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The Costa Rican experience in improving nutrition and health care
In the 1950s the nutrition and health status of the rural population of Costa Rica was as poor as in the other countries of Central America. In the 1960s a remarkable improvement began that was not paralleled in the other countries of the region. The story has been told from the viewpoint of the nutrition and public health community of Costa Rica, with major credit given to the political consensus and support that followed the economic crisis of recent years. Costa Rica's health statistics have remained close to those of industrialized countries. The following article describes the remarkable nutrition and health achievements from the perspective of the president of the country during the critical 19741978 period. At this time the social security programme was expanded to include all citizens and was integrated with preventive medicine as the chief priority. The striking continued fall in child mortality rates is shown in figure 1 of the article by A. Horwitz in this issue (p. 21).
Formal institutions for health improvement
During the 1940s and 1950s formal institutions in health and education were improved, but social security was limited to those workers making less than 300 colones per month (US$50). The trend was there, however, and middle education, higher education, and health-care buildings became important aims of society and government. Although private groups had been active in providing assistance to the ill ever since colonial days, with the arrival of new health ideas they became more and more active in this endeavour. It was the founding of the Ministry of Health and social security institutions that made these two decades extraordinary in providing the legal basis for the future expansion of the health-care system. This epoch saw the advent of a formal national health-care system because more laws were enacted and more programmes discussed than ever before, but the actual realizations were slow.
In 1961 a constitutional amendment was passed by congress which required that the whole population of the country should be covered by social security within 10 years. Thus, maternity and health, together with disability, old age, and death expenses, were to be guaranteed to the whole population starting in 1970. It was a gigantic challenge, difficult to admit as even a possibility. By 1965 all dependents of the insured workers had been guaranteed rights in the system. By 1971 the salary ceiling for coverage was eliminated, and by 1973 all hospital and medical facilities in the country, including those operated by the Ministry of Health and those operated privately by banana companies, were transferred to the social security system. A horizontal expansion of the system covered the whole territory with an aggressive construction programme, building dispensaries, clinics, and hospitals in distant areas. By the end of 1978, all Costa Ricans were guaranteed health care throughout the whole of the territory.
Around Christmas of 1974 legislation was approved to create family allocations. Very efficient work was done in constructing sanitary facilities and ensuring a pure water supply in the rural areas. All the programmes of the Ministry of Health in preventive medicine and sanitation were reinforcer, and a new concept of providing adequate nutrition for the whole population evolved. Pregnant mothers (when necessary), newborns, pre-school children, school children, and, in some cases, high-school pupils in distant areas were to be given free meals with balanced diets.
By 1978 all health building in the country had been transferred to social security. Studies were made to include all citizens not covered by labour contracts in all the facilities and programmes of the Caja Costarricense del Seguro Social. Old-age pensions for workers not covered by other programmes began in 1974. In many areas of the country preventive medicine became the primary activity of community associations, which promoted and helped government employees in their work of periodic control of illnesses, visiting distant communities and isolated homes.
All these efforts were dramatically integrated during the eight years between 1970 and 1978, and only adjustments have been required since. The economic crisis of the 1980s weakened the effort and created new problems that are now being faced by health authorities. Important reforms have been achieved, however, as reflected in the impressive tables and figures attached to this brief study.
I can convey little idea of the enthusiasm and sacrifice of those involved in the building of these programmes or of the co-ordination that was achieved among different institutions. Sanitation, nutrition, preventive medicine, and medical assistance became modernizing influences for Costa Rica similar to what education had been in the nineteenth century.
In the field of education, the number of high schools increased from 12 to 240 between 1950 and 1978. Higher education was limited and weak even after the Second World War, with fewer than 1,000 students attending a very small and poor university, By 1984 there were more than 50,000 university students attending five universities, four of which were state universities. In 1980 the country was spending a higher percentage of its gross national product on higher education than any other country in the world except the United States.
So since 1970 health and education have become the major achievements of the country. The idea behind it all was that health and education are investments, not expenses, a concept that many governments still find difficult to admit. This investment in development has given Costa Rica the most important record of health improvement in Latin America, and probably in all of the developing nations.
It is impossible to achieve such results as these in a poor country unless very strict political decisions are taken at the moment of establishing priorities in income distribution. Most Latin American countries have chosen since independence to allocate substantial amounts to the military. It is clear that in the nineteenth and early twentieth centuries bilateral conflicts demanded the existence of armies in order to defend territories. But, as time went by, military expenses became in the first place an instrument to protect feudal lords and foreign interests and later a means to offer military groups not only social status but also an opportunity for graft. Fortunes were made by kickbacks in arms-purchasing, and huge fortunes were amassed by the high military classes.
TABLE 1. Budget expenditures and health indicators for several developed and developing countries, 1982
|Expenditure (US$ per capita)||Infant mortality (per 1,000)||Mean life expectancy (years)||GNP (US$ per capita)|
Sources: Ruth Leger Sivard, World Military and Social Expenditures, 1983. World Bank, World Development Report 1984, New York: Oxford University Press, 1984.
TABLE 2. Socio-economic and health indicators of Caribbean basin nations, 1980-1981
at birth, 1981
|Infants immunized,||Literacy rate, 1980 (%)||GNP per capita, (US$)|
|1980 (%) Polio||Measles||Male||Female|
Sources: World Bank, Unesco, WHO
The armed forces became less and less efficient for protecting the national interests. On the other hand, these forces felt brave and competent when confronting poor peasants asking for land, or middle class students demanding democracy. The cost of the military made investment in health and education very difficult and insignificant.
The history of Costa Rica shows the contrary trend: investment in health and education have taken priority. Several generations of leaders have taken the position that what protects society from extremists in the long run is a healthy and well-educated citizenry.
In table 1 and 2 comparisons are made regarding how other countries similar to Costa Rica have established their priorities. In table 1, for example, we have a comparison of military and health and education expenditures for 1 982. As is indicated there, the abolition of the military in 1949 in Costa Rica has allowed a much larger investment in education and health care. The results are that infant mortality and mean life expectancy are much more like those of developed countries such as Belgium and Sweden than like these of other developing countries.
Figures 1 and 2 give some indication of the progress that has been made in health care in Costa Rica in the last several decades. Figure 1 shows that infant mortality has dropped from the range of 75 per 1,000 live births in 1 965 (comparable to rates still common in other Central American nations) to about 1 8 per 1,000 in 1 980. Deaths preventable by vaccination have shown similarly steep declines, as is shown in figure 2. Diseases such as measles, tetanus, and whooping cough that once claimed many lives in Costa Rica have dropped sharply.
FIG. 1. Infant mortality in Costa Rica, 1960- 1980
FIG. 2. Deaths preventable by vaccination in Costa Rica, 1970-1980
The performance of Costa Rica in terms of other educational and health care indicators have shown continual improvement. Table 2 compares Costa Rica with several other Caribbean nations in terms of socio-economic indicators. In terms of literacy of the population, only Cuba and Jamaica compare favourably, while only Cuba compares with Costa Rica in terms of such health-care indicators as infant mortality, life expectancy, and rates of immunization against once common diseases.
Health care and education continue to improve in Costa Rica in spite of a state of war in Central America that has forced the country to think a bit more about its national security. Nevertheless, Costa Rica has rejected military solutions for the Central American conflict and has continued to insist on its own neutrality and disarmament. This country sees negotiation as the only possible means to achieve peace in the region.
It would be possible to talk about many of the other programmes that have been started with different institutions in Costa Rica, such as natural-resources conservation, pollution control, and so on. But the main object of this paper has been to show, through achievements, why we in Costa Rica believe that military expenses should play a secondary role to expenditures on the improvement of health and education.
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