or develop programs involving occupational health. There are three elements that are responsible for this situation:

· Physicians are not trained in occupational health.

· Businesses hire physicians to offer curative medicine to their workers, thus eliminating the need for visits to the outside clinics.

· It is difficult for a physician hired by a business to solve workers' health problems that are caused largely by the inadequate working environment.

Health, Service Cooperatives

The first cooperative enterprise for the administration of SILOS (COOPESALUD R.L.) was created in 1986. The project was launched with PAVAS in 1988 through the services of CCSS, and in 1989 the Ministry of Health adopted the cooperative in its programs. In January 1990, another cooperative (COOPESAIN R.L.), in the county of Tib began to administer and oversee the clinic in this location.

Both cooperatives were organizations run by their members and defined as

those enterprises organized for the production of goods and services in which the working members oversee all activities and provide the working force with the main purpose of realizing productive activities in return for economic and social benefits that are proportional to their effort. (Marie and Vargas, 1991).

These cooperatives promote the development of a new health care model based on:

· A biosocial approach to the health-disease process.

· Global and equitable coverage of the population.

· Incorporation of the community in the process of diagnosis, programming, evaluation, and control of health services.

· Development of a family and primary health care model that strengthens and promotes the system of integral health care.

· Programmed activities based on the health diagnosis of the community and the definition of priorities.

The development of this model is based on the health area (subregion or health district) with a population of 15,000 to 30,000 in rural areas and 15,000 to 45,000 in urban areas.

Health areas are themselves subdivided into sectors with 500 to 2,000 houses. Each sector is assigned basic equipment in integral care (EBAI) consisting at least of a general physician, a nurse's aide, a technician in community health, and a consultory assistant. This team is responsible for the primary health care activities in each community. In the large sectors, two or more EBAIS are included.

The services provided by both cooperatives include:

· General medical attention and basic specialties such as gynecology and obstetrics, pediatrics, internal medicine, surgery, psychiatry, dentistry, and family and community medicine.

· Dental services.

· Pharmacy.

· Laboratory.

· Radiology.

· Emergencies.

· Health promotion and preventive services.

· Community medical care.

Four years after the first experience with health services administered under the cooperative model, it was noteworthy that there were only two clinics that followed this approach. Some reasons that have been mentioned for explaining the limited development of the model are:

· Lack of managers who are capable of overseeing these types of projects.

· Lack of a legal framework for public health institutions to hire managers.

· The monopoly of public services by CCSS.

· Lack of motivation of government officials to get involved with privatization efforts.

· Opposition from technocratic sectors in CCSS.

· Delayed payments from the Ministry of Health, which threatens the financial viability of this type of project.

Capitation

In 1987 the community of Barva de Heredia launched a very original project (the capitation project) that attempted to break with the traditional norms in the field of medicine within CCSS.

Capitation is a mode of organization for health visits which relies on payment to the physician based on the number of patients enrolled, regardless of the number of visits from the patients. The maximum number of patients that can be seen by each physician is about 2,500, and the physician has to work full-time for the system.

Capitation promotes the following principles:

· Competitiveness among physicians.
· Patients can freely select their physicians.
· A physician can freely decline to take care of a patient.
· Physicians can freely organize their working style.

In practice, the capitation system in Barva experienced multiple problems that might be responsible for the lack of diffusion of this system. The outpatient study conducted by Ugalde and Ruede (1988) concluded that:

· In practice, the model implemented differs from the European model.

· The model has not diminished the level of bureaucratization and centralization of outpatient care.

· There is no competition among physicians, due to the small size of the population.

· Existing data do not show an improvement in the productivity of the physicians; therefore, it is likely that the costs per visit have not declined.

· Physicians and health workers and managers responsible for the process in CCSS in general show a lack of understanding of the system of capitation.

· The program has a biomedical orientation and does not integrate curative and preventive activities.

· From the beginning, it was noticed that the program had a legal limitation, given that according to the legal criteria of CCSS the relationship between physicians and CCSS is a worker-employer relationship.

The model of capitation was later extended to two additional communities, one located in Heredia and the other in Alajuela. Nevertheless, the internal problems of the system have prevented it from serving as a new model for the provision of health care.

Restructuring of the Health Sector

Toward the end of 1989, the need was first recognized to reorganize and reorient the functions of the Ministry of Health with the purpose of "renovating and assuming the directive role attributed to it by the legislation." According to Dr. Mohs, this process would allow the Ministry to "guarantee the provision of integral services to the community... and the fulfillment of health policies" (Ministerio de Salud, 1989, p. 1).

The structural changes proposed for the Ministry at that moment included the elimination of the General Directorate and the creation of three areas: service to the public, environmental care, and administration. In addition, the elimination of a significant number of departments was proposed. However, this proposal was abandoned by the Ministry of Health due to the opposition from unions and an inadequate political moment (the proposal was to be implemented only six months before the election).

With the arrival of the Calderdministration (1990-1994), the idea that the health sector needed restructuring gained force and had the support of the World Bank and the Interamerican Bank for Development (BID). The basic idea was to assign direction of the health sector to the Ministry and to move its health services to CCSS.

A health reform proposal that was recently elaborated by the Ministry and CCSS with the assistance of the World Bank lists the following components or areas of intervention as priorities: strengthening a single directorate of the Health System whose chairman would be in charge of the Ministry; decentralization in the administration of services and implementation of actions; diversity in the provision of services; transparency in the origin and destiny of resources; provision of services based on criteria of integration, quality, and efficiency; reorganization of the structure and function of the sector; evaluation of the models and programs that meet the needs of the population.

It is obvious that these initiatives cannot be accomplished with only a change in the administration of services. These actions would involve a new mentality about the responsibilities and the role of the government with regard to the health care of the population. This also signals a redefinition of the role that traditionally has been played by the private sector in the health system. The idea is that the private sector assumes a more active role in the provision of health services, in an effort to overcome the problems of efficacy and efficiency that are currently present in the Costa Rican government. All these aspects will need to be taken into account when addressing the challenges posed by new policies, strategies, and models for the provision of services that are delivered by the health sector.

Balance of the 1980s and perspectives for the 1990s in the health sector

By the end of the 1980s, the two most important institutions in the health sector were submerged in a profound crisis. On its part, the Ministry of Health, after receiving constant budgetary cuts beginning in 1980 and facing a population increase of 700,000, had become basically paralyzed and was only able to pay the salary of its employees.

The preventive activities were reduced to a minimum due to the lack of resources, such as cash flow, transportation, fuel, and per diem expenses. The programs based on the primary health care strategy (Education and Nutrition Centers [CEN], Integrated Centers for Child Health Care [CINAI], dental prevention school program, and the so-called primary care) substantially reduced their coverage, which weakened the first level of health care in the country.

On its part, CCSS was able largely to overcome the economic crisis through the increase in fees and the implementation of measures for the control of internal expenses, which limited even more the capacity of the institutional response to meet the demand of the beneficiaries. During the second half of the 1980s and the first two years of the 1990s, CCSS suffered an unprecedented economic crisis worsened by the country's large external debt, and by the lack of satisfaction of the beneficiaries with the services provided, particularly those related to outpatient care. This indicates that the modest efforts that have been devoted to developing alternative models have not yielded the expected results and are far from becoming the short- and medium-term solution to the complex problems facing the institution.

The two most important efforts carried out by the Ministry of Health and CCSS in response to the crisis were the integration of services during the first half of the decade and the implementation of the SILOS strategy during the second half. These efforts were not able to meet their goals, in part due to administrative, legal, and financial restrictions present in both institutions.

The integration of CCSS and Ministry of Health services was proposed as a strategy to create a new model of health care in the country that would culminate in an integrated National health Care System (Jaramillo and Miranda, 1985). However, the goals of this process, which was initiated in 1983, were defined very broadly. The integration of the institutions consisted only of placing the CCSS and the Ministry of Health centers in the same location. Moreover, there were no established goals for the distribution of resources or the quality of services. The results show lack of coordination and cooperation among the personnel in both institutions, as represented by duplication of activities, schedule conflicts, and the absence of a hierarchical structure (Sanguinetti et al., 1988). Unfortunately, the process of integration did not anticipate the need for structural adjustments in the organization of clinics and health centers with the goal of establishing a unique administrative system that would facilitate the process. At the end of the government administration that promoted it, the level of integration was far from the goals originally proposed.

The SILOS strategy launched in 1987 was also far from reaching its intended objectives, and by 1990 it was no longer considered a viable health policy for the new government. As with the integration of CCSS and the Ministry of Health, an important limitation for the development of SILOS has been the absence of changes in the administrative and financial organization of both institutions that would allow them to decentralize and consolidate true community participation The limitations imposed by the adjustment process made it more difficult to provide human resources for the implementation of SILOS, diminishing the medium- and long-term possibilities of survival of this model. In 1988, faced with the urgency of supporting the administrative sector of SILOS with human resources, the personnel working on primary health care were transferred to meet these functions. This caused the breakdown of the whole supervision system of the primary health care program without resolving the administrative problem of SILOS.

During the 1980s, CCSS experimented with the implementation of several alternative health care models, including mixed, private, capitation, and health cooperatives, but none of them emerged as a viable alternative to the prevailing models in CCSS and in the Ministry of Health.

The mixed and private models essentially reproduce the health care model based on curative medicine and the prescription of medications, and are far from being integrated models. The cooperatives of Pavas and Tibhave been great individual successes. However, the replicability of the model is in question, and after four years of experience it does not seem to be a viable alternative for the whole country.

Capitation has had even greater problems, and calls into question the idea that the Costa Rican model corresponds to the European capitation model. After five years, there is no indication that this model can become a viable alternative for the whole country. In conclusion, by the end of the 1980s none of the alternative models implemented by CCSS seemed to be a viable alternative to the existing ones.

At the beginning of the 1990s, the Ministry of Health became severely decapitalized and its main programs weakened. CCSS was undergoing its most severe financial crisis without the option of increasing the fees paid by its beneficiaries or their employers, and facing ever-increasing complaints about the deterioration of its services and health care. These problems, are becoming more difficult on a daily basis and a new restructuring seems necessary. In the meantime the achievements and momentum of the preventive medicine and nutrition initiative of the 1970s continue to be reflected in favorable health statistics for Costa Rica compared with the rest of Central America.

References

Alfaro J. Chaves M. 1986. "Proceso de Integracie Servicios de Salud en Costa Rica. 1983-1984. " Tesis de grado, Universidad de Antioqu Medell

Ayala N. et al. 1992. Grado de desarrollo de la estrategia de SILOS. Segunda EvaluaciFebrero 1992. Caja Costarricense Seguro Social. Ministerio de Salud. March 1992.

Bustelo E, Isuani E. 1990. "El ajuste en su laberinto. Fondossociales y polca social en Amca Latina." Seminario de Fondos de Desarrollo Social UNICEF-PREALC-OEA-PNUD-ILPES-GRUPO ESQUEL, Santiago de Chile, November 1990.

CIIAS-CIID. 1990. Ansis del desarrollo e investigacie los programas basados en la estrategia de atencirimaria en salud en los pas de Amca Central y Repa Dominicana. Memoria Taller Internacional, Roberto Alvarado, Coordinador, San JosJanuary 1990.

CCSS. 1988. "Evaluaciel programa de atencica por capacitacin el Cante Barva durante 1987." San Jos1988.

CCSS. 1991. "La Caja Costarricense de seguro social en la coyuntura crisis." Documento presentado por la CCSS al "II Foro de salud y desarrollo. Ajuste estructural y bienestar social en la crisis." San JosMarch 1991.

CCSS and Ministerio de Salud. 1992. Proyecto Reforma Sector Salud, Unidad Preparatoria del Proyecto. San JosMay 1992.

GarcR. et al. 1992. Evaluaciel grado de desarrollo del proceso de integracioordinacintre el Ministerio de Salud y la CCSS. August-September 1991. San JosJanuary 1992.

Jaramillo J. Miranda G. 1985. La Integracie servicios de salud en Costa Rica. CCSS, San Jos1985.

MarF, Vargas M. 1991. SILOS y empresas cooperativas de salud. El cave de Costa Rica. San JosFebruary 1991.

Ministerio de Planificaciacional y polca Econa 1987. "El gasto po en los sectores sociales - aspectos metodolos." Documento 9. MIDEPLAN, San JosJuly 1987.

Ministerio de Planificaciacional y polca Econa. 1987. "Propuesta de indicadores sobre salud - aspectos metodicos." Documento 3. MIDEPLAN, San JosJune 1987.

Ministerio de Salud. 1989. "Resumen de propuesta de desarrollo institucional." November 1989.

Ministerio de Salud. 1990. "Sistemas de Salud en Costa Rica." Aporte del MS al Seminario-Taller: "Presente y futuro de los sistemas de salud en Centroamca." San Jos25-26 October 1990.

Ministerio de Salud. 1991. “El gasto de operacie los servicios de la salud al nivel local del Ministerio de Salud de Costa Rica." Documento preliminar. OPS/OMS, Costa Rica, December 1991.

Ministerio de Salud. 1990. Sistema de InformaciDepartamento de Atencirimaria, 1990.

Miranda G. 1992. Entrevista al presidente ejecutivo de la CCSS en el pero 1982-1990. August 1992.

Miranda G. 1988. La Seguridad Social y el desarrollo en Costa Rica. Editorial EDNASS-CCSS, San Jos1988.

Mohs E. 1991. "Polcas y estrategias de salud durante dos ddas. 1970-1990 (documento into)." San Jos1991.

Novygrodt R. 1992. Deterioro de indicadores de salud, nutrici la pobreza. Costa Rica, September 1992.

Sanguinetti JA, et al. 1988. Los servicios pos de salud de Costa Rica. Integraci coordinaciB>. Development Technologies. Pragma Corp, San JosApril 1988.

Sanguinetti JA. 1988. "La salud y el seguro social en Costa Rica. " Informe ConsultorPresentado a MIDEPLAN por Development Technologies Inc., San Jos1988.

Trejos ME, Villalobos R. 1992. Lo aparente y lo oculto del ajuste estructural en Costa Rica. Projecto por una Opcie Desarrollo Alternativa, Escuela de Econom Universidad Nacional, Costa Rica, 1992.

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Valverde JM. 1990. Crisis y polca social en Costa Rica 1980-1988: Tendencias y perspectivas. Informe final de projecto. Instituto de Investigaciones Sociales, Universidad de Costa Rica y Confederaciuperior Universitaria Centroamericana, Costa Rica, February 1990.

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Appendix 1 - Glossary

English	Spanish
Area Technical Council	Consejo Tico de Area
Associations for Integrated Development	Asociaciones de Desarrollo Integral (ADI)
Atlantic Port Administration	Junta de Administraciortuaria de la Vertiente Atlica
Basic Equipment in Integral Care	Equipp Bco de Atencintegral (EBAI)
Basic Statutes of the Ministry	Ley Orgca del Ministerio
Basic Technical Council	Consejo Tico Bco
Block Leaders	Ladders de Manzana
Board of Directors	Junta Directiva
Board for Social Assistance	Junta de Asistencia Social
Board for Social Protection	Juntas de Protecciocial
Center for Development Strategy and Information on Health and Social Security	Centro de Desarrollo Estratco e Informacin Salud y Seguridad Social
Charity Tax	Impuesto de Beneficencia
Civil Service	Servicio Civil
Committees of Neighbors	Comitde Vecinos
Communist Party of Costa Rica	Partido Vanguardia Popular
Community Health Areas	Areas de Salud Comunitaria
Community Health Centers	Medicaturas del Pueblo
Community Health Program	Programa de Salud Comunitaria
Community Health Program for Urban Areas	Proyecto de Salud Comunitaria para Areas Urbanas
Community Health Sectors	Sectores de Salud Comunitaria
Community Outreach Programs	Programas de Cobertura
Complementary Food Program	Programa de alimentaciomplementaria
Congress	Asamblea Legislativa
Cooperative for American Relief Everywhere (CARE)	Cooperacie Americana de Recursos al Exterior
Coordinating Council for Medical Services	Consejo Coordinador de los servicios Mcos
Corporation for the Development of Costa Rica	Corporaciare el Desarrollo de Costa Rica (CODESA)
Costa Rican Association of Public Health Specialists	Asociaciostarricense de Especialistas en Salud Publica
Costa Rican Institute of Electricity	Instituto Costarricense de Electricidad
Costa Rican Social Security Institute	Caja Costarricense de Seguro Social (CCSS)
Council for the Social Protection of San Jos/TD>	Junta Social de Proteccif San Jos/TD>
County	Cant/TD>
County Agricultural Committees	ComitAgrlas Cantonales
Department of Statistics	Departmento de Estadistica
Development Associations	Asociaciones de Desarrollo
Development Committee	Comite Desarrollo
Directorate of Census and Statistics	Direccieneral de Estadica y Censos
Directorate General of Medical and Social Assistance	Direccieneral de Asistencia Mco Social
Disabled, Elderly, and Death initiative	Rmen de Invalidez, Vejez y Muerte
Education and Nutrition Centers	Centros de Educaci NutriciCENs).
Electric Institute of Costa Rica	Instituto Costarricense de Electricidad
Emergency System	Caja de Emergencias
Family Allotment Fund	Fondo de Asignaciones Familiares
Family Benefits Law	Ley Sobre Asignaciones Familiares
Federal Budget	Presupuesto Nacional Field Operations
Manager	Jefe de Operaciones de Campo
Field Supervisor	Supervisor de Campo
First Charity Board	Primera Junta de Caridad
Fund for Family Benefits	Fondo de Asignaciones Familiares
General Directorate	Direccieneral
General Directorate of Family Resources	Direccieneral de Asignaciones Familiares (DESAF)
General Health Law	Ley General de Salud
General Medical-Social Assistance Law	Ley General de Asistencia Mco Social
General Regulations on Foundations and Boards for Social Protection	Reglamento General de Patronatos y Juntas de Protecciocial
Government Council	Consejo de Govierno
Health Code	Co Sanitario
Health Posts	Puestos de Salud
Health Service Cooperatives	Cooperativas Autogestionarias de Servicios de Salud
Health and Social Security Council	Juntas de Salud y Seguridad Social
Health and Social Security Teaching Research National Center	Centro Nacional de Docencia e and Investigacin Salud y Seguridad Social (CENDEISS)
Hospital Without Walls	Hospital Sin Paredes
Illness and Maternity Insurance	Seguro de Enfermedad y Maternidad
Illness and Maternity Program	Rmen de Enfermedad y Maternidad
Institute for Agrarian Development	Instituto de Desarrollo Agrario
Institute for the Protection of Coffee	Instituto de Defensa del Caf/TD>
Institute of Land and Settlements	Instituto de Tierras y Colonizaci/TD>
Institute of Nutrition of Central America and Panama	Instituto Nutricie Centro America y Panama (INCAP)
Insurance Bank	Banco de Seguros
Insurance Institute	Instituto Nacional de Seguros
Interamerican Bank for Development	Banco Interamericano de Desarrollo (BID)
Interamerican Development Bank	Banco Interamericano de Desarrollo
Integrated Centers for Child Health Care	Centros Integrales de Atencinfantil (CINAI)
Integrated Health Program	Programa de Salud Integral
Labor and Employer Council	Consejo de Obreros y Patronos
Labor Minister	Ministro de Trabajo
Labor Ministry	Ministerio de Trabajo
Land and Settlement Institute	Instituto de Tierras y ColonizaciITCO)
La Sabana Recreation Park	Parque Recreativo La Sabana
Law for Social Development and Family Allowances	Desarrollo Social y Asignaciones Familiares
Local Health Committees	ComitLocales de Salud
Local Health Systems	Sistemas Locales de Salud (SILOS)
Local Technical Council	Consejo Tico Local
Malaria Control Program	Programa de control de Malaria
Manager's Office for Medical and Social Assistance	Direccieneral de Asistencia Mco-Social
Medical and Administrative Divisions	Sub-gerencia Mca y la Administrativa
Minimal Program of Political Action	Programa Mmo de Acciolca
Ministry of Culture, Youth, and Sports	Ministerio de Cultura, Juventud, y Deportes
Ministry of Health	Ministerio de Salud
Ministry of Health and Social Assistance	Secretarde Salubridad y Asistencia Social
Ministry of Public Health and Social Protection	Secretaria de Estado en el Despacho de Salubridad Pa y Protecciocial
Ministry of the Interior	Ministerio de Gobernaci/TD>
Ministry of Public Works and Transportation	Ministerio de Obras Publicas y Transportes
Mixed Health Care System	Sistema de Medicina Mixta
Mixed Institute for Social Assistance	Instituto Mixto de Ayuda Social (IMAS)
Municipal Council	Consejo Municipal
National Banking System	Sistema Bancario Nacional
National Budget	Presupuesto Nacional
National Children's Hospital	Hospital Nacional de Ni
National Committee on Human Resources	Comisiacional de Recursos Humanos
National Community Development Department	Direcciacional de Desarrollo de la Comunidad (DINADECO)
National Congress	Congreso Nacional
National Constitution	Constituciolca
National Dance Company	CompaNacional de Danza
National Development Plan	Plan Nacional de Desarrollo
National Education Development Plan	Plan Nacional de Desarrollo Educativo
National Foundation for Children	Patronato Nacional de la Infancia
National Fund for the Blind	Patronato Nacional de Ciegos
National Health Care System	Sistema Nacional de Salud (SNS)
National Health Council	Consejo Nacional de Salud
National Health Plan	Plan Nacional de Salud
National Hospital System	Sistema Hospitalario Nacional
National Institute for Housing and Urban Planning	Instituto Nacional de Vienda y Urbanismo (INVU)
National Institute of Learning	Instituto Nacional de Aprendizaje
National Insurance Institute	Instituto Nacional de Seguros (INS)
National Liberation Party	Partido Liberaciacional
National Lottery	LoterNacional
National Nutrition Clinic	Clca Nacional de Nutrici/TD>
National Oil Company	Refinadora Costarricense de Petr
National Park System	Sistema de Parques Nacional
National Planning System	Sistema Nacional de Planificaci/TD>
National Production Council	Consejo Nacional de la ProducciCNP)
National Rehabilitation Program	Programa Nacional de Rehabilitaci/TD>
National Savings and Loans System	Sistema Nacional de Ahorro y Pramo
National Sectorial Council	Consejo Nacional Sectorial
National Theater Company	CompaNacional de Teatro
National Water Service	Servicio Nacional de Acueductos y Alcantarillados
Noncontributory Pension Scheme	Rmen no Contributivo de Pensiones
Nurse's Aide	Auxiliar de Enfermeria
Nutritional Recovery Program	Programa de Recuperaciutricional
Nutrition and Family/School Garden Program	Programa de Nutrici Hyertas Escolares y Familiares
Pacific Electric Railways	Ferrocarril Elrico del Pacco
Police Secretariat	Secretaria de Polic
Popular Bank	Banco Popular
Popular and Community Development Bank	Banco Popular y de Desarrollo Popular
Primary Health Care	Atencirimaria
Primary Health Care Assistant	Assistente de Atencirimaria
Private Sector System	Medicina de Empresa
Professional Risk System	Rmen de Riesgos Profesionales
Progressive Cooperatives	Juntas Progresistas
Reformist Party	Partido Reformista
Regional Technical Interinstitutional Council	Consejo Tico Regional Interinstitucional
Rural Credit Unions	Juntas Rurales de Crto
Rural Health Assistant	Assistente de Salud Rural
Rural Health Program	Programa de Salud Rural
School Committees	Patronatos Escolares
School Lunch Program	Programa de Comedores Escolares
Secretariat for Public Health and Social Sectoral Director	Secretarde Salubridad Pa y Jefe de Sector Protection
Sectoral Planning Unit	Unidad Sectorial de Planificaci/TD>
Social Medicine Technical Council	Consejo Tico de Asistencia Mco-Social
Social Security Institute	Instituto de Seguro Social
Social Security Law	Ley Constitutiva de la Caja
Social Worker to Combat Tuberculosis	Trabajadora Social en la Lucha contra la Tuberculosis
State University	Universidad Estatal a Distancia
Subsystem for Regional and Urban Planning and Coordination	Sub-sistema de Planificaci Coordinaciegional y Urbana
System of Administrative Information	Sistema de Informacierencial
System for Administrative Reforms	Sistema de Reforma Administrativa
Technical Interinstitutional Council	Consejo Tico Interinstitucional
Technological Institute of Costa Rica	Instituto Tecnolo de Costa Rica
The National University	Universidad Nacional de Costa Rica
Treasury Department	Caja Unica
Treasury Minister	Ministro de Hacienda
Undersecretary's Office for Hygiene and Public Health	Subsecretaria de Higiene y salud publica
United Nations Children's Fund	UNICEF
University Residence and Internship Commission	Comisie Internados y Residencias Universitarias (CIRU)
Volunteer Groups	Grupos Voluntarios (ONGs)
Workers Confederation	Confederacie Trabajadores
World Food Program (WFP)	Programa Mundial de Alimentos
Workers Insurance Program	Seguro Obrero
World Bank	Banco Mundial
Youth Symphony Orchestra	Orquesta Sinfa Juvenil

(introduction...)

The chapters in this book largely report the perspective on Costa Rica's nutrition and health transition of persons who were involved in bringing it about. A further understanding of the process can be obtained from the additional references listed below, many of them written by opponents of the governments of the period or by expatriots. Further incites into the Costa Rican transition will be obtained from them.

English-language supplementary reading list

Bell JP. 1971. Crisis in Costa Rica: The 1948 revolution. Austin: University of Texas Press.

Bossert TJ. 1984. "Health-policy innovation and international assistance in Central America." Pol Sci Quart 99(3):441-455.

Bossert TJ. 1990. "Can they get along without us? Sustainability of donorsupported health projects in Central America and Africa." Soc Sci Med 30(9):1015-1023.

Braveman P, Mora F. 1987. "Training physicians for community-oriented primary care in Latin America: Model programs in Mexico, Nicaragua, and Costa Rica." Am J Publ Health 77(4)485-490.

Bulmer-Thomas V. 1987. The political economy of Central America since 1920. Cambridge University Press, Cambridge.

Casas A, Vargas H. 1980. "The health system in Costa Rica: Toward a national health service." J Publ Health Pol 1:250-279.

Castro Gutiez M. 1983. Economic development and nutrition in Costa Rica. College of Human Resources, Title XII Program Publication No. 9, University of Delaware.

Edelman M. 1983. "Recent literature on Costa Rica's economic crisis.” Lat Am Res Rev 18:166-180.

Edelman M, Kenen J, eds. 1989. The Costa Rica reader. Grove Weidenfeld, New York.

Gudmundson L. 1986. Costa Rica before coffee. Louisiana State University, Baton Rouge.

Herrick B. Hudson B. 1981. Urban poverty and economic development: A case study of Costa Rica. St. Martin's Press, New York.

Hertz E, Hebert JR, Landon J. 1994. "Social and environmental factors and life epectancy, infant mortality, and maternal mortality rates: Results of a cross-national comparison." Soc Sci Med 39(1):105-114.

Jaramillo Antill. 1987. "Changes in health care strategies in Costa Rica.” PAHO Bull 21:136-148.

Low SM. 1982. "Dr. Moreno Ca A symbolic bridge to the demedicaliation of healing.” Soc Sci Med 16:527-531.

Low SM. 1985. Culture, politics, and medicine in Costa Rica. Redgrave Publishing, Bedford Hills, New York.

May JM, McLellan DL. 1972. The ecology of malnutrition in Mexico and Central America. Studies in medical geography, volume 11. Hafnor Publishing Co, New York.

Mesa-Lago C. 1978. Social security in Latin America: Pressure groups, stratification and inequality. University of Pittsburgh Press, Pittsburgh.

Mesa-Lago C. 1985. "Health care in Costa Rica: boom and crisis. " Soc Sci Med 21(1):13-21.

Mesa-Lago C. 1992. Health care for the poor in Latin America and the Caribbean. PAHO, Washington, DC.

Mohs E. 1983. "Infectious diseases and health in Costa Rica: The development of a new paradigm." Pediatr Inf Dis 1:212-216.

Morales JO, Scrimshaw N. Arca AM. 1953. "Health systems." In: Loomis CP, et al., eds. Turrialba: Social systems and the introduction of change. The Free Press, Glencoe, IL.

Morgan LM. 1987. "Health without wealth? Costa Rica's health system under economic crisis." J Pub Health Pol 8(1):126-151.

Morgan LM. 1989. "'Political will' and community participation in Costa Rican primary health care." Med Antropol Quart (n.s.) 3(3):232-245.

Morgan LM. 1990. "International politics and primary health care in Costa Rica." Soc Sci Med. 30(2):211-219.

Morgan LM. 1993. Community participation in health. The politics of primary care in Costa Rica. Cambridge University Press, Cambridge.

Pezza PE, Barquero BolaJF. 1994. "Clca Tibas: An experimental response to health system challenges in Costa Rica." J R Soc Health 114(5):252-255.

Richardson M, Bode B. 1971. "Popular medicine in Puntarenas, Costa Rica: Urban and societal features." In: Adams RN, et al., eds. Community culture and national change. Middle American Research Institute Publication 24, Tulane University.

Roemer MI. 1963. "Medical care in Costa Rica." In: Medial Care in Latin America. Organization of American States, Washington, DC, 169-192.

Rosenberg MB. 1981. "Social reform in Costa Rica: Social security and the presidency of Rafael Angel Calderon." Hispanic American Historical Rev 61 (2):278-296.

Rosero-Bixby L. 1986. "Infant mortality in Costa Rica: Explaining the recent decline." Stud Fam Plan 17(2):57-65.

Sanders SW. 1986. The Costa Rican laboratory. Priority Press/A Twentieth Century Fund Paper, New York.

Saligson M. 1979. "Public policies in conflict: Land reform and family planning in Costa Rica.” Comp Pol 12(1):49-62.

Saligson M. 1980. Peasants of Costa Rica and the development of agrarian capitalism. University of Wisconsin Press, Madison.

Sojo A. 1989. "Social policies in Costa Rica." CEPAL Rev 38:105-119.

Stycos JM, 1982. "The decline of fertility in Costa Rica: Literacy, modernization, and family planning." Pop Stud 36(1):15-30.

Taylor JE. 1980. "Migration: A study of population movements in Costa Rica." Latin Am Perspec 7(2-3):75-90.

Thrupp LA. 1991. “Sterilization of workers from pesticide exposure: The causes and consequences of DBCP-induced damage in Costa Rica and beyond." Int J Health Serv 21 (4):731-757.

Trejos JD. 1985. "Costa Rica: Economic crisis and public policy, 1978-1984." Latin American and Caribbean Center, Occasional Papers Series, no. 11, Florida International University, Miami.

Whiteford MB. 1985. "The social epidemiology of nutritional status among Costa Rican children: A case study." Humn Org 44(3):241-250.

Williams CD. 1973. "Health services in the home. " Pediatrics 52:773-781.

Wilson CM. 1942. Ambassadors in white: The story of American tropical medicine. Henry Holt and Co, New York.

Spanish-language supplementary reading list

Alvarado Aguirre R. 1987. "Analisis de la organizaci funcionamiento de las polcas de salud a travde los programas materno-infantiles en centroamca. El cave de Costa Rica, I etapa." Unpublished manuscript funded by the Instituto Centroamcana de Administracia and the Ford Foundation.

Bogan Miller MW, Montejo JO. 1979. Salud y enfermedad. En Costa Rica Contempora, tome II. Chester Zelaya, dirrecciEditorial Costa Rica, San Jos73-119.

Bonilla Masis O. 1981. Desarrollo de la comunidad: polcas sanitarias y participaciomunitaria en Costa Rica. Ministerio de Salud, San Jos

Fallas H. 1982. Crisis econa en Costa Rica. Editorial Nueva Dda, San Jos

Jaramillio Antill. 1984. Los problemas de la salud en Costa Rica. Ministerio de Salud, San Jos

Jaramillio Antill. 1988. Reflexiones: Medicina, salud, medio ambiente, desarrollo. LitografAmbar, San Jos

Mesa-Lago C. 1987. “Atencie salud en Costa Rica: Auge y crisis." Bol Of Sanit Panam 102 (1):1-18.

Ministerio de Salud. 1978. Costa Rica: Extensie cobertura de los servicios de salud en el marco del desarrollo socio-economics. Ministerio de Salud, San Jos

Ministerio de Salud. 1981. Salud en Costa Rica. Editorial Universidad Estatal a Distancia, San Jos

Mohs E. 1983. La salud en Costa Rica. Editorial Universidad Estatal a Distancia, San Jos

Mohs E. 1986. Salud pare la paz. Libro Libre, San Jos

Mohs E. 1988. La reforma del sector salud en Costa Rica durante la dde de los 70. Ministerio de Salud, San Jos

Morgan LM. 1988. "Salud sin riqueza? El sistema de salud de Costa Rica bajo la crisis econa." Revista Centroamericana de Administracia 12:25-39.

Morgan LM. 1990. "La voluntad polca y la participacie la comunidad en la Atencie la salud primaria en costa Rica." Trad. por MarCecilia Alvarado Van Patten. Revista Centroamericana de Administracia 19 (julio-deciembre):5-23.

Morgan LM. 1993. "Polca internacional y Atencirimaria de salud en Costa Rica." Trad. por Consuelo Fernez. Anuario de Estudios Centroamericanos 19(1):91-105.

Newell KW. 1975. La salud por el pueblo. WHO, Geneva.

Naranjo F. et al. 1977. "Desarrollo de los programas de seguridad social en Costa Rica: Universalizaci extensie servicios mcos asistenciales." Seguridad Social 105-106:59-138.

Rosenberg MB. 1983. Las luchas por el seguro social en Costa Rica. Editorial Costa Rica, San Jos

Serra J. Brenes C. 1983. "Recuperacirca de indicadores socioeconos: la experiencia del programa de salud comunitaria ‘Hospital sin paredes.’" In: Ramalinga Iyer R. et al., eds. Centroamca: Indicadores socioeconos para el desarrollo. FLACSO, San Jos269-313.

Valverde Jimz, E. 1972. "Plan de salud rural." Acta Mca Costarricense 15(1):77-90.

Vargas Fuentes M.1993. "Privatizacie servicios pos. El caso de los servicios de salud en Costa Rica.” Salud Publica de Mco 35(2):186-93.

Vargas Gonzs W. 1977. "El programa de salud rural de Costa Rica: un modelo par las poblaciones marginadas. "Amca Indna 37(3):353-365.

Vega Carballo JL. 1981. La formaciel estado nacional en Costa Rica. Instituto Centroamcano de Administracia San Jos

Villalobos LB. 1989. Salud y sociedad: Un enfoque pare Centroamca. Instituto Centroamcano de Administracia San Jos

Villegas H. 1977. "Extensie la cobertura de salud en Costa Rica." Boletde la Oficina Sanitaria Panamericana 83(6):537-543.

Villegas H. 1978. "Costa Rica: Recursos humanos y participacie la comunidad en los servicios de salud en el medio rural." Boletde la Oficina Sanitaria Panamericana 84(1):13-22.

Supplementary reading list - INCAP publications

INCAP References on Clinical Nutrition and Health in Costa Rica 1949-1991

BermA, Valverde V, Teller C. 1980. "Ansis de algunos factores relacionados con el bajo peso al nacer en Costa Rica." Boletin Informativo del S.I.N. 1:4-11.

Bressani R. Mez J, Scrimshaw NS. 1960. “Valor nutritivo de los frijoles Centroamericanos III. Variaci en el contenido de protes metionina, triptofano, tiamina, riboflavina y niacina de muestras de Phaseolus vulgaris cultivadas en Costa Rica, El Salvador, y Honduras." Arch Venezolanos de Nutr 10:71-84.

Castro L, G. 1991. Patre Actividad Fca, Aspectos Dietcos y Estimacie Gasto Energco de Preescolares Obseos y no Obesos en la Provincia de LimCosta Rica. Universidad de San Carlos de Guatemala, Facultad de IngenierQuca/INCAP

Flores M, Aranada-Pastor J. 1980. “Evaluacion dietetica a nivel nacional en Costa Rica: Cambios en una decada." Archivos Latinamericos de Nutricion 30:432-450.

Flores M, Brice Flores Z. 1963. "Resultados de una encuesta nutricional en el cante Bagaces, provincia de Guanacaste, Costa Rica." Bol Of San Pan 55:405-415.

Flores M, Mench Lara MY, Br M. 1970. Dieta adecuada de costo mmo pare la Repa de Costa Rica. INCAP, Guatemala, 27.

INCAP. 1969. Evaluaciutricional de la poblacie Centro Amca y PanamB>. Oficina de Investigaciones Internacionales de los Institutos Nacionales de Salud (EEU), Ministerio de Salubridad Pa de Costa Rica. INCAP, Guatemala, 113.

Laure J. Batres de Bonilla R. Alarc. 1990. Costa Rica: Medio siglo de Polcas a favor del incremento de salarios mmos mbajos. INCAP, Guatemala, 31 p. (Colecciocumentos Ticos No. 19.)

Leal CartF. Salazar-Baldioceda A. 1955. "Hallazgos hematolos y coprolos en algunas poblaciones de la provincia de San JosCosta Rica." La Juventud Mca 11 (78):24-28.

Mata LJ, Mayorga R. 1966. "Dermatofitosis por Microsporum gypseum en Costa Rica y Guatemala. " Microbiol Parasitol 8:139-145.

Mez J. Brice, Flores M. 1966. "Niveles de colesterol sco en grupos de pobalcientroamericana. III. Bagaces provincia de Guanacaste, Costa Rica. Interrelaciones entre vitamina A y carotenos y lipidos sericos." Arch Latinoamer Nutr 16:133-143

Pz C, Salazar-Baldioceda A, Tandon OB, Scrimshaw NS. 1956. "Endemic goiter in Costa Rican school children." Am J Publ Health 46:1283-1286.

Rawson IG, Valverde V. 1976. "The Etiology of Malnutrition among Preschool Children in Rural Costa Rica." J Trop Pediat 22:12-17.

Scrimshaw NS, Morales JO, Salazar A, Loomis CP. 1953. "Health aspects of the community development project, rural area, Turrialba, Costa Rica, 1948-51." Am J Trop Med Hyg 2:583-592.

Scrimshaw NS, Trulson M, Tejada C, Hegsted DM, Stare FJ. 1959. "Serum lipoprotein and cholesterol concentrations. Comparisons of rural Costa Rican, Guatemalan and United States populations." Circulation 15:805-813.

Strong JP, Tejada V. C, McGill HC Holman RL. 1957. "Comparison of early lesions of atherosclerosis in New Orleans Guatemala and Costa Rica (abst)." American Society for the Study of Atherosclerosis Meeting, Chicago, November 1957.

Strong JP, McGill HC, Tejada C, Holman RL. 1958. “The natural history of atherosclerosis. Comparison of the early aortic lesions in New Orleans, Guatemala and Costa Rica." Am J Pathol 34:731-744.

Tejada C, Gore I, Strong JP, McGill H. 1958. "Comparative severity of atherosclerosis in Costa Rica, Guatemala, and New Orleans." Circulation 18:92-97.

Valverde V, Arroyave G. GuzmM, Flores m. 1980. Nutritional status in central America and Panama. Nutrition in the 1980s Constraints on our Knowledge. New York, 271-282.

Valverde V. 1980. "Regionalizacie los problemas nutricionales y ansis de la talla y la edad de ingreso a primer grado de los nicostarricenses." Boletin Informativo del S.I.N. 1:23-31.

Valverde V, Rojas Z. Vinocur P. Payne P. Thomson A. 1981. "Organization of an information system for food and nutrition programmes in Costa Rica." Food and Nutrition 7:32-40.

Valverde V, Vargas W Payne P, Thomson A. 1981. "Data requirements and use in nutrition planning in Costa Rica." Food Policy 6:19-26.

Valverde V, Vargas W. Rawson I, Calder. Rosabal R. Gutiez R. 1975. "La deficiencia cala en preescolars del a rural de Costa Rica." Separata de Archivos Latinoamericanos de Nutricion 25:351-361.

Valverde V, Vinocur P. Salazar S. Zillyham R. 1981. "Relacion entre la prevalencia de retardo en taalla en escolares e indicadores socioeconos a nivel de canton en Costa Rica." Boletin Informativo del S.I.N. 2:4-9.

Vargas N. Mari. Epidemilogde la Obesidad en Costa Rica. 1989. Centero de Estudios Superiores en Nutrici Ciencias de Alimentos (CENSA), Universidad de San Carlos de Guatemala, Facultad de Ciencias Mcas/INCAP, Guatemala C.A.

General information

Population

In 1987 Costa Rica had 2,790,600 inhabitants. Based on official projections, the 1992 population was estimated at 3,099,063, with an age structure as follows: 0-4 years of age, 12.8%; 5-14 years, 23.1%; 15-64 years, 59.8%; 65 years or older, 4.3%. The population density increased from 50 inhabitants per km² in 1984 to 60.7 in 1992. The Central region is home to 65% of the population, with a density of 230.1 inhabitants per km²; in other regions of the country the population density ranges from 19 to 40 inhabitants per km². The population is 47% urban and 53% rural. Between 1960 and 1990 the urban population grew at an average annual rate of 3.9%.

The growth of the Central region has been largely the result of internal migration, although international migration has also played a part, particularly during the period 1975 to 1985, when three regions of the country registered net immigration (Central, Huetar Norte, Huetar Atlica). There continue to be two main currents of migration: from small cities and rural areas to the country's principal urban centers, and from economically depressed rural areas where employment opportunities are limited and most of the land is owned by a few individuals to other rural areas in which development is taking place and the demand for workers is greater.

In 1989, 40,800 refugees were living in the country. By July 1993, the number had fallen to 31,875. In addition, there are an estimated 250,000 undocumented aliens.

The natural population growth rate for the period 1991-1992 was 2.26%. The total fertility rate decreased from 3.5 children per woman between 1980 and 1985 to 3.26 between 1985 and 1990. In 1991 the birth rate was 26.3 per 1,000 population, and life expectancy at birth for the period 1990-1995 was estimated at 75.2 years.

Mortality

Birth and death records suffer from late registration of mortality, which is estimated at 2.8% for general mortality and 3% for infant mortality. No medical death certificate is issued for 24% of deaths in general, whereas only 2.8% of infant deaths lack medical certification.

The general mortality rate recorded in 1991 was 3.8 per 1,000 population and there were a total of 11,792 deaths. The infant mortality rate in 1991 was 13.9 per 1,000 live births. Deaths attributed to signs, symptoms, and ill-defined conditions made up 1.7% of the total.

In 1991 four major groups of causes accounted for 70% of all deaths: 29.4% were due to diseases of the circulatory system, 20% to malignant neoplasms, 10.5% to external causes, and 10.2% to diseases of the respiratory system, with rates of 11.2, 7.6, 4.0, and 3.9 per 10,000 population, respectively. Infectious and parasitic diseases, which in 1970 ranked as the leading cause of death and accounted for 20.5% of all deaths (a mortality rate of 13.6 per 10,000 population), in 1991 ranked 10th and were responsible for 2.8% of all deaths (a rate of 1.1 per 10,000 population).

Among the general population in 1991 acute myocardial infarction was the leading cause of death, accounting for 9.6% of all deaths. The mortality rate from this cause increased from 2.6 per 10,000 population in 1970 to 3.7 in 1991. In second place was malignant neoplasm of the stomach, which caused 5% of all deaths. The mortality rate from this cause, 2.0 per 10,000 population, has changed very little since 1970. The third leading cause of death was other forms of chronic ischemic heart disease, at a rate of 1.6. Chronic airway obstruction ranked fourth, at a rate of 1.2, and acute cerebrovascular disease and diabetes mellitus ranked fifth and sixth, respectively, at rates of 1.2 and 1.0 per 10,000 population.

Specific health problems

Analysis by Population Group

Perinatal and Child Health

The decline in infant mortality between 1970 and 1980 (from 61.5 to 19.1 per 1,000 live births) slowed between 1980 and 1985, when the rate was 17.6 per 1,000. In 1991 the rate recorded was 13.9 per 1,000 live births. The neonatal mortality rate fell from 25.2 per 1,000 live births in 1970 to 11.2 in 1980 and 8.6 in 1991. Similarly, the postneonatal mortality rate decreased from 36.3 per 1,000 live births in 1970 to 7.9 in 1980 and 5.2 in 1991. The perinatal mortality rate, which in 1975 was 23.7 per 1,000 live births, declined to 12.1 per 1,000 in 1991. The highest infant mortality rate registered in any of the country's counties in 1991 was 31.4 per 1,000 live births, and the lowest was 2.7 per 1,000.

Children under 1 year of age accounted for 9.5% of all deaths in 1991. The leading causes of death in this age group changed between 1970 and 1991. Intestinal infectious diseases moved from first to seventh place, the rate declining from 16.7 to 0.4 per 1,000 live births. In 1991 conditions originating in the perinatal period, congenital anomalies, and diseases of the respiratory system were the three leading causes of death in this age group, with rates of 6.1, 3.9, and 1.5 per 1,000 live births, respectively.

In 1990 the leading causes for outpatient medical visits among children under 1 year, in descending order, were bronchitis (10%), well-child visits (8%), acute respiratory infections (6%), acute tonsillitis (6%), and infections of the skin end subcutaneous tissue (5.5%). In 1990, date on hospital discharges from institutions of the Costa Rican Social Security Institute (CCSS) show that the leading causes of hospitalization in this age group were conditions originating in the perinatal period (39.3% - a proportion equal to 3.5% of all discharges), intestinal infectious diseases (12.5%), pneumonia (7%), and congenital anomalies (6.5%).

The proportion of children with low birthweight (under 2,500 g) has remained at around 6.7% since 1988.

Breast-feeding increased between 1975, when 85.3% of infants were breast-fed from birth, and 1990, when 93.9% were breast-fed. The proportion of children exclusively breast-fed for 3 months increased from 16.7% to 47.9% between 1975 and 1990, while the proportion exclusively breast-fed for 6 months increased from 11.2% to 21.7%.

The mortality rate among children age 1-4 years decreased from 51.1 per 10,000 in 1970 to 10.1 in 1980 and 6.5 in 1991. In the latter year, 1.8% of all deaths occurred in this age group. Between 1970 and 1991 infectious and parasitic diseases dropped from first to fourth place among the leading causes of death in this age group, with the rate falling from 25.9 per 10,000 in 1970 to 0.9 in 1991. Congenital anomalies ranked as the leading cause of death in 1991, followed, in descending order, by external causes and diseases of the respiratory system. The five leading causes of doctor visits were acute tonsillitis, bronchitis, nasopharyngitis and sinusitis, anemia, and asthma. In 1990 this age group accounted for 5% of all hospital discharges, with intestinal infections being the most frequent cause of hospitalization (18.2%), followed by bronchial asthma, pneumonia, and other respiratory infections, and by congenital anomalies.

Based on the indicator weight-for-height, in 1991 the reported prevalence of mild malnutrition among children under 6 years of age, was 17.9%, that of moderate malnutrition was 2.4%, and that of severe malnutrition was 0.1%. The prevalence of overweight was 2% among children under 1 year, 1.7% among children ages 1 to 2, and 1.7% among those ages 3 to 5 years.

The age group 5 to 9 years accounted for 0.8% of total mortality in 1991. External causes were the leading cause of death, followed by malignant neoplasms, diseases of the nervous system and sensory organs, infectious and parasitic diseases, and endocrine and metabolic diseases and immunity disorders. The causes for outpatient medical visits in this age group were similar to those for the group ages 1 to 4 years. Hospital discharges in this group made up 3.4% of all discharges. The leading causes of hospitalization were acute respiratory infections and bronchial asthma (14.4%), appendicitis (6.6%), congenital anomalies (5.2%), and intestinal infections (5%).

Adolescent and Adult Health

In 1991 young people ages 10 to 19 made up 20.4% of the population and those ages 20 to 24 constituted 9.4%; thus, almost one-third of the national population was between 10 and 24 years of age. According to 1984 census data, 15.9% of the economically active population was composed of young people ages 15 to 19 years. The 1989 household survey showed that 24% of the adolescent population was employed.

In 1991, deaths in the age group 10 to 14 years accounted for 0.8% of total mortality, deaths in the group 15 to 19 for 1.2%, and deaths in the group 20 to 24 for 1.7%. The leading cause of death among persons 10 to 14 years of age was external causes, with a rate of 1.4 per 10,000 population; accidental drowning and submersion and transport accidents were the predominant external causes. The second leading cause of death was diseases of the nervous system and sensory organs, with a rate of 0.62 per 10,000 population, the principal ones being, in descending order, infantile cerebral palsy, other brain disorders, and epilepsy. Malignant neoplasms ranked third, with a rate of 0.22 per 10,000 population.

Mortality in the group ages 15 to 24 accounted for 2.9% of total mortality. Two-thirds of the deaths in this group were of males, and the leading cause was external causes, mainly transport accidents of all types.

In regard to morbidity, 10.5% of all doctor visits at CCSS institutions (close to 6 million) and 11 % of all hospital discharges in 1987 involved persons ages 10 to 19 years. The leading reasons for consultations were prenatal care (6%), acute tonsillitis (4.9%), and pharyngitis-nasopharyngitis (4.7%). Among males, the most common reasons were infections of the skin and subcutaneous tissue (13.2%); sinusitis, laryngopharyngitis, and acute tonsillitis (10.1%); and "other" parasitic diseases (5%). Among females they were nasopharyngitis and sinusitis (8.9%); prenatal care (6.7%); and infections of the skin and subcutaneous tissue (6%).

The leading causes associated with hospital discharge in the group 10 to 19 years of age in 1990 were direct obstetric causes (27%), normal delivery (21.2%), and appendicitis (4.5%) for females, and appendicitis (10%), wounds and injury to blood vessels (7.9%), and intracranial and internal injuries (6.4%) for males.

In 1991, 16.2% of all live births (81,110) were to mothers under 20 years of age. Complications of pregnancy, childbirth, and the puerperium accounted for 71.3% of hospital discharges among the female adolescent population.

Mortality among the population aged 15 to 49 accounted for 16.2% of total mortality in 1991 (1,922 deaths). The leading cause was the group of external causes, which accounted for 36% of the deaths, or a rate of 4.3 per 10,000 population (down from the rate of 6.3 reported in 1980). Malignant neoplasms ranked second, causing 19.2% of the deaths, with a rate of 2.3. In third place were diseases of the circulatory system, which accounted for 14.3% (a rate of 1.7 per 10,000 population). Of the total number of deaths, 65% were of males, among whom violent causes, including both accidents and suicide, predominated.

In 1991 persons aged 50 years and over accounted for 71 % (8,136) of all deaths. Over three-quarters of these deaths (77.7%) were due to four groups of causes. The leading cause, accounting for 36% of all deaths in this group, was diseases of the circulatory system, with a rate of 83.2 per 10,000, and of these diseases acute myocardial infarction was the most important (29%). The second leading cause, with a rate of 51.0 per 10,000, was malignant neoplasms, which accounted for 23% of the deaths; malignant neoplasm of the stomach was the predominant cause in this group. Diseases of the respiratory system, with a rate of 25.7 per 10,000, ranked third, accounting for 11.7% of the deaths; chronic obstructive pulmonary disease and bronchopneumonia predominated in this group. In fourth place were external causes, which accounted for 5% of all the deaths in this age group and had a rate of 11.3 per 10,000.

Persons 20 to 59 years of age made 51.3% of all outpatient visits to CCSS institutions. Of these visits, 70% involved persons ages 20 to 44 and 71% were visits made by women of childbearing age. According to a survey carried out in 1987, the primary causes for outpatient visits in this age group were diseases of the skin and subcutaneous tissue (88%), upper and lower back problems (6.7%), and gastroduodenitis (5%) among males, and hypertensive disease (6.2%), prenatal care (6.1%), and neurotic disorders (4.1%) among females. Hospital discharge records for 1990 indicate that the 20 to 59 year age group accounted for 58.7% of all discharges from CCSS institutions; of these discharges, 76% were women aged 20 to 44 years. Direct obstetric causes were the leading cause of hospitalization among females (34.4%), followed by normal delivery (19.8%), and abortion (5%). Among the male population, the leading causes were psychoses and neurotic disorders (5.8%), osteomuscular diseases (5.3%), and intracranial and internal injury (5.1%).

Health of Women

In 1991 females made up an estimated 49% of the total population; 24% were under 10 years of age, 21.2% were 10 to 19 years, 38.4% were 20 to 44 years, 9.8% were 45 to 59 years, and 6.9% were 60 years of age or older.

Regarding leading causes of death in the female population, cardiovascular diseases account for 30.6% of all female deaths, malignant neoplasms for 20.2%, diseases of the respiratory system for 12.1 %, and external causes for 5.6%. The most frequent sites of malignant neoplasms are the stomach, uterine cervix, and breast. The contributions of these three types of cancer to total female deaths are 19.4%, 11.3%, and 9.4%, respectively, and the corresponding mortality rates are 13.8,8.1, and 6.7 per 100,000 females. As with males, the leading external cause among females was transport accidents, which accounted for 30.9%, followed by accidental falls, especially among elderly women.

Females made 63.4% of the outpatient visits to CCSS establishments, with women ages 20 to 44 years accounting for 58%. The most frequent reasons for seeking medical care among females ages 20 to 59 years were pregnancy related causes, hypertensive disease (6.2%), neurotic disorders (4.1 %), and upper and lower back problems (3.7%). Females accounted for 69% of all hospital discharges in 1990; of those discharges, 68% were of women ages 20 to 59 years. Direct obstetric causes, normal delivery, and abortion together accounted for 59% of the discharges among women in this age group, and other diseases of the female genital organs accounted for 3.8%. Diabetes mellitus, disorders of the eye, ischemic heart disease, respiratory diseases, and hypertensive disease together were responsible for 30% of hospitalizations in women age 60 years and over.

In 1991 a total of 89,221 pregnancies (80% low-risk and 20% high-risk) and 81,110 live births were recorded. Of these births, 16.2% were to women under the age of 20 years, 73% were to women 20 to 35 years, and 10.7% were to women over 35 years. Overall, 38% of the total number of births were to single mothers, with considerably higher proportions in the provinces of Guanacaste, Puntarenas, and Lim60.7%, 53%, and 60%, respectively); 65% of all live births among adolescent women were to single mothers.

In 1991, 96% of all births took place in hospitals, and 95% were attended by a physician or an obstetric nurse; 20% of all births were by cesarean section. Only 55% of the women giving birth in hospitals had received prenatal care. In 1990 the number of prenatal visits per birth averaged 2.4. Maternal mortality declined from 7.0 (41 deaths) to 3.5 (28 deaths) per 10,000 live births between 1975 and 1990. The leading causes of maternal death were hemorrhage, infections, and toxemia of pregnancy.

Rape, incest, sexual abuse, and other types of physical aggression are important problems for women. According to information for 1993, every day 60 complaints of domestic violence are lodged with the Office of the Public Defender for Women and the Program for Abused Women. This number is undoubtedly an underestimate of the problem, since most cases of abuse are not reported. A study carried out in 1993 found that an estimated 77.8% of women had been victims of some type of violent conduct by their male partners. According to the Office of Women's Affairs, the majority of the 14 rapes reported on average every day, involve adolescents ages 11 to 16 years, and 90% of the pregnancies occurring among girls under 14 years are the result of sexual abuse, generally committed by a close relative.

Health of the Elderly

In 1991 persons 60 years of age and over made up 6.4% of the population, up from 5.5% in 1980. Of all the deaths that year, 62% were persons in this age group, and most (74%) of those deaths were due to three causes: diseases of the circulatory system, which accounted for 39% (a rate of 143.6 per 10,000 population); malignant neoplasms, which accounted for 22% (81.2 per 10,000 population); and diseases of the respiratory system, which accounted for 13% (46.3 per 10,000 population).

This age group accounted for 14.1 % of the outpatient visits to CCSS institutions and 12.5% of the discharges from CCSS hospitals. Among females 60 years and over, the three leading causes of outpatient visits were hypertensive disease (18.4%), diabetes mellitus (8.1 %), and arthropathies and related disorders (5.8%). Among males in the age group, these causes for outpatient visitis accounted for 15.4%, 5.9%, and 5.1 %, respectively. Neurotic disorders were the fourth leading cause for outpatient visits among women (3.6%) and the seventh leading cause among men (2.8%). The three principal causes associated with hospital discharge in 1990 for both sexes were ischemic heart disease (7.2%), diseases of the eye, ear, and mastoid process (5.9%), and diabetes mellitus (5.8%). Ischemic heart disease ranked first among men (8.4%) and third among women (6%), while diabetes mellitus was the leading cause among women (7.5%) and ranked seventh among men (4%). Diseases of the eye, ear, and mastoid process ranked second among women (6.4%) and third among men (5.5%). Diseases of the male genital organs were the second leading cause associated with hospital discharge among elderly men (7.4%).

A study of morbidity carried out in the county of Coronado in 1986 and 1987 found the most prevalent chronic diseases to be osteomuscular and joint diseases (49.1 %), followed by arterial hypertension (38.4%), diabetes mellitus (13.9%), cerebrovascular accident (6.7%), and malignant neoplasms (4.5%).

Workers' Health

The work force in 1990 totaled 1,017,151 persons - 38% of the total population. Only 573,321 employed persons (56%) had insurance coverage for work-related accidents and diseases, although by law all workers must be covered. That same year there was an average of 10,357 occupational accidents per month, or 345 per day.

According to a report by the National Insurance Institute (INS), the four leading types of work-related accidents in 1990 were accidental falls (21.6%); accidents caused by submersion, suffocation, and foreign bodies (5.3%); accidental poisoning by solid or liquid substances (4.7%); and transport accidents (2.7%).

Diseases and Health Impairments

Vector-Borne Diseases

In 1975 a total of 304 cases of malaria were reported, for a rate of 1.5 per 10,000 population. Between 1980 and 1985 the number of cases rose from 368 to 722, while the rate increased from 1.6 to 2.7 per 10,000 population. In 1990 the number of reported cases totaled 1,142 (a rate of 3.8 per 10,000), and in 1991, 3,247 cases (a rate of 10.5). Seventy-four percent of the cases occurred in the Huetar Atlica region (province of Lim In 1992 there were 6,951 cases (22.5 per 10,000 population). Of that total, 1,173 (16.9%) occurred in foreigners and 5,210 were detected in the (province of Lim which experienced considerable immigration in connection with the growth of the banana industry in the area. In addition, ecological changes in the province as a result of banana-growing - deforestation and flooding of large areas - created favorable conditions for proliferation of the vector.

Vaccine-Preventable Diseases

The last six eases of diphtheria in the country were reported in 1975. No cases of poliomyelitis have been reported since 1973. Tetanus cases decreased from 46 in 1975 to just 2 in 1992 (rates of 2 and 0.1 per 100,000, respectively, in those years). A total of 1,165 cases of whooping cough were reported in 1975 (a rate of 5.9 per 10,000) and 29 in 1992 (a rate of 0.1 per 10,000). Costa Rica continued to experience cyclical outbreaks of measles, and an epidemic in 1979-1980 resulted in 7,883 cases and 42 deaths, for a case-fatality rate of 5.3 per 1,000. An outbreak in 1986-1987 was responsible for 8,457 cases and 16 deaths, making the case-fatality rate 1.9 per 1,000. During the period 1988-1990 there were only 467 cases and no deaths. However, in 1991-1992 another epidemic produced 8,701 cases and a case-fatality rate of 6 per 1,000 (54 deaths); 60% of those deaths were of persons under 1 or over 19 years of age.

Cholera and Other Intestinal Infectious Diseases

The first case of cholera in the country was detected in 1992, and as of April 1993 a total of 16 cases had been reported, 9 of which were imported. Mortality from diarrheal diseases has decreased among both children and adults. In 1970 these diseases were the leading cause of death, accounting for 10.5% of all deaths, with a mortality rate of 7.0 per 10,000. By 1991 they had dropped to 22nd place and accounted for only 0.9% of deaths, with a rate of 0.4 per 10,000. As a cause of infant death, diarrheal diseases moved from first place in 1970, when they accounted for 27% of all infant deaths (rate of 16.7 per 1,000 live births), to seventh place in 1991, when they accounted for 3% of all infant deaths (rate of 0.4 per 1,000 live births).

In 1990 intestinal infectious diseases accounted for 3% of all discharges from CCSS hospitals. According to Ministry of Health records on notifiable diseases, in 1991 a total of 68,887 cases of diarrheal disease were reported, yielding a rate of 2,231 per 100,000 population.

The incidence rate of hepatitis (all types) has declined steadily, from 95.0 per 100,000 population in 1985 to 85.1 in 1990 and 39.7 in 1991. Nevertheless, outbreaks of hepatitis A continue to occur in small communities in which fecal contamination of water has been confirmed.

Chronic Communicable Diseases

Fifty cases of tuberculosis (all forms) were reported in 1990, (a rate of 1.6 per 100,000 population), and 201 in 1991 (6.5 per 100,000). By comparison, in 1980 and 1985 the rates had been 20.5 and 13.9 per 100,000 population, respectively.

The number of cases of leprosy has declined. In 1980 there were 47 reported cases and the rate was 2.1 per 100,000 population, while the rates in 1985 and 1991 fell to 1.1 and 0.5 per 100,000 population, respectively.

Respiratory Diseases

In 1991 respiratory diseases were the fourth leading cause of death overall, accounting for 10% of total mortality, with a rate of 3.9 per 10,000 population. Among the population ages 50 years and over, these diseases were the third leading cause of death, with a rate of 25.7 per 10,000 population. The most important of these diseases in 1991 were chronic obstructive pulmonary disease and bronchopneumonia. Mortality from respiratory diseases has decreased substantially, especially among children under 1 year of age. In that group bronchopneumonia ranked fourth as a cause of death in 1991 (rate of 0.6 per 1,000 live births), whereas in 1970 it had ranked second (rate of 6.9 per 1,000 live births).

A national survey of outpatient visits found that in 1987 acute respiratory infections and other respiratory diseases were the leading causes of outpatient visits to CCSS institutions, accounting for 17.8%, and in 1989 they were the diagnosis associated with 7.6% of all hospital discharges among children under 10 years of age. Bronchitis is second only to acute tonsillitis as a reason for outpatient visits among children ages 1 to 4 years.

AIDS and Other Sexually Transmitted Diseases

As of December 1992, 433 cases of AIDS had been reported: 57.5% in homosexuals, 15.2% in bisexuals, and 8.5% in heterosexuals. Of all the reported cases, 86.8% occurred in persons 20 to 49 years of age, and 7% (32 cases) were in females. Seven cases resulting from perinatal transmission have been reported since 1988.

The rates of gonorrhea reported by the Ministry of Health were 380.8 and 313.6 per 100,000 population in 1980 and 1985, respectively. In 1990 and 1992 the rates were 141.8 and 107.6 per 100,000 population.

Nutritional and Metabolic Diseases and Deficiencies

In 1975, 53% of children under 6 years of age showed some degree of malnutrition: 40.9% mild, 11.2% moderate, and 1.1 % severe. Among the same age group in 1982, the proportion was around 44%: 38% mild, 5% moderate, and 0.3% severe. In 1990, 21% of the children under 6 years that were covered by the Ministry of Health's primary health care program showed malnutrition: 18.2% mild, 2.6% moderate, and 0.17% severe.

Other assessments made on the basis of height-for-age among 7-year-olds, indicated that the proportion exhibiting growth retardation had decreased from 20.4% in 1979 to 9.2% in 1989. The children who are malnourished belong to families whose principal source of income is agriculture, and children living in rural areas are the most severely affected.

A nutrition survey in 1982 found that 10% of children under 6 years of age were obese. In 1990, 3.2% of the population in this age group covered by the primary health care program was found to be overweight. Among adults a study using data from 1982 showed the prevalence of obesity to be 31.5% overall, with a higher proportion in urban areas (38.5%) than in rural areas (28.2%). Obesity was more frequent among women (40%) than men (22%), and increased markedly with age among persons of both sexes. In the population under 35 years of age the prevalence was 32% among females and 14% among males, while in the population over 35 it was 51% among females and 30% among males. Another study indicated that the prevalence of obesity was 14.4% and 33.3% among rural males and females, respectively, and 20.7% and 39.2% among urban males and females.

The prevalence of diabetes mellitus in persons age 15 and over was 4.2%; however, in persons age 60 and over a study conducted in 1986-1987 found the frequency to be 13.9% overall, 15.8% among women, and 11.5% among men. Diabetes accounted for 2.3% of outpatient visits by women to CCSS establishments and 1.6% of visits by men. Among patients over the age of 44, the proportion of visits due to this disease increased to 5% for both sexes, and for those over 59 years of age, it increased to 8.2% for women and 6% for men. The death rate from diabetes in 1985 was 0.7 per 10,000 population, but it climbed to 1.0 per 10,000 in 1991, and diabetes ranked 16th among all defined causes of death.

Cardiovascular Diseases

Diseases of the circulatory system are the leading cause of death in Costa Rica. Since 1975 the death rate from this cause has fluctuated between 10.3 and 11.2 per 10,000 population. In 1991 cardiovascular diseases were responsible for 29% of all deaths. The leading causes within the group of circulatory diseases were acute myocardial infarction, atherosclerosis, ischemic heart disease, and cerebrovascular disease.

Malignant Neoplasms

Malignant neoplasms are the second leading cause of death. Since 1975 they have accounted for 20% of total mortality. The cancer death rate rose from 6.6 per 10,000 population in 1970 to 7.6 in 1991, and was higher among persons older than 45 years of age. Among males, the most common sites of malignancy were the stomach, with rates of 26.1 per 100,000 males in 1975 and 24.8 in 1991; prostate, with rates of 4.9 per 100,000 males in 1975 and 9.0 in 1991; trachea, bronchus, and lung, with rates of 6.4 per 100,000 population in 1975 and 7.8 in 1991; and liver and bile ducts, with a rate of 4.4 per 100,000 population (in 1975 this type of cancer ranked 14th among causes of death, with a rate of 1.4 per 100,000).

Among females, stomach cancer was the most common type, with a rate of 13.4 per 100,000 females in 1975 and 13.8 in 1991. The second most common type was cancer of the uterine cervix, which in 1975 was the third leading cause of death among women. The mortality rate from this cancer increased from 5.5 per 100,000 women in 1975 to 8.1 in 1991. Third was breast cancer, which moved from second place among the leading causes of female death in 1975, with a rate of 5.7 per 100,000 women, to third place in 1991, with a rate of 6.7. The fourth most common site of malignancy was the pancreas, with a rate of 4.3 per 100,000 women.

In 1990 malignant neoplasms accounted for 3.6% of all CCSS hospital discharges.

Accidents and Violence

The group of causes comprising accidents, injuries, and poisoning is the third leading cause of death among the 17 major cause groups and was responsible for 4.4 deaths per 10,000 population in 1990. Deaths from transport accidents in 1990 made up 32% of total mortality from external causes. The most affected age groups were those 45 years and over, 35 to 39, and 20 to 34, among whom the rates were 30.3, 20.3, and 19.1 per 100,000 population, respectively. More males than females died in each of these age groups. Among all types of transport accidents, the leading cause of death was motor vehicle collisions with pedestrians.

In 1990 mortality from suicide accounted for 12% of total mortality from external causes. The 60-and-over age group was the most affected, with a rate of 9.8 per 100,000, followed by the 20 to 44 age group, with a rate of 9.2 per 100,000. Mortality from homicide constituted 10% of total mortality from external causes in 1990. Of the homicides investigated by the Judicial Investigation Agency in 1990, 18% were the result of conflicts between individuals, 16.5% resulted from fights, and 15.8% stemmed from robbery or assault.

Injuries, fractures, poisoning, and other external causes accounted for 6.4% of all CCSS hospital discharges in 1990.

Alcoholism, Smoking, and Drug Dependence

The prevalence of smoking among the population age 18 years and over is 22.3%. The prevalence is higher among males (33.8%) than females (11.2%) in all age groups. Male smokers also smoke more cigarettes per day. Fifty-four percent of males and 84.7% of females have never smoked, and 12.2% of males and 4.1% of females are ax-smokers. In 1984 the prevalence of smoking in the adolescent population was estimated at 12.7% (17.0% among males and 9.6% among females). Among those under the age of 15 the prevalence was 9.6% and among those aged 15 to 20 it was 14.9%.

The prevalence of alcohol consumption is 57% (10% of those who drink are excessive drinkers and 5% are alcoholics). The problem is greater among men than women. Drinking begins at very early ages: 10% of drinkers started drinking by 12 years of aye, 26% by 15, and 46% by 18. Of the excessive drinkers and alcoholics, 80% and 59%, respectively, are between 15 and 34 years of age. In 1992 an increase in alcohol consumption among women was noted, with a 27% rise in moderate drinking and an 11.1 % increase in excessive drinking in relation to 1980 levels.

In regard to the use of psychotropic drugs, 37 million doses of benzodiazopines were prescribed in 1990. It is estimated that 7.6% of persons aged 12 and over regularly take hypnotics, 6.9% take tranquilizers, and 5.1% take stimulants. In addition, 1.6% of this population uses marijuana and 0.5% uses cocaine.

Mental and Behavioral Disorders

In 1987 mental and behavioral disorders accounted for 6.3% of all outpatient visits to CCSS institutions; neurotic disorders were the leading cause for both sexes (3.2% among females and 2% in males), especially for those over the age of 20. In the population ages 20 to 59 years, neurotic disorders were the third leading reason for outpatient visits among women (4.1%) and the fifth among men (3.5%). In the group age 60 and over, these disorders were the fourth leading cause among women (3.6%) and the seventh among men (9.8%). In 1990 psychoses, neurotic disorders, drug abuse, and other mental disorders accounted for 3% of hospital discharges. Such disorders were the sixth leading cause of hospitalization (1.9%) in the group ages 20 to 44, the fourth (4.2%) in the group ages 45 to 50, and the 12th (2.6%) in the group age 60 and over.

Oral Health

In 1991 the DMF (decayed, missing, filled teeth) index among children under 12 years of age was 8.4, which is a reduction from the figure of 9.1 reported in 1984. The problem is most severe in the provinces of LimGuanacaste, and Puntarenas. Periodontal disease becomes more common at advanced ages.

Risk Factors

Risks in the Physical Environment

Costa Rica has experienced increases in the accumulation of solid wastes, air pollution (caused mainly by motor vehicles), and contamination of water by chemical substances.

In 1990, according to the Costa Rican Institute of Water and Sewerage Systems (ICAA), 92.8% of the population countrywide was being supplied with water; nevertheless, in many communities the quality of the water is not optimum for human consumption. The ICAA reported that national coverage for collection and sanitary disposal of wastewater was 39%. Solid waste collection reaches only 46% of the population, and it is estimated that only 30% of the total amount collected is disposed of properly. The San Josetropolitan area has one sanitary landfill, which is not satisfactorily managed.

Risks in the Work Environment

The number of pesticide poisonings in Costa Rica increased from 193 cases in 1987 (6.9 per 100,000 population) to 293 cases in 1990 (9.7 per 100,000). Information from the Ministry of Health indicates that 64% of the banana plantations studied did not have suitable systems for managing agrochemicals and 82% lacked adequate procedures for handling contaminated liquid wastes.

Natural Disasters and Industrial Accidents

Hurricane Joan, which skirted the Atlantic coast on 23 October 1988, caused serious flooding and cut off communication with several communities. The storm caused 21 deaths and left more than 7,500 persons homeless, in addition to destroying road systems. The most serious consequence of hurricane Joan was the economic damage it caused through destruction of crops and livestock in the affected areas.

An earthquake occurred on 22 December 1990, affecting primarily the province of Alajuela. Although many homes and buildings in the area were damaged, only one person died. Another earthquake occurred on 16 February 1991 in the Central Valley, destroying approximately 35 homes and causing moderate damage to 15 and slight damage to 66. The earthquake of 22 April 1991 in the province of Limas one of the strongest ever to have occurred in Costa Rica. It caused tremendous infrastructure damage to the port of Limnd to road systems in the Caribbean region. Some damage was also reported in the provinces of San Josnd Cartago. Forty-eight people died and 561 were injured as a result of this earthquake, and another 6,841 sustained earthquake-related damages. A total of 2,894 homes were destroyed and 4,427 were damaged.

Contamination of Food

The most common type of foodborne disease is poisoning by Staphylococcus aureus, followed by shigellosis and salmonellosis. The reported incidence of staphylococcal food poisoning was 7.7 per 100,000 population in 1987 and 18.2 in 1990. The incidence of shigellosis was 1.6 per 100,000 in 1987 and 6.4 in 1990, and that of salmonellosis was 1.8 per 100,000 in 1987 and 3.4 in 1990.

A study conducted over the period 1985 to 1988 demonstrated the presence of aflatoxins in white corn; more than 50% of the samples analyzed showed levels ³20 parts per million.

Available Resources

Human Resources

Together, the CCSS and the Ministry of Health employ close to 90% of the human resources in the health sector. In 1991 the CCSS had 25,599 health employees, (approximately 75% of the resources of the sector), and the Ministry had 5,718, for a total of 31,317 (10.3 per 10,000 population). Of these workers, 2,759 were physicians (9 per 10,000 population), 339 were dentists (1.1 per 10,000 population), 397 were microbiologists (1.29 per 10,000 population), 221 were pharmacists (0.72 per 10,000 population), and 1,630 were professional nurses (5.28 per 10,000).

In 1990 the ICAA had 3,100 employees, and the INS had 58 workers engaged directly in health-related activities (2.5% of its total staff).

The human resources in all areas, in terms of rates per 10,000 population, increased between 1970 and 1987. Approximately 49% of the health sector work force carries out activities related to personal health care and environmental protection. The rest perform administrative or general service duties. Although two-thirds of the work force is concentrated in the Central region - where the central offices, the principal medical centers, and a large proportion of the population are located - only one-tenth of these persons are engaged in central-level administrative activities.

The three cooperatives in existence in 1993 - which provided services under contract to the CCSS and the Ministry of Health - had a total work force of about 350.

Training for health personnel is provided by several public and private institutions, which are either part of a university or linked to one, especially the University of Costa Rica. Each institution in the sector has responsibility for the continuing education and training of its personnel. The CCSS, in particular, provides such training through the Center for Strategic Development and information on Health and Social Security.

The country has never had coordinated programs and policies with regard to human resources development, which has led to imbalances between the quantity, type, and distribution of available resources, on the one hand, and the health needs of the population and the programs carried out to address them, on the other.

In 1989 there were 3,179 students enrolled in university programs in the health sciences: 70.6% at the University of Costa Rica, 9.2% at other public institutions, and 20.2% at private universities. The University of Costa Rica established a graduate degree program in public health in 1989.

Financial Resources

During 1990 public spending on health represented 7.8% of the GDP. Spending remained at around this level throughout the period 1988-1992. The revenues of health sector institutions in 1990 amounted to US$ 378.98 million, while spending by these institutions totaled US$ 385.78 million; spending by the Ministry of Health and the CCSS accounted for 87% of the US$ 6.80 million deficit.

The breakdown of health spending by the various sector institutions was as follows: Ministry of Health, 10.8%; CCSS, 72%; IAFA, 0.5%; INCIENSA, 0.3%; ICAA, 8.1%; and INS, 8.3%. Most (69%) of the revenues of the health sector come from employer-employee contributions to the social security system and workers' insurance plan, 7% from funds allocated under the national budges, 8.7% from fees charged for goods and cervices, 4.7% from the Fund for Social Development and Family Allowances, and 11.6% from the proceeds of lotteries and other sources.

Hospital services account for 34% of total spending (54% of CCSS spending), CCSS outpatient services for 27%, and Ministry of Health programs for 10%. Services provided by other sector institutions account for the remainder.

According to a survey carried out in 1987 and 1988 by the Department of Statistics and Censuses, private spending on health amounted to US$ 77.20 million in 1988, which is equal to 23% of the amount spent by the Ministry of Health and the CCSS that year.

Physical Resources

In 1992 the Ministry of Health had 61 health centers and 379 health posts. In addition, it provided services jointly with the CCSS in 60 establishments (1 regional hospital, 4 peripheral hospitals, and 55 clinics), making a total of 500 health centers and posts wholly or partially under Ministry responsibility. The resources of the Ministry of Health also include 64 school dental clinics, 24 mobile medical unite, 59 mobile dental units, 462 health education and nutrition centers (CEN), 62 health education and nutrition centers and school cafeterias (CENCE), and 44 comprehensive child health and nutrition centers (CINAI).

The CCSS operates 29 hospitals (9 national, 7 regional, and 13 peripheral) and 141 outpatient clinics, 2 of which are administered by health cooperatives. In addition, it provides outpatient services at 2 health centers and 2 health posts of the Ministry of Health (joint health centers). CCSS resources also include 21 community health posts or clinics, which operate out of their own facilities or out of facilities owned by the community or by a health cooperative.

According to data from 1989, the Ministry of Health had 40 beds in rural health centers, 50 at the INCIENSA, and 127 at the IAFA. In 1991 the CCSS had 6,382 beds (20.6 per 10,000 population); 66.4% were in the national hospitals, 18.6% were in the 7 regional hospitals, and 15.0% were in the 13 peripheral hospitals. Of the total number of beds available, 27% (5.5 per 10,000) are designated for chronically ill patients and the rest for acutely ill patients. There are 742 pediatric beds, 47% of which are at the National Children's Hospital.

In 1991 there were 289,316 hospital discharges. The bed occupancy rate was 78.2%, the average hospital stay was 6.1 days, and the bed turnover rate was 45.4. As for outpatient services, productivity was 3.8 medical consultations per contracted hour (1,573,309 hours), 2.4 dental consultations per contracted hour (267,414 hours), and 2.1 consultations per contracted hour for other professionals (101,665 hours). The number of both hospital discharges and outpatient services remained more or less constant during the period 1989-1990.

The Ministry of Health/CCSS network of services in 1992 included 119 clinical and 16 specialized laboratories, 175 pharmacies, 45 diagnostic imaging facilities (3 with CAT scan equipment), and 27 blood banks associated with the laboratories of the hospital network and with the National Blood Bank, which is operated jointly with the Red Cross.

In the public sector, infrastructure for the production of drugs and biologicals is limited. Only the CCSS has any facilities, and they consist of one small laboratory that makes pharmaceutical products, one that produces parenteral solutions, and another that makes chemical reagents.

The INS operates one temporary shelter and health center, one central clinic that provides outpatient services, and 16 small dispensaries located strategically throughout the country. It contracts out the bulk of the services it offers to CCSS and to private clinics and physicians.

In 1991 the ICAA operated 118 water systems. It has five regional offices and several local agencies.

The private health care sector is not extensive. As of early 1992 it included only four small private clinics with a total of 155 hospital beds; 352 pharmacies; 195 clinical laboratories; and 25 diagnostic imaging facilities (one with CAT scan equipment). The sector also includes a large number of private physicians and dentists and a small number of rehabilitation clinics and dental, pathology, and cytology laboratories distributed throughout the country. However, no records or reliable data are available on the size of this private network.

The country has 26 private laboratories or companies engaged in the manufacture of pharmaceutical products; 20 are domestically owned and six are run by multinational firms. Two of the latter are located in trade areas and process products for export.

Adapted from:

PAHO. 1994. Health conditions in the Americas, Volume II. PAHO, Washington, DC, 140-152.

The Nutrition and Health Transition of Democratic Costa Rica

The remarkable improvement in health and nutrition statistics in Costa Rica from those of a developing country to a rate characteristic of industrialized countries in a single decade in the 1970s is without precedent. This book, written mainly by Costa Rican health officials intimately involved in this health revolution, explores what was accomplished, how it was done, and why it was done. It describes the astonishingly wide range of social initiatives taken by the governments of the 1970s. It is intended as a reference text for students of public health and social medicine and as a stimulus to persons everywhere responsible for health and policy planning. It is a uniquely and authoritative and readable summary of a successful health and demographic transition by a poor developing country in advance of and contributing to its economic development.

International Nutrition Foundation for Developing Countries (INFDC)
Charles Street Station, P.O. Box 500
Boston, MA 02114-0500 USA
Telephone (617) 227-8747
Fax (617) 227-9405
Telex 650 3978146 MCI UW
E-mail UNUCPO@INF.UNU.EDU